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ORIGINAL ARTICLE

Advance Statements to Prevent Treatment
Disengagement in Substance Use Disorders
Louise Penzenstadler, MD1, Carina Soares1, Ariella Machado1, Stéphane Rothen, PhD1, Alberto Picchi, MD1, Pascale Ferrari2,3,
Daniele Zullino, MD1,4, Yasser Khazaal, MD5,6

ABSTRACT
Objectives: Some individuals with substance use
disorders find it difficult to engage in outpatient treatment
programs. In order to promote clients’ recovery they need
to be actively involved in illness management. This implies
for both client and health care professional identifying
possible signs for treatment disengagement and strategies
to regain contact with their service providers. We used
advance statements (AS) in order to discuss these signs,
strategies, and treatment preferences with service users.
This study aims to examine the content of AS developed to
prevent treatment disengagement.
Methods: Thematic analysis of 62 AS developed by
service users with addictive disorders and their care team
as part of a substudy of a larger trial on transitional case
management for individuals with substance use disorders. The AS used predefined questions and were
discussed before hospital discharge.
Results: The main reasons for loss of contact were relapse,
psychiatric, and more general psychological symptoms,
loss of therapeutic alliance, as well as social circumstances.
Most service users requested to be contacted by their

DECEMBER 2019

Affiliation: 1 Department of Psychiatry, Geneva University Hospitals,
Geneva, Switzerland, 2 Service of Community Psychiatry, University
Hospital, Lausanne, Switzerland, 3 Health Institute La Source,
University of Applied Sciences and Arts of Western Switzerland,
Lausanne, Switzerland, 4 Faculty of Medicine, Geneva University,
Geneva, Switzerland, 5 Addiction Medicine, Department of
Psychiatry, Lausanne University Hospitals, Lausanne, Switzerland,
6
Research Center, Montreal University Institute of Mental Health,
Montreal, QC
Corresponding Author: Louise Penzenstadler, MD, Geneva University
Hospitals, Rue de Grand-Pré, 70 C, 1202 Geneva, Switzerland. Tel:
+41 22 372 57 50, fax: +41 22 372 55 70, e-mail:
Louise.E.Penzenstadler@hcuge.ch
Author contributions: LP, CS, and YK designed the strategy for the
present trial and drafted the manuscript. LP, CS, AM, and AP
collected the data. LP and YK developed the coding frame,
analyzed the content, and discussed the results. LP and SR
analyzed the participants’ characteristics. All authors reviewed the
manuscript and helped with the final writing.
Conflicts of interest statement: The authors declare that the research
was conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of
interest.
Copyright © 2019 by the Canadian Society of Addiction Medicine
DOI: 10.1097/CXA.0000000000000067

10

caregiver. Many participants were able to name specific
coping strategies in case of loss of contact. The clients’
networks can play an important role in regaining contact.
Conclusion: There is evidence that the AS-related
intervention is a feasible and acceptable tool to help
service users assess their risk situations and early warning
signs for treatment drop-outs. The AS also allow them to
plan the interventions or actions they request in case of
such situations. Further studies are needed to examine
whether AS lead to less treatment disengagement and
whether possible loss of contact with caregivers is shorter
and with fewer negative consequences.
Keywords: Addiction, Advance Directives, Advance
Statements, Recovery, Substance Use Disorders

Objectifs: Certaines personnes atteintes de troubles liés
aux troubles d’utilisation de substances (TUS) ont du mal à
s’engager dans des programmes de traitement ambulatoires.
Pour favoriser le rétablissement des clients, ceux-ci doivent
participer activement à la gestion de la maladie. Cela
implique à la fois pour le client et pour le professionnel de la
santé l’identification des signes possibles de désengagement
du traitement et des stratégies pour reprendre contact avec
leurs fournisseurs de services. Nous avons utilisé les
déclarations préalables (DP) pour discuter de ces signes,
stratégies et préférences de traitement avec les utilisateurs
du service. Cette étude vise à examiner le contenu de DP
développées pour prévenir le désengagement du traitement.
Méthodes: L’analyse thématique de 62 DP élaborées par
des utilisateurs de services avec des TUS et leur équipe de
soins dans le cadre d’une sous-étude d’un essai clinique
plus vaste sur le case management de transition pour les
personnes atteintes de troubles liés aux TUS. Les DP ont
utilisé des questions prédéfinies et ont été discutées avant
la sortie de l’hôpital.
Résultats: Les principales raisons de la perte de contact
étaient les rechutes, les symptômes psychiatriques et
psychologiques plus généraux, la perte d’alliance thérapeutique et les circonstances sociales. La plupart des
utilisateurs du service ont demandé à être contactés par
leur fournisseur de soins. De nombreux participants ont
pu nommer des stratégies d’adaptations spécifiques en
www.canadianjournalofaddiction.org

cas de perte de contact. Les réseaux des clients peuvent
jouer un rôle important dans la reprise des contacts.

treatment planning.11,14 Such types of advance planning
were not specifically assessed for people with SUD.

Conclusions: Il est prouvé que l’intervention liée au DP
est un outil réalisable et acceptable pour aider les
utilisateurs de services à évaluer leurs situations de
risque et les signes avant-coureurs de l’abandon du
traitement. Les DP leur permettent également de planifier
les interventions ou actions qu’ils demandent en cas de
telles situations. D’autres études sont nécessaires pour
déterminer si les DP entraînent moins de désengagement
du traitement et si la perte de contact possible avec les
soignants est plus courte et entraîne moins de conséquences négatives.

In the present study, treatment drop-outs were considered as possible signs of crises and patients were actively
invited to investigate such episodes and to give directives
for advance planning specifically related to such events.

INTRODUCTION
Substance use disorders (SUD) are an important health
problem which are known for being of chronic nature.
Relapse is a common feature and can lead to frequent
hospitalizations and emergency department (ED) visits.
Hospital discharge has been shown to be a particularly
critical period associated with high risk of relapse mostly
within the first weeks after discharge.1 This is also a
critical time for suicide,2 rehospitalization, homelessness,
and violent behavior.3
Treatment disengagement is common in SUD outpatient
programs.4 Relapse and various other barriers to access
treatments increase the risk of disengagement from care.
Service users with severe SUD, comorbidities, and social
problems are at higher risk of disengagement.5 Individuals who disengage very early from treatment seem to have
greater difficulties reengaging.6 Treatment continuity
between hospital and community care has been positively
linked to higher abstinence rates7 and fewer hospital
readmissions8 and is necessary in order to provide
comprehensive support for patients.
Advance statements (AS) such as advance directives
(AD)9,10 and joint crisis plans (JCP) have been used in
mental health settings in order to help people anticipate
future crises and define the help they request or refuse in
case of crises. ADs have the potential to reduce coercion.11
The JCP, a form of non-legally binding AS also contains
treatment preferences in the event of a future crisis but
has unique features resulting from a shared decisionmaking process between users and their caregivers.12,13 In
this paper, the term “caregiver” refers to professional
service providers. A randomized controlled trial showed a
reduction in compulsory hospital admissions for the
group using JCP.12 AS allow service users to actively
participate in crisis prevention and to be involved in their
www.canadianjournalofaddiction.org

The paper aims to present qualitative analysis of the
content of the AS developed to prevent treatment
disengagement. The feasibility and acceptability of this
tool amongst a population with SUD at high risk of
disengagement will also be discussed.

METHODS
Sample
The data are drawn from an ongoing trial on transitional
case management (TCM) for individuals with addictive
disorders. The trial was approved by the Geneva Ethics
Committee (ClinicalTrials.gov, number NCT03551301).
Individuals hospitalized in our addiction treatment unit
of Geneva University Hospital from September 2017 to
October 2018 were suggested to participate if they
responded to the inclusion criteria. Inclusion criteria
were older than 18 years, able to give informed consent,
diagnosis of an addiction according to the Diagnostic and
Statistical Manual of Mental Disorders (DSM–5), more
than 3 psychiatric hospital admissions or ED visits in the
past year, more than 40 days of hospitalization in a
psychiatric ward during the last 12 months, no preexisting or regular outpatient follow-up care, or first
admission to the addiction treatment hospital unit.
Exclusion criteria were the evidence of organic brain
disease or learning disability based on the chart review. In
total, 214 individuals were hospitalized during the
recruitment period. Ninety-five service users (44.4%)
responded to the inclusion criteria. Twenty-three (24.2%)
refused to participate in the trial. Ten service users (10.5%)
were discharged from hospital at their own demand
without completing the TCM program and AS. Sixty-two
(65.3%) individuals completed the TCM program. Fourtynine (79%) of the 62 participants completed the AS which
were included in the final analysis.
TCM is a very flexible community treatment and aims to
improve the transition after hospital discharge to
outpatient treatment facilities. The program begins
during the hospital stay and lasts for 4 weeks after
discharge.15 The case managers (CM) assist clients in
11

VOLUME 10 NO. 4

Mots clés: déclarations préalables, dépendance, directives anticipées, rétablissement, troubles liés à l’utilisation
de substances

The study at hand used AS in case of treatment dropout in
order to discuss possible disengagement, critical factors
for relapse, and strategies to regain contact. This goal was
to allow the service user to make decisions and be actively
involved in the advance planning related to such risk. The
AS were modified from existing models of ADs.9,10

developing a discharge plan and help refer and coordinate
the care after discharge. They also facilitate the
communication between different parties of the client’s
personal and healthcare-related network. The AS were
part of the treatment offered to the study participants.

The AS intervention
The AS used in our group of clients contains the service
user’s reflection on risk factors for loss of contact with the
caregiver and preferences as well as strategies to reengage
with caregivers. The questions used for the AS can be
found in Table 1. The service user is also asked to suggest
measures she or he could take to reduce the risk of
disengaging with treatment and how to reestablish
contact.
The AS are discussed before hospital discharge with the
CM and are written down on a predefined document with
specific questions. CM received initial training for AS.
This document is then added to the service user’s
electronic health record and is accessible to all involved
caregivers. On condition that the client consents, their
personal network consisting of family and friends is also
given a copy of the AS. This is important when a personal
contact is named as a ressource in the AS.

Measures and data collection
Demographic data, age, gender, and marital status were
collected by interview. Addiction and psychiatric diagnoses were collected from chart review. DSM-5 diagnoses
were made by psychiatric trainees and 1 senior psychiatrist. Number of ED and hospitalizations were automatically collected and were extracted from the electronic
patient files.

AS’ related content analysis
Service user statements from the AS were analyzed using
inductive thematic analysis.16 The authors LP and YK
developed the coding frame inductively based on the data
Table 1: Advance statements
Advance statements in case of treatment dropout

rather than predefining it. LP and YK randomly selected
10 AS and independently coded all the answers to the
predefined questions. Differences between coding were
compared and discussed. Thereafter, an initial coding
frame was developed focusing the initial codes into
groups according to commonalities and differences found
between the initial coding. LP coded all AS according to
this system adding items which did not fit in the original
coding frame. These items were discussed with YK after
the initial coding. Most items could be added to existing
codes, but some required an adaption of the coding
frame. The final coding frame and the results for each
question can be found in Table 2.

RESULTS
The most common reason for non-completion was being
discharged from the hospital before completion (n = 13).
The demographics of the sample is shown in Table 3.
The most common SUD was alcohol use disorder (55.1%)
followed by polysubstance use disorder (26.5%). Depressive disorder (55.1%) and borderline personality disorder
(24.5%) were the most common psychiatric comorbidities.
Results of the content analysis of the AS are presented in 3
main categories, each one regrouping specific questions
of the predefined document: (1) reasons for loss of
contact, (2) strategies to regain contact, and (3) service
users’ preferences on caregivers’ attitudes.

Reasons for loss of contact
What could stop me from receiving treatment?
The most frequently reported reason for dropping out of
treatment was relapse (n = 33: 67.3%), followed by loss of
therapeutic alliance with the care team (n = 12: 24.5%):
“Lack of connexion (therapeutic alliance) with the
therapist.”
Eleven participants (22.4%) expressed feelings that we
named as hopelessness:
“I don’t see the point of my treatment anymore.”

What could stop me from receiving treatment?
Which signs could announce a risk of disengaging from treatment?

DECEMBER 2019

What could I do if these signs appear?
What can my network do or offer if they observe these signs?
What could I do to contact my caregivers?
How can my network help me to contact my caregivers?
In case of loss of contact, in which situation am I likely to be?
How quickly should I be contacted?
Who should be contacted by the caregivers?
Who should not be contacted by the caregivers?

12

Symptoms which were likely to prevent service users from
receiving care were also due to psychiatric disorders (n =
12: 24.5%). The most common ones were depressive and
anxiety disorders: “If I am very depressed and lack the
energy.” Thirteen participants (26.5%) suggested psychological symptoms without specifying a given psychiatric
disorder such as feelings of guilt or shame, boredom, and
fear:
“If I relapse I will feel ashamed,” “If I don’t find any
activities I will be bored (and more likely relapse).”
www.canadianjournalofaddiction.org

Table 2: Final coding frame with answers

Table 2
(continued).
Number of
responses

Question 1: What could stop me from receiving treatment?
Answers
Relapse

33 (67.3%)

Contextual circumstances

16 (32.7%)

Non-specific psychological symptoms

13 (26.5%)

Loss of therapeutic alliance or contact with
caregivers

12 (24.5%)

Psychiatric comorbidity

12 (24.5%)

Advance statements
Contact caregivers

43 (87.8%)

Talk to family or friends

7 (14.3%)

I do not know

2 (4.1%)

Go to the emergency department

1 (2.0%)

Wait for the crisis to pass

1 (2.0%)

Go home

1 (2.0%)

Very unlikely to lose contact with caregivers

1 (2.0%)

Question 6: How can my network help me to (re)contact my caregivers?

Hopelessness

11 (22.4%)

Exposition to stress

5 (10.2%)

Call me

Physical impairment (illness, accident, death)

5 (10.2%)

Home visit

19 (38.8%)

This will not happen

5 (10.2%)

Call my family or friends

15 (30.6%)

Feeling cured

2 (4.1%)

Contact me by letter or email

10 (20.8%)

My family or friends should call the caregivers

3 (6.1%)

Be insistent

3 (6.1%)
3 (6.1%)

Question 2: Which signs could announce a risk of treatment drop-out?
Answers

Answers
39 (79.6%)

Non-specific symptoms

32 (65.3%)

Nothing noted

Symptoms of psychiatric disorders

25 (51.0%)

Accompany me to a meeting

2 (4.1%)

Relapse

21 (42.9%)

Identify the signs which announce relapse

1 (2.0%)

Isolation

20 (40.9%)

Do not leave me alone for long

1 (2.0%)

Hopelessness

16 (32.7%)

Give me time to get back in touch

1 (2.0%)

Support me and my network

1 (2.0%)

Interpersonal stress
With caregiver

12 (24.5%)

With relative or friend

5 (10.2%)

Environmental, contextual stress

7 (14.3%)

I will tell you directly

1 (2.0%)

Question 3: What could I do if these signs appear?
Answers
Contact caregivers

26 (53.1%)

Specific coping strategies

20 (40.9%)

Ask for help without specifying who

14 (28.6%)

Contact family or friends

11 (22.4%)

Take medication

6 (12.2%)

Hospitalization

4 (8.2%)

Nothing noted or “I do not know”

2 (4.1%)

Withdrawal in outpatient setting

1 (2.0%)

Question 4: What can my network do or offer if they observe these signs?
Answers

Question 7: In case of loss of contact with the care team, in which
situation am I likely to be?
Answers
Relapse

34 (69.4%)

Illness

21 (42.9%)

Gone away or busy

8 (16.3%)

Hopelessness

6 (12.2%)

Nothing noted

4 (8.2%)

Forgotten

2 (4.1%)

Well

2 (4.1%)

Have legal problems

2 (4.1%)

Question 7: How quickly should I be contacted?
Answers
Short absence from care (1st missed appointment,
24–72 hours)

28 (57.1%)

Medium absence from care (1–2 weeks)

12 (24.5%)

Longer absence from care (>2 weeks)

5 (10.2%)

Call/Speak to me

44 (89.8%)

Suggest treatment

15 (30.6%)

Family member

Help of family or friends specifically asked for

10 (20.4%)

Friend

18 (36.7%)

Motivate me

6 (12.2%)

Healthcare professional

12 (24.5%)

Distract me/Calm me down

6 (12.2%)

Nothing noted

2 (4.1%)

Help me to find a solution or the cause for my
problem

3 (6.1%)

Police

1 (2.0%)

Home visit

1 (2.0%)

Participate in group session

1 (2.0%)

Nothing can be done

1 (2.0%)

Leave me alone

1 (2.0%)

Question 5: What could I do to (re)contact my caregivers?
Answers

Question 8: Who should be contacted by the caregivers?
30 (61.2%)

VOLUME 10 NO. 4

Advance statements

Question 10: Who should not be contacted by the caregivers?
Answers
Family member

23 (46.9%)

Everybody can be contacted

19 (38.8%)

Work

3 (6.1%)

Nobody except the persons specifically mentioned in
question before

3 (6.1%)

(continued )

www.canadianjournalofaddiction.org

13

Table 3: Demographics of sample (n = 49)
Variables
Age (years)

Category

Value (%)

Min

18

Median

44

Max

70

Mean

43.06

SD

13.24

Gender

Female (%)

13 (26.5)

Marital status

Single (%)

21 (42.9)

Married (%)

6 (12.2)

Separated, divorced

21 (42.9)

Widowed
Outpatient treatment

Substance use disorders

General practitioner

34 (69.4)

Psychiatrist, psychologist

21 (42.9)

Addiction facility

21 (42.9)

Social worker

19 (38.8)

Home care nurse

2 (4.1)

Other

7 (14.3)

Alcohol

27 (55.1)

Polysubstance

13 (26.5)

Cannabis

Psychiatric comorbidity

1 (2.0)

3 (6.1)

Cocaine

3 (6.1)

Heroine

2 (4.1)

Benzodiazepine

1 (2.0)

Depressive disorder

27 (55.1)

Borderline personality
disorder

12 (24.5)

Anxiety disorder

6 (12.2)

Psychotic disorder

4 (8.2)

Unspecified personality
disorder

4 (8.2)

Attention deficit disorder

4 (8.2)

Bipolar disorder

1 (2.0)

Gender identity disorder

1 (2.0)

Five participants (10.2%) said that exposure to stress could
prevent them from attending treatment:
“If bad things happen to me.”

DECEMBER 2019

Contextual circumstances were a risk factor for disengaging from care for about 1/3 of service users interviewed
(n = 16: 32.7%). These were for example organizational
issues such as having too many appointments in a short
period of time or distance from treatment center (n = 7:
14.3%), financial issues like lack of money for public
transport (n = 1: 2.0%), or not having stable housing (n = 2:
4.1%). Also having other projects (n = 3: 6.1%) or not
having any activities (n = 1: 2.0%) or being out late (n = 1:
2.0%) were risks of dropping out of treatment.
14

Five (10.2%) service users said there was no reason why
they might disengage and could not name any risk factors.
Two participants (4.1%) said they might not come to their
appointment if they felt cured and therefore no longer
needed treatment.
Which signs could announce a risk of treatment
drop-out?
For 21 service users (42.9%) the warning sign was relapse
in substance use and for 20 (40.9%) it was the isolation
from their personal network of family and friends. We
were able to find 16 answers (32.7%) as feelings of
hopelessness:
“I don’t feel capable of doing what I promised myself
to do.”
A commonly reported warning sign of treatment drop-out
was interpersonal stress with a caregiver (n = 12: 24.5%):
“I don’t feel I can trust the caregivers or treatment.”
Interpersonal stress with a relative or friend was reported
in 5 cases (10.2%) (family problems).
Seven participants (14.3%) expressed contextual problems
or stress. This could refer to problems in the service users
agenda or not writing down appointments (n = 4: 8.2%),
the treatment center being too far away (n = 1: 2.0%) not
finding work (n = 1: 2.0%), visiting places which are
associated with risk of consumption (n = 1: 2.0%).
Symptoms linked to a given psychiatric disorder (n = 25:
51.1%) (“changes in mood,” “anxiety,” “sadness”) to nonspecific psychological symptoms (n = 32: 65.3%) (“mental
confusion,” “boredom,” “not feeling well”) and to somatic
ones (n = 5: 10.2%) (“flu or other illness,” “muscle loss”)
were very common.
In case of loss of contact with the care team, in which
situation am I likely to be?
Participants were asked in what situation they would most
likely be if they drop out from care. A total of 34 service
users (69.4%) said they would have relapsed in substance
use and 21 (42.9%) suggested they would be suffering from
symptoms of mental (n = 18: 36.7%) or somatic illness (n =
3: 6.1%). Feelings of hopelessness were described by 6
participants (12.2%). Eight service users (16.3%) wrote they
might be otherwise occupied or elsewhere. Two participants (4.1%) thought they might have forgotten their
appointment. Two service users (4.1%) said they might be
feeling well and 2 thought they could have legal problems.
Four participants (8.2%) did not answer this question.

Strategies to regain contact
What could I do if these signs appear?
When asked what they could do as an individual if these
signs appeared, the most common answer was to request
www.canadianjournalofaddiction.org

help. Slightly more than half of the service users (n = 26:
53.1%) said they would contact their professional service
provider. Eleven participants (22.4%) also suggested
contacting family members or friends and 14 (28.6%)
would ask for help without specifying whom they would
contact. One participant (2.0%) wrote it was important
“to be patient and wait for people (which were asked for
help) to be available.”

Other answers were “not to be left alone too long” (n = 1:
2.0%), “identify signs which announce relapse” (n = 1:
2.0%), and “support me and my network” (n = 1: 2.0%).

Taking medication (n = 6: 12.2%) as well as specific coping
strategies were named 20 times (40.9%):

How quickly should I be contacted?

Only 4 clients (8.2%) asked to be hospitalized and 1
service user (2%) asked to do be treated for substance use
withdrawal in an outpatient setting.
One service user (2.0%) did not mention anything, and
one said he did not know what he or she could do.
What could I do to contact my caregivers?
The majority (n = 43: 87.8%) said they would contact
them by calling or coming to the office in person. Seven
participants (14.3%) suggested to contact family or friends
who could help them contact the caregivers. In 2 AS
(4.1%) we found the importance of strong pre-existing
therapeutic alliance to increase the possibility of contact
and a non-judgmental attitude:
“I can speak to a professional with whom I have a
strong alliance which will make contacting them
easier and ease the shame and guilt of not having
managed.”
Other options were going to the ED (n = 1: 2.0%), waiting
for the crisis to pass (n = 1: 2.0%), or going home (n = 1:
2.0%). One participant (2.0%) thought it was very
unlikely to happen and 2 (4.1%) did not know what they
could do.

Service users’ preferences on caregivers’
attitudes
How can my network help me to contact my
caregivers?
The majority (n = 39: 79.6%) wanted to be called by their
caregivers. Seven service users (14.3%) asked to be
contacted by email and 3 (6.1%) by letter. Fifteen
(30.6%) asked the caregivers to call their family or friends
instead of them. Three service users (6.1%) demanded
their network to show an assertive attitude. Two
participants (4.1%) asked for their family or friends to
contact the caregivers in their place. Nineteen (38.8%)
asked for a home visit. Two participants (4.1%) wanted to
www.canadianjournalofaddiction.org

One participant (2.0%) asked to be given time to get back
in touch and 3 (6.1%) did not answer this question.

The delay after drop-out by which service users wished to
be contacted ranged from very short (24–72 hours after a
missed appointment), medium delay (1–2 weeks) to
longer absences of over 2 weeks. A slight majority wished
to be contacted quickly (n = 28: 57.1%), 12 (24.5%) after a
medium delay and only 5 (10.2%) after a long delay.
Who should be contacted by the caregivers?
A large number of clients (n = 30: 61.2%) asked for a
specific family member to be contacted, 18 (36.7%) for a
friend, 12 (24.5%) for a healthcare professional and 1
service user (2.0%) asked for the police to be informed.
Two participants (4.1%) did not answer the question.
Who should not be contacted by the caregivers?
A total of 23 service users (46.9%) specified certain family
members and 3 (6.1%) did not want their work place to be
informed. 19 participants (38.8%) wrote that anyone
could be contacted. Three (6.1%) specified, that they did
not want anybody to be informed except the designated
persons in the latter question.

DISCUSSION
The present content analysis of the ASs reveals several
important points. The main reasons for loss of contact
were relapse, psychiatric symptoms due to comorbidities
and other more general psychological symptoms, loss of
therapeutic alliance, and social circumstances.
Most service users requested active outreach from
caregivers and specifically requested to be contacted by
them and to suggest treatment. Home visits were
frequently asked for. Furthermore, many participants
were able to name specific coping strategies in case of loss
of contact and/or relapse. The service users’ networks can
play an important role in regaining contact with caregivers and can provide help in case of crisis.
The present findings underline the fact that in most cases
loss of contact is not expression of the service user’s wish
to end treatment but is rather a sign of distress,
psychiatric, or somatic problems, substance use related
relapse or therapeutic alliance-related problems. Unsurprisingly, relapse was one of the main reasons for loss of
15

VOLUME 10 NO. 4

“avoid certain places and people,” “relaxation
techniques,” “do an activity such as sport, take the
dog out.”

be accompanied by a person of their choice to the meeting
with their caregivers.

contact as well as a sign of risk of disengagement. This
underlines the importance of developing strategies to
allow individuals to continue treatment even when
experiencing relapse. Some service users find it very
difficult to discuss possible risk factors once they have
completed withdrawal during a hospital stay. The event of
relapse may seem unimaginable or a failure to them. One
of the roles of the service providers could be to normalize
the possible adverse events in the critical time of hospital
discharge and to encourage them through the AS to
develop new skills to face them. The AS tool allows or
facilates an open discussion about shared responsibilities
in advance in case of critical events and relapse. Assessing
this risk by actively inviting the service user to plan what
he wants for her or himself may help to destigmatize such
difficulties and reduce the cognitive and emotional
avoidance related to such difficult events17 and may
increase the empowerment process.
Loss of therapeutic alliance, perception, or fear of being
judged by the caregivers, feeling of shame for having
relapsed or difficulties in communication were frequent
reasons for treatment disengagement. Research shows that
better therapeutic alliance is consistently related to fewer
treatment dropouts and improved outcomes.18 Strategies
to improve alliance are therefore important to prevent
treatment disengagement. The AS allows service users and
caregivers to discuss factors which might endanger the
therapeutic alliance. AD and JCP have shown to contribute
positively to the therapeutic alliance as long as they are
available and operable in case of need.19,20
The feeling of hoplessness was also often mentioned as a
reason for disengagement. In the process of recovery, it is
important to manage self-defeating patterns of thinking
and acting21 and to promote hope.22 The AS can help
identify these patterns. These can be used in subsequent
therapy to develop new ways of thinking.

DECEMBER 2019

A high proportion of the participants involved in the
present study were facing comorbid psychiatric disorders
confirming findings in other studies.23–27 Research has
shown that individuals with dual diagnoses often present
more severe symptoms and higher treatment disengagement rates.28 Study participants often stated that
symptoms caused by their comorbidities were signs
and reasons for disengaging. Therefore, the management
of comorbid disorders has to be considered as an
important part of SUD treatment. The AS can also be
considered as a psychoeducational tool helping service
users to identify early signs of possible crisis or relapse. By
identifying warning signs and strategies the service user
can collaborate on a more in-depth process of her or his
illness management. Collaborative relationships between
service users and caregivers have been shown to promote
treatment engagement for clients with co-occurring
mental illness and SUD.29
16

Possible coping strategies were mentioned by more than
half the participants. This positive finding shows that
service users already imagine certain strategies to manage
critical situations. However, in a crisis it might be difficult
to retrieve them and to implement them when needed. To
have written the strategies down in the AS may help
service users or their relatives to use them more actively.
The development of further individual strategies and the
identification of possible difficulties in advance is
promoted with AS. The possibility for service users to
develop their own strategies may enhance the feeling of
self-efficacy which is necessary for recovery.30
Social support and the use of environmental resources are
necessary for recovery.31 Most service users asked for the
involvement of their network. The AS promote the
implication of service users’ networks by identifying
resourceful contacts. This could be used to increase the
use of service users’ networks in the recovery process, to
help improve meaningful social relationships, and even to
ease the emotional burden of the caregivers in the sense
that they know what to do and where to call for help.
However, some service users asked not to be contacted or
preferred a letter or email. Hence, the AS can provide
valuable information and avoid possible experience of
intrusion or potential exposure to stigma by clients.
The AS allow a creative risk-focused collaborative and
transparent approach in order to discuss in depth the
reasons for disengagement. These include relapse,
interpersonal difficulties with staff or others, and
environmental factors.32 The caregivers try to adapt their
treatment to the clients’ needs by considering possible
interpersonal difficulties which could lead to disengagement. The service users take an active role in defining
their individual vulnerabilities and ressources. This allows
them to participate in their illness management and to
remain in control during moments of crisis promoting
self-efficacy and self-confidence. These feelings likely
protect them against relapse and strengthen personal
responsibility. The intervention also helps strengthen preexisting social support.

STUDY LIMITATIONS
There are several limitations to this study. The first
limitation is the small number of participants which
makes it difficult to generalize results. Second, the
predefined questions might have inhibited service users
from developing other ideas on how to prevent
disengagement with treatment. However, this tool should
be seen as a facilitator to discuss possible disengagement
and risk factors which can be modified by each service
user if needed. Third, the present study lacks the clinical
assessment of the possible impact of such an approach on
further treatment drop-outs.
www.canadianjournalofaddiction.org

CONCLUSION
There is evidence that the AS-related intervention is a
feasible and acceptable tool to help service users assess
the risk related to treatment drop-outs and to plan the
interventions or actions they request in case of such
situations. Such interventions may help patients to
remain in contact with caregivers during relapse or
psychiatric crisis or may reduce duration of drop-outs and
their associated burden. Further studies are needed to
examine whether AS lead to less treatment disengage-

ment and whether possible loss of contact with caregivers
is shorter and with fewer negative consequences.

ACKNOWLEDGMENTS
The authors wish to thank the Case Managers Jacques
Batshika, Stephan Marhuenda, and Bénédicte Virot for
their clinical work and their help with data collection and,
especially, all the patients who assisted with the study.

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