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The community-oriented programs environment scale (COPES) and the prediction of dropouts in an inpatient… Browning, James Joseph 1978

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THE COMMUNITY-ORIENTED PROGRAMS ENVIRONMENT SCALE (COPES) AND THE PREDICTION OF DROPOUTS IN AN INPATIENT PROGRAMME FOR ALCOHOLICS by JAMES JOSEPH BROWNING B.A. , Queen's U n i v e r s i t y , 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y , 1978 © James Joseph Browning, 1978 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f i an advanced degree at the U n i v e r s i t y o f B r i t i s h Co lumb ia , I ag ree tha the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s tudy . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d tha t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i thout my w r i t t e n p e r m i s s i o n . Department o f The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 i i ABSTRACT The Community-Oriented Programs Environment Sca le (COPES), Form I, which asks c l i e n t s about t h e i r e x p e c t a t i o n s of an i d e a l t reatment environment, was admin is te red to 51 dropouts and 151 completers who began a four -week i n p a t i e n t programme f o r a l c o h o l i c s . A d i s c r i m i n a n t a n a l y s i s d i d not r e v e a l s i g n i f i c a n t d i f f e r e n c e s between dropouts and completers on the COPES s u b s c a l e s . I t was concluded tha t t h i s i n s t r u -ment may not be a u s e f u l e a r l y p r e d i c t o r of d ropouts . E s t i m a t i o n s of e x p e c t a t i o n d i s c o n f i r m a t i o n were d e r i v e d f o r each c l i e n t by c a l c u l a t i n g the d i f f e r e n c e between the c l i e n t ' s subsca le scores on Form I of the COPES and the t h e r a p i s t ' s subsca le scores on Form R of the COPES (which asks about p e r c e p t i o n s of the r e a l t r e a t -ment env i ronment) . Comparison of dropouts and completers i n terms of these d i f f e r e n c e scores i n d i c a t e d tha t t h i s i n f o r m a t i o n was a l s o not u s e f u l f o r the e a r l y p r e d i c t i o n of d ropouts . The r e s u l t s :are r e l a t e d to p r e v i o u s f i n d i n g s i n the l i t e r a t u r e on c l i e n t e x p e c t a t i o n s and dropping out of t reatment . The p o t e n t i a l u t i l i t y of c o n v e n t i o n a l approaches to the p r e d i c t i o n of dropouts i s ques t ioned . TABLE OF CONTENTS A b s t r a c t L i s t of Tables L i s t of Appendices Acknowledgements I n t r o d u c t i o n Problem and R a t i o n a l e Hypotheses Method R e s u l t s D i s c u s s i o n References i i i Page i i i v v v i 1 22 24 . 26 30 34 43 Appendices 51 i v LIST OF TABLES Page Table 1. Mean D i f f e r e n c e Scores f o r Dropouts and Completers 31 V LIST OF APPENDICES Page Appendix 1. Demographic In fo rmat ion and Ana lyses 51 Appendix 2. R a t i o s of Dropouts to Completers 55 Appendix 3 . Dropouts Form I vs Completers Form I 56 Appendix 4. The rap is t Form R Sca les 57 Appendix 5 . Mean Dropout Scores f o r F i r s t , Second, and T h i r d Week 59 v i ACKNOWLEDGEMENTS I would l i k e to thank Dr . Char les Aharan , d i r e c t o r of the V i c t o r i a L i f e Enrichment S o c i e t y , f o r a l l o w i n g the study to be conducted at t h i s agency. S p e c i a l thanks are due to M a r t i n B. Spray, who oversaw the a d m i n i s t r a t i o n of the COPES. I would a l s o l i k e to acknowledge the members of my t h e s i s committee — D r s . Lynn A l d e n , Park Dav idson , and Tom Storm — f o r t h e i r u s e f u l comments d u r i n g the p l a n n i n g stages of the s tudy . F i n a l l y , a note of thanks i s extended to Judy Hawkins who typed t h i s manusc r ip t . Th is study was supported i n par t by Non -Med ica l Use of Drugs D i r e c t o r a t e summer support grant #1216-9-86 and Non -Med ica l Use of Drugs D i r e c t o r a t e r e s e a r c h grant #1213-9 -13. 1 INTRODUCTION The e a r l y t e r m i n a t i o n of a l c o h o l i c s from treatment has been w e l l -documented i n the l i t e r a t u r e . Whi le f i g u r e s vary w i d e l y ac ross p r o -grammes, the problem seems to be u n i v e r s a l . Baekeland and Lundwal l (1977) , i n t h e i r e x t e n s i v e rev iew of the l i t e r a t u r e , r e p o r t tha t 13.7 percent to 39 .2 percent of a l c o h o l i c c l i e n t s drop out of i n p a t i e n t programmes, w h i l e 52 percent to 75 percent of a l c o h o l i c o u t p a t i e n t s te rminate before the f o u r t h s e s s i o n . When these f i g u r e s are compared to those f o r g e n e r a l p s y c h i a t r i c c l i n i c s ( i . e . , 31 percent to 56 p e r -c e n t , Baekeland & L u n d w a l l , 1975) , i t can be seen t h a t e a r l y t e r m i n a -t i o n i s even more f requent among a l c o h o l i c s than f o r the average p s y c h i a t r i c c l i e n t . Two major concerns a s s o c i a t e d w i t h e a r l y t e r m i n a t i o n are the c o s t -e f f e c t i v e n e s s of the programme and treatment outcome f o r those who t e r m i n a t e . The i s s u e of c o s t - e f f e c t i v e n e s s i s not d e a l t w i t h e x t e n s i v e l y i n the l i t e r a t u r e on dropouts as i t i s l a r g e l y an a d m i n i s t r a t i v e prob lem, but the s p e c i f i c c o s t s are e a s i l y r e c o g n i z a b l e . Outpat ient programmes which exper ience l a r g e numbers of missed appointments by e a r l y t e r m i -na to rs , s u f f e r from wasted s t a f f t ime . I n p a t i e n t programmes exper ience f i n a n c i a l i n e f f i c i e n c y due to the i n c r e a s e d i n t a k e t ime r e q u i r e d to r e p l a c e dropouts . In a d d i t i o n , i f an i n p a t i e n t programme does not a l l o w f o r cont inuous admiss ion (as i n the case of a shor t s e q u e n t i a l programme), then dropouts may r e q u i r e the programme to f u n c t i o n a t l e s s than c a p a c i t y , thus s u b s t a n t i a l l y reduc ing i t s c o s t - ^ e f f e c t i v e n e s s . 2 These statements concern ing reduced c o s t - e f f e c t i v e n e s s r e l y , to some e x t e n t , on the assumption tha t the c l i e n t s who drop out do not r e c e i v e the maximum b e n e f i t from the programme are a r e , i n f a c t , " t reatment f a i l u r e s . " Under t h i s assumpt ion , the programme i s seen to have expended some degree of energy and t i m e , and produced l i t t l e or no improvement i n the c l i e n t . Th is r e s u l t s i n lowered c o s t - e f f e c -t i v e n e s s . Thus, the q u e s t i o n of t reatment outcome f o r d ropouts , a s i d e from be ing an important c o n s i d e r a t i o n i n i t s own r i g h t , i s d i r e c t l y t i e d to c o s t - e f f e c t i v e n e s s . Some cont roversy e x i s t s i n the l i t e r a t u r e over the i s s u e of whether dropouts can i n v a r i a b l y be c o n c e p t u a l i z e d as t reatment f a i l u r e s ( L i t t l e p a g e et a l . , 1976; F i e s t e r & Rudestam, 1975). There i s e v i -dence, f o r g e n e r a l p s y c h i a t r i c c l i e n t s , tha t c l i e n t s a t i s f a c t i o n and s e l f - r e p o r t e d improvement are not r e l a t e d to dropping out ( L i t t l e p a g e et a l . , 1976) and that the r e l a t i o n s h i p between d u r a t i o n of t reatment and outcome i s poor ( L o r i o n , 1974; M e l t z o f f & K o r n r e i c h , 1970) . A l -though s i m i l a r ev idence e x i s t s f o r a l c o h o l i c s ( e . g . , Knox, 1972) , i t i s l e s s c o n v i n c i n g i n the midst of s t u d i e s which i n d i c a t e t h a t a l c o -h o l i c dropouts do more p o o r l y than completers (Bowen & Androes , 1968; Tomsovic, 1970). In a d d i t i o n , the f i n d i n g tha t spontaneous r e m i s s i o n r a t e s f o r a l c o h o l i c s are on ly about four to f i f t e e n percent (Baekeland & L u n d w a l l , 1975) lends more support to the argument tha t engaging the a l c o h o l i c i n t reatment i s l i k e l y to be b e n e f i c i a l . When a t tempt ing to understand the r e l a t i o n s h i p between treatment d u r a t i o n and outcome, i t i s necessary to cons ider the c l i n i c a l p o p u l a -t i o n that i s be ing s t u d i e d . Some c l i e n t p o p u l a t i o n s may be seek ing 3 shor t term symptomatic r e l i e f of acute s i t u a t i o n a l problems ( e . g . , s p e c i f i c a n x i e t y neuroses , c r i s i s problems) and may not b e n e f i t from more extended therapy . For i n s t a n c e , S t r a k e r (1968) was a b l e to reduce the l e n g t h of t reatment f o r c l i e n t s w i t h c l e a r l y de f ined d e -p r e s s i v e or a n x i e t y r e a c t i o n s by i n s t i t u t i n g a b r i e f psychotherapy programme. Shor ten ing treatment d u r a t i o n had no n e g a t i v e e f f e c t on outcome, and the o v e r a l l percentage of dropouts was reduced from s i x t y - f o u r to t h i r t y - t w o . I t i s c o n c e i v a b l e tha t be fo re i n s t i t u t i n g t h i s shortened treatment programme, many of the ( s i x t y - f o u r percent ) dropouts were s u e c e s s f u l y t r e a t e d e a r l y / i n the t h e r a p e u t i c p r o -cess and t h e r e f o r e dropped out . In c o n t r a s t , c l i e n t s w i t h l e s s t r a n s i e n t d i s o r d e r s such as a l c o h o l i s m seem to r e q u i r e t reatment of longer d u r a t i o n . Consequent ly , the problem of e a r l y t e r m i n a t i o n should r e c e i v e p a r t i c u l a r a t t e n t i o n w i t h t h i s c l i n i c a l group. Research p e r t a i n i n g to a l c o h o l i c s who drop out of t reatment has focused l a r g e l y on c l i e n t c h a r a c t e r i s t i c s which show d i f f e r e n c e s between those who s tay and those who drop ou t . A number of s t u d i e s have examined demographic d i f f e r e n c e s between dropouts and remainers (Al tman, Evenson, & Cho, 1978; Baeke land , L u n d w a l l , & Shanahan, 1973; G e r t l e r , Raynes, & H a r r i s , 1973; Heinemann, Moore, & G u r e l , 1976; M i l l e r , Pokorny , & Hanson, 1968; P i s a n i & Motanky, 1970; W i l k i n s o n , P rado , W i l l i a m s , & Schnadt , 1971; Zax, Marsey, & B i g g s , 1961) . The g e n e r a l format f o r these s t u d i e s has been to o b t a i n i n f o r m a t i o n on a l a r g e number of demographic v a r i a b l e s , and then to f i n d which v a r i a b l e s show s i g n i f i c a n t d i f -fe rences between dropouts and comple te rs . 4 Four o u t p a i t i e n t s t u d i e s were a b l e to i s o l a t e s e v e r a l demographic v a r i a b l e s r e l a t e d to dropping o u t , though there i s l i t t l e c o n s i s t e n c y i n f i n d i n g s ac ross s t u d i e s . Dropouts were found to be of lower s o c i o -economic s t a t u s i n two s t u d i e s (Baekeland, L u n d w a l l , & Shanahan, 1973; P i s a n i & Motanky, 1970) , w h i l e i n a t h i r d study l e n g t h of attendance was not r e l a t e d to socioeconomic s t a t u s (Zax, Marsey , & B i g g s , 1961). The P i s a n i and Motanky (1970) study a l s o i n d i c a t e d t h a t dropouts had a g rea te r number of s i b l i n g s . The dropout sample s t u d i e d by Baeke land , L u n d w a l l , and Shanahan (1973) showed a g r e a t e r f a m i l y h i s t o r y of a l c o -h o l i s m . G e r t l e r , Raynes, and H a r r i s (1973) found tha t t h e i r dropouts had shor ted p rev ious p e r i o d s of abs t inence than c o m p l e t e r s , but f a i l e d to f i n d d i f f e r e n c e s on any other demographic v a r i a b l e s . They c o n -c luded tha t demographic v a r i a b l e s may not be ve ry u s e f u l f o r the p r e -d i c t i o n of d ropouts . Zax, Marsey, and Biggs (1961) i n d i c a t e d t h a t dropouts were more l i k e l y to be l i v i n g apar t from t h e i r spouse than were remainers . Two i n p a t i e n t s t u d i e s ( M i l l e r , Pokorny , & Hanson, 1968; W i l k i n s o n et a l . , 1971) lend support to t h i s f i n d i n g by showing tha t dropouts had l e s s s t a b l e m a r i t a l and j o b h i s t o r i e s , w h i l e a c o n t r a d i c t o r y f i n d i n g by A l tman , Evenson, and Cho (1978) s t a t e s tha t i n p a t i e n t s were more l i k e l y to drop out i f they had a spouse w i t h which to l i v e . The s t u d i e s by A l tman , Evenson, and Cho (1978) and M i l l e r , Pokorny, and Hanson (1968) agreed t h a t dropouts were s i g n i f i -c a n t l y younger than r e m a i n e r s , and W i l k i n s o n et a l . (1971) found t h a t dropouts began d r i n k i n g at an e a r l i e r age. S e v e r a l problems become apparent a f t e r r e v i e w i n g the l i t e r a t u r e on demographic v a r i a b l e s and e a r l y t e r m i n a t i o n . F i r s t l y , the f i n d i n g s 5 are i n c o n s i s t e n t ac ross s t u d i e s . Th is may be p a r t i a l l y due to the he te rogene i t y i n types of t reatment and c r i t e r i a used f o r d e f i n i n g dropouts ( i . e . , programmes w i t h no f i x e d t ime l i m i t used v a r y i n g cut o f f t imes f o r d e f i n i n g d r o p o u t s ) . At any r a t e , the a p p l i c a t i o n of these f i n d i n g s to o ther programmes must only be attempted w i t h extreme c a u t i o n , and i t has been suggested tha t each programme should d e t e r -mine i t s own p r e d i c t o r s ( G e r t l e r , Raynes, & H a r r i s , 1973) . Secondly , a l l of the aforementioned s t u d i e s examined a l a r g e number of v a r i a b l e s u s i n g s tandard u n i v a r a t e t e c h n i q u e s , a procedure tha t i n c r e a s e s the p r o b a b i l i t y of f i n d i n g d i f f e r e n c e s by chance a l o n e . T h i r d l y , a l though each study was a b l e to show some d i f f e r e n c e between average dropouts and average remainers , none of the s t u d i e s d e a l t w i t h the i s s u e of p r e -d i c t i o n . Only one study cou ld be found i n the a l c o h o l l i t e r a t u r e which attempted to t e s t the p r e d i c t i v e power of demographic v a r i a b l e s . Heinemann, Moore, and G u r e l (1976) looked a t 159 remainers and 25 dropouts and found t h a t , w h i l e s i g n i f i c a n t d i f f e r e n c e s were found f o r s o c i a l support and socioeconomic s t a t u s , when these v a r i a b l e s were f i t t e d to a r e g r e s s i o n e q u a t i o n , they accounted f o r on ly s i x percent of the v a r i a n c e f o r dropping ou t . I t appears t h a t c e r t a i n demographic v a r i a b l e s such as age, socioeconomic s t a t u s , and m a r i t a l s t a t u s may p o t e n t i a l l y c o n t r i b u t e to accura te p r e d i c t i o n of dropouts i n some p o r -grammes, though t h i s c o n t e n t i o n awa i t s e m p i r i c a l i n v e s t i g a t i o n . How-e v e r , there i s no a v a i l a b l e evidence to i n d i c a t e that demographic v a r i a b l e s by themselves enable the r e l i a b l e p r e d i c t i o n of d ropouts . A l a r g e number of s t u d i e s have attempted to examine the psycho -l o g i c a l c h a r a c t e r i s t i c s of dropouts and remainers (Blane & Myers , 6 1963; G e r r e i n , Rosenberg, & Manohar, 1973; G o l d f r i e d , 1969; Gross & N e r v i a n o , 1 9 7 3 ; Hoy, 1969; Karp , K i s s i n , & Hustmyer, 1970; K r a s n o f f , 1976; K r a s n o f f , 1977; McWi l l iams & Brown, 1977; M i l l e r , Pokorny , & Hanson, 1968; M o z d z i e r z , M a c c h i t t e l i , Conway, & K r a u s s , 1973; P a n e p i n t o , H i g g i n s , Keane-Dawes, & Smi th , 1970; W i l k i n s o n et a l . , 1971) . The m a j o r i t y of these s t u d i e s have t r i e d to d i s c o v e r d i f f e r e n c e s u s i n g v a r i o u s p e r s o n a l i t y i n v e n t o r i e s . These s t u d i e s have g e n e r a l l y been conducted w i t h i n p a t i e n t s e t t i n g s . For i n s t a n c e , Mozdz ie rz et a l . (1973), s t u d i e d dropouts from a s i x week i n p a t i e n t programme u s i n g the MMPI and found tha t they engaged i n s i g n i f i c a n t l y more d e n i a l of i n t e r p e r s o n a l problems and somatic d i s t r e s s and were more d e f e n s i v e than remainers . However, a subsequent study by K rasnof f (1977) showed no d i f f e r e n c e between dropouts and remainers on four MMPI s c a l e s , i n -c l u d i n g the D e n i a l s c a l e . S i m i l a r l y , McWi l l iams and Brown (1978) a l s o found no d i f f e r e n c e between dropouts and remainers i n an i n p a t i e n t programme on any of the MMPI s c a l e s . W i l k i n s o n et a l . (1971) a d m i n i s -t e r e d the MMPI before and a f t e r t reatment to dropouts and completers i n a n i n e t y - d a y i n p a t i e n t programme. He found tha t on ly one s c a l e of the MMPI (Cont ro l ) was s i g n i f i c a n t be fo re t rea tment , w h i l e seven s c a l e s were s i g n i f i c a n t a f t e r t reatment . A f t e r t reatment , the com-p l e t e r s tended to be l e s s h o s t i l e and a g g r e s s i v e , l e s s prone to s e l f -doubt and wor ry , and p e r c e i v e d o thers more f a v o u r a b l y than d i d d r o p -o u t s . Whi le these r e s u l t s emphasize the p o t e n t i a l l y adverse e f f e c t s of dropping o u t , they do not i n d i c a t e t h a t the MMPI i s a u s e f u l i n s t r u -ment f o r p r e d i c t i n g d ropouts . M i l l e r , Pokorny , & Hanson (1968) 7 found — i n a s i m i l a r type of programme — t h a t dropouts and completers d i d not d i f f e r on any s c a l e s of the MMPI. In the same s t u d y , a s i x t y - f o u r i tem S o c i a l Adjustment C h e c k l i s t was a d m i n i s t e r e d . I t showed t h a t dropouts were s i g n i f i c a n t l y more i r r e s p o n s i b l e , shy and i s o l a t e d , l e s s m o t i v a t e d , l e s s f r i e n d l y , and more p a s s i v e and d e f e a t i s t than comple te rs . S e l f - r e p o r t measures i n d i c a t e d a tendency f o r d r o p -outs to s o l v e problems by l e a v i n g the s i t u a t i o n (and d r i n k i n g ) . How-e v e r , when one c o n s i d e r s t h a t the number of dependent measures used i n the combined C h e c k l i s t and s e l f - r e p o r t was s e v e n t y - s e v e n , these u n i v a r i a t e f i n d i n g s must be i n t e r p r e t e d w i t h c a u t i o n . In other s t u d i e s employing p e r s o n a l i t y i n v e n t o r i e s , Hoy (1969) found dropouts to be more e x t r a v e r t e d and l e s s depressed as r e f l e c t e d by scores on C a t t e l l ' s 16PF. However, Gross and Nerv iano (1973) found no d i f f e r e n c e s between dropouts and remainers on the 16 PF (or on the Edwards P e r s o n a l P r e f e r e n c e Schedule) and suggested tha t dropping out may i n v o l v e an i n t e r a c t i o n between s i t u a t i o n and p e r s o n a l i t y domains. O 'Leary , Rohsenow, and Donovan (1976) found no d i f f e r e n c e s between dropouts and remainers i n an i n p a t i e n t programme on R o t t e r ' s I n t e r n a l -E x t e r n a l Locus of C o n t r o l S c a l e . I t appears from the f o r e g o i n g tha t d i f f e r e n c e s between dropouts and remainers on p e r s o n a l i t y i n v e n t o r i e s and c h e c k l i s t s a r e , a t b e s t , i n c o n s i s t e n t ac ross s t u d i e s . In a d d i t i o n , the use of u n i v a r i a t e p r o -cedures w i t h l a r g e numbers of dependent v a r i a b l e s p l a c e s the s c a t t e r e d f i n d i n g s i n an even weaker p o s i t i o n . F i n a l l y , the f a i l u r e to con f ron t the i s s u e of p r e d i c t i o n , r a t h e r than s imply i d e n t i f y i n g s i g n i f i c a n t d i f f e r e n c e s , leaves the reader wondering about the p r a c t i c a l i m p l i c a t i o n s 8 of the f i n d i n g s . As w i t h the work on demographic v a r i a b l e s , on ly one study cou ld be found that attempted to assess the p r e d i c t i v e a b i l i t y of responses to p e r s o n a l i t y i n v e n t o r i e s . K rasnof f (1976) attempted to i d e n t i f y dropouts from an i n p a t i e n t programme u s i n g the L i e s c a l e of the MMPI, the Marlowe-Crowne S o c i a l D e s i r a b i l i t y S c a l e , and the number of f a v o u r a b l e a t t i t u d e s toward d r i n k i n g . Us ing a d i s c r i m i n a n t f u n c t i o n he was a b l e to c o r r e c t l y c l a s s i f y 73 percent of the t o t a l sample, w i t h 11 percent of the dropouts and 16 percent of the completers be ing i n -c o r r e c t l y c l a s s i f i e d . K r a s n o f f d i s c u s s e s the need f o r c r o s s - v a l i d a -t i o n of the r e s u l t s i n h i s paper . S e v e r a l other f i n d i n g s r e l a t i n g to the p s y c h o l o g i c a l c h a r a c t e r i s -t i c s of dropouts and remainers (but not u s i n g p e r s o n a l i t y i n v e n t o r i e s ) are of i n t e r e s t . The i s s u e of c l i e n t m o t i v a t i o n was i n v e s t i g a t e d by G o l d f r i e d (1969) who found tha t c l i e n t s who were s e l f - r e f e r r e d (and presumably more mot ivated) were l e s s l i k e l y to drop out of an i n p a t i e n t programme. However, G e r r e i n , Rosenberg, and Manoher (1973) found tha t the tendency to drop out was reduced i n c l i e n t s who were w i l l i n g to take d i s u l f r a m , o n l y . i f they took i t under s u p e r v i s i o n (which p r e -sumably r e q u i r e s l e s s m o t i v a t i o n than unsuperv ised d i s u l f r a m a d m i n i s -t r a t i o n ) . I t may be tha t the a d d i t i o n a l a t t e n t i o n r e c e i v e d by s u p e r -v i s e d c l i e n t s was more important than the r e l a t i v e l . l e v e l s of m o t i v a t i o n . Panepinto et a l . (1970) found tha t a l c o h o l i c s diagnosed as s c h i z o p h r e n i c were l e s s l i k e l y to drop out of a s u p p o r t i v e drug p r o -gramme than a l c o h o l i c s diagnosed as hav ing a p e r s o n a l i t y d i s o r d e r . They suggest t h a t d i a g n o s t i c l a b e l s may be u s e f u l i n p r e d i c t i n g the l i k e l i h o o d of e a r l y t e r m i n a t i o n . However, g i ven the u n r e l i a b i l i t y of 9 p s y c h i a t r i c d i a g n o s i s , the u s e f u l n e s s of t h i s procedure ac ross c l i e n t samples and across other d i a g n o s t i c c a t e g o r i e s remains q u e s t i o n a b l e . The concepts of dependence and counterdependence have r e c e i v e d some a t t e n t i o n i n r e l a t i o n to dropping out i n a l c o h o l i c s . However, the two s t u d i e s reviewed seem to r e p o r t somewhat c o n t r a d i c t o r y f i n d i n g s . Blane and Myers (1963) found that counterdependent a l c o h o l i c s were more l i k e l y to drop out of an i n p a t i e n t programme than dependent a l c o -h o l i c s . Karp , K i s s i n , and Hustmyer (1960) , on the other hand, found that a l c o h o l i c s who dropped out of o u t p a t i e n t i n s i g h t therapy were s i g n i f i c a n t l y more dependent. These apparent l y c o n t r a d i c t o r y f i n d i n g s make sense when the o r i e n t a t i o n s of the programmes are c o n s i d e r e d . I n p a t i e n t therapy i n the Blane and Myers (1963) study s t r e s s e d the fo rmat ion of dependency t i e s w i t h c o u n s e l o r s , whereas the K a r p , K i s s i n , and Hustmyer (1960) programme s t r e s s e d nons t ruc tu red i n s i g h t therapy t h a t attempted to f o s t e r independence. T h e r e f o r e , one might expect independent c l i e n t s to do p o o r l y i n the former programme and depen-dent c l i e n t s to do p o o r l y i n the l a t t e r programme. These f i n d i n g s h i g h l i g h t the need to cons ide r the i n t e r a c t i o n between c l i e n t c h a r a c -t e r i s t i c s and type of programme when a t tempt ing to understand the dropout phenomenon. One p o s s i b l e e x p l a n a t i o n f o r the i n c o n s i s t e n c i e s i n the l i t e r a t u r e (which has attempted to r e l a t e c l i e n t demographics and p s y c h o l o g i c a l c h a r a c t e r i s t i c s - to e a r l y t e r m i n a t i o n ) i s that t h i s l e v e l of a n a l y s i s f a i l s to d e a l w i t h c e r t a i n i n t e r a c t i o n s which may be of s i g n i f i c a n c e i n understanding the phenomenon. The s a l i e n c e of the i n t e r a c t i o n s b e -tween v a r i o u s types of c l i e n t s and treatment s i t u a t i o n s f o r e a r l y 10 t e r m i n a t i o n has been suggested by s e v e r a l i n v e s t i g a t o r s i n t h e i r attempt to make sense of the l i t e r a t u r e ( e . g . , Gross & Nerv iano , 1973; G e r t l e r , Raynes, & H a r r i s , 1973). I t i s c o n c e i v a b l e t h a t the a n a l y s i s of c l i e n t - s i t u a t i o n i n t e r a c t i o n may not o n l y l e a d to techniques which a l l o w f o r more accura te p r e d i c t i o n of dropouts ac ross programmes, but t h i s approach might a l s o be u s e f u l f o r the d i s c o v e r y and unders tanding of the med ia t ing v a r i a b l e s which may u n d e r l i e the s i t u a t i o n a l r e l a t i o n -sh ips between e a r l y t e r m i n a t i o n and demographics such as age and s o c i o -economic s t a t u s . The g e n e r a l c l i n i c a l l i t e r a t u r e p rov ides s u b s t a n t i a l ev idence f o r the importance of c l i e n t - t h e r a p i s t i n t e r a c t i o n . i n d e t e r m i n i n g both the process and outcome of psychotherapy . For i n s t a n c e , Moos and Clemes (1967) , i n a m u l t i v a r i a t e study of the c l i e n t - t h e r a p i s t " s y s t e m " , observed tha t the c l i e n t , the t h e r a p i s t , and the p a r t i c u l a r i n t e r a c t i o n of c l i e n t and t h e r a p i s t were important i n de te rmin ing c l i e n t and t h e r a -p i s t behaviour d u r i n g therapy s e s s i o n s . C l i e n t - t h e r a p i s t i n t e r a c t i o n s s i g n i f i c a n t l y determined the percentage of f e e l i n g words used by the c l i e n t and t h e r a p i s t and the t o t a l number of re in fo rcements g i ven i n the s e s s i o n . A subsequent study u s i n g a s i m i l a r d e s i g n (Moos & M a c i n t o s h , 1970) i n d i c a t e s tha t the i n t e r a c t i o n between c l i e n t and t h e r a p i s t accounted f o r a r e l a t i v e l y l a r g e p r o p o r t i o n of the v a r i a n c e i n determin ing accura te empathy by the t h e r a p i s t and problem e x p r e s -s i o n by the c l i e n t . These s t u d i e s demonstrate the p o t e n t i a l u s e f u l -ness i n go ing beyond main e f f e c t s to l ook at the c l i e n t - t h e r a p i s t match and i t s e f f e c t on the t h e r a p e u t i c p r o c e s s . Dougherty (1976) matched c l i e n t s and t h e r a p i s t s u s i n g a b a t t e r y 11 of p e r s o n a l i t y t e s t s and observed the d i f f e r e n c e s between o p t i m a l matches., d e t e r i o r a t i o n (poor) matches and random matches on t h e r a p i s t r a t i n g s of t h e r a p e u t i c outcome. He found that the o p t i m a l matches d i d s i g n i f i c a n t l y b e t t e r than the d e t e r i o t a t i o n matches, w h i l e on ly the l a t t e r group d i f f e r e d s i g n i f i c a n t l y from randomly matched c o n t r o l s . These r e s u l t s suggest t h a t the avoidance of a poor match may be e s p e c i -a l l y important i n determin ing t h e r a p e u t i c outcome. C l i e n t - t h e r a p i s t match has been shown to be r e l a t e d to e a r l y t e r -m i n a t i o n i n a number of s t u d i e s . F i e s t e r and Rudestam (1975) p e r -formed a p r i n c i p l e components a n a l y s i s on c l i e n t - d e r i v e d and t h e r a -p i s t - d e r i v e d i n f o r m a t i o n concern ing c l i e n t and t h e r a p i s t demographics, c l i e n t e x p e c t a t i o n s , and c l i e n t p e r c e p t i o n s of the t h e r a p e u t i c e n -counter i n an attempt to i n v e s t i g a t e the e a r l y t e r m i n a t i o n p r o c e s s . They found t h a t c l i e n t - t h e r a p i s t match i tems accounted f o r twenty -one percent of the v a r i a n c e f o r dropping out . Dropouts tended to see t h e i r t h e r a p i s t i n a n e g a t i v e l i g h t , were l i k e l y to be e x p e c t i n g a " t e a c h e r " f i g u r e , and were ass igned ' to lower s t a t u s t h e r a p i s t s . Mendelson (1966) p r o v i d e s some data to i n d i c a t e t h a t the s i m i -l a r i t y between c l i e n t and t h e r a p i s t may be r e l a t e d to dropping out . Us ing the M y e r - B r i g g s Type I n d i c a t o r to c l a s s i f y c l i e n t s and counse lo rs i n t o types a t a u n i v e r s i t y c o u n s e l i n g c e n t r e , he found tha t h igher s i m i l a r i t y between the c l i e n t and counse lo r was a s s o c i a t e d w i t h a g r e a t e r number of c o u n s e l i n g s e s s i o n s . In a subsequent s tudy , Mendeison and G e l l e r (1967) found t h a t , f o r some c l i e n t s ( i . e . , non -freshmen) , hav ing a counse lo r of the same sex r e s u l t e d i n a reduced dropout u ra te . 12 G a r f i e l d , A f f l e c k , and M u f f l y (1963) measured c l i e n t s ' r a t i n g s of t h e i r t h e r a p i s t s and t h e r a p i s t s ' r a t i n g s of t h e i r c l i e n t s i n terms of r e s p e c t , l i k i n g , p e r c e i v e d competence or p o t e n t i a l f o r i m -provement, and a number of other d imens ions . They found a s t rong r e l a t i o n s h i p between dropping out of t reatment and the degree of concordance between c l i e n t and t h e r a p i s t r a t i n g s of each o t h e r . The h igher the concordance between c l i e n t and t h e r a p i s t r a t i n g s , the l e s s chance t h e r e .was that the c l i e n t would drop ou t . T h i s suggests t h a t c e r t a i n c l i e n t - t h e r a p i s t matches such as " c r i t i c a l c l i e n t / a c c e p t i n g t h e r a p i s t " or " a c q u i e s c e n t c l i e n t / c r i t i c a l t h e r a p i s t " may be more l i k e l y to l ead to e a r l y t e r m i n a t i o n . A more d e t a i l e d a n a l y s i s of c l i e n t and t h e r a p i s t e v a l u a t i o n s of each other i s r e q u i r e d b e f o r e any d e f i n i t e statements can be made r e g a r d i n g d y s f u n c t i o n a l matches of t h i s k i n d . Freedman, E n g e l h a r d t , Hankof f , G l i c k , Kaye, Buchwald, and S t a r k (1958) found tha t i n o u t p a t i e n t s a t t e n d i n g a p s y c h i a t r i c u n i t , the tendency to drop out was s i g n i f i c a n t l y r e l a t e d to an i n t e r a c t i o n b e -tween the c l i e n t ' s d e n i a l of h i s "mental i l l n e s s " and the warmth of the r e l a t i o n s h i p i n the i n i t i a l i n t e r v i e w . Den ie rs who were met w i t h warmth were more l i k e l y to drop out than accepto rs who were met w i t h warmth. The d i f f e r e n c e d i d not h o l d when c l i e n t s were not met w i t h warmth. These s t u d i e s a l l p o i n t to the importance of the match between the c l i e n t and t h e r a p i s t , on v a r i o u s d imens ions , f o r keeping the c l i e n t i n t reatment . Not on ly does the c l i e n t - t h e r a p i s t match p l a y a major r o l e i n determin ing whether the c l i e n t w i l l drop o u t , but the match between 13 the c l i e n t and type of t reatment i s i m p o r t a n t . K i s s i n , P l a t z , and Su . (1970) conducted a study w i t h a l c o h o l i c s i n which they o f f e r e d t h r e e k i n d s of t h e r a p y : drug the rapy , psycho -therapy , or i n p a t i e n t r e h a b i l i t a t i o n . They a l lowed the a l c o h o l i c c l i e n t s v a r i o u s degrees of cho ice as to which treatment they cou ld have, some hav ing no c h o i c e , some two a l t e r n a t i v e s , and some t h r e e a l t e r n a t i v e s . They found t h a t the more s o c i a l l y and p s y c h o l o g i c a l l y i n t a c t c l i e n t s tended to accept psychotherapy and r e j e c t i n p a t i e n t r e h a b i l i t a t i o n , w h i l e the r e v e r s e p re fe rence was t r u e f o r the l e s s i n t a c t c l i e n t s . I n t a c t n e s s was not r e l a t e d to acceptance or r e j e c -t i o n of drug therapy . Fur thermore , a d e f i n i t e r e l a t i o n s h i p was found between outcome measures and the c l i e n t - t r e a t m e n t match. S o c i a l l y i n t a c t , but l e s s p s y c h o l o g i c a l l y s o p h i s t i c a t e d c l i e n t s d i d best i n drug therapy ; s o c i a l l y i n t a c t and p s y c h o l o g i c a l l y s o p h i s t i c a t e d c l i e n t s d i d best i n psychotherapy ; and s o c i a l l y u n s t a b l e , but p s y c h o l o g i c a l l y s o p h i s t i c a t e d . c l i e n t s d i d best i n the i n p a t i e n t r e h a b i l i t a t i o n p r o -gramme. In a d d i t i o n , c l i e n t s who had more cho ice had b e t t e r success r a t e s on the average. These r e s u l t s i n d i c a t e tha t matching c l i e n t type w i t h t reatment type a f f e c t s the c l i e n t ' s acceptance of therapy (and, by i m p l i c a t i o n , the l i k e l i h o o d of dropping out) and degree of t h e r a p e u t i c g a i n . One dimension of the c l i e n t - t r e a t m e n t match t h a t has shown some promise f o r d i s t i n g u i s h i n g dropouts from completers has been the c l i e n t ' s e x p e c t a t i o n s r e g a r d i n g therapy . The r e l a t i o n of c l i e n t e x p e c t a t i o n to dropping out b e c o m e s p a r t i c u l a r l y , i n t e r e s t i n g when one i s a t tempt ing to p r e d i c t , as e x p e c t a t i o n s may be assessed be fo re 14 treatment and used to s e l e c t p o t e n t i a l d ropouts . E a r l y ev idence that c l i e n t e x p e c t a t i o n s were r e l a t e d to dropping out came from Heine and Trosman (1958) . They found t h a t dropouts from psychotherapy were more l i k e l y to be seek ing medic ine or d i a g -n o s t i c i n f o r m a t i o n w i t h the expectancy of " p a s s i v e c o o p e r a t i o n " , w h i l e c o n t i n u e r s tended to be seek ing a d v i c e r e g a r d i n g behaviour change through " a c t i v e c o l l a b o r a t i o n . " The f i n d i n g by W i l l i a m s , L ipman, Uh lenhuth , R i c k e l s , C o v i , and Mock (1967) t h a t lower c l a s s p a t i e n t s expect a m e d i c a l , a c t i v e , s u p p o r t i v e t h e r a p i s t . c o m b i n e d w i t h the o b s e r v a t i o n by Smart, Schmidt , and Moss (1969) tha t o f f e r i n g the s e r v i c e s of a p h y s i c i a n i n a d d i t i o n t o . t h o s e of a p s y c h i a t r i s t to lower c l a s s c l i e n t s reduces d ropouts , supports the f i n d i n g s of Heine and Trosman that e x p e c t a t i o n s may be r e l a t e d to e a r l y t e r m i n a t i o n . Orne and Wender (1968) d i s c u s s the need to prepare c l i e n t s (who have m e d i c a l e x p e c t a t i o n s ) f o r the psychotherapy r o l e . They term t h i s process ' a n t i c i p a t o r y s o c i a l i z a t i o n . ' G e r t l e r , Raynes, and H a r r i s (1973) found tha t A l c o h o l i c s Anony-mous a t t e n d e r s were more l i k e l y to drop out of an o u t p a t i e n t c l i n i c f o r a l c o h o l i c s and suggested that these c l i e n t s may have developed a set of e x p e c t a t i o n s which were d i f f e r e n t from the e x p e c t a t i o n s of c l i e n t s who.were not i n v o l v e d i n A l c o h o l i c s Anonymous. However, these i n v e s t i g a t o r s d i d not a c t u a l l y measure e x p e c t a t i o n s , so that t h i s f i n d i n g must be cons idered as on ly s u g g e s t i v e . S e v e r a l r e s e a r c h e r s have exp lo red the p o s s i b i l i t y tha t the d i s -c o n f i r m a t i o n of c l i e n t e x p e c t a t i o n s i n t reatment i s r e l a t e d to dropping ou t . Bo rgh i (1968) r e t r o s p e c t i v e l y analyzed i n f o r m a t i o n gathered from 15 29 t e r m i n a t o r s and 29 remainers i n a menta l h e a l t h center and c o n -c luded tha t t e r m i n a t o r s seemed to have t reatment e x p e c t a t i o n s t h a t were incongruent w i t h the t h e r a p i s t ' s e x p e c t a t i o n s . A l though no q u a n t i t a t i v e a n a l y s i s was c a r r i e d o u t , the author noted t h a t i n no case were a r e m a i n e r ' s e x p e c t a t i o n s incongruent w i t h those of h i s t h e r a p i s t and i n no case were a t e r m i n a t o r ' s e x p e c t a t i o n s congruent w i t h those of h i s t h e r a p i s t . Clemes and D'Andrea (1965) assessed the e x p e c t a t i o n s of 85 o u t -p a t i e n t s u s i n g Heine and Trosman's q u e s t i o n n a i r e . A f t e r s e p a r a t i n g c l i e n t s i n t o those who were expec t ing guidance and those who were expec t ing p a r t i c i p a t i o n , they randomly ass igned them to a p s y c h i a t r i c i n t e r v i e w s i t u a t i o n t h a t was e i t h e r compat ib le or i n c o m p a t i b l e w i t h t h e i r e x p e c t a t i o n s . They found tha t c l i e n t s who r e c e i v e d i n c o m p a t i b l e i n t e r v i e w s exper ienced s i g n i f i c a n t l y more a n x i e t y than c l i e n t s who r e c e i v e d compat ib le i n t e r v i e w s . T h i s study p r o v i d e s ev idence tha t the d i s c o n f i r m a t i o n of c l i e n t e x p e c t a t i o n s may i n c r e a s e the s t r a i n and unpleasantness of the t h e r a p e u t i c s i t u a t i o n f o r the c l i e n t . O v e r a l l and Aronson (1963) dev ised a 3 9 - i t e m P a t i e n t ' s Expec-t a t i o n Ques t ionna i re to measure c l i e n t e x p e c t a t i o n s of t h e r a p i s t behaviour on f i v e d imens ions : a c t i o n , m e d i c a l f o c u s , suppor t , p a s -s i v i t y , and p s y c h i a t r i c f o c u s . They a d m i n i s t e r e d the q u e s t i o n n a i r e to 40 lower socioeconomic s t a t u s o u t p a t i e n t s be fo re t reatment (ex -p e c t a t i o n s ) and a f t e r t reatment (percept ions ) and found tha t remainers had s i g n i f i c a n t l y s m a l l e r d i f f e r e n c e s between e x p e c t a t i o n s and p e r -c e p t i o n s than d i d t e r m i n a t o r s . These f i n d i n g s p r o v i d e d i r e c t ev idence tha t d i f f e r e n c e s between c l i e n t e x p e c t a t i o n and the a c t u a l t reatment 16 approach may l e a d to e a r l y t e r m i n a t i o n . The m a j o r i t y of the s t u d i e s tha t have i n v e s t i g a t e d the r e l a t i o n -s h i p between c l i e n t e x p e c t a t i o n s and dropping out have used measures t h a t are designed to assess the c l i e n t ' s e x p e c t a t i o n s about t h e r a p i s t behav iour . Only one study has been r e p o r t e d tha t attempted to mea-sure e x p e c t a t i o n s about the wider treatment environment. Otto and Moos (1974) used the Community-Oriented Programs Environment S c a l e (COPES), Form E to assess the e x p e c t a t i o n of c l i e n t s who were e n t e r i n g four community-based p s y c h i a t r i c programmes. The COPES i s a 100-i tem q u e s t i o n n a i r e which measures p e r c e p t i o n s or e x p e c t a t i o n s about the s o c i a l c l i m a t e of t reatment programmes. They found tha t c l i e n t s who subsequent ly became poor a t t e n d e r s had h igher e x p e c t a t i o n s than good a t t e n d e r s on seven of the ten subsca les of the COPES. The authors concluded tha t " u n r e a l i s t i c " e x p e c t a t i o n s may be r e l a t e d to dropping out . A l though no s t a t i s t i c a l ana lyses were r e p o r t e d i l i n the study to t e s t the d i f f e r e n c e s between the groups, the f i n d i n g s suggest that e x p e c t a t i o n s . o f s o c i a l c l i m a t e may be r e l a t e d to e a r l y t e r m i n a t i o n . They a l s o p o i n t to some ins t ruments which may be u s e f u l i n measuring e x p e c t a t i o n s and p e r c e p t i o n s of t reatment . S o c i a l c l i m a t e i s a term that has come to rep resent the g e n e r a l p e r c e p t i o n t h a t a group of p a r t i c i p a n t s have of a p a r t i c u l a r e n v i r o n -ment w i t h which they are i n v o l v e d . I t has been used to study the r e l a t i o n s h i p between i n d i v i d u a l s and environments i n a v a r i e t y of s e t t i n g s i n c l u d i n g p s y c h i a t r i c s e t t i n g s (Cohen & S t r u e n i n g , 1964; E l l s w o r t h & Maroney, 1971) , work s e t t i n g s (James & Jones , 1974; 17 L a w l e r , H a l l , & Oldham, 1974; Meyer, 1968; Schne ider , 1975) , and c o l l e g e s e t t i n g s (Pace, 1968). S o c i a l c l i m a t e has o f t e n been r e f e r r e d to as " o r g a n i z a t i o n a l c l i m a t e " i n work s e t t i n g s and "ward atmosphere" i n p s y c h i a t r i c s e t t i n g s . Whi le there i s some debate ( H a l l & P i l l , 1975; James & Jones , 1974) as to whether s o c i a l c l i m a t e i s a measure of the o b j e c t i v e c h a r a c t e r i s t i c s of the environment or the s u b j e c t i v e p e r c e p t i o n s of the env i ronment 's p a r t i c i p a n t s , t h e r e i s ev idence t o support the c o n -t e n t i o n t h a t i t i s a measure which r e f l e c t s both the a c t u a l e n v i r o n -ment and the i d i o s y n c r a t i c a t t r i b u t i o n s of the p a r t i c i p a n t s . In p s y c h i a t r i c s e t t i n g s measures of s o c i a l c l i m a t e have been shown to vary w i t h s t r u c t u r a l changes i n the programme ( B l i s s , Moos, & Bromet, 1976) and w i t h v a r y i n g c l i e n t p o p u l a t i o n s ( K i s h , G o l b e r g , & Ueker , 1976). S o c i a l c l i m a t e can a l s o be c o n c e p t u a l i z e d as a m e d i a t i n g v a r i -ab le between the o b j e c t i v e s t r u c t u r e of the environment and behav iour . In t h i s sense , i t can be seen as a dependent v a r i a b l e which i s a f f e c t e d by env i ronmenta l s t r u c t u r e and i n t u r n as an independent v a r i a b l e which a f f e c t s the behaviour of the p a r t i c i p a n t s . L a w l e r , H a l l , and. .Oldham (1974) found t h a t measures of o r g a n i z a t i o n a l c l i m a t e i n the work environment c o r r e l a t e d r e l a t i v e l y h i g h l y w i t h o b j e c t i v e measures of o r g a n i z a t i o n a l s t r u c t u r e and w i t h outcome measures of employee performance and s a t i s f a c t i o n . These c o r r e l a t i o n s were h igher than the d i r e c t c o r r e l a t i o n between s t r u c t u r e and outcome, thus i m p l y i n g a med ia t ing r o l e f o r s o c i a l c l i m a t e . In p s y c h i a t r i c s e t t i n g s , measures of s o c i a l c l i m a t e have been shown to r e l a t e to the s t r u c t u r e 18 of the programme ( B l i s s , Moos, & Bromet, 1976; Bromet, Moos, & B l i s s , 1976) and to v a r i o u s i n d i c e s of t reatment outcome ( E l l s w o r t h & Maroney, 1971; Moos & Schwartz , 1972; Moos, S h e l t o n , & P e t t y , 1973) . So, i t appears tha t s o c i a l c l i m a t e may be u s e f u l f o r m o n i t o r i n g g e n e r a l p e r c e p t i o n s of s t r u c t u r a l change i n an environment and may a l s o be u s e f u l f o r p r e d i c t i n g outcome. A number of ins t ruments have been developed f o r the measurement of s o c i a l c l i m a t e i n p s y c h i a t r i c and community-based t reatment s e t -t i n g s . Cohen and S t ruen ing (1964) attempted to measure the " s o c i a l atmospheres" of p s y c h i a t r i c h o s p i t a l s by f a c t o r - a n a l y z i n g employee responses to f i f t y - o n e i tems concern ing t reatment . The r e s u l t i n g ins t rument , c a l l e d the Opin ions about Menta l I l l n e s s s c a l e , was com-posed of f i v e f a c t o r s r e l a t i n g to the atmosphere of p s y c h i a t r i c h o s -p i t a l s as p e r c e i v e d by employees. These f a c t o r s were found to be r e -l a t e d to measures of r e l e a s e r a t e s and community tenure f o r s c h i z o -p h r e n i c s . E l l s w o r t h and Maroney (1972) a l s o produced a s c a l e , through f a c t o r a n a l y s i s , c a l l e d the P e r c e p t i o n of Wards s c a l e . They a d m i n i s t e r e d a l a r g e number of i tems to s t a f f and p a t i e n t s i n n i n e t e e n Veterans A d m i n i s t r a t i o n p s y c h i a t r i c wards. They subsequent ly generated four s t a f f s c a l e s and f i v e p a t i e n t s c a l e s which were ab le to s i g n i f i c a n t l y d i f f e r e n t i a t e between the wards. A number of s t a f f and p a t i e n t s c a l e s were found to be s i g n i f i c a n t l y r e l a t e d to r e l e a s e r a t e s and community tenure f o r the v a r i o u s wards. Th is inst rument has the advantage of be ing a b l e to assess both s t a f f and p a t i e n t p e r c e p t i o n s of s o c i a l c l i m a t e . Moos and h i s a s s o c i a t e s (Moos, 1974; Moos & Houts , 1968) d e r i v e d 19 two ins t ruments f o r the assessment of s o c i a l c l i m a t e s . The Ward Atmosphere S c a l e (Moos & Houts , 1968) was des igned f o r use i n h o s p i t a l -based programmes and the Community-Oriented Programmes Environment S c a l e (COPES) (Moos, 1974) was des igned f o r use i n community-based programmes. These ins t ruments are very s i m i l a r and there i s s u b s t a n -t i a l overlap between the two i n terms of the i tems which comprise them. In c o n t r a s t to the Opin ions about Menta l I l l n e s s and P e r c e p t i o n of Wards S c a l e s , which were d e r i v e d f a c t o r - a n a l y t i c a l l y , the s c a l e s of the Ward Atmosphere Sca le and the COPES are based on M u r r a y ' s (1938) and S t e r n ' s (1970) work on env i ronmenta l ' p r e s s . ' The i tem p o o l f o r the Ward Atmosphere Sca le and the COPES was d e r i v e d from a number of sources i n c l u d i n g p r o f e s s i o n a l r e p o r t s , books, and a c t u a l f r o n t l i n e s t a f f . The i tems were then f i t i n t o a number of p ress c a t e g o r i e s and a d m i n i s t e r e d to v a r i o u s p s y c h i a t r i c wards and community-based p r o -grammes. When i tems w i t h poor i n t e r n a l c o n s i s t e n c y were e l i m i n a t e d , the ins t ruments were l e f t w i t h 100 i tems compr is ing t e n subsca les or ' p r e s s ' c a t e g o r i e s . The subsca les are meant to tap r e l a t i o n s h i p d i -mensions ( invo lvement , su p p o r t , s p o n t a n e i t y ) , t reatment o r i e n t a t i o n dimensions (autonomy, p r a c t i c a l o r i e n t a t i o n , p e r s o n a l problem o r i e n t a -t i o n , anger , and a g g r e s s i o n ) , and system maintenance dimensions (order and o r g a n i z a t i o n , programme c l a r i t y , s t a f f c o n t r o l ) . The Ward Atmosphere Sca le and the COPES have s e v e r a l advantages over other measures of s o c i a l c l i m a t e . One advantage i s t h a t s t a f f and c l i e n t p e r c e p t i o n s of programmes may be measured on the same s c a l e s , so tha t easy comparisons can be made between s t a f f p e r c e p t i o n s and c l i e n t p e r c e p t i o n s . A second advantage i s t h a t the Ward Atmosphere 20 Sca le and the COPES are e a s i l y m o d i f i e d to measure i d e a l concept ions of programmes and c l i e n t e x p e c t a t i o n s of programmes. Through t h i s method, a c l i e n t ' s i d e a l concept ion or expectancy of a programme can be measured over s e v e r a l dimensions and can be d i r e c t l y compared to h i s or her r e a l p e r c e p t i o n of the programme or the s t a f f ' s r e a l p e r c e p t i o n of the programme. A l though f a c t o r a n a l y s i s of the Ward Atmosphere S c a l e i n d i c a t e s tha t the ten subsca les may not be f a c t o r i a l l y d i s c r e t e (A lden , 1978) , the i n t e r n a l c o n s i s t e n c y of the s c a l e s i s around . 8 0 (Moos, 1974) and s p e c i f i c s c a l e s have been found to show changes when cor responding changes are made i n t reatment programmes (Bromet, Moos, & B l i s s , 1976). S i m i l a r arguments are l i k e l y to app ly to the COPES, though a f a c t o r a n a l y s i s has not been r e p o r t e d on t h i s ins t rument . The Ward Atmosphere Sca le and the COPES have been w i d e l y used i n r e s e a r c h on s o c i a l c l i m a t e i n p s y c h i a t r i c and community s e t t i n g s . The Ward Atmosphere Sca le has been used to examine changes i n s t a f f concept ions of i d e a l p s y c h i a t r i c wards a f t e r programme change (Cooper, 1973) , to assess the r e l a t i o n s h i p between s o c i a l c l i m a t e and h e l p i n g behaviour on p s y c h i a t r i c wards (Sidman & Moos, 1973) and to look a t the r e l a t i o n s h i p between s o c i a l c l i m a t e on p s y c h i a t r i c wards and t r e a t -ment outcomes (Moos & Schwartz , 1972; Moos, S h e l t o n , & P e t t y , 1973) . The COPES has been used to assess the s o c i a l c l i m a t e i n a l c o h o l i s m treatment programmes (Bromet, Moos, & B l i s s , 1976) , to moni tor change i n a l c o h o l i s m treatment programmes ( B l i s s , Moos, & Bromet, 1976) , and to examine the r e l a t i o n s h i p between c l i e n t e x p e c t a t i o n s and attendance i n community t reatment programmes (Otto & Moos, 1974) . 21 Three of these s t u d i e s bear d i r e c t l y on the i s s u e of d r o p o u t s , though none are concerned e x c l u s i v e l y w i t h an a l c o h o l i c p o p u l a t i o n . The Ward Atmosphere Sca le was used to look a t the r e l a t i o n s h i p b e -tween p e r c e i v e d treatment environment and th ree measures of outcome (dropout r a t e , r e l e a s e r a t e , and community tenure) f o r s c h i z o p h r e n i c s i n seven l a r g e wards of one Veterans A d m i n i s t r a t i o n h o s p i t a l (Moos, S h e l t o n , & P e t t y , 1973) and e i g h t s m a l l wards of another Veterans A d m i n i s t r a t i o n h o s p i t a l (Moos & Schwartz , 1972). Wards w i t h h i g h dropout r a t e s were p e r c e i v e d by p a t i e n t s and s t a f f as b e i n g low i n invo lvement , suppor t , autonomy, order and o r g a n i z a t i o n , and programme c l a r i t y . A Dropout S c a l e was d e r i v e d from t h i s data (Moos, 1974) c o n -s i s t i n g of 15 i tems which were most s t r o n g l y r e l a t e d to wards w i t h h i g h dropout r a t e s . No attempt has been made to c r o s s - v a l i d a t e t h i s s c a l e on other k i n d s of wards. However, the s c a l e has h e u r i s t i c m e r i t i n tha t i t p r o v i d e s i n f o r m a t i o n about ;wh ich s c a l e s are most c l o s e l y r e l a t e d to dropping o u t . The order and o r g a n i z a t i o n s c a l e accounted f o r f i v e of the 15 i t e m s , i n d i c a t i n g t h a t programmes t h a t were p e r c e i v e d as d i s o r g a n i z e d may have s i g n i f i c a n t l y more d ropouts . The t h i r d study t h a t r e l a t e d to dropouts was the study d i s c u s s e d e a r l i e r i n t h i s rev iew (Otto & Moos, 1974) i n which the COPES was used to measure the e x p e c t a t i o n s of good and poor a t t e n d e r s i n four com-muni ty -based programmes. S ince the COPES seems to be a u s e f u l inst rument f o r measuring both e x p e c t a t i o n s and p e r c e p t i o n s about t reatment programmes, and s i n c e i t has been found i n s e v e r a l s t u d i e s to r e l a t e to dropping o u t , t h i s inst rument appears to be a p o t e n t i a l l y u s e f u l t o o l f o r the e a r l y 22 p r e d i c t i o n of d ropouts . Problem and R a t i o n a l e The f o r e g o i n g rev iew i n d i c a t e s tha t e a r l y t e r m i n a t i o n from t r e a t -ment may decrease the e f f i c i e n c y of t reatment programmes and r e s u l t i n n e g a t i v e outcome f o r the c l i e n t . Hence, the e a r l y d e t e c t i o n of p o t e n t i a l dropouts can be seen as a d e s i r a b l e g o a l . However, attempts to r e l a t e dropping out to v a r i o u s demographic and p s y c h o l o g i c a l c h a r a c t e r i s t i c s have f a i l e d to produce any u s e f u l p r e d i c t i v e measures. Genera l c l i n i c a l r e s e a r c h p rov ides s u b s t a n t i a l ev idence t h a t the match between the c l i e n t and the type of therapy i s important i n a f f e c t i n g c l i e n t behaviour and c l i e n t s a t i s f a c t i o n w i t h therapy . More -over , the work of Moos and o thers suggests t h a t the i n v e s t i g a t i o n of the wider t reatment environment may p r o v i d e more complete i n f o r m a t i o n about t h i s matching process i n programmes t h a t i n v o l v e more than j u s t a one to one c l i e n t - t h e r a p i s t i n t e r a c t i o n . One aspect of t h i s c l i e n t - t h e r a p y match t h a t has been s u c c e s s f u l l y r e l a t e d to dropping out i s c l i e n t e x p e c t a t i o n s about t reatment . S tud ies have shown that (1) dropouts o f t e n d i f f e r from completers i n t h e i r e x p e c t a t i o n s of t reatment .and (2) dropouts may d i f f e r .from com-p l e t e r s i n the degree to which t h e i r expec ta t ions are d i s c o n f i r m e d a f t e r e x p e r i e n c i n g therapy . The present study w i l l attempt to i n v e s -t i g a t e the p r e d i c t i v e a b i l i t y of e x p e c t a t i o n s w i t h r e s p e c t to both of these f i n d i n g s . One of the problems i n v o l v e d w i t h u s i n g c l i e n t e x p e c t a t i o n s of the treatment programme f o r p r e d i c t i v e purposes i s tha t there i s 23 l i k e l y to be l a r g e i n t r a - c l i e n t v a r i a n c e i n these e x p e c t a t i o n s over t i m e . The c l i e n t ' s s p e c i f i c e x p e c t a t i o n s of the programme may change s u b s t a n t i a l l y w i t h new i n f o r m a t i o n about the programme r e c e i v e d from brochures , t h e r a p i s t s , or other c l i e n t s . T h e r e f o r e , a sampl ing of these e x p e c t a t i o n s at any g i ven t ime may not r e f l e c t e x p e c t a t i o n s at a l a t e r t i m e . S ince the most p r e d i c t i v e set of e x p e c t a t i o n s may occur at d i f f e r e n t t imes f o r d i f f e r e n t c l i e n t s , i t may be d i f f i c u l t to ob -t a i n good p r e d i c t i o n w i t h a . s i n g l e a d m i n i s t r a t i o n procedure . An a l -t e r n a t i v e measure of e x p e c t a t i o n s which may be more s t a b l e over t ime i s the c l i e n t ' s e x p e c t a t i o n s of what an i d e a l or good programme would be l i k e . S p e c i f i c i n f o r m a t i o n about the programme w i l l l i k e l y not have as g reat an impact on t h i s set of e x p e c t a t i o n s , so t h a t a t any g i ven t i m e , they might p rov ide a more r e l i a b l e i n d i c a t o r of c o g n i t i v e s e t . One purpose of the present study was to assess the u s e f u l n e s s of t h i s k i n d of c l i e n t e x p e c t a t i o n f o r p r e d i c t i n g dropouts i n an i n -p a t i e n t programme f o r a l c o h o l i c s . The COPES (Form I) was used i n order to o b t a i n e x p e c t a t i o n s of the wider t reatment environment. The second purpose of the study was to i n v e s t i g a t e the p o s s i b i l i t y t h a t i n f o r m a t i o n about the p o t e n t i a l f o r d i s c o n f i r m a t i o n of the c l i e n t ' s e x p e c t a t i o n s may be of p r e d i c t i v e . v a l u e . S ince the c l i e n t ' s p e r c e p t i o n s of the programme were not o b t a i n a b l e be fo re t reatment to e s t a b l i s h the degree of d i s c o n f i r m a t i o n , i t was necessary to use a measure of the t reatment environment tha t would a l l o w us to s p e c i f y c l i e n t s who, w i t h a g i ven set of e x p e c t a t i o n s , would be l i k e l y to exper ience d i s c o n f i r m a t i o n . One p o t e n t i a l l y u s e f u l measure, which was o b t a i n a b l e , was the t h e r a p i s t s ' p e r c e p t i o n of the treatment programme. 24 If large discrepancies existed between the expectations of certain clients and their therapists' perceptions of the programme, then dis-continuation should be more apt to occur in these clients. The pre-sent study explored the f e a s i b i l i t y of this method for prediction by examining the difference scores between client ideal expectations (as measured by Form I of the COPES) and their therapists' perceptions of the programme (as measured by Form R of the COPES) separately for dropouts and completers. Hypotheses Two general hypotheses were formulated in relation to the pur-poses outlined above concerning the expected differences between dropouts and completers on their COPES responses. In addition, under each major hypothesis, several specific predictions were made regar-ding dropout/completer differences on various subscales of the COPES. These specific predictions were derived from the general literature on the COPES and dropping out and from personal knowledge of the pro-gramme. Rationales are given for each prediction. Hypothesis #1: There w i l l be differences between dropouts and completers on subscales of the COPES (Form I). Specifically, d i f -ferences should be expected to occur on the following scales: a. Order and Organization Scale. As five of the 15 items on Moos' Dropout Scale are taken from this scale on the COPES, i t appears that programmes perceived by clients as low on this dimension have very high dropout rates. Given that this dimension is related to dropping out, i t was predicted 25 t h a t dropouts would have h igher e x p e c t a t i o n s f o r order and o r g a n i z a t i o n than complete rs . b. S t a f f C o n t r o l S c a l e : One of the expressed p h i l o s o p h i e s of the VLES programme i s p e r s o n a l r e s p o n s i b i l i t y and freedom of cho ice and, as such , minimum s t a f f c o n t r o l over c l i e n t s . T h e r e f o r e , i t was p r e d i c t e d t h a t dropouts should have h igher e x p e c t a t i o n s f o r s t a f f c o n t r o l than complete rs . c . Autonomy S c a l e ; S i m i l a r l y , autonomy i s h i g h l y s t r e s s e d i n the programme. Dropouts were p r e d i c t e d to score lower on the autonomy s c a l e than complete rs . T h i s s c a l e accounts f o r two of the 15 i tems on Moos' Dropout S c a l e . d . P e r s o n a l Problem O r i e n t a t i o n S c a l e : Many c l i e n t s appear to enter the programme w i t h the e x p e c t a t i o n tha t they w i l l not have to express p e r s o n a l f e e l i n g s or d i s c u s s p e r s o n a l problems, though much of t h i s does occur d u r i n g therapy . T h e r e f o r e , dropouts were p r e d i c t e d to score lower e x p e c t a t i o n s on t h i s s c a l e than complete rs . Hypothes is # 2 : There w i l l be s i g n i f i c a n t d i f f e r e n c e s between dropouts ' scores on the COPES (Form I ) subsca les and t h e i r t h e r a p i s t ' s scores on the COPES (Form R) s u b s c a l e s , but no s i g n i f i c a n t d i f f e r e n c e s between the c o m p l e t e r ' s Form I scores and t h e r a p i s t Form R s c o r e s . S p e c i f i c a l l y , the dropouts should score h igher on o rder and o r g a n i z a -t i o n and on s t a f f c o n t r o l and lower on autonomy and p e r s o n a l problem o r i e n t a t i o n than the t h e r a p i s t s do. The r a t i o n a l e f o r the p r e d i c t i o n of these s c a l e s i s s i m i l a r to t h a t g i ven f o r hypothes is one, though i n d i v i d u a l c l i e n t - t h e r a p i s t d i f f e r e n c e scores may be expected to g i v e somewhat d i f f e r e n t p r e d i c t i v e power than mean dropout s c o r e s . 26 METHOD Subjects The s u b j e c t s were 202 a l c o h o l i c s who entered treatment a t the V i c t o r i a L i f e Enrichment S o c i e t y i n V i c t o r i a , B .C . between J u l y , 1977 and A p r i l , 1978. There were 170 males and 32 females i n the sample. Ages ranged from 20 years to 75 years w i t h a mean of 42 .5 y e a r s . A d d i t i o n a l demographic i n f o r m a t i o n r e g a r d i n g the s u b j e c t s i s a v a i l a b l e i n Appendix 1. The V i c t o r i a L i f e Enrichment S o c i e t y o f f e r s a f a i r l y w e l l - d e f i n e d and s e q u e n t i a l i n p a t i e n t programme which l a s t s f o r four weeks and can accommodate up to 26 c l i e n t s a t a t i m e . A new group of c l i e n t s l i s a d -m i t t e d every f i v e weeks, so tha t the present sample i s drawn from n ine separate treatment groups. The agency p r e f e r s to admit c l i e n t s who have some apparent o c c u p a t i o n a l or s o c i a l p o t e n t i a l i n the community such as a job or job s k i l l s , or suppor t ing f a m i l y members. In f a c t , about 28 percent of the c l i e n t s i n t h i s sample were r e f e r r e d d i r e c t l y by t h e i r employers . The t h e o r e t i c a l o r i e n t a t i o n of the programme i s s i m i l a r to r e a l i t y therapy , emphasiz ing awareness and acceptance of p e r s o n a l r e s p o n s i b i l i t y f o r one 's own behav iour . The core of the programme i n v o l v e s i n t e n s i v e group therapy s e s s i o n s which focus l a r g e l y on the p r e s e n t . b e h a v i o u r : and f e e l i n g s of the c l i e n t . Other components of the programme i n -c lude a thorough m e d i c a l : e x a m i n a t i o n , p h y s i c a l f i t n e s s and r e l a x a t i o n e x e r c i s e s , communication e x e r c i s e s , and l e c t u r e s and d i s c u s s i o n s on the e f f e c t s and p r e c u r s o r s of a l c o h o l i s m . C l i e n t s a re s t r o n g l y 27 encouraged to use Antabuse and A l c o h o l i c s Anonymous as t o o l s f o r c o n -t i n u e d a b s t i n e n c e . A f i v e - d a y "spouse programme" i s a v a i l a b l e i n the f o u r t h week f o r those c l i e n t s who w i s h to i n v o l v e t h e i r spouse or com-panion i n t h e i r t reatment . C l i e n t s who do not p a r t i c i p a t e i n t h i s p a r t of the programme cont inue w i t h group therapy s e s s i o n s and " s p e c i a l s k i l l s t r a i n i n g " ( e . g . , a s s e r t i o n t r a i n i n g , l i s t e n i n g e x e r c i s e s ) . The average dropout r a t e over the n ine therapy groups was 26 p e r -c e n t . However, the re was a l a r g e v a r i a t i o n i n the percentage of d r o p -outs over the groups. Percentages ranged from four percent i n one group (where o n l y one c l i e n t dropped out and 25 completed) , to 43 p e r -cent i n another group (where ten c l i e n t s dropped out and 13 completed) . The r a t i o s of dropouts to completers f o r the n i n e therapy groups are l i s t e d i n Appendix 2 . Apparatus The COPES i s d e s c r i b e d i n d e t a i l e lsewhere ( e . g . , Moos, 1974) . I t i n v o l v e s 100 t r u e - f a l s e type quest ions which compose ten s u b s c a l e s , so tha t each subsca le d e r i v e s i t s score from ten ques t ions which are counterbalanced to prevent ' h a l o ' responses . The ten s u b s c a l e s , which may be c a t e g o r i z e d i n t o th ree major k i n d s of d imensions (Moos, 1974) , a re as f o l l o w s : I R e l a t i o n s h i p dimensions 1) involvement 2) support 3) spontane i t y I I Treatment O r i e n t a t i o n 4) autonomy dimensions 5) p r a c t i c a l o r i e n t a t i o n 28 6) p e r s o n a l problem o r i e n t a t i o n 7) anger and a g g r e s s i o n I I I System Maintenance 8) order and o r g a n i z a t i o n dimensions 9) programme c l a r i t y 10) s t a f f c o n t r o l Two forms of the COPES were used i n the s tudy : Form R ( R e a l ) , which measures p e r c e p t i o n s of r e a l programmes, and Form I ( I d e a l ) , which measures c l i e n t s ' e x p e c t a t i o n s of an i d e a l programme. These COPES forms have been s t a n d a r d i z e d on 54 and 47 programmes of v a r i o u s k i n d s , r e s p e c t i v e l y (Moos, 1974) , and are d i r e c t l y comparable. Procedure A l l c l i e n t s e n t e r i n g the n ine therapy groups between J u l y , 1977 and A p r i l , 1978 were asked to complete Form I of the COPES on t h e i r f i r s t day of the programme. C l i e n t s had g e n e r a l l y a r r i v e d a t the agency the preced ing evening and had r e c e i v e d l i t t l e or no i n f o r m a t i o n r e g a r d i n g the content of the programme. A l l c l i e n t s were e n t e r i n g the programme f o r the f i r s t t i m e . The f o l l o w i n g r a t i o n a l e was g i v e n to c l i e n t s b e f o r e they f i l l e d out the COPES: We b e l i e v e t h a t how you see the programme may be important i n determin ing how much you b e n e f i t from i t . We wou ld , t h e r e f o r e , l i k e to know what you expect an i d e a l t reatment programme would be l i k e . Here i s a q u e s t i o n n a i r e t h a t asks you about your e x p e c t a t i o n s of an i d e a l programme. C l i e n t s a l s o completed two q u e s t i o n n a i r e s r o u t i n e l y used by the agency to o b t a i n i n f o r m a t i o n r e g a r d i n g the c l i e n t ' s s o c i a l h i s t o r y , s a t i s f a c t i o n w i t h v a r i o u s aspects of h i s or her l i f e ( e . g . , f a m i l y , work, s o c i a l ) , and past and present d r i n k i n g p r a c t i c e s . Some demographic 29 information was extracted from these instruments for use in the present study. Specifically, the information included the client's age, sex, marital status, education, income, employment status, type of refer-r a l , number of years that alcohol had been a problem, and the longest previous period of abstinence since beginning regular drinking. Form R of the COPES was completed by a l l five therapists at the beginning and at the end of the data collection period (which spanned about ten months). Therapist scores which were used in the analyses were the average scores for each therapist over the two administrations. Clients were designated as dropouts i f they l e f t the programme within the f i r s t three weeks. Clients who remained t i l l the f i n a l day of the programme were designated completers. Those clients who le f t during the fourth week of treatment were excluded from the study. This cutoff point for dropouts was an attempt to obtain a sample of clients who dropped out of the core programme which was relatively uniform across clients for the f i r s t three weeks. Using this proce-dure, a sample of 51 dropouts and 151 completers was obtained. Seven clients were excluded from the study because they dropped out in the fourth week. 30 RESULTS Hypothes is #1 was t e s t e d by per forming a two-group d i s c r i m i n a n t a n a l y s i s , which compared dropouts and completers on t h e i r responses ;to the COPES (Form I ) . T h i s a n a l y s i s r e v e a l e d no s i g n i f i c a n t o v e r a l l d i f f e r e n c e s between the groups ( x 2 = 1 2 . 9 , p_ < . 2 3 ) . M u l t i p l e com-p a r i s o n s showed no s i g n i f i c a n t d i f f e r e n c e s between the groups on any of the separate subsca les of the COPES. A B a r t l e t t - B o x t e s t which was performed on the d a t a , was not s i g n i f i c a n t (F = 1 . 7 3 , j> < . 1 8 ) , i n -d i c a t i n g t h a t the covar iance m a t r i c e s were homogeneous. Means and standard d e v i a t i o n s are summarized i n Appendix 3 . I t i s i n t e r e s t i n g to note tha t the s tandard d e v i a t i o n s a re l a r g e r f o r the dropout group on every, s u b s c a l e , though not s i g n i f i c a n t l y s o . Hypothes is #2 was t e s t e d u s i n g d i f f e r e n c e scores t h a t were c a l -c u l a t e d f o r each dropout and completer by s u b t r a c t i n g each c l i e n t ' s scores on the Form I subsca les from h i s or her t h e r a p i s t ' s scores on Form R. Th is y i e l d e d a set of ten d i f f e r e n c e scores f o r each d r o p -out and completer . Two s i n g l e sample H o t e l l i n g ' s T 2 ana lyses were then performed (one f o r the dropout group and one f o r the completer group) to t e s t the n u l l h y p o t h e s i s tha t these d i f f e r e n c e scores were, on the average, not s i g n i f i c a n t l y d i f f e r e n t from z e r o . Mean d i f f e r e n c e scores and standard d e v i a t i o n s f o r both groups a re shown i n Table 1 . The dropout group showed o v e r a l l d i f f e r e n c e scores tha t were s i g n i f i c a n t l y d i f f e r e n t from zero (T 2 = 1 7 4 . 2 , F = 1 4 . 2 9 , p_ < . 0 0 1 ) . However, the completer group showed a s i m i l a r o v e r a l l d i f f e r e n c e (T 2 = 6 8 0 . 0 , J£ = 6 3 . 9 2 , £ < . 0 0 1 ) . M u l t i p l e compar isons , i n both 31 Table 1 Mean Difference Scores f or Dropouts and Completers Dropouts Completers X SD X SD Involvement 0. 14 (1. 84) -0. 14 (1. 69) Support 0. 10 (2. 62) -0. 10 (2. 02) Spontaneity 0. 25 a . 66) 0. 26 (1. 76) Autonomy 1. 29 (1. 76) a 1. 08 (1. 41) d P r a c t i c a l Orientation 0. 40 (2. ,48) 0. 42 (1. ,89) Personal Problem Orientation 1. 02 (2. .50) 0. 33 (1. ,90) Anger and Aggression 2. 51 (3. .08)b 2. 63 (2. .60)d Order and Organization -2. .33 (2. .51)° -2. 30 (1. .96)d Programme C l a r i t y 0. 02 (2. .07) -0. 27 (.2. 00) Staff Control -2. .88 (2, .80) C -3. ,18 (2, .35) d multiple comparisons s i g n i f i c a n t at _p < .04 k multiple comparisons s i g n i f i c a n t at p < .02 multiple comparisons s i g n i f i c a n t at _p < .002 d multiple comparisons s i g n i f i c a n t at p_ < .001 32 groups, found four subsca les t h a t showed d i f f e r e n c e -scores which were s i g n i f i c a n t l y d i f f e r e n t from z e r o . These subsca les were autonomy, anger and a g g r e s s i o n , order and o r g a n i z a t i o n , and s t a f f c o n t r o l . Both dropouts and completers scored lower on the autonomy s c a l e ( i . e . , p o s i t i v e mean d i f f e r e n c e s c o r e ) , lower on the anger and a g g r e s s i o n s c a l e ( i . e . , p o s i t i v e mean d i f f e r e n c e s c o r e ) , h igher on the order and o r g a n i z a t i o n s c a l e ( i . e . , n e g a t i v e mean d i f f e r e n c e s c o r e ) , and h igher on the s t a f f c o n t r o l s c a l e ( i . e . , n e g a t i v e mean d i f f e r e n c e s c o r e ) . The s i g n i f i c a n c e l e v e l s f o r these m u l t i p l e comparisons a re l i s t e d i n Table 1. T h e r a p i s t Form R raw scores f o r the two a d m i n i s t r a t i o n s and the mean scores over the two a d m i n i s t r a t i o n s f o r each t h e r a p i s t are l i s t e d i n Appendix 4. The responses of the t h e r a p i s t s appear to be r e l a t i v e l y s t a b l e over the two a d m i n i s t r a t i o n s . By l o o k i n g a t the d i f f e r e n c e between f i r s t and second a d m i n i s t r a t i o n scores f o r f i v e t h e r a p i s t s w i t h t e n subsca les each , the re a re 50 p o s s i b l e compar isons. The t h e r a p i s t s d i f f e r e d by one p o i n t or l e s s on 38 (76 percent ) of the compar isons , d i f f e r e d by two p o i n t s on n ine (18 percent ) of the compar isons , and by th ree p o i n t s on on ly th ree of the comparisons. There do not appear to be major d i f f e r e n c e s between the t h e r a p i s t s i n t h e i r degree of s t a b i l i t y , nor are any p a t t e r n s apparent i n the s t a b i l i t y of any one s u b s c a l e . The agreement ac ross t h e r a p i s t s i n terms of t h e i r mean scores (over two a d m i n i s t r a t i o n s ) i s f a i r l y h i g h w i t h s tandard d e v i a -t i o n s on the subsca les rang ing from 0.55 f o r the p e r s o n a l problem o r i e n t a t i o n s c a l e to 1.68 f o r the anger and a g g r e s s i o n s c a l e . One a d d i t i o n a l a n a l y s i s was performed on the COPES d a t a . A 33 MANOVA was performed to compare raw Form I scores between dropouts who te rminated i n the f i r s t week (N = 1 3 ) , those who te rminated i n the second week (N = 1 8 ) , and those who te rminated i n the t h i r d week (N = 20) of the programme. The a n a l y s i s r e v e a l e d no o v e r a l l s i g n i -f i c a n t d i f f e r e n c e s between the groups (F = 0 . 9 2 , £ < . 5 5 ) . Means and standard d e v i a t i o n s f o r the th ree groups are l i s t e d i n Appendix 5 . A n a l y s i s of the demographic v a r i a b l e s revea led s e v e r a l d i f f e r e n c e s between dropouts and complete rs . These ana lyses are summarized i n Appendix 1. Dropouts were found to be s i g n i f i c a n t l y d i f f e r e n t from completers i n terms of o v e r a l l s e l f - r e p o r t e d income (x 2 = 7 . 1 5 , £ < . 0 0 8 ) . S p e c i f i c a l l y , s i g n i f i c a n t l y fewer dropouts than completers r e p o r t e d making over $16,000 i n the l a s t 12 months ( x 2 = 8 . 2 6 , £ < . 0 0 4 ) . Only 59 percent of the dropouts were employed compared to 81 percent of the completers ( x 2 = 9 . 6 4 , £ < .01) and, of those employed, s i g n i -f i c a n t l y fewer dropouts were r e f e r r e d by t h e i r employers than were completers ( x 2 = 4 . 6 8 , £ < . 0 5 ) . No s i g n i f i c a n t d i f f e r e n c e s were found between dropouts and com-p l e t e r s i n terms of age, sex , m a r i t a l s t a t u s , e d u c a t i o n , number of years tha t a l c o h o l was r e p o r t e d as be ing a problem, or longest p r e -v i o u s p e r i o d of a b s t i n e n c e . 34 DISCUSSION The results of the discriminant analysis that compared the COPES, Form I responses of the dropouts to those of the completers indicate that this instrument does not seem to be a useful early predictor of dropouts. The means for the two client groups are remarkably similar on a l l of the ten subscales (see Appendix 1). The largest difference between the groups occurs for the personal problem orientation sub-scale. . Here, i t seems that the dropouts expect an ideal programme to have less of an emphasis on the discussion of personal problems than do completers. However, the difference did not reach s t a t i s t i c a l significance. Although the Bartlett-^Box Test indicates that the distribution of the responses is similar for the two groups, i t is interesting to note that the standard deviations are larger for the dropout scores than for the completer scores on every subscale. Observation of the data indicates that this may be due to the presence of a few extreme scores in the dropout group on some of the subscales. However, there i s no indication that these extreme scores are significantly more frequent in the dropout group, nor potentially useful for general pre-diction. The failure of the COPES, Form I to discriminate successfully be-tween dropouts and completers contrasts with previous studies that have been somewhat successful using other measures of client expecta-tion (e.g., Heine & Trosman, 1958; Overall & Aronson, 1963; Otto & Moos, 1974). There are several differences between these studies and 35 the present study that may account for the discrepancy in findings. F i r s t , the questionnaires that were used by Heine and Trosman (1958) and Overall and Aronson (1963) focused on specific information re-garding whether the client expected a passive, medical approach or an active .psychiatric approach. Furthermore, these studies were examining client populations that were exclusively of lower socioeconomic class. It may be that, while the expectation of a medical approach is a useful predictor of dropping out for lower class clients entering non-medical treatment, the relationship between expectations and dropping out becomes less direct with broader measurements of expec-tations and with mixed client populations. The Otto and Moos (1974) study represents a more comparable assessment of expectations to that which was used in the present study. The major difference between the two instruments is that Otto and Moos (1974) used Form E ( which asks for expectations of the real pro-gramme) , while the present findings are based on an assessment of ex-pectations of an ideal programme (using Form I). In addition, Otto and Moos (1974) were examining attendence in an outpatient programme, not dropouts in an inpatient programme. The failure to replicate their finding (that poor attenders scored higher on seven of the ten COPES subscales) in the present dropout sample may be related to the di f -ference in the choice of independent variables (attendence vs. dropping out) or to a difference in the kind of expectations measured by the two forms of the COPES. Since there has been no psychometric data reported on Form E of the COPES and no reported administration of Form I to 'naive' clients, the question of construct validity for 36 the two forms of the inst rument remains open to s p e c u l a t i o n . Given that Otto and Moos (1974) d i d not r e p o r t any s t a t i s t i c a l ana lyses to support t h e i r r e p o r t e d d i f f e r e n c e s u s i n g Form E, there e x i s t s , as y e t , no s o l i d ev idence to suggest tha t e i t h e r form of the COPES i s a u s e f u l p r e d i c t o r of d ropouts . Examinat ion of the present f i n d i n g s concern ing dropout / t h e r a p i s t d i f f e r e n c e scores between t h e i r r e s p e c t i v e forms of the. COPES suggests tha t the COPES may be u s e f u l f o r a s s e s s i n g areas of d i scordance b e -tween d ropouts ' e x p e c t a t i o n s and s t a f f p e r c e p t i o n s of the programme. Dropouts were found to expect l e s s autonomy, more s t a f f c o n t r o l , and more order and o r g a n i z a t i o n i n an i d e a l programme than t h e r a p i s t s a c t u a l l y p e r c e i v e d i n the V i c t o r i a programme. These d i f f e r e n c e s are c o n s i s t e n t w i t h p r e d i c t i o n s made from the l i t e r a t u r e on dropouts and from knowledge of the programme. Dropouts a l s o expected an i d e a l p r o -gramme to i n v o l v e l e s s anger and a g g r e s s i o n than was p e r c e i v e d by t h e i r t h e r a p i s t s i n the V i c t o r i a programme. T h i s f i n d i n g was not p r e -d i c t e d e a r l i e r , but makes sense i n l i g h t of the programme's emphasis on openness and the e x p r e s s i o n of f e e l i n g s . A l though the d i f f e r e n c e between the dropouts and t h e i r t h e r a p i s t s on the p e r s o n a l problem o r i e n t a t i o n subsca le was not s t a t i s t i c a l l y s i g n i f i c a n t , i t was i n the p r e d i c t e d d i r e c t i o n , w i t h dropouts expect ing s l i g h t l y l e s s emphasis on p e r s o n a l problems than t h e i r t h e r a p i s t s . In summary, the COPES r e -vea led s i g n i f i c a n t d i s c r e p a n c i e s between dropout e x p e c t a t i o n s and t h e r a p i s t p e r c e p t i o n s on th ree of the f o u r subsca les t h a t were p r e -d i c t e d to show a d i s c r e p a n c y , and these d i s c r e p a n c i e s were i n the expected d i r e c t i o n . 37 However, almost i d e n t i c a l d i s c r e p a n c i e s were found f o r the com-p l e t e r s . I t appears , t h e r e f o r e , tha t t h i s measure of d i sco rdance b e -tween c l i e n t e x p e c t a t i o n s of an i d e a l programme and s t a f f p e r c e p t i o n of the treatment environment i s a l s o not u s e f u l f o r the e a r l y d e t e c -t i o n of p o t e n t i a l d ropouts . Th is f i n d i n g suggests t h a t i n i t i a l c o n -cordance between c l i e n t and t h e r a p i s t e x p e c t a t i o n s f o r t reatment may be l e s s important f o r dropping out than was p r e v i o u s l y thought o r , a t l e a s t , tha t the r e l a t i o n s h i p between the two v a r i a b l e s may be more complexly mediated . For i n s t a n c e , i t has been suggested that d i s c o r -dant e x p e c t a t i o n s do not i n e v i t a b l y l ead to dropping out and that they can be d e a l t w i t h i n therapy w i t h some c l i e n t s (Grosz , 1968) . Fur thermore, Horens te in and Houston (1976) p r o v i d e some ev idence t h a t c l i e n t s w i t h d i f f e r e n t e d u c a t i o n a l backgrounds may respond d i f f e r e n t l y to d i s c o r d a n t e x p e c t a t i o n s . I t may be t h a t s p e c i f i c areas of d i s c o r -dant e x p e c t a t i o n are f u n c t i o n a l l y r e l a t e d to e a r l y t e r m i n a t i o n i n some c l i e n t s and not o t h e r s , depending on a number of c l i e n t f a c t o r s and on the nature of the t h e r a p e u t i c i n t e r v e n t i o n which at tempts to con f ron t the d i s c o r d a n c e . U n f o r t u n a t e l y , l i t t l e i s known about the r e l a t i o n s h i p between s p e c i f i c combinat ions of e x p e c t a t i o n , c l i e n t t y p e , and t h e r a p e u t i c i n t e r a c t i o n w i t h respec t to dropping ou t . C e r -t a i n l y the present f i n d i n g s i n d i c a t e tha t g e n e r a l assessments of the p o t e n t i a l d i sco r d ance between c l i e n t and t h e r a p i s t e x p e c t a t i o n s f o r t reatment may not p r o v i d e s u f f i c i e n t i n f o r m a t i o n to enable the p r e -d i c t i o n of dropouts i n a h e t e r o g e n e o u s . c l i e n t p o p u l a t i o n . One p o t e n t i a l source of v a r i a n c e which may account f o r the poor r e l a t i o n s h i p between e x p e c t a t i o n s and dropping out in i : the present 38 study i s i n d i v i d u a l p e r c e p t i o n of the programme.. Two c l i e n t s who i n d i c a t e s i m i l a r e x p e c t a t i o n s may have these e x p e c t a t i o n s d i f f e r e n -t i a l l y conf i rmed by the same treatment programme because they p e r -c e i v e the environment d i f f e r e n t l y . I f c l i e n t s d i f f e r s u b s t a n t i a l l y i n the way they p e r c e i v e the same treatment environment, then i n f o r -mat ion about these p e r c e p t i o n s might be necessary b e f o r e e x p e c t a -t i o n s cou ld be f u n c t i o n a l l y r e l a t e d to dropping ou t . Moos and Bromet (1978) m a i n t a i n tha t c l i e n t s do not d i f f e r a p p r e c i a b l y i n t h e i r p e r -c e p t i o n s of the t reatment environment. A c c o r d i n g l y , the approach of Moos and h i s a s s o c i a t e s (Bromet, Moos, & B l i s s , 1976; B l i s s , Moos, & Bromet, 1976; Moos, S h e l t o n , & P e t t y , 1972; Moos & Schwartz , 1973) has been to focus on d i f f e r e n c e s i n the average c l i e n t p e r c e p t i o n of s t r u c t u r a l l y d i f f e r e n t wards or programmes. Used i n t h i s way, s o c i a l c l i m a t e measures may be a b l e to i s o l a t e areas f o r programme change which r e l a t e to o v e r a l l programme e f f i c i e n c y (Bromet, Moos, & B l i s s , 1976) . However, the l i t t l e work t h a t has been done on p e r s o n a l i t y v a r i a b l e s and i n d i v i d u a l p e r c e p t i o n of the t reatment environment has i n d i c a t e d that c l i e n t s who d i f f e r on dimensions such as locus of c o n t r o l ( K i s h , S o l b e r , & Uecker , 1971) may p e r c e i v e the t reatment environment d i f f e r e n t l y . The q u e s t i o n of whether s o c i a l c l i m a t e s c a l e s may be u s e f u l i n p r e d i c t i n g i n d i v i d u a l c l i e n t outcome w i t h i n a g i ven programme, or whether they are s t r i c t l y u s e f u l f o r comparing g e n e r a l outcome across programmes, remains l a r g e l y unresearched a t p r e s e n t . The f i n d i n g s of the present study i n d i c a t e t h a t i n d i v i d u a l d i f f e r e n c e s i n e x p e c t a t i o n s of an i d e a l t reatment programme do not d i s t i n g u i s h between c l i e n t s w i t h v a r i a b l e outcome i n a p a r t i c u l a r 39 programme. However, i f i t i s t r u e tha t there e x i s t l a r g e i n d i v i d u a l d i f f e r e n c e s i n p e r c e p t i o n s of the r e a l t reatment environment f o r some c l i e n t p o p u l a t i o n s , then the use of e x p e c t a t i o n s f o r e a r l y p r e d i c t i o n may not be f e a s i b l e f o r these groups u n l e s s measurable determinants of these p e r c e p t i o n s can be d i s c o v e r e d . E x p e c t a t i o n s , by themselves , may on ly be a u s e f u l p r e d i c t o r f o r programmes i n which c l i e n t p e r -c e p t i o n s a re ve ry s i m i l a r . T h i s i s an e m p i r i c a l l y t e s t a b l e q u e s t i o n tha t cou ld have important p r a c t i c a l i m p l i c a t i o n s f o r p r e d i c t i o n . One f u r t h e r a n a l y s i s of the present COPES data deserves some ment ion . The MANOVA that compared the Form I responses of the d r o p -outs who terminated i n the f i r s t , second, and t h i r d weeks of the p r o -gramme showed no s i g n i f i c a n t d i f f e r e n c e among the groups. Baekeland, L u n d w a l l , & Shanahan (1973) r e p o r t data to suggest tha t r a p i d and slow dropouts may d i f f e r on s e v e r a l p e r s o n a l i t y and demographic v a r i -a b l e s . The present r e s u l t s i n d i c a t e tha t c l i e n t e x p e c t a t i o n probab ly i s not one of these v a r i a b l e s . The demographic i n f o r m a t i o n which was chosen f o r a n a l y s i s i n the present study r e v e a l e d some d i f f e r e n c e s between completers and d r o p -o u t s . Completers were s i g n i f i c a n t l y more l i k e l y to be employed and to be r e f e r r e d by t h e i r employer than were the d ropouts . T h i s agrees w i t h p rev ious f i n d i n g s tha t a l c o h o l i c s w i t h more s t a b l e j o b h i s t o r i e s ( M i l l e r , Pokorny, & Hanson, 1968; W i l k i n s o n et a l . , 1971) and g r e a t e r m o t i v a t i o n ( G o l d f r i e d , 1969) are more l i k e l y to s tay i n t reatment . The completers were a l s o s i g n i f i c a n t l y more l i k e l y to be making over $16 ,000 , a f i n d i n g t h a t may be r e l a t e d to the d i f f e r e n c e i n employe ment s t a t u s and r e f e r r a l by employer. A p p a r e n t l y , i n the V i c t o r i a 40 programme, c l i e n t s who have good pay ing jobs and/or employers who are concerned enough to r e f e r them to t reatment are r e l a t i v e l y low r i s k s f o r dropping out . Whereas, c l i e n t s who are r e t i r e d or unemployed are r e l a t i v e l y h igher r i s k s f o r dropping out . There were no d i f f e r e n c e s found between dropouts and completers i n terms of age, sex , m a r i t a l s t a t u s , e d u c a t i o n , number of years t h a t a l c o h o l had been a problem, and the longes t p r e v i o u s p e r i o d of a b s t i -nence. These r e s u l t s are a t v a r i a n c e w i t h p rev ious f i n d i n g s d e r i v e d from other programmes which found dropouts to be younger (Al tman, Evenson, & Cho, 1978; M i l l e r , Pokorny , & Hanson, 1968) and more l i k e l y to be l i v i n g apar t from t h e i r spouse (Zax, Marsey, & B r i g g s , 1961) , to have longer p rev ious p e r i o d s of abs t inence ( G e r t l e r , Raynes, & H a r r i s , 1973) and longer h i s t o r i e s of problem d r i n k i n g ( W i l k i n s o n e t a l . , 1971) . These c o n t r a s t i n g f i n d i n g s r e i n f o r c e the a s s e r t i o n by G e r t l e r , Raynes, and H a r r i s (1973) t h a t every programme should i s o -l a t e i t s own p r e d i c t o r s f o r d ropouts . On a broader l e v e l of a n a l y s i s , the f a i l u r e to i s o l a t e any c o n -s i s t e n t and e f f e c t i v e p r e d i c t o r s of e a r l y t e r m i n a t i o n may r e f l e c t the narrowness and s i m p l i c i t y of the approaches to p r e d i c t i o n used up to t h i s p o i n t . The m a j o r i t y of s t u d i e s have concent ra ted on the i s o l a t i o n of p e r s o n a l c h a r a c t e r i s t i c s of the c l i e n t which may determine whether or not dropping out o c c u r s . Other s t u d i e s have focused on t reatment c h a r a c t e r i s t i c s and t h e i r r o l e i n determin ing dropouts . These two approaches, which use s t a t i c i n f o r m a t i o n about the person or the environment, have achieved very l i t t l e success i n a l l o w i n g f o r i n d i -v i d u a l p r e d i c t i o n . S tud ies which attempt to examine the i n t e r a c t i o n 41 or match between v a r i o u s c l i e n t c h a r a c t e r i s t i c s and t reatment e n v i r o n -ments appear to have more p romise , but have a l s o not produced i n f o r m a -t i o n which a l l o w s f o r e f f e c t i v e p r e d i c t i o n . These s t u d i e s have g e n e r a l l y assumed that behaviour may be p r e -d i c t e d from c e r t a i n s t a b l e i n f o r m a t i o n about the c l i e n t or the e n v i r o n -ment. Recent c o n c e p t u a l i z a t i o n s about human behaviour (Bandura, 1978) p o i n t out tha t these c h a r a c t e r i s t i c s of the c l i e n t and envi ronment , which were h i t h e r t o t r e a t e d as s t a t i c ' independent v a r i a b l e s ' , may, i n f a c t , be dynamic and bear a r e c i p r o c a l l y d e t e r m i n i s t i c r e l a t i o n s h i p to behav iour . The n o t i o n that p e r s o n a l c h a r a c t e r i s t i c s , env i ronments , and b e -hav iour are interdependent and dynamic has p a r t i c u l a r i m p l i c a t i o n s f o r the use of c o g n i t i o n s (such as c l i e n t e x p e c t a t i o n s ) as independent v a r i a b l e s . C o g n i t i o n s , a c c o r d i n g to t h i s model , would be c o n s t a n t l y changing due to changes i n the environment ( e . g . , new i n f o r m a t i o n , s t r u c t u r a l changes i n the programme, the behaviour of o the rs ) and due to the feedback r e s u l t i n g from the c l i e n t ' s own behav iour . S i m i l a r l y , the treatment environment would be c o n s t a n t l y changing due to the behaviour and c o g n i t i o n s of the c l i e n t s who are a p a r t of i t . T h i s means that measures of c l i e n t e x p e c t a t i o n s of the t reatment e n v i r o n -ment may be d i f f e r e n t a t any g i ven measurement t i m e . Consequent ly , i f a g i ven e x p e c t a t i o n was c a u s a l l y r e l a t e d to dropping o u t , a s i n g l e measure taken a t a c e r t a i n t i m e , may on ly d e t e c t t h a t e x p e c t a t i o n i n some of the c l i e n t s , thus a l l o w i n g f o r o n l y p a r t i a l p r e d i c t i o n . For example, the r a t h e r l a r g e v a r i a n c e i n the number of V i c t o r i a c l i e n t s who dropped out i n each of the n i n e therapy groups may be an i n d i c a t i o n 42 tha t the c o g n i t i o n s and behaviour of o ther c l i e n t s have an important i n f l u e n c e on dropping out . That i s , the dynamics of the s i t u a t i o n f o r any one c l i e n t at any one t ime i n therapy may vary c o n s i d e r a b l y and, t h u s , not r e l a t e d i r e c t l y to a measure of c o g n i t i o n taken a t i n t a k e . S ince t h i s c o n c e p t u a l i z a t i o n i m p l i e s tha t behaviour i s complexly and d y n a m i c a l l y determined , behaviour must be seen as p r o b a b i l i s t i c and not determined by a set of p r e - e x i s t i n g c o n d i t i o n s (Bandura, 1978) . A c c o r d i n g l y , i t may be u n r e a l i s t i c to expect h i g h degrees of p r e d i c -t i o n from s imple or even r e l a t i v e l y complex i n f o r m a t i o n about the c l i e n t and the t reatment environment u n t i l the dynamics of the b e -hav iour a re more f u l l y understood . Long range r e s e a r c h e f f o r t s should move away from the s u p e r f i c i a l p r e d i c t o r - o u t c o m e approach to a more d e t a i l e d i n v e s t i g a t i o n of the b a s i c processes tha t i n t e r v e n e between i n t a k e and t e r m i n a t i o n . T h i s r e s e a r c h approach would attempt to examine the p a t t e r n s of e n v i r o n -menta l and c o g n i t i v e events which precede dropping o u t . The d e v e l o p -ment of techniques f o r the cont inuous (or f requent ) measurement of c o g n i t i o n s and env i ronmenta l events would p r o v i d e a means f o r the assessment of these p a t t e r n s i n n a t u r a l i s t i c s e t t i n g s , w h i l e s p e c i f i c components of the process cou ld be examined i n the l a b o r a t o r y . Even -t u a l l y , t h i s l i n e of i n v e s t i g a t i o n might produce i n f o r m a t i o n about the dropout process that would a l l o w agencies to i n t e r v e n e by a l t e r i n g t h e i r programme or by mod i f y ing c o g n i t i o n or behaviour on an i n d i v i d u a l l e v e l to reduce the g e n e r a l p r o b a b i l i t y of e a r l y t e r m i n a t i o n . 43 REFERENCES A l d e n , L. Fac to r a n a l y s i s o f . t h e Ward Atmosphere S c a l e . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psycho logy , 1978, 4^6, 175-176. A l tman , H . , Evenson, R . , & Cho, D. 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Age Dropouts Completers T o t a l Mean 44.30 41 .90 42.50 Standard d e v i a t i o n 12.52 10.41 11.00 _t = 1.34 ( n o n s i g n i f i c a n t ) 3 . M a r i t a l S ta tus Dropouts Completers T o t a l S i n g l e 3(6%) 13(9%) 16(8%) M a r r i e d 26(51%) 93(61%) 119(59%) cont inued 52 M a r i t a l S ta tus cont inued Dropouts Completers T o t a l Widowed 2 (4%) 1(1%) 3(2%) D ivorced 5(10%) 14(9%) 19(9%) Separated 10(20%) 19(13%)_ 29(14%) Common Law 5(6%) 11(7%) 16(8%) X 2 = 2.72 ( n o n s i g n i f i c a n t ) - w i t h "widowed" category removed Educat ion Dropouts Completers T o t a l Pr imary 10(20%) 20(13%) 30(15%) Some h i g h s c h o o l 14(27%) 60(40%) 74(36%) High s c h o o l 11(21%) 29(19%) 40(20%) High s c h o o l + t r a i n i n g 5(10%) 17(11%) 22(11%) Some c o l l e g e 6(12%) 14(10%) 20(10%) U n i v e r s i t y graduate 5(10%) 11(7%) 16(8%) X 2 = 3 .36 ( n o n s i g n i f i c a n t ) cont inued Income Dropouts Completers T o t a l 0 - 7 , 0 0 0 12(24%) 25(16%) 37(19%) 8 , 0 0 0 - 1 5 , 0 0 0 24(48%) 51(34%) 75(37%) 16,000+ 14(28%) 75(50%) 89(44%) X2 ( o v e r a l l ) = 7.15 (JD < .008) X2 (16,000) = 8.26 (£ < .004) Employed v s . Unemployed Dropouts Completers - T o t a l Employed 30(59%) 122(81%) 152(75%) Unemployed/ret i red 21(41%) 29(19%) 50(25%) X2 = 9.64 (£ < .01) R e f e r r a l Source f o r Employed Dropouts Completers T o t a l Employer 6(20%) 50(41%) 56(37%) Other 24(80%) 71(59%) 95(63%) X2 = 4 .68 (p_ < .05) . c o n t i n u e d 54 8. Years A l c o h o l had been a Problem Dropouts Completers T o t a l Mean 10.7 13 .3 12.6 Standard d e v i a t i o n 8.79 9 .48 9.36 _t = 1.714 ( n o n s i g n i f i c a n t ) 9. Longest P r e v i o u s P e r i o d of Abs t inence Dropouts Completers T o t a l Mean 12.7 9.64 10 .4 Standard d e v i a t i o n 18.7 20.7 20 .2 t = .894 ( n o n s i g n i f i c a n t ) 55 APPENDIX 2 R a t i o s of Dropouts to Completers J u l y Aug Sept Oct Nov Jan Feb Mar A p r i l Dropouts 4 7 5 2 1 6 8 8 10 Completers 15 11 16 21 25 18 17 15 13 T o t a l 19 18 21 23 26 24 25 23 23 % Dropouts 20 39 24 9 4 25 32 35 43 56 APPENDIX 3 Dropouts Form I vs Completers Form I Dropouts Completers Sca le X SD X Involvement 8. 65 ( 1 . 18) 8. 94 (1 . 16) Support 7. 10 , (2- 26) 7. 10 (1 . 76) Spontanei ty 7. 65 (1 . 68) 7. 59 (1 . 53) Autonomy 5 . 92 (1. 58) 6. 23 (1. 30) P r a c t i c a l O r i e n t a t i o n 6. 10 (2 . 23) 6. 20 (1 . 83) P e r s o n a l Problem O r i e n t a t i o n 6. 80 (2. •24) 7. 61 , (1. 84) Anger and Aggress ion 5 . 78 (2. 48) 5. ,99 (2. 32) Order and O r g a n i z a t i o n 7. 45 (2. 27) 7. .43 a . ,70) Program C l a r i t y 6. 86 (1. 71) 7, .70 (1-,68) S t a f f C o n t r o l 4. 75 (2. .54) 4, .98 (1. .84) APPENDIX 4 T h e r a p i s t Form R Scores S c a l e .Therapist . .1 Therap is t 2 Therap is t 3 Therap is t 4 Therap is t 5 J u l y A p r i l J u l y A p r i l J u l y A p r i l J u l y A p r i l J u l y A p r i l Involvement 9 10 10 10 9 10 9 8 5 7 Support 9 8 7 6 9 7 5 6 7 6 Spontanei ty 10 8 9 8 7 7 10 7 5 7 Autonomy 7 6 7 7 8 9 7 7 8 ... 7 P r a c t i c a l O r i e n t a t i o n 7 6 6 8 7 8 7 5 6 6 P e r s o n a l Problem O r i e n t a t i o n 8 6 8 8 8 9 8 8 8 8 Anger and Aggress ion 10 10 10 9 10 10 7 5 8 9 Order and O r g a n i z a t i o n 5 6 3 5 5 5 4 4 7 8 Programme C l a r i t y 7 10 7 6 7 7 5 5 8 6 S t a f f C o n t r o l 3 4 2 1 1 1 0 1 3 2 APPENDIX 4 cont inued Sca le T h e r a p i s t 1 ( J u l y + A p r i l ) X T h e r a p i s t 2 ( J u l y + A p r i l ) X Therap is t 3 ( J u l y + A p r i l ) X Therap is t 4 ( J u l y + A p r i l ) X Therap is t 5 ( Ju l y+Apr i l ) X SD f o r Mean T h e r a p i s t R a t i n g s Involvement 9 . 5 10 .0 9 .5 8 .5 6 .0 (1.60) Support 8 . 5 6 .5 8 . 0 5 .5 6.5 (1.22) Spontanei ty 9 . 0 8 . 5 7 .0 8 .5 6 .0 (1 .25) Autonomy 6 . 5 7 .0 8 .5 7 .0 7.5 (0.76) P r a c t i c a l O r i e n t a t i o n 6 .5 7 .0 7.5 6 .0 6 .0 (0.65) P e r s o n a l Problem O r i e n t a t i o n 7 .0 8 . 0 8 . 5 8 . 0 8 .0 (0 .55) Anger & Aggress ion 10.0 9 . 5 10.0 6 .0 8 .5 (1 .68) Order & O r g a n i z a t i o n 5 . 5 4 . 0 5 . 0 4 . 0 7.5 (1.44) Programme C l a r i t y 8 . 5 6 . 5 7 .0 5 . 0 7.0 (1 .25) S t a f f C o n t r o l 3 . 5 1.5 1.0 0 .5 2 .5 (1.20) 59 APPENDIX 5 Mean Dropout Scores f o r F i r s t , Second, and T h i r d Week Week 1 Week 2 Week 3 Sca le X SD X SD X SD Involvement 8 . 31 (1 . 38) 8 . 83 (1 . 50) 8 . 70 (1. 08) Support 7. 31 (2. 59) 6. 83 (2. 28) 7. 20 (2. 12) Spontanei ty 6. 77 (2. 13) 8. 00 (0. 97) 7. 90 (1 . 74) Autonomy 5 . 15 (1. .63) 6. .33 (1 . 71) 6. 05 (1 . 32) P r a c t i c a l O r i e n t a t i o n 6. 31 (3. ,04) 6. .22 (2. 26) 5 . 05 (1. 98) P e r s o n a l Problem O r i e n t a t i o n 5 . 77 (2. .77) 6. 94 (2. 24) 7. 35 (2. 25) Anger & Aggress ion 4. 92 (2. .43) 6. ,44 (2. 12) 5 . 75 (2. 75) Order & O r g a n i z a t i o n 7. 15 (2. .23) 7, .66 (2. 17) 7. 45 (2. ,39) Programme C l a r i t y 6. 70 (2, .20) . 6. .77 (1. 26) 7. 05 (1. ,90) S t a f f C o n t r o l 5 . 38 (2 .87) 4. .66 (2. .28) 4. ,40 (2. ,58) 

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