Introduction

Building a model of an effective rehabilitation process is one of the most significant problems in organizing beneficial aid for drug and alcohol addicts. As previous experience shows, to stop consuming alcohol and drugs is just the beginning of a complex process to rehabilitate and resocialize addicts. Devising further rehabilitation and recovery measures aimed at keeping the remission stable is a complex but important task.

The factors that lead to stable remission are tightly connected with the processes of resocialization for people addicted to drugs and alcohol. Cessation of drug consumption in itself is one of the main factors that promote solutions to many social and psychological problems of people addicted to drugs. However, the problem of the informal relationships of respondents on remission remains mostly unsolved because of many potentially dangerous stimuli that go along with informal communication in a healthy environment.

Factors influencing the stability of remission

According to previous research, several groups of factors influence the stability of remission.

Individual biological factors

Individual biological factors are general health condition and co-existing diseases, including incurable diseases. Research on respondents who returned to drug and alcohol consumption after a long period of abstinence showed that in 70% of the cases the breakdown was connected with abrupt health aggravation caused by co-existing diseases (HIV, hepatitis) (Petrova, Kozyakov, & Udodov 2015, p. 26; Yakovlev, Zavarzina, Kozyakov, & Dubrovinskaya 2015, p. 30). In these cases, intoxication served as a means of stress relief after the health aggravation.

Individual psychological factors

Individual psychological factors include the ability to learn coping strategies and take responsibility for one’s rehabilitation. The stability of remission increases if the addicted person acquires certain tools and skills for problem-solving, including coping strategies such as “attention shift,” “self-control,” and “keeping oneself at a distance” (Broome, Knight, Hiller, & Simpson, 1996, p. 487). The possibility of ceasing drug consumption improves as well if the addicted person takes responsibility for the delayed results of rehabilitation. Having an occupation and support in one’s environment for one’s psychic state can also have substantial value.

Improvement of the psychological state of drug and alcohol addicts as a factor that promotes the refusal of drugs has been noted by American researchers. Because of the value of this factor, during the first months of remission, psychological training oriented toward gaining confidence and the ability to refuse drugs has been emphasized (Gossop, Marsden, & Stewart, 1998, p. 348).

Almost 80 years ago three factors were determined to play a role in the recidivism of opioid addiction: (1) the presence of a premorbid pathology; (2) the presence of physical addiction, which leads to overfatigue and lasts for 6 to 9 months after rehabilitation; (3) memories of relief from discomfort during drug consumption (Kolb, 1938, p. 32). This research showed that heavy depression leads to the reduction of opiate consumption, but hostility and aggressiveness promote an increase in consumption.

Program factors

Program factors are the period of rehabilitation, the rehabilitation measures, the form of rehabilitation, and the conditions for entering a rehabilitation center. Rehabilitation measures have a major influence on the formation of an orientation to a sober way of life and on the acquisition of useful life skills.

To analyze the influence of rehabilitation programs, it is necessary to note the results of the MATCH research project (Project MATCH Research Group, 1998), which was conducted in the United States at the request of the National Institute of Alcohol Abuse and Alcoholism (NIAAA). The project took 8 years; its goal was to research the types of alcohol-addicted people who respond best to different kinds of treatment and rehabilitation. Three types of treatment and rehabilitation were researched:

• Cognitive and behavior therapy, in which special attention is given to the correction of low self-esteem and its distortions, as well as to negative thinking


• Motivational therapy, which helps clients to become aware of and to develop personal power and resources that help to stop alcohol consumption


• “12 steps,” which is a system of recovery based on support groups and step-by-step assignments

The research revealed that all three types are equal in their efficiency in addiction therapy.

In addition, comparative research on the influence of different rehabilitation programs (a 12-step program and a confessional Orthodox rehabilitation program), conducted in 2006 with 170 respondents, revealed that different rehabilitation programs have different kinds of influence on the social and psychological characteristics and beliefs of drug-addicted people. Many personal problems that were successfully solved by individuals on remission who had completed the confessional program — in particular, problems such as poor attitudes toward rules and norms, poor family relations, lack of honesty, high aggressiveness, and low self-confidence — remained unsolved or even aggravated in individuals who had completed a nonreligious form of rehabilitation. But the program of nonreligious rehabilitation had a stronger influence on reducing anxiety during further resocialization than did the religious program of rehabilitation. A specific religious influence on drug addicts manifested itself in their involvement with traditional and altruistic values (family, faithfulness, and honesty). A specific nonreligious influence was defined by an accent on the value of friendship and the value of life and inner harmony (Kytianova, 2007, p. 147).

One of the key predictors of the efficiency of a rehabilitation program is the length of stay in a therapeutic community (TC). Three months constitute a minimum period for positive results (Simpson, & Sells 1982, p. 7). Other researchers mention 90 days as an optimal period of stay (Sanchez-Carbonel, Brigos B., & Cami J., 1989, p.136).

Regardless of the fact that early quitting and further relapses in TC programs are more the law than the exception, a group of American experts has come to the conclusion that such programs are rather effective and necessary for a significant number of people addicted to drugs and alcohol. A 12-year study of 405 men addicted to drugs showed that relapse risk was reduced with prolongation of the period of abstinence from drug consumption (Simpson & Marsh, 1986, p.87). Furthermore, as the years go by, the number of people who do not consume drugs daily increases.

A three-year study of 73 people addicted to opiate drugs in Barcelona revealed positive results in almost two-thirds of the respondents (Guardo Serecigni, 1988, p.72). Factors improving treatment and rehabilitation were staying longer in the treatment program, moving from a city to a village, and staying in a TC. The research also revealed that detoxification without additional rehabilitation measures did not promote stable remission.

Other studies have confirmed that the key factors of success are a staying longer in a treatment program, having an occupation, and lacking criminal experience (Nurco, 1994, p.52).

Social factors

Social factors that may influence the success of a rehabilitation program include having family support, participating in alternative activities, living in a community devoid of drug consumption, having a high level of social and labor adaptation, participating in social life, rehabilitating together with children.

One study was dedicated to the change in the identity of women going through rehabilitation with their children. Success in building a positive identity was higher in women going through rehabilitation together with their children than in women going through rehabilitation without them. The women who had children with them were evaluated as rejecting their deviant identity and accepting their parent role as their main personal identity (Surratt, 2005, p.75).

Other research has shown that many respondents in remission give as the reason for resuming drug consumption their inability to resist the negative expectations of their relatives. The best results were obtained in parallel work with addicts and their relatives when both sides could be successfully reoriented in the direction of constructive cooperation (Rokhlina, & Voronin, 1991, p. 46). The most significant criterion of successful remission was the increase of independence and responsibility for their lives of individuals in remission; their remission may be proof of their confirmation of the healthy part of their personality. Other significant criteria may be social characteristics, such as work placement; a stable, nonaddict social circle; and formation of a family.

Two follow-up studies were unique in their length (over 30 years). One of them was conducted by American researchers (Hser, Hoffman, Grella, & Anglin, 2001, p. 503) with 581 men addicted to drugs of the opiate group; the men were enrolled in a treatment program in 1962-1964. The follow-up was conducted 33 years later with 526 people (over 90%) for whom information was available: 242 people were interviewed, and 284 people had passed away by that time. Long abstinence from heroin consumption was connected with lower indices of criminal activity, general disease, and psychological distress. High indices of occupation were associated with the cessation of narcotization. In the criminal group, the rate of drug consumption remained high even over a period of time.

Spiritual factors

In the opinion of some researchers, addiction is the function mainly of spiritual factors — specifically, individually preferred attachments that substitute for God (Kozyakov, 2013, 2014, Petrova, 2014, Veraksa, 2011, 2013, Zinchenko &, Pervichko, 2012). Hence, addiction may be cured by filling the emptiness when false attachments grow weaker; doing so enables one to plunge into a love relationship with God. In the opinion of the researchers, the majority of addicted people can stay away from drug consumption by themselves; this opinion contradicts the widespread belief that addiction can be cured only with outer help. In this type of treatment, special attention is given to the growth of spiritual qualities and turning for help to a divine power.

Background of the research

Our analysis of already-conducted research on the factors of stable remission revealed that the results of rehabilitation are influenced by different groups of factors: both outer (social) factors and individual ones (biological and psychological). In addition, many studies were conducted without using a systematic approach, and, as a result, the conclusions were sometimes contradictory. Therefore, it is necessary to continue research on stable remission and also to comparatively study the different types of rehabilitation programs.

Our research of the factors that influence the stability of remission provided the results of testing people going through rehabilitation in different programs (models): nongovernmental 12-step programs, confessional (Orthodox) programs, and state programs. People in remission and specialists of rehabilitation centers also took part in the research. As a result, we have a complex view of remission factors from different people: addicts who have made a decision to stop consuming drugs and who are staying at a rehabilitation center; people in remission with more than 1 year of abstinence; and specialists in rehabilitation centers.

Several groups participated in our research; the total number of people was 945:

• Addicted people going through different rehabilitation programs, 613 people (PRP)


• People in remission for a period of more than 1 year, 146 people (Rem.)


• Specialists in rehabilitation centers, 139 people (Spec.)


• Specialists at the National Association of Rehabilitation Centers (a nonprofit partnership) who filled out questionnaires describing the programs of the centers, 47

Purpose of the research

Our research has an applied character and was aimed also at studying the structural components of rehabilitation programs; these components provide the maximum impulse for altering the personality of addicted people and thus further lead to the complete cessation of drug and alcohol consumption.

Method

To conduct our research of stable remission factors, we developed questionnaires for the addicted people in our study, as well as for people in stable remission and for specialists. The questionnaires consisted of 26 questions about the following topics: general information (sex, age, and education), information about the addiction (type of addiction, period of drug consumption, remission, previous experience of treatment and rehabilitation, reasons for recidivism), health condition (subjective health evaluation, presence of co-existing diseases), social characteristics (having a family, relationships in the family). Then, the addicted people gave open responses to questions about the rehabilitation programs: what they liked, what they did not like, which components of the programs brought maximum results, what were the reasons for breakdowns, what measures of the programs and qualities of the specialists helped them stay sober.

Organization of the research

The collection of questionnaire data occurred from January to June 2014; 47 rehabilitation centers with their affiliates took part in the testing (including out-patient and postrehabilitative services). The research covered almost the whole territory of the Russian Federation. It included rehabilitation centers in Kaliningrad, Moscow and the Moscow district, St. Petersburg and the Leningrad district, the Pskov district, the Belgorod district, Rostov-on-Don, Stavropol and the Stavropol district, Yessentuki, Mineralnye Vody, Buddenovsk, Ufa, Kazan, Tomsk, Surgut, Vladivostok

The research covered three types of rehabilitation centers that use the most popular programs in the Russian Federation. The first group included secular (nonconfessional) centers of rehabilitation that use the 12-step program (PRP-12) as their basic model. There were 301 respondents in rehabilitation in these centers who took par t in this research. Although all these centers used the 12-step program, there were some differences in the number of specialists with different profiles and also in the measures used in the programs. The following centers and their subdivisions constituted this group: Healthy Country (Moscow and the Moscow district). Steps (Ufa, Kazan, the Leningrad district), Doctor Isayevs Clinic (Moscow and the Moscow district), Bekhterev (St Petersburg), Harmony (Surgut), Generation (Moscow).

The second group comprised confessional (Orthodox) centers of rehabilitation (PRP-conf.); their programs are based on community forms of rehabilitation and use elements of the 12-step program as well. Taking part in the research were 194 addicted people going through Orthodox rehabilitation programs at the time of the test. The following rehabilitation centers took part in the research: Voskresenie (Malye Mayachki in the Belgorod district). Spas Center for Community Pedagogics(Obninsk in the Kaluga district), Stream, Poshitni (the Pskov district), Sologubovka (the Leningrad district), the Return of the Perished Center for Spiritual and Moral Restitution of Personality (Tomsk), Rostov without Drugs (Rostov-on-Don), Healthy Stavropol Regional State Organization (Stavropol and the Stavropol region), Healthy Generation of the Caucasus, Soul.

The third group consisted of state centers of rehabilitation (PRP-stat.) working within the Narcological Service. This group included state drug-abuse clinics, hospitals, and ambulant centers of rehabilitation. Taking part in the research were 118 participants in state rehabilitation programs. The research took place at these centers: Rehabilitation departments Nos. 1 and 8 of the City Narcological Hospital of St. Petersburg, ambulant rehabilitation centers Nos. 2, 3, 4, and 5 of the Interdistrict Drug Abuse Clinic of St. Petersburg, and rehabilitation departments of the Kaliningrad Drug Abuse Clinic.

Some centers included in the group of Orthodox confessional centers, as well as state centers, used elements of the 12-step program in their work. The division into groups was determined by the organizational features of each group. In particular, secular nonstate centers that used the 12-step program rendered their services on a paid basis. Another trait of these programs was the minimal amount of labor therapy provided. According to these criteria, such centers were united in one group.

In the group of confessional rehabilitation centers situated outside of cities, mostly spiritual instruments of recovery were used: attending church, talking with a priest, and so forth. Rehabilitation patients in such centers were actively involved in labor for adjacent farms. As a rule, these centers were more accessible than the 12-step or the state centers: they either did not charge any fee for rehabilitation or they charged an acceptable price for it. These centers were united in a separate group as well

A special feature of the state rehabilitation centers that were taking part in the researchwas the location of almost all of them in big cities. Some centers worked on internal treatment conditions, and others, on external treatment conditions. All state centers had medical staff, specialists in narcological psychiatry, clinical psychologists, and nurses. As a rule, rehabilitation services were rendered for free. These centers were united in one group.

To process the data, content analysis of the responses of the participants to open questions was applied.

Results

During the research it was revealed that various measures of the rehabilitation programs influenced the results of the whole rehabilitation to different degrees (Table 1).

Content analysis revealed that among the most helpful measures were the educational component (lectures, talks, and seminars), individual work (written tasks, diaries of feelings, self-analysis), measures aimed at physical recovery (sports, gymnastics, yoga, tennis etc.), psychology sessions, individual consultations.

Table 1. Results of the content analysis of the responses of people in rehabilitation and people in remission to the question “Which measures of your rehabilitation program help people to stay sober?”

Note. The following abbreviations are used in the table: PRP-12 — people in 12-step rehabilitation programs; PRP-conf. — people in confessional (Orthodox) programs; PRP-stat. — people in state programs; Rem. — people in remission for more than 1 year; Spec. — qualified specialists in rehabilitation centers, former addicts.

Also, some measures were helpful to respondents in certain programs and not so helpful to respondents in other rehabilitation programs. For people taking part in 12-step programs, the most relevant measures were connected with the 12 steps: group or individual work, sessions with a psychotherapist, and physical development. In general, for participants in 12-step programs the most helpful measures were the social and psychological, as well as the physical, components of rehabilitation.

Respondents in confessional (Orthodox) programs considered the following measures to be the most helpful: attending church; reading religious literature; prayer; labor activity; sports, physical training; lectures, talks; help for newcomers; volunteering; written tasks; individual sessions with a psychologist. Thus, the most helpful measures for people in confessional rehabilitation programs were those connected with the spiritual aspects of rehabilitation, labor and social activity, and physical training.

The most helpful measures for people in state rehabilitation programs were the following: work with a psychotherapist; sports activities; communication with other rehabilitants; lectures and seminars; excursions, visits to the theater, cinema; training; written tasks. As a whole, these respondents found the sociopsychological and physical spheres of rehabilitation to be the most helpful.

People in remission marked the following measures as the most helpful: attending church; prayer; individual sessions with a psychologist, psychotherapy; educational lectures, seminars; training, group classes; sports; labor; written tasks; communication with rehabilitants; help to newcomers and to weaker participants; volunteering; morning meetings; stories of recovering addicts; monitoring with a consultant, harmonization of emotions; small groups.

Thus, for people in remission who had previously gone through programs of rehabilitation, the most helpful measures were the spiritual ones. Other important measures were those connected with the psychological component (group or individual psychological sessions), the social component (providing help to others, communication), and the physical component (sports and physical activities).

Table 2. Results of the content analysis of the responses of people in rehabilitation and people in remission to the question “What do you like in your rehabilitation program?”

Note. See note to Table 1 for abbreviations.

Therefore, for people in remission all components were helpful, and the effectiveness of the rehabilitation consequently increased.

All the measures reflected in the responses, reveal the content of the rehabilitation programs, and our content analysis indicates which measures were most successful. In addition, all the measures are in one way or another instruments that should be further developed. It is thus possible to integrate the most effective instruments of rehabilitation in different models of rehabilitation programs.

Content analysis of the responses to the question “What do you like in your rehabilitation program?” revealed that respondents in all groups most frequently appreciated professionalism, considerate attitudes, and care of the participants by management and staff (Table 2).

Respondents in all groups marked the friendly and respectful atmosphere, the communication with other residents, and the educational component of the program (lectures, talks) as important characteristics. The warm and friendly atmosphere in the centers was especially meaningful; many of the rehabilitants used such terms as home and family when referring to their centers.

The research also revealed that respondents who were in the traditional programs examined here were likely to return to the same methods of rehabilitation when their attempts at rehabilitation were unsuccessful. This was not true for people in rehabilitation centers with nontraditional programs or confessions (Table 3).

Table 3. Previous programs of rehabilitation

Note. For other abbreviations, see note to Table 1.

The research also revealed that both outer (social and family) and inner (psychological) factors influenced the length and stability of previous remissions of the people currently in rehabilitation (Table 4).

The people in remission gave, above all, the following reasons for previous ineffective attempts at rehabilitation: insufficient number of group and individual psychological classes; lack of spiritual and moral component; insufficient amount of labor training and physical training; insufficient number of meetings with people who had completed the rehabilitation program or meetings with healthy people. Thus, the people in remission were more likely to see the reason for previous ineffective attempts at rehabilitation in the structure of the rehabilitation programs, while the people in rehabilitation were inclined to explain previous ineffective attempts to give up drugs on their own insufficient motivation to get sober.

Table 4. Main reasons for ineffective (or less effective) previous attempts at rehabilitation by addicted people

These conclusions demonstrate that it is necessary to develop the content and professional components of rehabilitation programs and to increase motivation in those addicted when building a complex system of rehabilitation.

Discussion

The data indicated a demand for a complex approach to rehabilitation that takes into account the biological, psychological, social, and spiritual components of addiction.

Among the most helpful measures of the rehabilitation programs were the following: the educational component of rehabilitation (lectures, talks, seminars); individual work (written tasks, diaries of feelings, self-analysis); activities for physical recovery (sports, warm-ups, yoga, tennis), work with a psychologist, individual consultations, introduction to religion, prayer, labor, communication with graduates of rehabilitation programs.

All groups of respondents marked the following qualities as among the most relevantones formed during rehabilitation that help them to stay sober the following: frankness, sincerity; having goals and a sense of purpose, persistence; kindness, responsiveness; ability to turn for help, mutual support. This result demonstrates that a properly organized social and psychological rehabilitation is in itself a powerful influence on the personalities of addicted people; this kind of rehabilitation enables them to establish their motivation for soberness and promotes the full cessation of drug and alcohol consumption.

In general, the research revealed that during positive remission the addicts had fewer social and psychological problems than they had previously, and their social and psychological personal characteristics improved; these developments facilitate the further development of remission.

Conclusion

Our research on the factors of stable remission for people with chemical addictions enabled us to discover the most effective measures of the rehabilitation programs and the outer and inner factors that may influence the stability and length of remission. The results of our research correspond with the results of other research conducted in this area — in particular, with the MATCH results (Project MATCH Research Group, 1998). These results demonstrated that different rehabilitation programs can be equally effective. The present research completed these results in relation to a complex approach to the rehabilitation process for people with chemical addictions. If the components of programs aimed at the holistic recovery of a personality and its biological, psychological, social, and spiritual potential are present, the effectiveness of rehabilitation increases, regardless of the model (or system) of rehabilitation. The current data are important for estimating efficiency, developing and constructing rehabilitation programs, and choosing individual rehabilitation and resocialization programs for people with chemical addictions.

The limitations of our research are both its short duration, which gave no opportunity for longer observation of the results, and the rather generalized division of the existing rehabilitation programs into models currently used in the Russian Federation.

We plan to expand the research of different rehabilitation programs, to conduct longitude research on the factors that influence the stability of remission, and to expand the research on the personal and psychological factors of stable remission for people with different forms of addiction.

The received data are important to estimate efficiency, to develop and construct rehabilitation programs, to choose individual rehabilitation and resocialization programs for people having chemical addictions.

Acknowledgements

The research was supported by funding according to the Russian Federation President's decree No 115-pn of 29.03.2013

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