Addiction

Published on May 2016 | Categories: Types, Presentations | Downloads: 54 | Comments: 0 | Views: 314
of 19
Download PDF   Embed   Report

Comments

Content

Journal of Psychiatric and Mental Health Nursing, 2010, 17, 46–64

Treatment and recovery as perceived by patients with
substance addiction
jpm_1477

46..64

T. N O R D F J Æ R N 1 m s c p h d - c a n d . , T. R U N D M O 2 d r. p h i l o s . &
R. HOLE3 cand.psychol.
1

Research Scientist, 3Profession Manager, The Drug and Alcohol Treatment in Central Norway, Strandveien 1,
Stjørdalen, and 2Professor, The Norwegian University of Science and Technology, Department of Psychology,
Trondheim, Norway

Keywords: perception, qualitative

Accessible summary

method, recovery, substance addiction,
treatment



Correspondence:
T. Nordfjærn



Drug and Alcohol Competence Center
box 2655



7415 Trondheim
Norway
E-mail: [email protected]

Abstract

Accepted for publication: 15 June 2009
doi: 10.1111/j.1365-2850.2009.01477.x

Social relations to therapists and other patients in treatment are important for
positive and negative experiences among patients with substance addiction.
Improvements in mental health and substance use were considered as the more
important areas of recovery among these patients.
One of the core reasons for premature dropout could be a failure to establish
positive social relations and temptations to relapse to substance use.

Research concerning patients with substance addiction and how they perceive their
treatment remains scant. The objective of this study was therefore to examine positive
and negative perceptions of treatment and recovery from the perspectives of these
patients. Data were collected with semi-structured interviews among seven patients
who completed treatment and six patients who prematurely dropped out from their
programme (n = 13). Patients were strategically sampled from five inpatient facilities
and one outpatient opioid maintenance treatment clinic located in two Norwegian
counties. All interviews were transcribed and thereafter analysed with contextual
content analysis aided by the qsr nvivo 8.0 software. This was carried out to obtain
information about the manifest positive and negative content in the interviews. The
results showed that the therapeutic alliance and mutual influences among patients were
important for perceptions of treatment. Frequent staff turnover also related to these
perceptions. The more important domains of recovery were psychosocial functioning
and substance use. The implications of the results were discussed in relation to clinical
practice and further research.

Introduction
Consequences related to substance addiction are highly
complex and do often have severe somatic and psychosocial implications both for the individuals and their significant others. Substance addiction may also have consequences at the broad level of society, for instance in terms
of criminal activities. Because of the diversity of consequences related to substance addiction, treatment consists
of various approaches and models. These approaches
46

vary considerably in content, durability, intensity and
objectives.
The society has considerable expenses related to substance addiction treatment programmes. Consequently,
more studies should be carried out in order to gain knowledge about how patients perceive their treatment as well
as recovery. Examples of treatment perceptions are user
evaluations about the quality of the applied interventions,
availability of treatment staff and programme regulations. Because of the variety of biological, psychological
© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

and social consequences related to substance addiction,
perceptions of recovery may occur in differentiated
domains ranging across mental health, substance use,
employment, economy and social relations.
The last decade, matching between substance addiction
treatment programmes and specific individual needs of the
patients has received increased attention (Smith & Marsh
2002). An additional aim has been to increase the involvement of the patients and their significant others in decisionmaking regarding treatment. In order to gain knowledge
about whether such approaches have succeeded, more
studies should examine how patients perceive treatment.
This is an argument underlined by several researchers in
general psychiatric health care (Cooper-Patrick et al. 2002)
as well as in somatic hospitals (Morgan et al. 2004).
Researchers point to patient perceptions as quality indicators of the health services delivered. For instance, Finney &
Moos (1984) argued that positive perceptions of treatment
are associated with improvements in retention rates and
outcomes among patients with substance addiction. On the
contrary, Joe & Friend (1989) only found a moderate correlation between perceptions of treatment and patient outcomes. Despite these contradictions, perceptions among the
patients should be taken into account because it is desirable
to carry out treatment that is relevant and well adjusted to
the specific needs of the patients (Jones et al. 1994).
Two of the more important predictors of successful
recovery are treatment persistence and the duration of time
spent in treatment (De Leon et al. 1982). These variables
may for instance increase the probability of staying abstinent from substances after leaving the treatment facilities
(Gottheil et al. 1992). According to Stark (1992) outcomes
among patients who prematurely drop out of treatment are
often analogous to outcomes among untreated patients.
From a scientific and ethical point of view, studies of how
patients perceive treatment and recovery should therefore
include patients who prematurely dropped out of their
programmes. Investigations of how these patients perceive
treatment and recovery should be prioritized, because such
efforts may identify important risk factors of premature
dropout. After these risk factors have been identified, countermeasures can be implemented in clinical practice.
The core aim of the present study was to investigate how
patients with substance addiction perceived their treatment
and recovery. This was carried out among patients from
five inpatient facilities and one opioid maintenance treatment (OMT) clinic in the central region of Norway.

Empirical review
Perceptions of treatment and recovery among patients with
substance addiction have received increased attention
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

during the last decades. This has resulted in some studies,
which have investigated these psychological entities both
with qualitative and quantitative approaches. Lovejoy
et al. (1995) used a qualitative methodology when patient
perceptions of treatment and recovery were investigated in
a relapse prevention treatment programme for cocaine
addiction. The results illustrated that one of the more
important factors for treatment perceptions was how the
patients evaluated the quality of their relations to treatment
staff. Specific interventions, for instance group therapy and
strategy courses for coping with abstinence, were also considered as critical components. The most important aspects
related to perceptions of recovery were levels of substance
use, motivational factors as well as the abilities to cope
with negative emotions. Interpersonal relations and levels
of self-esteem were also considered important for recovery.
The results from the above-mentioned study indicated
that the patients were predominately positive to their
treatment and recovery. As Lovejoy et al. (1995) suggested,
however, the results could have been positively biased
because all patients recruited to the study had completed
their treatment programme. The authors thereby suggested
that samples in qualitative studies should also include
patients who prematurely dropped out of treatment.
Furthermore, the sample included significantly more
male patients than female patients. An increasing body
of empirical evidence suggests that female and male
patients have differential needs in substance addiction
treatment (Copeland & Hall 1992, Nelson-Zlupko et al.
1996). Hence studies to come should aim to have a fairly
balanced gender distribution in the samples.
Conners & Franklin (2000) launched an alternative
explanation for the biased results in studies of perceptions
regarding treatment and recovery. They argued that these
studies obtain positive results regardless of the investigated
treatment programmes because of the measurement instruments applied in quantitative studies of patient perceptions. As a possible source of positivity bias they suggested
that patients do not reflect as freely upon positive and
negative aspects of treatment when the response options
are restricted to a Likert scale. Although this can not
explain the results in the qualitative study carried out by
Lovejoy et al. (1995), this argument is still valid when
considering the need for more qualitative studies regarding
perceptions of treatment and recovery.
Qualitative methods were applied when perceptions of
inpatient treatment were investigated among patients who
finalized treatment at two facilities in the UK (Bacchus
et al. 1999). Congruent with Lovejoy et al. (1995), relations to clinical staff were considered as a significant factor
in treatment by the interviewed patients. Furthermore, the
results illustrated the importance of the interpersonal rela47

T. Nordfjærn et al.

tions between the patients attending the inpatient treatment programmes. Specifically, it was indicated that these
patients had important impacts on each other in terms of
treatment motivation. For example did patients who had
stayed longer in treatment report satisfaction with the
responsibility they had for tutoring new patients enrolled in
the programme. Moreover, the patients were positive when
the facilities planned and offered them aftercare. The most
important categories regarding negative treatment perceptions were related to programme regulations and the
enclosed physical environment at the treatment facilities.
Conners & Franklin (2000) investigated treatment perceptions among female patients enrolled in a programme
for substance addiction treatment in the USA. During focus
groups, patients reported that one of the core benefits of
the programme were that they learnt to cope with life
events without using substances. This was exemplified
through a range of learnt abilities, varying across child
caring, job skills, how to establish a stable economy and
social skills. Patients also pointed to the importance of
specific interventions, such as individual therapy, group
therapy and relapse prevention education. The patients
focused on the therapeutic relationships and told that they
preferred a respecting, understanding and non-confronting
approach from their therapists. These results illustrate that
perceptions of treatment and recovery can not solely be
understood by considering specific interventions and a
limited set of behavioural outcomes. It is likely that
these perceptions are influenced by a complex interaction
between several interrelated components.
Comorbid psychiatric disorders, such as major depression and anxiety, are highly prevalent among patients in
treatment for substance addiction (Landheim et al. 2002).
Furthermore, a substantial number of patients in general
psychiatric health care have substance addiction in addition to other psychiatric diagnoses (Möller & Linaker
2004). Because the majority of these patients share problems, and thus several similar treatment needs, it is possible
that perceptions of treatment and recovery among inpatients in psychiatric health care and substance addiction
treatment have resemblances.
This assumption was supported by an empirical investigation of perceptions among patients in treatment of
depression (Cooper-Patrick et al. 2002). The results indicated that factors such as specific interventions, relations
between the patients and clinical staff, social support
systems and stigma had the strongest influences on perceptions of treatment. These findings are relatively similar to
the results reported in Lovejoy et al. (1995) and Bacchus
et al. (1999). Finney & Moos (1984) underline that variables related to the social climate at the facilities may
influence treatment outcomes. Such variables can for
48

instance be the working environment and social relations
between staff and patients. A recent study (Jörgensen et al.
2009) found that differences in the social climate measured
by the Ward Atmosphere Scale (Moos 1974) were significantly related to variations in patient satisfaction among 80
patients enrolled in three psychiatric wards in Norway.
Indirect support for the importance of the social climate is
also found in validated international questionnaires, which
measure perceptions of treatment and recovery among
patients with substance addiction (e.g. Marsden et al.
2000). These questionnaires tend to include test items
related to social climate variables.
In a recent study, interviews about recovery were conducted among patients who had attended psychosocial
treatment for alcohol addiction in the UK (Orford et al.
2009). Among several interesting findings, the results
showed that significant others had important influences
on positive changes regarding substance use and overall
mental health. Furthermore, the perceived consequences of
alcohol consumption as well as the determination, commitment and decision-making regarding change were considered important. Mcintosh & McKeganey (2000) found
that patients recovering from substance addiction focused
on several different coping strategies. These strategies were
in particular oriented towards avoidance of their former
substance abusing network and an establishment of meaningful occupational activities. The patients also focused at
establishing new social networks that did not abuse substances. These studies indicate that significant others as
well as meaningful occupational activities have important
influences on recovery from substance addiction. As a
possible explanation, Robins (1993) hypothesized that
occupational activities and social networks provide social
contexts that do not facilitate substance use.
Summarizing, the available evidence indicates that the
quality of the provided therapies and interventions are
important for perceptions of treatment. It is also probable
that factors such as social relations among patients, the
working environment at the facilities, communication flow
among staff and patients as well as programme regulations
are important for perceptions of treatment. Unsurprisingly,
substance use is an important variable for how patients
with substance addiction perceive their recovery. Several
studies also point to changes in psychological functioning,
abilities to take part in meaningful occupational activities
and supportive networks as critical components of these
perceptions.

The present study
The majority of the cited studies have solely included
patients who completed their treatment programme. The
© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

present study adds to the literature through a qualitative
investigation of treatment and recovery among a sample
that includes patients who completed their programme as
well as patients who prematurely dropped out of treatment. Further, to the authors’ knowledge most similar
studies to date have been carried out in the UK and USA.
This was also reflected during a search in several international literature databases, which did not reveal significant
additional studies to those reported in the empirical review.
To address some of the gaps indicated in the empirical
review the specific aims of this study were: (1) to investigate
positive and negative perceptions of substance addiction
treatment; and (2) investigate positive and negative perceptions of recovery. This was carried out among patients from
five inpatient clinics and one outpatient OMT clinic in the
central region of Norway. Patients who completed treatment and patients who prematurely dropped out were
recruited from each facility. The patients included in the
present study were recruited from facilities that differ in
treatment approaches and philosophy. Patients who were
enrolled to these facilities also had different psychosocial
problems and addiction patterns. Considering the cited
literature, however, we expected communalities in positive
and negative perceptions of treatment and recovery among
patients across different treatment programmes.
A qualitative methodology was chosen because of two
reasons. First, qualitative studies often provide a richer and
a more complete description of a phenomenon compared
with quantitative survey investigations. The latter empirical approach is feasible under the right conditions, but
usually has a more specific and delimited focus on empirical data (Yardley 2000). Second, there are to the authors’
knowledge no validated Norwegian questionnaires that
measure treatment perceptions and recovery among
patients with substance addiction. Although some international questionnaires concerning perceptions of treatment
and recovery have shown promising feasibility (e.g.
Marsden et al. 2000), a review of relevant international
measurement instruments concluded that these questionnaires were not suitable in a Norwegian context (Danielsen
& Garratt 2007).

Methods
Sampling procedure
The patients were recruited from five inpatient facilities
and one outpatient OMT facility in two different counties
in the central region of Norway. Two of the inpatient
facilities consist of short-term (8 weeks) treatment programmes mainly aimed at alcohol-related problems. One
of the facilities is a therapeutic community, based on the
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

Minnesota model (De Leon 1985). Although there are
important differences across these programmes, they also
have similarities. Inpatient treatment is usually targeted to
various problem domains experienced by poly-substance
users. Such domains range from psychological and somatic
health, to substance abuse, social relations and regulatory
framework components such as employment, education,
economical issues and housing (Bacchus et al. 1999). Inpatient treatment usually consists of detoxification followed
by psychosocial interventions carried out by multidisciplinary teams. The patients often receive additional
support from various community programmes and aftercare services as part of such treatment.
The OMT clinic involved in the study has a programme
for individuals over 25 years of age with an addiction
pattern dominated by opiates. An important precondition
for receiving such treatment is that the individuals have
previously attended alternative treatment approaches, and
that these approaches have failed at reducing their opiate
addiction. OMT mainly consists of regular psychosocial
outpatient consultations coupled with medically assisted
treatment. In the central region of Norway, this programme
is first carried out at an outpatient facility for 2 years, and
patients are thereafter transferred to community services in
an open-ended aftercare system.
During sampling we aimed to recruit a minimum of
one patient who was about to complete treatment in
maximum 2 months and one patient who had prematurely
dropped out during the last 6 months from each of
these treatment facilities. The sample was recruited during
18 weeks from June to October 2008. The study was
approved by the Regional Committee for Medical
Research Ethics in Central Norway (REK) and the Norwegian Social Science Data Services (NSD) before patients
were recruited. Strategic sampling was conducted for the
purpose of recruiting patients who had completed treatment and patients who prematurely dropped out from
the same programmes. An inclusion criteria was that the
recruited patients had stayed in treatment long enough to
articulate a perception of the treatment programme (i.e. 3
weeks) and that they were 18 years or older. During sampling, the distribution of gender, age and education was
carefully monitored by the first author and strategically
balanced out when necessary.
Research coordinators affiliated with the project purposefully selected patients from the patient lists and contacted them either by phone or approached them at the
facilities. Thereby the patients were orally informed about
the study. The patients also received a consent letter that
described the content of the interviews and underlined
that participation was voluntary. The consent letter also
explained the applied methods to secure confidentiality.
49

T. Nordfjærn et al.

The letter was signed by patients who agreed to participate
and returned to the research coordinators at the treatment
facilities.
Among patients who had a premature programme
dropout we recruited those who had voluntarily left treatment before it was completed as well as patients who had
been asked to leave their programmes because of violations of programme regulations. Patients who prematurely
dropped out of treatment were complicated to reach, and
consequently we recruited some of these patients from other
inpatient treatment sites than they had previously dropped
out from. When these patients had approached a new
treatment programme they were retrospectively interviewed
about the treatment programme relevant to their dropout.

Sample
Of the 14 approached patients, 13 agreed to participate
and the response rate was 92.86%. The age of the patients
ranged from 22 to 47 years (M = 31.38, SD = 8.87). Six
patients were male and seven were female. Five patients
had primary and secondary school as their highest completed education, six patients had completed high school,
and two patients had university or college as their highest
completed education. Six patients were unemployed, four
patients had a full time job, one patient had a part-time job,
and two patients were students.
Regarding substance use, eight patients were polysubstance users, three patients had an addiction pattern
dominated solely by alcohol, whereas two patients had an
opiate-dominated pattern. Six patients had prematurely
dropped out of treatment, and seven patients completed
their programme. Four patients had received treatment in a
short-term inpatient treatment programme, whereas two
patients had attended outpatient OMT. In addition, three
patients had been enrolled in a therapeutic community, and
four patients had attended long-term inpatient treatment.
Among patients who completed treatment, three individuals were currently at the end of their active treatment,
which had on average lasted for 10 months. Four patients
had completed their programme and left the facilities.
Among patients who prematurely dropped out of treatment, two patients attended other inpatient treatment programmes when the interviews were conducted. Treatment
had on average lasted one and a half months for these
patients. Further, two patients who had a premature programme dropout were enrolled in psychiatric outpatient
treatment, which had on average lasted for 2 months.

Semi-structured interviews
The interviews were carried out by two research assistants
affiliated with the project. Both assistants had previous
50

experiences with semi-structured interviews among
patients with substance addiction, and they also had relevant clinical working experience. An interview guide was
developed in cooperation with the research assistants as
well as experienced clinicians and researchers. To maximize
the reliability and validity of the data, the research assistants were extensively trained in the interview guide. Two
pilot interviews were carried out before the data collection
was initiated. The interview guide was adjusted accordingly after feedback from these interviews. The research
assistants were supervised to include all questions and
topics in the interview guide during the interviews. They
were further instructed to use the provided follow-up
questions and to ask for specific examples when patient
responses were considered to provide insufficient information. It was emphasized that when for instance patient
responses were inflated in a positive direction, the interviewer should encourage the patients to also reflect upon
negative aspects regarding the topic of discussion. Finally,
the research assistants were encouraged to follow interesting cues and topics brought up by the patients. All interviews were conducted individually in a private room at the
treatment facilities where the patients were recruited. The
interviews took between 1 and 2 h to complete and were
recorded with a digital sound recorder.

Interview guide
The questions in the interview guide were structured into
three core topics. The first topic was reasons for initiating
treatment. This topic contained questions about how the
patients perceived their psychosocial situation before treatment was initiated, and reasons for why they started in
treatment.
The second topic covered questions related to positive
and negative perceptions of treatment. These were questions about how patients perceived the quality of the
applied interventions, relations to other patients and clinical staff, how their treatment was adjusted to match their
specific problems and how they perceived the regulations in
the treatment programme. This section also covered questions regarding involvement of themselves and significant
others during important decision-making concerning their
treatment.
The third topic included questions about how patients
perceived their current life situation. They were asked
about their current substance use and psychological functioning as compared with before treatment. The patients
were also asked questions about their perceptions concerning their current social support and networks. This section
also covered questions regarding occupational issues, such
as education and employment. After these core topics were
© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

covered, the patients were asked whether they could reflect
upon other topics concerning addiction treatment, which
had not been discussed during the interviews. The guide
also included a section with questions about demographic
characteristics, such as age, education, employment status
and time spent in treatment.

Data analysis
When all interviews had been conducted, they were transcribed. The transcribed material consisted of in total
113 056 words. On average each interview included
8697 words. Data were analysed with contextual content
analysis.

Contextual content analysis
When contextual content analysis is conducted upon
written material, words, phrases or sentences are usually
reduced into a smaller number of mutually exclusive categories (Mctavish & Pirro 1990). This method is not limited to
cover the frequency of specific words in the material as is
the case with quantitative content analysis (Stemler 2001).
One of the critical decisions concerning contextual content
analysis is the unit of analysis (i.e. the counting unit). In the
present study, coding was carried out with sentences as the
counting unit. First, all the transcribed interviews were read
through twice to get a sense of the whole. Second, two main
categories were articulated. These categories were termed
treatment perceptions and perceptions of recovery. The
coding was carried out by one researcher, and distinct
definitions of the main categories were established to
increase the likelihood of consistent and valid coding.
Contextual content analysis was conducted with the qsr
nvivo 8.0 software. During the coding process each sentence belonging to the same concepts was given a common
label. The sentences were categorized according to whether
they were positive or negative in content. Subcategories with
belonging definitions were inductively established throughout the coding process. A positive and negative distinction
was made because of two reasons. First, this allowed us to
illustrate and examine contradictory evidence in the material more directly. In addition, preliminary reading showed
that most sentences regarding perceptions of treatment and
recovery were either positive or negative in content.
During coding the context of sentences was carefully
attended to. This means that a typical negative event, such
as for instance a relapse to substance use, could be defined
as a positive event if the patients mentioned such events in
a positive context (e.g. learning useful coping strategies by
the relapse). When the coder encountered items that were
complicated to label either positive or negative, sentences
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

before and after the coded sentence (the context) were first
carefully investigated. When the context was uninformative about positive or negative characteristics, the audiorecordings were consulted, and the intonation of patient
voices was examined to determine whether the content was
positive or negative. Perceptions considered to be neutral
or unrelated to the perceptions under examination were
excluded from further analysis (Weber 1990). When identical sentences were repeated by patients within an interview, these sentences were coded once.
In order to investigate the reliability of coding, the first
author and one independent researcher coded three identical transcribed interviews chosen at random before the first
author coded all interviews. The level of agreement was
recorded and Cohen’s Kappa (k) was 0.43. According to
Landis & Koch (1977) this could be interpreted as moderate inter-coder reliability. Further, six researchers blind to
the purpose of the study qualitatively investigated the
validity of the definitions used for all categories. Adjustments of the definitions were carried out until sufficient
agreement was obtained.
The specific sentences are presented by free text descriptions. The sentences as expressed by the patients were
articulated into themes in order to cover a more general
meaning and to exclude sensitive data. Such data could for
instance be names of treatment facilities and staff members.
Single sentences that differed to such an extent that they
could not be accumulated in a general thematic description
were located in a description termed ‘other’. This was
carried out for space-preserving purposes when these sentences exceeded a threshold of four sentences within a
subcategory.

Results
First, positive and negative perceptions of treatment were
investigated. A general overview of the categories derived
from this analysis is illustrated in Fig. 1. Thereafter,
descriptions of the manifest content of each subcategory
are provided. Tables 1 and 2 illustrate in further detail free
text descriptions of positive and negative sentences in the
subcategories. These tables also provide information about
the frequency of specific content in each category.
Second, positive and negative perceptions of recovery
were examined. A general overview of the identified categories is provided in Fig. 2. Descriptions of the manifest
content in the subcategories were also provided for these
perceptions. Free text descriptions of positive and negative
content related to perceptions of recovery are illustrated in
Tables 3 and 4.
The percentages presented in Figs 1 and 2 illustrate the
proportion of sentences in subcategories in relation to all
51

T. Nordfjærn et al.

Treatment perceptions (n=476)

53 %
n=254
Relation to
clinical staff
and other
patients

23%
n=108

Therapy and
interventions

18%
n=86

User
involvement

6%
n=29

Aftercare

4%
n=18

Facility
regulations
Treatment
climate

Positive
perceptions

2%
n=8
1%
n=5

47%
n=222

Negative
perceptions

13%
n=61
8%
n=37
7%
n=35

Relation to
clinical staff
and other
patients
Facility
regulations
Therapy and
interventions

6%
n=29

Aftercare

4%
n=20

Treatment
climate

3%
n=15

Facility
resources

3%
n=11

Pacification

2%
n=8

Stigma

1%
n=6

User
involvement

Figure 1
Contextual content analysis of semi-structured interviews (n = 13) – positive and negative treatment perceptions

sentences coded into the two major categories respectively.
Percentages in the tables show in further detail the proportions of sentences in subcategories, according to whether
they were positive or negative in content, within these two
major categories.

Positive and negative perceptions of treatment
Contextual content analysis was conducted to investigate
positive and negative perceptions of treatment. Figure 1
illustrates the outcome of this analysis. A total number
of 476 sentences were identified. The results showed that
both positive (53%) and negative (47%) perceptions were
common among the patients.
Six categories concerning positive treatment perceptions were identified: (1) relation to clinical staff and other
patients; (2) therapy and interventions; (3) user involvement; (4) aftercare; (5) facility regulations; and (6) treatment climate. Negative content revealed the same six
categories in addition to: (7) pacification; (8) stigma; and
(9) facility resources. The most frequent positive perceptions concerned relations to clinical staff and other patients
at the treatment facilities. Specific therapies and interventions were also considered as important contributors to
52

positive treatment perceptions among the interviewed
patients. In terms of negative perceptions of treatment,
relations to staff and other patients was the most important
category.
As illustrated in Fig. 1, relations to clinical staff and
other patients was the most important category in terms of
positive as well as negative perceptions of treatment. The
patients discussed how other patients repeatedly had convinced them to stay at the clinics, when they were tempted
to relapse to substances or leave prematurely. The patients
also indicated that they appreciated treatment together
with other individuals in similar situations. These patients
reported that other patients understood their problems and
concerns better than family and friends outside the clinics.
In relation to negative perceptions of treatment, it was
underlined that arguments occurred relatively often among
patients in treatment. These patients also told that other
patients had tried to sabotage the treatment programme for
them. In relation to this, negative perceptions of being
treated together with patients who lacked sufficient motivation were frequently discussed.
Perceptions of therapy and interventions were mainly
positive among the interviewed patients. Several expressions showed that the patients experienced group therapy
© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

Table 1
Categories regarding positive perceptions in treatment with free text descriptions of statements
Category 1 Relation to clinical staff and other patients 43% (n = 108)
The treatment personnel cared about me and treated me with respect
The relation between the patients was dominated by solidarity
The staff was very available to us
The staff was clever at involving us in social activities
It was possible to talk to the staff about virtually everything
The patients have an indirect therapeutic effect on each other
My therapist had a positive behaviour
When I re-entered treatment after dropping out I felt welcome by the other patients
The other patients helped me to stay abstinent
The staff have confidence, and you are given another chance after a relapse
Other

(n = 254)
36
33
8
5
5
4
3
3
2
2
7

Category 2 Therapy and interventions 34% (n = 86)
The interventions were well adjusted to my psychosocial problems
Group therapy made me talk about problems related to economy, social networks and addiction
Excursions in nature were especially meaningful
Therapy learnt me strategies for coping with my substance addiction
Group therapy allows us to criticize, praise and draw boundaries for each other
In therapy I learnt to structure and handle practical activities
Methadone improved our overall health and removed our abstinences
I learned a lot from group therapy, because I could discuss my problems with people who shared the same problems
Conversation groups helped me in focusing deeply on myself
Group therapy helped, because it made me more illustrious
Other

18
11
11
10
8
5
5
4
4
2
8

Category 3 User involvement 11% (n = 29)
I took part in decisions regarding my treatment and activities, and we wrote guidelines for my treatment together
They ask and listen to my opinions regarding the problem domains we should pay attention to
My significant others were invited to conversations and gained insight into my situation
I think we have been successful in changing parts of the treatment structure at this facility

12
10
6
1

Category 4 Aftercare 7% (n = 18)
It is comforting to know that I can always call the facility when I have had relapses or other problems in my daily life
They have made it so I get regular psychiatric consultations and help at the social office after my stay
I receive great aftercare from social services in the municipality
The staff even invited me over to dinner and they have visited me at home
Other

6
3
2
2
5

Category 5 Facility regulations 3% (n = 8)
After a while I adapted to the regulations at the facility
In retrospect I think most of the regulations at the facility make sense
I did not have any problems regarding the facility regulations
I understand that we have to take urine tests to prove that we are clean
One cannot suddenly change the regulations, because then treatment would not be the same for all individuals

3
2
1
1
1

Category 6 Treatment climate 2% (n = 5)
I was in a safe and stable environment where it was possible to focus on other things than intoxication

5

as a setting where they were given the opportunity to
discuss their problems and needs with others. Several
patients also pointed to positive effects from learning practical abilities, such as cleaning and cooking. Excursions in
nature were evaluated as a positive shift of scene, where the
patients could focus on other stimuli than intoxication.
Some patients discussed negative perceptions related to a
too low frequency of conversational therapy. In addition,
several female patients pointed to the lack of dedicated
therapy groups for male and female patients.
Perceptions regarding active user involvement in treatment were mainly positive in content. Positive perceptions
were discussed in relation to individual treatment plans
articulated together with clinical staff. The patients also
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

appreciated that significant others were invited to the
facilities for conversations, because these conversations
provided their social networks with information about
their situation and treatment progress. Negative perceptions regarding user involvement were mainly expressed by
patients in OMT. These patients raised concern about the
lack of influence they had on their doses during methadone
or buprenorphine escalation. These patients reported that
they had repeatedly asked to reduce their methadone doses
because of severe negative side effects, but these requests
were not accommodated by the clinic.
Figure 1 shows that facility regulations were mainly
considered in negative terms. These considerations were
more often articulated by patients who had prematurely
53

T. Nordfjærn et al.

Table 2
Categories regarding negative perceptions of treatment with free text descriptions of statements
Category 1 Relation to clinical staff and other patients 27% (n = 61)
Patients on methadone maintenance should not be treated together with other patients, because they lack motivation
I failed to establish a good relation to the treatment staff
The overall confidence between patients and clinical staff are not good
The staff are inconsequent and dishonest, because they tell us one thing and thereafter do the opposite
It is not motivating when other patients neglect their working tasks and relapses while in treatment
Specific patients created conflict and were detrimental to the treatment programme overall
I failed to reinitiate treatment because my relationship to the other patients became superficial
I feel that I have abused the confidence that I gained from the other patients
As female you have to be so tough all the time, because it is a male-dominated environment
The staff is to conform when they receive resistance from difficult patients
I felt left alone when the other patients relapsed without involving me
Sometimes the treatment staff puts too much pressure on us in order to involve us in activities

(n = 222)
12
10
9
8
6
6
2
2
2
2
1
1

Category 2 Facility regulations 17% (n = 37)
Several of the regulations result in a loss of personal independence
The sanctions administered after a relapse are inconsequent and too often unreasonable
Because this facility does not accept Vival use, my anxiety increased to such levels that I was unable to stay
Structuring and planning of everyday activities was extremely difficult and unfamiliar
The equipment and routines for urine tests too often result in false-positive results
To me it seems unreasonable that we are not allowed to use protein shake to improve our physique
I do not understand why they simply throw patients who fail to comply with the regulations out of the programme without
offering alternative treatment facilities for those patients

11
8
8
4
3
2
1

Category 3 Therapy and interventions 16% (n = 35)
Therapy focused too much on addiction, and psychological problems were not discussed
Group therapy focused too much on collective problems while they should have paid more attention to the individuals
I grew tired of therapy, because I had to scrutinize and tell about my personal life all the time
The frequency of individual conversation therapy was too low
I think the treatment programme was too tough in the beginning and the patients got exhausted
Other

13
9
4
3
2
4

Category 4 Aftercare 13% (n = 29)
After my dropout I heard nothing more from the treatment facility
I was looking forward to be transferred to community services, but there is something lacking in what they can offer
I think they should have something to offer us when we drop out of treatment prematurely
They should provide an emergency service that we can attend when we feel that a relapse is tempting
Other

6
6
6
3
8

Category 5 Treatment climate 9% (n = 20)
The qualities of communication and the management structure at the facility are dysfunctional for us
It is difficult to establish trust and continuity because there are replacements among the clinical staff all the time
Several persons among the clinical staff seemed unmotivated and stressed at work
The communication flow between the clinical staff was poor
The staff ,who were present during evenings and nights, did not have sufficient competence and they were too few

7
6
3
2
2

Category 6 Facility resources 7% (n = 15)
The treatment unit has enrolled too many patients compared to their available personnel
Due to an insufficient number of qualified personnel, patients do not get their required amount of counselling
The treatment unit can not offer us regular physical training due to the lack of personnel
All of a sudden our motivational activity funds were removed, such actions generate uncertainty
We get jealous when we hear about patients from other clinics who travel abroad

4
4
3
2
2

Category 7 Pacification 5% (n = 11)
Sometimes I get a feeling that the only reason we are around is to deliver negative urine tests
It is meaningful to become abstinent, but the things we do at the clinic do not provide meaning to our lives
Other

4
3
4

Category 8 Stigma 4% (n = 8)
You are considered as a liar, they only trust you when you can back up your statements by an urine test
We often receive hostile attitudes in the society, and sometimes you encounter treatment personnel with such attitudes
I get provoked when they treat us as monkeys and give us instructions on how to clean the floors
Sometimes the staff consider you as rather unintelligent, but I try to ignore it

4
2
1
1

Category 9 User involvement 3% (n = 6)
The staff carries out the actions they believe is correct and do not listen to our opinions and needs at all

6

54

© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

Perceptions of recovery (n=375)

67 %
n=251

Psychosocial
condition

21%
n=78

Substance use

Positive
perceptions

33%
n=124

Substance use

19%
n=71

12%
n=46
7%
n=26

Social network

16%
n=61

6%
n=24

Psychosocial
condition

Occupation

5%
n=18

3%
n=10

Occupation

Housing

4%
n=14

2%
n=6

Economy

Daily routines

2%
n=6

Economy

1%
n=3

Negative
perceptions

Social network

2%
n=6

Housing

2%
n=6

Stigma

Figure 2
Contextual content analysis of semi-structured interviews (n = 13) – positive and negative perceptions of recovery

dropped out of their programme. These patients were concerned about inconsequent practice of sanctions after a
relapse to substance abuse. Some patients told that they
had been asked to leave their facilities after a relapse, but
that they had observed other patients who had got off with
a warning for identical violations. Some patients had also
experienced false-positive urine tests because of technical
problems with the applied measurement instruments.
The contextual content analysis identified more negative
than positive perceptions related to aftercare provided by
the treatment facilities. These statements were predominately by patients who prematurely dropped out of treatment. These patients were concerned about the lack of
communication with the treatment facilities and community services after they had left the facilities. Several of these
patients felt that they were left by themselves after treatment and attributed this to increased temptations of substance abuse. Examples of positive perceptions were that
patients had additional outpatients counselling organized
for them after the treatment programme was completed.
Furthermore, some patients told that they had extensive
phone contact with the facilities after they had finalized
their treatment. According to these patients this was helpful
when they were tempted to use substances or experienced
psychosocial difficulties.
Treatment climate was also considered important in
terms of negative treatment perceptions. The content in this
category was mainly about the stability in the working
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

environments at the facilities. Patients frequently reported
how continuous replacements among the clinical staff
made them feel insecure and unable to establish adequate
therapeutic relationships over time. For example, some
patients told that they spent more time by presenting their
problems to new employees than learning coping strategies
for these problems. The patients also pointed to communication problems between clinical staff and facility management as an obstacle of efficient treatment.
Figure 1 reports that perceptions related to the available
resources at the facilities were important for negative perceptions of treatment. These statements were mainly about
financial resources available to the patients and an insufficient number of personnel at the facilities. Patients told
that they received insufficient frequencies of conversational
therapy and physical activity because of the lack of qualified personnel. Related to this, patients questioned the
number of people who were available to them during evenings and nights as well as the clinical competence among
staff on night-shifts. In addition, patients talked about
economical incentives and recreational funds that had been
divested from them because the facilities had been told to
spend less economical resources.
Another important aspect of negative treatment perceptions concerned pacification and boredom during treatment. Some patients told that they had frequently been left
alone, because the clinical staff had meetings. Patients also
told that they were in lack of meaningful activities at the
55

T. Nordfjærn et al.

Table 3
Categories regarding positive perceptions of recovery with free text descriptions of statements
Category 1 Psychosocial condition 31% (n = 78)
I have improved my feelings about myself and I feel more capable of coping with my situation
I am not afraid to speak out my opinions and concerns anymore
My overall psychosocial functioning is better than it was before treatment
Additional help received from psychiatric outpatient clinics improved my psychological functioning
I have become a human being again
My social skills have improved and I feel more comfortable in social situations
I now understand that it is up to me to do something in order to recover
I have had severe psychological problems, but my problems have improved
I am better at setting limits for myself
I have become more open-hearted about my psychiatric disorder
I try to turn negative thoughts into positive thoughts
I am more engaged in having meaningful activities in my everyday life
Previously I did everything to avoid conflicts, but not anymore
I am more patient and tolerating than I was before
There is so much more stability and security in my life now
I am less impulsive than before
Now I feel capable of carrying out interests that I previously had
Other

(n = 251)
17
7
5
4
4
4
3
3
3
3
2
2
2
2
2
2
2

Category 2 Substance use 28% (n = 71)
My control over my substance use has improved and I am confident that I can become totally abstinent one day
When I have a relapse, I have more control and succeed in reducing substance consumption faster than before
I do not use substances anymore, I am clean
Certain situations may trigger temptation to use substances, but I have learnt how to cope with those situations
I have learnt to value a life without substances
I have gained perspective about the social destructiveness of my substance abuse
Treatment has significantly increased the threshold for using substances
During the first period before my relapse, the medicine worked and I had no abstinences and used no drugs
Obviously relapses are negative, but I now have a bad conscience after each of them and feel that I am learning
I have started to focus on my interests instead of intoxication
Now I am able to walk downtown and turn down offers of drugs
Previously I used Vival for breakfast, but now I have significantly reduced my use of pills
After treatment I have been much more open-hearted with my alcohol problems
I feel proud about that I have not relapsed
I know that I cannot enjoy alcohol in a normal manner and have to avoid drinking
I have become more aware about why I used substances
Other

11
8
8
8
6
5
4
4
3
3
3
3
3
3
2
2
2
4

Category 3 Social network 24% (n = 61)
The relation to my family and significant others has improved significantly
My loved one supports me in remaining abstinent
My family supported and motivated me throughout treatment
I do not have any contact with those people I used to do drugs with, because I want to stay clean
The relation to my significant others have always been good
I got several new friends now
I have a good social network, who do not use substances
I am more reflected about my substance abusing friends; it is a social environment based on who has the drugs and not on real friendship
Other

21
10
10
4
2
2
2
2
8

Category 4 Occupation 7% (n = 18)
I started my own business when I was in treatment
I am much more motivated to work now than I was before treatment
I started to work with horses and begun at school again
During this summer I have worked for my parents and I will soon start to study again
I have been successful in obtaining a new job
I have ambitions of getting a job soon
Now I write applications and I am really looking forward to start working
This has been a good period for me and I have got a lot of work done
I still have my old job

3
3
2
2
2
2
2
1
1

Category 5 Housing 6% (n = 14)
I have obtained a new apartment with good help from the facility
I have always had a place to live
You soon understand the importance of having your own place, I do not want to live at random places

12
1
1

Category 6 Daily routines 2% (n = 6)
I have learnt practical skills, such as cleaning, which I use regularly in my every day life now
Although I do not have anything to do a particular day, I understand that I should get out of bed and eat breakfast

5
1

Category 7 Economy 1% (n = 3)
I have been able to pay my rent because I have taken initiatives for talks with the social office
I have never had any dept
We are currently working with the dept I have obtained during the latest years

1
1
1

56

© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

Table 4
Categories regarding negative perceptions of recovery with free text descriptions of statements
Category 1 Substance use 30% (n = 46)
After dropout I started to use higher doses than before treatment
I have used substances during treatment at this clinic
I lost control when I relapsed, and I have used morphine regularly for one and a half years now
The first thing I did when dropping out was to get hold of a prescription of Vival
Other patients on the clinic have used drugs during their stay and it makes me ambivalent about abstinence
Two months after my dropout I had a series of relapses to alcohol
I just need to have these pills available
In the beginning I solely remembered the positive sides of my abuse, but soon the negative aspects hit back on me
Other
Category 2 Social network 17% (n = 26)
I try to keep my social network away from my problems; I do not want to bother them with my personal problems
The worst issue is to learn what you have been doing to your family
I get sad when I see how my old substance abusing friends are doing
I feel that I have failed my significant others
I am more reflected about my substance abusing friends; it is a social environment based on who has the drugs and not on
real friendship
Other

(n = 24)
7
5
5
5
3
3
3
2
13
4
3
3
2
2
12

Category 3 Psychosocial condition 16% (n = 24)
I have been diagnosed with schizophrenia and I am struggling both with the symptoms and social implications
I feel more miserable than ever before
Many of the psychological problems are still present
I feel that I have failed
My self-confidence is far from good
I feel indifferent about being alive or dead
Other

4
3
3
2
2
2
8

Category 4 Occupation 7% (n = 10)
I lost my job in the process
I have not begun any studies or job yet
My job situation is unchanged; I have no job
I was unable to keep studying
I am under a contract with my workplace and they will take random urine tests and may come over to my house
I still have a job, but I have to stay on sick leave for a long time

3
2
2
1
1
1

Category 5 Economy 4% (n = 6)
They should provide more help with financial issues; I have been close to relapse due to a lack of creditors
I had to sell everything I owned in order to finance my substance abuse
I get medicine by my doctor and I have to pay for it myself since the social security barely cover these expenses

3
2
1

Category 6 Housing 4% (n = 6)
I did not have any housing when I left the collective and I lived among substance abusing friends
They have not provided me any help in obtaining an apartment
In order to avoid criminality, I had to sell my house to finance drugs after I relapsed
I think the facility should be more apparent towards social services about housing for substance abusers

2
2
1
1

Category 7 Stigma 4% (n = 6)
I think an important reason of relapse into substance abuse is the attitudes we receive in society
I feel that people judge me as a drug addict
I do not want to tell others that I have been in treatment, I know they will react negatively

4
1
1

facilities, and consequently felt bored and passive. Finally,
a few negative statements were about stigmatization at the
treatment sites. These statements were mainly related to a
lack of confidence in patients’ abilities to tell the truth and
to carry out simple instructions.
The specific breakdown of frequencies and percentages
regarding positive treatment perceptions is reported in
Table 1. As illustrated, social relations at the facilities
(43%) and therapy and interventions (34%) were the two
most important subcategories regarding positive treatment perceptions. As reported in the free text descriptions, positive content regarding social relations at the
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

facilities were often related to levels of respect and care
received from treatment personnel (n = 36). These perceptions were mainly about qualities in the therapeutic
relationships between treatment personnel and the
patients. A common statement pointed to the capabilities
of therapists to establish contact and show genuine interest in the unique situations of the patients. Several of
these statements were also about therapists who provided
positive feedback to the patients when they made progression in treatment. The results show that when such
factors were present, they were highly appreciated by the
patients.
57

T. Nordfjærn et al.

Relations among patients in treatment were also frequently described (n = 33). Mainly, these statements related
to perceived support from other patients in treatment.
It is noteworthy that several patients reported that other
patients had prevented them from relapses and had motivated them to stay in treatment. This was also reflected by
a patient who told that he had become tempted to neglect
working tasks and instructions, but kept his persistence for
the sake of the other patients. Perceptions in the description
termed ‘other’ (n = 7) are different statements that occurred
only once in the transcribed material. The majority of
these statements were positive perceptions about treatment
for the male and female patients in the same system. In
addition, some of these perceptions reflected respect for
personnel who regulated and provided feedback on the
behaviours of patients.
As reported in Table 1, several statements (n = 18) indicate successful matching between specific psychosocial
problems and interventions. For instance, patients reported
that they had attended courses that dealt with identification
of automatic processing of negative cognitions in depression. Several of these patients realized that these coping
strategies were relevant to their own problems. Other perceptions (n = 8) consist of positive statements about therapies aimed to improve the relations to significant others, as
well as positive remarks concerning physical training and
relapse prevention courses.
Table 2 shows the breakdown of frequencies and percentages regarding negative perceptions of treatment. The
more important subcategories were relations to clinical
staff and other patients at the facilities (27%), programme regulations (17%) and therapy and interventions
(16%). As reported, negative perceptions regarding the
social climate at the clinics were often discussed in relation to other patients attending the programmes. A relative large proportion (n = 12) of these statements were
specifically targeted to patients who received methadone
or buprenorphine while enrolled into inpatient treatment
together with patients with other addiction patterns.
Several patients reported that they thought individuals
who received methadone or buprenorphine attended
inpatient treatment just to maintain their access to medicaments. They also reported that this negatively influenced the motivation and efforts among other patients.
Underlining the importance of the relation between therapists and patients, barriers for well-functioning therapeutic relationships were often discussed. These barriers
specifically pointed to the importance of consequent information from treatment personnel.
Table 2 reports negative perceptions (n = 37) concerning
facility regulations. As illustrated in the free text descriptions, these statements were mainly about how programme
58

regulations influenced the perceptions of personal freedom
among the patients. Several patients reported that they had
lost their autonomy because of mandatory socialization and
monitoring of their behaviour, especially during early phases
of their programme. Furthermore, it was reported that the
regulations were practised inconsequently, and that patients
received different sanctions after identical violations of programme regulations. The results indicate that the patients
were more concerned about how the regulations were
carried out in practice, rather than negative towards the
regulative nature of the treatment programmes.
Negative treatment perceptions were also discussed in
relation to the therapies and interventions conducted at the
facilities. The most frequent statements (n = 13) postulated
that the interventions were too focused on substance addiction instead of underlying psychological problems. Several
patients, who had been diagnosed with depression and
anxiety, reported that they were frustrated when therapy
groups merely discussed strategies for coping with alcohol
abstinence. According to them, this was done without discussing the underlying causes of alcohol consumption,
which were attributed to psychological disorders (i.e. selfmedication) by these patients. Miscellaneous statements
(n = 4) indicated a lack of dedicated therapy groups for
female patients and specialized therapies for patients who
used antipsychotic medication.

Positive and negative perceptions of recovery
The next step was to investigate the content of positive and
negative perceptions regarding recovery. The outcome of
this analysis is illustrated in Fig. 2. As reported a total
number of 375 statements were identified. Of these sentences, the majority (67%) was positive whereas 33% were
negative. Seven categories emerged for positive perceptions
of recovery: (1) psychosocial condition; (2) substance use;
(3) social network; (4) occupation; (5) housing; (6) daily
routines and (7) economy. Although negative perceptions
revealed similar categories, a category termed (8) stigma
emerged for these perceptions and the category named
daily routines was not revealed. The results indicated that
the most important positive perceptions of recovery were
related to the psychosocial situation among patients. Perceptions of recovery related to substance use and social
networks were also important. Negative perceptions were
mainly related to substance use.
Positive perceptions of recovery were frequently
reported in relation to the psychosocial conditions among
patients. These perceptions were mainly about psychiatric
symptoms and general psychological functioning. For
instance, several patients reported that their capabilities of
controlling their impulsive behaviours had improved.
© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

Negative perceptions were mainly related to psychiatric
symptoms. Patients reported that they experienced symptoms related to depression and anxiety after treatment.
As reported in Fig. 2, the patients had both positive and
negative perceptions of recovery regarding substance use.
Several patients reported that they had started to focus on
their hobbies and interests instead of intoxication. A
number of patients also told that they were totally abstinent from substances after treatment. Examples of negative
aspects of recovery were that some patients reported higher
levels of substance use immediately after treatment termination. This was more common among patients who had a
premature dropout from their programme.
The majority of statements concerning changes in social
networks were positive in content. Patients reported that
they were motivated to establish new social relations and
told that they did not want to return to the substance
abusing networks they were part of before treatment. It
was also reported that they had learnt how to talk about
their addiction with their children. Several patients also
had established contact with old friends, who they had
excluded when they initiated their substance abuse. On the
negative side, patients told that they often experienced a
bad conscience because they had discovered how destructive their behaviours had been to their significant others.
Recovery related to occupational activities, such as
employment and education, was fairly balanced between
positive and negative perceptions (Fig. 2). Although several
patients reported that they had neglected their occupational activities because of substance addiction, they also
told that they currently felt more motivated to reinitiate
such activities. Some patients reported that they had been
capable of keeping their jobs throughout the treatment
programme and were looking forward to return to their
occupational activities.
As shown in Fig. 2, several patients mentioned that
housing was an important aspect of recovery. Most of these
statements were positive in content. A number of patients
told that that they had obtained a new apartment in collaboration with the treatment facilities, and that this provided them with a safe framework that helped them in
staying abstinent from substances. Some patients also told,
however, that they had failed to obtain housing and were
consequently concerned that they had to return to neighbourhoods with extensive substance abuse in order to have
a place to live after treatment.
The manifest content of the category termed daily routines covers perceptions by patients who told that they
transferred some of the routines they learnt at the facilities
over to their daily lives. It was for instance stated that
patients had learnt how to keep a regular circadian rhythm
and learnt practical abilities, such as cooking and cleaning,
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

during their stay at the facilities. These patients reported
that they currently applied these abilities actively in their
daily lives. Related to life outside the clinics, economy was
also regarded as an important issue for recovery by some
patients. One patient told that he currently was working
with financial creditors, and that the facility helped him to
deal with his personal Department. On the negative side,
one patient mentioned that the facility had not aided him in
terms of financial issues, and that he almost relapsed to
substances because of the Department he had established.
Furthermore, a few of the interviewed patients pointed to
stigma as a negative factor in recovery. These patients
thought that they were negatively evaluated as ex-addicts
by other people in society. Some of these individuals also
told that they hesitated to tell friends and colleagues that
they had been in treatment in fear of the social reactions.
Table 3 illustrates in further detail the breakdown of
frequencies and percentages concerning subcategories of
positive perceptions about recovery. As illustrated, the
more important subcategories were psychosocial conditions (31%), substance use (28%) and social network
(24%). As reported in the free text descriptions of statements, the most dominant improvements concerning
psychosocial conditions were related to self-confidence and
social abilities. Patients reported that they had regained
their beliefs in their personal coping skills and told that
their threshold to openly express their opinions and concerns to others were markedly reduced. Such improvements
were by some patients attributed to additional psychiatric
services received in outpatient programmes. The description with other statements (n = 11) contains perceptions
about improved conscience as well as increased abilities to
engage in daily duties.
Concerning recovery in substance use, the patients often
told that they had improved their control and gained coping
strategies regarding abstinence. Several patients told that
they had improved their abilities to identify situations where
they were likely to use substances, and that they were more
capable of coping with these situations without relapsing to
substance abuse after treatment. Although, several patients
told that they were totally abstinent from substances after
treatment, this was more frequent among patients who
completed their programme. Patients who prematurely
dropped out of treatment had more often positive perceptions regarding relapse. Some of these perceptions were
considered as positive in content, because the context of
these sentences indicated that the relapses lasted for a
shorter period than before treatment. Some of these sentences also indicated that the patients had increased their
control when relapses occurred. Other perceptions (n = 4)
were sentences from patients who had used substances after
treatment, but realized that substance abuse did not add
59

T. Nordfjærn et al.

anything to their quality of life. This description also
contains statements from patients who avoided substances
after treatment, because they had learnt that substances
could trigger symptoms related to psychiatric disorders.
Perceptions of improvements in relations to significant
others dominated the category concerning social networks
(n = 21). Specifically, patients reported improved capabilities of communicating their addiction-related problems to
their significant others. Several patients told that this contributed to an improved understanding and support from
their family members and friends. It was also reported that
patients who were involved in intimate relationships gained
further motivation for recovery throughout and after the
treatment programme. Some patients indicated that an
important strategy in order to avoid relapses was to avoid
their previously substance abusing networks. It was indicated that these patients aimed to establish new social
networks through occupational activities, such as work or
education. Other statements (n = 8) were mainly about
abilities to socialize with friends and colleagues who used
alcohol, without becoming tempted to relapse.
Table 4 shows that substance use (30%), social network
(17%) and psychosocial conditions (16%) were the most
important subcategories related to negative perceptions of
recovery. The patients often described negative perceptions
of recovery related to relapse to substance abuse. These
statements were more common among patients who prematurely dropped out of their programme. Several patients
reported that they had used higher doses of substances
immediately after programme dropout compared with
before treatment was initiated. Most of these patients
attributed increased substance use to perceptions of failure,
as well as a lack of meaningful occupational activities when
they had left the facilities. Other statements (n = 13) indicated temptations to relapse to substance abuse after significant negative life events. Examples were broken
intimate relationship, refusals of job applications and
decease among close friends.
The more frequent (n = 4) statements about social networks were stated by patients who told that they would
receive help from significant others if they asked, but
reported that they did not want to involve them in their
personal problems. The patients also told that one of the
most disturbing aspects of recovery from substance addiction was to learn that their activities had been destructive
upon their significant others. Miscellaneous statements
(n = 12) related to negative perceptions were reported by
patients who returned to their substance abusing networks
after treatment. These perceptions were mainly about how
these networks made them ambivalent in terms of staying
abstinent from substances. In addition, this description
covers statements regarding inabilities to focus on personal
60

recovery because of conflicts with significant others outside
the facilities.
In terms of the psychosocial conditions among patients,
negative statements were predominately related to symptoms of psychological disorders. Table 4 illustrates that
patients reported that they experienced severe symptoms
related to psychological disorders ranging from schizophrenia to depression and anxiety. Several of these patients
reported that they had been diagnosed with comorbid
psychological disorders during treatment. Although the
majority of these statements were articulated by patients
who prematurely dropped out of their programme, some
patients who completed treatment told that they frequently
experienced symptoms related to these psychological disorders. Other statements (n = 8) concerned perceptions
regarding a reduced belief in psychological improvement as
well as perceptions of shame and guilt related to premature
programme dropout.

Discussion
The core objective of the present study was to investigate positive and negative perceptions of treatment and
recovery among patients with substance addiction. One of
the more interesting findings related to treatment perceptions was the emphasis patients had to aspects of the
social climate at the facilities. A growing body of evidence
(Project MATCH Research Group 1993, Meier et al. 2005)
indicates that the therapeutic alliance explains more variance in treatment outcomes than specific interventions.
The present study supported the notion that a therapeutic
relationship characterized by mutual respect, understanding and availability is of high importance for how patients
perceive the quality of treatment. These results are congruent with previous studies (Lovejoy et al. 1995, Bacchus
et al. 1999) carried out among patients with substance
addiction. Clinical communities tend to consider the therapeutic alliance as an important and robust component for
the quality of treatment. Researchers, however, have only
recently begun to investigate and debate this alliance as
an important ingredient in substance addiction treatment
(Najavits et al. 2000).
The mutual influences among patients in substance
addiction treatment are important to discuss. Data from
the semi-structured interviews indicated that the patients
have mutual influences on each other in terms of treatment motivation. The interviewed patients told that other
patients had convinced them to stay in treatment when they
considered leaving the programmes prematurely. Moreover, some patients told that they refused to re-enter treatment after a premature programme dropout because they
were ashamed and felt they had lost confidence among the
© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

other patients. This was also underlined by several patients,
who indicated that they were more tempted to relapse
or leave the facilities prematurely when other patients
expressed similar desires.
Patients pointed to negative influences from peers who
received methadone or buprenorphine during long-term
inpatient treatment. According to the interviewed patients,
individuals who receive these medicaments during inpatient programmes have a lack of motivation and do consider medication as the most important component in
treatment. In order to provide patients in OMT with components from psychosocial treatment, a recent effort in the
Drug and Alcohol Treatment in Central Norway has been
to enrol a number of these patients into a long-term inpatient facility. Within this facility they receive psychosocial
treatment among patients with other addiction patterns.
The results raise a hypothesis whether treatment in an
integrated system for these patients negatively influences
the motivation among patients who do not receive methadone or buprenorphine. A possibility is also that patients
on medical maintenance receive stigmatizing attitudes from
patients with other addiction patterns. Our data do indicate that out-group stereotyping may occur from patients
with other addiction patterns towards patients who receive
medically assisted treatment. Considering the importance
of interpersonal relations among patients during inpatient
treatment, research to come should further investigate how
these specific patients influence each other on motivational
variables.
Another important aspect of the social climate was the
stability of the working environments at the facilities. One
of the more important issues underlined by several patients
were that frequent replacements among therapists negatively influenced their ability to establish proper therapeutic relations. Staff turnover represents a major threat to
the consistency, continuity and predictability of health care
within a number of disciplines (Lum et al. 1998). The
present results indicated that this assumption could also be
valid for substance addiction treatment. Because the consistency of treatment services may be associated with treatment outcomes (Lamb et al. 1998), this relation should be
subjected to further investigations.
In line with the differential needs among patients with
substance addiction, the quality of therapy and interventions were frequently perceived in relation to levels of
matching to specific individual problem domains. Overall,
the patients were positive to therapy and interventions,
and they predominantly attributed positive perceptions to
group therapy. This could be a consequence of the sample
in the study. Most of the patients in the current sample
were inpatients, where social training and group therapy
are the most common therapeutic approaches.
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

Although most patients were positive to therapy, some
patients who had been enrolled in short-term treatment
reported dissatisfaction about the provided therapies.
According to these patients this was as a result of groups,
which solely discussed relapse prevention techniques
related to alcohol, without bringing underlying psychological disorders to attention. This underscores a need
for proper screening as well as adjustments to individual
problems in the treatment of addiction disorders. A possible solution is to carry out screening among patients with
validated measurement instruments before treatment. In
central Norway, such efforts (Stallvik 2008) are now
prioritized through a validation of The American Society
of Addiction Medicine Patient Placement Criteria for the
Treatment of Substance-Related Disorders (ASAM-PPC).
Despite that matching instruments have been extensively
used in clinical settings, studies of the effects of treatment
matching remain scarce. Client–treatment matching may
ultimately result in more relevant treatment for specific
individual problems (Gastfriend & McLellan 1997). On
the contrary, international multi-centre studies have indicated that the effects of treatment matching are relatively
limited (Project MATCH Research Group 1993, Kaminer
2001).
The results underlined the importance of consistent
practice of programme regulations. These regulations were
often mentioned in negative terms by patients who prematurely dropped out of treatment. This could be as a result of
the fact that several of these patients had been asked to
leave their facilities because they had violated programme
regulations. Moreover, the patients were concerned about
the lack of consistency in how sanctions were carried out
when they had a relapse during treatment. This was as a
result of observations of other patients who were not
asked to leave after such violations. The data suggest that
the facilities should prioritize to establish consistent
regulations regarding relapse, which applies equally to all
patients in the programmes.
Related to the above, some patients who had dropped out
from the therapeutic community reported that they thought
the programme was too strict during early phases of treatment and were concerned about the loss of individual
freedom experienced in the programme. These patients
requested possibilities to spend some time alone without
continuous behavioural monitoring during early phases of
the step-wise programme. These issues have already been
considered by service-delivery evaluators, and the programme has become less intensive during early phases.
The data suggested that the majority of patients
improved their coping mechanisms in relation to substance
use. Such improvements were reported both among
patients who had completed treatment and among indi61

T. Nordfjærn et al.

viduals who prematurely dropped out of their programme.
This indicates that patients who prematurely leave their
programme also utilize abilities learnt during treatment.
This is partly incongruent with Stark (1992) hypothesis
that patients who prematurely drop out of treatment have
similar outcomes as those who have not received treatment.
Perceptions among patients who prematurely dropped out
of their programme indicated that the risk for extensive
substance use was highest immediately after they left the
programme. Several studies have demonstrated that relapse
to substance use is more likely during the first months after
treatment (Hunt et al. 1971, Brownell et al. 1986). The
facilities should therefore strive to establish alternative
treatment and aftercare for patients who leave their programme early. Empirical data indicate that a combination
of high-intensity outpatient treatment coupled with aftercare of lower intensity could reduce the risk of relapse
after treatment (Kaminer 2001). Moreover, a valid
approach among some of these patients could simply be to
maintain communication after they have left the facilities
and aim to motivate them to re-enter treatment.
Congruent with previous findings (Lovejoy et al. 1995)
one of the more common domains of psychological
recovery was related to self-confidence and overall ability
to cope with everyday problems. Furthermore, several
patients reported improved abilities to share their concerns
and feelings with others. The latter may be related to
abilities learnt during group therapy, where patients usually
learn to become more extroverted and talkative. However,
a number of patients also reported that severe psychological symptoms were present after treatment. This advocates
an integration of psychiatric services in substance addiction
treatment. According to Landheim et al. (2002) psychiatric
competence in substance addiction treatment should be
raised to the same levels as in general psychiatric health
care. Psychological disorders may significantly worsen the
prognosis of recovery from substance addiction (Grella
et al. 2001). Substance addiction and additional psychological disorders should therefore be considered as interrelated, and thus become treated within the same system.
The findings added indirectly support to previous results
(Mcintosh & McKeganey 2000) that have demonstrated
that an important social strategy in recovery is to avoid
former substance abusing social networks. The interviewed
patients told that when they had to return to substance
abusing networks after treatment they perceived negative
influences from these networks. When the facilities and
community services assist patients in terms of housing, the
importance of these coping strategies should be carefully
considered. Patients, who did not receive assistance in
respect of housing before they left the facilities, reported
that they were forced to come among substance abusing
62

friends in order to have a place to live. Thereby the patients
reported that they were exposed to substances and thus
became ambivalent to stay abstinent. The importance
of a stable substance-free housing and meaningful occupational activities for maintaining abstinence should not be
underestimated.

Limitations of the study
The present study has methodological limitations that need
consideration when interpreting the results. First, a strategic sample of 11 inpatients and two outpatients does not
yield a representative picture of the population of patients
with substance addiction. However, semi-structured interviews among a large representative sample would have
been extremely resource demanding and resulted in a too
comprehensive data material for a qualitative analysis. The
purpose of the study was to obtain a deeper understanding
of how the recruited patients perceived their treatment and
recovery. Generalization from the sample to the population
of patients with substance addiction was not part of the
objective.
Second, the coding reliability was only moderate in this
study. Although coder bias can not be entirely excluded, the
pre-definitions of categories and discussions with other
researchers improved reliability and validity. Furthermore,
Yardley (2000) argued that a too restricted coding scheme
may cause the researcher to be less creative and attentive to
the context of statements.
Third, it is possible that specific material occurred frequently because some patients were more willing to give
lengthy descriptions of certain topics (Joffe & Yardley
2004). The interview guide and techniques used during
the interviews have probably reduced this influence. The
patients were asked to reflect upon several different topics,
and most of these topics included an equal amount of
questions. During the interviews no particular topics were
systematically left uncovered by the patients, and we were
overall impressed about the willingness and abilities the
patients had to elaborate over the different aspects in the
guide. Hence, the frequencies of the reported categories
were likely to emerge because of their relative importance
to each other, and not because the patients chose to delimit
their focus to specific topics.

Implications for clinical practice and further research
In summary, we think that the present study has been
successful in revealing content with implications for clinical
practice and further research. The present study adds to the
growing body of empirical literature, which suggests that
perceptions of treatment and recovery can not be investi© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Treatment and recovery as perceived . . .

gated merely in relation to the sum of interventions and
therapies or a strictly limited number of outcome measures.
As illustrated, patients were more preoccupied with the
possibilities to establish adequate relations to their therapists and other patients in treatment, when they were
allowed to talk relatively freely about their treatment perceptions. The results also provide an indication of the
various domains where patients with substance addiction
experience recovery. Substance use appears to be only one
of several domains where there is potential for changes and
recovery for these patients.
Because of the high frequency of patients who struggle
with substance addiction in psychiatric wards, mental
health nurses will often encounter patients with addictionrelated disorders. Thus, nurses in psychiatric practice
should be provided with sufficient knowledge about how
these patients experience treatment and which life domains
that should receive clinical focus. An implication of the
present study is that nurses should increase their focus on
contextual variables that facilitate recovery (e.g. housing
economy, occupation and social networks). As indicated in
the study, such contextual variables may relate to relapse.
Because relapse rates tend to be higher during the first
months after treatment it is preferable that this is carried
out while the patients are at the facilities. Nurses should
also strive to establish non-confronting therapeutic alliances and be attentive to the mutual positive and negative
influences between patients with addiction-related problems. The present study suggests that these social-climate
factors may be of significant importance for treatment
motivation and persistence. A holistic approach to substance addiction could be more important for outcomes
than the applied interventional techniques.
Only a few studies with qualitative methods have been
conducted to investigate positive and negative perceptions
of substance addiction treatment and recovery. Another
application of the present study is that the identified themes
could serve as a basis for the development of more specific
questionnaires. Although we acknowledge patients in substance addiction treatment as a heterogeneous group, we
do think that it is possible to develop common measurement instruments of these perceptions suitable for use in a
range of treatment programmes.

Acknowledgments
The authors would like to express their gratitude to Katrin
Øien and Trine Dyrhaug who carried out the interviews.
Most of all we would like to thank the patients who participated in the study as well as the research coordinators at the
treatment facilities in the Drug and Alcohol Treatment in
Central Norway. The first author is indebted to research
© 2009 Drug and Alcohol Treatment in Central Norway
© 2009 Blackwell Publishing Ltd

Journal compilation

colleagues at the Drug and Alcohol Competence Center and
the department of psychology at NTNU for suggestions,
proof-reading, reliability testing and excellent working environments. The authors also express their gratitude to the
two anonymous reviewers who contributed with constructive suggestions for improvements of the article.

References
Bacchus L., Marsden J., Griffiths P., et al. (1999) Client perceptions of inpatient treatment: a qualitative account with implications for service delivery. Drugs: Education, Prevention &
Policy 6, 87–97.
Brownell K.D., Marlatt G.A., Lichtenstein E. & Wilson G.T.
(1986) Understanding and preventing relapse. American
Psychologist 41, 765–782.
Conners N.A. & Franklin K.K. (2000) Using focus groups to
evaluate client satisfaction in an alcohol and drug treatment
program. Journal of Substance Abuse Treatment 18, 313–320.
Cooper-Patrick L. Powe N.R., Jenckes M.W., et al. (2002) Identifaction of patient attitudes and preferences regarding treatment
of depression. Journal of General Internal Medicine 12, 431–
438.
Copeland J. & Hall W. (1992) A comparison of women seeking
drug and alcohol treatment in a specialist women’s and two
traditional mixed-sex treatment services. British Journal of
Addiction 87, 1293–1302.
Danielsen K. & Garratt A.M. (2007) Måling av brukererfaringer
med avhengighetsbehandling: en litteraturgjennomgang av
validerte måleinstrumenter. Available at: http://www.
kunnskapssenteret.no/binary?download=true & id=3163 [Norwegian only] (accessed 20 January 2009).
De Leon G. (1985) The therapeutic community: status and evolution. The International Journal of the Addictions 20, 823–
844.
De Leon G., Wexler H.K. & Jainchill N. (1982) The therapeutic
community: success and improvement rates five years after
treatment. The International Journal of the Addictions 17, 603–
747.
Finney J.W. & Moos R.H. (1984) Environmental assessment and
evaluation research: examples from mental health and substance abuse programs. Evaluation and Program Planning 7,
151–167.
Gastfriend D.R. & McLellan A.T. (1997) Treatment matching,
theoretic basis and practical implication. Medical Clinics of
North America 81, 945–966.
Gottheil E., McLellan A.T. & Druley K.A. (1992) Length of stay,
patient severity and treatment outcome: sample data from the
field of alcoholism. Journal of Studies on Alcohol 53, 69–75.
Grella C.E., Hser Y.I., Joshi V., et al. (2001) Drug treatment
outcomes for adolescents with comorbid mental and substance
use disorders. Journal of Nervous and Mental Disease 189,
384–392.
Hunt W.A., Barnett L.W. & Branch L.G. (1971) Relapse rates in
addiction programs. Journal of Clinical Psychology 27, 455–
456.
Joe G.W. & Friend H.J. (1989) Treatment process factors and
satisfaction with drug abuse treatment. Psychology of Addictive
Behaviours 3, 53–64.

63

T. Nordfjærn et al.

Joffe H. & Yardley L. (2004) Content and thematic analysis.
In: Research Methods for Clinical and Health Psychology (eds
Marks, D. & Yardley, L.), pp. 56–68. Sage, London.
Jones S.S., Power R. & Dale A. (1994) The patients charter: drug
users views on the ‘ideal’ methadone programme. Addiction
Research 1, 323–334.
Jörgensen K.N., Römma V. & Rundmo T. (2009) Associations
between ward atmosphere, patient satisfaction and outcome.
Journal of Psychiatric and Mental Health Nursing 16, 113–120.
Kaminer Y. (2001) Alcohol & drug abuse: adolescent substance
abuse treatment: where do we go from here? Psychiatric
Services 52, 147–149.
Lamb S. Greenlick M.R. & McCarty D., eds (1998) Bridging the
Gap between Practice and Research: Forging Partnerships with
Community-Based Drug and Alcohol Treatment. National
Academy Press, Washington, DC.
Landheim A.S., Bakken V. & Vaglum P. (2002) Psychiatric disorders among substance abusers treated in the substance abuse
field. Nordic Journal of Epidemiology 12, 309–318.
Landis J.R. & Koch G.G. (1977) The measurement of observer
agreement for categorical data. Biometrics 33, 159–174.
Lovejoy M., Rosenblum A., Magura S., et al. (1995) Patients’
perspectives on the process of change in substance abuse
treatment. Journal of Substance Abuse Treatment 12, 269–282.
Lum L., Kervin J., Clark K., et al. (1998) Explaining nursing
turnover intent: job satisfaction, pay satisfaction, or organizational commitment? Journal of Organizational Behavior 19,
305–320.
Mcintosh J. & McKeganey N. (2000) The recovery from dependent drug use: addicts’ strategies for reducing the risk of relapse.
Drugs: Education, Prevention and Policy 7, 179–192.
McTavish D.G. & Pirro E.B. (1990) Contextual content analysis.
Quality and Quantity 24, 245–265.
Marsden J., Nizzoli U., Corbelli C., et al. (2000) New European
instrument for treatment outcome research: reliability of the
Maudsley addiction profile and treatment perceptions questionnaire in Italy, Spain and Portugal European Addiction Research
6, 115–122.
Meier P., Barrowclough C. & Donmall M. (2005) The role of the
therapeutic alliance in the treatment of drug abuse. Addiction
100, 500–511.
Moos R.H. (1974) Ward Atmosphere Manual. Consulting
Psychologist Press, Palo Alto, CA.

64

Möller T. & Linaker O.M. (2004) Symptoms and lifetime treatment experiences in psychotic patients with and without substance abuse. Nordic Journal of Psychiatry 58, 237–242.
Morgan E.D., Pasquarella M. & Holman J.R. (2004) Continuity
of care and patient satisfaction in a family practice clinic. The
Journal of the American Board of Family Practice 17, 341–
346.
Najavits L.M., Crits-Christoph P. & Dierberger A. (2000) A
clinicans’ impact on substance abuse treatment. Substance Use
and Misuse 35, 2161–2190.
Nelson-Zlupko L., Dore M.M., Kauffman E., et al. (1996)
Women in recovery: their perceptions of treatment effectiveness.
Journal of Substance Abuse Treatment 13, 51–59.
Orford J., Hodgson R., Copello A., et al. (2009) To what factors
do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol treatment trial. Journal of
Substance Abuse Treatment 36, 49–58.
Project MATCH Research Group (1993) Project MATCH: rationale and methods for a multisite clinical trial matching patients
to alcoholism treatment. Alcoholism: Clinical and Experimental
Research 17, 1130–1145.
Robins L.N. (1993) The sixth thomas james okey memorial
lecture. Vietnam veterans’ rapid recovery from heroin
addiction: a fluke or normal expectation? Addiction 88, 1041–
1054.
Smith B.D. & Marsh J.C. (2002) Client-service matching in
substance abuse treatment for women with children. Journal of
Substance Abuse Treatment 22, 161–168.
Stallvik M. (2008) Matching patients with substance addiction to
optimal treatment level. Congress for the international society
of addiction medicine 2008. Cape-Town 16–20 November,
2008. (Oral presentation).
Stark M.J. (1992) Dropping out of substance abuse treatment:
a clinically oriented review. Clinical Psychology Review 12,
93–116.
Stemler S. (2001) An overview of content analysis. Practical
Assessment, Research and Evaluation 7. Available at: http://
pareonline.net/getvn.asp?v=7 & n=17 (accessed 19 January
2009).
Weber R.P. (1990) Basic Content Analysis, 2nd edn. Sage publications, Newbury Park, CA.
Yardley L. (2000) Dilemmas in qualitative health research.
Psychology and Health 15, 215–228.

© 2009 Drug and Alcohol Treatment in Central Norway
Journal compilation © 2009 Blackwell Publishing Ltd

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close