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Table 3 Summary of findings 1 (a, b, and c)

From: Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work

1) Intervention contexts that elicit and/or support (or not) engagement
(a) Client-centered contexts Examples of client-centered contexts are those where clients are: Examples of contexts that are not client-centered (and do not support psychosocial and/or employment needs/issues skills) are those where:
  • Supported to think through their own problems and select a range of options to help reach a realistic goal (Coviello et al. [2009]). • Clients are already receiving the therapy they need through the methadone program (Rounsaville et al. [1983]).
  • Involved with social and recreation activities (e.g., going to the movies) and discussions of "issues of self-declared importance" (Nurco et al. [1995]). • Intervention is not what clients want or feel they need: it appears that seminars may not have allowed clients to articulate their own issues (Cohen et al. [1982]).
  • Assisted (through group discussions, role playing etc.) in clarifying their attractions and barriers to work, and helped to create individualized objectives and plans for action to find work (Platt et al. [1993]). • Manual-based format does not address real barriers to employment (e.g., how to explain past criminal behaviours) so realistic solutions to the barriers are not addressed during group discussions (Lidz et al. [2004]).
  • Involved with readings and exercises from a workbook that are focused on relevant "themes and psychoeducation" (Najavits et al. [2007]). • Counselors select specific treatment goals and design and implement treatment techniques (suggesting that treatment goals are not what clients want) (Bigelow et al. [1980]).
  • Encouraged to articulate their issues in an accepting and supportive atmosphere (Ronel et al. [2011])
  • Supported (through visual mapping) to articulate their issues (Joe et al. [1994]; Dansereau et al. [1996]) (although not going so far as to overwhelm with personal issues) (Joe et al. [1997]).
  • Provided assistance with needed skills development such as:
  • how to complete applications, creating resumes, and identifying job and volunteer openings (Kidorf et al. [1998]).
  • how to use public transportation, budget money, request a day off from work, communicate with employers, etc. (Zanis and Coviello [2001]).
(b) Responsiveness to clients' socio-economic lives Examples of contexts that recognize/address the socio-economic conditions and needs of clients are those that provide: Examples of contexts where clients' socio-economic lives are not recognized are those where:
  • Socio-economic assistance (e.g., help with transportation etc.) (Aszalos et al. [1999]). • The literacy level or social skills of the clients are not recognized (e.g., video feedback techniques used that embarrassed some clients) (Lidz et al. [2004]).
• Help with literacy issues (McLellan et al. [1993]).
  • Vouchers for subsistence items (e.g., food, clothes) (Farabee et al. [2002]). • Employment that includes taxable income is the goal of the program but this type of employment can negatively impact clients (e.g., taxable income can mean losing coverage for methadone treatment) (Coviello et al. [2004]).
(c) Positive or supportive relationships between counselors and clients, and among clients Examples of contexts that support positive relationships between counselors and clients are those where counselors: Examples of contexts that support positive relationships among clients are those where clients:
• Are committed to the success of the intervention; and are aware of clients' issues and express "empathy, respect and genuineness" towards clients (Nurco et al. [1995]). • Help each other through structured exercises which provide peer feedback and support (Platt et al. [1993]).
  • Are engaged in mediation on behalf of clients (e.g., working with a local employer to restructure job hours to meet a client's methadone schedule) (Zanis and Coviello [2001]). • Help one another with homework and connect with each other outside of formal meetings (Ronel et al. [2011]).
  • Work with clients over a period of time and have an established relationship (Kidorf et al. [1998]).
  • Go into the community and work with clients (Magura et al. [2007]).
  • Can identify with clients (e.g., understand clients' experiences) (Connett [1980]).