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Contrasting faith-based and traditional substance
abuse treatment programs
James Alan Neff, (Ph.D., M.P.H.)
a,
4, Clayton T. Shorkey, (Ph.D.)
b,1
,
Liliane Cambraia Windsor, (M.S.S.W.)
b,1
a
College of Health Sciences, Old Dominion University, Norfolk, VA 23529, USA
b
School of Social Work, University of Texas at Austin, Austin, TX, USA
Received 29 December 2003; received in revised form 31 August 2005; accepted 6 October 2005
Abstract
This article (a) discusses the definition of faith-based substance abuse treatment programs, (b) juxtaposes Durkheim’s theory regarding
religion with Simpson’s (2004) treatment process model to highlight key dimensions of faith-based and traditional programs, and (c) presents
results from a study of seven programs to identify key program dimensions and to identify differences/similarities between program types.
Focus group/Concept Mapping techniques yielded a clear bspiritual activities, beliefs, and ritualsQdimension, rated as significantly more
important to faith-based programs. Faith-based program staff also rated bstructure and disciplineQas more important and bwork readinessQas
less important. No differences were found for bgroup activities/cohesionQand brole modeling/mentoring,Qbsafe, supportive environment,Q
and btraditional treatment modalities.QPrograms showed substantial similarities with regard to core social processes of treatment such as
mentoring, role modeling, and social cohesion. Implications are considered for further research on treatment engagement, retention, and other
outcomes. D2006 Elsevier Inc. All rights reserved.
Keywords: Substance abuse treatment; Faith-based treatment; Health disparities; Concept Mapping
1. Introduction
bFaith-basedQinitiatives in areas of welfare-to-work, child
care, and substance abuse treatment have recently received
an increasing amount of public attention, both positive and
negative (Johnson, 2002; Sider & Unruh, 1999). Growing
interest in faith-based approaches coincides with increasing
attention directed to conceptual and methodological issues
surrounding spirituality, religiosity, and their implications for
health and well-being (Fetzer Institute, 1999).
Unfortunately, systematic empirical research regarding
the efficacy of faith-based interventions (i.e., those rooted
in some spiritual or religious content) for alcohol or
substance abuse is sparse. Although general evidence
regarding the efficacy of faith-based interventions is
reviewed elsewhere (Johnson, 2002), we emphasize that
efforts to understand the effectiveness of faith-based
programs presumes an understanding of (at the very least)
what faith-based programs are and what they do. There is a
growing literature on the definition of faith-based organ-
izations involved in the provision of social services (Vidal,
2001), although we will argue that faith-based substance
abuse treatment may occupy a unique niche and must be
understood in relation to traditional substance abuse treat-
ment programs — particularly in light of the preeminence of
12-step philosophy (Roman & Blum, 1999) and emphasis
upon spirituality in the recovery process (Albers, 1997;
White, 1998).
The literature regarding religion and spirituality dimen-
sions in relation to substance abuse and substance abuse
treatment has been aptly reviewed by Gorsuch (1995) and
0740-5472/06/$ – see front matter D2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2005.10.001
4Corresponding author. Research College of Health Sciences, Old
Dominion University, Norfolk, VA 23529, USA. Tel.: +1 757 683 6482;
fax: +1 757 683 4753.
E-mail addresses: janeff@odu.edu (J.A. Neff)8
cshorkey@mail.utexas.edu (C.T. Shorkey)8
liliw@mail.utexas.edu (L.C. Windsor).
1
Tel.: +1 512 471 0520; fax: +1 512 471 9514.
Journal of Substance Abuse Treatment 30 (2006) 49 – 61
Miller (1997). The interested reader is referred to those
sources for background information. The present explor-
atory analysis focuses upon substance abuse treatment,
presenting an empirically grounded, qualitative and quanti-
tative study of a range of treatment programs to identify
differences and similarities between faith-based and more
btraditionalQsubstance abuse treatment programs. Our hope
is that identification of unique (and common) elements
will demystify the notion of bfaith-basedQtreatment, while
highlighting more fundamental dimensions common to treat-
ment programs in general.
To clarify the nature and diversity of faith-based
substance abuse treatment programs, the present article will
(a) discuss the definition of faith-based organizations,
specifically as they relate to substance abuse treatment
programs, (b) contrast classical theory regarding the
structure and functions of religious organizations with
contemporary middle-range theory of substance abuse
treatment process to highlight key dimensions of faith-
based and traditional treatment programs, and (c) present
results from an exploratory qualitative/quantitative study of
a range of substance abuse treatment programs seeking to
identify key dimensions of such programs and to identify
sources of variation between program types.
Specifically, seven programs are studied, ranging from
btraditionalQtreatment programs employing licensed pro-
fessional staff to more clearly bfaith-basedQprograms
employing largely lay staff and endorsing more explicitly
Christian philosophies. Focus group and Concept Mapping
(Trochim, 1993a) methodologies are used to identify key
program dimensions of these programs and to see if
traditional and faith-based programs can be differentiated
based on these dimensions. Ultimately, the goals of our
research program are to clarify the nature of faith-based
treatment, to assess the extent to which these programs
differ (or are similar to) btraditionalQtreatment programs,
and to develop hypotheses regarding possible implications
of differences for treatment outcomes of these programs.
1.1. The definition of faith-based organizations
A critical starting point for this discussion is the
definition of bfaith-basedQprograms, as extant definitions
appear many and varied. Castelli and McCarthy (1997)
define faith-based organizations to include congregations,
national networks (such as Catholic Charities or YMCA),
freestanding religious organizations, or other urban or social
ministries providing some community service (Vidal, 2001).
AWhite House White Paper (2001, p. 3) takes a broader
view, including both religious and secular organizations,
referring to bfaith-based grassroots groups...[involving
networks]...of local congregations...small nonprofit organ-
izations (both religious and secular)...and neighborhood
groups that spring up to respond to a crisis....QIn contrast,
Scott (2003) emphasizes (a) the linkage of faith-based
organizations to an organized faith community, (b) the
presence of a particular religious ideology, and (c) staff and
volunteers drawn from a particular religious group.
In considering the differing emphases of such definitions,
we argue that an appreciation of the diversity of faith-based
groups requires a broad, inclusive approach allowing for
both secular and religious organizations. Thus, Sider and
Unruh (1999) posit four types of faith-based providers: (a)
secular providers who make no explicit to reference to God
or any ultimate values, (b) religiously affiliated providers
who use standard nonreligious techniques and approaches
without religious content, (c) exclusively faith-based pro-
viders who rely on religious content and technologies to the
exclusion of traditional nonreligious approaches, and (d)
holistic faith-based providers who combine religious and
nonreligious content and approaches. Sider and Unruh
emphasize a combination of religious affiliation and reli-
gious content similar to the Working Group on Human
Needs and Faith-Based and Community Initiatives (2002),
who emphasize the degree to which a program is imbued
with religious and/or spiritual content (e.g., a continuum
ranging from bfaith-saturatedQto bfaith-secular partnershipQ).
We argue that a broad definition is a necessity, in
particular, in examining faith-based providers of substance
abuse treatment. With regard to the definition of faith-based
substance abuse treatment programs, we downplay the
importance of the religious or congregational affiliation of
the program itself. Rather, for purposes of this article, we
define bfaith-basedQprograms broadly in terms of the
presence of implicit or explicit religious and/or spiritual
content underlying program activities. This follows from the
fact that many programs, although not associated with any
organized religion, may endorse 12-step conceptions of
spirituality and the existence of a bhigher power.QThus,
although they may not constitute a religion per se, 12-step
programs do promote practices such as prayer, meditation,
confession, and penance (White, 1998) and as well involve
elements of ideology and recruitment of volunteers and bstaffQ
from existing 12-step members proposed as characteristics of
faith-based organizations (Scott, 2003). In this sense, even a
secular treatment program may have bfaith-basedQelements.
The line between secular and faith-based programs
becomes further blurred in that recovery programs endors-
ing 12-step philosophy typically emphasize bspiritual trans-
formationQ(Albers, 1997; Alcoholics Anonymous [AA],
1995) as fundamental to the recovery process. In this regard,
an approach emphasizing the degree to which a program is
imbued with religious and/or spiritual content (Sider &
Unruh, 1999) becomes critical with regard to examining
substance abuse treatment programs where even a tradi-
tional program (emphasizing conventional medical and
psychosocial treatments) may incorporate the 12-step
philosophy or other spiritual content to some extent.
A final definitional issue involves the credentials of
program staff. That is, as noted, 12-step-oriented treatment
programs often recruit staff members who are in recovery.
Although this is common and although faith-based pro-
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 6150
grams may recruit their bgraduatesQas well, an important
distinction lies in the degree of training of staff in more
traditional versus faith-based programs. That is, we suggest
that traditional treatment programs that emphasize conven-
tional medical and psychosocial treatment modalities will
generally be more likely to have professional, licensed staff
(in part a function of licensing requirements) than less
formal faith-based programs who may be more likely to hire
unlicensed nonprofessional staff.
1.2. Theoretical foundations for approaching bfaith-basedQ
and traditional treatment
Although the emphasis of the current study is primarily
empirical— to contrast bfaith-basedQand traditional sub-
stance abuse treatment programs — it may be useful to
briefly examine these programs from a broader theoretical
perspective. Specifically, it is noted that much of the extant
conceptual work on faith-based organization is typological
rather than explanatory in nature. As such, we might look
conceptually beyond the structure of faith-based programs
to consider what those structures accomplish for the
individuals and groups involved. Additionally, it is relevant
to ask whether faith-based programs would necessarily
appear different conceptually and procedurally from tradi-
tional substance abuse treatment programs?
In thinking about faith-based programs, we start by
considering Durkheim’s (1948) classic structural–functional
analysis of religious organization as an bintegrated system
of beliefs and practices relative to sacred things...which
unite in one moral community...all those who adhere
to it.QReligion was thus viewed as fulfilling basic collective
social functions (Alpert, 1961) including promoting self-
discipline, social cohesion, brevitalizingQthe social heritage
of the group, and promoting well-being. In this sense,
specifically religious practices (prayer, singing, testifying,
etc.) reinforce the underlying belief system and promote
integration of the individual into the collective.
Against the structural–functional background provided
by Durkheim (1948), it may be instructive to juxtapose
Simpson’s (2004) heuristic, empirically supported, general
model of the substance abuse treatment process. This model
(Fig. 1) begins with inputs involving both patient attributes
(treatment readiness, illness severity, and program attributes
(resources, staff, organizational climate, and management
information). These dimensions impact early engagement in
the program (processes of program participation and
development of a therapeutic relationship), which subse-
quently feed into the early recovery stage (behavioral and
psychosocial changes) and the stabilized recovery stage
(program retention), which ultimately leads to better or
worse posttreatment outcomes (drug use, criminal activity,
and social relations).
In considering possible points of conceptual convergence
between Durkheim’s and Simpson’s models and their
implications with regard to faith-based and traditional
treatment, several points might be noted. First, Simpson’s
treatment process model does not mention concepts of
bspiritualityQor bspiritual/12-stepQorientation. Although not
mentioned, such elements, whether found in faith-based or
traditional programs, might appropriately fall within the
program attributes dimension (e.g., organizational climate)
as might recruitment of staff in recovery as a structural
characteristic of a treatment program.
Second, Simpson notes the importance of treatment
readiness and motivation for change with regard to engage-
ment, retention, and outcomes. As substance abuse is often
associated with loss of social ties and a marginalized social
status (Jellinek, 1960), substance abusers may be particularly
likely to be disenfranchised from key societal institutions as
well as from the church. Given low levels of treatment
readiness, the critical question is how a treatment program
Fig. 1. Simpson’s (2004) treatment process model.
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 61 51
(faith-based or traditional) can be structured or organized
(i.e., program dimensions or elements) to engage and retain
the individual in the program and in the recovery process?
Simpson (2004) notes that the least developed dimension
of his model involves program attributes (and organizational
climate dimensions). In this regard, Durkheim’s (1948)
conceptualization may be relevant in suggesting the impor-
tance of (a) structure and discipline and (b) engaging
participants in rituals and activities that foster social
integration and adoption of new norms, values, and behav-
iors. With regard first to structure and discipline, note that
Simpson (2004) cites Moos, King, Burnett, and Andrassy
(1997), who demonstrate the importance of bhigh expect-
ations for patients, clear policies, structured programming,
high proportion of staff in recovery, and emphasis upon
psychosocial treatmentQas predictors of treatment participa-
tion (engagement) and treatment outcomes. Thus, given
the rather chaotic lifestyles experienced by many out-
of-treatment substance abusers, such clear program struc-
ture might be hypothesized to be crucial to engagement
and outcomes.
With regard to elements of organizational culture that
promote social cohesion, Durkheim (1948) and Alpert
(1961) might suggest the important functions of rituals
and group activities.In a more faith-based setting, such
activities may involve group Bible study; in a traditional
treatment setting, this might involve 12-step study. White
(1998) has extensively detailed the importance of rituals in
12-step culture such as prayer/meditation, testifying or
witnessing regarding faith (or recovery), testimonials
regarding individual salvation (or recovery), or simply
group activities (such as recreational activities or even
housecleaning). Such activities might be found in either
faith-based or traditional treatment settings (at least in
traditional programs with a 12-step emphasis).
Further, Simpson (2004) notes the potential usefulness of
special binductionQefforts such as individual and group-
based motivational interventions (Foote et al., 1999), to foster
treatment readiness and program engagement. Among other
elements contributing to the induction process, interpersonal
skills and empathy (Miller, 2000) are cited as contributing to
the development of productive therapeutic relationships —
consistent with evidence from Miller, Taylor, and West
(1980) regarding empathic, warm, accepting, and nurturing
counseling style as characteristic of effective substance abuse
counselors. To the extent that such empathic therapeutic
relationships can be interpreted in terms of fundamental
Christian tenets of agape as Miller (2000) suggests,
then these may represent elements common to effective
treatment approaches, whether faith-based or traditional.
Perhaps, a final convergence between Durkheim and
Simpson, a critical psychosocial component (as in Moos
et al., 1997) of either faith-based or traditional treatment
programs that promote social cohesion and the engagement
and recovery process would be activities that specifically
provide mentoring or social support to the individual. This
could involve the presence of formal or informal mentors
(or sponsors) such as use of recovering program staff
members (providing role models of successful recovery; cf.
Moos et al, 1997), AA, or other 12-step meetings to
provide support and social reinforcement, or more general
emphasis upon the group as a source of support for
recovery. All of these activities or elements would serve to
reinforce a brecoveryQbelief system — whether explicitly
faith-based or traditional.
The point of this brief conceptual overview is not to
formally derive specific hypotheses, but rather to lay a
foundation for interpreting what our empirical work may
uncover. That is, the above review may suggest that more
spiritually oriented programs might emphasize activities,
beliefs, and rituals that promote social cohesion and
integration, although such elements may be viewed as
motivational induction mechanisms and elements of orga-
nizational climate that serve to increase engagement and
retention. Core social processes such as role modeling and
support may be common to both faith-based and traditional
programs.
1.3. Overview of the research questions
Thus far, we have discussed definitional issues involving
faith-based programs, noting that dimensions of spirituality
may pervade both faith-based and traditional programs
given the pervasiveness of 12-step philosophy. Further, we
have examined both classic theory and Simpson’s model of
treatment process, suggesting that common features such as
an empathic climate, elements to promote engagement and
integration, and role modeling and support, may pervade
both faith-based and traditional programs. These discussions
provide a point of departure. We feel that an understanding
of such programs must come from an empirical examination
of a range of programs themselves. In this regard, following
from our earlier discussion, we argue that faith-based
programs can best be understood in comparison to more
traditional programs so that similarities and differences can
be examined. Thus, our guiding research question is
whether and how traditional treatment programs differ from
faith-based programs. That is, to the extent that social
processes are essential to effective treatment, there may be
more similarities between traditional and faith-based pro-
grams than differences. To that end, we present the results of
an exploratory study, which provides qualitative and
quantitative data on key program dimensions identified in
a range of substance abuse treatment programs.
2. Materials and methods
2.1. Overview of participating treatment programs
To provide a range of variation in program structures
and philosophies, seven Central Texas treatment programs
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 6152
were studied. Names of these programs are not given
here to maintain the confidentiality of the programs.
Characteristics of these programs (based upon program
literature and interviews with program leaders) are pre-
sented in Table 1.
All programs provide residential services, with the more
faith-based programs offering longer term residential care.
All of the programs incorporate some elements of spiritu-
ality, either in terms of 12-step philosophy or Christian
tenets. As the table indicates, programs included two
traditional treatment programs (Programs 1 and 2) involving
licensed professional staff and medical/psychosocial treat-
ment modalities. Both programs incorporate spiritual
dimensions in terms of 12-step programming; Program 2
also incorporates specifically Christian elements. Toward
the more traditional end of the continuum, Program 3
represents somewhat of a mix, with a combination of
licensed professional and volunteer staff, with a philosophy
that is Christian in orientation, emphasizing biblical teach-
ings combined with more traditional counseling, 12-step
programming, and work therapy.
At the less traditional end of the continuum are four more
explicitly faith-based programs, characterized by unlicensed
nonprofessional staff (often program graduates) and an
emphasis upon biblical teachings, prayer, individual and
group worship, and some emphasis upon supervised work
experience. These faith-based programs do not necessarily
endorse 12-step programming. Thus, for example, Program
4(Garcia & Garcia, 1988) promotes b17 lessons for living Q
and Program 5 (Diez, 1991) emphasizes b4 pillars of
evangelism, discipleship, social work, and individual faithQ
as alternatives to 12-step philosophy.
It is noted that no therapeutic communities (TCs) were
included in the study. Although there was one TC in
operation in the area, it was excluded from the study on the
assumption that, as a prison-based program, it would not be
comparable to the other programs. The implications of the
exclusion of TCs from the study will be discussed in the
Conclusions section of the article.
2.2. Concept Mapping methodology: Establishing treatment
program dimensions
To help to understand the nature of faith-based and
traditional treatment programs, the present study utilizes
Concept Mapping (Trochim, 1993a) to (a) identify core
dimensions of these treatment programs, defined through
focus group methods conducted with program staff and
residents, and (b) assess the utility of these dimensions to
differentiate between traditional and faith-based programs.
The goal here, simply put, is to examine the extent to
which faith-based programs differ from more traditional
treatment programs.
Concept Mapping methodology (Trochim, 1993a) has
been described by Johnsen, Biegel, and Shafran (2000,
p. 68) as a bprocess that involves a series of structured and
discrete steps to arrive at a pictorial representation, in the
form of a map, of the interrelationships among ideas.QThe
process involves several stages. To generate the concepts,
respondents in focus groups or individual interviews
brainstorm in response to a focus question and generate
a pool of statements or items that describe the concept.
Later, the combined set of statements is sorted by
respondents (same or different) into categories reflecting
similarity of statements (i.e., statements reflecting a similar
concept). This procedure yields a similarity matrix.
Respondents also rate the importance of each statement
to the focus question (e.g., how important they feel each
statement/descriptor is to the concept, generally on a
Likert scale).
After the similarity matrix is constructed, Concept
Mapping software generates two sets of statistical analyses.
First, a two-dimensional nonmetric multidimensional scal-
ing of the group similarity matrix is applied to the table of
similarities or distances that iteratively place points on a
map so that the original table is as fairly represented as
possible (Trochim, 1993a). This procedure produces a map
of points that represent the set of statements. The distance
between two points (statements) indicates the similarity.
Second, a hierarchical cluster analysis is used to group
individual statements on the map into clusters of statements
that presumably reflect similar concepts (Trochim, 1993a).
The analyses generate a point map and a cluster map. From
the rating data obtained from group participants, average
importance ratings across participants can be overlaid
graphically on the maps to produce a point rating map
and a cluster rating map.
Several different cluster maps can be generated to
represent a range of cluster solutions. The default number
of clusters generated by the Concept System software is
equal to approximately 20% of the number of statements
entered. The next step is to bnameQthe clusters, which can
be done by the original focus groups, groups reflecting the
same or similar populations (Trochim, 1993a), or by the
research team or other experts (Johnsen et al., 2000).
A few statistical points regarding the Concept Mapping
approach merit consideration. First, as a Concept Mapping
can yield a number of bmaps,Qthe question of model fit to
the data arises. Multidimensional scaling procedures pro-
vide a measure of goodness of fit of the obtained map
(called a bstress valueQ), where smaller stress values indicate
better model fit-expressed in terms of the goodness of fit of
the map to the original dissimilarity map that served as
input. Stress values more than 0.35 suggest that interpreta-
tion of the obtained map may be problematic (Trochim,
1993b) and values less than 0.25 indicate a reasonable
solution. A second issue involves sample size. As Trochim
(1993b) notes, Concept Mapping is designed for small
samples of rater/sorters (rule of thumb of 15; Trochim,
1993b, p. 8), although he cites data to support a positive
correlation between number of raters and various measures
of reliability.
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 61 53
Table 1
Characteristics of participating programs
Characteristics Program 1 Program 2 Program 3 Program 4 Program 5 Program 6 Program 7
Type Nonprofit Nonprofit Nonprofit Nonprofit Nonprofit Nonprofit Nonprofit
Established 1967 1970 1865 1972 1992 1995 1993
Denomination None None None None None None None
Program Residential/outpatient Residential/outpatient/after-care Residential Residential Residential Residential Residential/outpatient
Number of staff 124 28 10 2 Church leaders 10 4 6
Length of stay 28– 90 days Varies 6 – 12 months 3–6 months 6 months 9 months 3–6 months
Number of Clients 132 38 116 19 men, 2 youth 12– 15 20 22
Clients per year 2700 143 600 300 – 400 820 350 – 400 300
Services
provided
Assessment, medical
detoxification,
residential, outpatient,
family, relapse
prevention, aftercare,
and alumni
Adult men and women, 24-hour
supervision, 12-step, group/
individual counseling, Bible
study, church services, alcohol/
drug education, assessment, and
referral, GED, vocational
planning, life skills, parenting,
family counseling, mentoring
Vocational/group/individual
counseling, group/personal
worship, recreation, food,
shelter, clothing, health
concerns, lab tests,
education, referrals
Chapel, Bible
studies, discipleship,
book reports
Spiritual guidance,
meeting, Bible study,
job training, counseling,
and legal services
Room and board,
Bible study, counseling,
prayer, work opportunity
Classes, group
therapy, worship
services, 12-step
program, job
counseling, training,
and placement
Costs Free for the needy Fee for service Free Free Free Free Free
Funding State, county, city,
United Way, self-pay
United Way, individual/corporate
donors, private pay, probation
Thrift store donations,
vehicle auctions
Contributions Grants, donations,
services provided,
thrift store
Community and
individual
contributions f
Private donations and
client services
Staff
qualifications
LCDC, MSSW,
volunteers,
RN, RLVN, MD
LCDC, BS, MS,
PhD-level counselors
Volunteers, licensed
professionals,
unlicensed
professionals
Lay, unlicensed
disciples
Lay, unlicensed
disciples
Lay, unlicensed disciples
(12 months in program);
program director has CPR
and First Aid training
Paid/volunteers, lay,
licensed pastor
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 6154
3. Results
3.1. Concept Mapping implementation and results
All research activities were conducted under an approved
Institutional Review Board protocol with a waiver of written
informed consent to assure respondent anonymity. Our first
step in applying the Concept Mapping method involved
asking key informants (one or more program leaders) in each
program to blist some elements of your program (or things
that you do in your programs) that helping individuals to
successfully recover from alcohol or drug abuse.QInformants
generated a list of 68 program activities or elements. Groups
of staff (n= 29) and residents (n= 32) from each program
then individually sorted statements into conceptual catego-
ries (i.e., into groups of statements reflecting bsimilarQtypes
of program activities) and rated statements on bimportance
to their programQ(a four-point Likert scale ranging from
4=very much like my program to 1 = not at all like my
program). In each program, an attempt was made to obtain
sorting and rating data from a minimum or two staff and two
residents. Where there were separate programs for men and
women (Programs 1, 2, and 4), separate sorting/rating
groups were conducted for men and women.
Overall, sorting/rating respondents were ethnically
diverse (46% White, 30% African American, 21% His-
panic), 67% men, and 48% with a high school education or
less. Raters were predominantly unmarried (42% single,
42% separated or divorced, 11.7% currently married).
Resident raters were 34.8 years on average and had received
previous treatment in an average of 1.2 treatment programs.
Most common drugs of choice among residents included
alcohol (64%), crack cocaine (45%), marijuana (43%), and
heroin (26%). Polydrug use was the norm in the sample,
with 51% of residents reporting use of two or more drugs
(average of 2.85).
More detailed demographic data on sorter/raters, broken
out by program and respondent type (staff vs. resident) are
presented in Table 2 to provide a better sense of the
heterogeneity of programs, both between and within tradi-
tional and nontraditional categories. Minority staff and
residents were more common among the faith-based
programs studied. The faith-based programs were more
targeted to male residents (except for Program 4, which had
a special women’s program). Residents tended to be
somewhat more likely to have education beyond the high
school level in the traditional programs (Programs 1 –3),
which also served a higher proportion of White residents.
Among staff, raters were consistently more likely to be
licensed among traditional programs (ranging from 33% to
67%) compared with the faith-based programs, which had
no licensed staff among the raters. It is notable that, in all
Table 2
Demographic characteristics of sorting/rating respondents by program and respondent type (staff vs. resident)
Program
White
(%)
Black
(%)
Hispanic
(%)
Men
(%)
Mean age
(years)
a
Higher than high
school education (%)
a
Licensed
(%)
b
Prior treatment
(%)
b
Program 1
Staff (n= 16) 83 17 0 33 – – 50 50
Resident (n= 6) 38 25 38 75 33 100 – –
Program 2
Staff (n=6) 50 33 17 33 – – 67 50
Resident (n= 6) 83 17 0 50 27.8 50 – –
Program 3
Staff (n= 3) 100 0 0 67 – – 33 67
Resident (n= 3) 67 33 0 100 45.3 67 – –
Program 4
Staff (n=8) 12 38 50 63 – – 0 75
Resident (n= 8) 37 25 38 75 36.2 38 – –
Program 5
Staff (n= 2) 0 100 0 100 – – 0 100
Resident (n= 3) 33 0 67 100 35.7 0 – –
Program 6
Staff (n= 2) 0 0 100 100 – – 0 0
Resident (n= 2) 0 0 100 100 21.0 0 – –
Program 7
Staff (n= 2) 0 100 0 100 – – 0 100
Resident (n= 5) 20 80 0 100 41.4 40 – –
Total sample
Staff (n= 29) 41 35 21 59 – – 25 62
Resident (n= 32) 50 25 22 75 34.8 47 – –
Total (n= 61) 46 30 21 67 – – – –
Note. Education coding: 1 = high school education or less; 2 = high school/GED; 3 = high school or more; 4 = some college; 5 = college degree. - denotes data
not available for staff (a) or resident (b) comparisons.
a
Residents only.
b
Staff only.
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 61 55
programs but Program 6, staff were likely to have had some
history of substance abuse treatment, ranging from 50% to
67% among traditional programs to 75% to 100% among
faith-based programs.
3.2. Concept Mapping solution and interpretation
Concept Mapping software was used to generate bmapsQ
of key program dimensions for traditional (three programs;
n= 32) and nontraditional (four programs; n=29)
programs. Because of our interest in faith-based programs,
maps were first generated for those programs, and maps
were then used as a reference to compare with traditional
programs. Concept System software generated a seven-
cluster solution (Fig. 2), which yielded an acceptable bstress
valueQof 0.249. Although several alternative solutions
were generated, investigators felt that the seven-cluster
solution appeared most reasonable. Cluster labels were
developed by the investigators. A listing of statements in
each cluster and their rated importance is available from the
first author upon request.
Clusters generated by the Concept Mapping procedure
(and sample statements in each) included spiritual activ-
ities, beliefs, and rituals (17 items: Bible as a guide for
behavior, providing regular Bible study, encourages spiri-
tual rather than material values, encourages public affirma-
tions of faith, provides regular scripture readings), safe,
supportive environment (five items: let residents know they
are accepted, provide supportive environment, provides for
basic needs, encourages role modeling of health recovery),
structure and discipline (four items: penalties for rule
violation, prohibits drug talk, prohibit cursing, emphasize
respect for others), role modeling and mentoring (nine
items: use recovering staff as models, use mentors to work
with residents, emphasize importance of group as com-
munity, provides daily recreation), group activities and
cohesion (seven items: emphasize group as family, regular
group meetings, encourages group participation, regular
activities such as singing/music/drama), work readiness
and referrals (eight items: emphasize importance of
work, provide job training, referrals to medical and legal
services, referrals to job counseling and placement), and
traditional alcohol and drug treatment modalities (eight
items: group as source of support, detoxification services,
drug and alcohol education, offers AA or Celebrate
Recovery meetings).
The obtained concept map is of interest in that, to the
extent that the mapping procedure places statements and
clusters on the maps in terms of similarity and distance
indices, the location of a cluster in the map may be viewed
as providing information regarding the bcentralityQof
individual clusters in terms of meaning. Here, note that
bwork readinessQand btraditional treatment modalities Q
clusters appear on the periphery of the map. Interestingly,
the bspiritual activities, beliefs, and ritualsQcluster appears
noncentral at the right lower corner of the map. However,
brole modeling and mentoringQand bsafe, supportive
environmentQappear in the map center. Thus, although the
map was generated based on the sorting/rating data from the
faith-based programs, explicitly spiritual dimensions did not
emerge as central activities in the map.
3.3. Internal consistency reliability of observed cluster items
Trochim (1993b) has presented an elaborate analysis of
issues related to estimating reliability of maps and sorting/
rating results, finding that reliability generally increases
with number of sorters, although adequate reliability is
generally obtained with small samples, as discussed earlier.
Although he suggests that similarity matrices and multi-
dimensional scaling procedures do not lend themselves to
traditional internal consistency reliability analyses (to
establish the reliability of the bmapQin terms of sorting or
ratings), it may be useful to examine whether clusters
Fig. 2. Seven-cluster concept map of spiritual dimensions of treatment programs, based upon sorting/rating data from nontraditional programs as
reference group.
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 6156
of items identified through the Concept Mapping proce-
dure would also represent reasonable bscalesQin terms of
internal consistency reliability. To examine this question,
Cronbach’s alpha estimates computed for bimportance
ratingsQof items in each cluster indicated adequate
reliabilities for each dimension: spiritual activities (a=
.95), structure and discipline (a= .71), safe, supportive
environment (a= .78), role modeling and mentoring (a=
.74), group activities and cohesion (a= .81), work readiness
and referrals (a= .82), and traditional alcohol and drug
treatment modalities (a= .67).
3.4. Pattern-matching analyses comparing mean cluster
ratings for subgroups
Concept Mapping software was also used to examine
mean cluster ratings of bimportance to your program.Q
Specifically, these pattern-matching analyses (Trochim,
1993a) can be used to compare mean cluster ratings for
specific subgroups to identify differences in mean ratings.
At least two comparisons are of interest here, both
substantively and methodologically. First, comparisons
between ratings of traditional and faith-based programs are
clearly of substantive interest in terms of identifying
differences in program emphases. Second, as both program
staff and residents did the sorting/rating tasks, the consis-
tency of their ratings is of interest — especially as staff might
be expected to be more familiar with their programs than
residents would. Both main effects of program type (faith-
based vs. traditional) and respondent type (staff vs. resident)
and possible Program Respondent Type interactions were
examined for each cluster rating domain using two-factor
analysis of variance (Table 3).
Overall, it is notable that no significant main effects of
respondent type or significant interaction effects were
obtained. However, significant main effects of program
type were observed with regard to bspiritual activities and
beliefs,QF(1, 56) = 26.76, pb.001, and bstructure and
discipline,QF(1, 56) = 4.22, pb.05. To further explore the
nature of program type differences, single degree of freedom
contrasts (one sided tests; pb.05) were conducted within
respondent type groups. The direction of mean differences
was consistent for both staff and resident ratings on all
dimensions. Differences were significant for both groups on
bspiritual activities, beliefs, and rituals,Qwith nontraditional
programs (compared with traditional programs) reporting
significantly higher importance ratings for that dimension.
Other significant differences were specific to staff, with
higher ratings for faith-based programs for bstructure and
discipline.QAt the same time, faith-based programs had
significantly lower importance scores on bwork readiness
and referrals.QNo significant differences were found
between traditional and nontraditional programs on ratings
of the importance of brole modeling and mentoring,Qbgroup
activities and cohesion,Qbsafe, supportive environment,Q
and btraditional treatment modalities.Q
4. Discussion
This article represents a preliminary empirical explora-
tion of the structure of faith-based substance abuse treatment
programs. Beginning with the premise that distinctions
between bfaith-basedQand secular substance abuse treatment
may be blurred given the preeminence of 12-step philoso-
phy emphasizing spirituality and bhigher power,Qthe
question of interest is how similar or different explicitly
faith-based treatment programs are when compared with
more traditional programs. Thus, we have examined tradi-
tional and faith-based programs from the standpoint of
both staff and resident perspectives using focus group
and Concept Mapping methodologies to identify key
bdimensionsQof programs and then to assess differences
between traditional and nontraditional programs on these
dimensions. It is acknowledged that the traditional versus
faith-based distinction may be somewhat arbitrary, partic-
ularly as we have argued that both program types may have
some spiritual elements. However, as the term bfaith-basedQ
may have political and other connotations, we would not go
as far as to argue that all substance abuse treatment is faith-
based. Rather, although somewhat awkward, we maintain a
distinction between btraditionalQand bfaith-basedQpro-
Table 3
Mean cluster ratings for bimportance to your programQby program type (traditional vs. nontraditional) and respondent type (staff vs. resident) (SD in
parentheses)
Program attributes
Staff Residents
Traditional (n= 13) Nontraditional (n= 18) Traditional (n= 15) Nontraditional (n= 14)
Spiritual activities and beliefs 2.864(0.99) 3.78 (0.40) 2.764(0.95) 3.79 (0.42)
Structure and discipline 3.474(0.72) 3.7 (0.49) 3.32 (0.69) 3.72 (0.49)
Supportive environment 3.52 (0.61) 3.68 (0.54) 3.53 (0.62) 3.64 (0.54)
Role modeling and mentoring 3.20 (0.82) 3.16 (0.89) 3.07 (0.89) 3.14 (0.77)
Group activities and cohesion 3.27 (0.75) 3.26 (0.85) 3.18 (0.85) 3.38 (0.75)
Work readiness and referrals 2.59
4
(0.90) 2.43 (1.04) 2.83 (0.89) 2.23 (1.00)
Traditional treatment modalities 3.00 (0.90) 2.64 (1.08) 2.94 (0.93) 2.48 (0.91)
Note. Scales are scored on a four-point Likert format (4 = very important to my program;1=not at all important to my program).
4Significant single degree of freedom contrast between traditional and faith-based program types within respondent type groups ( pb.05) by one-tailed
ttest.
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 61 57
grams, while acknowledging that traditional programs
may have spiritual elements. The degree to which program
types differ on these dimensions is the empirical focus of
the present investigation.
Our Concept Mapping study yielded a very clearly
defined bspiritual activities, beliefs, and ritualsQdimension,
which clearly differentiated traditional from faith based
programs. At the same time, other key dimensions identified
reflected bstructure and discipline,Qabsafe supportive
environment,Quse of brole models and mentoring,Qbgroup
activities and cohesion,Qas well as bwork readiness/
referralsQand btraditional treatment modalities.QOverall,
faith-based programs rated bstructure and disciplineQas
significantly more important than did traditional programs,
although within-groups analyses indicated that these differ-
ences were specific to staff. Among staff also, faith-based
programs rated bwork readinessQas less important to their
programs. In contrast to these differences, there were
fundamental similarities between traditional and faith-based
programs in terms of bgroup activities and cohesionQand
brole modeling and mentoring,Qas well as bsafe, supportive
environmentQand btraditional treatment modalities.QAgain,
although differences emerged in the spiritual overlay of
faith-based programs, fundamental similarities exist with
regard to core dimensions of treatment.
Before interpreting the specific Concept Mapping results,
a number of methodological points merit consideration.
First, although the present study is limited to a relatively
small number of programs (four faith-based and three
traditional), it is emphasized that most extant studies have
focused on a single program (e.g., Bicknese, 1999). From
this standpoint, the present exploratory investigation pro-
vides a strong foundation for future research. Second,
although the sample size in the present study (approximately
60) may not appear large by survey design standards, this
represents a substantial sample in Concept Mapping terms,
where maps are found to stabilize with samples of 15 raters.
Given roughly 15 sorter/raters per subgroup in the present
analyses, findings should be robust. Third, reliability
analyses presented here support the internal consistency of
the dimensions identified. Fourth, the general consistency of
mean cluster ratings between staff and residents is reassur-
ing, particularly with regard to highly significant differences
obtained between faith-based and traditional programs on
bspiritual activities, beliefs, and rituals.Q
In examining the concept maps, we acknowledge that
this is a preliminary exploratory study, so our interpretations
should be viewed as suggestive. However, one issue of
interest in the observed maps involves the bcentralityQof
clusters. As noted earlier, given that the original maps were
developed on the sorting and rating data of the faith-based
programs, it might seem odd that the bspiritual activities,
beliefs, and ritualsQdimensions did not appear to be more
central. More central in the map were brole modeling/
mentoringQand bsafe, supportive environmentQdimensions.
Although these dimensions may not appear to be explicitly
bspiritualQin focus, it is noted that the bsafe, supportive
environmentQdimension includes not only provision of
basic needs, but also (a) provision of a warm supportive
environment, (b) letting residents know that they are
accepted, (c) role modeling of spiritual recovery, and (d)
provision of testimonials regarding spirituality.
Although both bmentoringQand benvironmentQdimen-
sions emphasize fundamental social integration processes,
the bsafe, supportive environmentQdimension clearly
incorporates elements of warmth and acceptance that are
fundamental to what Miller (1997, 2000) would call the
central Christian tenet of agape. Thus, in his discussion of
what bworksQin brief motivational interventions, he
emphasizes the importance of warm, nonjudgmental,
accepting counseling styles, noting the Christian origins of
the approach. From the point of view of bagape,Qelements
of faith may well be central in the concept maps obtained
here, although more fundamental values appear to be
emphasized rather than specific biblical content.
This view of bsafe, supportive environmentQas a
reflection of agape is consistent with observed differences
between traditional and faith-based programs in ratings of
the importance of specific cluster dimensions. Not surpris-
ingly, faith-based programs rated bspiritual activities, beliefs,
and ritualsQas more important to their programs than did the
traditional programs. However, faith-based program staff
also placed significantly more importance upon bstructure
and disciplineQthan did traditional program staff. Although
an emphasis upon bstructure and disciplineQmight appear
inconsistent with warmth and acceptance, this finding
appears consistent with a growing body of literature arguing
that more restrictive or bstricterQchurches may be more
successful at attracting and engaging members than less
restrictive churches. This bstrict churchQthesis (Iannaccone,
1992; 1994) argues that highly conservative, strict churches
may repel less committed individuals who seek to avoid the
costs of joining, thus leaving more committed individuals
who generate more collective benefits for the group. In terms
of faith-based substance abuse treatment, this view would
suggest that the more conservative, stricter programs may be
more selective in terms of who they attract, although they
may fare better than less restrictive programs in terms of
retention. The suggestion is that the faith-based programs
studied here may combine warmth and acceptance with
structure and discipline, all informed by an emphasis upon
faith and spirituality. Such a view would be consistent with
the communal, familial, atmosphere promoted in these
programs. This application of the bstrict churchQargument
to this situation is, of course, highly speculative as the
present study does not address retention or other outcomes.
However, as a hypothesis for future research, it would be
interesting to test whether program bstructure and disciplineQ
is positively or negatively related to engagement, retention,
and outcomes.
Important similarities between traditional and faith-
based programs were noted in terms of the rated
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 6158
importance of bgroup activities/cohesionQand brole mod-
eling/mentoring.QbRole modeling and mentoringQoccupied
a central location in the map, consistent with the im-
portance of social influence and social learning pro-
cesses in substance abuse treatment. bGroup activities
and cohesionQincluded elements such as emphasizing the
group as a family, group meetings, group rituals such as
singing and prayer, in addition to counseling and assess-
ment— all oriented toward promoting social integration
and cohesion. Thus, both traditional and faith-based
programs appear to share these common bsocial processQ
dimensions. Faith-based programs may add a layer of
spiritual and/of biblical content, ritual, and structure and
discipline. Again, the important question for future
research involves the implications of these dimensions
for treatment outcomes.
With regard to extending the present approach to the
study of treatment outcomes, it is noted that fundamental
differences existed between our traditional and faith-based
programs— particularly in terms of length of stay—which
could ultimately confound efforts to compare these types of
programs with regard to treatment outcomes. Thus, it is
acknowledged that our study focused upon residential
programs. Specifically, not being funded by third-party
payers, faith-based programs studied here had lengths of
stay ranging anywhere from 2 to 9 months (and beyond in
some cases). To the extent that length of treatment is a key
predictor of successful outcomes (Simpson, Joe, & Brown,
1997), as third-party payers increasingly move toward
shorter residential stays or use of intensive or other
outpatient modalities, comparisons between shorter (28 days
or less) residential programs and longer, and potentially
open-ended, faith-based programs will become increasingly
problematic. Indeed, an implication of this discussion (and
a potential limitation of the study) is that a btraditionalQ
residential treatment (i.e., 28 days) model may no longer be
a standard referent.
An additional methodological point concerns selection
bias. As Miller (1997) suggests, spiritually oriented
programs may be effective, although only for those who
are bspiritually inclined.QThose not spiritually inclined or
not willing to conform to strict discipline may either not
enter faith-based programs or leave prematurely. Given
these differences, it is difficult to envision a randomized
trial comparing faith-based and traditional programs,
although the present study clearly should not be taken to
suggest that longer faith-based programs would necessarily
yield more positive outcomes than shorter traditional
programs. There are obviously a myriad of factors that
would need to be taken into account in such comparisons,
and the present study just begins to scratch the surface of
what faith-based programs may look like and does not
address outcomes.
Several limitations of the present study are acknowl-
edged. As noted in describing the study methodology, a
limitation of the current study is the lack of a TC among our
programs studied. This omission was, in part, intentional, as
the only available TC was prison-based and serious
questions arose regarding the comparability of a mandated
prison-based program to the generally more voluntary
programs examined here. However, in principle, a TC
model should offer a useful comparison to the faith-based
programs examined here. Specifically, a TC approach may
involve longer term residential care, characterized as
bcommunity as method,Qutilizing peer influence process
and discipline to change negative patterns of thinking and
behavior through individual and group therapy, group
sessions with peers, community-based learning, confronta-
tion, games, and role playing (National Institute on Drug
Abuse, 2002; Yates, 2003). However, in contrast to our
emphasis upon bwarmthQand acceptance, the TC model has
traditionally emphasized a confrontational bverbal-attack
therapyQapproach (Yablonsky, 1965). Although the benefits
of confrontation in TC have recently been questioned
(Polcin, 2003), TCs could well pose a thought-provoking
comparison group to the traditional and faith-based pro-
grams studied here-particularly in terms of structure/
discipline, supportive environment, and mentoring dimen-
sions in the Concept Mapping analysis.
Another limitation is that although the present study has
examined four faith-based programs, these can in no way
be assumed to be representative of the universe of such
programs. Indeed, three of the programs studied here are
part of larger organizations having programs located across
the country, which may vary in unknown ways from those
studied here. An important next step in the present line of
research would perhaps be to extend the current study to
some of these multisite programs to examine variation in
structure and organizational climate. As some of these
larger programs such as Teen Challenge are well estab-
lished, they might well serve as useful models of faith-
based programs for future research. In addition, the present
exploratory study is limited in focusing only upon structure
and climate variables — and indeed, only perceived struc-
ture and climate. Clearly, further research is needed to
extend the present line of research to measure these
structural and climate dimensions more precisely and to
examine the implications of the dimensions identified here
for treatment outcomes. Indeed, it is acknowledged that
measurement is crude in the present study. Both faith-based
and traditional staff or residents may be involved in
bindividual counseling,Qfor example, although the content
may vary.
It is noted that our reference to the TCU treatment
process model (Simpson, 2004) has not been accidental. As
that model has an extensive history of application to
traditional treatment programs and involves a well-validated
set of treatment process measures (e.g., treatment readiness
and engagement; Joe, Broome, Rowan-Szal, & Simpson,
2002), we suggest that a combination of the present
approach to establishing dimensions of faith-based pro-
grams (particularly organizational climate dimensions) with
J.A. Neff et al. / Journal of Substance Abuse Treatment 30 (2006) 49 – 61 59
the TCU model and associated instrumentation might prove
quite useful in further research in the area.
A final limitation to be considered before concluding
involves our distinction between traditional licensed pro-
grams with professional staff and faith-based programs with
nonprofessional staff. Although we are attempting to
identify differences between program types, staff character-
istics— beyond professional training —likely influence our
findings in ways that we cannot assess in study. Thus, our
traditional programs are generally state-licensed and are
more likely to include staff such as nurses and credentialed
substance abuse counselors. In contrast, our faith-based
programs are generally not state-licensed and are more
likely to have noncredentialed staff, often lay program
graduates. However, the degree to which our apparent
bprogramQdifferences on dimensions identified here are
attributable to program-level differences or to differences in
staff characteristics or orientations cannot be disentangled in
the present data. For example, our findings suggest greater
structure and discipline in nontraditional programs.
Although we have suggested that this may result from the
fundamentalist orientation of the faith-based programs
studied (i.e., the strict church thesis), we do not have direct
evidence of this. One potentially important variable that we
do not have information on involves the recovery status of
staff in both program types and, among those in recovery,
whether they are involved in 12-step or other traditions. As
our nontraditional programs generally eschewed 12-step
philosophy and promoted their own approaches, we must be
wary of attributing differences to bprogramsQper se. Further
investigation of the role of staff backgrounds and orienta-
tions as an influence upon program orientation is needed.
5. Conclusion
Although complex issues remain in terms of studying the
effectiveness of these programs, the present study has
sought to provide an exploratory first look at the nature
and structure of bfaith-basedQsubstance abuse treatment
programs, utilizing both qualitative and quantitative meth-
ods. Although generalizations may be limited by the
relatively small sample size and focus upon seven programs
in the same state, the present study is unique in examining a
range of programs, both traditional and faith-based. Thus, in
contrast to studies of a single program (e.g., Teen Challenge;
cf. Bicknese, 1999), a comparative focus is essential in
highlighting both the unique and common elements of faith-
based programs. The findings of our preliminary study
suggest substantial similarities between traditional and faith-
based programs, with differences on dimensions related to
spiritual beliefs, activities, and content as well as in structure
and discipline. Whether variation between programs on such
dimensions will be associated with program retention and/or
treatment outcomes is a crucial question to be pursued in
future studies.
Acknowledgments
This work was supported by NIDA Administrative
Supplement for Health Disparities grant R24-DA13579-S1
(J. A. Neff, principal investigator). Portions of the manuscript
were presented at the Health Services and Addictions
Conference, Atlanta, GA, October 2003, and at the NIDA
Health Disparities Meeting, Rockville, MD, July 2005. The
authors wish to thank all of the staff and residents of the
participating programs for their help and support. Byron
Johnson, Stephen Cook, and Sam MacMaster and the Journal
reviewers provided helpful comments on a previous draft.
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