Waiting time is a reality for substance abusers seeking both assessment and treatment services. In this study, the wait for services was conceptualized as two phases, the first being a preassessment period that lasted from the time a substance abuser called a CIU to the time one was assessed, and the second being a postassessment period that lasted from assessment to actual treatment entry. The view of waiting as two phases, influenced by different characteristics, expands on previous studies that viewed waiting as either preassessment (Chawdhary et al., 2007
) or post-assessment (Friedmann et al., 2003
). Elsewhere, only total wait time was used in predicting alcohol and drug outcomes (Best et al., 2002
). In this study, the substantial difference between the length of preassessment and postassessment waiting (4 and 65 days) suggests that different characteristics would be influential during the two periods.
4.1. Preassessment waiting
Bivariate associations with longer preassessment waiting time were dominated by indictors that signified a lower readiness to begin the process of entering treatment. These included being court referred and believing that there were time conflicts to entering treatment. Early stages of motivation (Problem Recognition and Desire for Change) also influenced the length of wait. There was no clear indication that either individual or system characteristics were more powerful in contributing to longer waiting time.
The finding that treatment program characteristics influenced waiting during the preassessment period was unexpected. Having more active cases, higher daily census, and higher caseloads may be proxies for treatment programs operating at or near capacity. It was expected that these system influences would exert an influence during the waiting time following substance abusers' assessment and referral. We can only speculate that program-level influences before the assessment were the result of treatment program staff requesting that the CIU forestall assessments, up to the mandated limits, until treatment slots were available. Word-of-mouth communication to CIU staff may have led to the same result. Referral to outpatient treatment also predicted longer waiting time, possibly a consequence of an inadequate number of treatment slots. In addition, there may be an unidentified profile of substance abusers that are more likely to be referred to outpatient treatment; outpatient treatment may be an indicator of the profile.
When all characteristics were controlled, involvement in the criminal justice system was a predictor of preassessment waiting time, as were early stages of motivation for treatment, specifically Problem Recognition and Desire for Change. Longer wait for an assessment among court-involved substance abusers was similar to that found earlier (Brown et al., 1989
). It may be that being mandated to attend treatment, as well as not seeing a problem or need to change, resulted in cancelled appointments and other delays that led to a longer wait. It is also possible that longer waiting was the result of hearings and other court actions. Administrative staff at the CIU may have assigned a longer wait to substance abusers who showed little motivation or who were court referred.
4.2. Postassessment waiting
Characteristics that influenced the postassessment waiting period were similar to those influencing preassessment wait in bivariate analyses. Gender replaced age as the only predisposing characteristic that exerts an influence on waiting. Treatment Readiness, a later stage of motivation, replaced Problem Recognition and Desire for Change. Homelessness predicted longer waits as well. More severe employment and alcohol problems led to a longer wait as did average daily caseload, the only treatment program characteristic present. Subjects who were assigned to the case management group experienced shorter waiting times for treatment.
When all variables were controlled in multivariate analyses, characteristics different from those present during the preassessment period were influential or had different effects. Homelessness was associated with a longer wait to get into treatment, although it had led to a shorter wait for an assessment. The different role for homelessness may be attributable to the fact that, unlike for assessment, there is no mandated requirement to facilitate treatment entry for homeless substance abusers; homeless substance abusers are frequently at a disadvantage in taking the necessary steps to enter treatment. Recontacting the CIU to learn of a treatment start date can be a formidable problem; frequently, several attempts are required, and failure to make contact may be perceived as resistance rather than a problem connected to homelessness. Similarly, residential treatment programs frequently have preadmission group sessions that potential clients must attend. Failure to attend one of these sessions may result in a treatment entry date being withdrawn. Lack of transportation and a daily need to find shelter can interfere with group attendance, resulting in removal from the waiting list. Structured assistance such as that provided by case managers might effectively reduce the barriers homeless persons face in entering treatment.
Longer postassessment wait was influenced by less readiness to enter treatment, whereas the first two stages of the change process (Problem Recognition and Desire for Change) predicted preassessment wait. This suggests that substance abusers may have had a very specific concern about entering treatment itself rather than overall lack of motivation. Reluctance to enter treatment may be the result of tangible barriers such as lack of childcare or fear of the treatment experience itself.
4.3. Total waiting time
Total waiting time represents the entire period between substance abusers' call for an assessment appointment and the time they either enter treatment or have waited 90 days and are no longer on a waiting list. The characteristics of this total period are similar to those of the postassessment wait, predicted by substance abusers being less ready for treatment, having more severe problems relative to alcohol use and employment during the preceding 30 days, and not having a case manager. Among system factors, a higher average daily census at a treatment program predicted less waiting time, whereas higher average caseloads predicted longer waits. Smaller treatment programs with fewer staff may have a larger average caseload and take longer to accommodate new clients.
4.4. Motivational interviewing and strengths-based case management
The current study was part of a larger trial to establish the effectiveness of two brief interventions—a motivational intervention and strengths-based case management—on improving treatment linkage and engagement. The one-session motivational intervention, delivered at the beginning of the postassessment period, had no direct influence on waiting for treatment admission. It is possible that the motivational intervention exerted its influence on waiting by improving readiness for treatment, a factor that did predict less wait time. Motivational interventions may be valuable in improving substance abusers' readiness but do not offer the support necessary for those who have barriers such as lack of transportation or inability to pay for treatment.
Strengths-based case management was designed to address multiple individual and system barriers substance abusers often face while seeking treatment—barriers that can lead to increased time spent on waiting lists (Hser et al., 1998
; Rapp et al., 2006
). There are several possible reasons why subjects assigned to the strengths-based case management group had shorter postassessment wait times. One barrier to linking with treatment is the requirement that substance abusers call the CIU several days following their assessment to find out the actual start date for treatment. Case managers mitigate this potential barrier by getting the date and time from the assessment therapist and delivering it to the client. Case managers can advocate for an earlier treatment admission date, thereby reducing the time clients must wait to receive services after an assessment. Case managers also remind clients about their admission date and help arrange childcare or transportation to ensure that these potential barriers do not impede treatment entry and thereby make the postassessment waiting period longer.
Despite offerings of tangible assistance, substance abusers will have varying levels of motivation to enter treatment. For that reason, the strengths-based approach to case management is also designed to improve substance abusers' perceived self-efficacy, leading to better motivation and optimism about treatment outcomes (Rapp, 2006
; Siegal et al., 1995
). These findings are congruent with other research demonstrating that strengths-based case management facilitated linkage with medical care and improved treatment retention during aftercare services (Gardner et al., 2005
; Rapp, Siegal, Li, & Saha, 1998
; Rapp et al., 2006
The subjects in this study represent a convenience sample of substance abusers recruited at a CIU. This setting is available only to substance abusers who are eligible for public financial support to attend treatment. It is possible that the individual and system factors that influence the waiting time continuum within the context of a CIU are different from those of other assessment and treatment settings; waiting time may be different among substance abusers with more resources such as insurance. Furthermore, we did not know whether the time individual substance abusers spent waiting for an assessment or treatment was due to individual or system factors.
The system factors included in this study are limited to indicators of program capacity. Future research should include a broader mix of system factors that could potentially influence waiting time at different points in the treatment continuum. Efforts need to be made to discover both formal structural and policy considerations, and subtle influences of informal factors (e.g., staff reaction to clients who repeatedly receive assessments, word-of-mouth communication).
Only a small amount of the variance in preassessment and postassessment waiting times was explained by predis-posing attributes, system characteristics, current functioning, treatment readiness, and subjects' perceived barriers. The limited ability to explain waiting time has been a consistent problem (Brown et al., 1989
; Chawdhary et al., 2007
). Different policy mandates, treatment structures, and funding streams in different geographical areas may make it difficult to find common causes of waiting time. The informal attributes that influence waiting time may be very difficult to quantify; qualitative methods such as participant observation, focus groups, and ethnographic interviews may help elucidate these dynamics.