Community mental health provider modifications to cognitive therapy: implications for sustainability

OBJECTIVE

This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation.

METHODS

A coding system, consisting of four types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system.

RESULTS

Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level.

CONCLUSIONS

Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the client's needs or to the clinician's therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.

Clinicians' perspectives on cognitive therapy in community mental health settings: implications for training and implementation

Policymakers are investing significant resources in large-scale training and implementation programs for evidence-based psychological treatments (EBPTs) in public mental health systems. However, relatively little research has been conducted to understand factors that may influence the success of efforts to implement EBPTs for adult consumers of mental health services. In a formative investigation during the development of a program to implement cognitive therapy (CT) in a community mental health system, we surveyed and interviewed clinicians and clinical administrators to identify potential influences on CT implementation within their agencies. Four primary themes were identified. Two related to attitudes towards CT: (1) ability to address client needs and issues that are perceived as most central to their presenting problems, and (2) reluctance to fully implement CT. Two themes were relevant to context: (1) agency-level barriers, specifically workload and productivity concerns and reactions to change, and (2) agency-level facilitators, specifically, treatment planning requirements and openness to training. These findings provide information that can be used to develop strategies to facilitate the implementation of CT interventions for clients being treated in public-sector settings.

Measuring Outcome in the Treatment of Cocaine Dependence

BACKGROUND

Little in known about the extent to which outcome measures used in studies of the treatment of cocaine dependence are associated with longer-term use and with broader measures of clinical improvement. The current study examined reductions in use, and abstinence-oriented measures, in relation to functioning and longer-term clinical benefits in the treatment of cocaine dependence.

METHODS

Overall drug use, cocaine use, and functioning in a number of addiction-related domains for 487 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions in the NIDA Cocaine Collaborative Treatment Study were assessed monthly during 6 months of treatment and at 9, 12, 15, and 18 month follow-up.

RESULTS

Measures of during-treatment reduction in use were moderately correlated with drug and cocaine use measures 12 months, but showed non-significant or small correlations with measures of functioning at 12 months. Highest correlations were evident for abstinence measures (maximum consecutive days abstinence and completely abstinent) during treatment in relation to sustained (3 month) abstinence at 12 months. Latent class analysis of patterns of change over time revealed that most patients initially (months 1 to 4 of treatment) either became abstinent immediately or continued to use every month. Over the couse of follow-up, patients either maintained abstinence or used regularly - intermittent use was less common.

CONCLUSIONS

There were generally small associations between various measures of cocaine use and longer-term clinical benefits, other than abstinence was associated with continued abstinence. No one method of measuring outcome of treatment of cocaine dependence appears superior to others.

Supportive-expressive dynamic psychotherapy in the community mental health system: a pilot effectiveness trial for the treatment of depression

The goal of the current article is to present the results of a randomized pilot investigation of a brief dynamic psychotherapy compared with treatment-as-usual (TAU) in the treatment of moderate-to-severe depression in the community mental health system. Forty patients seeking services for moderate-to-severe depression in the community mental health system were randomized to 12 weeks of psychotherapy, with either a community therapist trained in brief dynamic psychotherapy or a TAU therapist. Results indicated that blind judges could discriminate the dynamic sessions from the TAU sessions on adherence to dynamic interventions. The results indicate moderate-to-large effect sizes in favor of the dynamic psychotherapy over the TAU therapy in the treatment of depression. The Behavior and Symptom Identification Scale-24 showed that 50% of patients treated with dynamic therapy moved into a normative range compared with only 29% of patients treated with TAU.

Process predictors of the outcome of group drug counseling

OBJECTIVE

This study examined the relation of process variables to the outcome of group drug counseling, a commonly used community treatment, for cocaine dependence.

METHOD

Videotaped group drug counseling sessions from 440 adult patients (23% female, 41% minority) were rated for member alliance, group cohesion, participation, self-disclosure, as well as positive and non-positive feedback and advice during the 6-month treatment of cocaine dependence. Average, session-level, and slopes of process scores were evaluated. Primary outcomes were monthly cocaine use (days using out of 30), next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were endorsement of 12-step philosophy and beliefs about substance abuse.

RESULTS

More positive alliances (with counselor) were associated with reductions in days using cocaine per month and next-session cocaine use and increases in endorsement of 12-step philosophy. Patient self-disclosure about the past and degree of participation in the group were generally not predictive of group drug counseling outcomes. More advice from counselor and other group members were consistently associated with poorer outcomes in all categories. Individual differences in changes in process variables over time (linear slopes) were generally not predictive of treatment outcomes.

CONCLUSIONS

Some group behaviors widely believed to be associated with outcome, such as self-disclosure and participation, were not generally predictive of outcomes of group drug counseling, but alliance with the group counselor was positively associated, and advice giving was negatively associated, with the outcome of treatments for cocaine dependence.

Distribution-free models for longitudinal count responses with overdispersion and structural zeros

Overdispersion and structural zeros are two major manifestations of departure from the Poisson assumption when modeling count responses using Poisson log-linear regression. As noted in a large body of literature, ignoring such departures could yield bias and lead to wrong conclusions. Different approaches have been developed to tackle these two major problems. In this paper, we review available methods for dealing with overdispersion and structural zeros within a longitudinal data setting and propose a distribution-free modeling approach to address the limitations of these methods by utilizing a new class of functional response models. We illustrate our approach with both simulated and real study data.

Does the alliance cause good outcome? Recommendations for future research on the alliance

Research has consistently documented that the quality of the therapeutic alliance is related to the outcome of diverse psychotherapies. Insufficient attention, however, has been directed at identifying the nature and magnitude of the causal relationship between the alliance and outcome. In this commentary, we discuss the major threats to causal interpretation of alliance-outcome correlations and provide suggestions for future research that would help clarify the extent to which the alliance causes positive outcomes. Assuming the alliance is a causal factor in relation to outcome, we provide recommendations for research on the alliance that would attempt to improve patient care by enhancing the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Do supervisors and independent judges agree on evaluations of therapist adherence and competence in the treatment of cocaine dependence?

The current study examined the agreement between supervisors' and independent judges' evaluations of therapist adherence and competence in three treatments of cocaine dependence: supportive expressive therapy (SE), cognitive therapy CT), and individual drug counseling (IDC). We used data from The National Institute on Drug Abuse Collaborative Cocaine Treatment Study (n = 295). Trained and experienced supervisors and independent judges rated treatment fidelity. At the therapist level of analysis, the agreement between supervisors' and independent judges' ratings was weak for SE competence, CT adherence, and CT competence. Moderate relations were found for IDC adherence and competence. Supervisors consistently rated adherence and competence more positively than judges in CT and IDC. The potential bias in supervisors' ratings is discussed.

How many treatment sessions and patients are needed to create a stable score of adherence and competence in the treatment of cocaine dependence?

The study utilized a generalizability theory analysis of adherence and competence ratings to evaluate the number of sessions and patients needed to yield dependable scores at the patient and therapist levels. Independent judges' ratings of supportive expressive therapy (n = 94), cognitive therapy (n = 103), and individual drug counseling (n = 98) were obtained on tapes of sessions from the NIDA Collaborative Cocaine Treatment Study. Generalizability coefficients revealed that, for all three treatments, ratings made on approximately five to 10 sessions per patient are needed to achieve sufficient dependability at the patient level. At the therapist level, four to 14 patients need to be evaluated (depending on the modality), to yield dependable scores. Many studies today use fewer numbers.

Effects of transference work in the context of therapeutic alliance and quality of object relations

OBJECTIVE

Transference interpretation is considered as a core active ingredient in dynamic psychotherapy. In common clinical theory, it is maintained that more mature relationships, as well as a strong therapeutic alliance, may be prerequisites for successful transference work. In this study, the interaction between quality of object relations, transference interpretation, and alliance is estimated.

METHOD

One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment, but without the use of transference interpretation. Quality of Object Relations (QOR)-lifelong pattern was evaluated before treatment (P. Høglend, 1994). The Working Alliance Inventory (A. O. Horvath & L. S. Greenberg, 1989; T. J. Tracey & A. M. Kokotovic, 1989) was rated in Session 7. The primary outcome variable was the Psychodynamic Functioning Scales (P. Høglend et al., 2000), measured at pretreatment, posttreatment, and 1 year after treatment termination.

RESULTS

A significant Treatment Group × Quality of Object Relations × Alliance interaction was present, indicating that alliance had a significantly different impact on effects of transference interpretation, depending on the level of QOR. The impact of transference interpretation on psychodynamic functioning was more positive within the context of a weak therapeutic alliance for patients with low quality of object relations. For patients with more mature object relations and high alliance, the authors observed a negative effect of transference work.

CONCLUSION

The specific effects of transference work was influenced by the interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory.

Changes in psychotherapy utilization among consumers of services for major depressive disorder in the community mental health system

The goal of this investigation was to explore changes in psychotherapy utilization for patients with major depressive disorder (MDD) treated in community mental health agencies across two cohorts. We used a Medicaid claims database including approximately 300,000 public sector clients. Although the use of psychotherapy alone showed a small decrease, there was a large increase in the use of combined medication and psychotherapy as a treatment for MDD. Race was a significant predictor of both treatment type received and length of treatment. African American consumers were more likely to receive psychotherapy alone than combined treatment and attended significantly fewer psychotherapy sessions.

Gender, race, and group behavior in group drug treatment

BACKGROUND

Group drug counseling is the primary treatment modality used to treat drug dependence in community settings in the United States. Findings from the social psychology literature suggest that gender may influence how individuals participate in groups, and that race may moderate the effects of gender on group behavior. This study examined gender, race, and their interaction as predictors of alliance, participation, self-disclosure, and receipt of advice and feedback in drug counseling groups, and explored how gender and racial differences in drug counseling group behavior related to outcome of cocaine dependence treatment.

METHOD

Ratings of group behavior were made from videotaped sessions of group drug counseling drawn from a randomized trial of treatment for cocaine-dependent individuals (n=438). Analyses examined the effects of race (African American or non-Hispanic White), gender, and the race by gender interaction on group behavior. Additional analyses examined race, gender, and group behavior, and interactions among these variables in predicting monthly cocaine use.

RESULTS

Race and the race by gender interaction, but not gender alone, predicted many group behaviors. Non-Hispanic White women had the highest rates of self-disclosure and receipt of advice and non-positive feedback, followed by men of both races, with African American women having the lowest levels. These differences were unrelated to cross-sectional cocaine outcome.

CONCLUSIONS

Women, but not men, of different races acted differently in mixed-race, mixed-gender cocaine treatment groups, with African American women exhibiting less of several behaviors. Additional research on causes and consequences of these differences could inform interventions for drug-dependent women.

Combined medication and cognitive therapy for generalized anxiety disorder

The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV-diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.

A generalizability theory analysis of group process ratings in the treatment of cocaine dependence

Videotaped group drug counseling sessions were rated for alliance, self-disclosure, positive and negative feedback, group cohesion, and degree of participation of each group member. Interrater reliability was good to excellent for most measures. However, generalizability coefficients based on statistical models that included terms for patient, counselor, session, group, and rater revealed that some measures had inadequate dependability at the patient level if only two raters and two sessions were used to create patient-level scores. In contrast, good generalizability coefficients based on two raters and two sessions were obtained for alliance, non-positive learning statements received from counselor, participation variables, and self-disclosures about the past. The implications of the findings for the design of process-outcome studies are discussed.

A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

The purpose of this study was to examine the effects of feedback provided to counselors on the outcomes of patients treated at community-based substance abuse treatment programs. A version of the Outcome Questionnaire (OQ-45), adapted to include drug and alcohol use, was administered to patients (N = 304) in 3 substance abuse treatment clinics. Phase I of the study consisted only of administration of the assessment instruments. Phase II consisted of providing feedback reports to counselors based on the adapted OQ-45 at every treatment session up to Session 12. Patients who were found to not be progressing at an expectable rate (i.e., "offtrack") were administered a questionnaire that was used as a second feedback report for counselors. For offtrack patients, feedback compared with no feedback led to significant linear reductions in alcohol use throughout treatment and also in OQ-45 total scores and drug use from the point of the second feedback instrument to Session 12. The effect for improving mental health functioning was evident at only 1 of the 3 clinics. These results suggest that a feedback system adapted to the treatment of substance use problems is a promising approach that should be tested in a larger randomized trial.

Outcome assessment via handheld computer in community mental health: consumer satisfaction and reliability

Computerized administration of mental health-related questionnaires has become relatively common, but little research has explored this mode of assessment in "real-world" settings. In the current study, 200 consumers at a community mental health center completed the BASIS-24 via handheld computer as well as paper and pen. Scores on the computerized BASIS-24 were compared with scores on the paper BASIS-24. Consumers also completed a questionnaire which assessed their level of satisfaction with the computerized BASIS-24. Results indicated that the BASIS-24 administered via handheld computer was highly correlated with pen and paper administration of the measure and was generally acceptable to consumers. Administration of the BASIS-24 via handheld computer may allow for efficient and sustainable outcomes assessment, adaptable research infrastructure, and maximization of clinical impact in community mental health agencies.

The dependability of alliance assessments: the alliance-outcome correlation is larger than you might think

OBJECTIVE

To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship.

METHOD

We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used.

RESULTS

At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3-9 explained 14.7% of outcome variance.

CONCLUSION

Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance-outcome relationship.

Sexual risk behavior and sex under the influence: an event analysis of men in substance abuse treatment who have sex with women

The objective of this study was to determine if there is evidence for a causative link between sex under the influence of drugs or alcohol and risky sex for men in substance abuse treatment. Men in treatment participating in a multisite HIV prevention protocol who reported on baseline, 3, or 6 months computerized assessments the details of their most recent sexual events, and who reported having sexual events under the influence and not under the influence, and who reported most recent events that did and did not include condom use served as participants (n = 37). Safe sex was not significantly more likely to happen when participants were under the influence of drugs or alcohol during their most recent sexual event (48.3%) than when they were not under the influence (49%, p = .82). In this high-risk in treatment sample, a causative link between sex under the influence of drugs or alcohol and sexual risk behavior was not supported. 

Psychosocial treatments for cocaine dependence: the role of depressive symptoms

BACKGROUND

The association between cocaine use and depression has been frequently observed. However, less is known about the significance of depression in the treatment of cocaine use disorders. This study examined possible interrelations between drug use and depression severity among cocaine-dependent patients in psychosocial treatments for cocaine dependence.

METHODS

Monthly assessed drug use and depression severity scores of N = 487 patients during 6-month psychosocial treatments for cocaine dependence were analyzed using hybrid latent growth models.

RESULTS

Results indicated a moderate but statistically significant (z = 3.13, p < .01) influence of depression severity on increased drug use in the upcoming month, whereas drug use did not affect future depression severity.

CONCLUSIONS

Findings suggest that depression symptoms are an important predictor of drug use outcomes during psychosocial treatments for cocaine dependence and, hence, underline the importance of adequately addressing depression symptoms to improve treatment outcomes.

Program, counselor, and patient variability in the alliance: a multilevel study of the alliance in relation to substance use outcomes

We explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N = 1,613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale. Using multilevel modeling, we found that alliance was related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance-outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient-counselor alliance.

Developing research and recruitment while fostering stakeholder engagement in a National Institutes of Mental Health-funded Interventions and Practice Research Infrastructure Programs grant for depression

BACKGROUND

In the context of a National Institutes of Mental Health-funded Interventions and Practice Research Infrastructure Programs (IP-RISP) grant for the treatment of depression, a partnership was developed between a community mental health organization and a team of researchers.

OBJECTIVES

This paper describes the collaborative process, key challenges, and strategies employed to meet the goals of the first phase of the grant, which included development of a working and sustainable partnership and building capacity for recruitment and research.

METHODS

This paper was developed through the use of qualitative interviews and discussion with a variety of IP-RISP partners.

LESSONS LEARNED

Communication with multiple stakeholders through varied channels, feedback from stakeholders on research procedures, and employing a research liaison at the clinic have been key strategies in the first phase of the grant.

CONCLUSION

The strategies we employed allowed multiple stakeholders to contribute to the larger mission of the IP-RISP and helped to establish an ongoing research program within the mental health organization.

The risk of depression, anxiety, and suicidality in patients with psoriasis: a population-based cohort study

OBJECTIVE

To determine the incidence of depression, anxiety, and suicidality in patients with psoriasis compared with the general population.

DESIGN

A population-based cohort study using data collected as part of patient's electronic medical record from 1987 to 2002.

SETTING

General Practice Research Database.

PATIENTS

Analyses included 146 042 patients with mild psoriasis, 3956 patients with severe psoriasis, and 766 950 patients without psoriasis. Five controls without psoriasis were selected from the same practices and similar cohort entry dates as patients with psoriasis.

MAIN OUTCOME MEASURE

Clinical diagnoses of depression, anxiety, and suicidality among patients.

RESULTS

The adjusted hazard ratios (HRs) for receiving a diagnosis of depression, anxiety, and suicidality in patients with psoriasis compared with controls were 1.39 (95% confidence interval [CI], 1.37-1.41), 1.31 (95% CI, 1.29-1.34), and 1.44 (95% CI, 1.32-1.57), respectively. The adjusted HR of depression was higher in severe (HR, 1.72; 95% CI, 1.57-1.88) compared with mild psoriasis (HR, 1.38; 95% CI, 1.35-1.40). Younger patients with psoriasis had elevated HRs of outcomes compared with older patients with psoriasis.

CONCLUSIONS

Patients with psoriasis have an increased risk of depression, anxiety, and suicidality. We estimate that in the United Kingdom, in excess of 10 400 diagnoses of depression, 7100 diagnoses of anxiety, and 350 diagnoses of suicidality are attributable to psoriasis annually. It is important for clinicians to evaluate patients with psoriasis for these conditions to improve outcomes. Future investigation should determine the mechanisms by which psoriasis is associated with psychiatric outcomes as well as approaches for prevention.