Informal discussions in substance abuse treatment sessions

Therapeutic Relationships in Applied Behavior Analysis: Current Status and Future Directions

For behavior analytic practitioners, skills related to building a therapeutic alliance (e.g., empathic statements, reflective listening, affirmations) may be as important as knowledge of and skills in implementation of the science of behavior analysis. We surveyed 277 board certified behavior analysts (BCBAs) to learn more about their training, use of these skills, and their perceptions of how their skills might have changed over years of practicing. The findings suggest that behavior analysts may benefit from explicit training in skills required to establish and maintain therapeutic relationships with parents of children with autism. In this article we review recent research in this area and suggest directions for training of behavior analysts. Further, motivational interviewing is introduced as an evidence-based clinical approach that encompasses many of the skills required to build a therapeutic alliance.

Improvement in therapist skills over sessions in brief motivational interventions predicts client language and alcohol use outcomes

Brief motivational interventions (BMIs) are widely used and efficacious interventions that address alcohol misuse in mandated college students. Consistent with motivational interviewing (MI; Miller & Rollnick, 2013) theory, within-therapist improvements in MI-consistent (MICO) skills over time-that is, as a therapist gains skill through repeated practice-may be associated with concurrent increases in client change language and subsequent changes in behavior. This study examined how therapist skill changed over time and whether within-therapist improvement in MICO skills impacted in-session client change language and subsequent alcohol-related outcomes. BMI sessions (N = 228) from 2 randomized clinical trials that had led to significant reductions in alcohol use and alcohol-related problems in mandated student drinkers were coded using the Motivational Interviewing Skills Code 2.0 (Miller, Moyers, Ernst, & Amrhein, 2003). In both studies, the BMI consisted of a single 45- to 60-min session. Analyses examined session-by-session changes in therapist MICO skills, client change language, and alcohol use outcomes. Therapist MICO skills improved over time, and there were significant increases in client change language and decreases in client discussion of topics other than personal alcohol use. Among relatively heavy-drinking clients, those treated by a more experienced therapist demonstrated greater reductions in alcohol use; however, this association was not mediated by client change language. Increased experience conducting BMIs improved therapist MICO skills over time, which in turn increased the focus on personal alcohol use during the session. However, it remains unclear how client language predicts behavior change following a BMI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Examining the influence of active ingredients of motivational interviewing on client change talk

Motivational Interviewing (MI) is an evidenced-based intervention designed to help clients explore and resolve ambivalence around substance use. MI combines a humanistic tradition with behavioral components to facilitate client decisions concerning behavior change. As such, there is marked interest in the relationship between the two active ingredients of MI - the relational, or person-centered, components and the technical, or directional, behavioral components - on client in-session language. Yet, few studies have examined how these active ingredients operate in concert. Therefore, the current study evaluated the constellation of relational skills associated with client language, as well as the influence of technical skills on the relationship between provider relational skills and client change language. Specifically, we tested a latent construct of relational skill and its direct association with the proportion of client change talk. We then explored the mediating role of reflections of change and sustain talk (RefCT and RefST) on this relationship. The data for this secondary analysis are from Project ELICIT (N = 131), a randomized control trial evaluating the effects of MI training on client change language. We found support for a latent construct of relational skill (i.e., empathy, acceptance, collaboration, and autonomy/support). However, the relational skill construct did not predict client change language. There was support for an indirect effect, such that relational skills predicted RefCT and RefST, and RefCT and RefST predicted client change language. These results suggest that the synergistic implementation of the relational and technical components of MI is critical to facilitating a higher percentage of change talk.

Complexities with group therapy facilitation in substance use disorder specialty treatment settings

In spite of increased attention to research-based interventions for substance use disorders (SUDs), a formidable research-practice gap impedes the implementation of evidence-based treatments (EBTs). An underappreciated dimension of this gap is a mismatch in treatment modality: Whereas clinical trial and implementation research has focused primarily on individual therapy, the majority of SUD specialty treatment is in group format, with open-enrolling groups being most common. This study aims to narrow this research-practice gap by exploring clinicians' perspectives on complexities with group therapy facilitation in SUD specialty treatment settings. Semi-structured interviews were conducted with 13 group clinicians from among three outpatient SUD specialty clinics-diverse in their operational structures, treatment philosophies, clientele, and services-located in the same Midwestern U.S. metropolitan area. Interview questions addressed organizational characteristics, services provided, group therapy curricula, and use of EBTs or other structured treatments. Clinicians emphasized the importance of having flexibility in facilitating groups, through built-in group processes and clinicians' own adaptions and accommodations; this flexibility was especially emphasized for the use of EBTs or manualized interventions. Clinicians also had difficulties with group facilitation generally, as evidenced by their reported difficulty in managing complex group dynamics, their limited group therapy experience and training, and their reliance on educational groups. We discuss specific strategies for improved innovation and implementation of EBTs for SUD group therapy.

The Current State of Pharmacological Treatments for Cannabis Use Disorder and Withdrawal

Cannabis use disorder (CUD) commonly occurs and carries a notable economic and functional burden at both individual and societal levels. While there are no clearly efficacious medication treatments for CUD, 20 years of committed and high-quality research in the human laboratory and clinical settings have resulted in medications with demonstrated effectiveness in the treatment of cannabis withdrawal, the ability to reduce cannabis use, and results that point to promising future work. The current state of pharmacology research for CUD highlights the need to consider particular characteristics of patients, such as gender, impulsivity, and severity of cannabis use, when selecting a medication in the off-label treatment of CUD or cannabis withdrawal. As a field, the body of work also exposes some areas in need of improvement in study design, selection of outcome measures, interpretation of results, and the overall process of evaluating candidate medications. Coming to a consensus as a field and addressing these gaps in future research will likely lend itself to further advances in improving the lives of patients with CUD.

Group Therapy for Substance Use Disorders: A Survey of Clinician Practices

Substance use disorder (SUD) treatment is typically delivered in group format, but clinical research focuses on individual therapy. This exploratory study narrows this gap through a survey of 566 SUD group clinicians in the United States, concerning most commonly used group practices, attitudes about evidence-based treatments (EBTs), and beliefs about addiction. Clinicians reported high use of open groups, moderately high utilization of EBT practices, and moderate use of questionable practices. Clinicians' attitudes about EBTs and beliefs about addiction were correlated with the use of certain EBTs and questionable practices. Strategies for implementation of EBTs in group settings are discussed.

Internet-delivered treatment for substance abuse: a multisite randomized controlled trial

OBJECTIVE

Computer-delivered interventions have the potential to improve access to quality addiction treatment care. The objective of this study was to evaluate the effectiveness of the Therapeutic Education System (TES), an Internet-delivered behavioral intervention that includes motivational incentives, as a clinician-extender in the treatment of substance use disorders.

METHOD

Adult men and women (N=507) entering 10 outpatient addiction treatment programs were randomly assigned to receive 12 weeks of either treatment as usual (N=252) or treatment as usual plus TES, with the intervention substituting for about 2 hours of standard care per week (N=255). TES consists of 62 computerized interactive modules covering skills for achieving and maintaining abstinence, plus prize-based motivational incentives contingent on abstinence and treatment adherence. Treatment as usual consisted of individual and group counseling at the participating programs. The primary outcome measures were abstinence from drugs and heavy drinking (measured by twice-weekly urine drug screens and self-report) and time to dropout from treatment.

RESULTS

Compared with patients in the treatment-as-usual group, those in the TES group had a lower dropout rate (hazard ratio=0.72, 95% CI=0.57, 0.92) and a greater abstinence rate (odds ratio=1.62, 95% CI=1.12, 2.35). This effect was more pronounced among patients who had a positive urine drug or breath alcohol screen at study entry (N=228) (odds ratio=2.18, 95% CI=1.30, 3.68).

CONCLUSIONS

Internet-delivered interventions such as TES have the potential to expand access and improve addiction treatment outcomes. Additional research is needed to assess effectiveness in non-specialty clinical settings and to differentiate the effects of the community reinforcement approach and contingency management components of TES.

Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less

AIMS

To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive-behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence.

SETTING

Community-based out-patient treatment program in New Haven, Connecticut, USA.

DESIGN

Twelve-week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion.

PARTICIPANTS

A total of 127 treatment-seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years).

MEASUREMENTS

Weekly urine specimens testing positive for cannabis, days of cannabis use via the time-line follow-back method.

FINDINGS

Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis-free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis-negative urine specimens and the highest mean number of consecutive cannabis-free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1-year follow-up increased most rapidly for the two enhanced groups.

CONCLUSIONS

Combining contingency management and cognitive-behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system.

Developing an evidence-based, multimedia group counseling curriculum toolkit

Training community-based addiction counselors in empirically supported treatments (ESTs) far exceeds the ever-decreasing resources of publicly funded treatment agencies. This feasibility study describes the development and pilot testing of a group counseling toolkit (an approach adapted from the education field) focused on relapse prevention (RP). When counselors (N = 17) used the RP toolkit after 3 hours of training, their content adherence scores on "coping with craving" and "drug refusal skills" showed significant improvement, as indicated by very large effect sizes (Cohen's d = 1.49 and 1.34, respectively). Counselor skillfulness, in the "adequate-to-average" range at baseline, did not change. Although this feasibility study indicates some benefit to counselor EST acquisition, it is important to note that the impact of the curriculum on client outcomes is unknown. Because a majority of addiction treatment is delivered in group format, a multimedia curriculum approach may assist counselors in applying ESTs in the context of actual service delivery.

Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future

BACKGROUND

The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings.

METHODS

We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure.

RESULTS

The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research.

CONCLUSIONS

Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.

The Influence of Rural and Urban Substance Abuse Treatment Counselor Characteristics on Client Outcomes

Focus group data was collected from 28 substance abuse treatment counselors employed in rural and urban areas to examine their perceptions of factors influencing treatment outcomes. The influence of the counselor characteristics (i.e., education, experience, and recovery status) on client outcomes and geographic differences are explored. Focus group data was analyzed by three raters using line-by-line coding, focused coding, and memoing. This analytic approach revealed geographic differences in the counselors' perceptions of the effect of counselor education, experience, and recovery status on client outcomes. Recommendations for treatment planning and future research are provided.

Informal discussions in substance abuse treatment sessions with Spanish-speaking clients

This study investigated the extent to which bilingual counselors initiated informal discussions about topics that were unrelated to the treatment of their monolingual Spanish-speaking Hispanic clients in a National Institute on Drug Abuse Clinical Trial Network protocol examining the effectiveness of motivational enhancement therapy (MET). Session audiotapes were independently rated to assess counselor treatment fidelity and the incidence of informal discussions. Eighty-three percent of the 23 counselors participating in the trial initiated informal discussions at least once in one or more of their sessions. Counselors delivering MET in the trial initiated informal discussion significantly less often than the counselors delivering standard treatment. Counselors delivering standard treatment were likely to talk informally the most when they were ethnically non-Latin. In addition, informal discussion was found to have significant inverse correlations with client motivation to reduce substance use and client retention in treatment. These results suggest that informal discussion may have adverse consequences on Hispanic clients' motivation for change and substance abuse treatment outcomes and that maintaining a more formal relationship in early treatment sessions may work best with Hispanic clients. Careful counselor training and supervision in MET may suppress the tendency of counselors to talk informally in sessions.

Study results from the Clinical Trials Network's first 10 years: where do they lead?

The National Drug Abuse Treatment Clinical Trials Network (CTN) began in 2000 with the goal of "improv[ing] the quality of drug abuse treatment throughout the country using science as the vehicle." Since then, 24 discrete clinical trials were launched, 20 are completed, and 15 have published main outcome papers. Of the latter, 4 tested pharmacological treatment, 8 psychosocial/behavioral treatment, 1 a combination of medication and counseling, and 2 targeted HIV/hepatitis C virus risk behavior. We review main study findings for these trials, including treatment retention, substance use or risk behavior outcomes, and secondary outcomes when analyzed. The purpose of this review is to identify the incremental progress toward improving drug treatment made by these trials and to propose next steps for the CTN and for the field arising from these studies. The CTN provides a unique opportunity to systematically design trials that incorporate treatment improvements from previous trials and to direct efforts toward innovations most likely to be incorporated into practice.

Partnerships and pathways of dissemination: the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative in the Clinical Trials Network

Since 2001, the National Drug Abuse Treatment Clinical Trials Network (CTN) has worked to put the results of its trials into the hands of community treatment programs, in large part through its participation in the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative and its close involvement with the Center for Substance Abuse Treatment's Addiction Technology Transfer Centers. This article describes (a) the CTN's integral role in the Blending Initiative, (b) key partnerships and dissemination pathways through which the results of CTN trials are developed into blending products and then transferred to community treatment programs, and (c) three blending initiatives involving buprenorphine, motivational incentives, and motivational interviewing. The Blending Initiative has resulted in high utilization of its products, preparation of more than 200 regional trainers, widespread training of service providers in most U.S. States, Puerto Rico, and the U.S. Virgin Islands and movement toward the development of Web-based implementation supports and technical assistance. Implications for future directions of the Blending Initiative and opportunities for research are discussed.