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Schwenker R, Dietrich CE, Hirpa S, Nothacker M, Smedslund G, Frese T, Unverzagt S. Motivational interviewing for substance use reduction. Cochrane Database Syst Rev 2023; 12:CD008063. [PMID: 38084817 PMCID: PMC10714668 DOI: 10.1002/14651858.cd008063.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues. OBJECTIVES To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment. SEARCH METHODS We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022. SELECTION CRITERIA We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up). MAIN RESULTS We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision. AUTHORS' CONCLUSIONS Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.
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Affiliation(s)
- Rosemarie Schwenker
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Carla Emilia Dietrich
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Selamawit Hirpa
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies in Germany, Berlin, c/o Philipps University Marburg, Berlin & Marburg, Germany
| | | | - Thomas Frese
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
| | - Susanne Unverzagt
- Institute of General Practice and Family Medicine, Center of Health Sciences, Martin Luther University Halle Wittenberg, Halle (Saale), Germany
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Kelly LM, Crane CA, Zajac K, Easton CJ. The Impact of Depressive Symptoms on Response to Integrated Cognitive Behavioral Therapy for Substance Use Disorders and Intimate Partner Violence. ADVANCES IN DUAL DIAGNOSIS 2021; 14:85-98. [PMID: 34733357 DOI: 10.1108/add-09-2020-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Past studies demonstrated the efficacy of integrated cognitive-behavioral therapy (CBT) for substance use disorder (SUD) and intimate partner violence (IPV) as well as high rates of depressive symptoms in this population. However, little is known about how depressive symptoms impact treatment outcomes. We hypothesized that integrated CBT, but not standard drug counseling (DC), would buffer the negative effects of depressive symptoms on treatment response. Design/methodology/approach A secondary analysis of a randomized trial compared men assigned to 12 weeks of integrated CBT for SUD and IPV (n=29) to those in DC (n=34). Findings Most (60%) of the sample reported any depressive symptoms. Controlling for baseline IPV, reporting any depressive symptoms was associated with more positive cocaine screens during treatment. Among men with depressive symptoms, integrated CBT but not DC was associated with fewer positive cocaine screens. Controlling for baseline alcohol variables, integrated CBT and depressive symptoms were each associated with less aggression outside of intimate relationships (e.g., family, strangers) during treatment. For men without depressive symptoms, integrated CBT was associated with less non-IPV aggression compared to DC. Effects were not significant for other substances, IPV, or at follow-up. Originality Although integrated CBT's efficacy for improving SUD and IPV has been established, moderators of treatment response have not been investigated. Practical Implications Integrated CBT buffered depressive symptoms' impact on cocaine use, yet only improved non-IPV aggression in men without depressive symptoms. Research Limitations/Implications This study found some evidence for differential response to CBT by depressive symptoms on cocaine and aggression at end of treatment, which did not persist three months later. Future studies should explore mechanisms of integrated CBT for SUD and IPV, including mood regulation, on depressive symptoms in real-world samples.
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Affiliation(s)
- Lourah M Kelly
- Rochester Institute of Technology, College of Health Sciences and Technology, 153 Lomb Memorial Drive, Rochester, NY, 14623.,University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT, 06030
| | - Cory A Crane
- Rochester Institute of Technology, College of Health Sciences and Technology, 153 Lomb Memorial Drive, Rochester, NY, 14623
| | - Kristyn Zajac
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT, 06030
| | - Caroline J Easton
- Rochester Institute of Technology, College of Health Sciences and Technology, 153 Lomb Memorial Drive, Rochester, NY, 14623.,University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT, 06030
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Kuhlemeier A, Desai Y, Tonigan A, Witkiewitz K, Jaki T, Hsiao YY, Chang C, Van Horn ML. Applying methods for personalized medicine to the treatment of alcohol use disorder. J Consult Clin Psychol 2021; 89:288-300. [PMID: 34014691 PMCID: PMC8284918 DOI: 10.1037/ccp0000634] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Numerous behavioral treatments for alcohol use disorder (AUD) are effective, but there are substantial individual differences in treatment response. This study examines the potential use of new methods for personalized medicine to test for individual differences in the effects of cognitive behavioral therapy (CBT) versus motivational enhancement therapy (MET) and to provide predictions of which will work best for individuals with AUD. We highlight both the potential contribution and the limitations of these methods. METHOD We performed secondary analyses of abstinence among 1,144 participants with AUD participating in either outpatient or aftercare treatment who were randomized to receive either CBT or MET in Project MATCH. We first obtained predicted individual treatment effects (PITEs), as a function of 19 baseline client characteristics identified a priori by MATCH investigators. Then, we tested for the significance of individual differences and examined the predicted individual differences in abstinence 1 year following treatment. Predictive intervals were estimated for each individual to determine if they were 80% more likely to achieve abstinence in one treatment versus the other. RESULTS Results indicated that individual differences in the likelihood of abstinence at 1 year following treatment were significant for those in the outpatient sample, but not for those in the aftercare sample. Individual predictive intervals showed that 37% had a better chance of abstinence with CBT than MET, and 16% had a better chance of abstinence with MET. Obtaining predictions for a new individual is demonstrated. CONCLUSIONS Personalized medicine methods, and PITE in particular, have the potential to identify individuals most likely to benefit from one versus another intervention. New personalized medicine methods play an important role in putting together differential effects due to previously identified variables into one prediction designed to be useful to clinicians and clients choosing between treatment options. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Alena Kuhlemeier
- Department of Sociology, University of New Mexico, Albuquerque, New Mexico
| | - Yasin Desai
- Department of Mathematics and Statistics, Lancaster University, Lancaster, United Kingdom
| | - Alexandra Tonigan
- Department of Individual, Family, and Community Education, University of New Mexico, Albuquerque, New Mexico
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, United Kingdom
| | - Yu-Yu Hsiao
- Department of Individual, Family, and Community Education, University of New Mexico, Albuquerque, New Mexico
| | - Chi Chang
- Office of Medical Education Research and Development & Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan
| | - M. Lee Van Horn
- Department of Individual, Family, and Community Education, University of New Mexico, Albuquerque, New Mexico
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Mastroleo NR, Humm L, Williams CM, Kiluk BD, Hoadley A, Magill M. Initial testing of a computer-based simulation training module to support clinicians' acquisition of CBT skills for substance use disorder treatment. J Subst Abuse Treat 2020; 114:108014. [PMID: 32527511 DOI: 10.1016/j.jsat.2020.108014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 02/01/2020] [Accepted: 04/22/2020] [Indexed: 11/17/2022]
Abstract
Cognitive behavioral therapy (CBT) is one of the most common and effective treatments for substance use disorders (SUD); however, effective delivery of CBT depends on a wide variety of nuanced skills that require practice to master. We created a computer-based simulation training system to support the development of necessary skills for student trainees to be able to apply CBT effectively for clients with SUDs. CBT: Introducing Cognitive Behavioral Therapy is an interactive, role-play simulation that provides opportunities for clinician trainees to hone their skills through repeated practice and real-time feedback before application in a clinical setting. This is the first study that tests whether such a simulation improves trainee skills for the treatment of clients with SUDs. Graduate students (N = 65; social work, clinical psychology) completed standardized patient (SP) interviews, were randomized to the simulation training program or manual comparison condition (Project MATCH manual), and completed SP interviews three months post-baseline. Using general linear models, results indicated a significant time x group effect, with students assigned to the simulation training program showing greater improvement in "extensiveness" and "skillfulness" ratings across three skill categories: general agenda setting (p = .03), explaining CBT concepts (p = .007), and understanding of CBT concepts (p = .001). However, manual comparison participants showed greater improvement than simulation trainees in "assessing primary drug use" (prange = .013-.024). No changes in extensiveness or skillfulness of motivational interviewing (MI) style were observed. This pilot test of CBT: Introducing Cognitive Behavioral Therapy offers support for use of this novel technology as a potential approach to scale up CBT training for students, and perhaps clinicians, counseling people with SUDs.
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Affiliation(s)
- Nadine R Mastroleo
- Binghamton University, College of Community and Public Affairs, PO Box 6000, Binghamton, NY 13902, United States of America.
| | - Laura Humm
- SIMmersion, LLC, 8681 Robert Fulton Drive #E, Columbia, MD 21046, United States of America
| | - Callon M Williams
- Binghamton University, College of Community and Public Affairs, PO Box 6000, Binghamton, NY 13902, United States of America
| | - Brian D Kiluk
- Yale School of Medicine, Department of Psychiatry, Temple Medical Center, 40 Temple St., Suite 6C, New Haven, CT 06510, United States of America
| | - Ariel Hoadley
- Brown University, Center for Alcohol and Addiction Studies, School of Public Health, Box G S-121-5, Providence, RI 02912, United States of America
| | - Molly Magill
- Brown University, Center for Alcohol and Addiction Studies, School of Public Health, Box G S-121-5, Providence, RI 02912, United States of America
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Sokol R, Albanese M, Chew A, Early J, Grossman E, Roll D, Sawin G, Wu DJ, Schuman-Olivier Z. Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation. Addict Sci Clin Pract 2019; 14:47. [PMID: 31882001 PMCID: PMC6935085 DOI: 10.1186/s13722-019-0176-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? METHODS To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components. RESULTS We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. CONCLUSION While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.
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Affiliation(s)
- Randi Sokol
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Mark Albanese
- Outpatient Addiction Services, 26 Central St, Somerville, MA 02143 USA
| | - Aaronson Chew
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Jessica Early
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Ellie Grossman
- Somerville Hospital Primary Care, 236 Highland Avenue, Somerville, MA 02143 USA
| | - David Roll
- Revere Care Center, 454 Broadway, Revere, MA 02151 USA
| | - Greg Sawin
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Dominic J. Wu
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Zev Schuman-Olivier
- Center for Mindfulness and Compassion, 1035 Cambridge Street, Suite 21, Cambridge, MA 02141 USA
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Lindenger C, Castedal M, Schult A, Åberg F. Long-term survival and predictors of relapse and survival after liver transplantation for alcoholic liver disease. Scand J Gastroenterol 2018; 53:1553-1561. [PMID: 30678557 DOI: 10.1080/00365521.2018.1536226] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Studies of predictive factors of alcohol recidivism and survival post-LT are not up-to-date. With evolving LT activity and with longer-term outcomes becoming increasingly available, re-evaluating post-LT outcomes is imperative. We analyzed recent data on survival, alcohol recurrence and predictive factors. METHODS We compared long-term survival among 159 consecutive ALD patients transplanted 2003-2016 with 159 propensity-score matched controls transplanted for non-ALD. Alcohol 'slips' (occasional lapse) and relapse to moderate or harmful drinking were assessed from medical records and structured forms filled in by home-district physicians, and analyzed by competing-risk and multivariate Cox regression analyses. RESULTS Patient and graft survival at 10 years were 75 and 69% in the ALD group and 65 and 63% in the control group (p=.06 and .36). In ALD patients, the 10-year cumulative rate of alcohol slip was 52% and of relapse, 37%. Duration of pre-LT abstinence (HR 0.97, 95% CI 0.94-0.99) and a history of prior alcohol relapses (HR 3.05, 95% CI 1.41-6.60) were significant predictors of relapse, but failed to predict death/graft loss. Patients with <6 months abstinence relapsed sooner than those with 7-24 months abstinence, but 10-year relapse rates were similar (40-50%). Ten-year relapse rate with 2-5-year pre-LT abstinence was 21%, and with >5-year abstinence, 0%. In patients with <6 months pre-LT abstinence, years of heavy drinking, prior addiction treatments, and lack of children predicted inferior survival. CONCLUSIONS Although 37% of our ALD patients relapsed to drinking by 10 years post-LT, 14-year survival was not significantly different from survival in non-ALD patients. Short duration of pre-LT abstinence and prior relapses predicted post-LT relapse.
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Affiliation(s)
- Christine Lindenger
- a The Transplant Institute, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg , Gothenburg , Sweden
| | - Maria Castedal
- a The Transplant Institute, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg , Gothenburg , Sweden
| | - Andreas Schult
- a The Transplant Institute, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg , Gothenburg , Sweden
| | - Fredrik Åberg
- a The Transplant Institute, Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg , Gothenburg , Sweden
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Easton CJ, Crane CA, Mandel D. A Randomized Controlled Trial Assessing the Efficacy of Cognitive Behavioral Therapy for Substance-Dependent Domestic Violence Offenders: An Integrated Substance Abuse-Domestic Violence Treatment Approach (SADV). JOURNAL OF MARITAL AND FAMILY THERAPY 2018; 44:483-498. [PMID: 29108096 DOI: 10.1111/jmft.12260] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The current study evaluates a therapy for substance-dependent perpetrators of partner violence. Sixty-three males arrested for partner violence within the past year were randomized to a cognitive behavioral substance abuse-domestic violence (SADV; n = 29) or a drug counseling (DC; n = 34) condition. Seventy percent of offenders completed eight core sessions with no differences between SADV and DC conditions in the amount of substance or aggression at pretreatment. SADV participants had fewer cocaine-positive toxicology screens and breathalyzer results during treatment, were less likely to engage in aggressive behavior proximal to a drinking episode, and reported fewer episodes of violence than DC participants at posttreatment follow-up. SADV shows promise in decreasing addiction and partner violence among substance-dependent male offenders.
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Najavits LM, Enggasser J, Brief D, Federman E. A randomized controlled trial of a gender-focused addiction model versus 12-step facilitation for women veterans. Am J Addict 2018; 27:210-216. [DOI: 10.1111/ajad.12709] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/07/2018] [Accepted: 03/03/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lisa M. Najavits
- Veterans Affairs Boston Healthcare System; Boston Massachusetts
- Boston University School of Medicine; Boston Massachusetts
| | - Justin Enggasser
- Veterans Affairs Boston Healthcare System; Boston Massachusetts
- Boston University School of Medicine; Boston Massachusetts
| | - Deborah Brief
- Veterans Affairs Boston Healthcare System; Boston Massachusetts
- Boston University School of Medicine; Boston Massachusetts
| | - Edward Federman
- Edith Nourse Rogers Memorial Veterans Hospital; Boston Massachusetts
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Perrier-Ménard E, Castellanos-Ryan N, O'Leary-Barrett M, Girard A, Conrod PJ. The impact of youth internalising and externalising symptom severity on the effectiveness of brief personality-targeted interventions for substance misuse: A cluster randomised trial. Addict Behav 2017; 75:138-144. [PMID: 28734153 DOI: 10.1016/j.addbeh.2017.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/16/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
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Leggio L, Lee MR. Treatment of Alcohol Use Disorder in Patients with Alcoholic Liver Disease. Am J Med 2017; 130:124-134. [PMID: 27984008 PMCID: PMC5263063 DOI: 10.1016/j.amjmed.2016.10.004] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/03/2016] [Accepted: 10/04/2016] [Indexed: 12/18/2022]
Abstract
Alcohol is a leading cause of liver disease worldwide. Although alcohol abstinence is the crucial therapeutic goal for patients with alcoholic liver disease, these patients have less access to psychosocial, behavioral, and/or pharmacologic treatments for alcohol use disorder. Psychosocial and behavioral therapies include 12-step facilitation, brief interventions, cognitive behavioral therapy, and motivational enhancement therapy. In addition to medications approved by the US Food and Drug Administration for alcohol use disorder (disulfiram, naltrexone, and acamprosate), recent efforts to identify potential new treatments have yielded promising candidate pharmacotherapies. Finally, more efforts are needed to integrate treatments across disciplines toward patient-centered approaches in the management of patients with alcohol use disorder and alcoholic liver disease.
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Affiliation(s)
- Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, Md; Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI.
| | - Mary R Lee
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, Md.
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Abstract
Purpose of Review Personality factors have been implicated in risk for substance use disorders through longitudinal and neurobiologic studies for over four decades. Only recently, however, have targeted interventions been developed to assist individuals with personality risk factors for substance use disorders manage their risk. This article reviews current practices in personality-targeted interventions and the eight randomised trials examining the efficacy of such approaches with respect to reducing and preventing substance use and misuse. Recent Findings Results indicate a moderate mean effect size for personality-targeted approaches across several different substance use outcomes and intervention settings and formats. Conclusions Personality-targeted interventions offer several advantages over traditional substance use interventions, particularly when attempting to prevent development of problems in high-risk individuals or when addressing concurrent mental health problems in brief interventions.
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McIntosh VVW, Jordan J, Carter JD, Luty SE, Carter FA, McKenzie JM, Frampton CMA, Joyce PR. Assessing the distinctiveness of psychotherapies and examining change over treatment for anorexia nervosa with cognitive-behavior therapy, interpersonal psychotherapy, and specialist supportive clinical management. Int J Eat Disord 2016; 49:958-962. [PMID: 27566961 DOI: 10.1002/eat.22555] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Therapist adherence to cognitive-behavior therapy (CBT), interpersonal psychotherapy (IPT), and specialist supportive clinical management (SSCM) for anorexia nervosa (AN), was examined across three phases of therapy in a randomized clinical trial. METHOD Adherence in early, middle, and late phase therapy sessions from 53 of 56 participants in the trial was assessed using the CSPRS-AN by independent raters after listening to complete therapy sessions. RESULTS The three forms of psychotherapy were distinguishable by blind raters. Subscale scores were higher for the corresponding therapy than the other therapy modalities. In CBT and SSCM, a phase-by-therapy effect was found, with the CBT subscale highest for CBT, intermediate for SSCM, lowest for IPT, and elevated in the middle phase of CBT and SSCM. The SSCM subscale was highest for SSCM, intermediate for CBT, lowest for IPT, and elevated in the middle phase of SSCM. Adherence to activities around normalizing eating, weight gain, and education about anorexia nervosa was higher in SSCM than in either CBT or IPT. DISCUSSION Ensuring the distinctiveness of therapies in existing clinical trials with differential treatment outcome is essential. Research on adherence to therapy modalities has the potential to help understanding of the effective components of new and existing treatments for AN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:958-962).
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Affiliation(s)
- Virginia V W McIntosh
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand. .,Specialist Mental Health, Canterbury District Health Board, Christchurch, New Zealand.
| | - Jennifer Jordan
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand.,Specialist Mental Health, Canterbury District Health Board, Christchurch, New Zealand
| | - Janet D Carter
- Department of Psychology, University of Canterbury, Christchurch, New Zealand
| | - Suzanne E Luty
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Frances A Carter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand.,Specialist Mental Health, Canterbury District Health Board, Christchurch, New Zealand
| | - Janice M McKenzie
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | | | - Peter R Joyce
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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Magill M, Apodaca TR, Walthers J, Gaume J, Durst A, Longabaugh R, Stout RL, Carroll KM. The Alcohol Intervention Mechanisms Scale (AIMS): Preliminary Reliability and Validity of a Common Factor Observational Rating Measure. J Subst Abuse Treat 2016; 70:28-34. [PMID: 27692185 DOI: 10.1016/j.jsat.2016.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/27/2016] [Accepted: 07/25/2016] [Indexed: 11/16/2022]
Abstract
The present work provides an overview, and pilot reliability and validity for the Alcohol Intervention Mechanisms Scale (AIMS). The AIMS measures therapist interventions that occur broadly across modalities of behavioral treatment for alcohol use disorder. It was developed based on identified commonalities in the function rather than content of therapist interventions in observed therapy sessions, as well as from existing observer rating systems. In the AIMS, the primary function areas are: explore (four behavior count codes), teach (five behavior count codes), and connect (three behavior count codes). Therapist behavior counts provide a frequency rating of occurrence (i.e., adherence). The three functions (explore, teach, connect) are then rated on global skillfulness, which provides a quality valence (i.e., competence) to the entire session. In the present study, three independent raters received roughly 30 hours of training on the use of the AIMS by the first author. Data were a sample of therapy session audio files from a Project MATCH clinical research site. Reliability results showed generally good performance for the measure. Specifically, 2-way mixed intraclass coefficients were 'excellent', ranging from .94 to .99 for function summary scores, while prevalence-adjusted, bias-adjusted kappa for global skillfulness measures were in the 'fair' to 'moderate' range (k=.36 to.40). Internal consistency reliability was acceptable, as were preliminary factor models by behavioral treatment function (i.e., explore, teach, connect). However, confirmatory fit for the subsequent three factor model was poor. In concurrent validity analyses, AIMS summary and skillfulness scores showed associations with relevant Project MATCH criterion measures (i.e., MATCH Tape Rating Scale) that were consistent with expectations. The AIMS is a promising and reliable observational measure of three proposed common functions of behavioral alcohol treatment.
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Affiliation(s)
- M Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA.
| | - Timothy R Apodaca
- Children's Mercy Kansas City, USA; University of Missouri-Kansas City School of Medicine, USA
| | - Justin Walthers
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Jacques Gaume
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA; Lausanne University Hospital, Lausanne, Switzerland
| | - Ayla Durst
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Richard Longabaugh
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Robert L Stout
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA; Pacific Institute for Research and Evaluation, Providence, RI, USA
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Magill M, Walthers J, Mastroleo NR, Gaume J, Longabaugh R, Apodaca T. Therapist and client discussions of drinking and coping: a sequential analysis of therapy dialogues in three evidence-based alcohol use disorder treatments. Addiction 2016; 111:1011-20. [PMID: 26780564 PMCID: PMC4861699 DOI: 10.1111/add.13313] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/31/2015] [Accepted: 01/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Research into the active ingredients of behavioral interventions for alcohol use disorders (AUD) has focused upon treatment-specific factors, often yielding disappointing results. The present study examines common factors of change in motivational enhancement therapy, cognitive-behavioral therapy and 12-Step facilitation therapy by (1) estimating transitional probabilities between therapist behaviors and subsequent client Change (CT) and Sustain (ST) Talk and (2) examining therapist skillfulness as a potential predictor of transition probability magnitude. DESIGN Secondary data analysis examined temporal associations in therapy dialogues. SETTING United States: data were from Project MATCH (Matching Alcoholism Treatments to Client Homogeneity) (1997). PARTICIPANTS One hundred and twenty-six participants who received motivational enhancement therapy, cognitive-behavioral therapy or 12-Step facilitation therapy. MEASUREMENTS Therapist behaviors were measured in three categories (exploring, teaching, connecting) and client statements included five categories (CT-distal, ST-distal, CT-proximal, ST-proximal, neutral). Therapist skillfulness was measured using a five-point ordinal scale. FINDINGS Relative to chance, therapist exploratory behaviors predicted subsequent client discussion of distal, drinking behavior [odds ratio (OR) = 1.37-1.78, P < 0.001] while suppressing discussion of proximal coping and neutral content (OR = 0.83-0.90, P < 0.01). Unexpectedly, therapist teaching suppressed distal drinking language (OR = 0.48-0.53, P < 0.001) and predicted neutral content (OR = 1.45, P < 0.001). Connecting behaviors increased both drinking and coping language, particularly language in favor of change (CT OR = 1.15-1.84, P < 0.001). Analyses of exploring and connecting skillfulness revealed that high skillfulness maximized these behaviors effect on client responses, but not teaching skillfulness. CONCLUSIONS In motivational enhancement therapy, cognitive-behavioral therapy, and 12-Step facilitation therapy for alcohol use disorders, the therapists who explore and connect with clients appear to be more successful at eliciting discussion about change than therapists who engage in teaching behavior. Therapists who are more skilled achieve better results than those who are less skilled.
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Affiliation(s)
- M. Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - J. Walthers
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - NR Mastroleo
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - J. Gaume
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA,Lausanne University Hospital, Lausanne, Switzerland
| | - R. Longabaugh
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - T.R. Apodaca
- Children’s Mercy Kansas City, MO, USA,University of Missouri - Kansas City School of Medicine, MO, USA
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Abstract
OBJECTIVES Alcohol Behavioral Couple Therapy (ABCT) is an efficacious treatment for alcohol use disorders. Coding treatment integrity can shed light on the active ingredients of ABCT, but there are no published studies of treatment integrity instruments for ABCT. The present study describes the development and initial reliability of the Treatment Integrity Rating System - Couples Version (C-TIRS) for ABCT. METHODS The C-TIRS was used to rate 284 first- and mid-treatment ABCT sessions of 188 couples in four randomized clinical trials. RESULTS Average inter-rater reliability for distinguishing ratings between C-TIRS items was fair-to-good for quantity items (intraclass correlation [ICC] = 0.64) and poor-to-fair for quality items (ICC = 0.41). Five C-TIRS subscales were defined a priori to measure treatment components involving cognitive-behavioral therapy, spouse involvement, couple therapy, common therapeutic factors, and overall adherence to the treatment protocol and had adequate internal reliability (α = 0.74-0.89). Inter-rater reliability was fair to good on seven of ten scales but poor on three scales (ICC range = 0.17-0.72). CONCLUSIONS The C-TIRS was designed to provide information about quantity and quality of the delivery of ABCT components; however, further refinement of the C-TIRS is warranted before it should be used in frontline practice. Clinical implications and recommendations for future research are discussed.
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Bourke E, Magill M, Apodaca TR. The In-Session and Long-Term Role of a Significant Other in Motivational Enhancement Therapy for Alcohol Use Disorders. J Subst Abuse Treat 2016; 64:35-43. [PMID: 26951920 DOI: 10.1016/j.jsat.2016.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 01/14/2016] [Accepted: 01/18/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine how significant other (SO) language in support of or against client abstinence from alcohol influences clients' in-session speech and drinking behavior over the 9 months post-Motivational Enhancement Therapy (MET). METHOD Sequential analyses were used to examine the language of Project MATCH clients who invited an SO to participate in an MET session. Hierarchical regressions investigated the predictive relationship between SO language and clients' post-treatment drinking behavior. A cohort analytic design compared the change language of these SO-involved participants against a matched group who chose client-only therapy. RESULTS 'SO Support Change' language increased the odds of client Change Talk in the next utterance (p<.01). SO Support Change did not significantly predict reduced post-treatment drinking, whereas 'SO Against Change' significantly predicted an increase in average drinks per drinking day (DDD) across months 7-9 post-MET (p=.04). In the matched comparison, the proportion of change-related client language was comparable across the SO-involved and client-only groups. CONCLUSIONS Motivational interviewing theory was supported by the sequential association between SO and client language as well as the predictive link between SO Against Change and client drinking intensity. Given the centrality of pro-sobriety language in the literature, it was surprising that SO Support Change did not predict alcohol use outcomes. Findings are discussed in relation to contemporary treatment process research and clinical practice.
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Affiliation(s)
- Emilie Bourke
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA.
| | - Molly Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Timothy R Apodaca
- Children's Mercy Hospital Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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A randomized factorial trial of disulfiram and contingency management to enhance cognitive behavioral therapy for cocaine dependence. Drug Alcohol Depend 2016; 160:135-42. [PMID: 26817621 PMCID: PMC4767616 DOI: 10.1016/j.drugalcdep.2015.12.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/21/2015] [Accepted: 12/26/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study evaluated the extent to which the addition of disulfiram and contingency management for adherence and abstinence (CM), alone and in combination, might enhance the effects of cognitive behavioral therapy (CBT) for cocaine use disorders. METHODS Factorial randomized double blind (for medication condition) clinical trial where CBT served as the platform and was delivered in weekly individual sessions in a community-based outpatient clinic. 99 outpatients who met DSM-IV criteria for current cocaine dependence were assigned to receive either disulfiram or placebo, and either CM or no CM. Cocaine and other substance use was assessed via a daily calendar with thrice weekly urine sample testing for 12 weeks with a one-year follow-up (80% interviewed at one year). RESULTS The primary hypothesis that CM and disulfiram would produce the best cocaine outcomes was not confirmed, nor was there a main effect for disulfiram. For the primary outcome (percent days of abstinence, self report), there was a significant interaction, with the best cocaine outcomes were seen for the combination of CM and placebo, with the two groups assigned to disulfiram associated with intermediate outcomes, and poorest cocaine outcome among those assigned to placebo and no CM. The secondary outcome (urinalysis) indicated a significant effect favoring CM over no CM but the interaction effect was not significant. One year follow-up data indicated sustained treatment effects across conditions. CONCLUSIONS CM enhances outcomes for CBT treatment of cocaine dependence, but disulfiram provided no added benefit to the combination of CM and CBT.
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Magill M, R Apodaca T, Karno M, Gaume J, Durst A, Walthers J, L Stout R, DiClemente C. Reliability and Validity of an Observational Measure of Client Decision-Making: The Client Language Assessment - Proximal/Distal (CLA-PD). J Subst Abuse Treat 2016; 63:10-7. [PMID: 26898715 DOI: 10.1016/j.jsat.2015.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 11/24/2015] [Accepted: 12/03/2015] [Indexed: 11/30/2022]
Abstract
OVERVIEW The Client Language Assessment - Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are sub-divided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multi-session and skill-based (e.g., cognitive behavioral therapy). METHOD Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N=126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (cognitive behavioral therapy, twelve-step facilitation therapy, motivational enhancement therapy). RESULTS Inter-rater reliability results for summary scores showed "excellent" reliability for the measure. Specifically, two-way mixed intraclass coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from "fair" to "good" (α=.74-.84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent correlations, by valence (i.e., change and sustain talk), between CLA-PD Distal and MISC-based language scores were moderate (r=.46-.55, p<.001) while discriminant correlations by valence for CLA-PD Proximal and MISC-based language scores were small (r=.22-.24, p<.05). Finally, proportion Change Talk Proximal predicted subsequent session coping behaviors (i.e., processes of change) as well as 3-month Alcoholics Anonymous involvement and attendance (ps<.05-.005), but not 3-month alcohol abstinence self-efficacy. Further, analyses of criterion predictive validity showed that proportion Change Talk Distal predicted 3- and 12-month drinking frequency and quantity measures (ps<.05-.005). CONCLUSIONS When behavior change treatments are multi-session and/or skill-based, the present analyses suggest the CLA-PD is a promising, psychometrically sound observational rating measure of client verbalized decision-making.
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Affiliation(s)
- Molly Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA.
| | - Timothy R Apodaca
- Children's Mercy Kansas City, USA; University of Missouri-Kansas City School of Medicine, USA
| | - Mitchell Karno
- Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA
| | - Jacques Gaume
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA; Lausanne University Hospital, Lausanne, Switzerland
| | - Ayla Durst
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Justin Walthers
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA
| | - Robert L Stout
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI, USA; Pacific Institute for Research and Evaluation, Providence, RI, USA
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Hartzler B, Peavy KM, Jackson TR, Carney M. Finding harmony so the music plays on: pragmatic trial design considerations to promote organizational sustainment of an empirically-supported behavior therapy. Addict Sci Clin Pract 2016; 11:2. [PMID: 26801244 PMCID: PMC4724112 DOI: 10.1186/s13722-016-0049-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 01/14/2016] [Indexed: 12/22/2022] Open
Abstract
Background Pragmatic trials of empirically-supported behavior therapies may inform clinical and policy decisions concerning therapy sustainment. This retrospective trial design paper describes and discusses pragmatic features of a hybrid type III implementation/effectiveness trial of a contingency management (CM) intervention at an opioid treatment program. Prior reporting (Hartzler et al., J Subst Abuse Treat 46:429–438, 2014; Hartzler, Subst Abuse Treat Prev Policy 10:30, 2015) notes success in recruiting program staff for voluntary participation, durable impacts of CM training on staff-level outcomes, provisional setting implementation of the intervention, documentation of clinical effectiveness, and post-trial sustainment of CM. Methods/design Six pragmatic design features, and both scientific and practical bases for their inclusion in the trial, are presented: (1) a collaborative intervention design process, (2) voluntary recruitment of program staff for therapy training and implementation, (3) serial training outcome assessments, with quasi-experimental staff randomization to either single or multiple baseline assessment conditions, (4) designation of a 90-day period immediately after training in which the setting implemented the intervention on a provisional basis, (5) inclusive patient eligibility for receipt of the CM intervention, and (6) designation of two staff as local implementation leaders to oversee clinical/administrative issues in provisional implementation. Discussion Each pragmatic trial design feature is argued to have contributed to sustainment of CM. Contributions implicate the building of setting proprietorship for the CM intervention, culling of internal staff expertise in its delivery, iterative use of assessment methods that limited setting burden, documentation of setting-specific clinical effectiveness, expanded penetration of CM among staff during provisional implementation, and promotion of setting self-reliance in the oversight of sustainable implementation procedures. It is hoped this discussion offers ideas for how to impact local clinical and policy decisions via effective behavior therapy dissemination.
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Affiliation(s)
- Bryan Hartzler
- Alcohol and Drug Abuse Institute, University of Washington, Box 354805, 1107 NE 45th Street, Suite 120, Seattle, WA, 98105-4631, USA.
| | - K Michelle Peavy
- Alcohol and Drug Abuse Institute, University of Washington, Box 354805, 1107 NE 45th Street, Suite 120, Seattle, WA, 98105-4631, USA.
| | - T Ron Jackson
- Alcohol and Drug Abuse Institute, University of Washington, Box 354805, 1107 NE 45th Street, Suite 120, Seattle, WA, 98105-4631, USA.
| | - Molly Carney
- Alcohol and Drug Abuse Institute, University of Washington, Box 354805, 1107 NE 45th Street, Suite 120, Seattle, WA, 98105-4631, USA.
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A four-phase approach for systematically collecting data and measuring medication discrepancies when patients transition between health care settings. Res Social Adm Pharm 2015; 12:548-58. [PMID: 26781670 DOI: 10.1016/j.sapharm.2015.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/01/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND No methodological standards are available for researchers and clinicians to examine medication discrepancies between health care settings. Systematic methods of examining medication discrepancies will allow researchers and clinicians to better understand factors driving medication discrepancies, to better measure effects of medication reconciliation interventions, and to compare findings across studies. OBJECTIVE This article proposes a four-phase approach for systematically collecting medication data and measuring medication discrepancies between a hospital and community pharmacies. Methodologic considerations related to studying medication discrepancies in health services research are also discussed. METHODS A multi-disciplinary study team developed a four-phase systematic approach to improve quality of data and study rigor: 1) operationalization of a medication discrepancy, 2) acquiring medication data, 3) abstraction of medication data and creation of dataset, and 4) measuring and reporting medication discrepancies. RESULTS Using this phase-based approach, the study team successfully identified and reported medication discrepancies between a hospital and community pharmacies at the patient, medication, and community pharmacy units of analyses. CONCLUSIONS Systematically measuring medication discrepancies that occur in the care transitions process is a critical step as researchers, clinicians, and other stakeholders work to improve health care quality and patient outcomes. This article detailed how a phase-based approach can be used in research to examine medication discrepancies as well as address the complexity of collecting medication data and analyzing medication discrepancies. Such methods should be considered when developing, conducting, and reporting research on medication discrepancies.
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D’Ippolito M, Lundgren L, Amodeo M, Beltrame C, Lim L, Chassler D. Addiction Treatment Staff Perceptions of Training as a Facilitator or Barrier to Implementing Evidence-Based Practices: A National Qualitative Research Study. Subst Abus 2015; 36:42-50. [DOI: 10.1080/08897077.2013.849646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Carroll KM. Lost in translation? Moving contingency management and cognitive behavioral therapy into clinical practice. Ann N Y Acad Sci 2014; 1327:94-111. [PMID: 25204847 PMCID: PMC4206586 DOI: 10.1111/nyas.12501] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the treatment of addictions, the gap between the availability of evidence-based therapies and their limited implementation in practice has not yet been bridged. Two empirically validated behavioral therapies, contingency management (CM) and cognitive behavioral therapy (CBT), exemplify this challenge. Both have a relatively strong level of empirical support but each has weak and uneven adoption in clinical practice. This review highlights examples of how barriers to their implementation in practice have been addressed systematically, using the Stage Model of Behavioral Therapies Development as an organizing framework. For CM, barriers such as cost and ideology have been addressed through the development of lower-cost and other adaptations to make it more community friendly. For CBT, barriers such as relative complexity, lack of trained providers, and need for supervision have been addressed via conversion to standardized computer-assisted versions that can serve as clinician extenders. Although these and other modifications have rendered both interventions more disseminable, diffusion of innovation remains a complex, often unpredictable process. The existing specialty addiction-treatment system may require significant reforms to fully implement CBT and CM, particularly greater focus on definable treatment goals and performance-based outcomes.
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Affiliation(s)
- Kathleen M Carroll
- Division of Substance Abuse, Yale University School of Medicine, West Haven, Connecticut
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23
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Walton MA, Bohnert K, Resko S, Barry KL, Chermack ST, Zucker RA, Zimmerman MA, Booth BM, Blow FC. Computer and therapist based brief interventions among cannabis-using adolescents presenting to primary care: one year outcomes. Drug Alcohol Depend 2013; 132:646-53. [PMID: 23711998 PMCID: PMC3770780 DOI: 10.1016/j.drugalcdep.2013.04.020] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 04/12/2013] [Accepted: 04/15/2013] [Indexed: 12/30/2022]
Abstract
AIMS This paper describes outcomes from a randomized controlled trial examining the efficacy of brief interventions delivered by a computer (CBI) or therapist (TBI) among adolescents in urban primary care clinics. METHODS Patients (ages 12-18) self-administered a computer survey. Adolescents reporting past year cannabis use completed a baseline survey and were randomized to control, CBI or TBI, with primary (cannabis use, cannabis related consequences - CC) and secondary outcomes [alcohol use, other drug use (illicit and non-medical prescription drugs), and driving under the influence of cannabis (DUI)] assessed at 3, 6, and 12 months. RESULTS 1416 adolescents were surveyed; 328 reported past year cannabis use and were randomized. Comparisons of the CBI relative to control showed that at 3 months the group by time interaction (G × T) was significant for other drug use and CC, but not for cannabis use, alcohol use, or DUI; at 6 months, the G × T interaction was significant for other drug use but not for cannabis use, alcohol use, or CC. For analyses comparing the TBI to control, at 3 months the G×T interaction was significant for DUI, but not significant for cannabis use, alcohol use, or CC; at 6 months, the G×T interaction was not significant for any variable. No significant intervention effects were observed at 12 months. CONCLUSION Among adolescent cannabis users presenting to primary care, a CBI decreased cannabis related problems and other drug use and a TBI decreased cannabis DUI in the short-term. Additional boosters may be necessary to enhance these reductions over time.
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Affiliation(s)
- Maureen A Walton
- University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA.
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O'Leary-Barrett M, Topper L, Al-Khudhairy N, Pihl RO, Castellanos-Ryan N, Mackie CJ, Conrod PJ. Two-year impact of personality-targeted, teacher-delivered interventions on youth internalizing and externalizing problems: a cluster-randomized trial. J Am Acad Child Adolesc Psychiatry 2013; 52:911-20. [PMID: 23972693 DOI: 10.1016/j.jaac.2013.05.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 04/01/2013] [Accepted: 06/07/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the 2-year impact of teacher-delivered, brief, personality-targeted interventions on internalizing and externalizing symptoms in an adolescent U.K. sample. METHOD This cluster-randomized trial was run in 19 London schools (N = 1,024 adolescents). Trained school-based professionals delivered two 90-minute, CBT-based group interventions targeting 1 of 4 personality-risk profiles: anxiety sensitivity, hopelessness, impulsivity, or sensation seeking. Self-report depression, anxiety, and conduct disorder symptoms were assessed at 6-month intervals. RESULTS Interventions were associated with significantly reduced depressive, anxiety, and conduct symptoms (p < .05) over 2 years in the full sample, reduced odds of severe depressive symptoms (odds ratio [OR] = 0.74, CI = 0.58-0.96), and conduct problems (OR = 0.79, CI = 0.65-0.96), and a nonsignificant reduction in severe anxiety symptoms (OR = 0.79, CI = 0.59-1.05). Evaluating a priori personality-specific hypotheses revealed strong evidence for impulsivity-specific effects on severe conduct problems, modest evidence of anxiety sensitivity-specific effects on severe anxiety, and no evidence for hopelessness-specific effects on severe depressive symptoms. CONCLUSIONS Brief, personality-targeted interventions delivered by educational professionals can have a clinically significant impact on mental health outcomes in high-risk youth over 2 years, as well as personality-specific intervention effects in youth most at risk for a particular problem, particularly for youth with high levels of impulsivity. Clinical trial registration information-Adventure: The Efficacy of Personality-Targeted Interventions for Substance Misuse and Other Risky Behaviors as Delivered by Educational Professionals.
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Larson MJ, Amodeo M, Locastro JS, Muroff J, Smith L, Gerstenberger E. Randomized trial of web-based training to promote counselor use of cognitive behavioral therapy skills in client sessions. Subst Abus 2013; 34:179-87. [PMID: 23577913 DOI: 10.1080/08897077.2012.746255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND METHODS The authors designed and delivered an innovative Web course on cognitive behavioral therapy (CBT), a specific empirically based treatment, to a diverse group of addiction counselors and supervisors in 54 addiction units across the country, and conducted a randomized controlled trial of its effectiveness with 127 counselors. The primary focus of the trial was to assess "adequate adherence to CBT practice" after training as judged by raters blinded to training condition who listened to audiotapes of actual client sessions. Counselors who passed were judged to satisfy 2 criteria: (a) low pass or greater on at least 1 of 3 "CBT-generic skills" assessing session structure; and (b) low pass or greater on at least 1 of 3 "CBT-specific skills" related to use of functional analysis, cognitive skills practice, or behavioral skills practice. RESULTS Although the counselors' use of CBT skills in sessions increased after Web course training, it was not statistically significant and not larger than the gain of control-group counselors trained with a written CBT manual.
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Affiliation(s)
- Mary Jo Larson
- Schneider Institutes for Health Policy, Heller School, Brandeis University, Waltham, MA 02454, USA.
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Hogue A, Ozechowski TJ, Robbins MS, Waldron HB. Making fidelity an intramural game: Localizing quality assurance procedures to promote sustainability of evidence‐based practices in usual care. ACTA ACUST UNITED AC 2013. [DOI: 10.1111/cpsp.12023] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Carroll KM. Treatment integrity and dissemination: Rethinking fidelity via the stage model. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2013. [DOI: 10.1111/cpsp.12025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Carroll KM, Nich C, Shi JM, Eagan D, Ball SA. Efficacy of disulfiram and Twelve Step Facilitation in cocaine-dependent individuals maintained on methadone: a randomized placebo-controlled trial. Drug Alcohol Depend 2012; 126:224-31. [PMID: 22695473 PMCID: PMC3461119 DOI: 10.1016/j.drugalcdep.2012.05.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 05/16/2012] [Accepted: 05/17/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cocaine use remains a major problem within methadone maintenance programs. Disulfiram's efficacy in reducing cocaine use has been demonstrated in several trials, but its relative efficacy among individuals who use versus abstain from alcohol remains unclear. Treatment approaches which seek to enhance substance users' involvement in self-help activities (Twelve Step Facilitation, TSF) have been associated with better outcomes among alcohol and cocaine users, but have rarely been evaluated among methadone-maintained cocaine-opioid users. METHODS We conducted a randomized, placebo-controlled, double blind (for medication condition), factorial (2×2) trial with 4 treatment conditions: Disulfiram plus TSF, disulfiram plus standard counseling only, placebo plus TSF, and placebo plus standard counseling in the context of a community-based methadone maintenance program. Participants (N=112) received either disulfiram (250 mg/d) or placebo in conjunction with daily methadone maintenance. RESULTS Assignment to TSF was associated with less cocaine use throughout treatment and a higher number of cocaine-negative urines. While there were no significant main effects of disulfiram versus placebo, individuals without an alcohol use disorder demonstrated greater reductions in cocaine use over time when assigned to disulfiram. CONCLUSIONS TSF appears feasible in this methadone maintenance program and was associated with modest reductions in cocaine use, an often intractable problem in this setting. Support for the efficacy of disulfiram was weaker, as it appeared effective only for those without a current alcohol use disorder for this sample.
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Affiliation(s)
- Kathleen M. Carroll
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, 151D, West Haven, CT 06516
| | - Charla Nich
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, 151D, West Haven, CT 06516
| | - Julia M. Shi
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, 151D, West Haven, CT 06516,The APT Foundation, New Haven Connecticut, 1 Long Wharf, New Haven CT 06511
| | - Dorothy Eagan
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, 151D, West Haven, CT 06516
| | - Samuel A. Ball
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, 151D, West Haven, CT 06516,The APT Foundation, New Haven Connecticut, 1 Long Wharf, New Haven CT 06511
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McIntosh VVW, Jordan J, McKenzie JM, Luty SE, Carter FA, Carter JD, Frampton CMA, Joyce PR. Measuring therapist adherence in psychotherapy for anorexia nervosa: Scale adaptation, psychometric properties, and distinguishing psychotherapies. Psychother Res 2012; 15:339-44. [PMID: 22011162 DOI: 10.1080/10503300500091124] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Abstract An adaptation of the Collaborative Study Psychotherapy Rating Scale (CSPRS) was used to rate therapist adherence to three psychotherapies for anorexia nervosa. One audiotaped psychotherapy session from each of 30 patients was rated independently by two raters. Analysis of the psychometric properties of the instrument revealed good interrater agreement and high internal consistency. For all three therapies, therapists were rated as exhibiting significantly more behaviors appropriate to the therapy to which patients were randomized than the other two therapies, indicating very satisfactory adherence to therapy. The three therapies were clearly distinguishable by raters unaware of therapy condition using the modified CSPRS.
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Carroll KM, Nich C, LaPaglia DM, Peters EN, Easton CJ, Petry NM. Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less. Addiction 2012; 107:1650-9. [PMID: 22404223 PMCID: PMC3509418 DOI: 10.1111/j.1360-0443.2012.03877.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Kathleen M. Carroll
- Division of Substance Abuse, Yale University School of Medicine, New Haven, CT, USA
| | - Charla Nich
- Division of Substance Abuse, Yale University School of Medicine, New Haven, CT, USA
| | - Donna M. LaPaglia
- Division of Substance Abuse, Yale University School of Medicine, New Haven, CT, USA
| | - Erica N. Peters
- Division of Substance Abuse, Yale University School of Medicine, New Haven, CT, USA
| | - Caroline J. Easton
- Division of Substance Abuse, Yale University School of Medicine, New Haven, CT, USA
| | - Nancy M. Petry
- University of Connecticut Health Center, Farmington, CT, USA
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Michie S, Whittington C, Hamoudi Z, Zarnani F, Tober G, West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012; 107:1431-40. [PMID: 22340523 DOI: 10.1111/j.1360-0443.2012.03845.x] [Citation(s) in RCA: 204] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Interventions to reduce excessive alcohol consumption have a small but important effect, but a better understanding is needed of their 'active ingredients'. AIMS This study aimed to (i) develop a reliable taxonomy of behaviour change techniques (BCTs) used in interventions to reduce excessive alcohol consumption (not to treat alcohol dependence) and (ii) to assess whether use of specific BCTs in brief interventions might be associated with improved effectiveness. METHODS A selection of guidance documents and treatment manuals, identified via expert consultation, were analysed into BCTs by two coders. The resulting taxonomy of BCTs was applied to the Cochrane Review of brief alcohol interventions, and the associations between the BCTs and effectiveness were investigated using meta-regression. FINDINGS Forty-two BCTs were identified, 34 from guidance documents and an additional eight from treatment manuals, with average inter-rater agreement of 80%. Analyses revealed that brief interventions that included the BCT 'prompt self-recording' (P = 0.002) were associated with larger effect sizes. CONCLUSIONS It is possible to identify specific behaviour change techniques reliably in manuals and guidelines for interventions to reduce excessive alcohol consumption. In brief interventions, promoting self-monitoring is associated with improved outcomes. More research is needed to identify other behaviour change techniques or groupings of behaviour change techniques that can produce optimal results in brief interventions and to extend the method to more intensive interventions and treatment of alcohol dependence.
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Affiliation(s)
- Susan Michie
- Centre for Outcomes Research and Effectiveness, Department of Clinical, Educational and Health Psychology, University College London, 1–19 Torrington Place, London, UK.
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Manuel JK, Houck JM, Moyers TB. The impact of significant others in motivational enhancement therapy: findings from project MATCH. Behav Cogn Psychother 2012; 40:297-312. [PMID: 22047637 PMCID: PMC3294053 DOI: 10.1017/s1352465811000592] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Social network support for abstinence has been associated with improved treatment outcomes among samples of individuals with alcohol use disorders. As a result, research studies have focused on the inclusion of significant others (SOs) in the treatment process. Nonetheless, little is known about 1) the specific influence SOs may have on clients during treatment sessions or 2) whether SO within-session behaviors have any relationship to client post-treatment drinking. METHOD In the current study, Motivational Enhancement Therapy sessions in which a SO was present were coded using a behavioral coding system designed to measure SO and client within-session language. RESULTS Relationships were observed between SO and client within-session language. Furthermore, some specific SO categories of language predicted post-treatment client drinking. CONCLUSIONS This study is the first systematic evaluation of SO contributions in substance abuse treatment sessions. Future research examining SO language in the treatment of alcohol use disorders might allow clinicians to avoid contributions from SOs that are associated with poorer drinking outcomes.
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Gifford EV, Kohlenberg BS, Hayes SC, Pierson HM, Piasecki MP, Antonuccio DO, Palm KM. Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation. Behav Ther 2011; 42:700-15. [PMID: 22035998 DOI: 10.1016/j.beth.2011.03.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 03/23/2011] [Accepted: 03/23/2011] [Indexed: 10/18/2022]
Abstract
This study evaluated a treatment combining bupropion with a novel acceptance and relationship focused behavioral intervention based on the acceptance and relationship context (ARC) model. Three hundred and three smokers from a community sample were randomly assigned to bupropion, a widely used smoking cessation medication, or bupropion plus functional analytic psychotherapy (FAP) and acceptance and commitment therapy (ACT). Objective measures of smoking outcomes and self-report measures of acceptance and relationship processes were taken at pretreatment, posttreatment, 6-month, and 1-year follow-up. The combined treatment was significantly better than bupropion alone at 1-year follow-up with 7-day point prevalence quit rates of 31.6% in the combined condition versus 17.5% in the medication-alone condition. Acceptance and the therapeutic relationship at posttreatment statistically mediated 12-month outcomes. Bupropion outcomes were enhanced with an acceptance and relationship focused behavioral treatment.
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Affiliation(s)
- Elizabeth V Gifford
- Department of Veterans Affairs, Center for Health Care Evaluation, 795 Willow Rd., Menlo Park, CA 94025, USA.
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Therapist competence and treatment adherence for a brief intervention addressing alcohol and violence among adolescents. J Subst Abuse Treat 2011; 42:429-37. [PMID: 22119182 DOI: 10.1016/j.jsat.2011.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 08/24/2011] [Accepted: 09/15/2011] [Indexed: 11/23/2022]
Abstract
This study examines therapist competency and treatment adherence for a brief intervention addressing alcohol misuse and violent behaviors among adolescents aged 14-18 years. Three observational measures of fidelity were used by independent raters to evaluate 60 therapist-delivered sessions (M = 32.5 minutes). Individual items from the Content Adherence scale, the Global Rating of Competence (Global Rating of Motivational Interviewing Therapist [GROMIT]), and the Self Exploration and Change Talk (SECT) demonstrated fair to excellent interrater reliability (intraclass correlations ranged from .40 to 1.0). Principal components analysis was used to identify the underlying factor structure of the Content Adherence and the GROMIT. Parallel analysis suggested the extraction of three components for the Content Adherence reflecting the three distinct goals for each segment of the intervention. Two components were identified for the GROMIT representing the general spirit of motivational interviewing and empowerment. Findings provide support for the fidelity instruments adapted for this study and offer direction for future training and clinical supervision.
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Manuel JK, Hagedorn HJ, Finney JW. Implementing evidence-based psychosocial treatment in specialty substance use disorder care. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2011; 25:225-37. [PMID: 21668085 DOI: 10.1037/a0022398] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Implementing evidence-based psychosocial or behavioral treatments for clients with substance use disorders (SUDs) presents significant challenges. In this article, we first identify the treatments for which there is some consensus that sufficient empirical support exists to designate them as "evidence-based," and then briefly consider the nature of that evidence. Following that, we review data from a Substance Abuse and Mental Health Services Administration survey on the extent to which these evidence-based treatments (EBTs) are used in SUD treatment in the United States. The main focus of the article is a review of 21 studies attempting to implement EBTs from which we glean information on factors associated with more and less successful implementation. We conclude that more conceptually driven, organizationally focused (not just individual-provider-focused) approaches to implementation are needed and that, at least with some providers in some organizational contexts, it may be more effective to implement evidence-based practices or processes (EBPs) rather than EBTs.
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Affiliation(s)
- Jennifer K Manuel
- Health Services Research & Development (HSR&D) Center for Health Care Evaluation, VA Palo Alto Health Care System, CA, USA.
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Short EE, Fernandez A, Borsari B, Hustad JTP, Wood M. Does clinician continuity over two brief motivational sessions improve outcomes in college students? J Subst Abuse Treat 2011; 41:313-20. [PMID: 21696911 DOI: 10.1016/j.jsat.2011.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 04/26/2011] [Accepted: 04/27/2011] [Indexed: 10/18/2022]
Abstract
Previous research has shown that brief motivational interventions (BMIs) are an effective treatment approach for reducing college student alcohol use and associated negative consequences. The purpose of this study was to determine whether clinician continuity (having the same vs. a different clinician) across an initial BMI and follow-up booster session was related to differences in session satisfaction, self-reported alcohol use, and alcohol-related negative consequences. Participants included 358 undergraduate students who were part of a larger randomized clinical trial. Results revealed no significant differences in alcohol use and associated consequences at follow-up between participants who met with the same versus a different clinician. Clinician continuity was not significantly related to intervention fidelity in terms of BMI-consistent qualities, relevance of information presented, or session satisfaction. These findings suggest that clinician continuity across BMIs for college students is not related to participant satisfaction or intervention effectiveness, especially if the clinicians adhere to empirically supported techniques.
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Affiliation(s)
- Erica Eaton Short
- Brown University Center for Alcohol and Addiction Studies Box G-S121-5 Providence, RI 02903, USA.
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37
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Mutual influence in therapist competence and adherence to motivational enhancement therapy. Drug Alcohol Depend 2011; 115:229-36. [PMID: 21227601 PMCID: PMC3397170 DOI: 10.1016/j.drugalcdep.2010.11.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 10/27/2010] [Accepted: 11/11/2010] [Indexed: 11/22/2022]
Abstract
Although psychotherapy involves the interaction of client and therapist, mutual influence is not typically considered as a source of variability in therapist adherence and competence in providing treatments assessed in clinical trials. We examined variability in therapist adherence and competence in Motivational Enhancement Therapy (MET) both within and between caseloads in a large multi-site clinical trial. Three-level multilevel models (repeated measures, nested within clients, nested with therapists) indicated significant variability both within and between therapists. There was as much and sometimes more variability in MET adherence and competence within therapist caseloads than between therapists. Variability in MET adherence and competence within caseloads was not consistently associated with client severity of addiction at baseline. However, client motivation at the beginning of the session and days of use during treatment were consistent predictors of therapist adherence and competence. Results raise questions about the nature of therapist adherence and competence in treatment protocols. Accordingly, future analysis of clinical trials should consider the role of mutual influence in measures of therapist performance.
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Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. Motivational interviewing for substance abuse. Cochrane Database Syst Rev 2011; 2011:CD008063. [PMID: 21563163 PMCID: PMC8939890 DOI: 10.1002/14651858.cd008063.pub2] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective. OBJECTIVES To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions. SEARCH STRATEGY We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO. SELECTION CRITERIA Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction. DATA COLLECTION AND ANALYSIS Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups. MAIN RESULTS We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect . For other active intervention there were no significant effects for either follow-up.There was not enough data to conclude about effects of MI on the secondary outcomes. AUTHORS' CONCLUSIONS MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
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Affiliation(s)
- Geir Smedslund
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Rigmor C Berg
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Karianne T Hammerstrøm
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Asbjørn Steiro
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Kari A Leiknes
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Helene M Dahl
- Institute of Clinical MedicineDepartment of Clinical PsychiatryUniversity of Tromsø, Asgard,TromsøNorway9291
| | - Kjetil Karlsen
- Institute of Clinical MedicineDepartment of Clinical PsychiatryUniversity of Tromsø, Asgard,TromsøNorway9291
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Freedland KE, Mohr DC, Davidson KW, Schwartz JE. Usual and unusual care: existing practice control groups in randomized controlled trials of behavioral interventions. Psychosom Med 2011; 73:323-35. [PMID: 21536837 PMCID: PMC3091006 DOI: 10.1097/psy.0b013e318218e1fb] [Citation(s) in RCA: 244] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the use of existing practice control groups in randomized controlled trials of behavioral interventions and the role of extrinsic health care services in the design and conduct of behavioral trials. METHOD Selective qualitative review. RESULTS Extrinsic health care services, also known as nonstudy care, have important but under-recognized effects on the design and conduct of behavioral trials. Usual care, treatment-as-usual, standard of care, and other existing practice control groups pose a variety of methodological and ethical challenges, but they play a vital role in behavioral intervention research. CONCLUSIONS This review highlights the need for a scientific consensus statement on control groups in behavioral trials.
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Magill M, Mastroleo NR, Apodaca TR, Barnett NP, Colby SM, Monti PM. Motivational interviewing with significant other participation: assessing therapeutic alliance and patient satisfaction and engagement. J Subst Abuse Treat 2011; 39:391-8. [PMID: 20817382 DOI: 10.1016/j.jsat.2010.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 07/09/2010] [Accepted: 07/16/2010] [Indexed: 11/18/2022]
Abstract
Inclusion of concerned significant others (SOs) in alcohol use treatment has demonstrated efficacy but has not been tested in the context of brief interventions. In this study, individual motivational interviewing (MI) sessions were compared with MI sessions including a significant other on within-treatment outcomes (alliance, fidelity, client satisfaction, and engagement). Participants (N = 382) were adult alcohol users recruited in a Level I trauma center. Perceived alliance did not differ across conditions, but patients and SOs reported higher alliance, satisfaction, and engagement than was perceived by the therapist. The occurrence of MI components, or discussion areas, was consistent across conditions. Higher baseline SO drinking was associated with lower patient engagement, whereas higher baseline SO acceptance of patient drinking was associated with lower SO engagement. Results suggest that individual MI sessions can be adapted to include an SO with minimal impact on patient acceptability and treatment fidelity. Research should, however, consider SOs' influence on participant outcomes and the relevance of specific SO characteristics.
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Affiliation(s)
- Molly Magill
- Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA.
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Gibbons CJ, Nich C, Steinberg K, Roffman RA, Corvino J, Babor TF, Carroll KM. Treatment process, alliance and outcome in brief versus extended treatments for marijuana dependence. Addiction 2010; 105:1799-808. [PMID: 20840200 PMCID: PMC3422659 DOI: 10.1111/j.1360-0443.2010.03047.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIMS The Marijuana Treatment Project, a large multi-site randomized clinical trial, compared a delayed treatment control condition with a brief (two-session) and extended (nine-session) multi-component treatment among 450 marijuana-dependent participants. In this report we present treatment process data, including the fidelity of treatment delivery in the three community-based treatment settings as well as the relationships between treatment process and outcome. DESIGN Independent evaluations of clinician adherence and competence ratings were made based on 633 videotaped sessions from 163 participants. Relationships between clinician adherence and competence, ratings of the working alliance and marijuana treatment outcomes were evaluated. FINDINGS Protocol treatments were implemented with strong fidelity to manual specifications and with few significant differences in adherence and competence ratings across sites. In the brief two-session treatment condition, only the working alliance was associated significantly with frequency of marijuana use, but in the extended treatment therapist ratings of working alliance predicted outcomes, as did the interaction of alliance and curvilinear adherence. CONCLUSIONS Behavioral treatments for marijuana use were delivered in community settings with good fidelity. Participant and therapist working alliance scores were associated significantly with improved marijuana use outcomes in a brief behavioral treatment for adults with marijuana dependence. In extended treatment the therapist ratings of working alliance were associated with more positive outcome. However, in that treatment there was also a significant interaction between alliance and curvilinear adherence.
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Affiliation(s)
- Carly J. Gibbons
- Yale University, VA CT Healthcare Center (151D), West Haven, CT, USA
| | - Charla Nich
- Yale University, VA CT Healthcare Center (151D), West Haven, CT, USA
| | - Karen Steinberg
- University of Connecticut Health Center, Farmington, CT, USA
| | | | - Joanne Corvino
- Yale University, VA CT Healthcare Center (151D), West Haven, CT, USA
| | - Thomas F. Babor
- University of Connecticut Health Center, Farmington, CT, USA
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O'Leary-Barrett M, Mackie CJ, Castellanos-Ryan N, Al-Khudhairy N, Conrod PJ. Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers. J Am Acad Child Adolesc Psychiatry 2010; 49:954-963.e1. [PMID: 20732631 DOI: 10.1016/j.jaac.2010.04.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 04/26/2010] [Accepted: 04/28/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This trial examined the efficacy of teacher-delivered personality-targeted interventions for alcohol-misuse over a 6-month period. METHOD This randomized controlled trial randomly allocated participating schools to intervention (n = 11) or control (n = 7) conditions. A total of 2,506 (mean age, 13.7 years) were assessed for elevated levels of personality risk factors for substance misuse: sensation-seeking, impulsivity, anxiety sensitivity, and hopelessness. Six hundred ninety-six adolescents were invited to participate in teacher-delivered personality-targeted interventions, and 463 were assigned to the nontreatment condition. Primary outcomes were drinking, binge-drinking status, quantity by frequency of alcohol use, and drinking-related problems. RESULTS School delivery of the personality-targeted intervention program was associated with significantly lower drinking rates in high-risk students at 6-month follow-up (odds ratio, 0.6), indicating a 40% decreased risk of alcohol consumption in the intervention group. Receiving an intervention also predicted significantly lower binge-drinking rates in students who reported alcohol use at baseline (odds ratio, 0.45), indicating a 55% decreased risk of binge-drinking in this group compared with controls. In addition, high-risk intervention-school students reported lower quantity by frequency of alcohol use (beta = -.18) and drinking-related problems (beta = -.15) compared with the nontreatment group at follow-up. CONCLUSION This trial replicates previous studies reporting the efficacy of personality-targeted interventions and demonstrates that targeted interventions can be successfully delivered by teachers, suggesting potential for this approach as a sustainable school-based prevention model. Clinical trial registration information-Personality-Targeted Interventions for Adolescent Alcohol Misuse, URL: http://www.clinicaltrials.gov, unique identifier: NCT00344474.
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Affiliation(s)
- Maeve O'Leary-Barrett
- Institute of Psychiatry, King's College London, and the South London and Maudsley National Health Service Foundation Trust, London, United Kingdom
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Rakovshik SG, McManus F. Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clin Psychol Rev 2010; 30:496-516. [DOI: 10.1016/j.cpr.2010.03.004] [Citation(s) in RCA: 192] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 03/12/2010] [Accepted: 03/18/2010] [Indexed: 12/18/2022]
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Moyers TB, Martin T, Houck JM, Christopher PJ, Tonigan JS. From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing. J Consult Clin Psychol 2009; 77:1113-24. [PMID: 19968387 PMCID: PMC2819223 DOI: 10.1037/a0017189] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Client speech in favor of change within motivational interviewing sessions has been linked to treatment outcomes, but a causal chain has not yet been demonstrated. Using a sequential behavioral coding system for client speech, the authors found that, at both the session and utterance levels, specific therapist behaviors predict client change talk. Further, a direct link from change talk to drinking outcomes was observed, and support was found for a mediational role for change talk between therapist behavior and client drinking outcomes. These data provide preliminary support for the proposed causal chain indicating that client speech within treatment sessions can be influenced by therapists, who can employ this influence to improve outcomes. Selective eliciting and reinforcement of change talk is proposed as a specific active ingredient of motivational interviewing.
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Affiliation(s)
- Theresa B Moyers
- Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, Albuquerque, NM 87106-1161, USA.
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Litt MD, Kadden RM, Kabela-Cormier E. Individualized assessment and treatment program for alcohol dependence: results of an initial study to train coping skills. Addiction 2009; 104:1837-8. [PMID: 19712124 PMCID: PMC2763044 DOI: 10.1111/j.1360-0443.2009.02693.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Cognitive-behavioral treatments (CBT) are among the most popular interventions offered for alcohol and other substance use disorders, but it is not clear how they achieve their effects. CBT is purported to exert its beneficial effects by altering coping skills, but data supporting coping changes as the mechanism of action are mixed. The purpose of this pilot study was to test a treatment in which coping skills were trained in a highly individualized way, allowing us to determine if such training would result in an effective treatment. DESIGN Participants were assigned randomly to a comprehensive packaged CBT program (PCBT), or to an individualized assessment and treatment program (IATP). The IATP program employed experience sampling via cellphone to assess coping skills prior to treatment, and provided therapists with a detailed understanding of patients' coping strengths and deficits. SETTING Out-patient treatment. PARTICIPANTS A total of 110 alcohol-dependent men and women. MEASUREMENTS Participants in both conditions completed experience sampling of situations, drinking and coping efforts prior to, and following, 12 weeks of treatment. Time-line follow-back procedures were also used to record drinking at baseline and post-treatment. FINDINGS IATP yielded higher proportion of days abstinent (PDA) at post-treatment (P < 0.05) than did PCBT, and equivalent heavy drinking days. IATP also elicited more momentary coping responses and less drinking in high-risk situations, as recorded by experience sampling at post-treatment. Post-treatment coping response rates were associated with decreases in drinking. CONCLUSIONS The IATP approach was more successful than PCBT at training adaptive coping responses for use in situations presenting a high risk for drinking. The highly individualized IATP approach may prove to be an effective treatment strategy for alcohol-dependent patients.
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Affiliation(s)
- Mark D Litt
- Department of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, CT 06030, USA.
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Tober G, Brearley R, Kenyon R, Raistrick D, Morley S. Measuring Outcomes in a Health Service Addiction Clinic. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/16066350009004418] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Collins SE, Eck S, Kick E, Schröter M, Torchalla I, Batra A. Implementation of a smoking cessation treatment integrity protocol: treatment discriminability, potency and manual adherence. Addict Behav 2009; 34:477-80. [PMID: 19162408 DOI: 10.1016/j.addbeh.2008.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Revised: 12/03/2008] [Accepted: 12/11/2008] [Indexed: 11/26/2022]
Abstract
Testing manual adherence and treatment discriminability and potency have become increasingly important to ensuring the internal validity of treatment studies [Moncher, F.J., & Prinz, R.J., (1991). Treatment fidelity in outcome studies. Clinical Psychology Review, 11, 247-266.]. The objective of this study was therefore to implement the treatment integrity protocol based on the standardized framework proposed by Waltz, Addis, Koerner and Jacobson [Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S., (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61, 620-630.] to assess manual adherence and treatment discriminability and potency in a smoking cessation trial. Audio recordings of 15, 6-week smoking cessation groups were randomly selected from a sample of 31 groups and were rated for treatment integrity. Findings offered partial evidence for manual adherence which did not differ according to treatment condition. Analyses also indicated that the treatments were potent yet not highly discriminable across conditions. Despite some challenges, this preliminary application of the Waltz et al. [Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S., (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61, 620-630.] protocol indicated that it is a promising and flexible tool that may be used to examine different aspects of treatment integrity.
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Hogue A, Henderson CE, Dauber S, Barajas PC, Fried A, Liddle HA. Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems. J Consult Clin Psychol 2009; 76:544-55. [PMID: 18665684 DOI: 10.1037/0022-006x.76.4.544] [Citation(s) in RCA: 155] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed.
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Affiliation(s)
- Aaron Hogue
- Health and Treatment Research, National Center on Addiction and Substance Abuse at Columbia University, 633 Third Avenue, 19th floor, New York, NY 10017, USA.
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Orford J, Hodgson R, Copello A, Wilton S, Slegg G. To what factors do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol Treatment Trial. J Subst Abuse Treat 2009; 36:49-58. [DOI: 10.1016/j.jsat.2008.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 04/11/2008] [Indexed: 10/22/2022]
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