Less Directiveness by Therapists Improves Drinking Outcomes of Reactant Clients in Alcoholism Treatment

Harm reduction for perinatal cannabis use: protocol for a scoping review of clinical practices

INTRODUCTION

The American College of Obstetricians and Gynaecologists recommends against cannabis use during pregnancy and lactation ('perinatal cannabis use') given its association with negative parent-child health outcomes. However, cannabis is becoming increasingly available and used during pregnancy, and perceptions of safety are correspondingly increasing. For individuals who are unable or unwilling to cease use during pregnancy and lactation, harm reduction is the best available evidence-based practice to promote health. Further, there have been calls for increased employment of harm reduction for perinatal cannabis use. However, the field currently lacks understanding of what harm reduction for this population looks like in practice. Likely contributing to this lack of understanding is the fact that the concept of harm reduction is not consistently defined, and strategies that comprise harm reduction may not always be labelled as such. This makes it challenging to comprehensively collect articles using search terms meant to pull for harm reduction specifically. The aim of this scoping review is to collect all articles discussing perinatal cannabis use published since the discovery of the endocannabinoid system, and then screen for references that describe concrete clinical practices that comprise harm reduction for this population.

METHODS AND ANALYSIS

The Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and the Arksey and O'Malley methodology for scoping reviews, as updated by Levac and colleagues, guide this review. The protocol is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR). A systematic search of the literature was initially conducted to identify English-language articles authored between January 1990 and 2023 present in these databases as of 22 September 2023: PubMed (National Library of Medicine), Embase (Elsevier), Web of Science Core Collection (Clarivate), APA PsycINFO (EBSCO), CINAHL(EBSCO) and Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley). Preceding submission of the results for publication, the search will be run again in order to ensure capturing later publications relevant for this review. Google search results will also be hand-searched for patient-facing materials. Additional grey literature sources include clinical trials, preprints and conference proceedings that were not excluded from the database search results. We will 'bookend' our search from 1990 to the present, as the 1990s saw the discovery of the endocannabinoid system, and the first passing of legalised medical cannabis in the USA. Literature will be eligible for inclusion if it includes a description of clinical approaches that comprise harm reduction for perinatal cannabis use. Two reviewers will independently complete title/abstract screening followed by full-text screening of the references that meet title/abstract criteria. Data, including the description of the clinical practice(s), dates of data collection, when and where the reference was published, legal status of cannabis in the place where the data was collected and any reported outcomes associated with the use of the harm reduction practice(s), will be extracted from the studies that remain eligible after full-text review. The studies will also be appraised for quality using the Mixed Methods Appraisal Tool (MMAT).

ETHICS AND DISSEMINATION

Ethics approval was not sought as this review does not constitute data collection on human subjects (no information or specimens were collected from interaction or intervention with an individual). This scoping review will systematically examine the scope and coverage of existing clinical harm-reduction approaches for perinatal cannabis use in research and clinical practice. Findings will inform practice and elucidate future directions for research. The scoping review study team includes individuals who are themselves actively engaged in treating perinatal patients and they will participate in dissemination activities that allow review findings to reach patients and other providers (eg, presentations, publications).

STUDY REGISTRATION

Registered with the Open Science Framework (OSF Registries; https://osf.io/wb3jc).

Who benefits from brief motivational intervention among young adults presenting to the emergency department with alcohol intoxication: A latent-class moderation analysis

BACKGROUND

Research has not identified which patients optimally benefit from brief Motivational Interviewing (bMI) for heavy drinking when delivered to young adults in the Emergency Department (ED).

METHODS

We conducted secondary analyses of data from a randomized controlled trial in which 344 young adults (18-35 years) presenting to the ED with alcohol intoxication received either bMI or Brief Advice (BA, control group). We used Latent Class Analysis to derive participants' profiles from baseline characteristics (i.e., sex, age, severity of alcohol use disorder, attribution of ED admission to alcohol use, importance, and confidence to change, cognitive discrepancy, anxiety, depression, and trait reactance). We then conducted a moderation analysis to assess the number of heavy drinking days at short-term (1-month) and long-term (12-month) follow-up using negative binomial regressions with interactions between the intervention and derived classes.

RESULTS

Fit statistics indicated that a 4-class solution best fit the data. Class 3 (high severity, importance and discrepancy, and low confidence and anxiety) benefitted more from bMI than BA at short- and long-term follow-up than Class 1 (younger; lowest severity, importance, discrepancy, reactance, anxiety and depression, and highest confidence). Class 2 (older; highest severity, importance, discrepancy, reactance, anxiety and depression, and lowest confidence) also benefitted more from bMI than BA than did Class 1 at short-term follow-up. In these significant contrasts, Class 1 benefitted more from BA than bMI. There were no significant interactions involving Class 4 (more likely to be women; low severity; high levels of anxiety, depression, and reactance).

CONCLUSIONS

This study identified the patient profiles that benefitted more from bMI than BA among nontreatment-seeking young adults who present intoxicated to the ED. The findings have implications for intervention design and argue for the importance of research aimed at developing intervention content tailored to patient profiles.

Analysis and Psychoeducational Implications of the Behavior Factor During the COVID-19 Emergency

This theoretical analysis seeks to contribute to three objectives within the context of the proposed Frontiers Research Topic: (1) delimit two levels of analysis in the present pandemic situation: medicine-epidemiology and behavioral psychology, still under-addressed. While medicine has its essential role on the biological side, psychology has a comparable role on the behavioral side. (2) Analyze the importance of behavioral-educational factors in the pandemic situation, using a precise theoretical model from educational psychology for this analysis. (3) Propose preventive, psychoeducational intervention strategies based on the previous analyses.

Adapting psychotherapy to patient reactance level: A meta-analytic review

Resistance and its extreme variation, reactance, are uniformly observed across varieties of psychotherapy. Social psychologists note that reactant individuals prove to be less so when offered a receptive and nondirective environment. We provide definitions of reactance, review its frequent measures, and offer a clinical example. A meta-analysis of 13 controlled studies (1,208 patients) examined the degree to which treatment outcomes are enhanced when therapists offer less directive treatments to high-reactance patients. The results revealed a large effect size (d = .79), confirming that highly reactant individuals did better in psychotherapy when the therapist assumed a reflective and nondirective stance than a directive and authoritative one. To a lesser degree, the opposite was also true. Limitations of the research and diversity considerations are noted. Practice recommendations are provided to minimize a patient's reactant behavior.

Therapeutic agency, in-session behavior, and patient-therapist interaction

OBJECTIVE

The aim of this study was to investigate associations between patients' subjective agency, their observable in-session behavior, and the patient-therapist interaction during the early phase of psychotherapy.

METHODS

The sample included 52 depressed patients in psychodynamic psychotherapy. After Session 5, the patients' agency and the quality of the therapeutic alliance were assessed. Based on session recordings, two independent observers rated the patients' involvement, their interpersonal behavior, and the therapists' directiveness.

RESULTS

Higher agency was associated with stronger therapeutic alliances. Patients who indicated higher agency in their therapy participated more actively in the session and showed less hostile impact messages. Patients' agency was not related to therapists' directiveness.

CONCLUSIONS

Patients' sense of agency in psychotherapy was associated with more active involvement and affiliative interaction. The findings support the idea that patients need to feel capable of acting within and having an influence on their therapy to benefit from it.

Exploration of treatment matching of problem drinker characteristics to motivational interviewing and non-directive client-centered psychotherapy

Motivational Interviewing (MI) is a known effective intervention for alcohol use disorder (AUD). MI's mechanisms of action remain inconsistently substantiated, and research in this area has been reliant on identifying relationships through strength of association rather than experimental manipulation of active ingredients. In two previous studies, a pilot and a larger replication study, we disaggregated MI into its hypothesized active ingredients by creating three conditions: MI, Spirit Only MI (SOMI, in which evocation of change talk was proscribed), and a non-therapy condition (NTC). Results from both studies yielded equivalent findings across all three conditions. In the current analyses, data from both studies were combined to test five participant characteristics as moderators of MI's component parts: 1) severity of baseline drinking, 2) severe AUD (met 6 or more criteria), 3) baseline self-efficacy to moderate drinking, 4) mean daily confidence to resist heavy drinking in the week prior to treatment initiation, and 5) depression. There were no significant findings related to baseline drinking, severe AUD, or baseline self-efficacy. Confidence yielded a significant interaction effect. When participants had high baseline confidence, drinking for those in MI increased compared to those in SOMI. Depression also yielded a significant moderating effect such that in the context of higher depressive symptoms, receipt of either therapy reduced drinking relative to NTC. Results are discussed in light of existing literature on MOBC with MI and the potential role exploring ambivalence may play for participants with particular characteristics.

Developing a Tailored Texting Preventive Intervention: A Card Sort Methodology

PURPOSE

Intervention content written by adults for youth can result in miscommunication due to generational and cultural differences. Inviting at-risk youth to participate in the creation of intervention material can augment acceptability for their peers.

METHODS

To improve intervention messaging, the present study examines the utility of a card sort technique when creating cellular phone text messages to be used in a preventive substance use intervention. During focus groups with 24 youth who are exiting the foster care system - a population with distinct cultural attributes - participants were asked to rate stage of change-specific health messages rooted in Motivational Interviewing and the Transtheoretical Model.

RESULTS

Participants unanimously favored content that encouraged autonomy and choice. Statements that invited a "look to the future" were also rated favorably. Messages that referenced the past were not rated well, as were suggestions for professional assistance. Finally, encouragement to receive social support for change was met with ambivalence. While some participants regarded support as helpful, many others felt a severe lack of support in their lives, possibly prompting further substance use.

CONCLUSIONS

Youth exiting foster care constitute a unique population whose voice is paramount in the development of interventions. The content present in traditional approaches to substance use prevention (e.g., increasing social support) may not apply to this group of vulnerable youth. The card sort technique has strong potential to evoke youth-specific intervention content that is more readily understood and accepted by target audiences.

Assessing the Unidimensionality of Trait Reactance Using a Multifaceted Model Assessment Approach

This study employed a multifaceted model assessment approach to investigate the dimensionality and nomological network of a popular measure of trait reactance, the Hong Psychological Reactance Scale (HPRS; Hong & Page, 1989 ). To address confusion regarding the scoring and modeling of the HPRS as well as its limited external validity evidence, we tested competing factor models, diagnosed model-data misfit, examined relationships between competing factor models and key personality traits, and cross-validated the results. Confirmatory factor analytic results supported modeling the HPRS via a bifactor model and, when this model was applied, trait reactance was negatively related to agreeableness, conscientiousness, and conformity, and positively related to entitlement, as expected. However, we also demonstrated the consequences of championing a 1-factor model by highlighting differences in relationships with external variables. Specifically, although modeling the HPRS scores with the bifactor model resulted in greater model-data fit than the 1-factor model, relationships with external variables based on the 2 models differed negligibly. Moreover, bifactor statistical indexes indicted that scores were essentially unidimensional, providing some support that HPRS scores can be treated as unidimensional in structure. Implications for using and scoring the HPRS are discussed.

Mental Health Care Providers' Views of Their Work with Consumers and Their Reports of Recovery-Orientation, Job Satisfaction, and Personal Growth

The research examined the role of mental health care providers' perceptions of their professional relationships with consumers in understanding their reports of agency recovery-oriented services and their own sense of job satisfaction and personal growth. Multidisciplinary community mental health care providers (N = 105) responded to an online self-report questionnaire. Providers' reports of higher levels of working alliance and greater provider directiveness in working with consumers was significantly related to providers' reports of higher levels of agency recovery-orientation and higher levels of personal growth. Providers' reports of working alliance accounted for the largest proportion of variance in providers' reports of job satisfaction. Mental health providers' perceptions of relationships with consumers are central to understanding providers' views of agency recovery-orientation and sense of professional and personal well-being.

Therapist and client discussions of drinking and coping: a sequential analysis of therapy dialogues in three evidence-based alcohol use disorder treatments

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.

Mechanisms of change in adolescent substance use treatment: how does treatment work?

BACKGROUND

Adolescent substance use treatment outcome research generally shows small to moderate effects in reducing substance use, with no specific "brand" of treatment emerging as clearly superior to any other, and treatment gains that fade over time. The relatively weak and temporary effects of treatment call for improving the potency and durability of intervention effects. In response to this call, this critical narrative review summarizes research on mechanisms of change for both adults and adolescents in substance use treatment, with a particular focus on reviewing what is known regarding "how" adolescent substance use treatment works.

METHODS

A comprehensive review of the adolescent (aged 11-18) substance use treatment literature was conducted to identify empirical studies that examined mediators of intervention effects. Relevant databases (e.g., PsychINFO, MEDLINE) were searched using key words (e.g., "mediator"), and relevant articles from reference sections of identified studies and review papers were considered.

RESULTS

Studies of mechanisms of psychotherapy change are rare in the adult, and particularly adolescent, substance use treatment outcome literature. The 4 adolescent studies that examined substance use treatment mechanisms found that positive social support, motivation to abstain, and positive parenting behaviors mediated treatment effects. To date, research has not supported therapy-specific mechanisms of change, finding instead that "common" processes of change largely account for improvements in outcome across distinct "brands" of treatment.

CONCLUSIONS

The lack of empirical support for treatment-specific mechanisms of change may be due to the need for greater precision in defining and measuring treatment-specific causal chains. Future directions include neuroscience approaches to examining changes in brain functioning that are associated with treatment response and recovery and examining mechanisms in adaptive treatment designs, which can accommodate individual differences in targets for intervention and response to treatment.

Fear and Psychological Reactance

Abstract. Psychological reactance and related defensive processes have been long cited as an explanation for failure of fear appeal messages. The overwhelming majority of studies on fear and reactance have only examined the intensity of fear from a between-individuals perspective, in which individuals who have higher peak fear are predicted to experience stronger levels of psychological reactance. Recent development in the fear appeal research suggests an alternative perspective: Psychological reactance is activated when fear is aroused but not reduced within each individual; on the other hand, psychological reactance is mitigated or inhibited when fear is aroused and then reduced. Empirical data from a quasi-experimental study using graphic tobacco warning labels are used to test and compare the two approaches to studying the relationship between fear and psychological reactance. Implications for psychological reactance and fear appeal are discussed.

Antecedents to Psychological Reactance: The Impact of Threat, Message Frame, and Choice

A 2 (Threat: high vs. low) × 2 (Frame: gain vs. loss) × 2 (Choice: yes vs. no) × 2 (Behavior: prevention vs. detection) factorial design Web-based experiment (N = 814) was conducted to investigate the impact of threat to freedom, message frame, and behavioral choice as antecedents to psychological reactance. The intertwined model for reactance measure was replicated. Results showed that threat to freedom and the loss frame increased, and the gain frame and choice mitigated psychological reactance. The advantages of choice and the gain frame were most salient when threat was high.

Understanding the process of motivational interviewing: A review of the relational and technical hypotheses

OBJECTIVE

The current study systematically reviews evidence for a causal chain model suggested by Miller and Rose to account for the efficacy of Motivational Interviewing (MI).

METHOD

Literature searches were conducted to identify studies delivering MI in an individual format to treat various problem areas.

RESULTS

Thirty-seven studies met inclusion criteria. The results suggest that when clinicians utilise MI consistent behaviours, clients are more likely to express language in favour of change. Furthermore, this client language was consistently related to positive client outcome across studies.

CONCLUSIONS

While the results support some parts of the Miller and Rose model, additional research is needed to confirm the findings in diverse populations. Understanding the mechanisms of MI's effectiveness may maximise the implementation of MI, potentially contributing to better client outcomes.

Do brief alcohol motivational interventions work like we think they do?

BACKGROUND

Questions remain about how brief motivational interventions (BMIs) for unhealthy alcohol use work, and addressing these questions may be important for improving their efficacy. Therefore, we assessed the effects of various characteristics of BMIs on drinking outcomes across 3 randomized controlled trials (RCTs).

METHODS

Audio recordings of 314 BMIs were coded. We used the global rating scales of the Motivational Interviewing Skills Code (MISC) 2.1: counselor's acceptance, empathy, and motivational interviewing (MI) spirit, and patient's self-exploration were rated. MI proficiency was defined as counselor's rating scale scores ≥5. We also used the structure, confrontation, and advice subscale scores of the Therapy Process Rating Scale and the Working Alliance Inventory. We examined these process characteristics in interventions across 1 U.S. RCT of middle-aged medical inpatients with unhealthy alcohol use (n = 124) and 2 Swiss RCTs of young men with binge drinking in a nonclinical setting: Swiss-one (n = 62) and Swiss-two (n = 128). We assessed the associations between these characteristics and drinks/d reported by participants 3 to 6 months after study entry.

RESULTS

In all 3 RCTs, mean MISC counselor's rating scales scores were consistent with MI proficiency. In overdispersed Poisson regression models, most BMI characteristics were not significantly associated with drinks/d in follow-up. In the U.S. RCT, confrontation and self-exploration were associated with more drinking. Giving advice was significantly associated with less drinking in the Swiss-one RCT. Contrary to expectations, MI spirit was not consistently associated with drinking across studies.

CONCLUSIONS

Across different populations and settings, intervention characteristics viewed as central to efficacious BMIs were neither robust nor consistent predictors of drinking outcome. Although there may be alternative reasons why the level of MI processes was not predictive of outcomes in these studies (limited variability in scores), efforts to understand what makes BMIs efficacious may require attention to factors beyond intervention process characteristics typically examined.

Patient reactance moderates the effect of directive telephone counseling for methamphetamine users

OBJECTIVE

This study examined the impact of the interaction between patient reactance and treatment directiveness on the effectiveness of telephone aftercare for methamphetamine dependence.

METHOD

Reactance was assessed at baseline, and participants were randomly assigned to directive or nondirective treatment conditions. Logistic regression tested for the significance of the interaction as a predictor of 3-month and 12-month use of methamphetamine and stimulants.

RESULTS

A significant interaction was observed at the 3-month follow-up, in which the directive condition was less effective for patients higher in reactance and was more effective for patients lower in reactance. Among patients at a high level of reactance, the nondirective condition increased the likelihood of abstinence.

CONCLUSIONS

This study suggests that, in the context of telephone-based care, directive interventions offer short-term clinical benefit for methamphetamine users who readily accept influence from authority figures, whereas nondirective interventions offer benefit for patients who do not readily accept influence. The short-term nature of these effects indicates that there is a need for brief but ongoing telephone support to maintain treatment gains.

The contributions of cognitive neuroscience and neuroimaging to understanding mechanisms of behavior change in addiction

In the last decade, there has been an upsurge of interest in understanding the mechanisms of behavior change (MOBC) and effective behavioral interventions as a strategy to improve addiction-treatment efficacy. However, there remains considerable uncertainty about how treatment research should proceed to address the MOBC issue. In this article, we argue that limitations in the underlying models of addiction that inform behavioral treatment pose an obstacle to elucidating MOBC. We consider how advances in the cognitive neuroscience of addiction offer an alternative conceptual and methodological approach to studying the psychological processes that characterize addiction, and how such advances could inform treatment process research. In addition, we review neuroimaging studies that have tested aspects of neurocognitive theories as a strategy to inform addiction therapies and discuss future directions for transdisciplinary collaborations across cognitive neuroscience and MOBC research.

Parallel demand-withdraw processes in family therapy for adolescent drug abuse

Isomorphism, or parallel process, occurs in family therapy when patterns of therapist-client interaction replicate problematic interaction patterns within the family. This study investigated parallel demand-withdraw processes in brief strategic family therapy (BSFT) for adolescent drug abuse, hypothesizing that therapist-demand/adolescent-withdraw interaction (TD/AW) cycles observed early in treatment would predict poor adolescent outcomes at follow-up for families who exhibited entrenched parent-demand/adolescent-withdraw interaction (PD/AW) before treatment began. Participants were 91 families who received at least four sessions of BSFT in a multisite clinical trial on adolescent drug abuse (Robbins et al., 2011). Prior to receiving therapy, families completed videotaped family interaction tasks from which trained observers coded PD/AW. Another team of raters coded TD/AW during two early BSFT sessions. The main dependent variable was the number of drug-use days that adolescents reported in timeline follow-back interviews 7 to 12 months after family therapy began. Zero-inflated Poisson regression analyses supported the main hypothesis, showing that PD/AW and TD/AW interacted to predict adolescent drug use at follow-up. For adolescents in high PD/AW families, higher levels of TD/AW predicted significant increases in drug use at follow-up, whereas for low PD/AW families, TD/AW and follow-up drug use were unrelated. Results suggest that attending to parallel demand-withdraw processes in parent-adolescent and therapist-adolescent dyads may be useful in family therapy for substance-using adolescents.

A comparison of four telephone-based counseling styles for recovering stimulant users

The continuing development and refinement of empirically supported interventions to increase participation in posttreatment care and promote sustained abstinence from illicit drug use is a priority for the addictions field. The purpose of this study was to assess the combined and relative effectiveness of four types of counseling styles, delivered by telephone, relative to a no call control condition. Stimulant users (N = 302) were randomized to one of four low-cost, telephone support protocols (unstructured/nondirective, unstructured/directive, structured/nondirective, structured/directive) or a standard referral to aftercare without telephone counseling (control). All of the study participants were nearing the completion of (or had completed) an intensive phase of structured, outpatient stimulant abuse treatment. Drug use and aftercare participation were assessed at 3 and 12 months following randomization. Intent-to-treat analyses showed no significant time-by-group interactions for these primary outcomes. Subsequent analyses, however, revealed a significant difference between the aggregated call groups and the control group at the time of the 3-month follow-up. The mean ASI drug use severity composite score for subjects in the call conditions declining from .058 at baseline to .048 at 3 months, whereas the no call/control group average score increased from .053 to .062 (χ (1) = 4.95, p = .026). A similar-and slightly stronger-effect was found when the study sample was restricted to those reporting any use during the month prior to the baseline interview (n = 152). This study provides modest support for the telephone-based counseling approaches strategies examined in this project. Subsequent research will assess interactions between patient characteristics and counseling styles, and improved identification of which treatment graduates might be more likely to benefit from this type of continuing support. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

"Old dogs" and new skills: how clinician characteristics relate to motivational interviewing skills before, during, and after training

OBJECTIVE

The relationships between the occupational, educational, and verbal-cognitive characteristics of health care professionals and their motivational interviewing (MI) skills before, during, and after training were investigated.

METHOD

Fifty-eight community-based addiction clinicians (M = 42.1 years, SD = 10.0; 66% Female) were assessed prior to enrolling in a 2-day MI training workshop and being randomized to one of three post-workshop supervision programs: live supervision via tele-conferencing (TCS), standard tape-based supervision (Tape), or workshop training alone. Audiotaped sessions with clients were rated for MI skillfulness with the Motivational Interviewing Treatment Integrity (MITI) coding system v 2.0 at pre-workshop and 1, 8, and 20 weeks post-workshop. Correlation coefficients and generalized linear models were used to test the relationships between clinician characteristics and MI skill at each assessment point.

RESULTS

Baseline MI skill levels were the most robust predictors of pre- and post-supervision performances. Clinician characteristics were associated with MI Spirit and reflective listening skill throughout training and moderated the effect of post-workshop supervision method on MI skill. TCS, which provided immediate feedback during practice sessions, was most effective for increasing MI Spirit and reflective listening among clinicians with no graduate degree and stronger vocabulary performances. Tape supervision was more effective for increasing these skills among clinicians with a graduate degree. Further, TCS and Tape were most likely to enhance MI Spirit among clinicians with low average to average verbal and abstract reasoning performances.

CONCLUSIONS

Clinician attributes influence the effectiveness of methods used to promote the acquisition of evidence-based practices among community-based practitioners.

A randomized trial of computer-delivered brief intervention and low-intensity contingency management for smoking during pregnancy

INTRODUCTION

Implementation of evidence-based interventions for smoking during pregnancy is challenging. We developed 2 highly replicable interventions for smoking during pregnancy: (a) a computer-delivered 5As-based brief intervention (CD-5As) and (b) a computer-assisted, simplified, and low-intensity contingency management (CM-Lite).

METHODS

A sample of 110 primarily Black pregnant women reporting smoking in the past week were recruited from prenatal care clinics and randomly assigned to CD-5As (n = 26), CM-Lite (n = 28), CD-5As plus CM-Lite (n = 30), or treatment as usual (n = 26). Self-report of smoking, urine cotinine, and breath CO were measured 10 weeks following randomization.

RESULTS

Participants rated both interventions highly (e.g., 87.5% of CD-5As participants reported increases in likelihood of quitting), but most CM-Lite participants did not initiate reinforcement sessions and did not show increased abstinence. CD-5As led to increased abstinence as measured by cotinine (43.5% cotinine negative vs. 17.4%; odds ratio [OR] = 10.1, p = .02) but not for CO-confirmed 7-day point prevalence (30.4% abstinent vs. 8.7%; OR = 5.7, p = .06). Collapsing across CM-Lite status, participants receiving the CD-5As intervention were more likely to talk to a doctor or nurse about their smoking (60.5% vs. 30.8%; OR = 3.0, p = .02).

CONCLUSIONS

Low-intensity participant-initiated CM did not affect smoking in this sample, but the CD-5As intervention was successful in increasing abstinence during pregnancy. Further research should seek to replicate these results in larger and more diverse samples. Should CD-5As continue to prove efficacious, it could greatly increase the proportion of pregnant smokers who receive an evidence-based brief intervention.

Moderators and Mediators in Social Work Research: Toward a More Ecologically Valid Evidence Base for Practice

SUMMARY: Evidence-based practice involves the consistent and critical consumption of the social work research literature. As methodologies advance, primers to guide such efforts are often needed. In the present work, common statistical methods for testing moderation and mediation are identified, summarized, and corresponding examples, drawn from the substance abuse, domestic violence, and mental health literature, are provided. FINDINGS: While methodologically complex, analyses of these third variable effects can provide an optimal fit for the complexity involved in the provision of evidence-based social work services. While a moderator may identify the trait or state requirement for a causal relationship to occur, a mediator is concerned with the transmission of that relationship. In social work practice, these are questions of "under what conditions and for whom?" and of the "how?" of behavior change. IMPLICATIONS: Implications include a need for greater attention to these methods among practitioners and evaluation researchers. With knowledge gained through the present review, social workers can benefit from a more ecologically valid evidence base for practice.

Does readiness to change predict in-session motivational language? Correspondence between two conceptualizations of client motivation

AIMS

Client language reflecting motivation for changing substance use (i.e. change talk) has been shown to predict outcomes in motivational interviewing. While previous work has shown that change talk may be elicited by clinician behaviors, little is known about intrapersonal factors that may elicit change talk, including clients' baseline motivation for change. The present study tested whether in-session change talk differs between clients based on their readiness for change.

DESIGN AND SETTING

First-session audio recordings from Project MATCH, a large multi-site clinical trial of alcohol treatments.

PARTICIPANTS

Project MATCH out-patients (n = 69) and aftercare patients (n = 48) receiving motivational enhancement therapy (MET).

MEASUREMENTS

Client language from first-session MET was coded using the Sequential Code for Observing Process Exchanges. Readiness and stages of change were assessed using both categorical and dimensional variables derived from the University of Rhode Island Change Assessment and the Stages of Change Readiness and Treatment Eagerness Scale, administered prior to first treatment sessions.

FINDINGS

Stage of change scales followed some of the expected correspondence with change talk, although the associations were generally small in magnitude and inconsistent across measures and treatment arms. Higher overall readiness did not predict more overall change talk, contemplation had mixed associations with preparatory change talk, and preparation/action did not predict commitment language.

CONCLUSIONS

Motivational language used in initial sessions by people receiving counselling for excessive alcohol consumption does not appear to be associated with readiness to change as construed by the Transtheoretical Model.

What explains the relationship between the therapist structure × patient reactance interaction and drinking outcome? An examination of potential mediators

Recent research found that among patients in aftercare treatment for alcoholism the level of therapist structure interacted with the level of patients' interpersonal reactance to predict alcohol use outcomes. The present study examined two sets of potential mediators of this interaction effect among a sample from two aftercare sites of Project MATCH (n = 127). The mediator constructs were types of pro-recovery change talk and resistance to therapeutic work. Dependent variables were percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD) across the year after treatment. Multiple-mediator models using bootstrapped estimates of indirect effects were used to test for mediation. Results indicated that the 'taking steps' aspect of change talk partially mediated the Structure × Reactance interaction effect on both PDA and PHDD post treatment. Resistance was not found to mediate the interaction effect though resistance did predict worse drinking outcomes. Depending on patients' openness to being influenced by others, therapist structure early in treatment may promote or inhibit pro-recovery steps taken by aftercare patients between treatment sessions. Those steps in turn play an important role in predicting future alcohol use.

Negative affect, relapse, and Alcoholics Anonymous (AA): does AA work by reducing anger?

OBJECTIVE

Anger and other indices of negative affect have been implicated in a stress-induced pathway to relapse. The Alcoholics Anonymous (AA) literature states that reduction of anger is critical to recovery, yet this proposed mechanism has rarely been investigated. Using lagged, controlled hierarchical linear modeling analyses, this study investigated whether AA attendance mobilized changes in anger and whether such changes explained AA-related benefit.

METHOD

Alcohol-dependent adults (N = 1,706) receiving treatment as part of a clinical trial were assessed at intake and at 3, 6, 9, 12, and 15 months.

RESULTS

Findings revealed substantially elevated levels of anger compared with the general population (98th percentile) that decreased over 15-month follow-up but remained high (89th percentile). AA attendance was associated with better drinking outcomes, and higher levels of anger were associated with heavier drinking. However, AA attendance was unrelated to changes in anger.

CONCLUSIONS

Although support was not found for anger as a mediator, there was strong convergence between AA's explicit emphasis on anger and the present findings: Anger appears to be a serious, enduring problem related to relapse and heavy alcohol consumption. Methodological factors may have contributed to the lack of association between AA and anger, but results suggest that AA attendance alone may be insufficient to alleviate the suffering and alcohol-related risks specifically associated with anger.

Patient reactance as a moderator of the effect of therapist structure on posttreatment alcohol use

OBJECTIVE

We sought to replicate findings about the effect of therapist-imposed structure on alcoholism-treatment effectiveness for aftercare patients at different levels of interpersonal reactance and to examine if the effect generalizes to patients in a primary phase of treatment.

METHOD

Analyses were based on ex post facto observer ratings combined with outcome data from a randomized clinical trial. Participants had alcohol abuse or dependence (N = 247) and received treatment at either a primary outpatient treatment site (n = 125) or an aftercare site (n = 122) of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). Patients' trait reactance and therapist structure were assessed via observer ratings based on videotaped therapy sessions. Dependent variables included percentage days abstinent, percentage heavy-drinking days, time to first drinking day, and time to first heavy-drinking day throughout a 1-year posttreatment period.

RESULTS

The results indicated that increased therapist structure during aftercare treatment predicted fewer abstinent days and more heavy-drinking days for persons at a high level of reactance than for persons at a low level of reactance. The effect was a consistent predictor of alcohol use throughout each 3-month interval within the follow-up period. The interaction effect was not supported in the primary outpatient treatment sites, and it was not supported as a predictor of time to first drink or time to first heavy drink in either the aftercare or the outpatient sites.

CONCLUSIONS

This study successfully replicated the finding that level of patient reactance appears to moderate the effect of therapist structure on alcohol-use outcomes in aftercare treatment settings. The lack of support for this effect in primary outpatient treatment settings suggests that the negative effect of structured treatment may be limited to patients who are further along in the recovery process.

Improving adherence in mood disorders: the struggle against relapse, recurrence and suicide risk

Medication nonadherence is a major obstacle to translating treatment efficacy from research settings into effectiveness in clinical practice for patients with affective disorders. Adherence to beneficial drug therapy is associated with lower mortality compared with poor adherence. Reduced adherence is associated with increased suicide risk, especially when lithium is discontinued. The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders. Studies were identified through Medline and PsycInfo searches of English language publications between 1976 and 2009. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice. Estimates of medication nonadherence for unipolar and bipolar disorders range from 10 to 60% (median: 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side effects in predicting adherence. The limited number of empirical studies on reducing nonadherence indicate that, if recognized, the problem may be overcome. Clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of patients with affective disorders.

Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence

AIMS

Motivational interviewing (MI) is an efficacious treatment for substance use disorders. However, little is known about how MI exerts its therapeutic effects. This review is a first attempt to summarize and evaluate the evidence for purported within-session mechanisms of change. The primary question of interest was: which MI constructs and variables appear to be the most promising candidates for mechanisms of change?

METHODS

Literature searches were conducted to identify studies delivering MI in an individual format for the treatment of substance use disorders. Our search identified a total of 152 studies for review; 19 studies met inclusion criteria by providing data on at least one link in the causal chain model under examination. Effect size estimates were calculated for every possible step in the causal model where sufficient data were provided by study authors.

RESULTS

Four constructs of therapist behavior were evaluated: MI-Spirit, MI-Consistent behaviors, MI-Inconsistent behaviors and therapist use of specific techniques. Five constructs of client behavior were evaluated: change talk/intention, readiness to change, involvement/engagement, resistance and the client's experience of discrepancy. The absence of experimental and full mediation studies of mechanisms of change was notable. Effect sizes were generally mixed.

CONCLUSIONS

The most consistent evidence was found for three constructs: client change talk/intention (related to better outcomes); client experience of discrepancy (related to better outcomes); and therapist MI-Inconsistent behavior (related to worse outcomes). Regarding therapist use of specific techniques, use of a decisional balance exercise showed the strongest association to better outcomes.

Working with reactant patients: are we prescribing nonadherence?

OBJECTIVE

In spite of high levels of antidepressant nonadherence frequently observed among depressed samples, relatively little research has investigated psychosocial predictors of adherence. Fostering greater collaboration in depression treatment to increase adherence has been advocated, but this strategy has not been adequately studied. The aim of this study was to examine the interaction of provider collaboration and patient reactance in the prediction of antidepressant adherence during the acute treatment phase.

METHOD

Fifty outpatients diagnosed with major depressive disorder beginning antidepressant treatment within psychiatry clinics of the VA San Diego Healthcare System comprised the study sample. Patients were administered questionnaires following their medication evaluations to measure predictor variables. Antidepressant adherence was assessed via brief telephone interviews 3, 6, 9, and 12 weeks after treatment initiation. The roles of provider collaboration, patient reactance, and their interaction in adherence were examined using multiple regression analyses.

RESULTS

The interaction between provider collaboration and patient reactance accounted for 18.3% of the variance in 3-week adherence (P<.01). Among more reactant patients, greater levels of collaboration predicted better adherence, whereas among patients lower in reactance less collaboration predicted better adherence. No relationships were observed beyond the initial 3 weeks of treatment.

CONCLUSIONS

This study demonstrates that interpersonal process variables are important in influencing antidepressant adherence and challenges the advocacy of more collaboration in antidepressant treatment as a "blanket strategy." Establishing a more collaborative set with reactant patients may ensure greater early treatment adherence, a critical period during which antidepressants have typically not yet taken effect.

Counselor skill influences outcomes of brief motivational interventions

The aim of this study was to estimate the influence of counselor skills during brief motivational interventions (BMIs) on patient alcohol use 12 months later. Ninety-five BMIs delivered by five counselors of similar background and training were recorded and coded using the Motivational Interviewing Skills Code (MISC). Baseline alcohol measures and sociodemographics of patients did not differ across counselors, whereas MISC scores and outcome at 12 months did. Multilevel models showed that counselors with better motivational interviewing (MI) skills achieved better outcomes overall and maintained efficacy across all levels of an important predictor (patient ability to change), whereas counselors with poorer MI skills were effective mostly at high levels of ability to change. Findings indicated that avoidance of MI-inconsistent skills was more important than frequency of using MI-consistent skills and that training and selection of counselors should be based more on the overall MI-consistent gestalt than on particular MI techniques.

Development of an outcome prediction measure for alcoholism therapy by multimodal monitoring of treatment processes

Outcome prediction in alcoholism therapy is of major sociopolitical and economic significance. Instruments based on psychotherapeutic processes are lacking. Therefore, treatment processes of 64 chronic alcohol dependent patients have been investigated at three time-points, t(1) (week 3), t(2) (month 6), and t(3) (month 12) during the first year of a comprehensive outpatient treatment program, guaranteeing strictly controlled alcohol abstinence. Main focus of the study was the prediction of cumulative abstinence probability over a follow-up period of up to 4 years based on these treatment processes. One hundred and seventy-five video recordings of therapy sessions were analyzed with the behavior observational system VAMP (Video-Assisted Monitoring of Psychotherapeutic Processes in Chronic Psychiatric Disease). Patients' self-rating of treatment processes was measured with questionnaires for self-efficacy, abstinence confidence, self-consciousness and stress coping. Prediction of cumulative abstinence probability was determined with Cox regression analysis. By integrating the observer rated process variables with the highest predictive validity, the composite score TOPPS (Therapy Orientation by Process Prediction Score) was constructed. It includes the process variables experience of resources, abstinence self-efficacy, implicit craving, relapse alertness, relapse risk, disease concept, dysfunctional therapeutic engagement, and dysfunctional problem solving of current problems. Whereas patients' self-rating of treatment processes was insufficiently predictive, the TOPPS strongly predicted four-year abstinence probability at any of the 3 time-points (p<0.001). The results suggest to validate the item combination described in the TOPPS in addiction therapy as a treatment guideline of individual relapse prevention strategies.

Conceptual and design essentials for evaluating mechanisms of change

BACKGROUND

Considerable progress has been made toward the development of evidence-based treatments for a wide range of psychological disorders; however, little is known about the mechanisms through which these treatments actually lead to clinical change. Although the use of traditional randomized controlled treatment designs and tests of statistical mediation have significantly advanced understanding of psychological treatments, they are insufficient to test mechanisms of change.

METHOD

This article outlines the conceptual and methodological requirements for evaluating mechanisms of change, highlights the importance of such a focus, and offers specific recommendations for research aimed at elucidating change mechanisms.

RESULTS AND CONCLUSIONS

Conceptualizing and conducting studies that test mechanisms of change requires substantial modifications to traditional research designs, but doing so will significantly enhance scientific understanding as well as the efficiency and effectiveness of clinical interventions.

Lessons learned from psychotherapy research

BACKGROUND

In addictions treatment research, there has been a relative paucity of work on mechanisms of action that account for observed treatment effects. In studies that have been done, there is little evidence that the purported active ingredients of behavioral interventions such as cognitive-behavioral treatment or motivational interviewing actually mediate treatment effects. This suggests that new approaches are needed to study the process of change in behavioral treatments for addiction.

METHOD

This article reviews several approaches that have been taken by psychotherapy researchers to identify mechanisms of change, including studies of critical sessions, change across sessions, and the relative importance of general vs. specific therapeutic factors.

RESULTS

These approaches all involve careful assessment of both therapist and patient behaviors during treatment sessions and study the relation of these factors to improvements or deteriorations in symptoms over the following weeks.

CONCLUSIONS

Suggestions are offered for how these methods could be used in addiction treatment research to generate hypotheses regarding mechanisms of change that could subsequently be tested in controlled studies.

Perspectives and future directions

BACKGROUND

Mechanisms of behavior change (MOBC) in treating drinking problems is a topic of growing importance.

METHODS

This article identifies salient themes presented in talks during the first Annual RSA Satellite on Mechanisms of Behavior Change in Alcoholism Treatment.

RESULTS

Themes focused on the need to move beyond a passive approach to identifying MOBC in alcoholism treatment and a number of conceptual and methodological advances were proposed.

CONCLUSIONS

While a consensus has emerged that more attention should be paid to MOBC in alcoholism treatment research, a subgroup of experts are calling for MOBC to be the primary focus in future efforts.

The search for mechanisms of change in behavioral treatments for alcohol use disorders: a commentary

BACKGROUND

Definitive results from efforts to identify mechanisms of change in behavioral treatments for alcohol use disorders have been elusive. The working hypothesis guiding this paper is that one of the reasons for this elusiveness is that the models we hypothesize to account for treatments effectiveness are unnecessarily restricted and too simple.

METHODS

This paper aims to accomplish 3 things. First, a typography for locating potential mediators of change will be presented. In the course of doing so, a nomenclature will be proposed with the hope that this will facilitate communications among alcohol treatment researchers studying mechanisms of change. Second, alternatives to the classic test of mediation of alcohol treatment effects will be considered and one such alternative described. Third, alternative ways of conceptualizing, constructing and analyzing variables to measure mediators will be suggested.

RESULTS

It is hoped that this commentary will facilitate research on mechanisms of change in behavioral treatments for alcohol use disorders.

CONCLUSIONS

Behavioral change is a complex process, and the models that we develop to account for this process need to reflect this complexity. Advances in statistical approaches for testing mediation, along with a better understanding as to how to use these tools should help in moving toward this goal.

A Case Study of Mediators of Treatment Effectiveness

BACKGROUND

Recent research has observed that the use of confrontation in psychosocial treatment for alcohol abuse or dependence has a negative effect on posttreatment alcohol use among patients at average or above average levels of trait anger. It is not known what mediates that negative effect. The current study examines the role of session attendance as a mediator of the effect of confrontation on patients' subsequent alcohol use. In doing so, the study demonstrates the process of testing for mediation as well as planning analyses to meet additional conditions that can lend support to a causal mechanism of change.

METHODS

Multiple regression analyses were used to test for session attendance as a mediator among 107 individuals with alcohol abuse or dependence who received either cognitive behavioral therapy (CBT) (n = 39), motivational enhancement therapy (MET) (n = 34), or twelve-step facilitation therapy (TSF) (n = 34). Emphasis was placed on achieving the desired temporal sequence of the therapy intervention, the mediator, and the outcome variable.

RESULTS

The data supported the role of session attendance as a partial mediator of the effect of confrontation on future alcohol use among patients who received CBT, but not among patients who received MET or TSF. In CBT, other potential mediators (e.g., therapeutic alliance and in-session resistance) were not supported and did not change the support for session attendance in the model. Beyond mediation, some but not all criteria for a causal mechanism of change were also met.

CONCLUSIONS

This study suggests that in CBT the negative impact of confrontation early in treatment is partially explained by a reduction in the number of sessions patients attended. Different processes appear to be occurring in MET and TSF. By carefully constructing analytic models, results can speak both to issues of mediation and to causal mechanisms of change.

Theory-based active ingredients of effective treatments for substance use disorders

This paper describes four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. It then provides an overview of the rationale and evidence for four effective psychosocial treatments for substance use disorders: motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive-behavioral treatment and behavioral family counseling, and contingency management and community reinforcement approaches. The presumed active ingredients of these treatments are described in terms of how they exemplify the social processes highlighted by the four theories. The identified common components of effective treatment include support, goal direction, and structure; an emphasis on rewards that compete with substance use, a focus on abstinence-oriented norms and models, and attempts to develop self-efficacy and coping skills. Several issues that need to be addressed to enhance our understanding of the active ingredients involved in effective treatment are discussed, including how to develop measures of these ingredients, how well the ingredients predict outcomes and influence conceptually comparable aspects of clients' life contexts, and how much their influence varies depending upon clients' demographic and personal characteristics.

Does matching matter? Examining matches and mismatches between patient attributes and therapy techniques in alcoholism treatment

AIMS

This study assessed the predictive validity of the level of matching and mismatching between patients' personal attributes and aspects of outpatient psychotherapy they received.

DESIGN AND PARTICIPANTS

On the basis of patient-by-treatment interactions observed for this sample in previous research, patients with alcohol abuse or dependence (n = 137) were designated retrospectively as being matched, unmatched or mismatched on each of four patient and treatment variable pairings. These pairings included (1) patient depressive symptoms and therapy emotion focus, (2) patient trait anger and therapy confrontation, (3) patient interpersonal reactance and therapy confrontation and (4) patient interpersonal reactance and therapy structure.

MEASUREMENTS

Analyses of variance and logistic regression were used to assess the individual and additive effects of being matched and mismatched on the percentage of abstinent days (PDA) and recovery status in the year after treatment.

FINDINGS

Being mismatched on any of the four patient-treatment pairings was a significant predictor of more frequent alcohol use post-treatment. Being matched on only two pairings predicted less frequent alcohol use, namely matches on therapy emotion focus with patient depressive symptoms and therapy structure with patient reactance. Matches appeared to optimize otherwise good outcomes, while mismatches had larger effect sizes and tended to predict relatively poor outcomes. The data supported the presence of an additive effect for mismatches on post-treatment PDA. The group with the most mismatches fared considerably worse than a group with fewer mismatches. Several matches and mismatches also predicted recovery status, with some support found for additive effects.

CONCLUSIONS

Mismatches between patient attributes and treatment appear to have serious consequences, and this effect is magnified with multiple mismatches. Matches, on the other hand, while beneficial, may not be necessary to achieve good outcomes.

Active ingredients: how and why evidence-based alcohol behavioral treatment interventions work

This article summarizes the proceedings of a symposium that was organized and chaired by Richard Longabaugh and presented at the 2004 Research Society on Alcoholism meeting in Vancouver, British Columbia, Canada. The aim of the presentation was to focus on evidence for the active ingredients of behavioral therapies for patients with alcohol use disorders. Dennis M. Donovan, PhD, reviewed evidence for the active ingredients of cognitive behavioral therapy. Barbara S. McCrady, PhD, presented a conceptual model for mechanisms of change in alcohol behavior couples therapy and reviewed evidence for this model. J. Scott Tonigan, PhD, presented data testing three hypothesized mechanisms of change in twelve-step facilitation treatment. Mitchell P. Karno, PhD, presented therapy process data that tested whether matching therapist behaviors to client attribute across three therapies affected drinking outcomes. Jon Morgenstern served as discussant.