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

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

Alcohol use disorders, self-help groups as a supplement to pharmacological and psychological therapy? A retrospective study in a population with alcohol related liver disease

BACKGROUND

According to the new criteria in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V), the prevalence of alcohol use disorders (AUDs) is 20-30% in men and 10-15% in women worldwide.2,3 The anticraving therapy/psychotherapy combination is currently used routinely in clinical practice. However, the results after one year are unsatisfactory. Meta-analytic studies found failure rates of 57 to 75%. These percentages vary in relation to the intensity and length of the treatment. In addition, the abstinence rates gradually decrease over time. In this study, the clinical outcome of alcohol related liver disease (ALD) patients who spontaneously attended self-help groups (SHGs) (club of alcoholics in treatment - multi-family community/ alcoholics anonymous) regularly versus those who did not want to start the path or did not complete it was evaluated.

METHODS

From January 2005 to December 2010, 1337 alcohol use disorder patients affected by compensated alcohol related liver disease, were prospectively followed and retrospectively assessed. Two hundred thirty-one patients were enrolled: 74 attended self-help groups assiduously, 27 attended sporadically and 130 refused participation in SHGs.

RESULTS

Constant attendance at SHGs compared to non-attendance allows for a significant increase (<0.0001) in the period of sobriety found in the median of distribution. Frequent attendance at SHGs is effectively "preventive," reducing the fraction of relapses by about 30%. The percentage of cases of cirrhosis is significantly different (P=0.0007) between those who have regularly attended SHG meetings (about 1% of patients) and those who have never attended or only occasionally (various percentages between 21 and 31% of patients); in both groups the incidence of new cases would seem to be 0.014 cases/ year. Similar difference in percentages regarding the onset of hepatocellular carcinomas (HCCs), although with a lower level of significance (P=0.017) among those who attended regularly, 4% of patients with an incidence of 0.006 cases/ year, compared to those who have never attended or only occasionally: over 14% of patients with an incidence of 0.022 cases/year.

CONCLUSIONS

This study suggests the importance of attending SHGs not only for the long-term achievement of alcoholic abstention, but also in positively influencing the course of alcohol-related diseases.

Alcohol use problems and conflict among couples: A preliminary investigation of the moderating effects of maladaptive cognitive emotion regulation strategies

Alcohol use can operate as a chronic relationship stressor with adverse influences on individual and relationship functioning, including negative conflict behaviors; however, it remains unclear what modifiable individual-level factors may moderate this association. The current study examined the effects of maladaptive cognitive emotion regulation strategies on the relation between alcohol use problems and negative relationship conflict behaviors. Participants were 30 couples (N=60) wherein at least one partner engaged in recent hazardous drinking or illicit drug use. Participants completed a measure of maladaptive cognitive emotion regulation strategies (i.e., catastrophizing, self-blame, blaming others, rumination) and engaged in a 10-minute dyadic conflict task in the laboratory. Couple conflict behaviors were video-recorded and assessed using a validated coding system. Actor partner interdependence models indicated that (1) men with more maladaptive cognitive emotion regulation strategies displayed more negative relationship conflict behaviors and (2) among women who use fewer maladaptive cognitive emotion regulation strategies, those who report alcohol use problems display more negative relationship behaviors than women who report fewer alcohol use problems. These findings suggest that the tendency to engage in fewer maladaptive cognitive emotion regulation strategies buffers the effect of conflict among women without alcohol use problems. Results also suggest that women with alcohol use problems engaged in more negative conflict behaviors regardless of their tendency to use maladaptive cognitive emotion regulation strategies. This research has important implications for integrating emotion regulation skills into alcohol use treatment for women, particularly later in the course of treatment.

Teacher's Corner: An R Shiny App for Sensitivity Analysis for Latent Growth Curve Mediation

Mechanisms of behavior change are the processes through which interventions are hypothesized to cause changes in outcomes. Latent growth curve mediation models (LGCMM) are recommended for investigating the mechanisms of behavior change because LGCMM models establish temporal precedence of change from the mediator to the outcome variable. The Correlated Augmented Mediation Sensitivity Analyses (CAMSA) App implements sensitivity analysis for LGCMM models to evaluate if a mediating path (mechanism) is robust to potential confounding variables. The CAMSA approach is described and applied to simulated data, and data from a research study exploring a mechanism of change in the treatment of substance use disorder.

Engagement in Harm Reduction Strategies After Suspected Fentanyl Contamination Among Opioid-Dependent Individuals

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially (Centers for Disease Control and Prevention in Opioid overdose, 2020c, https://www.cdc.gov/drugoverdose/data/otherdrugs.html#:~:text=Polysubstance%20drug%20use%20occurs%20with,or%20other%20non%2Dopioid%20substances ). Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates (Centers for Disease Control and Prevention in Drug overdose deaths involving fentanyl, 2011-2016, 2019a, https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf ). Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations (Kennedy et al. in Drug Alcohol Depend 185:248-252, 2018, https://doi.org/10.1016/j.drugalcdep.2017.12.026 ; Laing et al. in Int J Drug Policy 62:59-66, 2018, https://doi.org/10.1016/j.drugpo.2018.10.001 ). Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID's engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

Effects of couple conflict on alcohol craving: Does intimate partner violence play a role?

OBJECTIVE

Social stress in the form of maladaptive relationship conflict is a common precipitant to alcohol misuse and problems. Research has also established a clear causal association between alcohol misuse and relationship conflict in the form of intimate partner violence (IPV). Despite the robust literature linking relationship conflict and problematic drinking using survey methodology, no laboratory studies have examined the proximal association between relationship conflict and alcohol craving among couples, or the influence of IPV perpetration and victimization on this association.

METHOD

As part of a larger randomized controlled trial, 30 different-sex community couples with substance misuse completed a laboratory conflict resolution task. Participants reported subjective alcohol craving on a Likert-type scale immediately, before, and after the task. Conflict behaviors were coded by trained observers. Analyses were conducted using a multilevel modeling framework to account for the dyadic nature of the data.

RESULTS

Findings indicate that psychological and physical IPV perpetration and victimization strengthened the associations between negative and positive conflict behaviors and alcohol craving among men only. Contrary to our hypotheses, no main or moderating effects of conflict behaviors, IPV perpetration, or IPV victimization were found for women.

CONCLUSIONS

Findings from this exploratory study suggest that in this sample, relationship conflict and IPV in one's current relationship played a more impactful role on acute alcohol craving among men compared to women. Future studies should examine the role of specific conflict behaviors on alcohol craving and relapse risk, and patterns of communication that might increase or reduce risk for exacerbated alcohol craving.

The effects of alcohol dose, exposure to an in-vehicle alcohol feedback device, and subjective responses to alcohol on the decision to drink-drive in young drivers

BACKGROUND

Several factors may influence the decision to drink-drive (DD) in young drivers, such as the amount of alcohol consumed, exposure to an in-vehicle alcohol feedback device, and subjective responses to alcohol. Understanding of their influence on DD is lacking and may be key for targeted intervention. This randomized controlled, double-blinded, driving simulation experiment tested three main hypotheses; young drivers are more likely to engage in DD with: i) lower alcohol dose; ii) lack of exposure to an in-vehicle alcohol feedback (FB) device; and iii) lower subjective responses to alcohol intoxication (SR). Interactions between the decision to DD and SR, FB and sex were also explored.

METHODS

Males (n = 80) and females (n = 80) aged 20-24 years old were randomly assigned to two conditions: i) alcohol dose (0.45 g/kg or 0.65 g/kg); and ii) exposure to an in-vehicle alcohol feedback device (no or yes). Assessment of participants' SR following alcohol intake was based upon two measures: i) subjective intoxication measured by the discrepancy between an objective measure of intoxication and their subjective estimate of intoxication; and ii) perception of capacity to drive safely under alcohol (for both variables, a higher score represents lower SR). Participants were then asked to make either a negative or positive decision to DD while confronted with time-based contingencies related to their decision. Logistic regression and moderation analyses tested hypotheses.

RESULTS

Approximately 60 % of participants decided to DD. Higher odds of DD were found in participants reporting higher capacity to drive (adjusted odds ratio [β] = 1.03, 95 % confidence interval [CI] = 1.01-1.05) and who were males (β  = 7.70; 95 % CI = 1.34-5.57). A main effect of either FB exposure or alcohol dose was not detected. Moderation analysis showed that lower SR, represented by higher perceived capacity to drive safely under alcohol was selectively predictive of greater likelihood of a decision to DD in participants not exposed to FB (effect = .054, p < .001, 95 % CI = .026-.083).

CONCLUSIONS

Lower SR was found to be associated with a greater likelihood of the decision to DD in young drivers, while exposure to an in-vehicle FB device had no effect on DD. Importantly, FB exposure appeared to disrupt the relationship between lower SR and the decision to DD, signaling that FB may be selectively effective for young drivers possessing lower SR. Future studies are needed to clarify whether FB technology, and other interventions, can be targeted to deter DD in the young drivers most likely to benefit.

Pilot trial investigating a brief behavioral economic intervention as an adjunctive treatment for alcohol use disorder

OBJECTIVE

Behavioral economic research suggests that increasing the salience of a delayed reward may improve capacity for delaying gratification and increase behavior allocated toward obtaining larger, delayed substance-free reward rather than smaller, more immediate reward such as alcohol use. This study aimed to improve the efficacy of outpatient alcohol use disorder (AUD) treatment by adding elements that target behavioral economic mechanisms of change.

METHOD

Forty-one (N = 41) adults in outpatient AUD treatment were recruited and 37 participants were retained at follow-up. Following baseline assessment, participants received either the Substance Free Activity Session (SFAS), a single-session behavioral economic-informed intervention focused on increasing future orientation and engagement in values-based substance-free activities or a health education control intervention. Participants in both conditions received weekly prompts (via text or email) relevant to their respective intervention for four weeks. Participants (68.3% male; 70.7% Caucasian, M age = 38.24, SD = 12.69) reported an average of 3.95 (SD = 4.72) binge drinking episodes (4/5 drinks per occasion for a woman/man) and 5.05 (SD = 5.32) drinks per drinking day 30-days prior to treatment entry.

RESULTS

The study provided initial support for the feasibility and acceptability of implementing the SFAS within a treatment setting. Participants reported high levels of satisfaction with the SFAS (M = 9.08 (SD = 0.94), on a scale of 1-10). At 3-month follow-up, the SFAS was associated with reductions in the proportion of activity participation and enjoyment (reinforcement) related to substance-use relative to substance-free activities and in alcohol demand compared to control.

CONCLUSION

These preliminary results provide initial support for targeting behavioral economic mechanisms of change in an outpatient AUD treatment with a single-session intervention plus remote delivery of booster prompts.

Mechanisms of change in female-specific and gender-neutral cognitive behavioral therapy for women with alcohol use disorder

OBJECTIVE

In a randomized trial for women with alcohol use disorders (AUD), the efficacy of Female-Specific Cognitive Behavioral Therapy (FS-CBT) was compared with Gender-Neutral CBT (GN-CBT; Epstein et al., 2018). The current study examined whether putative mechanisms of change differed between treatment conditions, using a novel statistical approach. Both treatments were hypothesized to work by increasing use of alcohol-related coping skills (coping) and confidence to abstain from drinking (confidence), but FS-CBT additionally targeted female-salient mechanisms: anxiety, depression, sociotropy (i.e., overinvestment in others' opinion of oneself), autonomy, and social networks supportive of abstinence.

METHOD

Ninety-nine women with AUD (55 in GN-CBT, 44 in FS-CBT) completed self-report assessments at baseline and 0, 6, and 12 months posttreatment. Multilevel vector autoregression estimation was used to analyze associations between putative mechanisms of change, and network models of those associations were generated using network analysis.

RESULTS

Across conditions, higher confidence and coping were directly associated with less drinking; autonomy was directly and indirectly associated with drinking. Additionally, network analysis indicated that although variation in depression was associated with change in other variables specifically for GN-CBT, sociotropy was associated with change specifically in FS-CBT.

CONCLUSIONS

Women receiving CBT-AUD changed their drinking through increased confidence to abstain and greater use of coping skills. Autonomy played a central role in behavior change across treatment conditions. Participants receiving treatment tailored to women also changed through decreases in sociotropy and increases in social support for abstinence. For women who received standard CBT, changes in depression were important to clinical improvement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Changes in Hypothesized Mechanisms of Change Before and After Initiating Abstinence in Cognitive-Behavioral Therapy for Women With Alcohol Use Disorder

Abstinence self-efficacy, coping skills, and therapeutic alliance are hypothesized mechanisms of behavioral change (MOBCs) in cognitive-behavioral therapy (CBT) for alcohol use disorder (AUD). However, little is known about when these hypothesized MOBCs change during treatment or in relation to the initiation of abstinence from alcohol, which the current study investigated. Patient-reported abstinence self-efficacy, drinking-related coping skills, and therapeutic alliance were measured at every session throughout a 12-session clinical trial that previously showed equivalent drinking reductions in female-specific individual- and group-based CBT for AUD. Participants (N = 121 women) were classified into subgroups based on whether and when they first initiated 14 days of continuous abstinence from alcohol during treatment. Interrupted time-series analyses evaluated the magnitude and timing of change in MOBC variables in relation to the initiation of abstinence. All three MOBC measures showed gradual improvements throughout treatment (within-subjects d = 0.03 to 0.09 change per week). Participants who initiated abstinence during treatment experienced additional sudden improvements in abstinence self-efficacy (d = 0.47) and coping skills (d = 0.27), but not therapeutic alliance (d = -0.02), the same week they initiated abstinence. Participants who were already abstinent when treatment started maintained higher abstinence self-efficacy and coping skills, but not therapeutic alliance, throughout treatment compared to participants who never initiated abstinence. Initiating abstinence may help facilitate improvements in abstinence self-efficacy and drinking-related coping skills. Clinicians may help patients anticipate when and how much these variables are expected to improve during treatment and encourage initiation of abstinence to potentially help facilitate improvements in abstinence self-efficacy and coping skills.

Broad Coping Repertoire Mediates the Effect of the Combined Behavioral Intervention on Alcohol Outcomes in the COMBINE Study: An Application of Latent Class Mediation

OBJECTIVE

Few studies have found support for coping as a mechanism of behavior change (MOBC) following coping skills training interventions for alcohol use disorder (AUD). One potential reason for null findings is heterogeneity in the patterns of coping skills acquired during treatment. This study sought to identify latent classes of coping and to test the latent class variable as a mediator of the effect of a combined behavioral intervention for AUD.

METHOD

Secondary analyses of data from the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) Study (N = 1,124; mean age = 44.4 years; 69.1% male; 23.2% non-White), a multisite study of medication and behavioral treatments for individuals with AUD. Latent class mediation models were estimated to test whether patterns of alcohol-specific coping mediated the effect of combined behavioral intervention with medication management, as compared with medication management only, on drinking outcomes 12 months following treatment.

RESULTS

Three classes were identified, which differed in repertoire broadness, or the degree in which a wide range of different skills were used. Coping repertoire class was a significant mediator of the effect of the combined behavioral intervention on drinking outcomes. Receiving the combined behavioral intervention, in addition to medication management, predicted a greater likelihood of expected classification in the broad coping repertoire class, which in turn was associated with significant improvements in drinking outcomes.

CONCLUSIONS

Using the novel methodological approach of latent class mediation, this study identified coping repertoire as a significant mediator of behavioral intervention efficacy for AUD. Future work examining heterogeneity in mediators and outcomes may help refine AUD treatment to be maximally effective.

Computerized Cognitive Behavioral Therapy for Substance Use Disorders: A Summary of the Evidence and Potential Mechanisms of Behavior Change

Cognitive-behavioral therapy (CBT) is one of the most evaluated behavioral interventions for substance use disorders, with considerable empirical evidence supporting its efficacy. However, despite CBT's strong support from efficacy trials, broad dissemination and implementation have been challenging. Furthermore, there remains limited understanding regarding CBT's mechanisms of behavior change; the theory-driven assumption that individuals acquire new skills for coping with triggers for substance use has notoriously lacked statistical support. The emergence of computer-delivered interventions has the potential to address dissemination and implementation challenges, as well as offer advantages toward understanding treatment mechanisms. This article will provide a summary of the current evidence supporting one particular computerized CBT program, CBT4CBT. Multiple clinical trials in different treatment settings have indicated CBT4CBT's efficacy at reducing rates of alcohol and drug use when provided as an add-on to standard addiction treatment, as well as when provided with minimal clinical monitoring (i.e., virtual stand-alone). These effects have also been relatively durable after treatment termination, consistent with findings of traditional CBT. It is important to note that the evaluation of individuals' cognitive and behavioral coping skills prior and following treatment has indicated the acquisition/improvement of these skills may be a mechanism of behavior change for those who engage with CBT4CBT. Thus, computerized delivery may be a strategy for enhancing individuals' learning of cognitive and behavioral skills for successfully avoiding substance use. Future work should aim to identify the optimal type of setting, clinician role, and patient characteristics for targeted dissemination and implementation.

AA attendance and abstinence for dually diagnosed patients: a meta-analytic review

BACKGROUND AND AIMS

There is consensus that best clinical practice for dual diagnosis (DD) is integrated mental health and substance use treatment augmented with Alcoholics Anonymous (AA) attendance. This is the first quantitative review of the direction and magnitude of the association between AA attendance and alcohol abstinence for DD patients.

METHOD

A systematic literature search (1993-2017) identified 22 studies yielding 24 effect sizes that met our inclusion criteria (8075 patients). Inverse-variance weighting of correlation coefficients (r) was used to aggregate sample-level findings and study aims were addressed using random- and mixed-effect models. Sensitivity and publication bias analyses were conducted to assess the likelihood of bias in the overall estimate of AA-related benefit.

RESULTS

AA exposure and abstinence for DD patients were associated significantly and positively [r_w  = 0.249; 95% confidence interval (CI) = 0.203-0.293; tau = 0.097). There was also significant heterogeneity in the distribution of effect sizes and high between-sample variance (I²  = 74.6, P < 0.001). Subgroup analyses indicated that the magnitude of AA-related benefit did not differ between 6- (k = 7) and 12- (k = 12) month follow-up (Q = 0.068, P = 0.794), type of treatment received (in-patient k = 9; intensive out-patient, out-patient, community k = 15; Q = 2.057, P = 0.152), and whether a majority of patients in a sample had (k = 11) or did not have (k = 13) major depression (Q = 0.563, P = 0.453). Sensitivity analyses indicated that the overall meta-analytical estimate of AA benefit was not impacted adversely or substantively by pooling randomized controlled trial (RCT) and observational samples (Q = 0.763, P = 0.382), pooling count, binary and ordinal-based AA (Q = 0.023, P = 0.879) and outcome data (Q = 1.906, P = 0.167) and reversing direction of correlations extracted from studies (Q = 0.006, P = 0.937). No support was found for publication bias.

CONCLUSIONS

Clinical referral of dual diagnosis patients to Alcoholics Anonymous is common and, in many cases, dual diagnosis patients who attend Alcoholics Anonymous will report higher rates of alcohol abstinence relative to dual diagnosis patients who do not attend Alcoholics Anonymous.

Therapist-delivered and self-help interventions for gambling problems: A review of contents

Background and aims To date, no systematic approach to identifying the content and characteristics of psychological interventions used to reduce gambling or problem gambling has been developed. This study aimed to develop a reliable classification system capable of identifying intervention characteristics that could, potentially, account for greater or lesser effectiveness. Methods Intervention descriptions were content analyzed to identify common and differentiating characteristics. A coder manual was developed and applied by three independent coders to identify the presence or absence of defined characteristics in 46 psychological and self-help gambling interventions. Results The final classification taxonomy, entitled Gambling Intervention System of CharacTerization (GIST), included 35 categories of intervention characteristics. These were assigned to four groups: (a) types of change techniques (18 categories; e.g., cognitive restructuring and relapse prevention), (b) participant and study characteristics (6 categories; e.g., recruitment strategy and remuneration policy), and (c) characteristics of the delivery and conduct of interventions (11 categories; e.g., modality of delivery and therapist involvement), and (d) evaluation characteristics (e.g., type of control group). Interrater reliability of identification of defined characteristics was high (κ = 0.80-1.00). Discussion This research provides a tool that allows systematic identification of intervention characteristics, thereby enabling consideration, not only of whether interventions are effective or not, but also of which domain-relevant characteristics account for greater or lesser effectiveness. The taxonomy also facilitates standardized description of intervention content in a field in which many diverse interventions have been evaluated. Conclusion Application of this coding tool has the potential to accelerate the development of more efficient and effective therapist-delivered and self-directed interventions to reduce gambling problems.

Effects of Initiating Abstinence from Alcohol on Daily Craving and Negative Affect: Results from a Pharmacotherapy Clinical Trial

BACKGROUND

Craving and negative affect are distressing and commonly experienced during alcohol use disorder (AUD) treatment. Patients may assume that initiating abstinence will intensify their cravings and negative affect despite limited empirical data to support this assumption. This study extends and replicates, under improved methodological conditions, previous work that found reductions in daily craving associated with initiating abstinence.

METHODS

Seventy-eight adults (80.8% male, 57.1% Caucasian) in a clinical trial testing prazosin for AUD provided daily reports of drinking, craving, and negative affect for up to 12 weeks (mean = 64.77 daily reports). Participants were classified into 3 subgroups based on whether and when they initiated 14 days of continuous abstinence, including (i) "abstinence initiators" who quit drinking during treatment (n = 17), (ii) "already abstainers" who were abstinent at the start of treatment (n = 20), and (iii) "continued drinkers" who never initiated abstinence (n = 41). The timing and degree of change in craving and negative affect were compared across these groups using multivariate growth curve modeling.

RESULTS

All participant subgroups reported gradual reductions in craving over the course of treatment, with "abstinence initiators" reporting additional sudden reductions in craving upon initiating abstinence from alcohol. "Continued drinkers" reported higher levels of craving than "already abstainers" throughout the full course of treatment. Negative affect followed a different pattern of change, with "abstinence initiators" experiencing gradual reductions in negative affect after initiating abstinence but no changes prior to or immediately upon initiating abstinence, and with "already abstainers" and "continued drinkers" experiencing no changes in negative affect over time.

CONCLUSIONS

Initiating abstinence is associated with immediate reductions in craving, followed by gradual reductions in both craving and negative affect. Results provide insight into the timing and magnitude of changes in theoretically and clinically important variables and may help patients anticipate when to expect improvement in craving and negative effect.

Advancing Analytic Approaches to Address Key Questions in Mechanisms of Behavior Change Research

OBJECTIVE

Interest in studying mechanisms of behavior change (MOBCs) in substance use disorder (SUD) treatments has grown considerably in the past two decades. Much of this work has focused on identifying which variables statistically mediate the effect of SUD treatments on clinical outcomes. However, a fuller conceptualization of MOBCs will require greater understanding of questions that extend beyond traditional mediation analysis, including better understanding of when MOBCs change during treatment, when they are most critical to aiding the initiation or maintenance of change, and how MOBCs themselves arise as a function of treatment processes.

METHOD

In the present study, we review why these MOBC-related questions are often minimally addressed in empirical research and provide examples of data analytic methods that may address these issues. We highlight several recent studies that have used such methods and discuss how these methods can provide unique theoretical insights and actionable clinical information.

RESULTS

Several statistical approaches can enhance the field's understanding of the timing and development of MOBCs, including growth-curve modeling, time-varying effect modeling, moderated mediation analysis, dynamic systems modeling, and simulation methods.

CONCLUSIONS

Adopting greater diversity in methods for modeling MOBCs will help researchers better understand the timing and development of key change variables and will expand the theoretical precision and clinical impact of MOBC research. Advances in research design, measurement, and technology are key to supporting these advances.

Reasons for Testing Mediation in the Absence of an Intervention Effect: A Research Imperative in Prevention and Intervention Research

OBJECTIVE

Mediation models are used in prevention and intervention research to assess the mechanisms by which interventions influence outcomes. However, researchers may not investigate mediators in the absence of intervention effects on the primary outcome variable. There is emerging evidence that in some situations, tests of mediated effects can be statistically significant when the total intervention effect is not statistically significant. In addition, there are important conceptual and practical reasons for investigating mediation when the intervention effect is nonsignificant.

METHOD

This article discusses the conditions under which mediation may be present when an intervention effect does not have a statistically significant effect and why mediation should always be considered important.

RESULTS

Mediation may be present in the following conditions: when the total and mediated effects are equal in value, when the mediated and direct effects have opposing signs, when mediated effects are equal across single and multiple-mediator models, and when specific mediated effects have opposing signs. Mediation should be conducted in every study because it provides the opportunity to test known and replicable mediators, to use mediators as an intervention manipulation check, and to address action and conceptual theory in intervention models.

CONCLUSIONS

Mediators are central to intervention programs, and mediators should be investigated for the valuable information they provide about the success or failure of interventions.

Depressive symptoms mediate the relationship between changes in emotion regulation during treatment and abstinence among women with alcohol use disorders

Women with alcohol use disorders (AUD) experience high rates of co-occurring conditions, such as depression and posttraumatic stress disorder (PTSD), which can complicate treatment engagement and response. Therefore, identifying factors that underlie alcohol use, depression, and PTSD symptoms in women with AUD has important treatment implications. The current study investigated emotion regulation as one such underlying factor. We tested a model that examined the extent to which changes in emotion regulation during treatment predicted women's depression and PTSD symptom severity at treatment completion and subsequent alcohol use following treatment. The study included 48 participants enrolled in a randomized controlled trial of interpersonal psychotherapy versus usual care for women with co-occurring alcohol dependence and major depression. Assessments were conducted at baseline, posttreatment (16 weeks), and follow-up (24 weeks). Descriptive statistics of baseline data revealed heightened levels of emotion dysregulation in this sample, which were related to fewer days abstinent from alcohol, more negative consequences from alcohol, and greater PTSD symptom severity. Women's lower depressive symptoms at the end of treatment were found to mediate the relationship between improved emotion regulation during the treatment period and greater abstinence following treatment. Posttreatment PTSD symptoms, however, were not found to mediate that relationship. These results suggest that improvements in depressive symptoms during treatment are associated with emotion regulation at the end of treatment, which may contribute to greater abstinence from alcohol following treatment. (PsycINFO Database Record

Interventions for comorbid problem gambling and psychiatric disorders: Advancing a developing field of research

Despite significant psychiatric comorbidity in problem gambling, there is little evidence on which to base treatment recommendations for subpopulations of problem gamblers with comorbid psychiatric disorders. This mini-review draws on two separate systematic searches to identify possible interventions for comorbid problem gambling and psychiatric disorders, highlight the gaps in the currently available evidence base, and stimulate further research in this area. In this mini-review, only 21 studies that have conducted post-hoc analyses to explore the influence of psychiatric disorders or problem gambling subtypes on gambling outcomes from different types of treatment were identified. The findings of these studies suggest that most gambling treatments are not contraindicated by psychiatric disorders. Moreover, only 6 randomized studies comparing the efficacy of interventions targeted towards specific comorbidity subgroups with a control/comparison group were identified. The results of these studies provide preliminary evidence for modified dialectical behavior therapy for comorbid substance use, the addition of naltrexone to cognitive-behavioral therapy (CBT) for comorbid alcohol use problems, and the addition of N-acetylcysteine to tobacco support programs and imaginal desensitisation/motivational interviewing for comorbid nicotine dependence. They also suggest that lithium for comorbid bipolar disorder, escitalopram for comorbid anxiety disorders, and the addition of CBT to standard drug treatment for comorbid schizophrenia may be effective. Future research evaluating interventions sequenced according to disorder severity or the functional relationship between the gambling behavior and comorbid symptomatology, identifying psychiatric disorders as moderators of the efficacy of problem gambling interventions, and evaluating interventions matched to client comorbidity could advance this immature field of study.

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.

Therapist empathy, combined behavioral intervention, and alcohol outcomes in the COMBINE research project

OBJECTIVE

Common factors such as therapist empathy play an important role in treatment for addictive behaviors. The present study was a secondary analysis designed to evaluate the relation between therapist empathy and alcohol treatment outcomes in data from a large, multisite, randomized controlled trial.

METHOD

Audio-recorded psychotherapy sessions for 38 therapists and 700 clients had been randomly selected for fidelity coding from the combined behavioral intervention condition of Project COMBINE. Sessions were evaluated by objective raters for both specific content (coping with craving, building social skills, and managing negative mood) and relational components (empathy level of the therapist). Multilevel modeling with clients nested within therapists evaluated drinks per week at the end of treatment.

RESULTS

Approximately 11% of the variance in drinking was accounted for by therapists. A within-therapist effect of empathy was detected (B = -0.381, SE = 0.103, p < .001); more empathy than usual was associated with subsequent decreased drinking. The Social and Recreational Counseling module (B = -0.412, SE = 0.124, p < .001), Coping with Cravings and Urges module (B = -0.362, SE = 0.134, p < .01), and the Mood Management module (B = -0.403, SE = 0.138, p < .01) were also associated with decreased drinking. No between-therapist effect was detected, and the Empathy × Module Content interactions were not significant.

CONCLUSIONS

The results of the study appear consistent with the hypothesis that skills building and therapist empathy are independent contributions to the overall benefit derived from the combined behavioral intervention.

Active Ingredients of Treatment and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later

BACKGROUND

The current review revisits the article entitled: "Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work" published in Alcoholism: Clinical and Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that.

METHODS

The current review revisits state-of-the-art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12-step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future.

RESULTS

Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence-based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods.

CONCLUSIONS

Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.

Measurement error and outcome distributions: Methodological issues in regression analyses of behavioral coding data

Behavioral coding is increasingly used for studying mechanisms of change in psychosocial treatments for substance use disorders (SUDs). However, behavioral coding data typically include features that can be problematic in regression analyses, including measurement error in independent variables, non normal distributions of count outcome variables, and conflation of predictor and outcome variables with third variables, such as session length. Methodological research in econometrics has shown that these issues can lead to biased parameter estimates, inaccurate standard errors, and increased Type I and Type II error rates, yet these statistical issues are not widely known within SUD treatment research, or more generally, within psychotherapy coding research. Using minimally technical language intended for a broad audience of SUD treatment researchers, the present paper illustrates the nature in which these data issues are problematic. We draw on real-world data and simulation-based examples to illustrate how these data features can bias estimation of parameters and interpretation of models. A weighted negative binomial regression is introduced as an alternative to ordinary linear regression that appropriately addresses the data characteristics common to SUD treatment behavioral coding data. We conclude by demonstrating how to use and interpret these models with data from a study of motivational interviewing. SPSS and R syntax for weighted negative binomial regression models is included in online supplemental materials.

Using spiritually modified cognitive-behavioral therapy in substance dependence treatment: therapists' and clients' perceptions of the presumed benefits and limitations

Cognitive-behavioral therapy (CBT) that has been modified to incorporate clients' spiritual beliefs and practices has been used to treat a variety of problems. This study examines the utility of this modality with the treatment of alcohol dependence and other forms of substance abuse. Toward this end, six focus groups (three therapist groups and three client groups) were conducted to identify the presumed benefits and limitations of using spiritually modified CBT in substance dependence treatment. In terms of benefits, spiritually modified CBT was perceived to enhance outcomes through operationalizing horizontal and vertical sources of social support, divine coping resources, and spiritual motivation. Potential challenges include the risk of therapists inadvertently imposing their own beliefs during the modification process and the possibility of offending clients when conflicts in belief systems emerge, particularly in group setting. The article concludes by providing suggestions for incorporating spiritually modified CBT into treatment and develops a number of illustrative examples of spiritually modified CBT self-statements.

Multiple dimensions of spirituality in recovery: a lagged mediational analysis of Alcoholics Anonymous' principal theoretical mechanism of behavior change

Alcoholics Anonymous (AA) states that recovery is possible through spiritual experiences and spiritual awakenings. Research examining spirituality as a mediator of AA's effect on drinking has been mixed. It is unknown whether such findings are due to variations in the operationalization of key constructs, such as AA and spirituality. To answer these questions, the authors used a longitudinal model to test 2 dimensions of AA as focal predictors and 6 dimensions of spirituality as possible mediators of AA's association with drinking. Data from the first 18 months of a 3-year longitudinal study of 364 alcohol-dependent individuals were analyzed. Structural equation modeling was used to replicate the analyses of Kelly et al. (Alcohol Clin Exp Res. 2011;35:454-463) and to compare AA attendance and AA involvement as focal predictors. Multiple regression analyses were used to determine which spirituality dimensions changed as the result of AA participation. A trimmed, data-driven model was employed to test multiple mediation paths simultaneously. The findings of the Kelly et al. study were replicated. AA involvement was a stronger predictor of drinking outcomes than AA attendance. AA involvement predicted increases in private religious practices, daily spiritual experiences, and forgiveness of others. However, only private religious practices mediated the relationship between AA and drinking.

The effect of drinking goals at treatment entry on longitudinal alcohol use patterns among adults with alcohol dependence

BACKGROUND

Drinking goals at treatment entry are a promising, yet under-studied mechanism of change in alcohol use following treatment. It is not known who, upon treatment entry, is likely to desire abstinence as a drinking goal and whether desiring abstinence as a drinking goal influences alcohol use following treatment.

METHODS

Data from a 2.5-year longitudinal study of alcohol-dependent adults from 3 treatment sites is examined in a secondary data analysis. At treatment entry, participants reported sociodemographic and clinical characteristics, as well as whether they desired abstinence as a drinking goal or not. At each subsequent wave, participants reported their alcohol use.

RESULTS

Bivariate analyses showed that individuals from a VA outpatient treatment site, men, and racial or ethnic minorities were most likely to desire abstinence as a drinking goal at treatment entry. Multi-level mixed effects regression models indicated that individuals who at baseline desired abstinence as a drinking goal sustained higher percentage of days abstinent and higher percentage of days since last drink 2.5 years following treatment entry, compared to individuals who did not desire abstinence.

CONCLUSIONS

Understanding who is most likely to desire the specific drinking goal of abstinence can assist clinicians in anticipating client response to goal setting. Furthermore, by understanding the benefits and risks associated with drinking goals, clinicians can focus attention to individuals who desire a more risk-laden goal, including goals of non-abstinence, and tailor interventions, including motivational interviewing techniques, to support effective goals.

Efficacy combined with specified ingredients: a new direction for empirically supported addiction treatment

AIMS

With the increased need for sanctioning behavioral addiction treatments to guide key stakeholders, focus has shifted to developing and applying criteria for establishing empirically supported treatments (EST). Among the many criteria offered, demonstration of incremental efficacy over a placebo or comparison in at least two independent randomized clinical trials (RCTs) has been the gold standard. While necessary, the present EST criteria are not sufficient. The present work: (i) argues for empirically supported specificity in behavioral addiction treatment, (ii) explores the limitations of empirical support for EST efficacy without evidence of specificity and (iii) discusses implications and recommendations for ultimately raising the bar for status as an EST.

METHODS

The authors review relevant literature on ESTs, evidence-based practice and clinical trial design in the addictions and related disciplines.

RESULTS

We clarify that the additional bar of specificity does not denote uniqueness in causal processes and we argue that specificity should not be inferred only via the nature of the experimental contrast. Rather, a treatment has specificity if its active ingredients are identified and validated empirically as predictors of subsequent treatment-related outcomes. Within this new definition, there are implications for clinical research and other key stakeholders.

CONCLUSIONS

A heightened centrality of empirically supported addiction treatment ingredients moving forward will advance clinical knowledge and evaluation methodology at a far greater pace.

Abstinence self-efficacy in people with severe mental illness

To validate the Brief Situational Confidence Questionniare (BSCQ) with people diagnosed with severe mental illness (N=129), we examined the associations between abstinence self-efficacy (BSCQ) and alcohol consumption level (within the previous 6months), drug use, and problems related to substance use while controlling for key symptoms of major mental illness and motives for alcohol use (Drinking Motives Questionnaire). Regression models revealed that abstinence self-efficacy was a significant predictor of all three substance use measures suggesting that, even when controlling for psychiatric symptoms and substance use motives, abstinence self-efficacy accounts for unique variance in alcohol use, drug use, and related problems. This study is limited by the cross sectional design and lack of structured diagnostic interviewing.

12-step affiliation and attendance following treatment for comorbid substance dependence and depression: a latent growth curve mediation model

Among substance-dependent individuals, comorbid major depressive disorder (MDD) is associated with greater severity and poorer treatment outcomes, but little research has examined mediators of posttreatment substance use outcomes within this population. Using latent growth curve models, the authors tested relationships between individual rates of change in 12-step involvement and substance use, utilizing posttreatment follow-up data from a trial of group Twelve-Step Facilitation (TSF) and integrated cognitive-behavioral therapy (ICBT) for veterans with substance dependence and MDD. Although TSF patients were higher on 12-step affiliation and meeting attendance at end-of-treatment as compared with ICBT, they also experienced significantly greater reductions in these variables during the year following treatment, ending at similar levels as ICBT. Veterans in TSF also had significantly greater increases in drinking frequency during follow-up, and this group difference was mediated by their greater reductions in 12-step affiliation and meeting attendance. Patients with comorbid depression appear to have difficulty sustaining high levels of 12-step involvement after the conclusion of formal 12-step interventions, which predicts poorer drinking outcomes over time. Modifications to TSF and other formal 12-step protocols or continued therapeutic contact may be necessary to sustain 12-step involvement and reduced drinking for patients with substance dependence and MDD.

Associations between Relationship Satisfaction and Drinking Urges for Women in Alcohol Behavioral Couples and Individual Therapy

This study examined the association between relationship satisfaction and drinking urges among women who participated in alcohol behavioral individual therapy (ABIT) and Alcohol Behavioral Couples Therapy (ABCT). Relationship satisfaction and drinking urges were not related on a daily level, but urges were related to mean levels of relationship satisfaction and this association was moderated by treatment condition and time in treatment. Women with higher relationship satisfaction had fewer drinking urges, and women in ABCT with higher relationship satisfaction experienced greater reductions in urges during treatment. These findings suggest that ABCT may target the association between relationship satisfaction and drinking urges.

Two approaches to tailoring treatment for cultural minority adolescents

At this time, compared with mainstream (Caucasian) youth, cultural minority adolescents experience more severe substance-related consequences and are less likely to receive treatment. Although several empirically supported interventions (ESIs), such as motivational interviewing (MI), have been evaluated with mainstream adolescents, fewer published studies have investigated the fit and efficacy of these interventions with cultural minority adolescents. In addition, many empirical evaluations of ESIs have not explicitly attended to issues of culture, race, and socioeconomic background in their analyses. As a result, there is some question about the external validity of ESIs, particularly in disadvantaged cultural minority populations. This review seeks to take a step toward filling this gap, by addressing how to improve the fit and efficacy of ESIs like MI with cultural minority youth. Specifically, this review presents the existing literature on MI with cultural minority groups (adult and adolescent), proposes two approaches for evaluating and adapting this (or other) behavioral interventions, and elucidates the rationale, strengths, and potential liabilities of each tailoring approach.

Drink refusal training as part of a combined behavioral intervention: effectiveness and mechanisms of change

OBJECTIVE

Many trials have demonstrated the effectiveness of cognitive behavioral interventions for alcohol dependence, yet few studies have examined why particular treatments are effective. This study was designed to evaluate whether drink refusal training was an effective component of a combined behavioral intervention (CBI) and whether change in self-efficacy was a mechanism of change following drink refusal training for individuals with alcohol dependence.

METHOD

The present study is a secondary analysis of data from the COMBINE study (COMBINE Study Research Group, 2003), a randomized clinical trial that combined pharmacotherapy with behavioral intervention in the treatment of alcohol dependence. The goal of the present study was to examine whether a drink refusal skills training module, administered as part of a 16-week CBI (n = 776; 31% female, 23% non-White, average age = 44) predicted changes in drinking frequency and self-efficacy during and following the CBI, and whether changes in self-efficacy following drink refusal training predicted changes in drinking frequency up to 1 year following treatment.

RESULTS

Participants (n = 302) who received drink refusal skills training had significantly fewer drinking days during treatment (d = 0.50) and up to 1 year following treatment (d = 0.23). In addition, the effect of the drink refusal skills training module on drinking outcomes following treatment was significantly mediated by changes in self-efficacy, even after controlling for changes in drinking outcomes during treatment (proportion mediated = 0.47).

CONCLUSIONS

Drink refusal training is an effective component of CBI, and some of the effectiveness may be attributed to changes in client self-efficacy.

Review of outcome research on marital and family therapy in treatment for alcoholism

This review of controlled studies of marital and family therapy (MFT) in alcoholism treatment updates the earlier review by O'Farrell and Fals-Stewart (2003). We conclude that, when the alcoholic is unwilling to seek help, MFT is effective in helping the family cope better and motivating alcoholics to enter treatment. Specifically, both Al-Anon facilitation and referral and spouse coping skills training (based on new findings) help family members cope better, and CRAFT promotes treatment entry and was successfully transported to a community clinic in a new study. Once the alcoholic enters treatment, MFT, particularly behavioral couples therapy (BCT), is clearly more effective than individual treatment at increasing abstinence and improving relationship functioning. New BCT studies showed efficacy with women alcoholics and with gay and lesbian alcoholics, and BCT was successfully transported to a community clinic, a brief BCT version was tested, and BCT was adapted for family members other than spouses. Future studies should evaluate the following: MFT with couples where both members have a current alcohol problem and with minority patients, mechanisms of change, transportability of evidence-based MFT approaches to clinical practice settings, and replication of MFT outcomes of reduced partner violence and improved child functioning.

The PALS prevention program and its long-term impact on student intentions to use alcohol, tobacco, and marijuana

A unique Alcohol, Tobacco, and Other Drug (ATOD) prevention program called PALS (Prevention through Alternative Learning Styles) was implemented with middle school students with the goal of enhancing student knowledge of the harmful effects of ATOD, promoting the use of refusal skills and reducing intentions to use ATOD in the future. Intentions to use were measured at four points: pre-PALS, post-PALS, and at 1-year and 2-year follow-ups. Student survey responses were then matched and compared across the four time periods. This article reports on the long-term effectiveness of PALS on student intentions to use ATOD in high school. When follow-up surveys of PALS students were compared to students not exposed to PALS (comparison group), the PALS students had significantly lower intentions to use alcohol and tobacco, providing evidence that the PALS intervention did have a long-term impact on intentions to use these substances.

Do women differ from men on Alcoholics Anonymous participation and abstinence? A multi-wave analysis of treatment seekers

BACKGROUND

Given the widespread use of Alcoholics Anonymous (AA) and other similar groups in the United States and the increasing membership of women, this study compares women with men on their meeting attendance and AA-prescribed behaviors, factors associated with that AA participation, and tests how these relate to women's and men's abstinence across time.

METHODS

All consecutive new admissions (age ≥ 18) from county-wide public and private treatment programs representing the larger population of treatment seekers were approached to be in the study at treatment entry. Those consenting at baseline (n = 926) were sought for follow-up interviews 1, 3, 5, and 7 years later. Generalized linear models were used to test whether various help-seeking factors were associated with AA participation differentially by gender and, controlling for AA and other confounders, whether women differ from men on abstinence.

RESULTS

At each follow-up interview, women and men attended AA at similar rates and similarly practiced specific AA behaviors, and they were alike on most factors associated with AA participation and abstention across time including abstinence goal, drink volume, negative consequences, prior treatment, and encouragement to reduce drinking. Relative to men, women with higher drug severity were less likely to participate in AA. Although higher AA participation was a predictor of abstinence for both genders, men were less likely to be abstinent across time. Men were also more likely to reduce their AA participation across time.

CONCLUSIONS

These findings add to an emerging literature on how women compare with men on factors related to AA participation and subsequent drinking outcomes across time. Findings have clinical implications for service providers referring clients to such groups.

The role of self-efficacy in the treatment of substance use disorders

Self-efficacy is the belief that one has the ability to implement the behaviors needed to produce a desired effect. There has been growing interest in the role of self-efficacy as a predictor and/or mediator of treatment outcome in a number of domains. The present paper reviews the recent literature on self-efficacy in the substance abuse field. In numerous studies of substance abuse treatment, self-efficacy has emerged as an important predictor of outcome, or as a mediator of treatment effects. Despite these repeated positive findings, the self-efficacy concept has had little impact on the design of treatments. Since the concept was first introduced, there have been numerous suggestions regarding the means by which self-efficacy may be enhanced in clinical settings, but very little by way of empirical tests of those suggestions. This review concludes with a number of recommendations for further research to improve understanding of this potentially valuable concept and its interactions with other variables, and to develop effective strategies for enhancing self-efficacy.

Substance use in lesbian, gay, and bisexual populations: an update on empirical research and implications for treatment

Historically, substance use problems were thought to be more prevalent in lesbian, gay, and bisexual (LGB) populations, and correcting skewed perceptions about substance abuse among LGB individuals is critically important. This review provides an update on empirical evidence on LGB substance use patterns and treatment outcome, with specific focus on clinical implications of findings. Compared to earlier studies, the recent research included in this review has used more sophisticated methodologies and more representative samples, and also has investigated multiple dimensions of sexual orientation in relation to substance use patterns. Findings from recent research suggest that lesbians and bisexual women are at greater risk for alcohol and drug use disorders and related problems, and that gay and bisexual men are at greater risk for illicit drug use and related problems. Several sociocultural factors have emerged as correlates of substance use patterns in LGB populations (e.g., affiliation with gay culture, HIV status), and several demographic characteristics (e.g., female, older age) do not appear to be as robust of protective factors against substance abuse for LGB individuals compared to heterosexual populations. Bisexual identity and/or behavior in particular seem to be related to increased risk for substance abuse. In terms of treatment outcome, limitations of extant research prevent conclusions about the relative impact of LGB-specific interventions, and further research that includes women and uses more equivalent comparison interventions is needed. Clinical implications of research findings are discussed for case identification, selection of treatment goals (e.g., moderation vs. abstinence), targets for intervention, and specific treatment modalities.

Female condom skill and attitude: results from a NIDA Clinical Trials Network gender-specific HIV risk reduction study

The female condom is effective in reducing unprotected sexual acts; however, it remains underutilized in the United States. This study examined whether a five-session HIV prevention intervention (Safer Sex Skills Building [SSB]), including presentation, discussion, and practice with female condoms, improved female condom skills and attitude among women in outpatient substance abuse treatment. Mixed-effects modeling was used to test the effect of SSB on skills and attitude over 3- and 6-month posttreatment among 515 randomized women. SSB was significantly associated with increases in skills and attitude, and the female condom demonstration session was primarily responsible for skills improvement. Attitude was a partial mediator of the intervention effect in reducing unprotected sex. Findings emphasize the utility of integrating female condom messages targeting proximal behavioral outcomes into HIV prevention. The study supports the use of female condom skill instruction via brief, hands-on exercises, as well as further research to enhance attitudinal change to reduce sexual risk.

Relapse prevention for addictive behaviors

The Relapse Prevention (RP) model has been a mainstay of addictions theory and treatment since its introduction three decades ago. This paper provides an overview and update of RP for addictive behaviors with a focus on developments over the last decade (2000-2010). Major treatment outcome studies and meta-analyses are summarized, as are selected empirical findings relevant to the tenets of the RP model. Notable advances in RP in the last decade include the introduction of a reformulated cognitive-behavioral model of relapse, the application of advanced statistical methods to model relapse in large randomized trials, and the development of mindfulness-based relapse prevention. We also review the emergent literature on genetic correlates of relapse following pharmacological and behavioral treatments. The continued influence of RP is evidenced by its integration in most cognitive-behavioral substance use interventions. However, the tendency to subsume RP within other treatment modalities has posed a barrier to systematic evaluation of the RP model. Overall, RP remains an influential cognitive-behavioral framework that can inform both theoretical and clinical approaches to understanding and facilitating behavior change.

Do women differ from men on Alcoholics Anonymous participation and abstinence? A multi-wave analysis of treatment seekers

BACKGROUND

Given the widespread use of Alcoholics Anonymous (AA) and other similar groups in the United States and the increasing membership of women, this study compares women with men on their meeting attendance and AA-prescribed behaviors, factors associated with that AA participation, and tests how these relate to women's and men's abstinence across time.

METHODS

All consecutive new admissions (age ≥ 18) from county-wide public and private treatment programs representing the larger population of treatment seekers were approached to be in the study at treatment entry. Those consenting at baseline (n = 926) were sought for follow-up interviews 1, 3, 5, and 7 years later. Generalized linear models were used to test whether various help-seeking factors were associated with AA participation differentially by gender and, controlling for AA and other confounders, whether women differ from men on abstinence.

RESULTS

At each follow-up interview, women and men attended AA at similar rates and similarly practiced specific AA behaviors, and they were alike on most factors associated with AA participation and abstention across time including abstinence goal, drink volume, negative consequences, prior treatment, and encouragement to reduce drinking. Relative to men, women with higher drug severity were less likely to participate in AA. Although higher AA participation was a predictor of abstinence for both genders, men were less likely to be abstinent across time. Men were also more likely to reduce their AA participation across time.

CONCLUSIONS

These findings add to an emerging literature on how women compare with men on factors related to AA participation and subsequent drinking outcomes across time. Findings have clinical implications for service providers referring clients to such groups.

Onset and course of alcoholism over 25 years in middle class men

BACKGROUND

Patterns of drinking and alcohol problems change with age. However, few studies use multiple data points and detailed history spanning early adulthood to middle age. This study reports such data from 373 men in the San Diego Prospective Study.

METHODS

Data were generated at baseline (T1) at ∼age 20, and through face-to-face followup interviews ∼every 5 years in >90% of these eligible Caucasian and relatively higher educated men. Subjects were placed into 4 groups regarding their course: 62.5% with no alcohol use disorder (AUD); 17.2% with AUD onset 5 years before the 25-year followup.

RESULTS

On a univariate level, low level of response (LR) to alcohol, family history of AUDs, and higher Novelty Seeking at ∼age 20 predicted AUDs with onset before age 30 (mean age∼25), but among these only LR predicted later onset (mean age 38) as well. Additional predictors of AUDs included demography (lower education), and greater involvement with alcohol, drugs, and nicotine prior to T1. Sustained remission from AUDs among alcoholics was predicted by lower T1 and T10 drinking frequencies, and being separated or divorced at T10, along with a trend for higher Reward Dependence.

CONCLUSION

These data indicate that information available in ages of the late teens to early twenties can help predict the future onset and course of AUDs, and underscore the importance of longitudinal studies in substance use disorders.

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.

Fidelity: an essential component of evidence-based practice in speech-language pathology

PURPOSE

To provide a primer regarding treatment fidelity as it affects evidence-based practice (EBP) for speech-language pathologists.

METHOD

This tutorial defines treatment fidelity, examines the role of treatment fidelity for speech-language pathologists, provides examples of fidelity measurement, and describes approaches for assessing treatment fidelity.

CONCLUSION

Treatment fidelity is a neglected construct in the EBP literature; however, fidelity is a crucial construct for documenting intervention effectiveness and engaging in EBP.

Gender differences in mutual-help attendance one year after treatment: Swedish and U.S. samples

OBJECTIVE

In the United States, many people turn to Alcoholics Anonymous (AA) and other mutual-help groups as a first source of help for an alcohol or drug problem, whereas others are introduced to AA while in treatment. Because AA and similar groups in the United States add to the treatment system and function without governmental funds, they represent an important element in ongoing care for individuals with substance-use disorders in the health care system. In countries with free (or more affordable) and more comprehensive systems of care, their role is less clearly defined.

METHOD

In this study, we compared men and women from representative treatment samples from studies with parallel designs, one Swedish (n = 1,525) and the other American (n = 926), to explore whether rates and correlates of attendance at 1-year follow- up (63% and 78% followed) differ by gender. We explore individual characteristics (demographic, severity, motivational) and formal and informal influences (treatment, mutual help, coercive, social) as possible help-seeking correlates of attendance.

RESULTS

In both countries, similar proportions of men and women attended mutual-help groups. However, twice as many U.S. clients reported attendance. Moreover, twice as many U.S. clients set abstinence as a treatment goal. In multivariate models, having an abstinence goal, a perceived need for treatment, suggestions from one's employment environment, and prior mutual-help attendance predicted posttreatment attendance for men and women in both countries. Gender differences were also found.

CONCLUSIONS

Given the stages in which individuals seek care and the cyclical nature of relapse and recovery, mutual-help groups are an efficient resource in the continuum of services.

The language of motivational interviewing and feedback: counselor language, client language, and client drinking outcomes

Previous research has suggested that motivational interviewing (MI) may affect client language, which in turn predicts client drinking outcome. In this study, we examined the relationship between counselor language and client language, personalized feedback and client language, and client language and client drinking outcome, in a sample of heavy-drinking college students. MI was delivered in a single session with or without a personalized feedback report (MI with feedback [MIF]; MI only). Sessions were coded using the Motivational Interviewing Skill Code 2.1. A composite drinking outcome score was used, consisting of drinks per week, peak blood alcohol concentration, and protective drinking strategies. We found three main results. First, in the MIF group, MI consistent counselor language was positively associated with client change talk. Second, after receiving feedback, MIF clients showed lower levels of sustain talk, relative to MI only clients. Finally, in the MIF group, clients with greater change talk showed improved drinking outcomes at 3 months, while clients with greater sustain talk showed poorer drinking outcomes. These results highlight the relationship between counselor MI skill and client change talk, and suggest an important role for feedback in the change process.