Samuel A Ball

Yale-New Haven Hospital, New Haven, Connecticut, United States

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Publications (105)326.08 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Despite extensive research on gender differences in addiction, there are relatively few published reports comparing treatment outcomes for women versus men based on evidence-based treatments evaluated in randomized clinical trials. An aggregate sample comprised of data from five randomized clinical trials of treatment for cocaine dependence (N=434) was evaluated for gender differences in clinical outcomes. Secondary analyses compared gender differences in outcome by medication condition (disulfiram versus no medication) and across multiple behavioral treatment conditions. Women, compared with men, had poorer treatment outcomes on multiple measures of cocaine use during treatment and at post-treatment follow-up. These results appear to be primarily accounted for by disulfiram being less effective in women compared with men. There was no evidence of meaningful gender differences in outcome as a function of the behavioral therapies evaluated. These findings suggest that women and men may benefit to similar degrees from some empirically validated behavioral treatments for addiction. Conversely, some addiction pharmacotherapies, such as disulfiram, may be associated with poorer outcomes among women relative to men and point to the need for careful assessment of pharmacological treatments in both sexes prior to widespread clinical implementation. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    Drug and Alcohol Dependence 10/2014; 145C:156-167. · 3.28 Impact Factor
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    ABSTRACT: Few studies have examined exercise as a substance use disorder treatment. This pilot study investigated the feasibility and acceptability of an exercise intervention comprising the Wii Fit PlusTM and of a time-and-attention sedentary control comprising WiiTM videogames. We also explored their impact on physical activity levels, substance use, and psychological wellness. Twenty-nine methadone-maintained patients enrolled in an 8-week trial were randomly assigned to either Active Game Play (Wii Fit PlusTM videogames involving physical exertion) or Sedentary Game Play (WiiTM videogames played while sitting). Participants had high satisfaction and study completion rates. Active Game Play participants reported greater physical activity outside the intervention than Sedentary Game Play participants despite no such differences at baseline. Substance use decreased and stress and optimism improved in both conditions. Active Game Play is a feasible and acceptable exercise intervention, and Sedentary Game Play is a promising time-and-attention control. Further investigations of these interventions are warranted.
    Journal of Substance Abuse Treatment 10/2014; · 3.14 Impact Factor
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    ABSTRACT: Background Selection of an appropriate indictor of treatment response in clinical trials is complex, particularly for the various illicit drugs of abuse. Most widely-used indicators have been selected based on expert group recommendation or convention rather than systematic empirical evaluation. Absence of an evidence-based, clinically meaningful index of treatment outcome hinders cross-study evaluations necessary for progress in addiction treatment science. Method Fifteen candidate indicators used in multiple clinical trials as well as some proposed recently are identified and discussed in terms of relative strengths and weaknesses (practicality, cost, verifiability, sensitivity to missing data). Using pooled data from five randomized controlled trials of cocaine dependence (N = 434), the indicators were compared in terms of sensitivity to the effects of treatment and relationship to cocaine use and general functioning during follow-up. Results Commonly used outcome measures (percent negative urine screens; percent days of abstinence) performed relatively well in that they were sensitive to the effects of the therapies evaluated. Others, including complete abstinence and reduction in frequency of use, were less sensitive to effects of specific therapies and were very weakly related to cocaine use or functioning during follow-up. Indicators more strongly related to cocaine use during follow-up were those that reflected achievement of sustained periods of abstinence, particularly at the end of treatment. Conclusions These analyses did not demonstrate overwhelming superiority of any single indicator, but did identify several that performed particularly poorly. Candidates for elimination included retention, complete abstinence, and indicators of reduced frequency of cocaine use.
    Drug and alcohol dependence 04/2014; · 3.60 Impact Factor
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    ABSTRACT: The Social Security Administration (SSA) provides financial support to adults disabled by psychiatric conditions to provide for their basic needs. For beneficiaries identified as incapable of managing their funds, representative payee assignment is mandated. However, studies indicate that the current SSA method of determining capability leads to idiosyncratic payee assignment, with a tendency to under-identify beneficiaries needing payees. Over two phases with data from 78 mental health clinicians treating 134 patient-beneficiaries, we describe the development of a new assessment, the Clinician Assessment of Financial Incapability (CAFI). Item generation, subscale construction, and preliminary assessments of validity are described. We also describe the simultaneous development of a criterion measure of capability, a comprehensive review of all data. Experts identified four subscales mapping to four criteria of incapability; factor analysis provided support for this item structure. Close to one-half of patients were determined to be incapable by review of all data. CAFI and SSA methods correctly classified 73% of cases, but errors with CAFI were more evenly distributed between false negatives and false positives. The implications of classification error are considered, and advantages of CAFI over the SSA method are enumerated. Plans for future instrument revision are briefly described.
    Psychiatry Research 03/2014; · 2.68 Impact Factor
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    ABSTRACT: Background and Objectives Cocaine use during randomized clinical trials (RCTs) is typically assessed by participant self-report or biological assay (eg, urinalysis). There have been few direct comparisons of these assessment methods to investigate their concordance and their predictive validity for cocaine use and psychosocial outcomes following treatment completion.Method In a combined sample of 380 participants from 5 cocaine RCTs, the concordance between cocaine use assessment methods was examined. Sequential multiple linear and logistic regression models evaluated the predictive validity of two assessment methods for cocaine use and psychosocial outcomes assessed at 1, 3, 6, and 12 months after treatment.ResultsConcordance for self-report and urinalysis indicators of cocaine use was high within-treatment (k = 0.72) and moderate during follow-up (k = 0.51). Rates of concordance were higher in studies using test cups with immediate urinalysis results. Regression analyses indicated that self-report data within-treatment predicted self-reported cocaine use at all post-treatment points (β 0.22–0.30, p < .01), while urinalysis results within-treatment predicted urinalysis results at 1, 3, and 6 months post-treatment (OR 3.92–20.99, p < .05). Cocaine-positive urinalyses within-treatment were negatively associated with a composite “good outcome” indicator at 1 and 3 months post-treatment (OR 0.17–0.32, p < .05).Discussion and Conclusions These results suggest a significant role of method variance in predicting post-treatment outcomes from within-treatment cocaine use indices.Scientific SignificanceResults support recommendations that cocaine treatment trials should include both biological assay and self-report assessment. Test cups may facilitate increased self-report accuracy. (Am J Addict 2014;XX:1–9)
    American Journal on Addictions 03/2014; · 1.74 Impact Factor
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    ABSTRACT: OBJECTIVE A previous pilot trial evaluating computer-based training for cognitive-behavioral therapy (CBT4CBT) in 77 heterogeneous substance users (alcohol, marijuana, cocaine, and opioids) demonstrated preliminary support for its efficacy in the context of a community-based outpatient clinic. The authors conducted a more definitive trial in a larger, more homogeneous sample. METHOD In this randomized clinical trial, 101 cocaine-dependent individuals maintained on methadone were randomly assigned to standard methadone maintenance or methadone maintenance with weekly access to CBT4CBT, with seven modules delivered within an 8-week trial. RESULTS Treatment retention and data availability were high and comparable across the treatment conditions. Participants assigned to the CBT4CBT condition were significantly more likely to attain 3 or more consecutive weeks of abstinence from cocaine (36% compared with 17%; p<0.05, odds ratio=0.36). The group assigned to CBT4CBT also had better outcomes on most dimensions, including urine specimens negative for all drugs, but these reached statistical significance only for individuals completing the 8-week trial (N=69). Follow-up data collected 6 months after treatment termination were available for 93% of the randomized sample; these data indicate continued improvement for those assigned to the CBT4CBT group, replicating previous findings regarding its durability. CONCLUSIONS This trial replicates earlier findings indicating that CBT4CBT is an effective adjunct to addiction treatment with durable effects. CBT4CBT is an easily disseminable strategy for broadening the availability of CBT, even in challenging populations such as cocaine-dependent individuals enrolled in methadone maintenance programs.
    American Journal of Psychiatry 02/2014; · 14.72 Impact Factor
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    ABSTRACT: Introduction: Sleep disturbance is common among cigarette smokers and predicts smoking cessation failure. Aims: The purpose of this study was to conduct a pilot test of whether provision of a sleep intervention might bolster smoking cessation outcomes among this vulnerable group. Methods: Smokers with insomnia (N = 19) seeking smoking cessation treatment were randomly assigned to receive 8 sessions over 10 weeks of either: (1) cognitive-behavioural therapy for insomnia + smoking cessation counselling (CBT-I+SC; n = 9) or (2) smoking cessation counselling alone (SC; n = 10). Counselling commenced 4 weeks prior to a scheduled quit date, and nicotine patch therapy was also provided for 6 weeks starting on the quit date. Results: There was no significant effect of counselling condition on smoking cessation outcomes. Most participants had difficulty initiating and maintaining smoking abstinence in that 7-day point prevalence abstinence rates at end of treatment (CBT-I+SC: 1/7, 14%; SC: 2/10, 20%) and follow-up (CBT-I+SC: 1/7, 14%; SC: 0/10, 0%) were low for both conditions. CBT-I+SC participants reported improvements in sleep efficiency, quality, duration and insomnia symptoms. Sleep changes were not associated with the likelihood of achieving smoking abstinence. Conclusions: This randomised pilot study suggests that behavioural interventions may improve sleep among smokers with insomnia, but a larger sample is needed to replicate this finding and evaluate whether these changes facilitate smoking cessation.
    The Journal of Smoking Cessation 01/2014; 9(1):31-38.
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    ABSTRACT: Although the current diagnostic manual conceptualizes personality disorders (PDs) as categorical entities, an alternative perspective is that PDs represent maladaptive extreme versions of the same traits that describe normal personality. Existing evidence indicates that normal personality traits, such as those assessed by the five-factor model (FFM), share a common structure and obtain reasonably predictable correlations with the PDs. However, very little research has investigated whether PDs are more extreme than normal personality traits. Utilizing item-response theory analyses, the authors of the current study extend previous research to demonstrate that the diagnostic criterion for borderline personality disorder and FFM neuroticism could be fit along a single latent dimension. Furthermore, the authors' findings indicate that the borderline criteria assessed the shared latent trait at a level that was more extreme (d = 1.11) than FFM neuroticism. This finding provides further evidence for dimensional understanding of personality pathology and suggests that a trait model in DSM-5 should span normal and abnormal personality functioning, but focus on the extremes of these common traits.
    Journal of personality disorders 10/2013; 27(5):625-35. · 3.08 Impact Factor
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    ABSTRACT: The current pilot study evaluated feasibility, acceptability, and initial efficacy of a therapeutic Interactive Voice Response (IVR) system ("the Recovery Line") for patients receiving methadone maintenance who continue to use illicit drugs. Patients were randomized (N=36) to 4weeks of treatment-as-usual (TAU) or Recovery Line plus TAU. Ratings of the Recovery Line were high and remained stable throughout the study. However, despite instructions and reminders, patients used substantially less than the recommended daily use (<10days of 28). Patients were more likely to report abstinence from opioids and cocaine on days they used the Recovery Line (p=.01) than those they did not. Conditions did not differ significantly on patient satisfaction, urine screen outcomes, or coping efficacy. As with other computer-based treatments, findings suggest the Recovery Line is acceptable and feasible. However, additional methods to increase patient utilization of automated systems and larger clinical trials are needed.
    Journal of substance abuse treatment 01/2013; · 2.90 Impact Factor
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    ABSTRACT: Cocaine use remains a major problem within methadone maintenance programs. Disulfiram's efficacy in reducing cocaine use has been demonstrated in several trials, but its relative efficacy among individuals who use versus abstain from alcohol remains unclear. Treatment approaches which seek to enhance substance users' involvement in self-help activities (Twelve Step Facilitation, TSF) have been associated with better outcomes among alcohol and cocaine users, but have rarely been evaluated among methadone-maintained cocaine-opioid users. We conducted a randomized, placebo-controlled, double blind (for medication condition), factorial (2×2) trial with 4 treatment conditions: Disulfiram plus TSF, disulfiram plus standard counseling only, placebo plus TSF, and placebo plus standard counseling in the context of a community-based methadone maintenance program. Participants (N=112) received either disulfiram (250mg/d) or placebo in conjunction with daily methadone maintenance. Assignment to TSF was associated with less cocaine use throughout treatment and a higher number of cocaine-negative urines. While there were no significant main effects of disulfiram versus placebo, individuals without an alcohol use disorder demonstrated greater reductions in cocaine use over time when assigned to disulfiram. TSF appears feasible in this methadone maintenance program and was associated with modest reductions in cocaine use, an often intractable problem in this setting. Support for the efficacy of disulfiram was weaker, as it appeared effective only for those without a current alcohol use disorder for this sample.
    Drug and alcohol dependence 06/2012; 126(1-2):224-31. · 3.60 Impact Factor
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    ABSTRACT: The DSM-5 proposal indicates that personality disorders (PDs) be defined as collections of maladaptive traits but does not provide a specific diagnostic method. However, researchers have previously suggested that PD constructs can be assessed by comparing individuals' trait profiles with those prototypic of PDs and evidence from the five-factor model (FFM) suggests that these prototype matching scores converge moderately with traditional PD instruments. The current study investigates the convergence of FFM PD prototypes with interview-assigned PD diagnoses in a sample of 99 homeless individuals. This sample had very high rates of PDs, which extends previous research on samples with more modest prevalence rates. Results indicated that diagnostic agreement between these methods was generally low but consistent with the agreement previously observed between explicit PD measures. Furthermore, trait-based and diagnostic interview scores evinced similar relationships with clinically important indicators such as abuse history and past suicide attempts. These findings demonstrate the validity of prototype methods and suggest their consideration for assessing trait-defined PD types within DSM-5.
    Assessment 04/2012; 19(3):287-98. · 3.29 Impact Factor
  • Douglas B. Samuel, Samuel A. Ball
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    ABSTRACT: Early maladaptive schemas are stable, negative beliefs about oneself, others, or the environment that are formed early in life and subsequently organize an individual’s experiences and behaviors. We evaluated the factor structure and validity of the self-report Early Maladaptive Schema Questionnaire—Research version (EMSQ-R) that assesses 15 maladaptive schema identified by Young (1991) within a sample of 908 individuals in treatment for substance use and personality pathology. We first employed confirmatory factor analytic techniques and found the data fit this expected model poorly. We then utilized exploratory factor analysis to examine the hierarchical structure of the EMSQ-R and then tested its concurrent validity using available chart data and another self-report questionnaire. In contrast with previous research, we concluded that the schemas do not have a replicable lower-order structure. However, we did retain a four-factor solution for the scales that demonstrated significant correlations with expected variables and provided partial support for the higher-order structure of EMSQ-R.
    Cognitive Therapy and Research 02/2012; 37(1). · 1.70 Impact Factor
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    ABSTRACT: Although personality disorders (PDs) have been defined categorically throughout the history of psychiatric nomenclatures, the DSM-5 Personality and Personality Disorders Work Group proposed a substantial shift to a dimensional conceptualization and diagnosis of personality pathology. This proposal included the adoption of a trait model with 37 specific traits that fell within six higher-order domains. In addition, they specified that half of the current diagnoses be recast as types defined by narrative description, with the other half deleted. Instead, the deleted categories would be diagnosed through ratings on specifically assigned traits. The Work Group also specified a number of traits that are relevant to each of the five DSM-5 types. However, these assignments for the types and deleted DSM-IV PDs lack empirical justification. The current study examined the relations between the DSM-5 traits and PDs slated for inclusion and exclusion using an expert consensus approach. Researchers with expertise on specific PDs provided descriptions of either the DSM-5 type narratives or a prototypic case of DSM-IV PDs in terms of the trait model. The ratings by experts in the current study demonstrated moderate agreement with the Work Group's assignments, but also identified notable discrepancies between how these types were described by the Work Group and how they were perceived by other PD researchers. These results hold promise for improving the currently proposed system and will help inform researchers and clinicians who will ultimately use the DSM-5 model.
    Personality Disorders: Theory, Research, and Treatment 01/2012; 3(1):1-16. · 3.54 Impact Factor
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    ABSTRACT: Although previous surveys have indicated high rates of illicit and prescription drug misuse among college students, few have assessed negative consequences, personal concerns, or interest in interventions for drug use. In a survey of 262 college students who self-reported lifetime use of an illicit drug, 69% reported at least one negative consequence over the course of their lifetime and 63% in the past year. Many also reported being moderately concerned (28%) about their drug or medication misuse and moderately interested in some form of intervention (76%). The frequency of marijuana use and medication misuse in the past month was related to increased negative consequences and personal concerns even when controlling for the frequency of past month alcohol use. There were relatively few differences as a function of gender or year in college.
    Journal of College Student Development 01/2012; 53(1). · 0.68 Impact Factor
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    ABSTRACT: Using cross-sectional data and structural equation modeling, we evaluated whether coping self-efficacy to abstain from drinking in various situations accounted for the relationship between internalizing (depression, anxiety) and externalizing (aggression, low socialization) dimensions with problematic alcohol use in 292 first-time DWI offenders. Results indicated that an internalizing dimension indirectly predicted problematic alcohol use through coping self-efficacy in negative situations only, whereas an externalizing dimension indirectly predicted problematic alcohol use through coping self-efficacy in positive situations only. These findings support two potential pathways to problematic drinking behavior among DWI offenders and suggest that internalizing and externalizing dimensions may differentially predict high risk drinking situations due to one's inability to abstain in specific situations.
    Psychology of Addictive Behaviors 10/2011; 26(1):133-9. · 2.09 Impact Factor
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    ABSTRACT: Although therapeutic community (TC) treatment is a promising intervention for substance use disorders, a primary obstacle to successful treatment is premature attrition. Because of their prevalence within substance use treatment facilities, personality disorder (PD) diagnoses have been examined as predictors of treatment completion. Prior research on TC outcomes has focused almost exclusively on antisocial personality disorder (ASPD), and the results have been mixed. This study extends previous research by examining the impact of the 10 Axis II PDs on early (first 30 days) attrition as well as overall time to dropout in a 9-month residential TC. Survival analyses indicated that borderline was the only PD negatively related to overall program retention. In contrast, ASPD, as well as histrionic PD, were related to very early attrition, but not to overall program retention. Early assessment and identification of at-risk individuals may improve treatment retention and outcome for TC treatment. (Am J Addict 2011:20:555–562)
    American Journal on Addictions 10/2011; 20(6):555 - 562. · 1.74 Impact Factor
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    ABSTRACT: The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings. We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure. The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research. Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.
    The American Journal of Drug and Alcohol Abuse 09/2011; 37(5):275-82. · 1.55 Impact Factor
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    ABSTRACT: The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 Personality and Personality Disorders Work Group proposed the elimination of diagnostic criterion sets in favor of a prototype matching system that defines personality disorders using narrative descriptions. Although some research supports this general approach, no empirical studies have yet examined the specific definitions proposed for DSM-5. Given the wide interest in borderline personality disorder (BPD), it is crucial to determine how this methodological shift might affect the content and conceptualization of the diagnosis. Eighty-two experts on BPD provided ratings of the DSM-IV-TR or DSM-5 version of BPD in terms of 37 traits proposed for DSM-5. Analyses revealed significant and meaningful differences among the two constructs, with the DSM-5 version evincing increased interpersonal dependency but a decreased emphasis on antagonism and disinhibition. A second study within a clinical sample demonstrated that both antagonism and disinhibition mediated the relationships between DSM-IV BPD and impairment, suggesting that the proposed changes might have important consequences for BPD's coverage, prevalence, and nomological network. More globally, our results illustrate that unanticipated shifts in diagnostic constructs can stem from seemingly minor revisions and suggest that research is needed to understand how these, or other changes, might affect our conceptualization, diagnosis, and treatment of BPD.
    Journal of Abnormal Psychology 08/2011; 121(2):467-76. · 4.86 Impact Factor
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    ABSTRACT: Although psychotherapy involves the interaction of client and therapist, mutual influence is not typically considered as a source of variability in therapist adherence and competence in providing treatments assessed in clinical trials. We examined variability in therapist adherence and competence in Motivational Enhancement Therapy (MET) both within and between caseloads in a large multi-site clinical trial. Three-level multilevel models (repeated measures, nested within clients, nested with therapists) indicated significant variability both within and between therapists. There was as much and sometimes more variability in MET adherence and competence within therapist caseloads than between therapists. Variability in MET adherence and competence within caseloads was not consistently associated with client severity of addiction at baseline. However, client motivation at the beginning of the session and days of use during treatment were consistent predictors of therapist adherence and competence. Results raise questions about the nature of therapist adherence and competence in treatment protocols. Accordingly, future analysis of clinical trials should consider the role of mutual influence in measures of therapist performance.
    Drug and alcohol dependence 06/2011; 115(3):229-36. · 3.60 Impact Factor
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    ABSTRACT: We conducted a randomized comparison of dual-focus schema therapy with individual drug counseling as enhancements to the residential treatment of 105 substance-dependent patients with specific personality disorders versus those without. Both therapies were manual-guided and delivered for 6 months by experienced psychotherapists intensively trained and supervised with independent fidelity assessment. Using the Cox proportional hazards model, we found no psychotherapy differences in retention (days in treatment). Hierarchical linear modeling indicated that participants with personality disorders started with higher psychiatric, interpersonal, and dysphoria symptoms and that both therapies reduced symptoms in 6 months. Contrary to predictions, individual drug counseling resulted in more sustained reductions than did dual-focus schema therapy in several symptoms for several personality disorders. Our findings raised important questions about the added value of integrative or dual-focus therapies for co-occurring personality disorders and substance dependence relative to empirically supported therapies focused more specifically on addiction symptoms.
    The Journal of nervous and mental disease 05/2011; 199(5):319-28. · 1.81 Impact Factor

Publication Stats

3k Citations
326.08 Total Impact Points


  • 1996–2014
    • Yale-New Haven Hospital
      • Department of Laboratory Medicine
      New Haven, Connecticut, United States
  • 2011–2012
    • Purdue University
      • Department of Psychological Sciences
      West Lafayette, IN, United States
  • 1993–2011
    • Yale University
      • Department of Psychiatry
      New Haven, CT, United States
  • 2009
    • West Haven University
      West Haven, Connecticut, United States
    • University of Pennsylvania
      • Department of Psychiatry
      Philadelphia, PA, United States
  • 2008
    • University of Illinois at Chicago
      Chicago, Illinois, United States
    • University of Washington Seattle
      • Alcohol and Drug Abuse Institute
      Seattle, WA, United States
  • 2000
    • University of Amsterdam
      • Amsterdam School of Economics Research Institute
      Amsterdam, North Holland, Netherlands
    • The Netherlands Institute for Addiction Healthcare
      Arnheim, Gelderland, Netherlands
  • 1999
    • Fordham University
      • Department of Psychology
      New York City, NY, United States