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ABSTRACT: 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.
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.
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).
Drink refusal training is an effective component of CBI, and some of the effectiveness may be attributed to changes in client self-efficacy.
Journal of Consulting and Clinical Psychology 01/2012; 80(3):440-9. · 4.85 Impact Factor
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ABSTRACT: Benefits of empirically supported interventions hinge on clinician skill, particularly for motivational interviewing (MI). Existing MI skill assessments are limited with respect to validity (e.g., self-report) and practicality (e.g., coding session tapes). To address these limitations, we developed and evaluated two versions of a web-based assessment of MI skills, the Computer Assessment of Simulated Patient Interviews (CASPI).
Ninety-six counselors from the community and 24 members of the Motivational Interviewing Network of Trainers (MINT) completed the CASPI (N = 120), in which they verbally responded via microphones to video clips comprising three 9-item vignettes. Three coders used an emergent coding scheme, which was compared with alternative MI skills measures.
CASPI demonstrated excellent internal consistency when averaging across two or three vignettes (α's = .86-.89). Intraclass correlations were above .40 for most items. Confirmatory factor analyses supported a correlated three-factor model: MI-consistent, resistance-engendering, and global change talk orientation rating. Means and factor loadings were invariant across forms (i.e., the two alternative versions of CASPI), and factor loadings were invariant across subgroup (i.e., community counselor or MINT member). Test-retest reliability was good for MI-consistent and resistance-engendering scores (r = .74 and .80, respectively) but low for change talk orientation (r = .29) unless coder was taken into account (r = .69). CASPI showed excellent construct and criterion-related validity.
CASPI represents a promising method of assessing MI skills. Future studies are needed to establish its performance in real-world contexts.
Journal of studies on alcohol and drugs 01/2012; 73(1):154-64. · 2.25 Impact Factor
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ABSTRACT: Extant literature on contingency management (CM) transportability, or its transition from academia to community practice, is reviewed. The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) guides the examination of this material.
PsychInfo and Medline database searches identified 27 publications, with reviewed reference lists garnering 22 others. These 49 sources were examined according to CFIR domains of the intervention, outer setting, inner setting, clinicians, and implementation processes.
Intervention characteristics were focal in 59% of the identified literature, with less frequent focus on clinicians (34%), inner setting (32%), implementation processes (18%), and outer setting (8%). As intervention characteristics, adaptability and trialability most facilitate transportability whereas non-clinical origin, perceived inefficacy or disadvantages, and costs are impediments. Clinicians with a managerial focus and greater clinic tenure and CM experience are candidates to curry organizational readiness for implementation, and combat staff disinterest or philosophical objection. A clinic's technology comfort, staff continuity, and leadership advocacy are inner setting characteristics that prompt effective implementation. Implementation processes in successful demonstration projects include careful fiscal/logistical planning, role-specific staff engagement, practical adaptation in execution, and evaluation via fidelity-monitoring and cost-effectiveness analyses. Outer setting characteristics-like economic policies and inter-agency networking or competition-are salient, often unrecognized influences.
As most implementation constructs are still moving targets, CM transportability is in its infancy and warrants further scientific attention. More effective dissemination may necessitate that future research weight emphasis on external validity, and utilize models of implementation science.
Drug and alcohol dependence 12/2011; 122(1-2):1-10. · 3.60 Impact Factor
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ABSTRACT: Adoption of contingency management (CM) by the addiction treatment community is limited to date despite much evidence for its efficacy. This study examined systemic and idiographic staff predictors of CM adoption attitudes via archival data collected from treatment organizations affiliated with the National Drug Abuse Treatment Clinical Trials Network. Multilevel modeling analyses evaluated potential predictors from organizational, treatment unit, and workforce surveys. Among these were individual and shared perceptions of staff concerning aspects of their clinic culture and climate. Modeling analyses identified three systemic predictors (clinic provision of opiate agonist services, national accreditation, and lesser shared perception of workplace stress) and five idiographic predictors (staff with a graduate degree, longer service tenure, managerial position, e-communication facility, and openness to change in clinical procedures). Findings are discussed as they relate to extant literature on CM attitudes and established implementation science constructs, and their practical implications are discussed.
Journal of substance abuse treatment 12/2011; 42(2):213-21. · 2.90 Impact Factor
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ABSTRACT: There is need to improve treatment effectiveness for stimulant misusers, and one means of doing so is by tailoring services to account for common diagnostic comorbidities and psychosocial challenges they face.
Using its publicly available datasets, this CTN-approved secondary analysis project examined prevalence of alcohol use disorders (AUDs) among primary stimulant misusing treatment-seekers as well as impact of AUD comorbidity on their pre-treatment psychosocial functioning.
Upon identifying a primary stimulant misuser subsample (N = 1133) from among aggregated treatment-seekers across eight CTN trials, diagnostic data were used to document lifetime AUD rates. Paired comparisons, stratified by stimulant drug type (e.g., amphetamine, cocaine) then tested the influence of AUD comorbidity on psychosocial indices from the Addiction Severity Index - Lite.
A high AUD rate (45%) was found in this client population. Among primary cocaine misusers, those with AUD were more likely to: (i) show elevated Addiction Severity Index composite scores, (ii) perceive greater importance of drug treatment, and (iii) endorse psychiatric symptoms and perceived need for their treatment. Among primary amphetamine misusers, those with AUD were more likely to endorse specific psychiatric symptoms.
Study findings document AUD comorbidity as a fairly common diagnostic feature of primary stimulant misusers, and suggest it is a pervasive influence on the pre-treatment psychosocial functioning of cocaine misusers.
This study demonstrates the utility of CTN common assessment battery for secondary analysis projects, though challenges noted during its conduct highlight the value of consistent data collection and documentation within and across CTN trials.
The American Journal of Drug and Alcohol Abuse 09/2011; 37(5):460-71. · 1.55 Impact Factor
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ABSTRACT: Empirically-supported treatments for alcohol dependence exist, yet understanding of influences contributing to the intended behavior change is limited. The current study, a secondary analysis of the recent multisite COMBINE trial (The COMBINE Study Research Group, 2003), tested a mediational model wherein change in client self-efficacy for abstinence was examined as a potential mediator of associations between client report of the therapeutic bond and one-year outcomes of drinking frequency, drinking consequences, and psychiatric functioning. For analyses, the 1383 COMBINE trial participants were grouped as follows: 1) those receiving study medications (naltrexone, acamprosate, naltrexone + acamprosate, placebo) and enrolled in medication management (MM) only (n = 607), 2) those receiving study medications/MM and also enrolled in a combination behavioral intervention (CBI) as well (n = 619), and 3) those enrolled in CBI only (n = 157). Mediation analyses using the product-of-coefficients approach indicated self-efficacy change during treatment significantly mediated associations between the therapeutic bond with the CBI therapist and each of the three one-year outcomes among those exclusively receiving CBI, but failed to do so among those receiving pills/MM (with or without CBI). Effect sizes were small, but indicated that variance in bond-outcome associations was partially mediated by self-efficacy change for trial participants. Findings advance understanding of proximal client change processes during delivery of treatments for alcohol dependence.
Psychology of Addictive Behaviors 03/2011; 25(2):269-78. · 2.09 Impact Factor
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ABSTRACT: Determining whether a particular treatment works for specific groups of people can help tailor dissemination of evidence-based alcohol treatments. It has been proposed that individuals from different racial groups might have better outcomes in treatments that are sensitive to sociocultural issues that impact alcohol use among these groups. The current study was a secondary analysis of data from the combined behavioral intervention (CBI) condition of the COMBINE study. Those randomly assigned to CBI (n = 776) had the opportunity to receive up to 9 skills training modules, which were chosen by the therapist. The goal of the current study was to determine whether receiving 1 of the CBI modules, drink refusal and social pressure skills training, predicted differential outcomes among African American clients. Results indicated that African American clients who received the drink refusal skills training module (n = 25) had significantly fewer heavy drinking days (d = 0.79) 1 year following treatment than African Americans clients who did not receive the module (n = 35). African American clients who received the module also had significantly fewer heavy drinking days (d = 0.86) than non-Hispanic White clients who received the module (n = 241). Good clinical outcomes at 1 year posttreatment were observed among 80% of African Americans who received the module, compared with 54% of African Americans who did not receive the module and 52% of non-Hispanic White clients who did receive the module. Although small sample size limits interpretation, findings provide preliminary evidence supporting the inclusion of drink refusal skills training as part of alcohol interventions for African American clients.
Psychology of Addictive Behaviors 03/2011; 25(1):162-7. · 2.09 Impact Factor
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ABSTRACT: Proficient delivery of motivational interviewing (MI) is often determined by global rating of relational elements or cumulative tallies of technical elements. Yet limited empirical evidence exists to clarify how relational and technical elements are associated, or if rates of skill indices and their constituent technical elements vary within a clinical encounter.
This study sought to document temporal variance in rates of MI skill indices and their constituent technical elements during brief clinical encounters with a standardized patient wherein delivery was "MI-proficient", and to distinguish those temporal patterns from those observed in encounters with "MI-inconsistent" delivery.
Data were accessed from a large MI training trial wherein relational and technical elements of MI delivery were scored for 503 recordings of a simulated 20-minute clinical encounter. Notably, independent raters tallied technical elements in 5-minute segments, allowing evaluation of potential variance among the encounter's quartile intervals. Global ratings of MI spirit identified subsets of recordings with MI-proficient (n = 49) and MI-inconsistent (n = 43) delivery for stratified analyses.
Analyses contrast temporal trajectories of technical aspects of MI-proficient and MI-inconsistent delivery, with the former characterized by: 1) elicitation and reflective listening as primary opening strategies; 2) increased depth of reflective listening as a predominant strategy in subsequent, focused therapeutic discussion; and 3) increased use of elicitation and information provision in change planning as the encounter approached conclusion.
Findings are generally consistent with seminal descriptions of MI (Miller and Rollnick, 1991, 2002), and document temporal aspects of skilful MI delivery in brief encounters.
Behavioural and Cognitive Psychotherapy 10/2010; 38(5):611-28. · 1.69 Impact Factor
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ABSTRACT: Many persons seeking opiate treatment present with complex clinical challenges, which may be exacerbated by alcohol misuse. This report details secondary data analyses aggregating treatment-seeking samples across 10 National Institute on Drug Abuse (NIDA) Clinical Trials Network treatment trials to examine alcohol-related characteristics of opiate-primary (OP) clients and compare broad pretreatment characteristics of those with and without an alcohol use disorder (AUD). Analysis of this aggregate OP client sample (n = 1,396) indicated that 38% had comorbid AUD and that a history of alcohol treatment episodes and recent alcohol problems were common. Further, comparisons of OP clients with and without AUD revealed the former were more likely to have had a history of pervasive difficulties in psychosocial functioning. Findings suggest the need for detection of and intervention for alcohol misuse at the outset of opiate treatment and support for the practice of availing medical, psychological, case management, and other support services.
Journal of substance abuse treatment 09/2010; 39(2):114-23. · 2.90 Impact Factor
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ABSTRACT: The current study was designed to re-examine the motivation matching hypothesis from Project MATCH using growth mixture modeling, an analytical technique that models variation in individual drinking patterns.
Secondary data analyses of data from Project MATCH (n = 1726), a large multi-site alcoholism treatment-matching study.
Percentage of drinking days was the primary outcome measure, assessed from 1 month to 12 months following treatment. Treatment assignment, alcohol dependence symptoms and baseline percentage of drinking days were included as covariates.
The results provided support for the motivation matching hypothesis in the out-patient sample and among females in the aftercare sample: the majority of individuals with lower baseline motivation had better outcomes if assigned to motivation enhancement treatment (MET) compared to those assigned to cognitive behavioral treatment (CBT). In the aftercare sample there was a moderating effect of gender and alcohol dependence severity, whereby males with lower baseline motivation and greater alcohol dependence drank more frequently if assigned to MET compared to those assigned to CBT.
Results from the current study lend partial support to the motivation-matching hypothesis and also demonstrated the importance of moderating influences on treatment matching effectiveness. Based upon these findings, individuals with low baseline motivation in out-patient settings and males with low levels of alcohol dependence or females in aftercare settings may benefit more from motivational enhancement techniques than from cognitive-behavioral techniques.
Addiction 08/2010; 105(8):1403-13. · 4.31 Impact Factor
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ABSTRACT: That pediatric resident trainees would demonstrate increased counseling skill following training in brief motivational interviewing (MI).
Randomized controlled trial.
University of Washington Pediatric Residency.
Pediatric residents (N = 18), including residents in postgraduate years 1, 2, 3, and 4.
Collaborative Management in Pediatrics, a 9-hour behavior change curriculum based on brief MI plus written feedback on communication skills (based on a 3-month Objective Standardized Clinical Evaluation [OSCE]).
The percentage of MI-consistent behavior (%MICO), a summary score for MI skill, was assessed via OSCEs in which standardized patients portray parents of children with asthma in 3 clinical scenarios (stations). The OSCEs were conducted at baseline and 3 and 7 months. Blinded coders rated videotaped OSCEs using a validated tool to tally communication behaviors. Training effects were assessed using linear regression controlling for baseline %MICO. Global ratings of counseling style served as secondary outcome measures.
Trained residents demonstrated a trend toward increased skill (%MICO score) at 3 months compared with control residents. At 7 months, %MICO scores increased 16% to 20% (P < .02) across all OSCE stations after the combined intervention of Collaborative Management in Pediatrics training plus written feedback. The effect of training on global ratings supported the main findings.
Pediatric trainees' skills in behavior change counseling improved following the combination of training in brief MI plus personalized feedback.
Archives of pediatrics & adolescent medicine 06/2010; 164(6):561-6. · 3.73 Impact Factor
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ABSTRACT: There is great need to sustain harm reduction programmes for opiate-dependent persons, given variable retention of opioid agonist treatment (OAT) enrolees. Resource challenges may lead some health organizations to discontinue such programmes, though just as programmatic evaluation may determine efficacy and cost-effectiveness so to does it aid in examining impacts of programme dissolution.
This retrospective evaluation investigated impacts of the dissolution of a 'Minimal Services' (MS) harm reduction programme for substance-abusing OAT clientele at an urban U.S. Veterans Affairs Medical Centre. Targeted clinical data concerning treatment retention, substance use and service utilization was abstracted from medical records of MS-assignees (N=32) and a matched comparison group of standard OAT enrolees. Chart reviewers gathered data for a two-year period encompassing baseline, transitional, and dissolution study phases.
Relative to matched-controls, MS-assignees exhibited: (1) disproportionately poor treatment retention over the two-year period; (2) high and temporally stable rates of documented substance use across study phases, and (3) increased utilization of resource-laden VAMC services after MS dissolution.
Collective results suggest MS programme dissolution was associated with adverse conditions for assignees and the larger treatment setting, and reinforce the need for pragmatic, humane treatment policies to facilitate retention of opiate-dependent persons.
The International journal on drug policy 04/2009; 21(1):82-5. · 2.54 Impact Factor
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ABSTRACT: Few empirical studies are available to guide best practices for transferring evidenced-based treatments to community substance abuse providers. To maximize the learning and maintenance of new clinical skills, this study tested a context-tailored training (CTT) model, which used standardized patient actors in role-plays tailored to agency clinical context, repetitive cycles of practice and feedback, and enhanced organizational support. This study reports the results of a randomized pilot evaluation of CTT for motivational interviewing (MI). Investigators randomly assigned community substance abuse treatment agencies to receive either CTT or a standard 2-day MI workshop. The study also evaluated the effects of counselor-level and organizational-level variables on the learning of MI. No between-condition differences were observed on the acquisition and maintenance of MI skills despite reported higher satisfaction with the more costly context-tailored model. Analyses revealed that those counselors with more formal education and less endorsement of a disease model of addiction made the greatest gains in MI skills, irrespective of training condition. Similarly, agencies whose individual counselors viewed their organization as being more open to change and less supportive of autonomy showed greater average staff gains in MI skills, again, irrespective of training method. Posttraining activities within agencies that supported the ongoing learning and implementation of MI mediated the effects of organizational openness to change. This pilot study suggests that tailored training methods may not produce better outcomes than traditional workshops for the acquisition of evidence-based practice, and that efforts to enhance skill acquisition can be focused on characteristics of learners and ongoing organizational support of learning.
Journal of substance abuse treatment 04/2009; 37(2):191-202. · 2.90 Impact Factor
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ABSTRACT: Because nearly half of injured patients admitted to trauma centers misuse alcohol, the American College of Surgeons has required that Level I trauma centers have a mechanism for providing brief bedside counseling interventions (BI) to patients with alcohol problems. We hypothesized that with minimal training, surgical interns could become proficient at performing BI.
First-year surgical interns were trained in an 8-hour BI workshop. A group of first-year medicine interns who were not trained in BI served as the comparison group. BI skills of both groups were assessed before and 5 weeks after this training using simulated interviews with standardized patient actors trained to depict a scenario of a challenging patient with an alcohol problem. Audiotapes of those interviews were rated by trained, blinded coders.
Before the training, both groups demonstrated similar BI skill levels. Compared with the control group, after training, the surgical interns showed marked improvements in BI skills, including more frequently giving patients feedback on their blood alcohol concentration results (p=0.000), providing guidelines for low-risk drinking (p=0.000), offering patients more than 1 change option (p=0.000), asking permission to discuss drinking (p=0.003), and offering patients hope and encouragement (p=0.003).
After training, surgery interns effectively demonstrated BI skills when challenged to do so in a standardized patient actor scenario. This model of intern screening and brief intervention training constitutes a viable alternative for trauma centers as they look for options to meet the American College of Surgeons' new requirement to provide BI for trauma patients with alcohol problems. Future research should further evaluate surgical interns' ability to routinely implement these skills in their daily clinical environments.
Journal of the American College of Surgeons 12/2008; 207(5):639-45. · 4.55 Impact Factor
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ABSTRACT: Homeless adolescents who used alcohol or illicit substances but were not seeking treatment (n = 54) were recorded during brief motivational interventions. Adolescent language during sessions was coded on the basis of motivational interviewing concepts (global ratings of engagement and affect, counts of commitment to change, statements about reasons for change, and statements about desire or ability to change), and ratings were tested as predictors of rates of substance use over time. Results indicate that statements about desire or ability against change, although infrequent (M = 0.61 per 5 min), were strongly and negatively predictive of changes in substance use rates (days of abstinence over the prior month) at both 1- and 3-month postbaseline assessment (ps < .001). Statements about reasons for change were associated with greater reductions in days of substance use at 1-month assessment (p < .05). Commitment language was not associated with outcomes. Results suggest that specific aspects of adolescent speech in brief interventions may be important in the prediction of change in substance use. These relationships should be examined within larger samples and other clinical contexts.
Psychology of Addictive Behaviors 12/2008; 22(4):570-5. · 2.09 Impact Factor
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ABSTRACT: The video assessment of simulated encounters-revised (VASE-R) is a video-based method, administered in individual or group settings, for assessing motivational interviewing (MI) skills. The 18-item instrument includes three video-based vignettes, in which actors portray substance abusers, with each vignette followed by questions that prompt examinees to write responses that are then scored against MI standards. The VASE-R was administered to two independent samples: (1) substance abuse practitioners participating in a study of MI training methods, and (2) MI training facilitators with a high level of MI skill and expertise. This multi-study report describes basic VASE-R psychometric properties -- including scoring reliability, internal consistency, concurrent validity, and sensitivity to the effects of training -- and then presents proficiency standards based on administration to a sample of MI training facilitators (MI Experts). The findings indicate excellent inter-rater reliability using intra-class correlations for the full-scale score (.85) and acceptable levels for subscales (.44 to .73). The instrument displayed strong concurrent validity with the Helpful Responses Questionnaire (HRQ) and a behavioral sample of clinician behavior with a standardized patient scored using the MI Treatment Integrity (MITI) system, as well as good sensitivity to improvement in MI skill as a result of training. The findings provide an empirical basis for suggesting VASE-R benchmarks for beginning proficiency and expert MI practice.
Drug and Alcohol Dependence 10/2008; 97(1-2):130-8. · 3.38 Impact Factor
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ABSTRACT: The authors developed and evaluated a group-administered method for measuring motivational interviewing (MI) skills. The video assessment of simulated encounters (VASE) consists of three videotaped vignettes of actors playing substance abusers. Each vignette is followed by eight questions asking examinees to generate written responses consistent with MI principles. Twenty-two clinicians completed the VASE questionnaire and two other measures of MI skill: a paper-and-pencil measure that elicited responses to written scenarios and an audiotaped interaction with a standardized patient (SP), subsequently scored for MI skill by independent tape raters. Psychometric analyses of this original VASE scale evaluated: (1) scoring reliability of the 24 VASE items; (2) internal reliability of the VASE full-scale score, seven subscale scores and the three vignettes; and (3) concurrent validity with aforementioned indices of MI skill. Analyses informed the removal of two subscales, redesign of a third and revisions to a fourth. The resulting 18-item VASE-R scale retains its three-vignette format, and assesses overall MI skill as well as the following five MI "microskills": reflective listening, responding to resistance, summarizing, eliciting change talk and developing discrepancy. The VASE-R requires further analysis to evaluate these revisions, but shows promise as a cost-effective alternative for use in MI skill assessment in a variety of training and research contexts.
Drug and Alcohol Dependence 10/2005; 79(3):321-30. · 3.38 Impact Factor
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ABSTRACT: We evaluated a 2-day training workshop on motivational interviewing (MI) for addiction and mental health clinicians (n = 22). Clinicians completed the helpful responses questionnaire (HRQ) and taped interactions with a standardized patient (SP). Independent, blinded coders rated the tapes using the motivational interviewing skills code (MISC). Post-training assessment showed significant increase on the HRQ and two of four MISC summary scores for SP interviews. At 2-month follow-up, means of the HRQ and two MISC summary scores remained higher than baseline, but declined from post-training. Some MI skills improved to a greater degree than others, and a subset of clinicians (> 40%) showed continued improvement at follow-up. Results were consistent across interviews with different SPs, supporting the use of this assessment method. Findings highlight the need for additional research on the use of standardized patients, alternative assessment techniques, and effective methods of technology transfer for MI skill acquisition and retention.
Drug and Alcohol Dependence 02/2004; 73(1):99-106. · 3.38 Impact Factor
