ArticleLiterature Review

The Forest and the Trees: Relational and Specific Factors in Addiction Treatment

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Abstract

AimsIncreased expectations for the use of evidence-based methods in addiction treatment have fueled a debate regarding the relative importance of “specific” versus “common” factors in treatment outcome.This review explores the influence of these factors on addiction treatment outcome.Methods The authors review and link findings from four decades of research on specific and general factors in addiction treatment outcome research.FindingsThough few would argue that what one does in addiction treatment is immaterial, outcome studies do tend to find small to no difference when specific treatment methods are compared with each other or with treatment as usual.In contrast, there are usually substantial differences among therapists in client outcomes, and relational factors such as therapist empathy and therapeutic alliance can be significant determinants of addiction treatment outcome.Conclusions In addiction treatment, relational factors such as empathy, which are often described as common, non-specific factors, should not be dismissed as “common” because they vary substantially across providers and it is unclear how common they actually are.Similarly they should not be relegated to “non-specific” status, because such important relational influences can be specified and incorporated in clinical research and training.

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... Findings in the addictions counseling literature indicate a similar impact of specific EBRFs in addictions treatment regarding the therapeutic alliance and accurate empathy (Miller & Moyers, 2015;Moyers & Miller, 2013). Miller and Moyers (2015) argued that these EBRPs strongly contributed to positive outcomes in addictions counseling, particularly in studies of motivational interviewing (MI) on client outcomes. ...
... Findings in the addictions counseling literature indicate a similar impact of specific EBRFs in addictions treatment regarding the therapeutic alliance and accurate empathy (Miller & Moyers, 2015;Moyers & Miller, 2013). Miller and Moyers (2015) argued that these EBRPs strongly contributed to positive outcomes in addictions counseling, particularly in studies of motivational interviewing (MI) on client outcomes. These findings are not surprising, as Miller and Rollnick (2013) described MI as client-centered, such that the counselor demonstrates respect, acceptance, and a deep trust in the client's ability to make change. ...
... Authors in the MI literature criticized the tendency for addictions counseling researchers to focus on isolating the technical components of evidence-based interventions like MI and cognitive-behavioral treatments, whereby meta-analyses of the technical components of motivational interventions found small, but indirect, effects on use outcomes (Lundahl et al., 2010;Magill et al., 2018). Miller and Moyers (2015) compared this trend in the addictions literature to seeing the forest for the trees, arguing that a counselor who establishes a strong therapeutic alliance with a client delivers these interventions. The client does not experience these conditions in a vacuum. ...
Article
In observation of empirical support and theoretical support for relational and attachment-based interventions in addictions counseling education and research, the authors explore the relational depth model as a potential training model in addictions counseling education. This piece offers training activities for addictions counseling educators targeted at enhancing student capacity and understanding of presence and connection with clients. The authors detail the use of experiential activities to enhance these capacities that include questions for reflection and discussion of application to practice. The authors develop the rationale for this training with a brief review of the relational depth literature and the recent addictions literature regarding research and training in relational factors in addictions counseling. Finally, the authors offer future implications for the addictions counseling education literature including the need for the development and empirical validation of relational training programs in addictions counseling education and practice.
... Monti and colleagues [22] found significant differences on alcohol-related re-injuries and problems, and drinking and driving among 94 young adults (aged [18][19]. Smith and colleagues [23] found significant differences on alcohol use and on alcohol-related problems among 151 young adults with facial injury (aged [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. Spirito and colleagues [24] found no significant effects among 152 adolescents (aged [13][14][15][16][17] overall, but found significant effects on alcohol drinking days and binge drinking when limiting analyses to those reporting pre-existing problematic alcohol use. ...
... Relational factors: Empathy, acceptance, collaboration, and avoidance of confrontation. Relational factors can be significant determinants of addiction treatment outcome [35]. Empathy has been relatively well established as an active ingredient in the general psychotherapy literature [e.g. ...
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Background Unhealthy alcohol use among young adults is a major public health concern. Brief motivational interventions for young adults in the Emergency Department (ED) have shown promising but inconsistent results. Methods Based on the literature on brief intervention and motivational interviewing efficacy and active ingredients, we developed a new motivational intervention model for young adults admitted in the ED with alcohol intoxication. Using an iterative qualitative design, we first pre-tested this model by conducting 4 experimental sessions and 8 related semi-structured interviews to evaluate clinicians’ and patients’ perceptions of the intervention’s acceptability and feasibility. We then conducted a consultation meeting with 9 international experts using a nominal group technique. The intervention model was adjusted and finally re-tested by conducting 6 new experimental sessions and 12 related semi-structured interviews. At each round, data collected were analyzed and discussed, and the intervention model updated accordingly. Results Based on the literature, we found 6 axes for developing a new model: High level of relational factors (e.g. empathy, alliance, avoidance of confrontation); Personalized feedback; Enhance discrepancy; Evoke change talk while softening sustain talk, strengthen ability and commitment to change; Completion of a change plan; Devote more time: longer sessions and follow-up options (face-to-face, telephone, or electronic boosters; referral to treatment). A qualitative analysis of the semi-structured interviews gave important insights regarding acceptability and feasibility of the model. Adjustments were made around which information to provide and how, as well as on how to deepen discussion about change with patients having low levels of self-exploration. The experts’ consultation addressed numerous points, such as information and advice giving, and booster interventions. Discussion This iterative, multi-component design resulted in the development of an intervention model embedded in recent research findings and theory advances, as well as feasible in a complex environment. The next step is a randomized controlled trial testing the efficacy of this model.
... Treatment retention and effectiveness have also been linked to common relational factors, such as empathy and alliance [15]. ...
... There is a continuous effort to find new treatment modalities that motivate patients to remain for sufficient time in treatment to enable beneficial changes in morbidity [3,13,15,16]. One innovative strategy is animalassisted therapy [17][18][19][20][21]. Horse (or equine)-assisted/ facilitated (psycho) therapy, for which we use the acronym HAT, is an innovative complementary approach to psychotherapy that actively involves horses or other equines in the therapeutic process [19]. ...
Article
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Background: Treatment completion is the greatest challenge for the treatment of substance use disorders (SUDs). A previous investigation showed that complementary horse-assisted therapy (cHAT) was associated with higher retention in treatment and completion than standard treatment alone. This randomized controlled trial further explored the benefits of cHAT for patients with SUDs. Methods: Fifty patients in residential SUD treatment at the Department of Addiction Treatment, Oslo University Hospital, were randomly allocated to either cHAT (cHAT group) or treatment as usual alone (TAU-only group). The primary end-point was treatment completion. Secondary end-points were dropout, transfer to another treatment, and time in treatment. Results: The multinomial logistic regression analysis found no statistically significant association between intervention (cHAT) and treatment outcome (completion, dropout, transferred) among the 37 participants who were ultimately recruited to the study. Some unforeseen challenges were encountered in the study: a high number of subjects transferred to another treatment, variable attendance at cHAT sessions, and long temporary exits. Nevertheless, 44% of participants in the cHAT group completed their treatment, compared with 32% in the TAU-only group; this observation encourages further investigation in a larger sample. Conclusions: Though no association was identified between cHAT and treatment retention or completion, our study may have been underpowered. Further work in a larger clinical population is needed; observational studies with repeated measures may also be useful for investigating whether cHAT increases retention in treatment or rates of completion, two important factors for successful SUD treatment. Trial registration The trial was registered and approved on 14 October 2011 by the Regional Committee for Medical and Health Research Ethics with registration number 2011/1642 and registered at ClinicalTrials.gov on 21 February 2013 with registration number NCT01795755.
... Moreover, regardless of treatment modality, strong therapeutic alliances, and therapist characteristics (e.g. fidelity, interpersonal skills, allegiance to certain treatment models) are suggested to be important predictors of engagement and outcome (Meier, Barrowclough and Donmall, 2005;Miller and Moyers, 2015). ...
... Several others agreed that if they could not envisage that behaviour change would alter the course of poor health, fear appeals might cause them to "push the 'fuck it' button" (Daniel). Moreover, other qualitative work has found that conversations with medical staff focusing on the connection between heavy alcohol use and risk of serious ill-health or death can sometimes alienate patients and block the development of a therapeutic relationship (Clark et al., 2017); this is a poignant finding because therapeutic alliance is considered an important variable in the behaviour change process (Meier, Barrowclough and Donmall, 2005;Miller and Moyers, 2015). However, other research has found limited support for therapeutic alliance predicting drinking outcomes in medical inpatients, hypothesised because of short (often single) encounters (Bertholet et al., 2014). ...
Thesis
Most individuals with alcohol use disorders (AUD) never seek or receive specialist treatment. However, much of what is known about addiction and recovery is based on pre- and postintervention studies with patients in specialist treatment settings who tend to have severe dependence. These studies often fail to capture the complex and circuitous nature of recovery, and findings might not be generalisable to most people with AUD. The work described within this thesis therefore aimed to: 1) gain an in-depth understanding of how those with a range of drinking patterns and treatment experiences, whose narratives are largely absent in the literature, conceptualise their relationship with alcohol, and 2) generate theory about processes and determinants of recovery. A mixed-methods constructivist grounded theory approach, comprising two separate but related studies, was employed. Study 1 involved in-depth telephone interviews with 31 members and browsers of a previously unresearched online mutual aid group (Soberistas.com) which resulted in the development of a theoretical framework of recovery entitled: ‘managing multiple facets of self’. This analysis highlighted important personal and social identity processes that appeared to underpin change. To advance the framework, a further two-phased study with a more heterogeneous population was conducted. During the first phase, an observational follow-up cohort study recruited 141 patients with AUD during their unscheduled attendance at a general hospital, and gained quantitative estimates of alcohol use, and related measures such as psychological dependence and readiness to change. Participants were re-interviewed six months later, and variables examined for change (or lack thereof). The second phase employed face-toface in-depth qualitative interviews with a sub-sample of the hospital cohort, purposively selected to be a maximum variation sample using quantitative data collected previously. Quantitative and qualitative data were synthesised to develop the final theoretical framework, ‘alcohol and recovery self-concept fluidity’, which illustrates the dynamic, fluid, and complex nature of living with, and moving beyond, a problematic relationship with alcohol. The theory posits that conceptualisations of problematic alcohol use and recovery are diverse and subject to constant (re)negotiation; individuals navigate numerous, and at times conflicting, explanatory frameworks, in order to make sense of their experiences and align themselves to an approach most suited to their needs at the time. This thesis contributes new understanding of how problematic alcohol use and recovery can be conceptualised, addressed, and researched, by gaining the perspectives of individuals whose voices are largely absent in the literature.
... Research indicated that SUD clients receiving care in residential treatment settings experienced significant improvements in the medical, social and psychiatric measures six months after treatment completion compared to clients in a therapeutic community setting (Guydish et al., 1998) and reported higher treatment completion rate compared to clients in outpatient treatment settings (Brecht, 2006;Hser et al., 2004;Ilgen et al., 2005). Studies from Miller and Moyers (2015) and Reyre et al. (2017) suggested that a therapeutic relationship with a counselor is a strong predictor of positive treatment outcomes. ...
... For many respondents in the current study, and consistent with previous studies, in-patient treatment settings that had structured and controlled environments were instrumental in helping them to achieve recovery (Bradshaw et al., 2015;Morris et al., 2018;Simpson & Broome, 1998). Results also revealed the critical role of counselors and the bond of trust that helped in initiating, achieving, and sustaining recovery as affirmed through earlier research (Miller & Moyers, 2015;Reyre et al., 2017). ...
Thesis
The National Survey of Substance Abuse Treatment Services (N-SSATS) reported 197, 559 full-time practitioners working in SUD treatment facilities in 2016, including approximately 34 to 50% of people in recovery from addiction (Gallagher 2010; Knudsen et al., 2006; Ryan et al., 2012). Despite these high percentages, very few qualitative studies have explored the motivations for people in recovery from SUD to work in the addiction treatment field as licensed and certified counselors. A narrative inquiry approach was used to explore the lived experiences of 18 individuals recovering from a substance use disorder (SUD) working as counselors in the addiction treatment field. This study was informed by Expectancy theory, and findings revealed a range of issues that motivated SUD populations to become counselors. These included wanting to give back, perceived self-efficacy to work with SUD populations, and previous experiences with addiction staff members. Intrinsic rewards included a sense of fulfillment, witnessing clients’ progress over time, and the opportunity to sustain their own recovery. Themes of experiences as a person in recovery working with SUD clients, including navigating incomprehensible social policies related to insurance and housing while providing services to clients and seeking support from colleagues, peers and therapist also emerged. Participants shared that the use of evidence-based practices including Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) had impacted clients’ treatment outcomes. Implications for social work theory, education, practice, policy, and future research are offered.
... By combining relational (e.g., demonstration of empathy and respect for patient autonomy) and technical (e.g., open-ended questioning) elements in MI sessions, it is possible to create this safe environment for patients to speak freely (Magil et al., 2014). According to Miller and Moyers (2014), these factors should not be considered common or non-specific in assessing the efficacy of the intervention, since they are very important for the success of the intervention (Miller & Moyers, 2014). ...
... By combining relational (e.g., demonstration of empathy and respect for patient autonomy) and technical (e.g., open-ended questioning) elements in MI sessions, it is possible to create this safe environment for patients to speak freely (Magil et al., 2014). According to Miller and Moyers (2014), these factors should not be considered common or non-specific in assessing the efficacy of the intervention, since they are very important for the success of the intervention (Miller & Moyers, 2014). ...
Article
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The aim of this review is to synthesize what is known about the efficacy of Motivational Interviewing (MI) in addicted substance users. MI is a guide and an empathic process based on assisting the patients on exploring and resolving the ambivalence in the process of behavior change. In this systematic review, we analyzed documents from several databases, following the Cochrane Collaboration guidelines. The studies were identified by searching multiple literature databases in EBSCOhost, including Academic Search Complete, Business Source Complete, ERIC, Library, Information Science & Technology Abstracts, PsycARTICLES, PsycINFO and SPORTDiscus with Full Text. Plus, with Full Text, Academic Search Complete and PsycINFO. To avoid publication and source selection bias, these database searches were supplemented by an additional manual search. A total of 393 studies, published between 1994 and 2019, were identified from all databases and search methods. The studies’ abstracts were available, and 23 studies were selected. In addition, 1 study was included from the manual research. Thus, a total of 24 studies were selected for review. The results of the studies suggest that MI is effective on reducing substance use, whether of legal or illegal drugs. Additionally, MI increases the efficacy of treatment due to the therapeutic alliance between patients and therapists throughout treatment, allowing them to accomplish behavioral changes.
... A good alliance is characterised by the therapist and patient working as a team in full agreement about the goals and targets, and about how they should be working together. Several studies show that the quality of the relationship between the therapist and the patient is one of the best treatment outcome indicators (1,20,21). ...
... There is some evidence that use of a manual can undermine effectiveness with one meta-analysis reporting smaller effect sizes with manual-guided MI (Hettema et al. 2005). As described in section 3.11.1 (page 58) attempts to standardise treatments often result in an excessive focus on technical matters and practical steps for implementation, at the expense of the interpersonal essence that is important for treatment outcomes (Miller and Moyers 2015). ...
Thesis
Aim: To explore the feasibility of motivational interviewing (MI) as an adjunct to pulmonary rehabilitation (PR). Method: A mixed methods research design was used, involving three linked studies, guided by the Medical Research Council complex intervention framework. Study 1: following a 1-day introductory workshop, respiratory clinicians’ (n=9) views of MI were gathered, and their insights informed a model for combining MI with PR, and a MI training package. Study 2 employed a pre-post, single group quantitative design to evaluate the effectiveness of the MI training package (2-day workshop and five coaching/feedback sessions) for PR clinicians (n=24). The learning and implementation experiences of a sample of these participants (n=9) were explored in study 3. Results: Study 1: Respiratory clinicians deemed MI acceptable for maximising PR engagement and adherence but raised feasibility issues regarding training and implementation. Study 2: PR clinicians made progressive improvements in MI skill at each stage of training, with mean values for MI spirit (3.5 ±0.61) and mean global ratings of skill (3.57±0.63) reaching basic competency targets (3.5). The relative frequency and depth of reflective listening did not alter sufficiently (reflection question ratio 0.71 ±0.40, target 1; percent complex reflections 24.25 ±13.54, target 40) and participants struggled to achieve the depth of conversation advocated in the PREAMP intervention manual developed for the study. Participants took longer than expected to complete training (total training time 20.55 weeks ±9.78, target 10 weeks) and n=12 (50%) did not complete training. Study 3 highlighted three themes. Within these are some possible explanations for the failure to achieve desired levels of reflective listening, depth of conversation and timely completion of training within study 2: 1) Cultural context: service/organisational issues result in prioritisation of short-term measures of impact, which compromise the time available for MI. A disconnect exists between an MI style of working and the approach that PR clinicians are used to and feel comfortable with; 2) Challenging: the prospect of using novel skills led to performance anxiety. Using MI required participants to accept that sessions may take longer, cover unanticipated topics and may not result in change. Concerns were raised that not all patients are immediately ready to take a more active role in consultations and decision making. Trying novel skills and suppressing behaviours that are antithetical to MI demanded attentional resource and detracted from key tasks such as maintaining empathy. Participants found recognising the limitations of existing practice, yet feeling underprepared to deliver MI effectively, to be destabilising. MI may reveal emotive issues that are uncomfortable for both patients and clinicians. However, all participants noted improvements in their skills and confidence over time, which reinforced positive perceptions of MI; 3) Lessons learnt for the future: training was well received but greater volume of training, protected time for learning and extended appointments to support the integration of MI in practice were deemed important. Conclusion: MI maybe a feasible adjunct to PR. It can be delivered by health professionals, but there are some training issues that need to be addressed to ensure competence. The next stage in the MRC framework should be a pilot randomised controlled trial, but the author recommends use of a stepwise training model whereby training continues until basic competency is achieved, and that additional appointment time is provided to allow for the integration of MI.
... Participants that were required to complete services to comply with a legal mandate were less likely to return for MHD/SUD services and less likely to experience positive outcomes from treatment. Personal motivation to change is therefore an important factor for engagement in MHD/SUD services (Miller and Moyers 2015;O'Connor et al. 2014;Prochaska 2015) and engagement has been positively related to improved medication adherence, decreased feelings of shame, and increased quality of life for PWH (Langebeek et al. 2014;McDoom et al. 2015;Mutabazi-Mwesigire et al. 2015). Site of services and types of services (i.e., group, individual, residential) was also an important factor for retention in MHD/SUD treatment. ...
Article
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People with HIV (PWH) who have mental health disorders (MHD) and substance use disorders (SUD) have lower HIV medication adherence, higher unsuppressed viral loads, and higher mortality rates than those who do not. Individuals who have triple diagnoses (HIV, MHD and SUD) are at an exponential risk for these adverse outcomes. This study explored the barriers and facilitators to accessing and linking PWH with MHD and SUD services. Qualitative interviews with 90 participants were conducted to explore their experiences seeking treatment for MHD and SUD. Results of a thematic analysis found two important barriers to treatment access and utilization: unstable motivation to change and negative experiences with providers. Conversely, an internal drive to heal and rapport with providers facilitated positive treatment experiences. Findings of the study also indicate a need for an integrated treatment model where MHD, SUD, and HIV treatment are available at the same location.
... This is of particular concern in settings where the clinical direction is inherent in the agency's purpose, as is the case in substance use treatment centers. If counselors who practice MI avoid its directional elements, this may be the result of decisions by those who train the method, and may partly explain MI's loss of effectiveness in the science-to-service pathway (Miller & Moyers, 2014). ...
Article
Motivational Interviewing (MI) is comprised of a client-centered relationship and a clear intention on the part of the practitioner to influence behavior change. This study explores MI trainers’ decisions about their use of directionality in MI as they instruct others in the method. 111 MI trainers were asked to select content they would include in a hypothetical MI training. Almost half of trainers chose to teach trainees to “always maintain an attitude of equipoise”, a strategy that is contradicted by MI theory and empirical data. This finding suggests a theoretical rift within the MI community with implications for substance use counseling.
... Half of the authors reported no benefit from adding counseling, cognitive-behavioral therapy or contingency management to buprenorphine, while the other half demonstrated the efficacy of behavioral interventions, particularly contingency management. This could be due to the substantial differences that exist among therapists in drug addict outcomes because the relational factors such as therapist empathy and therapeutic alliance can be significant determinants of addiction treatment outcome (77). To promote these relational factors, clinicians must begin by "taming" their addicted patient. ...
Article
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Psychotherapeutic consultations of drug addict's patients in a Care, Support and Prevention Center in Addictology led us to propose several hypotheses on the genesis of addiction and its articulation with currently available neurobiological data. This care center dispenses both pharmacological maintenance medications for heroin dependence, such as methadone or buprenorphine, and psychological support. Our first hypothesis posits that the addictive process is driven by the narcissistic vulnerability of these patients, its neurobiological foundations being mainly mediated by the activation of endogenous opioid systems. Drug use/abuse could be a way to make arise the “True Self,” therefore overcoming the defensive system's set up to protect oneself from early traumas. The neurobiological impact of traumas is also developed and articulated with psychodynamic concepts, particularly those of Winnicott. Additionally, functions of addiction such as defensive, anti-depressant roles and emotional regulation are discussed in relationship with their currently known neuroscientific bases. Although the experience in the psychodynamic clinic is at a level of complexity much higher than what is currently accessible to the neurosciences, most of the research in this domain stays in line with our psychological understanding of the addictive process. Finally, we outline some critically sensitive points regarding the therapeutic support.
... Not only should gambling treatment researchers report and agree on a set of gambling-specific variables, but they should also expand data collection to other important variables such as the therapeutic alliance and therapist factors (Meier et al., 2006;Roos & Werbart, 2013). An increasingly growing number of studies have attended to therapists' effects on dropout and other treatment outcomes, in which low therapeutic alliance and specific therapist factors increase dropout risk (Miller & Moyers, 2015;Zimmermann et al., 2017). However, these issues have received little to no attention in studies of gambling treatment. ...
Article
Objective: The aims of this systematic review and meta-analysis were to examine the overall prevalence of dropout from psychological treatments for problem gambling and gambling disorder and to examine how study, client, and treatment variables influenced dropout rates. Method: A systematic search was conducted to identify studies of cognitive and/or behavioral therapies and motivational interventions for problem gambling and gambling disorder. Meta-analysis was used to calculate an overall weighted dropout rate. Random effect meta-regressions were used to examine covariates of dropout rates. Mixed-effect subgroup analyses were used to examine moderators of dropout rates. Results: The systematic search identified 24 studies (31 dropout rates) comprising 2,791 participants. Using a random-effects model, the overall weighted dropout rate was 39.1%, 95% CI [33.0%, 45.6%]. Increases in the percentage of married participants were significantly associated with lower dropout rates. Dropout rates were significantly higher when dropout was defined as attending all sessions of a treatment protocol compared to when defined as attending a prespecified number of sessions different from the total in the protocol and when defined as study therapists judging participants to be dropouts. Insufficient reporting of some gambling-related variables and other psychological symptom variables prevented a thorough examination of covariates and moderators. Conclusions: A large proportion of individuals drop out of treatment for problem gambling and gambling disorder. Future research should examine the reasons for dropout across marital statuses and should adopt dropout definitions that consider session-by-session symptom change. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Identifying a therapist having lived experience can also help foster empathy, which is identified as a partial mediator of therapeutic alliance (Leonard, Campbell, & Gonzalez, 2018). Furthermore, in therapy that is focused on problematic substance use, empathy is a significant predictor of treatment outcomes, with absence of empathy associated with poor outcomes including higher dropout, higher rates of relapse, weaker therapeutic alliance, and worse patient progress (Miller & Moyers, 2015;Moyers & Miller, 2013). Finally, another adaptation made for implementation of BA following this formative feedback to tailor the intervention adaptation for patients with low literacy levels and providers with limited experience delivering psychological therapies was the use of a flipchart in session. ...
Article
South Africa has the largest HIV/AIDS burden globally. In South Africa, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, and yet it is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in South Africa. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly used to treat depression in low- and middle-income countries and substance use in high-income settings. Yet, to date, there is limited research on using BA for substance use in low- and middle-income countries. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in South Africa. We conducted semistructured individual interviews among patients (n = 19) with moderate/severe substance use and detectable viral load, and HIV care providers and substance use treatment therapists (n = 11) across roles and disciplines at 2 clinic sites in a peri-urban area of Cape Town. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on isiXhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard/housework as relevant substance-free activities. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... Empathic response has been highlighted in the literature as the key element of effective substance use treatment processes. It has been shown to be even more important in improving treatment outcomes that the type of therapeutic response (Ashton & Witton, 2004;P. G. Miller & Miller, 2009;W. Miller & Moyers, 2015). ...
... The findings of Aviram and colleagues may offer an explanation as to why pre-treatment MI therapist behaviours did not predict treatment outcome in the current study and may also indicate that the relational hypothesis (as opposed to the technical hypothesis) would be important to examine further. Although our exploratory analyses suggested that MI Spirit did not predict treatment outcome, it is possible that a variety of relational factors during both pre-treatment and active treatment phases contribute to treatment outcome, and it may be within the context of high levels of empathy and MI Spirit that technical factors have the most influence to foster enduring motivation to change (e.g., Miller & Moyers, 2015). ...
Article
Background and objective: Motivational interviewing (MI) was originally developed to treat problematic drinking but is increasingly integrated into treatment for anxiety disorders. A causal model has been proposed which suggests technical and relational factors may account for the efficacy of MI. The technical hypothesis suggests that therapist MI-consistent behaviours are related to client change talk, and change talk is linked to treatment outcome. Research examining the technical hypothesis has typically been conducted in MI for substance use; therefore, the current study aimed to explore the technical hypothesis in MI for social anxiety disorder (SAD). Method: Participants diagnosed with SAD (n = 85) each received MI prior to receiving group cognitive-behavioural therapy (CBT). MI sessions were coded for behaviours relevant to the MI technical hypothesis. Results: The proportion of MI-consistent therapist behaviours and reflections of change language significantly predicted the proportion of change talk by the client during MI sessions; however, therapist and client behaviours did not predict treatment outcome. Conclusion: The findings support one path of the MI causal model in the context of social anxiety, though indicate that the occurrence of these behaviours during an MI pre-treatment may not extend to predict treatment outcome following CBT.
... However, there is little critical evaluation of the 'why' there is low motivation in the first instance, nor of the 'sense-making' that the individual attributes to the attractiveness or appropriateness of the service. Significant literature does seem to indicate that individual characteristics are less important than the counsellor or project characteristics in predicting the resolution of dependent drug use and retention rates in opioid agonist programmes [37][38][39]. ...
Article
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Background: Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome. Methods: Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature. Results: The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project. Conclusions: We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.
... It is possible to examine the temporal changes within a session through sequential analysis. As this study was the first test of the technical and relational pathways within the context of medication adherence for any chronic physical condition, a less-resource intensive method than sequential analysis is advised as a first step to establish promising candidates for the MI model in a new population [50]. Future studies should focus on sequential analysis to address the temporality limitation of correlational designs. ...
Article
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Antiretroviral therapy (ART) for HIV requires strict regimen adherence. Motivational interviewing (MI) can improve ART adherence. MI process studies have rarely focussed on ART adherence. Such studies may facilitate MI modifications to improve outcomes. This study employed a single group pre and post-test design with 62 adults with HIV (16 female; mean age 40 years). Therapist use of MI-consistent (MICO) methods, MI spirit, and client change and sustain talk were coded from an MI session. Relationships were assessed with ART schedule adherence. MICO methods positively correlated with change and sustain talk and were negatively associated with proportion of change talk. No variables were associated with ART adherence change. Mediation analysis did not support the MI model of change. This may be due to the fact that ART adherence is determined by both motivational and non-motivational factors. It may also be that bidirectional relationships exist between therapist and client speech.
... For these reasons, it is recommended that treatment and support options allow sufficient time for professionals to establish trustworthy relationships with individuals in addiction recovery. In such relationships, professionals can support individuals in recovery to gain insight into, and express, what they perceive to be meaningful activities (Skipper and DuPont 2010;Miller and Moyers 2015;Topor et al. 2018). Moreover, professionals ought to support the development of resources in the community and facilitate individuals to (re)connect with these resources and engage in what they find to be meaningful activities (e.g. ...
Article
Background: Addiction recovery is receiving increasing attention in policy, practice and research. However, the concept remains vague, and it is unclear how the perspectives of important stakeholders – such as individuals in recovery and family members – relate to each other. Therefore, this study aims to capture these perspectives to provide a better understanding of what recovery entails and how optimized support can be provided. Method: To gain insight into these perspectives, 9 focus groups (6 with individuals in recovery, 3 with family members), focusing on what recovery means to the respondents, were conducted in both in- and outpatient treatment settings. The focus groups were audio-taped, transcribed and thematically analyzed. Results: Several tensions between the perspectives of individuals in recovery and family members and differences in pace emerged with regard to the 2 main categories we found in the data: (1) recovery as an act of change, and (2) the relational nature of recovery. Perspectives differ in relation to the change (existential or behavioral) that was needed for recovery, the roles of family members in recovery processes (tendency to control versus support), and the need for involvement in support. Conclusion: Differing perspectives on recovery lead to a different pace and different expectations of important stakeholders. Therefore, mutual understanding is essential to gain awareness and to better align mismatching perspectives. A supportive context can provide the needed support for both individuals in recovery and family members to go through their own recovery process, while accompanied and supported by others who proceed at their own speed.
... Behavior analyses are conducted to understand the patient's behavior, such as phobic reactions or drug relapse. Besides therapy and counselling techniques, treatment success heavily depends on relational factors, such as patient self-efficacy, therapist empathy and the therapeutic relationship (Miller and Moyers, 2015). ...
Thesis
With the growth of information technology, patient attitudes are shifting – away from passively receiving care towards actively taking responsibility for their well- being. Handling doctor-patient relationships collaboratively and providing patients access to their health information are crucial steps in empowering patients. In mental healthcare, the implicit consensus amongst practitioners has been that sharing medical records with patients may have an unpredictable, harmful impact on clinical practice. In order to involve patients more actively in mental healthcare processes, Tele-Board MED (TBM) allows for digital collaborative documentation in therapist-patient sessions. The TBM software system offers a whiteboard-inspired graphical user interface that allows therapist and patient to jointly take notes during the treatment session. Furthermore, it provides features to automatically reuse the digital treatment session notes for the creation of treatment session summaries and clinical case reports. This thesis presents the development of the TBM system and evaluates its effects on 1) the fulfillment of the therapist’s duties of clinical case documentation, 2) patient engagement in care processes, and 3) the therapist-patient relationship. Following the design research methodology, TBM was developed and tested in multiple evaluation studies in the domains of cognitive behavioral psychotherapy and addiction care. The results show that therapists are likely to use TBM with patients if they have a technology-friendly attitude and when its use suits the treatment context. Support in carrying out documentation duties as well as fulfilling legal requirements contributes to therapist acceptance. Furthermore, therapists value TBM as a tool to provide a discussion framework and quick access to worksheets during treatment sessions. Therapists express skepticism, however, regarding technology use in patient sessions and towards complete record transparency in general. Patients expect TBM to improve the communication with their therapist and to offer a better recall of discussed topics when taking a copy of their notes home after the session. Patients are doubtful regarding a possible distraction of the therapist and usage in situations when relationship-building is crucial. When applied in a clinical environment, collaborative note-taking with TBM encourages patient engagement and a team feeling between therapist and patient. Furthermore, it increases the patient’s acceptance of their diagnosis, which in turn is an important predictor for therapy success. In summary, TBM has a high potential to deliver more than documentation support and record transparency for patients, but also to contribute to a collaborative doctor-patient relationship. This thesis provides design implications for the development of digital collaborative documentation systems in (mental) healthcare as well as recommendations for a successful implementation in clinical practice.
... Relational factors also seem to be significant in other helping relations, such as community health interventions Ljungberg et al. 2015). Relational factors are insufficiently understood, operationalized and emphasised in research on mental health and substance use treatment (Davidson and Chan 2014;Miller and Moyers 2015). There is a need for research that explores therapist behaviour and qualities that enhance positive change, from the patients' perspective . ...
Thesis
Full-text available
People with co-occurring mental health and substance use disorders (COD) face challenges related to living conditions, community participation, and a lack of tailored and integrated health and social services. Recovery and person-centred approaches allow for an understanding of COD that is grounded in each individual person and his or her context, where lived experience is seen as a valued source of knowledge. There is a need for knowledge of how recovery and professional help are experienced by people with COD in different contexts. While recovery-oriented practice is recommended through national guidelines, there is little knowledge of how such practice works at the service delivery level. Knowledge is also needed on how practitioners experience recovery-oriented practice to support people with COD. This thesis has sought to contribute to the scientific knowledge on recovery and recovery-oriented practice in COD, with a particular focus on community services, by describing and exploring the lived experiences of people with COD and practitioners who work to support recovery in this group. An overarching purpose of the project was to make these lived experiences visible to decision makers in the field. The first aim was to explore and describe experiences of recovery among people with COD. The second aim was to explore and describe behaviour and attributes of professional helpers that support recovery, as experienced by people with COD. The third aim was to explore and describe practitioners’ experiences with dilemmas in recovery-oriented practice to support people with COD. This project is influenced by phenomenological and collaborative methodology and consists of two qualitative studies. Study 1 consisted of eight individual, in-depth, interviews with people with COD, which were analysed with systematic text condensation. Study 2 consisted of three focus group interviews with practitioners in a municipal mental health and addictions team that was committed to developing recovery-oriented practice. The interviews in Study 2 were analysed using thematic analysis. Both studies were conducted in the same local authority area in Norway. An advisory group with people from the community with lived experience of COD, experience as family members, and professional experience has been involved in the project throughout. Results from this project support findings from other qualitative studies which indicate that control over symptoms may be a pathway to, but not the essence of, recovery. Systematic investigation of first-person experiences in this project has painted a broader picture of recovery in COD, which includes community participation, living conditions, and existential phenomena. Community participation, particularly feeling useful, may be a central facilitator in recovery. Adverse living conditions and loneliness may be important barriers to recovery in COD. There were individual differences in how participants related to substance use, but control over substance use seemed necessary in the process of coming to love oneself and emerging as a person. Professional helpers may play a central role in the recovery process once a trusting relationship has been established. Professional helpers’ ability to understand and act on people’s everyday struggles, and to address substance use in a competent and straightforward way, appear as specific valued attributes in professional helpers by people with COD. Practitioners described dilemmas in recovery-oriented practice to support people with co-occurring disorders; these involved how to relate to substance use in a recoveryoriented way, how to give enough help and still facilitate empowerment, and how to relate to people’s own life goals with neither moralism nor indifference. People with COD were described as expecting too little from services and tolerating unacceptable living conditions, which elicited directiveness from practitioners. This thesis concludes that a better life is possible for people with COD. While perceptions of a good life are similar to, and equally diverse as, perceptions in the general population, the degree of adverse living conditions and the amount of barriers in solving them seem particular to this group of citizens. In order for professional helpers to support recovery for people with COD, a trusting relationship is fundamental. Practitioners may experience dilemmas in recovery-oriented practice to support people with COD. Different traditions of understanding substance use may lead to different understandings of what it means to address substance use in a recovery-oriented way. Results from this thesis suggest that services to people with COD need to be flexible, integrated and allow for continuity. Professional helpers and services should be able to address living conditions and loneliness, and increase opportunities for genuine community participation for people with COD. Services should be able to address substance use in competent and individualised ways.
... By doing so, treatment and support is not only adjusted to specific populations assumed to have similar characteristics and needs, but is tailor-made to the idiosyncratic features and unique needs of individuals within this group (DuPont & Humphreys, 2011;White, 2008b). To gain insight in the needs of individuals, drug and alcohol services need to create conditionsfor example the possibility for long-term/ongoing support or case management (Skipper & DuPont, 2010;Vanderplasschen, Rapp, De Maeyer, & Van Den Noortgate, 2019;White, 2008b)that enable professionals to build trustworthy therapeutic relationships (Miller & Moyers, 2015;Topor et al., 2018;White, 2008b). ...
Article
Addiction recovery has gained considerable attention over the past few years. Despite the diffuse conceptualization of ‘recovery’, a range of studies have been conducted on what recovery means. Even though cocaine is the most frequently used stimulant drug, little qualitative research has been done on recovery from cocaine addiction. This study provides more insight into the personal perspectives of (former) cocaine-dependent individuals. In-depth interviews (n = 23) were conducted in a cocaine-specific treatment programme (CRA + vouchers) in Belgium. According to respondents, cocaine addiction recovery is a process that concerns an identity shift, building on personal strengths and utilizing sources of support from the close social network and society. The results showed some specific features regarding the recovery process of individuals in recovery from cocaine addiction, since ‘socially integrated’ cocaine users had a head start due to advantages such as being employed and having a social network. Support should be tailored to the specific needs of individuals in recovery and social networks and communities that support recovery are needed.
... Therefore, counselling should be available alongside MMT but voluntary in nature to ensure they do not raise the threshold of MMT or dissuade clients from starting the recovery process with expectations they cannot meet (Damon et al., 2017). Furthermore, fostering positive, trusting relationships between MMT clients and healthcare providers appears to be a crucial factor in client satisfaction with treatment and may also promote more positive treatment outcomes (e.g., retention in MMT, long-term opioid abstinence, etc.; Damon et al., 2017;Miller & Moyers, 2014;Press et al., 2016). These recommendations may help address the current opioid crisis that is afflicting many Canadian communities. ...
Article
Background Methadone maintenance therapy remains the most common form of substitution therapy for opioid use disorder in Canada. Effectiveness of methadone maintenance therapy has been established, but recently newer treatment delivery models have emerged. Differences across these treatment models have not been examined. Purpose This descriptive qualitative study used semi-structured interviews to assess client experiences in three methadone maintenance therapy treatment delivery models: (a) comprehensive programs, (b) low-threshold/high-tolerance programs, and (c) fee-for-service programs. Methods A total of 32 participants were recruited from methadone maintenance therapy clinics in an Atlantic Canadian city and grouped into three models of care ( n a = 9, n b = 11, n c = 12). Content analysis was performed on interview data to assess the frequency of relevant themes in the data. Results Participants from all groups stressed the importance of supportive staff and having access to some form of counselling. However, low-threshold/high-tolerance and fee-for-service clients voiced a need for more formal counselling and programming at their clinics. Methadone was reported as the most helpful aspect of the methadone maintenance therapy programs; however, participants also expressed negative views about the substance. Conclusions These findings have important implications for the development and implementation of methadone maintenance therapy, specifically pertaining to further integration of addiction and mental health services.
... The literature suggests that MI consistent behaviours such as emphasising autonomy, collaboration, and reflecting change talk, increase the likelihood of change talk (and decrease the likelihood of sustain talk). This in turn predicts subsequent change (Miller & Moyers, 2015). Additionally, MI skills predict the frequency of change talk in sessions, whereas behaviours that are inconsistent with MI such as confrontational approaches, advice giving without permission, and low empathy, in turn predict sustain talk (Borsari et al., 2015;Gaume et al., 2010;Magill et al., 2016). ...
Article
Within the literature, school-based consultation has been conceptualised as an adult behaviour change process (Noell & Gansle, 2014). This study examined the process of consultation through the lens of Motivational Interviewing (MI). To do this, an adapted form of the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE; Martin et al., 2005) was used to code the interaction in consultation between educational psychologists (EPs) and teachers. In total, 1610 verbal utterances were parsed, coded, and analysed over the course of two consultations. Frequency analyses revealed that different kinds of motivational talk occur in consultations, and EPs communicate during consultation in ways that are consistent with the principles of MI. A sequential analysis of the interaction that occurred during consultation showed that different kinds of EP talk during consultation evoke different kinds of teacher response in a predictable way. Findings were used to create a state transition map of the interaction in consultation. Transitions of interest in the consultation were then considered in relation to the consultative literature, and theoretical and empirical learnings from Motivational Interviewing, Self-Determination Theory, and Self-Efficacy. The findings of this study may be used to optimise the consultative practice of EPs, and thus implications are potentially far-reaching, albeit tentative given the early stage of research in this area. The cross-pollination of ideas from MI to school-based consultation appears to be a worthy area of study for EPs which warrants further research to expand upon the findings presented here.
... Studies have shown that even when treatment delivery was standardized and guided by manuals, differences in client outcomes appeared to be related to the counselor providing the services. Specifically, people who received SUD treatment from a counselor with high empathy tended to have better outcomes such as treatment retention and decreased alcohol use (Miller & Moyers, 2014). Those who received treatment from a counselor with low empathy tended to experience increased drop-out and relapse rates, and less behavior change (Moyers & Miller, 2013). ...
Technical Report
Full-text available
Motivational Interviewing Skills in Action for Juvenile Drug Treatment Court Teams is a technical assistance package designed to translate the MI spirit, skills, and strategies directly to the juvenile drug treatment court setting. Published by the National Council of Juvenile and Family Court Judges, this package is available free and consists of three parts: 1. Technical Assistance Bulletin (TAB): A document describing how the spirit, skills, and strategies of MI apply to the work of JDTC teams; 2. MI Info Card: Double-sided handout highlighting essential MI concepts; and 3. MI Cue Cards: Portable prompts for using specific MI skills and strategies in court, staffing, and meetings with youth and families. Written in clear language, these materials are intended to guide practitioners through the use of examples, dialogue, and options for navigating challenging situations. Download the publication, or request free hard copies by emailing Jessica Pearce at jpearce@ncjfcj.org. We welcome questions and feedback!
... Two components of motivation predict good treatment outcomes [8]. According to Finney [9], Motivation readiness for change is an important consideration in treatment planning, a study conducted by Breda and Haflinger [4] show that more serious substance users are motivated better to change at the outset of treatment and experience more rapid declines in substance use after treatment begins [4]. ...
Article
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Abstract The study aimed to evaluate the effectiveness of cognitive behaviour therapy (CBT) program in reinforcing motivation to change among patients with substance use disorders (SUDs) in the Gaza Strip. The experimental design was used, Participants were 30 males distributed randomly into two groups: experimental and control, (n = 15) per group, using a random sampling method. The experimental group was subjected to a CBT program consisting of (16) sessions over two months. The control group did not undergo any program. Motivation to change scale was applied pre, post- and after two months of follow up. The study shows that weight mean for motivation to change in the pre-experimental group equals to 49.4% and the weight mean post-experimental group equals 65.07%, in another hand, the weight mean in pre-control group equals 41.8% and the weight mean post- control group equals 41.3%. The study found P-value equals 0.000, which is less than 0.05 in both groups in the posttest. Also, p-value 0.001 “ which is less than 0.05 in pre-test and post-intervention. Besides, the effect size for the CBT program in motivation to change equals 24.7%. The results revealed that p-value equals 0.001 which is less than 0.05 in post-test and follow-up, the results proved the significant effectiveness of CBT and its survival, The study conclude that CBT sessions have been effective and successful in reinforcing the motivation to change among patients with SUDs. Keywords: Cognitive Behaviour Therapy; Motivation to change; Substance Use Disorder
... The statistically significant advantage for BAIs over control was 8% across the entire population, including nondrinkers at both 1-3 months and 6 months. If a 10% difference is accepted by clinicians as a clinically meaningful change (see Miller & Moyers, 2015), this 8% difference comes close to meeting the threshold for "brief" interventions that typically require less than 2 h to deliver. Our previous discussion on whether BAIs effectively reduce alcohol consumption for college students has been guarded . ...
Article
Full-text available
To evaluate and optimize brief alcohol interventions (BAIs), it is critical to have a credible overall effect size estimate as a benchmark. Estimating such an effect size has been challenging because alcohol outcomes often represent responses from a mixture of individuals: those at high risk for alcohol misuse, occasional nondrinkers, and abstainers. Moreover, some BAIs exclusively focus on heavy drinkers, whereas others take a universal prevention approach. Depending on sample characteristics, the outcome distribution might have many zeros or very few zeros and overdispersion; consequently, the most appropriate statistical model may differ across studies. We synthesized individual participant data (IPD) from 19 studies in Project INTEGRATE (Mun et al., 2015b) that randomly allocated participants to intervention and control groups ( N = 7,704 participants, 38.4% men, 74.7% White, 58.5% first-year students). We sequentially estimated marginalized zero-inflated Poisson (Long et al., 2014) or negative binomial regression models to obtain covariate-adjusted, study-specific intervention effect estimates in the first step, which were subsequently combined in a random-effects meta-analysis model in the second step. BAIs produced a statistically significant 8% advantage in the mean number of drinks at both 1–3 months ( RR = 0.92, 95% CI = [0.85, 0.98]) and 6 months ( RR = 0.92, 95% CI = [0.85, 0.99]) compared to controls. At 9–12 months, there was no statistically significant difference in the mean number of drinks between BAIs and controls. In conclusion, BAIs are effective at reducing the mean number of drinks through at least 6 months post intervention. IPD can play a critical role in deriving findings that could not be obtained in original individual studies or standard aggregate data meta-analyses.
... A second reason for the potential absence of findings in the context of cannabis use is that treatment as usual, represented here as our ACE condition, increasingly represents "tough competition" in treatment examinations (Miller & Moyers, 2015). ACE might have been impactful here because it provided all adolescents 2 hr of individual attention with a caring adult. ...
Article
Hispanic youth represent one of the fastest-growing minority groups. Yet, we know little about Hispanic adolescents' response to empirically-supported interventions for adolescent addiction, including motivational interviewing (MI). This randomized controlled trial (RCT) compared MI to an active educational treatment for adolescent alcohol and cannabis use (alcohol and cannabis education; ACE). Adolescents who regularly use substances (N = 448; n = 347 Hispanic; n = 101 non-Hispanic white; ages 13-18) were randomized to two 1-hr individual sessions of MI or ACE. We examined 6-month outcomes and mechanisms of change across Hispanic and non-Hispanic white youth. Treatment response was comparable across ethnicities (Hispanic vs. non-Hispanic white youth). Additionally, adolescents in the MI condition showed greater reductions in alcohol use compared to those in ACE, with support for motivation and self-efficacy as mechanisms of treatment response. Direct effects of MI on cannabis use were not observed; however, a significant indirect effect of motivation was observed for reductions in cannabis use. Data support the efficacy of MI in reducing adolescent alcohol use, through the vehicle of enhanced motivation and self-efficacy. While consistent treatment response was observed for adolescent alcohol use across ethnicities (Hispanic vs. non-Hispanic white), further exploration into potential underexplored mechanisms of Hispanic adolescents' treatment response is requisite to strengthening prevention and intervention programming for Hispanic adolescents' cannabis use. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... TSPs exist in over 180 countries (GSO, 2020), are cost-free, accessible, and available online (Dossett, 2013). Treatment facilities often recommend TSPs for after-care, and 12-Step Facilitation (TSF) is used as a stand-alone treatment modality (Galanter, 2018;Kelly et al., 2017;Miller & Moyers, 2015). Project MATCH, the largest randomized trial for addiction treatment ever conducted, found TSF abstinence results to be as favourable as those for other well-tested approaches (PMRG, 1998). ...
Article
Full-text available
Spirituality is a broad concept and open to different perspectives. It is associated with a sense of connection to something larger than oneself and a search for life’s meaning. Many people find this meaning through a connection with nature, but less is known about how to create a connection for those who are actively seeking one. Individuals in early recovery from addiction are encouraged to engage in 12 Step programmes (TSPs). However, the spiritual nature of the programme with references to the word “god” can serve as a deterrent. Nature connectedness through the five pathways provides a potential opportunity to introduce the concept of a higher power (HP) through a connection with nature. In this pilot mixed-methods study, a group of participants (n=12) in outpatient treatment for SUD were exposed to the five pathways and compared to a control group. Semi-structured interviews were conducted following the initial intervention. Drawing upon nature as a higher power through the pathways led to significant increases in nature connectedness, well-being, quality of life, and spirituality compared to a control group. The pilot study indicates that nature through the five pathways to nature connectedness provides a potential alternative for a higher power to draw upon within Twelve-Step.
... To enable tailor-made support, insight into the personal needs of individuals in recovery is warranted. Professionals can gain understanding of these personal needs of the individual in recovery they work with by building close relationships (Miller & Moyers, 2015;Skipper & DuPont, 2010;Topor et al., 2018). Furthermore, building on their insight into what service users perceive as important and meaningful, professionals are able to identify possible sources of support in the social context and communities of those in recovery and support service users to build on these resources (Walsh et al., 2019). ...
Article
Even though various pathways to addiction recovery have been identified, knowledge on overarching essential components of addiction recovery processes remains limited. To explore these essential components , in-depth interviews were conducted with a heterogeneous group of individuals across pathways to addiction recovery (i.e. a low-threshold activation center, Narcotics Anonymous, a CRA þ vouchers outpatient program, residential treatment programs, and 'natural' recovery). The interviews (n ¼ 25) were audio-taped, transcribed verbatim, and thematically analyzed. In-depth analysis of the data resulted in a model that includes essential components of addiction recovery processes and their dynamic relationship. 'Time' and 'supportive environments' were identified as the foundations and facilitators for the transformative changes required in addiction recovery processes, which in turn contributed to 'developing a sense of self' and 'developing a sense of future'. These components, interrelated and in a continuous interplay with each other, facilitated recovery processes. As a result, recovery oriented support should be strengthened and specifically focus on supporting these essential components, by providing tailor-made and continuously available support. Given the relational character of addiction recovery processes, social networks and society at large should evolve towards the development of responsive and inclusive spaces to support persons in addiction recovery.
... Evidence has been challenging to assemble, but is nonetheless accumulating, which shows that motivational interviewing (MI) works through the ability of therapists to affect how clients talk about change within sessions, and specific MI skills may have greater impact than others (Brown, Masterson, Latchford, & Tober, 2018;Magill et al., 2018;Singla et al., 2020). Much of the content of MI is not unique to this approach (Miller & Moyers, 2015). ...
Article
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Introduction This study explored whether treatment-specific processes linking therapist behaviors, post-session client ratings, and 3-month proximal outcomes (i.e., end of treatment) can explain 12-month outcomes for two contrasting alcohol treatment conditions with equivalent overall outcomes. Methods This study is a secondary analysis of the UK Alcohol Treatment Trial (UKATT), a multi-center randomized controlled trial of treatment for alcohol problems comparing 3-session motivational enhancement therapy (MET) to 8-session social behaviour and network therapy (SBNT). Among 742 adult clients included in UKATT, 351 had one treatment session recorded and coded and were followed-up 3 and 12 months after baseline. The study team conducted serial mediation analyses to test whether the frequency and quality of MET and SBNT skills were related to 12-month alcohol outcomes (drinks per drinking day) through postsession client ratings of treatment progress (Processes of Change Questionnaire, PCQ), readiness to change (RTC) and social support for drinking after 3-months. Results Higher quality of MET skills was related to higher PCQ scores, which were in turn related to greater post-treatment RTC, and subsequently to better alcohol outcomes. Total indirect effect was consistently significant. In contrast, only PCQ was predictive of treatment outcome in the SBNT portion of the model. Conclusions This study provides evidence from a large pragmatic trial that the quality of MET skills positively influences alcohol outcomes in part through improvements in motivation during treatment and actively trying to change when treatment ends. Research should explore the ways in which SBNT secured outcomes that were equivalent to MET.
... The integration of a translational design also allows us to move beyond examination of simple black-box treatment outcomes to dive deeper into the neural mechanisms below the surface, which reveal a more nuanced picture of what is happening in the adolescent brain and how it is connected to youth behavioral treatment response. Further, this generates a compelling window into which mechanisms might be specific to certain treatments, and which might represent global factors undergirding adolescent behavior change across treatments (referred to in the behavioral treatment literature as "common factors") (Miller and Moyers, 2014). To better disaggregate how adolescent brains respond to therapist language in the context of brief addiction treatments, we examined adolescents' pre-to-post treatment brain response to therapist language. ...
Article
Full-text available
Objective One route to improve adolescent addiction treatment outcomes is to use translational approaches to help identify developmental neuroscience mechanisms that undergird active treatment ingredients and advance adolescent behavior change. Methods This sample included 163 adolescents (ages 15-19) randomized to motivational interviewing (MI) vs. brief adolescent mindfulness (BAM). Youth completed an fMRI paradigm assessing adolescent brain response to therapist language (complex reflection vs. mindful; complex reflection vs. confront; mindful vs. confront) at pre- (prior to the completion of the full intervention) and post-treatment (at 3-month follow-up) and behavioral measures at 3, 6 and 12 months. Results Youth in both treatment groups showed significant problem drinking reductions at 3 and 6 months, but MI youth demonstrated significantly better treatment outcomes than BAM youth at 12 months. We observed several significant treatment group differences (MI>BAM) in neural response to therapist language, including at pre-treatment when examining complex reflection vs. mindful and complex reflection vs. confront (e.g., superior temporal gyrus, lingual gyrus); and at post-treatment when examining mindful vs. confront (e.g., SMA; middle frontal gyrus). When collapsed across treatment groups (MI + BAM), we also observed significant differences by time, with youth showing a pattern of brain change in response to complex reflection vs. mindful and complex reflection vs. confront (e.g., precuneus; postcentral gyrus). There was no evidence of a significant group x time interaction. However, brain change in response to therapist language (complex reflection vs. confront) in regions such as middle frontal gyrus was associated with reductions in problem drinking at 12 months, but few treatment group differences were observed. Conclusions These data underscore the need to better understand therapist language and their impact on the developing brain, in order to aggregate the most impactful elements of addiction treatment to inform future treatment development for adolescents.
... Yet, it is also true that many individuals do not respond to treatment, do not adhere to treatment tasks, discontinue treatment prematurely, or, after initial success, are unable to maintain change [14,15]. Experts in both CBT and MI have suggested this may be due at least in part to CBT approaches not specifying the skills necessary to support the practitioner's relationship with the client and do not help practitioners strengthen motivation for change at both the onset and during the course of CBT [16,17]. Thus, integrating MI and CBT strategies may improve both initial response rates and maintenance of change after treatment is completed [18]. ...
Article
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Background: The National Institutes of Health Obesity-Related Behavioral Intervention Trials model for intervention development was used to establish the feasibility and proof of concept of a motivational ketogenic nutrition adherence program for older adults with mild cognitive impairment. Methods: This was a single-arm, single-center feasibility trial. A comprehensive assessment protocol, including a clinical interview, neuropsychological testing, and genetic sequencing was used as an initial screening. Nine participants (aged 64-75) with possible amnestic mild cognitive impairment were consented for the intervention. Participants completed pre- and post-intervention neuropsychological assessments using the updated Repeatable Battery for Assessment of Neuropsychological Status. Participants tracked their macronutrient consumption using food diaries and ketone levels using urinalysis test strips daily. Mood and other psychosocial variables were collected through surveys, and qualitative exit interviews were completed. Results: 100% of participants who began the trial completed the 6-week ketogenic nutrition adherence program, including completion of the pre- and post-assessments. Eight participants achieved measurable levels of ketones during the program. The average self-rated adherence across the program was 8.7 out of 10. A Wilcoxon Signed-Rank test demonstrated significant improvement in cognitive performance from baseline (median = 88) to follow up (median = 96, Z = - 2.26, p = .024). The average difference in cognitive performance from baseline to follow-up was - 7.33 (95% CI - 12.85, - 1.82). Conclusions: Results supported the feasibility for moving to the next phase and demonstrated proof of concept for the intervention. The next step is a randomized pilot trial to test clinical signals of effect compared to a control condition. Trial registration: This trial was retrospectively registered with clinicaltrials.gov on July 13, 2021. The trial number is NCT04968041.
Article
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This study explored the use of motivational interviewing (MI) in sport contexts by experts in that approach. Specifically, the purpose was to understand which aspects of the MI approach are deemed valuable for working in sport and to begin to understand how these aspects are best applied. Nine practitioners participated in semistructured interviews, and thematic analysis identified themes related to core and subcomponents of MI (e.g., relational spirit, technical microskills, applied tools, and the MI communication styles continuum). Additional themes relate to integrating MI with other interventions, the challenges of working with athletes (e.g., mandated attendance, ambivalence about change), and unique aspects of working in sport contexts (e.g., frequency, duration, and location of contact points). The participants also outlined essential ingredients for an MI training curriculum for practitioners in sport. This counseling approach appears to have valuable relational and technical components to facilitate the building of the therapeutic alliance, enhance athlete readiness for change, and support delivery of action-oriented interventions in applied sport psychology.
Article
The present study investigated the relationship between relational depth and motivation to change substance use in substance use disorder treatment. Linear multiple regression analyses revealed that participant perceived relational depth and participant involvement in substance abuse community support groups statistically significantly predicted participant recognition of a substance use problem.
Article
This nonexperimental field study examined the relationship between participant reported experiences of relational depth (RD) with their individual counselors in substance use disorder (SUD) treatment and participant reported motivation to change substance use. Participants in the study were clients enrolled in inpatient and outpatient levels of substance use disorder treatment.
Article
Background/purpose: Properly designed randomized controlled trials (RCTs) are the gold standard in patient-centered clinical research. Incomplete intervention reporting affects the readers' ability to evaluate treatment efficacy. Previous studies show that detailed descriptions of trial interventions remains insufficient for reliable replication. Understanding reporting areas in need of improvement can improve the quality of intervention reporting. Methods: This cross-sectional review uses the Template for Intervention Description and Replication (TIDieR) checklist to evaluate the quality of intervention reporting in RCTs. The primary outcome was to investigate the completeness of intervention reporting of RCTs reporting outcomes for patients with alcohol use disorder (AUD) published in highly ranked addiction journals. The secondary outcomes were to: 1) evaluate whether publication of the TIDieR checklist resulted in better intervention reporting practices and 2) determine whether particular trial characteristics were associated with the completeness of intervention reporting. Results: The final analysis included 56 records. The mean number of reported TIDieR items was 5.1 (SD = 1.47) of a possible 12. TIDieR checklist publication did not increase the average completion of the TIDieR checklist items (p = 0.76). Improved TIDieR adherence was associated with trials with double blinding, non-drug interventions, and CONSORT endorsement. Discussion/conclusions: We found the reporting of interventions to be inadequate in our sample of AUD-related RCTs. Fundamental details were often not reported, hampering both clinical and research reproducibility. Moving forward, it may be necessary to consider additional mechanisms to either improve TIDieR uptake or to find other solutions to improve intervention reporting.
Article
Background Health care systems are increasingly integrating screening and care for unhealthy alcohol use into primary care settings. However, gaps remain in receipt of evidence-based care after the detection of unhealthy alcohol use. Patient-centered primary care may be an important determinant of alcohol-related care receipt, but its role is underexamined. Methods We examined associations between previously developed, clinic-level measures of patient-centered care (indicative of medical home model implementation) and receipt of alcohol-related care in a national cohort of VA patients who screened positive for unhealthy alcohol use (defined by AUDIT-C alcohol screen of ≥5; n = 568,909) for whom brief intervention is recommended. We also assessed alcohol-related care in a subsample of these patients with a past-year alcohol use disorder (AUD) diagnosis (n = 144,511) for whom specialty addictions care and medications are recommended. The study used modified Poisson models to assess associations between measures of patient-centered care and individual-level receipt of recommended alcohol-related care. We presented prevalence ratios (PR) and marginal probabilities to illustrate relative and absolute differences, respectively, in outcomes associated with clinic-level measures. Results Compared to patients in the lowest-ranked clinics, patients were more likely to receive brief intervention in clinics with the highest rankings of self-management support (PR: 1.06; 95% CI: 1.10, 1.11), communication (PR: 1.08; 95% CI: 1.04, 1.12), access (PR: 1.11; 95% CI: 1.06, 1.17), and care coordination (PR: 1.09; 95% CI: 1.03, 1.15). The study also observed a greater likelihood of receiving AUD medications among those receiving care at clinics with higher ratings of comprehensiveness (PR: 1.35; 95% CI: 1.10, 1.66) and shared decision-making (PR: 1.35; 95% CI: 1.12, 1.61); higher clinic-level access ratings were associated with specialty addictions care (PR: 1.15; 95% CI: 1.00, 1.32). Patients in the clinics with the highest summary Pi² rankings, compared to the lowest, had higher likelihoods of receiving brief intervention (PR: 1.07; 95% CI: 1.03, 1.12) and medications (PR: 1.16; 95% CI: 1.00, 1.35). The study did not identify any other statistically significant findings. Conclusions This observational study found that dimensions of patient-centered care were associated with increased receipt of recommended alcohol-related care. Future studies should investigate strategies to improve patients' experience of alcohol-related care.
Article
Background Although motivational interviewing (MI) is an effective method for promoting change in problematic alcohol and other drug use, it does not benefit all clients. Clinicians have little empirical guidance on who is likely to benefit from MI and who is not. We hypothesized that differences in clients' spontaneously offered language early in the session would predict their responsiveness to MI during the remainder of the session. Method The study obtained coding data from 125 counseling sessions from a large randomized controlled trial of clinician training. A cluster analysis created one group of clients whose language reflected ambivalence, and one group whose language reflected readiness to change. We conducted a univariate analysis of variance to compare the mean change in percent change talk across the session between groups. Results Clients whose language reflected ambivalence early in the session had a greater change in their percent change talk during the remainder of the session, compared to those whose language reflected greater readiness to change (F (1,90) = 63.02, t = 7.94, p < .001). Surprisingly, the group whose language reflected readiness had a decrease in their percent change talk during the remainder of the session (M = −10.9%, SD = 16.3%). Adjusting the results for regression to the mean effects did not eliminate these differences. Conclusion Clients' language early in the session may offer clinicians some guidance on whether MI is likely to be useful or counterproductive in the treatment of substance use disorder.
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In Ghana, much attention has been given to the care and treatment of medical-surgical conditions other than mental health issues and the treatment of drug addiction. The predominant understanding is that alcohol/drug addiction or abuse is a chronic disorder on a par with other chronic conditions such as diabetes and asthma. This research study was conducted on the basis of making additions to existing scientific knowledge on rehabilitation of patients diagnosed with alcohol/drug abuse and how treatment helped in early recovery. It is a qualitative research with exploratory descriptive design. The study selected two (2) major rehabilitation centres in the Ku-masi Metropolis namely: Cheshire Rehabilitation Centre and Remar Rehabilitation Centre. A total of twenty-eight (28) participants were selected for the study. sSixteen (16) patients were selected purposively for the study. Thus, eight (8) rehabilitants were chosen from each centre. The study also sampled eight (8) relatives of patients from both homes and two (2) care givers from each centre who also undertook the interview voluntarily using a semi-structured interview guide. Audiotaped interviews were conducted with the participants at the two rehabilitation centres. The data was transcribed and coded using grounded theory and conversation analysis. The data was managed with ATLAS.ti. The study revealed that, though both rehabilitation centres were doing their best, they were under-resourced both in qualified personnel and finances. Unavailability of prescribed medications too caused incessant relapse. The results confirmed the finding of other studies which showed that no rehabilitation physicians are identified in any of the rehabilitation facilities in Ghana.
Article
Reviews of the motivational interviewing (MI) training literature demonstrate MI is a nuanced skill set that takes carefully planned didactic training, application of skills in context-specific practice settings, and ongoing support to promote reflective practice and sustained proficiency. Despite the robust knowledge base related to training and how MI works to achieve favorable outcomes, these two literature bases are not well integrated. In an effort to inform and guide future research, we propose the mechanisms of motivational interviewing (MMI) conceptual framework, which expands upon previous work. Specifically, the framework adds training as an ongoing process consistent with Bennett-Levy’s (Behav Cogn Psychother 34:57–78, 2006) model of skill development and acquisition to the existing two-path framework that helps us to understand how MI works to achieve its desired effects (Magill et al., J Consult Clin Psychol 82:973–983, 2014). Herein, we describe measures used to evaluate the mechanisms within the four MMI framework links: initial training to competency, competency to proficiency, proficiency to talk about change, and talk about change to behavior change. Next, we synthesize the literature associated with each of the mechanisms of the MMI. We conclude by discussing implications for practice and research. This framework offers a more complete path structure to understand the mechanisms of change associated with MI that could improve our understanding of inconsistent effect sizes observed across prior trials evaluating MI effectiveness.
Chapter
Motivational Interviewing (MI) is a communication style intended to help people make difficult behavior changes. Individuals with pulmonary disease often struggle with making healthy changes (e.g., quitting smoking, increasing exercise, and treatment adherence). MI, which emphasizes nonjudgmental and empathic communication with open-ended inquiries, can help patients clarify and resolve their ambivalence about making desired behavior changes. All healthcare professionals who work with pulmonary patients, including physicians, respiratory therapists, nurses, and others, may find MI useful and more effective than traditional prescriptive communication or lecturing, which may lead to defensiveness on the part of the patient. This chapter will introduce the history and basic principles of MI, with a description of specific strategies such as open-ended questions, affirmations, reflections, and summaries. Collaborating with a patient on how to effect change will be discussed, as will be typical roadblocks. Research on MI efficacy will be reviewed, including for pulmonary disease-relevant behaviors such as smoking, physical exercise, treatment compliance, and risk behaviors. Examples of implementing MI in individual and group formats for pulmonary patients will be presented, with the aim of encouraging healthcare professionals to integrate MI principles in their care.
Article
As the prevalence of substance use disorders and drug-related deaths continue to rise, addiction treatment facilities are charged with providing effective and efficient services to curb the national substance use crisis. Direct-care staff in treatment service facilities play a crucial role in whether or not evidence-based practices are incorporated. Without their understanding and utilization of patient engagement best practices, an organization risks maintaining the status quo rather than actively pursuing improved outcomes through empirically supported approaches. Through in-depth interviews (N=13) with nurses, counselors, and behavioral health technicians in an inpatient detoxification facility, this study evaluates the perspectives and experiences of direct-care staff through a lens of patient engagement in treatment planning. The findings from these interviews elucidate how participants’ personal characteristics and values, perspectives of patient engagement, understanding of treatment planning, and organizational culture and operations facilitate or inhibit the integration of patient engagement for treatment planning in detox.
Article
The importance of attending to the therapeutic process despite the challenges in manualizing it is demonstrated in the empirical evolution of motivational interviewing (MI). Whereas manuals exist for adaptations of MI, no manual has been developed and tested for MI in its pure form (pure MI). This study evaluated the feasibility and initial efficacy of a pure MI intervention manual - MI for risky social drinking (MI-RSD) - designed to target risky social drinking behaviors in college students with social anxiety. A pilot sample of 42 college students completed measures of alcohol use and mental health symptoms and the MI-RSD intervention. We developed a manual for the 2-session MI-RSD intervention, trained 4 clinical doctoral students, and used observer-, therapist- and participant-completed measures to evaluate fidelity. Therapists met beginner proficiency in MI fidelity and participant gave high ratings of therapist adherence to MI and working alliance, demonstrating intervention feasibility. Also, participants reported significant reductions in hazardous drinking and evaluation fears, but not in social interaction anxiety. We offer preliminary evidence that pure MI can be manualized and effective. Specifically, MI-RSD represents an alternative to MI adaptations in mitigating alcohol-related harm for young adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Article
Background: As the nature of the association between Alcohol Use Disorder (AUD) and other disorders is not well understood, the ways in which psychological distress changes during the course of treatment for AUD are relatively unknown. Existing literatures posit two competing hypotheses such that treatment for AUD concurrently decreases alcohol use and psychological distress or treatment for AUD decreases alcohol use and increases psychological distress. The current study examined the ways in which psychological distress changed as a function of treatment for AUD, including the relationship between psychological distress and drinking behaviors. Methods: Secondary data analysis was conducted on an existing clinical trial dataset that investigated the effect of cognitive-behavioral therapy and therapeutic alliance feedback on AUDs. Specifically, data collected at baseline, post-treatment, 3-month, 6-month, 9-month, and 12-month follow-up assessments were examined. Results: Results indicated decreases in heavy drinking days, increases in percentage of days abstinent, and decreases in overall psychological distress. Findings also revealed that changes in psychological distress did not predict changes in drinking at the next time interval; however, decreases in drinking predicted higher psychological distress at the next assessment. Further, average levels of psychological distress were positively associated with rates of drinking. Conclusions: The current study provides some insight for how psychological distress changes during the course of treatment for AUD, including the relationship between changes in drinking and such symptoms. Future research should continue to explore these relationships, including the ways in which treatment efforts can address what may be seen as paradoxical effects.
Article
Introduction Justice-involved adolescents are at high risk for sexually transmitted infections; one primary reason is co-occurring substance use. This study investigates the additive benefit of including alcohol and cannabis use content in a theory-based sexual risk reduction intervention, delivered using group-based motivational enhancement therapy. Study design This study had a cluster randomized design, with randomization of single-sex clusters to 1 of 3 interventions. Setting/participants Participants were male and female justice-involved adolescents (N=460) residing in youth detention facilities. Data were collected from 2010 to 2014; analyses were completed in 2018–2019. Intervention Adolescents were randomized to 1 of 3 motivational enhancement therapy interventions: sexual risk reduction intervention, sexual risk reduction intervention with alcohol content, or sexual risk reduction intervention with alcohol and cannabis content. Main outcome measures The primary outcome was risky sexual behavior (aggregation of condom use and frequency of intercourse), measured every 3 months for 1 year. Secondary outcomes were theoretical mechanisms on which the intervention was based (condom use attitudes, self-efficacy, peer norms, and behavioral intentions), collected at baseline and post-test. Results Risky sexual behavior significantly decreased from baseline to 3-month follow-up (t=10.59, p<0.001) and this decrease was maintained 1 year later (t=9.04, p<0.001). Intervention was associated with improved values on all theoretical mechanisms. Although all outcomes improved over time, changes did not differ by intervention condition (p>0.29 for all). Comparisons to a historical, information-only, sexual risk reduction control arm conducted with a similar juvenile justice sample confirm the effectiveness of all 3 motivational enhancement therapy–based interventions. Conclusions All 3 interventions were associated with decreased sexual risk up to 1 year later, suggesting that the intervention modality (motivational enhancement therapy) may resonate with this population beyond the specific substance use content. This single-session manualized intervention can be readily disseminated to juvenile justice settings. Trial registration This study is registered at www.clinicaltrials.gov NCT01170260.
Chapter
These mysterious influences reveal how psychotherapy actually works by directly advancing mental health. Research is reviewed demonstrating how potent these factors, including the placebo effect, are in psychotherapy outcomes. The range of non-specific factors is covered including general, social, psychological, and therapist-based, with interactive effects described. Key ones consist of the therapeutic alliance, hope, and empathy. The placebo effect is examined focusing on shaping expectancies and beliefs. Each of the states and processes for mental health are advanced by non-specific factors, with the strongest impact hope for psychological defense mechanisms (positive cognitive distortions) and the therapeutic alliance for social connectedness.
Article
Purpose Behavioral interventions to reduce hazardous drinking are only moderately successful in promoting sustained behavior change and post-intervention effect sizes among adolescents remain modest. This study aimed to explore a relevant therapeutic active ingredient, adolescent:provider alliance, as a moderator of short-term (3 month) adolescent intervention outcomes within the course of a larger parent randomized control trial (RCT). Methods. Participants were community-based youth engaged in hazardous drinking (N=168) who were randomized to 2 sessions of either motivational interviewing (MI) or mindfulness (brief adolescent mindfulness; BAM). Youth reported pre-intervention hazardous drinking at baseline and rated therapeutic alliance (a metric of adolescent:provider “connectedness” that helps facilitate working relationships during interventions) immediately post-intervention; they reported hazardous drinking again at 3 months post-intervention. Negative binomial regressions predicted post-intervention hazardous drinking score from adolescent:provider alliance, intervention condition, and their interaction. Results. Mean hazardous drinking was reduced by 34-40% across both intervention conditions, with no significant between-condition differences. Stronger adolescent:provider alliance was associated with lower hazardous drinking scores at 3 months, but this effect was attenuated after controlling for baseline hazardous drinking. Contrary to predictions, adolescent:provider alliance did not appear to moderate the effect of intervention condition in this sample of young people engaged in hazardous drinking. Conclusions. Consistent with prior literature, baseline hazardous drinking was a robust predictor of treatment outcomes. At the same time, these results suggest that future work may benefit from continuing to examine and disaggregate the nature of adolescent:provider alliance across the spectrum of empirically supported brief interventions for adolescent hazardous drinking. Clinical Trials Registration Number: ClinicalTrials.gov identifier: NCT03367858 Data Sharing Statement: Requests for deidentified individual participant data can be made to the first author.
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The two-volume third edition of this book identifies effective elements of therapy relationships (what works in general) as well as effective methods of tailoring or adapting therapy to the individual patient (what works in particular). Each chapter features a specific therapist behavior (e.g., alliance, empathy, support, collecting feedback) that demonstrably improves treatment outcomes or a nondiagnostic patient characteristic (e.g., reactance, preferences, culture, attachment style) by which to effectively tailor psychotherapy. Each chapter presents operational definitions, clinical examples, comprehensive meta-analyses, moderator analyses, and research-supported therapeutic practices. New chapters in this book deal with the alliance with children and adolescents, the alliance in couples and family therapy, and collecting real-time feedback from clients; more ways to tailor treatment; and adapting treatments to patient preferences, culture, attachment style, and religion/spirituality.
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Prior research indicates that therapist effects can be sizeable in substance-abuse treatment. Therapist differences were examined within a multisite (N = 1726) randomized trial of three psychosocial treatments for alcohol problems: twelve-step facilitation (TSF), cognitive-behavioral skills training (CBT), and motivational enhancement therapy (MET). Therapists (N = 80) were nested within treatments, selected and trained for expertise in a specific approach. This report describes: (1) differences in therapist characteristics across the three treatments; (2) the magnitude of therapist effects within each treatment; and (3) exploratory analyses of therapist attributes associated with successful outcomes. Therapist characteristics differed between TSF and the other two conditions. Significant therapist effects were found in client satisfaction and outcomes, even after covarying for effects of treatment sites and client baseline characteristics. Specific therapist attributes were predictive of client outcomes. Outlier therapists whose caseloads showed unusually poor outcomes accounted for most of the observed effects.
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The United Kingdom Alcohol Treatment Trial (UKATT) is intended to be the largest trial of treatment for alcohol problems ever conducted in the UK. UKATT is a multicentre, randomized, controlled trial with blind assessment, representing a collaboration between psychiatry, clinical psychology, biostatistics, and health economics. This article sets out, in advance of data analysis, the theoretical background of the trial and its hypotheses, design, and methods. A projected total of 720 clients attending specialist services for treatment of alcohol problems will be randomized to Motivational Enhancement Therapy (MET) or to Social Behaviour and Network Therapy (SBNT), a novel treatment developed for the trial with strong support from theory and research. The trial will test two main hypotheses, expressed in null form as: (1) less intensive, motivationally based treatment (MET) is as effective as more intensive, socially based treatment (SBNT); (2) more intensive, socially based treatment (SBNT) is as cost-effective as less intensive, motivationally based treatment (MET). A number of subsidiary hypotheses regarding client-treatment interactions and therapist effects will also be tested. The article describes general features of the trial that investigators considered desirable, namely that it should: (1) be a pragmatic, rather than an explanatory, trial; (2) be an effectiveness trial based on 'real-world' conditions of treatment delivery; (3) incorporate high standards of training, supervision and quality control of treatment delivery; (4) pay close attention to treatment process as well as treatment outcome; (5) build economic evaluation into the design at the outset. First results from UKATT are expected in 2002 and the main results in 2003.
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The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment. Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased. Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations. There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style. It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate. Confrontation: Page 2 Treatment for substance use disorders in the United States took a peculiar turn in the mid-20th century. There arose a widespread belief that addiction treatment required the use of fairly aggressive confrontational strategies to break down pernicious defense mechanisms that were presumed to accompany substance use disorders. Although this approach was emulated to some extent in certain treatment centers outside the United States, such reliance on confrontation was predominantly an American phenomenon. As discussed below, there was some broader exploration of confrontational therapies, but nowhere did they take such deep root as in U.S. addiction treatment. Indeed, few would now regard such harsh methods as therapeutic for any other Axis I disorder in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). What accounts for this odd detour in American addiction treatment? In this article we trace the historical roots of belief in and practice of confrontational treatment, and explore relevant scientific evidence on the effects of such methods. We then offer summary conclusions and recommendations for treatment of substance use disorders in the 21 st century.
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There have been concerns about impacts of various aspects of taking part in research studies for a century. The concerns have not, however, been sufficiently well conceptualized to form traditions of study capable of defining and elaborating the nature of these problems. In this article we present a new way of thinking about a set of issues attracting long-standing attention. We briefly review existing concepts and empirical work on well-known biases in surveys and cohort studies and propose that they are connected. We offer the construct of "research participation effects" (RPEs) as a vehicle for advancing multi-disciplinary understanding of biases. Empirical studies are needed to identify conditions in which RPE may be sufficiently large to warrant modifications of study design, analytic methods, or interpretation. We consider the value of adopting a more participant-centred view of the research process as a way of thinking about these issues, which may also have benefits in relation to research methodology more broadly. Researchers may too readily overlook the extent to which research studies are unusual contexts, and that people may react in unexpected ways to what we invite them to do, introducing a range of biases.
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Objective: The goal of measuring therapist adherence is to determine whether a therapist can perform a given treatment. Yet, the evaluation of therapist behaviors in most clinical trials is limited. Typically, randomized trials have few therapists and minimize therapist variability through training and supervision. Furthermore, therapist adherence is confounded with uncontrolled differences in patients across therapists. Consequently, the extent to which adherence measures capture differences in actual therapist adherence versus other sources of variance is unclear. Method: We estimated intra-class correlations (ICCs) for therapist adherence in sessions with real and standardized patients (RPs and SPs), using ratings from a motivational interviewing (MI) dissemination trial (Baer et al., 2009) in which 189 therapists recorded 826 sessions with both patient types. We also examined the correlations of therapist adherence between SP and RP sessions, and the reliability of therapist level adherence scores with generalizability coefficients (GCs). Results: ICCs for therapist adherence were generally large (average ICC for SPs = .44; average ICC for RPs = .40), meaning that a given therapist's adherence scores were quite similar across sessions. Both ICCs and GCs were larger for SP sessions compared to RPs on global measures of MI adherence, such as Empathy and MI Spirit. Correlations between therapist adherence with real and standardized patients were moderate to large on 3 of 5 adherence measures. Conclusion: Differences in therapist-level adherence ratings were substantial, and standardized patients have promise as tools to evaluate therapist behavior.
Article
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Behavioral intervention trials may be susceptible to poorly understood forms of bias stemming from research participation. This article considers how assessment and other prerandomization research activities may introduce bias that is not fully prevented by randomization. This is a hypothesis-generating discussion article. An additivity assumption underlying conventional thinking in trial design and analysis is problematic in behavioral intervention trials. Postrandomization sources of bias are somewhat better known within the clinical epidemiological and trials literatures. Neglect of attention to possible research participation effects means that unintended participant behavior change stemming from artifacts of the research process has unknown potential to bias estimates of behavioral intervention effects. Studies are needed to evaluate how research participation effects are introduced, and we make suggestions for how research in this area may be taken forward, including how these issues may be addressed in the design and conduct of trials. It is proposed that attention to possible research participation effects can improve the design of trials evaluating behavioral and other interventions and inform the interpretation of existing evidence.
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Objective: The authors investigated the unique contribution motivational interviewing (MI) has on counseling outcomes and how MI compares with other interventions. Method: A total of 119 studies were subjected to a meta-analysis. Targeted outcomes included substance use (tobacco, alcohol, drugs, marijuana), health-related behaviors (diet, exercise, safe sex), gambling, and engagement in treatment variables. Results: Judged against weak comparison groups, MI produced statistically significant, durable results in the small effect range (average g = 0.28). Judged against specific treatments, MI produced nonsignificant results (average g = 0.09). MI was robust across many moderators, although feedback (Motivational Enhancement Therapy [MET]), delivery time, manualization, delivery mode (group vs. individual), and ethnicity moderated outcomes. Conclusions: MI contributes to counseling efforts, and results are influenced by participant and delivery factors.
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The present paper reports on the basic principles of a treatment approach currently being used in a National Multicentre Randomised Controlled Trial of Alcohol Treatments in the United Kingdom (UK Alcohol Treatment Trial). The treatment: Social Behaviour and Network Therapy (SBNT) is novel as a package but has been developed by integrating a number of strategies found to be effective in other treatment approaches. The intervention is based on the notion that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change. A brief review of the evidence supporting social treatments for alcohol problems is followed by an outline of the feasibility work and the basic principles that guided the development of SBNT. Process data from the first 33 trial cases and 2 case vignettes are described and discussed. It is concluded that SBNT is a feasible and coherent treatment approach that can be delivered by a range of therapists in the alcohol field.
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In a meta-analysis, we examined factors that could account for the differences in therapist efficacy evidenced in psychotherapy outcome studies. The factors investigated were: (1) the use of a treatment manual, (2) the average level of therapist experience, (3) the length of treatment, and (4) the type of treatment (cognitive/behavioral versus psychodynamic). Data were obtained from fifteen psychotherapy outcome studies that produced 27 separate treatment groups. For each treatment group, the amount of outcome variance due to differences between therapists was calculated and served as the dependent variable for the meta-analysis. Each separate treatment group was coded on the above four variables, and multiple regression analyses related the independent variables to the size of therapist effects. Results indicated that the use of a treatment manual and more experienced therapists were associated with small differences between therapists, whereas more inexperienced therapists and no treatment manual were associated with larger therapist effects. The findings are discussed in terms of the design and the analysis of psychotherapy outcome research.
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Background: Effectiveness of evidence-based behaviour change interventions is likely to be undermined by failure to deliver interventions as planned. Behavioural support for smoking cessation can be a highly cost-effective, life-saving intervention. However, in practice, outcomes are highly variable. Part of this may be due to variability in fidelity of intervention implementation. To date, there have been no published studies on this. The present study aimed to: evaluate a method for assessing fidelity of behavioural support; assess fidelity of delivery in two English Stop-Smoking Services; and compare the extent of fidelity according to session types, duration, individual practitioners, and component behaviour change techniques (BCTs). Methods: Treatment manuals and transcripts of 34 audio-recorded behavioural support sessions were obtained from two Stop-Smoking Services and coded into component BCTs using a taxonomy of 43 BCTs. Inter-rater reliability was assessed using percentage agreement. Fidelity was assessed by examining the proportion of BCTs specified in the manuals that were delivered in individual sessions. This was assessed by session type (i.e., pre-quit, quit, post-quit), duration, individual practitioner, and BCT. Results: Inter-coder reliability was high (87.1%). On average, 66% of manual-specified BCTs were delivered per session (SD 15.3, range: 35% to 90%). In Service 1, average fidelity was highest for post-quit sessions (69%) and lowest for pre-quit (58%). In Service 2, fidelity was highest for quit-day (81%) and lowest for post-quit sessions (56%). Session duration was not significantly correlated with fidelity. Individual practitioner fidelity ranged from 55% to 78%. Individual manual-specified BCTs were delivered on average 63% of the time (SD 28.5, range: 0 to 100%). Conclusions: The extent to which smoking cessation behavioural support is delivered as specified in treatment manuals can be reliably assessed using transcripts of audiotaped sessions. This allows the investigation of the implementation of evidence-based practice in relation to smoking cessation, a first step in designing interventions to improve it. There are grounds for believing that fidelity in the English Stop-Smoking Services may be low and that routine monitoring is warranted.
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Alcoholism has traditionally been viewed as a persistent and chronic disorder. Recent years, however, have seen a growing belief that the disorder can be completely transformed into stable, long-term improvement after intervention. Yet we know relatively little about the course of alcoholism over the long run. Although research has documented substantial rates of remission after treatment, the stability of such remission is very much an unanswered question. The purpose of this study is to extend knowledge about the remission process by examining the history of a sample of treated alcoholics over a period of 4 years. We find it is common for alcoholics to reach a state of remission, but that state is generally intermittent rather than stable. The study is based on a random sample of 922 males who made contact in 1973 with any one of eight Alcoholism Treatment Centers (ATCs} funded by the National Institute on Alcohol Abuse and Alcoholism The same cohort was interviewed in previous follow ups at 6 months and 18 months, and has been the subject of other research, including an earlier Rand study. At 4 years, information was obtained from 85 percent of the target sample. In addition to extensive interviews, the 4-year follow up data base included psychological tests, self reported psychiatric and medical information, measures of blood alcohol concentration, validation interviews with subject collaterals, and officially recorded causes of death for deceased subjects. Although all subjects had some contact with a treatment facility, the study was not an experimental evaluation of competing treatment methods. Rather, the principal objective was to trace the natural sequence of events, including treatment, in the course of alcoholism.
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The relationship between the therapeutic alliance and treatment participation and drinking outcomes during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were significant predictors of treatment participation and drinking behavior during the treatment and 12-month posttreatment periods, after a variety of other sources of variance were controlled. Ratings of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes. Therapists ratings of the alliance in the aftercare sample predicted only percentage of days abstinent during treatment and follow-up. The results document the independent contribution of the therapeutic alliance to treatment participation and outcomes among alcoholic outpatients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Factors that influence client outcome can be divided into four areas: extratherapeutic factors, expectancy effects, specific therapy techniques, and common factors. Common factors such as empathy, warmth, and the therapeutic relationship have been shown to correlate more highly with client outcome than specialized treatment interventions. The common factors most frequently studied have been the person-centered facilitative conditions (empathy, warmth, congruence) and the therapeutic alliance. Decades of research indicate that the provision of therapy is an interpersonal process in which a main curative component is the nature of the therapeutic relationship. Clinicians must remember that this is the foundation of our efforts to help others. The improvement of psychotherapy may best be accomplished by learning to improve one's ability to relate to clients and tailoring that relationship to individual clients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Professional discourse and practice have long privileged the position and point of view of the therapist. The time has come to spotlight the largest yet most neglected factor in treatment outcome: the client. Although experimental studies of client factors are few and far between and most research favors correlational, qualitative, and retrospective designs, a strong case emerges for the potency of the human client in successful psychotherapy. This chapter begins with a short survey of the potential for self-righting and self-healing. We then consider research regarding the client's role as an active contributor to the therapy process. We review data regarding the factors traditionally thought to account for the effectiveness of psychotherapy and offer an alternative account highlighting the importance of the client. The chapter concludes with the assertion that the client offers the best explanation for the dodo verdict as well as a discussion of the implications of a client-centered paradigm for psychotherapy practice, training, and the broader field of mental health. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Patients' expectations about the efficacy and nature of psychotherapy have long been considered important common treatment factors, and the empirical literature has largely supported this perspective. In this practice-oriented review, we examine the research on the association between patients' psychotherapy expectations and both adaptive treatment processes and outcomes. We also examine the research on specific psychotherapist interventions and patient and psychotherapist characteristics that influence the development of positive expectations for psychotherapy and psychotherapeutic change. The primary function of this review is to derive applied clinical strategies from the extant empirical literature in order to help clinicians in their attempts to address and influence their patients' psychotherapy-related expectations. Although the literature is not yet conclusive in supporting such strategies, we place the results in theoretical, clinical, and empirical contexts to suggest the most likely best practices at this time, and to stimulate further research on the expectation construct. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
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One of the largest determinants of client outcomes is the counselor who provides treatment. Therapists often vary widely in effectiveness, even when delivering standardized manual-guided treatment. In particular, the therapeutic skill of accurate empathy originally described by Carl Rogers has been found to account for a meaningful proportion of variance in therapeutic alliance and in addiction treatment outcomes. High-empathy counselors appear to have higher success rates regardless of theoretical orientation. Low-empathy and confrontational counseling, in contrast, has been associated with higher drop-out and relapse rates, weaker therapeutic alliance, and less client change. The authors propose emphasis on empathic listening skills as an evidence-based practice in the hiring and training of counselors to improve outcomes and prevent harm in addiction treatment. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
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The National Drug Abuse Treatment Clinical Trials Network (CTN) has faced many challenges over its first eleven years. This review explores some of these challenges and the paths the CTN took to meet these challenges, including: designing clinical trials that reflect the CTN's mission and changing public health needs, finding the synergies in the varied expertise of clinical treatment providers and academic researchers, promoting evidence-based practices and expanding the Network into mainstream medical practices to reach a broader patient population. Included in this exploration are specific examples from CTN clinical trials.
Article
Objective: This study examined the interactions of therapist directiveness with patient anger and patient reactance among an alcohol-treatment-seeking sample. Method: Participants in the study consisted of 139 individuals with alcohol abuse or dependence who received treatment at a single clinical research unit of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). Analyses tested for the independence of the two interactions, identified components within the directiveness construct and examined the relationship between those components and the patient attributes. Results: Results showed that the interactions between directiveness and anger and between directiveness and reactance each accounted for unique variance in predicting posttreatment alcohol use as measured by percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD). Principal components analysis of the directiveness Construct generated two underlying components that were interpreted to be confrontation and structure. Significant interactions were observed between patient reactance and both the confrontation and structure components. Confrontation also interacted with patient anger; however, no interaction was found between anger and structure. Conclusions: The interactions of therapist directiveness with patient anger and reactance demonstrated both shared and unique qualities. These results highlight the importance of focusing on specific aspects of directiveness to better understand the effect of patient-treatment interactions on alcohol use. This study has implications for theory and research as well as for the delivery of treatment services.
Book
What are the most promising strategies to treat alcohol and drug abuse? What are their medical implications? Despite the enormous resources spent on treating alcoholism and drug dependence, there is still no satisfactory evaluation of their effectiveness or of the cost of the different alternatives. Programs designed to treat substance abuse should be built on a foundation of evidence-based knowledge. Yet it is almost impossible to cope with the increasing amount of scientific literature. This book thus represents a guide through the myriads of articles. The most comprehensive scientific review of its kind, it presents the findings from more than 1,600 studies on the effectiveness of different treatments. The work also includes a summary of the methods available to intervene against harmful levels of alcohol, with most of the studies making use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) system. The extensive results are arranged in detailed tables, which may be searched using the accompanying CD-ROM. Also enclosed are a quality checklist and an extensive glossary explaining more than 70 terms. An invaluable tool for medical researchers, clinicians and doctors as well as healthcare providers and insurers, allowing them to save major resources by identifying ineffective treatments and being aware of cost-effective alternatives. © 2003 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim. All rights reserved.
Article
The impact of the counselor in substance abuse rehabilitation has been questioned. The unexpected resignations of two counselors provided a natural opportunity to examine the effects of counselor assignment in a methadone maintenance treatment program with the effects of the medication philosophy, program rales, and supplementary services held constant. Sixty-one patients who had been assigned to these two counselors were assigned to four other counselors in a virtually random manner. It was reasoned that if the new counselor had relatively little impact, then there would be little difference in performance from pre to posttransfer or among the four caseloads during the 6-month period following the transfer. Performance measures included urinalysis results, methadone dosage, prescriptions for psychotropic medications, employment, and arrest rates. Results indicated statistically significant and clinically meaningful differences in the posttransfer performance of the four caseloads. One counselor significantly reduced the average methadone dose of his/her caseload as well as the number of patients prescribed ancillary medications, while concurrently reducing positive urine tests, unemployment and arrests. In contrast, another counselor significantly increased the average methadone dose in his/ her caseload but still showed increases in positive urine tests and unemployment. As has been found in prior studies, background and formal education differences among the counselors were not related to the observed performance differences. However, differences in the content and process of counseling among the counselors were associated with the differences in patient outcome. These process differences are discussed in relation to earlier studies of professional psychotherapy.
Article
This study reports 3-year outcomes for clients who had been treated in the five outpatient sites of Project MATCH, a multisite clinical trial designed to test a priori client treatment matching hypotheses. The main purpose of this study was to characterize the status of the matching hypotheses at the 3-year follow-up. This entailed investigating which matching findings were sustained or even strengthened across the 3-year study period, and whether any hypotheses that were not supported earlier eventually emerged at 3 years, or conversely, whether matching findings discerned earlier dissipated at this later time. This research also examines the prognostic effects of the client matching attributes, characterizes the overall outcomes at 37 to 39 months, and explores differential effects of the three treatments at extended follow-up. With regard to the matching effects, client anger demonstrated the most consistent interaction in the trial, with significant matching effects evident at both the 1-year and 3-year follow- ups. As predicted, clients high in anger fared better in Motivational Enhancement Therapy (MET) than in the other two MATCH treatments: Cognitive- Behavioral Therapy (CBT) and Twelve-Step Facilitation (TSF). Among subjects in the highest third of the anger variable, clients treated in MET had on average 76.4% abstinent days, whereas their counterparts in the other two treatments (CBT and TSF) had on average 66% abstinent days. Conversely, clients low in anger performed better after treatment in CBT and TSF than in MET. Significant matching effects for the support for drinking variable emerged in the 3-year outcome analysis, such that clients whose social networks were more supportive of drinking derived greater benefit from TSF treatment than from MET. Among subjects in the highest third of the support for drinking variable, TSF participants were abstinent 16.1% more days than MET participants. At the lower end of this variable, difference in percent days abstinent between MET and TSF was 3%, with MET clients having more abstinent days. A significant matching effect for psychiatric severity that appeared in the first year posttreatment was not observed after 3 years. Of the 21 client attributes used in testing the matching hypotheses, 11 had prognostic value at 3 years. Among these, readiness-to-change and self- efficacy emerged as the strongest predictors of long-term drinking outcome. With regard to the overall outcomes, the reductions in drinking that were observed in the first year after treatment were sustained over the 3-year follow-up period: almost 30% of the subjects were totally abstinent in months 37 to 39, whereas those who did report drinking nevertheless remained abstinent an average of two-thirds of the time. As in the 1-year follow-up, there were few differences among the three treatments, although TSF continued to show a possible slight advantage.
Article
Objective: To assess the benefits of matching alcohol dependent clients to three different treatments with reference to a variety of client attributes. Method: Two parallel but independent randomized clinical trials were conducted, one with alcohol dependent clients receiving outpatient therapy (N = 952; 72% male) and one with clients receiving aftercare therapy following inpatient or day hospital treatment (N = 774; 80% male). Clients were randomly assigned to one of three 12-week, manual guided, individually delivered treatments: Cognitive Behavioral Coping Skills Therapy, Motivational Enhancement Therapy or Twelve-Step Facilitation Therapy. Clients were then monitored over a 1-year posttreatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 10 primary matching variables and 16 contrasts specified a priori. The primary outcome measures were percent days abstinent and drinks per drinking day during the 1-year posttreatment period Results: Clients attended on average two-thirds of treatment sessions offered, indicating that substantial amounts of treatment were delivered, and research follow up rates exceeded 90% of living subjects interviewed at the 1-year posttreatment assessment. Significant and sustained improvements in drinking outcomes were achieved from baseline to 1-year posttreatment by the clients assigned to each of these well-defined and individually delivered psychosocial treatments. There was little difference in outcomes by type of treatment. Only one attribute, psychiatric severity, demonstrated a significant attribute by treatment interaction: In the outpatient study, clients low in psychiatric severity had more abstinent days after 12 step facilitation treatment than after cognitive behavioral therapy. Neither treatment was clearly superior for clients with higher levels of psychiatric severity. Two other attributes showed time-dependent matching effects: motivation among outpatients and meaning-seeking among aftercare clients. Client attributes of motivational readiness, network support for drinking, alcohol involvement, gender, psychiatric severity and sociopathy were prognostic of drinking outcomes over time. Conclusions: The findings suggest that psychiatric severity should be considered when assigning clients to outpatient therapies. The lack of other robust matching effects suggests that, aside from psychiatric severity, providers need not take these client characteristics into account when triaging clients to one or the other of these three individually delivered treatment approaches, despite their different treatment philosophies.
Article
• Male alcoholics (n=460) and drug addicts (n=282) were evaluated at six-month follow-up after treatment in six rehabilitation programs. Initial analyses of the unstratified samples showed significant patient improvement, but no evidence of differential effectiveness from different treatments or from "matching" patients to treatments. The two samples were then divided into groups based on the number, duration, and intensity of their psychiatric symptoms at admission, ie, their overall "psychiatric severity." Patients with low psychiatric severity improved in every treatment program. Patients with high psychiatric severity showed virtually no improvement in any treatment. Patients with midrange psychiatric severity (60% of the samples) showed outcome differences from different treatments and especially from specific patient-program matches. These findings support the effectiveness and specificity of different substance abuse treatments, suggest methodologic reasons for the lack of similar findings in previous studies, and demonstrate the importance of psychiatric factors in substance abuse treatment.(Arch Gen Psychiatry 1983;40:620-625)
Article
Objective To compare the effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy. Design Pragmatic randomised trial. Setting Seven treatment sites around Birmingham, Cardiff, and Leeds. Participants 742 clients with alcohol problems; 689 (93.0%) were interviewed at three months and 617 (83.2%) at 12 months. Interventions Social behaviour and network therapy and motivational enhancement therapy. Main outcome measures Changes in alcohol consumption, alcohol dependence, and alcohol related problems over 12 months. Results Both groups reported substantial reductions in alcohol consumption, dependence, and problems and better mental health related quality of life over 12 months. Between groups we found only one significant difference in outcome, probably due to chance: the social network group showed significantly better physical health at three months. Non-significant differences at 12 months in the motivational group relative to the social network group included: the number of drinks consumed per drinking day had decreased by an extra 1.1 (95% confidence interval - 1.0 to 3.2); scores on the Leeds dependence questionnaire had improved by an extra 0.6 (- 0.7 to 2.0); scores on the alcohol problems questionnaire had improved by an extra 0.5 (- 0.4 to 1.4); but the Dumber of days abstinent from drinking had increased by 1.2% less (- 4.5% to 6.9%). Conclusion The novel social behaviour and network therapy for alcohol problems did not differ significantly in effectiveness from the proved motivational enhancement therapy.
Article
• This study examined the relatively unexplored contribution of the therapist's performance in determining outcomes of treatment. Nine therapists were studied: three performed supportive-expressive psychotherapy; three, cognitive-behavioral psychotherapy; and three, drug counseling. Profound differences were discovered in the therapists' success with the patients in their case loads. Four potential determinants of these differences were explored: (1) patient factors; (2) therapist factors; (3) patient-therapist relationship factors; and (4) therapy factors. Results showed that (1) patient characteristics within each case load (after random assignments) were similar and disclosed no differences that would have explained the differences in success; (2) therapist's personal qualities were correlated with outcomes but not significantly (mean r=.32); (3) an early-in-treatment measure of the patienttherapist relationship, the Helping Alliance Questionnaire, yielded significant correlations with outcomes (mean r=.65); (4) among the therapy techniques, "purity" provided significant correlations with outcomes (mean r=.44), both across therapists and within each therapist's case load. The three therapist-related factors were moderately associated with each other.