Characteristics of the Sample
Twenty-three participants consented to the research before starting CBT, but two withdrew immediately after treatment ended. They did not initiate the ATIVR component of the research and provided no assessment data. Analyses of data from the ATIVR calls correspond to the remaining 21 participants, who all made at least one call to the ATIVR. Demographic and alcohol use characteristics for the 21 participants are displayed in . Three participants who made calls to the ATIVR did not return for the post-ATIVR interview, so the outcomes assessment analyses are based on the 18 participants who completed the post-ATIVR interview.
Demographics and Substance Use Characteristics (N = 21)
shows the survival curve associated with participants’ “days to last call” to the ATIVR, our measure of treatment engagement. All participants remained engaged with the ATIVR for the first 52 days, at which time one participant stopped calling. Two others stopped at 58 days and 71 days. Three additional participants made their last calls within a week of their 90-day mark. The mean duration of treatment engagement was 84 days (SD = 12) with 71% of participants remaining engaged with the ATIVR system for the full 90 days. Participants called on an average of 59% (SD = 22) of scheduled days.
Survival curve associated with participant engagement in the Alcohol Therapeutic Interactive Voice Response (ATIVR). Engagement defined as “days to last call.”
Usage rates for the additional ATIVR components are outlined in . Therapeutic Feedback Messages was the only component accessed by every participant. Usage of CBT Skills Practice and Didactic Skills Review components was variable, but the most commonly selected were Managing Negative Moods or Anger, and Managing Thoughts of Use (data not shown).
ATIVR Components in Order of Usage Rate
Alcohol consumption was measured just before starting and just after completing the ATIVR calling period using a TLFB that covered the prior 3 months. As shown in , significant improvements were noted in abstinence rate [McNemar’s S = 4.5, p = .03, Cohen’s d = 0.75], percent days drank [t(12) = 4.34, p < .001, Cohen’s d = 0.46], and number of drinks per week [t(12) = 4.36, p < .001, Cohen’s d = 0.36].
Alcohol Use Outcomes (N = 18)
Self-Efficacy and Coping Ability
Assessments of self-efficacy to avoid relapse were obtained prior to CBT, after CBT (before ATIVR) and after ATIVR using the ECBI (Litman et al., 1984
) and the SCQ (Annis & Graham, 1988
). Mean scores on the ECBI improved from baseline (29.6, SD
= 18.8) to post-CBT [41.4, SD
= 12.6; t
(31) = 2.80, p
= .01, Cohen’s d
= 0.63], and to post-ATIVR [42.9, SD
= 12.7; t
(31), = 3.39, p
= .002, Cohen’s d
= 0.71]. Higher scores on the ECBI indicate greater effectiveness of coping strategies; thus, rather than show any deterioration after CBT, overall perceived coping ability was maintained during the use of the ATIVR. On the SCQ, the mean overall score improved significantly from baseline (70.8, SD
= 17.5) to post- CBT [80.42, SD
= 14.7; t
(30) = 2.12, p
= .04, Cohen’s d
= 0.55], and to post-ATIVR [88.72, SD
= 9.01, t
(30) = 4.02, p
< .001, Cohen’s d
= 1.02]. As displayed in , all of the eight SCQ individual subscales significantly improved from baseline to post-ATIVR. There was no significant change in SCQ scores from post-CBT to post-ATIVR on the total score or any of the subscales.
Situational Confidence Questionnaire subscale scores (mean ± standard error) for each assessment.
Participants were interviewed about their perceptions of the ATIVR after the 3-month calling period. They were asked to rate on a 5-point scale (not at all to very) their impressions of how logical the ATIVR treatment seemed as an add-on to CBT and their honesty in responding to the Daily Questionnaire items. After the ATIVR, mean treatment logic was rated 3.9 (SD = 1.1), and reported honesty level was 4.6 (SD = 0.6).
In the post-ATIVR Feedback Interviews, participants indicated the system was easy to use and that the calls increased their awareness of their thoughts, feelings, and actions in reference to alcohol. Participants particularly liked the Therapist Feedback Message, saying it was “refreshing,” made them feel good, and encouraged them to make calls. One participant commented, “it was nice to get a personalized message from someone who really knows me.” Over half of the participants indicated ATIVR was helpful to their sobriety and/or that ATIVR helped them to feel accountable to themselves. In particular, some reported that what made them accountable was the expectation that calls be made daily, instead of some less frequent time interval, and that calls be made on good as well as bad days.
Unexpectedly, in the Feedback Interview some participants offered spontaneous comparisons of ATIVR and features of other support options, primarily Alcoholics Anonymous (AA). For example, ATIVR was considered to be, “like an electronic sponsor,” but also, “good because it’s not judgmental, unlike an AA sponsor.” One person said, “I called when I couldn’t reach my sponsor.” Others made analogies to meetings. ATIVR was described as, “like an AA meeting on the phone: a way to reach out and grab some sobriety,” and, “like AA: some people are going to stay and some are going to go but the meetings [and the ATIVR] are always there.” Conversely, it was noted that, “I don’t feel as accountable to an automated system as I do face-to-face AA meeting, ” and, “The ATIVR does not take the place of showing my face at AA each day.” Finally, one participant said he was not interested in AA but found the ATIVR study to be a more appealing option for him.
Participants who did not call typically said it was because they forgot, although some reported they did not need the ATIVR because they were doing well and/or had other supports in place.