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1.  System-Level Influences on the Sustainability of a Cognitive Therapy Program in a Community Behavioral Health Network 
Objective
The purpose of this study was to examine influences on the sustainability of a program to implement an evidence-based psychotherapy in a mental health system.
Methods
Interviews with program administrators, training consultants, agency administrators, and supervisors (N=24), along with summaries of program evaluation data and program documentation, were analyzed with a directed content-analytic approach.
Results
Findings suggested a number of interconnected and interacting influences on sustainability, including alignment with emerging sociopolitical influences and system and organizational priorities; program-level adaptation and evolution; intervention flexibility; strong communication, collaboration, planning, and support; and perceived benefit. These individual factors appeared to mutually influence one another and contribute to the degree of program sustainability achieved at the system level. Although most influences were positive, financial planning and support emerged as potentially both facilitator and barrier, and evaluation of benefits at the patient level remained a challenge.
Conclusions
Several factors appeared to contribute to the sustainability of a psychosocial intervention in a large urban mental health system and warrant further investigation. Understanding interconnections between multiple individual facilitators and barriers appears critical to advancing understanding of sustainability in dynamic systems and adds to emerging recommendations for other implementation efforts. In particular, implications of the findings include the importance of implementation strategies, such as long-term planning, coalition building, clarifying roles and expectations, planned adaptation, evaluation, diversification of financing strategies, and incentivizing implementation.
doi:10.1176/appi.ps.201400147
PMCID: PMC4490058  PMID: 25828878
2.  Predicting Outcome of Substance Abuse Treatment in a Feedback Study: Can Recovery Curves be Improved Upon? 
Objective
The goal of the study was to evaluate whether enhanced normative feedback recovery curves are needed for treatment of substance use problems.
Method
Patient predictors of outcome were examined using data from 4 substance abuse treatment clinics.
Results
Baseline severity of symptoms/functioning, employment, and craving were found to be associated with rate of change in symptoms/functioning. Several other variables were associated with rate of change in alcohol use, although in the opposite direction than found in efficacy trials.
Conclusions
The results point to the complexity of designing feedback systems using normative recovery curves for those with substance use problems, and highlight the important differences between real-world treatment of those with substance use problems compared to data from efficacy trials.
doi:10.1080/10503307.2014.994146
PMCID: PMC4551657  PMID: 25588189
substance abuse; alcohol; feedback; Outcome Questionnaire-45; recovery curve
3.  Measuring Outcome in the Treatment of Cocaine Dependence 
Background
Little in known about the extent to which outcome measures used in studies of the treatment of cocaine dependence are associated with longer-term use and with broader measures of clinical improvement. The current study examined reductions in use, and abstinence-oriented measures, in relation to functioning and longer-term clinical benefits in the treatment of cocaine dependence.
Methods
Overall drug use, cocaine use, and functioning in a number of addiction-related domains for 487 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions in the NIDA Cocaine Collaborative Treatment Study were assessed monthly during 6 months of treatment and at 9, 12, 15, and 18 month follow-up.
Results
Measures of during-treatment reduction in use were moderately correlated with drug and cocaine use measures 12 months, but showed non-significant or small correlations with measures of functioning at 12 months. Highest correlations were evident for abstinence measures (maximum consecutive days abstinence and completely abstinent) during treatment in relation to sustained (3 month) abstinence at 12 months. Latent class analysis of patterns of change over time revealed that most patients initially (months 1 to 4 of treatment) either became abstinent immediately or continued to use every month. Over the couse of follow-up, patients either maintained abstinence or used regularly – intermittent use was less common.
Conclusions
There were generally small associations between various measures of cocaine use and longer-term clinical benefits, other than abstinence was associated with continued abstinence. No one method of measuring outcome of treatment of cocaine dependence appears superior to others.
doi:10.4172/2329-6488.1000108
PMCID: PMC4564116  PMID: 26366427
Cocaine Dependence; Psychosocial Treatment; Patterns of Change; Abstinence; Relapse
4.  The Relation of Baseline Skills to Psychotherapy Outcome Across Diverse Psychotherapies 
Journal of clinical psychology  2015;71(6):491-499.
Objective
We explored whether patients with varied levels of baseline deficits in compensatory skills and self-understanding had different outcomes across cognitive and dynamic therapies.
Method
The assessment battery was administered at intake and termination (N=97; 66% female, 81% Caucasian). We conducted regression analyses predicting symptom change from baseline levels of self-understanding and compensatory skills. We also evaluated the interaction between baseline skill levels and treatment condition in the prediction of psychotherapy outcome.
Results
There was a significant interaction between treatment group and baseline compensatory skills in the prediction of HAMD symptom change, F(1,76) = 4.59, p = .035. Baseline deficits in compensatory skills were significantly related to symptom change for patients who received cognitive treatment, ηρ = .40, p = .037, while baseline levels of self-understanding were not significantly predictive of treatment outcome in either condition. Baseline skill variables did not predict symptom change as measured by the HAMA.
Conclusions
The findings support a capitalization model of cognitive therapy, whereby patients with relative strengths in compensatory skills at baseline have better treatment outcomes.
doi:10.1002/jclp.22165
PMCID: PMC4560345  PMID: 25779087
cognitive therapy; dynamic therapy; psychotherapy process; compensatory skills; self-understanding
5.  Psychotherapy Credibility Ratings: Patient Predictors of Credibility and the Relation of Credibility to Therapy Outcome 
Very little is known about what factors may influence credibility ratings. The current investigation examined the relation between credibility ratings for adult psychotherapies and a variety of patient factors as well as the relation between credibility ratings and subsequent symptom change. A pooled study database that included studies evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders was used. For all studies, a 3-item credibility scale was administered at session 2. Early symptom change, expectation of improvement, demographic characteristics, clinical measures, and functioning and interpersonal measures were used to predict credibility at session 2. We found that early symptom improvement was significantly associated with higher credibility ratings at session 2; higher ages, higher levels of education, and lower expectations of improvement were associated with lower credibility ratings at session 2; and credibility ratings predicted subsequent symptom improvement.
doi:10.1080/10503307.2013.847988
PMCID: PMC4560353  PMID: 24219179
6.  Do supervisors and independent judges agree on evaluations of therapists’ adherence and competence? 
The current study examined the agreement between supervisors’ and independent judges’ evaluations of therapist adherence and competence in three treatments of cocaine dependence: supportive expressive therapy (SE), cognitive therapy CT), and individual drug counseling (IDC). We used data from The National Institute on Drug Abuse Collaborative Cocaine Treatment Study (N=295). Trained and experienced supervisors and independent judges rated treatment fidelity. At the therapist level of analysis, the agreement between supervisors’ and independent judges’ ratings was weak for SE competence, CT adherence, and CT competence. Moderate relations were found for IDC adherence and competence. Supervisors consistently rated adherence and competence more positively than judges in CT and IDC. The potential bias in supervisors’ ratings is discussed.
doi:10.1080/10503307.2012.716528
PMCID: PMC4550095  PMID: 22900944
adherence; competence; cognitive therapy; supportive expressive therapy; drug counseling
7.  Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy 
Background
Clinicians often modify evidence-based psychotherapies (EBPs) when delivering them in routine care settings. There has been little study of factors associated with or implications of modifications to EBP protocols. This paper differentiates between fidelity-consistent and fidelity-inconsistent modifications and it examines the potential influence of two clinician characteristics, training outcomes, and attitudes toward EBPs on fidelity-consistent and fidelity-inconsistent modifications of cognitive behavioral therapy in a sample of clinicians who had been trained to deliver these treatments for children or adults.
Methods
Survey and coded interview data collected 2 years after completion of training programs in cognitive behavioral therapy were used to examine associations between successful or unsuccessful completion of training, clinician attitudes, and modifications. Modifications endorsed by clinicians were categorized as fidelity-consistent or fidelity-inconsistent and entered as outcomes into separate regression models, with training success and attitudes entered as independent variables.
Results
Successful completion of a training program was associated with subsequent fidelity-inconsistent modifications but not fidelity-consistent modifications. Therapists who reported greater openness to using EBPs prior to training reported more fidelity-consistent modifications at follow-up, and those who reported greater willingness to adopt EBPs if they found them appealing were more likely to make fidelity-inconsistent modifications.
Conclusions
Implications of these findings for training, implementation, EBP sustainment, and future studies are discussed. Research on contextual and protocol-related factors that may impact decisions to modify EBPs will be an important future direction of study to complement to this research.
doi:10.1186/s13012-015-0308-z
PMCID: PMC4534152  PMID: 26268633
8.  The Effectiveness of Clinician Feedback in the Treatment of Depression in the Community Mental Health System 
Objective
We describe the development and evaluation of a clinician feedback intervention for use in community mental health settings. The Community Clinician Feedback System (CCFS) was developed in collaboration with a community partner to meet the needs of providers working in such community settings.
Method
The CCFS consists of weekly performance feedback to clinicians as well as a clinical feedback report that assists clinicians with patients who are not progressing as expected. Patients in the randomized sample (N=100) were pre-dominantly female African-Americans, with a mean age of 39.
Results
Satisfaction ratings of the CCFS indicate that the system was widely accepted by clinicians and patients. An HLM analysis comparing rates of change across conditions controlling for baseline gender, age, and racial group indicated a moderate effect in favor of the feedback condition for symptom improvement (t(94) = 2.41, p = .017, d = .50). Thirty-six percent of feedback patients compared to only 13% of patients in the no feedback condition demonstrated clinically significant change across treatment (χ2(1) = 6.13, p = .013).
Conclusions
These results indicate that our CCFS is acceptable to providers and patients of mental health services, and has the potential to improve the effectiveness of services for clinically meaningful depression in the community mental health setting.
doi:10.1037/a0039302
PMCID: PMC4516646  PMID: 26052874
feedback; psychotherapy; community mental health; depression
9.  Combined Medication and CBT for Generalized Anxiety Disorder with African American Participants: Reliability and Validity of Assessments and Preliminary Outcomes 
Behavior therapy  2014;45(4):495-506.
Using data from a study of combined cognitive behavioral therapy (CBT) and venlafaxine XR in the treatment of generalized anxiety disorder (GAD), the current article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American compared to European American patients. Internal consistency and short-term stability coefficients for African Americans (n=42) were adequate and similar or higher compared to those found for European Americans (n=164) for standard scales used in GAD treatment research. Correlations among outcome measures among African Americans were in general not significantly different for African Americans compared to European Americans. A subset of patients with DSM-IV–diagnosed GAD (n = 24 African Americans; n = 52 European Americans) were randomly selected to be offered the option of adding 12 sessions of CBT to venlafaxine XR treatment. Of those offered CBT, 33.3% (n = 8) of the African Americans, and 32.6% (n = 17) of the European Americans accepted and attended at least one CBT treatment session. The outcomes for African Americans receiving combined treatment were not significantly different from European Americans receiving combined treatment on primary or secondary efficacy measures.
doi:10.1016/j.beth.2014.02.008
PMCID: PMC4260926  PMID: 24912462
Generalized Anxiety Disorder; Cognitive-Behavioral Therapy; venlafaxine; combined treatment; African American
10.  Comparative effectiveness of cognitive and dynamic therapies for major depressive disorder in a community mental health setting: study protocol for a randomized non-inferiority trial 
BMC psychology  2014;2(1):47.
Background
There is substantial evidence that cognitive therapy is an effective intervention for the treatment of major depressive disorder. Although dynamic psychotherapies have been widely studied and are commonly practiced worldwide, there are few randomized comparisons of cognitive therapy and dynamic therapy for major depressive disorder.
Methods
We are completing data collection on a randomized non-inferiority trial comparing the effectiveness of cognitive therapy and short-term dynamic psychotherapy in the treatment of major depressive disorder in the community mental health setting. Therapists employed in the community setting have been recruited for training in either short-term dynamic psychotherapy or cognitive therapy. Patients seeking services at the community site who meet criteria for major depressive disorder based on a blind independent diagnostic interview are randomized to 16 sessions of treatment. All patients are assessed at baseline and months 1, 2, 4, and 5 utilizing a comprehensive battery.
Discussion
This study adds to the growing literature evaluating the effectiveness of short-term dynamic psychotherapy for specific diagnostic groups. These results will have implications for the dissemination of effective interventions for major depressive disorder in community mental health settings.
Trial registration
This trial is registered at ClinicalTrials.gov, a service of the United States National Institute of Health. NIH Identifier: NCT01207271. Registered 21 September 2010.
doi:10.1186/s40359-014-0047-y
PMCID: PMC4270014  PMID: 25566391
Dynamic therapy; Cognitive therapy; Non-inferiority trial; Community mental health
11.  Modifications to Cognitive Therapy by Community Mental Health Providers: Implications for Effectiveness and Sustainability 
Psychiatric services (Washington, D.C.)  2013;64(10):10.1176/appi.ps.201200456.
Objective
This study identified modifications to an evidence-based psychosocial treatment (cognitive therapy) within a community mental health system after clinicians had received intensive training and consultation.
Methods
A coding system, consisting of five types of contextual modifications, 12 types of content-related modifications, seven levels at which modifications can occur, and a code for changes to training or evaluation processes, was applied to data from interviews with 27 clinicians who treat adult consumers within a mental health system.
Results
Nine of 12 content modifications were endorsed, and four (tailoring, integration into other therapeutic approaches, loosening structure, and drift) accounted for 65% of all modifications identified. Contextual modifications were rarely endorsed by clinicians in this sample. Modifications typically occurred at the client or clinician level.
Conclusions
Clinicians in community mental health settings made several modifications to an evidence-based practice (EBP), often in an effort to improve the fit of the intervention to the client’s needs or to the clinician’s therapeutic style. These findings have implications for implementation and sustainability of EBPs in community settings, client-level outcomes, and training and consultation.
doi:10.1176/appi.ps.201200456
PMCID: PMC3851297  PMID: 24081406
12.  Structural zeroes and zero-inflated models 
Shanghai Archives of Psychiatry  2014;26(4):236-242.
Summary
In psychosocial and behavioral studies count outcomes recording the frequencies of the occurrence of some health or behavior outcomes (such as the number of unprotected sexual behaviors during a period of time) often contain a preponderance of zeroes because of the presence of ‘structural zeroes’ that occur when some subjects are not at risk for the behavior of interest. Unlike random zeroes (responses that can be greater than zero, but are zero due to sampling variability), structural zeroes are usually very different, both statistically and clinically. False interpretations of results and study findings may result if differences in the two types of zeroes are ignored. However, in practice, the status of the structural zeroes is often not observed and this latent nature complicates the data analysis. In this article, we focus on one model, the zero-inflated Poisson (ZIP) regression model that is commonly used to address zero-inflated data. We first give a brief overview of the issues of structural zeroes and the ZIP model. We then given an illustration of ZIP with data from a study on HIV-risk sexual behaviors among adolescent girls. Sample codes in SAS and Stata are also included to help perform and explain ZIP analyses.
doi:10.3969/j.issn.1002-0829.2014.04.008
PMCID: PMC4194007  PMID: 25317011
count response; structural zeroes; random zeroes; zero-inflated models
13.  The Social Health Intervention Project (SHIP): Protocol for a randomized controlled clinical trial assessing the effectiveness of a brief motivational intervention for problem drinking and intimate partner violence in an urban emergency department 
Background
There is a strong reciprocal association between two highly prevalent public health problems: intimate partner violence and heavy drinking, both of which remain major sources of morbidity and mortality. Brief interventions in the Emergency Department setting have been found to be effective in reducing alcohol-related injury but neither classic intimate partner violence nor substance abuse interventions have adequately integrated assessment and treatment for these co-occurring conditions. The overall goal of this study is to determine whether a motivational intervention delivered at the time of an Emergency Department visit will reduce heavy drinking and improve the safety of women experiencing intimate partner violence.
Methods and design
We are completing data collection for a randomized controlled trial enrolling 600 female patients, age 18–64, presenting to one of two urban Emergency Departments, who self-disclose both problem drinking and intimate partner violence. Eligible patients are randomized to a brief manual-guided motivational intervention, and a phone booster at 10 days. The intervention, which is delivered by masters-level therapists during the Emergency Department visit, is recorded and monitored for fidelity. Primary outcomes are episodes of heavy drinking and incidents of intimate partner violence, assessed weekly by Interactive Voice Response System for 12 weeks and at 3, 6 and 12 months by interviewers blinded to group assignment. To identify the impact of assessment alone, we included a no-contact control group assessed only once at 3 months. Secondary outcomes include violence severity, changes in the Composite Abuse Scale and alcohol quantity/frequency, along with other health-related behaviors. The analysis will also explore the impact of likely mediators and moderators of the intervention.
Discussion
While screening and intervention for intimate partner violence is now recommended for women of child bearing age in health care settings, there is a need for rigorous evaluations of what works for whom. Upon completion, we will have high-quality evidence regarding the effectiveness of a low-intensity, brief motivational intervention, delivered by social workers in the Emergency Department setting, for decreasing episodes of heavy drinking and intimate partner violence. Ultimately, this is a model could be generalizable to other acute health care settings.
Trial Registration
ClinicalTrials.gov Registration Number: NCT01207258
doi:10.1186/1471-227X-14-10
PMCID: PMC4101846  PMID: 24742322
Problem drinking; Motivational interviewing; Intimate partner violence; Emergency department; Screening brief; Intervention and; Referral to treatment
14.  Process Predictors of the Outcome of Group Drug Counseling 
Objective
This study examined the relation of process variables to the outcome of group drug counseling, a commonly used community treatment, for cocaine dependence.
Method
Videotaped group drug counseling sessions from 440 adult patients (23% female, 41% minority) were rated for member alliance, group cohesion, participation, self-disclosure, positive and non-positive feedback and advice, during the 6-month treatment of cocaine dependence. Average, session-level, and slopes of process scores were evaluated. Primary outcomes were monthly cocaine use (days using out of 30), next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were endorsement of 12-step philosophy and beliefs about substance abuse.
Results
More positive alliances (with counselor) were associated with reductions in days using cocaine per month and next-session cocaine use, and increases in endorsement of 12-step philosophy. Patient self-disclosure about the past and degree of participation in the group were generally not predictive of group drug counseling outcomes. More advice from counselor and other group members were consistently associated with poorer outcomes in all categories. Individual differences in changes in process variables over time (linear slopes) were generally not predictive of treatment outcomes.
Conclusions
Some group behaviors widely believed to be associated with outcome, such as self-disclosure and participation, were not generally predictive of outcomes of group drug counseling, but alliance with the group counselor was positively associated, and advice giving negatively associated, with the outcome of treatments for cocaine dependence.
doi:10.1037/a0030101
PMCID: PMC3565014  PMID: 23106760
group drug counseling; cocaine dependence; predictors; process ratings
15.  Predictors and moderators of outcomes of HIV/STD sex risk reduction interventions in substance abuse treatment programs: a pooled analysis of two randomized controlled trials 
Background
The objective of the current study was to examine predictors and moderators of response to two HIV sexual risk interventions of different content and duration for individuals in substance abuse treatment programs.
Methods
Participants were recruited from community drug treatment programs participating in the National Institute on Drug Abuse Clinical Trials Network (CTN). Data were pooled from two parallel randomized controlled CTN studies (one with men and one with women) each examining the impact of a multi-session motivational and skills training program, in comparison to a single-session HIV education intervention, on the degree of reduction in unprotected sex from baseline to 3- and 6- month follow-ups. The findings were analyzed using a zero-inflated negative binomial (ZINB) model.
Results
Severity of drug use (p < .01), gender (p < .001), and age (p < .001) were significant main effect predictors of number of unprotected sexual occasions (USOs) at follow-up in the non-zero portion of the ZINB model (men, younger participants, and those with greater severity of drug/alcohol abuse have more USOs). Monogamous relationship status (p < .001) and race/ethnicity (p < .001) were significant predictors of having at least one USO vs. none (monogamous individuals and African Americans were more likely to have at least one USO). Significant moderators of intervention effectiveness included recent sex under the influence of drugs/alcohol (p < .01 in non-zero portion of model), duration of abuse of primary drug (p < .05 in non-zero portion of model), and Hispanic ethnicity (p < .01 in the zero portion, p < .05 in the non-zero portion of model).
Conclusion
These predictor and moderator findings point to ways in which patients may be selected for the different HIV sexual risk reduction interventions and suggest potential avenues for further development of the interventions for increasing their effectiveness within certain subgroups.
doi:10.1186/1747-597X-9-3
PMCID: PMC3929547  PMID: 24433412
HIV prevention intervention; Skills building; Randomized controlled trial; Predictors; Moderators
16.  Supportive-Expressive Dynamic Psychotherapy in the Community Mental Health System: A Pilot Effectiveness Trial for the Treatment of Depression 
Psychotherapy (Chicago, Ill.)  2012;49(3):303-316.
The goal of the current article is to present the results of a randomized pilot investigation of a brief dynamic psychotherapy compared with treatment-as-usual (TAU) in the treatment of moderate-to-severe depression in the community mental health system. Forty patients seeking services for moderate-to-severe depression in the community mental health system were randomized to 12 weeks of psychotherapy, with either a community therapist trained in brief dynamic psychotherapy or a TAU therapist. Results indicated that blind judges could discriminate the dynamic sessions from the TAU sessions on adherence to dynamic interventions. The results indicate moderate-to-large effect sizes in favor of the dynamic psychotherapy over the TAU therapy in the treatment of depression. The Behavior and Symptom Identification Scale-24 showed that 50% of patients treated with dynamic therapy moved into a normative range compared with only 29% of patients treated with TAU.
doi:10.1037/a0027694
PMCID: PMC3784980  PMID: 22962971
dynamic psychotherapy; effectiveness; adherence; depression
17.  Clinicians’ Perspectives on Cognitive Therapy in Community Mental Health Settings: Implications for Training and Implementation 
Policymakers are investing significant resources in large-scale training and implementation programs for evidence-based psychological treatments (EBPTs) in public mental health systems. However, relatively little research has been conducted to understand factors that may influence the success of efforts to implement EBPTs for adult consumers of mental health services. In a formative investigation during the development of a program to implement cognitive therapy (CT) in a community mental health system, we surveyed and interviewed clinicians and clinical administrators to identify potential influences on CT implementation within their agencies. Four primary themes were identified. Two related to attitudes towards CT: (1) ability to address client needs and issues that are perceived as most central to their presenting problems, and (2) reluctance to fully implement CT. Two themes were relevant to context: (1) agency-level barriers, specifically workload and productivity concerns and reactions to change, and (2) agency-level facilitators, specifically, treatment planning requirements and openness to training. These findings provide information that can be used to develop strategies to facilitate the implementation of CT interventions for clients being treated in public-sector settings.
doi:10.1007/s10488-012-0418-8
PMCID: PMC3434254  PMID: 22426739
Evidence-based psychosocial treatments; Cognitive therapy; Dissemination and implementation
18.  How many treatment sessions and patients are needed to create a stable score of adherence and competence in the treatment of cocaine dependence? 
The study utilized a generalizability theory analysis of adherence and competence ratings to evaluate the number of sessions and patients needed to yield dependable scores at the patient and therapist levels. Independent judges’ ratings of supportive expressive therapy (n = 94), cognitive therapy (n = 103), and individual drug counseling (n = 98) were obtained on tapes of sessions from the NIDA Collaborative Cocaine Treatment Study. Generalizability coefficients revealed that, for all three treatments, ratings made on approximately five to 10 sessions per patient are needed to achieve sufficient dependability at the patient level. At the therapist level, four to 14 patients need to be evaluated (depending on the modality), to yield dependable scores. Many studies today use fewer numbers.
doi:10.1080/10503307.2012.674790
PMCID: PMC3411921  PMID: 22449079
statistical methodology; generalizability theory; adherence; competence
19.  MET meets the real world: design issues and clinical strategies in the Clinical Trials Network 
The Clinical Trials Network (CTN) represents a major initiative intended to bridge the gap between research and practice in substance abuse treatment by implementing a range of studies evaluating behavioral, pharmacologic, and combined treatments in community-based drug abuse treatment programs across the country. This article describes the development of CTN protocols evaluating the effectiveness of Motivational Enhancement Therapy and Motivational Interviewing. Design, training, and implementation challenges associated with conducting a clinical trial of brief behavioral treatments in community programs are discussed. Issues requiring attention included the diversity in treatments offered across sites, heterogeneity in the study sample, and training of clinicians drawn from the staff of community programs to deliver the study treatments.
PMCID: PMC3651591  PMID: 12220604
Substance abuse treatment; Randomized clinical trials; Behavioral therapies; Motivational interviewing
20.  A Preliminary Study of the Effects of Individual Patient-Level Feedback in Outpatient Substance Abuse Treatment Programs 
The purpose of the current study is to examine the effects of feedback provided to counselors on the outcomes of patients treated at community-based substance abuse treatment programs. A version of the Outcome Questionnaire (OQ-45), adapted to include drug and alcohol use, was administered to patients (N=304) in three substance abuse treatment clinics. Phase I of the study consisted only of administration of the assessment instruments. Phase II consisted of providing feedback reports to counselors based on the adapted OQ-45 at every treatment session up to session 12. Patients who were found to not be progressing at an expectable rate (i.e., “off-track”) were administered a questionnaire that was used as a second feedback report for counselors. For off-track patients, feedback compared to no feedback led to significant linear reductions in alcohol use throughout treatment and also in OQ-45 total scores and drug use from the point of the second feedback instrument to session 12. The effect for improving mental health functioning was evident at only one of the three clinics. These results suggest that a feedback system adapted to the treatment of substance use problems is a promising approach that should be tested in a larger randomized trial.
doi:10.1016/j.jsat.2011.09.003
PMCID: PMC3270209  PMID: 22036697
Substance abuse; feedback; Outcome Questionnaire-45; quality improvement
21.  Gender, Race, and Group Behavior in Group Drug Treatment 
Drug and alcohol dependence  2011;119(3):e39-e45.
Background
Group drug counseling is the primary treatment modality used to treat drug dependence in community settings in the United States. Findings from the social psychology literature suggest that gender may influence how individuals participate in groups, and that race may moderate the effects of gender on group behavior. This study examined gender, race, and their interaction as predictors of alliance, participation, self-disclosure, and receipt of advice and feedback in drug counseling groups, and explored how gender and racial differences in drug counseling group behavior related to outcome of cocaine dependence treatment.
Method
Ratings of group behavior were made from videotaped sessions of group drug counseling drawn from a randomized trial of treatment for cocaine-dependent individuals (n = 438). Analyses examined the effects of race (African American vs. non-Hispanic White), gender, and race by gender on group behavior. Additional analyses examined race, gender, and group behavior, and interactions among these variables in predicting monthly cocaine use.
Results
Race and the race by gender interaction, but not gender alone, predicted many group behaviors. Non-Hispanic White women had the highest rates of self-disclosure and receipt of advice and non-positive feedback, followed by men of both races, with African American women having the lowest levels. These differences were unrelated to cross-sectional cocaine outcome.
Conclusions
Women, but not men, of different races acted differently in mixed-race, mixed-gender cocaine treatment groups, with African American women exhibiting less of several behaviors. Additional research on causes and consequences of these differences could inform interventions for drug-dependent women.
doi:10.1016/j.drugalcdep.2011.05.023
PMCID: PMC3178731  PMID: 21689897
cocaine dependence; group drug counseling; race; gender; group process
22.  Combined Medication and Cognitive Therapy for Generalized Anxiety Disorder 
Journal of anxiety disorders  2011;25(8):1087-1094.
The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV–diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.
doi:10.1016/j.janxdis.2011.07.007
PMCID: PMC3196054  PMID: 21840164
Generalized Anxiety Disorder; Cognitive-Behavioral Therapy; venlafaxine; combined treatment
23.  Perspectives on Cognitive Therapy Training within Community Mental Health Settings: Implications for Clinician Satisfaction and Skill Development 
Despite the mounting evidence of the benefits of cognitive therapy for depression and suicidal behaviors over usual care, like other evidence-based psychosocial treatments (EBTs), it has not been widely adopted in clinical practice. Studies have shown that training followed by intensive consultation is needed to prepare providers to an appropriate level of competency in complex, multisession treatment packages such as cognitive therapy. Given the critical role of training in EBT implementation, more information on factors associated with the success and challenges of training programs is needed. To identify potential reasons for variation in training outcomes across ten agencies in a large, urban community mental health system, we explored program evaluation data and examined provider, consultant, and training program administrator perspectives through follow-up interviews. Perceptions of cognitive therapy, contextual factors, and reactions to feedback on audio recordings emerged as broad categories of themes identified from interviews. These factors may interact and impact clinician efforts to learn cognitive therapy and deliver it skillfully in their practice. The findings highlight experiences and stakeholder perspectives that may contribute to more or less successful training outcomes.
doi:10.1155/2012/391084
PMCID: PMC3465974  PMID: 23056933
24.  Program, Counselor, and Patient Variability in the Alliance: A Multilevel Study of the Alliance in Relation to Substance Use Outcomes 
We explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N=1613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale. Using multilevel modeling, we found that alliance was related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance-outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient-counselor alliance.
doi:10.1016/j.jsat.2011.01.003
PMCID: PMC3081942  PMID: 21349680
Substance Abuse; Alliance; Program; Counselor
25.  The Dependability of Alliance Assessments: The Alliance–Outcome Correlation is Larger than You Might Think 
Objective
To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship.
Method
We used data from a study (N=45 patients; N=9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used.
Results
At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (> .90) dependability at the patient level is only achieved through aggregating four or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance but the average of sessions 3 to 9 explaining 14.7% of outcome variance.
Conclusion
Adequately assessing the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial to fully understanding the size of the alliance-outcome relationship.
doi:10.1037/a0023668
PMCID: PMC3111943  PMID: 21639607
alliance; outcome; generalizability theory; therapist

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