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.
Substance abuse; feedback; Outcome Questionnaire-45; quality improvement
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.
Generalized Anxiety Disorder; Cognitive-Behavioral Therapy; venlafaxine; combined treatment
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.
Substance Abuse; Alliance; Program; Counselor
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.
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.
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.
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.
alliance; outcome; generalizability theory; therapist
Videotaped group drug counseling sessions were rated for alliance, self-disclosure, positive and negative feedback, group cohesion, and degree of participation of each group member. Interrater reliability was good to excellent for most measures. However, generalizability coefficients based on statistical models that included terms for patient, counselor, session, group, and rater revealed that some measures had inadequate dependability at the patient level if only two raters and two sessions were used to create patient-level scores. In contrast, good generalizability coefficients based on two raters and two sessions were obtained for alliance, non-positive learning statements received from counselor, participation variables, and self-disclosures about the past. The implications of the findings for the design of process-outcome studies are discussed.
group psychotherapy; process research; alliance; substance abuse
We report here on the results of a randomized, controlled trial evaluating the efficacy of a semi-automated performance improvement system (“Patient Feedback”) that enables real-time monitoring of patient outcomes in outpatient substance abuse treatment clinics. The study involved 118 clinicians working at 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Ten clinics received 12 weeks of the Patient Feedback performance improvement intervention and ten clinics received no intervention during the 12 weeks. Over 1500 patients provided anonymous ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use. There was no evidence of an intervention effect on the primary drug and alcohol use scales. There was also no evidence of an intervention effect on secondary measures of therapeutic alliance. Clinician-rated measures of organizational functioning and job satisfaction also showed no intervention effect. Possible insights from these findings, and alternative methods of utilizing feedback reports to enhance clinical outcomes are proposed.
performance improvement; substance abuse; feedback; alliance; treatment satisfaction
To facilitate effectiveness testing and dissemination of treatments to community based setting, therapist training manuals that are more “community friendly” are needed. The aim of the current project was to create revised versions of individual drug counseling (IDC) and group drug counseling (GDC) treatment manuals for cocaine dependence and to conduct a preliminary study of their effectiveness. After changing the format and context of existing drug counseling manuals to have greater ease of use in the community, draft manuals were given to 23 community-based counselors for their feedback. Final versions were then used in a pilot randomized clinical trial involving 41 cocaine dependent patients who received 3 months of either IDC + GDC or GDC alone treatment. Counselors implemented the new treatment manuals with acceptable levels of adherence and competence. Outcome results indicated that substantial change in drug use was evident, but the amount of abstinence obtained was limited.
Cocaine dependence; drug counseling; randomized trial
The goal of this paper was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. The University of Pennsylvania Center for Psychotherapy Research database that includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.
Mechanism; Cognitive therapy; Dynamic therapy; Psychotherapy outcome
The objective of this study was to examine the level of additional treatment services obtained by patients enrolled in the NIDA Cocaine Collaborative Study, a multi-center efficacy trial of four treatments for cocaine dependence, and to determine whether these services impact treatment outcome. Cocaine-dependent patients (N = 487) were recruited at five sites and randomly assigned to six months of one of four psychosocial treatments. Assessments were made at baseline, monthly during treatment, and at follow-ups at 9, 12, 15, and 18 months post-randomization. On average, patients received little or no additional treatment services during active treatment (first 6 months), but the rate of obtaining most services increased during the follow-up phase (month 7 to 18). In general, the treatment groups did not differ in the rates of obtaining non-protocol services. For all treatment groups, patients with greater psychiatric severity received more medical and psychiatric services during active treatment and follow-up. Use of treatment services was unrelated to drug use outcomes during active treatment. However, during the follow-up period, increased use of psychiatric medication, 12-step attendance, and 12-step participation was related to less drug use. The results suggest that during uncontrolled follow-up phases, additional non-protocol services may potentially confound the interpretation of treatment group comparisons in drug use outcomes.
substance abuse; treatment services; treatment outcome; cocaine dependence
Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically-oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12 month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 days per month at baseline to a mean of 1.3 days at 12 months.
The objective of this study was to examine patients’ reports of positive quality of life over the course of multiple forms of psychotherapy and disorders. Data from five studies using a common assessment battery were pooled to evaluate the magnitude of change in positive quality of life and explore the relation of change in positive quality of life to change in symptoms, and how these relations vary by disorder. Positive quality of life was measured at intake, termination, and during two post-treatment visits 6 and 12 months following termination. Results revealed that positive quality of life improves moderately over the course of psychotherapy and sustains the improvement through follow-up. Levels of positive quality of life and the degree of change in positive quality of life varied considerably by disorder. There also were moderate sized correlations between changes in positive quality of life and changes in symptomatic response and interpersonal functioning from intake to termination. Implications of the findings for clinical practice and future research are discussed.
positive quality of life; symptom reduction; cognitive therapy; supportive-expressive therapy
The need for a self-report measure of work functioning that is flexible to involvement in work across three domains (employment, school, and home) led to the development of the Work History Inventory (WHI). The WHI was administered to 185 patients who participated in psychotherapy studies and to 110 community control respondents who were not in treatment. The WHI Total score and subscales (Performance and Interpersonal) demonstrated adequate to good reliability. WHI scores correlated moderately with symptom measures and strongly with another work functioning measure. Changes across treatment indicated that the WHI Total and Performance scores increased significantly across psychotherapy. The WHI appears to be a reliable and valid instrument for measuring treatment related changes in work functioning.
work functioning; work performance; interpersonal; psychotherapy; self-report measure
Cocaine use is a significant problem in the US and it is well established that cocaine binds to the dopamine transporter (DAT) in the brain. This study was designed to determine if the DAT levels measured by 99mTc TRODAT SPECT brain scans are altered in cocaine dependent subjects and to explore clinical correlates of such alterations. SPECT brain scans were acquired on 21 cocaine dependent subjects and 21 healthy matched controls. There were significantly higher DAT levels in cocaine dependent subjects compared to controls for the anterior putamen (p = 0.003; Cohen’s d effect size = 0.98), posterior putamen (p < 0.001; effect size = 1.32), and caudate (p = 0.003; effect size = 0.97). DAT levels in these regions were 10%, 17%, and 8% higher in the cocaine dependent subjects compared to controls. DAT levels were unrelated to craving, severity of cocaine use, or duration of cocaine use, but DAT levels in the caudate and anterior putamen were significantly (p < 0.05) negatively correlated with days since last use of cocaine.
Dopamine transporter; Cocaine dependence; SPECT