Summary

Evidence-based practice involves the consistent and critical consumption of the social work research literature. As methodologies advance, primers to guide such efforts are often needed. In the present work, common statistical methods for testing moderation and mediation are identified, summarized, and corresponding examples, drawn from the substance abuse, domestic violence, and mental health literature, are provided.

Findings

While methodologically complex, analyses of these third variable effects can provide an optimal fit for the complexity involved in the provision of evidence-based social work services. While a moderator may identify the trait or state requirement for a causal relationship to occur, a mediator is concerned with the transmission of that relationship. In social work practice, these are questions of “under what conditions and for whom?” and of the “how?” of behavior change.

Implications

Implications include a need for greater attention to these methods among practitioners and evaluation researchers. With knowledge gained through the present review, social workers can benefit from a more ecologically valid evidence base for practice.

In the latter half of the 20th century, research on behavioral treatments for addictions aimed to develop and test effective treatments. Among treatments found to be at least moderately effective, direct comparisons failed to reveal consistent superiority of one approach over another. This ubiquitous finding held true despite underlying theories that differed markedly in their proposed causal processes related to patient change. In the 21st century the focus of treatment research is increasingly on how treatment works for whom, rather than whether it works. Studies of active treatment ingredients and mechanisms of behavioral change, while promising, have yielded inconsistent results. Simple mediation analysis may need to be expanded by inclusion of models testing for moderated mediation, mediated moderation, and conditional indirect effects. Examples are offered as to how these more complex models can lead to increased understanding of the conditions under which specific treatment interventions will be effective and mechanisms of change operative in improving behavioral treatments for addictions.

Objective

Many individuals entering treatment are involved in social networks and activities that heighten relapse risk. Consequently, treatment programs facilitate engagement in social recovery resources, such as Alcoholics Anonymous (AA), to provide a low risk network. While it is assumed that AA works partially through this social mechanism, research has been limited in rigor and scope. This study used lagged mediational methods to examine changes in pro-abstinent and pro-drinking network ties and activities.

Method

Adults (N = 1,726) participating in a randomized controlled trial of alcohol use disorder treatment were assessed at intake, and 3, 9, and 15 months. Generalized linear modeling (GLM) tested whether changes in pro-abstinent and pro-drinking network ties and drinking and abstinent activities helped explain AA's effects.

Results

Greater AA attendance facilitated substantial decreases in pro-drinking social ties and significant, but less substantial increases in pro-abstinent ties. Also, AA attendance reduced engagement in drinking-related activities and increased engagement in abstinent activities. Lagged mediational analyses revealed that it was through reductions in pro-drinking network ties and, to a lesser degree, increases in pro-abstinent ties that AA exerted its salutary effect on abstinence, and to a lesser extent, on drinking intensity.

Conclusions

AA appears to facilitate recovery by mobilizing adaptive changes in the social networks of individuals exhibiting a broad range of impairment. Specifically by reducing involvement with pro-drinking ties and increasing involvement with pro-abstinent ties. These changes may aid recovery by decreasing exposure to alcohol-related cues thereby reducing craving, while simultaneously increasing rewarding social relationships.

Clinical trials often aggregate daily alcohol consumption data across long-term follow-up intervals (e.g., 6 or 12 months). Although important in understanding general treatment outcomes, these analyses tell us little about when treatment effects emerge or decline. We previously demonstrated that motivational interviewing (MI) reduced heavy drinking (vs. personalized feedback only; FO) among young adult drinkers (N = 198; ages 18-24) recruited in a hospital Emergency Room (ER) using aggregated drinking data from 6-month follow up. In the current study, we used daily alcohol consumption data from a calendar-assisted interview (Timeline Followback) to examine the timing and course of these treatment effects. Participants in both conditions received brief telephone booster sessions at 1 and 3 months. There were no treatment effects in the time between the initial intervention session and the 3-month booster session. Significant effects emerged after the 3-month booster and were driven by an increase in heavy drinking within the FO group. This suggests that the effects of brief interventions may not emerge immediately following an initial session. Aggregated data would be unable to detect this time trend. This research underscores the potential value added by examining the day-to-day timing of effects following treatments for alcohol use.

Background

Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through “spiritual” practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes.

Method

Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects.

Results

Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day).

Conclusions

Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals’ spiritual practices and provides support for AA’s own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.

Inclusion of concerned significant others (SO) in alcohol use treatment has demonstrated efficacy but has not been tested in the context of brief interventions. In this study, individual Motivational Interviewing (MI) sessions were compared to MI sessions including a significant other (SOMI) on within treatment outcomes (alliance, fidelity, client satisfaction and engagement). Participants (N = 382) were adult alcohol users recruited in a Level I Trauma Center. Perceived alliance did not differ across conditions, but patients and SOs reported higher alliance, satisfaction and engagement than was perceived by the therapist. The occurrence of MI components, or discussion areas, was consistent across conditions. Higher baseline SO drinking was associated with lower patient engagement, while higher baseline SO acceptance of patient drinking was associated with lower SO engagement. Results suggest individual MI sessions can be adapted to include an SO with minimal impact on patient acceptability and treatment fidelity. Research should, however, consider SOs’ influence on participant outcomes and the relevance of specific SO characteristics.

Rationale

Indices of negative affect, such as depression, have been implicated in stress-induced pathways to alcohol relapse. Empirically-supported continuing care resources, such as Alcoholics Anonymous (AA), emphasize reducing negative affect to reduce relapse risk, but little research has been conducted to examine putative affective mechanisms of AA’s effects.

Method

Using lagged, controlled, hierarchical linear modeling and mediational analyses this study investigated whether AA participation mobilized changes in depression symptoms and whether such changes explained subsequent reductions in alcohol use. Alcohol dependent adults (N = 1,706), receiving treatment as part of a clinical trial, were assessed at intake, 3, 6, 9, 12, and 15 months.

Results

Findings revealed elevated levels of depression compared to the general population, which decreased during treatment and then remained stable over follow-up. Greater AA attendance was associated with better subsequent alcohol use outcomes and decreased depression. Greater depression was associated with heavier and more frequent drinking. Lagged, mediation analyses revealed that the effects of AA on alcohol use was partially mediated by reductions in depression symptoms. However, this salutary effect on depression itself appeared to be explained by AA’s proximal effect on reducing concurrent drinking.

Conclusions

AA attendance was both concurrently and predictively associated with improved alcohol outcomes. Although AA attendance was additionally associated with subsequent improvements in depression, it did not predict such improvements over and above concurrent alcohol use. AA appears to lead both to improvements in alcohol use and psychological and emotional well-being, which, in turn, may reinforce further abstinence and recovery-related change.

This study is the first to examine within-session therapist and client language/process predictors of a client’s decision to complete a written Change Plan in an alcohol-focused motivational interview (MI). Data were from an ongoing hospital-based clinical trial (N = 291). Trained raters coded audio-recorded MI sessions using the Motivational Interviewing Skill Code. Logistic regression analyses found that therapist MI-consistent behaviors (b = .023, p < .001) and client change talk (b = .063, p < .001) were positive predictors, and client counter change talk (b = −.093, p < .001) was a negative predictor of the decision to complete a Change Plan regarding alcohol use. Mean comparisons showed that compared to non-completion, Change Plan completion did not result in significantly greater changes in client motivational readiness. Completion of a Change Plan is a proximal outcome in MI that is associated with client intention to change (change talk), and may predict follow-up alcohol outcomes. Analyses of such theory-driven proximal client mechanisms provide a more complete model of MI process and may inform MI providers of necessary treatment ingredients.

Objective

Evaluate moderators and mediators of brief alcohol interventions conducted in the Emergency Department.

Methods

Patients (18–24 years; N = 172) in an Emergency Department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow ups. Gender, alcohol status/severity group (ALC+ Only, AUDIT+ Only, ALC+/AUDIT+), attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event, and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy, and alcohol treatment seeking.

Results

Alcohol status, attribution, and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event, and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ Only group those who received MI showed lower rates of alcohol-related injury at follow up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.

Conclusions

Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.