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1.  Therapist Focus on Ambivalence and Commitment: A Longitudinal Analysis of Motivational Interviewing Treatment Ingredients 
The present study examines two core therapeutic principles of Motivational Interviewing (MI) with alcohol and other substance use disorders. Specifically, therapist focus on client ambivalence and commitment to change, as well as a more general indicator of goal assessment, were tested as process predictors of subsequent alcohol use across four sessions of Motivational Enhancement Therapy. Participants were adult alcohol users involved in a large multi-site clinical trial (Project MATCH; two arms Aftercare [AC] and Outpatient [OP]). A series of multi-level models examined the effect of proposed MI ingredients on alcohol use (percent abstinent days; drinks per drinking day) over a 12-week treatment period, and whether these effects interacted with time and client baseline motivation. Therapist effort to elicit client commitment to change alcohol use was associated with greater rates of abstinence among both AC and OP participants, and reduced drinking quantity among OP participants. However, therapist focus on ambivalence was associated with greater drinking quantity among OP participants, and when motivation was low, among AC participants. Goal assessment was a marginal to non-significant predictor across outcomes, and all interactions with time were non-significant. Therapist reported treatment foci are important to subsequent patterns of drinking within a multi-session MI, but the role of ambivalence and discrepancy is worthy of further clinical and empirical consideration.
PMCID: PMC3650101  PMID: 22905897
Ambivalence; Brief Interventions; Commitment to Change; Process Research; Stages of Change; Treatment Ingredients; Motivational Interviewing
2.  Efficacy combined with specified ingredients: A new direction for empirically-supported addiction treatment 
Addiction (Abingdon, England)  2012;108(5):874-881.
With the increased need for sanctioning behavioral addiction treatments to guide key stakeholders, focus has shifted to developing and applying criteria for establishing empirically-supported treatments (EST). Among the many criteria offered, demonstration of incremental efficacy over a placebo or comparison in at least two independent randomized clinical trials (RCT) has been the gold standard. While necessary, the present EST criteria are not sufficient. The present work: (1) argues for empirically supported specificity in behavioral addiction treatment, (2) explores the limitations of empirical support for EST efficacy without evidence of specificity, and (3) discusses implications and recommendations for ultimately raising the bar for status as an EST.
The authors review relevant literature on ESTs, evidence-based practice, and clinical trial design in the addictions and related disciplines.
We clarify that the additional bar of specificity does not denote uniqueness in causal processes and we argue that specificity should not be inferred only via the nature of the experimental contrast. Rather, a treatment has specificity if its active ingredients are identified and empirically validated as predictors of subsequent treatment-related outcomes. Within this new definition, there are implications for clinical research and other key stakeholders.
A heightened centrality of empirically-supported addiction treatment ingredients moving forward will advance clinical knowledge and evaluation methodology at a far greater pace.
PMCID: PMC3566277  PMID: 23072622
Active Ingredients; Empirically-Supported Treatment; Evidence-Based Practice; Mechanisms of Behavior Change; Randomized Clinical Trials
3.  Effect of a Significant Other on Client Change Talk in Motivational Interviewing 
Journal of consulting and clinical psychology  2012;81(1):10.1037/a0030881.
To examine significant-other (SO) and therapist behaviors as predictors of client change language within motivational interviewing (MI) sessions.
Participants from an emergency department received a single session of MI that included SO participation (N = 157). Sessions were coded using therapy process coding systems. Sessions were subdivided into ten equal deciles to facilitate sequential analyses. Multilevel modeling was used to examine the relationships among the following variables: therapist MI-consistent and MI-inconsistent behavior; client change talk and sustain talk; SO Support Change and SO Against Change.
Therapist MI-consistent and MI-inconsistent behaviors failed to predict either client change talk or sustain talk at the decile level. Global measures of therapist MI spirit and acceptance were associated with lower levels of client sustain talk (p = .002 and p < .001 respectively). Higher levels of SO Support Change were more likely to be followed by higher levels of client change talk (p < .001) and lower levels of client sustain talk (p <.001). SOs who engaged in behaviors that discouraged the patient’s drinking in the six months prior to the intervention had higher levels of SO Support Change language (p = .02). When analyzed at the aggregate level, therapist behavior was significantly associated with client change talk, but effect sizes were quite modest.
Within-session SO behavior impacts client verbalizations regarding changes in alcohol use. Results raise questions about the role of therapist behavior when an SO is present.
PMCID: PMC3808251  PMID: 23231575
Motivational Interviewing; therapy process; alcohol use; brief intervention; change language
4.  Psychometric Validation of the Leeds Dependence Questionnaire (LDQ) in a Young Adult Clinical Sample 
Addictive behaviors  2009;35(4):331-336.
Measures of substance dependence severity that are both clinically efficient and sensitive to change can facilitate assessment of clinical innovation necessary for improving current evidence-based practices. The Leeds Dependence Questionnaire (LDQ) is a 10-item, continuous, self-report measure of dependence that is not specific to any particular substance and has shown promise in preliminary psychometric research. The present study investigates its psychometric properties in a large clinical sample of young adults.
Emerging adults (N = 300) were enrolled in a naturalistic treatment process and outcome study of residential substance dependence treatment (mean age 20.4 [1.6], range 18–25; 27% female; 95% White). Dependence severity by demographic and diagnostic groupings, factor structure and internal consistency, and criterion- and construct-related validity were examined.
Dependence severity in this cohort of youth overall was high (M = 18.65 [8.65]). LDQ scores were highest among opiate and stimulant users, and there was a trend for higher scores among women compared to men (t = 1.869, p = .063). Factor analysis using a robust alpha factoring extraction revealed a single factor accounting for 63% of the variance in reported dependence severity. The internal consistency was also very high (alpha = .93). Concurrent and convergent validity with dependence criteria, substance use frequency, and general symptom severity, respectively, were also acceptable.
The LDQ shows considerable promise as a brief, psychometrically sound, measure of substance dependence useful across a variety of substances, that has clinical and research utility. This study supports its use among emerging adults.
PMCID: PMC3773982  PMID: 20004062
Assessment; Substance Abuse or Dependence; Psychometric; Young or Emerging Adults
5.  Do Research Assessments Make College Students More Reactive to Alcohol Events? 
Psychology of Addictive Behaviors  2011;26(2):338-344.
This study examines possible synergistic effects of alcohol-related events and post-event assessments on changes in college student readiness to change alcohol use, frequency of alcohol use, and negative consequences. Students were participants in a longitudinal study of drinking behavior. A portion of those reporting negative alcohol events/consequences (e.g., injury, vomiting, memory loss) during the parent study were randomly selected to participate in the present study (n = 492) and randomized to a post-event assessment (n = 296) or a no-assessment control (n = 196). Participants in the post-event assessment group were interviewed soon after their event, and participants in both conditions were interviewed three months after their event. Linear regression models showed higher 3-month readiness to change alcohol use in participants who received a post-event assessment than those who did not. There were reductions in drinking days, heavy drinking days, and further consequences post-event, but no differences by assessment group. However, female participants showed greater reductions in drinking days and heavy drinking days if they were assigned to assessment compared to control. There also was greater post-event reduction in drinking days among assessment group participants with high pre-college alcohol severity compared to low pre-college alcohol severity. Conversely, participants who reported high aversiveness of their event and were in the control group showed greater reduction in heavy drinking days than those assigned to the assessment group. Findings suggest that college student heavy drinking is reactive to alcohol events, whereas reactivity to post-event assessments may depend on gender, alcohol severity, and event aversiveness. This work highlights the importance of considering possible interactions among extra-therapeutic factors in clinical outcome research.
PMCID: PMC3257404  PMID: 21928871
Alcohol Abuse; Alcohol Consequences; Assessment Reactivity; College Student Drinking; Readiness to Change; Research Reactivity
8.  Moderators and Mediators in Social Work Research: Toward a More Ecologically Valid Evidence Base for Practice 
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.
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 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.
PMCID: PMC3402093  PMID: 22833701
Evidence-Based Practice; Mediation; Mechanisms of Behavior Change; Moderation; Social Work Research; Statistical Methods
9.  Recent Advances in Behavioral Addiction Treatments: Focusing on Mechanisms of Change 
Current Psychiatry Reports  2011;13(5):382-389.
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.
PMCID: PMC3350646  PMID: 21750958
behavioral treatment; addictions; mechanisms of behavioral change; active ingredients of treatment; mediation analysis; mediated moderation; moderated mediation; conditional indirect effects; clinical trials; causal models; causal chains; model misspecification; treatment outcome studies
10.  The role of Alcoholics Anonymous in mobilizing adaptive social network changes: A prospective lagged mediational analysis 
Drug and alcohol dependence  2010;114(2-3):119-126.
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.
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.
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.
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.
PMCID: PMC3062700  PMID: 21035276
Alcoholics Anonymous; social networks; self help groups; alcoholism; alcohol dependence
11.  Using Daily Drinking Data to Characterize the Effects of a Brief Alcohol Intervention in an Emergency Room 
Addictive behaviors  2010;36(3):248-250.
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.
PMCID: PMC3021247  PMID: 21126827
Daily Drinking; Timeline Followback; Motivational Interviewing; Screening and Brief Intervention; Young Adult
12.  Spirituality in Recovery: A Lagged Mediational Analysis of Alcoholics Anonymous’ Principal Theoretical Mechanism of Behavior Change 
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.
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.
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).
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.
PMCID: PMC3117904  PMID: 21158876
Alcoholics Anonymous; Spirituality; self help groups; alcoholism; alcohol dependence
16.  Motivational Interviewing with Significant Other Participation: Assessing Therapeutic Alliance and Patient Satisfaction and Engagement 
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.
PMCID: PMC2967605  PMID: 20817382
Alcohol Treatment; Emergency Department; Motivational Interviewing; Significant Others; Treatment Fidelity
17.  The Route to Change: Within-Session Predictors of Change Plan Completion in a Motivational Interview 
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.
PMCID: PMC2835844  PMID: 20149571
Alcohol Use; Change Language or Change Talk; Mechanisms of Behavior Change; Motivational Interviewing; Therapy Process
18.  Mechanisms of Behavior Change in Alcoholics Anonymous: Does AA lead to better alcohol use outcomes by reducing depression symptoms? 
Addiction (Abingdon, England)  2010;105(4):626-636.
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.
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.
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.
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.
PMCID: PMC2857524  PMID: 20102345
Alcoholics Anonymous; mechanisms; alcohol dependence; depression; self-help groups; mutual-help groups
19.  Moderators and Mediators of Two Brief Interventions for Alcohol in the Emergency Department 
Addiction (Abingdon, England)  2010;105(3):452-465.
Evaluate moderators and mediators of brief alcohol interventions conducted in the Emergency Department.
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.
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.
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.
PMCID: PMC2858352  PMID: 20402989
Alcohol; Brief Intervention; Emergency Room

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