Arlene Frank

Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study.

The authors examined the relation between therapeutic alliance, retention, and outcome for 308 cocaine-dependent outpatients participating in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. High levels of alliance were observed in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC), and alliance levels increased slightly but significantly from Session 2 to Session 5 in all groups. In contrast to other studies, alliance was not a significant predictor of drug outcome. However, alliance did predict patient retention differentially across the 3 treatments. In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention.

Retention in Psychosocial Treatment of Cocaine Dependence: Predictors and Impact on Outcome

This report describes retention in treatment in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (CCTS), a multi-site trial of four psychosocial treatments for 487 cocaine dependent patients. Younger, African-American, and unemployed patients were retained in treatment for fewer days than their counterparts. African-American patients who lived with a partner were retained in treatment for less time than if they lived alone. Higher psychiatric severity kept men in treatment longer but put women at risk for dropping out sooner. Patients who completed the full treatment used drugs less often than patients who dropped out, but outcome did not differ at each month. Patients in the drug counseling condition stayed in treatment for fewer days than patients in psychotherapy, but they were more likely to be abstinent after dropout. Patients with higher psychiatric severity were more at risk for continuing to use drugs after dropout.

Predictors of dropout from psychosocial treatment of cocaine dependence.

The current study assessed demographic, drug and psychiatric predictors of dropout in the pilot/training phase of a large, multi-site psychotherapy outcome study for patients with cocaine dependence. The different predictors of dropout were assessed throughout the phases of the study: screening, intake, stabilization and assessment phase, and following randomization to treatment. Results showed that (1) younger patients were less likely to keep their intake appointment. (2) Of the patients who had an intake visit, those who did not complete high school and with more days of cocaine use in the previous month were less likely to complete an initial stabilization and assessment phase requiring 1 week of abstinence from all drugs. A survival analysis was used to examine time to dropout for the 286 patients randomized to individual treatment. (3) Again, younger age was associated with dropout after randomization. (4) Drug use variables did not predict time to dropout. (5) Presence of any current Axis I disorder was associated with later dropout from treatment. Minority treatment information seekers and treatment initiators were less likely to go on to complete the full treatment program.

Levels of dissociation and histories of reported abuse among women outpatients

A total of 99 female patients consecutively admitted to an adult psychiatric outpatient clinic were surveyed about their history of physical and sexual abuse. Sixty-five percent of this sample reported having been physically abused, sexually abused, or both during their lifetimes. Scores on the Dissociative Experiences Scale were significantly higher among those reporting a history of sexual abuse than among those reporting a history of physical abuse or no history of abuse, who did not differ from each other. Dissociative Experiences Scale scores were important predictors of histories of sexual abuse among this sample. The implications of these findings for outpatient evaluation are discussed.

Differential Transitions between Cocaine Use and Abstinence for Men and Women.

The longitudinal course of cocaine dependence is characterized by alternating periods of abstinence and relapse. Although gender has emerged as an important predictor of relapse, previous studies have examined mean differences in use by gender. Focusing strictly on differences in averages between men and women does not address potential gender differences in transitions between use and abstinence. Transition rates for men and women were compared using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Abstinence and nonabstinence for each of the 6 months of active treatment was determined by using a composite measure of use that incorporated information from weekly and monthly self-reports and urine toxicology screenings. Random effects were introduced to describe intersubject heterogeneity in transition rates. In this sample of 454 patients, rates of transition between abstinence and use were significantly different between men and women, with men showing twice the rate of transition between states despite similar average levels of use. These data may have important implications for both treatment planning and the types of outcomes considered in clinical practice and research.

Mediators of Outcome of Psychosocial Treatments for Cocaine Dependence

This study examined endorsement of 12-step philosophy and engagement in recommended 12-step activities as a mediator of the outcomes of individual plus group counseling for cocaine dependence. Assessments of drug use outcomes and the mediator were made at baseline and monthly for 6 months. Engagement in recommended 12-step activities was found to be a partial statistical mediator of drug use outcomes of individual (plus group) drug counseling, but no evidence for change in the mediator preceding change in drug use was found. In addition, a measure of beliefs about addiction developed to test mediation of outcome of cognitive therapy was found to correlate moderately with drug use outcomes in both cognitive therapy and individual drug counseling.

THERAPIST SATISFACTION WITH FOUR MANUAL-BASED TREATMENTS ON A NATIONAL MULTISITE TRIAL: AN EXPLORATORY STUDY

Lisa M. Najavits and Roger D. Weiss, Department of Psy-chiatry, Harvard Medical School, and McLean Hospital, Bel-mont, Massachusetts; Frank Ghinassi and Michael E. Thase,Department of Psychiatry, Western Psychiatric Institute andClinic, University of Pittsburgh; Amanda Van Horn, LynneSiqueland, and Lester Luborsky, Department of Psychiatry,University of Pennsylvania Medical School; Arlene Frank,Department of Psychiatry, Brookside Hospital, Nashua, NewHampshire.Arlene Frank is now at Health Enhancement Services, Inc.,Research Division, Boca Raton, Florida, and Department ofEpidemiology & Public Health, University of Miami Schoolof Medicine.The National Institute on Drug Abuse (NIDA) Collabora-tive Cocaine Treatment Study was a NIDA-funded coopera-tive agreement involving four clinical sites, a coordinatingcenter, and NIDA staff. The coordinating center at the Uni-versity of Pennsylvania included Paul Crits-Christoph, PhD(principal investigator), Lynne Siqueland, PhD (project coor-dinator), Karla Moras, PhD (assessment unit director), JesseChittams, MA (director of data management/analysis), andLarry R. Muenz, PhD (statistician). The collaborating scien-tists at the Treatment Research Branch, Division of Clinicaland Research Services at NIDA, were Jack Blaine, MD, andLisa Simon Onken, PhD. The four participating clinical siteswere University of Pennsylvania: Lester Luborsky, PhD(principal investigator), Jacques P. Barber, PhD (co–principalinvestigator), Delinda Mercer, MA (project director); Brook-side Hospital: Arlene Frank, PhD (principal investigator), Ste-phen F. Butler (co–principal investigator), Sarah Bishop, MA(project director); Harvard Medical School, McLean Hospital,and Massachusetts General Hospital: Roger D. Weiss, MD(principal investigator), David R. Gastfriend, MD (co–principal investigator), Lisa M. Najavits, PhD (project direc-tor), and Margaret Griffin (research associate); and University ofPittsburgh, Western Psychiatric Institute and Clinic: MichaelThase, MD (principal investigator), Dennis Daley, MSW (co–principal investigator), Ishan M. Salloum, MD (co–principalinvestigator), and Judy Lis, MSN (project director). The train-ing unit heads of the Cognitive Therapy Training Unit wereAaron T. Beck, MD (University of Pennsylvania), and BruceS. Liese, PhD (University of Kansas Medical Center); headsof the Supportive–Expressive Therapy Training Unit wereLester Luborsky and David Mark, PhD (University of Penn-sylvania); heads of the Individual Drug Counseling Unit wereGeorge Woody, MD (Veterans Administration, University ofPennsylvania Medical School), and Delinda Mercer, MA(University of Pennsylvania); and heads of the Group Drug

hiv Risk Reduction in the National Institute on Drug Abuse Cocaine Collaborative Treatment Study

HIV risk was evaluated among 487 cocaine-dependent patients recruited from five treatment programs in a trial that examined the efficacy of four outpatient-based psychosocial treatments. Treatments were offered two to three times per week for 6 months and consisted of group drug counseling (GDC) or group counseling plus individual drug counseling (IDC), cognitive therapy (CT), or supportive-expressive therapy (SE). The average patient had used cocaine for 7 years, with 10 days of use in the last month. Crack smoking was the main route in 79%, and HIV risk was mainly due to multiple partners and unprotected sex. Treatment was associated with a decrease in cocaine use from an average of 10 days per month at baseline to 1 day per month at 6 months. Reduction in cocaine use was associated with an average 40% decrease in HIV risk across all treatment, gender, and ethnic groups, mainly as a result of fewer sexual partners and less unprotected sex. The combination of IDC and GDC was associated with an equal or even greater reduction in HIV risk than the other treatment conditions and thus shows promise as an effective HIV prevention strategy, at least for some patients.

Who Starts Treatment: Engagement in the NIDA Collaborative Cocaine Treatment Study

This study addressed the role of demographic variables, severity of drug dependence, and drug-related problems infacilitating or impeding engagement into a research treatment. Patients were tracked through various stages of entry for the research treatment: phone screening, intake, and randomization to treatment. Results suggested that certain demographic factors put patients more at risk for dropping out at intake and randomization. African-American and unemployed patients were less likely to stay in treatment at both stages, with largest differences at intake. Younger patients were less likely to complete both phases, with bigger differences noted at randomiZation. Patients with more days of cocaine use andpatients referred from advertisements were less likely to keep their intake appointments.

A Measure of Readiness for Substance Abuse Treatment: Psychometric Boperties of the RAATE-R Interview

The Recovery Attitude and Treatment Evaluator-Research (RAATE-R) scale is a structured interview that assesses readiness for substance abuse treatment in five subscales: resistance to treatment, resistance to continuing care, bio-medical acuity, psychological acuity, and environmental/ social problems. Psychometric properties, based on an interrater reliability analysis of 23 raters and administration of the scale to 116 cocaine-dependent outpatients, included high interrater reliability, high internal consistency, independence of subscales, and a factor structure that partially supports the scales original design. The authors discuss limitations of these conclusions and the lack of concurrent validity with a self-report measure of therapy readiness.