Jeffrey Foote

Moderators of Effects of Motivational Enhancements to Cognitive Behavioral Therapy

Patient treatment matching hypotheses were tested for substance users randomly assigned to a group cognitive behavioral therapy (CBT; n= 114) or a group motivational intervention (GMI; n= 116). Treatment was scheduled twice weekly for 10 weeks. Using a patient attribute by treatment interaction design with a 15-week follow-up, the study predicted that alexithymia, antisocial personality disorder (ASPD), and network support for alcohol and drug use would be associated with less substance use for CBT subjects and that hostility and lower treatment motivation would be associated with less substance use for GMI subjects. Three of the hypothesized moderators were empirically supported: alexithymia, network support for alcohol, and ASPD. Results indicate the use of assessing specific patient attributes to better inform treatment recommendations.

Predictors of drinking outcomes among alcoholics

Predicting outcomes for individual patients entering substance abuse treatment has long been a clinical goal in the addictions field. Intake data from the Addiction Severity Index and other standardized scales were collected on 248 alcohol dependent/abusing patients entering an urban hospital treatment program. The outcome measure was frequency of drinking days in the past 30 days. Baseline data were used to identify predictors of posttreatment drinking frequency at two follow-up interviews (3 and 12 months postbaseline). Stepwise multiple regressions indicated that a set of baseline predictors accounted for similar and substantial proportions of outcome variance at the two follow-ups. When psychosocial predictors were combined with an index of alcohol use severity (which included drinking frequency), the proportions of variance explained were 31% and 28% at 3 and 12 months, respectively. Two psychosocial predictors were significant at both time periods, and thus most likely to be replicated in future research: a treatment motivation index (a combination of measures of commitment to treatment success and internal motivation to seek treatment) and an index of 12-step (self-help) participation (a combination of measures of frequency of 12-step meeting attendance and perceived helpfulness of 12-step participation). While the predictability of short-term (3 month) outcomes could help clinicians tailor treatment strategies to maximize patient motivation and reduce drinking behavior, the predictability of longer term (12 month) outcomes could help counselors plan aftercare programs, encourage self-help participation, and promote recovery-oriented activities to sustain initial treatment-induced gains.

Patients' perspective on the process of change in substance abuse treatment

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patients view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

An enhanced positive reinforcement model for the severely impaired cocaine abuser.

This article describes a cognitive-behavioral treatment approach that has been extensively modified to work with inner-city methadone-maintained cocaine users. Modifications were deemed essential to address the problems of engagement and retention in treatment that are typically encountered with this population. While this approach relies on such basic tenets of treatment as relapse prevention, cognitive restructuring, and psychoeducation, an understanding of the particular psychological vulnerabilities of this population has been incorporated into the model. The modified approach utilizes positive reinforcement extensively. This includes use of concrete reinforcers to facilitate initial engagement, and use of interpersonal reinforcers (therapist positive regard, attention, and respect) to increase program retention and sustain posttreatment change. Preliminary results indicate that 63% of patients can complete this intensive 6-month program, with considerable reductions in cocaine use and significant change in drug injection behavior.

The Autonomy of Mood Disorders Among Cocaine-Using Methadone Patients

This study uses an algorithm to determine whether patients dually diagnosed with a mood disorder and cocaine dependence have either (a) an autonomous mood disorder (onset of mood disorder prior to substance use disorder (SUD) or mood disorder symptoms persist during periods of abstinence or (b) a nonautonomous mood disorder (onset of SUD preceded mood disorder and mood disorder symptoms remit during periods of abstinence). The relationship among autonomy, patient characteristics, and treatment completion is examined. The sample included 67 methadone patients with a mood disorder (87% major depression, 13% bipolar) who were enrolling in a 6-month psychosocial treatment for cocaine use. Of these subjects, 27% were rated as having an autonomous mood disorder and 73% a nonautonomous mood disorder. Mean age was 37 years; 55% were female and 82% were Hispanic or African-American. All subjects had been stabilized on methadone (mean = 70 mg). During the 30 days prior to study intake, subjects with an autonomous mood disorder, compared to subjects with a nonautonomous mood disorder, reported fewer days using cocaine (12.5 versus 21.1) and fewer days drinking four or more drinks of alcohol (1.1 versus 6. 1). Treatment completion was associated with less cocaine use, autonomy, and African-American ethnicity. However, when these variables were controlled using logistic regression, only autonomous mood disorder and ethnicity predicted treatment completion. These results suggest that autonomy may be a useful construct to measure, and that subjects with nonautonomous mood disorders may need special efforts to ensure treatment retention.

The Combined Effects of Treatment Intensity, Self-Help Groups and Patient Attributes on Drinking Outcomes

Abstract Better understanding of the diverse factors that predict alcoholism treatment outcomes is essential to improving treatment strategies. Patients accepted for treatment at a multimodality program were interviewed and followed-up at three months and one year after admission. The study tested a set of hypotheses relating to the effects on drinking outcomes of treatment modality, modality matching, treatment retention, aftercare, self-help group participation and patient attributes at admission. Drinking frequency diminished substantially between baseline and the two follow-ups. Outcomes for inpatient were better than for outpatient treatment in bivariate analysis, but outcomes for these modalities were equal after adjusting for the effect of patient-treatment mismatching. Aftercare treatment, time in treatment for outpatients, community 12-Step group participation, and several patient attributes such as motivation for change and psychiatric severity significantly predicted drinking outcomes at one or both follow-ups. Clinical implications of the results are discussed.

Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients

Significant proportions of opiate-dependent persons entering methadone treatment are also addicted to cocaine and continue to use cocaine during treatment. One standard response to cocaine use has been inpatient detoxification. This study examined the effectiveness of this procedure by comparing pre- and posttreatment urine toxicologies for methadone patients who had been hospitalized for cocaine withdrawal. The results showed a negligible effect on cocaine abstinence (less than 1 out of 10 patients abstinent 12 weeks after detox) and a modest reduction in the frequency of cocaine use (one-quarter decline in urine tests positive after 12 weeks). These findings raise serious doubts about the cost-effectiveness of inpatient cocaine detoxification. Better strategies need to be implemented to enhance the chances of remaining abstinent once detoxified.

Video Techniques with Chemically-Dependent Patients

This paper describes the use of videotaping as an adjunctive intervention in the treatment of substance-dependent patients. In the context of a cognitive-behavioral treatment extensively modified to work with inner-city, methadone-maintained cocaine users, videotaping in both individual and group formats is described. Video sessions create an opportunity for patients to reflect on their experience, enhance their self-esteem, aid in teaching social skills, and help hard-to-engage patients begin to participate in treatment. In order to compete with both the powerfully reinforcing qualities of cocaine and the extreme degree of avoidance exhibited by this population, therapy has to provide intense capturing experiences at the outset of treatment. Patients reactions indicate that the experience they have is captivating and stimulating more than most other early therapy experiences. It is additionally concluded that the use of video can be instrumental in addressing the severe psychological deficits of this population that otherwise impede treatment efforts. While the role of video was not independently evaluated for its contribution to patient retention, 62% of patients were retained through completion of an intensive 6-month protocol.