Jon Morgenstern

Affiliation With Alcoholics Anonymous After Treatment: A Study of Its Therapeutic Effects and Mechanisms of Action

Relatively little is known about how substance abuse treatment facilitates positive outcomes. This study examined the therapeutic effects and mechanisms of action of affiliation with Alcoholics Anonymous (AA) after treatment. Patients (N = 100) in intensive 12-step substance abuse treatment were assessed during treatment and at 1- and 6-month follow-ups. Results indicated that increased affiliation with AA predicted better outcomes. The effects of AA affiliation were mediated by a set of common change factors. Affiliation with AA after treatment was related to maintenance of self-efficacy and motivation, as well as to increased active coping efforts. These processes, in turn, were significant predictors of outcome. Findings help to illustrate the value of embedding a test of explanatory models in an evaluation study.

Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy

This expert consensus statement reviews evidence on the effectiveness of drug and alcohol self-help groups and presents potential implications for clinicians, treatment program managers and policymakers. Because longitudinal studies associate self-help group involvement with reduced substance use, improved psychosocial functioning, and lessened health care costs, there are humane and practical reasons to develop self-help group supportive policies. Policies described here that could be implemented by clinicians and program managers include making greater use of empirically-validated self-help group referral methods in both specialty and non-specialty treatment settings and developing a menu of locally available self-help group options that are responsive to clients needs, preferences, and cultural background. The workgroup also offered possible self-help supportive policy options (e.g., supporting self-help clearinghouses) for state and federal decision makers. Implementing such policies could strengthen alcohol and drug self-help organizations, and thereby enhance the national response to the serious public health problem of substance abuse.

The comorbidity of alcoholism and personality disorders in a clinical population: prevalence rates and relation to alcohol typology variables.

This study assessed prevalence rates and overlap among Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised; DSM-III-R; American Psychiatric Association, 1987) personality disorders in a multisite sample of 366 substance abusers in treatment. In addition, the relation of antisocial personality disorder (APD), borderline personality disorder (BPD), and paranoid personality disorder (PPD) to alcohol typology variables was examined. Structured diagnostic interviews and other measures were administered to participants at least 14 days after entry into treatment. Results indicated high prevalence rates for APD and non-APD disorders. There was extensive overlap between Axis I disorders and personality disorders, and among personality disorders themselves. APD, BPD, and PPD were linked to more severe symptomatology of alcoholism and other clinical problems. However, only APD and BPD satisfied subtyping criteria, after controlling for other comorbidity. Implications for classifying alcoholics by comorbid disorders are discussed.

Manual-guided cognitive-behavioral therapy training: A promising method for disseminating empirically supported substance abuse treatments to the practice community

A gap exists between empirically supported substance abuse treatments and those used in community settings. This study examined the feasibility of training substance abuse counselors to deliver cognitive-behavioral treatment (CBT) using treatment manuals. Participants were 29 counselors. Counselors were randomly assigned to receive CBT training or to a control group. Counselor attitudes were assessed pre- and posttraining. In addition, CBT therapy sessions were videotaped and rated for adherence and skillfulness. CBT counselors reported high levels of satisfaction with the training, intention to use CBT interventions, and confidence in their ability to do so. Ratings indicated that 90% of counselors were judged as having attained at least adequate levels of CBT skillfulness. Findings demonstrate the feasibility of using psychotherapy technology tools as a means of disseminating science-based treatments to the substance abuse practice community.

Active ingredients: how and why evidence-based alcohol behavioral treatment interventions work.

This article summarizes the proceedings of a symposium that was organized and chaired by Richard Longabaugh and presented at the 2004 Research Society on Alcoholism meeting in Vancouver, British Columbia, Canada. The aim of the presentation was to focus on evidence for the active ingredients of behavioral therapies for patients with alcohol use disorders. Dennis M. Donovan, PhD, reviewed evidence for the active ingredients of cognitive behavioral therapy. Barbara S. McCrady, PhD, presented a conceptual model for mechanisms of change in alcohol behavior couples therapy and reviewed evidence for this model. J. Scott Tonigan, PhD, presented data testing three hypothesized mechanisms of change in twelve-step facilitation treatment. Mitchell P. Karno, PhD, presented therapy process data that tested whether matching therapist behaviors to client attribute across three therapies affected drinking outcomes. Jon Morgenstern served as discussant.

Assessing consequences of substance use: psychometric properties of the inventory of drug use consequences.

Negative consequences are an important component of the substance use change process, yet no standardized measure exists to assess consequences of use. This study evaluated the psychometric properties of the Inventory of Drug Use Consequences, a self-report measure assessing drinking and drug use consequences. Participants (N=252) were assessed at entry into outpatient substance abuse treatment. Items loaded strongly on 1 factor, and internal consistency of the total scale was high. Fifteen items with the highest correlations with the total scale were chosen to represent the construct. The shortened measure exhibited good internal consistency, convergent and discriminant validity, and detected change over time and may be the measure of substance use consequences that is lacking in the field.

Alcohol and Sexual HIV Risk Behavior Among Problem Drinking Men Who Have Sex With Men: An Event Level Analysis of Timeline Followback Data

While heavy drinking among men who have sex with men (MSM) has been shown to be associated with an increase in sexual risk taking, a temporal relationship between drinking and an increase in subsequent HIV risk behaviors among adult samples has been less obvious. This study used an event level analysis to examine this relationship among HIV negative problem drinking MSM. Within subjects analyses show a higher probability of unprotected anal intercourse after drinking. Post-hoc analyses of within subjects data indicate that drinking increases risk taking when engaging in receptive anal intercourse but not for insertive anal intercourse. Findings from this study support evidence that drinking is a factor that increases risk taking among HIV negative problem drinking MSM, particularly for receptive anal intercourse.

Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: within treatment and posttreatment findings.

This study evaluated the short-term effectiveness of cognitive-behavioral treatment (CBT) for substance abuse delivered in a community setting. At entry into outpatient community substance abuse treatment, participants (N = 252) were randomly assigned to 3 conditions: high-standardization CBT, low-standardization CBT, and treatment as usual. Treatment consisted of 12 weekly individual therapy sessions. There was a significant decrease in substance use from baseline, with participants reporting being abstinent on 90% of within-treatment days and 85% of days during the 6 months posttreatment. However, there were no significant differences in outcomes across conditions. Findings do not support the hypothesis that disseminating CBT to community settings will improve outcomes and suggest that standard substance abuse counseling may be more effective than previously thought.

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men.

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed.

MET meets the real world: design issues and clinical strategies in the Clinical Trials Network

The Clinical Trials Network (CTN) represents a major initiative intended to bridge the gap between research and practice in substance abuse treatment by implementing a range of studies evaluating behavioral, pharmacologic, and combined treatments in community-based drug abuse treatment programs across the country. This article describes the development of CTN protocols evaluating the effectiveness of Motivational Enhancement Therapy and Motivational Interviewing. Design, training, and implementation challenges associated with conducting a clinical trial of brief behavioral treatments in community programs are discussed. Issues requiring attention included the diversity in treatments offered across sites, heterogeneity in the study sample, and training of clinicians drawn from the staff of community programs to deliver the study treatments.