Lester Luborsky

An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index.

The Addiction Severity Index (ASI) is a structured clinical interview developed to fill the need for a reliable, valid, and standardized diagnostic and evaluative instrument in the field of alcohol and drug abuse. The ASI may be administered by a technician in 20 to 30 minutes producing 10-point problem severity ratings in each of six areas commonly affected by addiction. Analyses of these problem severity ratings on 524 male veteran alcoholics and drug addicts showed them to be highly reliable and valid. Correlational analyses using the severity ratings indicated considerable independence between the problem areas, suggesting that the treatment problems of patients are not necessarily related to the severity of their chemical abuse. Cluster analyses using these ratings revealed the presence of six subgroups having distinctly different patterns of treatment problems. The authors suggest the use of the ASI to match patients with treatments and to promote greater comparability of research findings.

Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: role of treatment services.

This study examined the patient and treatment factors associated with 6-month outcome in 649 opiate-, alcohol-, and cocaine-dependent (male and female) adults, treated in inpatient and outpatient settings, in 22 publicly and privately funded programs. Outcomes were predicted by similar factors, regardless of the drug problem of the patient or the type of treatment setting or funding. Greater substance use at follow-up was predicted only by greater severity of alcohol and drug use at treatment admission, not by the number of services received during treatment. Better social adjustment at follow-up was negatively predicted by more severe psychiatric, employment, and family problems at admission and positively predicted by more psychiatric, family, employment, and medical services provided during treatment.

Meta‐Analysis of Therapist Effects in Psychotherapy Outcome Studies

In a meta-analysis, we examined factors that could account for the differences in therapist efficacy evidenced in psychotherapy outcome studies. The factors investigated were: (1) the use of a treatment manual, (2) the average level of therapist experience, (3) the length of treatment, and (4) the type of treatment (cognitive/behavioral versus psychodynamic). Data were obtained from fifteen psychotherapy outcome studies that produced 27 separate treatment groups. For each treatment group, the amount of outcome variance due to differences between therapists was calculated and served as the dependent variable for the meta-analysis. Each separate treatment group was coded on the above four variables, and multiple regression analyses related the independent variables to the size of therapist effects. Results indicated that the use of a treatment manual and more experienced therapists were associated with small differences between therapists, whereas more inexperienced therapists and no treatment manual were a...

Increased effectiveness of substance abuse treatment. A prospective study of patient-treatment "matching".

An earlier study retrospectively evaluated the effectiveness of six separate substance abuse treatment programs and generated a set of hypotheses for matching patients to the most appropriate programs. In the present study, these predictors and the matching strategy were tested in a prospective design, using the same treatment programs and a new sample of 130 alcohol-and 256 drug-dependent patients. The new group of patients who were treated in their predicted program (matched patients) were compared with those patients from the same sample who were not treated in their predicted program (mismatched patients). Treatment staff were not apprised of the matching criteria or which patients were matched, thus permitting an experimental test of the predictions. Results indicated superior performance during treatment and an average of 19 per cent better 6-month outcomes for the matched patients than for their mismatched counterparts. The matching effect was seen in both the alcohol-and drug-dependent samples and in all treatment programs. The authors discuss the application of these findings to other types of patients and treatments in substance abuse and other fields of psychiatry.

Two helping alliance methods for predicting outcomes of psychotherapy: a counting signs Vs. a global rating method

This paper reports on the development of measures of helping alliances in psychotherapy, i.e., the patients experience of the treatment or relationship with the therapist as helpful, or potentially helpful. The helping alliance counting signs measure, which is the special focus of this paper, entails the counting of certain types of patient statements (signs) which are identified in a manual. The main findings were: a) these types of statements were found to be “scorable” with moderate interjudge agreement; b) scores based on the manual showed moderate agreement with a similar helping alliance manual based upon global ratings; c) scores were fairly to moderately consistent from early to late in treatment; d) scores predicted outcome significantly, e.g., early positive signs of helping alliance correlated .57 (p < .01) with rated benefits, and .59 (p < .01) with change in the first target complaint (Battle, C., Imber, S., Hoehn-Saric, R., et al. Target complaints as criteria of improvement. Am. J. Psychother., 20:184–192, 1966); and e) basic background similarities between patient and therapist, such as in age and religious activity, attained highest correlations with the helping alliance measure, e.g., the sum of 10 similarities correlated .60 (p < .01) with early positive helping alliance counting signs.

The use of psychotherapy treatment manuals: A small revolution in psychotherapy research style☆

Abstract In the space of just the last few years it has become a virtual research requirement to incorporate manuals in comparative psychotherapy studies. Such manuals serve to guide the training of the therapists and then the measurement of their conformity to the intended treatments. A short history of this small revolution is provided. It is followed by a review of the findings of comparative treatment studies which were manual guided versus nonmanual guided. While many of the expected differences among conceptually different treatments appear with both approaches, with manual guided studies it tends to be easier to do exact comparisons. A study comparing manual guided versus nonmanual guided treatments should be the logical next step.

Measuring a Pervasive Psychic Structure in Psychotherapy: The Core Conflictual Relationship Theme

I’ll first tell the story of the preparation for tracking a whale-sized theme, “the core conflictual relationship theme,” and then tell its method. The idea surfaced recently after a long search for the curative factors in psychotherapy (Luborsky, in press). It took shape as part of the perspective gained after seeing the consistent results of the three largest multivariate predictive psychotherapy studies: the Chicago Counseling Center Project (Fiske, Cartwright & Kirtner, 1964), the Mitchell et al. Arkansas Project (1973), and the Penn Psychotherapy Project (Luborsky et al., in progress).

Do therapists vary much in their success? Findings from four outcome studies

Success rates of psychotherapists were compared across each of four treatment outcome studies, with results indicating: considerable difference between therapists in their average success rates; considerable variability in outcome within the caseload of individual therapists; little support for the widely held view that certain therapists are best for certain kinds of patients; and variations in success rate typically have more to do with the therapist than with the type of treatment.

Is the Counselor an ???Active Ingredient??? in Substance Abuse Rehabilitation?: An Examination of Treatment Success among Four Counselors

The impact of the counselor in substance abuse rehabilitation has been questioned. The unexpected resignations of two counselors provided a natural opportunity to examine the effects of counselor assignment in a methadone maintenance treatment program with the effects of the medication philosophy, program rules, and supplementary services held constant. Sixty-one patients who had been assigned to these two counselors were assigned to four other counselors in a virtually random manner. It was reasoned that if the new counselor had relatively little impact, then there would be little difference in performance from pre to posttransfer or among the four caseloads during the 6-month period following the transfer. Performance measures included urinalysis results, methadone dosage, prescriptions for psychotropic medications, employment, and arrest rates. Results indicated statistically significant and clinically meaningful differences in the posttransfer performance of the four caseloads. One counselor significantly reduced the average methadone dose of his/her caseload as well as the number of patients prescribed ancillary medications, while concurrently reducing positive urine tests, unemployment and arrests. In contrast, another counselor significantly increased the average methadone dose in his/ her caseload but still showed increases in positive urine tests and unemployment. As has been found in prior studies, background and formal education differences among the counselors were not related to the observed performance differences. However, differences in the content and process of counseling among the counselors were associated with the differences in patient outcome. These process differences are discussed in relation to earlier studies of professional psychotherapy.

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.