Samuel A. Ball

Computer-Assisted Delivery of Cognitive-Behavioral Therapy for Addiction: A Randomized Trial of CBT4CBT

OBJECTIVES This study evaluated the efficacy of a computer-based version of cognitive-behavioral therapy (CBT) for substance dependence. METHOD This was a randomized clinical trial in which 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomly assigned to standard treatment or standard treatment with biweekly access to computer-based training in CBT (CBT4CBT) skills. RESULTS Treatment retention and data availability were comparable across the treatment conditions. Participants assigned to the CBT4CBT condition submitted significantly more urine specimens that were negative for any type of drugs and tended to have longer continuous periods of abstinence during treatment. The CBT4CBT program was positively evaluated by participants. In the CBT4CBT condition, outcome was more strongly associated with treatment engagement than in treatment as usual; furthermore, completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of treatment involvement. CONCLUSIONS These data suggest that CBT4CBT is an effective adjunct to standard outpatient treatment for substance dependence and may provide an important means of making CBT, an empirically validated treatment, more broadly available.

Comorbid psychopathology in binge Eating disorder : Relation to Eating Disorder severity at baseline and following treatment

Individuals with binge eating disorder (BED) have high rates of comorbid psychopathology, yet little is known about the relation of comorbidity to eating disorder features or response to treatment. These issues were examined among 162 BED patients participating in a psychotherapy trial. Axis I psychopathology was not significantly related to baseline eating disorder severity, as measured by the Structured Clinical Interview for DSM-III-R (SCID-I and SCID-II) and the Eating Disorder Examination. However, presence of Axis II psychopathology was significantly related to more severe binge eating and eating disorder psychopathology at baseline. Although overall presence of Axis II psychopathology did not predict treatment outcome, presence of Cluster B personality disorders predicted significantly higher levels of binge eating at 1 year following treatment. Results suggest the need to consider Cluster B disorders when designing treatments for BED.

Personality, temperament, and character dimensions and the DSM-IV personality disorders in substance abusers.

The authors evaluated the relationship between P. T. Costa and R. R. McCraes (1992) NEO 5-factor model, C. R. Cloningers (1993) 7-factor Temperament and Character Inventory (TCI), and the American Psychiatric Associations (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th ed., personality disorders in 370 inpatient and outpatient alcohol, cocaine, and opiate abusers. NEO Neuroticism was associated with many disorders, and different patterns for Agreeableness, Conscientiousness, and Extraversion emerged for the different disorders. Several TCI scales were associated with different personality disorders, although not as strongly as the NEO dimensions. Results did not support most predictions made for the TCI. Normal personality dimensions contributed significantly to the prediction of personality disorder severity above and beyond substance abuse and depression symptoms.

Site Matters: Multisite Randomized Trial of Motivational Enhancement Therapy in Community Drug Abuse Clinics

The effectiveness of motivational enhancement therapy (MET) in comparison with counseling as usual (CAU) for increasing retention and reducing substance use was evaluated in a multisite randomized clinical trial. Participants were 461 outpatients treated by 31 therapists within 1 of 5 outpatient substance abuse programs. There were no retention differences between the 2 brief intervention conditions. Although both 3-session interventions resulted in reductions in substance use during the 4-week therapy phase, MET resulted in sustained reductions during the subsequent 12 weeks whereas CAU was associated with significant increases in substance use over this follow-up period. This finding was complicated by program site main effects and higher level interactions. MET resulted in more sustained substance use reductions than CAU among primary alcohol users, but no difference was found for primary drug users. An independent evaluation of session audiotapes indicated that MET and CAU were highly and comparably discriminable across sites.

PERSONALITY, SUBSTANCE OF CHOICE, AND POLYSUBSTANCE INVOLVEMENT AMONG SUBSTANCE DEPENDENT PATIENTS

The authors compared the association of several personality traits, drug of choice, and polysubstance involvement in 325 individuals (44% male) receiving treatment for substance dependence on heroin, cocaine, and/or alcohol. Measures included the Structured Clinical Interview for DSM-III-R, the MacAndrew Alcoholism Scale (MAC), the socialization scale of the California Psychological Inventory (CPI-Soc), the novelty seeking dimension of the Temperament and Character Inventory (TCI-NS), and the conscientiousness domain of the NEO Five-Factor Inventory (NEO-C). Analyses adjusted for demographic covariates, affective and antisocial personality disorder, and substance dependence severity. Although scant evidence supported the hypothesis that these personality traits were associated with substance choice, CPI-Soc and MAC were associated linearly with the extent of polysubstance involvement. Also, patients who were dependent on two or more substances displayed higher levels of TCI-NS, CPI-Soc, and MAC. Findings implicate an association between behavioral disinhibition and a continuum of addiction defined primarily in terms of polysubstance involvement.

Community program therapist adherence and competence in motivational enhancement therapy

The extent to which clinicians in addiction treatment programs can implement empirically validated therapies with adequate fidelity that can be discriminated from standard counseling has rarely been evaluated. We evaluated the treatment adherence and competence of 35 therapists from five outpatient community programs who delivered either a three-session adaptation of motivational enhancement therapy (MET) or an equivalent number of drug counseling-as-usual sessions to 461 clients within a National Institute on Drug Abuse Clinical Trial Network multi-site effectiveness protocol. MET therapists were carefully prepared to implement MET using a combination of expert-led intensive workshop training followed by program-based clinical supervision. Independent rating of sessions demonstrated that the adherence and competence items were very reliable (mean interclass correlation coefficients for adherence=.89 and competence=.81) and converged to form two a priori defined skill factors conceptually related to motivational interviewing. Moreover, the factors discriminated between MET therapists and those who delivered drug counseling-as-usual sessions in predicted ways, and were significantly related to in-session change in client motivation and some client treatment outcomes (percent negative drug urine screens). These findings demonstrate the reliability and validity of evaluating motivational interviewing fidelity and suggest that the combination of expert-led workshops followed by program-based clinical supervision may be an effective method for disseminating motivational interviewing in community treatment programs.

Manualized treatment for substance abusers with personality disorders: Dual focus schema therapy☆

The presence of an untreated personality disorder may be associated with worse compliance and outcome in substance abuse treatment. Therapeutic attention to the symptoms of personality disorder may reduce the severity of substance abuse and other Axis I symptoms which potentially contribute to relapse. A 24-week manual-guided individual cognitive-behavioral therapy approach has been developed that integrates relapse prevention with targeted intervention for early maladaptive schemas (enduring negative beliefs about oneself, others, and events) and coping styles. This Dual Focus Schema Therapy is being compared to 12-Step Drug Counseling for opioid-dependent individuals with personality disorders in an ongoing study funded by the National Institute on Drug Abuse. This article reviews Youngs (1994) schema-focused theory and approach and summarizes the treatment manual, which integrates relapse prevention for substance abuse.

Subtypes of Cocaine Abusers: Support for a Type A-Type B Distinction.

The replicability and generalizability of a multidimensional alcoholism typological system was systematically assessed in 399 inpatient, outpatient, and non-treatment-seeking cocaine abusers. Two different cluster-analytic procedures supported the construct, concurrent, and predictive validity of the Type A-Type B distinction in cocaine abusers. Participants classified as Type B (33%) cocaine abusers exhibited higher rates of premorbid risk factors (family history, childhood behavior problems, personality, age of onset), more severe drug and alcohol abuse, more addiction-related psychosocial impairment, more antisocial behavior, and more comorbid psychiatric problems than Type A participants (67%). Multidimensional typological systems have had a major impact on the alcoholism field and may be equally important for the assessment, prevention, treatment, and theoretical understanding of other substance use disorders.

Characteristics, beliefs, and practices of community clinicians trained to provide manual-guided therapy for substance abusers

The successful dissemination of empirically supported addiction therapies to community providers requires an appreciation of the characteristics of those practitioners who might be willing participants in this process of technology transfer. Clinicians (N = 66) from 11 community treatment programs associated with six research-clinic partnerships of the National Drug Abuse Clinical Trials Network volunteered to be trained in Motivational Interviewing or Motivational Enhancement Therapy (MET/MI) and were assessed prior to training. The sample of clinicians was heterogeneous in education and credentials, had a high level of counseling experience, reported using a wide range of counseling techniques and orientations, but had limited prior exposure to MET/MI or to the use of treatment manuals of empirically supported therapies. In general, many of the clinicians reported beliefs and techniques that were consistent with their stated theoretical orientation and recovery status. Relatively few participants reported relying on one dominant orientation or set of techniques.

Enduring effects of a computer-assisted training program for cognitive behavioral therapy: A 6-month follow-up of CBT4CBT ☆ ☆☆

OBJECTIVES To evaluate the durability of effects of a computer-assisted version of cognitive behavioral therapy (CBT) as treatment for substance dependence through a 6-month follow-up. METHODS Following a randomized clinical trial in which 73 individuals seeking outpatient treatment for substance dependence in an outpatient community setting were randomized to either standard treatment-as-usual (TAU) or TAU with 8 weeks of biweekly access to computer-based training for CBT (CBT4CBT), participants were interviewed 1, 3, and 6 months after the termination of study treatments. RESULTS Sixty of the 73 participants were reached for follow-up (82%); follow-up rates and availability of data were comparable across treatment conditions. Random regression analyses of use across time indicated significant differences between groups, such that those assigned to TAU increased their drug use across time while those assigned to CBT4CBT tended to improve slightly. The durability of the CBT4CBT effect remained even after controlling for treatment retention, treatment substance use outcomes, and exposure to other treatment during the follow-up period. CONCLUSIONS Computerized CBT4CBT appears to have both short-term and enduring effects on drug use.