Steve Martino

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.

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.

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.

Motivational Interviewing with Psychiatrically Ill Substance Abusing Patients

This pilot study reports the relative efficacy of a one-session preadmission motivational interview (n = 13) compared to a standard preadmission interview (n = 10) for psychiatrically ill substance abusing patients in a partial hospital program.

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.

Development of the drug abuse screening test for adolescents (DAST-A).

The development and initial validation of the Drug Abuse Screening Test for Adolescents (DAST-A) is summarized. The DAST-A, derived from a modification of the original adult version called the Drug Abuse Screening Test (DAST: Skinner, 1982), was psychometrically tested in a study group of adolescent inpatients. The DAST-A demonstrated good internal consistency, high test-retest reliability, unidimensional factor structure, and good concurrent validity. Using the classification system of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1994), DAST-A scores of greater than 6 yielded sensitivity, specificity, and positive predictive powers of 78.6%, 84.5%, and 82.3%, respectively, in differentiating adolescent psychiatric inpatients with and without drug-related disorders. These findings suggest that the DAST-A holds promise as a drug abuse screening measure in psychiatrically impaired adolescent populations.

Implementing rapid HIV testing with or without risk-reduction counseling in drug treatment centers: Results of a randomized trial

OBJECTIVES We examined the effectiveness of risk reduction counseling and the role of on-site HIV testing in drug treatment. METHODS Between January and May 2009, we randomized 1281 HIV-negative (or status unknown) adults who reported no past-year HIV testing to (1) referral for off-site HIV testing, (2) HIV risk-reduction counseling with on-site rapid HIV testing, or (3) verbal information about testing only with on-site rapid HIV testing. RESULTS We defined 2 primary self-reported outcomes a priori: receipt of HIV test results and unprotected anal or vaginal intercourse episodes at 6-month follow-up. The combined on-site rapid testing participants received more HIV test results than off-site testing referral participants (P<.001; Mantel-Haenszel risk ratio=4.52; 97.5% confidence interval [CI]=3.57, 5.72). At 6 months, there were no significant differences in unprotected intercourse episodes between the combined on-site testing arms and the referral arm (P=.39; incidence rate ratio [IRR]=1.04; 97.5% CI=0.95, 1.14) or the 2 on-site testing arms (P=.81; IRR=1.03; 97.5% CI=0.84, 1.26). CONCLUSIONS This study demonstrated on-site rapid HIV testings value in drug treatment centers and found no additional benefit from HIV sexual risk-reduction counseling.

Correspondence of motivational enhancement treatment integrity ratings among therapists, supervisors, and observers

Abstract This study examined the correspondence of treatment integrity ratings (adherence and competence) among community program therapists, supervisors, and observers for therapists who used motivational enhancement therapy (MET) within a National Institute on Drug Abuse Clinical Trials Network protocol. The results suggested there was reasonable agreement between the three groups of raters about the presence or absence of several fundamental MET strategies. Moreover, relative to observers, therapists and supervisors were more positive in their evaluations of the therapists’ MET adherence and competence. These findings underscore the need for objective monitoring of therapists’ performance when using empirically supported treatments and for adequately training therapists and supervisors to evaluate their treatment implementation in community programs, and are consistent with observations that different perspectives on the therapeutic process are not interchangeable.

A multisite randomized effectiveness trial of motivational enhancement therapy for Spanish-speaking substance users.

Hispanic individuals are underrepresented in clinical and research populations and are often excluded from clinical trials in the United States. Hence, there are few data on the effectiveness of most empirically validated therapies for Hispanic substance users. The authors conducted a multisite randomized trial comparing the effectiveness of 3 individual sessions of motivational enhancement therapy with that of 3 individual sessions of counseling as usual on treatment retention and frequency of substance use; all assessment and treatment sessions were conducted in Spanish among 405 individuals seeking treatment for any type of current substance use. Treatment exposure was good, with 66% of participants completing all 3 protocol sessions. Although both interventions resulted in reductions in substance use during the 4-week therapy phase, there were no significant Treatment Condition x Time interactions nor Site x Treatment Condition interactions. Results suggest that the individual treatments delivered in Spanish were both attractive to and effective with this heterogeneous group of Hispanic adults, but the differential effectiveness of motivational enhancement therapy may be limited to those whose primary substance use problem is alcohol and may be fairly modest in magnitude.

Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders

Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmation, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.