Suzanne E. Decker

Toward empirical identification of a clinically meaningful indicator of treatment outcome: features of candidate indicators and evaluation of sensitivity to treatment effects and relationship to one year follow up cocaine use outcomes.

BACKGROUND Selection of an appropriate indictor of treatment response in clinical trials is complex, particularly for the various illicit drugs of abuse. Most widely used indicators have been selected based on expert group recommendation or convention rather than systematic empirical evaluation. Absence of an evidence-based, clinically meaningful index of treatment outcome hinders cross-study evaluations necessary for progress in addiction treatment science. METHOD Fifteen candidate indicators used in multiple clinical trials as well as some proposed recently are identified and discussed in terms of relative strengths and weaknesses (practicality, cost, verifiability, sensitivity to missing data). Using pooled data from five randomized controlled trials of cocaine dependence (N=434), the indicators were compared in terms of sensitivity to the effects of treatment and relationship to cocaine use and general functioning during follow-up. RESULTS Commonly used outcome measures (percent negative urine screens; percent days of abstinence) performed relatively well in that they were sensitive to the effects of the therapies evaluated. Others, including complete abstinence and reduction in frequency of use, were less sensitive to effects of specific therapies and were very weakly related to cocaine use or functioning during follow-up. Indicators more strongly related to cocaine use during follow-up were those that reflected achievement of sustained periods of abstinence, particularly at the end of treatment. CONCLUSIONS These analyses did not demonstrate overwhelming superiority of any single indicator, but did identify several that performed particularly poorly. Candidates for elimination included retention, complete abstinence, and indicators of reduced frequency of cocaine use.

Therapist Training in Empirically Supported Treatments: A Review of Evaluation Methods for Short- and Long-Term Outcomes

Therapist training efforts have been assessed using several outcomes. A model for evaluating therapist training in empirically supported treatments is presented, adapted from Kirkpatrick’s (in: Craig and Bittel (eds.) Training and development handbook, 1967) training evaluation model. The adapted framework includes short-term outcomes, such as reactions to training and changes in attitude, knowledge, or skills, and longer-term outcomes, such as changes in therapist behavior in practice or client outcomes. Evaluation methods for these outcomes are reviewed, with information on their validity, reliability, and feasibility. An agenda for further research to improve therapist training evaluation is presented, with discussion of how evaluation can inform other areas of the field.

Military Sexual Assault and Homeless Women Veterans: Clinical Correlates and Treatment Preferences

BACKGROUND Both homeless women and women who have experienced military sexual assault (MSA) are at high risk of serious psychological sequelae. However, little is known about the combined impact of MSA and current homelessness on psychological distress, or about distinctive treatment preferences among homeless female veterans affected by MSA. METHODS This observational study compared clinical symptoms, pre-military experiences, and treatment preferences among 509 female veterans with and without MSA who enrolled in 11 VA Homeless Women Veterans Programs. RESULTS Over one third of participants (41.1%) reported MSA. In multivariate analyses, homeless female veterans who reported MSA endorsed greater severity of PTSD and other psychiatric symptoms. Those who had experienced MSA were more likely to report interest in treatment, and treatment focused on safety was reported as especially attractive. CONCLUSIONS Among homeless female veterans, MSA is associated with greater mental health symptoms and greater interest in safety-focused treatment. Services targeting the needs of homeless MSA survivors should be encouraged.

Development of the Therapist Empathy Scale.

BACKGROUND Few measures exist to examine therapist empathy as it occurs in session. AIMS A 9-item observer rating scale, called the Therapist Empathy Scale (TES), was developed based on Watsons (1999) work to assess affective, cognitive, attitudinal, and attunement aspects of therapist empathy. The aim of this study was to evaluate the inter-rater reliability, internal consistency, and construct and criterion validity of the TES. METHOD Raters evaluated therapist empathy in 315 client sessions conducted by 91 therapists, using data from a multi-site therapist training trial (Martino et al., 2010) in Motivational Interviewing (MI). RESULTS Inter-rater reliability (ICC = .87 to .91) and internal consistency (Cronbachs alpha = .94) were high. Confirmatory factor analyses indicated some support for single-factor fit. Convergent validity was supported by correlations between TES scores and MI fundamental adherence (r range .50 to .67) and competence scores (r range .56 to .69). Discriminant validity was indicated by negative or nonsignificant correlations between TES and MI-inconsistent behavior (r range .05 to -.33). CONCLUSIONS The TES demonstrates excellent inter-rater reliability and internal consistency. RESULTS indicate some support for a single-factor solution and convergent and discriminant validity. Future studies should examine the use of the TES to evaluate therapist empathy in different psychotherapy approaches and to determine the impact of therapist empathy on client outcome.

Correspondence of Motivational Interviewing Adherence and Competence Ratings in Real and Role-Played Client Sessions

Treatment integrity ratings (adherence and competence) are frequently used as outcome measures in clinician training studies, drawn from recorded real client or role-played client sessions. However, it is unknown whether clinician adherence and competence are similar in real client and role-played sessions or whether real and role-play clients provide similar opportunities for skill demonstration. In this study, we examined the correspondence of treatment adherence and competence ratings obtained in real client and role-played sessions for 91 clinicians trained in motivational interviewing (MI), using data from a multisite trial examining 3 methods of clinician training (Martino et al., 2011). Results indicated overall poor integrity rating correspondence across the 2 session types, as indicated by weak correlations (rs=.05-.27). Clinicians were rated significantly more MI adherent overall and specifically used more advanced MI strategies in role-played than real client sessions at several assessment time points (ds=0.36, 0.42). Real clients, in comparison to the role-play actor, demonstrated greater motivation at the beginning of the session (d=1.09), discussion of unrelated topics (d=0.70), and alliance with the clinician (d=0.72). These findings suggest that MI integrity rating data obtained from real client and role-played sessions may not be interchangeable. More research is needed to improve the procedures and psychometric strength of treatment integrity assessment based on role-played sessions.

Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001–2014

OBJECTIVES To evaluate gender, age, and race/ethnicity as predictors of incident mental health diagnoses among Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans. METHODS We used US Veterans Health Administration (VHA) electronic health records from 2001 to 2014 to examine incidence rates and sociodemographic risk factors for mental health diagnoses among 888 142 veterans. RESULTS Posttraumatic stress disorder (PTSD) was the most frequently diagnosed mental health condition across gender and age groups. Incidence rates for all mental health diagnoses were highest at ages 18 to 29 years and declined thereafter, with the exceptions of major depressive disorder (MDD) in both genders, and PTSD among women. Risk of incident bipolar disorder and MDD diagnoses were greater among women; risk of incident schizophrenia, and alcohol- and drug-use disorders diagnoses were greater in men. Compared with Whites, risk incident PTSD, MDD, and alcohol-use disorder diagnoses were lower at ages 18 to 29 years and higher at ages 45 to 64 years for both Hispanics and African Americans. CONCLUSIONS Differentiating high-risk demographic and gender groups can lead to improved diagnosis and treatment of mental health diagnoses among veterans and other high-risk groups.

Just showing up is not enough: Homework adherence and outcome in cognitive–behavioral therapy for cocaine dependence.

OBJECTIVE Homework in cognitive-behavioral therapy (CBT) provides opportunities to practice skills. In prior studies, homework adherence was associated with improved outcome across a variety of disorders. Few studies have examined whether the relationship between homework adherence and outcome is maintained after treatment end or is independent of treatment attendance. METHOD This study combined data from 4 randomized clinical trials of CBT for cocaine dependence to examine relationships among homework adherence, participant variables, and cocaine use outcomes during treatment and at follow-up. The data set included only participants who attended at least 2 CBT sessions to allow for assignment and return of homework (N = 158). RESULTS Participants returned slightly less than half (41.1%) of assigned homework. Longitudinal random effects regression suggested a greater reduction in cocaine use during treatment and through 12-month follow-up for participants who completed half or more of assigned homework (3-way interaction), F(2, 910.69) = 4.28, p = .01. In multiple linear regression, the percentage of homework adherence was associated with greater number of cocaine-negative urine toxicology screens during treatment, even when accounting for baseline cocaine use frequency and treatment attendance; at 3 months follow-up, multiple logistic regression indicated homework adherence was associated with cocaine-negative urine toxicology screen, controlling for baseline cocaine use and treatment attendance. CONCLUSIONS These results extend findings from prior studies regarding the importance of homework adherence by demonstrating associations among homework and cocaine use outcomes during treatment and up to 12 months after, independent of treatment attendance and baseline cocaine use severity. (PsycINFO Database Record

Positive and negative affect in cocaine use disorder treatment: Change across time and relevance to treatment outcome: Positive and Negative Affect in Cocaine Treatment 1

BACKGROUND Cognitive-behavior therapy (CBT) for substance use disorder is empirically supported, and may be associated with change in affect over time. OBJECTIVES Understanding the role of affect in cocaine use disorder could help to improve CBT outcomes. METHODS This secondary analysis included 140 adults with cocaine use disorder, 57.9% female, drawn from two randomized controlled studies of web-based cognitive-behavior therapy who completed the Positive and Negative Affect Scale (PANAS) before and during treatment. RESULTS In mixed-effects regression models, baseline negative affect (NA) scores were not associated with self-reported cocaine use during treatment, but baseline PA scores were associated with less frequent cocaine use (β = -0.04, p = .02). During treatment, NA scores reduced over time in CBT and treatment as usual (β = -0.27, p < .01), although PA scores did not change. Higher weekly NA scores were associated with weekly cocaine use (β = .02, SE = .01, t(746.15) = 2.37, p = .02), although weekly PANAS PA scores were not associated with weekly cocaine use. DISCUSSION AND CONCLUSIONS Results indicated that individuals with higher baseline PA were more likely to abstain from cocaine use during treatment, even when controlling for baseline cocaine use frequency. Although baseline NA was not associated with cocaine use, NA during treatment was associated with greater cocaine use. SCIENTIFIC SIGNIFICANCE PA at baseline and NA during treatment were associated with cocaine use. If findings are replicated, treatment developers may wish to include treatment interventions to boost early PA and reduce NA throughout treatment. (Am J Addict 2018;XX:1-8).