Project Matching Alcoholism Treatments To Client Heterogeneity Research Articles

Who achieves low risk drinking during alcohol treatment? An analysis of patients in three alcohol clinical trials.

There is evidence that low-risk drinking is possible during the course of alcohol treatment and can be maintained following treatment. Our aim was to identify characteristics associated with low-risk drinking during treatment in a large sample of individuals as they received treatment for alcohol dependence. Integrated analysis of data from the Combined Pharmacotherapies and Behavioral Intervention (COMBINE) study, Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) and the United Kingdom Alcohol Treatment Trial (UKATT) using repeated-measures latent class analysis to identify patterns of drinking and predictors of low-risk drinking patterns during treatment. United States and United Kingdom. Patients (n=3589) with alcohol dependence receiving treatment in an alcohol clinical trial were primarily male (73.0%), white (82.0%) and non-married (41.7%), with an average age of 42.0 (standard deviation=10.7). Self-reported weekly alcohol consumption during treatment was assessed using the Form-90 and validated with biological verification or collateral informants. Seven patterns of drinking during treatment were identified: persistent heavy drinking (18.7% of the sample), increasing heavy drinking (9.6%), heavy and low-risk drinking (6.7%), heavy drinking alternating with abstinence (7.9%), low-risk drinking (6.8%), increasing low-risk drinking (10.5%) and abstinence (39.8%). Lower alcohol dependence severity and fewer drinks per day at baseline significantly predicted low-risk drinking patterns [e.g. each additional drink prior to baseline predicted a 27% increase in the odds of expected classification in heavy drinking versus low-risk drinking patterns; odds ratio=1.27 (95% confidence interval (CI)=1.10, 1.47, P=0.002]. Greater negative mood and more heavy drinkers in the social network were significant predictors of expected membership in heavier drinking patterns. Low-risk drinking is achievable for some individuals as they undergo treatment for alcohol dependence. Individuals with lower dependence severity, less baseline drinking, fewer negative mood symptoms and fewer heavy drinkers in their social networks have a higher probability of achieving low-risk drinking during treatment.

Testing a Matching Hypothesis for Emerging Adults in Project MATCH: During-Treatment and One-Year Outcomes.

Compared with older adults, emerging adults (18-29 years old) entering treatment typically have less severe alcohol use consequences. Also, their unique clinical presentations (e.g., modest initial abstinence motivation) and developmental contexts (e.g., drinking-rich social networks) may make a straightforward implementation of treatments developed for adults less effective. Yet, this has seldom been examined empirically. This study was a secondary analysis of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) data examining (a) overall differences between emerging adults and older adults (≥30 years old) on outcomes during treatment and at 1-year follow-up, and (b) whether emerging adults had poorer outcomes on any of the three Project MATCH treatments in particular. Participants were 267 emerging adults and 1,459 older adults randomly assigned to individually delivered cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), or 12-step facilitation (TSF). Multilevel growth curve models tested differences on percentage of days abstinent (PDA) and drinks per drinking day (DDD) by age group and treatment assignment. During treatment, compared with older adults, emerging adults reported more DDD but similar PDA. Further, emerging adults assigned to TSF had less PDA and more DDD than emerging adults and older adults assigned to CBT or MET during treatment (i.e., emerging adults in TSF has poorer outcomes initially), but this matching effect was not evident at 1-year follow-up. This study is among the first to test age group differences across three psychosocial interventions shown to be efficacious treatments for alcohol use disorder. Although emerging adults generally did as well as their older counterparts, they may require a more developmentally sensitive approach to bolster TSF effects during treatment.

Finding success in failure: using latent profile analysis to examine heterogeneity in psychosocial functioning among heavy drinkers following treatment.

To estimate differences in post-treatment psychosocial functioning among treatment 'failures' (i.e. heavy drinkers, defined as 4+/5+ drinks for women/men) from two large multi-site clinical trials and to compare these levels of functioning to those of the purported treatment 'successes' (i.e. non-heavy drinkers). Separate latent profile analyses of data from two of the largest alcohol clinical trials conducted in the United States, COMBINE (Combined Pharmacotherapies and Behavioral Interventions) and Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), comparing psychosocial outcomes across derived classes of heterogeneous treatment responders. Eleven US academic sites in COMBINE, 27US treatment sites local to nine research sites in Project MATCH. A total of 962 individuals in COMBINE (69% male, 77% white, mean age: 44years) treated January 2001 to January 2004 and 1528 individuals in Project MATCH (75% male, 80% white, mean age: 40years) treated April 1991 to September 1994. In COMBINE, we analyzed health, quality of life, mental health symptoms and alcohol consequences 12 months post-baseline. In Project MATCH, we examined social functioning, mental health symptoms and alcohol consequences 15 months post-baseline. Latent profile analysis of measures of functioning in both samples supported a three-profile solution for the group of treatment 'failures', characterized by high-, average- and low-functioning individuals. The high-functioning treatment 'failures' generally performed better across measures of psychosocial functioning at follow-up than participants designated treatment 'successes' by virtue of being abstainers or light drinkers. Current United States Food and Drug Administration guidance to use heavy drinking as indicative of treatment 'failure' fails to take into account substantial psychosocial improvements made by individuals who continue occasionally to drink heavily post-treatment.

End-of-treatment abstinence self-efficacy, behavioral processes of change, and posttreatment drinking outcomes in Project MATCH.

This study evaluated whether alcohol abstinence self-efficacy at the end of alcohol treatment was moderated by utilization of behavioral processes of change (coping activities used during a behavior change attempt). It was hypothesized that self-efficacy would be differentially important in predicting posttreatment drinking outcomes depending on the level of behavioral processes, such that the relation between self-efficacy and outcomes would be stronger for individuals who reported low process use. Analyses were also estimated with end-of-treatment abstinence included as a covariate. Data were analyzed from alcohol-dependent individuals in both treatment arms of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity; N = 1,328), a large alcohol treatment study. Self-efficacy was moderated by behavioral process use in predicting drinking frequency 6 and 12 months posttreatment and drinking quantity 6 months posttreatment such that self-efficacy was more strongly related to posttreatment drinking when low levels of processes were reported than high levels, but interactions were attenuated when end-of-treatment abstinence was controlled for. Significant quadratic relations between end-of-treatment self-efficacy and 6- and 12-month posttreatment drinking quantity and frequency were found (p < .001, ƒ² = 0.02-0.03), such that self-efficacy most robustly predicted outcomes when high. These effects remained significant when end-of-treatment abstinence was included as a covariate. Findings highlight the complex nature of self-efficacy's relation with drinking outcomes. Although the interaction between self-efficacy and behavioral processes was attenuated when end-of-treatment abstinence was controlled for, the quadratic effect of self-efficacy on outcomes remained significant. The pattern of these effects did not support the idea of "overconfidence" as a negative indicator.

Evaluating Alcoholics Anonymous's Effect on Drinking in Project MATCH Using Cross-Lagged Regression Panel Analysis

The objective of the study is to determine whether Alcoholics Anonymous (AA) participation leads to reduced drinking and problems related to drinking within Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), an existing national alcoholism treatment data set. The method used is structural equation modeling of panel data with cross-lagged partial regression coefficients. The main advantage of this technique for the analysis of AA outcomes is that potential reciprocal causation between AA participation and drinking behavior can be explicitly modeled through the specification of finite causal lags. For the outpatient subsample (n = 952), the results strongly support the hypothesis that AA attendance leads to increases in alcohol abstinence and reduces drinking/ problems, whereas a causal effect in the reverse direction is unsupported. For the aftercare subsample (n = 774), the results are not as clear but also suggest that AA attendance leads to better outcomes. Although randomized controlled trials are the surest means of establishing causal relations between interventions and outcomes, such trials are rare in AA research for practical reasons. The current study successfully exploited the multiple data waves in Project MATCH to examine evidence of causality between AA participation and drinking outcomes. The study obtained unique statistical results supporting the effectiveness of AA primarily in the context of primary outpatient treatment for alcoholism.

Patient Reactance as a Moderator of the Effect of Therapist Structure on Posttreatment Alcohol Use

We sought to replicate findings about the effect of therapist-imposed structure on alcoholism-treatment effectiveness for aftercare patients at different levels of interpersonal reactance and to examine if the effect generalizes to patients in a primary phase of treatment. Analyses were based on ex post facto observer ratings combined with outcome data from a randomized clinical trial. Participants had alcohol abuse or dependence (N = 247) and received treatment at either a primary outpatient treatment site (n = 125) or an aftercare site (n = 122) of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). Patients' trait reactance and therapist structure were assessed via observer ratings based on videotaped therapy sessions. Dependent variables included percentage days abstinent, percentage heavy-drinking days, time to first drinking day, and time to first heavy-drinking day throughout a 1-year posttreatment period. The results indicated that increased therapist structure during aftercare treatment predicted fewer abstinent days and more heavy-drinking days for persons at a high level of reactance than for persons at a low level of reactance. The effect was a consistent predictor of alcohol use throughout each 3-month interval within the follow-up period. The interaction effect was not supported in the primary outpatient treatment sites, and it was not supported as a predictor of time to first drink or time to first heavy drink in either the aftercare or the outpatient sites. This study successfully replicated the finding that level of patient reactance appears to moderate the effect of therapist structure on alcohol-use outcomes in aftercare treatment settings. The lack of support for this effect in primary outpatient treatment settings suggests that the negative effect of structured treatment may be limited to patients who are further along in the recovery process.

A Validation Study of the Alcohol Dependence Scale

The primary purpose of this study was to provide a comprehensive assessment of the underlying factor structure of the Alcohol Dependence Scale (ADS). Secondary goals included assessing concurrent validity of the total ADS and subscales derived from the factor analyses with variables related to alcohol dependence and further evaluating the validity of two proposed dichotomously scored, reduced-item ADS measures. Responses to the ADS were obtained from participants who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for alcohol dependence in two large randomized clinical trials: COMBINE (Combining Medications and Behavioral Interventions Study; n = 1,335; 69% male) and Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity; n = 1,666; 75% male). Both exploratory and confirmatory factor analyses were conducted, and validity coefficients were obtained. Across samples, analyses supported a correlated, three-factor solution representing loss of behavioral control and heavy drinking, obsessive-compulsive drinking style, and psychoperceptual and psychophysical withdrawal. The ADS was significantly related to other measures of severity of dependence, craving for and preoccupation with drinking, temptation to drink and confidence in the ability to not drink in high-risk relapse situations, heavy and sustained drinking patterns, concerns about negative alcohol-related consequences, and awareness of problematic drinking. These findings support a three-factor solution for the ADS and its ability to assess the construct of alcohol dependence in a reliable and valid manner. The 12-item reduced ADS measure (reflecting mostly dependence-related items), as opposed to the 9-item reduced ADS measure (generally excessive drinking items), provided validity coefficients comparable to the total, 25-item ADS.

Predictors of Initial AA-Related Helping: Findings From Project MATCH

The purpose of this article is to identify the factors that predict initial Alcoholics Anonymous (AA)-related helping following treatment admission. Data were derived from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a longitudinal investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Cox proportional hazard regressions were performed to determine the extent to which demographic, clinical, belief, and AA factors predicted initial AA-related helping. Demographic characteristics, drinking severity, antisocial personality, and purpose in life were not associated with initial AA-related helping. Increased self-efficacy, faith-based practices, meeting attendance, number of steps worked, having a sponsor, and length of sobriety predicted initial AA-related helping. Alcoholics reported elevated depressive symptoms before initial AA-related helping, lowered depressive symptoms at the start of AA-related helping, and similarly lowered depressive symptoms in the interval following initial AA-related helping. The profile of prospective helpers in AA is not limited to alcoholics from certain backgrounds or higher functioning in terms of drinking or clinical severity. To increase participation in AA-related helping, and hence outcomes, results suggest strengthening self-efficacy and progress in other AA programmatic components.

Lapses following Alcohol Treatment: Modeling the Falls From the Wagon

This study investigated transitions between drinking and nondrinking during the first 12 months following treatment and whether transitions in posttreatment drinking are related to alcohol-dependence symptoms. Data from individuals in the outpatient (n = 952) and aftercare (n = 774) arms of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) were included in the analyses. Drinking consequences, percentage of drinking days, and drinks per drinking day were used as indicators of drinking behavior. Latent transition analysis was used to estimate a model of drinking patterns, defined by transition probabilities between drinking classes, from immediately following treatment to 6 and 12 months following treatment. Across both aftercare and outpatient samples, three drinking classes were identified at each time point: frequent heavy drinking with high consequences, moderate infrequent drinking with low consequences, and nondrinking with low consequences. Many participants maintained nondrinking, and, of those who drank, there was a trend toward transitioning to less drinking over time. Transition probabilities were noninvariant across treatment arms: The probability of transitioning from moderate drinking to frequent drinking was more than six times more likely in the aftercare arm, as compared with the outpatient arm. In both samples the transition to heavy drinking and membership in the heavy-drinking class were significantly positively related to alcohol dependence symptoms. There were no differences across MATCH treatment groups. This study examined transitions in post treatment drinking and the role of alcohol dependence in predicting posttreatment drinking. The results suggest a low probability of moderate drinking among individuals with greater alcohol dependence.

Web-based norms for the Drinker Inventory of Consequences from the Drinker's Checkup

To date, the only published norms for the Drinker Inventory of Consequences (DrInC) have come from a sample of heavy drinkers in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) who were enrolling in a treatment program. We have generated an additional set of norms for the DrInC based on a large sample ( N = 1,564) of heavy drinkers who have completed the DrInC as part of a Web-based brief motivational intervention, the Drinker's Checkup (DCU; www.drinkerscheckup.com). Although these drinkers were not seeking formal treatment, they were concerned enough about their drinking to pay $25 to use the DCU. Comparing the means and decile scores for lifetime and recent total scores and subscale scores between the DCU and MATCH samples revealed that DrInC scores for the DCU sample were significantly lower than the MATCH sample. These findings have implications for giving normative feedback using the DrInC with non-treatment-seeking populations. The use and limitations of these findings are discussed.

Network Support for Drinking: An Application of Multiple Groups Growth Mixture Modeling to Examine Client-Treatment Matching

The current study re-examined the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) hypothesis that individuals with high network support for drinking would have the best treatment outcomes if they were assigned to twelve-step facilitation (TSF). Drinking consequences, as measured by the Drinking Inventory of Consequences, was the primary outcome measure. Growth mixture models with multiple groups were used to estimate the drinking consequence trajectories of 952 outpatients during the 12 months following treatment for each of the three Project MATCH treatment conditions. Growth factors within latent trajectory classes were regressed on network support for drinking to assess whether treatment condition moderated the relationship between network support for drinking and drinking consequences over time. Three latent classes were identified, representing low (n = 154, 16.2%), medium (n = 400, 42%), and high (n = 398, 41.8%) levels of drinking consequences. Classes did not differ across treatment groups. Greater network support for drinking predicted more drinking consequences over time but only for clients assigned to cognitive-behavioral therapy and motivational enhancement therapy, not TSF. This study provides further support for one of the original Project MATCH matching hypotheses: Clients with social networks supportive of drinking had better outcomes immediately after treatment if they were assigned to TSF. Because the original Project MATCH studies found this matching effect only at the 3-year follow-up, these results add validity to the network support for drinking matching effect. The study also provides additional evidence that accounting for heterogeneity in alcohol treatment outcomes is important for accurately estimating treatment effectiveness.

Social networks and their influence on drinking behaviors: differences related to cognitive impairment in clients receiving alcoholism treatment.

Mechanisms of behavioral change that support positive addiction treatment outcomes in individuals with co-occurring alcohol-use disorders and cognitive impairment remain largely unknown. This article combines person- and variable-centered approaches to examine the interrelated influence of cognitive impairment and social support on stability of and changes in drinking behaviors of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) outpatients and aftercare clients (N = 1,726) during the first year after their entry into treatment. Latent class analysis identified homogeneous groups of clients based on the nature and extent of social support for abstinence or drinking at treatment entry. Cognitive impairment and drinking outcomes were compared across latent classes, and the interaction between impairment and social support on drinking outcomes was examined using mixture probit regression. Three independent social support classes (frequent positive, limited positive, and negative) were identified. In the outpatient sample, the frequent positive support class had greater cognitive impairment at treatment entry versus other classes, and extent of impairment significantly predicted improved drinking outcomes in this class. In the aftercare sample, the frequent positive and negative support classes had heightened impairment, yet cognitive impairment significantly predicted relatively poorer drinking outcomes in the negative support class only. Cognitive impairment may increase the influence of the social network on the drinking outcomes of persons receiving treatment for alcohol-use disorders, but more research is needed to understand client characteristics that determine whether this influence is more likely to be manifest as increased salience of helping agents or of hindering agents in the social network.

The Factor Structure of the Alcohol Use Disorders Identification Test (AUDIT)

Past research assessing the factor structure of the Alcohol Use Disorders Identification Test (AUDIT) with various exploratory and confirmatory factor analytic techniques has identified one-, two-, and three-factor solutions. Because different factor analytic procedures may result in dissimilar findings, we examined the factor structure of the AUDIT using the same factor analytic technique on two new large clinical samples and on archival data from six samples studied in previous reports. Responses to the AUDIT were obtained from participants who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for alcohol dependence in two large randomized clinical trials: the COMBINE (Combining Medications and Behavioral Interventions) Study (N = 1,337; 69% men) and Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity; N = 1,711; 76% men). Supplementary analyses involved six correlation matrices of AUDIT data obtained from five previously published articles. Confirmatory factor analyses based on one-, two-, and three-factor models were conducted on the eight correlation matrices to assess the factor structure of the AUDIT. Across samples, analyses supported a correlated, two-factor solution representing alcohol consumption and alcohol-related consequences. The three-factor solution fit the data equally well, but two factors (alcohol dependence and harmful alcohol use) were highly correlated. The one-factor solution did not provide a good fit to the data. These findings support a two-factor solution for the AUDIT (alcohol consumption and alcohol-related consequences). The results contradict the original three-factor design of the AUDIT and the prevalent use of the AUDIT as a one-factor screening instrument with a single cutoff score.

Moderate Drinking in the First Year After Treatment as a Predictor of Three-Year Outcomes

The relationship between moderate alcohol consumption in the first year following alcohol treatment admission and longer-term functioning is clinically important and pertains to the clinical course of alcohol-use disorders. This study investigated these relationships, focusing on the first year posttreatment admission and 3 years later. Analyses were conducted on the outpatient Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) sample (n = 952 at baseline, and n = 802 at Months 37-39). Participants were classified as first-year "abstainer," "moderate drinker," or "heavy drinker." Drinker classification predicted percentage of days abstinent from alcohol, drinks per drinking day, and alcohol-related negative consequences at 3 years. The abstainers had better drinking outcomes than either of the other two groups, and the moderate drinkers' outcomes were better than those of the heavy drinkers. The heavy drinkers had a higher rate of negative consequences at 3 years than did the abstainers and the moderate drinkers, who did not differ from each other. Analyses of change in drinker status between 1 and 3 years explored variability in clinical course. First-year posttreatment alcohol use on the group level predicts longer-term alcohol use and related functioning, and moderate drinking may be considered a treatment goal option for some individuals. The data also reaffirm the variability among individuals in clinical course following alcohol treatment. Future research should aim to understand the factors that determine the maintenance of patterns of alcohol use that are not associated with the occurrence of alcohol-related negative consequences.

Special Section: A Memorial Tribute: Exacerbation of Psychiatric Symptoms During Substance Use Disorder Treatment

Special Section: A Memorial Tribute: Exacerbation of Psychiatric Symptoms During Substance Use Disorder Treatment

One Small Step for Manuals: Computer-Assisted Training in Twelve-Step Facilitation

The burgeoning number of empirically validated therapies has not been met with systematic evaluation of practical, inexpensive means of teaching large numbers of clinicians to use these treatments effectively. An interactive, computer-assisted training program that sought to impart skills associated with the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) Twelve-Step Facilitation (TSF) manual was developed to address this need. Twenty-five community-based substance use-treatment clinicians were randomized to one of two training conditions: (1) access to the computer- assisted training program plus the TSF manual or (2) access to the manual only. The primary outcome measure was change from preto posttraining in the clinicians' ability to demonstrate key TSF skills. The data suggested that the clinicians' ability to implement TSF, as assessed by independent ratings of adherence and skill for the key TSF interventions, was significantly higher after training for those who had access to the computerized training condition than those who were assigned to the manual-only condition. Those assigned to the computer-assisted training condition also demonstrated greater gains in a knowledge test assessing familiarity with concepts presented in the TSF manual. Computer-based training may be a feasible and effective means of training larger numbers of clinicians in empirically supported, manual-guided therapies.

Drinking in the Year After Treatment as a Predictor of Three-Year Drinking Outcomes

Previous research suggests that abstinence from alcohol during the first year posttreatment for alcohol-use disorders (AUDs) is an important, independent predictor of longer-term alcohol consumption and related functioning. The purpose of this study was to test the hypothesis that abstinence during the first year posttreatment initiation predicts alcohol use at Months 37-39. A second aim of this study was to explore the relationship between "moderate" drinking in the first year and drinking at Months 37-39. Secondary data analyses were conducted on the outpatient Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) sample (N = 952 at baseline and 802 at Months 37-39). For these analyses, participants were classified first as abstainers, moderate drinkers, or heavy drinkers based on their alcohol use in the first year posttreatment initiation. Analyses of covariance showed that the first-year drinker classification predicted both percentage of days abstinent and drinks per drinking day at Months 37-39. Subsequent analyses showed that the abstainers functioned significantly better than (1) both of the other drinker groups combined and (2) either of the other two groups, which did not differ from each other on either measure of alcohol use. A third set of exploratory analyses evaluated first-year abstinence and heavy drinking as continuous variables and showed an essentially linear relationship between them and drinking at 3 years. This study confirmed the strong relationship between first-year abstinence and later drinking but did not show that participants who engaged in moderate drinking during the first year had positive alcohol-use outcomes at 3 years. The clinical implications of the findings, their generalizability to different populations of individuals presenting for specialty alcohol treatment, and future research directions are discussed.

Examining the Effects of Alcoholism Typology and AA Attendance on Self-Efficacy as a Mechanism of Change

Existing research indicates that increased self-efficacy to sustain abstinence is a strong causal mechanism explaining later reduction of drinking. Little is known about how mechanisms of change may differ among distinct subgroups of alcoholics. The purpose of this study was to evaluate the mediational role of self-efficacy on changes in drinking associated with Alcoholics Anonymous (AA) attendance in Type-A and Type-B alcoholics. Analysis of covariance and structural equation modeling were used to model 6-, 9-, 12-, and 15-month data from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) participants who were classified as Type-A or Type-B alcoholics (N=1,284; 72% male). Measures of AA attendance and percent days abstinent were taken from the Form 90. Self- efficacy was assessed with the Alcohol Abstinence Self-Efficacy Scale. Alcoholism typology and AA attendance were independent predictors of later self-efficacy, but there was no interaction between typology and AA attendance. Abstinence self-efficacy mediated a modest proportion of the effect of posttreatment AA attendance on later abstinence in both Type-A and Type-B alcoholics. The strength of this mediation did not differ by typology. Self-efficacy for abstinence has a strong direct relationship to abstinence across treatment conditions and typologies. Increases in self-efficacy mediate some of the beneficial effects of AA for Type-A and Type-B alcoholics. Further work is necessary to determine whether self-efficacy plays a different role in the recovery of Type-A versus Type-B alcoholics.

Self-Efficacy, Therapeutic Alliance, and Alcohol-Use Disorder Treatment Outcomes

High abstinence self-efficacy reliably predicts better treatment outcomes for patients with alcohol use disorders, but little is known about aspects of treatment that may be particularly beneficial for patients who enter treatment with low self-efficacy. This study examines whether the relationship between self-efficacy and treatment outcomes is influenced by the quality of the therapeutic alliance in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a multisite clinical trial of three treatments for alcohol use disorders. Information on 785 patients in the outpatient sample of Project MATCH was used to test for an interaction between baseline self-efficacy and therapeutic alliance in relation to 1-year alcohol use outcomes. A significant interaction was found between self-efficacy and the therapists' perception of the therapeutic alliance predicting I1year drinking outcomes. Patients with low self-efficacy who established a strong treatment alliance, as judged by the therapist, experienced I1year outcomes that were superior to those of patients with low self-efficacy with poorer treatment alliance and comparable with those of patients with high self-efficacy. Therapeutic alliance was not strongly related to the outcomes of patients with high baseline self-efficacy. In patients who are treated for alcohol-use disorders, a positive therapeutic alliance may counteract the negative impact of a low baseline self-efficacy. Potential reasons why the therapist's perception of the alliance may be particularly important for patients with low self-efficacy are discussed.

Therapist influence on client language during motivational interviewing sessions

Client language in favor of change is hypothesized to be a causal mechanism for motivational interviewing (MI), and specific therapist behaviors are prescribed to elicit such speech. This project examined 38 motivational enhancement therapy sessions from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), using a sequential behavioral coding system to investigate the relationship between therapist behaviors and client speech. Conditional probabilities were calculated between MI-consistent (MICO) therapist behaviors, MI-inconsistent (MIIN) therapist behaviors, and immediately subsequent client speech. MICO behaviors were more likely to be followed by self-motivational statements, whereas MIIN behaviors were more likely to be followed by client resistance. These results lend support to the importance of therapist behaviors in shaping client speech during MI sessions.