Treatment Outcome Research Research Articles

Reasons for and Attitudes Toward Follow-Up Research Participation Among Adolescents Enrolled in an Outpatient Substance Abuse Treatment Program

ABSTRACT Maintaining study cohorts over time is crucial to the success of treatment outcome research studies. This paper examines reasons why adolescents with substance use problems continued to participate in follow-up interviews. The sample consisted of 145 adolescents between the ages of 12 and 18, who completed an outcome study following out-patient treatment for substance use. Adolescents' top reason for continued participation was financial compensation; however, a high percentage of adolescents responded favorably to several other attitudinal questions concerning their follow-up participation, suggesting that the adolescents had a primarily positive view of their research experience and that reasons for research participation are multidimensional.

Children Exposed to Intra-Familial Violence

This investigation examined factors associated with attrition and retention within a sample of children with a history of intra-familial violence referred for outpatient services. The sample included 118 children, aged 4-17 years; of these 64% completed treatment, 20% did not engage in treatment and 16% terminated prematurely. Caregivers reporting high child-related parental distress (F(2, 32) = 3.9, p = 0.03) and high psychological distress (F(2, 70) = 3.3, p = 0.04) were less likely to engage in treatment. Making a child abuse report during assessment or treatment was not found to be associated with treatment engagement or attrition, χ2 (2)= 0.4, p = 0.82. The implications of these findings for clinical practice and treatment outcome research are discussed.

Nonresponse Bias in Adolescent Substance Abuse Treatment Outcomes Research: Implications for Evaluating Care

ABSTRACT Nonresponse bias was investigated in an outcomes study of adolescent substance abuse treatment. Treatment-related characteristics of respondents (n = 53) were compared with those of non respondents (n = 61). Statistical analysis showed that few differences were seen between respondents and nonrespondents. The results indicate that outcomes data can be collected in this treatment population that are relatively unaffected by nonresponse bias. Missing responses are shown to be very likely missing at random.

BRING ADDICTION TREATMENT OUT OF THE CLOSET

What is actually being done in most addiction treatment programs? The truth is that no one really knows, including the administrators and supervisors of those programs. One thing I have learnt in four decades of treatment outcome research is that what therapists actually do behind closed doors, even with specific training and with video or audiotape recorders running, often bears surprisingly little resemblance to what they say and believe they are doing. Self-reported skill in a specific treatment method is at best related modestly to actual behavioral proficiency and fidelity in delivering it [1]. Training does not ensure the acquisition or maintenance of proficiency. To know what is actually being done in treatment, there is quite simply no alternative to direct observation of practice. This indicates a need for a sea change in the culture of addiction service delivery, where treatment is done currently in private and often without any real clinical supervision. Medical care in general is much more observable and accountable than counseling. Primary care providers are expected to document in detail what they do, and their work interacts with a steady stream of other health care professionals (and students in teaching facilities) coming in and out of the treatment room. Surgery is not usually performed one-to-one in private, but is witnessed and assisted by others around the table, or observing live or via videotape. Addiction treatment needs to come out of the closet, and become an enterprise of open professional collaboration for continuous quality improvement. Competent supervision without observation is an oxymoron. The quality of treatment-as-usual can be quite good. We compared head-to-head the drinking outcomes of clients treated by the closely supervised manual-guided therapies in Project MATCH with those for clients admitted during the same period to normal treatment at the Albuquerque clinical site, who received whatever treatment their assigned therapist delivered. The outcomes for these two groups were virtually identical [2]. As Carroll & Rounsaville observe in this issue [3], it is not a foregone conclusion that retraining clinical staff in evidence-based treatment (EBT) methods will necessarily improve client outcomes. Site × treatment interactions in multi-site clinical trials indicate that such training improves outcomes in some programs but not others. Similarly, therapist training needs to come out of the closet. Training by reading books, watching videotapes and attending workshops usually has little or no impact on actual practice [4]. Rather than a fixed dose of instruction, training should be to a criterion of proficiency in observed practice. Counselors will vary widely in the length and amount of training needed to reach and maintain proficiency in an EBT. Meanwhile, there are several practical things to be undertaken to advance the standard of delivering EBTs in addiction services. Clearly, we ought to be training the next generation of providers to be proficient in EBTs. Shaping new practice is easier than retraining and unlearning established practice habits. It is simply unethical to continue training new providers in unproven or (worse) discredited treatment methods. In clinical policy, we should at a minimum call a moratorium on the use of treatment methods that have been shown to be generally ineffective or harmful, as one would hope and expect happens in health care more generally. In hiring new treatment staff, priority can be given to selecting those who demonstrate the characteristics of effective therapists (such as accurate empathy; [5,6]) and proficiency in EBTs. All this depends on the systemic change of making addiction treatment practices more observable and accountable, which in turn offers providers the opportunity, supervision and feedback needed to become better at what they do.

The Responses to Script-Driven Imagery Scale (RSDI): Assessment of State Posttraumatic Symptoms for Psychobiological and Treatment Research

Studies of PTSD employing symptom provocation have seldom included self-report measures of the symptoms provoked. Doing so could benefit psychobiological research by improving diagnostic discrimination and capturing the heterogeneity of responses to script-driven imagery, and treatment research by complementing existing outcome measures. This paper describes the initial development and psychometric properties of the Responses to Script-Driven Imagery Scale (RSDI), a brief self-report measure of state PTSD and dissociative symptoms evoked by script-driven imagery, a widely used symptom provocation method in PTSD research. Across three samples and three variants of the script-driven imagery paradigm, confirmatory factor analysis fit a hypothesized and sample-invariant three-factor structure for the RSDI, composed of reexperiencing, avoidance, and dissociative symptoms. Subscales exhibited acceptable to high internal consistency reliabilities, and construct validity evidence was strong and consistent with predictions. The RSDI shows promise as a tool for psychobiological and treatment outcome research on PTSD.

Long-term outcome of substance-dependent youth following 12-step treatment

The adolescent drug treatment outcome research literature primarily focuses on short-term follow-up periods (e.g., 1 year). This study extends the said literature by describing the pattern of drug use at 1, 4, and 5.5 years in three groups of adolescents: a Treatment group, which underwent a 12-step-based drug treatment program ( n = 159); a Waiting List group ( n = 62); and a Community Control group ( n = 94). The Treatment group consistently showed significantly lower levels of drug involvement than the Waiting List group. However, at all points, both the Treatment and Waiting List groups showed higher levels of drug use than the Community Controls. Within the Treatment group, completing treatment and involvement in aftercare were positively associated with improved outcomes. The treatment implications of the study are discussed.

Modeling the complexity of post-treatment drinking: It's a rocky road to relapse

The most widely cited road block to successful treatment outcomes for psychological and substance use disorders has been described as the return to the previous behavior, or “relapse.” The operational definition of “relapse” varies from study to study and between clinicians, but in general the term is used to indicate the return to previous levels of symptomatic behavior. One explanation for the variation in the operationalization of relapse is the wide variety of behaviors for which the term is applied, including (but not limited to): depression, substance abuse, schizophrenia, mania, sexual offending, risky sexual behavior, dieting, and the anxiety disorders. A second explanation for the multitude of definitions for relapse is the inherent complexity in the process of behavior change. In this paper we present the most recent treatment outcome research evaluating relapse rates, with a special focus on the substance use disorders. Following this review of the literature we present an argument for the operationalization of relapse as a dynamic process, which can be empirically characterized using dynamical systems theory. We support this argument by presenting results from the analysis of alcohol treatment outcomes using catastrophe modeling techniques. These results demonstrate the utility of catastrophe theory in modeling the alcohol relapse process. The implications of these analyses for the treatment of alcohol use disorders, as well as a discussion of future research incorporating nonlinear dynamical systems theory is provided.

Meta-analyses and systematic reviews of psychological treatments for chronic pain: Relevance to an evidence-based practice.

As evidence-based practitioners become more reliant on systematic reviews to inform treatment, it becomes important to systematize reporting details as well as improve the quality of the primary studies that will later be incorporated into this secondary literature. In this article, the authors consider several specific factors that can serve this function in the area of chronic pain: (a) adhering to a standardized set of reporting standards; (b) measuring a standardized set of short- and long-term outcome variables; (c) providing information about individual differences; and (d) providing detailed, easily accessible documentation of the treatment program (or progams). The article also highlights ways that practitioners and researchers can collaborate on treatment outcome research, thereby improving the ability to discover and disseminate effective treatments for patients who suffer from chronic pain.

Treatment Outcomes Research: A Response to Ryan (2006)

Purpose This is a response to B. Ryan’s (2006) letter to the editor regarding “Intensive Stuttering Modification Therapy: A Multidimensional Assessment of Treatment Outcomes,” by M. Blomgren, N. Roy, T. Callister, and R. Merrill (2005). Issues discussed relate to (a) the goals of stuttering modification treatment, (b) appropriate “documentation” of stuttering treatment programs, and (c) dose–response relationships as they pertain to stuttering treatment. A brief tutorial and discussion concerning appropriate use of terminology associated with stuttering treatment outcomes research is provided.

Development of the Pet Bereavement Questionnaire

The death of a pet can be a significant stressor for some people and is a known risk factor for depression. The Pet Bereavement Questionnaire (PBQ) was developed to fill the need for a brief, acceptable, well-validated instrument for use in studies of the psychological impact of losing a pet. Initial results suggest that the PBQ has good internal reliability (Cronbach's α = 0.87), as well as good construct validity, with three distinct factors reflecting grief, anger and guilt. Grief was found to correlate strongly with pet attachment. The anger and guilt scales, however, correlated with depressive symptoms. The PBQ discriminated between individuals seeking support after pet loss (who would be expected to show higher levels of bereavement) and those who simply acknowledge the recent loss of a pet. We suggest that future research into pet bereavement use this new questionnaire so that the results of different studies can be compared, normative scores can be developed and researchers in this area can use a single instrument with established construct validity. In particular, we hope the PBQ will be used in treatment outcome research to identify high-risk individuals and test the effectiveness of both existing and novel interventions. Moreover, the PBQ could also be used in clinical settings, such as tertiary care veterinary hospitals, to identify pet owners in need of clinical support services.

What future for the Therapeutic Community in the field of addiction? A view from Europe

What future for the Therapeutic Community in the field of addiction? A view from Europe

Cognitive-behavioral interventions with older adults: Integrating clinical and gerontological research.

Psychotherapeutic interventions utilizing cognitive–behavioral strategies have been used widely with older adults. To appropriately adapt these techniques, characteristics unique to older adults must be taken into account. These factors include aspects of the social environment, cohort effects, cognitive changes with aging, personality, and emotional development, which have been described in an emerging body of research literature from the field of gerontology. In addition, clinical studies have examined the efficacy of cognitive–behavioral interventions in treating older clients for anxiety, depression, insomnia, and other disorders. This review describes current empirical evidence in gerontology and treatment outcome research that informs the practice of psychotherapy in this population and provides recommendations for conducting therapy with older adults.

A modified DBT skills training program for oppositional defiant adolescents: promising preliminary findings

A modified skills training component of dialectical behavior therapy (DBT) was implemented in a group therapy format for non-suicidal outpatient young adolescents who met criteria for oppositional defiant disorder (ODD). Thirty-two youths completed the 16-week program, as well as pre- and post-treatment measures. The treatment was effective not only in decreasing negative behaviors, but also in increasing positive behaviors, per caregiver report. The youths reported a significant reduction in externalizing and internalizing symptoms and in depression. Reliable change indices indicated that far more participants were in the improved category than in the deteriorated category on the measures of interest. Despite the absence of control groups but consistent with the treatment outcome research literature for DBT-based treatments for other disorders, this study demonstrated that DBT skills training is feasible and shows promise in improving the behavior of ODD young adolescents.

Substance Use in Ethnic Minority Youth

As evidenced in the literature, there has been a recent interest in understanding drug and alcohol use in ethnic minority populations, particularly among adolescents. Although epidemiological and treatment outcome research involving substance use and abuse has improved among ethnic minority groups, this information has yet to be sufficientiy integrated. This paper provides a comprehensive review of the extent of drug and alcohol use and related problems among ethnic minority youth, including patterns of use and treatment implications and recommendations.

Innovations: Alcohol & Drug Abuse: Spirituality in Alcoholics Anonymous: A Valuable Adjunct to Psychiatric Services

Alcoholics Anonymous (AA) is described as a spiritual fellowship by many of its members, but its spiritual orientation needs to be better understood by clinicians and researchers. Spirituality is a latent construct, one that is inferred from multiple component dimensions, such as social psychology, neurophysiology, and treatment outcome research. Mechanisms related to its role in promotion of recovery in AA are discussed from the perspective of these findings, along with related options for professionally grounded treatment, such as Twelve-Step Facilitation. This discussion illustrates the importance of further research on AA and spirituality and of employing them in the provision of psychiatric services.

Studying Usual Care in Child and Adolescent Therapy: It's Anything but Routine.

Efforts to enhance the quality of mental health care provided to children and youth require an understanding of the nature and impact of existing clinical services. The Practice and Research: Advancing Collaboration (PRAC) study described by Garland, Hurlburt, and Hawley (2006) is currently documenting the diverse treatment practices used in community settings. The study reflects the use of a hybrid design that integrates methods commonly used in treatment outcome and services research paradigms. This article discusses some of the key issues, directions, and challenges associated with efforts designed to enhance the quality of usual care illustrated in their article. Suggestions are made to encourage integrative investigations in the context of practice-based research networks devoted to promoting effective child and adolescent treatment.

Evaluation of a Treatment Program for Sexually Abused Adult Males

This study evaluated the effectiveness of an individual treatment program for five adult males who experienced childhood sexual abuse. A treatment manual focusing on abuse-related self-blame, anger, and anxiety was developed. Daily self-blame, anger, and anxiety self-ratings were completed before and throughout treatment. A multiple-baseline approach was used to evaluate treatment effects. Overall findings indicated that most participants experienced significant reductions in self-blame, anger, and anxiety as a result of their involvement in the sexual abuse treatment program. Treatment was particularly helpful in decreasing feelings of self-blame and anger. The study made an important initial contribution to the development of systematic treatment outcome research for a population of individuals that has received relatively little attention. The results have implications for future clinical and research efforts with sexually abused adult males.

Abstinence and drug abuse treatment: Results from the Drug Outcome Research in Scotland study

Aims: To identify the proportion of drug users contacting drug treatment services in Scotland who were able to become abstinent 33 months after having started a new episode of treatment and to identify which services were most closely associated with such abstinence. Design: Follow-up survey of 695 of the Drug Outcome Research in Scotland respondents 33 months following recruitment into the study. Setting: Scotland. Participants: Injecting drug users who were initially contacted at drug treatment services and then followed up for 33 months post-recruitment. Measurements: Self-reported drug use and service usage. Findings: Although becoming drug free was the expressed goal of the majority of drug users recruited into the Drug Outcome Research in Scotland study, at 33 months following recruitment only 5.9% of females and 9.0% of males had been totally drug free (excluding possible alcohol and tobacco use) for a 90-day period in advance of being interviewed. There was considerable variation within this study in the proportion of drug users becoming drug free dependent upon the services they had been in contact with. The level of achieved abstinence in this Scottish study was substantially lower than that identified in the National Treatment Outcomes Research Study in England. Conclusions: There is a need to establish why so few drug users in contact with the methadone programme in Scotland appear able to become drug free 33 months after having contacted this service. On the basis of the results presented in this paper there is a need to ensure that drug users seeking help in becoming drug free are able to access residential rehabilitation services although at the present time such services are relatively rare within Scotland.

Applying Clinical Significance Methodology to Alcoholism Treatment Trials: Determining Recovery Outcome Status with Individual- and Population-Based Measures

The current analysis applies clinical significance methodology to alcoholism treatment outcome research using data available from Project MATCH. Because of its high internal validity and its inclusion of multiple measures assessing multiple outcome dimensions, MATCH was considered an ideal study to explore the utility of this methodology. Data reported here are from a total of 1,726 participants enrolled in either aftercare (n = 774) or outpatient (n = 952) arms of the study. First, a cutoff score was determined differentiating functional versus dysfunctional status on three outcome measures: percent days abstinent (PDA), mean drinks per drinking day (DDD) and negative consequences of alcohol use. Second, the reliable change in pre- to post-treatment scores on these three measures was calculated. The results reported herein support the importance of distinguishing between statistical and clinical significance of outcomes. During three months post-treatment, approximately one-half of the treated patients were "recovered" (i.e., both functional and reliably changed) with respect to both PDA (i.e., 51%) and negative consequences of drinking (i.e., 47%); however, only about one-third of individuals remained recovered throughout the full one-year follow-up period (i.e., 33% on PDA and 35% on negative consequences). These individual-based change outcomes compared similarly to a population-based indicator of heavy drinking. Alternatively, only about one-quarter of participants were recovered using two distinct criteria for mean DDD (i.e., 23-29%), and even fewer participants remained recovered on mean DDD over the full one-year follow-up period (i.e., about 14-18%). Based on study limitations, more work is required to make clinical significance methodology practically useful to alcoholism treatment trials including more precise definitions of functional status and relative change as well as better interpretation of the inter-relationship between multiple measures assessing multiple outcome domains.

Prevalence and predictors of research participant eligibility criteria in alcohol treatment outcome studies, 1970–98

To describe the eligibility criteria (i.e. study participant inclusion and exclusion rules) employed in alcohol treatment outcome research and to identify predictors of their use. The eligibility criteria of 683 alcohol treatment outcome studies conducted between 1970 and 1998 were coded reliably into 14 general categories. Predictors of the use of eligibility criteria were then examined. Patients were most often ruled ineligible for research studies because of their level of alcohol problems (39.1% of studies), comorbid psychiatric problems (37.8%), past or concurrent utilization of alcohol treatment (31.8%), co-occurring medical conditions (31.6%), and because they were deemed non-compliant and unmotivated (31.5%). The number of eligibility criteria employed in studies increased from the 1970s through the 1990s, and was positively associated with funding from the US National Institute of Alcohol Abuse and Alcoholism (NIAAA) and from the private sector, lack of an inpatient/residential treatment condition, presence of a pharmacotherapy, and use of a randomized, multiple-condition design. Principal investigators with doctoral degrees used more eligibility criteria than those with lower degrees. Participant eligibility criteria are extensively employed in alcohol treatment outcome research, and vary significantly across historical periods, funders and research designs. Researchers should report the details of subject eligibility criteria and excluded patients more fully, and, evaluate how eligibility criteria affect the cost, feasibility, and generalizability of treatment outcome research.