Counselor turnover in substance use disorder treatment research: Observations from one multisite trial.

Background: Counselor workforce turnover is a critical area of concern for substance use disorder (SUD) treatment providers and researchers. To facilitate the adoption and implementation of innovative treatments, attention must be paid to how SUD treatment workforce issues affect the implementation of clinical effectiveness research. Multiple variables have been shown to relate to turnover, yet reasons that are specific to conducting research have not been systematically assessed. Methods: In a randomized clinical trial testing a sexual risk reduction counselor training intervention, 69 counselors at 4 outpatient SUD treatment sites (2 opioid treatment programs [OTPs], 2 psychosocial) were enrolled and randomized to 1 of 2 training conditions (Standard vs. Enhanced). Study counselor and agency turnover rates were calculated. Agency context and policies that impacted research participation were examined. Results: Study turnover rates for enrolled counselors were substantial, ranging from 33% to 74% over approximately a 2-year active study period. Study counselor turnover was significantly greater at outpatient psychosocial programs versus OTPs. Counselor turnover did not differ due to demographic or training condition assignment. Leaving agency employment was the most typical reason for study counselor turnover. Conclusions: This secondary analysis used data from a multisite study with frontline counselors to provide a qualitative description of challenges faced when conducting effectiveness research in SUD treatment settings. That counselors may be both subjects and deliverers of the interventions studied in clinical trials, with implications for differential impact on study implementation, is highlighted. We offer suggestions for researchers seeking to implement effectiveness research in SUD clinical service settings.

A Latent Class Analysis of Heterosexual Young Men's Masculinities.

Parallel bodies of research have described the diverse and complex ways that men understand and construct their masculine identities (often termed "masculinities") and, separately, how adherence to traditional notions of masculinity places men at risk for negative sexual and health outcomes. The goal of this analysis was to bring together these two streams of inquiry. Using data from a national, online sample of 555 heterosexually active young men, we employed latent class analysis (LCA) to detect patterns of masculine identities based on men's endorsement of behavioral and attitudinal indicators of "dominant" masculinity, including sexual attitudes and behaviors. LCA identified four conceptually distinct masculine identity profiles. Two groups, termed the Normative and Normative/Male Activities groups, respectively, constituted 88 % of the sample and were characterized by low levels of adherence to attitudes, sexual scripts, and behaviors consistent with "dominant" masculinity, but differed in their levels of engagement in male-oriented activities (e.g., sports teams). Only eight percent of the sample comprised a masculinity profile consistent with "traditional" ideas about masculinity; this group was labeled Misogynistic because of high levels of sexual assault and violence toward female partners. The remaining four percent constituted a Sex-Focused group, characterized by high numbers of sexual partners, but relatively low endorsement of other indicators of traditional masculinity. Follow-up analyses showed a small number of differences across groups on sexual and substance use health indicators. Findings have implications for sexual and behavioral health interventions and suggest that very few young men embody or endorse rigidly traditional forms of masculinity.

The Relationship between Interpersonal Violence Victimization and Smoking Behavior across Time and by Gender.

The current study examined relationships between interpersonal violence victimization and smoking from childhood to adulthood. Data were from a community-based longitudinal study (N = 808) spanning ages 10 - 33. Cross-lag path analysis was used to model concurrent, directional, and reciprocal effects. Results indicate that childhood physical abuse predicted smoking and partner violence in young adulthood; partner violence and smoking were reciprocally related in the transition from young-adulthood to adulthood. Gender differences in this relationship were not detected. Social work prevention efforts focused on interpersonal violence and interventions targeting smoking cessation may be critical factors for reducing both issues.

"He enjoys giving her pleasure": diversity and complexity in young men's sexual scripts.

Research on heterosexual men's sexual expectations has focused on self-described personal traits and culturally dominant models of masculinity. In a pair of studies, we used a sexual scripts perspective to explore the range and diversity of young men's thoughts about sex and relationships with women and to develop measures for assessing these scripts. In the first study, we conducted semi-structured interviews to elicit young men's accounts of their sexual relationships. We used these narratives to produce brief sexual script scenarios describing typical sexual situations, as well as conventional survey items assessing sexual behavior themes. In the second study, we administered the scenarios and theme items to an ethnically diverse, national sample of 648 heterosexually active young men in an online survey. Using exploratory factor analysis, we delineated sets of sexual scripts and sexual behavior themes. In the scenarios, we found both a traditional masculine "player" script and a script that emphasized mutual sexual pleasure. Analysis of theme items produced scales of Drinking and Courtship, Monogamy and Emotion, and Sexual Focus and Variety. We discuss the implications of these findings for understanding heterosexual men's thinking about sexuality and how cultural change in sexual thinking may arise. We also discuss the need for measures of sexual thinking that better integrate perceptions and expectations about the partner as well as the self in relation to the partner, rather than solely self-assessed traits.

Negative and Positive Factors Associated With the Well-Being of Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning (LGBTQ) Youth.

Factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth were qualitatively examined to better understand how these factors are experienced from the youths' perspectives. Largely recruited from LGBTQ youth groups, 68 youth participated in focus groups (n = 63) or individual interviews (n = 5). The sample included 50% male, 47% female, and 3% transgender participants. Researchers used a consensual methods approach to identify negative and positive factors across 8 domains. Negative factors were associated with families, schools, religious institutions, and community or neighborhood; positive factors were associated with the youth's own identity development, peer networks, and involvement in the LGBTQ community. These findings suggest a pervasiveness of negative experiences in multiple contexts, and the importance of fostering a positive LGBTQ identity and supportive peer/community networks. Efforts should work towards reducing and eliminating the prejudicial sentiments often present in the institutions and situations that LGBTQ youth encounter.

Differences between men and women in condom use, attitudes, and skills in substance abuse treatment seekers.

BACKGROUND: For substance abuse treatment-seekers engaging in high risk sexual behavior, their inconsistent condom use may be related to their condom use attitudes and skills. OBJECTIVE: This study compared treatment-seeking male and female substance abusers in their reported barriers to condom use and condom use skills. METHODS: Men and women (N = 1,105) enrolled in two multi-site HIV risk reduction studies were administered the Condom Barriers Scale, Condom Use Skills, and an audio computer-assisted structured interview assessing sexual risk behavior. RESULTS: Men endorsed more barriers to condom use, especially on the Effects on Sexual Experience factor. For both men and women, stronger endorsement of barriers to condom use was associated with less use of condoms. However, the difference between condom users and non-users in endorsement of condom barriers in general is greater for men than women, especially for those who report having casual partners. CONCLUSIONS: Findings support the need to focus on gender-specific barriers to condom use in HIV/STI prevention interventions, especially risk behavior intervention techniques that address sexual experience with condoms. SCIENTIFIC SIGNIFICANCE: Results provide additional information about the treatment and prevention needs of treatment-seeking men and women.

Multidimensional characterization of sexual minority adolescents' sexual safety strategies.

Young adults have high rates of sexually transmitted infections (STIs). Sexual minority youths' risk for STIs, including HIV, is as high as or higher than sexual majority peers'. Sexual safety, while often treated as a single behavior such as condom use, can be best conceptualized as the result of multiple factors. We used latent class analysis to identify profiles based on ever-used sexual safety strategies and lifetime number of partners among 425 self-identified LGBTQ youth aged 14-19. Data collection took place anonymously online. We identified four specific subgroup profiles for males and three for females, with each subgroup representing a different level and type of sexual safety. Profiles differed from each other in terms of age and outness for males, and in outness, personal homonegativity, and amount of education received about sexual/romantic relationships for females. Youths' sexual safety profiles have practice implications for sexuality educators, health care professionals, and parents.

The role of gender in the association between child maltreatment and substance use behavior: a systematic review of longitudinal research from 1995 to 2011.

This systematic review analyzes the role of gender in the association between childhood maltreatment and substance use outcomes, among longitudinal papers published between 1995 and 2011. Ten papers examined gender as a moderating variable. Results on gender differences were mixed. When studies that found no gender effects were compared with studies that did identify gender effects, differences in measurement, sample composition, and developmental timing of outcomes were identified. This review also examines how gender effects are assessed. Implications and limitations of these findings are discussed. Areas for future research are identified.

A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients' sexual risk behavior.

INTRODUCTION: High risk sex-such as sex with multiple partners, condomless sex, or transactional or commercial sex-is a risk factor in individuals with substance use disorders (SUDs). SUD treatment can reduce sexual risk behavior, but interventions to reduce such behavior in this context have not been consistently effective. This study sought to determine if the impact of treatment on sexual risk behavior can be increased. METHODS: In a nested 2 × 2 factorial repeated measures design, we examined outcomes of two interventions: training for counselors in talking to patients about sexual risk; and availability to both counselors and patients of a personalized feedback report based on patient self-report of sexual behavior. Counselors received either a brief, information-based, Basic Training, or a multi-session, skills-based Enhanced Training. Their patients completed an audio-assisted computerized assessment of sexual behavior and received either No Feedback or a Personalized Feedback Report (PFR). Four hundred seventy six patients participated. Patient follow-up occurred 3- and 6-months postbaseline. Primary patient outcome measures were Number of Unsafe Sex Occasions (USO) and whether patients reported talking about sex in counseling sessions (Discussed Sex), both in the past 90 days. Secondary outcomes included Number of Sexual Partners, Sex Under the Influence of Substances, and Perceived Condom Barriers. RESULTS: Patients of Enhanced-condition counselors compared to those of Basic-condition counselors were more likely to report talking about sex with their counselor at 6-month follow-up. Personalized feedback also increased the likelihood of reporting counselor discussions at 6-month follow-up. Neither the training nor the feedback condition affected USO, Number of Partners, or Sex Under the Influence. DISCUSSION: We discuss why these two interventions apparently altered counselor-patient communication about sexual risk behavior without affecting the behavior itself.

Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future.

BACKGROUND: The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings. METHODS: We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure. RESULTS: The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research. CONCLUSIONS: Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.

The impact of trauma-focused group therapy upon HIV sexual risk behaviors in the NIDA Clinical Trials Network "Women and trauma" multi-site study.

Women in drug treatment struggle with co-occurring problems, including trauma and post-traumatic stress disorder (PTSD), which can heighten HIV risk. This study examines the impact of two group therapy interventions on reduction of unprotected sexual occasions (USO) among women with substance use disorders (SUD) and PTSD. Participants were 346 women recruited from and receiving treatment at six community-based drug treatment programs participating in NIDA's Clinical Trials Network. Participants were randomized to receive 12-sessions of either seeking safety (SS), a cognitive behavioral intervention for women with PTSD and SUD, or women's health education (WHE), an attention control psychoeducational group. Participants receiving SS who were at higher sexual risk (i.e., at least 12 USO per month) significantly reduced the number of USO over 12-month follow up compared to WHE. High risk women with co-occurring PTSD and addiction may benefit from treatment addressing coping skills and trauma to reduce HIV risk.

The "Women and Trauma" study and its national impact on advancing trauma specific approaches in community substance use treatment and research.

INTRODUCTION: The "Women and Trauma" Study (WTS) conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN-0015) resulted in research publications, presentations, and a train-the-trainer workshop to support dissemination efforts for skills-based trauma treatment in substance use community treatment. Twelve years after its completion, this paper aims to examine whether and how the WTS contributed to knowledge in the field of trauma and addictions and inspired community treatment programs (CTPs) to train staff to identify and provide trauma-related services. METHOD: We present findings from two different analyses that explored longer term study impacts on treatment and dissemination: (1) a post-study site survey covering 4 domains from 4/7 programs that participated in delivering the WTS to evaluate their perceptions of study impact on their treatment community; and (2) an analysis of citations of its publications to determine impact on the scientific community. RESULTS: Surveys from responding sites indicated that participation in the study significantly increased their agencies'' awareness of the need to take a focused approach to treating trauma issues in this population. Specifically, these sites increased their commitment to using skills-based trauma treatment with the study's target population of female patients with SUD and trauma histories, as well as expanding it to other groups affected by trauma. Citation analysis revealed that according to the Web of Science, as of August 2019, the number of citations of 24 CTN-0015 articles, ranged from 1 to 135 (Mean = 20, SD = 33; Median = 6). Four of the most influential are discussed. CONCLUSIONS: This manuscript provides original information about the contributions of the WTS study, demonstrating how the study contributed to serving women with trauma in community substance use treatment.

Increasing substance use disorder counselors' self-efficacy and skills in talking to patients about sex and HIV risk: A randomized training trial.

BACKGROUND: People with substance use disorder (SUD) experience increased risk for HIV, Hepatitis C, and sexually transmitted illnesses via risky sex. This high-risk population would benefit from sexual risk reduction interventions integrated into SUD treatment. However, many SUD counselors report lack of skill or confidence in addressing sexual risk with patients. METHODS: This study was part of a larger nested 2 × 2 factorial repeated measures design, which compared two levels of counselor training (Basic-2 h versus Enhanced-10 h plus ongoing coaching). We determined whether counselors receiving Enhanced training addressing their motivation, confidence and skills (a) increased knowledge about sexual issues; (b) increased self-efficacy to discuss sex with patients; and (c) improved skills in discussing sex as part of SUD treatment, compared with those receiving shorter information-based training. Counselors providing individual therapy at two opioid treatment programs (OTP) and two psychosocial outpatient programs in the United States were eligible. Randomization occurred after Basic training. Measures included self-report (self-efficacy and knowledge) and blinded coding of standardized patient interviews (skill). RESULTS: Counselors receiving Enhanced training (n = 28) showed significant improvements compared to their Basic training counterparts (n = 32) in self-efficacy, use of reflections, and use of decision-making and communication strategies with standardized patients. These improvements were maintained from post-training to 3-month follow-up. No adverse effects of study participation were reported. CONCLUSIONS: Results suggest that counselors can improve their knowledge, self-efficacy and skill related to sexual risk conversations with patients based on modest skills-based training.

The video assessment of simulated encounters-revised (VASE-R): reliability and validity of a revised measure of motivational interviewing skills.

The video assessment of simulated encounters-revised (VASE-R) is a video-based method, administered in individual or group settings, for assessing motivational interviewing (MI) skills. The 18-item instrument includes three video-based vignettes, in which actors portray substance abusers, with each vignette followed by questions that prompt examinees to write responses that are then scored against MI standards. The VASE-R was administered to two independent samples: (1) substance abuse practitioners participating in a study of MI training methods, and (2) MI training facilitators with a high level of MI skill and expertise. This multi-study report describes basic VASE-R psychometric properties -- including scoring reliability, internal consistency, concurrent validity, and sensitivity to the effects of training -- and then presents proficiency standards based on administration to a sample of MI training facilitators (MI Experts). The findings indicate excellent inter-rater reliability using intra-class correlations for the full-scale score (.85) and acceptable levels for subscales (.44 to .73). The instrument displayed strong concurrent validity with the Helpful Responses Questionnaire (HRQ) and a behavioral sample of clinician behavior with a standardized patient scored using the MI Treatment Integrity (MITI) system, as well as good sensitivity to improvement in MI skill as a result of training. The findings provide an empirical basis for suggesting VASE-R benchmarks for beginning proficiency and expert MI practice.

Adolescent change language within a brief motivational intervention and substance use outcomes.

Homeless adolescents who used alcohol or illicit substances but were not seeking treatment (n = 54) were recorded during brief motivational interventions. Adolescent language during sessions was coded on the basis of motivational interviewing concepts (global ratings of engagement and affect, counts of commitment to change, statements about reasons for change, and statements about desire or ability to change), and ratings were tested as predictors of rates of substance use over time. Results indicate that statements about desire or ability against change, although infrequent (M = 0.61 per 5 min), were strongly and negatively predictive of changes in substance use rates (days of abstinence over the prior month) at both 1- and 3-month postbaseline assessment (ps < .001). Statements about reasons for change were associated with greater reductions in days of substance use at 1-month assessment (p < .05). Commitment language was not associated with outcomes. Results suggest that specific aspects of adolescent speech in brief interventions may be important in the prediction of change in substance use. These relationships should be examined within larger samples and other clinical contexts.

Age differences in outcomes among patients in the "Stimulant Abuser Groups to Engage in 12-Step" (STAGE-12) intervention.

Emerging adults (roughly 18-29years) with substance use disorders can benefit from participation in twelve-step mutual-help organizations (TSMHO), however their attendance and participation in such groups is relatively low. Twelve-step facilitation therapies, such as the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), may increase attendance and involvement, and lead to decreased substance use. AIMS: Analyses examined whether age moderated the STAGE-12 effects on substance use and TSMHO meeting attendance and participation. DESIGN: We utilized data from a multisite randomized controlled trial, with assessments at baseline, mid-treatment (week 4), end-of-treatment (week 8), and 3- and 6- months post-randomization. PARTICIPANTS: Participants were adults with DSM-IV diagnosed stimulant abuse or dependence (N=450) enrolling in 10 intensive outpatient substance use treatment programs across the U.S. ANALYSIS: A zero-inflated negative binomial random-effects regression model was utilized to examine age-by-treatment interactions on substance use and meeting attendance and involvement. FINDINGS: Younger age was associated with larger treatment effects for stimulant use. Specifically, younger age was associated with greater odds of remaining abstinent from stimulants in STAGE-12 versus Treatment-as-Usual; however, among those who were not abstinent during treatment, younger age was related to greater rates of stimulant use at follow-up for those in STAGE-12 compared to TAU. There was no main effect of age on stimulant use. Younger age was also related to somewhat greater active involvement in different types of TSMHO activities among those in STAGE-12 versus TAU. There were no age-by-treatment interactions for other types of substance use or for treatment attendance, however, in contrast to stimulant use; younger age was associated with lower odds of abstinence from non-stimulant drugs at follow-up, regardless of treatment condition. These results suggest that STAGE-12 can be beneficial for some emerging adults with stimulant use disorder, and ongoing assessment of continued use is of particular importance.

'Tweaking 12-Step': the potential role of 12-Step self-help group involvement in methamphetamine recovery.

AIMS: To determine from a review of the available literature the extent to which involvement in 12-Step mutual support groups could play a role in the recovery process for individuals abusing or dependent on methamphetamine. METHOD: Review of the literature on outcomes associated with 12-Step meeting attendance and involvement in 12-Step activities among substance abusers, particularly those who abuse stimulants. RESULTS: There are few if any data available on methamphetamine abusers and their use of 12-Step approaches. Evidence derived from work with alcohol- and cocaine-dependent individuals indicates that involvement in 12-Step self-help groups, both attending meetings and engaging in 12-Step activities, is associated with reduced substance use and improved outcomes. Although involvement in 12-Step fellowship improves outcome, many individuals do not engage on their own in 12-Step activities, and there are high rates of dropout from such groups. There are a number of evidence-based therapies available to assist clinicians in facilitating 12-Step involvement; however, these have not been used with methamphetamine abusers. While there are some potential barriers to adopting manualized treatment interventions into clinical practice, the familiarity, in community-based practice, of the 12-Step approach may make this easier. CONCLUSION: More actively integrating 12-Step approaches into the treatment process may provide low- or no-cost options for methamphetamine abusers and increase the capacity for providing treatment. Further research and evaluation are necessary to determine the extent to which methamphetamine abusers do engage in 12-Step self-help programs, whether they prefer more general (e.g. Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous) or drug-specific (e.g. Crystal Meth Anonymous) meetings, the rate of dropout and the outcomes associated with their involvement. Further, the efficacy of efforts to facilitate involvement of methamphetamine abusers in such 12-Step groups needs to be determined.

Replicating a teen HIV/STD preventive intervention in a multicultural city.

Although there are now several adolescent HIV and STD preventive interventions of demonstrated efficacy in the literature, little is understood about the portability of these interventions. This study replicated Stanton's Focus on Kids intervention, developed for inner city African American adolescents, in a different population, transferring it to a multicultural city. Despite careful replication of the original study's procedures, youth in the preventive intervention condition of the replication study did not improve in attitudes, perceived norms, self-efficacy, or intentions toward sexual initiation, condom use, or abstinence compared with a carefully matched control condition. We discuss several possible reasons for this failure to replicate, concluding that the most likely reason is the lower rates of sexual activity among youth in the replication city.

Brief motivational intervention with homeless adolescents: evaluating effects on substance use and service utilization.

A brief motivational intervention with 117 homeless adolescents was evaluated using a randomized design and 3-month follow-up. The intervention was designed to raise youths' concerns about their substance use, support harm reduction, and encourage greater service utilization at a collaborating agency. The study was designed to strengthen initial promising results of an earlier study (P. L. Peterson, J. S. Baer, E. A. Wells, J. A. Ginzler, & S. B. Garrett, 2006). Several modifications in the clinical protocol were included to enhance engagement with the intervention. Analyses revealed no significant benefits for intervention participants when homeless youths' substance use rates were compared with those of control participants. Service utilization during the intervention period increased for those receiving the intervention but returned to baseline levels at follow-up. Participants reported overall reductions in substance use over time. Differences between sampling methods for the current and previous study are discussed, as are the limitations of brief interventions with this population. Future research needs to elucidate mechanisms of change and service engagement for highly vulnerable youth.