Schedule of voucher delivery influences initiation of cocaine abstinence.

This study examined whether voucher delivery arrangements affect treatment outcome. First, 90 cocaine-dependent adults were randomly assigned to behavioral counseling or counseling plus vouchers for cocaine-free urine samples. The value of each voucher was low at the beginning but increased as the patient progressed (Voucher Schedule 1). Voucher Schedule 1 produced no improvements relative to counseling only. Next, 23 patients received vouchers on either Voucher Schedule 1 or Voucher Schedule 2. Voucher Schedule 2 began with high voucher values, but requirements for earning vouchers increased as the patient progressed. Average durations of cocaine abstinence were 6.9 weeks on Voucher Schedule 2 versus 2.0 weeks on Voucher Schedule 1 (p = .02). This confirms that vouchers can assist in initiating abstinence and that voucher delivery arrangements are critical.

Decline in self-reported dysphoria after treatment entry in inner-city cocaine addicts.

This study examined self-reported dysphoria in 82 consecutive admissions to intensive outpatient treatment for cocaine abuse on whom data for the Beck scales for depression, anxiety, and hopelessness were available for intake and 4 subsequent weeks with no more than 1 missing data point. Mean scores on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) decreased significantly between intake and Week 1, with no further significant changes from Weeks 1-4. Similar drops in the rate of clinically significant BDI and BAI scores also were observed. Scores on the Beck Hopelessness Scale (BHS) showed no significant changes. By Week 4, rates of clinically significant depression, anxiety, and hopelessness were similar (17%, 13%, and 16%, respectively). These findings suggest that assessing depression and anxiety using the BDI and BAI in this population should be postponed for at least 1 week after intake and that intake levels of self-reported mood may be inappropriate baseline measures for evaluating treatment effects.

Community reinforcement training for family and significant others of drug abusers: a unilateral intervention to increase treatment entry of drug users.

We randomly assigned 32 concerned family members and significant others (FSOs) of drug users (DUs) to a community reinforcement training intervention or a popular 12-step self-help group. We measured problems arising from the DU's behavior, social functioning of the DU and FSO, and mood of the FSO at baseline and 10 weeks later. We also monitored the FSOs' treatment attendance and treatment entry of the DUs. The treatment groups showed equal reductions from baseline to follow-up in problems and improvements in social functioning and mood of the FSO. However the community reinforcement intervention was significantly better at retaining FSOs in treatment and inducing treatment entry of the DUs.

Assessment of coercive and noncoercive pressures to enter drug abuse treatment.

This paper reports preliminary data derived from a standardized interview scoring procedure for detecting and characterizing coercive and noncoercive pressures to enter substance abuse treatment. Coercive and noncoercive pressures stemming from multiple psychosocial domains are operationalized through recourse to established behavioral principles. Inter-rater reliability for the scoring procedure was exceptional over numerous rater trials. Substantive analyses indicate that, among clients in outpatient cocaine treatment, 'coercion' is operative in multiple psychosocial domains, and that subjects perceive legal pressures as exerting substantially less influence over their decisions to enter treatment than informal psychosocial pressures. Implications for drug treatment planning, legal and ethical issues, and directions for future research are proposed.

Structured interview versus self-report test vantages for the assessment of personality pathology in cocaine dependence.

The study compared structured interview (SCID-II) and self-report test (MCMI-II) vantages for the detection and characterization of personality pathology among 144 urban, poor, cocaine-addicted individuals seeking outpatient treatment. Diagnostic agreement was inadequate for most disorders, and the instruments at best shared only modest common variance. Positive predictive power was poor for all MCMI-II scales, though negative predictive power was good to excellent. This lends support for the use of the MCMI-II as a screening measure to rule out Axis II disorders; however, confirmation of positive diagnoses will require follow-up interview assessment. Future development of self-report personality inventories for substance abusers should focus on controlling for the acute dysphoric effects of drug use and related dysfunction, expanding attention to Cluster B content domains, and incorporating more objective criteria for assessing paranoia and "odd/eccentric" traits.

Multidimensional assessment of perceived treatment-entry pressures among substance abusers.

Motivational assessment instruments typically measure clients' attributions about their readiness to change problem behaviors. They do not indicate why a client may be motivated to change, or provide guidance on how to retain an unmotivated client in treatment. The authors interviewed 415 substance abuse clients about their reasons for entering treatment and scored their responses along the dimensions of (a) negative versus positive treatment-entry pressures, (b) internal versus external sources of those pressures, and (c) the life domain from which the pressures emanated. Exploratory cluster analysis yielded 5 types of clients characterized by different profiles of perceived treatment-entry pressures. Cluster membership was predictive of treatment outcomes, and the clusters differed by demographic variables. These data support the discriminative and predictive utility of performing a multidimensional assessment of pressures to enter treatment.

Counselor prompts to increase condom taking during treatment for cocaine dependence.

This study examined whether active prompting would increase the number of free condoms taken from dispensers placed in counselors' offices in a cocaine abuse treatment clinic. Using a combined multiple baseline and reversal design, two teams of counselors were instructed to actively prompt and encourage condom taking during some conditions and to avoid commenting on or encouraging condom use in other conditions. To monitor accuracy of implementing the intervention, counselors completed a checklist for every subject they saw in their office during the day. Overall, the number of condoms taken per visit during prompting conditions was almost six times greater than during baseline conditions. However, implementation declined during the study, and all counselors complained about the intervention. Implications for dispensing free condoms to reduce HIV risk in drug abuse treatment clinics are discussed.

PIP: HIV infection is increasing among noninjecting as well as iv drug users. Of particular concern, are users of cocaine and crack cocaine, who are likely to trade sex for money or drugs and to have multiple sexual partners. This study investigated whether an active counselor intervention could increase the number of free condoms taken from dispensers placed in counselors' offices in a cocaine abuse treatment program in Philadelphia, Pennsylvania (US). A multiple baseline design across 2 teams of counselors with reversals was utilized. During the initial 5-week baseline period, when condoms were displayed on the counselors' desks but no prompts were given, an average of 0.34 and 0.25 condoms were taken per visit per team. During weeks 6-13, when counseling Team 1 utilized prompting and encouraged condom taking, this average increased to 3.17/visit. When Team 2 implemented the intervention (weeks 13-20), an average of 2.78 condoms/visit were taken. When both teams stopped the intervention, the number of condoms taken fell close to baseline levels. Resumption of the intervention increased use, but not to the previous high level. Over the entire 28-week study period, clients took an average of 0.43 condoms/visit during baseline conditions, and 2.45/visit during counselor prompting conditions. The 6-fold increase in condom uptake associated with active encouragement suggests the feasibility of this strategy for cocaine treatment programs. However, the participating counselors voiced irritation with the mandatory, sometimes intrusive intervention. The availability of free condoms in the clinic waiting area or day room represents an alternative strategy documented to increase the taking of condoms.

Effect of dispenser location on taking free condoms in an outpatient cocaine abuse treatment clinic.

Crack cocaine use increases risky sexual behavior and HIV exposure; therefore, safe sexual practices should be encouraged during cocaine addiction treatment. Research indicates that placing condom dispensers in private restrooms increases taking free condoms. We investigated two other dispenser locations (a day room vs. counselors' offices) and found that substantially more condoms were taken when dispensers were in the day room. This is an important issue for public health facilities without private restrooms.

The accelerated intake: a method for increasing initial attendance to outpatient cocaine treatment.

We examined whether offering an accelerated (same-day) versus a standard (1- to 7-day delay) intake appointment increased initial attendance at an outpatient cocaine treatment program. Significantly more of the subjects who were offered an accelerated intake (59%) attended than those who were given a standard intake (33%), chi 2 (2, N = 78) = 4.198, p < .05. The accelerated intake procedure appears to be useful for enhancing enrollment in outpatient addiction treatment.

Assessment of depression: using the MMPI, Millon, and Millon-II.

The analysis examined how the MMPI, original Millon, and Millon-II may be used for the assessment of clinical and personality characteristics of depressed patients. High-point code-type analysis of data from 133 depressed inpatients yielded seven MMPI personality profiles (incapacitated-depressive, intropunitive-depressive, caught psychopath, hysteroid-dysphoric, schizotypal-depressive, ruminative-depressive, and psychotic-depressive) and eight Millon personality profiles (avoidant-depressive, conforming-depressive, hostile-depressive, hysteroid-depressive, disenfranchised-depressive, guilty-depressive, passive aggressive-depressive, and anaclitic-depressive). These profiles reflect important similarities in the personalities of the tested depressed inpatients and differences among them as well. Our interpretive framework is speculative but offers a basis for clinical hypothesis generation.

A hybrid decision framework for evaluating psychometric evidence.

The United States Supreme Court in Daubert v. Merrell Dow Pharmaceuticals (1993) directed federal trial judges to preliminarily evaluate the scientific bases of proffered expert evidence. This article presents a decision flowchart for evaluating psychometric data, and attempts to operationalize existing evidentiary standards in hybrid (part science/part law) terms. The resulting framework should better assist courts and forensic experts to understand, evaluate, and apply scientific reasoning in determining the admissibility and probative value of psychometric evidence.

The diagnosis and assessment of depression, mania, and psychosis by self-report.

We examined the usefulness of the Minnesota Multiphasic Personality Inventory (MMPI), the original and revised versions of the Millon Clinical Multiaxial Inventory (MCMI and MCMI-II), and the Symptom Checklist-90-R (SCL-90-R) for the diagnosis and assessment of depression, mania, and psychosis in a heterogeneous group of 272 psychiatric inpatients. We examined the following: diagnostic efficiency of single scales at specified cutoff scores for these conditions, multidimensional test profiles, MMPI high-point codes, and associated MCMI and MCMI-II personality disorders. The reported findings are discussed in terms of how these tests may and may not be used to answer particular assessment questions and what the self-report vantage contributes to the entire clinical assessment process.

Contributions of discriminant analysis to differential diagnosis by self-report.

We used discriminant function analyses of the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1983), Millon Clinical Multiaxial Inventory (MCMI; Millon, 1983), MCMI-II (Millon, 1987), and Symptom Checklist Ninety-Revised (SCL-90-R; Derogatis, 1983) profiles from a heterogenous group of 272 psychiatric inpatients to classify patients as depressed, manic, and/or psychotic. Most functions generated from these tests significantly discriminated depressed, manic (not MCMI-II), and psychotic (not MCMI) subjects from psychiatric controls. However, there was little improvement in diagnostic efficiency over the use of single scale elevations at specified cut scores. Functions derived from the MCMI for mania and the MCMI-II for psychosis show the most promise but require replication. The difficulty of using group profile differences for the diagnosis of individual psychiatric patients is discussed.

Voluntary intoxication and criminal responsibility.

This paper reviews the law related to voluntary intoxication and criminal responsibility in the 50 United States, the District of Columbia, the US Virgin islands, and Puerto Rico. Statutory and case law citations are provided which govern the use of intoxication evidence in each jurisdiction to negate mens rea (i.e., to establish diminished capacity), to support an insanity defense, and to mitigate criminal sentencing. Factors that courts typically focus on when deciding whether to admit this evidence in a particular case are discussed, and these factors are related to clinically relevant criteria.

Impact of comorbid personality disorders and personality disorder symptoms on outcomes of behavioral treatment for cocaine dependence.

Studies have revealed a significant adverse impact of comorbid personality disorders on treatment tenure and outcome in a variety of psychiatric and substance abuse populations. We investigated whether this negative relationship also exists among 137 urban, poor, cocaine abusers in behaviorally oriented treatment. Axis II diagnoses were generated categorically using the SCID-II as well as dimensionally using numbers of SCID-II symptoms within diagnostic categories. Contrary to expectations, there were no significant differences between subjects with and without various categorical personality disorders on any outcome measures. Categorical Axis II diagnoses were also minimally correlated with drug use severity, depression, and anxiety at intake, indicating that these were not potential coveriates of outcome. However, dimensional analyses of personality symptoms generated from the SCID-II accounted for substantial proportions of variance in treatment outcomes. Implications of these data for Axis II assessment and drug treatment planning are discussed.

Congruence of the MCMI-II and MCMI-III in cocaine dependence.

This study compared the MCMI-II and MCMI-III among 40 urban, poor, cocaine abusers in outpatient treatment. The mean group profiles had strikingly similar relative elevations on the Antisocial, Narcissistic, Aggressive-Sadistic, Alcohol Dependence, and Drug Dependence scales. However, the MCMI-III group profile was significantly lower in magnitude compared with the MCMI-II. Interval and rank-order correlations were moderate to low for most scales, and 90% of participants produced discrepant 2-point codetypes between the 2 tests. These results suggest that clinicians working in substance abuse settings should perhaps adjust MCMI-III profile elevations upward on most scales (particularly on the personality disorder scales) when comparing results to extant normative data and should use caution when referencing MCMI/MCMI-II interpretive manuals for descriptive correlates of MCMI-III scales and codetypes.