A controlled trial of adaptive disclosure-enhanced to improve functioning and treat posttraumatic stress disorder.

OBJECTIVE: This is a randomized controlled trial (NCT03056157) of an enhanced adaptive disclosure (AD) psychotherapy compared to present-centered therapy (PCT; each 12 sessions) in 174 veterans with posttraumatic stress disorder (PTSD) related to traumatic loss (TL) and moral injury (MI). AD employs different strategies for different trauma types. AD-Enhanced (AD-E) uses letter writing (e.g., to the deceased), loving-kindness meditation, and bolstered homework to facilitate improved functioning to repair TL and MI-related trauma. METHOD: The primary outcomes were the Sheehan Disability Scale (SDS), evaluated at baseline, throughout treatment, and at 3- and 6-month follow-ups (Brief Inventory of Psychosocial Functioning was also administered), the Clinician-Administered PTSD Scale (CAPS-5), the Dimensions of Anger Reactions, the Revised Conflict Tactics Scale, and the Quick Drinking Screen. RESULTS: There were statistically significant between-group differences on two outcomes: The intent-to-treat (ITT) mixed-model analysis of SDS scores indicated greater improvement from baseline to posttreatment in the AD-E group (d = 2.97) compared to the PCT group, d = 1.86; -2.36, 95% CI [-3.92, -0.77], t(1,510) = -2.92, p < .001, d = 0.15. Twenty-one percent more AD-E cases made clinically significant changes on the SDS than PCT cases. From baseline to posttreatment, AD-E was also more efficacious on the CAPS-5 (d = 0.39). These differential effects did not persist at follow-up intervals. CONCLUSION: This was the first psychotherapy of veterans with TL/MI-related PTSD to show superiority relative to PCT with respect to functioning and PTSD, although the differential effect sizes were small to medium and not maintained at follow-up. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychologist veteran status as a predictor of veterans' willingness to engage in psychotherapy.

Many veterans experience difficulties with mental health and functioning, yet many do not seek treatment and dropout rates are high. A small body of literature suggests that veterans prefer to work with providers or peer support specialists who are also veterans. Research with trauma-exposed veterans suggests that some veterans prefer to work with female providers. In an experimental study with 414 veterans, we examined whether veterans' ratings of a psychologist (e.g., helpfulness, ability to understand the participant, likelihood of making an appointment) described in a vignette were impacted by the psychologist's veteran status and gender. Results indicated that veterans who read about a veteran psychologist rated the psychologist as more able to help and understand them, reported being more willing to see and more comfortable seeing the psychologist, and reported greater belief that they should see the psychologist, relative to those who read about a non-veteran psychologist. Contrary to hypotheses, there was no main effect of psychologist gender nor any interaction between psychologist gender and psychologist veteran status on ratings. Findings suggest that having access to mental health providers who are also veterans may reduce barriers to treatment-seeking among veteran patients.

Fallen Between the Cracks: Protecting Research Staff From Participant-Perpetrated Harassment.

There has been a call to identify populations who are at-risk for harassment. At our institution, participant-perpetrated harassment led to the development of an institution-wide program called Cultivating Respect in Research Environments (CuRRE). In this article, we describe the proactive and multipronged approach used to promote and implement the CuRRE program. We describe a policy created to set guidelines and expectations for research participants and discuss the educational and skills-based trainings delivered to principal investigators and research staff members. Research staff members completed anonymous surveys before and after the training. Over half of the attendees reported having been harassed by a participant/patient. Attendees responded favorably to the training; they felt more confident and better equipped to address participant-perpetrated harassment at the conclusion of the training. Given the dearth of literature in this area, we offer our experiences to encourage others to address this issue within their own research environment and institution.

Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium.

In the current paper, we first describe the rationale for and methodology employed by an international research consortium, the Moral Injury Outcome Scale (MIOS) Consortium, the aim of which is to develop and validate a content-valid measure of moral injury as a multidimensional outcome. The MIOS Consortium comprises researchers and clinicians who work with active duty military service members and veterans in the United States, the United Kingdom, the Netherlands, Australia, and Canada. We describe the multiphase psychometric development process being conducted by the Consortium, which will gather phenomenological data from service members, veterans, and clinicians to operationalize subdomains of impact and to generate content for a new measure of moral injury. Second, to illustrate the methodology being employed by the Consortium in the first phase of measure development, we present a small subset of preliminary results from semistructured interviews and questionnaires conducted with care providers (N = 26) at three of the 10 study sites. The themes derived from these initial preliminary clinician interviews suggest that exposure to potentially morally injurious events is associated with broad psychological/behavioral, social, and spiritual/existential impacts. The early findings also suggest that the outcomes associated with acts of commission or omission and events involving others' transgressions may overlap. These results will be combined with data derived from other clinicians, service members, and veterans to generate the MIOS.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Definiendo y midiendo el daño moral: fundamentos, diseño y resultados preliminares de la escala consorcio de consecuencias del daño moral DEFINIENDO Y MIDIENDO EL DAÑO MORAL En el documento actual, describimos en primer lugar los fundamentos y la metodología empleados por un consorcio internacional de investigación, la Escala Consorcio de consecuencias del daño moral (MIOS en sus siglas en inglés), cuyo objetivo es desarrollar y validar una medida de daño moral con contenido válido y como consecuencias multidimensionales. El Consorcio MIOS está compuesto por investigadores y clínicos que trabajan con miembros del servicio militar activos y veteranos en los Estados Unidos, el Reino Unido, los Países Bajos, Australia y Canadá. Describimos el proceso de desarrollo psicométrico multifase que está llevando a cabo el Consorcio, que recopilará datos fenomenológicos de miembros del servicio, veteranos y clínicos para poner en práctica subdominios de impacto y generar contenido para una nueva medida de daño moral. En segundo lugar, para ilustrar la metodología empleada por el Consorcio en la primera fase de desarrollo de la medida, presentamos un pequeño subconjunto de resultados preliminares de entrevistas semiestructuradas y cuestionarios realizados con proveedores de atención (N = 26) en tres de los 10 sitios de estudio. Los temas derivados de estas primeras entrevistas clínicas preliminares sugieren que la exposición a eventos potencialmente dañinos moralmente está asociada con amplios impactos psicológicos / conductuales, sociales y espirituales / existenciales. Los primeros hallazgos también sugieren que los resultados asociados con actos de comisión u omisión y eventos que involucran las transgresiones de otros pueden superponerse. Estos resultados se combinarán con datos derivados de otros clínicos, miembros del servicio y veteranos para generar el MIOS.

Dynamic changes in marines' reports of PTSD symptoms and problem alcohol use across the deployment cycle.

Posttraumatic stress disorder (PTSD) and alcohol misuse are commonly co-occurring problems in active-duty service members (SMs) and veterans. Unfortunately, relatively little is known about the temporal associations between these problems in the acute period following exposure to combat stressors. Discerning the temporal associations between these problems across the deployment cycle could inform prevention and treatment efforts. In this study, we examined the association between PTSD symptom severity and problem alcohol use in a large cohort of United States Marines (n = 758) evaluated prior to deployment and approximately 1, 5, and 8 months postdeployment. Results indicate that problem alcohol use was associated with a subsequent exacerbation of PTSD symptoms between the 1st and 2nd and 2nd and 3rd postdeployment assessments. PTSD symptom severity was associated with increased problem alcohol use between the 1st and 2nd postdeployment assessments. These findings suggest that problem drinking may lead to new onset or worsening of PTSD symptoms over time and that SMs with greater PTSD symptom severity upon returning from deployment may increase alcohol use in the weeks immediately following homecoming. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

"God put weed here for us to smoke": A mixed-methods study of religion and spirituality among adolescents with cannabis use disorders.

BACKGROUND: A growing literature on adults with substance use disorders (SUDs) suggests that religious and spiritual processes can support recovery, such that higher levels of religiosity and/or spirituality predict better substance use outcomes. However, studies of the role of religion and spirituality in adolescent SUD treatment response have produced mixed findings, and religiosity and spirituality have rarely been examined separately. METHODS: The present study examined religiosity and spirituality as predictors of outcomes in an outpatient treatment adolescent sample (N = 101) in which cannabis was the predominant drug of choice. Qualitative data were used to contextualize the quantitative findings. RESULTS: Results showed that higher levels of spirituality at posttreatment predicted increased cannabis use at 6-month follow-up (ß = .237, p = .043), whereas higher levels of baseline spirituality predicted a lower likelihood of heavy drinking at posttreatment (odds ratio [OR] = .316, P = .040). Religiosity did not predict substance use outcomes at later time points. When asked to describe the relation between their religious/spiritual views and their substance use, adolescents described believing that they had a choice about their substance use and were in control of it, feeling more spiritual when under the influence of cannabis, and being helped by substance use. CONCLUSIONS: Together, findings suggest that for adolescents with SUDs, religion and spirituality may not counteract the use of cannabis, which may be explained by adolescents' views of their substance use as being consistent with their spirituality and under their control.

A pilot randomized clinical trial testing integrated 12-Step facilitation (iTSF) treatment for adolescent substance use disorder.

BACKGROUND AND AIMS: The integration of 12-Step philosophy and practices is common in adolescent substance use disorder (SUD) treatment programs, particularly in North America. However, although numerous experimental studies have tested 12-Step facilitation (TSF) treatments among adults, no studies have tested TSF-specific treatments for adolescents. We tested the efficacy of a novel integrated TSF. DESIGN: Explanatory, parallel-group, randomized clinical trial comparing 10 sessions of either motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT; n = 30) or a novel integrated TSF (iTSF; n = 29), with follow-up assessments at 3, 6 and 9 months following treatment entry. SETTING: Out-patient addiction clinic in the United States. PARTICIPANTS: Adolescents [n = 59; mean age = 16.8 (1.7) years; range = 14-21; 27% female; 78% white]. INTERVENTION AND COMPARATOR: The iTSF integrated 12-Step with motivational and cognitive-behavioral strategies, and was compared with state-of-the-art MET/CBT for SUD. MEASUREMENTS: Primary outcome: percentage days abstinent (PDA); secondary outcomes: 12-Step attendance, substance-related consequences, longest period of abstinence, proportion abstinent/mostly abstinent, psychiatric symptoms. FINDINGS: Primary outcome: PDA was not significantly different across treatments [b = 0.08, 95% confidence interval (CI) = -0.08 to 0.24, P = 0.33; Bayes' factor = 0.28). SECONDARY OUTCOMES: during treatment, iTSF patients had substantially greater 12-Step attendance, but this advantage declined thereafter (b = -0.87; 95% CI = -1.67 to 0.07, P = 0.03). iTSF did show a significant advantage at all follow-up points for substance-related consequences (b = -0.42; 95% CI = -0.80 to -0.04, P < 0.05; effect size range d = 0.26-0.71). Other secondary outcomes did not differ significantly between treatments, but effect sizes tended to favor iTSF. Throughout the entire sample, greater 12-Step meeting attendance was associated significantly with longer abstinence during (r = 0.39, P = 0.008), and early following (r = 0.30, P = 0.049), treatment. CONCLUSION: Compared with motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT), in terms of abstinence, a novel integrated 12-Step facilitation treatment for adolescent substance use disorder (iTSF) showed no greater benefits, but showed benefits in terms of 12-Step attendance and consequences. Given widespread use of combinations of 12-Step, MET and CBT in adolescent community out-patient settings in North America, iTSF may provide an integrated evidence-based option that is compatible with existing practices.

Psychosocial rehabilitation after war trauma with adaptive disclosure: Design and rationale of a comparative efficacy trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) from warzone exposure is associated with chronic and disabling social and occupational problems. However, functional impairment is rarely assessed or targeted directly in PTSD treatments, which instead focus on symptom reduction. Trauma-related contributors to diminished functioning, including guilt, shame, and anger resulting from morally compromising or loss-based war experiences, are also underemphasized. The goal of this clinical trial is to fill a substantial gap in the treatment of military-related PTSD by testing a modified Adaptive Disclosure (AD) therapy for war-related PTSD stemming from moral injury and traumatic loss focused on improving psychosocial functioning AD. METHOD AND DESIGN: This paper describes the rationale and design of a multi-site randomized controlled trial comparing AD to Present-Centered Therapy (PCT). We will recruit 186 veterans with PTSD, who will be assessed at baseline, post-treatment, and 3- and 6-months post-treatment. Primary outcomes are functional changes (i.e., functioning/disability and quality of life). Secondary outcomes are mental health variables (i.e., PTSD, depression, guilt, shame). We hypothesize that veterans treated with AD will experience greater improvements in all outcomes compared to those treated with PCT. DISCUSSION: This trial will advance knowledge in rehabilitation research by testing the first therapy specifically designed to address psychosocial functioning among veterans with war-related PTSD. The results may improve the quality of mental health care for veterans by offering an ecologically sound treatment for experiences that are uniquely impactful for war veterans.

Developing and Testing Twelve-Step Facilitation for Adolescents with Substance Use Disorder: Manual Development and Preliminary Outcomes.

Adolescent substance use disorder treatment programs are often based on the 12-step philosophy of Alcoholics Anonymous and/or link adolescents to these free resources. Despite this, no studies have developed and rigorously tested a twelve-step facilitation (TSF) intervention for young people, leaving a significant evidence gap. This study describes the first systematic development of an outpatient adolescent TSF treatment. An integrated twelve-step facilitation (iTSF) treatment incorporated TSF, motivational enhancement therapy, and cognitive behavioral therapy elements and was developed in an iterative manner with weekly feedback provided by 36 adolescents (M age 17 years [SD = 1.4]; 52.8% white) with DSM-IV substance use disorder recruited from the community. Assessments were conducted at baseline and at three and six months. Participants completed 6 of 10 sessions on average (8 participants completed all 10). Notable treatment developments were the inclusion of "in-services" led by Marijuana Anonymous members, including parents in a portion of individual sessions to provide a rationale for TSF, and use of a Socratic therapeutic interaction style. Acceptability and feasibility of the treatment were excellent (treatment satisfaction was 4.29 [SD = 0.59] out of 5). In keeping with TSF theory, the intervention substantially increased 12-step participation, and greater participation related to greater abstinence. iTSF is a replicable manualized treatment that can be implemented and tested in outpatient settings. Given the widespread compatibility of iTSF with the current adolescent treatment, if found efficacious, iTSF could be relatively easily adopted, implemented, and sustained and could provide an evidence-based option that could undergird current practice.

Religiosity as a Predictor of Adolescents' Substance Use Disorder Treatment Outcomes.

BACKGROUND: A growing body of research on adults with substance use disorders (SUDs) suggests that higher levels of religiosity and/or spirituality are associated with better treatment outcomes. However, investigation into the role of religiosity and spirituality in adolescent SUD treatment response remains scarce. The present study examines religiosity as a predictor of treatment outcomes in an adolescent sample, with alcohol/other drug problem recognition as a hypothesized moderator of this relationship. Problem recognition was selected as a moderator in an attempt to identify a subset of adolescents who would be more likely to use religious resources when attempting to change their substance use. METHODS: One hundred twenty-seven outpatient adolescents aged 14 to 19 (Mage=16.7, SD=1.2, 24% female) were followed for 1 year after treatment intake. Growth curve analyses were used to assess the impact of baseline religiosity and problem recognition on subsequent abstinence rates, drug-related consequences, and psychological distress. RESULTS: On average, abstinence did not change significantly during the follow-up period, whereas drug-related consequences and psychological distress decreased significantly. Religiosity did not predict changes in abstinence or psychological distress over time. Religiosity did predict reductions in drug-related consequences over time (b=-0.20, t=-2.18, P=.03). However, when problem recognition was added to the model, the impact of religiosity on consequences became nonsignificant, and there was no interaction between religiosity and problem recognition on consequences. CONCLUSIONS: The main hypothesis was largely unsupported. Possible explanations include that the sample was low in religiosity and few participants were actively seeking sobriety at treatment intake. Findings suggest adolescent outpatients with SUD may differ from their adult counterparts in the role that religiosity plays in recovery.

Does Mandated Treatment Benefit Youth? A Prospective Investigation of Adolescent Justice System Involvement, Treatment Motivation, and Substance Use Outcomes.

BACKGROUND: The majority of adolescents treated for substance use disorder (SUD) in the United States are now referred by the criminal justice system. Little is known, however, regarding how justice-system involvement relates to adolescent community treatment outcomes. Controversy exists, also, over the extent to which justice system involvement reflects a lack of intrinsic motivation for treatment. This study examined the relation between justice system referral and reported reason for treatment entry and tested the extent to which each predicted treatment response and outcome. METHOD: Adolescent outpatients (N = 127; M age = 16.7, 24% female) with varying levels of justice-system involvement (i.e., no justice system involvement [No-JSI; n = 63], justice-system involved [JSI; n = 40], justice system involved-mandated [JSI-M; n = 24]) and motivation levels (i.e., self-motivated [n = 40], externally-motivated [n = 87]) were compared at treatment intake. Multilevel mixed models tested these groups' effects on percent days abstinent (PDA) and odds of heavy drinking (HD) over 12 months. RESULTS: JSI-M were less likely to be self-motivated compared to No-JSI or JSI (p = 0.009). JSI-M had higher PDA overall, but with significant declines over time, relative to no-JSI. Self-motivated patients did not differ from externally-motivated patients on PDA or HD. CONCLUSIONS: Mandated adolescent outpatients were substantially less likely to report self-motivated treatment entry. Despite the notion that self-motivated treatment entry would be likely to produce better outcomes, a judicial mandate appears to predict an initially stronger treatment response, although this diminishes over time. Ongoing monitoring and/or treatment may be necessary to help maintain treatment gains for justice system-involved adolescents.

Empirical awakening: the new science on mutual help and implications for cost containment under health care reform.

Over the past 75 years, Alcoholics Anonymous (AA) has grown from 2 members to over 2 million members. AA and similar organizations (e.g., Narcotics Anonymous [NA]) are among the most commonly sought sources of help for substance-related problems in the United States. It is only relatively recently, however, that the scientific community has conducted rigorous studies on the clinical utility and health care cost-offset potential of mutual-help groups and developed and tested professional treatments to facilitate their use. As a result of this research, AA as an organization has experienced an "empirical awakening," evolving from its peripheral status as a "nuisance variable" and perceived obstacle to progress to playing a more central role in a scientifically informed recovery oriented system of care. Also, professionally delivered interventions designed to facilitate the use of AA and NA ("Twelve-Step Facilitation" [TSF]) are now "empirically supported treatments" as defined by US federal agencies and the American Psychological Association. Under the auspices of health care reform, a rational societal response to the prodigious health and social burden posed by alcohol and other drug misuse should encompass the implementation of empirically based strategies (e.g., TSF) in order to maximize the use of ubiquitous mutual-help recovery resources.

Ensuring Retention in Longitudinal Studies: A Practical Evaluation of an Intensive Follow-up Protocol and Suggested Adaptations.

Ensuring retention in longitudinal studies of individuals with substance use disorders (SUD) is a continual challenge for researchers. This study made several modifications to a highly intensive follow-up protocol (Scott, 2004), originally designed for adults with SUD, in order to adapt it to a group of adolescents in low-intensity outpatient SUD treatment (N = 127, M age 16.7 yrs) and to accommodate limitations in the financial resources available for study staffing and transportation. In the present sample, adolescent participants generally found it unreasonable for study staff to request to contact people outside their immediate family in order to locate them and to attempt to schedule interviews 3-6 months in advance, as specified in the original protocol. Changes were made to accommodate these concerns and follow-up rates remained high (85-91%). Even though this study is limited by its non-experimental nature, it provides a replicable example of a scaled-down, less costly version of a highly intensive follow-up protocol that can be used to achieve high follow-up rates in studies of adolescents with SUD. We hope this will be encouraging for researchers and program evaluators who have limited resources or who work with participants who express concerns about privacy or study burden.

How safe are adolescents at Alcoholics Anonymous and Narcotics Anonymous meetings? A prospective investigation with outpatient youth.

Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have proven to be cost-effective recovery resources for adults and also appear helpful for youth. However, anecdotal concerns about adolescents' safety at meetings have dampened enthusiasm regarding youth participation. Unfortunately, little information exists to evaluate such concerns. Outpatients (N = 127; 24% female) were assessed at intake and at 3, 6, and 12 months regarding perceived safety at AA/NA, experience of negative incidents, and reasons for nonattendance/discontinuation. By 12-month follow-up, 57.5% reported some AA/NA attendance with a combined lifetime exposure of 5,340 meetings. Of these, 21.9% reported at least one negative experience, which was more common among NA than AA attendees. Overall, youth reported feeling very safe at meetings, and ratings did not differ by age or gender. Reasons for discontinuation or nonattendance were unrelated to safety or negative incidents. Weighing risks against documented benefits, these preliminary findings suggest that referral to AA/NA should not be discouraged, but, similar to adults, youth experiences at meetings should be monitored.

The role of mutual-help groups in extending the framework of treatment.

Alcohol use disorders (AUDs) are highly prevalent in the United States and often are chronic conditions that require ongoing episodes of care over many years to achieve full sustained remission. Despite substantial scientific advances in specialized care, professional resources alone have not been able to cope with the immense burden of disease attributable to alcohol. Perhaps in tacit recognition of this, peer-run mutual-help groups (MHGs), such as Alcoholics Anonymous (AA), have emerged and proliferated in the past 75 years and continue to play an important role in recovery from AUDs. This article describes the nature and prevalence of MHGs, particularly AA, and reviews evidence for their effectiveness and cost-effectiveness and the mechanisms through which they may exert their effects. The article also provides details about how health care professionals can facilitate their alcohol-dependent patients' participation in such groups and reviews the evidence for the benefits of doing so.

Can 12-step group participation strengthen and extend the benefits of adolescent addiction treatment? A prospective analysis.

BACKGROUND: Despite advances in the development of treatments for adolescents with substance use disorders (SUD), relapse remains common following an index treatment episode. Community continuing care resources, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), have been shown to be helpful and cost-effective recovery resources among adults. However, little is known about the clinical utility and effectiveness of AA/NA for adolescents, despite widespread treatment referrals. METHOD: Adolescents (N=127; 24% female, 87% White, M age=16.7 years) enrolled in a naturalistic, prospective study of community outpatient treatment were assessed at intake, and 3 and 6 months later using a battery of standardized and validated measures. RESULTS: Just over one-quarter of youth attended AA/NA meetings during the first 3 months, which was predicted by a goal of abstinence, prior AA/NA attendance, and prior SUD treatment experiences. Controlled multiple regression analyses revealed an independent effect of AA/NA on abstinence, in both contemporaneous and lagged models, which persisted over and above the effects of pre-treatment AA/NA attendance, prior treatment, self-efficacy, abstinence goal, and concomitant outpatient treatment. CONCLUSIONS: Results suggest that, similar to findings comparing adult outpatients to inpatients, AA/NA participation is less common among less severe adolescent outpatients. Nonetheless, attendance appears to strengthen and extend the benefits of typical community outpatient treatment. Given the dramatic increase in rates of substance use among same-aged peers in the population at this life-stage, and the relative dearth of abstainers and recovery-specific supports, these resources may provide a concentrated cost-effective social recovery resource for young people.

TREATMENT STAFF REFERRALS, PARTICIPATION EXPECTATIONS, AND PERCEIVED BENEFITS AND BARRIERS TO ADOLESCENT INVOLVEMENT IN 12-STEP GROUPS.

Adolescents treated for substance use disorders (SUD) appear to benefit from AA/NA participation. However, as compared to adults, fewer adolescents attend, and those who do attend do so less intensively and discontinue sooner. It is unknown whether this disparity is due to a lowered expectation for youth participation by the clinicians treating them, as they may adapt the adult-based model to fit a less dependent cohort, or whether recommendations are similar to those of clinicians who work with adults, and other factors are responsible. All clinical staff (N = 114) at five adolescent programs (3 residential, 2 outpatient) were surveyed anonymously about referral practices and other beliefs about 12-step groups. Staff rated AA/NA participation as very important and helpful to adolescent recovery and referral rates were uniformly high (M = 86%, SD = 28%). Desired participation frequency was over 3 times per week. The theoretical orientation and level of care of the programs influenced some results. Findings suggest lower adolescent participation in 12-step groups is not due to a lack of clinician enthusiasm or referrals, but appears to be due to other factors.