A pilot test of Written Exposure Therapy for PTSD in residential substance use treatment.

BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUD) and can impede SUD recovery. Residential SUD treatment is a crucial opportunity to address PTSD. However, PTSD treatment is lacking in residential SUD care. METHODS: We conducted a nonrandomized feasibility study of Written Exposure Therapy (WET), a brief, evidence-based treatment for PTSD, with patients in residential SUD treatment. We assessed attitudes towards treatment (Credibility and Expectancy Questionnaire, Barriers to Treatment Participation Scale) and mental health indicators (PTSD Checklist for DSM-5, Trauma Coping Self-Efficacy, Difficulties in Emotion Regulation-Short Form, and Brief Assessment of Recovery Capital). RESULTS: Thirty of 49 eligible participants completed WET (61%) and 92% (n = 45) attended at least one WET session. Paired sample t-tests revealed significant posttreatment improvement across all mental health indicators, with medium to large effect sizes. DISCUSSION AND CONCLUSIONS: Attendance and completion rates compared favorably to prior exposure-based treatment for PTSD in SUD settings. Although causality cannot be inferred without a randomized controlled trial, mental health indicators, including PTSD, improved significantly following WET. SCIENTIFIC SIGNIFICANCE: These findings provide evidence that PTSD can be successfully treated in short-term residential care using brief exposure-based interventions, which is a crucial clinical need that has been minimally studied in the past.

The Effects of Prolonged Exposure on Substance Use in Patients With Posttraumatic Stress Disorder and Substance Use Disorders.

Despite research demonstrating the benefit of exposure-based therapy for posttraumatic stress disorder (PTSD) in patients with co-occurring substance use disorders, there remains a strong clinical expectation that this treatment will exacerbate substance use or other psychiatric symptoms. The present study evaluated within-session and session-to-session changes in (a) craving and use of substances for a range of drug classes and (b) symptoms of PTSD and other psychiatric distress in a sample of 44 SUD patients who received prolonged exposure (PE) therapy for PTSD. Visual analog scales showed no within-session increases in craving, except for cocaine, within Session 8. Across sessions, craving scores dropped for heroin, methadone, benzodiazepines, and cocaine; no increases in craving were found. Past-week substance use reported at each session did not differ. The severity of PTSD symptoms and self-reported serious emotional problems decreased from Session 1 to subsequent sessions, with no increases or decreases in other psychiatric, social, or medical problems. Finally, PTSD severity was unrelated to substance use reported 1 or 2 weeks later. Substance use during the past week was associated with higher PTSD severity scores at the next session, B = 6.86 (SE = 2.87), p = .018, but was not associated 2 weeks later. These findings indicate that the concern that exposure therapy for PTSD will increase SUD patients' substance use or other psychiatric symptoms may be unwarranted, and, thus, SUD patients, including those who are actively using, should have access to effective treatments for PTSD, like PE.

The Development and Evaluation of a Statewide Training Center for Home Visitors and Supervisors.

This paper informs practice in community-based home visiting workforce development by describing the development and evaluation of a university-based training certificate program for home visitors and supervisors. The Interactive Systems Framework for Dissemination and Implementation (ISF; Wandersman et al., 2008) guides our conceptualization and paper organization. The ISF describes the components involved in translating research findings into effective implementation of prevention programs. We describe implementation and lessons learned from seven development activities: (a) review of the literature, (b) survey of other training initiatives across the country, (c) focus groups with home visitors and supervisors, (d) consultation with individual home visitors, (e) creation of a state advisory board of home visiting providers and stakeholders, (f) evaluation of two pilot trainings, and (g) video development. We then present evaluation data from 49 home visitors and 23 supervisors who completed the training certificate program after the pilot trainings. Both home visitors and supervisors rated training satisfaction highly, reported significant increases in self-efficacy related to the training topics, and reported extensive use of motivational communication techniques, which are the foundational skills of the training content. These and other favorable results reflect the benefits of building on advances in theory and science-based practice and of involving providers and stakeholders repeatedly throughout the development process.

Working Memory Training for Adolescents With Cannabis Use Disorders: A Randomized Controlled Trial.

Adolescent cannabis use is associated with working memory impairment. The present randomized controlled trial assigned adolescents ages 14 to 21 enrolled in cannabis use treatment to receive either working memory training (experimental group) or a control training (control group) as an adjunctive treatment. Cognitive function, drug use, and other outcomes were assessed before and after training. We observed few differences in cognitive, functional, or self-reported drug use outcomes as a function of training group, although tetrahydrocannabinol (THC) urinalysis results favored the experimental group. These findings are similar to previous studies in substance users, which have shown limited transfer effects for working memory training.

Stress Exposure and PTSD in a Cross-Sectional Residential Substance Use Treatment Sample.

BACKGROUND: Aim 1 of this cross-sectional, observational study with people in residential treatment for substance use disorders (SUDs) was to document stress exposure. Aim 2 was to assess potential sociodemographic and health differences based on probable posttraumatic stress disorder (PTSD) status. Aim 3 was to assess relative contributions of Diagnostic and Statistical Manual (DSM)-congruent versus DSM-incongruent stressors (Criterion A vs non-Criterion A) to mental and physical health. We hypothesized that both types of stressors would significantly contribute to impairment across indicators and that DSM-congruent stressor exposure would be more strongly associated with impairment than DSM-incongruent exposure. METHODS: We assessed exposure to DSM-congruent traumatic stressors and DSM-incongruent life stressors, PTSD and depressive symptoms, emotion regulation difficulties, substance use recovery capital, and physical/mental health-related quality of life among 136 people in residential SUD treatment who were 64% men, 36% women; 49% white, 41% Black, 11% multiracial/another race; 18% lesbian, gay, or bisexual (LGB+); mean age = 39.82 (standard deviation = 12.24) years. RESULTS: Participants reported experiencing a mean of 9.76 (SD = 6.11) DSM-congruent events. Those with probable PTSD were younger and more likely to be LGB+ than those without probable PTSD (P < .05). Experiencing higher numbers of DSM-congruent events was associated with more severe PTSD and depressive symptoms, emotion regulation difficulties, and lower physical health-related quality of life (P < .05). DSM-incongruent stressor exposure was not independently associated with any indicators. Recovery capital was not associated with either type of stress exposure. CONCLUSIONS: Stressful event exposure among people in residential SUD treatment is very high. Those who are younger or LGB+ in residential SUD treatment may be at greater risk of developing PTSD. DSM-congruent stressors are more consistently associated with mental health indicators than are DSM-incongruent stressors. Prioritizing treatment targets and identifying implementable treatment strategies can be challenging with this complex population.

Risky sex: interactions among ethnicity, sexual sensation seeking, sexual inhibition, and sexual excitation.

Rates of sexually transmitted infections, including HIV, vary across ethnic minority groups, yet few studies have evaluated sexual risk behaviors and their psychological correlates to determine if risk and protective factors vary by ethnicity. The purpose of the current study was to assess sexual sensation seeking (SSS), sexual inhibition (SIS1 and SIS2), and sexual excitation (SES) as correlates of risky sexual behaviors in 106 (55 male and 51 female) Asian Americans, African Americans, and Caucasian Americans. Results revealed that higher SSS was associated with more vaginal and anal sex partners. Further, the association between SSS and the number of anal sex partners was positive among Asian Americans and Caucasians, but non-significant among African Americans. SIS1 was positively associated with unprotected sex on the first date among Asian Americans and African Americans. However, the association was not significant for Caucasians. SIS2 was negatively associated with general unprotected sex, and SES was positively associated with the number of vaginal sex partners. Findings suggest that ethnicity plays an important moderating role in the relationship between sexual traits and risky sexual behaviors.

Preventing Relationship Abuse Among College Students: A Controlled Trial of the Skills for Healthy Adult Relationships (SHARe) Program.

Intimate partner violence (IPV), which includes emotional, physical, and sexual violence in casual/dating and committed relationships, occurs at disproportionately high rates among college students. Prevention in college-age years is developmentally crucial, as college is associated with IPV risk. Relationship skills training has shown preliminary efficacy in decreasing IPV among college students. This article presents data from a controlled trial of Skills for Healthy Adult Relationships (SHARe), a weekly eight-session (12-hr) group program for college students, which aims to prevent interpersonal conflict and IPV through enhancing positive communication, reducing negative communication, promoting positive relationship attitudes, and strengthening ability to self-regulate in interpersonal contexts. Sixty-two college students (54.8% female) were allocated to the SHARe group or a wait-list control by randomizing to condition and then reassigning some individuals to control based on schedule availability to attend groups. Participants completed self-report measures of positive and negative communication, interpersonal confidence, and perpetration of physical, emotional, psychological, injurious, and sexual violence at baseline, post-group, and at a 3-month follow-up. At baseline, participants reported low levels of recent severe IPV perpetration, but controls reported higher levels of emotional abuse. Analyses controlled for baseline IPV. SHARe participants reported significantly higher confidence in their ability to manage conflicts at post-intervention and significantly lower psychological aggression at the follow-up compared with wait-listed controls. At the 3-month follow-up, self-reported perpetration of psychological abuse was 1.5 times higher for wait-list controls versus SHARe participants. The findings indicate that SHARe can help college students improve their interpersonal skills and develop healthy, non-abusive relationships.

Women's sexual arousal: effects of high alcohol dosages and self-control instructions.

The basic relationship between alcohol and women's sexual arousal - especially genital arousal - received little research attention for nearly 30 years (e.g. Wilson and Lawson, 1978) until very recently (e.g. George et al., 2009). To investigate hypotheses based on earlier findings and Alcohol Myopia Theory (AMT), two experiments evaluated the effects of high blood alcohol concentrations (BACs) and arousal instructional demands on indices of vaginal responding and self-reported sexual arousal. In Experiment 1, self-control instructions to maximize (versus suppress) arousal increased peak and average Vaginal Pulse Amplitude (VPA) change. Self-control also interacted with a target BAC of .08% (versus .00%) to influence latency to peak arousal onset: Intoxicated women instructed to maximize showed a shorter latency to peak arousal than did intoxicated women instructed to suppress; however, sober women showed an undifferentiated pattern. Also, in Experiment 1, the target BAC of .08% had no effect on VPA or subjective arousal measures. In Experiment 2, a target BAC of .10% (versus .00%) attenuated peak change and average change in VPA, but this dosage had no effects on latency to peak achieved arousal, or on subjective arousal. Instructions to maximize arousal (versus no instruction) had no effect on any arousal measures. Overall, among young moderate drinking women, alcohol had attenuating effects but only at the higher dosage. Maximize versus suppress instructions about arousal had predicted effects on arousal and interactive effects on latency, but only at the lower dosage. The findings highlight the importance of dosage and contextual factors in alcohol's impact on the variability of women's sexual responding.

Cognitive representations of sexual self differ as a function of gender and sexual debut.

This research evaluated the association between gender and sexual debut (initial sexual intercourse) and indirect measures of sexuality. A sample of 440 U.S. college students (pre-sexual debut: 144 women, 153 men; post-sexual debut: 49 women, 94 men) completed the Sexual Self-Schema Scale (SSSS), which assessed cognitive representations about sexual aspects of oneself, and three Implicit Association Tests (IAT), which measured the strength of the associations between the concepts of self + sex, women + sex, and men + sex. Results replicated previous findings that (1) men more strongly associated self + sex and women + sex than did women, and (2) men and women had similarly strong associations of men + sex. Post-sexual debut women's self + sexual and women + sexual associations were stronger than pre-sexual debut women's. Men's associations did not differ significantly as a function of sexual debut. Post-sexual debut women's SSSS scores were more direct, more romantic, and less conservative than pre-sexual debut women's. Post-sexual debut men's SSSS scores were more aggressive and more open-minded than pre-sexual debut men's. Sexual debut appeared to be associated with sexualized and sexually liberal cognitive representations in women and, to a lesser extent, sexually liberal and aggressive cognitive representations in men. Findings were consistent with theories of cognitive consistency and provide preliminary evidence that sexual debut status was associated with differing cognitive representations.

Asian American Women's Victimization History and In-The-Moment Responses to Partner Violence.

Between 20% and 50% of Asian American women report experiencing partner violence (PV). Furthermore, nearly half of PV victims experience their first assault between the age of 18 and 24 years, suggesting that Asian American college women may be particularly at risk of PV. Experiencing childhood abuse (CA) may impair women's capacity to perceive risk during a potential PV situation, increasing their risk for revictimization. The purpose of the current study was to examine differences among Asian American college women's (N = 324) in-the-moment behavioral intention, risk perception, and likelihood to stay in an abusive relationship during a progressively threatening PV scenario, based on victimization history and posttraumatic stress disorder (PTSD) symptoms. We tested three path models, each assessing the relations among CA, PV, PTSD, current and future risk perception, likelihood of staying in the relationship, and one of three behavioral intentions (soothe the perpetrator, escape, and escalation/resistance). As hypothesized, CA history positively predicted PV history and PTSD symptoms. Furthermore, CA and PV predicted more in-the-moment soothe behavioral intentions and fewer escape behavioral intentions which, in turn, predicted diminished current and future risk perception. CA and PV also predicted stronger escalation/resistance behavioral intentions, such that escalation/resistance intentions were associated with higher risk perception during a more violent part of the scenario but lower risk perception during a less violent part of the scenario. Finally, higher risk perception predicted lower likelihood of staying in the relationship. Findings indicate that victimization history is associated with increased risky behavioral intentions among Asian American college women and suggest that targeted interventions to improve assault-exposed Asian American women's awareness of risk cues may be warranted.

Assessing women's sexual arousal in the context of sexual assault history and acute alcohol intoxication.

INTRODUCTION: Few studies have examined differences in women's sexual arousal based on sexual assault history (SAH) or in-the-moment alcohol intoxication. Only one has examined combined effects. Findings regarding the relationship between SAH and arousal are contradictory. AIM: We aimed to determine the relationship between SAH, alcohol intoxication, and sexual arousal. METHODS: Women were randomly assigned to an alcohol (target blood alcohol level = 0.10%) or control condition and categorized as having an SAH or not. After beverage administration, all women watched erotic films while genital arousal (vaginal pulse amplitude; VPA) was measured. Afterward, self-reported sexual arousal was measured. MAIN OUTCOME MEASURES: Genital response was measured by VPA using vaginal photoplethysmography while watching erotic films. Self-reported sexual arousal was assessed after watching erotic films. RESULTS: Women with an SAH had smaller increases in genital arousal in response to the films than women without an SAH. Intoxicated women had smaller increases in genital arousal than sober women. However, no differences for SAH or intoxication were found in self-reported arousal. CONCLUSION: SAH and alcohol intoxication are associated with smaller increases in genital arousal compared to women without an SAH and sober women, suggesting that these co-occurring factors impact sexual arousal.

Idiographically determined versus standard absorption periods in alcohol administration studies.

BACKGROUND: Effects of alcohol vary depending on blood alcohol level and limb. Some researchers use standard absorption periods (SAPs) to determine when postdrinking experimental protocols should begin. Others use an idiographically determined absorption period (IDAP) based on criterion breath alcohol concentration (BrAC). We investigated and compared the characteristics of each method. METHODS: Sixty-eight social drinkers (47% women) consumed a bolus dose of alcohol intended to raise BrAC to 0.08%. BrACs were recorded every 3 minutes until beginning to descend. Minutes to reach criterion BrAC (0.06%) and between-subjects postdrinking BrAC variability were analyzed. RESULTS: Mean time to reach 0.06% BrAC was 22.9 +/- 14.6 minutes. Standard deviations in BrAC were 4 times greater using SAPs compared to IDAPs. Ten percent of participants' BrAC readings were on the descending limb 30 minutes postdrinking, and 25% were descending at 45 minutes postdrinking. CONCLUSIONS: IDAPs result in less BrAC variability and may reduce experimental noise relative to SAPs. Experimental control in future alcohol administration studies may be enhanced by the use of IDAPs instead of SAPs.

Sexual abuse history, alcohol intoxication, and women's sexual risk behavior.

We examined potential differences in women's likelihood of sexual risk taking in a laboratory setting based on alcohol intoxication and sexual abuse history. Participants (n = 64) were classified as non-sexually abused (NSA) or as having experienced sexual abuse in childhood only (CSA) or adulthood only (ASA) and randomly assigned to consume alcoholic (.06, .08, or .10% target blood alcohol content) or non-alcoholic drinks, after which participants read and responded to a risky sex vignette. Dependent measures included vaginal pulse amplitude, self-reported sexual arousal, likelihood of engaging in condom use and risky sexual behaviors described in the vignette, and mood. NSA and ASA women did not differ significantly on any dependent measures. CSA women reported significantly lower likelihood of condom use and unprotected intercourse relative to NSA and ASA women. Intoxicated women reported significantly greater sexual arousal, positive mood, and likelihood of risky sex relative to sober women. Intoxicated CSA women reported significantly more likelihood of unprotected oral sex and less likelihood of condom use relative to intoxicated NSA and ASA and sober CSA women. CSA women's increased risk of sexually transmitted infections (STIs) may be driven by non-condom use and behavioral changes while intoxicated. These findings provide preliminary insight into situational influences affecting CSA women's increased STI risk.

Indirect effects of acute alcohol intoxication on sexual risk-taking: The roles of subjective and physiological sexual arousal.

Three experiments supported the idea that alcohol fosters sexual risk-taking in men and women, in part, through its effects on sexual arousal. In Experiment 1, increasing alcohol dosage (target blood alcohol levels of .00, .04, .08%) heightened men's and women's risk-taking intentions. Alcohol's effect was indirect via increased subjective sexual arousal; also, men exhibited greater risk-taking than women. In Experiment 2, an extended dosage range (target blood alcohol levels of .00, .06, .08, .10%) heightened men's risk-taking intentions. Alcohol's effect again was indirect via subjective arousal. Physiological sexual arousal, which was unaffected by alcohol, increased risk-taking via increased subjective arousal. In Experiment 3, alcohol increased women's risk-taking indirectly via subjective arousal, but alcohol-attenuated physiological arousal had no effect on risk-taking. Implications for alcohol myopia theory and prevention interventions are discussed.

Domestic violence assessment procedures among couple therapists.

Guidelines for addressing domestic violence (DV) in couple therapy have been published, but reports of whether therapists routinely follow these suggestions are few. A national survey of 620 couple therapists randomly selected from American Association for Marriage and Family Therapy members was conducted in 2000 to assess therapists' strategies for assessing DV and selecting a treatment modality when violence is discovered. Less than 4% of respondents indicated consistently following key published guidelines for DV screening (universal screening using separate interviews and questionnaires). A minority indicated that they consider the victim's safety as a factor in treatment modality selection. DV may be under-identified by couple therapists and therapists may be using conjoint therapy with couples for whom such therapy is contraindicated because of relationship violence.

A statewide initiative to train behavioral health providers in smoking cessation.

Individuals with mental health and substance use disorders smoke at rates two to four times higher than the general population and account for over half of smoking-related deaths. Building capacity of behavioral health providers to provide smoking cessation treatment may decrease smoking prevalence in these groups. The present study evaluated a statewide rollout of a capacity building training program to teach behavioral health providers to deliver a manualized smoking cessation group intervention for patients with mental health and substance use disorders. Behavioral health treatment providers (N = 333) participated in a day-long training. Pretraining and posttraining evaluations were conducted on the day of training to assess changes in confidence, attitudes, and knowledge regarding smoking cessation and possible barriers to implementing the smoking cessation curriculum in treatment programs. These constructs were reassessed in follow-up surveys conducted online 2 and 6 months posttraining. A subset of providers participated in follow-up telephone calls to discuss implementation of smoking cessation programming. Posttraining evaluations indicated that trainees' confidence, attitudes, and knowledge of smoking interventions improved. Follow-up surveys indicated that these gains decreased but were maintained above baseline. Over one-half of survey respondents reported taking at least one implementation step. Interviewees reported that agency and staff-level barriers such as difficulty coordinating a group, staff turnover, and inadequate time with clients precluded more widespread implementation. Training for behavioral health providers is effective in improving confidence, attitudes, and knowledge regarding smoking cessation interventions. Consistent implementation requires ongoing support and agency problem solving to address common barriers.

Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial.

OBJECTIVE: To determine whether contingent monetary incentives increase opioid use disorder patients' attendance to Prolonged Exposure (PE) therapy and whether attendance is associated with improvement in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) outcomes. METHOD: Patients (N = 58) with PTSD were offered PE or PE with incentives (PE + I; max $480) to attend PE sessions. Participants were assessed at baseline and weeks 6, 12, and 24 postrandomization. RESULTS: Participants were mostly women (79%) and Caucasian (71%); mean age 37.43 years (SD = 11.33). PE + I participants attended a median of 9 (of 12) sessions compared to 1 session for PE participants (p < .001), which included more exposure sessions (PE + I mdn = 6; PE mdn = 0; p < .001). A Time × treatment condition interaction indicated that PE + I participants exhibited a greater decrease in PTSD severity over time than PE participants (OR = 3.1; 95% CI = 0.4-5.7; p = .024). PE + I participants remained in substance use treatment longer than PE participants (mdn days = 262 vs. 192; p = .039). There were no group differences in drug use. CONCLUSIONS: Monetary incentives increased SUD patients' attendance to an otherwise poorly attended treatment for PTSD. Better attendance in the incentivized group was associated with greater PTSD improvement, better SUD treatment retention, and no increased drug use. Incentives are well supported for improving adherence to substance use treatment goals and promising as a means to improve therapy attendance, which may improve the effectiveness of existing psychotherapies in difficult-to-treat populations. (PsycINFO Database Record

Alcohol and erectile response: the effects of high dosage in the context of demands to maximize sexual arousal.

Although drinking often precedes men's sexual activity, basic questions about alcohol's effects on men's sexual arousal remain unanswered. Inconsistencies in findings from studies examining subjective and physiological effects on erectile functioning suggest these effects are context specific, for example, dependent on whether a man wants to maximize or suppress his arousal. To address unresolved questions about alcohol and erectile functioning, the authors evaluated the effects of high blood alcohol concentrations (BACs) and arousal instructional demands on indices of penile circumference change and self-reported sexual arousal. In Study 1, a target BAC of .10% (vs. .00%) attenuated peak circumference change from a neutral baseline but did not affect mean change, latency to arousal onset (a 5% increase in circumference from baseline), latency to peak achieved arousal, or subjective arousal, which correlated moderately with physiological indices. In Study 2, instructions to maximize (vs. suppress) arousal increased peak and mean circumference change and interacted with a target BAC of .08% (vs. .00%) to influence latency to arousal onset. Sober men instructed to maximize showed a shorter latency to arousal onset than did those instructed to suppress arousal; however, intoxicated men did not show a differential pattern. Moreover, compared with intoxicated counterparts, sober men instructed to maximize arousal showed a marginally shorter latency to arousal onset. Overall, alcohol and arousal instructions had small but discernible effects. Findings highlight the importance of contextual factors in alcohol's impact on erectile functioning.

A randomized controlled trial of the effects of working memory training in methadone maintenance patients.

OBJECTIVE: Working memory impairment in individuals with chronic opioid dependence can play a major role in cognitive and treatment outcomes. Cognitive training targeting working memory shows promise for improved function in substance use disorders. To date, cognitive training has not been incorporated as an adjunctive treatment for opioid dependence. METHODS: Methadone maintenance patients were randomly assigned to experimental (n=28) or active control (n=28) 25-session computerized training and run in parallel. Cognitive and drug use outcomes were assessed before and after training. RESULTS: Participants in the experimental condition showed performance improvements on two of four working memory measures, and both groups improved on a third measure of working memory performance. Less frequent drug use was found in the experimental group than in the control group post-training. In contrast to previous findings with stimulant users, no significant effect of working memory training on delay discounting was found using either hypothetical or real rewards. There were no group differences on working memory outcome measures that were dissimilar from the training tasks, suggesting that another mechanism (e.g., increased distress tolerance) may have driven drug use results. CONCLUSIONS: Working memory training improves performance on some measures of working memory in methadone maintenance patients, and may impact drug use outcomes. Working memory training shows promise in patients with substance use disorders; however, further research is needed to understand the mechanisms through which performance is improved and drug use outcomes are impacted.