Mediational Analyses of the Effects of Social Behaviour and Network Therapy on Alcohol Use.

INTRODUCTION: Social behaviour and network therapy involves an active participation of the practitioner in recruiting a supportive network to change the client's alcohol use. Despite achieving beneficial effects on alcohol consumption, its possible mechanisms of change are a relatively under-studied topic compared to those of other alcohol treatment interventions. This study aimed to explore therapist skills through which social behaviour and network therapy may achieve effects on alcohol consumption in comparison with motivational enhancement therapy. METHODS: This study was secondary analysis of data from the UK Alcohol Treatment Trial, a multicentre, pragmatic, randomized controlled trial. The sample comprised 376 participants randomized to motivational enhancement therapy or social behaviour and network therapy. We used the UK Alcohol Treatment Trial Process Rating Scale to assess therapist skills. Outcomes drinks per drinking day and percentage of days abstinent were assessed 12 months after treatment initiation. Analyses were conducted in a simple mediation framework. RESULTS: Therapist skills score (combining frequency and quality) for involving others in behaviour change mediated social behaviour and network therapy effects on percentage of days abstinent (b = 0.06, 95% CI: 0.02; 0.10, p = 0.01). The frequency with which therapists acted as an active agent for change also mediated the effects of social behaviour and network therapy on percentage of days abstinent (b = 0.03, 95% CI: 0.003; 0.05, p = 0.03). The frequency with which the therapist stressed social support as a key factor in achieving change unexpectedly mediated an increase in drinks per drinking day (b = 0.10, 95% CI: 0.01; 0.18, p = 0.02). The two latter mediation effects were not sustained when quality was considered. All other indirect effects tested were non-significant. DISCUSSION/CONCLUSIONS: How social behaviour and network therapy exerts effects on alcohol outcomes is not yet well understood and in this study was not attributable to observed ratings of therapist treatment-specific skills. Therapist skill in planning the involvement of others during treatment, however, warrants further study. We suggest that the present findings should be regarded as hypothesis generating as it identifies specific targets for further investigation in alcohol treatment process studies.

The key therapeutic factors needed to deliver behavioural change interventions to decrease risky substance use (drug and alcohol) for looked after children and care leavers: a qualitative exploration with young people, carers and front line workers.

BACKGROUND: Looked after children and care leavers have an increased risk of drug and alcohol use compared to their non-LAC peers. Despite high prevalence rates within this population, looked after children are reported to show low levels of engagement in services resulting in unmet needs emerging from substance use. This paper reports on the initial formative phase of a pilot feasibility randomised controlled trial; SOLID (Supporting Looked After Children and Care Leavers In Decreasing Drugs, and Alcohol) that aimed to adapt two evidence-based psychosocial interventions, Motivational Enhancement Therapy and Social Behaviour and Network Therapy, which will aim to reduce substance misuse by looked after children. METHODS: We conducted qualitative semi-structured interviews and focus groups with 19 looked after children aged 12 to 20 years old, 16 carers and 14 professionals across four local authorities in the North East of England. The data gathered were analysed and then presented within co-production workshops inclusive of 13 young people and 14 professionals (drug and alcohol practitioners and social workers). Findings were used to adapt and refine the interventions prior to the trial. RESULTS: Overall findings suggested that whilst original components of both interventions were feasible to deliver and acceptable, specific process areas were highlighted including: increased emphasis upon therapeutic relationships, the benefits of using creative non-traditional methods of engagement and identification of treatment goals wider than those narrowly focused on substance misuse. CONCLUSION: This paper provides an example of methods used to collect multiple perspectives to refine and co-develop interventions to reduce drug and alcohol use in the specific population of looked after children. TRIAL REGISTRATION: ISRCTN80786829 (first registered 06.06.2016- prospectively registered).

Therapist-Client Interactions in Motivational Interviewing: The Effect of Therapists' Utterances on Client Change Talk.

AIMS: Motivational Interviewing is an effective treatment for a range of problematic behaviours, however, previous studies have revealed substantial variability in the effectiveness of therapists. Curiously, the specific behaviours which contribute to positive outcomes have rarely been studied. The aim of this study was to investigate hypothesised relationships between therapists' utterances and clients' change talk by analysing interactions sampled from the United Kingdom Alcohol Treatment Trial (UKATT). METHODS: This study comprised secondary analysis of process data and recordings selectively sampled from the UKATT database using sequential analyses of utterance categories, defined using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE). MI-SCOPE categories were modified on the basis of the existing literature. Observed and expected frequencies of change talk, transitional probabilities and their significance levels both immediately following therapists' statements (Lag 1), and after a delay (Lag 2) were calculated using the Generalised Sequential Querier (GSEQ) programme. Regression analyses were conducted using SPSS 21.0. RESULTS: In successful alcohol treatment sessions, therapists' open questions and complex reflections were significantly positively associated with client preparatory talk at Lag 1. Therapists' complex reflections were significantly positively associated with and predictive of strong client commitment talk at Lag 2. CONCLUSIONS: The findings extend those of previous studies, suggesting that open questions and complex reflections play a central role in preparing clients for, and facilitating strong commitment to, behaviour change.

Effectiveness and Cost-effectiveness of Opportunistic Screening and Stepped-care Interventions for Older Alcohol Users in Primary Care.

AIMS: To compare the clinical effectiveness and cost-effectiveness of a stepped-care intervention versus a minimal intervention for the treatment of older hazardous alcohol users in primary care. METHOD: Multi-centre, pragmatic RCT, set in Primary Care in UK. Patients aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test were allocated either to 5-min of brief advice or to 'Stepped Care': an initial 20-min of behavioural change counselling, with Step 2 being three sessions of Motivational Enhancement Therapy and Step 3 referral to local alcohol services (progression between each Step being determined by outcomes 1 month after each Step). Outcome measures included average drinks per day, AUDIT-C, alcohol-related problems using the Drinking Problems Index, health-related quality of life using the Short Form 12, costs measured from a NHS/Personal Social Care perspective and estimated health gains in quality adjusted life-years measured assessed EQ-5D. RESULTS: Both groups reduced alcohol consumption at 12 months but the difference between groups was small and not significant. No significant differences were observed between the groups on secondary outcomes. In economic terms stepped care was less costly and more effective than the minimal intervention. CONCLUSIONS: Stepped care does not confer an advantage over a minimal intervention in terms of reduction in alcohol use for older hazardous alcohol users in primary care. However, stepped care has a greater probability of being more cost-effective. TRIAL REGISTRATION: Current controlled trials ISRCTN52557360. SHORT SUMMARY: A stepped care approach was compared with brief intervention for older at-risk drinkers attending primary care. While consumption reduced in both groups over 12 months there was no significant difference between the groups. An economic analysis indicated the stepped care which had a greater probability of being more cost-effective than brief intervention.

Serial mediation analysis of treatment-specific processes in two contrasting alcohol treatments.

INTRODUCTION: This study explored whether treatment-specific processes linking therapist behaviors, post-session client ratings, and 3-month proximal outcomes (i.e., end of treatment) can explain 12-month outcomes for two contrasting alcohol treatment conditions with equivalent overall outcomes. METHODS: This study is a secondary analysis of the UK Alcohol Treatment Trial (UKATT), a multi-center randomized controlled trial of treatment for alcohol problems comparing 3-session motivational enhancement therapy (MET) to 8-session social behaviour and network therapy (SBNT). Among 742 adult clients included in UKATT, 351 had one treatment session recorded and coded and were followed-up 3 and 12 months after baseline. The study team conducted serial mediation analyses to test whether the frequency and quality of MET and SBNT skills were related to 12-month alcohol outcomes (drinks per drinking day) through postsession client ratings of treatment progress (Processes of Change Questionnaire, PCQ), readiness to change (RTC) and social support for drinking after 3-months. RESULTS: Higher quality of MET skills was related to higher PCQ scores, which were in turn related to greater post-treatment RTC, and subsequently to better alcohol outcomes. Total indirect effect was consistently significant. In contrast, only PCQ was predictive of treatment outcome in the SBNT portion of the model. CONCLUSIONS: This study provides evidence from a large pragmatic trial that the quality of MET skills positively influences alcohol outcomes in part through improvements in motivation during treatment and actively trying to change when treatment ends. Research should explore the ways in which SBNT secured outcomes that were equivalent to MET.

Validation of a scale for rating the delivery of psycho-social treatments for alcohol dependence and misuse: the UKATT Process Rating Scale (PRS).

AIM: The aim of this study was to describe the development and validation of the UK Alcohol Treatment Trial Process Rating Scale (UKATT PRS), a manual based method for monitoring and rating the delivery of psychosocial treatments of alcohol dependence and misuse. METHODS: Following adaptation and further development of a validated rating scale, the ability of the UKATT PRS to rate the delivery of video-recorded treatment in the UK Alcohol Treatment Trial (UKATT) was tested. RESULTS: Tests of the validity and reliability of the UKATT PRS show that it is valid and reliably able to detect the two treatments for which it was designed and to discriminate between them. CONCLUSIONS: The UKATT PRS is a valid and reliable method of rating the frequency and quality of therapeutic style and content in the delivery of two psycho-social treatments of alcohol use and dependence.

The effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care (AESOPS) - a randomised control trial protocol.

BACKGROUND: There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption. In older populations excessive alcohol consumption is associated with increased risk of coronary heart disease, hypertension, stroke and a range of cancers. Alcohol consumption is also associated with an increased risk of falls, early onset of dementia and other cognitive deficits. Physiological changes that occur as part of the ageing process mean that older people experience alcohol related problems at lower consumption levels. There is a strong evidence base for the effectiveness of brief psychosocial interventions in reducing alcohol consumption in populations identified opportunistically in primary care settings. Stepped care interventions involve the delivery of more intensive interventions only to those in the population who fail to respond to less intensive interventions and provide a potentially resource efficient means of meeting the needs of this population. METHODS/DESIGN: The study design is a pragmatic prospective multi-centre two arm randomised controlled trial. The primary hypothesis is that stepped care interventions for older hazardous alcohol users reduce alcohol consumption compared with a minimal intervention at 12 months post randomisation. Potential participants are identified using the AUDIT questionnaire. Eligible and consenting participants are randomised with equal probability to either a minimal intervention or a three step treatment approach. The step treatment approach incorporates as step 1 behavioural change counselling, step 2 three sessions of motivational enhancement therapy and step 3 referral to specialist services. The primary outcome is measured using average standard drinks per day and secondary outcome measures include the Drinking Problems Index, health related quality of life and health utility. The study incorporates a comprehensive economic analysis to assess the relative cost-effectiveness of the interventions. DISCUSSION: The paper presents a protocol for the first pragmatic randomised controlled trial evaluating the effectiveness and cost-effectiveness of stepped care interventions for older hazardous alcohol users in primary care. TRIAL REGISTRATION: ISRCTN52557360.

A mediation analysis of treatment processes in the UK Alcohol Treatment Trial.

OBJECTIVE: To determine whether treatment outcomes are mediated by therapist behaviors consistent with the theoretical postulates on which two contrasting treatments are based. METHOD: We used data from the U.K. Alcohol Treatment Trial (UKATT), a pragmatic, multicenter, randomized controlled trial comparing the effectiveness of Motivational Enhancement Therapy (MET) and Social Behavior and Network Therapy (SBNT) in the treatment of alcohol problems. N = 376 clients (mean age 42.5, 74.5% male) had 12-month follow-up data and one treatment session recorded and coded using the UKATT Process Rating Scale, a reliable manual-based assessment of treatment fidelity including frequency and quality ratings of treatment-specific therapist tasks and therapist styles. Analyses were conducted using a mediation framework. RESULTS: Analysis of individual paths from treatment condition to treatment process indices (a path) and from treatment process indices to alcohol outcomes (b path) showed that (a) SBNT therapists more often used SBNT-specific behaviors, and did so with overall higher quality; (b) MET therapists more often used MET-specific behaviors, but there was no evidence that they performed these behaviors with higher quality than SBNT therapists; (c) only the quality of MET behaviors significantly predicted 12-month alcohol outcomes, irrespective of treatment condition. Consistently, there were no significant indirect effects. Multiple component analysis indicated that therapist quality of specific tasks influenced outcomes. CONCLUSIONS: The quality of delivery of the same treatment tasks in both treatments studied transcended the impact of delivering treatments according to different theoretical underpinnings in UKATT. (PsycINFO Database Record

Client experiences of motivational interviewing: An interpersonal process recall study.

OBJECTIVES: To explore clients' experience of the therapy process in motivational interviewing (MI) for alcohol abuse. DESIGN: A qualitative study using grounded theory. METHODS: Interviews with nine clients were conducted using interpersonal process recall (IPR), a methodology which utilizes a video recording as a cue to aid memory recall. Clients watched a videotape of their MI session and were asked to identify and describe the important moments in the therapy session. The transcribed interviews were then analysed using grounded theory. RESULTS: A single session of MI is seen by the clients in this study as a complex interpersonal interaction between client and therapist, which impacts on the client's cognitive and affective intrapersonal processes. CONCLUSIONS: The themes which emerged partly confirm processes of MI previously hypothesized to be important, but also highlight the importance of factors common to all therapeutic approaches. PRACTITIONER POINTS: The aspects of therapy which clients in this study felt were important are similar to those hypothesized to underlie the effectiveness of MI, including a non-confrontational approach, affirmation, and developing discrepancies between beliefs and behaviour. These were embedded in aspects common to all therapies, including the qualities of the therapist and the therapeutic relationship. Client's perspectives on therapeutic processes are an important area of research, and IPR is a particularly suitable method.

ADAPTA: A pilot randomised controlled trial of an alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting.

AIM: To examine the relative feasibility, acceptability, applicability, effectiveness and explore cost-effectiveness of a healthy living focused intervention (HL) compared to an alcohol-focused intervention (AF) for problem drinkers identified in hospital. METHODS: A pragmatic, randomised, controlled, open pilot trial. Feasibility and acceptability were measured by recruitment, attrition, follow-up rates and number of treatment sessions attended. Effectiveness was measured using the Alcohol Use Disorders Identification Test score at six months. Additional economic and secondary outcome measures were collected. RESULTS: Eighty-six participants were randomised and 72% (n=62) were retained in full participation. Forty-one participants attended at least one treatment session (48%). A greater proportion in the HL group attended all four treatment sessions (33% vs 19%). Follow-up rates were 29% at six months and 22% at twelve months. There was no evidence of a difference in AUDIT score between treatment groups at six months. Mean cost of health care and social services, policing and the criminal justice system use decreased while EQ-5D scores indicated minor improvement in both arms. However, this pilot trial was not powered to detect differences in either measure between groups. CONCLUSIONS: While no treatment effect was observed, this study demonstrated a potential to engage patients drinking at harmful or dependent levels in a healthy living intervention. However, recruitment proved challenging and follow-up rates were poor. Better ways need to be found to help these patients recognise the harms associated with their drinking and overcome the evident barriers to their engagement with specialist treatment.

The Society for the Study of Addiction (SSA).

The Society for the Study of Addiction (SSA) is a learned society which is a company limited by guarantee with charitable status, an independent organization promoting the cause of research, public policy and treatment of addiction. Founded in London in 1884 with the aim of promoting a research-based understanding of inebriety, it is the oldest society of its kind. The pursuit and enhancement of evidence-based policy and treatment informed its work in the early days and has remained its organizing principle throughout its history. Led initially by medical political interests, the Society has grown to encompass a broader disciplinary base, reflecting the expansion of interest in addiction from biological, psychological and social science into nursing, social work, probation, other arms of criminal justice work and voluntary sector professionals. Today its membership is made up of researchers, practitioners and policy makers from all these disciplines, the majority of whom reside and work in the United Kingdom; its international membership makes up nearly one-third of the total membership and there are current endeavours to expand collaboration with other national societies in the field. Its activities are focused upon the Society journals, Addiction and Addiction Biology, other publishing activities, the annual symposium and a number of policy initiatives.

Social behaviour and network therapy basic principles and early experiences.

The present paper reports on the basic principles of a treatment approach currently being used in a National Multicentre Randomised Controlled Trial of Alcohol Treatments in the United Kingdom (UK Alcohol Treatment Trial). The treatment: Social Behaviour and Network Therapy (SBNT) is novel as a package but has been developed by integrating a number of strategies found to be effective in other treatment approaches. The intervention is based on the notion that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change. A brief review of the evidence supporting social treatments for alcohol problems is followed by an outline of the feasibility work and the basic principles that guided the development of SBNT. Process data from the first 33 trial cases and 2 case vignettes are described and discussed. It is concluded that SBNT is a feasible and coherent treatment approach that can be delivered by a range of therapists in the alcohol field.

Measuring clinically significant outcomes - LDQ, CORE-10 and SSQ as dimension measures of addiction.

Aims and method To determine values for reliable change and clinically significant change for the Leeds Dependence Questionnaire (LDQ) and Social Satisfaction Questionnaire (SSQ). The performance of these two measures with the Clinical Outcomes in Routine Evaluation (CORE-10) as three dimension measures of addiction was then explored. Results The reliable change statistic for both LDQ and SSQ was ⩾4; the cut-offs for clinically significant change were LDQ ⩽10 males, ⩽5 females, and SSQ ⩾16. There was no overlap of 95% CIs for means by gender between 'well-functioning' and pre- and post-treatment populations. Clinical implications These data enable the measurement of clinically significant change using the LDQ and SSQ and add to the evidence for the performance of the LDQ, CORE-10 and SSQ as dimension measures of addiction. The CORE-10 and SSQ can be used as treatment outcome measures for mental health problems other than addiction.

Factor analysis of treatment outcomes from a UK specialist addiction service: relationship between the Leeds Dependence Questionnaire, Social Satisfaction Questionnaire and 10-item Clinical Outcomes in Routine Evaluation.

INTRODUCTION AND AIMS: To examine the relationship between three outcome measures used by a specialist addiction service (UK): the Leeds Dependence Questionnaire (LDQ), the Social Satisfaction Questionnaire (SSQ) and the 10-item Clinical Outcomes in Routine Evaluation (CORE-10). DESIGN AND METHOD: A clinical sample of 715 service user records was extracted from a specialist addiction service (2011) database. The LDQ (dependence), SSQ (social satisfaction) and CORE-10 (psychological distress) were routinely administered at the start of treatment and again between 3 and 12 months post-treatment. A mixed pre/post-treatment dataset of 526 service users was subjected to exploratory factor analysis. Parallel Analysis and the Hull method were used to suggest the most parsimonious factor solution. RESULTS: Exploratory factor analysis with three factors accounted for 66.2% of the total variance but Parallel Analysis supported two factors as sufficient to account for observed correlations among items. In the two-factor solution, LDQ items and nine of the 10 CORE-10 items loaded on the first factor >0.41, and the SSQ items on factor 2 with loadings >0.63. A two dimensional summary appears sufficient and clinically meaningful. DISCUSSION AND CONCLUSIONS: Among specialist addiction service users, social satisfaction appears to be a unique construct of addiction and is not the same as variation due to psychological distress or dependence. Our interpretation of the findings is that dependence is best thought of as a specific psychological condition subsumed under the construct psychological distress.

Developing a web-based intervention to increase motivation to change and encourage uptake of specialist face-to-face treatment by hospital inpatients: change drinking.

INTRODUCTION AND AIM: Problem drinking is rarely identified unless health-care professionals are specifically instructed to assess alcohol consumption. Individualised web-based alcohol interventions provide opportunities to enhance screening and early identification. We aimed to create a web-based brief personalised feedback intervention to enable client-centred screening and self-referral by problem drinkers recently admitted to hospital. DESIGN AND METHODS: To increase transparency of the development process, this short report describes the theoretical underpinnings and development of ChangeDrinking including identification of needs and matching with resources, screening tool selection, and look and feel. RESULTS: The website structure and content was modelled on motivational dialogue. ChangeDrinking is closely coupled to an independent questionnaire management system; this architecture enables internal logic to allow branching based on dynamic user inputs. The motivational underpinnings led to development of personalised predetermined dialogue with strong theory-practice links. Applying principles of conveying empathy and reflection was challenging within the confines of a predetermined dialogue. Reflective listening in ChangeDrinking does not extend to inviting statements of resistance to be entered. DISCUSSION AND CONCLUSIONS: ChangeDrinking has become an optional component of routine treatment for patients with an alcohol-related admission in two large UK National Health Service general hospitals.

An alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting (ADAPTA): study protocol for a randomized, controlled pilot trial.

BACKGROUND: Alcohol misuse is a major cause of premature mortality and ill health. Although there is a high prevalence of alcohol problems among patients presenting to general hospital, many of these people are not help seekers and do not engage in specialist treatment. Hospital admission is an opportunity to steer people towards specialist treatment, which can reduce health-care utilization and costs to the public sector and produce substantial individual health and social benefits. Alcohol misuse is associated with other lifestyle problems, which are amenable to intervention. It has been suggested that the development of a healthy or balanced lifestyle is potentially beneficial for reducing or abstaining from alcohol use, and relapse prevention. The aim of the study is to test whether or not the offer of a choice of health-related lifestyle interventions is more acceptable, and therefore able to engage more problem drinkers in treatment, than an alcohol-focused intervention. METHODS/DESIGN: This is a pragmatic, randomized, controlled, open pilot study in a UK general hospital setting with concurrent economic evaluation and a qualitative component. Potential participants are those admitted to hospital with a diagnosis likely to be responsive to addiction interventions who score equal to or more than 16 on the Alcohol Use Disorders Identification Test (AUDIT). The main purpose of this pilot study is to evaluate the acceptability of two sorts of interventions (healthy living related versus alcohol focused) to the participants and to assess the components and processes of the design. Qualitative research will be undertaken to explore acceptability and the impact of the approach, assessment, recruitment and intervention on trial participants and non-participants. The effectiveness of the two treatments will be compared at 6 months using AUDIT scores as the primary outcome measure. There will be additional economic, qualitative and secondary outcome measurements. DISCUSSION: Development of the study was a collaboration between academics, commissioners and clinicians in general hospital and addiction services, made possible by the Collaboration in Leadership in Applied Health Research and Care (CLAHRC) program of research. CLAHRC was a necessary vehicle for overcoming the barriers to answering an important NHS question--how better to engage problem drinkers in a hospital setting. TRIAL REGISTRATION: ISRCTN47728072.

Identification of behaviour change techniques to reduce excessive alcohol consumption.

BACKGROUND: Interventions to reduce excessive alcohol consumption have a small but important effect, but a better understanding is needed of their 'active ingredients'. AIMS: This study aimed to (i) develop a reliable taxonomy of behaviour change techniques (BCTs) used in interventions to reduce excessive alcohol consumption (not to treat alcohol dependence) and (ii) to assess whether use of specific BCTs in brief interventions might be associated with improved effectiveness. METHODS: A selection of guidance documents and treatment manuals, identified via expert consultation, were analysed into BCTs by two coders. The resulting taxonomy of BCTs was applied to the Cochrane Review of brief alcohol interventions, and the associations between the BCTs and effectiveness were investigated using meta-regression. FINDINGS: Forty-two BCTs were identified, 34 from guidance documents and an additional eight from treatment manuals, with average inter-rater agreement of 80%. Analyses revealed that brief interventions that included the BCT 'prompt self-recording' (P = 0.002) were associated with larger effect sizes. CONCLUSIONS: It is possible to identify specific behaviour change techniques reliably in manuals and guidelines for interventions to reduce excessive alcohol consumption. In brief interventions, promoting self-monitoring is associated with improved outcomes. More research is needed to identify other behaviour change techniques or groupings of behaviour change techniques that can produce optimal results in brief interventions and to extend the method to more intensive interventions and treatment of alcohol dependence.