Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories.

OBJECTIVES: Two-year alcohol use trajectories were documented among residents in a project-based Housing First program. Project-based Housing First provides immediate, low-barrier, nonabstinence-based, permanent supportive housing to chronically homeless individuals within a single housing project. The study aim was to address concerns that nonabstinence-based housing may enable alcohol use. METHODS: A 2-year, within-subjects analysis was conducted among 95 chronically homeless individuals with alcohol problems who were allocated to project-based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records. RESULTS: Multilevel growth models indicated significant within-subjects decreases across alcohol use outcomes over the study period. Intervention exposure, represented by months spent in housing, consistently predicted additional decreases in alcohol use outcomes. CONCLUSIONS: Findings did not support the enabling hypothesis. Although the project-based Housing First program did not require abstinence or treatment attendance, participants decreased their alcohol use and alcohol-related problems as a function of time and intervention exposure.

Mindfulness and modification therapy for behavioral dysregulation: results from a pilot study targeting alcohol use and aggression in women.

OBJECTIVES: Increasing evidence suggests that deficits in mindfulness (awareness, attentiveness, and acceptance of the present moment) play a role in a range of disorders involving behavioral dysregulation. This paper adds to that literature by describing a transdiagnostic psychotherapy (Mindfulness & Modification Therapy; MMT) developed to target behavioral dysregulation. DESIGN: An open-treatment pilot-trial investigated the feasibility, acceptability, and pre-post effects of MMT targeting women (N = 14) court-referred for alcohol abuse/dependence and aggression. RESULTS: Pre-post comparisons revealed significant decreases in alcohol use, drug use, and aggression. In addition, the retention rate was 93%. CONCLUSION: Preliminary evidence suggests that MMT is a feasible and acceptable treatment that decreases dysregulated behaviors such as substance use and aggression, while also potentially increasing retention.

Update on harm-reduction policy and intervention research.

Harm reduction is a pragmatic approach to reduce the harmful consequences of alcohol and drug use or other high-risk activities by incorporating several strategies that cut across the spectrum from safer use to managed use to abstinence. The primary goal of most harm-reduction approaches is to meet individuals "where they are at" and not to ignore or condemn the harmful behaviors but rather to work with the individual or community to minimize the harmful effects of a given behavior. The current review addresses some of the newest developments with respect to harm-reduction policy, prevention, and treatment. In particular, this review highlights policies and programs that have been evaluated in peer-reviewed journals and shown to be effective at reducing the harms associated with alcohol and drug use. The overall goal of this review is to present some of the most recent developments in the field of harm reduction.

State of the art in harm reduction psychotherapy: an emerging treatment for substance misuse.

Harm reduction psychotherapy is an exciting and emerging treatment for a broad spectrum of substance use problems. This article introduces an issue of the Journal of Clinical Psychology: In Session devoted to the state of the art of harm reduction psychotherapy. We describe the harm reduction paradigm, the context for and history of the development of harm reduction psychotherapy, and its clinical principles. We then outline and frame the contributions to the issue. Our goal is that this issue will encourage psychotherapists to employ more harm reduction principles in practice and will provide many evidence-based methods to do so.

Harm reduction therapy: a practice-friendly review of research.

Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors. Although harm reduction was originally and most frequently associated with substance use, it is increasingly being applied to a multitude of other behavioral disorders. This article reviews the state of empirical research on harm reduction practices including alcohol interventions for youth, college students, and a variety of other adult interventions. We also review nicotine replacement and opioid substitution, as well as needle exchanges and safe injection sites for intravenous drug users. Dozens of peer-reviewed controlled trial publications provide support for the effectiveness of harm reduction for a multitude of clients and disorders without indications of iatrogenic effects. Harm reduction interventions provide additional tools for clinicians working with clients who, for whatever reason, may not be ready, willing, or able to pursue full abstinence as a goal.

The mindfulness-based relapse prevention adherence and competence scale: development, interrater reliability, and validity.

The present study describes the development of the Mindfulness-Based Relapse Prevention Adherence and Competence Scale (MBRP-AC), a measure of treatment integrity for mindfulness-based relapse prevention (MBRP). MBRP is a newly developed treatment integrating core aspects of relapse prevention with mindfulness practices. The MBRP-AC was developed in the context of a randomized controlled trial (RCT) of MBRP efficacy and consists of two sections: Adherence (adherence to individual components of MBRP and discussion of key concepts) and Competence (ratings of therapist style/approach and performance). Audio recordings from 44 randomly selected group treatment sessions (50%) were rated by independent raters for therapist adherence and competence in the RCT. Findings evinced high interrater reliability for all treatment adherence and competence ratings, and adequate internal consistency for Therapist Style/Approach and Therapist Performance summary scales. Ratings on the MBRP-AC suggested that therapists in the recent RCT adhered to protocol, discussed key concepts in each session, and demonstrated the intended style and competence in treatment delivery. Finally, overall ratings on the Adherence section were positively related to changes in mindfulness over the course of the treatment.

The role of executive cognitive functions in changing substance use: what we know and what we need to know.

BACKGROUND: Executive cognitive functions (ECF) have been linked to skills such as planning, organizing, problem solving, decision-making, initiating and self-regulating behavior, working memory, and motivation; critical activities needed to monitor and change substance use behavior. PURPOSE: The purpose of this study is to investigate how ECF may impact important variables associated with changing substance use behavior. METHODS: This study is a critical review of the extant literature about how ECF may influence substance abuse treatment outcomes and behavior change. RESULTS: A review of the literature found evidence that poorer ECF likely hinders substance use behavior change and is often associated with behavior labeled as denial. However, the relationship between ECF and substance abuse appears to be highly complex. CONCLUSIONS: Traditional methods of substance abuse assessment, interpretation of behavior, and intervention may need to be reconsidered in light of new research about executive cognitive dysfunction. Implications for future research are discussed.

Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.

CONTEXT: Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates. OBJECTIVE: To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington. MAIN OUTCOME MEASURES: Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls. RESULTS: Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs. CONCLUSIONS: In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.

The Community Pulling Together: A Tribal Community­University Partnership Project to Reduce Substance Abuse and Promote Good Health in a Reservation Tribal Community.

Alcohol and drug abuse are major areas of concern for many American Indian=Alaska Native communities. Research on these problems has often been less than successful, in part because many researchers are not sensitive to the culture and traditions of the tribes and communities with which they are working. They alsooften fail to incorporate tribal customs, traditions, and values into the interventions developed to deal with substance abuse. The authors describe the use of community-based participatory research and tribal participatory research approaches to develop a culturally sensitive substance abuse prevention program for Native youth. This project, The Community Pulling Together: Healing of the Canoe, is a collaboration between the Suquamish Tribe and the Alcohol and Drug Abuse Institute at the University of Washington, Seattle, Washington.

Risk, resilience, and natural recovery: a model of recovery from alcohol abuse for Alaska Natives.

AIM: The People Awakening (PA) study explored an Alaska Native (AN) understanding of the recovery process from alcohol abuse and consequent sobriety. DESIGN: PA utilized a cross-sectional, qualitative research design and community-based participatory research methods. SETTING AND PARTICIPANTS: The study included a state-wide convenience sample of 57 participants representing all five major AN groups: Aleut/Alutiiq, Athabascan, Inupiaq, Yup'ik/Cup'ik and Tlingit/Haida/Tsimshian. Participants were nominated and self-identified as being alcohol-abstinent at least five years following a period of problem drinking. MEASUREMENTS: Open-ended and semistructured interviews gathered extensive personal life histories. A team of university and community co-researchers analyzed narratives using grounded theory and consensual data analysis techniques. FINDINGS: A heuristic model of AN recovery derived from our participants' experiences describes recovery as a development process understood through five interrelated sequences: (i) the person entered into a reflective process of continually thinking over the consequences of his/her alcohol abuse; (ii) that led to periods of experimenting with sobriety, typically, but not always, followed by repeated cycling through return to drinking, thinking it over, and experimenting with sobriety; culminating in (iii) a turning point, marked by the final decision to become sober. Subsequently, participants engaged in (iv) Stage 1 sobriety, active coping with craving and urges to drink followed for some participants, but not all, by (v) Stage 2 sobriety, moving beyond coping to what one participant characterized as 'living life as it was meant to be lived. CONCLUSIONS: The PA heuristic model points to important cultural elements in AN conceptualizations of recovery.

The impact of adolescent tobacco-related associative memory on smoking trajectory: an application of negative binomial regression to highly skewed longitudinal data.

Tobacco use is prevalent in adolescents and understanding factors that contribute to smoking uptake remains a critical public health priority. While there is now good support for the role of implicit (preconscious) cognitive processing in accounting for changes in drug use, these models have not been applied to tobacco use. Longitudinal analysis of smoking data presents unique problems, because these data are usually highly positively skewed (with excess zeros) and render conventional statistical tools (e.g., OLS regression) largely inappropriate. This study advanced the application of implicit memory theory to adolescent smoking by adopting statistical methods that do not rely on assumptions of normality, and produce robust estimates from data with correlated observations. The study examined the longitudinal association of implicit tobacco-related memory associations (TMAs) and smoking in 114 Australian high school students. Participants completed TMA tasks and behavioural checklists designed to obscure the tobacco-related focus of the study. Results showed that the TMA-smoking association remained significant when accounting for within-subject variability, and TMAs at Time 1 were modestly associated with smoking at Time 2 after accounting for within subject variability. Students with stronger preconscious smoking-related associations appear to be at greater risk of smoking. Strategies that target implicit TMAs may be an effective early intervention or prevention tool. The statistical method will be of use in future research on adolescent smoking, and for research on other behavioural distributions that are highly positively skewed.

[Cognitive-behavioral therapy for alcohol and drug use disorders]. / Terapia cognitivo-comportamental de transtornos de abuso de álcool e drogas.

OBJECTIVE: Cognitive-behavioral therapies have been successfully used to treat addiction. This article is in part a review on addiction models such as relapse prevention by Marlatt & Gordon, stages of change by Prochaska, DiClemente & Norcross, deriving from motivational interview, developed by Miller & Rollnick, as well as the cognitive models by Beck et al. METHOD: Based on literature evidence for the development of effective treatment programs, we report on a group treatment model used in a group of alcoholics referred by the Department of Worker's Health Surveillance at Universidade Federal do Rio de Janeiro to the Alcoholism Rehabilitation and Research Center. RESULTS: Results are presented indicating that this type of treatment could be one alternative to others treatments in use. CONCLUSIONS: New research is needed to better validate cognitive-behavioral approach to alcohol and drug problems.

Modeling the complexity of post-treatment drinking: it's a rocky road to relapse.

The most widely cited road block to successful treatment outcomes for psychological and substance use disorders has been described as the return to the previous behavior, or "relapse." The operational definition of "relapse" varies from study to study and between clinicians, but in general the term is used to indicate the return to previous levels of symptomatic behavior. One explanation for the variation in the operationalization of relapse is the wide variety of behaviors for which the term is applied, including (but not limited to): depression, substance abuse, schizophrenia, mania, sexual offending, risky sexual behavior, dieting, and the anxiety disorders. A second explanation for the multitude of definitions for relapse is the inherent complexity in the process of behavior change. In this paper we present the most recent treatment outcome research evaluating relapse rates, with a special focus on the substance use disorders. Following this review of the literature we present an argument for the operationalization of relapse as a dynamic process, which can be empirically characterized using dynamical systems theory. We support this argument by presenting results from the analysis of alcohol treatment outcomes using catastrophe modeling techniques. These results demonstrate the utility of catastrophe theory in modeling the alcohol relapse process. The implications of these analyses for the treatment of alcohol use disorders, as well as a discussion of future research incorporating nonlinear dynamical systems theory is provided.

Nonnormality and divergence in posttreatment alcohol use: reexamining the Project MATCH data "another way.".

Alcohol lapses are the modal outcome following treatment for alcohol use disorders, yet many alcohol researchers have encountered limited success in the prediction and prevention of relapse. One hypothesis is that lapses are unpredictable, but another possibility is the complexity of the relapse process is not captured by traditional statistical methods. Data from Project Matching Alcohol Treatments to Client Heterogeneity (Project MATCH), a multisite alcohol treatment study, were reanalyzed with 2 statistical methodologies: catastrophe and 2-part growth mixture modeling. Drawing on previous investigations of self-efficacy as a dynamic predictor of relapse, the current study revisits the self-efficacy matching hypothesis, which was not statistically supported in Project MATCH. Results from both the catastrophe and growth mixture analyses demonstrated a dynamic relationship between self-efficacy and drinking outcomes. The growth mixture analyses provided evidence in support of the original matching hypothesis: Individuals with lower self-efficacy who received cognitive behavior therapy drank far less frequently than did those with low self-efficacy who received motivational therapy. These results highlight the dynamical nature of the relapse process and the importance of the use of methodologies that accommodate this complexity when evaluating treatment outcomes.

The role of thought suppression in the relationship between mindfulness meditation and alcohol use.

Previous studies have demonstrated that attempts to suppress thoughts about using substances may actually lead to increases in substance use. Vipassana, a mindfulness meditation practice, emphasizes acceptance, rather than suppression, of unwanted thoughts. A study by Bowen and colleagues examining the effects of a Vipassana course on substance use in an incarcerated population showed significant reductions in substance use among the Vipassana group as compared to a treatment - usual control condition [Bowen S., Witkiewitz K., Dillworth T.M., Chawla N., Simpson T.L., Ostafin B.D., et al. (2006). Mindfulness Meditation and Substance Use in an Incarcerated Population. Psychology of Addictive Behaviors.]. The current study further examines the mediating effects of thought suppression in the relationship between participation in the course and subsequent alcohol use. Those who participated in the course reported significant decreases in avoidance of thoughts when compared to controls. The decrease in avoidance partially mediated effects of the course on post-release alcohol use and consequences.

Family and peer interventions for adults: past approaches and future directions.

Through the use of published literature and empirical research, the authors explore the differing conceptual frameworks, techniques, and effectiveness of various family interventions for change-resistant, substance-abusing adults. The 2 dominant programs in place to help families and friends deal with the addiction of an adult loved one are the Johnson Intervention and Al-Anon. Research on these 2 programs is presented, followed by an outline of promising alternative approaches. These include A Relational Intervention Sequence for Engagement, Community Reinforcement Training, Community Reinforcement and Family Training, Unilateral Family Therapy, and Pressures to Change. The effectiveness and appropriateness of these approaches in different situations are discussed. In addition, areas in need of further study are pointed out.

The changing influences of self-worth and peer deviance on drinking problems in urban American Indian adolescents.

This study explored the changing relations among self-worth, peer deviance, and alcohol-related problems in a sample of 224 urban-dwelling, American Indian adolescents. Data were collected annually at 7 time points to test a proposed mediational model. As expected, peer deviance mediated the relation between low self-worth and alcohol-related problems in younger adolescents; however, this relation did not hold as participants became older. In older adolescents, low self-worth and peer deviance directly and independently contributed to alcohol problems. Possible explanations for and implications of these findings are discussed in terms of developmental changes during adolescence.

Mindfulness meditation and substance use in an incarcerated population.

Despite the availability of various substance abuse treatments, alcohol and drug misuse and related negative consequences remain prevalent. Vipassana meditation (VM), a Buddhist mindfulness-based practice, provides an alternative for individuals who do not wish to attend or have not succeeded with traditional addiction treatments. In this study, the authors evaluated the effectiveness of a VM course on substance use and psychosocial outcomes in an incarcerated population. Results indicate that after release from jail, participants in the VM course, as compared with those in a treatment-as-usual control condition, showed significant reductions in alcohol, marijuana, and crack cocaine use. VM participants showed decreases in alcohol-related problems and psychiatric symptoms as well as increases in positive psychosocial outcomes. The utility of mindfulness-based treatments for substance use is discussed.

Recent drinking consequences, motivation to change, and changes in alcohol consumption over a three month period.

Little is known about what type of drinking related consequences may enhance motivation to change or may hinder behavior change over time. In order to examine this research question, 120 adult participants abusing alcohol were administered the Drinker Inventory of Consequences-Recent (DrInC-R), the Brief Readiness to Change Questionnaire (BRTC), and the Steady Pattern Chart (SP). Subscale scores from the DrInC-R and the BRTC; and alcohol consumption as assessed by the SP at baseline and three month follow-up were retained for data analyses. Greater intrapersonal DrInC-R consequences scores significantly predicted greater contemplation stage scores (R2=.37, p<.001), and lower precontemplation stage scores (R2=.32, p<.001), and DrInC-R impulse control and interpersonal consequences scores significantly predicted alcohol consumption at three month follow-up after controlling for baseline consumption (R2=.50, p<.001). Increased awareness of intrapersonal drinking related consequences may motivate change, whereas numbers of impulse control and interpersonal consequences may predict changes in drinking behavior over the short-term.

Relapse in alcohol- and drug-disordered adolescents with comorbid psychopathology: changes in psychiatric symptoms.

This study examined reciprocal relationships between posttreatment substance use and psychiatric symptoms in adolescents with both a substance use disorder and an Axis I mental health disorder. Participants (13-18 years old) were recruited from inpatient treatment centers and interviewed during treatment and monthly for 6 months. Participants who relapsed (N=103; 48% female) reported the incidence and severity of psychiatric symptoms experienced before and after their 1st posttreatment substance use. The number of symptoms and depression symptoms experienced were related to use of stimulants and other drugs during relapse. There was evidence for both self-medication (symptom reduction) and rebound (symptom exacerbation) effects of substance use on symptom severity. These results demonstrate that, for adolescents with both substance use and mental health disorders, psychiatric symptoms are 1 factor influencing posttreatment substance use.