Effects of Therapist Feedback on the Therapeutic Alliance and Alcohol Use Outcomes in the Outpatient Treatment of Alcohol Use Disorder.

BACKGROUND: It is widely accepted that the therapeutic alliance (TA) is a mediator of psychotherapy effects, but evidence is sparse that the TA is an actual mechanism of behavior change. The purpose of this study was to provide the first systematic evidence regarding the TA as a mechanism of change in the treatment of alcohol use disorder (AUD). METHODS: Participants were 155 adult men and women presenting for individual outpatient treatment of AUD. Each was randomly assigned to 1 of 6 experienced therapists, who did or did not receive over 3 study phases postsession participant feedback on his/her ratings of the TA. All participants received a 12-session version of cognitive behavioral therapy for AUD. Participants rated the TA by use of the California Psychotherapy Alliance Scale (CALPAS) and reported their daily alcohol consumption between sessions and for 1 year posttreatment by use of the timeline followback interview. Multilevel statistical models that partitioned within- and between-participant effects and between-therapist effects were run to test the effects of feedback condition on the alliance and alcohol use, and the effects of the alliance on alcohol use. RESULTS: The study's main hypotheses that feedback causes an enhanced therapeutic alliance and that the alliance is associated with better alcohol use outcomes were not supported. CONCLUSIONS: Several methodological and substantive reasons for the pattern of findings are suggested, as well as directions for future research that would advance study of the TA as a mechanism of change in psychotherapy and in studying therapist effects on outcomes in general.

Reductions in Drinking Predict Increased Distress: Between- and Within-Person Associations between Alcohol Use and Psychological Distress During and Following Treatment.

BACKGROUND: As the nature of the association between alcohol use disorder (AUD) and other disorders is not well understood, the ways in which psychological distress changes during the course of treatment for AUD are relatively unknown. Existing literatures posit 2 competing hypotheses such that treatment for AUD concurrently decreases alcohol use and psychological distress or treatment for AUD decreases alcohol use and increases psychological distress. The current study examined the ways in which psychological distress changed as a function of treatment for AUD, including the relationship between psychological distress and drinking behaviors. METHODS: Secondary data analysis was conducted on an existing clinical trial dataset that investigated the effect of cognitive-behavioral therapy and therapeutic alliance feedback on AUDs. Specifically, data collected at baseline, posttreatment, 3-month, 6-month, 9-month, and 12-month follow-up assessments were examined. RESULTS: Results indicated decreases in heavy drinking days, increases in percentage of days abstinent, and decreases in overall psychological distress. Findings also revealed that changes in psychological distress did not predict changes in drinking at the next time interval; however, decreases in drinking predicted higher psychological distress at the next assessment. Further, average levels of psychological distress were positively associated with rates of drinking. CONCLUSIONS: The current study provides some insight into how psychological distress changes during the course of treatment for AUD, including the relationship between changes in drinking and such symptoms. Future research should continue to explore these relationships, including the ways in which treatment efforts can address what may be seen as paradoxical effects.

The indirect effect of the therapeutic alliance and alcohol abstinence self-efficacy on alcohol use and alcohol-related problems in Project MATCH.

BACKGROUND: Empirical literature indicates that the therapeutic alliance explains a modest but reliable proportion of variance in predicting alcohol-related outcomes among individuals in treatment for alcohol use disorders (AUDs). Hartzler and colleagues (2011) showed in the COMBINE data set that alcohol abstinence self-efficacy is a potentially important statistical mediator of the relationship between the alliance and client outcomes. METHODS: The purpose of this study was to replicate this finding in the Project MATCH data set. We used total alliance ratings on the Working Alliance Inventory and tested both client and therapist ratings in mediation analyses. RESULTS: We found that posttreatment self-efficacy accounted for the effect of therapist and client ratings of alliance (measured at session 2) on posttreatment drinking outcomes (drinks per drinking day and alcohol-related problems). In addition, we found a moderation effect of treatment, such that the association between the client's rating of the alliance and self-efficacy changes was positive for individuals in the cognitive behavioral treatment group but negative for those receiving motivation enhancement or Twelve-Step Facilitation. CONCLUSIONS: This study reaffirms the importance of the therapeutic alliance and self-efficacy in predicting AUD outcomes. Future research should examine changes in the therapeutic alliance throughout treatment and how these changes are related to self-efficacy and AUD treatment outcomes over time.

Super Bowl Sunday: risky business for at-risk (male) drinkers?

BACKGROUND: Major sporting events and other festive occasions are typically associated with alcohol consumption; however, little is known about risky drinking during events such as the "Super Bowl." OBJECTIVES: We sought to determine whether drinking on Super Bowl Sunday differed from Saturdays (the heaviest drinking day of the week) surrounding the date of the Super Bowl among at-risk drinkers. METHODS: Heavy drinking participants (N = 208) were recruited via advertisements for a 2-year prospective study of drinking behaviors. From this larger sample, 196 were selected for whom the date of the Super Bowl was included in their daily alcohol consumption reports (including reports of abstinence on those days) for 2006, 2007, and/or 2008. Participants' average age was 36.4 (SD = 12.9); 49.5% were women. Participants at the point of recruitment were not seeking treatment and had not been in alcohol treatment in the past year. RESULTS: Analyses using multilevel modeling comparing Super Bowl Sunday to Saturdays indicated that men drank more alcohol on Super Bowl Sunday across all 3 years, whereas women's drinking was higher in only one of the 3 years. CONCLUSIONS/IMPORTANCE: These findings suggest that heavy drinking during the Super Bowl (and in association with other sporting events), particularly among men, warrants additional attention due to the potential for deleterious public health consequences.

A pilot study of interpersonal psychotherapy for alcohol-dependent women with co-occurring major depression.

BACKGROUND: Co-occurring major depression is prevalent among alcohol-dependent women and is a risk factor for poor treatment outcomes. This uncontrolled pilot study tested the feasibility, acceptability, and initial effects of interpersonal psychotherapy (IPT) for women with co-occurring alcohol dependence and major depression (AD-MD) in an outpatient community addiction treatment program. METHODS: Fourteen female patients with concurrent diagnoses of alcohol dependence and major depression participated. Assessments were conducted at baseline, midtreatment (8 and 16 weeks), posttreatment (24 weeks), and follow-up (32 weeks). RESULTS: Participants attended a mode of 8 out of 8 possible sessions of IPT in addition to their routine addiction care, and reported high treatment satisfaction on the Client Satisfaction Questionnaire-8. Women's drinking behavior, depressive symptoms, and interpersonal functioning improved significantly over the treatment period and were sustained at follow-up. CONCLUSIONS: These preliminary findings suggest that IPT is a feasible, highly acceptable adjunctive behavioral intervention for AD-MD women.

Therapists' first impression of treatment motivation moderates the relationship between the client-rated therapeutic alliance and drinking outcomes during treatment.

INTRODUCTION: First impressions can influence interpersonal relationships for extended periods, with negative first impressions leading to more negative judgments and behaviors between individuals months after their initial meeting. Although common factors such as therapeutic alliance (TA) are well studied, less is known of the potential influence of a therapist's first impression of their client's motivation on TA and drinking outcomes. Based on data from a prospective study of the perceptions of the TA among clients receiving cognitive-behavioral treatment (CBT), this study examined how therapists' first impressions may moderate the relationship between client-rated TA and drinking outcomes during treatment. METHODS: One hundred fifty-four adults participated in a 12-week course of CBT and completed measures of TA and drinking behaviors following each treatment session. Additionally, therapists completed a measure of their first impression of their client's motivation for treatment following the first session. RESULTS: Time-lagged multilevel modeling revealed a significant within-person TA by therapists' first impression interaction that predicted percent days abstinent (PDA). Specifically, among participants rated as lower on first impressions of treatment motivation, higher within-person TA predicted greater PDA in the interval prior to the next treatment session. Within-person working alliance was not associated with PDA among individuals rated higher on first impressions of treatment motivation who demonstrated higher PDA throughout treatment. Furthermore, significant between-person TA by first impressions interactions were found for both PDA and drinks per drinking day (DDD), such that among individuals with lower treatment motivation, TA positively predicted PDA and negatively predicted DDD. CONCLUSION: Although therapists' first impressions of a client's treatment motivation are positively associated with treatment outcomes, clients' perception of the TA may mitigate the impact of poor first impressions. These findings highlight the need for additional nuanced examinations of the relationship between TA and treatment outcomes, emphasizing the contextual factors that influence this relationship.

Sources and frequency of secondhand smoke exposure during pregnancy.

INTRODUCTION: This study examined sources of exposure to secondhand smoke (SHS) during pregnancy and misclassification of women as having no SHS exposure if partner smoking was used as the only measure of SHS exposure. We also examined changes in SHS exposure across the three trimesters of pregnancy. METHODS: The sample consisted of 245 pregnant women who were in a serious relationship with a partner and 106 for examination of change over time. Women's smoking status was determined by a combination of self-reports and oral fluid assays. Women's reports of partner smoking, smoking by other social network members, and frequency of exposure to SHS were obtained. RESULTS: The most common source of SHS exposure during pregnancy was the partner (n = 245). However, reliance on the partner smoking measure alone would have misclassified a substantial number of women as having no SHS exposure during pregnancy. The importance of exposure from the general social network was also evident in the finding that among nonsmoking women with nonsmoking partners, 50% reported some level of SHS exposure in the preceding week. Contrary to expectations, there were no changes in SHS exposure across the three trimesters of pregnancy (n = 106). CONCLUSIONS: Results highlight the need for treatment plans to target sources of exposure from other members of women's social networks in addition to partners. It may be unrealistic to expect women's cessation efforts to be successful in the face of consistent and continued SHS exposure through pregnancy.

Evaluation of a Web-based Psychosocial Education and Peer Support Program for Alcohol Use Concerns.

This outcomes assessment was implemented to evaluate a web-based alcohol use recovery program, Tempest Sobriety School (TSS), and to provide a model for outcome evaluation. Adults (N=541) enrolled in TSS were assessed at pre-program start and Month 2, 6, and 12. Participants reported decreased alcohol use, drug use, craving for alcohol, and alcohol use disorder symptoms over the course of the program; changes were maintained at Month 6 and 12. Participants reported sustained increases in overall physical and mental health and quality of life. Findings will inform TSS students and stakeholders and provide a model for others conducting similar evaluations.

Identifying prenatal cannabis exposure and effects of concurrent tobacco exposure on neonatal growth.

BACKGROUND: Cannabis is the most frequently used illicit drug among pregnant women, but data describing the effects of prenatal cannabis exposure and concurrent nicotine and cannabis exposures on neonatal growth are inconsistent. Testing of meconium, the first neonatal feces, offers objective evidence of prenatal cannabis exposure, but the relative ability of meconium testing and maternal self-report to identify affected neonates remains unclear. METHODS: Eighty-six pregnant women provided detailed self-reports of daily cannabis and tobacco consumption throughout pregnancy. Cannabinoids and tobacco biomarkers were identified in oral fluid samples collected each trimester and quantified in meconium at birth. RESULTS: Cannabis-using women were significantly more likely to also consume tobacco, and smoked similar numbers of cigarettes as non-cannabis-using tobacco smokers. As pregnancy progressed, fewer women smoked cannabis and those who continued to use cannabis reported smoking a smaller number of cannabis joints, but positive maternal oral fluid tests cast doubt on the veracity of some maternal self-reports. More neonates were identified as cannabis exposed by maternal self-report than meconium analysis, because many women quit cannabis use after the first or second trimester; meconium was more likely to be positive if cannabis use continued into the third trimester. Cannabis exposure was associated with decreased birth weight, reduced length, and smaller head circumference, even after data were controlled for tobacco coexposure. CONCLUSIONS: Prenatal cannabis exposure was associated with fetal growth reduction. Meconium testing primarily identifies prenatal cannabis exposure occurring in the third trimester of gestation.

Use of the social competence interview and the anger transcendence challenge in individuals with alcohol use disorder.

Interpersonal stress is a significant determinant of relapse following treatment for Alcohol Use Disorders (AUDs), but there remains little specific information about the mechanisms underlying the relationship between interpersonal stress and AUD relapse. Application of Social Action Theory provides one new approach to advancing knowledge about the interpersonal stress-relapse relationship. Especially relevant are the Social Action Theory construct of social-emotional competence, with its accompanying measurement procedures of the Social Competence Interview and the Anger Transcendence Challenge. This study evaluated the use of the Social Competence Interview and Anger Transcendence Challenge in a sample of 63 men and women in AUD intensive outpatient treatment. The results support the use of the Social Competence Interview and the Anger Transcendence Challenge with an adult AUD clinical sample, so that these measures may help to advance knowledge about the relationship between interpersonal stress and alcohol relapse.

The role of craving in the treatment of alcohol use disorders: The importance of competing desires and pretreatment changes in drinking.

BACKGROUND: The current study aimed to contribute to the understanding of the session to session relationship between craving and drinking during the course of treatment via the incorporation into the analysis of both a) motivation to avoid alcohol and 2) pretreatment change, given that half of all individuals entering treatment change their drinking prior to the first session. METHODS: Sixty-three treatment-seeking participants received 12 weeks of CBT for alcohol dependence and completed assessments of approach inclinations, avoidance inclinations and drinking behaviors at the end of each session. RESULTS: Consistent with our hypothesis, motivations to avoid alcohol and pretreatment change significantly interacted with craving to predict both number of drinking days and heavy drinking days during the interval between sessions. Specifically, among lower pretreatment changers, motivation to avoid alcohol moderated the effect of craving on number of drinking days and number of heavy drinking days, such that craving positively predicted drinking among those lower on motivations to avoid only. In contrast, among higher pretreatment changers, cravings positively predicted drinking among those higher on motivations to avoid alcohol. CONCLUSIONS: These findings highlight the importance of measuring both desire to consume and desire to avoid consuming alcohol simultaneously, and suggest that ambivalence may function differently depending on whether one is initiating (low pretreatment change) versus maintaining change (high pretreatment change).

Factors affecting agreement between severely mentally ill alcohol abusers' and collaterals' reports of alcohol and other substance abuse.

This study examined subject-collateral reports of alcohol use among a sample of 167 dually diagnosed individuals seeking outpatient treatment at a community mental health clinic. All subjects met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for a schizophrenia-spectrum or bipolar disorder and for alcohol abuse or dependence. Subjects were recruited within 2 weeks of treatment entry and completed measures of cognitive functioning, alcohol dependence severity, psychiatric symptoms, and quantity and frequency of substance use over the previous 60 days using the Timeline Follow-Back interview (L. C. Sobell & M. B. Sobell, 1996). They also provided a urine sample, which was screened for recent drug use. Collateral interviews were conducted by phone and included an assessment of the subject's alcohol and drug use over the same 60-day period. Collaterals also reported their confidence in the accuracy of their reports. Overall, the results indicated generally poor subject-collateral agreement. However, subject-collateral agreement appeared better for those individuals (n = 97) with negative urine drug screens. The most consistent predictor of subject-collateral discrepancy scores was subjects' recent drug use. Recommendations for enhancing the validity of self-reports of substance use in a severely mentally ill population are discussed.

Impact of Pretreatment Change on Mechanism of Behavior Change Research: An Applied Example Using Alcohol Abstinence Self-Efficacy.

OBJECTIVE: With the growing recognition that, for some, significant changes in drinking occur before the first treatment session (i.e., pretreatment change), researchers have called for the careful assessment of when change occurs and its potential impact on mechanism of behavior change (MOBC) research. Using a commonly hypothesized MOBC variable, alcohol abstinence self-efficacy, the primary aim of this study was to examine the effect of pretreatment change on the study of MOBCs. METHOD: Sixty-three individuals diagnosed with alcohol dependence were recruited to participate in a 12-week cognitive-behavioral treatment. Participants completed weekly assessments of self-efficacy and drinking behaviors. RESULTS: Multilevel time-lagged regression models indicated that pretreatment change significantly moderated the effect of self-efficacy on the number of drinking days, such that among those higher on pretreatment change, higher self-efficacy ratings predicted lower rates of drinking days in the week until the next treatment session. In contrast, pretreatment change did not moderate the effect of self-efficacy on the rate of heavy drinking days. CONCLUSIONS: Results from the current study add to a small but growing body of research highlighting the importance of pretreatment change when studying MOBCs. Further, these results provide important insights into the conditions in which self-efficacy may play an important role in treatment outcomes.

Thirty-month follow-up of drinking moderation training for women: a randomized clinical trial.

This study examined the durability of a group-based drinking moderation training for heavily drinking women reporting low physical dependence on alcohol. A 30-month follow-up of participants was conducted based on a previous study of 144 women randomly assigned to treatment conditions (G. J. Connors & K. S. Walitzer, 2001). Thirty-month follow-up results indicated that women who at baseline were relatively heavier drinkers had significantly greater benefit from the drinking moderation training when exposed to intervention enhancements entailing life skills training and booster sessions. Further, the initial improvements in drinking, relative to baseline levels, did not statistically deteriorate over the 30-month follow-up. The findings support the application of treatment enhancements among women in this population who at baseline are relatively heavier drinkers.

Interest in pharmacotherapy and primary care alcoholism treatment among medically hospitalized, alcohol dependent patients.

This study assessed medically hospitalized alcoholics attitudes about pharmacotherapy and interest in primary care-based treatment. The survey included 50 medical inpatients with current alcohol dependence. Participants were asked to indicate their agreement with the following statements: (1) I need to stop drinking, (2) Some medications can help prevent drinking, (3) If a medication did help prevent drinking, I would like to receive this from a doctor, and (4) I would like a primary care doctor to treat or help treat my drinking problems. Eighty-four percent agreed they needed to stop drinking, 50% agreed that medications help prevent drinking, 66% agreed they would like to receive an effective medication to help prevent drinking, and 32% were interested in primary care treatment. Medically hospitalized patients with alcohol dependence were interested in effective medication for relapse prevention, but primary care follow-up alone may not adequately address patients' perceived treatment needs.

Ethnicity, alcohol drinking and changes in transaminase activity among heavy drinkers.

BACKGROUND: Liver cirrhosis mortality differs by ethnicity in the United States. Some studies suggest alcohol sensitivity may contribute to this finding. This analysis evaluated if alcohol-associated changes in aspartate aminotransferase (AST) and alanine transaminase (ALT) differed by ethnicity among heavy drinkers. METHODS: Subjects included 1691 subjects from Project MATCH, a multicenter alcohol use disorders treatment trial. Changes in AST and ALT over 15 months were modeled as functions of ethnicity, age, gender, time, study site and alcohol use. The main focus was on ethnic differences in changes in transaminase activity occurring with changes in alcohol use. RESULTS: At all levels of alcohol consumption AST was lower in non-Hispanic whites relative to African Americans and Mexican Americans. Changes in AST associated with changes in alcohol use did not vary by ethnicity. ALT significantly differed only between Mexican Americans and non-Hispanic whites. Similar to AST, alcohol-associated ALT change did not differ by ethnicity. CONCLUSIONS: Among individuals with alcohol use disorders participating in a treatment trial, the effect of alcohol drinking on transaminase activity did not vary by ethnicity. However, in the general population, alcohol may still interact with other factors in mediating ethnic differences in cirrhosis mortality.

Secondary Prevention of Alcohol Problems in Rural Areas Using a Bibliotherapy-Based Approach.

This study investigated the relative effects of three 12-week secondary prevention interventions for problem drinking men and women in rural counties in New York State. The participants were 111 self-referred men and women without severe dependence on alcohol who nevertheless reported heavy drinking and a desire to reduce their alcohol consumption. They were assigned randomly to one of three 12-week interventions focused on reducing alcohol intake: bibliotherapy (a self-directed manual) alone, bibliotherapy with one telephone-administered motivational interview, or bibliotherapy with one telephone-administered motivational interview and six biweekly telephone therapy sessions. Results showed that, across conditions, participants significantly increased their abstinent and light drinking days and significantly decreased their heavy drinking days over the course of treatment and a 12-month follow-up period. In addition, participants reported moderate reductions in alcohol consequences and increases in confidence not to drink heavily across a variety of situations from pre- to posttreatment, with these changes remaining stable across the course of the follow-up. Use of the drinking reduction strategies presented in the self-directed manual also remained stable from posttreatment to the 12-month follow-up. These results provide support for consideration of bibliotherapy for rural problem drinkers who are not severely dependent on alcohol, with or without the addition of telephone contacts.

Conducting Systematic Outcome Assessment in Private Addictions Treatment Settings.

Systematic outcome assessment is central to ascertaining the impact of treatment services and to informing future treatment initiatives. This project was designed to be conducted within the clinical operations of 4 private addictions treatment centers. A structured interview was used to assess patients' alcohol and other drug use and related variables (on treatment entry and at 1, 3, and 6 months following treatment discharge). The primary outcomes were percentage of days abstinent (PDA) from alcohol and drugs, PDA from alcohol, and PDA from other drugs. Collateral reports during follow-up also were gathered. A total of 280 patients (56% men) across the 4 programs participated. Percentage of days abstinent for each outcome increased significantly from baseline to the 1-month follow-up assessment, and this change was maintained at the 3- and 6-month follow-up assessments. Collateral reports mirrored the patient follow-up reports. Secondary outcomes of patient ratings of urges/cravings, depression, anxiety, and general life functioning all indicated significant improvement from baseline over the course of the follow-up. The results suggest the feasibility of conducting systematic outcome assessment in freestanding private addictions treatment environments.

Randomized clinical trial of matching client alcohol use disorder severity and level of cognitive functioning to treatment setting: A partial replication and extension.

In a tightly controlled, clinical research environment, Rychtarik et al. (2000) found that individuals with an alcohol use disorder (AUD) benefited more from inpatient (IP) than outpatient care, if they presented with high alcohol problem severity and/or low cognitive functioning. This study sought to (a) validate and extend these findings within the uncontrolled environment of a community-based treatment center and (b) test whether inpatients had fewer days of involuntary abstinence (e.g., incarcerations), controlling for differences in treatment expectancy across care settings. Clients (N = 176) with an AUD were deterministically assigned to inpatient-need group (needs IP = high severity and/or low cognitive functioning; no need for IP = neither high severity nor low cognitive functioning). Within need group, participants were randomly assigned to 21 days of routine inpatient or outpatient care, plus 6 months of continuing care. Primary outcomes of percentage of days abstinent (PDA), monthly point prevalence abstinence (PPA), and drinks per drinking day (DDD), and the secondary outcome of involuntary abstinence were assessed over 18 months. Among high-severity participants, inpatients significantly reduced DDD, and outpatients did not. Neither problem severity nor cognitive functioning moderated other setting effects. Treatment expectancy, assessed after being informed of scheduled setting, was higher among inpatients than outpatients. High-expectancy inpatients maintained the highest PDA throughout follow-up, had the highest PPA for most of follow-up, and delayed peak prevalence of involuntary abstinence by 6 months. In sum, the Alcohol Problem Severity × Setting interaction on DDD appears robust. The potential moderating role of expectancy will warrant further study. (PsycINFO Database Record

Relapse in the addictive behaviors: integration and future directions.

This paper identifies the major consistencies in substantive and methodological findings across the review papers in this special issue on relapse in the addictive behaviors. The papers were consistent in suggesting that there have been major methodological advances which have helped to move the field forward. Furthermore, the papers show the need for taking a biopsychosocial approach to the study of relapse and the major difficulty across addictive behaviors in creating an acceptable operational definition of relapse. Suggestions for future research directions that follow from the papers include deriving and evaluating relapse definitions, systematically developing and testing models and theories of relapse, and understanding and narrowing the relapse research-clinical practice gap.