Development of a Brief Motivational Enhancement Intervention for Intimate Partner Violence in Alcohol Treatment Settings.

The current studies were a manual development study and a small pilot study of a 90-minute motivational enhancement style intervention to address IPV in alcohol treatment-seeking men. Analyses of feedback provided during manual development suggest participants: (a) liked the intervention, (b) reported behavior change intentions, and (c) found the feedback compelling. Findings from the pilot study suggest the intervention may be superior to referral only in increasing short-term help-seeking and lead to marginally significant enhancements in motivation and self-reported intimacy. Help-seeking and motivation findings were associated with medium-large to large effect sizes. At 3- and 6-month follow-up, both groups showed improvements in self-reported alcohol outcomes, anger, and verbal and physical aggression. These findings support further research on this intervention.

Estimating statistical power for open-enrollment group treatment trials.

Modeling turnover in group membership has been identified as a key barrier contributing to a disconnect between the manner in which behavioral treatment is conducted (open-enrollment groups) and the designs of substance abuse treatment trials (closed-enrollment groups, individual therapy). Latent class pattern mixture models (LCPMMs) are emerging tools for modeling data from open-enrollment groups with membership turnover in recently proposed treatment trials. The current article illustrates an approach to conducting power analyses for open-enrollment designs based on the Monte Carlo simulation of LCPMM models using parameters derived from published data from a randomized controlled trial comparing Seeking Safety to a Community Care condition for women presenting with comorbid posttraumatic stress disorder and substance use disorders. The example addresses discrepancies between the analysis framework assumed in power analyses of many recently proposed open-enrollment trials and the proposed use of LCPMM for data analysis.

Computer-assisted cognitive rehabilitation for the treatment of patients with substance use disorders: a randomized clinical trial.

The purpose of this study was to examine the comparative efficacy of cognitive rehabilitation as an intervention for substance misuse. Patients with substance use disorders entering long-term residential care (N = 160) were randomly assigned to one of two conditions: (a) standard treatment plus computer-assisted cognitive rehabilitation (CACR), which was designed to improve cognitive performance in areas such as problem solving, attention, memory, and information processing speed; and (b) an equally intensive attention control condition consisting of standard treatment plus a computer-assisted typing tutorial (CATT). Participants were assessed at baseline, during treatment, at treatment completion, and 3-, 6-, 9-, and 12-month follow-up. Intent-to-treat analyses showed that, compared with those randomized to CATT, patients who received CACR were significantly more engaged in treatment (e.g., higher ratings of positive participation by treatment staff, higher ratings of therapeutic alliance), more committed to treatment (e.g., longer stays in residence) and reported better long-term outcomes (e.g., higher percentage of days abstinent after treatment). Mediational analyses revealed the positive comparative effect of CACR on abstinence during the year after treatment was mediated by treatment engagement and length of stay in residence.

The Case for Examining and Treating the Combined Effects of Parental Drug Use and Interparental Violence on Children in their Homes.

This review examines what have been, to this point, generally two divergent lines of research: (a) effects of parental drug abuse on children, and (b) effects of children's exposure to interparental violence. A small, but growing body of literature has documented the robust relationship between drug use and intimate partner violence. Despite awareness of the interrelationship, little attention has been paid to the combined effect of these deleterious parent behaviors on children in these homes. Thus, we argue for the need to examine the developmental impact of these behaviors (both individually and combined) on children in these homes and for treatment development to reflect how each of these parent behaviors may affect children of substance abusers.

Behavioral family counseling for substance abuse: a treatment development pilot study.

Substance-dependent patients (N=29) living with a family member other than a spouse were randomly assigned to equally intensive treatments consisting of either (a) Behavioral Family Counseling (BFC) plus Individual-Based Treatment (IBT) or (b) IBT alone. Outcome data were collected at baseline, post-treatment, and at 3- and 6-month follow-up. BFC patients remained in treatment significantly longer than IBT patients. BFC patients improved significantly from baseline at all time periods on all outcomes studied, and had a medium effect size reflecting better primary outcomes of increased abstinence and reduced substance use than IBT patients. For secondary outcomes of reduced negative consequences and improved relationship adjustment, both BFC and IBT patients improved significantly and to an equivalent extent. The present results show BFC is a promising method for retaining patients in treatment, increasing abstinence, and reducing substance use. These results also provide support for larger scale, randomized trials examining the efficacy of behavioral family counseling for patients living with family members beyond spouses.

Partner violence before and after couples-based alcoholism treatment for female alcoholic patients.

This study examined partner violence before and in the 1st and 2nd year after behavioral couples therapy (BCT) for 103 married or cohabiting women seeking alcohol dependence treatment and their male partners; it used a demographically matched nonalcoholic comparison sample. The treatment sample received M = 16.7 BCT sessions over 5-6 months. Follow-up rates for the treatment sample at Years 1 and 2 were 88% and 83%, respectively. In the year before BCT, 68% of female alcoholic patients had been violent toward their male partner, nearly 5 times the comparison sample rate of 15%. In the year after BCT, violence prevalence decreased significantly to 31% of the treatment sample. Women were classified as remitted after treatment if they demonstrated abstinence or minimal substance use and no serious consequences related to substance use. In Year 1 following BCT, 45% were classified as remitted, and 49% were classified as remitted in Year 2. Among remitted patients in the year after BCT, violence prevalence of 22% did not differ from the comparison sample and was significantly lower than the rate among relapsed patients (38%). Results for male-perpetrated violence and for the 2nd year after BCT were similar to the 1st year. Results supported predictions that partner violence would decrease after BCT and that clinically significant violence reductions to the level of a nonalcoholic comparison sample would occur for patients whose alcoholism was remitted after BCT. These findings replicate previous research among men with alcoholism.

Rapid cognitive screening of patients with substance use disorders.

To date, there has not been a time-efficient and resource-conscious way to identify cognitive impairment in patients with substance use disorders (SUDs). In this study, we assessed the validity, accuracy, and clinical utility of a brief (10-min) screening instrument, the Montreal Cognitive Assessment (MoCA), in identifying cognitive impairment among patients with SUDs. The Neuropsychological Assessment Battery-Screening Module, a 45-min battery with known sensitivity to the mild to moderate deficits observed in patients with SUDs, was used as the reference criterion for determining agreement, rates of correct and incorrect decision classifications, and criterion-related validity for the MoCA. Classification accuracy of the MoCA, based on receiver operating characteristic (ROC) analysis, was strong, with an area under the ROC curve of 0.86, 95% confidence interval [0.75, 0.97]. The MoCA also showed acceptable sensitivity (83.3%) and specificity (72.9%) for the identification of cognitive impairment. Using a cutoff of 25 on the MoCA, the overall agreement was 75.0%; chance-corrected agreement (kappa) was 41.9%. These findings indicate that the MoCA provides a time-efficient and resource-conscious way to identify patients with SUDs and neuropsychological impairment, thus addressing a critical need in the addiction treatment research community.

Parent training with behavioral couples therapy for fathers' alcohol abuse: effects on substance use, parental relationship, parenting, and CPS involvement.

This pilot study examined effects of Parent Skills with Behavioral Couples Therapy (PSBCT) on substance use, parenting, and relationship conflict among fathers with alcohol use disorders. Male participants (N = 30) entering outpatient alcohol treatment, their female partners, and a custodial child (8 to 12 years) were randomly assigned to (a) PSBCT; (b) Behavioral Couples Therapy (BCT); or (c) Individual-Based Treatment (IBT). Children were not actively involved in treatment. Parents completed measures of substance use, couples' dyadic adjustment, partner violence, parenting, and Child Protection Services (CPS) involvement at pretreatment, posttreatment, 6- and 12-month follow-up. PSBCT was comparable to BCT on substance use, dyadic adjustment, and partner violence; both groups showed clinically meaningful effects over IBT. Compared to BCT, PSBCT resulted in larger effect sizes on parenting and CPS involvement throughout follow-up. PSBCT for fathers may enhance parenting couple- or individual-based treatment, and warrant examination in a larger, randomized efficacy trial.

Behavioral couple therapy for gay and lesbian couples with alcohol use disorders.

Gay (n = 52) and lesbian (n = 48) patients with alcohol use disorder (AUD) and their non-substance-abusing same-sex relationship partners were randomly assigned to equally intensive interventions consisting of (a) behavioral couples therapy (BCT) plus individual-based treatment (IBT) or (b) IBT only. This study reports two separate trials, one with gay male participants and one with lesbian female participants. For both gay and lesbian patients with AUD, those who received BCT had a significantly lower percentage of days of heavy drinking during the year after treatment than patients who received IBT only. In addition, both gay and lesbian couples who received BCT reported higher levels of relationship adjustment at the end of treatment and in the year after treatment than those who received IBT only. Thus, the response of gay and lesbian couples with an alcoholic member to BCT was consistent with what has been observed with heterosexual couples.

Violence and substance use among female partners of men in treatment for intimate-partner violence.

To improve understanding of the complex dynamics in intimate partner violence (IPV) in heterosexual relationships, we explored violence and substance use among the female partners of men entering treatment for both IPV and substance-related problems. All male participants (n = 75) were alcohol dependent and had at least one domestic-violence arrest. Results showed that female partners were as likely as men to engage in substance use the week before treatment; however, according to reports by the men, the female partners were more likely than men to use substances during the last week of treatment, due to a reported increase in use during the men's treatment. Regarding violence, 59 percent of female IPV victims reported engaging in some form of mild violence against their male partners, and 55 percent reported engaging in some form of severe violence. By contrast, only 23 percent of male batterers reported that their female partners had engaged in mild violence, and only 19 percent reported that their partners had engaged in severe violence. Regardless of whether the violence was defensive in nature, the data suggest that women in relationships involving substance abuse and IPV are in need of treatment. Implications of these findings are discussed.

Mother-daughter and father-daughter attachment of college student ACOAs.

This 2005 study compared parent-child attachment in 89 American female Adult Children of Alcoholics (ACOAs) as compared to 201 non-ACOAs. Women attended a large university in the southeastern United States. Participants categorized as ACOA on the Children of Alcoholics Screen Test (CAST; Jones, 1983) reported significantly more negative affect and less support from their fathers as indicated on the Parental Attachment Questionnaire (Kenney, 1987). When results were examined by the gender of the alcohol-abusing(1) parent, participants who suspected their fathers were problem drinkers did not differ from non-ACOAs in their attachment to either parent. As compared to non-ACOAs, women who self-identified as daughters of problem-drinking mothers reported poorer attachment both to mothers and fathers.

Consequences of misspecifying the number of latent treatment attendance classes in modeling group membership turnover within ecologically valid behavioral treatment trials.

Historically, difficulties in analyzing treatment outcome data from open-enrollment groups have led to their avoidance in use in federally funded treatment trials despite the fact that 79% of treatment programs use open-enrollment groups. Recently, latent class pattern mixture models (LCPMM) have shown promise as a defensible approach for making overall (and attendance-class-specific) inferences from open-enrollment groups with membership turnover. We present a statistical simulation study comparing LCPMMs to longitudinal growth models (LGM) to understand when both frameworks are likely to produce conflicting inferences concerning overall treatment efficacy. LCPMMs performed well under all conditions examined; meanwhile, LGMs produced problematic levels of bias and Type I errors under two joint conditions: moderate to high dropout (30%-50%) and treatment by attendance class interactions exceeding Cohen's d approximately .2. This study highlights key concerns about using LGM for open-enrollment data: treatment effect overestimation and advocacy for treatments that may be ineffective in reality.

Effects of Parent Skills Training with Behavioral Couples Therapy for alcoholism on children: a randomized clinical pilot trial.

This pilot study examined preliminary effects of Parent Skills Training with Behavioral Couples Therapy on children's behavioral functioning. Participants were men (N=30) entering outpatient alcohol treatment, their female partners, and a custodial child between 8 and 12 years of age. Couples were randomly assigned to one of three equally intensive conditions: (a) Parent Skills with Behavioral Couples Therapy (PSBCT), (b) BCT (without parent training), and (c) Individual-Based Treatment (IBT; without couples-based or parent skills interventions). Parents completed measures of child externalizing and internalizing behaviors at pretreatment, posttreatment, 6- and 12-month follow up; children completed self-reports of internalizing symptoms at each assessment. Only PSBCT participants reported significant effects on all child measures throughout the 12-month follow up. PSBCT showed medium to large effects in child functioning relative to IBT, and small to medium effects relative to BCT from baseline through follow up. Effect sizes suggest clinically meaningful differences between PSBCT and both BCT and IBT that warrant further empirical evaluation of BCT with parent training for alcohol-abusing men and their partners.

Risky sexual behavior among married alcoholic men.

The current study explored whether the wives of men entering alcoholism treatment are at risk for sexually transmitted infections (STIs) exposure as a result of their husbands' sexual risk behaviors. The extramarital relationships of married alcoholic men entering outpatient treatment (n = 125) were compared with those of a demographically matched community sample of nonalcoholic married men (n = 125). The proportion of alcoholic men who reported 1 or more extramarital affairs in the previous year (14%) was significantly higher than that of the community sample (4%). Additionally, only 2 alcoholic husbands and 1 nonalcoholic husband reported that his wife was aware of the extramarital relationship. For both groups, none of the men who engaged in extramarital relationships reported consistent use of condoms when having sexual intercourse with their wives or with their extramarital partners. These results suggest that wives of alcoholic men are unknowingly placed at risk for indirect exposure to STIs as a result of their husbands' sexual risk behaviors. Thus, infidelity in treatment-seeking alcohol-abusing men represents a significant public health issue.

Brief family treatment intervention to promote continuing care among alcohol-dependent patients in inpatient detoxification: a randomized pilot study.

Alcohol-dependent patients in inpatient detoxification were randomized to treatment-as-usual (TAU) intervention or brief family treatment (BFT) intervention to promote continuing care postdetoxification. BFT consisted of meeting with the patient and an adult family member (in person or over the phone) with whom the patient lived to review and recommend potential continuing care plans for the patient. Results showed that BFT patients (n = 24) were significantly more likely than TAU patients (n = 21) to enter a continuing care program after detoxification. This was a medium to large effect size. In the 3 months after detoxification, days using alcohol or drugs (a) trended lower for treatment-exposed BFT patients who had an in-person family meeting than for TAU counterparts (medium effect), and (b) were significantly lower for patients who entered continuing care regardless of treatment condition (large effect).

Treating paternal drug abuse using Learning Sobriety Together: effects on adolescents versus children.

The focus of this study was whether couples-based treatment for substance abuse had comparable secondary benefits on the internalizing and externalizing behaviors of adolescent versus child siblings living in their homes. Couples took part in a couples-based treatment for substance abuse that combines Behavioral Couples Therapy and individual counseling (i.e., Learning Sobriety Together). During a 17-month assessment period, the relationship between parents' functioning (i.e., fathers' drug use as determined by percent days abstinent and parents' dyadic adjustment) as rated by mothers, fathers, and children's teachers and internalizing behavior (as rated by mothers' only) was stronger for children than their adolescent siblings, particularly in terms of children's externalizing behaviors. Interventions that reduce paternal drug use and improve couple functioning may reduce internalizing and externalizing symptoms for children in their homes; however, adolescents may need more intensive interventions to address internalizing and externalizing symptoms.

Analyzing data from open enrollment groups: current considerations and future directions.

Difficulties in modeling turnover in treatment-group membership have been cited as one of the major impediments to ecological validity of substance abuse and alcoholism treatment research. In this review, our primary foci are on (a) the discussion of approaches that draw on state-of-the-science analytic methods for modeling open-enrollment group data and (b) highlighting emerging issues that are critical to this relatively new area of methodological research (e.g., quantifying membership change, modeling "holiday" effects, and modeling membership change among group members and leaders). Continuing refinement of new modeling tools to address these analytic complexities may ultimately lead to the development of more federally funded open-enrollment trials. These developments may also facilitate the building of a "community-friendly" treatment research portfolio for funding agencies that support substance abuse and alcoholism treatment research.

Brief family treatment intervention to promote aftercare among substance abusing patients in inpatient detoxification: transferring a research intervention to clinical practice.

Two earlier studies showed that a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification increased aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member with whom the patient lived to review aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Based on the earlier research results, we trained a newly hired staff person to continue providing BFT. We monitored key process benchmarks derived from the earlier research studies to ensure ongoing fidelity in delivering BFT. This method proved successful in transferring BFT from delivery in a research study to ongoing delivery in routine clinical practice after the research ended. It also ensured that a high proportion of patients had their families contacted and included in planning the patients' aftercare.

Treating paternal alcoholism with learning sobriety together: effects on adolescents versus preadolescents.

The purpose of this study was to determine whether Learning Sobriety Together, a treatment for substance abuse that combines behavioral couples therapy and individual counseling, had comparable secondary benefits on the internalizing and externalizing behaviors of adolescent versus preadolescent siblings living in homes with their alcoholic fathers (N = 131) and their non-substance-abusing mothers. During a 17-month assessment period, the association between parents' functioning (i.e., fathers' drinking as determined by percentage of days abstinent and parents' dyadic adjustment) and children's adjustment (as rated by mothers, fathers, and children's teachers) was stronger for preadolescents than for their adolescent siblings, particularly in terms of children's externalizing behaviors. Interventions that reduce paternal drinking and improve couple functioning may serve as an important preventative intervention for preadolescents in these homes, whereas adolescents may need more intensive interventions to address internalizing and externalizing symptoms.

Analytic methods for modeling longitudinal data from rolling therapy groups with membership turnover.

Interventions for a variety of emotional and behavioral problems are commonly delivered in the context of treatment groups, with many using rolling admission to sustain membership (i.e., admission, dropout, and discharge from group are perpetual and ongoing). The authors present an overview of the analytic challenges inherent in rolling group data and outline commonly used (but flawed) analytic and design approaches to addressing (or sidestepping) these issues. Moreover, the authors propose use of latent class pattern mixture models (LCPMMs) as a statistically and conceptually defensible approach for modeling treatment data from rolling groups. The LCPMM approach is illustrated with rolling group data from a group-based alcoholism pilot treatment trial (N = 128). Different inferences were made with regard to treatment efficacy under LCPMM vs. the commonly used standard group-clustered latent growth model (LGM); coupled with other preliminary findings in this area, inferences from LGMs may be overly liberal when applied to data from rolling groups. Continued work on data analytic difficulties in groups with membership turnover is critical for furthering the ecological validity of research on behavioral treatments.