Marlatt's focus on the relapse situation has had a major impact upon research and clinical pr... more Marlatt's focus on the relapse situation has had a major impact upon research and clinical practice in treating addictions. One component of his work was the development of a taxonomy for classifying precipitants of relapse. This taxonomy has been incorporated into the nomenclature of clinicians and clinical researchers as part of an explanatory framework for understanding relapses. Despite the taxonomy's influence it has never been examined for the reliability of its use across research studies. The present study compared the reliability of independent classifications of 149 relapse episodes by trained raters at three research laboratories. Despite considerable across‐laboratory training, reliability was found to be inconsistent for research purposes. It is concluded that comparability of results based on Marlatt's relapse taxonomy across independent studies must be subject to question, and assumptions necessary for the aggregation of a knowledge base are not supported. Recommendations are offered for improving the reliability of the taxonomy and the methods used to collect taxonomy data. More generally, questions regarding the value of the specific relapse categories, as well as the overall taxonomy, are raised.
Journal of Consulting and Clinical Psychology, Oct 1, 1986
A total of 174 alcoholics were randomly assigned to partial hospital treatment (PHT) or extended ... more A total of 174 alcoholics were randomly assigned to partial hospital treatment (PHT) or extended inpatient (EIP) rehabilitation after inpatient evaluation and/or detoxification. This article reports the 12-month follow-up results for the 115 subjects who consented to continue past the 6th month of follow-up. There were few differences in clinical outcomes between the PHT and EIP groups. Both reported more than 80% abstinent days during follow-up, and over 70% had a full-time occupational role, although almost a third experienced job losses during the year. Subjects showed significant improvements in psychological well-being and social behavior. One third were rehospitalized during the follow-up year. Costs for the partial hospital group were significantly lower than the extended inpatient group, leading to an overall conclusion that partial hospital treatment provides a cost-effective alternative to inpatient treatment for many alcoholics. Implications for health care planning are addressed.
Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholi... more Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. Method-Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. Results-There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. Conclusions-These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober. Alcohol use disorders represent a major public health problem in the United States. Approximately 7.4% of the U.S. population meet the diagnostic criteria for alcohol abuse or dependence (Grant et al., 1994), a proportion that results in substantial costs to the individual and society, among them elevated morbidity and mortality rates, traffic accidents, injuries, crime, broken families, domestic violence and fetal alcohol syndrome (Gmel and
The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was dev... more The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors. The Collaborative Longitudinal Personality Disorders Study (CLPS) was developed to fill critical gaps in our understanding of the nature, course, and impact of personality disorders (PDs) (Gunderson et al., 2000). Unlike major Axis I disorders, little sound empirical knowledge existed regarding the short-or long-term course and outcome of PDs. Although PDs are among the most common disorders seen in mental health settings (Widiger & Rogers, 1989) and affect about 12 percent of the general population (Torgersen, 2005) valid estimates of their prognoses, with or without treatment, were nonexistent. Furthermore, stability or chronicity of personality psychopathology is a central defining feature of Axis II disorders in the DSM (American Psychiatric Association, 2000), yet there were few empirical data to support this assertion (Grilo, McGlashan, & Oldham, 1998; Grilo & McGlashan, 1999). Finally, PDs have been associated clinically with significant public health problems, such as criminal behavior, substance abuse and dependence, suicide, divorce, child abuse, occupational disability, and heavy use of mental and general health
Background: Professional treatment and non-professional mutual-help organizations (MHOs) play imp... more Background: Professional treatment and non-professional mutual-help organizations (MHOs) play important roles in mitigating addiction relapse risk. More recently, a third tier of recovery support services has emerged that are neither treatment nor MHO that encompass an all-inclusive flexible approach combining professionals and volunteers. The most prominent of these is Recovery Community Centers (RCCs). RCC's goal is to provide an attractive central recovery hub facilitating the accrual of recovery capital by providing a variety of services (e.g., recovery coaching; medication assisted treatment [MAT] support, employment/educational linkages). Despite their growth, little is known formally about their structure and function. Greater knowledge would inform the field about their potential clinical and public health utility. Method: On-site visits (2015-2016) to RCCs across the northeastern U.S. (K=32) with semistructured interviews conducted with RCC directors and online surveys with staff assessing RCCs': physicality and locality; operations and budgets; leadership and staffing; membership; and services. Results: Physicality and locality: RCCs were mostly in urban/suburban locations (90%) with very good to excellent Walk Scores reflecting easy accessibility. Ratings of environmental quality indicated neighborhood/grounds/buildings were moderate-good attractiveness and quality. Operations: RCCs had been operating for an average of 8.5 years (SD=6.
Bipolar disorder (BP) frequently co-occurs with other psychiatric disorders. We examine whether c... more Bipolar disorder (BP) frequently co-occurs with other psychiatric disorders. We examine whether course of anxiety disorders (ANX), attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), and substance use disorders (SUD) influence likelihood of recovery and recurrence of depression and mania in BP youth. Weekly ratings of psychiatric disorder intensity were obtained from 413 participants of the Course and Outcome of BP Youth project, followed for an average of 7.75 years. Multiple-event Cox proportional hazards regression analyses examined worsening of comorbid disorders as predictors of mood episode recovery and recurrence. Increased severity in ANX and SUD predicted longer time to recovery and less time to next depressive episode, and less time to next manic episode. Multivariate models with ANX and SUD found that significant effects of ANX remained, but SUD only predicted longer time to depression recovery. Increased severity of ADHD and DBD predicte...
Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholi... more Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. Method-Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. Results-There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. Conclusions-These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober. Alcohol use disorders represent a major public health problem in the United States. Approximately 7.4% of the U.S. population meet the diagnostic criteria for alcohol abuse or dependence (Grant et al., 1994), a proportion that results in substantial costs to the individual and society, among them elevated morbidity and mortality rates, traffic accidents, injuries, crime, broken families, domestic violence and fetal alcohol syndrome (Gmel and
This article reviews methodological and conceptual issues regarding the choice of drinking outcom... more This article reviews methodological and conceptual issues regarding the choice of drinking outcome measures in alcoholism treatment research. The following issues are discussed: Should drinking outcomes be conceptualized in terms of an underlying unitary disorder, or should provision be made for independent outcomes that cover a wide variety of dimensions? Which drinking outcomes are typically measured in treatment evaluation studies and how are they operationalized? What are the empirical associations among drinking outcome measures? If multiple outcomes are measured, which should be given primary importance? Over what period of time should treatment outcome be evaluated? What procedures can be used to detect, correct or prevent the response bias associated with verbal report methods? Because outcome measures need to fit the hypotheses and practical needs of a particular study, it is unlikely that complete standardization can be achieved across all studies. Nevertheless, given the importance of drinking outcomes and the need for economy, two primary dependent measures are recommended: (1) proportion of available drinking days abstinent; and (2) intensity of drinking, as defined by the total amount consumed (in ounces absolute alcohol) during the follow-up period divided by the number of actual drinking days. This article also proposes a strategy that may help to guide the selection of outcome measures in future research. (J. Stud. Alcohol, Supplement No. 12:101-111, 1994) N A 1988 EDITORIAL, Arnold Relman stated, "We can no longer afford to provide health care without knowing more about its successes and faiIures." Applying this admonition to the treatment of alcoholism, the Institute of Medicine (1990, p. 326) recommended that "consensus must be achieved on the need for outcome determination, on the parameters to be used in determining outcome, and on the optimal way(s) to go about making outcome determinations." The goal of this article is to review methodological and conceptual issues regarding the choice of alcohol-related outcome measures in alcoholism treatment research. Alcoholrelated outcomes are the measures of drinking behavior, alcohol dependence symptoms and alcohol-related consequences that are directly attributable to drinking following treatment. A secondary goal of this article is to suggest ways that greater standardization could be introduced to the planning, execution and reporting of treatment research. Because
This article describes a conceptual model developed to explain abusive use of alcohol and reports... more This article describes a conceptual model developed to explain abusive use of alcohol and reports results of an initial test of that conceptualization. General social support is hypothesized to affect the level of subjective well-being, while alcohol-relevant social support affects the degree of alcohol involvement. A cross-sectional test of two models derived from this formulation was made using data from 148 alcoholic clients entering treatment at a private nonprofit psychiatric facility. Results indicate that a model in which no direct relationship between alcohol involvement and subjective wellbeing is specified provides a more parsimonious explanation of interrelationships at the time of treatment entry. Alcohol involvement is explained by alcohol-relevant affiliative and instrumental support (al-beit weakly), and subjective well-being is explained by general affiliative and instrumental social support. There is virtually no interrelationship between alcohol involvement and subjective well-being once the support variables are taken into account. The findings indicate that treatment should more often incorporate others from a client's social network, using significant others first to provide general social support and later alcohol-relevant support as well. Further analyses involving samples with more heterogeneity in levels of social investment and exploring the utility of these variables for treatment matching categorization decisions are warranted. (J. Stud. Alcohol 54: 283-296, 1993) LCOHOLISM TREATMENT has a poor track record: lapses and relapses of patients are common, and in as short a time as 1 to 2 years following treatment less than half of the patients have maintained abstinence (see, e.g., Armor et al., 1978; Emrick and Hansen, 1983; Nathan, 1986; Saxe et al., 1983). Studies may have shown low treatment effectiveness, however, because samples included both those for whom a given intervention strategy or component would be beneficial (matches) and those for whom it would not (mismatches) (Gibbs, 1981). The search for matching factors that affect shortand long-term outcome-deficits that may be actively addressed in a given treatment modality, or characteristics that seem to make a client more receptive to one form of treatment and not others-has been largely post hoc (see review in Longabaugh, 1986; Miller and Hester, 1985; and cf., McLellan et al., 1983). The need to address this
Youth in foster care have limited access to substance use services for a variety of reasons. Atte... more Youth in foster care have limited access to substance use services for a variety of reasons. Attempts to unpack this health disparity have focused on foster care systems, administrators, providers, and foster parents. This study seeks to understand the perspectives of youth themselves, with the hope of understanding their experiences with and preferences for such services. Analyses of focus groups with youth who had recently left foster care suggested concrete and perceptual facilitators/barriers to treatment. Concrete facilitators/barriers included the need for expanding social support, access to multiple service options, and tailored intervention approaches. Perceptual concerns revolved around understanding each individual's readiness to change, feeling judged by authority figures, and desiring help from people with lived experience. Participants also described novel intervention ideas, including a focus on technology-based approaches. By relying on youth voices, we can improve upon the current state of substance use interventions within foster care.
Overview-The Client Language Assessment-Proximal/Distal (CLA-PD) is a language rating system for ... more Overview-The Client Language Assessment-Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are subdivided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multisession and skill-based (e.g., Cognitive Behavioral Therapy). Method-Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N = 126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (Cognitive Behavioral Therapy, Twelve-Step Facilitation Therapy, Motivational Enhancement Therapy). Results-Inter-rater reliability results for summary scores showed "excellent" reliability for the measure. Specifically, two-way mixed Intraclass Coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from "fair" to "good" (α = .74 to. 84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent
This article describes the protocol for a Hybrid Type I cost-effectiveness and implementation stu... more This article describes the protocol for a Hybrid Type I cost-effectiveness and implementation study of interpersonal psychotherapy (IPT) for men and women prisoners with major depressive disorder (MDD). The goal is to promote uptake of evidence-based treatments in criminal justice settings by conducting a randomized effectiveness study that collects implementation data, including a full cost-effectiveness analysis. More than 2.3 million people are incarcerated in the United States on any given day. MDD is the most common severe mental illness among incarcerated individuals. Despite the prevalence and consequences of MDD among incarcerated populations, this study will be the first fully-powered randomized trial of any treatment for MDD in an incarcerated population. Given the politically charged nature of the justice system, advantageous health outcomes are often not enough to get an intervention implemented in prisons. To increase the policy impact of this trial, we sought advice fr...
Research on the course of substance use disorders (SUDs) faces challenges in assessing behavior o... more Research on the course of substance use disorders (SUDs) faces challenges in assessing behavior over lengthy time periods. Calendar-based methods, like the Timeline Followback (TLFB), may overcome these challenges. This study assessed the reliability of self-reported weekly alcohol use, drug use, and HIV-risk behaviors over the past 90 days using an interview TLFB. Individuals with SUD in outpatient treatment (N = 26) completed the TLFB at baseline and then a week later with separate interviewers. Weekly ratings were aggregated across 4 week intervals for each administration. Intra-class correlations were used to compare agreement between the two administrations. Reliabilities for alcohol and drug use ratings ranged from good to excellent for most drug categories (ICCs = 0.76-1.00), except opioid use (other than heroin) and sedative use produced substandard reliabilities (ICCs = 0.29-0.74). HIV-risk behavior reliabilities also ranged from good to excellent (ICCs = 0.70-0.97), but were substandard for the number of casual sex partners for some intervals (ICCs = 0.29, 0.63). Findings extend support for the use of TLFB to produce reliable assessments of many drugs and HIV-risk behaviors across longitudinal intervals.
Background-Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; howeve... more Background-Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; however, no studies have examined symptom categories or subtypes as predictors of long-term clinical course in adults with primary OCD. Method-A total of 213 adults with DSM-IV OCD were recruited from several mental health treatment sites between July 2001 and February 2006 as part of the Brown Longitudinal Obsessive Compulsive Study, a prospective, naturalistic study of treatment-seeking adults with primary OCD. OCD symptoms were assessed annually over the 5-year follow-up period using the Longitudinal Interval Follow-Up Evaluation. Results-Thirty-nine percent of participants experienced either a partial (22.1%) or a full (16.9%) remission. Two OCD symptom dimensions impacted remission. Participants with primary obsessions regarding overresponsibility for harm were nearly twice as likely to experience a remission (P < .05), whereas only 2 of 21 participants (9.5%) with primary hoarding achieved remission. Other predictors of increased remission were lower OCD severity (P < .0001) and shorter duration of illness (P < .0001). Fifty-nine percent of participants who remitted subsequently relapsed. Participants with obsessive-compulsive personality disorder were more than twice as likely to relapse (P < .005). Participants were also particularly vulnerable to relapse if they experienced partial remission versus full remission (70% vs 45%; P < .05).
To test the value of a problem-focused nomenclature, problems were compared with DSM-II diagnoses... more To test the value of a problem-focused nomenclature, problems were compared with DSM-II diagnoses as predictors of treatment and outcome. Patient problems, diagnoses, and treatment plans were coded from the medical records of 779 psychiatric inpatients. Problems were found to predict treatment plans better than did diagnoses. The combination of problems and diagnoses, however, was the best predictor of treatment with psychotropic medications. Problems of over 300 patients were compared with diagnoses as predictors of patient outcomes in overall functioning, subjective well-being, family functioning and mental status. At two months, problems and diagnoses predicted outcome equally well while the two in combination afforded the best prediction. At one year, however, the variance in outcomes explained by diagnosis was one third less than that explained by problems.
Marlatt's focus on the relapse situation has had a major impact upon research and clinical pr... more Marlatt's focus on the relapse situation has had a major impact upon research and clinical practice in treating addictions. One component of his work was the development of a taxonomy for classifying precipitants of relapse. This taxonomy has been incorporated into the nomenclature of clinicians and clinical researchers as part of an explanatory framework for understanding relapses. Despite the taxonomy's influence it has never been examined for the reliability of its use across research studies. The present study compared the reliability of independent classifications of 149 relapse episodes by trained raters at three research laboratories. Despite considerable across‐laboratory training, reliability was found to be inconsistent for research purposes. It is concluded that comparability of results based on Marlatt's relapse taxonomy across independent studies must be subject to question, and assumptions necessary for the aggregation of a knowledge base are not supported. Recommendations are offered for improving the reliability of the taxonomy and the methods used to collect taxonomy data. More generally, questions regarding the value of the specific relapse categories, as well as the overall taxonomy, are raised.
Journal of Consulting and Clinical Psychology, Oct 1, 1986
A total of 174 alcoholics were randomly assigned to partial hospital treatment (PHT) or extended ... more A total of 174 alcoholics were randomly assigned to partial hospital treatment (PHT) or extended inpatient (EIP) rehabilitation after inpatient evaluation and/or detoxification. This article reports the 12-month follow-up results for the 115 subjects who consented to continue past the 6th month of follow-up. There were few differences in clinical outcomes between the PHT and EIP groups. Both reported more than 80% abstinent days during follow-up, and over 70% had a full-time occupational role, although almost a third experienced job losses during the year. Subjects showed significant improvements in psychological well-being and social behavior. One third were rehospitalized during the follow-up year. Costs for the partial hospital group were significantly lower than the extended inpatient group, leading to an overall conclusion that partial hospital treatment provides a cost-effective alternative to inpatient treatment for many alcoholics. Implications for health care planning are addressed.
Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholi... more Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. Method-Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. Results-There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. Conclusions-These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober. Alcohol use disorders represent a major public health problem in the United States. Approximately 7.4% of the U.S. population meet the diagnostic criteria for alcohol abuse or dependence (Grant et al., 1994), a proportion that results in substantial costs to the individual and society, among them elevated morbidity and mortality rates, traffic accidents, injuries, crime, broken families, domestic violence and fetal alcohol syndrome (Gmel and
The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was dev... more The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors. The Collaborative Longitudinal Personality Disorders Study (CLPS) was developed to fill critical gaps in our understanding of the nature, course, and impact of personality disorders (PDs) (Gunderson et al., 2000). Unlike major Axis I disorders, little sound empirical knowledge existed regarding the short-or long-term course and outcome of PDs. Although PDs are among the most common disorders seen in mental health settings (Widiger & Rogers, 1989) and affect about 12 percent of the general population (Torgersen, 2005) valid estimates of their prognoses, with or without treatment, were nonexistent. Furthermore, stability or chronicity of personality psychopathology is a central defining feature of Axis II disorders in the DSM (American Psychiatric Association, 2000), yet there were few empirical data to support this assertion (Grilo, McGlashan, & Oldham, 1998; Grilo & McGlashan, 1999). Finally, PDs have been associated clinically with significant public health problems, such as criminal behavior, substance abuse and dependence, suicide, divorce, child abuse, occupational disability, and heavy use of mental and general health
Background: Professional treatment and non-professional mutual-help organizations (MHOs) play imp... more Background: Professional treatment and non-professional mutual-help organizations (MHOs) play important roles in mitigating addiction relapse risk. More recently, a third tier of recovery support services has emerged that are neither treatment nor MHO that encompass an all-inclusive flexible approach combining professionals and volunteers. The most prominent of these is Recovery Community Centers (RCCs). RCC's goal is to provide an attractive central recovery hub facilitating the accrual of recovery capital by providing a variety of services (e.g., recovery coaching; medication assisted treatment [MAT] support, employment/educational linkages). Despite their growth, little is known formally about their structure and function. Greater knowledge would inform the field about their potential clinical and public health utility. Method: On-site visits (2015-2016) to RCCs across the northeastern U.S. (K=32) with semistructured interviews conducted with RCC directors and online surveys with staff assessing RCCs': physicality and locality; operations and budgets; leadership and staffing; membership; and services. Results: Physicality and locality: RCCs were mostly in urban/suburban locations (90%) with very good to excellent Walk Scores reflecting easy accessibility. Ratings of environmental quality indicated neighborhood/grounds/buildings were moderate-good attractiveness and quality. Operations: RCCs had been operating for an average of 8.5 years (SD=6.
Bipolar disorder (BP) frequently co-occurs with other psychiatric disorders. We examine whether c... more Bipolar disorder (BP) frequently co-occurs with other psychiatric disorders. We examine whether course of anxiety disorders (ANX), attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders (DBD), and substance use disorders (SUD) influence likelihood of recovery and recurrence of depression and mania in BP youth. Weekly ratings of psychiatric disorder intensity were obtained from 413 participants of the Course and Outcome of BP Youth project, followed for an average of 7.75 years. Multiple-event Cox proportional hazards regression analyses examined worsening of comorbid disorders as predictors of mood episode recovery and recurrence. Increased severity in ANX and SUD predicted longer time to recovery and less time to next depressive episode, and less time to next manic episode. Multivariate models with ANX and SUD found that significant effects of ANX remained, but SUD only predicted longer time to depression recovery. Increased severity of ADHD and DBD predicte...
Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholi... more Objective-Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. Method-Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. Results-There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. Conclusions-These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober. Alcohol use disorders represent a major public health problem in the United States. Approximately 7.4% of the U.S. population meet the diagnostic criteria for alcohol abuse or dependence (Grant et al., 1994), a proportion that results in substantial costs to the individual and society, among them elevated morbidity and mortality rates, traffic accidents, injuries, crime, broken families, domestic violence and fetal alcohol syndrome (Gmel and
This article reviews methodological and conceptual issues regarding the choice of drinking outcom... more This article reviews methodological and conceptual issues regarding the choice of drinking outcome measures in alcoholism treatment research. The following issues are discussed: Should drinking outcomes be conceptualized in terms of an underlying unitary disorder, or should provision be made for independent outcomes that cover a wide variety of dimensions? Which drinking outcomes are typically measured in treatment evaluation studies and how are they operationalized? What are the empirical associations among drinking outcome measures? If multiple outcomes are measured, which should be given primary importance? Over what period of time should treatment outcome be evaluated? What procedures can be used to detect, correct or prevent the response bias associated with verbal report methods? Because outcome measures need to fit the hypotheses and practical needs of a particular study, it is unlikely that complete standardization can be achieved across all studies. Nevertheless, given the importance of drinking outcomes and the need for economy, two primary dependent measures are recommended: (1) proportion of available drinking days abstinent; and (2) intensity of drinking, as defined by the total amount consumed (in ounces absolute alcohol) during the follow-up period divided by the number of actual drinking days. This article also proposes a strategy that may help to guide the selection of outcome measures in future research. (J. Stud. Alcohol, Supplement No. 12:101-111, 1994) N A 1988 EDITORIAL, Arnold Relman stated, "We can no longer afford to provide health care without knowing more about its successes and faiIures." Applying this admonition to the treatment of alcoholism, the Institute of Medicine (1990, p. 326) recommended that "consensus must be achieved on the need for outcome determination, on the parameters to be used in determining outcome, and on the optimal way(s) to go about making outcome determinations." The goal of this article is to review methodological and conceptual issues regarding the choice of alcohol-related outcome measures in alcoholism treatment research. Alcoholrelated outcomes are the measures of drinking behavior, alcohol dependence symptoms and alcohol-related consequences that are directly attributable to drinking following treatment. A secondary goal of this article is to suggest ways that greater standardization could be introduced to the planning, execution and reporting of treatment research. Because
This article describes a conceptual model developed to explain abusive use of alcohol and reports... more This article describes a conceptual model developed to explain abusive use of alcohol and reports results of an initial test of that conceptualization. General social support is hypothesized to affect the level of subjective well-being, while alcohol-relevant social support affects the degree of alcohol involvement. A cross-sectional test of two models derived from this formulation was made using data from 148 alcoholic clients entering treatment at a private nonprofit psychiatric facility. Results indicate that a model in which no direct relationship between alcohol involvement and subjective wellbeing is specified provides a more parsimonious explanation of interrelationships at the time of treatment entry. Alcohol involvement is explained by alcohol-relevant affiliative and instrumental support (al-beit weakly), and subjective well-being is explained by general affiliative and instrumental social support. There is virtually no interrelationship between alcohol involvement and subjective well-being once the support variables are taken into account. The findings indicate that treatment should more often incorporate others from a client's social network, using significant others first to provide general social support and later alcohol-relevant support as well. Further analyses involving samples with more heterogeneity in levels of social investment and exploring the utility of these variables for treatment matching categorization decisions are warranted. (J. Stud. Alcohol 54: 283-296, 1993) LCOHOLISM TREATMENT has a poor track record: lapses and relapses of patients are common, and in as short a time as 1 to 2 years following treatment less than half of the patients have maintained abstinence (see, e.g., Armor et al., 1978; Emrick and Hansen, 1983; Nathan, 1986; Saxe et al., 1983). Studies may have shown low treatment effectiveness, however, because samples included both those for whom a given intervention strategy or component would be beneficial (matches) and those for whom it would not (mismatches) (Gibbs, 1981). The search for matching factors that affect shortand long-term outcome-deficits that may be actively addressed in a given treatment modality, or characteristics that seem to make a client more receptive to one form of treatment and not others-has been largely post hoc (see review in Longabaugh, 1986; Miller and Hester, 1985; and cf., McLellan et al., 1983). The need to address this
Youth in foster care have limited access to substance use services for a variety of reasons. Atte... more Youth in foster care have limited access to substance use services for a variety of reasons. Attempts to unpack this health disparity have focused on foster care systems, administrators, providers, and foster parents. This study seeks to understand the perspectives of youth themselves, with the hope of understanding their experiences with and preferences for such services. Analyses of focus groups with youth who had recently left foster care suggested concrete and perceptual facilitators/barriers to treatment. Concrete facilitators/barriers included the need for expanding social support, access to multiple service options, and tailored intervention approaches. Perceptual concerns revolved around understanding each individual's readiness to change, feeling judged by authority figures, and desiring help from people with lived experience. Participants also described novel intervention ideas, including a focus on technology-based approaches. By relying on youth voices, we can improve upon the current state of substance use interventions within foster care.
Overview-The Client Language Assessment-Proximal/Distal (CLA-PD) is a language rating system for ... more Overview-The Client Language Assessment-Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are subdivided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multisession and skill-based (e.g., Cognitive Behavioral Therapy). Method-Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N = 126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (Cognitive Behavioral Therapy, Twelve-Step Facilitation Therapy, Motivational Enhancement Therapy). Results-Inter-rater reliability results for summary scores showed "excellent" reliability for the measure. Specifically, two-way mixed Intraclass Coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from "fair" to "good" (α = .74 to. 84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent
This article describes the protocol for a Hybrid Type I cost-effectiveness and implementation stu... more This article describes the protocol for a Hybrid Type I cost-effectiveness and implementation study of interpersonal psychotherapy (IPT) for men and women prisoners with major depressive disorder (MDD). The goal is to promote uptake of evidence-based treatments in criminal justice settings by conducting a randomized effectiveness study that collects implementation data, including a full cost-effectiveness analysis. More than 2.3 million people are incarcerated in the United States on any given day. MDD is the most common severe mental illness among incarcerated individuals. Despite the prevalence and consequences of MDD among incarcerated populations, this study will be the first fully-powered randomized trial of any treatment for MDD in an incarcerated population. Given the politically charged nature of the justice system, advantageous health outcomes are often not enough to get an intervention implemented in prisons. To increase the policy impact of this trial, we sought advice fr...
Research on the course of substance use disorders (SUDs) faces challenges in assessing behavior o... more Research on the course of substance use disorders (SUDs) faces challenges in assessing behavior over lengthy time periods. Calendar-based methods, like the Timeline Followback (TLFB), may overcome these challenges. This study assessed the reliability of self-reported weekly alcohol use, drug use, and HIV-risk behaviors over the past 90 days using an interview TLFB. Individuals with SUD in outpatient treatment (N = 26) completed the TLFB at baseline and then a week later with separate interviewers. Weekly ratings were aggregated across 4 week intervals for each administration. Intra-class correlations were used to compare agreement between the two administrations. Reliabilities for alcohol and drug use ratings ranged from good to excellent for most drug categories (ICCs = 0.76-1.00), except opioid use (other than heroin) and sedative use produced substandard reliabilities (ICCs = 0.29-0.74). HIV-risk behavior reliabilities also ranged from good to excellent (ICCs = 0.70-0.97), but were substandard for the number of casual sex partners for some intervals (ICCs = 0.29, 0.63). Findings extend support for the use of TLFB to produce reliable assessments of many drugs and HIV-risk behaviors across longitudinal intervals.
Background-Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; howeve... more Background-Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; however, no studies have examined symptom categories or subtypes as predictors of long-term clinical course in adults with primary OCD. Method-A total of 213 adults with DSM-IV OCD were recruited from several mental health treatment sites between July 2001 and February 2006 as part of the Brown Longitudinal Obsessive Compulsive Study, a prospective, naturalistic study of treatment-seeking adults with primary OCD. OCD symptoms were assessed annually over the 5-year follow-up period using the Longitudinal Interval Follow-Up Evaluation. Results-Thirty-nine percent of participants experienced either a partial (22.1%) or a full (16.9%) remission. Two OCD symptom dimensions impacted remission. Participants with primary obsessions regarding overresponsibility for harm were nearly twice as likely to experience a remission (P < .05), whereas only 2 of 21 participants (9.5%) with primary hoarding achieved remission. Other predictors of increased remission were lower OCD severity (P < .0001) and shorter duration of illness (P < .0001). Fifty-nine percent of participants who remitted subsequently relapsed. Participants with obsessive-compulsive personality disorder were more than twice as likely to relapse (P < .005). Participants were also particularly vulnerable to relapse if they experienced partial remission versus full remission (70% vs 45%; P < .05).
To test the value of a problem-focused nomenclature, problems were compared with DSM-II diagnoses... more To test the value of a problem-focused nomenclature, problems were compared with DSM-II diagnoses as predictors of treatment and outcome. Patient problems, diagnoses, and treatment plans were coded from the medical records of 779 psychiatric inpatients. Problems were found to predict treatment plans better than did diagnoses. The combination of problems and diagnoses, however, was the best predictor of treatment with psychotropic medications. Problems of over 300 patients were compared with diagnoses as predictors of patient outcomes in overall functioning, subjective well-being, family functioning and mental status. At two months, problems and diagnoses predicted outcome equally well while the two in combination afforded the best prediction. At one year, however, the variance in outcomes explained by diagnosis was one third less than that explained by problems.
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Papers by Robert Stout