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.

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).

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.

Does change in self-perceived problem drinker identity relate to change in alcohol use? An examination of nontreatment seeking hazardous drinkers.

Identity change is related to reductions in alcohol use among treatment seekers, but it is unclear the extent to which identity change is associated with reductions in alcohol use among nontreatment seeking hazardous drinkers. The goal of the current study was to examine whether change in problem drinker identity (i.e., self-reported identification as a problem or nonproblem drinker) was associated with reductions in heavy drinking among nontreatment seeking hazardous drinkers. Participants (n = 149) completed measures to assess alcohol use and were asked if they identified as a problem drinker at baseline and at 6-, 12-, 18-, and 24-month follow-ups. Two groups were compared: (a) those who identified as a problem drinker at baseline but identified as a nonproblem drinker at 12 months and (b) those who did not make the same transition. Latent mixture modeling was conducted to examine whether change in problem drinker identity was predictive of heavy drinking latent class growth trajectories. The results indicated that a self-reported transition from identification as a problem drinker to identification as a nonproblem drinker was associated with greater reductions in heavy drinking over the assessment period and a 7 times greater likelihood of being in a rapidly decreasing heavy drinking latent trajectory class compared with participants who did not make the same transition. Self-reported transitions in identity appear to be a good predictor of heavy drinking trajectories among nontreatment seekers. A better understanding of what predicts transitions in drinking identity among non-treatment and treatment seekers is needed. (PsycINFO Database Record

Development and Validation of a Video Measure for Assessing Women's Risk Perception for Alcohol-Related Sexual Assault.

OBJECTIVE: Using an iterative process, a series of three video scenarios were developed for use as a standardized measure for assessing women's perception of risks for alcohol-related sexual assault (SA). The videos included ambiguous and clear behavioral and environmental risk cues. METHOD: Focus group discussions with young, female heavy drinkers (N = 42) were used to develop three videos at different risk levels (low, moderate, and high) in Study 1. Realism, reliability, and validity of the videos were assessed using multiple methods in Studies 2 and 3. One hundred-four women were used to compare differences in risk perception across the video risk level in Study 2. In Study 3 (N = 60), we assessed women's perceptions of the low and high risk videos under conditions of no alcohol and alcohol. RESULTS: The realism and reliability of the videos were good. Women who viewed the low risk video compared to women who viewed the moderate and high risk videos perceived less risk for SA. We found an interaction between alcohol and risk perception such that, women in the alcohol condition were less likely to perceive risk when watching the high risk video. CONCLUSIONS: As the video risk level increased, women's perception of risk increased. These findings provide convergent evidence for the validity of the video measure. Given the limited number of standardized scenarios for assessing risk perception for sexual assault, our findings suggest that these videos may provide a needed standardized measure.

Therapeutic alliances predict session by session drinking behavior in the treatment of alcohol use disorders.

OBJECTIVE: The therapeutic alliance is recognized as an important contributor to treatment outcomes. In this study, the session-to-session interplay of the alliance (as perceived by the patient) and alcohol involvement (drinking days and heavy drinking days between successive treatment sessions) was examined. The analyses also tested the extent to which pretreatment changes in drinking altered these interrelationships. METHOD: Participants (N = 63) seeking treatment for an alcohol use disorder received 12 weeks of CBT for alcohol dependence and completed weekly assessments of the alliance. RESULTS: Higher session alliance scores at a given session significantly predicted lower alcohol involvement (both drinking days and heavy drinking days) in the period until the next treatment session, controlling for previous alcohol involvement. This relationship was further moderated by pretreatment change (changes in drinking before the first treatment session). Among those who demonstrated low pretreatment change, alliances continued to predict alcohol involvement. In contrast, alliances were not associated with alcohol involvement among those who significantly reduced their drinking before the first treatment session (high pretreatment changers). Finally, alcohol involvement during the period preceding a treatment session did not significantly predict alliance ratings. CONCLUSIONS: These data demonstrate that more positive patient ratings of the alliance at any given treatment session are associated with less alcohol involvement during the period until the next treatment session, most particularly among patients who have not initiated reductions in their drinking before the first treatment session. For such patients, efforts to maximize therapeutic alliances may be warranted and productive. (PsycINFO Database Record

Within treatment therapeutic alliance ratings profiles predict posttreatment frequency of alcohol use.

Although past research has demonstrated a positive relationship between the therapeutic alliance (TA) and improved drinking outcomes, specific aspects of the alliance have received less attention. In this study, we examined the association between alliance characteristics during treatment and 4-month follow-up drinking reports. Sixty-five treatment-seeking alcohol dependent clients who participated in 12 weeks of individual outpatient treatment provided weekly TA ratings during treatment and reported on pretreatment, during treatment, and posttreatment alcohol use. Latent profile analysis was conducted to discern distinct profiles of client and therapist ratings of therapeutic alliance with similar alliance characteristics. TA profiles were based on clients' and therapists' mean alliance rating, minimum alliance rating, maximum alliance rating, the range of alliance ratings, and the difference in session number between maximum and minimum alliance ratings. One- through 4-class models were fit to the data. Model fit was judged by comparative fit indices, substantive interpretability, and parsimony. Wald tests of mean equality determined whether classes differed on follow-up percentage of days abstinent (PDA) at 4-months posttreatment. Three-profile solutions provided the best fit for both client and therapist ratings of the therapeutic alliance. Client alliance rating profiles predicted drinking in the follow-up period, but therapist rating profiles did not. These results suggest that distinct profiles of the therapeutic alliance can be identified and that client alliance rating profiles are associated with frequency of alcohol use following outpatient treatment.

Tobacco smoking among male and female alcohol treatment-seekers: clinical complexities, treatment length of stay, and goal achievement.

BACKGROUND: Literature suggests that tobacco smoking among clients in alcohol treatment has important clinical implications, including poorer treatment outcome. Much of this literature, however, has been derived from research-based treatment samples that utilized stringent inclusion and exclusion criteria, limiting generalizability of findings. OBJECTIVE: In order to further our understanding of the correlates of smoking among clients with alcohol problems, the present research examines tobacco smoking status at admission for 21,128 adult treatment seekers from 253 community outpatient substance abuse clinics across New York State. METHODS: This sample includes tobacco smokers at admission (62%) and women (25%). Clinical complexities at admission (unemployment, lack of high school diploma/GED, criminal justice involvement, mental illness, polysubstance abuse) and length of treatment stay and alcohol-related goal achievement at discharge were assessed by clinic staff. RESULTS: Mixed models revealed that tobacco smoking was significantly associated with all five clinical complexities; interactions with gender indicated that this association was stronger for women with regard to criminal justice involvement and polysubstance abuse. Also, these smokers evidenced shorter substance disorder treatment duration and were less likely to achieve alcohol-related treatment goals relative to their nonsmoking counterparts. CONCLUSIONS: Admission tobacco smoking status of alcohol treatment seekers is an important client characteristic with regard to clinical presentation and treatment outcome. Our findings underscore the need to further our understanding of the complexities associated with smoking and especially as it pertains to female smokers.

Children's proneness to shame and guilt predict risky and illegal behaviors in young adulthood.

Do shame and guilt help people avoid doing wrong? Although some research suggests that guilt-proneness is a protective factor while shame-proneness puts individuals at risk, most research is either cross-sectional or short-term. In this longitudinal study, 380 5th graders (ages 10-12) completed measures of proneness to shame and guilt. We re-interviewed 68 % of participants after they turned 18 years old (range 18-21). Guilt-proneness assessed in childhood predicted fewer sexual partners, less use of illegal drugs and alcohol, and less involvement with the criminal justice system. Shame-proneness, in contrast, was a risk factor for later deviant behavior. Shame-prone children were more likely to have unprotected sex and use illegal drugs in young adulthood. These results held when controlling for childhood SES and teachers' ratings of aggression. Children's moral emotional styles appear to be well established by at least middle childhood, with distinct downstream implications for risky behavior in early adulthood.

Culturally (in)competent? Dismantling health care barriers for sexual minority women.

Lesbian and bisexual (LB) women exhibit elevated rates of a variety of behaviors (i.e., smoking, excessive caloric intake, physical inactivity, heavy alcohol consumption) that put them at risk for adverse health consequences. Furthermore, LB women experience numerous barriers to obtaining culturally competent health care. In this article we review risk behaviors and health care barriers and we discuss the role of stress as an important contributing factor in LB women's health outcomes. We suggest future research, health care delivery changes, and training improvements that will prepare social workers to effectively address the needs of their LB clients.

Alcohol use trajectories among non-treatment-seeking heavy drinkers.

OBJECTIVE: Heavy drinking, often defined as more than five drinks per occasion, is a major public health problem worldwide, yet most individuals who drink heavily never receive treatment. Focusing on those who receive treatment, numerous studies have found that alcohol use following treatment is discontinuous, with periods of abstinence alternating with periods of heavy drinking. In contrast, little is known about changes in alcohol use among the majority of individuals who engage in heavy drinking and never receive treatment. The goal of this study was to examine changes in alcohol consumption (proportion of heavy drinking days) in a sample of non-treatment-seeking heavy drinkers (n = 151). METHOD: The current study focused on three quantitative models--latent growth curve, latent growth mixture, and latent Markov models--to examine changes in the frequency of heavy drinking days (i.e., ≥ 5/4 drinks per day for men/women) among a sample of heavy drinkers who did not receive any form of treatment or self-help over a 2-year period. RESULTS: Participants significantly reduced their frequency of heavy drinking over a 2-year period, and changes in drinking did not show the discontinuity in trajectories often observed in treatment samples. Alcohol use disorder diagnosis predicted higher initial levels of frequent heavy drinking but did not predict changes in the frequency of heavy drinking over time. CONCLUSIONS: Most individuals, with or without an alcohol use disorder, reported significant reductions in heavy drinking frequency over time. These results have important implications for a public health approach to the problem of heavy drinking.

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.

Exploring shame, guilt, and risky substance use among sexual minority men and women.

This study examined the interrelations among shame-proneness, guilt-proneness, internalized heterosexism (IH), and problematic substance use among 389 gay, lesbian, and bisexual men and women. Problematic alcohol and drug use were positively related to shame-proneness and negatively related to guilt-proneness. Bisexuals reported riskier substance use behaviors, lower levels of guilt-proneness, and higher levels of IH than gay men and lesbians. Furthermore, study findings indicated that shame and IH are related. Additional investigations of these associations would supplement current understandings of sexual minority stress and advance the development of substance-related intervention and prevention efforts targeting sexual minorities.

Prospective changes in alcohol use among hazardous drinkers in the absence of treatment.

Gaining a better understanding of the natural course of hazardous alcohol consumption could inform the development of brief interventions to encourage self-change. In the current study, hazardous drinkers (based on Alcohol Use Disorders Identification Test score) were recruited using advertisements to participate in a 2-year multiwave prospective study. Participants (n = 206) provided self-reports every six months during the study, including reports of daily alcohol consumption. The current investigation focuses on self-initiated change in participants' frequency of heavy drinking days (i.e., ≥ 5/4 drinks per day for men/women), as predicted by a number of demographic (e.g., age) and psychosocial (e.g., guilt-proneness) variables. Latent growth curve models of the change in percent heavy drinking days over the 2-year period provided an excellent fit to the observed data and indicated a significant decline in percent heavy drinking days over time. Reductions in heavy drinking frequency were predicted by younger age and higher guilt-proneness. The identification of these predictors of reductions in heavy drinking frequency provides information to guide future work investigating self-change among hazardous drinkers.

Characteristics of alcoholic smokers, nonsmokers, and former smokers: personality, negative affect, alcohol involvement, and treatment participation.

INTRODUCTION: Previous research has indicated that smoking behavior in the general population is linked to personality traits such as behavioral undercontrol and negative emotionality, but it is unknown whether these traits pertain to alcoholic smokers. Further, prior research has not established whether alcoholic smokers differ from their nonsmoking counterparts in terms of alcohol involvement severity and treatment participation. Exploration of these associations is important, given the high prevalence of cigarette smoking among alcoholics. METHODS: Treatment-seeking alcoholics were categorized into daily cigarette smokers (n = 76), nonsmokers (n = 34), and former smokers (n = 33). These groups were compared on personality traits, negative affect, alcohol involvement, and alcohol outpatient treatment participation. RESULTS: All three groups scored similarly on a variety of personality traits (e.g., extraversion and neuroticism), and on most aspects of negative affect, with the exception of anxiety (smokers scored higher than nonsmokers and former smokers). In terms of alcohol involvement, alcoholic smokers reported greater negative drinking consequences and alcohol physical dependence relative to former smokers, even considering that alcoholic smokers had relatively more abstinent days. Finally, alcoholic smokers attended considerably fewer alcohol outpatient treatment sessions relative to both nonsmokers and former smokers. CONCLUSIONS: Common risk factors for both alcoholism and smoking behavior, such as personality traits and negative affect, may obscure personality differences between smokers and nonsmokers in an alcohol treatment sample. Furthermore, findings suggest that current nicotine use among alcoholics is associated with greater anxiety and severity of alcoholism than among their former-smoking counterparts.

WOMEN'S SOCIAL BEHAVIOR WHEN MEETING NEW MEN: THE INFLUENCE OF ALCOHOL AND CHILDHOOD SEXUAL ABUSE.

Heavy alcohol consumption (Testa & Parks, 1996) and childhood sexual abuse (CSA; Messman-Moore & Long, 2003) have been associated with adult sexual victimization. We examined the social behavior of 42 women under two alcohol conditions (high dose and low dose) in a bar laboratory. Women were videotaped interacting with a man they had just met. Women in the higher dose condition engaged in more open body position and talked, stood, and walked more than women in the lower dose condition. These behaviors are consistent with signs of intoxication or romantic interest. The women in the high-dose condition also frowned more than women in the low-dose condition. An increase in frowning could indicate less comfort or may be considered consistent with an increase in animation during the social interaction given the concomitant increase in other behaviors. Thus, the nonverbal behavior of women in the high-dose condition could be interpreted as mixed signals. CSA victims exhibited fewer head movements (e.g., nods), were less animated, and frowned more than non-CSA victims. These behaviors convey reticence or possibly even anxiety or discomfort during the social interaction. Thus, the nonverbal behavior of women with a history of CSA may convey an unease that could be viewed by a potential perpetrator as vulnerability. Our findings suggest that both acute alcohol consumption and history of CSA may influence nonverbal social behavior and may influence risk for sexual assault by sending mixed cues of romantic interest or signs of vulnerability to potential perpetrators.

Gender differences in alcohol and substance use relapse.

This review explores gender differences in relapse and characteristics of relapse events in alcohol and substance use. For alcohol, relapse rates were similar across gender. Although negative mood, childhood sexual abuse, alcohol-related self-efficacy, and poorer coping strategies predicted alcohol relapse, gender did not moderate these effects. Gender did moderate the association between marriage and alcohol relapse. For women, marriage and marital stress were risk factors for alcohol relapse; among men, marriage lowered relapse risk. This gender difference in the role of marriage in relapse may be a result of partner differences in problem drinking. Alcoholic women are more likely to be married to heavy drinking partners than are alcoholic men; thus, alcoholic women may be put at risk of relapse by marriage and alcoholic men may be protected by marriage. There are fewer studies documenting gender differences in substance abuse relapse so conclusions are limited and tentative. In contrast to the lack of gender differences in alcohol relapse rates, women appear less likely to experience relapse to substance use, relative to men. Women relapsing to substance use appear to be more sensitive to negative affect and interpersonal problems. Men, in contrast, may be more likely to have positive experiences prior to relapse.

On the importance of distinguishing shame from guilt: relations to problematic alcohol and drug use.

Previous research has demonstrated that shame-proneness (the tendency to feel bad about the self) relates to a variety of life problems, whereas guilt-proneness (the tendency to feel bad about a specific behavior) is more likely to be adaptive. The current analyses sought to clarify the relations of shame-proneness and guilt-proneness to substance use problems in three samples with differing levels of alcohol and drug problem severity: college undergraduates (Study 1 N=235, Study 2 N=249) and jail inmates (Study 3 N=332). Across samples, shame-proneness was generally positively correlated with substance use problems, whereas guilt-proneness was inversely related (or unrelated) to substance use problems. Results suggest that shame and guilt should be considered separately in the prevention and treatment of substance misuse.

Indicators of client engagement: influences on alcohol treatment satisfaction and outcomes.

This investigation explored the relationship of client engagement variables (client expectations, therapeutic/working alliance, and session attendance) with treatment satisfaction and posttreatment drinking-related outcomes using data from 2 outpatient alcohol treatment studies (N=208). Path analysis was used to test a model in which engagement variables jointly influence client satisfaction with treatment and subsequent drinking-related outcomes. The proposed model fit well with the data and accounted for 14-23% of the variance in posttreatment outcomes. The relationships in the model suggest that the link between treatment satisfaction and outcome is clarified by examining client engagement variables, which relate indirectly to outcome by means of client satisfaction.