Improving treatment response of cognitively impaired veterans with neuropsychological rehabilitation.

This pilot study examined the effect of computerized neuropsychological rehabilitation (NR) on cognitively impaired veterans' behavior while in treatment for polysubstance abuse. A group of 10 veterans participated in a 10-session adjunctive program of NR. This group was rated for length of stay in treatment and behavioral change and participation in treatment. Comparisons were made with a group of nine veterans who were in the standard substance abuse treatment with no adjunctive NR. Mild to moderate neuropsychological impairments were present in both groups in the areas of immediate and delayed memory, prospective memory, problem solving, and visual scanning and tracking. Relative to controls, the group that participated in NR was found to remain in treatment significantly longer and rated as having a better overall attitude in the general treatment program. These data suggest that NR may have positive treatment implications in patients with mild to moderate neuropsychological impairment.

Alcohol use and workplace aggression: an examination of perpetration and victimization.

PURPOSE: The purpose of the present investigation was to examine the relationship between victimization from and perpetration of workplace aggression between coworkers and frequency of alcohol use during the last year. METHODS: Civilian employees (N = 300) selected from the US population were interviewed over the telephone with psychometrically sound measures of workplace aggression and alcohol use frequency during the last year. Hierarchical regression analyses were used to examine the relationship between alcohol use and workplace aggression, after controlling for sociodemographic variables. RESULTS: Both percentage of days of any drinking and percentage of days of heavy drinking during the last year were positively related to (a) victimization from verbal and physical aggression at work and (b) perpetration of verbal and physical aggression at work. IMPLICATIONS: Consistent with research studies spanning the sociobehavioral literature, the present investigation found alcohol use was associated with perpetration of and victimization from verbal and physical workplace aggression. Although the study established an association exists between alcohol use and workplace aggression, future investigations should attempt to understand employee alcohol use in the context of a multifaceted model that includes other likely factors that contribute to the incidence of aggressive behavior on the job.

A national survey of the use of couples therapy in substance abuse treatment.

Although results from multiple studies conducted over the last two decades indicate that Behavioral Couples Therapy (BCT) is an effective treatment for married or cohabiting alcohol- and drug-abusing patients, both in terms of reduced substance use and improved relationship satisfaction, it is unclear whether BCT or other types of couples-based interventions are used in community-based substance abuse treatment programs. In the present study, program administrators (e.g., executive directors, clinical directors, staff physicians) from 398 randomly selected community-based outpatient substance abuse treatment programs in the U.S. were interviewed regarding use of different family- and couples-based therapies in their programs. According to the program administrators, 27% of the programs provided some type of couples-based treatment. However, less than 5% of the agencies used behaviorally oriented couples therapy and none used BCT specifically. Recommendations for researchers and clinicians to increase the use of BCT in community-based treatment programs are provided.

Family-involved alcoholism treatment. An update.

We reviewed 36 randomized studies of family-involved treatment and comparison conditions. A meta-analysis showed a medium effect size favoring family-involved treatments, over individual treatment or wait-list, for outcomes of alcohol use, treatment entry/attendance, and family adjustment. Studies of family-involved treatment when the alcoholic is unwilling to seek help show: (1) Al-Anon facilitation and referral help family members cope better; (2) the popular Johnson intervention apparently does not effectively promote treatment entry; and (3) Community Reinforcement and Family Training promotes treatment entry and should be disseminated if replicated. Studies of family-involved treatment to aid recovery when the alcoholic has sought help show: (1) evidence supporting behavioral couples therapy (BCT) has grown considerably; (2) the disulfiram contract procedure should be disseminated as part of a BCT treatment package; and (3) studies of family systems and of family disease approaches are beginning to appear in the literature. Future studies need to include more women and minority patients and focus on children.

Neurotoxicity and neurocognitive impairments with alcohol and drug-use disorders: potential roles in addiction and recovery.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The organisers/chairs were Stephen C. Bowden and Fulton T. Crews. The presentations were (1) Age, genetic and other factors that increase risk of alcoholism also increase alcohol-induced neurotoxicity, by Fulton T. Crews; (2) A neurocognitive moderation model of addictions treatment response, by Marsha E. Bates; (3) The relationship of neurocognitive impairment and longitudinal treatment outcome among substance-abusing patients, by William Fals-Stewart; and (4) Treatment of cognition in detoxifying alcohol-dependent participants, by Margaret L. Ambrose.

Behavioral couples therapy versus individual-based treatment for male substance-abusing patients. An evaluation of significant individual change and comparison of improvement rates.

Fals-Stewart, Birchler, and O'Farrell (1996) found that married or cohabiting substance-abusing men (n = 40) who participated in behavioral couples therapy (BCT) in addition to individual-based treatment (IBT) for substance abuse had fewer days of substance use and, along with their partners, reported higher levels of dyadic adjustment during and 1-year after treatment than husbands who received IBT only (n = 40). In the present study, significant individual change in posttreatment frequency of substance use and dyadic adjustment was evaluated and comparisons of the proportions of participants receiving IBT and BCT who were improved, unchanged, or deteriorated in these domains of functioning were made using data from Fals-Stewart et al. (1996). Growth curve analysis revealed that a larger proportion of husbands in the BCT condition showed significant reductions in substance use (n = 33, 83%) than husbands who received IBT (n = 24, 60%). Also, a larger proportion of couples who participated in BCT showed improvements in dyadic adjustment (n = 24, 60%) than couples whose husbands received IBT only (n = 14, 35%).

The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties.

The Timeline Followback (TLFB; L. C. Sobell & M. B. Sobell, 1996) interview, which uses a calendar method developed to evaluate daily patterns and frequency of drinking behavior over a specified time period, has well-established reliability and validity for assessing alcohol consumption. Although several investigators have used the TLFB to evaluate drug-using behavior, few studies have examined the psychometric properties of the interview for this purpose. The authors conducted TLFB interviews with a sample of adult drug-abusing patients seeking treatment for substance abuse (n = 113) at baseline, posttreatment, and quarterly thereafter for 12 months. It was found that the patients' reports about their drug consumption using this method generally had high (a) retest reliability, (b) convergent and discriminant validity with other measures, (c) agreement with collateral informants' reports of patients' substance use, and (d) agreement with results from patients' urine assays.

Behavioral couples therapy for alcoholism and drug abuse.

Behavioral couples therapy (BCT) sees the substance-abusing patient with the spouse to arrange a daily "sobriety contract" in which the patient states his or her intent not to drink or use drugs and the spouse expresses support for the patient's efforts to stay abstinent. BCT also teaches communication and increases positive activities. Research supports three conclusions. First, BCT for both alcoholism and drug abuse produces more abstinence and fewer substance-related problems, happier relationships, fewer couple separations and lower risk of divorce than does individual-based treatment. Second, domestic violence is substantially reduced after BCT for both alcoholism and drug abuse. Third, cost outcomes after BCT are very favorable for both alcoholism and drug abuse, and are superior to individual-based treatment for drug abuse. The Institute of Medicine (1998) documented a large gap between research and practice in substance abuse treatment. BCT is one example of this gap. BCT has relatively strong research support, but it has not yet become widely used.

Drug-abusing patients and their intimate partners: dyadic adjustment, relationship stability, and substance use.

The dyadic adjustment and substance use of couples with a drug-abusing husband (n = 94), couples with a drug-abusing wife (n = 36), couples in which both partners abused drugs (n = 87), and non-substance-abusing conflicted couples (n = 70) were examined. For couples with 1 drug-abusing partner, a higher percentage of days abstinent during the year before treatment for drug abuse was associated with a higher level of relationship satisfaction. When both partners abused drugs, the relationship between percentage of days abstinent and relationship satisfaction became stronger and more negative as the time partners spent together using drugs increased. A higher percentage of days abstinent was associated with relationship stability for couples with 1 drug-abusing partner during and 1 year after treatment; for couples in which both partners abused drugs, a higher percentage of days abstinent was associated with relationship instability.

Procedures for evaluating the dyadic adjustment of drug-abusing patients and their intimate partners. A multimethod assessment approach.

This article describes a basic multimethod relationship assessment procedure used by the authors in their recent investigations to evaluate the relationship adjustment of married or cohabiting drug-abusing patients and their intimate partners. The components of the assessment include (a) semistructured clinical interviewing; (b) a battery of paper-and-pencil self-report inventories; and (c) observations of partners engaging in a conflict resolution discussion, coded using a standardized rating system. The essential features of the relationship assessment procedure (i.e., brevity, breadth, depth, and use of psychometrically sound measures) would allow this method to be used routinely in nonresearch settings that treat substance-abusing patients. A case example is provided to illustrate the use of these relationship assessment methods with a drug-abusing couple.

Expressed emotion and relapse in alcoholic patients.

Although family members' expressed emotion (EE) predicts patients' elevated relapse rates in schizophrenia and mood disorders, little is known about the relationship between EE and relapse in alcoholism. For 86 alcoholic patients (78 men, 8 women), the association between the spouse's EE and the alcoholic patient's subsequent relapse status in the 12 months after the couple began an outpatient behavioral marital therapy (BMT) program for alcoholism was examined. Alcoholic patients with high EE spouses, when compared with their counterparts with low EE spouses, were more likely to relapse, had a shorter time to relapse, and drank on a greater percentage of days in the 12 months after starting BMT. EE continued to be associated with relapse after patients' age, education, and alcohol problem severity were taken into account. Greater use of Antabuse and more sessions of BMT were associated with reduced relapse for alcoholic patients with high EE spouses.

Behavioral couples therapy for male substance-abusing patients: a cost outcomes analysis.

The cost outcomes for married or cohabiting substance-abusing male patients (N = 80) who were randomly assigned to receive either behavioral couples therapy (BCT) or individual-based treatment (IBT) were compared. Social costs incurred by patients in several areas (e.g., cost of substance abuse treatment, support from public assistance) during the year before and the year after treatment were estimated. BCT was more cost-beneficial than IBT; although the monetary outlays for delivering IBT and BCT were not different, the average reduction in aggregate social costs from baseline to follow-up was greater for patients who received BCT (i.e., $6,628) than for patients who received IBT (i.e., $1,904). BCT was also more cost-effective than IBT; for each $100 spent on the treatment, BCT produced greater improvements than IBT on several indicators of treatment outcome (e.g., fewer days of substance use, fewer legal problems).

Confirmatory analyses of three scoring systems for the 90-item Alcohol Expectancy Questionnaire.

OBJECTIVE: The Alcohol Expectancy Questionnaire (AEQ) is a widely used instrument in the field of alcohol research, and several different versions and scoring systems for the AEQ are in current use. Two previous confirmatory factor analytic studies failed to provide support for two of the present scoring systems for the AEQ, but these studies' results may have been an artifact due to the methods employed. In this methodological study, three factor structures for the AEQ are tested, based on three different models: (1) the original multidimensional model, (2) a unidimensional model, and (3) a second-order or hierarchical model. METHOD: Data from a previous study provided an effective N of 507 college men and women, who completed a self-administered version of the AEQ. RESULTS: Nearly all of the models tested clearly did not fit the data. One model, a three-scale scoring system, may be cautiously viewed as having demonstrated a marginal fit. CONCLUSIONS: Within the context of the present study's limitations, the validity of current scoring systems for the AEQ is questionable.

Detection of neuropsychological impairment among substance-abusing patients: accuracy of the neurobehavioral cognitive status examination.

The accuracy of the Neurobehavioral Cognitive Status Examination (NCSE) in detecting the presence of cognitive impairment among substance-abusing patients was examined. The NCSE and the Neuropsychological Screening Battery (NSB), which has been shown in previous studies to discriminate reliably between cognitively impaired and intact substance-abusing patients, were administered to 51 detoxified patients. Using participants' performances on the NSB as the criterion measure, 22 (43%) were found to be cognitively impaired. The NCSE identified only 8 of these 22 patients (36%) as being impaired; additionally, 4 of the 29 patients found to be cognitively intact by the NSB (14%) were classified as impaired by the NCSE. Thus, the false-negative rate of the NCSE is too high to recommend its use with substance-abusing patients.

Identifying positive dissimulation by substance-abusing individuals on the Personality Assessment Inventory: a cross-validation study.

The accuracy of a classification equation (which combined scores on the Drug Problems, Alcohol Problems, and Positive Impression scales from the Personality Assessment Inventory [PAI], Morey, 1991), developed by Fals-Stewart (1996) to identify test-taking response sets among substance-abusing individuals, was evaluated. As in the Fals-Stewart (1996) study, three groups of participants completing the PAI were assessed: (a) substance-abusing patients administered the inventory under standard instructions (n = 25); (b) substance-abusing patients asked to respond defensively (n = 25) combined with a group of individuals suspected of abusing drugs, referred for an evaluation by the criminal justice system, who had reasons to conceal their drug use (n = 25); and (c) non-substance-abusing respondents administered the test under standard instructions (n = 25). Significant validity shrinkage in the classification equation was found when applied to the new sample; only 68% of participants were correctly classified into their respective groups, compared to 82% of participants correctly assigned in the Fals-Stewart (1996) investigation.

Ability to counselors to detect cognitive impairment among substance-abusing patients: an examination of diagnostic efficiency.

Counselors (N = 12) in 1 of 2 substance abuse treatment facilities were asked to identify which of their patients (N = 97) had general neurocognitive impairment. Counselors were required to base their judgements on information collected from patients during psychosocial history gathering, clinical interviews, physical examinations, brief cognitive screening tests, and substance abuse severity evaluations, but not on neuropsychological test results. All patients were subsequently administered a neuropsychological test battery. Diagnostic agreement between counselors' impressions of patients' cognitive status and patients' actual neuropsychological test performance was poor. Subsequent analyses revealed counselors' impressions about patients' neuropsychological functioning were based on information that did not reliably discriminate between cognitively impaired and intact patients (e.g., years of education and self-reported symptoms of cognitive dysfunction).

Spousal violence and cognitive functioning among men recovering from multiple substance abuse.

Experimental research suggests that substance use is associated with increased aggression, and other research suggests that substance use is also a risk factor in spousal violence. In addition, neuropsychological status is associated with both spousal violence and substance abuse. This study builds on previous work demonstrating an association between lower levels of performance on a brief neuropsychological test battery and higher levels of total couple, husband-to-wife, and severe husband-to-wife violence for 31 married men recovering from multiple substance abuse.

Behavioral couples therapy for male substance-abusing patients: effects on relationship adjustment and drug-using behavior.

Married or cohabitating substance-abusing patients (N = 80) who were entering individual outpatient treatment, most of whom were referred by the criminal justice system (n = 68; 85%), were randomly assigned to a no-couples-treatment control group (n = 40) or to 12 weekly sessions of adjunctive behavioral couples therapy (BCT; n = 40). Drug use and relationship adjustment measures were collected at pretreatment, posttreatment, and at 3-, 6-, 9-, and 12-month follow-ups. Couples who received BCT as part of individual-based treatment had better relationship outcomes, in terms of more positive dyadic adjustment and less time separated, than couples in which husbands received individual-based treatment only. Husbands in the BCT condition also reported fewer days of drug use, longer periods of abstinence, fewer drug-related arrests, and fewer drug-related hospitalizations through the 12-month follow-up period than husbands receiving individual-based treatment only. However, some of the drug use and relationship adjustment differences between these groups dissipated over the course of the follow-up period.

Measuring cocaine effect expectancies among therapeutic community inpatients.

Evidence has accumulated that beliefs about alcohol contribute to the etiology and maintenance of different patterns of drinking and drinking-related behavior. This research focus has been expanded from alcohol to include marijuana and cocaine. The present study was designed to improve upon earlier efforts to measure the domain of cocaine effect expectancies, which were based on samples of college students. Confirmatory factor analyses of the 24-item Cocaine Effect Expectancy Questionnaire (CEEQ) were conducted using a sample of 231 therapeutic community inpatients in the northeastern United States. The suggested factor structure was not confirmed. Empirical support was found for a 4-item Positive Effects scale. This scale did not have a significant effect on treatment participation.