Behavioral and cognitive-behavioral treatments for alcoholism: research opportunities.

This status report on behavioral and cognitive-behavioral treatments (CBT) for alcoholism is based on an article commissioned by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for a review of its treatment research priorities. A number of gaps in knowledge and consequent research opportunities were identified. Additional work on cue exposure is needed to identify the most potent cues for drinking, and strategies for reducing the impact of drinking cues. Regarding contingency management, there is need for further studies with alcoholics, investigation of reinforcement schedules, and exploration of maintenance factors. With respect to the community reinforcement approach (CRA), research should identify its most effective elements and ways to sustain gains following treatment. The mediating role assigned to coping skills in the cognitive-behavioral model needs to be substantiated, and the effectiveness of various coping skills components must be determined. Further studies of relapse prevention (RP) are needed to improve the system for classifying relapse episodes, and to identify the most effective interventions for each type of episode. Studies of behavioral marital therapy should include identifying active ingredients, and testing hypothesized mediators of change. Patient-treatment matching strategies may help to identify clients likely to benefit from these strategies. Finally, given the overlap among these approaches, it is likely that research along the lines suggested will impact several of them and lead to a consolidation of their most effective elements into a common treatment package.

Prospective matching of alcoholic clients to cognitive-behavioral or interactional group therapy.

OBJECTIVE: In earlier work, client sociopathy and global psychopathology were effective variables for treatment matching: clients low on both sociopathy and severity of psychopathology were likely to benefit from interactional group therapy, whereas those scoring high on either of these dimensions benefited more from a coping skills intervention. The present study assessed whether outcomes improve further when clients are assigned to group treatments prospectively based on a matching strategy derived from the previous findings. METHOD: All participants (N = 250, 66% men) met criteria for alcohol dependence or abuse. About half were prospectively assigned to either cognitive-behavioral (CB) coping skills training or interactional therapy, those with higher levels of psychiatric severity or sociopathy were given CB and those who were low on both dimensions were given interactional therapy. The other half were randomly assigned to those treatments, replicating the procedure of the earlier study. Outcome data were collected at the conclusion of treatment and at 3-month intervals for 1 year following. RESULTS: Prospective matching of clients to treatment did not produce superior drinking outcomes compared to random treatment assignment. Randomly assigned clients were more likely to be abstinent at the end of treatment, but this effect disappeared at later follow-ups. Prospectively matched clients had fewer negative consequences of drinking than did those assigned randomly (unmatched). Neither sociopathy nor psychiatric severity was particularly effective for matching. CONCLUSIONS: The matching effects from our previous study were not replicated. Nevertheless, prospective matching did reduce the negative consequences of drinking, consistent with our previous results.

Predicting the therapeutic alliance in alcoholism treatment.

OBJECTIVE: Prediction of the therapeutic alliance in alcoholism treatment (as rated by the client and by the therapist) was examined in light of a range of potentially relevant factors, including client demographics, drinking history, current drinking, current psychosocial functioning and therapist demographics. METHOD: The data were gathered in Project MATCH. The present analyses were based on data from 707 outpatients and 480 aftercare clients assigned to one of the three Project MATCH treatments. Potential predictor variables were evaluated by first examining bivariate linear relationships between the variables and ratings of the alliance, and then entering blocks of these predictors into multiple linear regression equations with alliance ratings as the dependent variables. All analysis incorporated adjustments for the nonindependence of ratings pertaining to clients seen by the same therapist. RESULTS: In simple regressions evaluating bivariate relationships, outpatients' ratings of the alliance were positively predicted by client age, motivational readiness to change, socialization, level of perceived social support and therapist age, and were negatively predicted by client educational level, level of depression, and meaning seeking. Therapist ratings in the outpatient sample were positively predicted by the client being female and by level of overall alcohol involvement, severity of alcohol dependence, negative consequences of alcohol use, and readiness to change. Among aftercare clients, ratings of the alliance were positively predicted by readiness to change, socialization and social support, and were negatively predicted by level of depression. Therapist ratings of the alliance in the aftercare sample were positively predicted by the client being female and therapist educational level, and were negatively predicted by pretreatment drinks per drinking day. Of the variables having significant bivariate relationships with alliance scores, only a few were identified as significant predictors in multiple regression equations. Among outpatients, client age and motivational readiness to change remained positive predictors and client education a negative predictor of client ratings of the alliance, while client gender remained a significant predictor of therapist ratings. Among aftercare clients, readiness to change and level of depression remained significant predictors of client ratings, while none of the variables remained a significant predictor of therapist ratings. CONCLUSIONS: While the data indicate that several client variables predict the nature of both the client's and therapist's perception of the therapeutic alliance, the significant relationships are of modest magnitude, and few variables remain predictive after controlling for causally prior variables. The strongest relationship identified in both the outpatient and aftercare samples is that between clients' motivational readiness to change and their ratings of the alliance.

Compliance with treatment and follow-up protocols in project MATCH: predictors and relationship to outcome.

Treatment and follow-up session attendance data from Project MATCH, a multisite clinical trial investigating patient-treatment matching, were analyzed to study compliance. High rates of compliance to both therapy and research protocols were achieved, enhancing treatment integrity and data quality. Strong baseline predictors of compliance did not emerge, and the small relationships found were consistent with reports from previous studies. Attendance at therapy sessions was moderately correlated with research follow-up participation. Treatment compliance predicted drinking outcome, underscoring the importance of retaining patients in treatment. Future studies should examine the associations between compliance and structural features of the treatment environment, treatment delivery, and context-features that are often under the control of the clinician/investigator.

Measuring treatment process in cognitive-behavioral and interactional group therapies for adolescent substance abusers.

The state of the art for treatment efficacy studies now requires manual guided treatments and tests of therapist adherence. This report provides findings regarding adherence assessment of therapists participating in an investigation of treatment matching in adolescent substance abusers. The Group Sessions Rating Scale (GSRS), a group-therapy process measure, was studied to determine its appropriateness for assessing group treatment of adolescents with a) substance use disorders (SUD), b) interrater reliability, c) internal consistency, and d) ability to discriminate the active ingredients of cognitive-behavioral therapy (CBT) from interactional therapy (IT). Interrater reliabilities were moderate to high, with those for CBT generally higher than those for IT. Internal consistency of CBT items was moderate, whereas those of IT were moderately high. Discriminability between the two treatment modalities was high. The frequency of active ingredients was generally therapy-specific: high for the relevant and low for the nonrelevant therapeutic modality items. The GSRS was found to be effective in the measurement of treatment process in adolescents with SUD.

Internal validity of Project MATCH treatments: discriminability and integrity.

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.

Validity of the longitudinal, expert, all data procedure for psychiatric diagnosis in patients with psychoactive substance use disorders.

The longitudinal, expert, all data (LEAD) procedure has been employed as a criterion for the assessment of the procedural validity of diagnostic instruments. This study evaluated the procedure's concurrent, discriminant and predictive validity. Interview and questionnaire data obtained from 100 individuals in a substance abuse treatment program were used to assess current and lifetime substance use disorders and common comorbid disorders. An experienced, doctoral-level clinician formulated LEAD diagnoses for each patient, based on an initial interview, ongoing clinical contact and the results of the research assessment and all available clinical records. LEAD-derived substance use diagnoses showed good concurrent, discriminant and predictive validity. The validity of comorbid diagnoses obtained using the LEAD procedure was generally fair to good. Comparison with diagnoses based only on the clinician's unstructured initial interview showed that the availability of additional data enhanced diagnostic validity. Diagnoses derived by a research technician using the Structured Clinical Interview for DSM-III-R showed validity comparable to that of LEAD diagnoses. To enhance its diagnostic validity, applications of the LEAD standard should include a structured interview. Other variations in the application of the LEAD standard, including a longer evaluation period, may also enhance its performance as a diagnostic criterion measure.

Is Marlatt's relapse taxonomy reliable or valid?

The Relapse Replication and Extension Project (RREP) has failed to provide empirical support for Marlatt's relapse taxonomy. Neither the reliability of the original Marlatt coding system nor its predictive or construct validity was supported by this group of studies. The present commentary explores a number of possible reasons for the generally negative outcomes. These findings should certainly lead to a re-evaluation of Marlatt's relapse taxonomy and its operationalization. Nevertheless, despite the negative results, there are a number of reasons why the general Relapse Prevention concept is likely to survive in some form: it has been widely adopted and imitated clinically, key elements of the taxonomy are often focal points of treatment, and clinical research studies have repeatedly supported some elements of the taxonomy (e.g. negative emotional states, social pressure, interpersonal conflict, positive emotional states and temptations/urges). The RREP also evaluated some modifications of the original taxonomy as well as the use of more structured assessment instruments, and some of these provided more promising results. Further developments will need to take into account both research needs for greater precision, most likely through the use of more structured assessment instruments, and clinical needs for richness of detail and sensitivity to a wide variety of life circumstances.

Validity of the SCID in substance abuse patients.

Structured or semi-structured interviews, including the Structured Clinical Interview for DSM-III-R (SCID), are used widely to maximize the reliability and validity of psychiatric diagnoses. Although the reliability of such interviews appears adequate, there has been little effort to evaluate their validity. In a sample of 100 substance abuse patients, we evaluated the concurrent, discriminant and predictive validity of SCID substance use diagnoses, as well as co-morbid disorders that occur commonly among these patients. The validity of current and life-time substance use diagnoses obtained by a research technician using the SCID was good; it was moderate for antisocial personality disorder and major depression and poor for anxiety disorders. Although accurate diagnosis of substance use disorders in substance abuse patients can be accomplished by a research technician, the diagnosis of co-morbid psychiatric disorders requires either additional expertise or the use of a diagnostic instrument specially designed for that purpose.

Validity of psychiatric diagnoses in patients with substance use disorders: is the interview more important than the interviewer?

Although structured diagnostic interviews are increasingly being used in substance abuse treatment settings, there has been limited systematic evaluation of their ability to enhance reliability and validity of psychiatric diagnoses. The present report provides data on the concurrent, discriminant, and predictive validity of current substance use disorders and common comorbid diagnoses in a sample of 100 substance abuse patients. Diagnoses formulated primarily by master's-level clinicians in the usual course of their duties were compared with diagnoses formulated by research technicians using a semistructured interview. Results indicated that the validity of clinician diagnoses was good for substance use disorders, moderate for personality disorders, and poor for anxiety disorders and major depression. Greater validity was observed for substance abuse diagnoses formulated by research technicians using the semistructured interview. Based on these findings, we conclude that psychiatric diagnosis in substance abuse patients may be improved by adding elements of structured interviews to the clinician's usual assessment.

Issues in the selection and development of therapies in alcoholism treatment matching research.

There are a large number of possible approaches to the treatment of alcohol abuse and dependence. From a practical and methodological standpoint, however, only a limited number of interventions can realistically be included in research studies of treatment matching. A key question in planning studies of matching is what treatments to include. The recent book by Beutler and Clarkin on systematic treatment selection in general psychotherapy provides a framework within which to discuss alcoholism treatment matching and the criteria applied to decisions concerning (1) modes of treatment, (2) treatment format, (3) specific therapeutic strategies and the (4) treatment setting. The methodological and practical issues raised and the decisions reached in Project MATCH are presented in each of these areas. The therapies chosen for Project MATCH, based on these criteria, are described.

Implementing treatment and protecting the validity of the independent variable in treatment matching studies.

Treatment matching research is predicated on heterogeneity among subjects and their differential response to treatments. The sine qua non of a treatment matching study is the integrity of the treatment variable, since detection of client-treatment interactions requires delivery of treatments that are highly specific, consistent and distinct. Matching research thus presents particular challenges in treatment implementation, as greater heterogeneity in subjects may generate a broader array of problems than study treatments are designed to address, leading to several potential threats to treatment integrity. Moreover, as practiced outside of research settings, treatments for alcoholism are marked by ideological heterogeneity and a lack of purity across approaches. In this article we describe the strategies used in Project MATCH to protect treatment integrity while treating a large and heterogeneous sample of alcoholics in a number of geographically distant sites. These include: strategies for treating a variety of alcoholics within a single treatment approach; development of clinical care guidelines and clinical deterioration criteria; specification of treatments in manuals with minimization of overlapping active ingredients; selection criteria for therapists intended to enhance both generalizability of findings as well as treatment integrity; and extensive therapist training and monitoring.

Process assessment in treatment matching research.

A complete understanding of the effects of treatment requires an examination of the process by which the treatment produces the outcome as well as a thorough assessment of the outcomes. Process assessment assumes even greater importance in matching research than in other types of treatment research, since client-treatment interactions are hypothesized to be moderated or mediated by specific treatment components. The role of process assessment in treatment matching research is examined using Project MATCH as an illustrative example. Four process domains, including dose of treatment, within-session treatment activities, the therapeutic alliance and extra-session activities, are described in terms of their role as mediators or moderators of treatment outcome and the perspectives by which they are assessed in Project MATCH.

A chronological review of empirical studies matching alcoholic clients to treatment.

During the past 20 years researchers have become increasingly interested in exploring the benefits of differential assignment of alcoholics to treatments based on client-specific characteristics, rather than searching for a single "most effective" intervention for all clients. Thirty-one empirical studies on "client-treatment matching" are reviewed, particularly from the perspective of how research methodology in this area has evolved. In addition, general observations are provided on how research methodology on this topic can be further enhanced. Finally, several promising interactions between client characteristics and particular interventions are noted, based on empirical studies to date.

Longitudinal, expert, all data procedure for psychiatric diagnosis in patients with psychoactive substance use disorders.

The Longitudinal, Expert, All Data (LEAD) procedure has been proposed as a criterion for the assessment of the procedural validity of diagnostic instruments. The authors evaluated the procedure's test-retest reliability and whether it enhanced diagnosis based on a single interview. Data were collected using interviews and questionnaires to assess current and lifetime substance use disorders and common comorbid disorders in 100 patients recruited from a substance abuse treatment program. An initial diagnostic interview was conducted by a primary expert who, at the end of treatment, formulated LEAD diagnoses for each patient, based on the results of the research assessment and all available clinical records. Secondary experts used a similar procedure in a subsample of 40 patients to provide a measure of test-retest reliability. Overall reliability of LEAD diagnoses was good, though it varied from excellent for substance use disorders to poor for some comorbid psychiatric disorders. As a consequence of the LEAD procedure, the total number of substance use diagnoses increased significantly, with no effect on diagnostic reliability. Based on these findings, we conclude that, while the overall reliability of the LEAD procedure is comparable to other diagnostic methods, there was considerable variability among groups of diagnoses. The additional cost of the procedure would appear to be justified only when diagnostic sensitivity is at a premium and principally for the diagnosis of psychoactive substance use disorders. Before it is widely used as a diagnostic criterion measure, the utility of the LEAD procedure should be evaluated in a variety of patient samples and under varying circumstances.

Cross system agreement for substance use disorders: DSM-III-R, DSM-IV and ICD-10.

This report presents results of a field trial of Substance Use Disorders as defined by DSM-III-R, DSM-IV (proposed) and ICD-10. Diagnoses based on the three systems were derived from interviews using the Composite International Diagnostic Interview (CIDI) in a heterogeneous sample of 521 adults drawn from clinical and community settings. Two issues are addressed: (1) cross system agreement; and (2) syndrome coherence of proposed criterion sets for Substance Dependence in each of the three systems. Findings were as follows: (1) Cross system agreement for Dependence was generally high, especially between DSM-III-R and DSM-IV. (2) Cross system agreement was lower for DSM-III-R and DSM-IV Abuse and very low for DSM-IV Abuse and ICD-10 Harmful Use. (3) Agreement varied across drug categories with lowest DSM-III-R/DSM-IV agreement for alcohol abuse and DSM-IV/ICD-10 agreement for marijuana use disorders. (4) Overall prevalence differed for the three systems with DSM-IV yielding highest rates followed by DSM-III-R and ICD-10 in that order. (5) Factor analysis of Dependence criteria showed high loadings of all items on a single factor across the three diagnostic systems and for all categories of drugs. Implications for validity of the dependence syndrome construct and for revisions in DSM-IV are discussed.

Relationship between role-play measures of coping skills and alcoholism treatment outcome.

Alcoholic clients were given role-play tests, involving various social and drinking-related scenarios, before and after two types of aftercare treatment. The assessments were used both to evaluate the effects of treatment and to determine whether any dimensions of pretreatment role-play performance interact with treatment type to predict treatment outcome. Eighty-nine patients were randomly assigned to aftercare group treatment involving either interactional therapy or coping skills training. Clients in both treatments experienced declines in their urge to drink during the role-play scenes from pre- to posttreatment, and these declines were related to reductions in heavy drinking. Three pretreatment role-play variables interacted with type of treatment to predict outcome: observer-rated skill, observer-rated anxiety, and self-reported urge to drink. In general, those patients who did better in the role plays had better drinking outcomes following interactional therapy. Those who experienced more difficulty in the role plays fared best with coping skills training. The results suggest that role-play measures could be used for patient-treatment matching, although it remains to be determined whether they will be superior to more easily assessed patient characteristics.

Types of alcoholics, II. Application of an empirically derived typology to treatment matching.

Data from 79 male alcoholics who were randomly assigned to either coping skills training or interactional group psychotherapy were used to replicate a multidimensional, empirically derived typology and to evaluate the typology's usefulness in matching patients to treatment. Consistent with previous cluster analysis research, indicators of risk for alcoholism, alcohol dependence, drinking history, and psychopathological impairment distinguished alcoholics along two broad dimensions of vulnerability and severity, with one subtype (type B alcoholics) manifesting an earlier onset of problem drinking, more familial alcoholism, greater dependence on alcohol, and more symptoms of antisocial personality than the other subtype (type A alcoholics). Analyses of outcome indicated that type A alcoholics fared better in interactional treatment and more poorly with coping skills training. Conversely, type B alcoholics had better outcomes with the coping skills treatment and worse outcomes with interactional therapy. Differences in treatment response were maintained for 2 years from the beginning of aftercare treatment.