Objective: In the present meta-analysis, we test the technical and relational hypotheses of Motivational Interviewing (MI) efficacy. We also propose an a priori conditional process model where ...heterogeneity of technical path effect sizes should be explained by interpersonal/relational (i.e., empathy, MI Spirit) and intrapersonal (i.e., client treatment seeking status) moderators. Method: A systematic review identified k = 58 reports, describing 36 primary studies and 40 effect sizes (N = 3,025 participants). Statistical methods calculated the inverse variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple target behaviors (i.e., alcohol use, other drug use, other behavior change). Results: Therapist MI-consistent skills were correlated with more client change talk (r = .55, p < .001) as well as more sustain talk (r = .40, p < .001). MI-inconsistent skills were correlated with more sustain talk (r = .16, p < .001), but not change talk. When these indicators were combined into proportions, as recommended in the Motivational Interviewing Skill Code, the overall technical hypothesis was supported. Specifically, proportion MI consistency was related to higher proportion change talk (r = .11, p = .004) and higher proportion change talk was related to reductions in risk behavior at follow up (r = −.16, p < .001). When tested as two independent effects, client change talk was not significant, but sustain talk was positively associated with worse outcome (r = .19, p < .001). Finally, the relational hypothesis was not supported, but heterogeneity in technical hypothesis path effect sizes was partially explained by inter- and intrapersonal moderators. Conclusions: This meta-analysis provides additional support for the technical hypothesis of MI efficacy; future research on the relational hypothesis should occur in the field rather than in the context of clinical trials.
What is the public health significance of this article?
Meta-analytic results suggest that MI clinicians, trainers, and implementers should adhere to MI proficiency indicators in order to elicit change, rather than sustain, talk. When the balance of client ambivalence is in the direction of behavior change, this is prognostic of positive outcome. Finally, study results highlight MI technical proficiency, but the role of relational proficiency should be further examined in primary research with naturalistic clinical samples.
Objective: This meta-analysis examined 30 randomized controlled trials (32 study sites; 35 study arms) that tested the efficacy of cognitive-behavioral therapy (CBT) for alcohol or other drug use ...disorders. The study aim was to provide estimates of efficacy against three levels of experimental contrast (i.e., minimal k = 5; nonspecific therapy k = 11; specific therapy k = 19) for consumption frequency and quantity outcomes at early (1 to 6 months kes = 41) and late (8+ months kes = 26) follow-up time points. When pooled effect sizes were statistically heterogeneous, study-level moderators were examined. Method: The inverse-variance weighted effect size was calculated for each study and pooled under random effects assumptions. Sensitivity analyses included tests of heterogeneity, study influence, and publication bias. Results: CBT in contrast to minimal treatment showed a moderate and significant effect size that was consistent across outcome type and follow-up. When CBT was contrasted with a nonspecific therapy or treatment as usual, treatment effect was statistically significant for consumption frequency and quantity at early, but not late, follow-up. CBT effects in contrast to a specific therapy were consistently nonsignificant across outcomes and follow-up time points. Of 10 pooled effect sizes examined, two showed moderate heterogeneity, but multivariate analyses revealed few systematic predictors of between-study variance. Conclusions: The current meta-analysis shows that CBT is more effective than a no treatment, minimal treatment, or nonspecific control. Consistent with findings on other evidence-based therapies, CBT did not show superior efficacy in contrast to another specific modality.
What is the public health significance of this article?
This meta-analysis provides an up-to-date summary of treatment efficacy in cognitive-behavioral therapy (CBT) for alcohol or other drug use disorders. CBT is effective for these conditions with outcomes roughly 15% to 26% better than average outcomes in untreated, or minimally treated, controls.
The emphasis in addictions research has shifted toward a greater interest in identifying the mechanisms involved in patient behavior change. This systematic review investigated nearly 30 years of ...mediation research on cognitive behavioral therapy (CBT) for alcohol or other drug use disorders (AUD/SUD).
Study inclusion criteria targeted analyses occurring in the context of a randomized clinical trial where both intervention/intervention ingredient to mediator (a path) and mediator to outcome (b path) paths were reported. Between- and within-condition analyses were eligible, as were studies that formally tested mediation and those that conducted path analysis only.
The review sample included K = 15 reports of primarily between-condition analyses. Almost half of these reports utilized Project MATCH (k = 2) or COMBINE (k = 4) samples. Among the mediator candidates, support for changes in coping skills was strongest, although the specificity of this process to CBT or CBT-based treatment remains unclear. Similarly, support for self-efficacy as a statistical mediator was found in within-, but not between-condition analyses.
A coherent body of literature on CBT mechanisms is significantly lacking. Adopting methodological guidelines from the Science of Behavior Change Framework, we provide recommendations for future research in this area of study.
•This systematic review investigated mediation research on cognitive behavioral therapy (CBT) for alcohol/drug use disorders.•Mediation study quality review showed good methodological progress in this literature.•The most promising candidate mechanism was changes to self-regulatory coping skills.•The review also suggests that the most conclusive mediation models have been conditional (i.e., moderated-mediation).•Adopting guidelines from the Science of Behavior Change Framework, we recommend future research directions.
Psychosocial intervention and Alcoholics Anonymous (AA)/mutual help organization attendance are both associated with alcohol use disorder (AUD) outcomes. However, no research has explored the ...relative or interactive associations of psychosocial intervention and AA attendance with AUD outcomes.
This was a secondary analysis of data from the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) outpatient arm participants (
= 952), who were randomly assigned to complete 12-session cognitive-behavioral therapy (CBT,
= 301), 12-session 12-step facilitation (TSF,
= 335), or 4-session motivational enhancement therapy (MET,
= 316). Regression analyses tested the association of psychosocial intervention attendance only, AA attendance only (measured as past-90-day attendance immediately after psychosocial intervention, as well as 1 and 3 years after intervention), and their interaction with the percentage of drinking days and percentage of heavy drinking days after intervention, 1 year after intervention, and 3 years after intervention.
When accounting for AA attendance and other variables, attending more psychosocial intervention sessions was consistently associated with fewer drinking days and heavy drinking days after intervention. AA attendance was consistently associated with a lower percentage of drinking days at 1 and 3 years after intervention, when accounting for psychosocial intervention attendance and other variables. Analyses failed to identify an interaction between psychosocial intervention attendance and AA attendance with AUD outcomes.
Psychosocial intervention and AA attendance are robustly associated with better AUD outcomes. Replication studies comprising samples of individuals who attend AA more than once per week are needed to further test the interactive association of psychosocial intervention attendance and AA attendance with AUD outcomes.
•Prenatal posttraumatic stress disorder is associated with risk of low birth weight.•Prenatal posttraumatic stress disorder is associated with lower gestational age.•Prenatal posttraumatic stress ...disorder is associated with risk of preterm birth.•Prenatal PTSD may adversely affect maternal and child well-being.•Prenatal PTSD screening and interventions may improve mother and child outcomes.
Although not routinely assessed, prenatal posttraumatic stress disorder (PTSD) is associated with poor maternal mental health and mother-infant bonding. Prenatal PTSD may also be associated with birth weight and gestational age outcomes, but this remains unclear. This systematic review and meta-analysis investigated the association of prenatal PTSD with risk of low birth weight (LBW) or preterm birth (PTB) (dichotomous medically-defined cut-offs) or with birth weight (BW) or gestational age (GA) (continuous variables).
A comprehensive literature search was conducted in Web of Science, MedLine, PubMed, and PsychInfo. Data were collected and processed according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Study quality was assessed with the Newcastle-Ottowa Quality Assessment Scale. Pooled effect sizes were estimated with random-effects models (correlation for continuous and odds ratios for dichotomous outcomes).
Sixteen studies with 51,470 participants (prenatal PTSD 8%) were included in 4 meta-analyses. Maternal prenatal PTSD was associated with higher risks of LBW (OR = 1.96; 95% CI, 1.26, 3.03; P = .003), PTB (OR = 1.42; 95% CI, 1.16, 1.73; P = .001), and reduced GA (r = -0.04; 95% CI, -0.06, -0.01; P = .002).
Different designs across studies, variety of PTSD assessment practices, and a small pool of studies were noted.
Findings suggest prenatal PTSD presents increased risks of LBW, PTB, and reduced GA. Evidence of physical harm to neonates from prenatal PTSD provides a powerful rationale to increase prenatal PTSD screening and identify effective prenatal interventions to improve maternal and child outcomes.
From In-Session Behaviors to Drinking Outcomes Moyers, Theresa B; Martin, Tim; Houck, Jon M ...
Journal of consulting and clinical psychology,
12/2009, Letnik:
77, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Client speech in favor of change within motivational interviewing sessions has been linked to treatment outcomes, but a causal chain has not yet been demonstrated. Using a sequential behavioral ...coding system for client speech, the authors found that, at both the session and utterance levels, specific therapist behaviors predict client change talk. Further, a direct link from change talk to drinking outcomes was observed, and support was found for a mediational role for change talk between therapist behavior and client drinking outcomes. These data provide preliminary support for the proposed causal chain indicating that client speech within treatment sessions can be influenced by therapists, who can employ this influence to improve outcomes. Selective eliciting and reinforcement of change talk is proposed as a specific active ingredient of motivational interviewing.
Background
The current review revisits the article entitled: “Active Ingredients: How and Why Evidence‐Based Alcohol Behavioral Treatment Interventions Work” published in Alcoholism: Clinical and ...Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that.
Methods
The current review revisits state‐of‐the‐art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12‐step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future.
Results
Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence‐based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods.
Conclusions
Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.
Background and Aims
There is consensus that best clinical practice for dual diagnosis (DD) is integrated mental health and substance use treatment augmented with Alcoholics Anonymous (AA) attendance. ...This is the first quantitative review of the direction and magnitude of the association between AA attendance and alcohol abstinence for DD patients.
Method
A systematic literature search (1993–2017) identified 22 studies yielding 24 effect sizes that met our inclusion criteria (8075 patients). Inverse‐variance weighting of correlation coefficients (r) was used to aggregate sample‐level findings and study aims were addressed using random‐ and mixed‐effect models. Sensitivity and publication bias analyses were conducted to assess the likelihood of bias in the overall estimate of AA‐related benefit.
Results
AA exposure and abstinence for DD patients were associated significantly and positively rw = 0.249; 95% confidence interval (CI) = 0.203–0.293; tau = 0.097). There was also significant heterogeneity in the distribution of effect sizes and high between‐sample variance (I2 = 74.6, P < 0.001). Subgroup analyses indicated that the magnitude of AA‐related benefit did not differ between 6‐ (k = 7) and 12‐ (k = 12) month follow‐up (Q = 0.068, P = 0.794), type of treatment received (in‐patient k = 9; intensive out‐patient, out‐patient, community k = 15; Q = 2.057, P = 0.152), and whether a majority of patients in a sample had (k = 11) or did not have (k = 13) major depression (Q = 0.563, P = 0.453). Sensitivity analyses indicated that the overall meta‐analytical estimate of AA benefit was not impacted adversely or substantively by pooling randomized controlled trial (RCT) and observational samples (Q = 0.763, P = 0.382), pooling count, binary and ordinal‐based AA (Q = 0.023, P = 0.879) and outcome data (Q = 1.906, P = 0.167) and reversing direction of correlations extracted from studies (Q = 0.006, P = 0.937). No support was found for publication bias.
Conclusions
Clinical referral of dual diagnosis patients to Alcoholics Anonymous is common and, in many cases, dual diagnosis patients who attend Alcoholics Anonymous will report higher rates of alcohol abstinence relative to dual diagnosis patients who do not attend Alcoholics Anonymous.
Damage to the brain's white matter is a signature injury of alcohol use disorders (AUDs), yet understanding of risks associated with clinical and demographic characteristics is incomplete. This study ...investigated alcohol problem severity, recent drinking behavior, and demographic factors in relation to white matter microstructure in heavy drinkers. Magnetic resonance imaging (MRI) scans, including diffusion tensor imaging (DTI), were collected from 324 participants (mean age = 30.9 ± 9.1 years; 30% female) who reported five or more heavy drinking episodes in the past 30 days. Drinking history and alcohol problem severity were assessed. A common white matter factor was created from fractional anisotropy (FA) values of five white matter tracts: body of corpus callosum, fornix, external capsule, superior longitudinal fasciculus, and cingulate gyrus. Previous research has implicated these tracts in heavy drinking. Structural equation modeling (SEM) analyses tested the hypothesis that, after controlling for duration of alcohol exposure, clinical and behavioral measures of alcohol use severity would be associated with lower white matter factor scores. Potential interactions with smoking status, gender, age, treatment-seeking status, and depression or anxiety symptoms also were tested. Controlling for number of years drinking, greater alcohol problem severity and recent drinking frequency were significantly associated with lower white matter factor scores. The effect of drinking frequency differed significantly for men and women, such that higher drinking frequency was linked to lower white matter factor scores in women but not in men. In conclusion, alcohol problem severity was a significant predictor of lower white matter FA in heavy drinkers, after controlling for duration of alcohol exposure. In addition, more frequent drinking contributed to lower FA in women but not men, suggesting gender-specific vulnerability to alcohol neurotoxicity.
This secondary data analysis examined patterns of drinking during alcohol treatment and associated drinking outcomes during the first year following treatment. The goal was to provide clinicians with ...guidance on which patients may be most at risk for negative long-term outcomes based on drinking patterns during treatment.
This study was an analysis of existing data (N = 3,851) from three randomized clinical trials for alcohol use disorder: the COMBINE Study (n = 1,383), Project MATCH (n = 1,726), and the United Kingdom Alcohol Treatment Trial (n = 742). Indicators of abstinence, non-heavy drinking, and heavy drinking (defined as 4/5 or more drinks per day for women/men) were examined during each week of treatment using repeated-measures latent class analysis. Associations between drinking patterns during treatment and drinking intensity, drinking consequences, and physical and mental health 12 months following intake were examined.
Seven drinking patterns were identified. Patients who engaged in persistent heavy drinking throughout treatment and those who returned to persistent heavy drinking during treatment had the worst long-term outcomes. Patients who engaged in some heavy drinking during treatment had better long-term outcomes than persistent heavy drinkers. Patients who reported low-risk drinking or abstinence had the best long-term outcomes. There were no differences in outcomes between low-risk drinkers and abstainers.
Abstinence, low-risk drinking, or even some heavy drinking during treatment are associated with the best long-term outcomes. Patients who are engaging in persistent heavy drinking are likely to have the worst outcomes and may require a higher level of care.
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