Client as colleague: Therapeutic contracting with the seriously mentally ill.

This article introduces the therapeutic contracting program as a comprehensive treatment system for persons with serious mental illness. Therapeutic contracting offers a promising framework for integrating medical, psychological, and social therapies in a manner that fosters clients' active involvement in treatment. This article outlines a multistage therapy program that mobilizes clients' adaptational resources through environmental interventions, structured goal-setting exercises, and skills-building experiences. Data illustrate the effectiveness of therapeutic contracting for (a) securing clients' treatment compliance, (b) promoting positive clinical outcomes, and (c) reducing overall treatment costs. The therapeutic contracting model is discussed as a potential vehicle for expanding the professional role of psychologists in psychiatric settings, particularly in areas of clinical and administrative decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders

To investigate the possibility of engrafting fetal liver hematopoietic cells by in utero intraperitoneal transplantation, we transplanted donor cells obtained from mouse fetuses at 13, 15 and 17 days of gestation to mouse fetuses at 15, 16 and 17 days of gestation. Engraftment was assessed by Sry gene amplification of DNA extracted from peripheral blood samples of transplanted mice six weeks after birth. In comparison, we performed an in vitro colony-assay of fetal liver cells at 13, 15, and 17 days of gestation. The incidence of engraftment was significantly higher in cells of 15 days of gestation than in cells of 13 or 17 days of gestation, whereas the colony forming activity decreased gradually from 13 to 15 days of gestation. From these results, we suggest that the 15 day liver contains hematopoietic progenitors which have the specific characteristics required for engraftment by intraperitoneal transplantation.     

Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders.

The authors compared the effectiveness of the Seeking Safety group, cognitive–behavioral treatment for substance use disorder and posttraumatic stress disorder (PTSD), to an active comparison health education group (Women’s Health Education [WHE]) within the National Institute on Drug Abuse’s Clinical Trials Network. The authors randomized 353 women to receive 12 sessions of Seeking Safety (M = 6.2 sessions) or WHE (M = 6.0 sessions) with follow-up assessment 1 week and 3, 6, and 12 months posttreatment. Primary outcomes were the Clinician Administered PTSD Scale (CAPS), the PTSD Symptom Scale–Self Report (PSS-SR), and a substance use inventory (self-reported abstinence and percentage of days of use over 7 days). Intention-to-treat analysis showed large, clinically significant reductions in CAPS and PSS-SR symptoms (d = 1.94 and 1.12, respectively) but no reliable difference between conditions. Substance use outcomes were not significantly different over time between the two treatments and at follow-up showed no significant change from baseline. Study results do not favor Seeking Safety over WHE as an adjunct to substance use disorder treatment for women with PTSD and reflect considerable opportunity to improve clinical outcomes in community-based treatments for these co-occurring conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The cultural context of interventions for family members with a seriously mentally ill relative

This chapter provides an overview of interventions for relatives of severely mentally ill individuals. The author discusses the design and use of these interventions in the context of the cultural characteristics of families and providers, as well as the culture of the interventions themselves.     

Psychosocial functioning of adults who experienced substance use disorders as adolescents.

The authors examined whether substance use disorder (SUD) before age 19 was associated with functioning at age 30. Participants (N = 773) were assessed twice during adolescence and at ages 24 and 30. Eight of 14 adult measures were associated with adolescent SUD: education, unemployment, income, risky sexual behavior, suicide attempt, coping, stressful life events, and global adjustment. After adolescent comorbidity and functioning and adult SUD were controlled for, education and unemployment remained associated, and three variables emerged as significant: being a parent (significant only for participants without adult SUD), being currently married, and having decreased life satisfaction (significant only for participants with adult SUD). Adolescent SUD is associated with numerous functioning difficulties at age 30, some of which appear to be related to recurrent SUD, comorbid adolescent disorders, or functioning problems already evident in adolescence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impulsivity and risk-taking in borderline personality disorder with and without substance use disorders.

Impulsivity and risk taking propensity were assessed in participants with borderline personality disorder (BPD-only; n = 19), BPD and a current or past substance use disorder (BPD-SUD; n = 32), and a matched comparison group (MC; n = 28). Participants were administered behavioral measures of two facets of the multidimensional construct of impulsivity [GoStop, delay discounting task (DDT)], one measure of risk-taking propensity [Balloon Analog Risk Task (BART)], and two self-report measures of impulsivity (i.e., Barrett Impulsiveness Scale, Eysenck Impulsiveness Scale). The BPD-SUD group, but not the BPD-only group, discounted delayed rewards faster than the MC group on the DDT, suggesting that the BPD-SUD/MC group difference may be because of the SUD rather than BPD. In contrast, both the BPD-SUD and BPD-only groups exhibited poorer behavioral response inhibition compared with the MC group, but the two BPD groups did not differ from one another. This finding suggests that the differences in behavioral response inhibition may be because of BPD rather than SUD and that behavioral response disinhibition may be a core feature of BPD. None of the groups differed on the measure of risk-taking propensity (i.e., BART). On self-report questionnaires, the BPD-SUD group reported more impulsivity than the BPD-only group and both BPD groups reported more impulsivity than the MC group. Data from the DDT and self-report measures provide partial support for the hypothesis that BPD individuals with a SUD are more impulsive than BPD individuals without a SUD on some facets of impulsivity (e.g., desire to obtain a smaller immediate reward rather than wait to obtain a larger reward in the future). Results suggest that behavioral response inhibition may be a novel treatment outcome variable for BPD treatment studies. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Longitudinal analyses of family functioning in veterans and their partners across treatment.

Objective: This study evaluated the relations between posttraumatic stress disorder (PTSD) symptoms and poor family functioning in veterans and their partners. Method: Data were collected from Caucasian veterans with PTSD (N = 1,822) and their partners (N = 702); mean age = 53.9 years, SD = 7.36. Veterans completed the Posttraumatic Checklist Military Version (PCL-M) and, along with their partners, completed the McMaster Family Assessment Device (FAD-12). Assessments were conducted at intake into a treatment program at 3 months and 9 months posttreatment. Results: Structural equation models (SEMs) were developed for veterans as well as for veterans and their partners. Poor family functioning for veterans at intake predicted intrusion (β = .08), hyperarousal (β = .07), and avoidance (β = .09) at 3 months posttreatment. At 3 months posttreatment, family functioning predicted hyperarousal (β = .09) and avoidance (β = .10) at 9 months. For veterans and their partners, family functioning at intake predicted avoidance (β = .07) at 3 months, and poor family functioning at 3 months predicted intrusion (β = .09) and hyperarousal (β = .14) at 9 months. The reverse pathways, with PTSD symptoms predicting poor family functioning, were only evident with avoidance (β = .06). Conclusion: Family functioning may play a role in treatment for veterans. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between victimization and cognitive schemata among episodically homeless, seriously mentally ill women

This study explored the extent to which specific aspects of violent victimization are associated with cognitive schemata in the context of ongoing, often lifelong, trauma and negative life events. Specifically, we examined the relationships between cognitive schemata (safety, self- and other esteem, intimacy, and trust) and three dimensions of physical and sexual assault histories (recentness, frequency, and variety) among 91 predominantly African American, episodically homeless, seriously mentally ill women. Findings indicated that even in the context of pervasive violence, more frequent, recent, and varied abuse was associated with more negative cognitive schemata. We discuss these findings in the context of research and practice with disenfranchised populations at high risk for violent victimization.     

Methodological innovation to increase the utility and efficiency of psychotherapy research for patients with co-occurring mental health and substance use disorders.

Psychotherapy research with chronic and difficult-to-treat populations, such as those with co-occurring mental health and addictive disorders, can employ flexible research designs, which allow for a systematic yet nonlinear relationship between efficacy and effectiveness designs. Outcomes research can bypass the efficacy-effectiveness dichotomy through use of a hybrid model (Carroll & Rounsaville, 2003) conducted in the context of community treatment settings in collaboration with community providers. We present the case for using this methodological approach as a means of advancing psychotherapy research and practice, while translating and disseminating empirically supported treatments with more efficiency. A hybrid model study conducted within the National Institute on Drug Abuse’s Clinical Trials Network illustrates the application. These findings inform new directions for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Task analysis training of case managers to assist seriously mentally ill patients find roommates and housing

This study examined the efficacy of task analysis training for case managers helping seriously mentally ill patients find roommates and housing. Behavioral objectives and task analysis were used to develop the task-oriented behavioral training program. Case managers were trained to use a checklist for every session with patients, which included the goal of the session, tasks required to accomplish that goal and lists of all the sub-tasks. The results of this study suggest that this methodology: (1) reduced the time required for patients to find roommates and housing; (2) increased the percentage of patients finding housing; and (3) decreased hospitalization rates occurring during the process of looking for roommates and housing.     

Prevalence of infection with HIV among the seriously mentally ill: Review of research and implications for practice.

The authors review the research literature for estimates of the prevalence of HIV infection among the seriously mentally ill. Data from nine studies suggest that 4%–23% of the seriously mentally ill have been infected with the virus that causes AIDS. Men have been infected at a higher rate than have women, but this gender difference is less pronounced than that found in the general population. Because most of these blinded seroprevalence studies have been conducted in New York City, the representativeness of these results remains unknown. Nonetheless, the findings call attention to the need for enhanced HIV-related services for the seriously mentally ill. The authors provide screening and counseling guidelines for practitioners who work with seriously mentally ill clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness and cost of specific treatment elements in a program for homeless mentally ill veterans

OBJECTIVES: The study examined relationships between specific treatment elements and their costs and ten outcome measures using data from a longitudinal outcome study of a Veterans Affairs program for homeless mentally ill veterans. METHODS: Baseline and outcome data over an eight-month period were analyzed for 406 homeless veterans with psychiatric and substance use disorders who were treated in VA's Homeless Chronically Mentally Ill Veterans Program. Multivariate techniques were used to examine the relationship between ten measures of outcome and six treatment elements: program entry via community outreach, the number of contacts with program clinicians, the number of referrals for other services, duration of program involvement, number of days of residential treatment, and increased public support payments. RESULTS: Each of the six treatment elements was significantly related to improvement on at least one of the ten outcome measures. The number of clinical contacts with program staff and the number of days in residential treatment were associated with improvement in the greatest number of outcome domains. However, improvement associated with residential treatment was far more costly than improvement related to other treatment elements. CONCLUSION: This study provides evidence of the effectiveness of a multimodal approach to the treatment of homeless mentally ill persons. However, results indicate that special attention should be paid to to differences in the cost of improvement associated with various treatment elements.     

Older and younger patients with substance use disorders: Outpatient mental health service use and functioning over a 12-month interval.

This observational study compared a nationwide sample of older patients with substance use disorders (n = 3,598; age > 55) with a demographically and diagnostically matched sample of younger patients on initial functioning, subsequent outpatient mental health service use, and 12-month follow-up outcomes. Older patients were initially functioning as well as or better than younger patients according to substance use, psychiatric, family, and legal criteria. The groups received comparable amounts of outpatient mental health care. At a 12-month follow-up, older patients generally had better substance use and functioning outcomes than did younger patients. The findings suggest that older patients with substance use disorders are keeping pace with demographically and diagnostically comparable younger patients in obtaining specialized outpatient mental health services and that they have positive treatment prognoses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality disorders in adolescents with major depression, substance abuse disorders, and coexisting major depression and substance use disorders.

This study examined the presence of personality disorders in adolescent inpatients with major depression (MDD; n?=?45), substance use disorders (SUD; n?=?27), or both disorders combined (MDD-SUD; n?=?42). A consecutive series of patients were given structured diagnostic interviews for Axes I and II disorders. The groups did not differ with regard to age, gender, ethnicity, socioeconomic status, psychiatric history, or global assessment of functioning. Borderline personality disorder was diagnosed more frequently in the MDD-SUD group than in the MDD or SUD groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family functioning and adolescent alcohol use disorders.

Adolescents with alcohol dependence or abuse (n?=?126) were compared with 124 adolescents with other (nondrug) mental disorders and with a control group of 94 adolescents with no mental disorders on dimensions of family functioning. General family functioning, mother–adolescent relationships, and parental monitoring and discipline practices were assessed by using both adolescent and mother reports. Although overall the groups differed significantly on all family variables, the relationships among groups differed for adolescent and mother reports. By mother reports, families of adolescents with alcohol use disorders functioned less well than did families of adolescents with other mental disorders, whereas by adolescent reports these groups were not significantly different. Examination of both adolescent and mother perspectives may be important in understanding the relationship between family functioning and adolescent alcohol use disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence of substance use disorders among veterans and comparable nonveterans from the National Survey on Drug Use and Health.

The Department of Veterans Affairs (VA) operates over 200 substance abuse treatment programs. Historically, planning for these services has not been informed by population-level prevalence data. Accordingly, the authors analyzed the National Survey on Drug Use and Health data from 2000 to 2003 to estimate substance use and substance use disorder prevalence among all veterans. The authors present the data in comparison to comparable nonveterans. Data show notable rates of substance use among veterans; 22.6% and 4.4% of veterans reported binge drinking and any illicit drug use in the past month, respectively. In addition, prevalence varied by geographic location. Monitoring substance use prevalence is needed to ensure the VA and other substance use providers can plan appropriate substance use disorder services for current and future enrollees, including veterans of the current military operations in Iraq and Afghanistan. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Constructive thinking in adolescents with substance use disorders.

This study examined the concurrent validity and clinical correlates of the Constructive Thinking Inventory (CTI), a measure of experiential coping, in 551 adolescents aged 14–18 years with and without Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) substance use disorders (SUDs). The CTI was correlated with depression, anxiety, and conduct problems. After controlling for demographics and comorbid lifetime psychiatric disorders, the CTI scales of Behavioral Coping and Categorical Thinking distinguished adolescents with and without SUDs. Implications of these findings for assessment and treatment are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discrepant substance use and marital functioning in newlywed couples.

The configuration of partners' drinking patterns may be most critical to marital functioning. Implications of discrepant husband and wife smoking, drinking, and drug use for relationship quality at the transition to marriage were examined. Participants were 642 couples entering into their 1st marriage. Separate, self-administered questionnaires were completed at home by each partner. Both husbands and wives in couples in which only 1 partner drank heavily or used drugs reported significantly lower marital quality than other spouses. Husband Use?×?Wife Use interactions were not significant for cigarette use, alcohol use, or regular drinking. Discrepancies in more deviant substance use behaviors may be most relevant to marital functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief screening for psychological and substance abuse disorders in veterans with long-term spinal cord injury.

Objective: To determine rates of positive screens for psychological and substance use disorders in persons with long-term spinal cord injury (SCI). Study Design: A naturalistic cohort design wherein consecutive admissions during an 8-month period completed the screening battery. Setting: Veterans Affairs SCI Center. Participants: One hundred fifteen men, 2 women, mean age 57.4 years, injured an average of 20 years, readmitted for various reasons. Main Outcome Measures: The Alcohol Use Disorders Identification Test (AUDIT) and screening items for depression and anxiety disorders. Results: Rates of positive screens ranged from 6.2% for alcohol problems to over 40% for anxiety disorders. Positive screens for depression and anxiety correlated positively with the number of recent hospital admissions. Conclusions: Systematic brief screening for psychological and substance abuse disorders in this population revealed rates of positive screens at least equal to those in other medical patient populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)