Supportive-expressive psychodynamic therapy for cocaine dependence: A closer look.

Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12-month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 day per month at baseline to a mean of 1.3 days at 12 months. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mediators of outcome of psychosocial treatments for cocaine dependence.

This study examined endorsement of 12-step philosophy and engagement in recommended 12-step activities as a mediator of the outcomes of individual plus group counseling for cocaine dependence. Assessments of drug use outcomes and the mediator were made at baseline and monthly for 6 months. Engagement in recommended 12-step activities was found to be a partial statistical mediator of drug use outcomes of individual (plus group) drug counseling, but no evidence for change in the mediator preceding change in drug use was found. In addition, a measure of beliefs about addiction developed to test mediation of outcome of cognitive therapy was found to correlate moderately with drug use outcomes in both cognitive therapy and individual drug counseling. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of homework in cognitive-behavioral therapy for cocaine dependence.

This study examines the effect of homework compliance on treatment outcome in 123 participants receiving cognitive-behavioral therapy (CBT) for cocaine dependence. Regression analyses revealed a significant relationship between homework compliance and cocaine use that was moderated by readiness to change. Homework compliance predicted less cocaine use during treatment but only for participants higher in readiness to change. For those lower in readiness to change, homework compliance was not associated with cocaine use during treatment. Homework compliance early in therapy was associated with better retention in treatment. Homework compliance was not predicted by participants' level of education or readiness to change. These findings support the use of homework during CBT for substance use disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The real relationship in psychotherapy: Relationships to adult attachments, working alliance, transference, and therapy outcome.

The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does the alliance cause good outcome? Recommendations for future research on the alliance.

Research has consistently documented that the quality of the therapeutic alliance is related to the outcome of diverse psychotherapies. Insufficient attention, however, has been directed at identifying the nature and magnitude of the causal relationship between the alliance and outcome. In this commentary, we discuss the major threats to causal interpretation of alliance-outcome correlations and provide suggestions for future research that would help clarify the extent to which the alliance causes positive outcomes. Assuming the alliance is a causal factor in relation to outcome, we provide recommendations for research on the alliance that would attempt to improve patient care by enhancing the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance.

Two decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome. The magnitude of this relation appears to be independent of the type of therapy and whether the outcome is assessed from the perspective of the therapist, client, or observer. Although the strength of the connection between alliance and therapy outcome appears to be relatively uniform throughout therapy, the client's report of the early alliance may be the most clinically useful indicator. In successful treatments, the therapist's and client's assessments of the alliance tend to converge over time. Recent research suggests that the therapist's skills and personal factors both influence the likelihood of developing a good therapeutic alliance with the client. Though the relation between the therapist's level of training and the quality of the alliance is inconsistent, it is likely that the more trained therapists are able to form better alliances with severely impaired clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance as mediator of expectancy effects in short-term individual therapy.

The authors investigated the hypothesis that the therapeutic alliance mediates the relationship between pretherapy expectancy of improvement and psychotherapy outcome. Data were drawn from a comparative trial of 2 forms of short-term, time-limited individual psychotherapy (W. E. Piper, A. S. Joyce. M. McCallum, & H. F. Azim, 1998). Measures of expectancy and outcome were based on an individualized assessment of target objectives; outcome was considered from 3 perspectives (patient, independent assessor, therapist). Using the R. M. Baron and D. A. Kenny (1986) procedure, the authors, found evidence in support of the hypothesized mediation effect. The effect was evident when the alliance was rated from the perspective of either patient or therapist, and it accounted for one third of the direct impact of expectancy on outcome. Clinical implications and limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of psychosocial treatments on associated problems of cocaine-dependent patients.

A previous report from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (P. Crits-Christoph et al., 1999) found relatively superior cocaine and drug use outcomes for individual drug counseling plus group drug counseling compared with other treatments. Using data from that study, the authors examined the relative efficacy of 4 treatments for cocaine dependence on psychosocial and other addiction-associated problems. The 487 patients were randomly assigned to 6 months of treatment with cognitive therapy, supportive-expressive therapy, or individual drug counseling (each with additional group drug counseling), or to group drug counseling alone. Assessments were made at baseline and monthly for 6 months during the acute treatment phase, with follow-up visits at 9 and 12 months. No significant differences between treatments were found on measures of psychiatric symptoms, employment, medical, legal, familysocial, interpersonal, or alcohol use problems. The authors concluded that the superiority of individual drug counseling in modifying cocaine use does not extend broadly to other addiction-associated problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting cocaine group treatment outcome in cocaine-abusing methadone patients.

The authors examined predictors of cocaine group treatment outcome in methadone maintenance treatment (MMT) patients, including cocaine urinalysis at intake and demographic variables. Clinic policy is that patients identified as using cocaine must attend a weekly cocaine-focused, cognitive–behavioral therapy (CBT) group. Cocaine treatment is based on a behavioral (escape) contingency model whereby completers must attend group-counseling sessions and produce cocaine-negative urinalysis results. Among the 113 patients enrolled in the cocaine group, 43 (38%) were treatment completers (who attended 6 consecutive weeks of group and produced 6 consecutive weeks of cocaine-free urine tests) and 70 (62%) were treatment noncompleters. Treatment completion (i.e., cocaine abstinence) was significantly associated with baseline cocaine-free urinalysis and higher methadone dose. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cocaine abusers with and without alcohol dependence respond equally well to contingency management treatments.

Contingency management (CM) treatments are efficacious in treating cocaine abuse. Despite high prevalence rates of alcohol dependence (AD) among individuals with cocaine use disorders, relatively little data are available regarding whether comorbid AD is associated with poorer treatment outcomes in general, or in response to CM in particular. Using data from 3 randomized trials of CM for cocaine abuse, we compared cocaine abusers (N = 393) with and without AD in terms of abstinence and psychosocial problems during treatment and follow-up. Alcohol dependent participants had more lifetime years of cocaine and alcohol use and greater severity of alcohol and psychiatric problems. CM was positively and significantly associated with longer durations of abstinence, regardless of AD status. Although not significantly associated with abstinence, the presence of AD was related to improvement in medical and alcohol-related problems during treatment, and these gains were maintained posttreatment. The results suggest that cocaine abusers benefit equally well from CM treatments, regardless of AD status. Further, alcohol dependent participants are able to offset greater baseline severity in psychosocial functioning and maintain these improvements with CM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Carbamazepine in the treatment of cocaine dependence: Subtyping by affective disorder.

Studies investigating carbamazepine (CBZ) in the treatment of cocaine dependence have been inconsistent. In this study, cocaine-dependent individuals with (n=57) and without (n=82) affective disorder were compared in a 12-week, double-blind, placebo-controlled trial. Urine drug screens (UDS) and self-report of drug use were collected weekly. Affective symptoms were measured monthly. Subjects receiving CBZ attended more medication sessions (p=.03). The CBZ-treated affective group had a trend toward fewer cocaine-positive UDS (p=.08) and a significantly longer time to first cocaine use (p=.06). CBZ treatment did not have any impact on cocaine use in individuals without affective disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient's and therapist's views of early alliance building in dynamic psychotherapy: Patterns and relation to outcome.

Patients and therapists have somewhat divergent perspectives of alliance. Usually in psychotherapy research, the focus is on the patient's view of alliance, predicting parts of outcome. This study questions this hypothesis by applying the shape-of-change procedure to patient's and therapist's view of alliance-building processes in dynamic psychotherapy. The results of this naturalistic study indicate that none of the 3 patient patterns is related to outcome at the end of psychotherapy, but a specific therapist's pattern--out of 2--is linked to positive symptom change. These results are discussed in the context of present research on therapeutic alliance, especially in terms of level and process, its measurement, and potential in predicting outcome in dynamic psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Buprenorphine medication versus voucher contingencies in promoting abstinence from opioids and cocaine.

During a 12-week intervention, opioid dependent participants (N = 120) maintained on thrice-a-week (M, W, F) buprenorphine plus therapist and computer-based counseling were randomized to receive: (a) medication contingencies (MC = thrice weekly dosing schedule vs. daily attendance and single-day 50% dose reduction imposed upon submission of an opioid and/or cocaine positive urine sample); (b) voucher contingency (VC = escalating schedule for opioid and/or cocaine negative samples with reset for drug-positive samples); or (c) standard care (SC), with no programmed consequences for urinalysis results. VC resulted in better 12-week retention (85%) compared to MC (58%; p = 0.009), but neither differed from SC (76% retained). After adjusting for baseline differences in employment, and compared to SC, the MC group achieved 1.5 more continuous weeks of combined opioid/cocaine abstinence (p = 0.030), while the VC group had 2 more total weeks of abstinence (p = 0.048). Drug use results suggest that both the interventions were efficacious, with effects primarily in opioid rather than cocaine test results. Findings should be interpreted in light of the greater attrition associated with medication-based contingencies versus the greater monetary costs of voucher-based contingencies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of outcome in LAAM, buprenorphine, and methadone treatment for opioid dependence.

This study examined (1) predictors of treatment outcome for opioid-dependent participants in a single-site controlled trial comparing methadone, buprenorphine, and LAAM treatments and (2) the extent to which various subpopulations of patients may have more successful outcomes with each medication. The relationships between patient demographics, drug use history, and psychological status and outcome measures of treatment retention, opiate use, and cocaine use were assessed. We believe this study to be the first to demonstrate that predictors of treatment success appear to be largely similar in LAAM, buprenorphine, and methadone treatment for opioid dependence. We did not find any factors that would strongly guide selection of one medication over others. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment preferences affect the therapeutic alliance: Implications for randomized controlled trials.

The influence of treatment preferences on the development of the therapeutic alliance was investigated. Seventy-five patients were followed while participating in a randomized controlled trial comparing supportive-expressive psychotherapy with sertraline or pill placebo in the treatment of major depressive disorder. Therapeutic alliance was assessed before treatment and at the 3rd, 5th, and 9th weeks of treatment. Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo. These relations were observed even when controlling for symptom severity. Thus, the congruence of patients' treatment preference and the treatment that they ultimately received influenced the development of the therapeutic alliance. Because alliance is a robust predictor of outcome, treatment preferences may need to be carefully considered in randomized controlled trial settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in behavior therapy.

It may be argued that behavior therapy has proceeded with minimal regard for the therapeutic alliance (TA) as a key mechanism of change. However, ignoring the role of TA in behavior therapy may not only be problematic on a practical level, but also may be inconsistent with basic principles that underlie behavior therapy. In beginning to address these issues, the authors consider the role of TA in behavior therapy with a focus on relevant basic principles. Keeping a focus on these basic principles, the authors then outline three contemporary behavior therapies that already incorporate a focus on the therapeutic relationship and conclude with a clinical case illustration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A step toward disentangling the alliance/improvement cycle in family therapy.

The authors focused on 2 unique aspects of the alliance in conjoint therapy: feeling safe in the therapeutic context with other family members and the family's shared sense of purpose about treatment (i.e., productive within-family collaboration). Low-income, multiproblem families were seen in a community clinic by therapists with varying theoretical orientations and a wide range of experience. Alliance-related behavior was assessed using the System for Observing Family Therapy Alliances (M. L. Friedlander, V. Escudero, & L. Heatherington, 2006). The significant mediated model showed that parent safety contributed to productive family collaboration in the 1st session, which, in turn, predicted global improvement rated after Session 3. Given the heterogeneous sample of clients, therapists, and therapy approaches, findings support the ecological validity of the alliance in family therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy.

This study examined adherence to specific psychotherapeutic techniques as a predictor of outcome in dynamic deconstructive psychotherapy (DDP), a new psychodynamic therapy for treatment-resistant clients with borderline personality disorder (BPD). Ten clients dually diagnosed with BPD and alcohol use disorders underwent 12 months of DDP. Outcome indexes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Independent raters coded videorecorded sessions on adherence to DDP techniques, using a scale developed for this study, as well as therapeutic alliance and standard cognitive–behavioral and psychodynamic techniques. The adherence instrument demonstrated excellent interrater and test–retest reliability. Adherence to DDP techniques was positively related to improvement in BPD symptoms (ρ = .64) and most secondary outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence.

In this 12-week double-blind placebo-controlled trial of methylphenidate (MTP) versus placebo in 48 cocaine-dependent attention-deficit/hyperactivity disorder (ADHD) adults, the authors sought to determine whether MTP would be safe, control ADHD symptoms, and affect cocaine use. Efficacy indexes revealed significantly greater ADHD symptom relief in the MTP group. There were no group differences in self-reported cocaine use, urinalysis results, or cocaine craving. Because of the relatively small sample size, the results are preliminary. However, the authors found that MTP improved subjective reports of ADHD symptoms and did not worsen cocaine use while participants were in treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)