Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-up.

Contingency management (CM) rapidly reduces cocaine use, but its effects subside after treatment. Cognitive-behavioral therapy (CBT) produces reductions months after treatment. Combined, the 2 might be complementary. One hundred ninety-three cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (CM contingent on cocaine-negative urine or noncontingent). Follow-ups occurred 3, 6, and 12 months posttreatment. Primary outcome was cocaine-negative urine (urinalysis 3 times/week during treatment and once at each follow-up). During treatment, initial effects of CM were dampened by CBT. Posttreatment, there were signs of additive benefits, significant in 3- versus 12-month contrasts. Former CBT participants were also more likely to acknowledge cocaine use and its effects and to report employment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Coping and self-efficacy in marijuana treatment: Results from the Marijuana Treatment Project.

This study examined whether a coping-skills-based treatment for marijuana dependence operated by encouraging the use of coping skills or via other mechanisms. Participants were 450 men and women treated in the multisite Marijuana Treatment Project who were randomly assigned to motivational enhancement therapy plus cognitive-behavioral (MET-CB) treatment, motivational enhancement therapy (MET), or a delayed treatment control group. Marijuana use and coping skills were measured at baseline and at follow-ups through 15 months. Results showed that marijuana outcomes were predicted by treatment type and by coping skills use, but that the coping-skills-oriented MET-CB treatment did not result in greater use of coping skills than did the MET treatment. The results suggest that mechanisms of coping skills treatment may need to be reconceptualized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An open trial of integrative therapy for generalized anxiety disorder.

Cognitive-behavioral therapy (CBT), although effective, has the lowest average effect size for generalized anxiety disorder (GAD), when compared to effect sizes of CBT for other anxiety disorders. Additional basic and applied research suggests that although interpersonal processes and emotional avoidance may be maintaining GAD symptomatology, CBT has not sufficiently addressed interpersonal issues or emotion avoidance. This study aimed to test the feasibility and preliminary efficacy of an integrative psychotherapy, combining CBT with techniques to address interpersonal problems and emotional avoidance. Eighteen participants received 14 sessions of CBT plus interpersonal emotional processing therapy and three participants (for training and feasibility purposes) received 14 sessions of CBT plus supportive listening. Results showed that the integrative therapy significantly decreased GAD symptomatology, with maintenance of gains up to 1 year following treatment. In addition, comparisons with extant literature suggested that the effect size for this new GAD treatment was higher than the average effect size of CBT for GAD. Results also showed clinically significant change in GAD symptomatology and interpersonal problems with continued gains during the 1-year follow-up. Implications of these results are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of brief interventions for problem and pathological gamblers.

Limited research exists regarding methods for reducing problem gambling. Problem gamblers (N = 180) were randomly assigned to assessment only control, 10 min of brief advice, 1 session of motivational enhancement therapy (MET), or 1 session of MET plus 3 sessions of cognitive-behavioral therapy. Gambling was assessed at baseline, at 6 weeks, and at a 9-month follow-up. Relative to assessment only, brief advice was the only condition that significantly decreased gambling between baseline and Week 6, and it was associated with clinically significant reductions in gambling at Month 9. Between Week 6 and Month 9, MET plus cognitive-behavioral therapy evidenced significantly reduced gambling on 1 index compared with the control condition. These results suggest the efficacy of a very brief intervention for reduction of gambling among problem and pathological gamblers who are not actively seeking gambling treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Low-cost contingency management in community clinics: Delivering incentives partially in group therapy.

This study examined the feasibility and effectiveness of prize-based contingency management (CM) when incentives for attendance were administered in group therapy and incentives for abstinence were administered in individual meetings. Three community substance abuse treatment programs participated in this two-phase, crossover design study. Outpatients (N = 103) entering treatment who met diagnostic criteria for cocaine, opiate, and alcohol abuse or dependence were recruited. During the standard condition, participants received standard treatment and submitted breath and urine samples that were tested for alcohol, cocaine, and opiates twice weekly during Weeks 1-6 and once weekly during Weeks 7-12. During the CM condition, participants received the same standard treatment and sample and attendance monitoring, plus the opportunity to win prizes for negative samples and treatment attendance. Demographic information and substance abuse history were evaluated at intake, and posttreatment substance use (toxicology results and self-report) was evaluated at Month 6 and Month 9 follow-up interviews. Primary outcomes were weeks retained in treatment and longest duration of sustained abstinence (LDA). LDA was significantly greater in CM-condition participants, but weeks retained did not differ between groups. Rates of substance use were lower in CM participants at Month 9 but not at Month 6. This study suggests that it is feasible to deliver incentives for attendance in group therapy, but that further research is needed to understand the modest effects on attendance. Strengths and limitations of this study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Cognitive-behavioral therapy with and without medication in the treatment of obsessive-compulsive disorder.

Cognitive-behavioral therapy (CBT) and pharmacotherapy with serotonin reuptake inhibitors (SRIs) are established monotherapies for obsessive-compulsive disorder (OCD), yet research on their combined efficacy is lacking. Practicing psychologists who treat OCD are thus unable to say definitively whether exposure and ritual prevention would be more successful with concomitant SRI pharmacotherapy. The authors explored this issue in a clinical sample of 56 outpatients who received fee-for-service CBT; 31 (55%) received CBT alone, and 25 (45%) received CBT plus SRI. Both groups made clinically significant and comparable posttreatment gains, suggesting that CBT is effective with or without concomitant pharmacotherapy. Clinical implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of contingency management delivered in the context of group counseling.

Objective: Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care. Method: Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100. Results: Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up. Conclusions: These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Contingency management for smoking cessation in adolescent smokers.

This pilot study evaluated the use of contingency management (CM) procedures in combination with cognitive-behavioral therapy (CBT) for smoking cessation in adolescents. Twenty-eight treatment-seeking adolescent smokers participated in a 1-month, school-based smoking cessation program and were randomly assigned to receive either CM with weekly CBT or CBT alone. In the CM+CBT group, biochemical verification of abstinence was obtained twice daily during the first 2 weeks, followed by daily appointments during the 3rd week and once every other day during the 4th week. Participants were monetarily reinforced for abstinence on an escalating magnitude schedule with a reset contingency. At the end of 1 week and 1 month of treatment, abstinence verified using quantitative urine cotinine levels was higher in participants in the CM+CBT group (1 week: 76.7%; 1 month: 53.0%) when compared with the CBT-alone group (1 week: 7.2%; 4 weeks: 0%). These preliminary results provide a strong initial signal supporting the utility of CM techniques for smoking cessation in adolescents and demonstrate the feasibility of implementing such a program in a school setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Group-based randomized trial of contingencies for health and abstinence in HIV patients.

Objective: Contingency management (CM) treatments are usually applied individually for drug abstinence, but CM can also be targeted toward health behaviors and implemented in groups. This study evaluated effects of a group-based CM intervention that focused on reinforcing health behaviors. Method: HIV-positive patients with cocaine or opioid use disorders (n = 170) were randomized to weekly CM or 12-step (TS) groups for 24 weeks (mean attendance was 10.8 ± 8.1 sessions for CM participants and 9.0 ± 6.9 session for TS participants). During the treatment period, both groups received compensation for attendance ($10 per session) and submission of urine samples (about $2 per sample). In addition, participants received $25 for submitting samples and completing evaluations at Months 1, 3, 6, 9, and 12; 65–75 of the 81 participants assigned to TS and 71–80 of the 89 participants assigned to CM completed these evaluations. During the treatment period, patients in the CM group received chances to win prizes contingent upon completing health activities and submitting substance-free specimens (M = $260, SD = $267). Results: Mean attendance was 10.8 ± 8.1 sessions for CM participants and 9.0 ± 6.9 sessions for TS participants. CM participants submitted a significantly greater number of consecutive drug-free specimens than did TS participants (5.2 ± 6.0 vs. 3.7 ± 5.6), but proportions of negative samples did not differ between groups during treatment or at follow-up evaluations. From pre- to posttreatment, CM participants showed greater reductions in viral loads and HIV-risk behaviors than did TS participants, but these effects were not maintained throughout the follow-up period. Conclusions: These data suggest the efficacy of group-based CM for HIV-positive substance abusers, but more research is needed to extend the long-term benefits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Strike while the iron is hot: Can stepped-care treatments resurrect relapsing smokers?

The efficacies of 2 group counseling step-up treatments for smoking cessation, cognitive-behavioral/skill training therapy (CBT) and motivational interviewing/supportive (MIS) therapy, were compared with brief intervention (BI) treatment in a sample of 677 smokers. Differential efficacy of the 2 step-up treatments was also tested in smokers at low and high risk for relapse (no smoking vs. any smoking during the first postquit week, respectively). All participants received 8 weeks of nicotine patch therapy. BI consisted of 3 brief individual cessation counseling sessions; CBT and MIS participants received BI treatment and 6 group counseling sessions. Neither CBT nor MIS treatment improved long-term abstinence rates relative to BI. Limited support was found for the hypothesis that high-risk smokers would benefit more from MIS than CBT. Other hypotheses were not supported. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions.

This study compared the efficacy of 2 approaches for the treatment of cocaine dependence among methadone-maintained patients with and without antisocial personality disorder (ASPD). Patients were randomly assigned to 4 study conditions: cognitive-behavioral treatment (CBT), contingency management (CM), CBT with CM, or methadone maintenance. The Structural Clinical Interview for Mental Disorders-IV was administered to 108 patients to assess ASPD. A 2-way analysis of variance showed that patients with ASPD were more likely to abstain from cocaine use during treatment than patients without ASPD. The strong treatment effect for ASPD patients was primarily due to the CM condition. Regression analyses showed that ASPD remained significantly related to CM treatment responsivity while controlling for other factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depression ratings, reported sexual risk behaviors, and methamphetamine use: Latent growth curve models of positive change among gay and bisexual men in an outpatient treatment program.

Although the cessation of substance use is the principal concern of drug treatment programs, many individuals in treatment experience co-occurring problems such as mood disruptions and sexual risk behaviors that may complicate their recovery process. This study assessed relationships among dynamic changes tracked over time in methamphetamine use, depression symptoms, and sexual risk behaviors (unprotected anal intercourse) in a sample of 145 methamphetamine-dependent gay and bisexual males enrolled in a 16-week outpatient drug treatment research program. Participants were randomly assigned into 1 of 4 conditions: contingency management (CM), cognitive behavioral therapy (CBT; the control condition), combined CM and CBT, and a tailored gay-specific version of the CBT condition. Using latent growth curve models, the authors assessed the relationship of means (intercepts) and the slopes of the 3 measures of interest over time to test whether changes in methamphetamine use predicted declining rates of depression and risky sexual behavior in tandem. Participants with the greatest downward trajectory in methamphetamine use (urine verified) reported the greatest and quickest decreases in reported depressive symptoms and sexual risk behaviors. The control group reported the most methamphetamine use over the 16 weeks; the tailored gay-specific group reported a more rapidly decreasing slope in methamphetamine use than the other participants. Findings indicate that lowering methamphetamine use itself has a concurrent and synergistic effect on depressive symptoms and risky sexual behavior patterns. This suggests that some users who respond well to treatment may show improvement in these co-occurring problems without a need for more intensive targeted interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prize Reinforcement Contingency Management for Cocaine Dependence: Integration With Group Therapy in a Methadone Clinic.

In this study, the authors evaluated a low-cost contingency management (CM) procedure for reducing cocaine use and enhancing group therapy attendance in 77 cocaine-dependent methadone patients. Patients were randomly assigned to 12 weeks of standard treatment or standard treatment with CM, in which patients earned the opportunity to win prizes ranging from $1 to $100 for submitting cocainenegative samples and attending therapy. Patients in the CM condition submitted more cocaine-negative samples and attended more groups than patients in standard treatment. The best predictor of cocaine abstinence at follow-up was duration of abstinence during treatment. On average, patients in the CM condition earned $117 in prizes. Data from this study suggest that some aspects of reinforcement can be implemented in group therapy in community-based clinics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder.

This first controlled psychotherapy trial for seasonal affective disorder (SAD) compared SAD-tailored cognitive-behavioral therapy (CBT), light therapy (LT), and their combination to a concurrent wait-list control. Adults (N = 61) with major depression, recurrent with seasonal pattern, were randomized to one of four 6-week conditions: CBT (1.5-hr twice-weekly group therapy), LT (10,000-lux for 90-min/day with administration time individually adjusted), combined CBT + LT, or a minimal contact/delayed LT control (MCDT; LT following 6 weeks of monitoring). CBT, LT, and CBT + LT significantly and comparably improved depression severity relative to MCDT in intent-to-treat and completer samples. CBT + LT (73%) had a significantly higher remission rate than MCDT (20%). Using prospectively measured summer mood status to estimate the "functional" population, CBT + LT also had a significantly larger proportion of participants with clinically significant change over treatment compared with MCDT. The LT condition outcomes virtually replicated results from prior trials. CBT, alone or combined with LT, holds promise as an efficacious SAD treatment and warrants further study. If replicated, CBT + LT's remission rate would represent a clinically meaningful improvement over the 53% observed across LT studies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary evidence for cognitive mediation during cognitive-behavioral therapy of panic disorder.

Cognitive-behavioral therapy (CBT) and pharmacotherapy are similarly effective for treating panic disorder with mild or no agoraphobia, but little is known about the mechanism through which these treatments work. The present study examined some of the criteria for cognitive mediation of treatment change in CBT alone, imipramine alone, CBT plus imipramine, and CBT plus placebo. Ninety-one individuals who received 1 of these interventions were assessed before and after acute treatment, and after a 6-month maintenance period. Multilevel moderated mediation analyses provided preliminary support for the notion that changes in panic-related cognitions mediate changes in panic severity only in treatments that include CBT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-effectiveness of guided self-help treatment for recurrent binge eating.

Objective: Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive–behavioral therapy guided self-help intervention (CBT–GSH) to treat recurrent binge eating compared to treatment as usual (TAU). Method: Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT–GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs. Results: Compared to those receiving TAU only, those who received TAU plus CBT–GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of ?$20.23 per binge-free day or ?$26,847 per QALY). Lower costs in the TAU plus CBT–GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT–GSH. Conclusions: Findings support CBT–GSH dissemination for recurrent binge-eating treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief Treatments for Cannabis Dependence: Findings From a Randomized Multisite Trial.

This study evaluated the efficacy of 2 brief interventions for cannabis-dependent adults. A multisite randomized controlled trial compared cannabis use outcomes across 3 study conditions: (a) 2 sessions of motivational enhancement therapy (MET); (b) 9 sessions of multicomponent therapy that included MET, cognitive-behavioral therapy, and case management; and (c) a delayed treatment control (DTC) condition. Participants were 450 adult marijuana smokers with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis of cannabis dependence. Assessments were conducted at baseline, and at 4, 9, and 15 months postrandomization. The 9-session treatment reduced marijuana smoking and associated consequences significantly more than the 2-session treatment, which also reduced marijuana use relative to the DTC condition. Most differences between treatments were maintained over the follow-up period. Discussion focuses on the relative efficacy of these brief treatments and the clinical significance of the observed changes in marijuana use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparing cognitive behavioral therapy and integrated cognitive behavioral therapy/psychodynamic therapy in group treatment for partner violent men.

This was a pilot study comparing the effectiveness of cognitive–behavioral therapy (CBT; n = 18) with integrated CBT and psychodynamic therapy (CBT/PT; n = 27) in reducing partner violence. The study examined differences between the two treatment groups at posttreatment with regard to attachment dimensions, interpersonal problems, psychological/behavioral functioning, and general symptom and relationship distress. Results indicated that the CBT/PT groups showed significantly more improvement than the CBT groups on measures of partner violence, attachment, and interpersonal problems at posttreatment. Conversely, the CBT groups showed significantly more improvement than the CBT/PT groups on measures of psychological/behavioral functioning and general symptom and relationship distress. Finally, there was a significant difference between the treatment groups on recidivism rate, with the CBT/PT groups having the lowest rate. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive versus behavior therapy in the group treatment of Obsessive-Compulsive disorder.

This study examined the effects of cognitive-behavior therapy (CBT) compared with traditional behavior therapy (exposure and response prevention [ERP]) in the group treatment of obsessive-compulsive disorder. Of the 76 participants who started treatment, 38 were wait-listed for 3 months before treatment to assess possible course effects. Both treatments were superior to the control condition in symptom reduction, with ERP being marginally more effective than CBT by end of treatment and again at 3-month follow-up. In terms of clinically significant improvement, treatment groups were equivalent on the conclusion of treatment, but 3 months later significantly more ERP participants met criteria for recovered status. Only 1 of 7 belief measures changed with treatment improvement, and the extent of this cognitive change was similar between CBT and ERP groups. Discussion includes consideration of optimal formats for the delivery of different types of treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)