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The Pennsylvania State University
School of Behavioral Sciences and Education
PSYCHOSOCIAL INTERVENTIONS FOR SUBSTANCE USE DISORDERS:
A LITERATURE REVIEW
Master’s Paper
by
Dawn R. McElhenny
©2016 Dawn R. McElhenny
Submitted in Partial Fulfillment
of the Requirement
for the Degree of
Master of Arts
December 2016
I grant the Pennsylvania State University the non-exclusive right to use this work for the
University’s own purposes and to make single copies of the work available to the public
on a non-for-profit basis if copies are not otherwise available.
___________________________________
Signature here
Dawn M. McElhenny
We approve the Master’s Paper of Dawn R. McElhenny.
Date of Signature
____________________________________
Marissa A. Harrison, Ph.D.
Associate Professor of Psychology
Master’s Paper Advisor
________________________
____________________________________
Rebecca M. LaFountain, Ed.D.
Assistant Professor of Psychology
________________________
____________________________________
Erin F. Miller, Ph.D.
Assistant Professor of Psychology
________________________
____________________________________
Gina M. Brelsford, Ph.D.
Associate Professor of Psychology
Coordinator, Applied Clinical Psychology
________________________
iii
Abstract
Substance use disorders (SUDs) are highly prevalent in the United States and cause
serious ramifications to a person’s physical, emotional, and mental health, as well as
increasing costs to society. Implementation of effective interventions are necessary in
order to combat this burden of disease. To ascertain which types of interventions are
most efficacious in reducing substance abuse, I assessed and synthesized recent
randomized controlled trials concerning psychosocial interventions and substance use.
The articles I reviewed presented examinations of participants age 18 or older with a
diagnosed substance use disorder. The majority of studies demonstrated significant
reductions in drug use and their effects. Results evinced improvements in participants’
mental health and changes in legal status. However, there were primary and secondary
outcomes that did not show significant improvements in substance and/or symptom
reduction. It is evident that there is not a one size fits all approach to treating SUDs.
Replicating some studies with a larger sample size is recommended to make finding
significance much easier and to allow generalizability to other populations.
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Table of Contents
INTRODUCTION...............................................................................................................1
METHOD ..........................................................................................................................18
RESULTS ..........................................................................................................................20
DISCUSSION ....................................................................................................................69
REFERENCES ..................................................................................................................78
1
Psychosocial Interventions for Substance Use Disorders: A Literature Review
Substance Use Disorders (SUDs) are highly prevalent among persons aged 12 or
older in the United States (US) (Bowen et al., 2014; Office of National Drug Control
Policy [ONDCP], 2004). SUDs are commonly chronic, relapsing conditions (Conners,
Maiston, & Donovan, 1996) with an estimated relapse rate surpassing 60% (McLellan,
Lewis, O’Brien, & Kleber, 2000). From the 2014 National Survey on Drug Use and
Health (NSDUH), Substances and Mental Health Services Administration (SAMHSA)
highlighted that approximately 21.5 million individuals aged 12 or older (8.1% of
population) were diagnosed with substance dependence or abuse in the past year, and
20.2 million adults aged 18 or older (8.6% of adults) had a substance use disorder within
the past year (2015).
Out of the 21.5 million persons with a substance use disorder, 17.0 million had an
alcohol use disorder, 7.1 million people had an illicit drug use disorder, and
approximately 2.6 million individuals had both an alcohol and illicit drug use disorder.
In 2007, the United States spent an estimated $193 billion in the utilization of resources
to focus on the deleterious effects of illicit drug use (i.e., lost productivity, healthcare
costs, criminal justice costs) (National Drug Intelligence Center, 2011). Despite this,
unfortunately, persons with SUDs often go untreated (Compton, Thomas, Stinson, &
Grant, 2007), with 22.5 million people aged 12 or older needing treatment for an alcohol
or illicit drug use disorder and only 6.7 million receiving any type of substance use
treatment (i.e., self-help group, rehabilitation facility as an outpatient or inpatient, mental
health center as an outpatient, specialty facility) (SAMHSA, 2015). By educating health
care professionals and the public about available and effective psychosocial
2
interventions, significant personal, societal, and economic costs could be reduced.
Therefore, the purpose of the present paper is to review and synthesize current literature
highlighting the effectiveness of psychosocial interventions for SUDs.
Definitions/Diagnosis
This literature review is comprised of empirical studies utilizing criteria and
terminology from the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text
rev.; DSM-IV-TR; American Psychiatric Association, 2000) for Substance-Related
Disorders. Substance-Related disorders are divided into two categories: SubstanceInduced Disorders and the Substance Use Disorders, which include Substance Abuse and
Substance Dependence (DSM-IV-TR, 2000).
A substance use disorder represents an uncertain style of using a substance or
alcohol, which ultimately leads to apparent discomfort or deficiency in daily living (APA,
2013). Substance Abuse is described as a maladaptive form of using a substance,
contributing to serious clinical distress or impairment and is revealed by at least one of
the subsequent criteria, happening within a 12-month period: repeated use of a substance
culminating in a lack of success to achieve primary commitments at home, work, or
school; repeated use of a substance in positions which are physically dangerous; frequent
problems with the law directly connected to substance use; or recurrent use of a substance
in spite of persistent frequent interpersonal or social difficulties produced or intensified
by the consequences of the substance (DSM-IV-TR, 2000)
Substance Dependence is described as a maladaptive form of using a substance,
contributing to serious distress or impairment, and is revealed by at least three of the
subsequent criteria, happening within a 12-month period. The first criterion is tolerance,
3
which is determined by either a requirement for considerably greater amounts of the
substance in order to produce the needed response or intoxication or a noticeably reduced
response with repeated use of identical amounts of the substance. The second criterion,
withdrawal, is revealed by the typical withdrawal condition for the substance consisting
of a maladjusted behavioral change associated with cognitive as well as physiological
symptoms or when an identical (or closely similar) substance is taken to alleviate
symptoms of withdrawal. Also, the substance is frequently taken in greater amounts over
an extended period of time than was expected. Likewise, having a relentless need or
failed attempts to limit or control the use of a substance. Furthermore, a significant
amount of time is used in ventures to acquire the substance, to utilize the substance, or
recoup from its consequences; meaningful occupational, social, or recreational events are
neglected or lessened due to substance use; and regardless of the awareness of having an
enduring psychological or physical problem that is possibly produced or worsened by the
substance, substance use continued (DSM-IV-TR, 2000).
I should note that a number of changes were made to the Diagnostic and
Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric
Association, 2013) criteria for Substance-Related Disorders and Addictive Disorders
(American Psychiatric Association, 2013). First, there is no longer a distinction made
between substance abuse and substance dependence. They are replaced with criteria for
substance use disorder, along with criteria for withdrawal, intoxication,
substance/medication-induced disorders, and unspecified substance-induced disorders
(APA, 2013). Second, gambling disorder is now included in the Substance-related and
Addictive Disorders category. Third, the criterion of recurrent legal problems has been
4
eliminated from DSM-5. Fourth, the criterion of craving or a continual need to use a
substance is included (APA, 2013). Because the available literature largely predates the
DSM change, the present paper will focus on research that follows DSM-IV-TR criteria
for substance abuse disorders.
Whom SUDs Affect
Men and women of all ages, of various ethnicities and races, marital statuses,
education, and income levels are affected by substance abuse or dependence (Compton et
al., 2007). According to the 2013 National Survey on Drug Use and Health (NSDUH)
(SAMHSA, 2014), the 12-month prevalence of substance dependence or abuse among
adults aged 18 to 25 (17.3%) exceeded the rate for adults aged 26 or older (7%)
(SAMHSA, 2014). The rate of substance dependence or abuse among individuals aged
12 or older was greatest among Alaska Natives or American Indians (14.9%) and among
men aged 12 or older (10.8% vs. 5.8% for women). Likewise, the NSDUH results
indicated an association between the rates of illicit drug abuse or dependence and amount
of education completed for those aged 26 or older. Lastly, a higher percentage of adults
aged 18 or older who were dependent on or abused substances were unemployed (15.2%)
or on probation (35%) (SAMHSA, 2014).
Correlates
The abuse and dependence of psychoactive substances often lead to significant
distress and debilitation and are associated with considerable psychological, health, and
social problems (Jhanjee, 2014). The term co-occurring disorder (COD) refers to the
existence of two types of disorders; one or more pertaining to substance use (dependence
or abuse) and one associated with one or more mental disorders (Center for Substance
5
Abuse Treatment, 2005). Results from the 2013 National Survey on Drug Use and Health
demonstrated a strong correlation between drug use disorders and mood and anxiety
disorders (SAMHSA, 2014). By measuring solely non-substance induced disorders, this
survey demonstrated that around 20% of the general population having a substance use
disorder also suffered at least one mood disorder, and 18% experienced an anxiety
disorder (Flynn & Brown, 2008).
McGovern, Xie, Segal, Siembab, and Drake (2006) aimed to document the
prevalence of COD among substance abuse treatment client populations. They surveyed
clinical supervisors, addiction treatment agency directors, and clinicians belonging to a
state system, and they found that among COD clientele, 26% experienced anxiety
disorders, 41% experienced mood disorders, 25% experienced PTSD, 17% experienced
borderline personality disorder, 8% experienced antisocial personality disorder, and 17%
experienced other serious mental illness.
Another concern involves the increased incidence of co-occurring substance use
and mental disorders among people in the criminal justice system. The percentage of
COD individuals absorbed in the criminal justice system are much greater than in the
general population for both alcohol/drug disorders (4 to 7 times greater) and mental
health disorders (4 times greater) (SAMHSA/GAINS, n.d.). Without adequate treatment
interventions, criminal offenders are likely to be institutionalized due to their inability to
behave independently in prisons, community correction settings, or jail. Further at risk
are the homeless population, people who experienced trauma and those with PTSD, and
people living with infectious diseases and HIV/AIDS (Center for Substance Abuse
Treatment, 2005).
6
Psychosocial Treatment Approaches
Because of the impact of substance use on society and the serious ramifications
that can result from substance dependence or abuse, researchers and clinicians have
studied a variety of approaches to treating a condition with a traditionally poor relapse
rate (McLellan et al., 2000). Below are examples of the types of treatment interventions
that have been used to effectively treat substance related disorders.
Cognitive-behavioral Treatment
Among the most widely assessed treatments for illicit drug and alcohol use
disorders are those based on a cognitive behavioral model approach (Magill & Ray,
2009). Cognitive behavioral therapy (CBT) views problem drinking and drug use as a
behavior that has been learned, and CBT interventions for illicit drug or alcohol use try to
recognize the affective, social, cognitive, and situational precipitants of harmful
substance use (Witkiewitz, Marlatt, & Walker, 2005). This treatment to substance use
disorders is comprised of the following approaches: (1) training in coping skills, (2)
recognizing interpersonal and intrapersonal triggers for relapse, (3) training in drugrefusal skills, (4) adding activities that do not involve substance use, and (5) functional
analysis of substance use (Magill & Ray, 2009).
One particular cognitive behavioral intervention, Relapse Prevention (RP), was
originally introduced by Marlatt and Gordon to be utilized along with current
interventions, but it has been applied as the sole treatment method when working with
individuals with substance use disorders (Larimer, Palmer, & Marlatt, 1999; Witkiewitz
et al., 2005). The RP model integrates cognitive interventions with behavioral skill
training to help prevent episodes of relapse and seeks to comprehend, describe, and
7
manage these occurrences (Witkiewitz et al., 2005). First, an individual substance user is
assessed for the probable intrapersonal, interpersonal, environmental, and physiological
risks for relapse. After possible high-risk conditions and relapse triggers are determined,
cognitive and behavioral interventions are put into action that include distinct strategies
designed to help the client boost self-efficacy, improve coping skills, and learn how to
apply urge-management and stimulus control techniques (Larimer et al., 1999).
Evidence from Magill and Ray’s (2009) meta-analytic review of 53 randomized
controlled trials of CBT demonstrated the effectiveness and utility of this approach for
both illicit drugs and alcohol use. Also, Rawson and colleagues’ (2006) randomized
clinical trial comparing cognitive behavioral and contingency management approaches
reported that 60% of patients assigned to the CBT intervention supplied a toxicology
screen that was stimulant free at the 52 week follow-up.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a type of cognitive behavioral treatment
that was originally developed for individuals experiencing numerous and serious
psychosocial disorders, as well as those who experience recurrent suicidal ideation
(Dimeff & Linehan, 2008). Since substance use disorders (SUDs) tend to be present in
this type of client, Dimeff and Linehan (2008) chose to expand the standard DBT,
creating DBT for Substance Abusers, which includes approaches formed to lessen the
negative effect and length of relapses. A considerable number of randomized controlled
trials utilizing DBT for Substance Abusers have discovered a reduction in substance
abuse among patients diagnosed with borderline personality disorder (Dimeff & Linehan,
2008).
8
DBT categorizes behaviors that interfere with a person’s quality of life in a
hierarchical fashion (Dimeff & Linehan, 2008). The goal is to decrease behaviors that
are likely threatening to one’s life. For individuals who are substance-dependent, the
target behavior at the top of the hierarchy is substance abuse. Similarly to 12-step
programs, DBT approaches abstinence as the goal that is continually strived for. If a
person relapses, they respond in a nonjudgmental manner with skills to aid in the
reduction of detrimental results (Dimeff & Linehan). Evidence suggests it is especially
useful in helping patients with a SUD who exhibit severe difficulty in regulating their
emotions originating from numerous, intricate problems (Dimeff & Linehan).
Mindfulness-based Treatment
Mindfulness-based treatment is another approach that incorporates a cognitive
component within its strategies. The underlying premise of mindfulness training is that
by experiencing the present moment in a nonjudgmental and open manner, one is able to
effectively resist the effects of stressors (Kabat-Zinn, 2003). Usually when one is
focused on the past or the future, feelings of anxiety or depression crop up. Mindfulnessbased treatments teach clients how to remain in touch with thoughts, sensations, and
bodily states and how to connect differently to challenging affective states (Witkiewitz &
Bowen, 2010). Likewise, the practice of mindfulness strategies trains clients to deal with
emotions by attentively focusing on the current experience (Lutz et al., 2013).
Mindfulness meditation has been shown to produce a number of beneficial effects,
including alleviation of stress-related and psychiatric symptoms, along with enhancing
overall well-being (Holzel, Lazar, Gard, Schuman-Olivier, Vago, & Ott, 2010).
9
Since its inception into mainstream society over 20 years ago, mindfulness has
gained attention by clinicians in the field of empirical psychology (Bishop et al., 2004).
The various forms of therapeutic interventions that exist which incorporate the use of
mindfulness practices and techniques (Bowen et al., 2009) include Mindfulness-Based
Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), and
Mindfulness-Based Relapse Prevention (MBRP). Research has displayed that
mindfulness therapy is associated with declines in depressive relapse, disordered eating,
anxiety, and maintains its effectiveness for SUD treatment (Brewer, Bowen, Smith,
Marlatt, & Potenza, 2010; Hofmann, Sawyer, Witt, & Oh, 2010; Kristeller, & Wolever,
2011).
Mindfulness-Based Stress Reduction (MBSR) is a program that was established
with the sole purpose of teaching clients different types of meditation practices to aid in
alleviating stress and regulating emotions associated with a variety of medical illnesses
(Bishop, 2002). Similar to MBSR, Mindfulness-Based Cognitive Therapy (MBCT)
integrates mindfulness techniques with cognitive therapy to help individuals who are
prone to depression prevent depressive relapse (Bishop et al., 2004; Williams & Kuyken,
2012). This is particularly effective for the substance abuser, since a strong connection
between depressive symptomatology and substance abuse relapse has been found in
clinical and laboratory studies (Witkiewitz & Bowen, 2010).
Mindfulness-based relapse prevention (MBRP), a cognitive behavioral
intervention, integrates mindfulness practices to educate, preferred parts of relapse
prevention (RP) therapy, such as typical antecedents of relapse and recognizing
individual risk factors, and Marlatt’s cognitive behavioral relapse prevention program
10
(Larimer et al., 1999; Witkiewitz et al., 2005). The mindfulness based techniques that are
taught during MBRP provide a different way for the substance user to respond to
emotional discomfort that normally signals the conditioned response of craving and is
accompanied by symptoms of depression (Witkiewitz & Bowen, 2010).
Additional Psychosocial Interventions
Community reinforcement approach. The Community Reinforcement
Approach (CRA) is another type of behavioral treatment that was originally designed to
help individuals with alcohol use disorders (Meyers, Roozen, & Smith, 2011). The
Community Reinforcement Approach (CRA) is based on operant conditioning and directs
individuals to reorganize their lifestyles around healthy, pleasurable activities instead of
alcohol and drug use. It is highly recommended that the environment in which an
alcoholic resides be altered in order for the alcoholic to receive reinforcement from
his/her community, friends, and family for living a sober lifestyle. The goal is for
individuals to experience this new healthy lifestyle as more rewarding than a life filled
with alcohol or drugs (Meyers et al., 2011). This approach has been successfully applied
to treat an array of substance use disorders for over 35 years.
Community reinforcement and family training (CRAFT). An alternative to
CRA, Community Reinforcement and Family Training (CRAFT), was established 10 to
15 years ago to help individuals who were substance abusers participate in treatment by
involving family members in the process (Meyers et al., 2011). CRAFT uses operantbased principles to assist in engaging the substance abuser who refuses treatment.
Contingency management. Similar to CRA, Contingency management (CM)
utilizes techniques rooted in operant conditioning to help individuals with alcohol and
11
other drug (AOD) use disorders (Higgins & Petry, 1999). This approach believes that
both environmental and neurobiological factors impact AOD behavior. Positive
behavior change (e.g., abstinence) is promoted by utilizing reinforcing consequences
when clients reach treatment goals and adding punishing acts or withholding
reinforcements when clients participate in undesirable behaviors. The reinforcers used in
this incentive-based intervention include vouchers, prizes, money, special privileges, and
methadone doses (Higgins & Petry). Research studies have displayed that CM
approaches are efficacious in improving attendance to treatment, adhering to a
medication regime, decreasing use of AOD, and securing employment (Higgins & Petry).
Motivational interviewing. Motivational Interviewing (MI) was introduced by
William R. Miller (1983), an American psychologist, as a therapeutic technique that was
successful in helping people with alcohol problems (Treasure, 2004). Over the years,
research has demonstrated that MI is especially useful with clients from the substance
abuse population who are commonly opposed and resistant to change (Hettema, Steele, &
Miller, 2005).
Motivational interviewing (MI) is a style that is both client-centered and directive,
allowing patients to delve into and work out their ambivalence concerning behavior
change. The therapist’s role is to be a partner in the change process by providing
empathy and support (SAMHSA/CSAT, TIP 35, 1999). Considerable significance is
placed on the patient’s internal attribution of change and accepting responsibility for
oneself (Miller, 1983).
The counseling style of Motivational interviewing (MI) is established on four
assumptions: The friendly agreement that exists between the therapist and client is a
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cooperative alliance in which both individuals transfer valuable knowledge; a counseling
style that is supportive, yet directive and empathic provides the environment in which
change can take place; It is normal to have ambivalence about substance use (and change)
and comprises an essential motivational barrier in recovery; and by engaging with client’s
values and intrinsic motivation, ambivalence can be dealt with (SAMHSA, CSAT TIP
35, 1999).
An essential principle of the approach is that through compassionate negotiation,
the patient’s motivation to change is increased and thereby learns to express the included
costs and benefits (Treasure, 2004). Hettema et al., (2005) reviewed the evidence
supporting motivational interviewing (MI) and its treatment of addictive and incessant
unhealthy behaviors. Seventy-two clinical trials were analyzed and 32 of those focused
on alcohol abuse. The strongest support for the effectiveness of MI was found in the
domain of modifying substance use (Hettema et al., 2005).
Previous Research on Psychosocial Interventions for Substance Use Disorders
Previous studies have sought to examine the effectiveness of psychosocial
interventions for treating SUDs by including different types of studies other than
randomized controlled trials. The present study focuses on presenting randomized
controlled trials (RCT), as these experimental designs allow causal inference.
Bowen and colleagues (2014) administered the first randomized clinical trial for
the purpose of determining the relative efficacy of treatment as usual [TAU (12-step
programming and psychoeducation)], cognitive-behavioral relapse prevention (RP), and
mindfulness-based relapse prevention (MBRP) on 12-month SUD outcomes. The
authors hypothesized that subjects in RP and MBRP would exhibit significant
13
improvement on main outcomes (relapse to drug use and heavy drinking) when compared
with those in TAU, and MBRP subjects would better sustain gains in treatment over the
long term compared with those in RP or TAU. The sample was random, comprising 286
individuals, aged 18 to 70 years, who finished initial treatment at a private, nonprofit
treatment facility for SUDs. Participants were assigned to RP, MBRP, or TAU aftercare
and monitored for 12 months.
Bowen et al. (2014) discovered that participants assigned to RP and MBRP
documented a powerfully lower risk of relapse to heavy drinking and substance use, as
well as reported significantly lesser days of heavy drinking and substance use at the 6month follow-up. At the 12-month follow-up, only MBRP subjects disclosed
significantly decreased heavy drinking and significantly lesser days of substance use
compared to TAU and RP. Confirmation of both hypotheses lends support to targeted
mindfulness practices helping to strengthen the ability to observe and proficiently cope
with the discomfort associated with negative affect or craving.
Rawson and colleagues (2006) carried out a randomized clinical trial with the
purpose of comparing the effectiveness of CM and cognitive behavioral therapy (CBT) in
reducing stimulant use among individuals who were either cocaine dependent or
methadone (MA) maintained. The sample included 177 individuals who were diagnosed
as MA or cocaine dependent according to DSM-IV criteria and exhibited use of MA or
cocaine through a positive urine sample during the 2 week screening term. Participants
were randomly assigned into one of three active treatment conditions: cognitive
behavioral therapy (CBT; n = 59); contingency management (CM; n = 60); or CBT and
CM combined (CBT + CM; n = 59). At baseline, participants were administered the
14
Structured Clinical Interview for DSM-IV (SCID), Addiction Severity Index (ASI), and
Beck Depression Inventory (BDI). Intervention duration was 16 weeks and included
three follow-up interviews at weeks 17, 26, and 52 during which the ASI and BDI were
conducted again. Urine samples were collected three times per week during the
intervention period, and an absence of the MA/cocaine metabolite was an indication of no
stimulant use. Findings indicated a statistically significant mean number of samples that
were absent of any stimulant for both the CM and the CBT + CM treatment conditions
during the 16-week trial and continued a reduction in stimulant use to the 52-week
follow-up. Also, participants assigned to either the CM or CBT + CM condition
remained in treatment for a longer duration than those assigned to the CBT only
condition. However, researchers found no significant difference for the CBT group’s
performance relative to the CM group at the 26- and 52-week follow-up points.
In addition, my search of the literature yielded three meta-analytic reviews of
studies that gauged the effectiveness of one or more of the therapies listed above for
treating SUDs. These included cognitive-behavioral treatment with alcohol and illicit
drug users, mindfulness-based interventions for substance use disorders, and relapse
prevention for alcohol, smoking, and other substance use.
First, Magill and Ray (2009) analyzed 53 randomized controlled trials published
between 1982 and 2006 of cognitive-behavioral treatment (CBT) for adults with an
alcohol or illicit drug use disorder diagnosis. There were two purposes to this review.
The first was to present a broad view of the effectiveness of CBT treatment, and the
second was to determine the treatment and client aspects that were foretelling of the
degree of CBT effect. A statistically significant small effect was found for CBT across a
15
wide, varied, and rigid sample of studies over comparison conditions. The pooled effect
was modest at 6-9 months and continued to decline at follow-up of 12 months.
Interestingly, marijuana use disorders had a homogenous and moderate effect compared
to a small pooled effect size for alcohol, cocaine/stimulants, polydrug, and opiate abuse.
Additionally, larger effects were found when CBT was joined with a supplementary
psychosocial intervention, which was in contrast to CBT combined with pharmacological
treatment or CBT used alone.
Second, Chiesa and Serretti (2014) examined the effectiveness of mindfulnessbased interventions (MBIs) for reducing substance use and misuse (SUM) by reviewing a
total of 24 studies published between 1999 and December 2011. Fourteen of the included
studies involved randomized controlled trials and 10 consisted of non-randomized
controlled trials. The interventions carried out comprised Acceptance and commitment
therapy (ACT), Mindfulness-based relapse prevention (MBRP), Dialectical behavior
therapy (DBT), Spiritual self schema therapy (SSST), and other interventions based on
mindfulness. Likewise, studies centered on various categories of substance use including
opiate use, alcohol and/or heterogeneous substance use, marijuana use, cigarette smoking,
and methamphetamine use. The authors concluded that MBIs supported the reduction of
use of a variety of types of opiates, other drugs, and alcohol consumption to a
significantly greater degree than non-specific educational support groups, waitlist
controls, and some particular control groups. Also, the authors noted a relationship
between MBIs, a growth in mindfulness, and a decline in craving. Most importantly,
these studies demonstrated that MBIs exhibit the potential as a therapeutic approach to
substance use disorders.
16
Third, in order to assess the long term efficacy of Relapse Prevention (RP) on
psychosocial adjustment and substance use behavior, Irvin, Bowers, Dunn, and Wang
(1999) conducted a meta-analysis comprised of 22 published and 4 unpublished studies
of RP between 1978 and 1995. An additional aim of their review was to determine the
moderator variables that may influence the effect of treatment. Based on a pragmatic
viewpoint, the researchers chose to compute effect size estimates by using the weighted
average correlation coefficient r. This meta-analysis demonstrated that overall, RP
interventions were reliable and effective for substance use disorders, smoking, and
alcohol use disorders (r = .14). However, RP had a greater degree of effect on enhancing
psychosocial adjustment (r = .48). Furthermore, many variables moderated the treatment
effect. Particularly, the most powerful treatment effect was obtained when RP was
utilized to treat polysubstance or alcohol use disorders, when assessed soon after
uncontrolled pre-/post-test treatment utilization, and when mixed with the additional use
of medication.
The Present Paper
This present paper will summarize and synthesize empirical literature on the
effectiveness of commonly utilized approaches to substance abuse treatment: cognitivebehavioral therapy, mindfulness based treatments, contingency management, and
additional psychosocial interventions. This review is different from that which exists
because only studies that involve random assignment of participants and a control
condition will be included, thereby increasing internal validity and reducing bias. This
also allows the results obtained from the studies to be causally inferred. Further, this
review will add to the literature, because it will focus on studies that have been published
17
since the reviews mentioned above. It is the hope of the author that this work will
provide the clinician with confidence when utilizing an intervention that was deemed
effective for treating substance related disorders.
18
Method
I identified studies to include in this review by searching PsycINFO and PubMed
databases. I searched for studies published in English between January 1, 2012 and May
31, 2015. I used the following search terms: treatment, intervention, or therapy
combined with the terms addiction, substance related disorder, substance use disorder,
alcohol abuse, drug abuse, or SUD* AND mindfulness, cognitive-behavioral,
contingency management, motivational interviewing, or relapse prevention.
I selected studies if (a) they were randomized controlled trials, (b) they included
adult samples (18 – 70 years of age), and (c) they included a psychosocial intervention.
Studies were excluded if (a) they involved a pharmacological treatment, (b) they included
a dependent variable other than a substance related disorder, or (c) they included an
adolescent sample.
After applying inclusion and exclusion criteria, I retrieved 14 articles. Three
studies focused on the effects of CBT on substance abuse and misuse (SUM) (Carroll et
al., 2012; Carroll et al., 2014; Zhuang, An, & Zhao, 2013); one study focused on DBT in
treating those comorbid in SUD and eating disorders (Courbasson, Nishikawa, & Dixon,
2011); four studies focused on Mindfulness-based Relapse Prevention (MBRP) for the
reduction of SUM (Bowen et al., 2014; Luoma, Kohlenberg, Hayes, & Fletcher, 2012;
Gonzalez-Menendez, Fernandez, Rodriguez, & Villagra, 2014; Witkiewitz, Bowen,
Douglas, & Hsu, 2013); one study focused on assessing the effectiveness of CRAFT-T in
boosting treatment retention and support in SUM recovery (Brigham, Slesnick,
Winhusen, Lewis, Guo, & Somoza, 2014); three studies focused on assessing the
effectiveness of CM in reducing SUM (Garcia-Fernandez, Secades-Villa, Garcia-
19
Rodriguez, Pena-Suarez, & Sanchez-Hervas, 2013; Petry, Alessi, & Rash, 2013; Weiss &
Petry, 2014); and two studies focused on examining the effectiveness of MI in reducing
SUM (Parsons, Lelutiu-Weinberger, Botsko, & Golud, 2014; Satre, Delucchi,
Lichtmacher, Sterling, & Weisner, 2013).
For the articles where the information was given, I computed descriptive
statistics. The mean age of participants was 36.01 years; 66.63% participants were men
and 33.37% were women; most were White (65.25 % ); most (59.61%) completed high
school; most (65.45%) never married, which may be due to the chaos pervading the lives
of many addicts, and a notable percentage (41.43%) were unemployed.
20
Results
Effects of CBT on Substance Use and Misuse (SUM)
Results revealed three studies that underscored the effects of cognitive behavioral
therapy (CBT) on substance abuse and misuse (SUM). Two of these studies provided
objective and/or subjective measures of the effects of CBT on SUM, and one study
provided objective and/or subjective measures of the effects of CBT and contingency
management on SUM. One study focused on cannabis dependence (Carroll et al., 2012),
another on cocaine dependence (Carroll et al., 2014), and the last focused on heroin
dependence (Zhuang, An, & Zhao, 2013).
Carroll and colleagues (2012) treated cannabis dependence by incorporating
particular improvements to cognitive behavioral therapy (CBT) and contingency
management (CM) to focus on their various weaknesses. Their aim was to identify
whether the combining of the two would improve the outcome of cannabis treatment.
The 12-week randomized clinical trial took place in New Haven, Connecticut at a
community based outpatient program. There were four treatment conditions: CBT alone,
CBT with CM for adherence (in which prizes were awarded for treatment attendance and
homework completion), CM for abstinence (prizes were awarded for negative urine
samples), and CM for abstinence plus CBT. The authors set out to test 4 hypotheses.
The first hypothesis stated that the effectiveness in the reduction of cannabis use
would increase by the addition of reinforcement for homework completion and
attendance through CM to standard CBT. The second hypothesis proposed that effects
for CM for abstinence would be enhanced by the inclusion of targeted skills training by
means of CBT. The third hypothesis suggested that receiving any type of CM
21
intervention while undergoing treatment would have improved consequences than CBT
alone. Lastly, the fourth hypothesis offered that amid the process of a 1-year follow-up,
the merger of CM for CBT attendance and homework would exceed CM for abstinence
as a result of the propensity of CM outcomes to diminish over time (Carroll et al., 2012).
The number of participants totaled 127 individuals aged 18 years and above who
were seeking treatment for cannabis dependence. Their demographic characteristics
included 93.7% referred by the criminal justice system, 84.3% of whom were men with
an average age of 25.7 years, and 81.1% were an ethnic minority (Carroll et al., 2012).
Carroll et al. (2012) used two instruments for assessing participants’ cannabis use
consisting of urinalysis with adulterant checks and temperature on a weekly basis, as well
as the Timeline Follow back method (TLFB). The TLFB is a highly reliable and
psychometrically sound self-report measure of participants’ daily substance use
(Robinson, Sobell, Sobell, and Leo). The third instrument was the Structured Clinical
Interview for DSM-IV (SCID) utilized to assess psychiatric diagnoses (First et al.,
1995).
Carroll and colleagues (2012) determined that none of their hypotheses were
supported. There was no significant improvement in the outcomes of CBT, and by
adding CBT to CM for abstinence, the outcomes of the study worsened. Also, by adding
CM for abstinence to CBT, a correlation with modest outcomes compared to CM for
abstinence alone was found. Therefore, rates of treatment success for adults who are
cannabis dependent and associated with the criminal justice system do not seem to
improve by merging cognitive behavioral therapy and contingency management.
22
The study possessed a number of limitations. Even though high rates of dropout
are relatively typical for cannabis-using samples, the researchers attempted to interview
drop outs and utilized random regression models, which slightly lessened concerns
regarding missing data. The demographic characteristic of antisocial personality disorder
(ASPD) was related to poorer outcome, and higher rates of ASPD were shown in the
CBT + CM for abstinence group. Evidence of ASPD rates being higher in this group
may have overly weakened outcomes in this condition. The tendency for better outcomes
to emerge for individuals with ASPD when allocated to CM is compatible with past
findings, but the size of the sample is too small to deal with this problem quickly (Carroll
et al., 2012).
The degree of decline of cannabis use across treatment groups correlates
positively with other current randomized clinical trials made up of adults who are
cannabis-dependent and endorse the effectiveness of CBT and CM without the use of
enhancements (Carroll et al., 2012).
In a second study on this topic, Carroll and associates (2014) examined computerbased training for cognitive-behavioral therapy (CBT4CBT) with the purpose of
assessing its efficacy with a larger, more homogeneous sample size of 101 individuals
who were cocaine dependent and maintained on methadone. A prior preliminary trial
was overseen by the same authors, but with a smaller sample size of 77 assorted
substance users (marijuana, opioids, alcohol, and cocaine).
Carroll et al. (2014) proposed two hypotheses. The leading hypothesis stated that
persons designated to CBT4CBTwould present less urine toxicology screens and
decrease their recurrence of other substance use and cocaine than persons assigned
23
randomly to treatment as usual. The second hypothesis stated that the results of
CBT4CBTwould be enduring comparative to treatment as usual via a 6-month follow-up.
The procedure involved selecting 101 participants at random from a methadone
maintenance program who were dependent on cocaine and randomly assigning them to
either the CBT4CBT condition or treatment as usual. Standard treatment was comprised
of weekly group sessions and daily methadone maintenance lasting 8 weeks. Meeting
twice a week with an independent research assistant who evaluated recent use of
substances, gathered urine specimens, and carefully watched other clinical symptoms was
also part of standard treatment. Participants who were selected for the CBT4CBT
condition were given admittance to the program, which was located on an allotted
computer in a separate room inside the clinic. They also took part in methadone
maintenance (Carroll et al., 2014).
Evaluations were administered by a research assistant at the start of treatment, 2
times a week during treatment, at the 8 week completion point, and 1, 3, and 6 months
after completion. Four assessments were utilized consisting of the Structured Clinical
Interview for DSM-IV (SCID), the Substance Use Calendar, the Risk Assessment
Battery, and participant self-reports. The SCID was administered prior to treatment
randomization to confirm additional psychiatric diagnoses and substance use. Daily selfreports of alcohol and drug use were gathered weekly by the Substance Use Calendar
during the 28 day span prior to randomization. It also collected self-reports during the
whole 56 day treatment phase and at the 6 month follow up. Finally, the Risk
Assessment Battery was utilized to examine HIV risk behaviors (Carroll et al., 2014).
24
The primary outcome measures included findings of urine toxicology screens,
operationalized as the percentage of drug negative urine samples gathered throughout
treatment; alterations in self-reported drug usage over time, operationalized as days of
cocaine use per week; and accomplishment of 3 or more weeks of uninterrupted
abstinence (which has been discovered to be a good predictor of improved cocaine
outcomes over time). Secondary outcomes consisted of declines in self-reported HIV
risk behaviors (Carroll et al., 2014).
A total of 69 individuals (35 in treatment as usual condition and 34 in CBT4CBT)
finished the entire 8-week treatment protocol. A significant number (36%) of persons
allocated to CBT4CBT achieved 3 or more continued weeks of abstinence from cocaine
within treatment compared with only 17% of individuals assigned to intention-to-treat.
Likewise, the individuals assigned to CBT4CBT had more excellent outcomes on the
majority of measures, comprising negative urine specimens for all drugs. However,
statistical significance was only attained for persons who finished the 8 week trial (N =
69). At the 6-month follow-up, 93% of the randomized sample was available for data
collection, which showed continual improvement for individuals allocated to the
CBT4CBT group. The findings from this trial repeat the ones from the previous study
demonstrating efficacy of CBT4CBT as an addition to addiction treatment, as well as its
effectiveness over time (Carroll et al., 2014).
The strengths of Carroll et al.’s (2014) randomized clinical trial involving
CBT4CBT include primary outcomes examined by utilizing validated self report
instruments and urine toxicology screen, randomization to treatment, satisfactory sample
size with intent-to-treat analyses of outcomes utilizing suitable statistical methods, 92%
25
of the sample completed a 6 month follow-up, degree of commitment with the CBT4CBT
program was relatively high, as subjects completed 73% of sessions provided, and
insisting that all subjects fulfill standardized diagnostic criteria for opioid and cocaine
dependence.
As well as the study’s strengths, various limitations were present. First,
CBT4CBT was assessed as an addition to treatment, leaving the conditions of attention
and time spent unbalanced. Likewise, the conclusion cannot be ascertained that
CBT4CBT’s effects are tantamount with the effects of individual clinician-delivered
CBT. As far as the intent-to-treat sample is concerned, the study’s treatment findings on
overall proportions of all drug-negative and cocaine-negative urine samples neared
statistical significance, but did not attain it (Carroll et al., 2014).
Next, Zhuang and colleagues (2013) conducted a randomized controlled study at a
Compulsory Detoxification Centre in Tianjin, China with the purpose of enhancing selfcare skills in individuals who were heroin dependent by assisting them in developing
correct cognitive ability and behavioral style, understand the damaging effects of heroin
dependence, and ultimately improve their quality of life (QOL). The sample consisted of
240 heroin-dependent inpatients from AnKang Hospital who were getting detoxification
treatment. Participants were assigned to either an experimental group or a control group.
The experimental group (n = 120) received a cognitive behavioral intervention
consisting of behavioral and educational components delivered by clinical nurses along
with the hospital’s routine care lasting for six months. The purpose of the cognitive
aspect of treatment was to change negative thought patterns and establish correct
cognition. The behavioral element was employed to help alleviate negative expressions
26
and adopt a healthful way of living thereby enhancing QOL. Routine care consisted of
nutritional support, manual labor, methadone treatment, physical examination, discipline
education and special legal education. The control group (n = 120) received only the
hospital’s routine care (Zhuang et al., 2013).
One instrument was utilized to determine the QOL between individuals who were
heroin dependent (Zhuang et al., 2013) which consisted of the Chinese version of QOL in
Drug Addiction Questionnaire (QOLDA). This test is comprised of 40 items divided into
four scales: Physical Component Summary (PH), Symptom Component Summary (ST),
Social Component Summary (SO), and Psychological Component Summary (PS). The
QOLDA was administered at baseline and after intervention to both the experimental and
control group.
Zhuang et al.’s (2013) study yielded three main findings. Two of the results
concerned participants’ QOL. At baseline, no significant difference between the two
groups was found. However, after 6 months of receiving the CBT intervention, the
experimental group showed a significant difference from the control group on each
domain (i.e., PH, ST, SO, and PS). Both psychological and physical health along with
social functioning was improved. Second, individuals who were dependent on heroin
scored lower on the QOLDA than the population in general. This was due in part to
individuals who are heroin dependent being prone to psychological and physical health
problems. Third, the overall majority of individuals dependent on heroin were male,
single, young, and uneducated. Also, they were more likely to have a serious dependence
on illegal drugs.
27
This study had its share of strengths. First, participants were randomly allotted to
either the treatment group or control group and questionnaires were answered on their
own void of tips or consultation from the researchers. Second, the sample size was
somewhat large, which was adequate in providing reliable findings. Third, treatment
retention was high with no dropouts, which removed the possibility of attrition having an
effect on the study’s findings (Zhuang et al., 2013).
Limitations were also present in Zhuang et al.’s (2013) study. The study’s sample
consisted of Chinese heroin dependent individuals, which created uncertain
generalizability to others in the same country or in other countries’ heroin-dependent
populations. Additionally, due to insufficient resources, the study was only capable of
tracking the participants for a period of 6 months. In the short term, the CBT intervention
proved to be effective on the QOL, but the long term advantages remain unexplored.
Effects of DBT on SUM
According to the National Comorbidity Survey Replication, the pervasiveness of
SUDs discovered are as great as 27%, 37%, and 23% in persons diagnosed with anorexia
nervosa, bulimia nervosa, and binge eating disorder (Munn-Chernoff & Baker, 2015). I
reviewed one study that evaluated the value of DBT in treating those comorbid for eating
disorders (ED) and SUD. Courbasson et al. (2011) assessed the effectiveness of DBT
developed specifically for the population of persons with comorbid SUD and ED. This
was the first published trial declaring effectiveness for individuals with concurrent ED
and SUD.
Courbasson et al. (2011) made four hypotheses pertaining to SUDs. The first
hypothesis was that members receiving DBT would show better improvement in SUD,
28
ED, and depressive symptomatology. The second hypothesis proposed that outcomes
would be favorable on the asperity of addiction, and on the effectiveness of coping for
substance use. The third hypothesis suggested that there would be considerable
improvements in the severity of depression, along with noticed capability to manage
negative emotions. The fourth hypothesis offered that due to substance users’ inability to
effectively regulate emotion, scores would rise on the Negative Mood Regulation Scale
(NMRS) and decrease on the Drug-Taking Confidence Questionnaire Short
Version(DTCQ-8) and on the Addiction Severity Index (ASI).
Courbasson et al.’ (2011) sample consisted of 25 women being treated for
comorbid ED and SUD attending an outpatient mental health clinic that was trained in
substance use. They randomly assigned participants to either the DBT condition or the
TAU condition. Four participants did not receive allocated intervention. They were
either unwilling to commit to the treatment (n = 3) or for reasons unknown ( n = 1) The
members received treatment for a span of 1 year. To assess improvement, they
administered the Eating Disorder Examination (EDE), Eating Disorder Inventory (EDI),
Emotional Eating Scale (EES), Addiction Severity Index (ASI), Drug-Taking Confidence
Questionnaire-Short Version (DTCQ-8), Beck Depression Inventory (BDI) and the
Negative Mood Regulation Scale (NMRS).
The procedure involved blind raters evaluating the participants at baseline, 3, 6, 9
and 12 months into receiving treatment, at post-treatment (1 year later) and at the 3
month and 6 month follow-ups. The TAU condition involved 1.5 hours of weekly group
therapy that directed attention at lessening psychiatric symptoms and substance use
behaviors that were problematic. Treatment consisted of chiefly motivational
29
interviewing, relapse prevention strategies, and cognitive behavioral therapy (CBT).
Participants assigned to the DBT condition received the adapted DBT for Substance
Abusers, which comprised a combination of CBT skills training and treatment strategies,
mindfulness teaching, and persistent attention on dialectics. Skills were taught first in a
group format then via intensive behavioral analysis strategies in individual therapy.
Treatment involved a program lasting 1 year, which included a 2 hour skills-training
group, 1 hour a week of individual psychotherapy, as needed telephone consultation,
daily self-monitoring reports, and weekly meetings to consult with a therapist
(Courbasson et al., 2011).
The researchers discovered that members who were randomly assigned to the
DBT treatment demonstrated a higher rate of retention compared to members assigned to
the TAU condition at different points in time. These points in time involved posttreatment (80% versus 20%) and follow-up (60% versus 20%). One major drawback to
the study was the fact that dropout rates increased, along with exacerbated ED-SUD
symptoms in the TAU condition, which lead to early termination of recruitment efforts
due to modest TAU response, thus prevailing a small sample size too deficient to produce
a useful comparison to the DBT condition (Courbasson et al., 2011).
Findings pertaining to the DBT condition affirmed that the DBT treatment had a
significant positive effect on substance use severity and use, attitudinal and behavioral
features of disordered eating, depressive symptoms, and negative mood regulation.
Lastly, a significant association was reported between the raise in participants’
recognized capability to manage and regulate negative emotional states with declines in
30
emotional eating and boosts in confidence relating to the capability of withstanding the
urge to use a substance (Courbasson et al., 2011).
The study had its share of various limitations. Many participants assigned to the
TAU condition revealed worsening of symptoms and not improvement, which resulted in
high dropout rates (n = 2) and subsequent early termination of recruitment efforts. Also,
a controlled comparison was obsolete, so definitive treatment effects cannot be
determined. Second, due to the sample size being small, it is uncertain if results would
generalize to the greater assortment of persons diagnosed with comorbid SUD and ED,
and the power may have decreased, making detection of treatment effects difficult.
Third, finding treatment effects that were significant was challenging because the variety
of the sample raised within-group variability. Fourth, higher degrees of ED symptoms
discovered within participants assigned to the DBT group may have biased findings.
Fifth, there is a chance that ratings were altered due to the benefit of blinding not being
empirically confirmed. Sixth, participants’ diagnostic status according to the DSM-IV
was not tracked at both post-treatment and follow-up time points. Seventh, participants
in both the DBT and TAU condition were recipients of individualized treatment,
however, TAU participants only received individualized treatment if the clinician
considered it to be necessary. The contact between participants and clinicians was much
higher in the DBT group compared to the TAU group and may have contributed to results
of the study. Finally, generalizability to male populations was restricted, since only
female participants were recruited (Courbasson et al., 2011).
Effects of MBIs on SUM
31
Mindfulness involves the practice of mentally focusing your attention on the
present moment while being accepting and open to it, void of judgment (Kabat-Zinn,
2003). Mindfulness-Based Relapse Prevention (MBRP) incorporates pivotal elements of
RP with practices modified from Mindfulness-Based Cognitive Therapy (MBCT)
(Teasdale et al., 2000) and Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn,
1990). Acceptance and Commitment Therapy (ACT) is a mindfulness-based behavioral
therapy with the goal of generating a full and meaningful life, while welcoming the pain
that accompanies it (Harris, 2006). ACT presumes that the human mind consists of
psychological systems, which are usually damaging and produce psychological distress
(Harris, 2006).
Four studies were reviewed that utilized a mindfulness-based treatment as an
approach to reducing substance use and misuse. In the first study, Witkiewitz and
colleagues (2013) conducted a clinical trial to compare the effectiveness of RP and
MBRP in preventing substance use relapse among women residing at a residential
treatment center who were referred by the criminal justice system. They undertook this
line of research due to the finding that recidivism rates were lowest among mentally ill
prisoners 4 years after release from prison compared to those with a dual diagnosis of
serious mental illness and substance abuse disorders (Wilson et al., 2011; Witkiewitz et
al., 2013). The study’s chief intent was to examine the effectiveness of MBRP in
decreasing drug use and its effects. The authors hypothesized that persons receiving
MBRP would disclose a decrease in drug use and its related effects, and less legal,
medical, family-social, and psychiatric problems than individuals assigned to RP.
32
Witkiewitz et al.’s (2013) sample consisted of 105 women residing at a residential
addiction treatment center who were formerly implicated in burglary, drug
use/possession, and prostitution. Within the sample, a broad array of substance use, legal
and mental health problems existed. Out of 86 women, 69.2% confirmed a serious
trauma, 89.2% revealed a history of emotional, verbal or physical abuse, 46% had
attempted suicide at least once, 73.5% mentioned experiencing anxiety, and 70.7%
revealed chronic depression. The leading drug of choice was methamphetamine at
35.5%, heroin and other opiates at 22.6%, cocaine at 19.4%, alcohol at 9.7%, marijuana
at 6.5%, nicotine at 3.2%, and all other drugs at 3.2%.
Witkiewitz et al.’s (2013) procedure involved participants completing a baseline
assessment during the last week of the stabilization and detoxification phase of treatment,
before beginning active treatment. Assessments were carried out 4 weeks after the start
of treatment, at 8 weeks when the treatment commenced, and again 15 weeks after the
treatment ended. Also, assessments were administered weekly during the treatment
phase.
Next, participants were randomly assigned to either the MBRP condition (n = 55)
or the relapse prevention condition (n = 50). Participants entered treatment on a rolling
basis and began receiving RP or MBRP when believed ready to begin active treatment.
Groups then met twice a week for 50-minute sessions throughout the 8 weeks of
treatment. For participants allocated to the MBRP intervention content, the main goals
were to assist them in identifying cravings and triggers, recognizing when in automaticpilot and how it pertains to relapse, and incorporating Mindfulness skills into everyday
situations (Witkiewitz et al., 2013). Between sessions, participants were given assorted
33
exercises to work on along with handouts. Also, meditation sitting groups were offered 4
days a week with arranged times where mindfulness lessons could be worked on.
Participants assigned to the RP condition received treatment that was based on
aspects of the Coping Sills Training Guide (Monti, Kadden, Rohsenow, Cooney, &
Abrams, 2002) and the RP manual written by Darley and Marlatt (2006). The RP group
experienced a similar design as the MBRP group concerning group format, scheduling,
and time commitment. In between sessions, participants were given exercises consisting
of skill-building tasks (Witkiewitz et al., 2013). First and foremost, participants were
taught how to evaluate situations of high risk for relapse and to strengthen both
behavioral and cognitive skills for handling high risk situations and craving. Likewise,
participants were coached on skills regarding drink refusal self-efficacy, problemsolving, social support, goal-setting, and a balanced lifestyle (Witkiewitz et al., 2013).
The primary outcomes included substance use consequences and days of
substance use. Measures utilized consisted of a 30 day Timeline Follow-Back (TLFB)
and the Short Inventory of Problems (SIP-M). Next, the secondary outcomes involved
medical problems, family and social problems, psychiatric symptoms, and legal
problems. Lastly, the individual subscales of the Addiction Severity Index (ASI) were
used to measure the secondary outcomes (Witkiewitz et al., 2013).
Witkiewitz et al. (2013) discovered that out of the 54 individuals maintained
through the follow-up, only six revealed drug use throughout the course of the 15 weeks.
Five people in the RP group had an average of 2.6 days of drug use and one person in the
MBRP group had one day of drug use. According to the negative binomial regression
models, persons who were randomly assigned to the MBRP condition experienced 96%
34
lesser days of drug use than persons assigned to the RP condition. Even though statistical
significance was not reached, the ramifications of drug use were 39% lower in the MBRP
condition.
Considering the secondary outcomes, significantly fewer scores on the medical
status and legal status subscales of the ASI were found among those allocated to the
MBRP condition. Also, the psychiatric and family/social subscale did not reveal any
significant variations. Lastly, lower scores were reported for the ASI total score for
individuals who received MBRP, but this difference was not statistically significant
(Witkiewitz et al., 2013).
There are many strengths to (Witkiewitz et al.’s (2013) study. First, there is a
lack of randomized trials for the population of adult drug using offenders, so the authors
chose to conduct a study that was randomly designed to assess the effectiveness of two
empirically supported treatments that are also manualized. Secondly, the study’s findings
produce initial data that backs MBRP as possibly a more compelling treatment than RP
for female offenders in residential treatment sites. Third, by showing definitively that
MBRP can be utilized at the same time as an active intervention instead of as an aftercare
treatment, this study increases the literature pertaining to MBRP. Also, participants will
continue applying techniques learned long after treatment ceases. Finally, this
randomized controlled trial is the first of its kind to present MBRP’s effectiveness in a
rolling group format, which makes it more inclined to be disbursed to community sites
than the previous closed cohort format.
Due to the study’s many limitations, discretion should be used when analyzing
findings. First and foremost, attrition rates were high and sample size was small, which
35
critically restricted power to identify significant outcomes. Second, a considerable
amount of data was lacking throughout measures. Data that was absent was due in large
part to participants’ unwillingness to finish the questionnaires (Witkiewitz et al., 2013).
Pertaining to the study’s design, it was unethical for the involvement of a notreatment control group located within a residential substance abuse treatment program
that was court mandated. Second, the residential treatment setting afforded the
participants a considerable number of favorable circumstances to share their treatment
encounters across settings (Witkiewitz et al., 2013).
In the second study, Bowen et al. (2014) administered a randomized clinical trial
with the aim of assessing the effectiveness of MBRP in lowering the relapse rate over the
long-term when compared to TAU and RP in the course of a 12 month follow-up. Based
on previous research, Bowen and colleagues proposed a hypothesis stating that
individuals assigned to the RP and MBRP group would exhibit significant advancement
on primary outcomes compared with individuals assigned to TAU, and that persons
receiving MBRP would better manage improvements in treatment over the long-term
compared to persons assigned to the RP or TAU condition (Bowen et al., 2014).
The trial took place between October 2009 and July 2012 comprising 286
individuals from a nonprofit treatment facility who were fortunate to complete the
beginning of treatment for substance use disorders. Participants were randomized to the
RP, TAU, or MBRP aftercare and observed for a span of 12 months. They ranged in age
from 18 to 70 years with 42.1% being of ethnic/racial minority and 71.5% being men
(Bowen et al., 2014).
36
The procedure involved eligible persons completing baseline assessments and
being randomly assigned to a treatment intervention. All interventions were held in a
group setup. The TAU program included 95 participants and was largely based off of the
Alcoholics/Narcotics Anonymous 12-step program, process oriented, and abstinence
based. The TAU groups met for 11/2 hours 1 to 2 times per week and consisted of
discussions pertaining to recovery (e.g., stress management and communication). The
MBRP program participants (n = 103) met weekly for 2 hours with 2 therapists. Each
weekly meeting had a central focus such as mindfulness in high risk situations,
“automatic pilot” in addiction, and balancing action and acceptance. Members also
received audio-recorded mindfulness exercises and handouts to do for homework along
with a journal to track their daily mood and craving. The RP program was comprised of
88 participants and modeled MBRP in format, location, size, and time. Central
objectives involved cognitive and behavioral coping skills, assessment of high risk
situations, goal setting, problem solving, social support, and self-efficacy. Selfmonitoring of daily mood and craving was also completed (Bowen et al., 2014).
Bowen et al.’s (2014) primary outcomes involved heavy drinking, relapse to drug
use, and frequency of substance use in the past 90 days. Evaluation of variables was
done at baseline and 3, 6, and 12 month follow up points. Measures consisted of
urinalysis alcohol and drug screenings and self-report of relapse.
A significant, but not statistically lower risk of relapse to heavy drinking and
substance use was found for substance users assigned to both RP and MBRP compared
with TAU. Also, at the 6 month follow-up, significantly lesser days of heavy drinking
and substance use was reported for the participants allocated to MBRP and RP. This also
37
was found to be not statistically significant. According to time to first drug use,
cognitive-behavioral RP demonstrated a preference over MBRP. Finally, MBRP
individuals revealed significantly lesser days of drug use at the 12 month follow-up along
with a significant decrease in heavy drinking compared with TAU and RP (Bowen et al.,
2014).
A strength of Bowen et al.’s (2014) study is that for all three treatment conditions,
the prevalence of heavy drinking and substance use were a lot lower when compared to
other studies involving the treatment of SUD. Likewise, the sample size was large (N =
286) and first to examine 12 month longitudinal effects of an operating evidence
established treatment for SUDs versus a treatment based on mindfulness meditation
(Bowen et al., 2014). Limitations of the study include various discrepancies among the
active treatment groups and TAU such as assignment of homework, training the
therapists received, and restricted urinalysis data and main treatment outcomes measured
by self-report.
In the third study, Luoma and colleagues (2012) conducted a randomized trial to
assess an ACT intervention to shame in a sample of individuals battling with substance
use disorders. Acceptance and Commitment Therapy (ACT) is a mindfulness-based
behavioral therapy with the goal of generating a full and meaningful life, while
welcoming the pain that accompanies it (Harris, 2006). The emotion of shame has long
been viewed as pertinent to substance use disorders and their treatment.
Luoma et al.’s (2012) sample consisted of 133 adults (72 male and 61 female)
with a mean age of 33.6 years who were diagnosed with a substance use disorder and
enrolled in a 28 day treatment program located in Reno, Nevada. Within the sample,
38
14% were non-Caucasian-African American, Asian/Pacific Islander, American Indian,
other, and 13% identified as Hispanic. The most prevalent drugs used were
methamphetamine, alcohol, and marijuana.
The procedure involved randomly allocating successive pairs of cohorts to
undergo either the 6 hour intervention coupled with treatment as usual (TAU + ACT) or
TAU alone. The TAU condition comprised 5 or 6 daily group therapies meeting 6 days a
week for a total of 28 days. A majority of the groups focused on relapse prevention,
health issues, life skills, physical health issues, parenting, anger management, and
recreational therapy while seven were process groups. Participants also received 2 hours
of therapy per week based on the 12-step model (Luoma et al., 2012).
The ACT intervention was comprised of three 2-hour group sessions that
followed a developed and tested manual and met during a single week. The groups were
designed to assist members with reducing stigmatization, shame, and judgments of others
and self. Usual ACT lessons were altered to concentrate on how to acknowledge selfstigmatizing thoughts and shame, so as to not hinder recovery (Luoma et al., 2012).
Both treatment groups were administered a pre and post assessment a week apart.
During the span of time between assessments, participants assigned to the ACT condition
received the group intervention, and individuals enrolled in the TAU condition followed
the normal program. The study consisted of 16 cohorts with half designated to each
condition and ranging in size from 3 to 17. Luoma et al. (2012) administered a follow-up
after 4 months that all participants completed.
Luoma et al. (2012)’s three primary outcomes included continued participation in
drug and alcohol treatment after release, internalized shame, and follow-up alcohol and
39
drug use. Instruments utilized to measure these outcomes involved the Internalized
Shame Scale (ISS; cited in Luoma et al., 2012), the Treatment Services Review (TSR;
cited in Luoma et al., 2012), and the Alcohol and Drug Timeline Follow-back Interviews
(TLFB; cited in Luoma et al., 2012).
Luoma et al’s (2012) secondary outcomes consisted of social support, mental
health, and quality of life. Instruments employed to measure these outcomes included the
General Health Questionnaire-12 (Luoma et al., 2011), the Quality of Life Scale (Luoma
et al., 2011), and the Multidimentional Scale of Perceived Social Support (Luoma et al.,
2011).
Luoma et al. (2012) found that the ACT intervention produced minor
instantaneous improvements in shame, but at 4 month follow-up bigger declines were
discovered. Considering the 4 month follow-up, participants receiving the ACT
treatment demonstrated an increase in treatment attendance and lesser days of substance
use. Also, there was a greater likelihood that participants exhibiting an increase in levels
of shame after treatment would be enrolled in treatment at follow-up. Finally,
consequences of the intervention on substance use at follow-up were affected by
treatment attendance, proposing that more involvement in treatment may be a result of
the intervention.
The strengths of the study include being the first randomized controlled trial to
focus on shame in a population of substance use and that by applying the skills of
acceptance and mindfulness in the treatment of shame, attendance to treatment improves
and there is a decrease in substance use (Luoma et al., 2012).
40
Limitations of Luoma et al. (2012)’s study include a considerable amount of data
that was missing at follow-up due to ethical restrictions, and the trouble in following
members of serious substance abusing populations; difficulty in distinguishing TAU in a
residential program due to the extent and intricacies of treatment obtained; only one
instrument utilized to measure shame, the ISS, making it hard to distinguish whether or
not the improvements were related to fluctuations in guilt; TLFB statistics were not
obtained pretreatment and not clear as to whether this sample could be compared to
others, since there was no collection of data from participants who were ineligible to take
part in the study or who failed to participate. Lastly, since there was no binding, the
possibility of improved findings in the ACT treatment being because of the beliefs of
increased progression among staff or participants on the treatment unit could be made.
In the fourth study, Gonzalez-Menendez, Fernandez, Rodriguez, & Villagra
(2014) ascertained the efficacy of ACT over time in a group of incarcerated women
diagnosed with substance abuse and co-occurring disorders. They employed a CBT
program as a comparison group due to Magill and Ray’s (2008) meta-analytic finding
that the effects of CBT with a group of adults with alcohol and illicit drug use lessened
from the 6 to 12 month follow-up. The authors set out to test two hypotheses.
Gonzalez-Menendez et al.’s (2014) first hypothesis was that both conditions
would decrease and maintain drug abuse. Likewise, both treatments would improve the
mental health of participants. Their second hypothesis proposed that ACT would attain
more improved effects than CBT over the long term.
The sample consisted of 37 women who were diagnosed with current dependence
and abuse and incarcerated at a state prison located in Villabona, Spain for a crime
41
relative to drugs. Within the sample, most of the participants were single with a mean
age of 33.59 years. On average, their sentences varied from 38.7 to 50 months.
According to the Addiction Severity Index-6, the overall recurrences of use were 29.7%
daily, 18.9% four days a week, 10.8% twice a week, and 40.5% twice a month. The legal
circumstances of inmates differed, so not every pre and post assessment was able to be
administered in prison. For inmates who were released from prison, the assessments
were handled following their release (Gonzalez-Menendez et al., 2014).
Gonzalez-Menendez and colleagues (2014) used six instruments: the Ad-hoc
interview, Addiction Severity Index-6 (ASI-6), Anxiety Sensitivity Index-6 (ASI),
Acceptance and Action Questionnaire-II (AAQ-II), Mini International Neuropsychiatric
Interview (MINI), and Multidrug Urinalysis (UA). Two psychologists conducted either
the ACT or the CBT assessment simultaneously. The group interventions met weekly for
a total of 16 weeks and continued for 90 minutes. Follow-up assessments for each
treatment group were conducted by the same psychologists at 6 months, 12 months, and
18 months.
Gonzalez-Menendez et al. (2014) discovered that for the ACT participants, 27.8%
were abstinent at post-treatment, 42.8% at 6 months, 84.6% at 12 months, and 85.7% at
18 months. This increase in abstinence over time was found to be statistically significant.
For the CBT participants, 15.8% were abstinent at post-treatment, 25% at 6 months,
54.5% at 12 months, and 50% at 18 months. Likewise, statistical significance was shown
for members of the CBT group. However, a statistically significant variation at 18
months was discovered in support of the ACT condition. According to the ASI-6, three
areas (psychological, drug, and family) revealed a significant therapy effect endorsing
42
ACT. Similarly, statistical significance was found for within-group declines in
Psychological, from baseline to 18 months; Drug, from baseline to 6, 12, and 18 months;
and Family, from baseline to 12 and 18 months (Gonzalez-Menendez, et al., 2014).
Significant declines were found in ASI for both interventions; but CBT
progressed more than ACT. Statistical significance was reported for CBT in a number of
domains including Cognitive, from baseline to post, 12, and 18 months, Somatic, from
baseline to post and 18 months, and Total from baseline to post, 12, and 18 months. As
for ACT, the Cognitive domain reported statistical significance from baseline to 18
months (Gonzalez-Menendez et al., 2014).
Both interventions revealed a statically significant therapy effect in AAQ-II, but
group differences was not found to be significant. Both groups lessened their anxiety
sensitivity, drug use, and the composite score of the ASI-6. Also, an increase in
psychological flexibility was reported for both conditions. However, only participants
receiving ACT were found to report a decline in the percentages of mental disorders. In
conclusion, the ACT treatment appears to be a suitable method of treatment for cooccurring disorders in women who are incarcerated and for addictive behaviors
(Gonzalez-Menendez et al., 2014).
Limitations of the study include the results not being generalizable to a population
other than incarcerated females, a small sample size, and only 66.7% of the ACT
participants and 47.4% of the CBT participants completed every one of the assessments.
This was due, in part, to participants relocating to other prisons. Also, the fact that
subjects abused more than one drug, and the long duration of drug abuse limited the
43
study. Lastly, there was no instrument utilized to measure therapists’ adherence
(Gonzalez-Menendez et al., 2014).
The strengths of the study include comparing the two treatment conditions and,
the setting of the study. There are scarcely any studies that compare both CBT and ACT
in the treatment of addictive behaviors and by doing so, ACT was found to be an
effective therapeutic option that is beneficial for drug addicted incarcerated women with
co-occurring disorders. The prison environment espouses its own unique values and
regulations, and is uncompromising and strict. Therefore, it was the optimal situation to
assess both CBT and ACT interventions (Gonzalez-Menendez et al., 2014).
Effects of CRAFT-T (Community Reinforcement and Family Training for
Treatment Retention) on SUM
Opiod abuse, misuse, mortality, and morbidity has reached epidemic proportions
in the last 20 years (Kanouse & Compton, 2015). According to the 2014 National Survey
on Drug Use and Health, (NSDUH) (SAMHSA, 2015) nearly 168,000 young adults aged
18 to 25 had a heroin use disorder and among adults aged 26 or older, roughly 400,000
had a heroin use disorder.
Of note, the most effective treatment for opioid dependence, drug agonist
maintenance, assists in greatly lowering mortality, morbidity, and transmission of
infectious disease (Sigmon, 2014). However, there remains a shortage in the availability
of opioid-substitution treatment for many areas of the country, especially in rural regions
where an excessively high prevalence of prescription opioid abuse exists (Rosenblum et
al., 2011). The result is methadone clinics having lengthy waitlists for lifesaving
treatment (Sigmon, 2014). Detoxification without access to methadone clinics creates an
44
increase in the rate of treatment dropout and rate of relapse (Strang et al., 2003). These
factors underscore the need for psychological intervention in this area.
One study, by Brigham et al. (2014), employed a 14-week randomized pilot
clinical trial to assess the effectiveness of CRAFT-T in boosting treatment retention and
support in recovery among opioid dependent patients. Brigham and colleagues’ (2014)
sample consisted of 104 participants admitted into an intent to treat (ITT) randomized
trial involving two groups located in Ohio at two separate sites. The first site was in a
metropolitan county populating 1.2 million residents, and the second site was in a smaller
county where 178,000 residents occupied.
Brigham et al.’s (2014) procedure involved participants registering as a set, which
included a concerned significant other (CSO) who was a willing participant (spouses,
relatives, or intimate partners), and an identified patient (IP) who was an opioid
dependent adult and had intentions of relocating from a buprenorphine-detoxification
program to outpatient. Next, by using urn randomization balanced on site (1 or 2), race
(Black or other), and CSO type (parent or other), participants were either randomized to
TAU (n = 24 couples) or CRAFT-T (n = 28 couples). During the 14 week treatment
phase, IPs received 2 weekly research assessment visits and CSOs received 12. Research
visits continued for 38 weeks for IPs and CSOs at weeks 14, 26, and 38. Follow- up
visits were conducted at 6 and 9 months post-treatment.
For the CSOs, TAU was
mainly educational and offered a referral to self-help (Nar-Anon or Al-Anon). For the
IPs, the SUD program in which they were admitted is where they received treatment as
usual. The primary outcome measure consisted of the number of days until the IPs first
45
decline of 30 or more days from all treatment. The secondary outcomes comprised days
of any drug use or opioid usage.
Brigham et al. (2014) used a timeline follow-back (TLFB) procedure (Brigham et
al., 2014), collection of urine samples, the Redi Test rapid screen system, and the
Structured Clinical Interview for DSM-IV (Brigham et al., 2014). The TLFB procedure
documented the IPs day to day usage of benzodiazepines, cocaine, alcohol,
methamphetamine, opioids, and other illicit drugs. During research visits of weeks 1, 2,
14, 26, and 38, the IPs provided a urine sample, which was next examined by using the
Redi Test rapid screen system for benzodiazepines, cocaine, methamphetamine, opioids,
and marijuana. In order to diagnose participants as opioid dependent, the Structured
Clinical Interview for DSM-IV was administered.
Results for the CRAFT-T intervention participants evinced a non-significant, but
fair (Brigham et al., 2014) effect on retention to treatment ( p = .058, hazard ratio = 0.57)
revealing that they were 57% as inclined to dropout at any point of the trial as their TAU
counterparts. When CSOs were parental-family, the CRAFT-T participants displayed a
lengthier time to drop out of the trial ( p < 0.01, hazard ration = 0.40). Further,
participants assigned to the CRAFT-T intervention showed significant declines shown on
the TLFB of opioid and drug use days. Overall, however, the rates of drug usage and
relapse were high. Follow- up rates were rather low, so it is recommended the study’s
outcomes be read with discretion. Finally, CRAFT-T reported a significant positive
effect on IP drug and opioid use (p < 0.0001).
There were a number of strengths pertaining to Brigham et al.’s (2014) study,
including a manual-guided treatment, the ITT randomized trial design, and primary
46
outcome measures reporting no data that was missing. Limitations involve loss of
generalizability due to the size of the sample being low, both therapist effects and CSO
relationship type unable to be assessed because of lack of power, and likelihood of effect
size estimates being distorted.
Brigham et al.’s (2014) findings indicate that the CRAFT-T intervention shows
potential for increasing drug use outcomes and treatment retention in adults diagnosed
with an opioid use disorder.
Effects of CM on SUM
Findings from three studies assessed the effectiveness of CM in different
populations, but with the same drug of abuse: cocaine. Contingency management (CM)
has been shown to be extremely compelling in improving drug abstinence and treatment
retention (Dutra et al., 2008).
In the first study, Garcia-Fernandez et al. (2013) examined primary or inducedbaseline symptoms of depression and whether or not they affected CM’s efficacy among
outpatients who were cocaine dependent over a span of 6 months. The authors’
hypothesis was twofold; suggesting one, that outpatients who were cocaine dependent
and experienced symptoms of depression would have inferior treatment outcomes than
patients without concomitant depressive symptomatology; and two, patients enduring
symptoms of depression would bear improved treatment outcomes with the CM
intervention than without the CM intervention. The CM intervention could be a
beneficial alternative for these patients who were cocaine dependent.
Garcia-Fernandez et al.’s (2013) sample included 108 adults who were cocaine
dependent and searching for outpatient treatment located at one of two community clinics
47
in Spain. Both clinics’ populations were similar, comprising cocaine-dependent adults
who were seeking outpatient treatment, data collection schedules, and methods of
recruitment. Also, both clinics included Community Reinforcement Approach (CRA)
vouchers and outpatient treatment and measures.
During intake appointments, the initial assessment was performed in agreement
with the original layout of the CRA-plus-vouchers program (Garcia-Fernandez et al.,
2013). Participants also replied to the following assessments: the psychoactive
substance abuse DSM-IV checklist , the European version of the Addiction Severity
Index, the EuropASI, the Beck Depression Inventory (BDI), and the Quickscreen Test by
the Perfelena Company (Garcia-Fernandez et al., 2013). The latter is a chromatographic
immunoassay that very quickly identifies whether or not a person used cocaine (GarciaFernandez et al., 2013).
Garcia-Fernandez et al. (2013) conducted the CRA corresponding to the original
manual, but with one distinction: at one of the facilities, in order to cut down on
expenses, a majority of CRA therapy components were executed in group sessions. The
approach was made up of five parts: lifestyle change, other substance abuse, drug
avoidance skills, relationship counseling, and other psychiatric problems. Moreover,
twice per week, from week 1 to week 25, urine samples were obtained. Urinalysis results
were given instantly after samples were provided, but there was no form of enticement
for remaining abstinent. The CRA-plus-vouchers’ condition used the same procedure as
in the CRA condition, but with the inclusion of a CM program (a vouchers program). In
agreement with the original setup, urine samples were gathered three times per week
corresponding to weeks 1 through 12 and for weeks 13 through 24, urine samples were
48
obtained twice per week. It was essential to alter the original protocol, so as to conform
to the aspects of the setting at one of the clinics. These alterations included collecting
only two urine specimens during weeks 1 through 12 instead of three. During weeks 1
through 12, if a urine sample tested negative for benzoylecgonine, the participant earned
points. For weeks 13 through 24, points were only earned for 50% of the randomly
chosen negative-for-benzoylecgonine samples. Participants had the opportunity to obtain
an assortment of merchandise or supplies that are consistent with a drug free lifestyle,
which the therapist had to authorize and presumed to be in agreement with individual
treatment goals.
Garcia-Fernandez et al.’s (2013) primary outcome variables were cocaine
abstinence and treatment retention. A period of extended cocaine abstinence was
described as the greatest amount of time a participant was abstinent in the course of the 6
months of treatment. If urine specimens were missing, they were assumed to be positive.
For the time participants were receiving treatment, the mean proportion of cocaine
negative samples were also examined, along with the percentage of participants abstinent
at 6 months of treatment. Retention was examined in connection to the percentage of
participants maintained during the 6 months of treatment and mean number of weeks
maintained during the same time span.
Garcia-Fernandez et al. (2013) found that patients with baseline depressive
symptoms were more inclined than patients with no baseline depressive symptoms to be
unemployed, female, and to have greater ASI Drugs, Psychiatric, and Family/Social
composite scores.
49
The study’s findings endorse three major conclusions; however, the extent of
these results is limited by the difficulty of classifying the symptoms of depression as
either primary or substance induced. First, outpatients who were cocaine dependent and
possessed baseline depressive symptoms had poorer treatment outcomes despite
treatment condition. Second, disregarding baseline depressive symptoms, adding CM to
CRA was more effective than CRA alone. Third, predictors of abstinence treatment
outcomes involve symptoms of depression and condition of treatment, while predictors of
treatment retention consist of the association of depression symptoms with employment
status (Garcia-Fernandez et al., 2013).
Due to the study’s limitations, Garcia-Fernandez et al.’s (2013) results should be
interpreted with caution. First, discovering statistically significant outcomes in some of
the statistical analyses was challenging due to the small sample size. Second, diagnostic
interviews were not used to examine depression or to classify the symptoms as
attributable to either a formal Axis I mood disorder or to acute cocaine cessation.
Finally, the sample being comprised of two community based clinics may be a limitation
as well.
The results of the study are applicable to routine care and naturalistic settings,
which, in turn, increases the study’s external validity. Additionally, the generalizability
of findings are bolstered by randomly selecting participants across all conditions of
treatment and by baseline depressive symptoms possessing a high rate of prevalence
(31.48%) (Garcia-Fernandez et al., 2013).
In the second study, Petry and colleagues (2013) wanted to assess CM’s efficacy
in patients with severe and significant mental illnesses, since there is insufficient data
50
indicating its promising usefulness for this population. Hence, the purpose of Petry and
colleagues’ study was to examine the effectiveness of CM for lessening the use of
cocaine in patients who were comorbid for drug use and other mental illnesses residing at
a community health center. The authors’ aim was to test the hypothesis that CM would
lessen the use of cocaine, along with psychiatric symptoms.
Petry et al.’s (2013) sample was comprised of 19 patients averaging 41.7 + 9.3
years of age who were cocaine dependent and obtaining treatment from an outpatient
mental health clinic. The patients also possessed lengthy histories of hospitalizations and
issues related to their mental health. Patients were primarily diagnosed with major
recurrent depression (with or without psychotic features) (47.4%), bipolar disorder
(36.8%), and schizophrenia/schizoaffective disorder for 15.8%. Documented inpatient
hospitalizations averaged 6.3 + 11.3 for psychiatric disorders and 63.2% were obtaining
disability payments for psychiatric issues. As well as cocaine dependent (100%), 36.8%
were dependent on alcohol, 15.8% were marijuana dependent, and 57.9% were dependent
on opioids and obtaining buprenorphine/naloxone or methadone maintenance. There was
no difference on any baseline characteristics between the two groups.
Petry et al. (2013) employed three measurements: the Structured Clinical
Interview for the DSM-IV (SCID-I), the Brief Symptom Inventory (BSI), and the Global
Severity Index (GSI). The SCID-I is a semistructured interview divided into separate
modules that are equivalent to the classifications of major DSM-IV Axis 1 diagnoses
(USDVA, 2016).The BSI assesses the asperity of past week psychiatric symptoms on a 5
point scale, and the GSI averages the severity of symptoms overall with a score of 0 to 4.
A mean of 0.30 (SD = 0.31) is considered healthy in controls.
51
Prior to beginning treatment, Petry and colleagues (2013) administered parts of
the SCID-I and the BSI to all patients to evaluate the severity of their psychiatric
problems. Next, 19 patients with cocaine dependency, as well as hospitalizations and
issues pertaining to mental health, were randomized to either 8 weeks of standard care or
standard care plus CM following the baseline assessment. Standard care consisted of
group and individual based psychiatric treatment and treatment for substance use,
however, not all patients chose to participate in the substance use treatment. Also,
patients provided urine specimens every Tuesday and Friday, which were examined for
cocaine employing iCup (Petry et al., 2013). A $1 item (e.g., gift card, token) was
awarded to patients each time a negative urine sample was provided. Standard care plus
CM consisted of the same standard care as above, but a $1 item was awarded, despite the
results. In addition, these patients earned the opportunity to receive prizes for every
cocaine sample that was negative by drawing from an urn. For each successive negative
specimen, the number of draws rose by one. For example, a patient earned the chance to
draw twice for the second successive negative sample, three times for the third, etc.,
reaching an eight draw max. Following the 8-week trial, researchers administered the
BSI to assess the severity of psychiatric symptoms after receiving treatment.
Petry and colleagues (2013) reported many benefits of CM in terms of promoting
cocaine abstinence. First, patients assigned to the CM condition demonstrated large
effect sizes on some of the drug use indices. Regardless of condition, 60% of provided
samples tested negative for cocaine use. On the other hand, when taking into
consideration expected samples, patients assigned to the CM condition submitted
significantly larger proportions of negative cocaine samples and attained longer periods
52
of abstinence versus standard care. Effect sizes were substantial, surpassing 1 (d = 1.17
for proportion of expected negative samples and d = 1.35 for longest consecutive weeks
of abstinence). Six negative cocaine samples indicated a good treatment response in 70%
of patients assigned to the CM condition compared to 11% randomized to standard care.
There was also a decrease in psychiatric symptoms in CM over time versus standard care
as reported on the BSI. As well as primary effects, these results demonstrate the
secondary effects of CM (Petry et al., 2013).
The study had its share of noteworthy limitations. The size of the sample was
small with only 19 patients, and the effects over the long term were not assessed. The
intervention lasted for only 8 weeks, so whether or not effects could be retained for a
longer duration absent reinforcement cannot be determined. Likewise, there was
inconsistency when dealing with missing samples. Not including missing samples in the
denominator produces a finding of no evident group differences, and when they are
included, the advantages of CM become noticeable. These findings are inconsistent
contingent on where the missing data is located and emphasize the need to acquire
extreme rates of sample submission in order to precisely measure the influence of
interventions on drug use (Petry et al., 2013).
Regardless of limitations, this randomized study is one of the few assessing the
effectiveness of CM for lessening drug use in a psychiatric population. Along with
reducing psychiatric symptoms, CM may have a spill-over effect into the economic costs
of mental health services. The advantages can be attained at reasonably low costs, which
could eventually increase distribution of CM in this unique population (Petry et al.,
2013).
53
In the third study on CM, Weiss and Petry (2014) directed a retrospective analysis
of a randomized controlled study with the purpose of assessing the correlation between
early onset cocaine use and psychosocial difficulties and cocaine dependent patients’
response to treatment. The authors set out to test the hypothesis that the earlier onset of
using cocaine would be associated with more severe psychopathology, modest response
to treatment, and legal issues. Likewise and for the first time, Weiss and Petry (2014)
evaluated whether or not CM would enhance outcomes in patients with early onset
cocaine usage. Their sample consisted of 41 patients who described using cocaine for the
first time at age 14 or younger and 387 patients who released using cocaine for the first
time after age 14.
Weiss and Petry’s (2014) procedure involved research assistants administering
interviews that contained demographic questionnaires, the Addiction Severity Index
(ASI) and drug dependence checklists obtained from the Structured Clinical Interview for
the DSM-IV (SCID-I). They used feedback from specific parts of the ASI to classify
particular difficulties for indices that contradicted between early and later onset subjects
(Weiss & Petry, 2014). A computerized urn randomization program to elect patients to
either a CM treatment condition or standard care was performed. The CM intervention
provided the opportunity to obtain prizes extending from $1 to $100.
They equalized treatment groups on baseline urine toxicology results, gender,
clinic, and uninterrupted relocation from inpatient detoxification assistance or not.
Standard care was received by all patients in both conditions and consisted of group
therapy relevant to relapse prevention, skills training, 12 step therapy, and AIDS
education. Patients were eligible for 6 weeks of intensive care extending to 4 hours per
54
day and 5 days per week. Afterwards, severity of care was cutback to one group per
week. Along with standard care, participants were required to present 21 breath and
urine samples extending a span of 12 weeks. This tapering schedule modeled declines in
clinical care over the long term. After the collection of urine samples, they were
analyzed for opioids and cocaine by administering the OnTrakTesTstiks (Weiss & Petry,
2014). Breath samples were scanned for alcohol utilizing an Intoximeter Breathalyzer
(Weiss & Petry 2014). Patients were congratulated when their results came back
negative for all three substances: opioids, cocaine, and alcohol. When results were
negative, research assistants recommended that patients talk about their use with a
member of the clinical staff. Patients allocated to the CM condition were awarded the
opportunity to select from a bowl and earn prizes varying from $1 to $100 for submitting
negative drug samples or frequenting treatment.
Weiss and Petry (2014) found that the treatment condition, in which one was
assigned, displayed a signification correlation with longest days of abstinence
accomplished (LDA), F(1, 420) = 14.58, p < .001 and patients receiving CM attained
significantly greater spans of abstinence compared to patients receiving standard care.
On average, patients receiving CM attained 5.0 + 0.4 weeks of uninterrupted abstinence
compared to 3.4 + 0.3 weeks for patients receiving standard care. A significant
association regarding the demographic, race, was reported regarding percent negative
specimens collected, F(2, 420) = 6.00, p < .01. Typically, African Americans presented
71.4% + 2.4 negative specimens compared to 82.7% + 2.4 for Whites and 80.5% + 3.9
for Hispanic Americans (Weiss & Petry, 2014).
55
Weiss and Petry (2014) found that age when starting use of cocaine was
significantly correlated with longest period of abstinence obtained, F(1, 420) = 14.58, p <
.001, and treatment meetings attended, F(1, 420) = 14.58, p <.001, however, percentage
of negative specimens collected was not, p > .30. Lastly, the interaction among age of
onset of cocaine usage and treatment condition was not significant, p > .58.
The main limitation of Weiss and Petry’s (2014) analysis was the fact that it was
restrospective. In order to report key data that is unbiased, it needs to be able to be
measured, which is difficult since reliance is on the participant to report accurate
information could result in measurement error. Also, power to detect between group
differences may have been limited due to a comparatively small number of patients
releasing their introduction to cocaine use before age 14. Furthermore, not all psychiatric
diagnoses were evaluated and the information attained regarding sexual abuse histories
was not comprehensive, lacking the type of sexual abuse experienced.
There were several strengths pertaining to Weiss and Petry’s (2014) study, which
involved the random assignment of patients to treatment conditions, an intent-to-treat
analysis was used, and various objective measures were determined longitudinally. In
addition, the large group of participants was selected from four community based
treatment sites producing a rather diverse sample both racially and ethnically, In turn,
generalizability of findings was expanded.
Effects of MI on SUM
Two studies examined the effectiveness of Motivational Interviewing in reducing
substance use among adults. The purpose of the first study was to assess MI’s efficacy as
an additive to typical outpatient care for patients experiencing depression (Satre et al.,
56
2013). The authors hypothesized that MI would decrease hazardous drinking and
possibly lessen depression and drug use. Also, the authors expected that depression
outcomes could possibly become better for participants receiving the MI intervention if
decreased substance use contributes to enhancement in effectiveness of depression
treatment. Therefore, at follow-up, Satre and colleagues (2013) assessed the differences
between treatment groups in symptoms of depression experienced. Likewise, declines in
hazardous drinking as a possible mediator of depression symptom decline was monitored.
Lastly, predictors of hazardous drinking at 6 months, along with baseline hazardous
drinking prevalence, severity of depression, and factors related to demographics was
assessed. The authors expected that findings would present initial documentation for the
significance of MI, including effect size estimates, and contribute to the advancement of
larger randomized controlled studies of MI with this critical population.
Satre et al.’s (2013) sample was comprised of 104 adults ages 18 and over who
revealed hazardous drinking (three or more drinks per event), scored >15 on the Beck
Depression Inventory –II (BDI-II), and disclosed misuse of prescription drugs or illegal
drug use in 30 days prior. The mean age of the sample was 42.4 (SD = 13.7) years and
64.4% were female. In regards to the BDI-II, the mean score was 24.7 (SD=10.4), which
is compatible with a major depressive disorder diagnosis (Satre et al., 2013). Cannabis
consumption and hazardous drinking were the most commonly reported drug uses.
They examined medical records to obtain demographic information and findings
of a computerized assessment battery (Satre et al., 2013), questions pertaining to drugs
and alcohol included type of substance (hallucinogens, cocaine, inhalants, cannabis,
amphetamine-type stimulants, opioids other than prescribed, sedatives other than
57
prescribed, methadone or heroin, tobacco, alcohol and other), the cannabis readiness ruler
and alcohol readiness ruler to measure readiness to change, the Beck Depression
Inventory-II (BDI-II), and computerized administrative records for gathering data on
usual care patients.
Satre et al.’s (2013) procedure involved participants randomized to receive either
3 sessions of MI or printed literature regarding the risks of drug and alcohol use, along
with usual outpatient depression care, and completed follow-up telephone interviews at 3
and 6 months. The MI intervention consisted of one 45 minute in-person session
succeeded by two 15 minute telephone “booster” sessions. Participants allocated to the
control group were given two-page brochures regarding substance use and risks unique to
the substances they disclosed from the study therapist during a brief (<5 minutes)
meeting. All participants underwent usual depression care that was established on
present best practices for medication management and individual and group
psychotherapy that was empirically supported. Lastly, follow-up measures were
conducted by telephone 3 and 6 months following enrollment. They consisted of 20
minute interviews administered by a research assistant (Satre et al., 2013).
At the 3-month telephone follow-up, 98 (93%) of the 104 enlisted participants
completed the assessment, and at the 6 month follow-up, 103 (99%) of the participants
completed the assessment. Seventy-three of the enrolled participants revealed three or
more days of drinking at baseline. Differences between the two treatment groups were
examined for these 73 participants. The authors found that MI and control groups were
alike in sex, baseline depression score, age and readiness to modify alcohol use.
Additionally, at 3 months, participants allocated to the MI condition were discovered to
58
be significantly less likely than controls to reveal any hazardous drinking in the previous
30 days (60.0% vs. 81.8%, p = .043), however, no effect was discovered on the use of
cannabis or on the experience of depression symptoms. Furthermore, at 6 months, both
groups trended lower, and the differences between groups narrowed (to 58.3% in the MI
group and 72.2% in the control group), but was not significant (Satre et al., 2013).
This study possessed a number of limitations, including a comparatively small
sample size, reliance on self-report of substance use instead of biochemical verification, a
short-term follow up period, and inclusion of a heterogeneous sample of participants who
utilized both drugs and alcohol. Likewise, a single therapist administered all intervention
sessions, so it is not feasible to detach therapist effects from intervention effects. Also,
computerized clinic drug and alcohol measures were utilized to recognize which patients
to recruit. These measures made it possible for some patients to have underreported their
use and therefore, unable to be detected making the patients who were selected for
recruitment not representative of all patients with drug and hazardous drinking use in the
clinic (Satre et al., 2013).
Additionally, 38% of patients who were likely qualified refused to fill out study
screening measures, and results cannot be drawn concerning the possible MI treatment
effect on these patients who may have been less persuaded to consider or alter drug and
alcohol use than study recruits. Furthermore, the control group consisted of more
cannabis users, which may have influenced group comparisons, but the importance of this
lack of balance is unclear, since MI seemed to have no influence on decreasing the use of
cannabis. Also, while both cannabis and alcohol use were the focus of intervention, it is
feasible that users of cannabis were more dependent than alcohol users in the sample.
59
Lastly, persons who use cannabis and also experience depression may need additional
sessions of MI or other adjustments to treatment in order to profit (Satre et al., 2013).
Although the number of limitations is great, Satre et al.’s (2013) study had its
share of strengths. First and foremost, this study was well-controlled with exceedingly
great follow-up rates. The authors regulated for the kind of clinic that participants
obtained usual care services in their randomization, and evaluated other factors of care.
Second, the study was administered in the framework of an outpatient treatment center
for depression. Third, the intervention was checked for fidelity utilizing the Motivational
Interviewing Treatment Integrity (MITI) code (Satre et al., 2013) and recorded therapist
training sessions along with current sessions with participants.
Next, Parsons and colleagues (2014) aimed to explore MI’s effectiveness among
young gay and bisexual men (YGBM) who are HIV-negative and use substances, so they
carried out a randomized controlled trial (RCT) that was intended to decrease both
unprotected anal intercourse (UAI) and substance use among YGBM who were not
looking for treatment. They applied a short MI intervention, that if found effective, could
easily be approved by direct service providers and conducted within community or clinic
settings. The authors set out to test the hypothesis that persons allocated to the MI
condition would reveal greater declines in UAI and substance use over a period of time
than their counterparts receiving content-matched education.
The sample was comprised of 143 YGBM between the ages of 18 and 29 who
were not seeking treatment and who revealed a negative or unknown HIV status.
Participants had to have reported engaging in unprotected anal intercourse (UAI) with a
male partner who was high risk (i.e., a casual partner of any HIV status, or a main partner
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whose HIV status was positive or unknown) and engaged in drug use for at least five
days in the last 90 days. Geographically, participants informed living in 68 NYC zip
codes with no more than 3.5% of the sample residing in any one zip code.
After scheduling participants who were interested and eligible for a baseline
appointment, Parson and colleagues’ (2014) trained staff went over the informed consent
form and explained details regarding the study. Audio computer-assisted self-interview
(ACASI) software was used to complete an examination relating to the psychosocial
characteristics of the participants, which was part of the baseline assessment.
Additionally, participants completed an interviewer-administered timeline follow back
(TLFB) calendar of sexual behaviors and substance use for the past 30 days (Parsons et
al., 2014). Randomization took place utilizing urn randomization procedures following
the baseline assessment, and participants came back at 3, 6, 9, and 12 months for followup assessments, in which retention was high.
The two outcome variables of interest were number of days of drug use, and UAI
with a casual partner (overall and while under the influence of alcohol/drugs). Days of
drug use was measured by utilizing a 30 day TLFB. Previously, this instrument has
displayed good convergent validity, good test-retest reliability, and concurrence with
secondary reports for drug abuse, sexual behavior, and has formerly been employed with
GBM who used substances (Parsons et al., 2014).
Shortly after the baseline assessment, participants were randomized to either 4
sessions of MI or 4 sessions of content-matched education. Sessions lasted for one hour
and participants were given 3 months to complete all 4 sessions. The MI intervention
was devised to transfer information concerning the risk of UAI with casual male partners
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and club drugs, increase personal responsibility and motivation, and create goals for
decreasing target behaviors. The education intervention included the delivery of factual
material regarding lessening the sexual risk of HIV and use of club drugs. The
researchers portions of educational video that included approved messages concerning
the lessening of sexual risk of HIV, accurate data regarding the cognitive and physical
ramifications of club drugs, and documentation concerning the association between high
risk sex and club drug use (Parsons et al., 2014).
Parsons et al. (2014) discovered that there was no significant difference between
participants in MI or education in drug use overall, kind of drug use or total amount of
drugs used at baseline. However, a significant decline in substance use between and
within both conditions over a period of 12 months was found. Participants enrolled in the
MI condition lessened their average odds of ever using any drug by 67% during the 12
month follow up, whereas participants allocated to the educational intervention decreased
their use of drugs by roughly 50%. Likewise, declines in the chance of using drugs on
any day within both of the 30 day TLFB post-intervention follow-up times were
significantly better among YGBM enrolled in the MI intervention compared to YGBM
allocated to the education condition. Participants assigned to the MI condition were 18%
less inclined than their counterparts in the education condition to disclose use of drugs on
any day within follow-up.
Regarding participation in UAI, YGBM participants in both the MI and education
conditions decreased their time averaged odds of ever involving themselves in UAI
significantly. In addition, participants receiving the MI intervention were 24% less
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expected to reveal UAI on any given day of follow-up compared to the odds of YGBM
receiving content-matched education (Parsons et al., 2014).
Additionally, Parsons and colleagues (2014) found a significant correlation with
both drug use and randomized treatment intervention in the odds of participation in UAI
throughout quarterly measurement periods. With time and condition being held stable,
drug use raised the chances of a participant’s UAI by over 300%. Treatment
intervention, however, significantly moderated the correlation between sexual risk and
drug use. Compared to the odds of participants who were assigned to the educational
condition, participants receiving MI were less inclined (21%) to participate in UAI
whenever they engaged in sex with a casual partner, holding stable their drug use.
The study possessed many limitations. Regarding UAI, Parsons and colleagues
(2014) aimed their attention on the 30 day TLFB statistics, while the inclusion criteria
requested that self-reported UAI took place in the preceding 90 days. Only this span of
time was examined at a day level. No data on substance use and sexual behavior was
available for the 60 days prior to the 30 days. Likewise, since the day level examinations
only assessed the past 30 days, 18% of participants receiving MI and 14% of participants
receiving education did not mention the use of drugs in the past 30 days. Additionally, at
baseline, 18% of MI participants and 20% of education participants did not disclose use
of drugs in the past 30 days. As a result, declines in risk behavior may have been
minimized in the researchers’ analyses due to the inability to account for every
participants’ risk behavior. Furthermore, without statistics on cost effectiveness there is
no way of knowing if applying MI is more cost effective than education. Lastly,
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inaccurate statistics could have been produced, since results were established on selfreport.
64
Discussion
Drug use poses serious physical, psychological, and social problems in the US
(United States Department of Health and Human Services, 2013), and it is evident that
effective treatment and prevention is of paramount importance. Results from these
randomized clinical trials of various treatment approaches support the efficacy of
reducing substance use among individuals with substance related disorders. Due to the
majority of the studies’ participants having co-occurring psychiatric disorders,
interventions were aimed at improving psychiatric conditions along with substance use.
Improvement in psychiatric disorders was also established. Each intervention applied
consisted of a behavioral component, which was essential to its overall effectiveness.
There are strengths and weaknesses to each approach discussed in this review.
Practitioners from the field view cognitive behavioral therapy views substance use as a
behavior that is learned, and through establishing and implementing new, healthy
behaviors, evidence suggests substance use will gradually decrease. Two out of the three
randomized controlled trials using a form of cognitive behavioral treatment indicated that
this intervention showed some type of improvement. In Carrol et al. (2014), the addition
of CBT4CBT improved drug and cocaine use outcomes in individuals dependent on
cocaine compared to using standard methadone maintenance treatment alone. The QOL
of Chinese, heroin-dependent individuals improved in Zhuang et al., (2013). However,
for individuals who were dependent on cannabis and receiving a combination of
contingency management and cognitive behavioral therapy, none of the 4 hypotheses
were supported, showing that enhancing either one of these interventions does not help
improve rates of success of cannabis treatment (Carroll et al., 2012). This is in contrast
65
to what Magill and Ray (2009) found in their meta-analysis of randomized controlled
trials, in which substantial effects were reported when CBT was added with another
psychosocial intervention.
Evidence suggests that CBT alone is an effective intervention in reducing
substance use among individuals who are drug dependent. However, it is difficult to
compare these studies due to design differences. The duration of each trial was different;
Zuang et al.’s (2013) trial ran for 6 months; Carroll et al.’s (2012) trial ran for 12 weeks,
and Carroll et al.’s (2014) ran for 8 weeks. Zhuang et al.’s sample consisted of a majority
of men (80%), as did the sample (84.3%) in Caroll et al.’s (2012) study. Two of the
studies comprised a relatively young sample with the average age of 25.7 years for
Carroll et al.’s (2012) and 32.32 years for Zhuang et al.’s (2013). Treatment retention
was high for the sample consisting of Chinese, heroin dependent individuals (no drop
outs) (Zhuang et al., 2013) compared to the cannabis dependent individuals, in which
participants remained in the study an average of 61 days (Carroll et al., 2012). Only 93
of the 101 individuals had begun the protocol in Carroll et al.’s trial (2014) and only 69
of the 93 completed the treatment protocol of 8 weeks. An overwhelming majority of all
three studys’ samples were unmarried, single, or divorced: 41.67% unmarried, and
28.33% divorced (Zhuang et al., 2013), 90.2% living alone (Carrol et al., 2012), and 88%
single or divorced (Carroll et al., 2014).
The statistics regarding marital status is of no surprise, since research reveals that
social support has been shown to help facilitate recovery, (Dobkin, De Civita,
Paraherakis, & Gill, 2002) and patients who are married are significantly more likely to
improve during and after treatment (Moos, Nichol, & Moos, 2002). Therefore, treatment
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for the single, unmarried, or divorced patient should include group therapy of a cognitive
behavioral nature and support of a community, such as 12 step support groups. These
groups provide the assurance of not being alone where sharing of life experiences
nurtures the emotional healing process (Dermatis & Galanter, 2016).
There are many reasons why the results of Witkiewitz et al.’s (2014) study should
be taken with caution. First, out of 105 women who began the trial, only a small number
(54) remained throughout the 15 week follow-up. Second, the trial was only for 8 weeks
in duration. Third, there was no control group, therefore, no baseline data to compare the
results to. I am not confident concluding that the findings obtained are representative of
this population. I would want the study replicated in several residential addiction
treatment centers with a larger sample size of women, the study lasting for a minimum of
6 months, and the trials consisting of a control group, so that there is data to compare the
findings to.
It is difficult to compare the Witkiewitz et al. (2014) study to the Bowen et al.,
(2014) study due to sampling and design contrasts, similar to the CBT studies.
Witkiewitz et al.’s (2014) trial consisted of all women, while the sample in Bowen et al.’s
(2014) study comprised 71.5% men. The majority of both studies were made up of
participants of non-hispanic white origin, and mean age for both ranged from 32.4 to 39.1
years. On the other hand, educational level was different for each study’s sample.
Within Witkiewitz et al.’s (2014) study most participants completed less than 12 years of
school and only 45.13% of Bowen et al.’s (2014) sample were high school graduates or
obtained their GED. There were 3 conditions (TAU, MBRP, RP) in Bowen et al.’s
(2014) trial compared to only 2 conditions (MBRP, RP) in Witkiewitz et al.’s (2014)
67
study. Participants were monitored for 12 months with 8 weekly sessions for each
condition and follow-ups at 3, 6, and 12 months (Bowen et al., 2014). The duration of
Witkiewitz and colleagues’ (2014) study was only 8 weeks with a follow-up assessment
15 weeks after treatment. Due to these integral differences between study samples, the
findings of each study should only be compared to studies involving similar populations.
Alternatively, both of the studies regarding ACT yielded findings that were
efficacious. Even though Luoma et al.’s (2012) trial targeted substance use disorders
indirectly by focusing on the emotion of shame, their application of ACT in a substance
use population resulted in an increase in treatment attendance, which lead to a decrease in
substance use.
Similarly, Gonzalez-Menendez et al., (2014) hypothesized that ACT would
improve the mental health of substance abusing, incarcerated females with co-occurring
disorders. Over time, there was an increase in abstinence along with a decrease in the
percentages of mental disorders. Also, both studies demonstrated the ACT intervention
as producing improvements over time. In Luoma et al. (2012), reductions in shame
occurred gradually; and in Gonzalez-Menendez et al., (2014) increases in abstinence
happened slowly.
Demographically, Gonzalez-Menendez et al.’s (2014) sample was comprised of
only female participants, while Luoma et al.’s (2012) consisted of 61 female and 72 male
participants. The mean age of participants was similar with the average age being 33.59
years (Gonzalez-Menendez et al., 2014) and 33.6 years (Luoma et al., 2012). An
overwhelming majority of participants within both trials were minorities; the GonzalezMenendez et al.,(2014) study took place in Spain with all participants being of Spanish
68
descent, and 86% of Luoma et al., (2012) participants identified as Caucasian, 14% as
non-Caucasians, and 13% as Hispanic. Lastly, all Luoma et al. (2012) participants
completed the 4 month follow-up and only 66.7% of ACT participants and 47.4% of CBT
participants in Gonzalez-Menendez et al.’s (2014) study completed all of the
assessments.
Even though I lack confidence in utilizing MBRP with substance using women
offenders (Witkiewitz, 2014), I am, however, certain that I would use ACT in a
population of drug dependent female inmates. Likewise, co-occurring disorders are
extremely common in individuals espousing substance use disorders, and ACT has been
shown to significantly reduce drug abuse, as well as minimize symptoms of mental
disorders (Gonzalez-Menendez, 2014).
Contingency management has been found to repeatedly illustrate effectiveness in
reducing substance use (Dutra et al., 2008). Three articles were previously discussed
regarding the application of CM to individuals who were cocaine dependent. The studies
varied on the number of participants enrolled in the randomized controlled trials. Petry et
al.’s study (2013) had the smallest number of participants (n = 19) overall, GarciaFernandez et al.’s (2013) included 108 participants, and Weiss et al., (2014) with the
largest number (n = 428). Petry et al., (2013) and Garcia-Fernandez et al. (2013) both
consisted of samples that were predominantly male (58%, 92.1%), as did Weiss et al.’s
(2014) sample (n = 52%). Mental health was a major factor in all three studies. Petry et
al.’s patients had considerable histories of psychiatric disorders with the leading
diagnosis being major recurrent depression (47.4%). Likewise, 100% of participants in
Garcia-Fernandez et al.’s (2013) trial experienced symptoms of depression either at
69
baseline or during treatment. Weiss and colleagues (2014) found that cocaine dependent
patients who initiated use of cocaine before age 14 had more psychiatric problems than if
they had started after the age of 14. A large percentage of patients in the GarciaFernandez et al. (2013) trial who scored a BDI > 21 were unemployed (45%) as were
patients in the Weiss et al. (2014) study (>50%).
Ethnicity was not reported for the Garcia-Fernandez et al. (2013) study, however,
68.4% of patients enrolled in the Petry et al. (2013) study were Caucasian, and 53% of
Weiss et al.’s (2014) participants were Caucasian. Since evidence suggests that drug use
and abuse varies with ethnicity (McCabe, Morales, Cranford, Delva, McPherson, &
Boyd, 2007), future studies should endeavor to recruit larger samples so as to make a
meaningful statistical comparison of ethnic groups with respect to effectiveness of
treatment.
A variation in ages was present in all trials. Petry et al. (2013) reported a mean of
41.7 + 9.3 years of age; Garcia-Fernandez et al.(2013) disclosed an average age of 31.4
years; and Weiss et al. (2014) documented a mean of 35.25 years of age. In addition,
treatment retention was greater among patients who experienced late onset depressive
symptoms and received CM as compared to standard care (Weiss et al., 2014). Six
months of continuous treatment attendance was achieved by 62.2 % of patients without
depressive symptoms and 41.2% of patients with depressive symptoms (GarciaFernandez et al., 2013).
Consequently, all three studies evinced effectiveness in treating patients with drug
dependent disorders. By the same token, the psychiatric problems all three studys’
participants experienced had greatly reduced by utilizing CM as the intervention.
70
In general terms, although it was not the aim of this review to examine the
behavioral neuroscience of SUDs, it is interesting that no articles reviewed in this work
considered the “bio” portion of the biopsychosocial model of behavior—the brain’s role
in addiction and the neurobiology of emotion regulation. Viewing addiction as a brain
disease would enhance interventions, which are already effective, but could also aid
clients with the symptoms associated with addiction. As scientific techniques become
more sophisticated, the role of the brain in SUDs will hopefully be elucidated.
From the research reviewed here, it appears that more studies should focus on
demographic factors as mediators of drug use and psychological treatment. The research
reviewed in this paper largely examined treatment for substance use disorders in minority
groups. Racial and ethnic minorities are often overrepresented in US cities where some
drugs are more prevalent and therefore abuse is more problematic (United States
Department of Health and Human Services, 2003). Future studies should employ
advanced analyses to determine specific demographic risk factors. Lastly, it is the hope of
this student that substance use clinicians refer clients to mental health professionals for
individual psychotherapy.
The studies reviewed in this paper focused on psychological disorders and the
treatment for SUDs among clients with various types of drugs used. It is possible that
what is an effective treatment for someone who uses one substance may not be an
effective treatment for someone who uses another, or for someone who abuses more than
one drug.
It is interesting to note that none of the articles reviewed in this paper mentioned
what the client’s needs are that are being met by using the substance, and further, how to
71
meet these needs in other ways. Helping your client become abstinent is only one part of
fixing the problem. The other part is the psychological problems, unresolved issues,
trauma sustained, life struggles, etc. that kept the addiction going. These do not simply
go away once the person becomes abstinent.
Limitations to the Present Paper
This review is limited in that it did not fully encompass all psychological
treatments for SUDs. As an example, I did not include articles concerning aspects of
spirituality and religiosity in treatment. Along these lines, I did not include evidence of
the effectiveness of adjunctive self-help strategies such as Alcoholics Anonymous (which
employs spirituality in recovery). The success rate of AA is hard to gauge, but
identifying and reviewing literature concerning its most promising components may
benefit individuals with SUDs (Kelly, 2003).
Another limitation to the current work is that I was able to examine articles
published only in English. International studies should be considered when gauging the
state of research on this topic.
Moreover, I reviewed experimental (randomized trial) data for the purposes of
this presentation. There is a body of correlational and case study evidence on
psychological treatments for SUDs that should be assessed to attempt to broaden one’s
understanding.
Clinical Implications
The evidence presented in this paper highlights the effectiveness of psychological
treatments for SUDs. However, a clinician must keep the various strengths and
weaknesses of each approach in mind.
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A critical issue a therapist may experience when working with SUD clients is
their resistance to treatment (McHugh et al., 2010). Providing empathy and support to
your client while guiding them through the change process allows the client to be in
control and view the clinician as a compassionate partner in the process.
Ethnic minorities were prevalent in samples of the studies I reviewed and can be a
substantial part of a therapist’s clientele. For this reason, it is important for a therapist to
provide culturally competent and sensitive treatment services. As a therapist, increasing
one’s knowledge and understanding of cultural differences is imperative.
73
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