Using Acceptance and Commitment Therapy During Methadone Dose Reduction: Rationale,Treatment Description,and a Case Report

Many clients who undergo methadone maintenance (MM) treatment for heroin and other opiate dependence prefer abstinence from methadone. Attempts at methadone detoxification are often unsuccessful, however, due to distressing physical as well as psychological symptoms. Outcomes from an MM client who voluntarily participated in an Acceptance and Commitment Therapy (ACT)–based methadone detoxification program are presented. The program consisted of a 1-month stabilization and 5-month gradual methadone dose reduction period, combined with weekly individual ACT sessions. Urine samples were collected twice weekly to assess for use of illicit drugs. The participant successfully completed the program and had favorable drug use outcomes during the course of treatment, and at the 1-month and 1-year follow-ups. Innovative behavior therapies, such as ACT, that focus on acceptance of the inevitable distress associated with opiate withdrawal may improve methadone detoxification outcomes.     

Acceptance and Commitment Therapy for a Heterogeneous Group of Treatment-Resistant Clients: A Treatment Development Study

Acceptance and commitment therapy (ACT) has been shown to have broad applicability to different diagnostic groups, and there are theoretical reasons to consider its use with clients with chronic mental health problems. We report an innovative treatment development evaluation of ACT for a heterogeneous group of ”treatment-resistant clients” (N = 10) who had attended a mean of 3.5 previous psychological interventions. All clients had Axis I presentations and half met diagnostic criteria for Axis II disorders. Functioning, assessed at pre- and postintervention, and at 6- and 12-month follow-up, showed improvements over time on all primary outcome measures, driven largely by significant changes occurring between baseline and 6-month follow-up. Improvements were associated with ACT processes of change. The data thus suggest that a broad range of clients who had not benefited from standard care may benefit from ACT.     

Baseline Client Interpersonal Agency Moderates the Indirect Effect of Treatment on Long-term Worry in Variants of CBT for Generalized Anxiety Disorder

In a recent trial for generalized anxiety disorder (GAD), cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) promoted more long-term worry reduction than CBT alone (Westra, Constantino, & Antony, 2016). A follow-up analysis found that CBT vs. MI-CBT clients evidenced greater increases in friendly submissiveness (FS) across treatment, which in turn promoted lower long-term worry (Constantino, Romano, Coyne, Westra, & Antony, 2018). It was unsurprising that traditional directive CBT promoted more FS than when person-centered MI was integrated; however, given that problematic low agency characterizes GAD, that greater FS promoted better outcome was unexpected. To further unpack this unexpected result, we tested the following moderated mediation hypothesis: for clients with more vs. less problematic low agency at baseline, CBT would still promote more in-session FS than MI-CBT, but this increase would in turn predict increased worry over follow-up. Clients receiving CBT (n = 43) or MI-CBT (n = 42) rated their interpersonal problems at baseline and their worry after treatment and across 12-month follow-up. Therapists rated clients’ in-session FS multiple times. As predicted, multilevel modeling revealed that for clients with more problematic low agency, CBT vs. MI-CBT facilitated greater FS, which in turn related to increased worry across follow-up. For clients with more problematic high agency, CBT’s facilitation of greater FS related to reduced worry across follow-up. A baseline interpersonal problem characteristic of GAD may have implications for treatment matching and for appreciating different pathways to long-term improvement, or deterioration, for different GAD subgroups.     

Sleepiness and days of recovery

In the literature recovery after work is taken for granted – one has 16 h off between work bouts and one has 36 h off each weekend. However, the situation for those working irregular work hours may be quite different because of night work, long shifts, or long sequences of working days. Strictly speaking we don't have any scientific support for theories on how recovery days should be patterned. This paper, therefore, brings together data from a series of our own studies that involve irregular work hours, with the specific purpose of looking at the recovery process. The results show that for the average normal office week worker two days of recovery are normally sufficient. For those who work long shifts in long sequences three days are needed for normalization, whereas 12 h shifts in 2–3 day sequences seem not to cause accumulated fatigue. Interestingly, fatigue/sleepiness is often at its peak during the first day of recovery – not the last day of the working week. Air crew and oil rig workers take a longer time to recover, probably because of too much adjustment of the biological clock. As a rule, long haul air crew is usually much more fatigued than short haul crew during their days off, despite the fact that long haul flying is voluntary and opted for by those who fly it. Also train drivers are affected during their days off by their irregular work hours – in particular backwards rotating schedules seem to cause accumulation of fatigue. The results suggest that one day of recovery never is sufficient, two days usually is, whereas 3–4 days are necessary after periods of severely disturbed circadian rhythmicity.     

Treating Cockroach Phobia With Augmented Reality

In vivo exposure is the recommended treatment of choice for specific phobias; however, it demonstrates a high attrition rate and is not effective in all instances. The use of virtual reality (VR) has improved the acceptance of exposure treatments to some individuals. Augmented reality (AR) is a variation of VR wherein the user sees the real world augmented by virtual elements. The present study tests an AR system in the short (posttreatment) and long term (3, 6, and 12 months) for the treatment of cockroach phobia using a multiple baseline design across individuals (with 6 participants). The AR exposure therapy was applied using the “one-session treatment” guidelines developed by Öst, Salkovskis, and Hellström (1991). Results showed that AR was effective at treating cockroach phobia. All participants improved significantly in all outcome measures after treatment; furthermore, the treatment gains were maintained at 3, 6, and 12-month follow-up periods. This study discusses the advantages of AR as well as its potential applications.     

A cognitive cascade in infancy: Pathways from prematurity to later mental development

Using data from a longitudinal study of preterms and full-terms, the present study examined the structure of infant cognition at 12 months, the extent to which five 12-month abilities (attention, processing speed, recognition, recall, and representational competence) mediated the relation from prematurity to mental development at 2–3 years, and how continuity and change in infant information processing from 7 to 12 months affected later outcome. The results indicated that 12-month measures of infant information processing completely mediated the effect of prematurity on outcome and the infant measures form a ‘cognitive cascade’, similar to that seen at 7 months, in which the two more elementary abilities (attention and speed) influenced the more complex ones, which in turn influenced later cognition. Additionally, despite cross-age stability, 7-month assessments contribute to outcome independently of their 12-month counterparts, suggesting that infant abilities undergo important developmental transformations in the second half of the first year of life.     

Randomized Controlled Trial of Cognitive–Behavioral Group Therapy for Irritable Bowel Syndrome in a Medical Setting

Standard medical treatments have not been effective for irritable bowel syndrome (IBS) patients. Though individualized cognitive–behavior therapy is an empirically supported treatment option, cognitive–behavioral group therapy (CBGT) has yet to be established as an effective alternative in a randomized controlled trial. This study compared the efficacy of a 10-session CBGT with a home-based symptom monitoring with weekly telephone contact (SMTC) treatment for IBS, extending previous quasi-experimental research in this area. Twenty-eight refractory IBS patients, evaluated and referred by gastroenterologists using the Rome criteria, participated in the study. IBS symptoms, psychological functioning, and health-related quality of life were assessed pre- and posttreatment, and at 3-month follow-up. CBGT patients reported significantly more gastrointestinal (GI) symptom improvement than SMTC patients on posttreatment global measures and had significantly reduced daily diary pain scores at 3-month follow-up. Based on MANOVA, there was significant improvement in psychological distress and health-related quality of life for the CBGT patients in comparison to the SMTC patients. These improvements were also maintained at the 3-month follow-up. Reductions in GI symptoms, psychological distress, and improved health related quality of life may contribute to less behavioral avoidance, disability, and health care utilization in refractory IBS patients.     

Short versus longer term effectiveness of an outreach program for the homeless mentally Ill

Presents 12-month follow-up results from an outreach/linkage intervention with persons who are homeless and mentally ill, contrasting these with results obtained at 4 months. Both sets reflect the success of the program in placing individuals in independent housing. However, longer term data provide useful information regarding client movement patterns and increased tenure in nonhomeless living arrangements beyond the termination of specialized services. Analyses of 12-month residential outcomes identified four variables as significant predictors: recruitment source, project service duration, CMH service duration, and client age. In contrast to 4-month predictors, variables reflecting baseline client functioning were no longer significantly related to outcome, suggesting that the positive effects of the intervention may take longer to achieve with some clients. Discussion focuses on the implications of these effectiveness results for future research designs and measures as well as the utility and limitations of preexperimental approaches for evaluating innovative service models when implementation and efficacy experiences are lacking. This research was supported in part by a grant from the National Institute of Mental Health, #H87 MH44373, to the Michigan Department of Mental Health.     

Family therapy vs. parent groups: Effects on adolescent drug abusers

Abstract

The families of adolescent drug abuse clients who were admitted to six outpatient drug-free (OPDF) treatment programs were randomly assigned to either a family therapy method or a parent group method. It was later found that in 93% of the family therapy families, one or both parents participated (N=85); but that in only 67% of the families assigned to a parent group did one or both parents participate (N=50). This is considered to be an important practical advantage for family therapy. At follow-up evaluation 15 months later (after a 6-month course of treatment and a 9-month follow-up period), the clients and their mothers in both groups reported significant improvement on numerous outcome criteria, including reduction in substance use. There was no significant difference between the two groups in degree of improvement.     

Suicide Attempts within 12 Months of Treatment for Substance Use Disorders

There are limited prospective data on suicide attempts (SA) during the months following treatment for substance use disorders (SUD), a period of high risk. In an analysis of the Drug Abuse Treatment Outcomes Study, a longitudinal naturalistic multisite study of treated SUDs, variables associated with SA in the 12 months following SUD treatment were examined. Participants included 2,966 patients with one or more SUDs. By 12 months, 77 (2.6%) subjects had attempted suicide. Multivariate logistic regression analyses were used to identify variables associated with SA. Variables collected at baseline that were associated with SA included lifetime histories of SA, suicidal ideation (SI), depression, cocaine as primary substance of use, outpatient methadone treatment, and short‐term inpatient treatment. Male sex, older age, and minority race or ethnicity were associated with lower likelihood of SA. After controlling for baseline predictors, variables assessed at 12 months associated with SA included SI during follow‐up and daily or more use of cocaine. The data contribute to a small but growing literature of prospective studies of SA among treated SUDs, and suggest that SUDs with cocaine use disorders in particular should be a focus of prevention efforts.     

An acceptance-based behavioral intervention for weight loss: a pilot study

On average, participants in behavioral weight-loss interventions lose 8 kilograms (kg) at 6 months, but there is marked variability in outcomes with some participants losing little or no weight. Individuals with difficulties with internal disinhibition (i.e., eating in response to emotions or thoughts) typically lose less weight in such programs and may require an innovative, specialized approach. This pilot study examined the preliminary acceptability and efficacy of a 24-week acceptance-based behavioral intervention for weight loss among overweight and obese adults reporting difficulty with eating in response to emotions and thoughts. Participants were 21 overweight or obese men and women (mean age=52.2±7.6 years; baseline mean body mass index=32.8±3.4). Eighty-six percent completed the 6-month program and a 3-month follow-up assessment. Ratings of program satisfaction averaged 4.9 on a five-point scale. Multilevel modeling analyses indicated participants lost an average of 12.0 kg (SE=1.4) after 6 months of treatment and 12.1 kg (SE=1.9) at 3-month follow-up, thus exceeding the weight losses typically seen in behavioral treatment programs. Decreases in internal disinhibition and weight-related experiential avoidance were found at 6- and 3-months follow-up. Greater decreases in weight-related experiential avoidance were associated with greater weight loss at the end of the program (r=.64, p=.002), suggesting a potential mechanism of action. Although there have been a few preliminary studies using acceptance-based approaches for obesity, this is the first study to specifically target emotional overeaters, a subgroup that might be particularly responsive to this new approach. Our findings provide initial support for the feasibility, efficacy, and acceptability of this approach for this subgroup of participants. Further study with longer follow-up, a more diverse sample, and comparison to a standard behavioral program is clearly warranted.     

Clients in Treatment for Alcohol Problems: Treatment Experiencesand Outcomes

This report presents an analysis of National Treatment Improvement Evaluation Study data describing the characteristics and treatment experiences of clients entering treatment for alcohol problems. Three client groups were contrasted—those entering treatment for alcohol only, for alcohol plus other drugs, or for other drugs only. Clients using alcohol only were more often white, male, and currently employed. Alcohol only clients were treated predominantly in outpatient settings. Alcohol only clients were frequently referred to treatment by the criminal justice system, and less often self-referred. In all 3 study groups, employment, general health, and mental health outcomes were improved following treatment. Illicit drug use increased marginally for the alcohol only group following treatment. No significant posttreatment reductions in reports of total abstinencefrom alcohol were found for any of the groups. Findings are discussed as they relate to research, treatment practice, and policyareas.     

Social Studies and Ideological Beliefs in Mainland China and Hong Kong

Research in the West suggests that social science education enables students to become more liberal and less prejudiced in their outlook towards other people. This is the first study to test this thesis – the enlightenment thesis – in Chinese societies. Data were collected from 1,221 college students in Mainland China and 1,174 students in Hong Kong enrolled in a total of 29 institutions. The results show that though social science students showed significantly less interest in individualistic explanation and gender role traditionalism than other students, they did not gain from longer stays in college. These findings do not support the enlightenment thesis in Chinese societies. Instead, the findings that Mainland students favored nationalism significantly more and authoritarianism and individualist explanation significantly less than did Hong Kong students are consistent with the dominant ideology thesis.     

Comparative evaluation of the Job Club program with welfare recipients

About 1000 WIN welfare clients were selected in five cities: Harlem, New Brunswick, Milwaukee, Wichita, and Tacoma, and half were randomly assigned to the Job Club program. Of the continuing clients, 87% of the Job Club sample obtained jobs vs 59% of the Control sample at the 12-month follow-up and 80 vs 48% at 6 months. The Job Club was more effective in each of the five cities, for men and women, for high school graduates or dropouts, for blacks, whites, and Spanish, for handicapped or nonhandicapped, veterans or nonveterans, the young and the older, and for those required to participate as well as those who volunteered. The jobs obtained by the Job Club clients were comparable to the Control clients' jobs in terms of mean salary, full-time status, and type of job, and were more likely to be enduring, nonsubsidized, and obtained by the job-seeker's own efforts. Job Club members obtained employment in a median of six sessions (mean of 11); 90% obtained jobs within 23 sessions. Follow-up questionnaire data indicated comparable job retention in the two samples but slightly greater advancement and job satisfaction for the Job Club clients. The method appears to assure employment to virtually all participating welfare clients.     

The long-term evaluation of a behavioral treatment program for child molesters

Recidivism data derived from various sources over a follow-up period of 1–11 yr, provided the basis for appraising the effectiveness of a comprehensive cognitive-behavioral treatment program for familial and nonfamilial child molesters. Unofficial records held by police and Children's Aid Societies proved to be the best data for estimating recidivism. These data revealed increases in recidivism with longer follow-up periods, but there were consistent advantages for the treated over the untreated patients. Men who had sexually abused the daughters of other people demonstrated the clearest treatment benefits. The younger offenders and those who had engaged in genital-genital contact with their victims were more likely to reoffend even if they were treated. Contrary to the expectations of behavior therapists, indices of deviant sexual preferences did not predict outcome.     

Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse

Discontinuation of benzodiazepine (BZD) treatment for insomnia can be a difficult task. Cognitive-behavior therapy (CBT) for insomnia, combined with a supervised medication taper, can facilitate withdrawal but there is limited evidence on long-term outcome after discontinuation. The objective of this study was to examine medication-free survival time and predictors of relapse (i.e., resumed BZD hypnotics) over a 2-year period in 47 older adults (mean age 62.1 years) with persistent insomnia and prolonged BZD use (average duration of 18.9 years), who had successfully discontinued BZD following CBT for insomnia, a supervised medication taper program, or a combined approach. The Kaplan-Meier product-limit method was used to estimate survival time, defined as time between end-of-treatment and relapse or end of follow-up. By the end of the 24-month follow-up, 42.6% of the samples had resumed BZD use. Participants in the Combined (33.3%) and Taper (30.8%) groups relapsed significantly less than their counterparts from the CBT group (69.2%). Survival rates at 3 months were 61.5% (CBT), 100% (Taper), and 80.9% (Combined). At 12 months, they were 38.5%, 83.3%, and 70.8%, respectively; and, at 24 months, they were 28.9%, 64.8% and 64.9%, respectively. Mean survival time was significantly longer for both the Taper (18.6 months, SE = 2.1) and Combined groups (12.6 months, SE = 1.4), relative to the CBT group (8.5 months, SE = 1.8). Significant predictors of relapse included treatment condition, end of treatment insomnia severity, and psychological distress. In conclusion, there is a substantial relapse rate following BZD discontinuation among prolonged users. CBT booster sessions might enhance compliance with CBT and prove useful in preventing relapse.     

Treatment of obsessions: A randomized controlled trial

This study tested Rachman's cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT). Of the 73 adults who were randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treatments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and depression as well as improved social functioning. Overall, CBT and SMT showed large and similar reductions in symptoms. Pre-post effect sizes on YBOCS Obsessions for CBT and SMT completers was d = 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment.     

Family Centered Brief Intensive Treatment: A Pilot Study of an Outpatient Treatment for Acute Suicidal Ideation

Family Centered Brief Intensive Treatment (FC BIT), a hospital diversion treatment program for individuals with acute suicidal ideation, was developed to treat suicidal clients and their families. Individuals who met criteria for hospitalization were treated as outpatients using FC BIT (n = 19) or an intensive outpatient treatment without the family component (IOP; n = 24). Clients receiving FC BIT identified family members or supportive others to participate in therapy. FC BIT clients had significantly greater improvement at the end of treatment compared to IOP clients on measures of depression, hopelessness, and suicidality. Further research is needed to test the efficacy of FC BIT.     

The SNAP™ Under 12 Outreach Project: Effects of a Community Based Program for Children with Conduct Problems

We examined the immediate, short- and long-term effectiveness of the SNAP™ Under 12 Outreach Project (ORP)—a community-based program for children under the age of 12 at risk of having police contact. Sixteen pairs of children were matched on age, sex and severity of delinquency at admission, and randomly assigned to the ORP or to a control group which received less intensive treatment. Level of antisocial behavior was assessed pre and post intervention (immediate effects) and at three follow-up periods (up to 15 months post treatment) to investigate maintenance of possible treatment effects. A search of criminal records was also performed to assess long term effects. Results indicated that ORP children decreased significantly more than controls on the Delinquency and Aggression subscales of the Child Behavior Checklist pre- to post-intervention, and these effects were maintained over time. For statistically significant differences, effect sizes were large (.79 to 1.19). Fewer ORP children (31%) had criminal records at follow-up compared to controls (57%), although this difference was not statistically significant. Overall, the ORP appears to be an effective cognitive-behavioral program for antisocial children in the short term, with possible effects that extend into adolescence and adulthood.     

Interpretation bias in preschool children at risk for anxiety: a prospective study

A story-stem paradigm was used to assess interpretation bias in preschool children. Data were available for 131 children. Interpretation bias, behavioral inhibition (BI), and anxiety were assessed when children were aged between 3 years 2 months and 4 years 5 months. Anxiety was subsequently assessed 12 months, 2 years, and 5 years later. A significant difference in interpretation bias was found between participants who met criteria for an anxiety diagnosis at baseline, with clinically anxious participants more likely to complete the ambiguous story-stems in a threat-related way. Threat interpretations significantly predicted anxiety symptoms at 12-month follow-up, after controlling for baseline symptoms, but did not predict anxiety symptoms or diagnoses at either 2-year or 5-year follow-up. There was little evidence for a relationship between BI and interpretation bias. Overall, the pattern of results was not consistent with the hypothesis that interpretation bias plays a role in the development of anxiety. Instead, some evidence for a role in the maintenance of anxiety over relatively short periods of time was found. The use of a story-stem methodology to assess interpretation bias in young children is discussed along with the theoretical and clinical implications of the findings.