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.     

Treatment Populations,Services, and Outcomes for Cocaine and Crack-Cocaine Dependence

This paper analyzes demographic and other pretreatment characteristics, measures of treatment services received, and treatment outcomes of participantsin the National Treatment Improvement Evaluation Study (NTIES), a large-scale longitudinal study of substance abuse treatment (D. R. Gerstein et al., 1997; R. A. Johnson & D. R. Gerstein, 2000). The focus here is those treated primarily for cocaine powder or crack-cocaine dependence, compared with those in treatment for other substances, particularly heroin. Crack-dependent users tend to be female and black, older than primary marijuana or alcohol users but younger than those in treatment for heroin. Primary cocaine powder or crack users are likely to have entered treatment under pressure from the criminal justice system. After treatment there are substantial reductions in use of cocaine powder and crack, especially among participants with fewer prior treatment episodes and lower pretreatment intensity of use. Longer duration and intensity of treatment result in greater reductions in cocaine and crack use.     

The Struggle of Behavioral Therapists With Exposure: Self-Reported Practicability,Negative Beliefs,and Therapist Distress About Exposure-Based Interventions

Exposure-based interventions are a core ingredient of evidence-based cognitive-behavioral treatment (CBT) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). However, previous research has documented that exposure is rarely utilized in routine care, highlighting an ongoing lack of dissemination. The present study examined barriers for the dissemination of exposure from the perspective of behavioral psychotherapists working in outpatient routine care (N = 684). A postal survey assessed three categories of barriers: (a) practicability of exposure-based intervention in an outpatient private practice setting, (b) negative beliefs about exposure, and (c) therapist distress related to the use of exposure. In addition, self-reported competence to conduct exposure for different anxiety disorders, PTSD, and OCD was assessed. High rates of agreement were found for single barriers within each of the three categories (e.g., unpredictable time management, risk of uncompensated absence of the patient, risk of decompensation of the patient, superficial effectiveness, or exposure being very strenuous for the therapist). Separately, average agreement to each category negatively correlated with self-reported utilization of exposure to a moderate degree (-.35 ≤ r ≤ -.27). In a multiple regression model, only average agreement to barriers of practicability and negative beliefs were significantly associated with utilization rates. Findings illustrate that a multilevel approach targeting individual, practical, and systemic barriers is necessary to optimize the dissemination of exposure-based interventions. Dissemination efforts may therefore benefit from incorporating strategies such as modifying negative beliefs, adaptive stress management for therapists, or increasing practicability of exposure-based interventions.     

Violence Exposure and Sexual Risk Behaviors for African American Adolescent Girls: The Protective Role of Natural Mentorship and Organizational Religious Involvement

African American adolescent girls are at increased risk of being exposed to community violence and being diagnosed with a sexually transmitted infection. Fewer studies, however, have examined the protective roles of natural mentorship and organizational religious involvement as potential moderators that could lessen the effects of violence exposure on health risk behavior. Data from 273 African American ninth grade girls were used to test hypothesized independent and moderated‐moderation models. Results suggest that natural mentorship and religious involvement were protective for girls who reported at least one mentor and moderate to high levels of religious involvement. Our findings may be relevant for community stakeholders and organizations that directly interact with religious institutions and community programs that focus on outreach to African American adolescent girls.     

No Easy Answers: Avoiding Potential Pitfalls of De‐implementation

In 2012, the Centers for Disease Control and Prevention (CDC) began to de‐emphasize and de‐implement multiple evidence‐based HIV prevention practices that had been around for 20 years, thus changing the scope of implementation across the globe. The authors provide evidence how existing interventions (e.g., CDC HIV interventions) may influence implementation of interventions that came after the program was discontinued. De‐implementation is an ecological event that influences, and is influenced by, many parts of a system, for instance, implementation of one type of intervention may influence the implementation of other interventions (biomedical and/or behavioral) after a long‐running program is discontinued. Researchers and policy makers ought to consider how de‐implementation of behavioral interventions is influenced by biomedical interventions mass‐produced by companies with lobbying power. The scientific study of de‐implementation will be inadequate without consideration of the political climate that surrounds de‐implementation of certain types of interventions and the promotion of more‐profitable ones.     

When Is Seeking Safety Functional? Taking a Pragmatic Approach to Distinguishing Coping From Safety

Currently, most exposure-based treatments call for clinicians to assess for and remove all safety behaviors during exposure tasks. However, the notion that safety behaviors are detrimental across all scenarios has recently been challenged, and research regarding the effects of safety behaviors on exposure outcomes is limited and inconsistent. In clinical practice, classifying a strategy as a safety behavior can be a complex and challenging endeavor, particularly when distinguishing between harmful safety behaviors and helpful coping behaviors. We outline an approach that emphasizes the pragmatic truth criterion and uses functional outcomes to classify behaviors as serving either safety or coping functions. Our focus on doing what “works” simplifies decision-making for clinicians and maintains the focus of treatment on enhancing functioning. We propose a model for using functional outcomes to distinguish between safety and coping behaviors and illustrate our approach through case examples.     

The interplay between relationship effectiveness,life stress,and sleep: A prospective study

Research has shown that greater stress responses predict worse sleep and that the quality of one's current romantic relationship predicts one's sleep. Despite these established links, research has not examined connections between ongoing patterns of interpersonal experiences and competencies (relationship effectiveness) and stress exposure on sleep. Participants in the Minnesota Longitudinal Study of Risk and Adaptation (MLSRA) completed measures assessing relationship effectiveness and stress exposure at ages 23 and 32 years, as well as sleep quality/duration at age 37 years. Analyses demonstrate that relationship effectiveness at age 23 years positively predicts sleep quality—but not sleep duration—at age 37 years via reduced stress exposure at age 32 years. These findings highlight the effects of relationship effectiveness and stress exposure across early to middle adulthood on sleep.     

Inhibitory Learning for Anxiety-Related Disorders

This article reviews the articles in this issue that describe the strategies derived from the inhibitory learning model as applied to exposure therapy for anxiety disorders. The major principles of inhibitory learning are to create and strengthen nonthreat associations in memory (largely by engaging prefrontal cortical regions), and to effectively retrieve those nonthreat associations in the long term. Several case vignettes are provided that demonstrate how the principles of inhibitory learning (which include maximizing expectancy violations, limiting distraction, fear antagonistic actions, deepened extinction, elimination of safety behaviors, occasional reinforced extinction, increasing variability of exposures and offsetting reinstatement and context renewal effects) can be applied in clinical practice.     

Using Multiple Contexts and Retrieval Cues in Exposure-Based Therapy to Prevent Relapse in Anxiety Disorders

The benefits of exposure-based interventions for anxiety disorders are substantial but not stable for everyone, given that these interventions are often followed by relapse of symptoms. A body of research provides a background on how to add certain strategies in exposure-based therapy to prevent relapse in anxiety disorders. This review summarizes some of these strategies and provides clear-cut clinical implications. Studies that provide support for two types of strategies to prevent relapse have been reviewed—the use of multiple contexts and the use of retrieval cues. The use of multiple contexts reduces context and stimulus specificity of extinction learning during exposure, while the use of retrieval cues enhances memory (re)consolidation and retrieval after exposure. The described strategies to enhance the accessibility and therefore the retrievability of exposure-based learning to prevent relapse in anxiety disorders can be summarized as advice to conduct exposure under variable conditions. This way, the generalizability of what is learned during exposure to the patients’ daily life after treatment improves. Therefore, adding these strategies in the course of exposure-based treatment of anxiety disorders seems beneficial. However, future replications and translational studies are needed to verify ecological validity.     

Dropping Safety Aids and Maximizing Retrieval Cues: Two Keys to Optimizing Inhibitory Learning During Exposure Therapy

The inhibitory learning model of exposure therapy posits that clinical anxiety is most effectively treated when clinicians employ strategies that maximize the (a) violation of negative expectancies and (b) generalization of nonthreat associations. Translation of basic learning research to exposure therapy via this explanatory model underscores two keys to optimizing inhibitory learning during exposure: dropping safety aids and maximizing retrieval cues. Although topographically similar, safety aids and retrieval cues are functionally distinct as well as therapeutically incompatible. In the present article, we delineate safety aids and retrieval cues in the context of exposure therapy from an inhibitory learning perspective, providing illustrative case examples of how clinicians may address the two when treating patients with clinical anxiety.