Journal of Consulting and Clinical Psychology

Burns, John W.; Nielson, Warren R.; Jensen, Mark P.; Heapy, Alicia; Czlapinski, Rebecca; Kerns, Robert D.

doi: 10.1037/a0037208pmid: 24979313

Objective: Many studies document efficacy of cognitive behavioral therapy (CBT) for chronic pain, but few studies have examined potential treatment mechanisms. In analyses of data from a controlled trial, we examined whether changes in attitudes toward adopting a pain self-management approach—CBT-specific mechanisms—and quality of working alliance and patient expectations—general mechanisms—early in treatment were related to later-treatment changes in outcomes. Method: Our sample was composed of 94 adults (primarily White; mean age: 55.3 years, SD = 11.7; 23% female) who participated in enhanced or standard CBT, and completed measures of attitudes toward self-management (mechanisms), pain intensity, pain interference, depressive symptoms and goal accomplishment (outcomes) at pretreatment, 4- and 8-week assessments, and posttreatment. Working alliance was measured at 4 and 8 weeks, and patient expectations at 3 weeks. Results: Because the CBT conditions produced comparable improvements, we combined them. Precontemplation and action attitudes toward pain self-management showed significant quadratic trends over assessments such that 67% and 94.1% (respectively) of total pre–post changes occurred in the first 4 weeks. Outcomes showed only significant linear trends. Cross-lagged regressions revealed that pretreatment-to-4-week changes in action attitudes and 4-week levels of working alliance were related significantly with 4-week-to-posttreatment changes in pain intensity and interference but not vice versa and that 3-week patient expectations were related to 4-week-to-posttreatment changes in interference. Analyses in which mechanism factors were entered simultaneously revealed nonsignificant unique effects on outcomes. Conclusions: Adopting an action attitude early in treatment may represent a specific CBT mechanism but with effects held largely in common with 2 general mechanisms.

Lewis, Frances Marcus; Brandt, Patricia A.; Cochrane, Barbara B.; Griffith, Kristin A.; Grant, Marcia; Haase, Joan E.; Houldin, Arlene D.; Post-White, Janice; Zahlis, Ellen H.; Shands, Mary Ellen

doi: 10.1037/a0038219

Davis, Mary C.; Zautra, Alex J.; Wolf, Laurie D.; Tennen, Howard; Yeung, Ellen W.

doi: 10.1037/a0038200pmid: 25365778

Objective: This study compared the impact of cognitive–behavioral therapy for pain (CBT-P), mindful awareness and acceptance treatment (M), and arthritis education (E) on day-to-day pain- and stress-related changes in cognitions, symptoms, and affect among adults with rheumatoid arthritis (RA). Method: One hundred forty-three RA patients were randomized to 1 of the 3 treatment conditions. CBT-P targeted pain-coping skills; M targeted awareness and acceptance of current experience to enhance coping with a range of aversive experiences; E provided information regarding RA pain and its management. At pre- and posttreatment, participants completed 30 consecutive evening diaries assessing that day’s pain, fatigue, pain-related catastrophizing and perceived control, morning disability, and serene and anxious affects. Results: Multilevel models compared groups in the magnitude of within-person change in daily pain and stress reactivity from pre- to posttreatment. M yielded greater reductions than did CBT-P and E in daily pain-related catastrophizing, morning disability, and fatigue and greater reductions in daily stress-related anxious affect. CBT-P yielded less pronounced declines in daily pain-related perceived control than did M and E. Conclusions: For individuals with RA, M produces the broadest improvements in daily pain and stress reactivity relative to CBT-P and E. These findings also highlight the utility of a diary-based approach to evaluating the treatment-related changes in responses to daily life.

Reid, Allecia E.; Carey, Kate B.; Merrill, Jennifer E.; Carey, Michael P.

doi: 10.1037/a0037634pmid: 25111432

Objective: To determine whether (a) social networks influence the extent to which college students initiate and/or maintain reductions in drinking following an alcohol intervention and (b) students with riskier networks respond better to a counselor-delivered, vs. a computer-delivered, intervention. Method: Mandated students (N = 316; 63% male) provided their perceptions of peer network members’ drinking statuses (e.g., heavy drinker) and how accepting each friend would be if the participant reduced his or her drinking. Next, they were randomized to receive a brief motivational intervention (BMI) or Alcohol Edu for Sanctions (EDU). In latent growth models controlling for baseline levels on outcomes, influences of social networks on 2 phases of intervention response were examined: initiation of reductions in drinks per heaviest week, peak blood alcohol content (BAC), and consequences at 1 month (model intercepts) and maintenance of reductions between 1 and 12 months (model slopes). Results: Peer drinking status predicted initiation of reductions in drinks per heaviest week and peak BAC; peer acceptability predicted initial reductions in consequences. Peer Acceptability × Condition interactions were significant or marginal for all outcomes in the maintenance phase. In networks with higher perceived acceptability of decreasing use, BMI and EDU exhibited similar growth rates. In less accepting networks, growth rates were significantly steeper among EDU than BMI participants. For consumption outcomes, lower perceived peer acceptability predicted steeper rates of growth in drinking among EDU but not BMI participants. Conclusions: Understanding how social networks influence behavior change and how interventions mitigate their influence is important for optimizing efficacy of alcohol interventions.

Milby, Jesse B.; Conti, Kimberly; Wallace, Dennis; Mennemeyer, Stephen; Mrug, Sylvie; Schumacher, Joseph E.

doi: 10.1037/a0037960pmid: 25329491

Objective: We examined comorbid disorders’ prevalence, their impact on abstinence, and the impact of depressive symptoms on abstinence and of abstinence on depressive symptoms. Method: A randomized controlled trial’s data on outcomes from treating cocaine dependence were used. It compared abstinence-contingent housing and work to contingency management plus behavioral day treatment. Regardless of original trial arm assignment, groups of participants with no additional Axis I disorders (n = 87) and 1 or more additional Axis I disorders (n = 113) were compared for abstinence. Changes in depression symptoms, measured by the Beck Depression Inventory, were analyzed as a function of 4 cohorts of increased consecutive weeks abstinent. An autoregressive cross-lagged path model examined reciprocal relationships between depression and abstinence. Results: Most prevalent additional disorders were depressive disorders, followed by anxiety disorders. Additional disorders did not significantly affect abstinence. Cohorts with more abstinence were linearly related to lower depression symptoms. The cross-lagged model showed that longer abstinence predicted decreases in depressive symptoms at 6 months. However, depressive symptoms did not predict changes in abstinence. Conclusions: Our study adds to others that have found an effective treatment targeted at specific problems such as substance abuse, social anxiety disorder, and posttraumatic stress disorder that may have the side benefit of reducing depression. Additionally, we find that depression does not interfere with effective substance abuse treatment for cocaine dependency. This may be the 1st formal analysis comparing the ability of cocaine abstinence to predict future depressive symptoms versus depressive symptoms to predict future cocaine abstinence.

Borsari, Brian; Apodaca, Timothy R.; Jackson, Kristina M.; Mastroleo, Nadine R.; Magill, Molly; Barnett, Nancy P.; Carey, Kate B.

doi: 10.1037/a0037635pmid: 25111429

Objective: Each year, thousands of college students receive mandated intervention as a sanction for alcohol use or alcohol-related behavior. For these mandated students, brief motivational interventions (BMIs) are currently the most efficacious individual intervention. However, little is known about how the technical (therapist behaviors) and relational (e.g., global ratings of therapist empathy) components of BMIs influence client language as well as subsequent change in alcohol use and consequences. Method: This study used the Motivational Interviewing Skills Code (MISC 2.0; Miller, Moyers, Ernst, & Amrhein, 2003) to code BMI sessions from 2 randomized clinical trials that facilitated significant reductions in alcohol use (Study 1, n = 91) and alcohol-related consequences (Study 2, n = 158) in mandated students. Results: There were significant relationships among therapist behaviors, global scores, and client language both for and against change, yet there were no links between in-session client language and subsequent changes in alcohol use or problems. In contrast, relational aspects of motivational interviewing (MI; global ratings of therapist MI Spirit and client self-exploration) were most predictive of postsession alcohol use. Mediation models incorporating both technical and relational components revealed that higher levels of client self-exploration mediated the relationship between higher therapist ratings of MI Spirit and reduced drinking at follow-up. Conclusions: Findings highlight the importance of considering how both technical and relational components of MI may influence alcohol use in mandated college students and also suggest more exact analyses to better understand this complex relationship.

D’Amico, Elizabeth J.; Houck, Jon M.; Hunter, Sarah B.; Miles, Jeremy N. V.; Osilla, Karen Chan; Ewing, Brett A.

doi: 10.1037/a0038155pmid: 25365779

Objective: Little is known about what may distinguish effective and ineffective group interventions. Group motivational interviewing (MI) is a promising intervention for adolescent alcohol and other drug use; however, the mechanisms of change for group MI are unknown. One potential mechanism is change talk, which is client speech arguing for change. The present study describes the group process in adolescent group MI and effects of group-level change talk on individual alcohol and marijuana outcomes. Method: We analyzed 129 group session audio recordings from a randomized clinical trial of adolescent group MI. Sequential coding was performed with the Motivational Interviewing Skill Code (MISC) and the CASAA Application for Coding Treatment Interactions software application. Outcomes included past-month intentions, frequency, and consequences of alcohol and marijuana use; motivation to change; and positive expectancies. Results: Sequential analysis indicated that facilitator open-ended questions and reflections of change talk increased group change talk. Group change talk was then followed by more change talk. Multilevel models accounting for rolling group enrollment revealed group change talk was associated with decreased alcohol intentions, alcohol use, and heavy drinking 3 months later; group sustain talk was associated with decreased motivation to change, increased intentions to use marijuana, and increased positive alcohol and marijuana expectancies. Conclusions: Facilitator speech and peer responses each had effects on change and sustain talk in the group setting, which were then associated with individual changes. Selective reflection of change talk in adolescent group MI is suggested as a strategy to manage group dynamics and increase behavioral change.

Fredman, Steffany J.; Baucom, Donald H.; Boeding, Sara E.; Miklowitz, David J.

doi: 10.1037/a0037713pmid: 25198285

Objective: The “critical comments” dimension of the expressed emotion (EE) construct has been found to predict the illness course of patients with bipolar disorder, but less is known about the “emotional overinvolvement” component. The goal of this study was to evaluate whether relatives’ observed appropriate and inappropriate emotional involvement (intrusiveness, self-sacrifice, and distress about patients’ well-being) moderated the effectiveness of a family-based intervention for bipolar disorder. Method: 108 patients with bipolar disorder (mean age = 35.61 years, SD = 10.07; 57% female) and their relatives (62% spouses) from 2 clinical trials completed 10-min problem-solving interactions prior to being treated with pharmacotherapy plus family-based therapy (FBT) or brief psychoeducation (crisis management [CM]). Patients were interviewed every 3–6 months over 2 years to assess mood symptoms. Results: When relatives showed low levels of inappropriate self-sacrifice, CM and FBT were both associated with improvements in patients’ manic symptoms over 2 years. When relatives showed high levels, patients in CM became more manic over time, whereas patients in FBT became less manic. Group differences in mania trajectories were also observed at high levels of inappropriate emotional response but not at low. When relatives showed high levels of appropriate self-sacrifice, patients in both groups became less depressed. At low levels of appropriate self-sacrifice, patients in CM did not improve, whereas patients in FBT became less depressed. Conclusions: Future studies of bipolar disorder should consider the prognostic value of the amount and appropriateness of relatives’ emotional involvement with patients in addition to their critical behaviors.

Lee, Jason Y.; Harvey, Allison G.

doi: 10.1037/a0037911pmid: 25222800

Objective: To examine the extent to which patients recall the contents of therapy from 1 session to the next and to determine whether recall is associated with treatment outcome. Method: Thirty interepisode individuals with bipolar disorder and comorbid insomnia (ages 21–62 years, 56.7% women, 56.7% Caucasian) participated in a randomized controlled trial of psychotherapies. Patients received either cognitive behavior therapy for insomnia (CBTI–BP; n = 17) or psychoeducation (PE; n = 13). At the beginning of each weekly session, patients freely recalled as many therapy points (i.e., distinct ideas, principles, and experiences) as they could from their previous session. After each session, therapists recorded a list of all therapy points delivered. Treatment outcome was measured via the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index, Patient-Reported Outcome Measurement Info System—Sleep, and Quality of Life—Sleep (QOL–Sleep), administered pre- and posttreatment, and treatment evaluation questions administered posttreatment. Results: Patients recalled 19.6% to 36.9% of therapy points listed by therapists. Raw numbers of therapy points recalled were positively correlated with reductions in ISI scores and gains in QOL–Sleep and with most treatment evaluation questions. Percentages of therapy points recalled were positively correlated with gains in QOL–Sleep but with no other sleep outcome measures or any of the treatment evaluation questions. Patients in CBTI–BP recalled more therapy points than did those in PE but did not differ in the percentages of points recalled. Conclusions: Memory for therapy is poor. The amount of content recalled is positively associated with treatment outcome. Enhancing memory for therapy might play a key role in improving treatment outcome.

Baucom, Brian R.; Atkins, David C.; Rowe, Lorelei Simpson; Doss, Brian D.; Christensen, Andrew

doi: 10.1037/a0038005pmid: 25265544

Objective: Building on earlier work examining predictors of short- and moderate-term treatment response, demographic, intrapersonal, communication, and interpersonal variables were examined as predictors of clinically significant outcomes 5 years after couples completed 1 of 2 behaviorally based couple therapies. Method: One hundred and thirty-four couples were randomly assigned to Integrative Behavioral Couple Therapy (IBCT; Jacobson & Christensen, 1998) or Traditional Behavioral Couple Therapy (TBCT; Jacobson & Margolin, 1979) and followed for 5 years after treatment. Outcomes include clinically significant change categories of relationship satisfaction and marital status at 5-year follow-up. Optimal subsets of predictors were selected using an automated, bootstrapped selection procedure based on Bayesian information criterion. Results: Higher levels of commitment and being married for a longer period of time were associated with decreased likelihood of divorce or separation (odds ratio [OR] = 1.39, p = .004; OR = 0.91, p = .015). Being married for a longer period of time was also associated with increased likelihood of positive, clinically significant change (OR = 1.12, p = .029). Finally, higher levels of wife-desired closeness were associated with increased odds of positive, clinically significant change and decreased odds of divorce for moderately distressed, IBCT couples (OR = 1.16, p = .002; OR = 0.85, p = .007, respectively), whereas the opposite was true for moderately distressed, TBCT couples (OR = 0.77, p < .001; OR = 1.17, p = .002, respectively). Conclusions: Commitment-related variables are associated with clinically significant outcomes at 5-year follow-up as well as at termination and moderate-term follow-up.