Faculty Bibliography

Four million adults in the U.S. have co-occurring serious mental illness and a substance use disorder. Mutual aid can usefully complement treatment, but people with co-occurring disorders often encounter a lack of empathy and acceptance in traditional mutual aid groups. Double Trouble in Recovery (DTR) is a dual focus fellowship whose mission is to bring the benefits of mutual aid to persons with dual diagnoses. Three hundred and ten persons attending 24 DTR groups in New York City during 1998 were interviewed and followed-up for two years. A mediational model was specified and results across time were summarized with generalized estimating equations (GEE). Degree of DTR Affiliation (attendance and involvement) was significantly associated with Self-efficacy for Recovery and three quality of life measures: Leisure Time Activities, Feelings of Well-Being and Social Relationships. Self-efficacy fully mediated the effects of DTR Affiliation on Leisure Time and Feelings and partially mediated DTR's effect on Social Relationships. The association of DTR involvement with self-efficacy is consistent with the processes inherent in mutual aid, although the observational nature of these data preclude causal inference. To improve outcomes, clinicians should facilitate affiliation with dual focus groups among persons with dual diagnoses as part of a comprehensive treatment approach.

Problem drinking is of great concern for mothers, especially those who are HIV-infected. We compared background characteristics, co-occurring drug use, and physical and mental health functioning of urban HIV-infected and uninfected mothers with problem drinking who were raising adolescents. Mothers in both groups reported similarly high levels of lifetime and current alcohol and drug use and poor physical and mental health. Health outcomes for mothers with problem drinking do not appear to be exacerbated by HIV status. Implications for intervention efforts with mothers and their adolescent children are discussed.

This cross-sectional study reports the prevalence and correlates of posttraumatic stress disorder (PTSD) and chronic severe pain in psychiatric outpatients (n = 295), a sample that has not previously been examined for the co-occurrence of these two disorders. Nearly half the participants (46%) met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for PTSD; 40% reported chronic severe pain; and 24% had both disorders. We compared four groups of subjects who had either both disorders, PTSD only, chronic severe pain only, or neither disorder for variables previously found to be associated with both disorders or either disorder alone (e.g., psychiatric distress, substance use, stressful life events, physical/sexual abuse). Multiple pairwise comparisons indicated that persons with both disorders were significantly different from persons with neither disorder for all dependent variables and that they had greater physical and psychosocial stressors. Persons with either PTSD or chronic severe pain alone were more likely to have a chronic medical condition, higher ratings of psychiatric distress, and more stressful life events than persons with neither disorder. Mental health treatment providers should be aware of the potential for the co-occurrence of PTSD and chronic severe pain and of the many related factors in psychiatric outpatients.

In 2001, New York State enacted legislation to allow the provision of syringes by pharmacies and healthcare providers without prescription (ESAP, the Expanded Syringe Access Demonstration Program). A longitudinal study of IDUs (n=130) found that pre-ESAP, about half used only the safest source (needle exchange programs [NEPs]). Post-ESAP implementation, ESAP sources were initiated by 14%. Frequency of injection was related to ESAP use and those who used unsafe (or possibly unsafe) sources were as likely to use ESAP as those who had previously used only NEPs. The findings indicate that providing multiple sources of safe syringes for IDUs is necessary.

Adult substance users are known to have above average rates of Attention Deficit-Hyperactivity Disorder (ADHD), but the psychometric properties of self-report measures of ADHD symptoms for adult substance users are unknown. Subjects (206 adults with a DSM-IV substance abuse disorder) were administered the Conners Adult ADHD Rating Scales (CAARS) upon enrolling in outpatient treatment. A factor structure similar to that reported for other populations was obtained and internal consistency reliabilities for the subscales and the overall index were high. Compared with CAARS norms, substance users scored significantly above average on all subscales as well as on the overall index. The CAARS may prove useful for measuring ADHD symptomatology among substance users, but additional reliability and validity evidence is needed. The CAARS should not be used by itself to diagnose individuals for ADHD.

Evaluation research on vocational counseling in substance dependency treatment should distinguish between the effects of counselors and counseling methods on clients' employment outcomes. Three experimental designs permit investigation of possible confounds between these types of effects: (a) nested designs (each counselor delivers one counseling method so counselors are nested under methods), (b) crossed designs (each counselor delivers all counseling methods so counselors are crossed with methods), and (c) no-treatment control group designs (experimental group's counselors all deliver the same method). Each design is optimal for one stage of evaluation research. No-treatment control group designs are best for exploratory evaluations of new types of vocational counseling. Nested designs are best for outcome evaluations of different types of interventions. Crossed designs are best for (causal) process evaluations of counseling methods of demonstrated efficacy. Despite the importance of methodological issues and problems, vocational rehabilitation in substance dependency treatment has a greater need for stronger interventions than better evaluation designs.

This study examines sexual risk behaviors among 197 women mandated to substance abuse treatment in therapeutic communities. The women's risk behaviors after treatment are compared with their behaviors prior to treatment, and risk behaviors among those who completed treatment are compared with those who did not. The women had a high prevalence of sexual risk behaviors (i.e., multiple partners, unprotected sex, sex trade, not asking partners to use condoms, sex with injection drug users [IDUs]) and relationship violence and conflict before treatment and a significant decrease in unprotected sex, sex trade, sex with multiple partners, and relationship violence or conflict after treatment. Those who completed treatment were significantly less likely to participate in sex trade or have sex with IDUs and were more likely to have a new sexual partner and only one sexual partner after treatment as compared with those who did not complete treatment. The present study shows that therapeutic community treatment is associated with the reduction of sexual risk behaviors among female substance abusers mandated to treatment.

Better understanding of the diverse factors that predict alcoholism treatment outcomes is essential to improving treatment strategies. Patients accepted for treatment at a multimodality program were interviewed and followed-up at three months and one year after admission. The study tested a set of hypotheses relating to the effects on drinking outcomes of treatment modality, modality matching, treatment retention, aftercare, self-help group participation and patient attributes at admission. Drinking frequency diminished substantially between baseline and the two follow-ups. Outcomes for inpatient were better than for outpatient treatment in bivariate analysis, but outcomes for these modalities were equal after adjusting for the effect of patient-treatment mismatching. Aftercare treatment, time in treatment for outpatients, community 12-Step group participation, and several patient attributes such as motivation for change and psychiatric severity significantly predicted drinking outcomes at one or both follow-ups. Clinical implications of the results are discussed.

OBJECTIVE:To determine the psychometric properties of the Toronto Alexithymia Scale (TAS-20), an established self-report measure of alexithymia, for a substance user sample participating in a clinical trial of outpatient cognitive-behavioral therapies (N=230). METHODS:Confirmatory and exploratory factor analyses were used to determine the number and nature of the factors underlying the TAS-20 in a sample of substance users. Structural equation modeling was used to determine the predictive validity of the TAS-20. RESULTS:A factor structure comparable, but not identical, with TAS-20 psychometric results with other populations was found; alpha coefficients were .88 for the feelings factor, .62 for the external thinking factor, and .87 for the total score. Although, on average, the substance users did not appear to have elevated alexithymia scores compared with the undergraduate students, alexithymia predicted less treatment engagement, i.e., fewer sessions attended and weaker helping alliance. Alexithymia also predicted alcohol use outcomes but not drug use outcomes. The relation between alexithymia and drinking outcome was conditional on whether the patient was using solely alcohol at baseline. CONCLUSION/CONCLUSIONS:The TAS-20 has reasonably good psychometric properties in this sample, which might be improved by dropping several marginal questionnaire items. Alexithymia appears to attenuate substance abuse treatment engagement. More clinical and research experience with this construct and specific instrument in substance user samples is needed.

This study examines the association of risk and protective factors with substance use among 77 early adolescents (11-15 years old) with an HIV-infected parent who were interviewed in 2000-2001 in the South Bronx, a HIV high-prevalence area of New York City. The subjects were 49%female, 53% African American, and 30% Hispanic; mean age was 13 years old. A face-to-face interview was used to administer a battery of instruments representing community, family, peer, and resiliency factors. Forty percent reported ever using tobacco, alcohol or drugs; 71% were aware of their parent's HIV seropositivity. An age-adjusted path analytic model was constructed which showed: 1) family functioning predicted resiliency (a composite measure of psychological adjustment and personal competencies); 2)positive community factors and resiliency predicted less affiliation with deviant peers; and 3) poorer family functioning and affiliation with deviant peers predicted substance use. These results underscore the need for interventions that address social influence factors among vulnerable early adolescents with HIV-positive parents.