Faculty Bibliography

OBJECTIVE: Regular measurement of craving during treatment for cocaine dependence can monitor patients' clinical status and potentially assess their risk for drug use in the near future. Effective treatment can reduce the correlation between craving and subsequent drug use by helping patients abstain despite high craving. This study examined the relationship between cocaine craving, psychosocial treatment, and cocaine use in the ensuing week. METHOD: In the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, which compared four psychosocial treatments for cocaine dependence, a three-item craving questionnaire was administered weekly to 449 patients to see whether it predicted cocaine use in the ensuing week. Cocaine use was assessed with self-reports and urine screening. RESULTS: With control for the previous week's cocaine use, a higher composite score on the craving questionnaire was associated with greater likelihood of cocaine use in the subsequent week; each 1-point increase on the composite score of the craving questionnaire increased the likelihood of cocaine use in the ensuing week by 10%. However, among patients who received individual plus group drug counseling, the treatment condition with the best overall cocaine use outcome, increased craving scores were not associated with greater likelihood of cocaine use in the subsequent week. CONCLUSIONS: A three-item cocaine craving questionnaire predicted the relative likelihood of cocaine use during the subsequent week. Moreover, the relationship between craving and subsequent cocaine use varied by treatment condition, suggesting that the most effective treatment in the study might have weakened the link between craving and subsequent use.

Therapeutic alliance has been a robust predictor of therapy outcome, yet little is known about which patient variables predict the development of an alliance between patient and therapist in time-limited manualized therapies. The authors evaluated pretreatment predictors of therapeutic alliance, controlling for symptom change before its assessment, using a large sample of patients treated with either supportive-expressive (SE) dynamic psychotherapy or cognitive therapy. They found that SE patients with greater pretreatment expectations of improvement formed better alliances with their therapist at Session 2, and expectations significantly predicted alliance at Session 10 for both treatment groups. Further, patients in the SE condition demonstrated a significant relation between positive expectations and growth in alliance. Women achieved better alliances at Session 10. Finally, hostile-dominant interpersonal problems significantly predicted poor alliance. Pretreatment symptom level was not significantly predictive of alliance.

Out of the Babel of psychotherapy models, concepts, and techniques, the therapeutic alliance stands out as a measurable phenomenon that has been shown to have a robust effect on treatment outcome. The therapeutic alliance may be a "holy grail" of psychotherapy competency because it is a validated concept that is predictive of outcome, more powerfully predictive than alternative indices, clearly defined, easily measured, and may have educational and training value. This communication reviews the concept of therapeutic alliance, the methods for measuring it, and its relationship with outcome. We also summarize the literature on how trainees acquire the ability to develop a therapeutic alliance, and evaluate the pedagogical techniques for improving trainees' skills in this area. Finally, we present recommendations for the use of therapeutic alliance measurement in residency training for competency assessment purposes, and for pedagogical approaches for improving residents' therapeutic alliance building skills.

The authors present basic psychometric data for a new 21-item Cognitive Therapy Adherence and Competence Scale (CTACS; Liese, Barber, & Beck, 1995), which is based on the widely used Cognitive Therapy Scale (CTS; Young & Beck, 1980). The CTACS attempts to provide a wider coverage of cognitive therapists' activities than the CTS. Two expert cognitive therapists rated randomly chosen audiotaped therapy sessions from cocaine-dependent patients randomized to receive cognitive therapy, supportive-expressive dynamic therapy, or individual counseling as part of the training phase and the clinical phase (n = 60 and n = 69, respectively) of the National Institute on Drug Abuse Cocaine Collaborative Treatment Study. Results indicate that the CTACS has acceptable levels of interjudge reliability and criterion validity.

The goal of the current investigation was to explore the variables that predict therapist responsiveness in implementing specific therapist interventions. The authors found that therapists who were trained to adherence in manualized cognitive-behavioral (CBT) and interpersonal (IPT) psychotherapies demonstrated flexibility in the delivery of specific therapist techniques in response to specific patient characteristics and in-session therapeutic processes. Therapists used more clarifications and restatements with patients who rated the therapeutic empathy higher, more clarifications and questions with patients who rated higher on depression, and more learning statements with patients who provided more complete interpersonal narratives. Differences in responsiveness between treatment groups are discussed.

This report describes retention in treatment in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (CCTS), a multi-site trial of four psychosocial treatments for 487 cocaine dependent patients. Younger, African-American, and unemployed patients were retained in treatment for fewer days than their counterparts. African-American patients who lived with a partner were retained in treatment for less time than if they lived alone. Higher psychiatric severity kept men in treatment longer but put women at risk for dropping out sooner. Patients who completed the full treatment used drugs less often than patients who dropped out, but outcome did not differ at each month. Patients in the drug counseling condition stayed in treatment for fewer days than patients in psychotherapy, but they were more likely to be abstinent after dropout. Patients with higher psychiatric severity were more at risk for continuing to use drugs after dropout.

This report provides a descriptive evaluation of the therapist interventions implemented in the cognitive and interpersonal sessions of the Treatment of Depression Collaborative Research Program. 135,552 therapist statements drawn from 548 treatment sessions were coded for response mode category, time frame, and person. Therapists in both treatments were quite active, using predominantly clarifications, questions, and facilitative comments focused on the present time frame. The treatments also revealed important differences: cognitive therapists used more questions, restatements, and information/directional statements. Variance component analyses further revealed that differences between patients and between therapists explained a significant amount of variance in therapist response modes, indicating that manual-guided treatments can still reveal flexibility to address unique patient needs.

Originally published in Contemporary Psychology: APA Review of Books, 2002, Vol 47(1), 73-75. According to the reviewer, why should one be interested in yet another form of therapy? One quick answer would be that James P. McCullough's Cognitive Behavioral Analysis System of Psychotherapy (see record 1999-04419-000) has recently been shown to be very effective for the treatment of chronic depression, a difficult-to-treat condition. In the book, McCullough presents a complex and multifaceted theory explaining the etiology of chronic depression pathology and its treatment. The theory is based on a "biopsychosocial model of psychopathology and health" and views depression as arising "from faulty coping, which results in perceptual disengagement of the individual from his/her environment". The book's biggest strength and appeal lie in presenting the fruits of McCullough's long experience studying and treating this clinically challenging subgroup of depressed patients, namely, those chronic depressives who are often resistant to treatment.

Examined the interpersonal problems and central relationship patterns of Holocaust survivors' offspring (HSO) who were characterized by different patterns of parental communication of their parents' Holocaust trauma. 56 adults born to mothers who were survivors of Nazi concentration camps and 54 adults born to parents who immigrated to Israel before 1939 with their own parents (non-HSO) were recruited randomly from an Israeli sample. Ss (aged 30-49 yrs) completed the Inventory of Interpersonal Problems Circumplex, the Central Relationship Questionnaire, the Mental Health Index, and the Parental Communication of Holocaust Experiences Questionnaire. While the groups did not differ in their current mental health, HSO who reported nonverbal communication with little information about their mother's trauma endorsed more interpersonal distress than HSO who experienced informative verbal communication and less affiliation than either HSO who experienced informative verbal communication or non-HSO. They also differed in their central relationship patterns with their parents and spouses. Findings are discussed in the context of the unique dynamics of growing up with the silent presence of the mother's trauma.

Investigated the hypothesis that psychiatric patients display consistent interpersonal themes in narratives across different important interpersonal relationships. Ninety-three patients (aged 19-66 yrs) with a diagnosable disorder were asked to give 5 narratives about each of the following people in their lives: mother, father, same-sex best friend, and romantic partner. From the transcribed interview material, independent judges reliably rated the intensity of wishes, responses of others, and responses from self associated with a modified Core Conflictual Relationship Theme (CCRT) method (L. Luborsky & P. Crits-Christoph, 1990). Consistency of specific relational themes was assessed across multiple interactions with the same person and across different relationships. Although only 1% to 3% of the variance was explained by an individual's consistency, there was substantial variability in specific interpersonal themes across narratives, both across and within relationships (explaining 27% to 30% of the variance). The discussion addresses methodological issues that may have contributed to the current findings and the implications of these findings for the CCRT method, psychodynamic theory and practice in general, and the psychodynamic concept of transference in particular.