ABSTRACT. Objective:This meta-analysis examined 53 controlled trials of cognitive-behavioral treatment (CBT) for adults diagnosed with alcohol-or illicit-drug-use disorders. The aims were to provide an overall picture of CBT treatment effi cacy and to identify client or treatment factors predictive of CBT effect magnitude. Method: The inverse variance weighted effect size (Hedges' g) was calculated for each study and pooled using fi xed and random effects methods. Potential study-level moderators were assessed in subgroup analyses by primary drug, type of CBT, and type of comparison condition. In addition, seven client and treatment variables were examined in meta-regression analyses. Results: Across studies, CBT produced a small but statistically signifi cant treatment effect (g = 0.154, p < .005). The pooled effect was somewhat lower at 6-9 months (g = 0.115, p < .005) and continued to diminish at 12-month follow-up (g = 0.096, p < .05). The effect of CBT was largest in marijuana studies (g = 0.513, p < .005) and in studies with a no-treatment control as the comparison condition (g = 0.796, p < .005). Metaregression analyses indicated that the percentage of female participants was positively associated and the number of treatment sessions was negatively associated with effect size. Conclusions: The fi ndings demonstrate the utility of CBT across a large and diverse sample of studies and under rigorous conditions for establishing effi cacy. CBT effects were strongest with marijuana users, when CBT was compared with no treatment, and may be larger with women than with men and when delivered in a brief format. (J. Stud. Alcohol Drugs 70: 516-527, 2009) C OGNITIVE-BEHAVIORAL TREATMENT (CBT) models are among the most extensively evaluated interventions for alcohol-or illicit-drug-use disorders. Based primarily on Marlatt and Gordon's (1985; Marlatt and Donovan, 2005) model of relapse prevention, these treatments target cognitive, affective, and situational triggers for substance use and provide skills training specifi c to coping alternatives. CBT treatment for alcohol or illicit drug use often includes the following strategies: (1) identifying intrapersonal and interpersonal triggers for relapse, (2) coping-skills training, (3) drug-refusal skills training, (4) functional analysis of substance use, and (5) increasing nonuse-related activities. These models have been manualized (e.g., Kadden et al., 1992;Monti et al., 1989) and adapted for implementation in a variety of clinical capacities. Further, CBT interventions have been tested in Stage III research to examine their utility in the "real-world" context, possible adaptations, and costeffectiveness (National Institute on Drug Abuse, 1992; cited from Carroll and Onkin, 2005). As argued by Carroll and Rounsaville (2007), the addictions fi eld would benefi t from greater and continued attention devoted to the dissemination of research-based substance-use treatments. Review data to guide such efforts, however, are needed.CBT interventions for substance-use disorde...
Objective The technical hypothesis of motivational interviewing (MI) posits that therapist implemented MI skills will be related to client speech regarding behavior change and that client speech will predict client outcome. The current meta-analysis is the first aggregate test of this proposed causal model. Method A systematic literature review, using stringent inclusion criteria, identified k = 16 reports describing 12 primary studies. Review methods calculated the inverse-variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple targeted behaviors (i.e., alcohol or illicit drug use, other addictive behaviors). Results Therapist MI-consistent skills were correlated with more client language in favor of behavior change (i.e., change talk; r = .26, p < .0001), but not less client language against behavior change (i.e., sustain talk; r = .10, p = .09). MI-inconsistent skills were associated with less change talk (r = −.17, p = .001) as well as more sustain talk (r = .07, p = .009). Among these studies, client change talk was not associated with follow-up outcome (r = .06, p = .41), but sustain talk was associated with worse outcome (r = −.24, p = .001). In addition, studies that examined composite client language (e.g., an average of negative and positive statements) showed an overall positive relationship with client behavior change (r = .12, p = .006; k = 6). Conclusions This meta-analysis provides an initial test and partial support for a key causal model of MI efficacy. Recommendations for MI practitioners, clinical supervisors, and process researchers are provided.
Objective In the present meta-analysis, we test the technical and relational hypotheses of Motivational Interviewing (MI) efficacy. We also propose an a priori conditional process model where heterogeneity of technical path effect sizes should be explained by interpersonal/relational (i.e., empathy, MI Spirit) and intrapersonal (i.e., client treatment seeking status) moderators. Method A systematic review identified k = 58 reports, describing 36 primary studies and 40 effect sizes (N = 3025 participants). Statistical methods calculated the inverse variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple target behaviors (i.e., alcohol use, other drug use, other behavior change). Results Therapist MI-consistent skills were correlated with more client change talk (r = .55, p < .001) as well as more sustain talk (r = .40, p < .001). MI-inconsistent skills were correlated with more sustain talk (r = .16, p < .001), but not change talk. When these indicators were combined into proportions, as recommended in the Motivational Interviewing Skill Code, the overall technical hypothesis was supported. Specifically, proportion MI consistency was related to higher proportion change talk (r = .11, p = .004) and higher proportion change talk was related to reductions in risk behavior at follow up (r = −.16, p < .001). When tested as two independent effects, client change talk was not significant, but sustain talk was positively associated with worse outcome (r = .19, p < .001). Finally, the relational hypothesis was not supported, but heterogeneity in technical hypothesis path effect sizes was partially explained by inter- and intra-personal moderators. Conclusions This meta-analysis provides additional support for the technical hypothesis of MI efficacy; future research on the relational hypothesis should occur in the field rather than in the context of clinical trials.
Rigorous reviews of the science on the effectiveness of Alcoholics Anonymous (AA) indicate that AA and related 12-step treatment are at least as helpful as other intervention approaches. Exactly how AA achieves these beneficial outcomes is less well understood, yet, greater elucidation of AA's mechanisms could inform our understanding of addiction recovery and the timing and content of alcohol-related interventions. Empirical studies examining AA's mechanisms were located from searches in Pubmed, Medline, PsycINFO, Social Service Abstracts and from published reference lists. Thirteen studies completed full mediational tests. A further six were included that had completed partial tests. Mechanisms examined fell into three domains: (1) Common processes; (2) AA-specific practices; and (3) Social and spiritual processes. Results suggest AA helps individuals recover through common process mechanisms associated with enhancing self-efficacy, coping skills, and motivation, and by facilitating adaptive social network changes. Little research or support was found for AA's specific practices or spiritual mechanisms. Conclusions are limited by between-study differences in sampling, measurement, and assessment time-points, and by insufficient theoretical elaboration of recoveryrelated change. Similar to the common finding that theoretically-distinct professional interventions do not result in differential patient outcomes, AA's effectiveness may not be due to its specific content or process. Rather, its chief strength may lie in its ability to provide free, long-term, easy access and exposure to recovery-related common therapeutic elements, the dose of which, can be adaptively selfregulated according to perceived need.
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