Showing papers by "Kenneth M. Carpenter published in 2012"

Measures of attentional bias and relational responding are associated with behavioral treatment outcome for cocaine dependence.

Abstract: Background: Psychosocial interventions for substance dependence have demonstrated efficacy. However, the mechanisms by which specific intervention strategies exert their effect have not been clearly identified. Objective: This study investigated the prospective relationships between two psychological processes, an attentional bias toward cocaine stimuli and beliefs about the consequences of cocaine use, and treatment outcome. Method: Twenty-five cocaine-dependent participants enrolled in a 6-month outpatient treatment program that included voucher incentives for abstinence. All participants were asked to complete two implicit assessment procedures, a Drug Stroop protocol and an Implicit Relational Assessment Procedure (IRAP), as well as explicit measures of cocaine craving and the consequences of cocaine use, prior to beginning treatment. Pearson's correlation coefficients tested the prospective relationships between treatment outcome and the implicit and explicit assessments. Results: Stronger implicit beliefs about the positive effects of cocaine use prior to treatment were associated with poorer treatment outcome when an escalating voucher-incentive program was in place. Further, an attentional bias for cocaine-related stimuli was associated with better treatment outcome when an escalating voucher-incentive program was removed. No association between cocaine use beliefs and treatment outcome was found when beliefs were measured with self-report instruments. Conclusions and scientific significance: These findings highlight the potential utility of performance-based measures for delineating the psychological mechanisms associated with variation in response to treatment for drug dependence.

Training substance abuse clinicians in motivational interviewing using live supervision via teleconferencing.

Abstract: The dissemination of new, evidence-based treatment methods into widespread clinical practice is a substantial challenge for the medical and mental health fields generally, and addiction treatment in particular (Institute of Medicine, 1998). Continuing education programs have traditionally used printed materials and didactic conferences for disseminating treatment advances. However, evidence suggests that these traditional approaches to training are relatively ineffective at changing actual medical or counseling practices. Training procedures that include interactive role-plays relevant to the clinical context allow opportunities for further practice, and provide feedback and reminders are more likely to enhance clinical skills in medical settings (Grol, 2001; Grol & Grimshaw, 2003). Similarly, Motivational interviewing (MI) workshop training procedures that include practice and feedback have been shown to increase the MI skill levels of counselors (Madison, Loignon, & Lane, 2009; Walters, Matson, Baer, & Ziedonis, 2005). Unfortunately, skill levels have been demonstrated to diminish after workshop training, indicating workshop training alone does not produce sustained improvement in MI skillfulness (Baer et al., 2004; Miller & Mount, 2001; Walters et al., 2005). Further, following workshop training, counselors tend to rate their MI proficiency more positively than their objectively assessed skill ratings (Miller & Mount, 2001). These findings suggest that training workshops may successfully expose clinicians to new treatment approaches and increase their confidence in the use of these techniques, but may not promote long-term proficiency, an important outcome that has direct implications for improving clinical practice. Thus, alternative training methods are needed to facilitate a more robust transfer of new treatment strategies to the clinical context. Accordingly, studies have begun to examine supervision offered after workshop training (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Moyers et al., 2008; Martino, Ball, et al., 2011), and generally support the conclusion that methods involving objective feedback and coaching will improve acquisition of MI skill (Miller & Rose, 2009). The importance of approximating a counselor's clinical context during MI training has been emphasized (Miller & Rollnick, 2002), and the evidence suggests that feedback should be based on ratings of actual therapy sessions (Miller et al., 2004; Miller & Rose, 2009). This has generally been achieved through audiotaping of clinical encounters, which provides a direct window into a clinician's counseling style, and facilitates remote supervision, an important feature for disseminating empirically based treatment strategies when time and distance limit the availability of expert trainers. However, audiotaping also has disadvantages including limited adherence and tape selection issues such as counselors may not make tapes, or may select sessions that went relatively well, limiting the ability to address problems with skill (Miller et al., 2004). Further, the use of audio recordings entails a delay between the clinical encounter and the provision of feedback to the counselor; the tape must be mailed and then reviewed by the supervisor before discussion and feedback can take place. This misses the opportunity for immediate feedback, a potentially powerful intervention for helping individuals learn new behavioral skills (Balcazar, Hopkins, & Suarez, 1986). Independent lines of evidence highlight three training parameters that may be particularly useful for guiding the learning of new counseling skills. First, immediate feedback is an important component in training programs that aim to bring behaviors to a particular performance level (Balcazar et al., 1986). Thus, supervisory practices that provide feedback to counselors closer in time to their clinical encounter may help promote the acquisition and retention of new counseling skills (Kivlighan, Angelone, & Swafford, 1991). Second, practice sessions distributed over time are more likely to produce lasting skill acquisition than training sessions of a longer duration but conducted over a shorter period of time (e.g., workshop training) (Donovan & Radosevich, 1999; Prescott et al., 2002). Third, differential reinforcement of specific behaviors from amongst a larger repertoire can be particularly effective at shaping new skills (Skinner, 1953). Differential reinforcement procedures may be particularly effective for developing proficiency in specific MI skills, while simultaneously reducing the use of counseling strategies that are incompatible with an MI style. Reducing the frequency of MI non-adherent (MINA) behaviors is of particular importance, since evidence suggests that therapist MINA behavior can increase client resistance and negatively influence treatment outcomes (Apodoca & Longabaugh, 2009; Guame, Bertholet, Faouzi, Gmel, & Daeppen, 2010; Guame, Gmel, Faouzi, & Daeppen, 2009; Miller, Benefield, & Tonigan, 1993; Moyers & Martin, 2006). Tele-conferencing supervision (TCS) was designed to address the limitations of workshop training and post-workshop supervision based on recordings of clinical encounters, by incorporating the principles of immediate feedback, distributed practice, and differential reinforcement. TCS provides real-time, live feedback to counselors while they interview standardized clients (actors) in their treatment clinics. Supervisors, located remotely, listen to the interview through telephone lines and provide immediate feedback and modeling through an earpiece worn by the clinician. TCS was constructed, tested, and then adjusted based on the favorable results of an uncontrolled pilot study (Smith et al., 2007). The present study employed a randomized controlled trial to test the efficacy of workshop training plus TCS for training clinicians in MI, compared to two control conditions, workshop training followed by tape review supervision (Tape), and workshop training only (Workshop).

"Old dogs" and new skills: how clinician characteristics relate to motivational interviewing skills before, during, and after training.

Abstract: Objective The relationships between the occupational, educational, and verbal-cognitive characteristics of health care professionals and their motivational interviewing (MI) skills before, during, and after training were investigated. Method Fifty-eight community-based addiction clinicians (M = 42.1 years, SD = 10.0; 66% Female) were assessed prior to enrolling in a 2-day MI training workshop and being randomized to one of three post-workshop supervision programs: live supervision via tele-conferencing (TCS), standard tape-based supervision (Tape), or workshop training alone. Audiotaped sessions with clients were rated for MI skillfulness with the Motivational Interviewing Treatment Integrity (MITI) coding system v 2.0 at pre-workshop and 1, 8, and 20 weeks post-workshop. Correlation coefficients and generalized linear models were used to test the relationships between clinician characteristics and MI skill at each assessment point. Results Baseline MI skill levels were the most robust predictors of pre- and post-supervision performances. Clinician characteristics were associated with MI Spirit and reflective listening skill throughout training and moderated the effect of post-workshop supervision method on MI skill. TCS, which provided immediate feedback during practice sessions, was most effective for increasing MI Spirit and reflective listening among clinicians with no graduate degree and stronger vocabulary performances. Tape supervision was more effective for increasing these skills among clinicians with a graduate degree. Further, TCS and Tape were most likely to enhance MI Spirit among clinicians with low average to average verbal and abstract reasoning performances. Conclusions Clinician attributes influence the effectiveness of methods used to promote the acquisition of evidence-based practices among community-based practitioners.