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CORK Bibliography: Clinicians

112 citations. January 2006 to present

Prepared: December 2009

Abraham AJ; Ducharme LJ; Roman PM. Counselor attitudes toward pharmacotherapies for alcohol dependence. Journal of Studies on Alcohol and Drugs 70(4): 628-635, 2009. (20 refs.)

Objective: Addiction treatment counselors play a central role in the dissemination of information about new treatment techniques to alcohol-dependent patients and are key in the implementation of new treatment technologies. Building on previous research, this study examines counselors' perceptions of the effectiveness and acceptability of pharmacotherapies for the treatment of alcohol dependence. Method: Mail questionnaires were received from 1,140 counselors employed in a nationally representative sample of public-sector addiction treatment programs in 2006. Counselors answered a series of questions about three U.S. Food and Drug Administration (FDA)-approved medications used in the treatment of alcohol dependence (disulfirarn [Antabuse], tablet naltrexone [Revia], and acamprosate [Campral]), indicating their extent of familiarity with the medication, its perceived effectiveness in the treatment of alcohol dependence, and its acceptability for use with alcohol-dependent patients. Results: The extent of diffusion of these pharmacotherapies was associated with time since FDA approval. Counselors reported receiving little or no pharmacotherapy-specific training. Multivariate models showed that the receipt of medication-specific training as well as indirect observation of the medication's use in the treatment program were significantly associated with diffusion of information about these pharmacotherapies and counselors' perceptions of the effectiveness and acceptability of the medications for use in addiction treatment. Conclusions: When exposed to information about medications to treat alcohol dependence, counseling staff appear quite receptive. More efforts are needed to disseminate information about alcohol pharmacotherapies to front-line addiction treatment staff.

Allman D; Myers T; Schellenberg J; Strike C; Cockerill R; Cavalieri W. Improving health and social care relationships for harm reduction. International Journal of Drug Policy 18(3): 194-203, 2007. (42 refs.)

This paper explores elements of the relationships that develop between people who use illicit drugs and people who provide services to them. It focuses on expectations people who use drugs and service providers have of health and social care relationships for harm reduction, as well as facilitators and barriers to effective and ineffective interactions, and to what governments might better do to help strengthen interactions. Prior to Canada's inaugural national harm reduction conference, informal discussion groups were organized to source local views regarding policy reform for harm reduction. One component of these discussion groups focused upon improving health and social care relationships for harm reduction. Community-based organizations providing services for harm minimisation were consulted to help develop themes and questions. Discussion groups conducted in French or English were held in 10 cities across Canada. Groups were audio-recorded, transcribed and thematically analysed. Disjuncture between understandings of the nature of health and social care relationships for harm reduction were found. Interpersonal and structural factors functioned both for and against the development of effective-interactions. Differences in expectation sets held by illicit drug users and service providers may reflect the fluid experience of boundaries as a population on society's margins moves between harm-causing and harm-reducing behaviours and identities. The research described in this paper targeted those most directly involved in receiving, developing and delivering harm reduction programmes across a very diverse nation. It did so by including representatives of those most directly involved in utilizing and providing services within the research process itself. By incorporating a process that was community-based, user-driven, and which strived to be non-judgmental, the research was able to explore suggestions for improving health and social care relationships for harm reduction proffered by professionals actively providing services, as well as a variety of users, including some isolated or structurally excluded from service access by geography, illiteracy and/or street-involvement.

Ana EJS; Carroll KM; Anez L; Paris M; Ball SA; Nich C et al. Evaluating motivational enhancement therapy adherence and competence among Spanish-speaking therapists. Drug and Alcohol Dependence 103(1-2): 44-51, 2009. (46 refs.)

Despite the fact that the number of Hispanic individuals in need of treatment for substance use problems is increasing internationally, no studies have investigated the extent to which therapists can provide empirically supported treatments to Spanish-speaking clients with adequate fidelity. Twenty-three bilingual Hispanic therapists from five community outpatient treatment programs in the United States were randomly assigned to deliver either three sessions of motivational enhancement therapy (MET) or an equivalent number of drug counseling-as-usual (CAU) sessions in Spanish to 405 Spanish-speaking clients randomly assigned to these conditions. Independent ratings of 325 sessions indicated the adherence/competence rating system had good to excellent interrater reliability and indicated strong support for an a priori defined fundamental MET skill factor. Support for an advanced MET skill factor was relatively weaker. The rating scale indicated significant differences in therapists' MET adherence and competence across conditions. These findings indicate that the rating system has promise for assessing the performance of therapists who deliver MET in Spanish and suggest that bilingual Spanish-speaking therapists from the community can be trained to implement MET with adequate fidelity and skill using an intensive multisite training and supervision model.

Auerbach SM; May JC; Stevens M; Kiesler DJ. The interactive role of working alliance and counselor-client interpersonal behaviors in adolescent substance abuse treatment. International Journal of Clinical and Health Psychology 8(3): 617-629, 2008. (38 refs.)

This descriptive study explored the relationship between client and counselor perceptions of the working alliance and the interpersonal relationship dimensions of affiliation and control, and evaluated the relationship of perceptions of the alliance and of client and counselor interpersonal reactions to each other to client outcome after 3-6 months of treatment for substance abuse. Clients were 39 adolescents. Client and counselor ratings of the working alliance (using the Working Alliance Inventory-WAI) and interpersonal appraisals of each other (using the Impact Message Inventory Circumplex-IMI-C) were obtained during the second week of treatment. Outcome data using the Global Appraisal of Individual Needs (GAIN) and the Child and Adolescent Functional Assessment Scale (CAFAS) were obtained during the second week of treatment and again after three months and six months of treatment. Interpersonally the predominant impact clients and counselors had on each other was friendliness. For both clients and counselors feelings of affiliation with their counterpart was the relationship dimension most strongly associated with the perception of a working alliance. These findings, and significant associations obtained between WAI and IMI measures and outcome measures, have implications for future research on the role of alliance and interpersonal variables in substance abuse clients' response to treatment.

Baer JS; Wells EA; Rosengren DB; Hartzler B; Beadnell B; Dunn C et al. Agency context and tailored training in technology transfer: A pilot evaluation of motivational interviewing training for community counselors. Journal of Substance Abuse Treatment 37(2): 191-202, 2009. (45 refs.)

Few empirical studies are available to guide best practices for transferring evidenced-based treatments to community substance abuse providers. To maximize the learning and maintenance of new clinical skills, this study tested a context-tailored training (CTT) model, which used standardized patient actors in role-plays tailored to agency clinical context, repetitive cycles of practice and feedback, and enhanced organizational support. This study reports the results of a randomized pilot evaluation of CTT for motivational interviewing (MI). Investigators randomly assigned community substance abuse treatment agencies to receive either CTT or a standard 2-day MI workshop. The study also evaluated the effects of counselor-level and organizational-level variables on the learning of MI. No between-condition differences were observed on the acquisition and maintenance of MI skills despite reported higher satisfaction with the more costly context-tailored model. Analyses revealed that those counselors with more formal education and less endorsement of a disease model of addiction made the greatest gains in MI skills, irrespective of training condition. Similarly, agencies whose individual counselors viewed their organization as being more open to change and less supportive of autonomy showed greater average staff gains in MI skills, again, irrespective of training method. Posttraining activities within agencies that supported the ongoing learning and implementation of MI mediated the effects of organizational openness to change. This pilot study suggests that tailored training methods may not produce better outcomes than traditional workshops for the acquisition of evidence-based practice, and that efforts to enhance skill acquisition can be focused on characteristics of learners and ongoing organizational support of learning.

Baird J; Longabaugh R; Lee CS; Nirenberg TD; Woolard R; Mello MJ et al. Treatment completion in a brief motivational intervention in the emergency department: The effect of multiple interventions and therapists' behavior. Alcoholism: Clinical and Experimental Research 31(10, Supplement S): 71S-75S, 2007. (18 refs.)

Background: The aim of this study was to identify therapist behaviors during a brief motivational intervention (BMI) given to injured emergency department patients that predicted participant return for a second BMI session and 12-month alcohol-related outcomes. Methods: This was a secondary data analysis of a randomized controlled trial (n = 539) previously demonstrating that random assignment to a BMI and booster session resulted in a significant reduction of 12-month postintervention alcohol-related injuries and negative consequences relative to standard care. Results: Participants who actually received 2 BMI sessions had significantly less alcohol-related negative consequences than those who received only 1 BMI session. Therapists who reported a higher focus on emotional support and low focus on participant drinking behaviors during the initial BMI session were more likely to have assigned participants return for the second BMI session. Conclusions: The results of these secondary analyses show that compliance with a 2-session therapeutic intervention (BIB) predicted fewer negative alcohol-related consequences, and that therapists' supportive emotional emphasis during the first BMI session was important in predicting participants returning for the second MI session.

Baldwin JA; Johnson RM; Gotz NK; Wayment HA; Elwell K. Perspectives of college students and their primary health care providers on substance abuse screening and intervention. Journal of American College Health 55(2): 115-119, 2006. (32 refs.)

The authors conducted a needs assessment among students and health-care providers of a southwestern university health center with the goal of developing health-care-provider training addressing substance-abuse screening and intervention. They collected data from focus groups of undergraduate students and structured interviews and questionnaires with health-care providers. They identified gaps in provider and student perspectives on the extent of substance abuse on campus and the perceived roles of health-care providers and patients in screening and conducting interventions for substance abuse. These findings suggest that training for college health-care providers regarding substance-abuse brief screening and intervention should emphasize confidentiality of student medical records, the importance of nonjudgmental attitudes toward students, and the role of the provider as one who is competent and appropriate to address substance abuse. Such training should also educate providers about the types of substances students are using.

Barber JP; Gallop R; Crits-Christoph P; Frank A; Thase ME; Weiss RD et al. The role of therapist adherence, therapist competence, and alliance in predicting outcome of individual drug counseling: Results from the National Institute Drug Abuse Collaborative Cocaine Treatment Study. Psychotherapy Research 16(2): 229-240, 2006. (48 refs.)

This study tested hypotheses related to linear and curvilinear relations among adherence, competence, and outcome and interactions of these effects with the quality of the therapeutic alliance among patients (N = 95) who received individual drug counseling as part of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Results support a hypothesized curvilinear relation between adherence and outcome as well as an interaction between this curvilinear effect and alliance early in treatment. For patients with a strong therapeutic alliance, counselor adherence to the treatment model was essentially irrelevant to treatment outcome. When the alliance was weaker, by contrast, a moderate (vs. high or low) level of counselor adherence was associated with the best outcome. The current results suggest that studies of the relation between therapist's adherence to models of treatment and outcome may need to take into account the complex moderating effect of therapeutic alliance.

Barnett NP; Murphy JG; Colb SM; Monti PM. Efficacy of counselor vs. computer-delivered intervention with mandated college students. Addictive Behaviors 32(11): 2529-2548, 2007. (76 refs.)

The purpose of this study was to evaluate the efficacy of two brief interventions and the inclusion of a 1-month booster session with college students who were referred to attend alcohol education following an alcohol-related incident. Participants (N= 225; 48.9% male) were randomly assigned to receive one session of a Brief Motivational Interview (BMI) or computer-delivered intervention (CDI) with the Alcohol 10 1 CD-ROM. Participants were also randomly assigned to booster/no booster. At 3-month follow up, participants in BMI reported greater help seeking and use of behavioral strategies to moderate drinking. At 12-month follow up, BMI participants were drinking more frequently and CDI participants were consuming a greater number of drinks per occasion than at baseline. Mediation analyses showed that the use of specific behavioral strategies mediated the effect of the BMI condition on drinking volume. There was no intervention effect on alcohol problems, and the booster condition did not significantly affect outcomes. Promoting specific behaviors in the context of in-person brief interventions may be a promising approach to reducing drinking volume among identified at-risk students.

Bell J. Speciality recognition of addiction medicine in Australia. (editorial). Addiction 103(5): 701-702, 2008. (7 refs.)

Bethea AR; Acosta MC; Haller DL. Patient versus therapist alliance: Whose perception matters? Journal of Substance Abuse Treatment 35(2): 174-183, 2008. (36 refs.)

Development of working alliance was examined for 25 opioid-abusing pain patients and their therapists. Patients participated in an eight-session intervention based on adherence strategies and employment of a supportive, psychoeducational approach; methadone was prescribed for pain. Treatment goals included opioid analgesic adherence and decreasing pain, functional interference, and substance abuse. Patients and therapists completed the Helping Alliance Questionnaire-II following each treatment session. At baseline, scores of patients and therapists indicated good alliance. Patient alliance grew significantly over time regardless of addiction severity and independent of treatment outcomes. In contrast, therapist alliance grew only for patients without Substance abuse comorbidity and/or who had good Outcomes. Patients' and therapists' alliance scores were consistent during sessions focused on emotional bonds but diverged during sessions that demanded behavior change, suggesting that therapists may have reacted negatively to patients' lack of progress. Whether therapists' reactions to poor performers impacted subsequent patient outcomes is unknown but should be investigated.

Bohman TM; Kulkarni S; Waters V; Spence RT; Murphy-Smith M; McQueen K. Assessing health care organizations' ability to implement screening, brief intervention, and referral to treatment. Journal of Addiction Medicine 2(3): 151-157, 2008. (18 refs.)

Objectives: To determine if a new measure of organizational readiness for change reflects site and staff role differences when implementing a screening, brief intervention, and referral to treatment (SBIRT) program) for alcohol and drug misuse in a healthcare organization. Sample: One hundred forty-one Community Health Program (CHP) and 45 Emergency Center (FC) respondents completed the survey. Methods: Medical and ancillary staff from a Level 1 trauma hospital EEC and 3 CHP clinics within a large, urban, publicly funded health-care system were asked to complete the 45-item Medical Organizational Readiness for Change (MORC) survey 5 to 7 months after the start of implementation planning. One-way ANOVAs compared the 4 sites' responses and independent t tests compared the clinical versus administrative staff responses on MORC scales. Results: There were statistically significant differences between the EC and CHP sites on Need for External Guidance, Pressure to Change, Organizational Readiness to Change, Workgroup Functioning, Work Environment, and Autonomy Support. Clinical and administrative staff differed significantly on Need for External Guidance, Pressure to Change, and Organizational Readiness to Change. When change agents used the MORC data to inform their implementation process, the results were positive. Conclusions: Among CHP sites, there were differences in organizational functioning, which were consistent with CHP implementation Outcomes. The MORC scales can help planners and change agents understand their organization's current readiness to integrate screening, brief intervention, and referral to treatment services into their medical setting.

Brener L; von Hippel W; Kippax S. Prejudice among health care workers toward injecting drug users with hepatitis C: Does greater contact lead to less prejudice? International Journal of Drug Policy 18(5): 381-387, 2007. (36 refs.)

The current research measured explicit (self-reported) and implicit (or unconscious) attitudes of health care workers and their drug injecting clients with hepatitis C virus (HCV) toward each other, and the association of these attitudes with contact. Sixty health care workers and 120 of their clients with HCV acquired from injecting drug use were administered attitude measures to determine whether greater contact with HCV positive clients would result in more favourable attitudes on the part of health care workers toward these clients, and also on the part of these clients towards their health care workers. Findings suggest that increased contact with clients with HCV is associated with more favourable explicit attitudes and more negative implicit attitudes among health care workers toward injecting drug users. Health care workers who had greater contact with HCV positive clients also had HCV positive clients who held more favourable explicit attitudes toward health care workers, but contact was uncorrelated with implicit attitudes of clients toward health care workers.

Broome KM; Knight DK; Edwards JR; Flynn PM. Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs. Journal of Substance Abuse Treatment 37(2): 160-170, 2009. (54 refs.)

Counselors are a critical component of substance abuse treatment programming, but their working experiences are not yet well understood. As treatment improvement efforts focus increasingly on these individuals, their perceptions of program leadership, emotional burnout, and job satisfaction and related attitudes take on greater significance. This study explores counselor views and the impact of organizational context using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. Results show counselors hold generally positive opinions of program director leadership and job satisfaction and have low levels of burnout, but they also have important variations in their ratings. Higher counselor caseloads were related to poorer ratings, and leadership behaviors predicted both satisfaction and burnout. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.

Brunette MF; Asher D; Whitley R; Lutz WJ; Wieder BL; Jones AM et al. Implementation of integrated dual disorders treatment: A qualitative analysis of facilitators and barriers. Psychiatric Services 59(9): 989-995, 2008. (23 refs.)

Objective: Approximately half of the people who have serious mental illnesses experience a co-occurring substance use disorder at some point in their lifetime. Integrated dual disorders treatment, a program to treat persons with co-occurring disorders, improves outcomes but is not widely available in public mental health settings. This report describes the extent to which this intervention was implemented by 11 community mental health centers participating in a large study of practice implementation. Facilitators and barriers to implementation are described. Methods: Trained implementation monitors conducted regular site visits over two years. During visits, monitors interviewed key informants, conducted ethnographic observations of implementation efforts, and assessed fidelity to the practice model. These data were coded and used as a basis for detailed site reports summarizing implementation processes. The authors reviewed the reports and distilled the three top facilitators and barriers for each site. The most prominent cross-site facilitators and barriers were identified. Results: Two sites reached high fidelity, six sites reached moderate fidelity, and three sites remained at low fidelity over the two years. Prominent facilitators and barriers to implementation with moderate to high fidelity were administrative leadership, consultation and training, supervisor mastery and supervision, chronic staff turnover, and finances. Conclusions: Common facilitators and barriers to implementation of integrated dual disorders treatment emerged across sites. The results confirmed the importance of the use of the consultant-trainer in the model of implementation, as well as the need for intensive activities at multiple levels to facilitate implementation. Further research on service implementation is needed, including but not limited to clarifying strategies to overcome barriers.

Burrow-Sanchez JJ; Lopez AL; Slagle CP. Perceived competence in addressing student substance abuse: A national survey of middle school counselors. Journal of School Health 78(5): 280-286, 2008. (20 refs.)

BACKGROUND: Student substance abuse is a serious concern for middle school personnel. School counselors are most likely to deliver mental health services, including substance abuse, in school settings. However, limited research is available on the perceived competence of middle school counselors for addressing student substance abuse concerns. The main purpose of this study was to determine how middle school counselors perceive their training in 9 competence areas related to student substance abuse. A secondary aim of this study was to identify which training areas counselors indicate as being most needed to address student substance abuse. METHODS: A survey study was conducted that included a national sample of 283 middle school counselors. Analysis of variance was used to determine differences between 9 competency areas rated by counselors. Further analysis was conducted to determine which training areas were most important to counselors. RESULTS: Counselors varied in their perceived competence depending on the specific area of student substance abuse; however, they were clearly able to identify the most important areas of training needed. CONCLUSIONS: Overall, the findings from this study indicate that middle school counselors require more training in the area of student substance abuse. Specifically, this study provides information on the most important areas of training as identified by counselors.

Bywood P; Lunnay B; Roche A. Effectiveness of opinion leaders for getting research into practice in the alcohol and other drugs field: Results from a systematic literature review. (review). Drugs: Education, Prevention and Policy 16(3): 205-216, 2009. (32 refs.)

Aims: To evaluate the effectiveness of opinion leaders for changing practitioners' behaviour; and determine how this strategy may be used to bridge the research-to-practice gap in the alcohol and drugs (AOD) field. Methods: A systematic literature review was undertaken to assess the use of opinion leaders for improving professional practice. Electronic databases, relevant websites, specialty journals and reference lists of included studies were searched systematically (1966-March 2005). Included studies were critically appraised according to level and quality of evidence and data on effectiveness of opinion leaders were extracted, tabulated and synthesized. Results: Four papers met the inclusion criteria for this review, including one existing systematic literature review comprising eight studies. Since no included studies were conducted in an AOD context, evidence was drawn from the broader medical and health fields. Overall, opinion leaders had variable effectiveness in changing professional practice. For the most part, studies lacked methodological quality and results were prone to bias. Conclusions: Despite good theoretical underpinnings for the use of opinion leaders to influence change in professionals' behaviour, current evidence of their effectiveness is sparse and inconsistent. There is a need for good quality, well-designed studies that are conducted in an AOD context using opinion leaders who are appropriately identified and adequately supported.

Bywood PT; Lunnay B; Roche AM. Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback. (review). Drug and Alcohol Review LA English 27(5): 548-558, 2008. (56 refs.)

In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.

Carroll KM; Ball SA; Nich C; Martino S; Frankforter TL; Farentinos C et al. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug and Alcohol Dependence 81(3): 301-312, 2006. (49 refs.)

Despite recent emphasis on integrating empirically validated treatment into clinical practice, there are little data on whether manual-guided behavioral therapies can be implemented in standard clinical practice and whether incorporation of such techniques is associated with improved outcomes. The effectiveness of integrating motivational interviewing (MI) techniques into the initial contact and evaluation session was evaluated in a multisite randomized clinical trial. Participants were 423 substance users entering outpatient treatment in five community-based treatment settings, who were randomized to receive either the standard intake/evaluation session at each site or the same session in which MI techniques and strategies were integrated. Clinicians were drawn from the staff of the participating programs and were randomized either to learn and implement MI or to deliver the standard intake/evaluation session. Independent analyses of 315 session audiotapes suggested the two forms of treatment were highly discriminable and that clinicians trained to implement MI tended to have higher skill ratings. Regarding outcomes, for the sample as a whole, participants assigned to MI had significantly better retention through the 28-day follow-up than those assigned to the standard intervention. There were no significant effects of MI on substance use outcomes at either the 28-day or 84-day follow-up. Results suggest that community-based clinicians can effectively implement MI when provided training and supervision, and that integrating MI techniques in the earliest phases of treatment may have positive effects on retention early in the course of treatment.

Carruth B, ed. Psychological Trauma and Addiction Treatment. Routledge: New York, 2006. (Chapter refs.)

This edited volume has 14 chapters and 17 contributors. A history of trauma is common among those in treatment for substance abuse disorders this book describes treatment approaches. Following an introduction, individual chapters are directed to different therapeutic techniques: cognitive-behavioral therapy, psychodynamic psychotherapy, attachment disorders and their relationship to addiction and trauma, and affect-centered therapy. This is following by chapters directed to managing issues related to trauma within intensive addiction treatment environments, the role of 12-step treatment programs, spirituality to promote resilience and hope, the use of the creative arts, and forgiveness therapy. Concluding chapters consider treatment issues specific to addicted women, and the importance of clinician self-care when working with traumatized addicted people.

Clancy C; Oyefeso A; Ghodse H. Role development and career stages in addiction nursing: an exploratory study. Journal of Advanced Nursing 57(2): 161-171, 2007. (32 refs.)

Aim. This paper reports a Study to explore factors influencing recruitment andretention in addiction nursing, and the stages and features of role acquisition and personal qualities important to that role. Background. Specialist addiction nurses engage in a number of roles ill the care of individuals with problematic use of psychoactive substances. These include assess outreach, prescribing, counselling, and harm reduction. In a climate of merit, increasing demand for specialist substance misuse workers, and a trend to identify key occupational competencies, there is a need for a framework ill which career progression can be supported. Studies exploring the roles of addiction nurses are minimal, and there is less comment oil how these roles are developed in the context of career stages. Method. A qualitative study using focus groups was undertaken with specialist addiction nurses between March and June 2004. The data were transcribed verbatim and analysed using Burnard's six content analysis stages. Findings. Positive factors identified as influencing recruitment and retention included: prior knowledge of the working environment (as a nursing student), opportunities for autonomous practice, the client profile, and associated treatment philosophy and care approach. There was consensus that nurses choosing to work in the field of addiction needed, in addition to being non-judgmental, personal qualities Including hardiness, patience and tolerance. Five role development stages, with a set of descriptors, were identified: encounter, engagement, stabilization, competency and mastery. Conclusion. Identification of these five role development stages for addiction nurses offers employers, nurse managers, educators and addiction nurses a starting point from which specific occupational competencies can be further explored. In addition, continuing professional development needs can be mapped to specific role development stages. Employers and nurse managers may wish to offer increased learning opportunities to student nurses to gain work experience within specialist addiction units.

Cournoyer LG; Brochu S; Landry M; Bergeron J. Therapeutic alliance, patient behaviour and dropout in a drug rehabilitation programme: The moderating effect of clinical subpopulations. Addiction 102(12): 1960-1970, 2007. (39 refs.)

Aim: Treatment dropout is an important concern for professionals working in mental health. While this problem is common, the highest attrition rates have been observed in drug rehabilitation programmes. The present study focuses on the therapeutic alliance, a process variable that has been associated repeatedly with positive treatment outcome in the scientific literature. Respondent behaviour indicative of commitment or resistance to treatment was examined in combination with therapist prognoses. Design: A total of 248 subjects, classified into three subpopulations (justice, n = 50; mental health, n = 53; comparison group, n = 145), participated in the study. Analyses aimed at predicting dropout were conducted using Cox proportional-hazards regressions. The moderating effect of sub-population was tested. Measurements Respondents completed a multi-dimensional measure of alliance [California Psychotherapeutic Alliance Scale (CALPAS-P)]. Therapists rated the behaviour of respondents in treatment and made prognoses about perseverance and improvement. Findings: An increased risk of dropout was predicted when patients viewed themselves as less committed and perceived the therapist as less understanding and less involved. Therapist prognosis of perseverance was also predictive of dropout. The relationship between patient/therapist evaluations and dropout is affected differently across subpopulations by means of a moderation effect. Conclusion: This paper demonstrates the capacity to predict dropout by measuring therapeutic alliance, therapist prognoses and therapist appraisal of patient behaviour. Moreover, the moderation effect of clinical subpopulation on treatment process variables and dropout is supported in the context of drug rehabilitation programmes.

Crits-Christoph P; Gibbons MBC; Ring-Kurtz S; Gallop R; Present J. A pilot study of community-friendly manual-guided drug counseling. Journal of Substance Abuse Treatment 37(1): 8-16, 2009. (30 refs.)

Therapist training manuals that are more "community friendly" are needed to facilitate effectiveness testing and dissemination of treatments to community based setting. The aim of the current project was to create revised versions of individual drug counseling (IDC) and group drug counseling (GDC) treatment manuals for cocaine dependence and to conduct a preliminary study of their effectiveness. After changing the format and context of existing drug counseling manuals to have greater ease of use in the community, draft manuals were given to 23 community-based counselors for their feedback. Final versions were then used in a pilot randomized clinical trial involving 41 cocaine-dependent patients who received 3 months of either IDC + GDC or GDC-alone treatment. Counselors implemented the new treatment manuals with acceptable levels of adherence and competence. Outcome results indicated that substantial change in drug use was evident, but the amount of abstinence obtained was limited.

De Weert-Van Oene GH; Jorg F; de Jong CAJ. Association between interpersonal behaviour and helping alliance in substance-dependent patients. European Addiction Research 12(2): 67-73, 2006. (15 refs.)

This paper focuses on exploring the association between the patient's perception of his own interpersonal behaviour on the one hand, and that of the therapist's behaviour and of helping alliance on the other hand. A crosssectional study was conducted, including 83 patients from substance dependence programs in The Netherlands. They completed the Helping Alliance Questionnaire (HAQ) and the Interpersonal Check List (ICL). Results indicate that the patient's perception of the therapeutic alliance, and his perception of his own and of the therapist's interpersonal behaviour are three separate domains, each playing their role in the context of the therapeutic relationship. Helping Alliance scores are predicted by both the patient's ( complaisance) and the therapist's interpersonal behaviour ( dominance). We conclude that patient's cognitions about himself and about his therapist do contribute significantly to the perception of the therapeutic relationship. Limitations to the study are discussed, as well as some clinical implications.

Drabble L. Pathways to collaboration: Exploring values and collaborative practice between child welfare and substance abuse treatment fields. Child Maltreatment 12(1): 31-42, 2007. (32 refs.)

Although recent research has highlighted the importance of "bridging the gap" between child welfare and substance abuse treatment delivery systems, few studies examine specfic factors that may facilitate such collaboration. This study examined similarities and differences in values and perceived capacity for collaboration between substance abuse and child we (are fields based on survey data from more than 350 respondents in 12 California counties. Although respondents across disciplines held similar values in some areas, such as priorities for services, significant differences between respondents from child welfare and substance abuse fields were found in other areas, including values and beliefs about drug use and drug-using parents, funding; and planning and measurement Of outcomes. Respondents from counties with a strong history of collaboration were more likely to report institutionalized collaborative practices in several areas, from use of multidisciplinary teams for case planning to use of multiyear budgeting to plan for integrated services.

Duraisingam V; Pidd K; Roche AM. The impact of work stress and job satisfaction on turnover intentions: A study of Australian specialist alcohol and other drug workers. Drugs: Education, Prevention and Policy 16(3): 217-231, 2009. (43 refs.)

Aims: A national study was conducted to investigate the extent and nature of job attitudes and well-being of specialist alcohol and other drug (AOD) workers in Australia. As part of that larger study, work stress and job satisfaction and their relationship with turnover intentions were examined. Method: A postal survey measuring working conditions, work stress, job satisfaction, turnover intention and key demographics among specialist frontline workers from AOD treatment services across Australia was undertaken. A total of 1345 responses from workers in 369 participating AOD treatment services were obtained. Findings: Although the majority of workers were satisfied with their jobs, one in five workers reported above average levels of stress. One in five workers also expressed intentions to leave the AOD field. Significant predictors of higher turnover intention were low job satisfaction, high work stress, low workplace social support and negative attitudes towards remuneration. Conclusion: This study was the first attempt to collect empirical data on levels of stress and job satisfaction among the Australian specialist AOD workforce. The findings presented here focus on work stress and job satisfaction and their association with turnover intention. The results indicate cause for concern and have important implications for the development of strategies to minimize turnover and improve the well-being of specialist AOD workers in Australia.

Edmundson E; McCarty D, eds. Implementing Evidence-Based Practices for Treatment of Alcohol and Drug Disorders. London: Routledge, 2006

This volume, directed to clinicians and program administrators, describes the results from a clinical research initiative Practice Improvement Collaboratives (PIC) conducted by the Veterans Administration. It highlights how substance abuse treatment can be improved by increasing the exchange of knowledge between community-based service providers and the research community and describes the collaborative efforts and the mentoring strategies used in adopting evidence-based practices. Among the topics discussed are how to determine the best treatment processes, how to deal with the hurdles faced in preparing and training counselors, and how to affect the needed changes in agency activities, taking into account differences in clinician backgrounds and training. Also discussed are the effectiveness of different training approaches so as to address the attitudes, behavior and knowledge and treatment

Egel D; Torino TM. Violence intervention prevention. Journal of Addictions Nursing 17(1): 13-19, 2006. (9 refs.)

The Office of Alcoholism and Substance Abuse Services (OASAS) operates 13 Addiction Treatment Centers located across New York State. This article examines the issues and problems faced by a joint labor/management team that designed and implemented a workplace violence intervention prevention program for inpatient drug addiction treatment programs.

Fahy A. The unbearable fatigue of compassion: Notes from a substance abuse counselor who dreams of working at Starbuck's. Clinical Social Work Journal 35(3): 199-205, 2007. (31 refs.)

Current research has determined that a larger percent of social workers and other counselors are affected by PTSD types of symptoms when working with traumatized clients than the general population. While much of this research addresses workers in specific trauma areas like sexual assault centers or child welfare agencies, little specific thought has been given towards the special stress that working with Substance Abuse Disorders (SA) and trauma may present. This paper takes a brief look at the issues of vicarious trauma and compassion fatigue with SA practice and describes future investigation pathways toward this goal.

Fairbairn CE; Dundon WD; Xie H; Plebani JG; Kampman KM; Lynch KG. Study blinding and correlations between perceived group assignment and outcome in a cocaine pharmacotherapy trial. American Journal on Addictions 17(5): 387-391, 2008. (19 refs.)

While much research has suggested that the integrity of the blind is compromised in psychotropic drug trials, little research has been conducted on blinding in substance abuse trials. The current study examines the integrity of the blind in an outpatient pharmacotherapy trial investigating the effectiveness of amantadine and propranolol in treating cocaine addiction. Results suggest that neither nurses (N = 174, kappa = 0.08, p = 0.22) nor participants (N = 163, kappa = 0.09, p = 0.26) could accurately predict treatment assignment. Furthermore, nurses' perceptions of treatment assignment were significantly related to trial completion, medication compliance, and cocaine use -- results that may have training implications for medical personnel.

Feldstein SW; Forcehimes AA. Motivational interviewing with underage college drinkers: A preliminary look at the role of empathy and alliance. American Journal of Drug and Alcohol Abuse 33(5): 737-746, 2007. (24 refs.)

This study evaluated the impact of a motivational interview (MI) on alcohol use in underage college drinkers, and examined the specific role of empathy and alliance in MI. Fifty-five underage heavy drinkers were randomized to a one-session MI or no-treatment control. Empathy and alliance were evaluated through the MITI, participant, and therapist ratings. At two-month follow-up, multivariate tests reveal no significant interaction effects. Means comparisons indicated that both groups showed reductions in alcohol-related problems, however, only the MI sample evidenced significant reductions in binge drinking. In addition, despite the reductions of both groups, effect sizes indicated that the MI group outperformed the control in terms of binge-drinking and alcohol-related problems. Contrary to predictions, empathy and alliance showed no relationships with outcomes.

Fenster J. Characteristics of clinicians likely to refer clients to 12-Step programs versus a diversity of post-treatment options. Drug and Alcohol Dependence 83(3): 238-246, 2006. (30 refs.)

Most clients in substance abuse treatment are referred for continuing care. However, post-treatment services vary widely in their approaches to helping individuals achieve better substance use outcomes. This study examined the attitudes of outpatient treatment staff who refer clients exclusively to 12-Step groups (12-Step subgroup) and staff who refer clients both to 12-Step groups and to other continuing care options (Diversity subgroup) toward seven mutual-aid and professional psychosocial post-treatment options: Twelve-Step Programs (12-Step), Cognitive-Behavioral Therapy (CBT), Moderation Management (MM), Smart Recovery(r) (SMART), Psychodynamic-oriented Therapy (PSY), Secular Organizations for Sobriety (SOS), and Women for Sobriety (WFS). A large percentage of clinicians lacked knowledge about the effectiveness of all alternatives to 12-Step programs with the exception of CBT. Clinicians in the 12-Step subgroup were more likely than those in the Diversity subgroup to be unfamiliar with alternatives to 12-Step programs and to believe less strongly in the effectiveness of CBT and PSY. A logistic regression found beliefs about CBT effectiveness and clinician preference for the 12-Step model to be related to the likelihood of referring exclusively to 12-Step groups. Findings suggest that clinicians could benefit from information and training on assessing and referring clients to various options for continuing care.

Fornili K. Another quality chasm: The failure of nursing to clearly communicate its role within the addiction treatment workforce. (editorial). Journal of Addictions Nursing 18(1): 57-59, 2007. (11 refs.)

Nurses in general, and addictions nurses in particular, are the "invisible" members of the addictions treatment workforce, which can be attributed, in part, to a critical failure of nursing to communicate its role within the addictions treatment workforce. This column highlights the relative lack of information available regarding the role of generalist as well as specialty nurses in the care of individuals with substance use disorders (SUDs). It challenges nurses and nurse educators to continue to critically evaluate the role of nurses in the addictions treatment workforce, and to promote recognition of the valuable contribution that nursing can, and has, contributed to the quality of care delivered to individuals that suffer from those disorders.

Foster J; Tyrell K; Cropper V; Hunt N. Two case studies of user involvement in the recruitment of staff for drug services. Drugs: Education, Prevention and Policy 14(1): 89-94, 2007. (3 refs.)

We provide a summary of our experience in two contrasting drug services where we attempted to involve the users of drug services in staff recruitment. This proved feasible and appears to offer several potential benefits for service users and treatment agencies; as well as complementing the wider development of user-involvement activities. A considerable investment of time and effort was initially required to develop and implement training but direct costs are low. Practical factors, such as an urgent need to recruit staff rapidly and keep services operating, made it difficult to involve service users on all occasions. Our experience suggests that the methods for involving service users need to be tailored to local circumstances and the size of the organization. Where services are encouraged to demonstrate 'user involvement', participation in staff recruitment may be a practical and meaningful performance indicator for drug services.

Freimuth M. Another missed opportunity? Recognition of alcohol use problems by mental health providers. Psychotherapy 45(3): 405-409, 2008. (16 refs.)

Alcohol use problems (AUPs) are prevalent among people seeking psychotherapy. Despite mandates from managed care companies to routinely screen for AUPs, little is known about the screening practices of providers or their ability to identify AUPs based on presenting symptoms. Participants (N = 117) read two case vignettes and suggested initial diagnoses and questions they would ask in order to clarify a diagnosis. Participants were more likely to ask about substance use and diagnose an AUP when the vignette contained explicit reference to the client's substance use as compared to a vignette where the signs of an A UP were more subtle. In both vignettes, a mental health problem was a more likely diagnosis than an AUP. Neither participant attributes nor personal or professional experiences with AUPs reliably shaped responses to the vignettes. The findings are discussed in light of their implications for future research and improved training in addictions for mental health providers.

Fuller BE; Guydish J; Tsoh J; Reid MS; Resnick M; Zammarelli L et al. Attitudes toward the integration of smoking cessation treatment into drug abuse clinics. Journal of Substance Abuse Treatment 32(1): 53-60, 2007. (44 refs.)

This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Organizational factors, attributes of the treatment setting, and staff attitudes toward smoking cessation treatment were assessed. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care.

Garner BR. Research on the diffusion of evidence-based treatments within substance abuse treatment: A systematic review. (review). Journal of Substance Abuse Treatment 36(4): 376-399, 2009

This article provides a comprehensive review of research studies that have examined the diffusion of evidence-based treatments (EBTs) within the field of substance abuse treatment. Sixty-five research studies were identified and were grouped into one of three major classifications: attitudes toward EBTs, adoption of EBTs, and implementation of EBTs. This review suggests significant progress has been made with regard to the advancement of the fields' knowledge about attitudes toward and the extent to which specific EBTs have been adopted in practice, as well as with regard to the identification of organizational factors related to EBT adoption. In an effort to advance the substance abuse treatment field toward evidence-based diffusion practices, recommendations are made for greater use of methodologically rigorous experimental or quasi-experimental designs, psychometrically sound instruments, and integration of quantitative and qualitative data collection.

Garner BR; Knight K; Simpson DD. Burnout among corrections-based drug treatment staff - Impact of individual and organizational factors. IInternational Journal of Offender Therapy and Comparative Criminology 51(5): 510-522, 2007. (33 refs.)

As a result of limited budgets, many treatment programs are forced to operate for extended periods at or beyond their capacity. The resulting pressure and stress on treatment staff can be taxing and lead to serious problems, including job burnout. Although the concept of burnout within other social service professions has been broadly researched, less attention has been given to burnout among drug abuse treatment staff, especially among corrections-based drug treatment staff. The goal of this article is to extend this area of research by exploring the impact of individual factors and organizational factors on burnout. Findings revealed that although a number of factors were related to staff burnout, younger counselor age, lower adaptability, poorer clarity of agency mission, and higher stress were most significant. Ways in which treatment programs might address these issues affecting staff burnout are discussed.

Gaume J; Gmel G; Faouzi M; Daeppen JB. Counsellor behaviours and patient language during brief motivational interventions: A sequential analysis of speech. Addiction 103(11): 1793-1800, 2008. (21 refs.)

Aims: To investigate empirically the hypothesized relationship between counsellor motivational interviewing (MI) skills and patient change talk (CT) by analysing the articulation between counsellor behaviours and patient language during brief motivational interventions (BMI) addressing at-risk alcohol consumption. Design: Sequential analysis of psycholinguistic codes obtained by two independent raters using the Motivational Interviewing Skill Code (MISC), version 2.0. Setting Secondary analysis of data from a randomized controlled trial evaluating the effectiveness of BMI in an emergency department. Participants: A total of 97 patients tape-recorded when receiving BMI. Measurements: MISC variables were categorized into three counsellor behaviours (MI-consistent, MI-inconsistent and 'other') and three kinds of patient language (CT, counter-CT (CCT) and utterances not linked with the alcohol topic). Observed transition frequencies, conditional probabilities and significance levels based on odds ratios were computed using sequential analysis software. Findings: MI-consistent behaviours were the only counsellor behaviours that were significantly more likely to be followed by patient CT. Those behaviours were significantly more likely to be followed by patient change exploration (CT and CCT) while MI-inconsistent behaviours and 'other' counsellor behaviours were significantly more likely to be followed by utterances not linked with the alcohol topic and significantly less likely to be followed by CT. MI-consistent behaviours were more likely after change exploration, whereas 'other' counsellor behaviours were more likely only after utterances not linked with the alcohol topic. Conclusions: Findings lend support to the hypothesized relationship between MI-consistent behaviours and CT, highlight the importance of patient influence on counsellor behaviour and emphasize the usefulness of MI techniques and spirit during brief interventions targeting change enhancement.

Gaume J; Gmel G; Faouzi M; Daeppen JB. Counselor skill influences outcomes of brief motivational interventions. Journal of Substance Abuse Treatment 37(2): 151-159, 2009. (38 refs.)

The aim of this study was to estimate the influence of counselor skills during brief motivational interventions (BMIs) on patient alcohol use 12 months later. Ninety-five BMIs delivered by five counselors of similar background and training were recorded and coded using the Motivational Interviewing Skills Code (MISC). Baseline alcohol measures and sociodemographics of patients did not differ across counselors, whereas MISC scores and outcome at 12 months did. Multilevel models showed that counselors with better motivational interviewing (MI) skills achieved better outcomes overall and maintained efficacy across all levels of an important predictor (patient ability to change), whereas counselors with poorer MI skills were effective mostly at high levels of ability to change. Findings indicated that avoidance of MI-inconsistent skills was more important than frequency of using MI-consistent skills and that training and selection of counselors should be based more on the overall MI-consistent gestalt than on particular MI techniques.

Grella CE; Greenwell L; Prendergast M; Farabee D; Hall E; Cartier J et al. Organizational characteristics of drug abuse treatment programs for offenders. Journal of Substance Abuse Treatment 32(3): 291-300, 2007. (74 refs.)

This article examines the association between the organizational characteristics of drug abuse treatment programs for offenders and the provision of wraparound services and three types of treatment orientations. Data are from the National Criminal Justice Treatment Practices Survey, which was conducted with program directors (N = 217). A greater number of wraparound services provided were associated with inpatient treatment, specialized treatment facilities, community setting (vs. correctional), services provided for more types of client populations, college-educated staff, and planned treatment for > 180 days. Therapeutic community orientation was associated with prison-based treatment and specialized treatment facilities. Cognitive-behavioral therapy orientation was associated with higher perceived importance of community treatment, more perceived staff influence on treatment, and treatment for 91-180 days. The 12-step orientation was most strongly associated with having staff specialized in substance abuse. Study findings have implications for developing effective reentry programs for offenders that bridge correctional and community treatment.

Hagedorn, WB. Editor's Note. Journal of Addictions & Offender Counseling 27(1): 46, 2006. (1 refs.)

In this article, the editor explains why an article from "Counselor Education and Supervision" is reprinted in this issue. For one, the edior states he does not believe there is much overlap in readership. Secondly, it there are the recent developments of the Council for Accreditation of Counseling and Related Educational Programs (CACREP) Board of Directors. First, the Board voted unanimously to forward the proposed Addictions Counseling Program area standards to be considered by the SRC for inclusion in the 2008 CACREP Standards. Furthermore, the Board voted unanimously for the SRC to consider the integration of addictions-related competencies into the core curriculum for every CACREP program area. This means that graduate students in all program areas, including School Counseling, College Counseling, Career Counseling, Student Affairs, Marital, Couple, and Family Counseling, and Counselor Education and Supervision doctoral programs, will have to demonstrate competence in addictions counseling.

Halonen M. Life stories used as evidence for the diagnosis of addiction in group therapy. Discourse & Society 17(3): 283-298, 2006. (30 refs.)

In this article I study how the life stories of patients are used as evidence in the diagnosis of addiction in Minnesota model group therapy. As part of this therapy, patients have to tell their life story, concentrating on their substance abuse. This story is used by the therapists as a means for getting patients to recognize and accept that they are addicts. For this purpose the therapists use intervening questions. This article concentrates on the placement and the structure of the patients' responses to these interventions and the kinds of attitudes or standpoints the patients express. I will also discuss ways in which the theory of the Minnesota model informs the therapists' actions by analysing the places within the patient's story where the therapists choose to intervene and the structure of their intervening turns. The data of the study consist of five 45-minute group therapy sessions and three multi-professional team meetings in a Finnish inpatient clinic. The therapists pose questions when the patient has said something that clearly hints at a symptom of addiction. The questions are designed as (disjunctive) yes/no questions which offer to the patient two alternative formulations of their talk to choose from. The first alternative hints at less problematic use of alcohol, and the latter, often an only implicit alternative, hints at more problematic consumption. This order offers to the patient an opportunity to choose the less problematic version in a preferred manner - if they are to display themselves as not having more problems with consumption than anyone else. The therapists can, then, use the patients' responses to monitor how they have adopted the treatment and the diagnosis of addiction, that is, whether they are resistant or compliant.

Harris GT; Parle D; Gagne J. Effects of a tobacco ban on long-term psychiatric patients. Journal of Behavioral Health Services & Research 34(1): 43-55, 2007. (50 refs.)

A total ban on all tobacco products was implemented in a diverse psychiatric institution. A post hoc evaluation examined the effect of the ban on long-term patients by comparing their characteristics the year before the ban to the year after. Several variables measuring physical health, psychiatric symptomatology, feelings of well-being, and interpersonal conflict were coded with very high reliability from health records. For the majority of patients who were in the maximum security forensic division, the tobacco ban was associated with almost no detectable ill effects with some clear benefits. Among the remainder of the long-term patients, the ban might have been associated with a temporary increase in physical aggression towards staff members. It was concluded that successful implementation, and the avoidance of ill effects, depended entirely on the success staff members had in actually preventing patient access to tobacco.

Hartzler B; Baer JS; Dunn C; Rosengren DB; Wells E. What is seen through the looking glass: The impact of training on practitioner self-rating of Motivational Interviewing skills. Behavioural and Cognitive Psychotherapy 35(4): 431-445, 2007. (25 refs.)

Training efforts for evidenced based treatments require evaluation, yet the value of practitioner self-reports of skills acquisition has been questioned. Thus, a key issue concerns how accurately practitioners assess their own clinical skills. In the current study, 23 community practitioners participated in training of Motivational Interviewing (MI), completed standardized patient (SP) interviews before and after training, and provided self-ratings of MI elements after each interview. Interview recordings were later coded independently. Results suggest training contributed to: 1) reasonable agreement between practitioner and independent ratings; and 2) more effective use of MI, despite a tendency for practitioners to underestimate training gains. This micro-analysis of training documents initial skill gains along with increased practitioner self-awareness. Further, it exemplifies how practitioner self-ratings and objective skill assessment methods may be used in tandem to more fully describe practitioner learning.

Hilton TF. Staff members are human subjects, too. Journal of Substance Abuse Treatment 31(1): 9-15, 2006. (25 refs.)

Top management, clinical supervisors, secretaries, government administrators, counselors, and patients are all examples of informants and agents used by health services researchers as they strive to learn how organizational and managerial factors affect the effectiveness, efficiency, quality, and the cost of substance abuse treatment and prevention services. Patients are clearly a vulnerable population, and researchers in clinical settings, as a rule, strive to protect patient safety and rights to privacy. However, as researchers begin to expand the scope of their study to the organizational contexts in which services are delivered, those responsible for providing services (staff members) are frequently enlisted to serve both as informants on policies and practices, and as participants acting as agents of the researchers in innovating therapeutic and business practices. Researchers need to be mindful that staff members, when acting as informants or as agents, are human subjects, too; and, as such, research procedures should be designed in a manner that minimizes their risk and conforms to sound ethical guidelines. In the interest of stimulating dialogue on ways to protect staff members from unintended harm, this essay overviews human subjects protection policy, describes examples of risks, and offers suggestions for preventing harm when designing studies.

Hobden K; Cunningham J. Barriers to the dissemination of four harm reduction strategies: A survey of addiction treatment providers in Ontario. Harm Reduction Journal 3: article 35, 2006. (29 refs.)

A sample of service providers at addictions agencies' in Ontario were interviewed by telephone to assess attitudes toward, anticipated internal and external barriers to implementing, and expected benefits of four harm reduction strategies: needle exchange, moderate drinking goals, methadone treatment, and provision of free condoms to clients. Respondents were also asked to define harm reduction, list its most important elements, and describe what they find most troubling and most appealing about harm reduction. Attitudes toward harm reduction in general and the services provided at each agency were also assessed. Results indicated that the service providers surveyed had positive attitudes toward each of the four harm reduction strategies and harm reduction in general, and the majority of respondents were aware of the benefits associated with each strategy. Almost all of the agencies surveyed allowed for moderate drinking outcomes in the treatment of alcohol problems, and most agencies provided free condoms to clients. In terms of barriers, anticipated negative community reaction to needle exchange, methadone treatment, and free condoms was a major concern for the majority of respondents. Lack of staff, of funding, or anticipated staff resistance were also cited as potential barriers to introducing these strategies. In the case of methadone maintenance, the unavailability of a qualified physician was listed as the primary constraint. Implications for future efforts directed at encouraging the adoption of these strategies and suggestions for future research are discussed.

Hogue A; Dauber S; Stambaugh LF; Cecero JJ; Liddle HA. Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology 74(1): 121-129, 2006. (50 refs.)

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive-behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.

Inciardi JA; Surratt HL; Kurtz SP; Burke JJ. The diversion of prescription drugs by health care workers in Cincinnati, Ohio. Substance Use & Misuse 41(2): 255-264, 2006. (16 refs.)

Data are reported from drug diversion cases involving health care workers who were investigated by the Cincinnati Police Division Pharmaceutical Diversion Squad over an 11-year period. This type of information is rarely available because few U.S. police jurisdictions dedicate resources to prescription drug diversion surveillance. Data from 1992 through 2002 show that opioids were the drugs most commonly diverted by health care workers, followed by benzodiazepines. Nurses, nursing assistants, and medical assistants were involved in almost three quarters of all cases. Hospitals were the most common sources of complaint to police, followed by pharmacies. Health care professional associations are advised to promote greater awareness of drug misuse and dependence concerns among their memberships, and health care facilities that stock pharmaceuticals liable for misuse and diversion are advised to increase the security of their supplies.

Jarvinen M. Approaches to methadone treatment: Harm reduction in theory and practice. Sociology of Health & Illness 30(7): 975-991, 2008. (29 refs.)

The paper analyses methadone treatment in Copenhagen - as it is described by methadone users and staff at different outpatient centres. The starting point is a theoretical model distinguishing between two different approaches to methadone treatment: 'palliative' and 'curative'. Included in the model are three dimensions (1) treatment goals at the methadone centres (abstinence vs. stabilisation) (2) treatment focus (focus on addiction vs. focus on the consequences of addiction) and (3) conceptualisation of methadone (methadone as similar to or different from heroin). The paper shows that there is a discrepancy between the attitudes of the staff and those of the users. While the staff favour an almost clear-cut palliative approach to methadone treatment, defining curative goals as both unrealistic and as belonging to the past, the users prefer an approach that does not exclude the goal of abstinence and does not focus on the consequences of drug use alone but also on their problematic relationship to drugs (legal as well as illegal). Furthermore, the users' attitudes towards methadone are far more ambivalent than the staff's. For the users, methadone is not just medicine; it is also a dependence-producing and 'dangerous' drug.

Jefferies RB. Counselling Young Binge Drinkers: Person Centred Diaglogues. Abington UK: Radcliffe Publishing Ltd, 2006

This book focuses upon describing the "center person approach" to dealing with binge drinking in young adults. It is part of the Living Therapy series and endeavors to describe a therapeutic process. It begins with a brief introduction to 'person-centered' theory and its clinical use. It is organized in person-centered dialogues, of client and therapist, and deals with the counseling experiences of two young people, each with problems related to binge drinking. Beyond depicting the counseling sessions, there is also chapters that deal with clinical supervision, thus highlighting the clinical encounter for the clinician. It does not describe the epidemiology of drinking patterns, the associated morbidity, or the like.

Karol DE; Schuermeyer IN; Brooker CA. The case of HS: The ethics of reporting alcohol dependence in a bus driver. International Journal of Psychiatry in Medicine 37(3): 267-273, 2007. (6 refs.)

The physician's duty to preserve patient confidentiality is challenged when doing so may endanger third parties. We present the case of a bus driver whose alcohol dependence raised concerns of a risk not only to his own health and safety, but to public safety as well. We first examine the legal and ethical obligations to report his alcohol use to his employer and then stress the importance of weighing the potential harm of violating patient-physician confidentiality against the severity of risk to the general public.

Kelly JF; Yeterian JD; Myers MG. Treatment staff referrals, participation expectations, and perceived benefits and barriers to adolescent involvement in twelve-step groups. Alcoholism Treatment Quarterly 26(4): 427-449, 2008

Adolescents treated for substance use disorders (SUDs) appear to benefit from participation in Alcoholics Anonymous/Narcotics Anonymous (AA/NA). However, as compared with adults, fewer adolescents attend, and those who do attend do so less intensively and discontinue sooner. It is unknown whether this disparity is due to a lowered expectation for youth participation by the clinicians treating them, as they may adapt the adult-based model to fit a less-dependent cohort, or whether recommendations are similar to those of clinicians who work with adults and other factors are responsible. All clinical staff (N= 114) at 5 adolescent programs (3 residential, 2 outpatient) were surveyed anonymously about referral practices and other beliefs about 12-step groups. Staff rated AA/NA participation as very important and helpful to adolescent recovery and referral rates were uniformly high (M= 86%, SD= 28%). Desired participation frequency was over 3 times per week. The theoretical orientation and level of care of the programs influenced some results. Findings suggest lower adolescent participation in 12-step groups is not due to a lack of clinician enthusiasm or referrals, but appears to be due to other factors.

Kidd SA; Miner S; Walker D; Davidson L. Stories of working with homeless youth: On being "mind-boggling". Children and Youth Services Review 29(1): 16-34, 2007. (31 refs.)

This study examines the narratives of 15 youth workers on their experiences with service provision for homeless and street-involved youth. Workers discussed a need to have a versatile approach which can be tailored to an individual youth's circumstances. Establishing a connection based upon valuing, respecting, and liking a youth allows for the development of a trusting relationship which is essential for effective interventions. Also addressed was the social context of this work including relationships among staff, agency structure, and the impact of the stigmatization of homelessness. Lastly, the process of becoming an effective worker was addressed, including the establishment of clear boundaries, recognizing the rewarding aspects of the work, and avoiding burnout.

Kim TW; Samet JH; Cheng DM; Winter MR; Safran DG; Saitz R. Primary care quality and addiction severity: A prospective cohort study. Health Services Research 42(2): 755-772, 2007. (45 refs.)

Background. Alcohol and drug use disorders are chronic diseases that require ongoing management of physical, psychiatric, and social consequences. While specific addiction-focused interventions in primary care are efficacious, the influence of overall primary care quality on addiction outcomes has not been studied. The aim of this study was to prospectively examine if higher primary care quality is associated with lower addiction severity among patients with substance use disorders. Study Population. Subjects with alcohol, cocaine, and/or heroin use disorders who initiated primary care after being discharged from an urban residential detoxification program. Measurements. We used the Primary Care Assessment Survey (PCAS), a well-validated, patient-completed survey that measures defining attributes of primary care named by the Institute of Medicine. Nine summary scales cover two broad areas of primary care quality: the patient-physician relationship (communication, interpersonal treatment, thoroughness of the physical exam, whole-person knowledge, preventive counseling, and trust) and structural/organizational features of care (organizational access, financial access, and visit-based continuity). Each of the three addiction outcomes (alcohol addiction severity (ASI-alc), drug addiction severity (ASI-drug), and any drug or heavy alcohol use) were derived from the Addiction Severity Index and assessed 6-18 months after PCAS administration. Separate longitudinal regression models included a single PCAS scale as the main predictor variable as well as variables known to be associated with addiction outcomes. Main Results. Eight of the nine PCAS scales were associated with lower alcohol addiction severity at follow-up (p <=.05). Two measures of relationship quality (communication and whole-person knowledge of the patient) were associated with the largest decreases in ASI-alc (-0.06). More whole-person knowledge, organizational access, and visit-based continuity predicted lower drug addiction severity (ASI-drug: -0.02). Two PCAS scales (trust and whole-person knowledge of the patient) were associated with lower likelihood of subsequent substance use (adjusted odds ratio, [AOR]=0.76, 95 percent confidence interval [95% CI] =0.60, 0.96 and AOR=0.66, 95 percent CI=0.52, 0.85, respectively). Conclusion. Core features of primary care quality, particularly those reflecting the quality of the physician-patient relationship, were associated with positive addiction outcomes. Our findings suggest that the provision of patient-centered, comprehensive care from a primary care clinician may be an important treatment component for substance use disorders.

Klingemann H; Bergmark A. The legitimacy of addiction treatment in a world of smart people. Addiction 101(9): 1230-1237, 2006. (63 refs.)

Aim: This paper discusses what type of legitimacy underpins addiction treatment in contemporary western societies. Method: Broad review of the relevant literature. Conclusions: The legitimacy of professional interventions and the future of service provision will depend largely on the relationship between the professional and the lay referral system. These in turn are intertwined with macro-societal changes. The basic categories in this relationship are, on one hand, the idea of evidence-based practice (i.e. the notion of using the most accurate scientific support for the choice of treatment interventions), and on the other hand the consumer perspective, which conceptualizes addiction treatment as an interactive process between the treatment provider and the consumer. The acceptance of addiction treatment depends in most cases on the client who chooses from a whole range of informal and formal problem solutions. To an extent, experts are thus controlled by their lay counterparts and need their consent to operate and succeed. This process is complicated by the trend towards evidence-based practice, which demands transparency and rigorous procedures and carries with it the basis for distrust in expert knowledge by displaying openly that every statement of fact is open to revision, and thus, to a certain extent, characterized by uncertainty.

Knudsen HK; Ducharme LJ; Roman PM. Clinical supervision, emotional exhaustion, and turnover intention: A study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse. Journal of Substance Abuse Treatment 35(4): 387-395, 2008. (59 refs.)

An intriguing hypothesis is that clinical supervision may protect against counselor turnover. This idea has been mentioned in recent discussions of the substance abuse treatment workforce. To test this hypothesis, we extend our previous research on emotional exhaustion and turnover intention among counselors by estimating the associations between clinical supervision and these variables in a large sample (N = 823). An exploratory analysis reveals that clinical supervision was negatively associated with emotional exhaustion and turnover intention. Given our previous findings that emotional exhaustion and turnover intention were associated with job autonomy, procedural justice, and distributive justice, we estimate a structural equation model to examine whether these variables mediated clinical supervision's associations with emotional exhaustion and turnover intention. These data support the fully mediated model. We found that the perceived quality of clinical supervision is strongly associated with counselors' perceptions of job autonomy, procedural justice, and distributive justice, which are, in turn, associated with emotional exhaustion and turnover intention. These data offer support for the protective role of clinical supervision in substance abuse treatment counselors' turnover and occupational well-being.

Kubiak SP; Arfken CL. Comparing credentialing requirements of substance abuse treatment staff by funding source. Journal of Substance Abuse Treatment 35(1): 93-98, 2008. (20 refs.)

Studies have found that clinicians with higher education and/or attainment of national certification have a more favorable outlook regarding the adoption of evidence-based practices. However, staff hiring decisions may be based on a multitude of factors, including available resources and demands stemming from different funders. Using a mixed-methods case study approach with 34 agencies within one state, we assessed administrators' perspectives of the most important funding source, views on clinical hiring practices, and current staffing. We found that funding source predicted views and actual staff level of credentialing and education. Those agencies citing a criminal justice entity as the most important funder had the lowest requirements for credentialing and education. As the substance abuse treatment delivery system evolves and expands, we must ensure that vulnerable groups have access to more highly-rather than less-skilled workers to assess and facilitate recovery.

Kunins H; Gilbert L; Whyte-Etere A; Meissner P; Zachary M. Substance abuse treatment staff perceptions of intimate partner victimization among female clients. Journal of Psychoactive Drugs 39(3): 251-257, 2007. (22 refs.)

Providing intimate partner violence (IPV)-related services to women enrolled in substance abuse treatment programs has the potential to reach a population disproportionately affected by IPV. Integrating basic IPV services into substance abuse treatment, however, poses challenges to organizations and staff. Using focus groups, the authors examined the experiences and attitudes of substance abuse treatment staff towards clients with IPV victimization experiences in order to elucidate factors that might affect the implementation of IPV services within substance abuse treatment. Seven focus groups were conducted with staff members from substance abuse treatment programs in New York City. Although participants believed that IPV is common and negatively affects client recovery, they felt competing time demands, complex confidentiality issues, insufficient training and lack of agency leadership would impede their provision of IPV-services. The study suggests that system-level assessment and change is needed to provide IPV-related services in substance abuse treatment settings.

Leontieva L; Horn K; Helmkamp J; Furbee M; Jarrett T; Williams J. Counselors' reflections on the administration of screening and brief intervention for alcohol problems in the emergency department and 3-month follow-up outcome. Journal of Critical Care 24(2): 273-279, 2009. (30 refs.)

Objectives: The purpose of this paper was to explore how events that counselors endorsed occurring during an emergency department-based screening and brief intervention (SBI) for drinking discriminate patients who reported change in Alcohol Use Disorder Identification Test (AUDIT) domains at follow-up from those who did not. Method: Patients who scored ">5" on the AUDIT were eligible for SBI. At the end of each intervention, counselors completed the questionnaire indicating which parts of the intervention they just used. Results: Discriminant function analyses indicated that "Referral made" discriminated for alcohol intake change (Wilks' lambda = 0.993, P < .05) "Did the patient set goals during intervention?" and "Referral made" discriminated for alcohol dependency change (Wilks' lambda = 0.940 and Wilks' lambda = 0.919, P < .05, respectively). "Intention to quit" (Wilks' lambda = 0.984, P < .05) discriminated for alcohol-related harm change. Conclusions: Making referrals to addiction treatment during motivational intervention discriminated for alcohol intake and dependency change. Working on intention to quit is an important point in changing alcohol-related harm. When conducting the SBI in ED, counselors may be mindful in making appropriate referrals to address alcohol use and examine intention to quit to maximize the efficacy of the harm-reduction approach.

Leung GM; Chan SSC; Johnston JM; Chan SKK; Woo PPS; Chi I et al. Effectiveness of an elderly smoking cessation counseling training program for social workers: A longitudinal study. Chest 131(4): 1157-1165, 2007. (30 refs.)

ground: To achieve greater coverage of the elderly smoking population, the provider/client interface could be broadened to include other professional groups who work with the elderly. We evaluated the effectiveness of a 9-h smoking cessation counseling training program for social workers. Methods: We recruited 177 social workers and used a preintervention/postintervention longitudinal design, analyzed by multilevel, multivariable modeling to adjust for between-subjects covariables and within-subjects correlation in repeated measurements at baseline, 3 months, 6 months, and 12 months after training. Results: Overall,, knowledge improved from a mean score of 6.70 +/- 1.03 (+/- SD) at baseline to 7.35 +/- 0.75 at 12 months (range, 0 to 8 correct responses), attitude from 2.84 +/- 0.41 to 3.10 +/- 0.48, and self-perceived competence from 2.49 +/- 0.38 to 2.85 +/- 0.36 (range, 1 to 4, where 4 is best). On multilevel modeling, three of the four "A"s (ask, advice, assist, arrange as per the Agency for Healthcare Research and Quality framework) registered significant gains from baseline to 12 months overall, whereas "advice" did not show any appreciable change. Conclusion: These findings demonstrate that our smoking cessation training program achieved sustained effectiveness in the first year after training in enhancing knowledge, positively shifting attitudes, boosting self-perceived competence, and increasing the self-reported frequency of practicing three of the four As in their routine interaction with elderly clients.

Liddle HA; Rowe CL; Gonzalez A; Henderson CE; Dakof GA; Greenbaum PE. Changing provider practices, program environment, and improving outcomes by transporting multidimensional family therapy to an adolescent drug treatment setting. American Journal on Addictions 15(Supplement 1): 102-112, 2006. (21 refs.)

Effective interventions for drug abusing adolescents are underutilized. Using an interrupted time series design, this study tested a multicomponent, multi-level technology transfer intervention developed to train clinical staff within an existing day treatment program to implement multidimensional family therapy (MDFT), an evidence-based adolescent substance abuse treatment. The sample included 10 program staff and 104 clients. MDFT was incorporated into the program and changes were noted in the program environment, therapist behavior, and in most (e.g., drug abstinence, and out of home placements) but not all (e.g., drug use frequency) client outcomes. These changes remained after MDFT supervision was withdrawn.

Lu M; Ma CA. Financial inncentives and gaming in alcohol treatment. Inquiry 43(1): 34-53, 2006. (29 refs.)

This study looks at the effect of performance-based contracting (PBC) on administrative information misreports in substance abuse treatment in Maine. For about 700 alcohol abuse treatment episodes in the period 1990-1995, we constructed clinician report gaming indicators from two data sets: the Maine Addiction Treatment System (MATS) and medical record abstracts. Gaming, in this study, refers to differences in MATS reports and the medical records for an episode. Under PBC, which was implemented in 1992, a provider's financial reward was positively related to treatment outcomes measured by some reports from MATS. We found that the introduction of PBC increased gaming. The data supported the hypotheses that clinicians overstated patient severity at the beginning of treatment episodes, and understated severity at the end. Our study suggests two policy implications. First, auditing should be used more often when regulatory authorities must rely on information supplied by providers for financial and funding decisions. Auditing may deter gaming, and gives more reliability to the veracity of reports. Second, establishing a gold standard should be considered whenever it is feasible. In our case, the analysis was possible precisely because we were able to compare the administrative reports against an appropriate standard, namely the medical record abstracts. Having an independent and reliable data source for validating the reliability of administrative data may seem obvious, but appears to have received less emphasis. Data collection methods should consider obtaining the same information in more than one way.

Mackinem MB; Higgins P. Tell me about the test: The construction of truth and lies in drug court. Journal of Contemporary Ethnography 36(3): 223-251, 2007. (77 refs.)

Through a multiyear participant observation study in three southeastern drug courts, we explore how staff members react to clients' responses when confronted with positive tests for illicit drug use. Within their professional beliefs about drug addiction, treatment, and testing, staff members interpret the clients' responses as truths or lies, though some lies are worse than others and some truths are better than others. The staff's evaluations of clients' responses are part of their construction of moral identities for drug offenders. Staff members produce the client outcomes that some observers and evaluators attribute to client characteristics or conduct. To understand how staff members produce organizational outcomes as they manage clients, interpretive studies that look beyond the most public arenas of drug and other problem courts need to be conducted as they have been in exploring other service agencies.

Manfredi C; LeHew C. Why implementation processes vary across the 5A's of the Smoking Cessation Guideline: Administrators' perspectives. Nicotine & Tobacco Research 10(11): 1597-1607, 2008. (36 refs.)

Unrelated to any research, 18 maternal and child health case management agencies adopted a smoking cessation program that included the ask, advise, assess, assist, and arrange components of the 2000 U.S. Public Health Service Smoking Cessation Guideline. To better understand what influences program implementation in practice, a study was conducted 18 months later at 16 (89%) of the agencies. Open-ended interviews with key administrative informants examined implementation processes (i.e., how each program component had been implemented at the organization level) and the administrators' rationales for such implementation. A separate structured telephone survey of the agency case managers (N=63) assessed their implementation of each program component with smokers. Results showed that all agencies implemented the ask and advise components. Implementation of these components was well supported by the policies, contractual requirements, and operational tools that guided and coordinated all case management activities. No agency implemented the initially adopted program or any other structured approach to implementing the assess, assist, and arrange components. Administrative explanations indicated that these components (a) were not addressed by, and could not be easily incorporated into, the above existing policies and operational tools and (b) were perceived to be in the realm of case manager responsibilities and professional decisions, not requiring administrative attention. Several administrators also cited time constraints, other pressing case management issues, or lack of resources as additional barriers. Based on the findings, recommendations for systemic program support strategies are offered that could improve case management implementation of smoking cessation interventions beyond basic advice to quit.

Martino S; Ball SA; Nich C; Frankforter TL; Carroll KM. Community program therapist adherence and competence in motivational enhancement therapy. Drug and Alcohol Dependence 96(1-2): 37-48, 2008. (63 refs.)

The extent to which clinicians in addiction treatment programs can implement empirically validated therapies with adequate fidelity that can be discriminated from standard counseling has rarely been evaluated. We evaluated the treatment adherence and competence of 35 therapists from five outpatient community programs who delivered either a three-session adaptation of motivational enhancement therapy (MET) or an equivalent number of drug counseling-as-usual sessions to 461 clients within a National Institute on Drug Abuse Clinical Trial Network multi-site effectiveness protocol. MET therapists were carefully prepared to implement MET using a combination of expert-led intensive workshop training followed by program-based clinical supervision. Independent rating of sessions demonstrated that the adherence and competence items were very reliable (mean interclass correlation coefficients for adherence = .89 and competence = .81) and converged to form two a priori defined skill factors conceptually related to motivational interviewing. Moreover, the factors discriminated between MET therapists and those who delivered drug counseling-as-usual sessions in predicted ways, and were significantly related to in-session change in client motivation and some client treatment outcomes (percent negative drug urine screens). These findings demonstrate the reliability and validity of evaluating motivational interviewing fidelity and suggest that the combination of expert-led workshops followed by program-based clinical supervision may be an effective method for disseminating motivational interviewing in community treatment programs.

Martino S; Ball SA; Nich C; Frankforter TL; Carroll KM. Informal discussions in substance abuse treatment sessions. Journal of Substance Abuse Treatment 36(4): 366-375, 2009

This study evaluated the extent to which counselors initiated informal discussions (i.e., general discussions and self-disclosures about matters unrelated to treatment) with their clients during treatment sessions within two National Institute on Drug Abuse Clinical Trial Network protocols involving adaptations of motivational interviewing (Ml). Sixty counselors across the two protocols had 736 sessions independently rated for counselor treatment fidelity and the occurrence of informal discussions. The results showed that 88% of the counselors initiated informal discussions in their sessions and that most of these discussions involved counselors sharing personal information or experiences they had in common with their clients. The major finding was that counselor training in MI was associated with significantly less informal discussion across sessions. A higher frequency of informal discussion was related to less counselor MI proficiency and less in-session change in client motivation, although unrelated to client program retention and substance use outcomes. The findings suggest that although some informal discussions may help build an alliance between counselors and clients, too much of it may hinder counselors' proficient implementation of MI treatment strategies and the clients' motivational enhancement process.

McMahon M. My first-hand encounter with teenage drug addiction. (editorial). Canadian Family Physician 52: 1064-1065, 2006. (0 refs.)

Meier BR; Patkar AA. Buprenorphine treatment: Factors and first-hand experiences for providers to consider. Journal of Addictive Diseases 26(1): 3-14, 2007. (40 refs.)

The viability of using buprenorphine to treat opiate dependence was well documented prior to federal approval in October 2002. What has been lacking in the literature is "hands-on" experience of providers from a clinical management and practice management perspective. This article adds to the knowledge base by providing information about buprenorphine treatment as well as anecdotes from patients treated by the authors, leading to a detailed list of factors worth considering for the treatment provider contemplating adding an opiate-addicted population to an existing treatment base.

Meier PS; Donmall MC; McElduff P; Barrowclough C; Heller RF. The role of the early therapeutic alliance in predicting drug treatment dropout. Drug and Alcohol Dependence 83(1): 57-64, 2006. (54 refs.)

Background: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment. Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention. Results: Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological wellbeing, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer. Conclusions: The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention.

Mensinger JL; Diamond GS; Kaminer Y; Wintersteen MB. Adolescent and therapist perception of barriers to outpatient substance abuse treatment. American Journal on Addictions 15(Supplement 1): 16-25, 2006. (46 refs.)

Attrition is one of the most vexing problems for the effective delivery of behavioral health services. Most prior studies focus on patient demographics and psychopathology factors predicting dropout. We examined patient and therapist post-treatment reports of barriers to attending treatment. Six hundred adolescents and their therapists completed the Perceived Barriers to Treatment scale (PBT) at discharge from a brief substance abuse intervention. After adjusting for covariates, results suggest that perceived barriers, in particular, practical obstacles, lack of treatment readiness, relevance, and compatibility, are related to sessions attended. Shifting to a more patient centered approach for understanding treatment retention is discussed.

Merkx MJM; Schippers GM; Koeter MJW; Vuijk PJ; Oudejans S; de Vries CCQ et al. Allocation of substance use disorder patients to appropriate levels of care: Feasibility of matching guidelines in routine practice in Dutch treatment centres. Addiction 102(3): 466-474, 2007. (29 refs.)

Aims: To examine the feasibility of implementing evidence-based guidelines for patient-treatment-matching to levels of care in two Dutch substance abuse treatment centres. Design: Multi-centre observational follow-up study. Setting: Two large substance abuse treatment centres (SATCs). Participants All 4394 referrals to the two SATCs in 2003. Measurements Baseline patient characteristics needed for treatment allocation according to protocol, treatment allocation according to matching protocol, treatment allocation according to actual level of care (LOC) entered. Analysis Comparison of recommended and actual LOC entered. Evaluation of reasons for observed differences between recommended and actual LOC entered. Findings Data needed for treatment allocation according to protocol were available for 2269 (51.6%) patients. Data needed for evaluation of actual LOC entered were available for 1765 (40.2%) patients. Of these patients, 1089 (60.8%) were allocated according to protocol: 48.4% based on the guideline algorithm and 12.4% based on clinically justified deviations from this algorithm. The main reason for deviation was a different appraisal of addiction severity, made by the intake counsellor compared to the protocol. Conclusion: The feasibility of guideline-based treatment allocation is seriously limited due to inadequate data collection of patient characteristics and suboptimal guideline- based treatment allocation. As a consequence, only 24.4% of the patients could be evaluated as being matched properly to the treatment planned. The results indicate several barriers which limit the adequate implementation of patient-treatment-matching guidelines: problems in the infrastructure of data collection and storage and the inertia of intake staff who did not adhere to the guidelines for assessment and matching.

Miller WR; Manuel JK. How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review 27(5): 524-528, 2008. (18 refs.)

Introduction and Aims. Treatment research is sometimes criticised as lacking in clinical relevance, and one potential source of this friction is a disconnection between statistical significance and what clinicians regard to be a meaningful difference in outcomes. This report demonstrates a novel methodology for estimating what substance abuse practitioners regard to be clinically important differences. Design and Methods. To illustrate the estimation method, we surveyed 50 substance abuse treatment providers participating in the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Practitioners identified thresholds for clinically meaningful differences on nine common outcome variables, indicated the size of effect that would justify their learning a new treatment method and estimated current outcomes from their services. Results. Clinicians judged a difference between two treatments to be meaningful if outcomes were improved by about 10-12 points on the percentage of patients totally abstaining, arrested for driving while intoxicated, employed or having abnormal liver enzymes. A 5 percentage-point reduction in patient mortality was regarded as clinically significant. On continuous outcome measures (such as percentage of days abstinent or drinks per drinking day), practitioners judged an outcome to be significant when it doubled or halved the base rate. When a new treatment meets such criteria, practitioners were interested in learning it. Discussion and Conclusions. Effects that are statistically significant in clinical trials may be unimpressive to practitioners. Clinicians' judgements of meaningful differences can inform the powering of clinical trials.

Mitcheson L; Bhavsar K; McCambridge J. Randomized trial of training and supervision in motivational interviewing with adolescent drug treatment practitioners. Journal of Substance Abuse Treatment 37(1): 73-78, 2009. (14 refs.)

Motivational interviewing is an empirically supported treatment for drug and alcohol problems. Training in this approach is very popular, although previous studies have identified that the acquisition of key skills is challenging and that postworkshop supervision inputs are helpful. This pilot trial investigated the training of adolescent drug treatment practitioners, comparing a group who received immediate training against a delayed training study condition. Training and supervision were found to have no impact upon skill levels as measured by the Motivational Interviewing Treatment Integrity Version 2, with the exception of a very specific effect on motivational interviewing spirit. Motivational interviewing was not easy to learn for these practitioners. Progress made indicates the importance of ongoing supervision, and for high level skill acquisition to occur requires more intensive support of learning from ongoing practice than was used here.

Morris J. Characteristics and clinical practices of rural marriage and family therapists. Journal of Marital and Family Therapy 33(4): 439-442, 2007. (11 refs.)

This report presents a subset of data collected from the American Association for Marriage and Family Therapy (AAMFT) Practice Research Network project conducted in 2002. A sample of 47 clinical members of AAMFT who indicated they practiced in a rural community provided descriptive information on demographic characteristics, training, clinical practices, and treatment of substance abuse disorders. Similarities and differences with the demographic characteristics and practice patterns of the overall sample of 285 are discussed.

Moyers TB; Martin T. Therapist influence on client language during motivational interviewing sessions. Journal of Substance Abuse Treatment 30(3): 245-251, 2006. (24 refs.)

Client language in favor of change is hypothesized to be a causal mechanism for motivational interviewing (MI), and specific therapist behaviors are prescribed to elicit such speech. This project examined 38 motivational enhancement therapy sessions from Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), using a sequential behavioral coding system to investigate the relationship between therapist behaviors and client speech. Conditional probabilities were calculated between MI-consistent (MICO) therapist behaviors, MI-inconsistent (MIIN) therapist behaviors, and immediately subsequent client speech. MICO behaviors were more likely to be followed by self-motivational statements, whereas MIIN behaviors were more likely to be followed by client resistance. These results lend support to the importance of therapist behaviors in shaping client speech during MI sessions.

Moyers TB; Martin T; Christopher PJ; Houck JM; Tonigan JS; Amrhein PC. Client language as a mediator of motivational interviewing efficacy: Where is the evidence? Alcoholism: Clinical and Experimental Research 31(10, Supplement S): 40S-47S, 2007. (19 refs.)

Background: Identifying in-session indicators of client outcomes is important in determining the mechanisms of psychotherapeutic treatments, including Motivational Interviewing (MI). The current studies sought to determine if clinician behavior influences client speech, and the extent to which client speech predicted treatment outcome in clients receiving treatment for substance abuse. Methods: Study 1 examined 38 sessions from 5 sites in Project MATCH. Sessions were coded using the Sequential Code for Process Exchanges (SCOPE) behavioral coding system. Transition probabilities and inter-rater reliability were calculated. Study 2 examined 45 sessions from the New Mexico site in Project MATCH. Sessions were coded using the MISC 1.0 behavioral coding system. Distal outcome measures were calculated for proportion of days abstinent (PDA) and drinks per drinking day (DDD). Hierarchical multiple regression and hierarchical logistic regression were used to characterize the relationship between client speech and outcome. Results: In Study 1, inter-rater reliability estimates indicate that coders reliably distinguished between the categories within the SCOPE. Behaviors consistent with MI (MICO) were significantly likely to be followed by client Change Talk (CT) and behaviors inconsistent with MI (MIIN) were significantly likely to be followed by Counterchange Talk (CCT). There was also a significant negative transition probability between MICO and CCT. In Study 2, CT was found to account for significant portions of outcome variability beyond that attributable to baseline measures of problem severity. Conclusion: Client speech during early therapy sessions appears to be a powerful predictor of substance abuse outcome. The pattern of therapist behaviors and subsequent client language found in this data supports the intervention test in the causal chain we have described for motivational interviewing. These studies provide preliminary support for a causal chain between therapist behaviors, subsequent client speech, and drinking outcomes within motivational interviewing sessions. The results of both studies provide further support to the proposition that client speech impacts the likelihood of behavioral change, and that the occurrence of such speech is influenced by the therapist.

Pbert L; Jolicoeur D; Reed G; Gammon WL. An evaluation of tobacco treatment specialist counseling performance using standardized patient interviews. Nicotine & Tobacco Research 9(1): 119-128, 2007. (26 refs.)

In the United States, tobacco treatment specialists are professionals from a variety of backgrounds trained to deliver moderate to intensive evidence-based tobacco treatment in a variety of settings across the country. This paper reports the results of a study that examined the extent to which specialists participating in a larger study adhered to clinical practice guidelines for tobacco dependence using standardized patient assessments. A total of 64 tobacco treatment specialists completed a survey and two audiotaped standardized patient interviews. Overall, 41% and 31% of tobacco treatment specialists demonstrated 80% or more of session content and interviewing skills assessed, respectively, when required to demonstrate the skill in both standardized patient interactions. These rates increased to 85% and 56%, respectively, when using the less stringent criteria of demonstrating the skill in at least one of the two standardized patient interactions. Tobacco treatment specialists who had attended a greater number of types of tobacco treatment training exhibited both greater coverage of session content (p < .06) and greater interviewing skills (p < .02). Those who had achieved certification as a tobacco treatment specialist exhibited greater coverage of session content (p < .02), and those perceiving more positive support from their agency for their services exhibited greater interviewing skills (p = .02). Although the tobacco treatment specialists evaluated appear to have the necessary skills to deliver guideline-based intervention, they demonstrated only moderate adherence to the guidelines when expected to do so consistently across multiple assessments. Findings suggest specific components of tobacco treatment and interviewing skills that would benefit from strengthening through training and support.

Peckover S; Chidlaw RG. Too frightened to care? Accounts by district nurses working with clients who misuse substances. Health & Social Care in the Community 15(3): 238-245, 2007. (46 refs.)

Drug misusers have complex health and social care needs, and experience considerable difficulties in accessing the assessment, care and treatment that they require. Despite the development of specialist services in many parts of the UK, substance misuse is often marginalised within mainstream general healthcare, and many practitioners are unprepared for the challenges of working with this client group. The present paper reports findings from a. qualitative study that aimed to explore district nurses' understandings and practices in relation to discrimination and inequalities issues. The research took place during 2003 in two city-based primary care trusts in the North of England. Semistructured interviews were undertaken with 18 'G' grade district nurses. The authors present findings that highlight some of the challenges and tensions district nurses encounter when providing care to clients who misuse substances. The discourses of 'prejudice' and 'risk' were intertwined throughout the data, and served to shape service provision for clients who misuse substances. This was reflected in the district nurses' accounts of their own practice and that of other services, suggesting that these clients receive suboptimal care. The discourse of 'risk' was also used by district nurses to construct themselves as 'vulnerable', and this helped to explain some of their own practices of care provision. Many participants acknowledged their limited knowledge and experience of working with this client group. There is an urgent need for district nurses and other health professionals to develop their practice with these clients, who may present as both vulnerable and dangerous, in order to ensure that care is provided equitably and safely.

Prokhorov AV; Fouladi RT; de Moor C; Warneke CL; Luca M; Jones MM et al. Computer-assisted, counselor-delivered smoking cessation counseling for community college students: Intervention approach and sample characteristics. Journal of Child & Adolescent Substance Abuse 16(3): 35-62, 2007. (43 refs.)

This report presents the experimental approach and baseline findings from "Look at Your Health," an ongoing study to develop and evaluate a computer-assisted, counselor-delivered smoking cessation program for community college students. It describes the expert system software program used for data collection and for provision of tailored feedback, individualized quitting strategies, and personalized newsletters. The transtheoretical model of change, the health belief model, and motivational interviewing provided the theoretical framework for the experimental cohort. Intervention participants received Individual counseling, completed computerized questionnaires, performed measures of spirometric lung functioning and carbon monoxide levels, and were given a calculated lung age. At baseline, participants exhibited measurable tobacco-related health problems and an optimism bias. Addressing this optimism bias appropriately might lead smokers to progress through the stages of smoking cessation toward complete abstinence.

Rigole H; Perney P; Bismuth M; Navarro F; Larrey D; Blanc F et al. Assessment of liver transplant candidates by an addiction medicine specialist: A prospective study. (meeting abstract). Hepatrology 46(4, Supplement S): 506A-506A, 2007. (0 refs.)

Roche AM. New horizons in AOD workforce development. Drugs: Education, Prevention and Policy 16(3): 193-204, 2009. (29 refs.)

The papers in this series are presented by Australia's National Research Centre on Workforce development, or as it is formally known as the National Centre for Education and Training on Addiction (NCETA), at Flinders University in Australia. NCETA is recognized nationally and internationally as a research centre that works as a catalyst for change in the alcohol and other drugs (AOD) sector. NCETA is one of the three national research Centres in Australia funded under the National Drug Strategy, and the only Centre briefed to specifically address issues related to workforce development. In this guise, the Centre's mission is to advance the capacity of human services organizations and workers to respond to alcohol and other drug related problems. NCETA's role is not restricted to the area of workforce development. The Centre also undertakes an important programme of work in relation to the workplace, law enforcement, complex data analyses on a range of topics and has an innovative programme of social research on issues such as young people and alcohol. The focus of attention selected for this issue however provides a sample of our work in the area of workforce development.

Roche AM; Todd CL; O'Connor J. Clinical supervision in the alcohol and other drugs field: An imperative or an option? Drug and Alcohol Review 26(3): 241-249, 2007. (54 refs.)

There is a growing interest in Clinical Supervision (CS) as a central workforce development (WFD) strategy. This paper provides a definition of and rationale for CS, characterises its various forms, identifies selection and training issues, and advises on policy and implementation issues central to redressing shortcomings in supervision practice within the alcohol and other drugs (AOD) field. Relevant selective literature is reviewed. Key conceptual issues were identified, and strategies developed to address implementation barriers and facilitate relevant policy. There is a common conceptual confusion between administrative supervision and CS. Clarification of the role, function and implementation of CS is required. Priority issues for the AOD field include: enhancing belief in CS; ensuring adequate resource allocation; developing evaluation protocols; and addressing specific arrangements under which supervision should occur. CS has been underutilised to date but holds considerable potential as a WFD strategy. It is fundamental to workers' professional development, can contribute to worker satisfaction and retention, and may improve client outcomes. Critical next steps are to establish the generalisability to the AOD field of the benefits observed from CS in other disciplines, and evaluate longer-term gains of CS programs.

Rosengren DB; Hartzler B; Baer JS; Wells EA; Dunn CW. The Video Assessment of Simulated Encounters-revised (VASE-R): Reliability and validity of a revised measure of motivational interviewing skills. Drug and Alcohol Dependence 97(1-2): 130-138, 2008. (19 refs.)

The Video Assessment of Simulated Encounters-revised (VASE-R) is a video-based method. administered in individual or group settings, for assessing motivational interviewing (MI) skills. The 18-item instrument includes three video-based vignettes in which actors portray substance abusers, with each vignette followed by questions that prompt examinees to write responses that are then scored against MI standards. The VASE-R was administered to two independent samples: (1) substance abuse practitioners participating in a study of MI training methods, and (2) MI training facilitators with a high level of MI skill and expertise. This multi-study report describes basic VASE-R psychometric properties - including scoring reliability, internal consistency, concurrent validity, and sensitivity to the effects of training - and then presents proficiency standards based oil administration to a sample of MI training facilitators (MI Experts). The findings indicate excellent inter-rater reliability using intra-class correlations for the full-scale score (.85) and acceptable levels for subscales (.44 to .73). The instrument displayed strong concurrent validity with the Helpful Responses Questionnaire (HRQ) and a behavioral sample of clinician behavior with a standardized patient scored using the MI Treatment Integrity (MITI) system. as well as good sensitivity to improvement in MI skill as a result of training. The findings provide an empirical basis for suggesting VASE-R benchmarks for beginning proficiency and expert MI practice.

Saitz R; Larson MJ; LaBelle C; Richardson J; Samet JH. The case for chronic disease management for addiction. Journal of Addiction Medicine 2(2): 55-65, 2008. (170 refs.)

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Saldana L; Chapman JE; Henggeler SW; Rowland MD. The Organizational Readiness for Change Scale in adolescent programs: Criterion validity. Journal of Substance Abuse Treatment 33(2): 159-169, 2007. (29 refs.)

This study examined the convergent validity and concurrent validity of the Organizational Readiness for Change (ORC; Lehman WEK, Greener JM, Simpson DD, 2002. Assessing organizational readiness for change. Journal of Substance Abuse Treatment. 22 197-210) scale among practitioners who treat adolescents. Within the context of a larger study, we administered the ORC scale and measures of practitioner attitudes toward evidence-based practices as well as treatment manuals to a heterogeneous sample of 543 community-based therapists in the state mental health and substance abuse treatment sectors. Using a contextual random-effects regression model, the association between ORC scale domains and measures of practitioner characteristics and attitudes were examined at both therapist and agency levels. The results support the convergent validity and concurrent validity of several domains. Namely, the domains focusing on motivational readiness and training needs were associated with higher appeal and openness to innovations. Those on program resources and climate were less related, however. Our discussion focuses on the utility of the ORC scale in helping evaluate the needs of programs considering the adoption of evidence-based practices.

Salyers KM; Ritchie MH; Cochrane WS; Roseman CP. Inclusion of substance abuse training in CACREP-accredited programs. Journal of Addictions & Offender Counseling 27(1): 47-58, 2006. (11 refs.)

Note: This article is reprinted from "Counselor Education & Supervision, 2005, 45[1], 30-42." Professional counselors and counselors-in-training continue to serve clients who have substance abuse issues, yet systematic training in substance abuse counseling is not available to many counselors. The authors investigated the extent to which students in programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2001) are exposed to clients presenting with substance abuse issues and the relationship between state licensure or certification in substance abuse and the resulting perception of the need for the inclusion of substance abuse training in these programs. Three methods are presented for possibly including substance abuse training in CACREP standards.

Salyers MP; Rollins AL; Bond GR; Tsai J; Moser L; Brunette MF. Development of a scale to assess practitioner knowledge in providing integrated dual disorders treatment. Administration and Policy in Mental Health 34(6): 570-581, 2007. (29 refs.)

As mental health providers increasingly adopt evidence-based practices, tools are needed to assess practitioner knowledge of these practices. We describe the development and psychometric evaluation of a paper-and-pencil test to assess provider attitudes and knowledge about Integrated Dual Disorders Treatment (IDDT). In this sample of clinicians who were implementing IDDT in two mental health centers, the test showed good internal consistency, inter-rater reliability, and for a subsample who took the test twice, significant improvement over time. Higher scores on the scale were correlated with greater education, but not greater experience or lower burnout. This test is a promising tool for assessing provider knowledge of a specific evidence-based practice.

Schoener EP; Madeja CL; Henderson MJ; Ondersma SJ; Janisse JJ. Effects of motivational interviewing training on mental health therapist behavior. Drug and Alcohol Dependence 82(3): 269-275, 2006. (23 refs.)

This study examined the effectiveness of training community mental health therapists in motivational interviewing (MI) adapted to treat clients with co-occurring disorders. Ten therapists with high caseloads of culturally diverse clients in two different community mental health settings fulfilled all study requirements. MI training consisted of a two-day didactic and experiential workshop followed by eight biweekly small group supervision (coaching) sessions. Using an interrupted time series design, 156 randomly selected therapy sessions involving 28 clients were coded for assessment of therapist fidelity to MI at multiple points in time, both pre- and post-training. Employing hierarchical linear modeling analysis, significant improvement in MI skill was observed after training on five of six key therapist ratings, and on the sole client rating (client change talk) that was examined. Importantly, the present study demonstrates training-related proficiency in motivational interviewing using: (a) a representative sample of mental health therapists from the community; (b) a protocol emphasizing adherence to a mental health treatment regimen as well as management of substance use behavior for clients with co-occurring disorders; (c) repeated random observations of therapy sessions; (d) measurement of training-related changes in clinician skills and self motivational statements by clients. Findings of this effectiveness study compared favorably with efficacy literature on MI training.

Simpson D; Rowan-Szal GA; Joe GW; Best D; Day E; Campbell A. Relating counselor attributes to client engagement in England. Journal of Substance Abuse Treatment 36(3): 313-320, 2009. (39 refs.)

Client functioning and treatment engagement were examined in relation to staff attributes and organizational climate across a diverse sample of drug treatment and outreach programs in England. Self-rating assessments were obtained from 1,539 clients and 439 counselors representing 44 programs, and results were interpreted using comparable data from studies of treatment programs in the United States. Client scores on treatment participation and counseling rapport in England were directly related to their higher levels of motivation and psychosocial functioning, as well as to staff ratings of professional attributes and program atmosphere. By linking records from English clients with their counselors in each program, findings also indicate these relationships are rooted in the personal interactions between clients and their counselor. Standardized assessments of treatment structure, process, and performance used across therapeutic settings and national boundaries show there is generalizability in the pattern of clinical dynamics, including the relationships between organizational functioning and quality of services.

Siques P; Brito J; Munoz C; Pasten P; Zavala P; Vergara J. Prevalence and characteristics of smoking in primary healthcare workers in Iquique, Chile. Public Health 120(7): 618-623, 2006. (21 refs.)

Objective: To determine the prevalence and characteristics of the smoking habits of primary healthcare workers in Iquique, Chile. Study design: Cross-sectional study through a survey of all personnel working in primary health care in Iquique, Chile. Methods: The following variables were investigated: biodemographical. characteristics and aspects of smoking, knowledge of the adverse effects of smoking, and some lifestyle factors. Results: Among the study population, a high prevalence of smokers was found (37%) and a further 26% were ex-smokers. The smokers were predominantly practical nurses, female, aged 25-45 years and married. The only significant relationship was between age and smoking habit (P=0.02), with smoking prevalence among younger groups being very high (56%). There was a high level of awareness about the adverse effects of smoking and its addictiveness (99 and 93%, respectively). Forty-three percent of participants had been smoking for more than 15 years, and the main reasons for smoking were 'social consumption' and 'stress' (36 and 29%, respectively). Thirty-two percent of the ex-smokers ceased smoking for discomfort or health reasons. There were no differences between smokers and ex-smokers with respect to participation in sports or working shifts. Fifty-two percent of those surveyed reported they they were annoyed when others smoked near them. Conclusion: This study revealed a high prevalence of smoking, particularly among practical nurses. Regarding attitudes to health, a dichotomy between knowledge and behaviour was found in this group. In pursuing the commitment to smoking cessation in healthcare personnel, a deeper review of cultural issues and motivation should be considered.

Skinner N; Feather NT; Freeman T; Roche A. Stigma and discrimination in health-care provision to drug users: The role of values, affect, and deservingness judgments. Journal of Applied Social Psychology 37(1): 163-186, 2007. (46 refs.)

This study examined the role of values, affect, and deservingness judgments in health professionals' views of patients with stigmatized conditions (e.g., drug dependence). Participants were 277 nurses who responded to a survey containing 2 scenarios of a nurse providing high- or low-quality care to a patient with a condition related to prolonged use of alcohol or heroin. Affective responses to the patient were more positive for nurses with higher self-transcendence values, and more negative for nurses with higher conservation values. Deservingness judgments were predicted by positive and negative affect toward the patient, but not by attributions of responsibility for drug use. Deservingness judgments emerged as strong predictors of nurses' satisfaction with the provision of high- or low-quality care. The findings imply that the deservingness judgments made by nurses reflected strong entitlement norms concerning the provision of proper care for patients that were independent of patients' perceived responsibility for their condition.

Skinner N; Roche AM; Freeman T; Mckinnon A. Health professionals' attitudes towards AOD-related work: Moving the traditional focus from education and training to organizational culture. (review). Drugs: Education, Prevention and Policy 16(3): 232-249, 2009. (104 refs.)

Aim: This article presents a critical review of research on health professionals' attitudes towards alcohol and other drug (AOD)-related work relevant to both researchers and practitioners. It moves beyond education and training programs to examine the relevance of organizational culture in influencing attitudes. Method: A review of research conducted on health professionals' attitudes towards AOD-related work, and strategies to develop positive attitudes was undertaken. Findings: 12 evidence-based tenets were identified in regard to attitudes towards AOD-related work. Key findings include the importance of professional attitudes related to confidence and perceived legitimacy of responding, and personal attitudes related to social justice concerns. Education/training and role support were identified as important evidence-based strategies to develop and support positive attitudes. Conclusion: To foster development of positive attitudes and effective responses in regard to AOD-related work a focus that extends beyond the individual worker is required. Education and training are a necessary, but not sufficient, condition to ensure health professionals' capacity and willingness to respond to AOD issues. Research on organizational culture provides valuable insight into the types of organizational and systems factors likely to influence AOD-related attitudes and work practice. Key strategies to develop an organizational culture supportive of AOD-related work and future research areas are highlighted.

Strauss SM; Astone-Twerell JM; Munoz-Plaza C; Des Jarlais DC; Gwadz M; Hagan H et al. Correlates of drug treatment program staff's self efficacy to support their clients' hepatitis C virus (HCV) related needs. American Journal of Drug and Alcohol Abuse 33(2): 245-251, 2007. (16 refs.)

Drug treatment staff are uniquely situated to support their clients' HCV related needs, and those with greater self efficacy to do so are more likely to provide this support. Using data collected from staff (N = 140) in 6 drug treatment programs in New York City, we determined the correlates of this self efficacy. Results indicate that medically credentialed staff and staff with more hepatitis C knowledge have greater self efficacy to support their clients' HCV related needs. There was no relationship between this self efficacy and the staff member's own HCV infection or that of a close relative. Efforts should focus on increasing staff's HCV knowledge in order to increase their confidence in providing HCV related support to their clients.

sxGaume J; Gmel G; Faouzi M; Daeppen JB. Counsellor behaviours and patient language during brief motivational interventions: A sequential analysis of speech. Addiction 103(11): 1793-1800, 2008. (21 refs.)

Aims: To investigate empirically the hypothesized relationship between counsellor motivational interviewing (MI) skills and patient change talk (CT) by analysing the articulation between counsellor behaviours and patient language during brief motivational interventions (BMI) addressing at-risk alcohol consumption. Design: Sequential analysis of psycholinguistic codes obtained by two independent raters using the Motivational Interviewing Skill Code (MISC), version 2.0. Setting Secondary analysis of data from a randomized controlled trial evaluating the effectiveness of BMI in an emergency department. Participants A total of 97 patients tape-recorded when receiving BMI. Measurements MISC variables were categorized into three counsellor behaviours (MI-consistent, MI-inconsistent and 'other') and three kinds of patient language (CT, counter-CT (CCT) and utterances not linked with the alcohol topic). Observed transition frequencies, conditional probabilities and significance levels based on odds ratios were computed using sequential analysis software. Findings MI-consistent behaviours were the only counsellor behaviours that were significantly more likely to be followed by patient CT. Those behaviours were significantly more likely to be followed by patient change exploration (CT and CCT) while MI-inconsistent behaviours and 'other' counsellor behaviours were significantly more likely to be followed by utterances not linked with the alcohol topic and significantly less likely to be followed by CT. MI-consistent behaviours were more likely after change exploration, whereas 'other' counsellor behaviours were more likely only after utterances not linked with the alcohol topic. Conclusions Findings lend support to the hypothesized relationship between MI-consistent behaviours and CT, highlight the importance of patient influence on counsellor behaviour and emphasize the usefulness of MI techniques and spirit during brief interventions targeting change enhancement.

Symington N. A Healing Conversation: How Healing Happens. London: Karnac Books, 2006

This book is not restricted to alcohol and substance abuse treatment per se, but deals a broader question of what lies behind the healing nature of conversation, which is integral to substance abuse counseling as it is psychotherapy. Based on a series of lectures, it endeavors to address the question: why does conversation have the power to heal. It examines broad themes of emotiion, communication, and learning about the self as one allows oneself to be known by another.

Szpunar SM; Williams PD; Dagroso D; Enberg RN; Chesney JD. Effects of the tobacco use cessation automated clinical practice guideline. American Journal of Managed Care 12(11): 665-673, 2006. (25 refs.)

Objective: To evaluate the effects of the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG) (a variation of the US Department of Health and Human Services Clinical Practice Guideline on Treating Tobacco Use and Dependence) on guideline adherence in a multisite health system. Study Design: The study used a pre-post cross-sectional design. Paneled patients were enrolled from 6 clinics, including 2 control clinics (arm 1), 2 control clinics that received a check-in screen only (the check-in screen provided a simplified method for entering patient vital signs into the electronic medical record) (arm 2), and 2 clinics that received the TUC intervention (arm 3). Methods: Baseline data on physician compliance with the 5 As (ask, assess, advise, assist, and arrange) at the last office visit were collected via telephone surveys from patients in the 3 study arms. The TUC-ACPG was then introduced in the TUC intervention clinics as part of the existing electronic medical record. Approximately 2 weeks after the TUC intervention, post-implementation data were collected via telephone survey. Results: In the TUC intervention arm, post-implementation adherence rates increased relative to baseline for all 5 points of the guideline, with the largest increases seen in the assess and arrange guideline points. Controlling for factors such as age, race, and relevant comorbidities, logistic regression analysis indicated that the time (pre-implementation vs post-implementation)-x-TUC intervention arm interaction demonstrated a statistically significant increase in the assess guideline point. Conclusion: Although baseline adherence rates were already high, the introduction of the TUC-ACPG led to further increases in guideline adherence.

Tajima B; Guydish J; Delucchi K; Passalacqua E; Chan M; Moore M. Staff knowledge, attitudes, and practices regarding nicotine dependence differ by setting. Journal of Drug Issues 39(2): 365-383, 2009. (34 refs.)

This study examined smoking-related knowledge, beliefs, self-efficacy, smoking cessation practices, and barriers to providing smoking cessation services in a workforce sample. The 11 participating clinics (N=335 staff) included substance abuse treatment and HIV care clinics categorized into three types: Veterans Affairs Medical Center (VAMC) clinics, hospital-based clinics, and community-based clinics. Staff in both VAMC and hospital-based settings shared characteristics that may predict smoking-related knowledge, beliefs, and practices (higher education level, low smoking rates, fewer staff in recovery, and location in hospital-affiliated environments where there was greater emphasis on physical health). However, staff in VAMC settings outperformed those in both hospital-based and community-based clinic settings on measures of smoking-related knowledge, beliefs, self-efficacy, and practices. Well-developed procedures to support VAMC clinicians in addressing smoking may account for these findings. Findings suggest that both reductions in staff smoking, and development and implementation of smoking policy are needed to support staff in better addressing nicotine dependence in community-based treatment settings.

Taleff MJ. Critical Thinking in the Addictions. New York: Springer Publishing, 2006

This volume is organized into two parts. Part I sets forth the core constructs associated with critical thinking in the addiction. Part II attends to major types of fallacies in critical thinking, those that are related to appeals to authority, those related to premature acceptance of conclusions, those related to perception problems and fallacies of manner and style.

Taylor CB; Chang VY. Issues in the dissemination of cognitive-behavior therapy. Nordic Journal of Psychiatry 62(Supplement 47): 37-44, 2008. (49 refs.)

In the past 40 years, cognitive-behavior therapy (CBT) has emerged as the initial treatment of choice for patients with mild to moderate depression, anxiety disorders and other problems. In this paper, we discuss issues related to the dissemination and implementation of CBT in various practice settings as well as the use of manuals, computers, the telephone, and the Internet to aid dissemination and implementation. We review key aspects of CBT dissemination, such as the reach of CBT, models of dissemination, and obstacles and barriers to dissemination including patient interest, therapist training and research priorities. The effectiveness of manualized programs is considered, as well as the increasing sophistication of computer-assisted therapy. Stepped-care approaches are discussed as a viable solution to some of these barriers. We provide two examples of successful CBT dissemination, the Staying Free program, a smoking cessation program for inpatients, and the Improving Access to Psychological Therapies program in Britain, which aims to improve access to psychological therapy. We argue that two critical factors will determine the Success of implementation of CBT in this century: 1) mandated outcomes and 2) leadership.

Thomas SE; Miller PA; Randall PK; Book SW. Improving acceptance of naltrexone in community addiction treatment centers: A pilot study. Journal of Substance Abuse Treatment 35(3): 260-268, 2008. (29 refs.)

Alcoholism pharmacotherapies are underused in community addiction treatment settings, in part because individuals who practice in these settings-nonmedical addiction counselors and administrators-lack knowledge about and confidence in the value of adjunctive alcohol pharmacotherapies. We developed and tested an intervention to improve knowledge and attitudes about naltrexone. A team of researchers, physicians, addiction treatment counselors, and administrators collaborated to develop a naltrexone educational intervention designed for nonmedical addiction professionals. The intervention was compared with a control condition in a pilot study with 6 addiction treatment agencies (3 agencies per group). Participants (counselors and administrators, N = 84) were assessed before and 6 months after the intervention. Results revealed that the intervention significantly improved naltrexone knowledge, and participants who received the intervention reported greater satisfaction with the education they received, as well as greater use of the information. The effect of the intervention on attitudes about naltrexone was encouraging but did not to reach statistical significance. This study is the first reported attempt to develop and test an intervention specifically to improve acceptance of adjunctive medications for alcoholism among nonmedical addiction professionals.

Treadway DC. A practitioner's response: Grace happens. Alcoholism Treatment Quarterly 26(1/2): 221-225, 2008

Treatment models are important. The person and commitment of the therapist are even more important.

Varra AA; Hayes SC. Assessing referrals for pharmacotherapy: A comparison of therapist and client report. Journal of Substance Abuse Treatment 32(4): 411-413, 2007. (12 refs.)

The primary goal of this study was to assess whether therapist self-reported use of referrals for pharmacotherapy with clients for the treatment of substance abuse disorders is consistent with actual rates of referrals experienced by clients. Participants were 20 substance abuse counselors and 120 clients at a large, multisite substance abuse treatment center. Therapists were asked to complete a brief measure of their current use of referrals for pharmacotherapy, including agonist and antagonist approaches. Clients were asked to complete a brief measure indicating whether their individual counselor had discussed with them a referral for medication. Counselor reports were linked to their individual clients and compared for validation. Results indicate that therapist self-report is significantly correlated with client report of referrals for pharmacotherapy. These results indicate that although therapist self-report of adherence to more involved treatment approaches is often unreliable, substance abuse counselors are able to reliably report their use of referrals.

Wang JF; Ma SJ; Mei CZ; Xu XF; Wang CP; Yang GH. Exploring barriers to implementation of smoking policies: A qualitative study on health professionals from three county-level hospitals. Biomedical and Environmental Sciences 21(3): 257-263, 2008. (25 refs.)

Objective: This study was to identify factors limiting the implementation of smoking policies in county-level hospitals. Methods We conducted qualitative interviews (17 focus groups discussions and 6 one-to-one in depth interviews) involving 103 health professionals from three target county-level hospitals. A combination of purposive and convenience sampling was used to recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. The transcripts were analyzed for themes and key points. Results: The main themes that emerged suggested that both smokers and non-smokers viewed smoking very negatively. However, it was clear that, underlying this acceptance of the health risks of smoking, there was a wide range of beliefs. Most of the health professionals pointed out that, as smoking was legal, addictive, and influenced by social norms, currently it was almost unrealistic to expect all smokers to give up smoking or not to smoke in the hospitals. Furthermore, they were concerned about the potentially detrimental effects of providing counseling advice to all smokers on the interpersonal relationship among colleagues or between doctors and patients. In addition, low level of employee participation influenced the sustainable implementation of smoking policies. Conclusions: Simply being aware of the health risks about smoking did not necessarily result in successful implementation of the smoking policies. Application of comprehensive intervention strategies such as implementing smoking policies in public places at the county level, creating supportive environments, promoting community participation, and conducting health education, may be more effective.

Watson, H.; Maclaren, W.; Kerr, S. Staff attitudes towards working with drug users: Development of the Drug Problems Perceptions Questionnaire. Addiction 103(2): 206-215, 2007. (33 refs.)

Aim: To evaluate the psychometric properties of an adaptation of the Alcohol and Alcohol Problems Perceptions Questionnaire to measure the attitudes of staff to working with drug users (the DDPPQ). Design Postal survey: a questionnaire was mailed to participants on two occasions. Setting A large urban National Health Service (NHS) mental health service. Participants A stratified random sample of medical staff, clinical psychologists. occupational therapists and nurses (n = 6 72) who work within generic mental health, adolescent psychiatry, forensic psychiatry and alcohol and drug services. Response rate at Time I was 56% and 68% at Time 2. Measurements A structured demographic questionnaire; individual item and total scores for the DDPPQ administered on two occasions 4 weeks apart; data relating to the content validity of the instrument. Findings A principal component analysis confirmed the DDPPQ's construct validity and participants confirmed its content validity. Following analysis of the instrument's test-retest reliability and its principal component structure it was reduced to a 20-item scale. Its five subscales related to role adequacy, role support, job satisfaction, role-specific self-esteem and role legitimacy. Conclusion: The refined DDPPQ was shown to be a valid and reliable tool which can be used to measure attitudes of people in relation to working with drug users.

Weigel DJ; Donovan KA; Krug KS; Dixon WA. Prescription opioid abuse and dependence: Assessment strategies for counselors. Journal of Counseling and Development 85(2): 211-215, 2007. (21 refs.)

The authors review the article "Prescription Drug Use and Abuse: Risk Factors, Red Flags, and Prevention Strategies" (J.H.Isaacson, J. A. Hopper, D. R Alford, & T Parran, 2005), which provides an overview of the recent increase in prescription opioid abuse and dependence from the physician's perspective. In the present article, the authors discuss the counselor's role in identifying issues related to client misuse and abuse of prescription opioids. Associated terminology, common drug acquisition strategies, and signs of problematic use are provided and discussed.

Weinberger AH; Reutenauer EL; Vessicchio JC; George TP. Survey of clinician attitudes toward smoking cessation for psychiatric and substance abusing clients. Journal of Addictive Diseases 27(1): 55-63, 2008. (50 refs.)

The current study examined mental health clinician attitudes regarding smoking cessation for psychiatric and substance abusing patients. Participants included n = 15 never smokers, n = 12 former smokers, and n = 7 current smokers. There was a trend (p = 0.08) for current smokers as compared to former and never smokers to be less likely to encourage their clients to stop smoking. Overall, clinicians strongly agreed that an individual's motivation is the most important determinant of success in quitting. Clinicians were concerned that smoking cessation would initiate a relapse to substance abuse. We suggest that mental health clinicians can be instrumental in providing information, encouragement, and opportunities for their patients to attempt smoking cessation.

Weingardt KR; Cucciare MA; Bellotti C; Lai WP. A randomized trial comparing two models of web-based training in cognitive-behavioral therapy for substance abuse counselors. Journal of Substance Abuse Treatment 37(3): 219-227, 2009. (29 refs.)

This study compared training outcomes obtained by 147 substance abuse counselors who completed eight self-paced online modules on cognitive-behavioral therapy (CBT) and attended a series of four weekly group supervision sessions using Web conferencing software. Participants were randomly assigned to two conditions that systematically varied the degree to which they explicitly promoted adherence to the CBT protocol and the degree of control that they afforded participants over the sequence and relative emphasis of the training curriculum. Outcomes were assessed at baseline and immediately following training. Counselors in both conditions demonstrated similar improvements in CBT knowledge and self-efficacy. Counselors in the low-fidelity condition demonstrated greater improvement on one of three measures of job-related burnout when compared to the high-fidelity condition. The study concludes that it is feasible to implement a technology-based training intervention with a geographically diverse sample of practitioners, that two training conditions applied to these samples of real-world counselors do not produce statistically or clinically significant differences in knowledge or self-efficacy, and that further research is needed to evaluate how a flexible training model may influence clinician behavior and patient outcomes.

Weingardt KR; Gifford EV. Expanding the vision of implementing effective practices. (editorial). Addiction 102(6): 864-865, 2007. (20 refs.)

This is a commentary on the article by Carroll and Rounsaville, "A vision of the next generation of behavioral therapies research in the addictions."

White WL. Alcohol, tobacco and other drug use by addictions professionals: Historical reflections and suggested guidelines. Alcoholism Treatment Quarterly 26(4): 500-535, 2008

Alcohol, tobacco, and other drug (ATOD) use by individuals working in the addictions field has existed as a complex, controversial personal and professional practice issue for more than 150 years. The central debate within this history involves the concept of nexus-the boundary that distinguishes rights to personal privacy from professional duties and obligations. Ambiguities related to this point of demarcation have contributed to misjudgments related to ATOD use by addictions professionals that have injured multiple parties. This essay reviews the history of ATOD use as a professional practice issue in the addictions field; discusses clinical, ethical, and legal issues related to ATOD use by addiction service professionals; and offers guidance on ATOD use decision making.

Winstock AR; Lea T. Evaluation of a training program to improve clinicians' assessment of patient stability. Drug and Alcohol Review 28(4): 353-359, 2009. (10 refs.)

Introduction and Aims. Public clinics in New South Wales (NSW), Australia play a central role in inducting and stabilising opioid dependent clients onto treatment before transfer to a community pharmacy. Clinical assessment of stability is a vital skill in ensuring that clients are appropriately and effectively transferred. A two-hour clinical training program was delivered to staff at 31 public clinics, that aimed to improve staff confidence in assessing client stability, and skills in negotiating the transfer of clients to community pharmacies. Design and Methods. Pre- and post-training evaluation was conducted examining self-ratings of confidence and ability in the assessment of client stability, and the perceived utility of a clinical algorithm to improve assessments. Follow-up was conducted 3 to 6 months post-training assessing individual and clinic level changes in clinical practice. Results. 205 staff completed pre- and post-training questionnaires. Staff demonstrated a moderate level of self-reported baseline knowledge and skills in assessing client stability (mean = 6.5; 1 = poor; 10 = excellent) that improved when re-assessed following the training (mean = 8.0). 76 staff responded to the follow-up questionnaire. >= 75% reported some level of improvement in their approach to clinical practice regarding stability assessment, and 59% reported being more effective in identifying clients appropriate for community pharmacy transfer. Of 19 public clinics, 14 reported an increased focus on stability assessment. Nine clinics reported barriers to achieving changes in clinical practice. Discussion and Conclusions. This evaluation demonstrates that it is possible to implement a targeted clinical training package to staff that translates into positive changes in clinical practice.