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CORK Bibliography: Clinicians

89 citations. January 2006 to present

Prepared: January 2008

Abatemarco DJ; Steinberg MB; Delnevo CD. Midwives' knowledge, perceptions, beliefs, and practice supports regarding tobacco dependence treatment. Journal of Midwifery & Women's Health 52(5): 451-457, 2007. (41 refs.)

Clinical practice guidelines and evidence-based reviews confirm the efficacy of tobacco dependence treatment for pregnant women. The purpose of this study was to examine tobacco dependence treatment practices among certified nurse-midwives who treat pregnant women who smoke. Midwives were surveyed to determine knowledge, perceptions, and beliefs about tobacco cessation treatment and to identify practice environmental factors that support treatment practices. Half of all midwives had not heard of the US Public Health Service Guidelines (5 A's) to assist smokers in cessation treatment. We found varying levels of adherence to the clinical practice guidelines. Nearly all midwives routinely ask, advise, and assess; while fewer encourage patients to set a quit date or discuss medication options (assist) and perform follow-up activities (arrange). Barriers significantly associated with clinical tobacco treatment practice are lack of training and competing priorities in the visit. One-office support, a system in place to provide smoking cessation information and resources, was associated with increased practice. In summary, midwives believe they should be providing tobacco dependence treatment, yet they identify a need for training. The findings of this study also indicate that sustained practice change, which includes the entire practice environment, should be targeted to enhance tobacco dependence treatment.

Amodeo M. Securing an equal role for substance abuse counselors: A commentary on Kerwin, Walker-Smith, and Kirby. (editorial). Journal of Substance Abuse Treatment 30(3): 169-170, 2006. (3 refs.)

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.

Bartholomew NG; Joe GW; Rowan-Szal GA; Simpson DD. Counselor assessments of training and adoption barriers. Journal of Substance Abuse Treatment 33(2): 193-199, 2007. (24 refs.)

The prevailing emphasis on adopting evidence-based practices suggests that more focused training evaluations that capture factors in clinician decisions to use new techniques are needed. This includes relationships between postconference evaluations and subsequent adoption of training materials. We therefore collected training assessments at two time points from substance abuse treatment counselors who attended a training on dual diagnosis and another on therapeutic alliance as part of a state-sponsored conference. Customized evaluations were collected to assess counselor perceptions of training quality, relevance, and resources in relation to its use during the 6 months after the conference. Higher ratings for relevance of training concepts and materials to service the needs of clients, desire to have additional training, and level of program support were related to greater trial use during the follow-up period. Primary resource-related and procedural barriers cited by the counselors included lack of time and redundancy with existing practices.

Berghuis J/Swift W; Roffman RA; Stephens RS; Copeland J. The Teen Cannabis Check-up: Exploring strategies for reaching young cannabis users. IN: Roffman RA; Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. London: Cambridge University Press, 2006. pp. 275-296

This chapter explores the "Teen Cannabis Check-up" as a tool for intervening in adolescent marijuana use. It begins with an overview of the extent of adolescent cannabis use and the associated negative consequences. It then reviews the intervention research with adolescents, and development issues in designing treatment for adolescents. The Check-up approach is then described, including two studies in process in the U.S. and Australia. There is discussion of approaches for recruiting participants, characteristics of study participants, the outcomes of the intervention, and how the participants perceived it. The final section of the chapter addresses what is entailed in implementing this kind of intervention, how to work with those concerned about an adolescent, confidentiality and consent, as well as the role of coercion. It concludes by dealing with issues related to counselor training and quality assurance.

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; Flynn PM; Knight DK; Simpson DD. Program structure, staff perceptions, and client engagement in treatment. Journal of Substance Abuse Treatment 33(2): 149-158, 2007. (56 refs.)

A key goal of drug abuse treatment providers is getting their clients to engage and participate in therapeutic activities as a first step toward deriving longer-term benefits. Much research had focused on personal characteristics that relate to client engagement; program characteristics have received less attention. This study explored client and program differences in engagement ratings using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. The results show that elements of program context, including structural features (e.g., smaller size and Joint Commission on the Accreditation of Healthcare Organizations/Commission on Accreditation of Rehabilitation Facilities accreditation) and staff's perceptions of personal efficacy, organizational climate, and communal workplace practices, relate to better overall client engagement. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.

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.

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.

Copello A; Williamson E; Orford J; Day E. Implementing and evaluating Social Behaviour and Network Therapy in drug treatment practice in the UK: A feasibility study. Addictive Behaviors 31(5): 802-810, 2006. (18 refs.)

This paper reports on the implementation and preliminary evaluation of Social Behaviour and Network Therapy (SBNT) within drug treatment services. SBNT was initially developed and evaluated as part of a trial for alcohol treatment in the UK (UKATT). For the study reported in this paper SBNT was adapted for application with drug users. Therapists (N=20) from community drug services in Birmingham, UK, were trained to deliver the intervention. Training methods were supported by a treatment manual and included a two-day workshop followed by video supervision and monitoring. Following training therapists were asked to implement the treatment within the services in which they worked. Twelve of the therapists that were trained delivered SBNT to 24 clients within the study period of 8 months. Baseline and 3-month follow-up measures were administered using both quantitative and qualitative methods. This paper reports the quantitative results including drug use, levels of dependence, drug users' social network variables and family environment. Results suggest that it was feasible to train a number of therapists to deliver SBNT, and preliminary outcome results are encouraging. Further evaluation is needed in order to continue developing this promising social intervention.

Crespi TD; Rueckert QH. Family therapy and children of alcoholics: Implications for continuing education and certification in substance abuse practice. Journal of Child & Adolescent Substance Abuse 15(3): 33-44, 2006. (35 refs.)

Clinicians involved in family therapy are increasingly concerned with the impact of parental alcoholism on individual development and family functioning. With more than 20 million adults raised within an alcoholic family, and with widespread problems associated with parental alcoholism, clinicians providing family treatment have a potentially large number of clients impacted by substance abuse. However, many clinicians lack specialty training. This article reviews the problems associated with parental substance abuse and examines substance abuse certification standards as a blueprint for continuing education and specialty credentialing.

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.

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.

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.

Fendrich M; Hubbell A; Lurigio AJ. Providers' perceptions of gender-specific drug treatment. Journal of Drug Issues 36(3): 667-686, 2006. (29 refs.)

This study examined substance abuse treatment providers' perceptions of the gender-specific service needs of women in treatment as well as the obstacles that impede the delivery of services to meet those needs. Surveys were administered to more than 100 staff members of five treatment agencies that were participating in the Chicago Practice Improvement Collaborative. These surveys were followed up with focus group discussions. Most participants reported that their treatment agencies delivered gender-specific services but also described the numerous barriers to addressing women's specific needs, such as limited resources and the psychosocial challenges experienced by women in treatment (e.g., depression, child care, and family responsibilities). We discuss these findings in light of previous studies, the strengths and limitations of our research design, and the value of collaborations between researchers and practitioners.

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� (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.

Frank B; Dewart T; Schmeidler J; Demirjian A. The impact of 9/11 on New York City's substance abuse treatment programs: A study of program administrators. Journal of Addictive Diseases 25(1): 5-14, 2006. (1 refs.)

Given the far-reaching effects of the terrorist attacks on September 11, 2001, a study was conducted under the supervision of the New York State Office of Alcoholism and Substance Abuse Services to assess the impact on New York City's substance abuse treatment programs. A stratified, random sample of 15 treatment programs was selected to represent the system's major modalities. Administrators representing these programs were interviewed face-to-face using a structured interview schedule. The questions mainly probed the problems experienced on 9/11. and afterwards, patient issues and the lessons learned. The findings show major concerns for the mental health of both staff members and patients, the failure of the telephone communication system, the particular sensitivity of drug-free outpatient clinics, the challenges experienced by methadone programs, and the need to update disaster planning. A host of problems came to the fore now requiring another level of thinking.

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; 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.

Greener JM; Joe GW; Simpson DD; Rowan-Szal GA; Lehman WEK. Influence of organizational functioning on client engagement in treatment. Journal of Substance Abuse Treatment 33(2): 139-147, 2007. (43 refs.)

This study focused on the relationship between organizational functioning factors measured in a staff survey using the Texas Christian University (TCU) Organizational Readiness for Change assessment and client-level engagement measured by the TCU Client Evaluation of Self and Treatment in drug treatment programs. The sample consisted of 531 clinical and counseling staff and 3,475 clients from 163 substance abuse treatment programs located in nine states from three regional Addiction Technology Transfer Centers. Measures of client engagement in treatment (rapport, satisfaction, and participation) were shown to be higher in programs with more positive staff ratings of organizational functioning. In particular, these programs had fewer agency needs and more favorable ratings for their resources, staff attributes. and climate. These findings help establish the importance of addressing organizational factors as part of an overall strategy for improving treatment effectiveness.

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.

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.

Hecksher D. Former substance users working as counselors. A dual relationship. Substance Use & Misuse 42(8): 1253-1268, 2007. (31 refs.)

All helping professionals risk participation in "dual relationships." But in the case of former substance users working as counselors, specific dilemmas and problems are accentuated. A qualitative analysis highlights some of the ethical and personal dilemmas faced by these counselors. The data are derived from an interview study initiated in 2000 in Denmark on former substance users with 4-8 years of abstinence. Through an analysis of interview data from a larger group of former substance users, it became evident that those working as counselors experienced specific dilemmas and problems. The current article is based on individual reports of five counselors with recovery status.

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, 2006 3:35 (14 December 2006) 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.

Horvatich PK. Enhancing the EBP repertoire of substance abuse counselors: A commentary on Kerwin, Walker-Smith, and Kirby. (editorial). Journal of Substance Abuse Treatment 30(3): 171-172, 2006. (3 refs.)

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.

Joe GW; Broome KM; Simpson DD; Rowan-Szal GA. Counselor perceptions of organizational factors and innovations training experiences. Journal of Substance Abuse Treatment 33(2): 171-182, 2007. (56 refs.)

Because work environment is central to understanding job performance, drug counselor perceptions of their programs and their skills were examined in relation to their attitudes about innovations training and its utilization. Latent profile analysis of measures on organizational climate and staff attributes for 1047 counselors from 345 programs defined three categories of counselors-labeled as isolated, integrated, and exceptional. All had generally positive views of their professional skills, although the isolated group scored lower on scales representing professional growth and influence on peers. They were less positive about the "climate" of programs in which they worked and were higher on stress. Program resources predicted the counselor groups, with the isolated having more limited resources. Counselor categorizations also differed in terms of workshop training experiences, with the isolated group of counselors reporting significantly less exposure, satisfaction, and program-wide use of workshop training.

Kerwin ME; Walker-Smith K; Kirby KC. Comparative analysis of state requirements for the training of substance abuse and mental health counselors. Journal of Substance Abuse Treatment 30(3): 173-181, 2006. (24 refs.)

Data on minimum state requirements for drug and alcohol counselors and mental health counselors in all 50 states and Washington, DC, suggest that training as a mental health counselor is primarily structured through formal education, whereas training as a substance abuse counselor resembles an apprentice model. Fewer states offer or require certification or licensure of substance abuse counselors, compared to mental health counselors. States that do offer such credentials for substance abuse counselors generally require more hours of supervised work experience and continuing education, but fewer hours of formal coursework and practicum courses, and a lower level of formal education. Although these different models for training are valid, they each have different implications for clinical practice, dissemination of research findings to practice, and management within the service delivery model.

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.

Kinney J. Loosening the Grip. A Handbook of Alcohol Information. 8th edition. New York: McGraw-Hill, 2006. (Chapter refs.)

This is the eighth edition of a handbook on alcohol use and alcohol problems. The book examines the full range of psychological factors, physiological effects, prevention strategies, treatment options, and family concerns related to substance abuse, focusing on alcohol as one of the most commonly used substances. The chapters deal with (1) history of alcohol use; (2) problems resulting from alcohol and other drug use; (3) acute effects of alcohol on the body; (4) the nature and course of alcohol dependence; (5) etiology, in terms of genetic, psychological, and environmental factors; (6) medical complications (7) behavioral aspects of alcohol dependence; (8) family issues; (9) evaluation and treatment; (10) special populations; (11) psychiatric considerations; (12) other drugs use, by drug class, with information of desired effects, acute effects, chronic effects, use patters, and types and patterns; and (13) professional principles and issues. Appendices include a list of North American substance abuse field organizations, a table presenting alcohol's interaction with other drugs, and online Internet resources for educators.

Kirby KC; Benishek LA; Dugosh KL; Kerwin ME. Substance abuse treatment providers' beliefs and objections regarding contingency management: Implications for dissemination. Drug and Alcohol Dependence 85(1): 19-27, 2006. (28 refs.)

Contingency management (CM) interventions are among the most effective methods for initiating drug abstinence, but they infrequently have been adopted by community drug and alcohol treatment programs. The primary purpose of this investigation was to determine the prevalence of specific beliefs that community treatment providers hold regarding contingency management interventions. We surveyed 383 treatment providers from three geographical areas of the United States regarding moral or ethical objections, negative side effects, practicality, limitations and positive opinions regarding tangible and social CM interventions. Results indicate that positive beliefs were surprisingly prevalent, with providers agreeing with an average of 67% of the positive statements regarding CM using tangible incentives and 54% indicating that they would be in favor of adding a tangible CM intervention to their treatment program. The most prevalent objections to incentive programs were that they cost too much, fail to address the underlying problems of addiction, and do not address multiple behaviors. Social incentives were viewed more favorably than tangible incentives and both were viewed more positively by providers who were supervisors, had advanced degrees, had more addictions experience, and had previous experience with tangible incentives. These findings have implications for improving the dissemination of this empirically-supported treatment.

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. Counselor emotional exhaustion and turnover intention in therapeutic communities. Journal of Substance Abuse Treatment 31(2): 173-180, 2006. (68 refs.)

Counselor turnover is a significant problem facing substance abuse treatment agencies. Understanding the role of organizational culture in predicting burnout and turnover intention may yield important information on how to address turnover in treatment organizations. Using data collected from 817 counselors employed in a national sample of 253 therapeutic communities (TCs), structural equation modeling was used to estimate the associations between emotional exhaustion, turnover intention, and three measures of organizational culture: centralized decision making, distributive justice, and procedural justice. The model controlled for counselor demographics, credentials, and earnings. Counselors' emotional exhaustion scores were higher in TCs with greater centralized decision making (p < .01) but lower in TCs where greater distributive justice (p < .05) and procedural justice (p < .001) were reported. Likewise, turnover intention was positively associated with centralized decision making (p < .05) and inversely associated with the workplace justice measures (p < .001). These data suggest that management practices in TCs and perhaps in other types of substance abuse treatment facilities likely play a substantial role in counselors' well-being and in their decisions to leave their jobs. Because these practices are not structural features of organizations, they may be targeted for intervention and change.

Knudsen HK; Ducharme LJ; Roman PM. Research participation and turnover intention: An exploratory analysis of substance abuse counselors. Journal of Substance Abuse Treatment 33(2): 211-217, 2007. (38 refs.)

Clinical research is increasingly being conducted in community-based addiction treatment settings. Although the primary focus of such research is on the development of effective clinical interventions, less attention has been paid to the potential impact of these projects on counseling staff who are involved in their implementation. Such involvement may be perceived as stressful or rewarding, and these perceptions may be associated with counselors' turnover intention. Using data from 207 counselors involved in research projects conducted within the National Institute on Drug Abuse's Clinical Trials Network, this study examines the associations between counselors' reactions to research experiences and turnover intention. When counselors perceived that research projects resulted in organizational benefits, turnover intention was significantly lower. However, there was a positive association between perceptions of research-related stressors and turnover intention. These findings suggest that the impact of clinical trials on treatment organizations and staff members warrants continued study.

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.

McCarty D; Fuller BE; Arfken C; Miller M; Nunes EV; Edmundson E et al. Direct care workers in the national drug abuse treatment clinical trials network: Characteristics, opinions, and beliefs. Psychiatric Services 58(2): 181-190, 2007. (22 refs.)

Objective: Individuals with direct care responsibilities in 348 drug abuse treatment units were surveyed to obtain a description of the workforce and to assess support for evidence-based therapies. Methods: Surveys were distributed to 112 programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN). Descriptive analyses characterized the workforce. Analyses of covariance tested the effects of job category on opinions about evidence-based practices and controlled for the effects of education, modality (outpatient or residential), race, and gender. Results: Women made up two-thirds of the CTN workforce. One-third of the workforce had a master's or doctoral degree. Responses from 1,757 counselors, 908 support staff, 522 managers-supervisors, and 511 medical staff (71% of eligible participants) suggested that the variables that most were most consistently associated with responses were job category (19 of 22 items) and education (20 of 22 items). Managers-supervisors were the most supportive of evidence-based therapies, and support staff were the least supportive. Generally, individuals with graduate degrees had more positive opinions about evidence-based therapies. Support for using medications and contingency management was modest across job categories. Conclusions: The relatively traditional beliefs of support staff could inhibit the introduction of evidence-based practices. Programs initiating changes in therapeutic approaches may benefit from including all employees in change efforts.

McGovern MP; Xie HY; Segal SR; Siembab L; Drake RE. Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment 31(3): 267-275, 2006. (33 refs.)

As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 45 3 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders.

McLellan T. What do you think: Introduction to commentaries on "Comparative analysis of state requirements for training of substance abuse and mental health counselors" (editorial). Journal of Substance Abuse Treatment 30(3): 167-167, 2006. (0 refs.)

McLellan TA. Communicating across the �chasm�: "Journal of Substance Abuse Treatment" and "Counselor" initiate cooperative agreement. (editorial). Journal of Substance Abuse Treatment 31(1): 1, 2006. (0 refs.)

This editorial describes a collaborative effort between the journal and "Counselor" a magazine directed to service providers. This is being marked by an article, on evidenced treatment, from the Journal being modifed and rewritten for Counselor. There is discussion of the importance of the research field making efforts to translate concepts for treatment providers, and beginning to bridge the gap between these two fields.

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

McNulty TL; Oser CB; Johnson JA; Knudsen HK; Roman PM. Counselor turnover in substance abuse treatment centers: An organizational-level analysis. Sociological Inquiry 77(2): 166-193, 2007. (85 refs.)

This article draws on institutional and ecological perspectives on work and organizations to develop a workplace level model of variation in voluntary counselor turnover rates across privately funded substance abuse treatment centers in the United States. Results show that participatory management structures reduce turnover rates principally by promoting organizational commitment. The analysis also tests hypotheses regarding the effects on turnover rates of other relevant theoretic domains of treatment center structure and organization. We discuss theoretical implications of the findings and suggest directions for future research.

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.

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.

Munoz-Plaza CE; Strauss SM; Astone-Twerwll JM; Des Jarlais DC; Hagan H. Staff perspectives on facilitating the implementation of hepatitis C services at drug treatment programs. Journal of Psychoactive Drugs 38(3): 233-241, 2006. (45 refs.)

Drug users are at risk of acquiring the hepatitis C virus (HCV). Although ancillary services available to clients at drug treatment programs are often limited, some of these programs are providing HCV services. Presenting qualitative data, the authors describe the HCV education and/or support services available at four drug treatment programs and examine staff and client perspectives on factors that facilitated the implementation of these services. Major findings include participants' perceptions that their programs had: (1) at least one change agent on staff who promoted the innovation and delivery of HCV services; (2) at least one administrator or director who encouraged and supported the adoption of these services; and (3) a treatment team that tended to collectively "buy into" and value the HCV service. Ultimately, we found that some drug treatment programs are finding creative and nonresource-intensive ways of delivering HCV services despite the existence of significant barriers. While programs need more funding and resources to overcome these barriers, these findings may prove helpful to other drug treatment programs that would like to offer HCV services to at least some of their clients.

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.

Polcin DL; Galloway GP; Greenfield TK. Measuring confrontation during recovery from addiction. Substance Use & Misuse 41(3): 369-392, 2006. (19 refs.)

The effect of confrontation on recovery from addiction continues to be a topic of considerable debate. Although many residential treatment programs view some form of confrontation as an integral part of recovery, a number of studies have found confrontation from professional treatment staff to be counterproductive. One of the problems inherent in the current debates about confrontation is the lack of a comprehensive measure of confrontation that assesses different dimensions. This study describes the development of the "Alcohol and Drug Confrontation Subscale" (ADCS), a 72-item instrument designed to measure the quantity and frequency of confrontation that individuals receive about drug or alcohol use-related problems. Confrontation is defined as an individual being told "bad things" might happen to them if they do not make changes to address a drug or alcohol use-related problem or make changes to maintain sobriety. The instrument also measures the respondents' perceptions about their relationships with confronters (three-item alpha = .79) and perceptions about the confrontational statements (three-item alpha = .63). The sample included 108 individuals entering three sober living housing organizations in Northern California between 2003 and 2005. They indicated that receiving confrontational statements about alcohol or drug use-related problems was common, especially from spouses/significant others (56% of those with significant others) and family members (60%). Participants who reported receiving more confrontation reported having more positive views about their relationships with confronters and about confrontational statements than those who received less confrontation. Additional studies are necessary to establish validity, generalize results to more diverse populations, and assess confrontation at different time points during recovery.

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.

Rieckmann T; Daley M; Fuller BE; Thomas CP; McCarty D. Client and counselor attitudes toward the use of medications for treatment of opioid dependence. Journal of Substance Abuse Treatment 32(2): 207-215, 2007. (32 refs.)

Attitudes, perceived social nonns, and intentions were assessed for 376 counselors and 1,083 clients from outpatient, methadone, and residential drug treatment programs regarding four medications used to treat opiate dependence: methadone, louprenorphine, clonidine, and ibogaine. Attitudes, social norms, and intentions to use varied by treatment modality. Methadone clients and counselors had more positive attitudes toward the use of methadone, whereas their counterparts in residential and outpatient settings had neutral or negative assessments. Across modalities, attitudes, perceived social norms, and intentions toward the use of buprenorphine were relatively neutral. Assessments of clonidine and ibogame were negative for clients and counselors in all settings. Social normative influences were dominant across settings and medications in determining counselor and client intentions to use medications, Suggesting that perceptions about beliefs of peers may play a critical role in use of medications to treat opiate dependence.

Robiner WN. The mental health professions: Workforce supply and demand, issues, and challenges. (review). Clinical Psychology Review 26(5): 600-625, 2006. (157 refs.)

The U.S. mental health (MH) workforce is comprised of core disciplines: psychology, psychiatry, social work, psychiatric nursing, and marriage and family therapy. A broader group of practitioners also deserves recognition. Diverse professions provide significant services in a variety of settings, extending the de facto mental health workforce. A tally of key disciplines estimates there are 537,857 MH professionals, or 182 per 100,000 U.S. population, This article provides an overview of the need and demand for mental health services and summarizes the MH professions (e.g., training, educational credentials, workforce estimates). It also discusses a range of challenges confronting MH professionals and the need for greater understanding of the workforce and integration of services. Methodological factors that confound estimates of the magnitude of the MH workforce are reviewed.

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.

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.

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.

Shepard DS; Calabro JAB; Love CT; McKay JR; Tetreault J; Yeom HS. Counselor incentives to improve client retention in an outpatient substance abuse aftercare program. Administration and Policy in Mental Health Services Research 33(6): 629-635, 2006. (32 refs.)

Pay for performance, the provision of financial incentives for favorable performance, is increasingly under study as an evidence-based practice. This study estimated the improvement in client retention from offering incentives to 11 substance abuse counselors providing outpatient aftercare treatment. During the incentive period, a counselor could earn a bonus of $100, in addition to his regular compensation, for each client who completed at least five aftercare sessions (the "milestone" which we considered the minimum adequate dose of the aftercare curriculum). We evaluated this and a similar, 12-session incentive using a logistic regression in which the retention "milestone" was the dependent variable and the proportion of time in the incentive condition was the independent variable. Among the 123 clients offered this aftercare program, their probability of completing at least 5 sessions was 59% with the incentive compared to 33% beforehand (odds ratio 4.1, P <.01). These findings suggest that counselor incentives are an effective strategy to improve client retention in substance abuse treatment.

Sholomskas DE; Carroll KM. One small step for manuals: Computer-assisted training in twelve-step facilitation. Journal of Studies on Alcohol 67(6): 939-945, 2006. (35 refs.)

Objective: The burgeoning number of empirically validated therapies has not been met with systematic evaluation of practical, inexpensive means of teaching large numbers of clinicians to use these treatments effectively. An interactive, computer-assisted training program that sought to impart skills associated with the Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) Twelve-Step Facilitation (TSF) manual was developed to address this need. Method: Twenty-five community-based substance use-treatment clinicians were randomized to one of two training conditions: (1) access to the computer-assisted training program plus the TSF manual or (2) access to the manual only. The primary outcome measure was change from pre- to posttraining in the clinicians' ability to demonstrate key TSF skills. Results: The data suggested that the clinicians' ability to implement TSF, as assessed by independent ratings of adherence and skill for the key TSF interventions, was significantly higher after training for those who had access to the computerized training condition than those who were assigned to the manual-only condition. Those assigned to the computer-assisted training condition also demonstrated greater gains in a knowledge test assessing familiarity with concepts presented in the TSF manual. Conclusions: Computer-based training may be a feasible and effective means of training larger numbers of clinicians in empirically supported, manual-guided therapies.

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.

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.

Strauss SM; Astone-Twerell JM; Munoz-Plaza C; Des Jarlais DC; Gwadz M; Hagan H et al. Hepatitis C knowledge among staff in US drug treatment programs. Journal of Drug Education 36(2): 141-158, 2006. (57 refs.)

Staff in drug treatment programs are in an optimal position to support the hepatitis C related needs of their patients. To do so effectively, however, staff need to have accurate information about the hepatitis C virus (HCV). This article examines the HCV knowledge of staff (N = 104) in two drug-free and two methadone maintenance treatment programs (MMTPs) in the New York metropolitan area. Five of 20 items on an HCV Knowledge Assessment were not answered correctly by the majority of the participating staff, and total scores on the Assessment averaged 70%, 71%, and 45% among the medically credentialed staff, non-medically credentialed staff in the NMTPs, and non-medically credentialed staff in the drug-free programs, respectively. The majority of those in the latter group had never participated in a training specifically devoted to HCV. Results suggest the need for effective HCV-related training for all staff in drug treatment programs.

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.

Thomas SE; Miller PM. Knowledge and attitudes about pharmacotherapy for alcoholism: A survey of counselors and administrators in community-based addiction treatment centres. Alcohol and Alcoholism 42(2): 113-118, 2007. (17 refs.)

Aims: Medications, when combined with psychosocial therapy, can improve treatment outcomes in alcoholics; however, medications are not widely utilized in community-based addiction treatment centres. Of interest is how non-medical addiction treatment professionals in these facilities view adjunctive pharmacotherapies for alcoholism. The present report focuses on baseline data collected during the course of an educational intervention project and explores predictors of positive attitudes about adjunctive pharmacotherapies among community addiction counselors and administrators. Methods: Questionnaires were administered to 84 counselors and administrators at six community-based addiction treatment centres in South Carolina. Demographic data were collected, and knowledge and attitudes regarding the value of pharmacotherapies in the treatment of alcoholism were assessed. Correlation coefficients were explored, and follow-up multiple regression analyses were conducted to examine variables that predict scores reflecting the degree to which one values adjunctive pharmacotherapies for alcoholism. Results: Respondents had little knowledge of naltrexone, with average test scores reflecting no better than chance performance. In addition, most participants believed that adjunctive pharmacotherapy is ineffectual. Higher valuation of adjunctive pharmacotherapy was related to knowledge about naltrexone, having a post-baccalaureate degree, and years of experience in the addictions treatment field. Conclusions: These data support that more widespread use of adjunctive pharmacotherapy for alcoholism may be impeded by the fact that addictions counselors, who are often the first contact for treatment-seeking individuals, have a lack of knowledge and a lack of confidence in the effectiveness of such treatments. Directed educational interventions are warranted for this population.

Treloar C; Holt M. Deficit models and divergent philosophies: Service providers' perspectives on barriers and incentives to drug treatment. Drugs: Education, Prevention and Policy 13(4): 367-382, 2006. (42 refs.)

Aims: To ascertain service providers' views on barriers and incentives to illicit drug users accessing or remaining in treatment. Methods: Interviews with service providers in Australia were conducted. Results: Two main themes were explored. Service providers suggested that the perception of a person seeking treatment was strongly associated with the image of that person as deficient, defective or lacking, and that this could impede treatment. Service providers also suggested that differing treatment philosophies and their related treatment goals were at the core of many barriers to treatment. We argue that it is important to find a balance between a model of treatment which works and is responsive to clients' needs while also avoiding the potential for feeding stigma of those who seek treatment for drug dependence. Conclusion: Our results suggest that knowledge and understanding of treatment philosophies are important for people seeking treatment so that clients can find services that match their needs and treatment goals.

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.

Villafranca SW; McKellar JD; Trafton JA; Humphreys K. Predictors of retention in methadone programs: A signal detection analysis. Drug and Alcohol Dependence 83(3): 218-224, 2006. (59 refs.)

Retention in opioid agonist therapy (OAT) is associated with reductions in substance use, HIV risk behavior, and criminal activities in opioid dependent patients. To improve the effectiveness of treatment for opioid dependence, it is important to identify predisposing characteristics and provider-related variables that predict retention in opioid agonist therapy. Participants include 258 veterans enrolled in 8 outpatient methadone/l-alpha-acetylmethadol (LAAM) treatment programs. Signal detection analysis was utilized to identify variables predictive of 1-year retention and to identify the optimal cut-offs for significant predictors. Provider-related variables play a vital role in predicting retention in opioid agonist therapy programs, as higher methadone dose (�59 mg/day) and greater treatment satisfaction were among the strongest predictors of retention at 1-year follow-up.

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.

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."

Weinstock J; Armentano C; Petry NM. Prevalence and health correlates of gambling problems in substance abuse counselors. American Journal on Addictions 15(2): 144-149, 2006. (35 refs.)

This study examined the prevalence of disordered gambling in substance abuse counselors. Participants (N = 328) completed an anonymous self-report survey assessing lifetime disordered gambling, past two-month gambling behavior, and current mental and physical health. The lifetime prevalence rates of pathological and problem gambling in this sample (11.9% and 6.4%, respectively) were higher than rates reported in general population surveys. Poorer physical health was associated with pathological gambling, but mental health was not. These results suggest that substance abuse counselors may benefit from education, prevention, and intervention efforts for disordered gambling.

Whittinghill D. A preliminary investigation of the components of a curriculum for the preparation of master's-level addiction counselors. Journal of Drug Education 36(4): 357-371, 2006. (22 refs.)

This study identified the preliminary curriculum components for the preparation of graduate-level addiction counselors. A review of the related literature revealed no agreed upon standards for post baccalaureate instruction of addiction counseling. The Delphi method was used to establish curriculum items from a list of 198 previously identified work behaviors associated with graduate-level addiction counseling. A panel of 28 addiction counseling experts responded to three administrations of an evolving questionnaire and reached consensus on a final list of 89 curriculum items. Consensus of expert judgments was corroborated by a post hoc multivariate of analysis of variance (MANOVA) that revealed no significant differences in ratings of importance among panelist subgroups.