پیش گویی کننده فرایند نتایج حاصل از مشاوره گروهی اعتیاد مواد مخدر

ABSTRACT Process Predictors of the Outcome of Group Drug Counseling

Group drug counseling is offered by 93% of the drug treatment programs in the United States (Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2010). The standard model for group drug counseling in the community is an abstinence-based approach that relies upon the 12-step (Alcoholics Anonymous [AA] and similar programs) philosophy, and this approach also has been specifically applied clinically to the treatment of cocaine abuse (Ehrlich & McGeehan, 1985). In many programs, drug counseling is the only or primary intervention received by participating patients (Simpson, Joe, Fletcher, Hubbard, & Anglin, 1999).

There is some evidence that group drug counseling can be an important component of effective treatment packages. For example, the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (NIDA CCTS; Crits-Christoph et al., 1999) reported that a package of manual-guided individual drug counseling (IDC) and group drug counseling (GDC) achieved superior results to cognitive therapy (CT) plus GDC, supportive-expressive (SE) psychotherapy plus GDC, and GDC alone. Noteworthy was the fact that all four of the treatment arms in the NIDA CCTS achieved very positive outcomes, and all arms included manual-based group drug counseling. Furthermore, the combination of individual plus group drug counseling was not superior to group alone on reduction in use of cocaine from baseline to the month 12 assessment, which is a remarkable finding given the substantial extra amount of treatment that patients in IDC
GDC obtained relative to GDC alone (Crits-Christoph et al., 1999). Thus, it appears as though the group counseling was an important aspect of the success of these treatments. Despite the success of the group drug counseling modality, alone or in combination with IDC, in the NIDA CCTS, there was substantial variability in patient outcomes, raising the question of whether variations in aspects of the treatment process might be associated with this variation in outcome. Group drug counseling is a specific and very common form of group counseling tailored to problems with substance abuse/dependence that shares a number of non-specific elements with other group therapy approaches. However, group processes (e.g., alliance, participation, self-disclosure, feedback) that have been linked to outcome in many kinds of group treatments have not been well-studied as predictors of outcome in group drug counseling. These common group processes may help to explain the wide variation in GDC outcomes.

The therapeutic alliance is one group process that has been a strong and consistent predictor of outcome in many kinds of treatment groups. A review of the group therapy literature (Johnson, Burlingame, Strauss, & Bormann, 2008) found that the alliance predicted positive outcomes in 10 of 12 studies across a range of theoretical orientations and patient populations. The only study involving a substance abuse population found that alliance in group interactional psychotherapy (not drug counseling) predicted reductions in psychological distress, but the study did not test associations between alliance and drug use (Gillaspy, Wright, Campbell, Stokes, & Adinoff, 2002). Alliance is also theoretically relevant to the GDC model used in the NIDA CCTS. The GDC treatment manual (Dailey, Mercer, & Carpenter, 1999) encourages therapists to non-judgmentally validate issues or struggles presented by group members and to be clear about the tasks and goals of therapy before problem-solving begins. Group cohesion also predicts better outcomes in groups for many clinical populations (Johnson et al., 2008). One study (Rice & Tonigan, 2011) found that participants’ perceptions of the cohesion of AA self-help groups predicted increased AA attendance. However, Gillaspy et al. (2002) failed to find effects of group cohesion on substance use consequences. The association between cohesion and reductions in substance use per se has not been tested. Furthermore, no study has examined the effects of cohesion in GDC groups on any outcome, although the GDC manual encourages counselors to “foster group cohesion and trust” (Dailey et al., 1999, p. 13). Participation in group therapy has long been believed to be an important determinant of outcome and a crucial component to the therapeutic processes of active learning, problem-solving, applying general principles to one’s specific behavior, skills acquisition, and exploring feelings and behavior (Yalom, 1995). This belief has been supported by classic studies, such as Conyne and Silver (1980), which found that active group participation produced significantly more change than did simply listening to others in group, and Lundgren and Miller (1965), which found that the number of words spoken by a group participant predicted positive change. The link between participation and outcome has been confirmed in other group treatment studies as well (Cummings, Sproul, & Kiesler, 2002; Rissel et al., 1996) but has not been examined in group drug counseling. Active participation is theoretically important to GDC: Dailey et al.’s (1999) manual encourages group leaders to facilitate group interaction among clients so that all members participate and share their thoughts, feelings, and experiences.

One particular kind of participation, self-disclosure, has also been linked to positive outcomes (Crouch, Bloch, & Wanlass, 1994; Tschuschke & Dies, 1994; Tschuschke, MacKenzie, Haaser, & Jaanke, 1996) and other positive group processes (Crouch et al., 1994). In GDC, disclosure is theorized to help members relate personally and affectively to concepts discussed, rather than abstractly and intellectually. Immediacy and quality of selfdisclosure is fostered in GDC by helping members to talk directly to each other, rather than talking abstractly or only to the therapist (Dailey et al., 1999). Feedback is a ubiquitous aspect of almost all types of psychotherapy (Claiborn, Goodyear, & Horner, 2001) and has long been held to be an integral part of group treatments (Fuhriman & Burlingame, 1994; Yalom, 1995). A number of reviews of the empirical literature on feedback in groups (Claiborn et al., 2001; Morran, Stockton, & Bond, 1991) have concluded that feedback is an important determinant of the group treatment outcomes. Feedback may help patients to become more aware of feelings, thoughts, or patterns of behavior or may provide group members with alternate perspectives on their behavior and how it affects others. Feedback, a “key component” of GDC sessions (Dailey et al., 1999), may lead to positive outcomes in GDC by encouraging and rewarding patients’ positive efforts to change their substance use behaviors, by indicating areas of concern or danger that the patient may not yet see, or occasionally by addressing counterproductive activities and behaviors in a non-confrontational way.

Although frequency of generic feedback has been found to be associated with good outcomes in many kinds of group therapy, unskilled feedback such as confrontation or unwanted advice has been found to predict negative outcomes in individual drug treatment (Miller, Benefield, & Tonigan, 1993). Within the substance abuse field, confrontation on drug use and denial and telling patients what to do are not uncommon approaches. Research, however, has suggested that a confrontational style of intervention is less effective than an empathic style in the treatment of substance use disorders. Miller, Taylor, and West (1980) found that ratings of therapists on empathy highly predicted drinking outcomes at 6 months. Similar findings were reported by Valle (1981). In contrast, Miller et al. (1993) found that frequency of therapist confrontational responses were highly related (r .65) to drinking outcomes, with high levels of confrontation associated with poor outcomes. These findings on confrontation versus empathic style are consistent with the general group therapy literature suggesting that positive feedback is more successful than negative feedback (Morran et al., 1991). Thus, in assessing feedback as a predictor of GDC outcomes, it is important to also account for whether such feedback is generally empathic/positive or confrontational/negative and how much attempted feedback takes place in the form of advice.

One methodological consideration that is highly relevant to psychotherapy process-outcome research, but is rarely addressed, is whether a single session (or two or three sessions averaged) is adequate to yield a dependable patient level score, given session to session variability and other potential sources of variability in such scores. Dependability can be assessed using generalizability coefficients derived from variance components that estimate the population covariation between random factors (e.g., sessions, patients) and a dependent variable (e.g., rating of alliance). When dependability is not considered, relationships between variables may be attenuated due to other sources of variability without the researcher knowing that this has occurred. A second methodological issue that is relevant to examination of process-outcome relations is whether the average process or trend in process is more relevant to positive outcomes. For example, several studies (Gelso & Carter, 1994; Kivlighan & Shaughnessy, 1995; Woody & Adessky, 2002) have suggested that measuring the trend in alliance rather than its absolute level might better capture its relationship to outcome in both individual and group treatments, although one of these studies (Woody & Adessky, 2002) failed to find a relationship between trend in alliance and outcome. An alternate way to operationalize processes over time is to examine the impact of process variables in a given session on proximal (e.g., next session) outcomes. This approach might capture the influence of process variables even if no systematic trends in such process variables occur over sessions. No group processoutcome articles have examined processes over average, trend, and individual session levels in the same study. The purpose of the current study was to examine the relation of process variables to the outcome of group drug counseling for cocaine dependence. Primary outcomes were monthly cocaine use (days using out of 30), next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were two possible mediator variables, endorsement of 12-step philosophy and beliefs about substance abuse, previously reported to correlate with outcome in the NIDA CCTS (Crits-Christoph et al., 2003). Group processes were examined as average scores, slopes over time, and proximal (e.g., next session) predictors. We hypothesized that higher group cohesion—and both average and increasing trends over sessions in alliance, participation/self-disclosure, and feedback—would be related to better proximal and distal outcomes and improvements in mediator variables. We hypothesized that more advice on average and within sessions would predict worse proximal and distal outcomes.