simplicities can be complications in intervention research carl leukefeld, faculty and staff...

Simplicities can be Complications in Intervention

Research Carl Leukefeld, faculty and staff

Department of Behavioral Science & Center on Drug and Alcohol Research, University of Kentucky

University of Texas, AustinNovember 2005

This project is funded by Grants No. RO1-13076, RO1 DA13076, U01 DA16205 awarded by the National Institute on Drug Abuse, Points of view in this presentation are those of the authors and do not necessarily

represent the official position or policies of the National Institutes of Health.

OVERVIEW

Assumptions and DefinitionsDeveloping a Therapy -- Structured

Behavioral Rural Therapy (SBORT)Describe two Intervention Approaches Employment and Work Behavioral TrialHIV Prevention Behavioral Trial Discussion

FOCUS

The presentation overviews a “…line of research” across two RO1’s and a center grant project.

ASSUMPTIONSand

DEFINITIONS

Alcohol and Drug Use

Can be Chronic

And

Relapsing

Disorders

Possible Pathways to Alcohol and Drug Abuse

Biological/Genetic

Psychological

Social

EnvironmentalCultural

Spiritual

Peers Familial

Spiritual

Alcohol and Drug

-Behavior

-Attitudes

-Values

-Knowledge

(Nat

ure

)(N

urt

ure

)

Alcohol and Drug Abuse Community Perceptions

Treatment Providers

Schools

Criminal Justice

Public Health

Politicians

General Public

Addiction

An excess, a reinforcing compulsion, and/or an inability to control dependency behavior and attitudes over time that can be harmful or beneficial with possible genetic underpinnings as well as psychological, social, spiritual and other pathways.

BEHAVIORAL THERAPY

Theoretical Grounding in the Stages of Change

(Prochaska&DiClemente, 1982)

PrecontemplationContemplationDetermination

ActionMaintenance

Relapse

Focus Group Findings

Don’t use jargon and “educated” words

Don’t overwhelm clients with paperwork

Don’t stereotype and depersonalize clients

Don’t try to control clients Don’t be humorless

Therapy Overview

Focus Antecedents, Behavior and

Consequences (Leukefeld et al, 2000) Stages of Change (Prochaska &

DiClemente, 1982)Methods Motivational Interviewing (Miller &

Rollnick, 1989). Structured Stories (Leukefeld et al,

2002) Thought Mapping -- Problem Solving

Therapy Focus - Antecedents, Behavior and Consequences

A Learning Theory focus on teaching behaviors and skills.

An assumption that a behavior can be learned using a cognitive behavioral approach.

A B C

“Alumni” Groups

“Alumni” Groups

Group Sessions

Problem Solving

Structured Stories

Thought Mapping

Group Sessions

Problem Solving

Structured Stories

Thought Mapping

Individual Sessions

using

Motivational Interviewing

Individual Sessions

using

Motivational Interviewing

Structure

Pre-TherapyPre-TherapyPre-TherapyPre-Therapy Therapy Therapy Therapy Therapy Follow-upFollow-upFollow-upFollow-up

Structured Stories

Structured Stories are used to focus on changing behavior (Leukefeld et al., 1999)

• Acceptable• Model specific behavior andconsequences

A person is put into a situation which

could have several outcomes

StorytellingStorytelling provides information about

beliefs, values, attitudes, and behaviors.

Stories can be used to give “how-to” and “how-not-to” information.

Personal stories are most often remembered and are used to transfer information to others.

Stories can be cognitive rehearsals for new behaviors and attitudes.

StoriesWe use stories when we

talk with others.Stories are not just

entertainment but a way of processing information.

Structured Stories Stories are structured and scripted to

target a specific behavior, the antecedents of the behavior -- what came before the behavior -- and the consequences of the behavior -- what came after the behavior.

Structured stories are used to “cue” or initiate individual and personal stories which are called “counter stories”.

Personal counter stories can then be discussed and examined.

Structured Stories

Structured stories can be modified to cognitively rehearse how different behaviors might change outcomes in the same story.

Some people can engage quickly in structured stories to cognitively “try out” new behaviors.

Structured Story (Rick)Rick is a young man who had opportunities and hard knocks. His father was an

alcoholic. His mother raised him. He finished high school and got a factory job and married his high school sweetheart. After 3 years, Rick lost his job. He used alcohol in addition to grass and served time.

He returned home and stopped using because his wife threatened to leave him. He got a construction job and made foreman. Rick’s wife fell in love with another man and left him. Rick stalked his wife, she filed a protective order, he kept stalking her, and he was jailed.

One evening after work and having a few hits, Rick met his friends at a bar. For the first time in weeks, he was laughing. He spotted a good looking woman at the bar. He smiled and she smiled back. She came over to him and asked his name. One thing led to

another and…

Thought Mapping Thought Mapping is a structured, preformatted

approach to help participants organize their own thoughts and behaviors visually using a “map”

Thought Mapping focuses on linking information using associations of antecedents, behaviors, and consequences for: – Personal feelings, – What others thought and did,

– What the person did, and – What could have been done differently.

Thought Map

Problem1. What is the problemor experience?

My feelingsWhat others thought

What I did2. What came

before theproblem or

experience? Leads to

My feelingsWhat others would

think and do

What I would do

6. How wouldthings be different?

Consequences3. What happened?

Different Behavior4. What could I have done instead?

Different Consequences

5. What would be different?

Comments

A Rural cognitive behavioral therapy was developed and tailored with rural clients which focuses on Antecedents, Behavior, and Consequences using:Structured StoriesThought mapping

EMPLOYMENT AND WORK

Employment

Employment is associated with:– Less relapse (Magure et al., 2005; Wickizer

et al., 1994; Wolkstein & Spiller, 1998)– Staying in treatment (McLellan, 1983; Platt,

1995; Schottenfeld et al., 1995)– Positive community functioning (Comerford,

1999; Platt, 1995; Room, 1998; Wolkstein et al., 2000)

– But no differences in jobs -- food service and construction -- between full-time and part-time work (Leukefeld et al. ,2004)

Background

This NIDA supported randomized trial examined an employment intervention focused on -- Getting a job (Obtaining), Keeping a job (Maintaining) and Getting a better job (Upgrading)

This study adds a focus on Upgrading Employment

This analysis examines12-month outcomes by upgrading dosage

Procedures

Participants were recruited during their first drug court session between March 2000 and November 2002

Face-to-face interviews were completed within two weeks after drug court entry

After face-to-face interviews, participants were randomized into the employment intervention or to the treatment as usual control condition

Baseline

Interview

Recruitment:

2 Drug Courts

Study Design

RandomAssignment

Employment Group(n=250)

Employment Group(n=250)

Control --Drug CourtAs Usual(n=250)

12-Month

Follow-up

Interview

Employment Intervention

ObtainingObtainingObtainingObtaining MaintainingMaintainingMaintainingMaintaining UpgradingUpgradingUpgradingUpgrading

Phase 1

Phase 2

Phase 3

Obtaining Employment

ObtainingObtainingObtainingObtaining

(Skills to (Skills to get a job)get a job)

Individual SessionsIndividual SessionsIndividual SessionsIndividual Sessions

• Job search• Resume writing• Job applications

• Cover letter• Job services• Job interviews

Group SessionsGroup SessionsGroup SessionsGroup Sessions

• Job readiness assessment• Getting immediate employment• Employment behavioral contracting

Maintaining Employment

MaintainingMaintainingMaintainingMaintaining

(Skills to (Skills to keep a job)keep a job)

Individual SessionsIndividual SessionsIndividual SessionsIndividual Sessions

• Self-esteemSelf-esteem• Job retentionJob retention• AssertivenessAssertiveness

• Goal settingGoal setting• Time managementTime management• Asking for a raiseAsking for a raise


• Resolving work conflicts Resolving work conflicts • Setting goals and problem solvingSetting goals and problem solving• Life skills at workLife skills at work

Upgrading Employment

UpgradingUpgradingUpgradingUpgrading

(Skills to (Skills to get a better job)get a better job)

Individual SessionsIndividual Sessions Individual SessionsIndividual Sessions

• Job searchesJob searches• Getting alongGetting along• Managing TimeManaging Time

• BudgetingBudgeting• Interviewing skillsInterviewing skills• Professional interactionProfessional interaction


• Finding new employersFinding new employers• Job developmentJob development• Job placementJob placement

Subjects

475 of the 500 baseline participants were interviewed at 12 month follow-up which is a 96% follow-up rate after excluding 4 deaths

Overall participants were: 30.5 years

old (range=18-57), male (65%), white (61.8%), never married (53.4%) with 11.8 years of education

Method

To examine the Upgrading intervention dose, the number of Upgrading Sessions each subject attended was divided by the number of possible Upgrading Sessions for subjects randomized into the intervention

Method (cont.)

Session attendance percentages were used to median split the intervention subjects into a Low dose upgrading group (n=120) and a High dose upgrading group (n=118) which were compared with the no intervention Control group (n=237)

These 3 groups (Control, Low dose upgrading, and High dose upgrading) were used in a series of ANOVA and Chi-square analyses to examine differences in outcomes at 12-month follow-up

Demographics for the three groups (n=475)

Control

(n=237)

Low Dose Upgrading

(n=120)

High Dose Upgrading

(N=118)

n 237 120 118

Age 31.3 28.4 31.3

% Male 64% 65% 65%

% Single 52% 59% 50%

% HS Education

67% 56% 65%

Employment status at 12 month follow-up

25

16

59

33

13

54

4

13

83

0

10

20

30

40

50

60

70

80

90

Control Low Dose High Dose

%Unemployed %Part-time %Full-time

Days legally employed

19.4 13.423.4

216.2

185.7

275.8

0

50

100

150

200

250

300

Past 30 days* Past year*


Days illegally employed

0.6 0.4 0.4

16.4

22.3

4.8

0

5

10

15

20

25

Past 30 days Past year*


Days with employment problems

2.94.4

2

34.936.8

20.6

0

5

10

15

20

25

30

35

40

Past 30 days Past year


Legal Income

$1,277$841

$1,297

$11,367

$7,414

$13,272

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000



Illegal Income

$472$326 $292

$3,892

$1,597

$321

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000



Drug use in the past year at follow-up (%)

41

56

21

26

39

8

31

40

25

30

37

11

0

10

20

30

40

50

60

Alcohol* Marijuana* Cocaine* Multiple Drugs*


Crimes at follow-up (%)

11

19

6

15

20

4

8

10

1

15

20

4

0

2

4

6

8

10

12

14

16

18

20

Damaged Property Received StolenProperty*

Stole Something>$50*

Sold Drugs*


Implications

Maybe this is not really new “news” since intervention outcome is associated with retention

Session participation could be an indirect indicator of motivation

The Low dose group is different from the High dose group which could suggest differences in intervention engagement

Implications (cont.)

Since subjects who received the higher Upgrading dose reported changes in employment, drug use and crime -- it appears that more attention should be placed on helping drug abusers get better jobs.

Practitioners should consider identifiable employment interventions.

Practitioners should consider separate employment assessments

Employment interventions should be tailored and examined in controlled studies.

Limitations

The employment market shifted during the project with fewer jobs available.

It is not known how truthful participants were.The employment variables are not

exhaustive.Only two sites and drug courts were included.Drug court data may not generalize to other

samples because of possible sanctions.

Restructuring Risky Relationships-HIV

(RRR-HIV)

Participating Centers:

University of Kentucky Center on Drug & Alcohol Research

University of Delaware

University of Maryland

Background

Relationships are important to women (Covington, 1998; Surrey, 1991; Staton Tindall, 2004).

Women adapt their sexual behavior – risky or not – to a relationship and their level of involvement with a partner (Morrill, et al., 1996).

A woman’s ability to recognize relationship “thinking errors”, which may increase her risk for HIV decisions, has not been fully examined.

Purpose

This study examines how women can change relationship thinking errors to reduce their HIV risk behaviors within intimate relationships.

This project will:

(1) Examine the unique issues of female drug abusing prisoners and HIV.

(2) Develop, pilot, and test a HIV intervention targeting relationship thinking errors for incarcerated women who are re-entering the community.

Predisposing ConditionsPredisposing Conditions

HIV RiskBehavior

Restructuring Risky

Relationships – HIV

(RRR-HIV)

Relationships

EnvironmentalPsychologicalHistorical Social Support

Conceptual framework

Phase 1:InterventionDevelopment

Phase 2:InterventionRefinement

Phase 3:InterventionEvaluation

RandomizationNIDA Standard

(n=120)

RRR-HIV Intervention

(n=120)

6 Month Follow-up

6 Month Follow-up

Study design

Procedures – Phase 1

During Phase 1, focus groups will be conducted with three groups of 10 women (n=30) who are:

(1) Incarcerated and receiving in-prison drug abuse treatment

(2) Recently released women who received in-prison drug abuse treatment and are receiving community treatment

(3) Recently released women who did not receive in-prison treatment but are receiving community drug treatment.


The RRR-HIV intervention will be piloted for feasibility during Phase 2 with two groups of women who are currently enrolled in prison-based substance abuse treatment in Kentucky.

Female inmates who are nearing the end of their treatment participation (approximately 8 weeks prior to seeing the parole board) will be eligible for the pilot.

Volunteer participants will be asked to meet with the RRR interventionist and to attend weekly groups for 5 weeks.


Study participants will be randomized into one of two groups: 1. RRR-HIV intervention group (n=120) 2. NIDA Standard group (n=120)

Data collection will take place at baseline and 6-months post-release to allow for comparisons in outcomes related to high risk behaviors, drug use, and relationships across the two groups.

The key outcomes examined will be HIV risk behaviors which include sexual activity and drug use.

The RRR-HIV intervention

The intervention is planned over 7 weeks, which includes individual and group sessions targeted on understanding the association between thinking errors about relationships and HIV risk behavior among women.

Seven Sessions are proposed– Sessions 1 to 5 will take place in prison immediately

before community re-entry. – Sessions 6 and 7 will take place in the community

after release.

The RRR-HIV intervention

Overview

Session 1

Session 2

Session 3 & 4

Session 5

Session 6 & 7

Relationships at re-entry

Presenting HIV risk behaviors

Cognitive skills building sessions

Individualizing skills for community re-entry

Personalization of relationships, risky sex & social skills

Four Initial Focus Group Themes

Relationship expectations are coupled with low self-esteem – (I expect to get hurt in bad relationships – That is what I deserve. But -- Getting hurt is harder to overcome in a good relationship)

Relationships are used to get things (He gives me what I need – I let him do what he needs to do)

Initial Focus Group Themes (cont.)

A cycle of bad relationships --Dysfunction is expected and can be “comfortable”

Recovering women do not stay out of relationships even thought they may be asked to.

Questions/Comments

simplicities can be complications in intervention research carl leukefeld, faculty and staff...

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