ABSTRACTS

Special Series: Current Strategies for Moving Evidence-Based Interventions Into Clinical Practice Introductory Comments
Sonja K. Schoenwald and Scott W. Henggeler, Family Services Research Center, Medical University of South Carolina

This special section presents four evidence-based practices that are currently being transported to community-based settings: Nurse-Family Partnership for infant health and development, Assertive Community Treatment for adults with serious and persistent mental illness, Oregon Therapeutic Foster Care for chronic juvenile offenders, and Parenting Wisely for caregivers of children with disruptive behavior. Although each model addresses a very different clinical population, their similarities in development, emphasis on fidelity and quality assurance, and use of dedicated organizations to support effective transport are noteworthy. Admirably, the intervention developers are taking the same care in crafting strategies to transport their models as they took in validating these clinical innovations. Such care is critical to increasing the probability that the intervention models will be transported to community settings with the fidelity needed to achieve intended outcomes.

Taking Preventive Intervention to Scale: The Nurse-Family Partnership
David L. Olds, Peggy L. Hill, and Ruth O’Brien, University of Colorado, David Racine, Replication and Program Strategies, Philadelphia, and Pat Moritz, University of Colorado

We outline a program of research aimed at improving the outcomes of pregnancy, child health and development, and maternal life-course with a program of prenatal and infancy home visiting by nurses for low-income mothers having first babies. We present the theoretical and epidemiologic foundations of the program, the major findings from the randomized controlled trials employed to test the program, and our efforts to translate these findings into effective community nurse home visitor programs. Particular attention is given to our development of the National Center for Children, Families, and Communities, which serves as the organization devoted to replicating the program, now called the Nurse-Family Partnership, in new communities with fidelity to the model tested in the trials. Our national replication work revolves around three major functions: helping organizations and communities become prepared to conduct and sustain the program over time; training nurses and providing them with structured guidelines to enable them to conduct the program with a high level of clinical excellence; and research, evaluation, and quality improvement activities designed to continuously improve the program and its implementation as it is offered to a larger number of communities over time.

The Program of Assertive Community Treatment: Implementation and Dissemination of an Evidence-Based Model of Community-Based Care for Persons With Severe and Persistent Mental Illness

Paul B. Gold, Neil Meisler, and Alberto B. Santos, Medical University of South Carolina
Jennie Keleher, South Carolina Department of Mental Health, Sumter
Deborah R. Becker, New Hampshire-Dartmouth Psychiatric Research Center
Mark A. Carnemolla, Medical University of South Carolina, Charleston, South Carolina
William H. Knoedler, Mendota Mental Health Institute, Madison, Wisconsin
Mark A. Carnemolla, Medical University of South Carolina
Deborah R. Becker, New Hampshire-Dartmouth Psychiatric Research Center, Lebanon, New Hampshire
Olivia H. Williams, South Carolina Department of Mental Health, Sumter
Rich Toscano, Charlotte, North Carolina
Gene Stormer, Springfield, Illinois

The Program of Assertive Community Treatment (PACT), a multidisciplinary team approach, delivers integrated community-based treatment, rehabilitation, and support services to help persons with severe and persistent mental illness to avoid psychiatric hospitalization and to live independently in natural community settings. Twenty-five randomized clinical trials of PACT and its adaptations, conducted over the past 30 years in several countries, demonstrate its effectiveness for this population in reducing use of inpatient psychiatric services and sustaining tenure in normalized housing. Programs based on the PACT model now operate in many countries and most states. Several states have disseminated these programs statewide using a mix of standards, financial incentives, monitoring of program performance, and expert training and consultation. However, despite the strong evidence base for PACT, most states have neither exerted the political will nor committed the necessary resources nor implemented fidelity assurance methods necessary to widely disseminate PACT and/or its close variants. For the PACT model, we offer our hypotheses about behavioral change processes underlying its approach, describe its major operational structure and process elements, briefly review the research evidence of its effectiveness, and summarize statewide dissemination efforts and factors facilitating effective dissemination. Lastly, as a case study of implementation and dissemination, we report our difficulties in implementing PACT in a rural South Carolina community mental health center (1995–2000), discuss how supervision and consultation by national PACT experts prevented a collapse of our project and turned it into a success, and outline our present plans, supported with a federal grant, to disseminate an integrated PACT and supported employment service in South Carolina’s community mental health center system.

The Oregon Treatment Foster Care Model: Features, Outcomes, and Progress in Dissemination
Patricia Chamberlain, Oregon Social Learning Center and OSLC Community Programs

The practice of placement in children and adolescents with severe antisocial behavior and delinquency in residential and group home settings is commonplace in most communities in the United States, yet little research exists on the short- or long-term effectiveness of such placements. Furthermore, recent evidence suggests that there are potentially damaging effects from placement in congregate care settings that relate to negative influences that problem youth who are placed together tend to have on each other. The Oregon Treatment Foster Care (TFC) model was developed as an alternative to group and residential care for youth with delinquency and severe emotional and behavioral problems. The central features of the Oregon TFC model are described, evidence on the efficacy of the model is reviewed, and practical aspects relating to dissemination are discussed along with conditions that act to facilitate or create barriers to implementation.

Lessons Learned From the Dissemination of Parenting Wisely, A Parent Training CD-ROM
Donald A. Gordon and Christine Rolland Stanar, Ohio University

An intervention was developed that did not rely upon trained or experienced service providers for its delivery to families with behavior disordered children and youth. The format is an interactive CD-ROM geared toward low-income, single-parent families. The very brief intervention offers privacy and engagement, unlike traditional methods, and its low cost to implement has enabled it to be disseminated to over 300 agencies in 4 years. The supporting research showing moderate effect sizes on child problem behavior, both in university and community settings, is described. Dissemination efforts began with the formation of a company for marketing the program through a university business incubation center. Of the agencies using the program, 93 were surveyed as to factors associated with successful implementation. Administrative support and practitioner buy-in, and a commitment to evaluate the program added accountability for client outcomes, all of which accounted for 30% to 40% of the variance in implementation success. Steps to maintain effective programs are outlined.

Cognitive Behavioral Therapy for Older Adults: Practical Guidelines for the Use of Homework Assignments
Nikolaos Kazantzis, Massey University, Nancy A. Pachana, University of Queensland, and David L. Secker, Institute of Psychiatry, London

There is emerging evidence to support the effectiveness of cognitive behavior therapy (CBT) for older adults. However, there are a number of clinical difficulties that practitioners often encounter when using homework assignments with the older adult population. In this article, we provide a brief summary of the research findings on homework in CBT, review common obstacles to the use of homework, and provide concrete suggestions for the adaptation of homework assignments to increase their potential effectiveness with older adults. We also describe several types of homework assignments that may be most helpful, augmenting these suggestions with clinical examples.

When Prolonged Exposure Fails: Adding an Imagery-Based Cognitive Restructuring Component in the Treatment of Industrial Accident Victims Suffering From PTSD
Brad K. Grunert, Mervin R. Smucker, Jo M. Weis, and Mark D. Rusch, Medical College of Wisconsin

Prolonged exposure (PE) is a widely promulgated treatment modality for PTSD. While successful with many subjects, PE also has a significant failure rate (i.e., dropouts, nonimprovement, symptom exacerbation). To date, outcome research has not examined why PE at times appears to be the treatment of choice for PTSD and why it sometimes needs to be combined with cognitive restructuring interventions to be effective. This study presents a detailed cognitive-behavioral analysis of two industrial victims suffering from PTSD who failed to benefit from PE alone, but who subsequently made a quick and lasting recovery when an imagery-based, cognitive restructuring component was added to their exposure treatment. A comparative analysis is presented of the theoretical underpinnings and treatment components of the behavioral and cognitive treatments used with the subjects in this study—PE and imagery rescripting and reprocessing therapy (IRRT). PE is as a behavioral treatment based upon theories of classical conditioning that relies on exposure, habituation, desensitization, and extinction to facilitate emotional processing of fear. By contrast, IRRT is cognitive therapy applied in the context of imagery modification. In IRRT, exposure is employed not for habituation, but for activating the trauma memory so that the distressing cognitions (i.e., the trauma-related images and beliefs) can be identified, challenged, modified, and processed.

Integrating an Interoceptive Exposure-Based Smoking Cessation Program Into the Cognitive-Behavioral Treatment of Panic Disorder: Theoretical Relevance and Case Demonstration
Michael J. Zvolensky, The University of Vermont, C. W. Lejuez, University of Maryland–College Park, Christopher W. Kahler, Brown University, and Richard A. Brown, Brown University/Butler Hospital

A theoretically driven approach to the cognitive-behavioral treatment of panic disorder and smoking is articulated. For persons with panic disorder who smoke, it is suggested that it may be useful to directly integrate smoking cessation within cognitive-behavioral treatment for panic disorder. To illustrate the potential viability of this type of treatment approach, the nature of the panic and smoking co-occurrence is first discussed. Then, a treatment model that integrates an interoceptive exposure-based program of smoking cessation into cognitive-behavioral therapy for panic disorder is presented. Finally, a case example is used to illustrate this approach, followed by a discussion of the potential implications of this therapeutic model.

Promotion of Emotional Disclosure Following Illness and Injury: A Brief Intervention for Medical Patients and Their Families
Matthew J. Cordova and Josef I. Ruzek, VA Palo Alto Health Care System, Maryse Benoit, Douglas Hospital Research Center, and Alain Brunet, McGill University and Douglas Hospital Research Center

While considerable resources are dedicated to preparing patients and their significant others for the process of physical recovery and rehabilitation following illness/injury, provision of information and support regarding the trajectory of psychosocial recovery from these stressors is not the standard of care in clinical medical settings. Given the strong influence of social environment on cognitive-emotional processing and psychosocial adjustment following illness and injury, it is important to identify interventions that help medical patients and their families to create a family environment that is conducive to processing and support. In this article, we (a) briefly review relevant literature on the psychosocial impact of illness and injury, the importance of cognitive-emotional processing and social environment to illness/injury-related adjustment, and existing models of intervention in the medical setting; (b) describe a brief intervention we have developed and pilot-tested to promote cognitive-emotional processing among medical patients and their families; (c) describe our clinical experiences with the intervention to date; and (d) offer suggestions for delivery of the intervention in clinical practice and for conducting research on its efficacy.

Are Nonparaphilic Sexual Addictions a Variant of Obsessive-Compulsive Disorder? A Pilot Study
Stefanie A. Schwartz and Jonathan S. Abramowitz, Mayo Clinic

Nonparaphilic sexual addictions (NPSAs), which are characterized by repetitive sexual thoughts and behaviors, have been proposed as an obsessive-compulsive spectrum disorder. In the present study we examined the functional differences in repetitive sexual thoughts and compulsive behaviors between patients with OCD (n = 6) and with NPSAs (n = 6). Compared to patients with NPSAs, those with OCD reported significantly more fear and avoidance related to their sexual thoughts. Individuals with NPSAs reported higher levels of sexual arousal associated with their thoughts and a greater degree of sexual pleasure from performing compulsive behaviors. These preliminary findings challenge the notion that NPSAs are related to OCD. Results are discussed in terms of their implications for treatment using cognitive-behavioral procedures.

Valued Directions: Acceptance and Commitment Therapy in the Treatment of Alcohol Dependence
Michelle Heffner, West Virginia University, Georg H. Eifert, Chapman University, and Benjamin T. Parker, Danielle H. Hernandez, and Jeannie A. Sperry, West Virginia University

This case study describes the treatment of a middle-aged, Caucasian male for alcohol dependence. Treatment focused on using the valued directions component of Acceptance and Commitment Therapy (ACT), a relatively new and promising intervention for substance use disorders. Rather than merely setting a treatment goal to “stop drinking,” we helped the client identify valued life directions that promote an environment to support sobriety and put a plan into action for the client to “start living.” Treatment resulted in improved quality of life and near 100% sobriety. The positive results of this clinical case complement the preliminary findings of a randomized clinical trial currently conducted to evaluate ACT in the treatment of polysubstance abuse. We discuss our treatment approach in relation to existing cognitive-behavioral interventions for alcohol dependence.

Characteristics and Motives of Problem Drinkers Seeking Help From Moderation Management Self-Help Groups

Elena Klaw, Center for Health Care Evaluation, Veterans Affairs, and Stanford University Medical Centers, Palo Alto, and San Jose State University, Shira Luft and Keith Humphreys, Center for Health Care Evaluation, Veterans Affairs, and Stanford University Medical Centers, Palo Alto

Moderation Management (MM) is a relatively new self-help/mutual aid organization that adopts a cognitive-behavioral conceptualization of alcohol abuse. Specifically, MM construes problem drinking as a habit that can be brought under control through the application of cognitive-behavioral principles in the context of a network of supportive peers. MM therefore serves as an alternative to the spiritually oriented disease model of Alcoholics Anonymous (AA), as well as to the abstinence goal orientation of AA and other self-help organizations (e.g., Women for Sobriety and SMART Recovery). To provide cognitive-behavioral therapists and researchers more information about MM, this paper describes the MM organization and presents survey data on the characteristics and help-seeking motives of 467 individuals who contacted the organization by telephone over a 1-year period. Callers to MM’s national telephone number had significantly less severe drinking problems and greater educational and economic resources than typical help-seeking populations of alcohol-dependent persons (e.g., AA members.) Study participants, particularly women, typically experienced MM as a better “fit” with their drinking problem, life experiences, and valuation of personal mastery than disease-model, abstinence-based approaches. Although the organization has never been subjected to a controlled outcome study, cross-sectional data indicate that MM members appear to reduce their level of alcohol-related harm over time. Cognitive-behavioral treatment professionals working with nondependent problem drinkers may thus wish to consider referring clients to MM.