Date April 2, 2002
Professional Competence.
The Research Division of Behavior Therapy Associates LLP (BTA) was organized
in 1996 as a separate division apart from the Clinical and Training Divisions.
Dr. Reid Hester has been its Director since then. Dr. Hester has been involved
in research in substance abuse since 1974 and clinical treatment since 1978.
He has published over 40 articles, chapters, and books in the field of assessment
and treatment of alcohol problems. His current federally funded (NIAAA) research
project is to develop, evaluate, and disseminate a computer-based brief motivational
intervention for drinkers which includes an automated program evaluation component
suitable for DWI treatment providers. He also is currently conducting a pilot
study of dissemination of this brief intervention and program evaluation software
with 7 DWI treatment providers around the State. Dr. Hester also developed an
empirically supported treatment protocol, Behavioral Self-Control Program for
Windows (BSCPWIN) and has demonstrated its efficacy in a controlled clinical
trial (Hester & Delaney, 1997). BSCPWIN is a computerized version of Behavioral
Self-Control Training, an empirically supported treatment protocol for DWI offenders.
Dr. Theresa Moyers is an associate in the Research Division. She has extensive
experience and expertise in substance abuse treatment, research, and training
protocols. She currently has a research grant to examine the effectiveness of
different levels of intensity of training in motivational interviewing training
workshops. She also is a trainer of trainers in motivational interviewing.
Similarly, Dr. Robert J. Meyers has extensive clinical and research experience
in substance abuse. He was a principal in the development of the Community Reinforcement
Approach (CRA), an empirically validated intervention for DWI offenders and
for substance abuse in general. In the last 15 years he has spearheaded clinical
research and further development of the CRA protocol. He has trained clinicians
in the CRA protocol throughout the State, the U.S., Europe, South Africa, and
Australia. He is the Principal Investigator on two NIH funded trials of CRA
and a consultant on several others.
Dr. A. Thomas Horvath is the President of SMART
Recovery and of Practical Recovery Services in LaJolla, CA. He is available
to conduct training workshops in the SMART Recovery protocol. SMART Recovery
is a self-help program that is an alternative to 12 step self-help groups. It
is based on empirically supported, cognitive behavioral principles.
Daniel Squires, M.S. is a Research Assistant and graduate student in the Psychology Department at UNM. On a National Research Scientist Award grant he is implementing the brief intervention/program evaluation software pilot project mentioned above. His services to DWI treatment providers are at no cost to the State other than travel costs.
Prior experience.
Drs. Hester, Moyers, and Meyers have been conducting clinical skills training
workshops for DWI treatment providers throughout the State since 1997. Evaluations
from participants in these workshops have been positive. For a typical workshop,
over 90% of the respondents rate the workshop elements either 5 or 7 on a 7
point Likert scale (a 7 being the highest score).
In addition, Drs. Hester, Moyers, Meyers, and Horvath have given numerous clinical skills training workshops around the U.S. and abroad. Their vitae below detail their recent training efforts.
Project Management
Planning, Development and Implementation
Dr. Hester will be the Principal Investigator for this contract. He will be
primarily responsible for planning, developing, and implementing training workshops
and consulting with County DWI Coordinators and treatment providers. He will
conduct clinical skills training workshops and spearhead the liaison efforts
with the judicial system in the ignition interlock program. He will be primarily
responsible for the performance of this contract.
Drs. Moyers, Meyers, and Horvath will be responsible primarily for conducting clinical skills training workshops in their respective areas of expertise. Dan Squires will continue to implement the pilot program of the DCU/FDCU program described below.
Proposed Scope of Activities
Assessment of offenders pre- and post-treatment. Comprehensive assessment
of offenders in DWI treatment programs is essential to appropriate and effective
treatment planning. At the same time, treatment providers often do not use assessment
instruments that are either comprehensive or have adequate psychometric properties.
Providers who treat DOH clients are required to use the ASI but they usually
encounter problems with inter-rater reliability caused by assessor "drift"
over time since training.
We propose to address these problems by integrating training in adequate assessment
protocols in our brief interventions and motivational interviewing workshops.
We will also offer training workshops that combine assessment and program evaluation.
Dr. Hester has developed a computer-based brief motivational intervention, the
Drinker's Check-up (DCU) which provides a comprehensive assessment, objective
feedback, and motivational enhancement. We are currently evaluating the effectiveness
of the DCU and a follow-up program, the Follow-up Drinker's Check-up (FDCU)
in a randomized clinical trial. Initial outcomes are demonstrating a substantial
treatment effect as a stand-alone intervention. The DCU also can be used as
a pre-treatment intervention which is how it could be used by treatment providers.
We have begun a pilot study of the DCU/FDCU with up to 12 DWI treatment providers
around the state. Each treatment provider is given training in how to use the
software both for assessment/intervention and for program evaluation. As we
collect data on its implementation in these seven sites, we will be better able
to expand its implementation state-wide. A copy of the DCU/FDCU software is
included with this application.
Level of service placement Understanding the level of intensity of treatment
a DWI offender needs is a function of a comprehensive assessment coupled with
an adequate knowledge of client-treatment matching to empirically supported
protocols. In each clinical skills workshop we give we will address this issue.
Level of severity of an offender's alcohol and drug dependence is a matching
variable.
Treatment matching and intervention including pre-contemplative strategies.
Recent research (Project MATCH) found relatively few matching variables that
predicted better outcomes with the treatments provided in this multi-site study:
Motivational enhancement therapy, cognitive behavioral treatment, and twelve
step facilitation. The few matching strategies that were found, however, will
be integrated in the clinical skills training workshops in empirical approaches.
We have been training DWI treatment providers in treatment protocols which
have the highest level of empirical support (Miller et al, 1995, in press).
We have included a copy of the Handbook of alcoholism treatment approaches book
which contains the Miller et al, (1995) chapter in the Appendix. We propose
to continue training based on that principle. The protocols we have and will
train include brief interventions and motivational interviewing, the Community
Reinforcement Approach (CRA), Behavioral Self-Control Training (BSCT) and SMART
Recovery.
The brief intervention and motivational interviewing workshop focuses on teaching
clinicians on how to enhance clients' own internal motivation to change their
drinking. The workshop will teach counselors how to help clients move through
the stages of change of pre-contemplation to contemplation to preparation to
action. This is done using motivational interviewing as a counseling style and
showing counselors how to conduct a comprehensive assessment and provide objective
feedback.
The CRA protocol includes a menu of different behavioral strategies. Its purpose
is to rearrange the offender's environment so that sobriety is more reinforcing
than drinking. Examples of elements include sobriety sampling, problem solving,
and behavioral marital counseling.
BSCT is an effective protocol for less severely dependent offenders. It teaches
moderate drinking skills. The protocol includes goal setting, self-monitoring,
rate control, setting rewards and penalties, functional analysis of drinking,
and relapse prevention. It is well supported by empirical research provided
clients are appropriately chosen (Hester, 1995; in press) and there are well
established pre-treatment predictors of success with this protocol. The BSCT
workshop focuses on these issues and presents the BSCPWIN software as an option
for providing this treatment.
SMART Recovery is self-help group, an alternative to 12 step groups (e.g.,
AA) that uses empirically supported (cognitive-behavioral) principles. The groups
can be led by either a professional or a person in recovery who is trained in
the protocol. Dr. Horvath developed SMART Recovery and is the President of this
non-profit organization. We will train providers in how to lead SMART Recovery
groups.
At the request of several police departments and jail administrators we have
also trained jail personnel in screening and referral protocols for suicide
prevention in DWI offenders. Interventions with offenders begin on arrest and
intoxicated DWI offenders are high risk for suicide attempts. We propose to
continue this training with jail personnel and police officers when asked.
We also have provided and propose to continue to provide treatment providers
with treatment manuals, treatment-oriented software (e.g., DCU/FDCU), and treatment-oriented
study review study courses. We have developed these resources ourselves but
we purchase materials such as books and manuals that are copyrighted from the
respective publishers. We receive authors' discounts from publishers, usually
35% off retail. Providing these resources gives counselors a reference they
can use when trying to incorporate the above protocols in their daily treatment.
Providing them with treatment-oriented software standardizes the provision of
those protocols. We recognize that we are providing and charging for software,
treatment manuals, and other resources that we have developed. We addressed
this issue in our current contract and we obtained approval to proceed before
we distributed any books, manuals, or software. We deal with this potential
issue by making providers aware of these resources. It is then their responsibility
to ask for them. When they do, we provide them and bill the contract accordingly.
Brief motivational intervention combined with ignition interlock Recent
evidence from Robert Voas and colleagues has found that brief motivational interventions
given to DWI offender when they come in for their ignition interlock data downloads
and inspections reduced the incidence of failed initial events in the interlock
data record. In other words, offenders who received the brief interventions
had fewer instances in which the vehicle did not start because their BAC was
above 40mg% (.04). While post-interlock follow-up data did not reveal a difference
in recidivism they speculate that the lack of lasting treatment effect stemmed
in part from less than ideal compliance with the brief motivational intervention
protocol by the counselors. In recent communications (Paul Marques, Personal
Communication, April 1, 2002) they indicated that they have developed manuals
for the intervention which they are implementing in a study in Texas and think
that the treatment effect will be longer lasting in their current study.
They also now have good predictor data about who will be re-arrested for DWI
in the first 24 months of the post-interlock period. This is based on the frequency
of failed tests as a proportion of total initial tests during the first five
months of interlock use. For instance, offenders who had zero failures during
that period had zero DWIs during the post-interlock follow-up period. This was
regardless of whether they were first or multiple offenders. On the other hand,
those with relatively high numbers of fails had the most DWIs post-interlock.
This also was independent of whether the offender was a first or multiple offender.
This isn't surprising when you consider that the biggest predictor of future
behavior is current behavior. But now with interlock data we will have objective,
real-time data collection of that behavior.
This predictor data can now be integrated into the brief motivational interventions
given to the offenders. It can also be used by judges or probation officers
to determine those who are more likely to re-offend. Finally, it could be used
as an indicator of whether the offender can do without the ignition interlock
program. We will advocate for a policy that extends probation for continued
interlock use when necessary, and mandates treatment for first offenders if
interlock use data indicate they are at high risk for recidivism. We also agree
with the policy recommendations of Voas and colleagues that offenders should
be required to continue using an ignition interlock use until such a time as
he or she can demonstrate a sustained period of no-fails.
There is a great deal of work to be done before the interlock program can be
implemented on January 1, 2003. We propose to work with Franklin Garcia of the
Traffic Safety Bureau to help him set up and implement a state-of-the-art ignition
interlock program that is empirically based. This would include setting policies
that are consistent with those advocated in the attached position paper. We
would complete these tasks on or about next January 1. Then we propose to turn
our attention to developing a brief intervention component. This brief intervention
component will require additional resources for counselors who would meet with
the DWI offenders. We would work with Paul Marques, Bob Voas, and their colleagues
to pursue research funding for a pilot program that could demonstrate efficacy.
We have discussed a number of possibilities including a CSAT (Center for Substance
Abuse Treatment) grant and a SBIR (Small Business Innovative Research) grant
from NIAAA. We (Paul Marques and myself) consider it important to demonstrate
that adding a brief motivational intervention affects outcomes before seeking
permanent state funding with DWI funds.
As an alternative we could set up a pilot program in Albuquerque that would
coincide with the start of the program state-wide. This pilot data would enhance
our chances of receiving federal funding. However, implementing such a pilot
program would be beyond the resources of this contract. We are willing to discuss
and negotiate how to proceed on this issue.
Treatment program evaluation In 1995-1997 we evaluated County funded
DWI programs State-wide. As part of that evaluation we looked at what providers
were doing in the area of program evaluation. State-wide, program evaluation
was the weakest of all the domains we evaluated. DWI treatment providers are
not unique in this respect. Few substance abuse treatment providers conduct
follow-ups post-treatment, let alone program evaluation. Even if providers do
collect follow-up data, they often lack the expertise and resources to evaluate
that data.
To address this need we propose to offer to help programs implement the DCU/FDCU
program described above. The FDCU automates the process of re-evaluating clients
at up to three follow-up points. Assessments used in the FDCU are the same as
those used in the DCU which the client would have taken at the beginning of
treatment. Assessments also are chosen at each follow-up point on the basis
of their assessment period. For instance, the Severity of Alcohol Dependence
(SADQ) asks about drinking over the last six months. Consequently, it would
be inappropriate to use the SADQ at a three month follow-up.
To collect follow-up data all providers will have to do is schedule clients
to come in for follow-ups, then set them in front of the computer. Compliance
with returning for follow-ups can be enhanced by the liaison efforts we propose
with the Judges who sentence the offenders. (See below.) Once follow-up data
is collected, the FDCU program can generate numerous and customizable outcome
reports automatically. Providers can produce outcome reports for their total
sample, by treatments provided, gender, age, ethnicity, mental health diagnosis,
etc. It is this ability to produce outcome reports that automates the process
of program evaluation. This, in turn, will enable DWI treatment providers to
be accountable to their County Coordinators, DWI Planning Councils, and ultimately
to DFA.
Liaison with the criminal justice system. We propose to liaise with
judges who adjudicate DWI offenders in two areas: extending probation periods
to enhance post-treatment follow-up compliance and ignition interlock systems.
As discussed above, if judges will extend probation periods out to at least
12 months and make post-treatment follow-ups a condition of probation then we
can significantly improve compliance with follow-ups. We plan to give presentations
to groups of judges addressing this issue as well as the ignition interlock
system. We will work with Franklin Garcia at Traffic Safety Bureau to coordinate
these presentations with those on the ignition interlock systems. He also has
asked for our input in helping develop the ignition interlock program discussed
above.
Recent research by Voas and colleagues has found that judicial cooperation is important in implementing ignition interlock systems. We will work to give presentations to groups of judges and help them understand and successfully implement the ignition interlock programs from a behavioral and contingency management standpoint. We will also consult with individual judges to help them problem solve these issues in their specific locale.
Literature Cited
Hester, R.K. (1995). Self-control training. In R.K. Hester & W.R. Miller
(Eds.), Handbook of alcoholism treatment approaches: Effective alternatives,
(2nd edition) (pp. 148-159). Needham Heights, MA: Allyn & Bacon.
Hester, R.K. (2003). Self-control training. In R.K. Hester & W.R. Miller
(Eds.), Handbook of alcoholism treatment approaches: Effective alternatives,
(3rd edition). Needham Heights, MA: Allyn & Bacon.
Hester, R.K. & Delaney, H.D. (1997). Behavioral Self-Control Program for
Windows: Results of a controlled clinical trial. Journal of Consulting and Clinical
Psychology, 65(4) 686-693.
Miller, W. R., Brown, J. M., Simpson, T. L., Handmaker, N. S., Bien, T. H.,
Luckie, L. F., Montgomery, H. A., Hester, R. K., & Tonigan, J. S. (1995).
What works? A methodological analysis of the alcohol treatment outcome literature.
Handbook of alcoholism treatment approaches: Effective alternatives, (2nd edition)
(pp. 12-44). Needham Heights, MA: Allyn & Bacon.
Miller, W. R., Willbourne, P., & Hettema, J. (2003). What works? A methodological
analysis of the alcohol treatment outcome literature. In R.K. Hester & W.R.
Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives,
(3rd edition). Needham Heights, MA: Allyn & Bacon.