Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes

Abstract

Background: The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented. Objectives: This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes. Methods: Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up. Results: Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity. Conclusions: The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.

• Addition therapy
• clinician characteristics
• evidence-based therapy
• integrated psychosocial treatments
• post traumatic stress disorder
• therapist adherence and competence

Acknowledgements

The authors are grateful to the administration, clinicians and patients from Central Vermont Substance Abuse Services, Clara Martin Center’s Quitting Time, Dartmouth-Hitchcock Addiction Treatment Program, Health Care and Rehabilitation Services, HowardCenter, Rutland Mental Health Services’ Evergreen Program, and Starting Now at the Brattleboro Retreat. We also acknowledge the assistance of Melissa An, Anna Franklin, Brandon Harrington, and Eunhee Kim who served as adherence and competence raters.

This paper was originally a presentation at the College on Problems of Drug Dependence Annual Meeting in San Diego, California (17 June 2013).

Funding

This research was supported by NIDA R01 DA027650 (McGovern, PI). Clinical trials NCT01457391.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.