Mark Litt

Aims Achieving abstinence in the treatment of marijuana dependence has been difficult. To date the most successful treatments have included combinations of motivation enhancement treatment (MET) plus cognitive–behavioral coping skills training (CBT) and/or contingency management (ContM) approaches. Although these treatment approaches are theoretically based, their mechanisms of action have not been explored fully. The purpose of the present study was to explore mechanisms of behavior change from a marijuana treatment trial in which CBT and ContM were evaluated separately and in combination. Design A dismantling design was used in the context of a randomized clinical trial. Setting The setting was an outpatient treatment research facility located in a university medical center. Participants Participants were 240 adult marijuana smokers, meeting criteria for cannabis dependence. Interventions Participants were assigned to one of four 9-week treatment conditions: a case management control condition, MET/CBT coping skills training, ContM and MET/CBT + ContM. Measurements Outcome measures were total 90-day abstinence, recorded every 90 days for 12 months post-treatment. Findings Regardless of treatment condition , abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence. Conclusions It was concluded that the most efficacious treatments for marijuana dependence are likely to be those that increase self-efficacy.

Background: The social network of those treated for alcohol use disorder can play a significant role in subsequent drinking behavior, both for better and worse. Network Support treatment was devised to teach ways to reconstruct social networks so that they are more supportive of abstinence and less supportive of drinking. For many patients this may involve engagement with AA, but other strategies are also used. Purpose: The current trial of Network Support treatment, building on our previous work, was intended to further enhance the ability of patients to construct abstinence-supportive social networks, and to test this approach against a strong control treatment. Methods: Patients were 193 men and women with alcohol use disorder recruited from the community and assigned to either 12 weeks of Network Support (NS) or Packaged Cognitive-Behavioral Treatment (PCBT), and followed for 27 months. Results: Results of multilevel analyses indicated that NS yielded better posttreatment results in terms of both proportion of days abstinent and drinking consequences, and equivalent improvements in 90-day abstinence, heavy drinking days and drinks per drinking day. Mediation analyses revealed that NS treatment effects were mediated by pre-post changes in abstinence self-efficacy and in social network variables, especially proportion of non-drinkers in the social network and attendance at Alcoholics Anonymous. Conclusion: It was concluded that helping patients enhance their abstinent social network can be effective, and may provide a useful alternative or adjunctive approach to treatment.

The Network Support Project was designed to determine whether a treatment could lead patients to change their social network from one that supports drinking to one that supports sobriety. This study reports 2-year posttreatment outcomes. Alcohol-dependent men and women (N 210) were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support contingency management (NS CM), or case management (CaseM, a control condition). Analysis of drinking rates indicated that the NS condition yielded up to 20% more days abstinent than the other conditions at 2 years posttreatment. NS treatment also resulted in greater increases at 15 months in social network support for abstinence, as well as in AA attendance and AA involvement than did the other conditions. Latent growth modeling suggested that social network changes were accompanied by increases in self-efficacy and coping that were strongly predictive of long-term drinking outcomes. The findings indicate that a network support treatment can effect long-term adaptive changes in drinkers' social networks and that these changes contribute to improved drinking outcomes in the long term.

The purpose of this study was to determine whether cognitive–behavioral treatment (CBT) operates by effecting changes in cognitions, affects, and coping behaviors in the context of painful episodes. Patients were 54 men and women with temporomandibular dysfunction-related orofacial pain (TMD) enrolled in a study of brief (6 weeks) standard conservative treatment (STD) or standard treatment plus CBT (STD + CBT). Momentary affects, pain, and coping processes were recorded on a cell phone keypad four times per day for 7 days prior to treatment, and for 14 days after treatment had finished, in an experience sampling paradigm. Analyses indicated no treatment effects on general retrospective measures of pain, depression, or pain-related interference with lifestyle at post-treatment. However, mixed model analyses on momentary pain and coping recorded pre-and post-treatment indicated that STD + CBT patients reported greater decreases in pain than did STD patients, significantly greater increases in the use of active cognitive and behavioral coping, and significantly decreased catastrophization. Analyses of experience sampling data indicated that post-treatment momentary pain was negatively predicted by concurrent active coping, self-efficacy, perceived control over pain, and positive-high arousal affect. Concurrent catastrophization was strongly predictive of pain. Active behavioral coping and self-efficacy reported at the prior time point (about 3 h previously) were also protective, while prior catastrophization and negative high arousal mood were predictive of momentary pain. The results suggest that CB treatment for TMD pain can help patients alter their coping behaviors, and that these changes translate into improved outcomes.

The aim of this study was to determine whether a socially focused treatment can effect change in the patient's social network from one that reinforces drinking to one that reinforces sobriety. Alcohol dependent men and women (N 210) recruited from the community were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support contingency management (NS CM), or case management (CaseM; a control condition). Analysis of drinking rates for 186 participants at 15 months indicated a significant interaction effect of Treatment Time, with both NS conditions yielding better outcomes than the CaseM condition. Analyses of social network variables at posttreatment indicated that the NS conditions did not reduce social support for drinking relative to the CaseM condition but did increase behavioral and attitudinal support for abstinence as well as Alcoholics Anonymous (AA) involvement. Both the NS variables and AA involvement variables were significantly correlated with drinking outcomes. These findings indicate that drinkers' social networks can be changed by a treatment that is specifically designed to do so, and that these changes contribute to improved drinking outcomes.

The purpose of the present study was to determine the extent to which modifiable social learning constructs predicted long-term adherence to an exercise program in older individuals. Participants were 189 women aged 59 to 78 years and diagnosed with low bone density. Exercise behavior was assessed at 3-month intervals. Self-efficacy, readiness for change, orientation toward exercise, social support in general, and support specifically for exercise were measured at baseline and at 12-month follow-up. Analyses indicated that initial adoption of exercise behavior was best predicted by readiness to change. Maintenance was predicted by self-efficacy for exercise, and exercise behavior at 12 months was predicted by social support for exercise. The results were seen as supportive of the stages and processes of change model of health behavior change. Implications of the findings for interventions to enhance adoption and maintenance of exercise programs by older women are discussed.

The aim of this study was to determine whether a socially focused treatment can effect change in the patient's social network from one that reinforces drinking to one that reinforces sobriety. Alcohol dependent men and women (N = 210) recruited from the community were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM; a control condition). Analysis of drinking rates for 186 participants at 15 months indicated a significant interaction effect of Treatment x Time, with both NS conditions yielding better outcomes than the CaseM condition. Analyses of social network variables at posttreatment indicated that the NS conditions did not reduce social support for drinking relative to the CaseM condition but did increase behavioral and attitudinal support for abstinence as well as Alcoholics Anonymous (AA) involvement. Both the NS variables and AA involvement variables were significantly correlated with drinking outcomes. These findings indicate that drinkers' social networks can be changed by a treatment that is specifically designed to do so, and that these changes contribute to improved drinking outcomes.

The Network Support Project was designed to determine whether a treatment could lead patients to change their social network from one that supports drinking to one that supports sobriety. This study reports 2-year posttreatment outcomes. Alcohol-dependent men and women (N = 210) were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM, a control condition). Analysis of drinking rates indicated that the NS condition yielded up to 20% more days abstinent than the other conditions at 2 years posttreatment. NS treatment also resulted in greater increases at 15 months in social network support for abstinence, as well as in AA attendance and AA involvement than did the other conditions. Latent growth modeling suggested that social network changes were accompanied by increases in self-efficacy and coping that were strongly predictive of long-term drinking outcomes. The findings indicate that a network support treatment can effect long-term adaptive changes in drinkers' social networks and that these changes contribute to improved drinking outcomes in the long term.

This study was designed to determine whether a physician-delivered bibliotherapy prescription would compare favorably with the prevailing usual care treatment for depression in primary care (that often involves medication) and potentially offer an alternative. Six family physicians were trained to write and deliver prescriptions for cognitive-behavioral bibliotherapy. Thirty-eight patients were randomly assigned to receive either usual care or a behavioral prescription to read the self-help book, Feeling Good (Burns, D. D. (1999). Feeling good: The new mood therapy. New York: HarperCollins). The treatment groups did not differ in terms of overall outcome variables. Patients in both treatment groups reported statistically significant decreases in depression symptoms, decreases in dysfunctional attitudes, and increases in quality of life. Although not statistically significant, the mean net medical expenses in the behavioral prescription group were substantially less. This study provided empirical evidence that a behavioral prescription for Feeling Good may be as effective as standard care, which commonly involves an antidepressant prescription.

Temporomandibular dysfunction (TMD) pain, like many chronic pain problems, appears to be multiply determined. Patients with TMD pain of at least 6 months duration (N = 30) were administered questionnaires measuring dispositional coping styles and appraisals to explore the dynamic interactions of the pain and coping process. Patients were then issued handheld computers that prompted them to record their momentary pain and coping processes 4 times per day for 7 days. Hierarchical linear regression models using both the dispositional and momentary predictors indicated that momentary pain was a function both of dispositional tendency to catastrophize and of momentary measures of catastrophization, self-efficacy, and mood states. Results were seen as supporting a situational model of intervention for chronic TMD pain.

Two studies are described in which dental patients were administered the Dental Fear Survey (DFS) and then received 1 of 5 anxiety reduction interventions to prepare them for extraction of 3rd-molar teeth. Interventions included standard clinic treatment, oral premedication, and several relaxation-based procedures. Dependent variables were self-reported and observer-rated distress. In the 1st study (N = 231), cluster analyses of the DFS subscales revealed that patients could be subtyped as low-fear, high-fear, or cue-anxious patients who admitted fear only in response to specific stimuli. Dental fear subtypes were distinguishable by situational cognitions reported, and fear subtype interacted with anxiety intervention to predict distress. These results were replicated in the 2nd study (N = 150). The results are seen as supportive of a multidimensional view of dental anxiety.

The present study explored the factors that contribute to mothers' decisions to seek urgent medical attention for their children when symptoms are not of a traumatic nature. One hundred mothers seeking treatment for their children at a prepaid clinic completed a questionnaire eliciting their expectations regarding the course of their children's problems, seriousness of the problems, perceived responsibility for the symptoms, and extent to which a variety of factors contributed to their decisions to seek treatment. Demographic data and information about each child's symptoms and medical history were also obtained. Four major "reasons for seeking treatment" factors were identified: family history of the presenting complaint, worry regarding the symptoms, situational variables, and the extent of the child's illness behavior. The appropriateness of the visit, delay in seeking treatment, and frequency of mothers' use of the pediatric clinic were predicted by the nature of the presenting symptoms (particularly the presence of fever), the ages of the mother and child, and two of the reasons for seeking treatment factors (i.e., family history and child's illness behavior). The present study suggests that mothers pay more attention to presenting symptoms and to the children's behavior than to psychosocial stressors in deciding to seek urgent care.

Achieving abstinence in the treatment of marijuana dependence has been difficult. To date the most successful treatments have included combinations of motivation enhancement treatment (MET) plus cognitive-behavioral coping skills training (CBT) and/or contingency management (ContM) approaches. Although these treatment approaches are theoretically based, their mechanisms of action have not been explored fully. The purpose of the present study was to explore mechanisms of behavior change from a marijuana treatment trial in which CBT and ContM were evaluated separately and in combination. A dismantling design was used in the context of a randomized clinical trial. The setting was an out-patient treatment research facility located in a university medical center. Participants were 240 adult marijuana smokers, meeting criteria for cannabis dependence. Participants were assigned to one of four 9-week treatment conditions: a case management control condition, MET/CBT coping skills training, ContM and MET/CBT + ContM. Outcome measures were total 90-day abstinence, recorded every 90 days for 12 months post-treatment. Regardless of treatment condition, abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence. It was concluded that the most efficacious treatments for marijuana dependence are likely to be those that increase self-efficacy.

Cognitive-behavioral therapy (CBT) is useful for treating substance abusers, and recent data suggest it is also efficacious for pathological gamblers. CBT is purported to exert its beneficial effects by altering coping skills, but data supporting coping changes as the mechanism of action are mixed. This study examined whether coping skills acquisition mediated the effects of CBT on decreasing gambling in pathological gamblers. Participants were assigned randomly to CBT plus referral to Gamblers Anonymous (GA) or to GA referral alone. Setting Out-patient clinic. A total of 127 pathological gamblers. Participants completed the Coping Strategies Scale (CSS) before treatment and 2 months later; indices of gambling behavior and problems were administered pretreatment and at months 2 and 12. Overall, CSS scores increased for participants in both conditions, but those receiving CBT evidenced larger increases than those in the GA condition (P < 0.05), and they also reduced gambling more substantially between pretreatment and month 2. Changes in CSS scores mediated the relationship between treatment assignment and gambling outcomes from pretreatment to month 2, but little evidence of mediation occurred for the long-term follow-ups. CBT's beneficial effects in decreasing gambling may be related partly to changes in coping responses, and improvements in coping are associated with long-term changes in gambling. However, relationships between coping skills and gambling behavior are fairly strong, regardless of treatment received.