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The role of therapist adherence, therapist competence, and alliance inpredicting outcome of individual drug counseling: Results from the NationalInstitute Drug Abuse Collaborative Cocaine Treatment StudyJacques P. Barber ab; Robert Gallop ab; Paul Crits-Christoph a; Arlene Frank c; Michael E. Thase d; Roger D.Weiss e; Mary Beth Connolly Gibbons b
a University of Pennsylvania Medical School, b West Chester University, c Health Enhancement Services, Inc.,d Western Psychiatric Institute and Clinic, e McLean Hospital and Harvard Medical School,
Online Publication Date: 01 March 2006
To cite this Article Barber, Jacques P., Gallop, Robert, Crits-Christoph, Paul, Frank, Arlene, Thase, Michael E., Weiss, Roger D. andGibbons, Mary Beth Connolly(2006)'The role of therapist adherence, therapist competence, and alliance in predicting outcome ofindividual drug counseling: Results from the National Institute Drug Abuse Collaborative Cocaine Treatment Study',PsychotherapyResearch,16:2,229 — 240
To link to this Article: DOI: 10.1080/10503300500288951
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ORIGINAL ARTICLES
The role of therapist adherence, therapist competence, and alliance inpredicting outcome of individual drug counseling: Results from theNational Institute Drug Abuse Collaborative Cocaine Treatment Study
JACQUES P. BARBER1,5, ROBERT GALLOP1,5, PAUL CRITS-CHRISTOPH1,
ARLENE FRANK2, MICHAEL E. THASE3, ROGER D. WEISS4, &
MARY BETH CONNOLLY GIBBONS5
1University of Pennsylvania Medical School, 2Health Enhancement Services, Inc., 3Western Psychiatric Institute and Clinic,4McLean Hospital and Harvard Medical School, and 5West Chester University
(Received 4 October 2004; revised 18 February 2005; accepted 6 April 2005)
AbstractThis study tested hypotheses related to linear and curvilinear relations among adherence, competence, and outcome andinteractions of these effects with the quality of the therapeutic alliance among patients (N�/95) who received individual drugcounseling as part of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Results support ahypothesized curvilinear relation between adherence and outcome as well as an interaction between this curvilinear effectand alliance early in treatment. For patients with a strong therapeutic alliance, counselor adherence to the treatment modelwas essentially irrelevant to treatment outcome. When the alliance was weaker, by contrast, a moderate (vs. high or low)level of counselor adherence was associated with the best outcome. The current results suggest that studies of the relationbetween therapist’s adherence to models of treatment and outcome may need to take into account the complex moderatingeffect of therapeutic alliance.
The widespread problems of drug and alcohol
dependence have motivated researchers and clini-
cians alike to search for increasingly effective treat-
ments. Several studies have found evidence for the
efficacy of psychosocial treatments for cocaine de-
pendence (e.g., Carroll, Nich, & Rounsaville, 1995;
Higgins, Budney, Bickel, Foerg, Donham, & Badger,
1994). In one multisite randomized clinical trial
of cocaine-dependent outpatients, Crits-Christoph
et al (1999) found that individual drug counseling
(IDC; Mercer & Woody, 1992) was more effective
than cognitive therapy (CT; Beck, Wright, Newman,
& Liese, 1993) or supportive�/expressive therapy
(SET; Mark & Faude, 1995) when each was
provided in conjunction with group drug counseling
(GDC; Mercer, Carpenter, Daley, Patterson, &
Volpicelli, 1994); and IDC plus GDC also was
more effective than GDC alone. It is rare in
psychotherapy research to find that a psychosocial
treatment (IDC�/GDC) is better than another
(CT�/GDC or SET�/GDC). Therefore, under-
standing the effective ingredients of the IDC�/
GDC treatment might point the way to enhancing
the outcomes for these difficult-to-treat patients. In
the current study, we focus on the IDC component
of the IDC�/GDC treatment and refer to the
treatment condition as IDC.
Studies of therapy ingredients have typically dis-
tinguished between technical factors (e.g., chosen
interventions) and nonspecific factors (e.g., the
therapeutic alliance). With manual-based therapies,
there has been an interest not only in what particular
techniques the therapist uses but in the extent to
which the therapist uses those that are prescribed by
the treatment model (i.e., adherence) as well as the
skill with which the therapist delivers them (i.e.,
competence). Results from the few existing studies
that have examined the relation between adherence
Correspondence: Jacques P. Barber, Room 648, Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania,
3535 Market Street, Philadelphia, PA 19104�/2648. E-mail: Barberj@mail.med.upenn.edu
Psychotherapy Research, March 2006; 16(2): 229�/240
ISSN 1050-3307 print/ISSN 1468-4381 online # 2006 Society for Psychotherapy Research
DOI: 10.1080/10503300500288951
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and outcome have been mixed, some positive (e.g.,
DeRubeis & Feeley, 1990; Barber, Crits-Christoph,
& Luborsky, 1996) and some negative (Elkin, 1988).
Similarly, competence has predicted outcome in
some studies (e.g., Barber, Crits-Christoph, &
Luborsky, 1996; Shaw et al., 1999) but not in others
(Sandell, 1985).
There are several possible reasons why adherence
has not been associated more consistently with
outcome besides the (unlikely) explanation that
techniques do not matter. One is that very high
levels of adherence might reflect a lack of flexibility
on the part of the therapist in responding to patients’
needs, whereas very low levels might reflect an
inability to translate a therapeutic model or theory
into practice as prescribed. If both extremes of
adherence represent failures on the part of the
therapist, it could be that moderate levels of ad-
herence are optimal. Thus, adherence might have a
curvilinear relation with outcome. However, most
studies that have examined the relation between
adherence and outcome have used small samples
(e.g., Barber, Crits-Christoph, & Luborsky, 1996,
DeRubeis & Feeley, 1990), making it difficult to
assess the presence of such a curvilinear relation. In
the current study, the sample was large enough to
permit such a test of both the linear and curvilinear
relation between adherence and outcome of a treat-
ment of known effectiveness.
It also is possible that competence moderates
the relation between adherence and outcome. For
example, it may be that as competence increases,
adherence has a stronger relation with outcome. In
this scenario, moderate levels of adherence coupled
with high levels of competence would produce the
best outcome. Attempts to discover a relation
between adherence and outcome (be it linear or
curvilinear) might fail if competence is not taken into
account. For example, if competence is very high (or
very low), it might not matter how much the
therapist is adhering to the treatment model or
manual (i.e., there would be no relation between
adherence and outcome under these circumstances).
Only if competence is adequate to high might a
relation emerge between adherence and outcome.
However, even with adequate to high competence,
outcome may not be positive if adherence is exces-
sively high (rigid). This suggests that it would be
useful to evaluate in this sample not only whether
competence predicts outcome but whether and in
what ways adherence might interact with compe-
tence to predict outcome. Only a few studies (see
Barber, Crits-Christoph, & Luborsky, 1996; Shaw et
al., 1999) have attempted to examine the linear
relation of adherence and competence to outcome.
No study has looked at the possibly curvilinear
relations among these variables, as is explored in
the current study.
By contrast, studies of the relation between the
therapeutic alliance and outcome have been more
common and positive results reported more consis-
tently (Martin, Garske, & Davis, 2000). However,
most of these have been conducted with non-drug-
abusing samples. Published studies of the alliance�/
outcome relationship in drug-abusing patients have
been more rare and the results less consistent. In one
study with alcoholics (Connors, Carroll, DiCle-
mente, Longabaugh, & Donovan, 1997) and one
with methadone-maintained, opiate-dependent pa-
tients (Luborsky, McLellan, Woody, O’Brien, &
Auerbach, 1985), stronger alliances were associated
with better outcomes. However, in two other reports
from the National Institute for Drug Abuse (NIDA)
Cocaine Collaborative Treatment Study (CCTS,
Barber et al., 1999, 2001), no such alliance�/out-
come relation was found. A number of factors may
account for this. One possibility is that treatment
somehow operates differently with cocaine abusers
than with other patients or that, with cocaine
patients, technical factors are simply more important
than the alliance. Alternatively, it may be that
technical factors are important only in the context
of a positive alliance (i.e., there is a statistical
interaction between alliance and technical factors
in predicting outcome that obscures any main effect
for the alliance in predicting outcome). A number
of studies of dynamic therapy have provided evi-
dence of just such an interaction, although here
too results have been mixed (Crits-Christoph,
Cooper, & Luborsky, 1988; Gaston, Piper, Deb-
bane, Biknvenu, & Garant, 1994; Gaston & Ring,
1992). An additional study (Gaston, Thompson,
Gallagher, Cournoyer, & Gagnon, 1998) investi-
gated how treatment interventions interacted with
the alliance to affect outcome in three manual-based
therapies (i.e., cognitive, behavioral, and brief dy-
namic) for depression in the elderly. They found that
the use of exploratory interventions in cognitive and
behavioral therapies was associated with better out-
comes when the alliance was poor. In brief dynamic
therapy, the reverse was found: The use of explora-
tory interventions was associated with better out-
comes when the alliance was strong. All of these
studies of were hampered, however, by small sam-
ples that had limited statistical power for testing
interaction effects. Furthermore, existing studies
examined the role of techniques rather than of
adherence. Therefore, there is a need for more
research on the ways in which the alliance and
technical factors, separately and in combination,
affect the outcomes of patients receiving treatments
of known efficacy, in this case IDC. In the current
230 J. Barber et al.
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study, we explore how alliance and adherence
interact in predicting outcome.
We tested the following hypotheses: (a) Linear
adherence predicts outcome; (b) curvilinear adher-
ence predicts outcome; (c) competent delivery of
IDC predicts outcome; (d) adherence and compe-
tence together predict outcome; (e) competence and
the curvilinear term of adherence predict outcome;
and (f) the interaction between the curvilinear term
of adherence and alliance predict outcome.
Method
Participants
Patients. Four hundred eighty-seven cocaine-de-
pendent outpatients were randomly assigned to
either IDC�/GDC, CT�/GDC, SE�/GDC, or
GDC alone (for more details, see Crits-Christoph
et al., 1999). Five treatment settings in the north-
eastern United States were involved in the study. In
the efficacious IDC condition, which is the focus of
the current investigation, there were 121 randomized
patients (86 [71%] men, 35 [29%] women; mean
age�/34 years). Seventy (58%) were Caucasian, 48
(40%) were African American, and 3 (2%) were
Hispanic. Eighty-eight (73%) lived alone, and 74
(62%) were employed. Most (92 [76%]) smoked
crack; the remainder used it intranasally (28 [23%])
or intravenously (1 [1%]). On average they had been
using cocaine for 6 years (SD�/5). In the month
before intake, the patients reported having used
cocaine an average of 11 days (SD�/8) and alcohol
7 days (SD�/8). In addition to being cocaine
dependent (a requirement for study participation),
the IDC patients had a variety of comorbid dis-
orders: 37 (31%) met criteria for alcohol depen-
dence, nine (7.4%) for cannabis dependence, and 27
(22%) for cannabis abuse; 40 (33%) met criteria for
a cocaine-induced mood disorder and eight (6.6%)
for a cocaine-induced anxiety disorder; 16 (13%)
met full criteria for antisocial personality disorder;
and 39 (32%) met criteria for an antisocial person-
ality disorder as an adult with no history of a
childhood conduct disorder.
Counselors. Individual drug counselors (n�/12;
eight women and four men) were selected based on
a combination of educational background and
training, letters of reference, and audiotaped samples
of their drug counseling work. Nine of the counse-
lors were Caucasian and three were African Amer-
ican. The maximum allowable terminal degree for
the drug counselors was a master’s degree in a
mental health�/related field. Professional certifica-
tion in addiction counseling was desirable but not
mandatory, although all counselors were required to
have at least 3 years experience in the field of
addiction counseling and substantial experience
with cocaine addicts in particular. Additionally,
counselors who were in recovery must have been in
full remission for at least 5 years. All counselors
selected for participation in the NIDA CCTS under-
went didactic and experiential training (workshops
and practice cases) before and received ongoing
supervision in the IDC model during the trial (see
Crits-Christoph et al., 1997, 1998, for details). No
counselor was ‘‘redlined’’ during the clinical trial for
being nonadherent to the IDC manual or delivering
the treatment in a less-than-competent manner.
Adherence�/competence judges. Because competence
evaluations require expertise in the specific form of
treatment being provided (Waltz, Addis, Koerner, &
Jacobson, 1993), only judges who were themselves
experts in IDC were selected for rating the adher-
ence and competence of the individual drug counse-
lors. Experts were chosen for this task in
collaboration with the heads of the IDC training
unit of the NIDA CCTS. Three IDC experts (one
man, two women; one African American, two
Caucasians) served as judges. They had between 8
and 17 years experience in the addiction-counseling
field (M �/ 13.70 years) and between 8 and 11 years
of counseling for cocaine addiction specifically (M
�/ 9.50 years). In addition to her capacity as a judge,
one female rater served as a supervisor for IDC
counselors. Therefore, her ratings as a judge, which
may have been influenced by her knowledge of
patient outcomes, are not included in this study.
Treatment
IDC is a semistructured, time-limited (6-month)
addictions-counseling model. Twice-weekly sessions
were permitted during the first 12 weeks. Thereafter,
weekly sessions were specified. The main focus is on
helping the client achieve and maintain abstinence
by encouraging behavioral changes, such as avoiding
triggers, structuring one’s life, and engaging in
healthy behaviors (e.g., exercise). The manual for
IDC was intended to provide an organized, concise
version of what is currently practiced by most
addiction counselors. In operationalizing this ap-
proach, the developers drew from their own clinical
experience and that of expert drug counselors in the
field as well as from the works of Washton (1990)
and Gorski (1988). The approach is consistent with
the 12-step approach in considering addiction a
disease that damages the person physically, emo-
tionally, and spiritually and regarding recovery as a
gradual process. Participation in self-help groups
Adherence, competence, alliance, and outcome 231
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such as Alcoholics Anonymous or Cocaine Anon-
ymous is strongly encouraged.
Measures
Adherence�/Competence Scale for IDC for Cocaine
Dependence (ACS-IDCCD; Barber, Mercer, Krakauer,
& Calvo, 1996). The scale was composed of 43
items. Thirty four of these items cover the main
techniques described in Mercer and Woody’s (1992)
manual for IDC; thus, their mean was used to create
an overall adherence score and overall competence
score. For each item, adherence and competence
were rated separately on Likert scales ranging from
1 (low) to 7 (high). The adherence ratings reflected
the frequency or extent to which the counselor
engaged in a specific prescribed intervention during
the course of the session. The competence ratings
reflected how well the intervention was delivered
(Barber & Crits-Christoph, 1996). Examples of
items included ‘‘Monitoring cocaine usage,’’ ‘‘Dis-
cussing client compliance or resistance to treat-
ment,’’ ‘‘Encouraging attendance at or involvement
in 12-step programs,’’ and ‘‘Discussing stressors and
how they influence recovery.’’ Using ratings of
session tapes obtained during the pilot phase of the
NIDA CCTS, Barber, Mercer, et al. (1996) found
acceptable levels of interjudge reliability for both
adherence and competence, as measured by intra-
class correlations for two pooled judges (ICC2,2;
Shrout & Fleiss, 1979). Furthermore, the scale has
been shown to discriminate IDC from cognitive and
dynamic therapies (Barber, Foltz, Crits-Christoph,
& Chittams, 2004; Barber, Mercer, et al., 1996).
Interjudge reliability of adherence�/competence rating
in the current sample. Internal consistency of these
measures was excellent. Cronbach as were .83 for
the adherence scale and .91 for the competence
scale. To examine interjudge reliability (see Table I),
we calculated intraclass correlations (ICC2,k ; Shrout
& Fleiss, 1979), in which rater is considered a
random effect and k is the number of raters. We
conducted a component of analysis of variance
(ANOVA) using a restricted maximum likelihood
estimation method and specified the following terms
as random effects: site, treatment, Site�/Treatment
interaction, therapist (nested in site and treatment),
patient (nested within site, treatment and therapist),
session (nested within site, treatment, therapist, and
patient), and judge. Thus, for our study, ICC2,2 is an
estimate of how two randomly selected judges will
perform. Interjudge reliability was good (ICC2,2�/
0.79) for the mean adherence score from two
judges. For the competence scale, we selected only
competence items for which there was adequate
interjudge reliability (i.e., ICC2,2�/0.6) and found
that the competence scale had an interjudge relia-
bility of 0.80.
Alliance scales. The alliance was assessed at Ses-
sions 2 and 5 using the patient self-report versions of
two established instruments: the California Psy-
chotherapy Alliance Scale (CALPAS; Gaston &
Marmar, 1994) and the Helping Alliance Question-
naire-II (HAq-II; Luborsky et al., 1996). Session 2
was chosen as representative of early sessions in
therapy, important because early-session alliance
ratings have been shown to predict outcome in other
studies (see Martin et al., 2000). Session 5 alliance
ratings, which were available for a smaller sample,
were used to replicate the findings from Session 2.
The patient versions of these measures were selected
because reviews (e.g., Martin et al., 2000) have
demonstrated that patients’ ratings of the alliance
tend to be more strongly associated with outcome
than therapists’ ratings. The CALPAS is a 24-item
questionnaire (in which each item is rated on a
7-point Likert scale [1�/not at all ; 7�/very much so])
composed of four scales: Patient Working Capacity,
Patient Commitment, Therapist Understanding and
Involvement, and Working Strategy Consensus.
Because these four scales were highly intercorrelated
in the current sample (see also Barber et al., 1999),
we used the total CALPAS score in this study. The
internal consistency of the CALPAS total was 0.86 at
Session 2 (similar values were reported by Barber
et al., 1999, and Luborsky et al., 1996). The HAq-II
is a 19-item questionnaire (in which each item is
rated on a 6-point Likert scale: 1�/I strongly feel it is
Table I. Percentage of Variance Explained and Interjudge Reliability for the Adherence�/Competence Scale for Individual Drug Counseling
for Cocaine Dependence.
Percentage of variance explained
Reliability scale Site Therapist Patient Session Judge Error Interjudge reliability
Adherence total .00 .20 .11 .34 .01 .34 .79
Competence total .00 .30 .08 .28 .02 .32 .80
Note. Interjudge reliability based on intraclass correlations for two pooled judges, ICC2,2 (Shrout & Fleiss, 1979).
232 J. Barber et al.
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not true ; 6�/I strongly feel it is true). Internal
consistency of the HAq-II was 0.91 at Session 2.
The correlation between the two instruments was
.82. In previous studies, correlations between patient
versions of the CALPAS and the HAq-II ranged
from .59 and .71 depending on the session assessed
(e.g., Luborsky et al., 1996).
The Addiction Severity Index (ASI; Fureman,
Parikh, Bragg, & McLellan, 1990). This is a struc-
tured interview that assesses past and current (pre-
vious 30 days) problems in seven domains: medical,
employment, alcohol use, drug use, legal, psychia-
tric, and family�/social relations. It has been shown
to be reliable and valid (Kosten, Rounsaville, &
Kleber, 1983; Makela, 2004; McLellan, Luborsky,
Cacciola, & Griffith, 1985). For example, test�/retest
reliability coefficients of .83 or higher have been
reported for all scales (Kosten et al., 1983). The ASI
was administered at baseline and each follow-up
assessment point (Months 1�/6). In the current
investigation, only the drug use composite score
was used because it was the main outcome variable
used in the clinical trial. In terms of its validity, the
ASI drug use composite score was compared with
two additional measures of cocaine usage gathered in
the CCTS (i.e., urine drug screens and cocaine
inventories), both done weekly. For the urine screens
and cocaine inventories, we defined a month as the
30 days before the acquired ASI (or scheduled ASI,
if missing). Within the designated month, we deter-
mined whether there was evidence of any cocaine
usage on either measure and, using cross-tabula-
tions, compared the observed agreement between
these three measures. We found an agreement of
70% or higher, suggesting that patients’ interview-
based self-reports were relatively consistent with
other measures of cocaine use.
The Beck Depression Inventory (BDI; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961). This is a 21-
item self-report measure of depression. It is a widely
used, reliable measure of depressive symptoms (see
Beck, Steer, & Garbin, 1988, for a review). The BDI
was administered at baseline and at each follow-up
assessment point (e.g., Months 1�/6). The BDI was
used as a secondary measure of outcome in the
current investigation because it has often been used
in other psychotherapy studies involving adherence
and competence (e.g., Barber, Crits-Christoph, &
Luborsky, 1996; DeRubeis & Feeley, 1990) and
because it was a secondary outcome measure in the
NIDA CCTS.
Psychiatric severity composite score (Crits-Christoph
et al., 1999). This was created by standardizing and
then averaging scores on four scales: the Hamilton
Rating Scale for Depression (HRSD; Williams,
1988), Beck Anxiety Inventory (BAI; Beck, Epstein,
Brown, & Steer, 1988), Brief Symptom Inventory
(Derogatis, 1992), and Psychiatric Severity Compo-
site of the ASI. Cronbach’s a for this composite
score was .80. The BDI was not included here
because of its high correlation with the BAI and
because the severity composite already included a
measure of depression (HRSD). As in the NIDA
CCTS (Crits-Christoph et al., 1999), baseline scores
on this psychiatric severity composite served as a
covariate in all of our analyses.
The Socialization Scale of the California Personality
Inventory (CPI; Megargee, 1972). This scale mea-
sures both sociopathy and an externalizing coping
style. Kadden, Litt, Donovan, and Conney (1996)
have presented detailed information on the psycho-
metric properties of the CPI Socialization scale,
including its good reliability (Cronbach’s a�/.72).
In terms of validity, they reported, for example, that
a low score on the CPI Socialization scale was
associated with the presence of an antisocial person-
ality disorder diagnosis (rpb�/�/.31). The scale was
included in this report as a covariate because it
served as a covariate in the outcome analysis of the
NIDA CCTS trial (Crits-Christoph et al., 1999).
Procedure
One audiotaped counseling session was randomly
selected for each patient from those held between
Sessions 2 and 10. Slightly more than 82% of the
tapes came from Session 2 through Session 6.
Of the 121 patients randomized to IDC, 14 failed
to show up for treatment and another 12 made it to
their first session but had no outcome, alliance, or
early-session audiotapes and thus could not be
included in the current study. This left an effective
sample of 95, all of whom had at least one post-
baseline ASI drug use composite score (the main
outcome measure) and 91 of whom had at least one
BDI (the secondary outcome measure). More spe-
cifically, of the 570 potential ASI outcome data
points (95 patients�/6 outcome assessments), 82%
were not missing. ASI data were available (nonmiss-
ing) for 86%, 80%, 75%, 80%, 83%, and 86% of
participants at Months 1 through 6, respectively,
with an average of 5.0 completed assessments per
participant in the current sample. Comparisons
of the 95 IDC patients who were included in this
study and the 26 who were not revealed no sig-
nificant differences between the groups in symp-
toms, drug dependence, or other measures at
baseline (all ps �/.30). Similarly, a comparison of
Adherence, competence, alliance, and outcome 233
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the 95 IDC patients and the 12 who were rando-
mized but for whom we had no data revealed no
significant differences between the groups on all
measures at baseline (all ps �/.21).
The two expert drug counselors who were trained
as judges for this study independently listened to and
rated all of the audiotapes in their entirety. The
judges were unaware of the patients’ outcomes and
the counselors’ identities.
Results
Examination of Distributions and Data
Transformation
Before modeling the effects of the process variables
on outcome, we examined the distributions of the
outcome variables. Scores on the ASI Drug Use
Composite were normally distributed at all assess-
ments, although, as expected, the percentage of
zeroes (indicating no drug use problem) increased
at later assessment points. The BDI, however, was
positively skewed at all assessments, with many low
scores and relatively few high scores. It was deter-
mined that a square root transformation was re-
quired. Thus, the BDI scores collected at all
assessment points were transformed. Although the
normality assumption is not required for the process
variables, regression-type approaches work best
when they have sufficient variability. When process
variables do not have sufficient variability, as is the
case with bimodal distributions or categorical vari-
ables, then regression- type approaches are less
efficient and the interpretations less clear. To address
these issues, we examined the distributions of both
the adherence and competence total scores and
found that both were near normal. The Shapiro-
Wilk (1965) statistic, which ranges from 0 to 1, in
which values near 1 indicate near normality, were
0.98 for the adherence score and 0.97 for compe-
tence score. This provided evidence that these two
measures had sufficient variability.
Descriptive Data on Adherence and
Competence
The mean level of adherence was 2.2 (SD�/0.35)
and the mean level of competence was 4.15 (SD�/
0.65). The correlation between adherence and
competence scores was substantial (r�/.58, n�/95,
p B/.001). The relatively low level of adherence
observed in this study was not due to inadequate
implementation of the IDC model but rather to the
fact that not all possible interventions contained in
the rating scale were, or could be, delivered in every
session. This was as expected.
Data Analytic Strategy
In the main clinical trial (Crits-Christoph et al.,
1999), we found that, on average, patient improve-
ment was sizable during the first month of treatment
and continued during the remainder of the 6-month
active phase of treatment, albeit at a lesser rate. For
this reason, we implemented a general mixed-model
approach that examined change from baseline to the
average of the post-baseline monthly assessments. To
accomplish this, we used PROC MIXED in SAS
(1997) and examined average drug use over the
active phase of treatment (Month 1�/6) rather than
assuming a linear change in drug use over time.
Unlike standard repeated measures ANOVA, this
approach permits flexibility in the assumptions made
about the covariance structure of the multiple
assessments. We specified a Toeplitz structure,
which assumes that assessments made closer to-
gether in time may not be correlated in the same way
as assessments separated by longer time intervals. A
likelihood ratio test revealed that this covariance
structure fits better than the compound symmetry
and first-order autoregressive covariance structures
(p B/.05).
Similar to hierarchical linear modeling (Bryk &
Raudenbush, 1992), PROC MIXED retains all
nonmissing observations; that is, it retains cases
even if some data points are missing. However,
unlike hierarchical linear modeling, time is not
considered linear. In addition, time intervals are
considered fixed (i.e., Month 1, Month 2, Month 3).
The independent variables in these analyses were
site, baseline scores on the outcome variables,
psychiatric severity composite, the CPI Socialization
score, and the adherence, competence, or alliance
scores (either adherence, adherence squared to
test the curvilinear prediction, competence, or a
Competence�/Adherence interaction or the Adher-
ence Squared�/Alliance interaction to test the curvi-
linear adherence by alliance prediction). The first
four variables were included as covariates because
they had been included as covariates in all outcome
analyses conducted for the NIDA CCTS (Crits-
Christoph et al., 1999).
Although the amount of missing data was not
large, the mixed-model applications must be able to
address the effect of attrition on the proposed
analyses. Likelihood estimation for mixed models,
as performed with Proc Mixed in SAS, is especially
robust with respect to missing data compared with
other procedures such as semiparametric generalized
estimating equations approaches. Of course, the
model assumptions of the likelihood approach are
more stringent under likelihood estimation and need
to be assessed with procedures such as residual
234 J. Barber et al.
Downloaded By: [Society for Psychotherapy Research (SPR)] At: 01:48 20 February 2009
analyses and sensitivity analyses (Little, 1995).
Estimates and inferences may, however, be invalid
if the missing data�/dropout mechanism is not
ignorable. To deal with this potential problem, we
specified and tested random-effects pattern-mixture
models. As described by Hedeker and Gibbons
(1997), such models allow us to assess whether
important estimates are dependent on dropout
patterns and provide overall estimates of effects by
averaging over the various dropout patterns.
Finally, to maintain our focus on a causal relation,
we only examined outcomes that occurred after the
assessment of our predictor variables.
Does Adherence Predict Outcome in a Linear
Fashion?
Performing separate analyses for the ASI drug use
composite scores and the transformed BDI scores,
adherence was entered as an independent variable
in a mixed-model ANOVA to determine whether
it was linearly associated with outcome. Greater
adherence to the IDC model did not predict
subsequent outcome as assessed by the ASI drug
composite, F(1, 86)�/0.25, ns, but was significantly
associated with a decrease in BDI scores (reduc-
tions in depressive symptoms) during treatment,
F(1, 81)�/4.07, p B/.05.
Does Adherence Predict Outcome in a
Curvilinear Fashion?
To evaluate this, the mixed-model analyses were
repeated. However, this time the squared adherence
term was entered as the independent variable. The
results of these analyses indicated that adherence did
have a significant curvilinear association with change
from Month 1 to 6 in both ASI drug use composite
scores, F(1, 85)�/4.68, p�/.03, and BDI scores,
F(1, 80)�/7.83, p B/.01. As predicted, low and high
levels of adherence resulted in worse outcome than
moderate levels of adherence (see Figure I).
Does the Competent Delivery of IDC Predict
Outcome?
Contrary to expectations, the results of the mixed-
model analysis indicated that the competent delivery
of IDC did not predict outcome as measured by
either the ASI drug use composite, F(1, 86)�/1.28,
ns, or the BDI, F(1, 81)�/2.69, ns.
Do Competence and Adherence Together
Predict Outcome?
We examined whether competence had an additive
effect with adherence in predicting outcome.
Inclusion of competence did not help resolve the
significance of adherence for either the ASI drug
use composite, F(1, 85)�/.04, ns , or the BDI,
F(1, 80)�/1.67, p�/.20. The decrease in the value
of the F statistic was due to the collinearity between
the adherence and competence measures (r�/ .58,
p B/.001), which resulted in both measures explain-
ing the same variance in outcomes.
We also examined whether there was a differential
effect of adherence depending on level of compe-
tence. To do this, we included an interaction
between adherence and competence in the model
in addition to the measures of each (adherence
and competence) individually. The interaction was
nonsignificant for both outcome measures: ASI,
F(1, 84)�/0.95, ns ; BDI, F(1, 79)�/0.92, ns.
Does the Relation Between Competence and
the Curvilinear Term of Adherence Predict
Outcome?
We examined whether the relation between curvi-
linear adherence and outcome was dependent on
competence. Testing of this hypothesis involved the
modeling of the interaction between the curvilinear
term of adherence and competence, with all linear
terms included in the model. The interaction was
nonsignificant, indicating that the previously ob-
served relation between curvilinear adherence and
outcome is not different for different levels of
competence.
Does the Interaction Between the Curvilinear
Term of Adherence and Alliance Predict
Outcome?
Although alliance at Session 2 did not predict
outcome (i.e., neither the CALPAS nor the HAq-II
predicted ASI drug use composite scores),
Quadratic Adherence
0.08
0.09
0.10
0.11
0.12
0.13
0.14
0.15
0.16
0.17
0.18
0.19
0.20
1.30 1.50 1.70 1.90 2.10 2.30 2.50 2.70 2.90 3.10 3.30
Adherence Score
Pre
dict
ed D
rug
Com
p
Figure I. Relation between adherence and drug use in 95
individual drug counseling patients.
Adherence, competence, alliance, and outcome 235
Downloaded By: [Society for Psychotherapy Research (SPR)] At: 01:48 20 February 2009
F(1, 86)�/1.34, ns, and F(1, 85)�/0.24, ns , respec-
tively, there was a significant interaction between
curvilinear adherence and alliance (CALPAS) in
predicting ASI drug use composite scores, F(1,
82)�/5.06, p B/.03. These results were replicated
with the HAq-II, F(1, 82)�/3.98, p�/.05. To under-
stand these results better, we plotted them using a
dichotomization of the CALPAS scores based on a
median split (see Figure II). The graph indicates that
when the early-treatment alliance was weak, the
curvilinear relationship between adherence and out-
come was more concave than when the alliance was
strong. That is, whereas a strong alliance negated the
impact of counselor adherence to the IDC model, a
weaker alliance was associated with the best out-
comes when there was a moderate level of counselor
adherence to the IDC model. These findings were
replicated when the HAq-II was used instead of the
CALPAS.
We conducted similar analyses using the Session
5 alliance ratings. To maintain the causal relation
between our process predictors and outcome, and
because Session 5 could have been held after
Month 1, we looked at the average change in
drug use from Month 2 through Month 6. This
analytical approach has less power than the analysis
presented previously and less generalizability be-
cause outcome focuses solely on Months 2 through
6. Nonetheless, we found the same curvilinear
relation between adherence and alliance at Session
5 in predicting drug use outcome, as was found for
Session 2 alliance ratings: CALPAS, F(1, 53)�/
4.04, p B/.05, and HAq-II, F(1, 53)�/5.90, p B/
.02. It should be noted that these findings held
despite a reduced sample size owing to the loss of
those patients who dropped out before Month 2
assessment.
Were Our Findings a Result of the Pattern of
Missing Data?
To determine whether our results were due to the
pattern of missing data, we applied the random-
effects pattern-mixture analysis described previously.
To make these analyses manageable, we had to limit
the number of patterns we tested. From inspection
of session attendance information, we classified
patients according to (a) whether they completed
treatment or dropped out and (b) the number of
sessions they attended. Session attendance ranged
from 1 to 38 sessions and was recoded into three
categories: low (one to nine sessions attended),
moderate (10�/25 sessions attended), and high
(26�/38 sessions attended). Category breakdowns
were determined by the quartiles for session atten-
dance; categories were designated as lower quartile,
middle half, and upper quartile. Therefore, 25% of
the patients had one to nine sessions and an
additional 25% of the patients had 26 to 38 sessions.
The remaining 50% had 10 to 25 sessions.
We followed Hedeker and Gibbons’s (1997)
analysis and included a three-way interaction term
(Attendance identifier�/Quadratic Adherence�/
Alliance). In addition, all subsequent two-way inter-
actions and main effects were included. If this three-
way interaction was significant, then the relation
between curvilinear adherence and alliance was
dependent on the dropout pattern. If it was non-
significant, then our finding was not dependent on
the dropout process. Inclusion of the three-way
interaction of completion status (completer�/drop-
out) with curvilinear adherence and alliance was
not significant in the prediction of ASI drug use
composite scores: CALPAS, F(1, 76)�/0.38, p�/
.54; HAq-II, F(1, 75)�/0.01, p�/.91. Inclusion of
the three-way interaction of session attendance (low,
moderate, and high) with curvilinear adherence
and alliance also was not significant: CALPAS,
F(2, 70)�/1.19, p�/.31; HAq-II, F(2, 71)�/0.30,
p�/.74. Therefore, we found no evidence that our
findings were dependent on the dropout pattern.
Discussion
Higher levels of counselor adherence to the IDC
model were marginally associated with better out-
comes, as measured by the BDI but not the ASI drug
use composite. The lack of a strong adherence�/
outcome relation is consistent with what has been
reported in other studies (e.g., Barber, Crits-Chris-
toph, & Luborsky, 1996; Elkin, 1988) and is what
led us to hypothesize that the relation might be
curvilinear.Figure II. Relation between curvilinear adherence and drug use in
patients with high versus low therapeutic alliance.
236 J. Barber et al.
Downloaded By: [Society for Psychotherapy Research (SPR)] At: 01:48 20 February 2009
We, in fact, did find support for a curvilinear
relation between adherence to the IDC treatment
model and subsequent outcome. Both low and high
levels of adherence were associated with worse
outcomes, whereas an intermediate level of adher-
ence was associated with the best outcomes (reduc-
tions in both drug use and depressive symptoms).
These findings are consistent with the clinical
wisdom that moderate use of model-specific treat-
ment techniques are more likely to lead to better
outcomes than either high or low levels of adherence.
If we had only examined the linear relation between
adherence and outcome, we would not have detected
this relation. The challenge for clinicians and their
trainers�/supervisors lies in teaching therapists and
counselors to conform to a treatment manual while
remaining moderate in the utilization of prescribed
interventions. In other words, practicing in a way
that is responsive to the clinical situation may, on
occasion, require a deviation from a treatment
manual even while maintaining overall adherence
to the manual. Moreover, it could be useful for
treatment manuals to offer suggestions regarding
situations in which adherence to the manual could
yield to other clinical considerations.
Contrary to our hypothesis, we did not find
support for an association between competent de-
livery of IDC techniques and outcome. Nor did
competence add to or interact with adherence to
predict outcome. The reasons for this are not readily
apparent. The observed correlation between adher-
ence and competence is based on the simultaneous
relation between these two variables irrespective of
session number, whereas the mixed-model analysis
took into account these cross-variable correlations
and the within-subject correlation. Maybe the use of
highly select counselors, who, before the clinical
trial, underwent extensive training to weed out those
who were least competent, left only the best counse-
lors. A uniformly high level of competence would
make detection of the hypothesized relation to out-
come difficult. It is also possible that overall techni-
cal competence is just not as important early in
treatment when the focus is more on engaging
patients in treatment and developing the alliance.
Finally, we found an interaction between alliance
and curvilinear adherence and outcome, suggesting
that the alliance can moderate the influence of
adherence on outcome. The interaction indicated
that, for cases in which the alliance was strong,
counselor adherence did not much matter; those
patients typically improved. However, for cases in
which the alliance was weak, adherence did matter.
Those patients improved more when their counse-
lors adhered moderately to IDC principles than
when the counselors were either minimally or highly
adherent. We were able to replicate our results with
two measures of the alliance at two different
sessions, suggesting some generalizability to our
findings. These results provide a partial explanation
as to why the alliance on its own did not predict IDC
patients’ outcomes in the NIDA CCTS (Barber
et al., 2001).
We cannot know whether the kinds of relations
between adherence and outcome and among adher-
ence, alliance, and outcome found in the current
study are specific to drug abusers, although we
suspect that they are not. It will be important in
future studies with other patient populations to
examine more complex models of the relation
between outcome and both treatment-specific tech-
nical and nonspecific relationship factors in a variety
of treatments for a range of disorders. However,
samples of sufficient size are needed to have ade-
quate statistical power to conduct such evaluations.
A limitation of this study was that our findings are
based on early-treatment ratings of the alliance,
adherence and competence, and on only one ran-
domly selected therapy session tape per patient.
Although we were able to replicate our Session 2
alliance-related findings using the Session 5 ratings
and either the CALPAS or the HAq II, we do not
know how the development and fluctuation of the
alliance during counseling impact the relation be-
tween adherence and outcome. Testing these hy-
potheses later in treatment would have resulted in a
marked loss of power as a result of progressive
attrition from treatment and the smaller number of
patients available for later outcome assessments. Our
findings indicate that further research is needed on
the mechanisms of action of drug counseling,
including an examination of whether motivation or
other patient characteristics moderate the ad-
herence�/outcome relationship. Another limitation
is that we tested six independent hypotheses and
conducted a relatively large number of analyses.
Thus, some of our findings may have occurred by
chance. Finally, it is possible that our adherence
scale was measuring counselor activity rather than
adherence per se (i.e., just doing more in the sessions
rather than doing more of what is prescribed by the
IDC manual). However, our results suggest that the
latter is important, although we cannot say for
certain that our findings were not due to general
activity level rather than manual-based activity,
because that was not examined in the current study.
Despite these limitations, we have presented novel
findings pointing to potential interactions and curvi-
linear relations among technical factors in treatment
(therapist adherence and competence), the thera-
peutic alliance, and outcome. Such interactions and
curvilinear relations are consistent with clinical
Adherence, competence, alliance, and outcome 237
Downloaded By: [Society for Psychotherapy Research (SPR)] At: 01:48 20 February 2009
experience and highlight the important role that
both relationship factors (alliance) and the applica-
tion of specific techniques play in the therapy
process. It remains to be seen to what extent the
current results are applicable to other forms of
psychotherapy for a variety of disorders and not for
drug abuse only.
Acknowledgements
The National Institute on Drug Abuse (NIDA)
Collaborative Cocaine Treatment Study is a
NIDA-funded cooperative agreement involving four
clinical sites, a coordinating center, and NIDA staff.
The coordinating center at the University of Penn-
sylvania includes Paul Crits-Christoph (principal
investigator [PI]), Lynne Siqueland (project coordi-
nator), Karla Moras (assessment unit director), Jesse
Chittams, and Robert Gallop (director of data
management), and Larry Muenz (statistician). The
collaborating scientists at the Treatment Research
Branch, NIDA Division of Clinical and Research
Services include Jack Blaine and Lisa Simon Onken.
The four participating clinical sites are University
of Pennsylvania (Lester Luborsky [PI], Jacques
P. Barber [co-PI], Delinda Mercer [project direc-
tor]); Brookside Hospital/Harvard Medical School
(Arlene Frank [PI], Stephen F. Butler [co-PI/inno-
vative training systems], Sarah Bishop [project
director]); McLean/Massachusetts General Hos-
pital�/Harvard University Medical School (Roger
D. Weiss [PI], David R. Gastfriend [co-PI], and
Lisa M. Najavits and Margaret L. Griffin [project
directors]); and University of Pittsburgh/Western
Psychiatric Institute and Clinic (Michael E. Thase
[PI], Dennis Daley [co-PI], Ishan M. Salloum [co-
PI], and Judy Lis [project director]). The training
unit includes heads of cognitive therapy training
unit: Aaron T. Beck (University of Pennsylvania) and
Bruce Liese (University of Kansas Medical Center);
heads of supportive�/expressive therapy training
unit: Lester Luborsky and David Mark (University
of Pennsylvania); head of the individual drug coun-
seling: George Woody (Veterans Administration/
University of Pennsylvania Medical School); and
heads of group drug counseling unit: Delinda
Mercer (head), Dennis Daley (assistant head; Uni-
versity of Pittsburgh/Western Psychiatric Institute
and Clinic), and Gloria Carpenter (assistant head;
Treatment Research Unit, University of Pennsylva-
nia). The monitoring board includes Larry Beutler,
Jim Klett, Bruce Rounsaville, and Tracie Shea.
This study was funded in part by NIDA
Grant 08237; NIDA Grants U01-DA07090, U01-
DA07663, U01-DA07673, U01-DA07693, and
U01-DA07085; NIMH Clinical Research Center
Grant P30-MH-45178; and NIDA Career Develop-
ment Awards K05-DA00168 and K02-DA 00326.
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Zusammenfassung
Diese Studie testete Hypothesen bezuglich linearer undkurvilinearer Beziehungen zwischen vorgabegetreuem Vor-gehen, Kompetenz und Erfolg, sowie der Interaktionzwischen diesen Variablen und der Qualitat der therapeu-tischen Allianz bei Patienten (n�/95), die individuelleDrogenberatung im Rahmen der gemeinsamen Drogen-abhangigkeits-Behandlungs-Studie des Nationalen Insti-tuts zur Kokain-Abhangigkeit erhielten. Die Ergebnisseunterstutzten die vorhergesagte kurvilineare Beziehungzwischen vorgabegetreuem Vorgehen und dem Ergebnis,sowie einer Interaktion dieses kurvilinearen Effekts undder Allianz zu einem fruhen Zeitpunkt der Behandlung.Fur Patienten mit einer starken therapeutischen Allianzwar das vorgabengetreue Vorgehen des Beraters zumBehandlungsmodell fur das Behandlungsergebnis ohneEinfluss. Dagegen zeigte ein moderat vorgabengetreuesVorgehen des Beraters (im Vergleich zu einem hohen oderniedrigen Festhalten an den Vorgaben) den besten Erfolg,wenn die Allianz schwacher war. Die vorliegenden Ergeb-nisse legen nahe, dass Studien zur Beziehung zwischeneinem Vorgehen des Therapeuten konform zu den Behan-dlungsrichtlinien und dem Ergebnis den komplexen Mod-eratoreffekt der therapeutischen Allianz berucksichtigenmussen.
Adherence, competence, alliance, and outcome 239
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Resume
Cette etude a teste des hypotheses au sujet de relationslineaires et curvilineaires entre adherence, competence etresultat, et des interactions de ces effets avec la qualite del’alliance therapeutique chez des patients (N=95) quiavaient recu du counseling individuel pour abus dedrogues dans le cadre de l’Etude en Collaboration del’Institut National pour l’Abus de Drogues sur le Traite-ment de la Cocaıne. Les resultats apportent du soutien al’hypothese d’une relation curvilineaire entre adherence etresultat ainsi que d’une interaction entre cet effet curvili-neaire et l’alliance en phase precoce du traitement. Pourles patients avec une alliance therapeutique forte, l’ad-herence du conseiller au modele de traitement ne jouaitpas de role essentiel pour le resultat du traitement. En casd’alliance plus faible, par contre, un niveau modere (versushaut ou bas) d’adherence du conseiller etait associe avec lemeilleur resultat. Ces resultats suggerent que des etudesde la relation entre l’adherence du therapeute a un modelede traitement et le resultat devraient tenir compte l’effet demoderation complexe de l’alliance therapeutique.
Resumen
Este estudio testeo hipotesis vinculadas con las relacioneslineales y curvilıneas entre adherencia, competencia yresultado ası tambien como interacciones de estos efectoscon la calidad de la alianza terapeutica entre pacientes(n�/95) que recibieron Cunseling individual por drogascomo parte del Estudio Colaborativo del tratamiento porcocaına del Instituto Nacional para el Abuso de Drogas.Los resultados apoyaron la hipotesis de la relacioncurvilineal entre adherencia y resultado, ası tambiencomo la interaccion entre este efecto curvilineal y laalianza temprana. Para los pacientes con una fuerte alianzaterapeutica, la adherencia del consejero al modelo detratamiento fue totalmente irrelevante al resultado. Enlos casos en los que la alianza fue mas debil, en cambio, unnivel de adherencia del consejero (ni alta ni baja) estuvoasociada con el resultado mejor. Estos resultados sugierenque los estudios de la relacion entre la adherencia delterapeuta a los modelos de tratamiento y resultado han detener en cuenta el efecto moderador de la alianzaterapeutica.
Let me know pls if this is all. Best, Beatriz.
Resumo
Il ruolo dell’adesione e della competenza del terapeuta edil ruolo dell’alleanza nella previsione dell’esito del counsel-ing individuale per le droghe: i risultati dall’IstitutoNazionale sull’abuso di droghe in equipe con lo Studio
di trattamento della cocaina. Questo studio ha valutato leipotesi collegate alle relazioni lineari e curvilinee traadesione, competenza ed esito e le interazioni tra questieffetti con la qualita dell’alleanza terapeutica in pazienti(N: 95) che hanno ricevuto un counseling individuale sulledroghe come parte dello Studio di trattamento dellacocaina in collaborazione con l’Istituto Nazionale di abusodi droghe.
I risultati supportano un’ipotizzata relazione curvilineatra adesione ed esito, cosı come un’interazione tra questoeffetto curvilineo e l’alleanza all’inizio del trattamento.
Per i pazienti con una forte alleanza terapeutica,l’adesione del counselor al modello di trattamento e stataessenzialmente irrilevante rispetto all’esito del trattamento.Quando l’alleanza era piu debole, al contrario, un moder-ato (verso l’alto o il basso) livello di adesione del counselore stato associato con un miglior esito.
I risultati attuali suggeriscono che gli studi sulla rela-zione tra l’adesione del terapeuta ai modelli di trattamentoe l’esito potrebbero aver bisogno di considerare il com-plesso effetto moderatore dell’alleanza terapeutica.
Sommario
Este estudo estudou as hipoteses de relacao linear ecurvilınea entre adesao, competencia e resultado e asinteraccoes destes efeitos com a qualidade da aliancaterapeutica em pacientes (N�/95) que receberam aconsel-hamento individual para toxicodependencia como parte doEstudo Colaborativo do Tratamento da Dependencia daCocaına do Instituto Nacional para o Abuso de Drogas. Osresultados apoiaram a relacao curvilınea entre adesao eresultado, bem como uma interaccao entre este efeitocurvilıneo e alianca inicial. Para pacientes com uma fortealianca terapeutica, a adesao do terapeuta ao modeloterapeutico era, essencialmente, irrelevante para os resul-tados do tratamento. Quando a alianca era mais fraca, emcontrate, um nıvel moderado (vs. baixo ou elevado) deadesao do terapeuta estava associado a melhores resulta-dos. Estes resultados sugerem que estudos da relacao entreadesao do terapeuta a modelos de tratamento e resultadosterapeuticos podem necessitar de ter em consideracao oefeito moderador complexo da alianca terapeutica.
240 J. Barber et al.
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