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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

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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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