Manual-Guided Cognitive–Behavioral Therapy Training: A Promising Method for Disseminating Empirically Supported Substance Abuse Treatments to the Practice Community

Abstract

A gap exists between empirically supported substance abuse treatments and those used in community settings. This study examined the feasibility of training substance abuse counselors to deliver cognitive-behavioral treatment (CBT) using treatment manuals. Participants were 29 counselors. Counselors were randomly assigned to receive CBT training or to a control group. Counselor attitudes were assessed pre- and posttraining. In addition, CBT therapy sessions were videotaped and rated for adherence and skillfulness. CBT counselors reported high levels of satisfaction with the training, intention to use CBT interventions, and confidence in their ability to do so. Ratings indicated that 90% of counselors were judged as having attained at least adequate levels of CBT skillfulness. Findings demonstrate the feasibility of using psychotherapy technology tools as a means of disseminating science-based treatments to the substance abuse practice community.

Full text

Psychology
of
Addictive Behaviors
2001, Vol.
15, No. 2,
83-88
Copyright
2001
by the
Educational Publishing Foundation
0893-164X/01/S5.00
DOI:
10.1037//0893-164X.15.2.83
Manual-Guided
Cognitive-Behavioral
Therapy Training:
A
Promising
Method
for
Disseminating Empirically Supported Substance Abuse
Treatments
to the
Practice Community
Jon
Morgenstern
Mount
Sinai
School
of
Medicine
Thomas
J.
Morgan
and
Barbara
S.
McCrady
Rutgers—The
State
University
of New
Jersey
Daniel
S.
Keller
New
York University
Kathleen
M.
Carroll
Yale
University
School
of
Medicine
A
gap
exists between empirically supported substance abuse treatments
and
those used
in
community
settings.
This
study examined
the
feasibility
of
training substance abuse counselors
to
deliver
cognitive-
behavioral treatment
(CUT)
using treatment manuals. Participants were
29
counselors. Counselors were
randomly
assigned
to
receive
CBT
training
or to a
control group. Counselor attitudes were
assessed
pre-
and
posttraining.
In
addition,
CBT
therapy sessions were videotaped
and
rated
for
adherence
and
skillfulness.
CBT
counselors reported high
levels
of
satisfaction with
the
training, intention
to use CBT
interventions,
and
confidence
in
their ability
to do so.
Ratings indicated that
90% of
counselors were
judged
as
having attained
at
least adequate levels
of CBT
skillfulness.
Findings demonstrate
the
feasibility
of
using psychotherapy technology tools
as a
means
of
disseminating science-based treatments
to the
substance abuse
practice
community.
Although demonstrated
effective
interventions have been devel-
oped
to
treat
a
number
of
mental disorders, there continues
to be
a
disjunction between treatments that
are
empirically supported
and
those used
in
practice settings.
The gap
between
research
and
practice
may be
especially wide
in
substance abuse, because sub-
stance abuse clinicians
and
scientists
differ
markedly
in
their
training, professional identifications,
and
treatment philosophies.
Despite long-standing concerns,
to
date disappointingly little
progress
has
been
made
in
disseminating empirically supported
treatments (ESTs)
to
substance abuse practitioners (e.g.,
Gordis,
1991).
Recent changes
in
health care policy
and the
development
of
treatment
standardization procedures
may
provide
a
fresh
impetus
and
potential
new
solutions
to
address this problem. Specifically,
evolving
criteria
for
third-party
reimbursement
of
services
are
likely
to be
based
on
evidence
of
effectiveness
and
cost (Barlow,
1996).
Thus, clinicians will have
a new and
powerful
incentive
for
changing
treatment practices.
In
addition, treatment manuals
may
offer
an
ideal tool
for
dissemination
efforts.
Treatment manuals
Jon
Morgenstern, Department
of
Psychiatry, Mount Sinai School
of
Medicine;
Thomas
J.
Morgan
and
Barbara
S.
McCrady,
Center
of
Alcohol
Studies,
Rutgers—The
State University
of New
Jersey; Daniel
S.
Keller,
Department
of
Psychiatry,
New
York University; Kathleen
M.
Carroll,
Department
of
Psychiatry, Yale University School
of
Medicine.
Preparation
of
this article
was
supported
by
Grant AA08747
from the
National Institute
on
Alcohol Abuse
and
Alcoholism
Correspondence concerning this article should
be
addressed
to Jon
Morgenstern, Mount Sinai School
of
Medicine, Department
of
Psychiatry,
Box
1230,
One
Gustave
L.
Levy Place,
New
York,
New
York
10029.
Electronic mail
may be
sent
to
jon.morgenstem@mssm.edu.
increase
the
accessibility
of
research
findings
to
clinicians because
they
describe procedures
to
implement treatments
at a
high
level
of
technical specificity, accelerate
the
learning
of new
techniques,
and
facilitate instruction
to
therapists
of
different
theoretical ori-
entations.
In
addition,
the use of
manuals
to
actually deliver
treatment
may
enhance
efficacy
and
provide
a
means
of
quality
control
for
therapist performance, similar
to
that achieved
in re-
search contexts.
The
potential
use of
manuals
as the
primary medium
for
dis-
seminating
ESTs
has
sparked considerable debate
and
calls
for
further
study
(e.g., Addis, 1997).
One
critical issue concerns
the
feasibility
of
training clinicians
to
deliver ESTs competently
and to
incorporate them into their practice routines. Community providers
are
typically less well trained than research clinicians
and
differ
in
theoretical orientation. Questions arise
as to
whether providers
can
learn
to
competently deliver ESTs using manuals
and
whether
providers will replace
favored
treatment strategies
with
ESTs
following
training.
Therapist
feasibility issues
are
particularly salient when consid-
ering
the
dissemination
of
ESTs
to
substance abuse practitioners
in
the
United States. Substance abuse counselors provide
the
majority
of
care
in the
current system. Counselors have markedly less
formal
education,
and
less
clinical
training, than
either
therapists
used
in
clinical trials
or
than their counterparts
in
mental health
treatment.
For
example,
a
substantial proportion
of
counselors
do
not
have master's degrees,
and
many have
not
completed
4
years
of
college (Institute
of
Medicine, 1997).
In
addition, interventions
developed
in
research settings have been predominantly
cognitive-
behavioral
in
orientation. However, most counselors espouse
a
12-step
approach
to
treating substance
use
problems (Wallace,
1996).
Cognitive-behavioral
therapy (CBT)
and
12-step treatment
83
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

84
MORGENSTERN,
MORGAN, McCRADY,
KELLER,
AND
CARROLL
approaches
differ
substantially,
especially
with
regard
to
their
underlying
theory.
Lower
levels
of
education
and
clinical
training,
and a
strong
allegiance
to a
conflicting
treatment
model,
raise
serious
questions
about
counselor
ability
to
master
the
delivery
of CBT for
substance
abuse
and
their
response
to
protocol-based
training
methods,
as
well
as
their willingness
to
embrace
the use of CBT
techniques
following
training.
Only
one
prior
study
has
reported
on
attempts
to
disseminate
protocol-based
substance
abuse
treatments
to
com-
munity
practitioners
(Sobell,
1996).
Sobell
(1996)
reported
on
clinician
response
but did not
evaluate
clinicians'
ability
to
deliver
CBT
following training.
The
primary
aim of
this
study
was to
examine
the
feasibility
of
training front-line
substance
abuse
providers
to
deliver
CBT
using
treatment
manuals.
We
addressed
three
specific
issues.
First,
we
were
interested
in
examining
counselors'
subjective
response
to
the
training.
Several
responses
were
assessed.
These
included
satisfaction with
learning
CBT,
satisfaction
with
the use of
manual-based
training
methods,
the
perceived
clinical
utility
of
CBT,
and
appraised
self-efficacy
in
delivering
CBT
following
training.
Second,
we
were
interested
in
exploring
the
relation
between
counselors'
beliefs
about
treatment
and the
nature
of
addictive
disorders
and the
training
experience.
Specifically,
we
assessed
whether
counselors'
allegiance
to the
12-step
approach
posed
an
obstacle
to
learning
CBT and
whether
the
training
served
to
modify
counselors'
beliefs
in
12-step
and
social
learning
theory
models.
Third,
we
evaluated
counselors'
ability
to
deliver
CBT
following training.
We
evaluated
performance
by
assessing
adher-
ence
and
skillfulness
in
delivering
CBT
based
on an
"expert"
standard
established
in a
rigorously
implemented
research
study
of
CBT
(Project
MATCH
Research
Group,
1997).
Method
Sample
and
Setting
Participants
were
29
front-line
substance abuse counselors drawn
from
the
clinical
staffs
of two
outpatient chemical dependency treatment pro-
grams
located
in
central
New
Jersey.
The
programs espoused
a
traditional
treatment
model
with
interventions focused
on
reducing denial, educating
clients
about
the
disease
of
addiction, facilitating
affiliation
with
12-step
self-help
groups,
and
maintaining
abstinence. Each employed
master's-
and
less
than
master's-level
trained personnel
as
front-line
clinical
staff.
Counselors
were eligible
to
participate
in the
study
if
they were currently
providing
substance abuse treatment
to
clients,
had a
minimum
of 1
year
of
prior
treatment experience,
and did not
have prior formal training
in CBT
for
substance abuse. Thirty-eight counselors representing
the
entire clinical
staffs
of
each program's
adult
treatment division were approached
and
agreed
to
participate.
Two
counselors
did not
meet
eligibility
criteria:
One
had
received prior
CBT
training,
and the
other
did not
meet
the
minimum
treatment
experience requirement. Four counselors were
not
included
be-
cause
of
scheduling conflicts,
and 3
left
the
programs prior
to the end of
training.
Twenty counselors were trained
in
CBT,
and 9
counselors served
as a
control group.
The
mean
age of the
sample
was
41.5
years
(SD =
11.4),
and 65%
(n
= 19)
were women.
The
ethnic composition
of the
sample
was 72% (n = 21)
Caucasian,
21% (n = 6)
African American,
and
7%
(n = 2)
Hispanic.
As is
typical
of
substance abuse program
staffs,
counselors
had
quite varied educational backgrounds. About
45% (n =
13)
had
at
least
a
master's degree
in
either psychology, counseling, social
work,
or
nursing
(1
counselor
had a
doctoral degree),
and 55% (n = 16)
either
a
bachelor's
degree,
an
associate's degree,
or had
graduated high
school.
Most
counselors
had
extensive
substance
abuse
treatment
experi-
ence
(M
= 8.7
years,
SD =
6.8).
Thirty-eight percent
of the
counselors
reported being
in
recovery.
Procedure
Participant
recruitment.
The
selection
of a
setting
for the
study
was
initiated
by a
review
of
substance abuse treatment programs located
in
central
New
Jersey. Programs were considered
if
they provided outpatient
substance abuse treatment using
a
traditional chemical dependency
care
model, were licensed
by the
state,
evidenced financial stability,
and
were
recognized
as
accepted members
of the
provider community
in New
Jersey.
Program adherence
to a
traditional chemical dependency care model
was
assessed based either
on our
knowledge
of the
program
or
through
an
interview
with
the
program's clinical director. Programs were considered
as
accepted members
of the
provider community
if
they belonged
to one of
several county
or
state substance abuse provider organizations. Seven
programs
met
these criteria
and
were contacted.
All
expressed interest
in
participating
in the
study.
Two
programs were selected
on the
basis
of
their
large
and
representative front-line clinical
staffs
and
their record
of
fiscal
and
clinical stability. These latter factors were important
in the
selection
process
because
the
future
fiscal viability
of
many outpatient programs
was
in
question because
of the
introduction
of
managed-care constraints
in New
Jersey
at the
time.
Counselors
who
agreed
to
participate were administered informed con-
sent
and
completed questionnaires, which
are
described below. Counselors
were
then assigned, using
urn
randomization procedures (Stout,
Wirtz,
Carbonari,
& Del
Boca, 1994),
to two
groups balanced
on the
following
six
factors:
treatment beliefs, clinical experience, ethnicity, gender, education,
and
employment status
at the
program.
Two
thirds
of the
counselors were
assigned
to a CBT
training group,
and one
third were assigned
to a
control
group.
CBT
training consisted
of 35 hr of
didactic classroom instruction
over
a
2-week period followed
by
clinical case training
and
intensive
supervision.
The
control group also received training designed
to
minimize
counselors' feelings
of
being deprived
of a
valuable learning experience
and
to
avoid
a
Hawthorne-like effect
on
counselor motivation.
The
control
group received
8 hr of
training
in
traditional substance abuse counseling
and
were offered
the
opportunity
to
receive training
in CBT at the end of
the
study.
CBT
training
is
described below.
Counselors assigned
to the CBT
group were administered
an
extensive
quantitative
and
qualitative evaluation survey
at the end of the
didactic
training
and
again following
the
clinical case training.
All
treatment
ses-
sions were videotaped,
and
sessions
selected
at the end of
training were
rated
for
adherence
and
skillfulness.
In
addition,
all
counselors were
re-administered questionnaires assessing beliefs
at the end of
training.
Responses
to
questionnaires
and
evaluation forms were treated
as
confi-
dential. Counselors
in the CBT
condition were asked
not to
share training
information
with those
in the
control condition,
and
this
was
monitored
throughout
the
study.
CBT
training. Cognitive Behavioral Coping
Skills
Training
(CBCST;
Kadden
et
al.,
1992)
was
selected
as the CBT
intervention. Protocol-based
methods used
to
train therapists
in
research studies were adapted
to
train
the
counselors.
To
increase
the
applicability
of
training results,
a
struc-
tured,
time-limited curriculum, similar
in
format
to a
continuing-education
course,
was
developed. Thus, although training
was
intensive,
all
counsel-
ors
were trained concurrent with
the
conduct
of
their regular counseling
duties.
Thirty-five
hr of
didactic training were provided. Didactic training
contained theoretical
and
experiential elements, including discussions
of
the
similarities
and
differences between
CBT and
12-step models,
the
role
of
therapeutic alliance
in the
delivery
of
protocol-driven treatments,
and
extensive role plays
for
each
of the
CBCST treatment sessions.
CBT
counselors then treated
at
least three and,
if
possible (depending
on
time
constraints), four clients
in
12-session
individual treatment using
the
CBCST manual during
the
training period. Twenty-six percent
of the
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MANUAL-GUIDED
CBT
85
clients
treated completed
all 12
sessions. Sessions were videotaped
and
viewed
by
supervisors
who
provided session-by-session feedback.
CBT
counselors received
1
hr
of
individual
and 1
hr
of
group supervision
per
week. Supervisors were
five
doctoral-level
clinical
psychologists with
extensive experience treating
and
supervising others
in CBT for
substance
abuse. Three study authors (Jon
Morgenstem,
Thomas
J.
Morgan,
and
Daniel
S.
Keller) were supervisors. Counselors received about
100 hr of
didactic
and
clinical training over
a
5-month period.
Although
the
structure
of the
training
was
similar
to
that used
in
Project
MATCH,
we
substantially augmented
and
modified training materials
to
address
the
challenges raised
in
training front-line counselors.
In
addition,
we
revised
many sections
of the
Project MATCH manual
to
simplify
and
streamline delivery.
Rating
CBT
adherence
and
skillfulness.
Clinical supervisors
and
trained raters
assessed
counselor performance
at the end of
training
on the
basis
of
session videotapes. Methods
and
standards used
in
Project
MATCH
to
assess therapist delivery were adapted
for
this study (Carroll
et
al.,
1998).
Specifically,
in
Project MATCH supervisors rated
the CBT
performance
of
therapists using relevant items
from the
MATCH Videotape Rating
Scale
(MTRS;
Carroll
et
al.,
1998).
In
that study, therapists
who
scored
below
3 on a
5-poinl
scale were judged less than adequate.
In
this study,
supervisors rated sessions using
CBT
items drawn
from
the
MTRS.
In
addition, supervisors provided
an
overall
score
for
counselor skillfulness
based
on
their session ratings
for the
last
case.
Overall performance
was
rated
on a
5-point
Likert
scale
with
anchors
of 1
(very
poor)
to 5
(excel-
lent).
We
attempted
to
calibrate supervisors' ratings
of
counselors
to
those
used
by
supervisors
in
Project MATCH.
First,
supervisors
met
regularly
to
discuss counselor performance
and
view session videotapes. These discus-
sions were
led by
Daniel
S.
Keller,
who was a CBT
trainer
and
clinical
supervisor
in
Project MATCH.
In
addition, Daniel
S.
Keller
and
Kathleen
M.
Carroll,
who are
very
familiar
with
CBT
therapists' performances
in
Project MATCH, rated representative counselor videotapes
and
indicated
how
these compared
to the
performance
of
Project MATCH therapists.
We
also trained raters
to
assess
CBT
adherence
and
competence cali-
brated
to
standards used
in
Project MATCH. Raters were
four
advanced
doctoral clinical psychology students with experience
in CBT for
substance
abuse. Training raters involved several steps.
First,
videotapes
for 8
coun-
selors
and 14
Project MATCH
CBT
therapists were selected
to
represent
a
wide
range
of
therapist performance. These videotapes were then rated
by
the
original raters used
in
Project MATCH. Videotapes were rated
for CBT
adherence
and
skillfulness using
the
MTRS
and a
scale developed specif-
ically
for
this study (see
the
following paragraph
for
description).
The
purpose
of
this step
was to
calibrate ratings
of
counselor
CBT
performance
to
those used
in
rating Project MATCH therapists.
Next,
study raters
received
20 hr of
didactic training
and
then rated
at
least
10
tapes that were
evaluated
with regard
to
consensus ratings provided
by the
Project
MATCH raters.
Measures
Videotape
rating
scales. Adherence
to
protocol
and
skillfulness were
assessed with
the
MTRS (Carroll
et
al.,
1998)
and the
Project IMPACT
(an
acronym
used
to
identify
this study;
it
stands
for
Improving Addiction
Counseling Through Technology Transfer) Tape Rating Scale
(ITRS).
The
MTRS
assesses
the
extent
of use of
active ingredients
of
treatments
delivered
in
Project MATCH, including CBCST.
In
this
study,
raters
assessed
only
the
eight items directly
related to
CBT.
In
addition, items
were
added
to
assess skillfulness
of
delivery
of
these eight
CBT
ingredi-
ents.
As
indicated
above,
we
accentuated
the
structured
aspects
of CBT
during counselor training, including providing
an
ideal prescribed sequence
for
the
delivery
of
protocol elements. This invariant session structure
contained
the
following eight
elements:
(a)
assessment
of the
client's
concerns
and
agenda,
(b)
addressing substance
use or
cravings since last
session,
(c) review of
practice exercise,
(d)
delivery
of
session rationale,
(e)
informal
skills assessment,
(f)
skill teaching,
(g)
in-session skill exercise,
and
(h)
assignment
of
practice exercise.
The
ITRS
was
constructed
to
assess
adherence
to and
skillfulness
in
delivering these eight elements.
The
scale contains
18
items:
1
item
to
assess
extent
of
delivery
and 1 to
assess
skillfulness
of
delivery
for
each
element,
as
well
as 2
summary items
for
the
entire session. Extent
of
delivery
was
rated
on a
5-point Likert scale
(anchors:
1 = not at
all,
5 =
extensively),
as was
skillfulness (anchors:
1 =
very
poor,
5 =
excellent).
We
computed
intraclass
correlations
(ICCs)
to
establish item reliabilities using ratings
of 20
randomly
selected
tapes rated
by
all
raters. Median
ICCs
and
ranges
for the
various scales were
as
follows:
MTRS Extent,
Man
=
.85
(.67-.96);
MTRS Skillfulness,
Man =
.80
(.6S-.96);
ITRS Extent,
Man = .87
(.6S-.92);
ITRS,
Man = .87
(.43-.94).
Evaluation
survey.
We
assessed counselors' responses
to
training
us-
ing
an
extensive quantitative
and
qualitative survey. Quantitative
responses
were
measured using
Likert-scaled
items. Responses
in five
domains were
assessed:
(a)
overall satisfaction
with
training,
(b)
satisfaction with training
methods,
(c)
perceived clinical utility
of
CBT,
(d)
appraised
self-efficacy
in
delivering CBCST,
and (e)
ideological conflict experienced
in
delivering
CBT. Satisfaction with training
was
assessed
with
several items. Items
were highly correlated (average
r —
.77)
and had
similar response distri-
butions. Quantitative
responses are
presented
for two
items: "How does
this training experience compare
to
others?"
and
"Would
you
recommend
this training
to a
colleague?"
We
assessed response
to
training methods
using
one
item: "Compared
to
other training methods
you've
encountered,
how
would
you
rate
the
combined
use of
treatment manuals, videotaping
sessions,
and
supervision
on
these videotapes?"
We
assessed
the
perceived
clinical utility
of CBT
using
the
following
two
items:
(a)
"How
often
do
you
plan
to use CBT
with your
clients
in
group
and
individual treatment?"
and
(b)
"To
what
extent have
the
patients
you
treated with
CBT
benefited
from
the
treatment?" Appraised
serf-efficacy
in
delivering CBCST
was
assessed
with
one
item: "How confident
are you
that
you can
deliver
CBT
effectively?"
Conflict experienced
in
delivering
CBT was
assessed
with
the
following
item:
"To
what extent does [the]
CBT you
have been taught
conflict
with
your convictions about what constitutes
effective
treatment
for
substance
abusers?"
Counselors responded
to
this item under
two
hypothetical conditions:
(a)
when
CBT is
delivered
as one
component
of a
traditional program
and (b)
when
CBT is
delivered
as a
stand-alone
intervention.
A
summary
of
qualitative responses
to
items
is
also
reported.
Qualitative data were analyzed
by
identifying
themes among
the
responses
and
ranking themes
by frequency of
occurrence. This analysis
was
con-
ducted
by Jon
Morgenstem.
Assessment
of
beliefs
about
the
nature
of
alcoholism
and
substance
abuse
treatment.
Two
scales were administered
to
assess
counselor
be-
liefs.
The
Understanding
of
Alcoholism Scale (UAS;
Moyers
&
Miller,
1993)
is a
50-item
self-report measure designed
to
assess beliefs about
the
etiology
and
appropriate treatment
of
alcoholism.
The UAS has two
sub-
scales:
the
Disease Model
Beliefs
subscale,
which reflects adherence
to the
disease model
of
alcoholism;
and the
Psychosocial
Beliefs subscale, which
reflects the
belief that alcoholism
in
influenced
by
cultural experiences,
familial
experience,
or
both. Item
are
presented
on a
5-point Likert scale
ranging
from
weakest agreement
(1) to
strongest agreement (5).
The
Treatment Processes Questionnaire
(TPQ;
Morgenstern
&
McCrady, 1992)
is
a
35-item
self-report measure designed
to
assess clinicians' beliefs about
the
therapeutic value
of
different
processes
for
treating substance abuse.
The
scale includes
10
Disease Model
and 17
Behavioral Treatment Pro-
cesses. Processes
are
represented
on a
7-point
Likert scale
with
anchors
of
+3
as
"essential";
-3 as
"detrimental";
and the
midpoint,
0, as "no
effect."
Results
Evaluation Survey
The top
part
of
Table
1
presents
results
of
counselors'
evalua-
tion
of
satisfaction
with
the CBT
training
as a
whole
as
well
as
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86
MORGENSTERN,
MORGAN, McCRADY, KELLER,
AND
CARROLL
Table
1
Results
of
Counselor Training Evaluation Survey
Response
Survey
topic
Training
satisfaction
COMPARED"
RECOMMEND*
MANUAL0
Perceived
utility
of CBT
USE
CBTd
BENEFIT6
CONFIDENT'
Experienced conflict
delivering
CBT
AS
COMPONENT8
STAND
ALONE"
1
0
0
5
0
0
0
0
5
2
5
5
5
0
0
0
0
20
3
11
15
10
5
32
20
5
20
4
32
5
65
40
53
60
25
20
5
53
75
15
55
16
20
70
35
Note.
N = 20.
Numbers represent percentages
of
counselors responding.
Response
formats
for all
items were 5-point
Likert
scales. Anchors
for
items
differed.
In
some cases responses
add to
more than 100% because
of
rounding.
CBT =
cognitive-behavioral
therapy.
"
Represents responses
to the
question
"How does
this
training
experience
compare
with
others
you
have had?" Anchors were
1 =
below average,
2
=
average,
3 =
above average,
4 =
very
good,
5 = one of the
best.
h
Represents responses
to the
question "Would
you
recommend this
training
experience
to a
colleague?" Anchors were
1 = no,
definitely
not;
2
= no, I
don't
think
so; 3 =
yes,
I
think
so; 4 =
yes, with some
reservations;
5 =
yes, enthusiastically.
c
Represents responses
to the
question
"Compared
to
other training methods
you
have encountered,
how
would
you
rate
the use of
manuals, videotaping sessions,
and
supervision
of
these videotapes?" Anchors were
1 =
worse
than
others,
2 =
about
the
same
as
others,
3 =
somewhat better
than
others,
4 =
better than others,
5 = far
better
than
others.
d
Represents responses
to the
question "How
often
would
you use CBT
interventions
with
patients either
in
group
or
individual
treatment?" Anchors
were
1 =
never,
2 =
rarely,
3 =
some-
times,
4 =
often,
5 =
very
often.
c
Represents responses
to the
question
"To
what
extent
have
the
patients
you
treated
benefited
from
the CBT
they
received?" Anchors were
1 = not at
all,
2 =
minimally,
3 =
moderately,
4 =
considerably,
5 =
extensively.
f
Represents
responses
to the
question
"How
confident
are you
that
you can
deliver
CBT
effectively
with
only
one
hour
of
group supervision
per
week?" Anchors were
1 =
very
low
confidence,
2 = low
confidence,
3 =
moderate confidence,
4 =
high
confidence,
5 =
very
high confidence.
E
Represents responses
to the
question
"To
what
extent
does
CBT
conflict
with
your
convictions about
what
constitutes
effective
treatment
for
substance abusers,
when
CBT is
delivered
as one
component
of a
comprehensive
treatment
program?"
Anchors
were
1 =
extreme
conflict,
2
=
considerable
conflict,
3 =
moderate
conflict,
4 =
slight
conflict,
5 = no
conflict.
h
Represents
responses
to the
question
"To
what
extent
does
CBT
conflict
with
your
convictions about what constitutes effective treatment
for
substance abus-
ers,
when
CBT is
delivered
alone? Anchors
are the
same
as for AS
COMPONENT.
with
the use of
manuals
and
videotape supervision
as a
training
method.
Counselors reported high levels
of
satisfaction with
the
training: Over
50%
endorsed
the
most
positive
anchor
for the two
training
satisfaction items (Compare, Recommend),
and
only
5%
gave
a
negative evaluation. Qualitative comments regarding over-
all
satisfaction
(presented
in the
order
of
frequency
of
occurrence)
were:
CBT is an
effective
treatment, therefore,
it is
valuable
to
learn;
the
training broadened
the
counselor's repertoire
of
clinical
skills; traditional treatment doesn't work
for
everyone, therefore,
it
is
important
to
know
an
alternative approach;
CBT is
appealing
because,
unlike
other approaches,
it
provides
a
systematic, step-
by-step,
concrete approach
to
address patient problems;
the
train-
ing
corrected
misperceptions
that
CBT is
dry,
mechanical,
or
incompatible
with
a
12-step
approach;
CBT is not
compatible with
an
experiential
or
psychodynamic
approach.
Satisfaction
with
manualized
training methods
was
also high
but
somewhat
less
so
than
for the
training experience
as a
whole.
Qualitative
comments were: supervision
via the use of
session
videotapes provides
a
unique opportunity
to
view
one's
perfor-
mance
objectively
and far
surpasses reliance
on
memory
to
convey
session events during supervision;
the
manual enhances learning
and
performance
by
providing structure
and a
reference
to
prepare
for
and
review
one's
performance; manuals
are too
dry, uninter-
esting,
and
restrictive.
In
the
middle section
of
Table
1 are
presented counselors'
evaluations
of the
clinical utility
and
appraised confidence
in
delivering CBT. Counselors endorsed high ratings
for the
clinical
utility
of
CBT, with
95%
indicating that they would
use CBT
interventions
often
or
very
often
with patients,
and
rated high
levels
of
benefit
for
clients whom they
had
treated with CBT.
Counselors also expressed confidence that they could treat patients
effectively
with
CBT
while receiving routine clinical supervision.
Relation
of
Counselor
Beliefs
and CBT
Training
In
the
bottom section
of
Table
1 are
presented counselors'
responses
regarding whether treating patients with
CBT
conflicted
with
their convictions about what constitutes effective substance
abuse treatment. This question
was
posed under
two
hypothetical
conditions:
when
CBT is
delivered
as
part
of (a) a
comprehensive
treatment
program
or as (b) a
stand-alone treatment. When
CBT is
delivered
as one
component
of a
comprehensive program
(as it was
during
this
training),
70% of
counselors experienced
no
conflict.
However, responses differed when
CBT is
delivered
as the
only
treatment:
About half
of the
counselors indicated this would rep-
resent
a
moderate
to
extreme conflict,
and the
remainder indicated
either
slight
or no
conflict.
Qualitative
comments
were:
eclectic
approaches work best
for
clients;
CBT
alone misses many ele-
ments needed
for
recovery, including developing sober peer sup-
ports, spirituality,
and
Alcoholics
Anonymous affiliation;
CBT
delivered
via a
manual
is too rigid and
didactic
to
effectively
address patient needs without additional treatment.
Next
we
examined
whether
the CBT
training influenced
coun-
selors' beliefs about
the
nature
of
alcoholism
and the
therapeutic
value
of
disease model
and
behavioral treatment
processes.
We
conducted
a
repeated
measures
analysis
of
variance
to
determine
if
counselors
in the CBT
group increased social learning theory
beliefs
and
decreased disease model beliefs following
the
training.
Group (CBT
vs.
control
counselors),
time (pre-
and
posttraining),
and
Group
X
Time interactions were
not
significant
for
disease
model
and
behavioral treatment processes
and
social learning
theory
beliefs
about
alcoholism.
There
was a
significant Group
x
Time interaction
for the
Disease Model Beliefs
subscale
of the
UAS,
F(l,
27) =
7.2,
p <
.01. Disease model beliefs decreased
in
the CBT
group
but
increased
in the
control group. Further exam-
ination suggested that, prior
to
training, counselors endorsed sim-
ilar levels
of
disease model
and
social learning theory beliefs.
For
example,
the
mean counselor rating
of
disease
model treatment
processes
was
1.84
(SD =
0.72),
and the
mean rating
of
behavioral
treatment
processes
was
1.77
(SD =
0.59), suggesting that neither
model
was
strongly favored over
the
other.
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MANUAL-GUIDED
CBT
87
Counselor
Adherence
and
Skillfulness
in
Delivering
CBT
In
Table
2 are
presented ratings
of
counselor performance
at the
end
of CBT
training. Supervisors rated
90% of the
counselors
(n =
18)
as at
least adequate. Raters'
independent
ratings
of
Session
2
videotapes yielded
a
similar percentage
of
counselors
who
were
judged
as at
least adequate based
on the
standards applied
to
therapist performance
in
Project MATCH.
A sum
score
of the
eight
CBT
items assessed
by the
MTRS
was
highly correlated with
the two
summary items
of the
ITRS
(adherence:
r =
.57,
p <
.01;
skillfulness:
r =
.71,
p <
.01). Therefore, there appeared
to be
consistency across observers
and
rating
scales.
Discussion
Overall,
the
results indicate that counselors responded well
to
the CBT
content
and
manualized-based
format
of the
training,
expressing high levels
of
satisfaction with
the
experience
and
confidence
in
their ability
to
effectively
use the
techniques. Very
few
dissemination studies have been conducted with substance
abuse counselors; therefore, formal hypotheses about training out-
comes were
not
formulated. However, counselor response
was
better than might
be
anticipated, given
the
expectation that adher-
ence
to a
conflicting treatment model, modest therapy skill levels,
and
general clinician resistance
to
using standardized protocols
would
pose
major
obstacles
to
training
the
counselors.
Counselors' qualitative responses
and our own
observations
of
the
training provide some insights into
why
these factors proved
less
problematic than anticipated. First, although most counselors
espoused
a
12-step
treatment orientation, there
was
little evidence
of
dogmatism
or
closed-mindedness
in
their approach
to
learning
and
using other treatment techniques. Rather, counselors acknowl-
edged
the
limits
of
current treatments
and
were actively searching
for
new
skills that could improve client outcomes.
Second, there
are
very significant
differences
between
CBT and
the
12-step
approach
at the
level
of
theory. However,
at the
level
of
technique—the
level addressed
by
treatment
manuals—both
approaches share elements that
are
compatible (McCrady,
1994).
For
example, both treatments
are
active
and
directive,
and
both
place
a
primary
focus
on
abstinence
and
make substantial
use of
didactic
materials.
Therefore,
the
style
and
content
of the CBT
Table
2
Ratings
of
Counselor Adherence
and
Skillfullness
in
Delivering
Cognitive-Behavioral
Therapy
Response*
Type
of
rating
Supervisors'
rating
of
skillfulnessb
Raters'
ratings
of
adherence"
Raters'
ratings
of
skillfulness0
1
5
0
0
2
5
5
10
3
45
30
50
4
45
55
40
5
0
10
0
Note.
N = 20.
*
Anchors
for
skillfulness ratings were:
1 =
very
poor,
1 =
poor,
3 =
adequate,
4 =
good,
5 =
excellent;
anchors
for
adherence
ratings
were
1 =
not
at
all,
2 = a
little,
3
=
somewhat,
4 =
considerably,
5 =
exten-
sively.
b
These
are
supervisors'
ratings
of
cognitive-behavioral
therapy
skillfiilness
of
counselors'
last training
case.
c
These
are
raters'
ratings
of
the two
summary items
of the
IMPACT
Tape
Rating
Scale
for the
second
session
of
each
counselors'
final
training
case.
interventions provided
a
good
fit
for
counselors. Third,
as
adapted
for
this study,
the
Project MATCH manual proved
to be an
excellent training device, providing counselors with rapid
access
to
a new set of
therapeutic skills they deemed valuable.
In
part,
satisfaction
with
the CBT
protocol training
may
stem
from
the
limited skill counselors have
in
specific therapeutic techniques.
For
example, counselors typically approach treatment with
the
goal
of
getting clients
to
actively cope with
situational
risks or
problematic thinking,
but
they lack specific techniques
to
accom-
plish
these goals.
The
manual provided them with these
techniques.
Some authors (e.g.,
Strupp
&
Anderson, 1997) have warned that
manuals
may
stifle
the
clinical artistry
of
therapists
and
limit their
autonomy.
We
anticipated that this would
be a
major
source
of
resistance. However,
our
experience
was
that manuals appeared
to
improve
the
clinical
work
of
many
counselors
by
providing
suffi-
cient
structure
and
specificity
to
facilitate
a
sustained, productive
therapeutic
focus.
Overall,
the
majority
of
counselors were able
to
learn
to
deliver
manualized
CBT
competently. Several caveats should
be
consid-
ered
in
evaluating
these
performance
results.
Rated
skillfulness
refers
to the
delivery
of
protocol-driven
CBT and
does
not
refer
to
less standardized modes
of CBT
treatment.
In
addition, ratings
of
skillfulness
refer
primarily
to
delivery
of the
core sessions
from
the
Project
MATCH
CBT
manual. These sessions address alcoholic-
specific
coping
skills.
The
Project MATCH manual
also
contains
a
series
of
elective skills sessions that address general coping
skills. Counselors
had
greater
difficulty
learning
to
deliver these
sessions. Finally, despite
the
general success,
10%-20%
of
coun-
selors expressed minimal satisfaction
with
the
training
or
were
not
judged
as
adequate. Counselors
not
judged
as
adequate were ones
who
expressed interest
in the
training
but
could
not
master
the
CBT
techniques.
Study
Limitations
Several
study
limitations should
be
noted.
The
study
reports
on
intensive
training
of 20
front-line
counselors. Several study pro-
cedures—selection
of
representative community programs
and
random
assignment
of
counselors—enhance
the
generalizability
of
findings;
nevertheless,
the
sample size
is
small,
and findings
require replication
with
a
larger sample.
In
addition, training cases
were
selected
from
clients
who
might
benefit
from
CBT
based
on
the
judgment
of the
counseling
staff.
Generalization
of
counselor
performance
to
other clients
and to
conditions that more
fully
mirror routine clinical practice
is not
warranted. Finally, this study
reports
only
on the
feasibility
of
training counselors
to
deliver
science-based treatments,
not on
clinical outcomes.
In
subsequent
studies
we
hope
to
report
on how the
trained counselors performed
under typical
clinical
conditions
as
well
as to
compare
the
clinical
outcomes
of CBT
provided
by
counselors versus treatment
as
usual.
Conclusions
Overall,
the
study's
findings
demonstrate
the
feasibility
of
using
psychotherapy
technology
tools—-manuals,
videotape monitoring,
and
supervision—as
a
means
of
disseminating science-based treat-
ments
to the
substance abuse practice community. Several issues
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

MORGENSTERN,
MORGAN, McCRADY, KELLER,
AND
CARROLL
require
consideration
in
planning
future efforts
to
capitalize
on
manual-guided
training
as a
dissemination
device.
Materials
de-
signed
to
train
expert
therapists
in
clinical
trials
are
inadequate
to
train front-line
counselors.
Further
work
is
needed
to
develop
better
training
methods.
In
addition,
work
is
needed
to
adapt
protocols
designed
for
controlled-trials
research
to
clinical
practice
settings.
For
example,
greater
implementation
flexibility
is
needed
in
clinical
settings
to
handle
such
issues
as
when
to end
treatment,
what
to do
with
clients
who are not
responding
to the
protocol,
or
the
advisability
of
combining
or
sequencing
treatments.
Finally,
further study
is
needed
to
determine
the
optimum
amount
and
types
of
training
experiences
counselors
need
to
learn
to
incorpo-
rate
new
techniques
into
routine
practice.
References
Addis,
M.
(1997). Evaluating
the
treatment manual
as a
means
of
dissem-
inating
empirically validated psychotherapies. Clinical Psychology,
4,
1-11.
Barlow,
D. H.
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Carroll,
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