Research Publication Abstracts 

Penn, P.E., & Brooks, A. J. (2000). 
Five years, twelve steps, and REBT in the treatment of dual diagnosis.
Journal of Rational Emotive and Cognitive-Behavior Therapy, 18, 197–208. 

A five-year NIDA-funded grant is described that compared client-centered 12-Step-oriented and REBT/SMART Recovery-oriented intensive outpatient treatment/partial hospitalization programs with severely impaired clients with dual diagnosis (serious mental illness/substance abuse).  Results are presented and suggestions made for applying the findings. (Supported by a grant from NIDA R01 DA08537 to Penn and by La Frontera Center, Inc.).

Penn, P. E., Brooks, A. J., & Worsham, B. D. (2002).
Treatment concerns of women with co-occurring serious mental illness and substance abuse disorders.
Journal of Psychoactive Drugs, 34(4), 355–362. 

The treatment needs of persons with co-occurring mental illness and substance abuse disorders is a relatively new area of inquiry.  Even less information is available concerning the treatment concerns of women with dual diagnosis.  A focus group was conducted with seven women as part of a larger study of effective treatments for adults with co-occurring disorders.  Women responded to questions about what worked and what did not work in their past treatment experiences and what needs to be added for effective treatment.  Five primary themes emerged: negative treatment experiences, negative system experiences, desirable treatment characteristics, therapeutic client characteristics, and life issues affecting treatment engagement.  Two of the main treatment recommendations that emerged were the need for advocacy assistance with child protective service agencies, and the need for providers to use client-centered treatment methods.

Brooks, A. J., & Penn, P. E. (2003).
Comparing treatments for dual diagnosis: Twelve-Step and Self Management and Recovery Training.
American Journal of Drug and Alcohol Abuse, 29(2), 359–383. 

The purpose of this study was to compare the effectiveness of 12-Step and cognitive-behavioral (Self-Management and Recovery Training [SMART]) approaches for persons with a dual diagnosis of serious mental illness and substance use disorder in an intensive outpatient/partial hospitalization setting.  Participants (n = 112) were alternately assigned to the two treatment conditions, with 50 participants completing the 6-month treatment program.  Assessments occurred at baseline, 3 months, and 6 months during treatment, and at 3- and 12-month follow-ups.  Analyses were conducted on participants who had completed 3 months of treatment (n = 70).  The 12-Step intervention was more effective in decreasing alcohol use and increasing social interactions.  However, a worsening of medical problems, health status, employment status, and psychiatric hospitalization was associated with the 12-Step intervention.  SMART was more effective in improving health and employment status, but marijuana use was greater for SMART participants.  Improvements in alcohol use and life satisfaction occurred in both approaches.  Covariates associated with treatment outcome were identified, with greater attendance being positively related to outcome.  Involvement with the criminal justice system was positively related to treatment completion but negatively associated with medical problems.  Less alcohol use, fewer medical problems, and better financial well-being at baseline were associated with better attendance.

Gallagher, S. M., Brooks, A. J., & Penn, P. E. (accepted for publication in 2006).
Chronic illness, pain and health behaviors of community behavioral health clients.  Psychological Services.

Persons with co-morbid medical disorders along with substance use disorders and mental illness present complex treatment needs that are seldom addressed.  Chronic physical illness negatively affects treatment participation and retention, decreasing effectiveness.  Studies documenting higher medical morbidity and mortality in such persons have long been available.  Less is known about their health behaviors.  Respondents (418) at a community behavioral health center were surveyed for prevalence of illness, pain, health behaviors, and interest in lifestyle change.  73% reported at least one chronic health problem and nearly half rated their health between "fair" and "very poor."  Most reported one or more negative health indicators or behaviors (e.g., smoking).  Encouragingly, nearly 50% desired lifestyle changes including smoking cessation, exercise, and stress management.

Gallagher, S. M., Penn, P. E., Brooks, A. J., & Feldman, J. (accepted for publication in summer 2006).
Comparing the CAAPE, a new assessment tool for co-occurring disorders, with the SCID.
Psychiatric Rehabilitation Journal.  

Co-occurring mental health and substance use disorders (COD) are common and frequently underdetected, which may lead to less than optimal treatment for persons in psychosocial rehabilitation settings.  A new, relatively brief instrument, the Comprehensive Addictions and Psychological Evaluation (CAAPE) was compared with the Structured Clinical Interview for DSM-IV (SCID).  The CAAPE required less time to administer than did the SCID, efficiently explored DSM substance use disorder criteria, and served as a screen for psychiatric disorders.  The CAAPE promises to be a useful screening and diagnostic instrument for persons with co-occurring disorders, especially suited for use in psychosocial rehabilitation.

Penn, P. E., Brooke, D., Gallagher, S. M., & Brooks, A. J. (in review).
Co-occurring disorder counselors and clients compare 12-Step & SMART® self-help. American Journal of Drug and Alcohol Abuse.

Client perspectives on treatment can provide valuable information on what approaches they find the most effective, yet such perspectives are not often sought.  Perspectives of persons with co-occurring disorders (P-COD) of serious mental illness and substance abuse are even rarer, despite the high prevalence of COD.  Twelve-step and cognitive-behavioral therapy are the two most-used approaches in substance abuse treatment and self-help, either as treatment adjuncts or aftercare.  We conducted focus groups with COD clients (n = 12) and counselors (n = 8) who had experience with these two different types of community self-help groups.  These were 12-Step and Self Management and Recovery Training® (SMART®), an abstinence-based cognitive-behavioral self-help group.  In both groups, positive comments about SMART® and negative comments about 12-Step were the most numerous types of comments.  However, both groups found much to like in both types of meetings, and half of the clients were using both.  Recent research suggests that the manner in which treatment is delivered can be as important as the content of treatment.  Client-centered treatment delivery is particularly crucial.  Although self-help groups are distinct from formal treatment, client comments from these focus groups suggest that interactions among participants and leaders in SMART® meetings are generally more in accordance with the principles of client-centered treatment than those in 12-Step meetings.  Our results also suggest that P-COD generally respond better to SMART® meetings than to 12-Step meetings.

Penn, P. E., Gallagher, S., Layne, W. & Schindler, E. (submitted.)
Developing a research and evaluation department within a community treatment agency.

We present a model for community behavioral health agencies that wish to develop in-house research and evaluation units. Doing so can improve service quality and client satisfaction, as well as provide accountability and support for funding. A dynamic feedback loop between the data clinicians routinely provide and continuous quality improvement is crucial. This forges a link between evaluation/research and program development. In-house research and evaluation functions can also help bridge the gap between research and practice that often exists. We learned to be willing to start small, to build mutually supportive relationships within the agency, and to use the findings to benefit all stakeholders.

Gallagher, S. M., Penn, P. E., Schindler, E.  & Layne, W. (submitted.)
Comparing smoking cessation treatments for persons with schizophrenia and other serious mental illness.

This study compared two smoking cessation interventions in persons with schizophrenia or other serious mental illness (PSMI). We focused on PSMI because national data suggest that (1) they smoke at 2–3 times the rate of the general population; (2) cessation interventions for this population are understudied; (3) most cessation studies exclude PSMI; and (4) cessation results in public health care savings and disposable income savings for clients. Furthermore, adults with any DSM-IV diagnosed mental illness smoke nearly half of the cigarettes in the U.S. (Lasser et al., 2000). PSMI (n = 181) were recruited from three sites within a large community behavioral health center and randomly assigned to one of three groups: contingent reinforcement (CR), contingent reinforcement plus nicotine replacement therapy by 21 mg patch (CR+NRT) for 16 weeks, and self-quit control group. These participants were followed for 36 weeks. CR was accomplished with escalating financial compensation for achieving and maintaining abstinence as verified by expired carbon monoxide (CO). Expired CO and self-report outcomes were discordant with saliva cotinine outcomes, which showed low quit rates and small differences between intervention and control participants at weeks 20 and 36. There was evidence of reduced smoking and importantly, no evidence of psychiatric exacerbation. Implications for intervention and research with this population are discussed.

Penn, P. E., & Brooks, A. J. (submitted).
SMART Recovery ® and 12-Step-based co-occurring disorders programs: Process evaluation provides a different perspective on outcomes.

A process evaluation can reveal important information not usually captured by quantitative outcome measures alone, and can be particularly useful for guiding program development. We conducted a process evaluation of a study comparing two group treatment approaches (12-Step based, and cognitive-behavioral modality: SMART Recovery ®) for persons with co-occurring substance use and mental health disorders. Our client satisfaction measures and method adherence forms revealed a counselor interaction style problem in the 12-Step intervention—a problem that was not readily apparent from the outcome measures alone. Remedial action was needed to ensure that both treatments were delivered in a client-centered manner. This enabled us to make necessary midcourse corrections to ensure that the two treatment interventions were equivalent except for treatment philosophy. This process evaluation also revealed information useful for designing treatment programs for persons with co-occurring disorders. Specifically, SMART Recovery ®, a cognitive-behavioral modality, was preferred by clients and may be a more efficient treatment modality than 12-Step.