Psychology ETDs

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Central to the debate over the implementation of empirically supported treatments is whether or not therapist skill in delivering these therapies has a measurable, positive relationship with client outcome. The fidelity and skill with which therapists deliver these treatments have been studied under the constructs of therapist adherence and competence. There has been mixed evidence of the relationship between adherence and competence and client outcomes, that could be due to small sample sizes, potentially inadequate measures for rating therapists' skill, and limited statistical methods. The current study utilized a data set from the Adolescent and Family Treatment (AAFT) project in which 91 therapists provided services to 384 clients at regionally diverse sites. Substance abuse therapists trained to deliver the Adolescent Community Reinforcement Approach (A-CRA) submitted audio-taped therapy sessions to expert raters for review. Measures of adherence and competence derived from these ratings were examined in a Multi-Level Model, for associations with client substance use outcomes at 3, 6 and 12-month follow-up periods. This study found that therapist competence was significantly predictive of decreases in clients' days of substance use. There was a non-significant trend for adherence being associated with decreased days of substance use as well. Client exposure to A-CRA treatment procedures also predicted decreased substance use across follow-ups, as did the cross-level interaction between A-CRA procedure exposure and therapist competence. Post-hoc analyses found that the number of co-morbid disorders of clients as well as client externalizing behaviors were predictive of therapist competence. This study adds to the evidence that treatment fidelity is associated with better treatment outcomes for clients.

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First Committee Member (Chair)

Moyers, Theresa

Second Committee Member

McCrady, Barbara

Third Committee Member

Bryan, Angela




adherence, competence, treatment fidelity, substance use, adolescent, community reinforcement approach, A-CRA, CRA, multilevel model

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