Daniel S. Keller New York University. Thomas J. Morgan and Barbara S. McCrady Rutgers The State University of New Jersey

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1 Psychology of Addictive Behaviors 21, Vol. 1, No. 2, Copyright 21 by the Educational Publishing Foundation X/1/S. DOI: 1.137// X 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 Daniel S. Keller New York University Thomas J. Morgan and Barbara S. McCrady Rutgers The State University of New Jersey 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 cognitivebehavioral 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 preand 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 9% 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 developed 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 substance 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 AA8747 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 123, One Gustave L. Levy Place, New York, New York 129. Electronic mail may be sent to jon.morgenstem@mssm.edu. 83 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 orientations. 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 research contexts. The potential use of manuals as the primary medium for disseminating 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 considering 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 cognitivebehavioral 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

2 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 community 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 adherence and skillfulness in delivering CBT based on an "expert" standard established in a rigorously implemented research study of CBT (Project MATCH Research Group, 1997). Sample and Setting Method Participants were 29 front-line substance abuse counselors drawn from the clinical staffs of two outpatient chemical dependency treatment programs 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'sand 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 because 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. years (SD = 11.4), and 6% (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 4% (n = 13) had at least a master's degree in either psychology, counseling, social work, or nursing (1 counselor had a doctoral degree), and % (n = 16) either a bachelor's degree, an associate's degree, or had graduated high school. Most counselors had extensive substance abuse treatment experience (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 consent 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 3 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 sessions 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 confidential. 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 structured, time-limited curriculum, similar in format to a continuing-education course, was developed. Thus, although training was intensive, all counselors 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

3 MANUAL-GUIDED CBT 8 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 1 hr of didactic and clinical training over a -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 -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 -point Likert scale with anchors of 1 (very poor) to (excellent). 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 discussions 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 calibrated 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 counselors 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 specifically 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 2 hr of didactic training and then rated at least 1 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 ingredients. 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 -point Likert scale (anchors: 1 = not at all, = extensively), as was skillfulness (anchors: 1 = very poor, = excellent). We computed intraclass correlations (ICCs) to establish item reliabilities using ratings of 2 randomly selected tapes rated by all raters. Median ICCs and ranges for the various scales were as follows: MTRS Extent, Man =.8 ( ); MTRS Skillfulness, Man =.8 (.6S-.96); ITRS Extent, Man =.87 (.6S-.92); ITRS, Man =.87 ( ). Evaluation survey. We assessed counselors' responses to training using 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 distributions. 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 conducted by Jon Morgenstem. Assessment of beliefs about the nature of alcoholism and substance abuse treatment. Two scales were administered to assess counselor beliefs. The Understanding of Alcoholism Scale (UAS; Moyers & Miller, 1993) is a -item self-report measure designed to assess beliefs about the etiology and appropriate treatment of alcoholism. The UAS has two subscales: 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 -point Likert scale ranging from weakest agreement (1) to strongest agreement (). The Treatment Processes Questionnaire (TPQ; Morgenstern & McCrady, 1992) is a 3-item self-report measure designed to assess clinicians' beliefs about the therapeutic value of different processes for treating substance abuse. The scale includes 1 Disease Model and 17 Behavioral Treatment Processes. Processes are represented on a 7-point Likert scale with anchors of +3 as "essential"; -3 as "detrimental"; and the midpoint,, as "no effect." Evaluation Survey Results The top part of Table 1 presents results of counselors' evaluation of satisfaction with the CBT training as a whole as well as

4 86 MORGENSTERN, MORGAN, McCRADY, KELLER, AND CARROLL Table 1 Results of Counselor Training Evaluation Survey Survey topic Training satisfaction COMPARED" RECOMMEND* MANUAL Perceived utility of CBT USE CBT d BENEFIT 6 CONFIDENT' Experienced conflict delivering CBT AS COMPONENT 8 STAND ALONE" Response Note. N = 2. Numbers represent percentages of counselors responding. Response formats for all items were -point Likert scales. Anchors for items differed. In some cases responses add to more than 1% 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, = 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; = 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, = 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 = sometimes, 4 = often, = 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, = 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, = 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, = no conflict. h 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 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 % endorsed the most positive anchor for the two training satisfaction items (Compare, Recommend), and only % gave a negative evaluation. Qualitative comments regarding overall 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, stepby-step, concrete approach to address patient problems; the training 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 performance 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, uninteresting, 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 9% 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), 7% of counselors experienced no conflict. However, responses differed when CBT is delivered as the only treatment: About half of the counselors indicated this would represent 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 elements needed for recovery, including developing sober peer supports, 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 counselors' 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 <.1. Disease model beliefs decreased in the CBT group but increased in the control group. Further examination suggested that, prior to training, counselors endorsed similar levels of disease model and social learning theory beliefs. For example, the mean counselor rating of disease model treatment processes was 1.84 (SD =.72), and the mean rating of behavioral treatment processes was 1.77 (SD =.9), suggesting that neither model was strongly favored over the other.

5 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 9% 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 =.7, p <.1; skillfulness: r =.71, p <.1). 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 outcomes were not formulated. However, counselor response was better than might be anticipated, given the expectation that adherence 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 acknowledged 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 Type of rating Supervisors' rating of skillfulness b Raters' ratings of adherence" Raters' ratings of skillfulness Response* Note. N = 2. * Anchors for skillfulness ratings were: 1 = very poor, 1 = poor, 3 = adequate, 4 = good, = excellent; anchors for adherence ratings were 1 = not at all, 2 = a little, 3 = somewhat, 4 = considerably, = extensively. 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 accomplish 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 sufficient 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 considered 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 alcoholicspecific 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, 1%-2% of counselors 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 2 front-line counselors. Several study procedures 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 treatments to the substance abuse practice community. Several issues

6 MORGENSTERN, MORGAN, McCRADY, KELLER, AND CARROLL require consideration in planning future efforts to capitalize on manual-guided training as a dissemination device. Materials designed 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 incorporate new techniques into routine practice. References Addis, M. (1997). Evaluating the treatment manual as a means of disseminating empirically validated psychotherapies. Clinical Psychology, 4, Barlow, D. H. (1996). Health care policy, psychotherapy research, and the future of psychotherapy. American Psychologist, 1, Carroll, K. M., Connors, G. J., Cooney, N. L., DiClemente, C. C., Donovan, D. M., Kadden, R. R., Longabaugh, R. L., Rounsaville, B. J., Wirtz, P. W., & Zweben, A. (1998). Internal validity of Project MATCH treatments: Discriminability and integrity. Journal of Consulting and Clinical Psychology, 66, Gordis, E. (1991). Linking research with practice: Common bonds, common progress. Alcohol Health & Research World, 1, Institute of Medicine. (1997). Managing managed care: Quality improvement in behavioral health. Washington, DC: National Academy Press. Kadden, R., Carroll, K. M., Donovan, D., Cooney, N., Monti, P., Abranms, D., Litt, M., & Hester, R. (1992). Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (NIAAA Project MATCH Monograph, Vol. 3, DHHS Publication No. ADM ). Washington, DC: U.S. Government Printing Office. McCrady, B. S. (1994). Alcoholics Anonymous and behavior therapy: Can habits be treated as diseases? Can diseases be treated as habits? Journal of Consulting and Clinical Psychology, 62, Morgenstem, J., & McCrady, B. (1992). Curative factors in alcohol and drug treatment: Behavioral and disease model perspectives. British Journal of Addiction, 87, Moyers, T. B., & Miller, W. R. (1993). Therapists' conceptualizations of alcoholism: Measurement and implications for treatment decisions. Psychology of Addictive Behaviors, 7, Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 8, Sobell, L. C. (1996). Bridging the gap between scientists and practitioners: The challenge before us. Behavior Therapy, 27(3), Stout, R. L., Wirtz, P. W., Carbonari, J. P., & Del Boca, F. K. (1994). Ensuring balanced distribution of prognostic factors in treatment outcome research. Journal of Studies on Alcohol, (Suppl. 12), 7-7. Strupp, H., & Anderson, T. (1997). On the limitations of therapy manuals. Clinical Psychology, 4, Wallace, J. (1996). Theory of 12-step-oriented treatment. In F. Rotgers, D. S. Keller, & J. Morgenstem (Eds.), Treating substance abuse: Theory and technique (pp ). New York: Guilford Press. Received May 7, 1999 Revision received May 9, 2 Accepted May 1, 2