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Journal of Consulting and Clinical Psychology - Vol 82, Iss 3

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Journal of Consulting & Clinical Psychology The Journal of Consulting and Clinical Psychology publishes original contributions on the following topics: (a) the development, validity, and use of techniques of diagnosis, treatment, and prevention of disordered behavior; (b) studies of populations of clinical interest, such as hospital patients, individuals who have experienced physical or psychological stressors, adolescents, children, and similar samples; (c) cross-cultural and demographic studies of interest for behavior disorders; (d) studies of personality where these have a clear bearing on problems of clinical dysfunction; (e) studies of gender, ethnicity, or sexual orientation that have a clear bearing on diagnosis, assessment, treatment, and prevention.
Copyright 2014 American Psychological Association
  • Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: A meta-analysis.
    Objective: Although cognitive-behavioral therapy (CBT) is effective for treating anxiety disorders, little is known about its effect on quality of life. To conduct a meta-analysis of CBT for anxiety disorders on quality of life, we searched for relevant studies in PubMed, PsycINFO, and the Cochrane Library and conducted manual searches. Method: The search identified 44 studies that included 59 CBT trials, totaling 3,326 participants receiving CBT for anxiety disorders. We estimated the controlled and within-group random effects of the treatment changes on quality of life. Results: The pre-post within-group and controlled effect sizes were moderately strong (Hedges’s g = 0.54 and Hedges’s g = 0.56, respectively). Improvements were greater for physical and psychological domains of quality of life than for environmental and social domains. The overall effect sizes decreased with publication year and increased with treatment duration. Face-to-face treatments delivered individually and in groups produced significantly higher effect sizes than Internet-delivered treatments. Conclusion: CBT for anxiety disorders is moderately effective for improving quality of life, especially in physical and psychological domains. Internet-delivered treatments are less effective than face-to-face treatments in improving quality of life. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Treatment engagement and response to CBT among Latinos with anxiety disorders in primary care.
    Objective: In the current study, we compared measures of treatment outcome and engagement for Latino and non-Latino White patients receiving a cognitive behavioral therapy (CBT) program delivered in primary care. Method: Participants were 18–65 years old and recruited from 17 clinics at 4 different sites to participate in a randomized controlled trial for anxiety disorders, which compared the Coordinated Anxiety Learning and Management (CALM) intervention (consisting of CBT, medication, or both) with usual care. Of those participants who were randomized to the intervention arm and selected CBT (either alone or in combination with medication), 85 were Latino and 251 were non-Latino White; the majority of the Latino participants received the CBT intervention in English (n = 77). Blinded assessments of clinical improvement and functioning were administered at baseline and at 6, 12, and 18 months after baseline. Measures of engagement, including attendance, homework adherence, understanding of CBT principles, and commitment to treatment, were assessed weekly during the CBT intervention. Results: Findings from propensity-weighted linear and logistic regression models revealed no statistically significant differences between Latinos and non-Latino Whites on symptom measures of clinical improvement and functioning at almost all time points. There were significant differences on 2 of 7 engagement outcomes, namely, number of sessions attended and patients’ understanding of CBT principles. Conclusions: These findings suggest that CBT can be an effective treatment approach for Latinos who are primarily English speaking and likely more acculturated, although continued attention should be directed toward engaging Latinos in such interventions. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Reaching new heights: Comparing interpretation bias modification to exposure therapy for extreme height fear.
    Objective: Cognitive models of anxiety disorders posit that biases in interpretation maintain, and potentially cause, anxiety. This study tested whether it is possible to decrease height fear symptoms through cognitive bias modification for interpretations (CBM-I). Additionally, the clinical utility of CBM-I was tested by comparing it to an already established treatment: exposure therapy. Method: Extremely height fearful individuals (N = 110) participated in the study. Acrophobic symptoms were measured before and after 2 sessions of CBM-I and were compared to the standard treatment for acrophobia (exposure therapy), a combination of CBM-I and exposure therapy, and a Control condition. Results: In line with hypotheses, participants in the 3 active conditions showed greater response to treatment than the Control condition in height-relevant interpretation bias, symptoms, and behavioral avoidance on a height stressor, with few differences between the active conditions. Further, symptom change was mediated by change in interpretation bias. Conclusions: Overall, findings suggest that different pathways to fear reduction (exposure vs. shifting interpretations) can lead to similar reductions in height fear. This study provides the first evidence that directly shifting cognitive processing, even with no therapist involvement, can reduce symptoms as effectively as the gold standard, therapist-directed exposure therapy. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Mediated and moderated effects of neurocognitive impairment on outcomes of treatment for substance dependence and major depression.
    Objective: Neurocognitive impairment has not consistently predicted substance use treatment outcomes but has been linked to proximal mediators of outcome. These indirect effects have not been examined in adults with substance dependence and co-occurring psychiatric disorders. We examined mediators and moderators of the effects of neurocognitive impairment on substance use among adults in treatment for alcohol or drug dependence and major depression (MDD). Method: Participants were veterans (N = 197, mean age = 49.3 years, 90% male, 75% Caucasian) in a trial of 2 group interventions for alcohol/drug dependence and MDD. Measures examined here included intake neurocognitive assessments and percent days drinking (PDD), percent days using drugs (PDDRG), self-efficacy, 12-step affiliation, and depressive symptoms measured every 3 months from intake to the 18-month follow-up. Results: Greater intake neurocognitive impairment predicted lower self-efficacy, lower 12-step affiliation, and greater depression severity, and these time-varying variables mediated the effects of impairment on future PDD and PDDRG. The prospective effects of 12-step affiliation on future PDD were greater for those with greater neurocognitive impairment. Impairment also interacted with depression to moderate the effects of 12-step affiliation and self-efficacy on PDD. Adults with greater impairment and currently severe depression had the strongest associations between 12-step affiliation/self-efficacy and future drinking. Conclusions: Greater neurocognitive impairment may lead to poorer outcomes from group therapy for alcohol/drug dependence and MDD due to compromised change in therapeutic processes. Distal factors such as neurocognitive impairment can interact with dynamic risk factors to modulate the association between therapeutic processes and future drinking outcomes. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Randomized controlled trial of a web-delivered personalized normative feedback intervention to reduce alcohol-related risky sexual behavior among college students.
    Objective: The purpose of this study was to evaluate the efficacy of personalized normative feedback (PNF) on college student alcohol-related risky sexual behavior (RSB). Method: In a randomized controlled trial, 480 (57.6% female) sexually active college students were stratified by gender and level of drinking and randomly assigned to an alcohol-only intervention, an alcohol-related RSB-only intervention, a combined alcohol and alcohol-related RSB intervention, or control. All assessment and intervention procedures were Web-based. Results: Results indicated a significant reduction in drinking outcomes for the alcohol only and the combined alcohol and alcohol-related RSB interventions relative to control. Findings further demonstrated a significant reduction in alcohol-related RSB outcomes for the alcohol-related RSB only and the combined alcohol and alcohol-related RSB interventions relative to control. There were no significant intervention effects on alcohol-related negative consequences. These findings demonstrate that the combined alcohol and alcohol-related RSB intervention was the only intervention successful at reducing both drinking and alcohol-related RSB outcomes relative to control. There were no significant differences when comparing the combined alcohol and alcohol-related RSB intervention to the alcohol-only intervention or the alcohol-related RSB-only intervention. Finally, results suggested that the intervention effects on high-risk behaviors were mediated by reductions in descriptive normative perceptions. Conclusions: These findings demonstrate that PNF specific to drinking in sexual situations was needed to reduce alcohol-related RSB. Furthermore, this study highlights the potential utility of a brief intervention that can be delivered via the Internet to reduce high-risk drinking and alcohol-related RSB among college students. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Stress moderates the effect of childhood trauma and adversity on recent drinking in treatment-seeking alcohol-dependent men.
    Objective: This study sought to clarify the relationship between childhood trauma and adversity with later alcohol consumption and the moderating effects of adult psychosocial stress. Method: Seventy-seven recently abstinent alcohol-dependent men attending residential treatment programs were assessed. Childhood trauma/adversity was assessed with the Childhood Trauma Questionnaire (CTQ), drinks per drinking day (DDD) with the Timeline Follow Back, and chronic psychosocial stress with the UCLA Stress Interview. Drinking and stress were retrospectively assessed for 6 months prior to the present treatment episode. Direct associations between childhood trauma/adversity and alcohol consumption and the moderating effects of recent psychosocial stress were assessed. All measures were considered as continuous variables. Results: Pretreatment drinking severity (DDD) was associated with CTQ Total score (p = .009) and the Emotional Abuse (p p p = .04). Whereas higher CTQ scores were significantly associated with a greater amount of pretreatment drinking in participants with high UCLA stress scores (p = .01), CTQ scores were not associated with the amount of drinking in those with low UCLA stress scores (p = .63). Conclusions: Childhood trauma predicts drinking severity in alcohol-dependent men, and this effect is stronger in participants with ongoing stress in adult life. These findings suggest that early childhood trauma/adversity may sensitize stress-response systems. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial.
    Objective: Opioid pharmacotherapy is now the leading treatment for chronic pain, a problem that affects nearly one third of the U.S. population. Given the dramatic rise in prescription opioid misuse and opioid-related mortality, novel behavioral interventions are needed. The purpose of this study was to conduct an early-stage randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention designed to simultaneously target mechanisms underpinning chronic pain and opioid misuse. Method: Chronic pain patients (N = 115; mean age = 48 ± 14 years; 68% female) were randomized to 8 weeks of MORE or a support group (SG). Outcomes were measured at pre- and posttreatment, and at 3-month follow-up. The Brief Pain Inventory was used to assess changes in pain severity and interference. Changes in opioid use disorder status were measured by the Current Opioid Misuse Measure. Desire for opioids, stress, nonreactivity, reinterpretation of pain sensations, and reappraisal were also evaluated. Results: MORE participants reported significantly greater reductions in pain severity (p = .038) and interference (p = .003) than SG participants, which were maintained by 3-month follow-up and mediated by increased nonreactivity and reinterpretation of pain sensations. Compared with SG participants, participants in MORE evidenced significantly less stress arousal (p = .034) and desire for opioids (p = .027), and were significantly more likely to no longer meet criteria for opioid use disorder immediately following treatment (p = .05); however, these effects were not sustained at follow-up. Conclusions: Findings demonstrate preliminary feasibility and efficacy of MORE as a treatment for co-occurring prescription opioid misuse and chronic pain. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Long-term effects of analysis of the patient–therapist relationship in the context of patients’ personality pathology and therapists’ parental feelings.
    Objective: Analysis of the patient–therapist relationship (relationship work) is considered a core active ingredient in dynamic psychotherapy. However, there are contradictory findings as for whom and under what circumstances these interventions are beneficial. This study investigates long-term effects of relationship work in the context of patients’ level of personality pathology and therapists’ self-reported parental feelings. Method: One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to weekly dynamic psychotherapy, either with or without relationship work, for 1 year. Personality pathology was evaluated before treatment as the sum of fulfilled personality disorder criteria items on the Structured Clinical Interview for DSM–III–R Personality Disorders. Therapist feelings were assessed using the Feeling Word Checklist-58. The outcome variables were the Psychodynamic Functioning Scales and Inventory of Interpersonal Problems, measured at pretreatment, midtreatment, posttreatment, 1 year, and 3 years after treatment termination. Results: A significant interaction of treatment group (relationship work vs. no relationship work) by personality pathology by parental therapist feelings was present, indicating that parental feelings were differentially associated with long-term effects of relationship work, depending on the level of personality pathology. In the context of low parental feelings, relationship work was positive for all patients. However, when parental feelings were stronger, the specific effects of such interventions were even more positive for patients with high levels of personality pathology, but negative for patients with low levels of personality pathology. Conclusion: The interaction of parental therapist feelings and patients’ personality pathology was strongly associated with the long-term specific effects of analysis of the patient–therapist relationship. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Evaluating therapist adherence in motivational interviewing by comparing performance with standardized and real patients.
    Objective: The goal of measuring therapist adherence is to determine whether a therapist can perform a given treatment. Yet, the evaluation of therapist behaviors in most clinical trials is limited. Typically, randomized trials have few therapists and minimize therapist variability through training and supervision. Furthermore, therapist adherence is confounded with uncontrolled differences in patients across therapists. Consequently, the extent to which adherence measures capture differences in actual therapist adherence versus other sources of variance is unclear. Method: We estimated intra-class correlations (ICCs) for therapist adherence in sessions with real and standardized patients (RPs and SPs), using ratings from a motivational interviewing (MI) dissemination trial (Baer et al., 2009) in which 189 therapists recorded 826 sessions with both patient types. We also examined the correlations of therapist adherence between SP and RP sessions, and the reliability of therapist level adherence scores with generalizability coefficients (GCs). Results: ICCs for therapist adherence were generally large (average ICC for SPs = .44; average ICC for RPs = .40), meaning that a given therapist’s adherence scores were quite similar across sessions. Both ICCs and GCs were larger for SP sessions compared to RPs on global measures of MI adherence, such as Empathy and MI Spirit. Correlations between therapist adherence with real and standardized patients were moderate to large on 3 of 5 adherence measures. Conclusion: Differences in therapist-level adherence ratings were substantial, and standardized patients have promise as tools to evaluate therapist behavior. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • A method for assessing fidelity of delivery of telephone behavioral support for smoking cessation.
    Objectives: Behavioral support for smoking cessation is delivered through different modalities, often guided by treatment manuals. Recently developed methods for assessing fidelity of delivery have shown that face-to-face behavioral support is often not delivered as specified in the service treatment manual. This study aimed to extend this method to evaluate fidelity of telephone-delivered behavioral support. Method: A treatment manual and transcripts of 75 audio-recorded behavioral support sessions were obtained from the United Kingdom’s national Quitline service and coded into component behavior change techniques (BCTs) using a taxonomy of 45 smoking cessation BCTs. Interrater reliability was assessed using percentage agreement. Fidelity was assessed by comparing the number of BCTs identified in the manual with those delivered in telephone sessions by 4 counselors. Fidelity was assessed according to session type, duration, counselor, and BCT. Differences between self-reported and actual BCT use were examined. Results: Average coding reliability was high (81%). On average, 41.8% of manual-specified BCTs were delivered per session (SD = 16.2), with fidelity varying by counselor from 32% to 49%. Fidelity was highest in pre-quit sessions (46%) and for BCT “give options for additional support” (95%). Fidelity was lowest for quit-day sessions (35%) and BCT “set graded tasks” (0%). Session duration was positively correlated with fidelity (r = .585; p <.01). Significantly fewer BCTs were used than were reported as being used, t(15) = –5.52, p <.001. Conclusions: The content of telephone-delivered behavioral support can be reliably coded in terms of BCTs. This can be used to assess fidelity to treatment manuals and to in turn identify training needs. The observed low fidelity underlines the need to establish routine procedures for monitoring delivery of behavioral support. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Long-term prevention of criminality in siblings of serious and violent juvenile offenders: A 25-year follow-up to a randomized clinical trial of multisystemic therapy.
    Objective: Family-based treatment models that have shown effectiveness with juvenile offenders may also lead to reduced criminality in siblings of those offenders. However, the lasting effects of such treatments on siblings have not been evaluated. In the present study, the authors examined criminal outcomes for siblings of serious and violent juvenile offenders who had participated on average 25.0 years earlier in a clinical trial of multisystemic therapy (MST; Borduin et al., 1995). Method: Participants were 129 closest-in-age siblings of individuals who were originally randomized to MST or individual therapy (IT) during adolescence. Arrest and incarceration data were obtained in middle adulthood when siblings were on average 38.4 years old. Results: Intent-to-treat analyses showed that arrest rates were significantly lower for siblings in the MST condition than in the IT condition (43.3% vs. 72.0%, respectively). In addition, siblings in the IT condition were about 3 times as likely to be convicted of a felony and more than twice as likely to be sentenced to incarceration and probation. Conclusion: The present study represents the longest follow-up to date of sibling participants in an MST clinical trial and demonstrates that the positive impact of an evidence-based treatment for serious and violent juvenile offenders can extend to other family members. Implications of the authors’ findings for policymakers and service providers are discussed. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Extreme response style and symptom return after depression treatment: The role of positive extreme responding.
    Objective: Evidence linking extreme response style (ER) to depressive relapse has been mixed. One reason might be high levels of extreme responses that are positive in nature (ER-Ps) compared with those negative in nature (ER-Ns) at posttreatment. ER-Ps likely consist of both maladaptive “style” responses and adaptive “content” responses (i.e., legitimate denials of dysfunction). The composition of ER-Ps might confound measures of total extreme responding as well as conventional scores on cognitive questionnaires. In the current study, we assessed ER in a new sample by (a) disambiguating ER-Ps that reflect style from those that reflect content and (b) assessing the contribution of ER-Ps to the prediction of relapse/recurrence. Method: Responders (N = 104) to a randomized controlled trial of cognitive therapy versus medications for moderate to severe depression had an average age of 40 years (SD = 12), and they were 58% female, 38% married/cohabitating, and 85% Caucasian. ER variables were calculated using the Dysfunctional Attitudes Scale (DAS; Weissman, 1979), with ER-Ps categorized as either content or style responses. ER indices and DAS scores were used to predict symptom return over 2 years. Results: No standard extreme responding variables (e.g., an index of total extreme responding) predicted symptom return, but higher relative levels of style ER-P predicted relapse/recurrence. Total DAS scores also predicted relapse/recurrence but only when high levels of style ER-P responses were controlled. Conclusions: ER-Ps, at least on the DAS, appear to contain indicators of both adaptive and maladaptive positive responses. Future research should attend to the valence of the extreme responses as well as to the content of extreme positive responses, which may reflect either healthy or unhealthy tendencies. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Randomized controlled trial of a friendship skills intervention on adolescent depressive symptoms.
    Objective: The Resourceful Adolescent Program (RAP) is a universal, school-based intervention that has been found to produce small to medium effects in the reduction of adolescent depressive symptoms. In the present study, we evaluated the effectiveness of a friendship-building skills program—the Peer Interpersonal Relatedness (PIR) program—in producing larger effects when used in conjunction with RAP. Method: A cluster-randomized controlled trial was used to assign whole classrooms of adolescent participants recruited from Sydney secondary schools to 1 of 3 conditions: (a) RAP–PIR, (b) RAP–placebo, or (c) assessment-only waiting-list control. Hierarchical linear modeling (HLM) was used to analyze the data. Results: Across the intervention period, RAP did not significantly reduce depressive symptoms relative to those students not receiving this intervention. RAP followed by PIR did significantly reduce depressive symptoms relative to those students not receiving PIR. Across the 12-month follow-up, the between-group reductions in depressive symptoms were no longer significant. At follow-up, participants in the RAP–PIR condition had achieved significant increases in their school-related life satisfaction and significant increases in social functioning with peers relative to their peers in the other conditions. Conclusion: The study provides preliminary support for the effectiveness of the PIR program in reducing depressive symptoms when used alongside RAP in the short term and in improving social adjustment and school-related life satisfaction in the longer term. Given the importance of social adjustment in adolescent mental well-being, the PIR program represents a potentially important addition to the prevention of depression in youth. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • A meta-analysis of motivational interviewing interventions for pediatric health behavior change.
    Objective: Motivational interviewing (MI) is an empirically supported intervention that has shown effectiveness in moving people toward positive lifestyle choices. Although originally designed for adult substance users, MI has since expanded to other health concerns with a range of client age groups. The present study investigated the overall effectiveness of MI in the context of child and adolescent health behavior change and health outcomes. Method: A literature search using PsycINFO, PubMed, GoogleScholar, and Social Work Abstracts was performed. Thirty-seven empirical studies were included in this meta-analysis, encompassing 8 health domains. Results: The overall effect size (Hedges’s g) of MI in this population as compared to both other active treatments and no treatment was g = 0.282 (95% CI [0.242, 0.323], SE = 0.021), slightly higher than a small effect size and also slightly higher than what has been typically found in the substance literature. Effect sizes varied by health condition such that the health domains with the largest overall effect sizes were Type 1 diabetes, asthma, and calcium intake. Conclusions: The effectiveness of MI in pediatric domains was moderated by factors such as practitioner background, health domain, and the family member who participated. Unexpectedly, number of MI sessions and follow-up length were not significant moderators. MI seems to be most effective when both parent and child participate in sessions and when the cultural background of the practitioner matches the family. Overall, these findings indicate that MI is an effective and appropriate intervention for targeting child health behavior changes. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • Multisystemic Therapy for high-risk African American adolescents with asthma: A randomized clinical trial.
    Objective: The primary purpose of the study was to determine whether Multisystemic Therapy adapted for health care settings (MST-HC) improved asthma management and health outcomes in high-risk African American adolescents with asthma. Method: Eligibility included self-reported African American ethnicity, ages 12 to 16, moderate to severe asthma, and an inpatient hospitalization or at least 2 emergency department visits for asthma in the last 12 months. Adolescents and their families (N = 170) were randomized to MST-HC or in-home family support. Data were collected at baseline and posttreatment (7 months) based on an asthma management interview, medication adherence phone diary, and lung function biomarker (forced expiratory volume in 1 s [FEV1]). Analyses were conducted using linear mixed modeling for continuous outcomes and generalized linear mixed modeling for binary outcomes. Results: In intent-to-treat analyses, adolescents randomized to MST-HC were more likely to improve on 2 of the measures of medication adherence and FEV1. Per-protocol analysis demonstrated that MST-HC had a medium effect on adherence measures and had a small to medium effect on lung function and the adolescent’s response to asthma exacerbations. Conclusion: There are few interventions that have been shown to successfully improve asthma management in minority youth at highest risk for poor morbidity and mortality. MST, a home-based psychotherapy originally developed to target behavior problems in youth, improved asthma management and lung function compared to a strong comparison condition. Further follow-up is necessary to determine whether MST-HC reduces health care utilization accounting for seasonal variability. A limitation to the study is that a greater number of participants in the control group came from single-parent families than in the MST group. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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  • A brief psychological intervention that reduces adolescent alcohol consumption.
    Objective: Alcohol consumption in adolescence is associated with problem drinking in later life, and there is a need to develop evidence-based interventions to reduce adolescent alcohol consumption. The aims of the present study were to test the ability of a very brief intervention based on self-affirmation theory to reduce alcohol consumption in a sample of adolescents and to examine potential mediators of the effects. Method: 67 adolescents were randomly allocated either to form a self-affirming implementation intention or to complete a distractor task. All participants were exposed to a threatening message concerning the health risks of alcohol consumption. The main outcome measure was subsequent alcohol intake, but message processing (operationalized as perceived threat and message derogation), behavioral intention, and self-efficacy were also measured as potential mediators. Results: The intervention produced a significant decrease in alcohol consumption: Participants in the self-affirming implementation intention condition consumed 2.48 fewer grams of pure alcohol per day at the end of the study than adolescents who completed the distractor task. The effect was not mediated by perceived threat, message derogation, behavioral intention, or self-efficacy. Conclusions: The findings provide support for the efficacy of the self-affirming implementation intention for promoting health behavior change and extend previous research by testing an adolescent sample and observing longer term effects. Further research is needed to find out what mediates the effects of self-affirming implementation intentions on health behavior change. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
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