Treatment process, alliance and outcome in brief versus extended treatments for marijuana dependence

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Abstract
Aims The Marijuana Treatment Project, a large multi‐site randomized clinical trial, compared a delayed treatment control condition with a brief (two‐session) and extended (nine‐session) multi‐component treatment among 450 marijuana‐dependent participants. In this report we present treatment process data, including the fidelity of treatment delivery in the three community‐based treatment settings as well as the relationships between treatment process and outcome. Design Independent evaluations of clinician adherence and competence ratings were made based on 633 videotaped sessions from 163 participants. Relationships between clinician adherence and competence, ratings of the working alliance and marijuana treatment outcomes were evaluated. Findings Protocol treatments were implemented with strong fidelity to manual specifications and with few significant differences in adherence and competence ratings across sites. In the brief two‐session treatment condition, only the working alliance was associated significantly with frequency of marijuana use, but in the extended treatment therapist ratings of working alliance predicted outcomes, as did the interaction of alliance and curvilinear adherence. Conclusions Behavioral treatments for marijuana use were delivered in community settings with good fidelity. Participant and therapist working alliance scores were associated significantly with improved marijuana use outcomes in a brief behavioral treatment for adults with marijuana dependence. In extended treatment the therapist ratings of working alliance were associated with more positive outcome. However, in that treatment there was also a significant interaction between alliance and curvilinear adherence.