The relationship between substance-use treatment retention and outcomes is well established, but whether improvements are due to specific treatment techniques or other variables is unclear. To determine the extent to which the Adolescent Community Reinforcement Approach (A-CRA) mediates treatment retention and outcomes, researchers compared components of A-CRA (e.g., functional analysis of behavior, skills training, homework, and urine testing) with subsequent drug and alcohol use and related problems.

Data from 399 adolescents participating in 1 of 4 randomized controlled trials of A-CRA were used in the analysis. Ninety-four percent of participants met DSM-IV criteria for drug abuse or dependence. After each treatment session, therapists completed the A-CRA Exposure Scale (AES), a fidelity measure of the 15 A-CRA procedures, to track A-CRA component use.

• A significant relationship was found between treatment fidelity (as measured by the AES) and reductions in substance use and related problems.
• Adolescents who were exposed to 12 or more A-CRA procedures were significantly more likely to be in recovery at 6-month follow-up (55% versus 35%).
• None of the baseline variables (e.g., substance use, related problems, days of residential or outpatient treatment) were found to be significant in predicting treatment retention.

Comments by Tom Delaney, MSW, MPH
These results suggest that A-CRA procedure exposure, distinct from other variables, mediates the relationship between retention and outcome. The importance of using fidelity measures such as the AES continues to grow as the substance abuse treatment field moves toward the use of evidence-based practices. This research highlights the critically important issue of determining what provokes behavioral change within the "black box" of treatment. Although many studies have examined outcomes from a before-and-after perspective, much more can be done to reliably measure the impact of particular treatment techniques.