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Table 1 Theoretical Foundations of RBT and WC

From: Feasibility and initial efficacy of a culturally sensitive women-centered substance use intervention in Georgia: Sex risk outcomes

RBT: Treatment Plan and Goals

Drug abstinence is the primary treatment plan focus. A Functional Assessment determines problem areas associated with drug use and is the basis for other goals. The individualized treatment plan focuses on goals directly related to decreasing/eliminating drug use. The priority of goals is dynamic, based on most pressing issues for drug abstinence initiation and continuation.

RBT: Reinforcing Small Goals to Reach the Large Goal

RBT is an active therapeutic approach. Each large treatment plan goal is broken into small steps. Progress of smaller and then larger goal behaviors are graphed at each visit (see below). Active counselor support overcomes “resistance” due to past failures.

RBT: Density of Alternative Reinforcers

RBT increases the density of alternative (non-drug) reinforcers in the person’s naturalistic environment. Thus, participants complete interest inventories and Functional Assessments with their counselor to determine what activities might serve as positive reinforcers and during periods of previous abstinence what activities or events were functioning as competing alternative reinforcers. Based upon urine tests negative for monitored substances (opioids, amphetamines, benzodiazepines, THC, buprenorphine and methadone), participants receive reward cards that have monetary value and exchangeable for goods and services.

RBT: Response to Drug Use and Proactive Outreach

Having participants provide urine samples twice weekly during treatment maximizes the ability to detect non-compliance when/if it occurs and can prevent lapses from escalating to relapses. A stimulant-positive urine test results in an individual lapse-focused counseling session (e.g., Functional Assessment; FA) and a “time out” from other RBT aspects. A missed RBT session results in proactive counseling outreach procedures that same day.

RBT: Graphing of Progress

Behaviors emitted that are congruent or incongruent with goals are graphed by the counselor with the participant. Frequent and consistent graphing of target behaviors helps to focus both counselor and participant on the tasks of treatment and also serves to provide “early warning signs” that precede a lapse or relapse. Graphing is a therapy process and does not constitute outcome measurement.

RBT: Skills Training in Recreation, Life Goals, and Other Life Skills

RBT delivers skills training in an individual or group format, with similar efficacy. Skills-training takes the form of recreational activity sampling, Social Club, and 12 educational modules (each topic is repeated three times during the 12 weeks). Each skill element is manualized, an approach previously found to be acceptable to participants.

WC: Reductions in Sex Risk and Interpersonal Violence

Four modules from Women’s Co-op were incorporated in RBT + WC. Module 1 educates women about the risks involved in alcohol and drug abuse and how certain sex behaviors increase HIV risk. Module 2 was adapted to focus on the context of sexual risk for women in Georgia, and was revised to include information gained in studies 1 and 2 (e.g., stigma, double-standards for men and women in number of sexual partners). During this time, participants are asked to practice the mechanics of correct use of male and female condoms using penile and vaginal models. Each woman has her own model to work with and has an opportunity to take home male and female condoms and experience them and return the next session to discuss how it felt to insert a female condom if they had never seen or used one. Module 3 teaches participants negotiation skills to be used with male partners and role-playing and rehearsal for practice. It directly addresses fears about intimate partner violence related to forced and unsafe sex practices and sexual negotiation. Module 4 focuses on interpersonal violence prevention, including domestic violence and rape, and strategies for violence prevention. Nonviolent resolutions are presented including a process with steps for “fair fighting” to address conflict resolution.

Because the Women’s Co-op modules were a key new component of RBT + WC, it was imperative that their messages were interwoven into RBT rather than having the modules seen as independent, parallel or add-on. Thus, to integrate this effective HIV prevention into RBT, we reinforced the Women’s Co-op messages in the individual counseling sessions by graphing the frequency of safe and unsafe sex acts, discussing condom use and condom protection negotiations, and employing a functional analysis when unprotected sexual acts were reported.

  1. Note. Appendix 1 in Jones HE, Kirtadze I, Otiashvili D, O’Grady KE, Murphy K, Zule W, Krupitsky E, Wechsberg WM. Process and product in cross-cultural treatment research: development of a culturally sensitive women-centered substance use intervention in Georgia. J Addict Sep 2014;Article ID 163603 © 2104 by Hendrée E. Jones et al. Used with permission