Behavior and Behavior Mechanisms; Mental Disorders; Homeless Persons; Personality; Personality Disorders; Psychiatry; Psychotherapy; Substance Abuse Detection; Treatment Outcome; Psychiatry and Psychology
My major research interests involve the evaluation of personality dimensions and disorders as important constructs for subtyping addicted individuals for the purpose of predicting treatment outcome and developing interventions. My diagnostic and assessment research has included the validation of a multidimensional substance abuse typology that defines subtypes of substance abusers based on multiple risk factors that may have prevention and treatment relevance. I have developed and evaluated the first manual-guided psychotherapy for the full range of personality disorders co-occurring with substance abuse. I also have been an investigator on various projects evaluating the effectiveness of cognitive-behavioral therapies and brief interventions to improve retention and symptom reduction in substance abuse patients.
Specialized Terms: Personality; Personality Disorders; Psychotherapy; Substance Abuse; Addiction Treatment; Psychodiagnosis; Homelessness; Treatment Dropout
Extensive Research Description
My research investigates the most prevalent and yet commonly overlooked type of psychiatric comorbidity – substance abuse and personality disorders. I have conducted a systematic series of studies that have: evaluated the personality dimensions common to both of these psychiatric disorders; identified personality-related subtypes of substance abuse with greater symptom severity and worse prognosis, and; developed and tested the first psychotherapeutic model for the full range of personality disorders found in substance abusers. Personality traits appear to be risk factors for substance use, as well as risk factors for personality disorders that have substance abuse as an important behavioral expression. Maladaptive personality traits and related personality disorders are not simply consequences of addiction. Previous, ongoing, and planned studies focus on two major areas related to personality and substance use disorders: 1) assessment and diagnosis; 2) psychotherapy efficacy.
1) Assessment and Diagnosis
Over half of treated substance abusers meet diagnostic criteria for a personality disorder. The separation of addiction symptoms from personality traits and disorders through careful assessment is critically important for improving diagnostic reliability and validity and predicting treatment response. Personality disorders influence symptom severity, persist and interfere with psychosocial functioning once abstinence is achieved, create significant ongoing risk for relapse, and may require additional specialized treatment.
Over the past 20 years, my research has focused on evaluating extreme, maladaptive personality traits and the prevalence and treatment implications of personality disorders in substance abusers. I have mapped personality dimensions from five factor and seven factor models onto personality disorder diagnoses and compared the reliability of personality disorder and trait dimensions. A constellation of maladaptive personality traits is related to substance dependence severity, polydrug use, earlier age of onset, chronic/heavy use, conduct and antisocial personality disorders, violence, arrests, HIV risk behaviors, psychiatric symptoms, mood disorders, suicide attempts, and early treatment drop-out. My work has emphasized the importance of utilizing dimensional models of personality disorders which incorporate symptom severity measures of diagnostic interview categories as well as self-report measures of maladaptive personality traits and problems.
Consistent with the increased appreciation of the heterogeneity of addicted persons, my research has emphasized that personality factors can be viewed as etiologically or prognostically linked to some, but not necessarily all, subtypes of substance abusers. I have evaluated an empirical framework for understanding the relation between personality dimensions, substance abuse, and personality disorders through a typological system which organizes diverse variables into broader constructs which are associated with different etiologies, patterns, and courses of the disorder. This work included the first extension of a multidimensional alcoholism typology to the drug abuse field. One type (variously called Type I or Type A) is characterized by later age of onset, lower heritability, fewer childhood risk factors, and less severe dependence. The second type (Type II or B) is characterized by earlier onset, higher heritability, more childhood risk factors, more severe dependence, greater psychosocial impairment, antisocial behavior, and psychiatric comorbidity. In a series of studies, I validated this Type A/B and established its connection to certain personality traits and disorders.
Although antisocial and borderline are the most common personality disorders in addiction treatment settings, other disorders (avoidant, paranoid, dependent, narcissistic) affect a significant minority of substance abuse patients, but have not been the focus of diagnostic or treatment research. Other personality disorders, referred to as Cluster A or psychotic spectrum (schizoid, schizotypal, paranoid), are the most common form of diagnostic comorbidity in a group of substance abusers who have had limited or ineffective interactions with the addiction and mental health treatment system (i.e., homeless persons). The development of an effective therapy for the diverse groups of treatment refractory, personality disordered substance abusers has been the focus of my second major area of research and contribution to the field.
2) Psychotherapy Efficacy
Although personality disorders are the most common form of psychiatric comorbidity in drug abusers and convey a negative prognosis, treatments have been adapted or tested for only two specific diagnoses (antisocial and borderline personality disorders). I am the originator of Dual Focus Schema Therapy (DFST) which is the only psychotherapy manual developed and tested for the full range of personality disorders encountered in substance abusers. The problem targets for this treatment are early maladaptive schemas and the associated coping styles related to addictive behaviors. The development of a personality disorder is conceptualized as an interaction between biologically-based personality or temperament traits and highly dysfunctional early caretaking environments which contribute to the development of enduring, unconditional, negative beliefs about oneself, others, and the world and coping behaviors that are inappropriate, rigid, and difficult to change.
DFST is an integrative, cognitive-behavioral therapy that targets these maladaptive personality processes (cognitive, behavioral, interpersonal, emotional) that heighten risk for relapse and adversely impacts treatment engagement, retention, and outcome and the social supports necessary for long-term recovery. It is a manual-guided individual therapy based on a detailed, multi-level assessment and conceptualization of personality traits, problems, and disorders. Cognitive, behavioral, relational, and experiential techniques are selected that focus on reducing addiction and psychiatric symptoms, the intensity of affective and behavioral reactions to schema activation, and maladaptive methods of coping with high risk situations. The choice and staging of interventions is guided by a detailed case formulation of personality functioning and an open, ongoing, collaborative dialogue between the therapist and patient about personality problems, addictive behaviors, and the identification of specific target problems for intervention. This therapeutic partnership fosters the type of strong working alliance that psychotherapy research has found associated with positive outcomes and seems especially important with challenging, refractory patients.
I have completed two smaller and one larger randomized clinical trials comparing DFST to standard addiction counseling approaches. All treatment studies involve very complex, traumatized, multi-problem patients. I have established the feasibility, safety, acceptability, and preliminary efficacy of DFST and developed a: detailed session-by-session treatment manual with prescribed and proscribed techniques; comprehensive, effective training and supervisory procedure for therapists, and; adherence/competence rating system to measure treatment discriminability and fidelity. In the first study in outpatient methadone maintained personality disordered patients, DFST was superior to 12 Step Facilitation Therapy on the primary substance use outcome and secondary therapeutic alliance measure. In the second study in homeless substance abusers with personality disorders, DFST promoted better therapy utilization than a Drug Counseling group. However, homeless clients with more severe forms of certain personality disorders exhibited better Drug Counseling group utilization. The third study of patients in long-term residential treatment found that DFST promoted significant psychiatric, interpersonal, and negative affect symptom reduction over the duration of therapy. However, patients with certain personality disorders had better psychiatric symptom reduction in Individual Drug Counseling than DFST.
The randomized clinical trial of DFST conducted in a homeless drop-in center unexpectedly found rates of Cluster A (paranoid, schizotypal, schizoid) and Cluster C (especially obsessive-compulsive) personality disorders that were 5 – 15 times (i.e., 40 – 75% prevalence rates) more common than typically found in mental health and addiction treatment programs. This was a new finding for the field as previous diagnostic research on the homeless had focused extensively on severe Axis I diagnoses (schizophrenic, mood, and substance use disorders) and ignored the Axis II diagnoses other than antisocial personality disorder. My team completed three additional diagnostic studies, all of which confirm the very high prevalence of these psychotic-spectrum personality disorders among the homeless. This has been the first research to conduct structured diagnostic interviews of the full range of personality disorders among homeless persons while controlling for the effects of other psychiatric disorders. This diagnostic work has established the independence of these very common severe personality disorders from their related, but less prevalent, mood, schizophrenic, anxiety, and substance use disorders. These severely traumatized, psychosocially challenged individuals have been insufficiently served by traditional treatment systems. Other recent research evaluates the relation between maladaptive personality dimensions and addiction symptom severity, psychosocial functioning, relapse risk, treatment motivation and response through a longitudinal evaluation of predictors of outpatient treatment engagement and attrition.
- Adaptive Brief Interventions for Drop-Out Re-Engagement
- Psychotic-Spectrum Personality Disorders in Homeless Persons
Conceptual changes to the definition of borderline personality disorder proposed for DSM-5
Samuel DB, Miller JD, Widiger TA, Lynam DR, Pilkonis PA, Ball SA. Conceptual changes to the definition of borderline personality disorder proposed for DSM-5. Journal of Abnormal Psychology. in press.
Randomized trial of dual-focused versus single-focused individual therapy for personality disorders and substance dependence
Ball SA, Maccarelli LM LaPaglia DM, Ostrowski MJ. Randomized trial of dual-focused versus single-focused individual therapy for personality disorders and substance dependence. Journal of Nervous and Mental Disease, 199: 319-328, 2011.
Axis I and II diagnoses among homeless drop-in center clients.
Connolly AJ, Cobb-Richardson P, Ball SA. Axis I and II diagnoses among homeless drop-in center clients. Journal of Personality Disorders 22: 573-588, 2008.
Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics
Ball SA, Martino S, Nich C, Frankforter TL, van Horn D, Crits-Christoph P, Woody GE, Obert JL, Farentinos C, Carroll KM. Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. Journal of Consulting and Clinical Psychology, 75: 556-567, 2007.
Millon Clinical Multiaxial Inventory-III subtypes of opioid dependence: Validity and matching to behavioral therapies
Ball SA, Nich C, Rounsaville BJ, Eagan D, Carroll KM. Millon Clinical Multiaxial Inventory-III subtypes of opioid dependence: Validity and matching to behavioral therapies. Journal of Consulting and Clinical Psychology, 72: 698-711, 2004.
Reliability of personality disorder and trait dimensions in substance dependent inpatients
Ball SA, Rounsaville BJ, Tennen H, Kranzler HR. Reliability of personality disorder and trait dimensions in substance dependent inpatients. Journal of Abnormal Psychology, 110: 341-352, 2001.
Full List of PubMed Publications
- Madden LM, Farnum SO, Eggert KF, Quanbeck AR, Freeman RM, Ball SA, Schottenfeld RS, Shi JM, Savage ME, Barry DT: An investigation of an open-access model for scaling up methadone maintenance treatment. Addiction. 2018 Feb 17; 2018 Feb 17. PMID: 29453891
- Richter L, Pugh BS, Ball SA: Assessing the risk of marijuana use disorder among adolescents and adults who use marijuana. Am J Drug Alcohol Abuse. 2017 May; 2016 Jun 13. PMID: 27292878
- Richter L, Pugh BS, Smith PH, Ball SA: The co-occurrence of nicotine and other substance use and addiction among youth and adults in the United States: implications for research, practice, and policy. Am J Drug Alcohol Abuse. 2017 Mar; 2016 Aug 5. PMID: 27494436
- Carroll KM, Nich C, Petry NM, Eagan DA, Shi JM, Ball SA: A randomized factorial trial of disulfiram and contingency management to enhance cognitive behavioral therapy for cocaine dependence. Drug Alcohol Depend. 2016 Mar 1; 2016 Jan 13. PMID: 26817621
- Wilkinson ST, Yarnell S, Radhakrishnan R, Ball SA, D'Souza DC: Marijuana Legalization: Impact on Physicians and Public Health. Annu Rev Med. 2016; 2015 Oct 19. PMID: 26515984
- DeVito EE, Babuscio TA, Nich C, Ball SA, Carroll KM: Gender differences in clinical outcomes for cocaine dependence: randomized clinical trials of behavioral therapy and disulfiram. Drug Alcohol Depend. 2014 Dec 1; 2014 Oct 20. PMID: 25457739
- Cutter CJ, Schottenfeld RS, Moore BA, Ball SA, Beitel M, Savant JD, Stults-Kolehmainen MA, Doucette C, Barry DT: A pilot trial of a videogame-based exercise program for methadone maintained patients. J Subst Abuse Treat. 2014 Oct; 2014 Jun 10. PMID: 25012555
- Decker SE, Frankforter T, Babuscio T, Nich C, Ball SA, Carroll KM: Assessment concordance and predictive validity of self-report and biological assay of cocaine use in treatment trials. Am J Addict. 2014 Sep-Oct; 2014 Mar 15. PMID: 24628970
- Fucito LM, Redeker NS, Ball SA, Toll BA, Ikomi JT, Carroll KM: Integrating a Behavioural Sleep Intervention into Smoking Cessation Treatment for Smokers with Insomnia: A Randomised Pilot Study. J Smok Cessat. 2014 Jun. PMID: 24995044
- Carr WA, Ball SA: Predictors and treatment outcomes of perceived ward atmosphere among therapeutic community residents. J Subst Abuse Treat. 2014 May-Jun; 2014 Jan 10. PMID: 24560437
- Carroll KM, Kiluk BD, Nich C, DeVito EE, Decker S, LaPaglia D, Duffey D, Babuscio TA, Ball SA: Toward empirical identification of a clinically meaningful indicator of treatment outcome: features of candidate indicators and evaluation of sensitivity to treatment effects and relationship to one year follow up cocaine use outcomes. Drug Alcohol Depend. 2014 Apr 1; 2014 Jan 31. PMID: 24556275
- Black AC, McMahon TJ, Rosenheck RA, Ball SA, Ries RK, Ames D, Rosen MI: Development of the Clinician Assessment of Financial Incapability (CAFI). Psychiatry Res. 2014 Mar 30; 2014 Jan 22. PMID: 24495575
- Moore BA, Fazzino T, Barry DT, Fiellin DA, Cutter CJ, Schottenfeld RS, Ball SA: The Recovery Line: A pilot trial of automated, telephone-based treatment for continued drug use in methadone maintenance. J Subst Abuse Treat. 2013 Jul; 2013 Jan 30. PMID: 23375114
- Carroll KM, Nich C, Shi JM, Eagan D, Ball SA: Efficacy of disulfiram and Twelve Step Facilitation in cocaine-dependent individuals maintained on methadone: a randomized placebo-controlled trial. Drug Alcohol Depend. 2012 Nov 1; 2012 Jun 12. PMID: 22695473
- Samuel DB, Miller JD, Widiger TA, Lynam DR, Pilkonis PA, Ball SA: Conceptual changes to the definition of borderline personality disorder proposed for DSM-5. J Abnorm Psychol. 2012 May; 2011 Aug 29. PMID: 21875165
- Schlauch RC, O'Malley SS, Rounsaville BJ, Ball SA: Internalizing and externalizing dimensions and alcohol use in first time DWI offenders: indirect effects through coping self-efficacy. Psychol Addict Behav. 2012 Mar; 2011 Oct 10. PMID: 21988478
- Palmer RS, McMahon TJ, Moreggi DI, Rounsaville BJ, Ball SA: College Student Drug Use: Patterns, Concerns, Consequences, and Interest in Intervention. J Coll Stud Dev. 2012 Jan. PMID: 24339478
- Samuel DB, Lynam DR, Widiger TA, Ball SA: An expert consensus approach to relating the proposed DSM-5 types and traits. Personal Disord. 2012 Jan. PMID: 22448858
- Samuel DB, LaPaglia DM, Maccarelli LM, Moore BA, Ball SA: Personality disorders and retention in a therapeutic community for substance dependence. Am J Addict. 2011 Nov-Dec; 2011 Oct 4. PMID: 21999502
- Carroll KM, Ball SA, Jackson R, Martino S, Petry NM, Stitzer ML, Wells EA, Weiss RD: Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future. Am J Drug Alcohol Abuse. 2011 Sep. PMID: 21854269
- Ball SA, Maccarelli LM, LaPaglia DM, Ostrowski MJ: Randomized trial of dual-focused vs. single-focused individual therapy for personality disorders and substance dependence. J Nerv Ment Dis. 2011 May. PMID: 21543951
- Martino S, Ball SA, Nich C, Canning-Ball M, Rounsaville BJ, Carroll KM: Teaching community program clinicians motivational interviewing using expert and train-the-trainer strategies. Addiction. 2011 Feb; 2010 Oct 6. PMID: 20925684
- Carroll KM, Kiluk BD, Nich C, Babuscio TA, Brewer JA, Potenza MN, Ball SA, Martino S, Rounsaville BJ, Lejuez CW: Cognitive function and treatment response in a randomized clinical trial of computer-based training in cognitive-behavioral therapy. Subst Use Misuse. 2011. PMID: 21190403
- Sindelar JL, Ball SA: Cost evaluation of evidence-based treatments. Addict Sci Clin Pract. 2010 Dec. PMID: 22002453
- Bamatter W, Carroll KM, Añez LM, Paris M Jr, Ball SA, Nich C, Frankforter TL, Suarez-Morales L, Szapocznik J, Martino S: Informal discussions in substance abuse treatment sessions with Spanish-speaking clients. J Subst Abuse Treat. 2010 Dec. PMID: 20817381
- Gibbons CJ, Carroll KM, Ball SA, Nich C, Frankforter TL, Martino S: Community program therapist adherence and competence in a motivational interviewing assessment intake session. Am J Drug Alcohol Abuse. 2010 Nov; 2010 Oct 14. PMID: 20942726
- Palmer RS, McMahon TJ, Rounsaville BJ, Ball SA: Coercive sexual experiences, protective behavioral strategies, alcohol expectancies and consumption among male and female college students. J Interpers Violence. 2010 Sep; 2009 Dec 29. PMID: 20040711
- Carroll KM, Martino S, Ball SA, Nich C, Frankforter T, Anez LM, Paris M, Suarez-Morales L, Szapocznik J, Miller WR, Rosa C, Matthews J, Farentinos C: A multisite randomized effectiveness trial of motivational enhancement therapy for Spanish-speaking substance users. J Consult Clin Psychol. 2009 Oct. PMID: 19803579
- Yonkers KA, Howell HB, Allen AE, Ball SA, Pantalon MV, Rounsaville BJ: A treatment for substance abusing pregnant women. Arch Womens Ment Health. 2009 Aug; 2009 Apr 7. PMID: 19350369
- Martino S, Ball SA, Nich C, Frankforter TL, Carroll KM: Informal discussions in substance abuse treatment sessions. J Subst Abuse Treat. 2009 Jun; 2008 Oct 5. PMID: 18835679
- Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Rounsaville BJ: Enduring effects of a computer-assisted training program for cognitive behavioral therapy: a 6-month follow-up of CBT4CBT. Drug Alcohol Depend. 2009 Feb 1; 2008 Nov 28. PMID: 19041197
- Schwarz RK, Bruce RD, Ball SA, Herme M, Altice FL: Comparison of tuberculin skin testing reactivity in opioid-dependent patients seeking treatment with methadone versus buprenorphine: policy implications for tuberculosis screening. Am J Drug Alcohol Abuse. 2009. PMID: 20014914
- Palmer RS, Murphy MK, Piselli A, Ball SA: Substance user treatment dropout from client and clinician perspectives: a pilot study. Subst Use Misuse. 2009. PMID: 19938942
- Santa Ana EJ, Martino S, Ball SA, Nich C, Frankforter TL, Carroll KM: What is usual about "treatment-as-usual"? Data from two multisite effectiveness trials. J Subst Abuse Treat. 2008 Dec; 2008 Mar 12. PMID: 18337053
- Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Nuro KF, Gordon MA, Portnoy GA, Rounsaville BJ: Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT. Am J Psychiatry. 2008 Jul; 2008 May 1. PMID: 18450927
- Martino S, Ball SA, Nich C, Frankforter TL, Carroll KM: Community program therapist adherence and competence in motivational enhancement therapy. Drug Alcohol Depend. 2008 Jul 1; 2008 Mar 6. PMID: 18328638
- Black RA, Rounsaville BJ, Rosenheck RA, Conrad KJ, Ball SA, Rosen MI: Measuring money mismanagement among dually diagnosed clients. J Nerv Ment Dis. 2008 Jul. PMID: 18626300
- Ball SA, Martino S, Nich C, Frankforter TL, Van Horn D, Crits-Christoph P, Woody GE, Obert JL, Farentinos C, Carroll KM, National Institute on Drug Abuse Clinical Trials Network.: Site matters: multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. J Consult Clin Psychol. 2007 Aug. PMID: 17663610
- Ball SA, Todd M, Tennen H, Armeli S, Mohr C, Affleck G, Kranzler HR: Brief motivational enhancement and coping skills interventions for heavy drinking. Addict Behav. 2007 Jun; 2006 Sep 1. PMID: 16945487
- Ball SA: Comparing individual therapies for personality disordered opioid dependent patients. J Pers Disord. 2007 Jun. PMID: 17536942
- Palmer RS, Ball SA, Rounsaville BJ, O'Malley SS: Concurrent and predictive validity of drug use and psychiatric diagnosis among first-time DWI offenders. Alcohol Clin Exp Res. 2007 Apr. PMID: 17374041
- Carroll KM, Ball SA, Nich C, Martino S, Frankforter TL, Farentinos C, Kunkel LE, Mikulich-Gilbertson SK, Morgenstern J, Obert JL, Polcin D, Snead N, Woody GE, National Institute on Drug Abuse Clinical Trials Network.: Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug Alcohol Depend. 2006 Feb 28; 2005 Sep 28. PMID: 16169159
- Ball SA, Carroll KM, Canning-Ball M, Rounsaville BJ: Reasons for dropout from drug abuse treatment: symptoms, personality, and motivation. Addict Behav. 2006 Feb; 2005 Jun 17. PMID: 15964152
- Ball SA, Cobb-Richardson P, Connolly AJ, Bujosa CT, O'neall TW: Substance abuse and personality disorders in homeless drop-in center clients: symptom severity and psychotherapy retention in a randomized clinical trial. Compr Psychiatry. 2005 Sep-Oct. PMID: 16122538
- Carroll KM, Nich C, Ball SA: Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. J Consult Clin Psychol. 2005 Aug. PMID: 16173864
- Ball SA, Nich C, Rounsaville BJ, Eagan D, Carroll KM: Millon Clinical Multiaxial Inventory-III subtypes of opioid dependence: validity and matching to behavioral therapies. J Consult Clin Psychol. 2004 Aug. PMID: 15301655
- Basu D, Ball SA, Feinn R, Gelernter J, Kranzler HR: Typologies of drug dependence: comparative validity of a multivariate and four univariate models. Drug Alcohol Depend. 2004 Mar 8. PMID: 15036551
- Carroll KM, Fenton LR, Ball SA, Nich C, Frankforter TL, Shi J, Rounsaville BJ: Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: a randomized placebo-controlled trial. Arch Gen Psychiatry. 2004 Mar. PMID: 14993114
- Carroll KM, Farentinos C, Ball SA, Crits-Christoph P, Libby B, Morgenstern J, Obert JL, Polcin D, Woody GE: MET meets the real world: design issues and clinical strategies in the Clinical Trials Network. J Subst Abuse Treat. 2002 Sep. PMID: 12220604