Yale Psychiatry Grand Rounds: September 10, 2021

September 10, 2021

"The Stage Model of Behavioral Intervention Development for Addictions: Special Recognition for Kathleen Carroll, PhD"

Lisa Onken, PhD, Director, Behavior Change & Intervention Program, Division of Behavioral and Social Research, National Institute on Aging/National Institutes of Health

Steve Martino, PhD, Professor of Psychiatry, Yale School of Medicine; Chief of Psychology, VA Connecticut Healthcare System

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00:00In our grand rounds we will have what I
00:04hope will be another special grand rounds,
00:06which is a grand rounds that will be led
00:09by Cindy Cruz to in myself and which will
00:13focus on the work of the department,
00:16Anti Racism Task Force which has been working
00:20now over 90 people since last September.
00:24On this incredibly important
00:27issue for our department.
00:30But before before we switched to the.
00:36To Kathy's celebration,
00:37what I'd like to do is to share
00:40some updates around COVID in our
00:43community that I hope will be helpful.
00:46I have shared the slides with Chris Gardner.
00:49If you'd like a copy of them,
00:52were happy to provide them and I
00:55think it's useful for us to to kind
00:59of all be on the same page today.
01:01And given all that's going on.
01:04So the information that I'm
01:05sharing was provided.
01:06By Rick Martinello who's been the
01:09head of infection control for Yale,
01:11New Haven Hospital.
01:15Uhm, something you probably all know
01:19which is displayed in this graph is that
01:22nearly all the infections in our community
01:25are now the delta variant of COVID,
01:27which as you know is very, very highly
01:30infective and and and as displaced.
01:33The other genetic variants
01:36of the delta coronavirus.
01:40Uhm, we're very close now to the projected
01:45peak of the COVID virus pandemic.
01:49Recent data have suggested that we
01:51may have actually turned a corner
01:54in terms of of the of the peak
01:56prevalence of coronavirus infections,
01:59COVID infections in our community
02:02in the last few days.
02:04However, there's a lot of anxiety about
02:07what the return to school is going to mean.
02:10The return of the college students
02:12to their college campuses and
02:14students to grade school campuses,
02:17and so we're all approaching this
02:19with a fair amount of caution in
02:23assuming that the worst is behind us.
02:26Also, it's important to know
02:28that although the peak number
02:30of new cases may be peaking,
02:32the peak number of people
02:35who get hospitalized.
02:36Doesn't peak for another week or
02:38two following the peak prevalence,
02:40so we're all you know approaching
02:44this in a very cautious way.
02:50One of the important issues,
02:52UM is that we're seeing growing numbers
02:55of people who have received two vaccines,
02:59vaccinations for the COVID virus.
03:04And those breakthrough infections are
03:07starting to lead to hospitalizations
03:11even among the the the.
03:15Vaccinated now the hospitalizations
03:17of people who have been vaccinated
03:20are generally much less severe than
03:23the hospitalizations of people
03:25who have not been vaccinated.
03:27Nearly all the people who are
03:30continuing to die from COVID,
03:32but not all are people who
03:35have not been vaccinated,
03:38and so it's really extraordinarily
03:40important that we continue to encourage
03:43all those that we care about.
03:46To get both vaccinations.
03:50Uhm?
03:51The breakthrough vaccinations are
03:53are are probably most come most
03:57breakthrough hospitalizations are
03:58probably most common among the elderly.
04:01Immunocompromised, obese people.
04:03People who have some compromise
04:06to to their immune function.
04:14And as I said before though,
04:16the big picture is that if
04:18you've gotten both vaccinations,
04:20you're much more protected even if
04:22you're in one of these risk groups,
04:25then people who are unvaccinated
04:27and these are the national
04:29hospitalization rates in blue.
04:32These are the people who have
04:34not been vaccinated in green.
04:36These are the people who
04:37have been vaccinated,
04:39and so you can see that,
04:40although although people who are
04:42vaccinated may still get infections.
04:44The rate of hospitalizations is
04:46still vanishingly low compared
04:48to people who are not vaccinated.
04:54But there is a sense that the
04:57protection from the two COVID
04:59vaccines that people have have
05:02gotten is beginning to decline, and.
05:07This is particularly so among the
05:11elderly and nursing home patients.
05:13These are the collected data about the
05:17rate of infection or percent in protected
05:22that that people are protected from
05:24infection with the duration of time.
05:26Since their vaccine and so,
05:30well, actually just by month and
05:32and as people began to get in,
05:35vaccinated in February and March.
05:38Uhm, even earlier initially they
05:43had very high rates of protection.
05:46And but now those rates of
05:49protection are beginning to decline,
05:51as you can see in these July data.
05:54This blue data,
05:56which has lower rate of protection
05:58are people who are in nursing homes
06:01and they do are showing a decline
06:04in their protection and some of us
06:08have been vaccinated before February
06:11and March as early as in December.
06:14And so we would predict that some
06:17of us may have even lower level
06:19of protection at the current time.
06:25So, uhm, the FDA and the hospital
06:31and CDC and various other groups have
06:34been trying to figure out what's the
06:37simplest and yet best strategy to roll
06:41out the delivery of COVID boosters in
06:44order to compensate for the declining
06:47level of protection and what you can
06:50see below is that the simplest rule,
06:53and the most likely way in
06:55which COVID vaccines.
06:56Will be ruled out is simply by saying
06:59the earlier you got your vaccination,
07:02the earlier.
07:03You should get your booster so the
07:06people who got the vaccine the earliest
07:09were active health care workers.
07:11High risk people who were
07:14immunocompromised and elderly,
07:16and so if if they base the rollout as
07:20they likely will on a time interval since
07:24the last receipt of their last dose,
07:28it's likely that high risk groups
07:30will get the vaccine first.
07:34So many people believe that this is
07:37the plan for the rollout of boosters.
07:41When will boosters be widely available?
07:45The president has suggested that
07:48September 20th is the date the
07:51FDA is going to meet to review
07:54data on September 17th and and we
07:59expect that boosters will be widely
08:04available shortly after that date.
08:09The reality is the reality though,
08:11is that if you're immunocompromised,
08:14if you're elderly,
08:16if you're a high risk group.
08:19If you have some other health reason
08:22to put you in a high risk group.
08:26You can already qualify for a booster.
08:31If you're not in one of those groups, uhm.
08:34We can't recommend that you get a booster,
08:38but we are aware that many people have
08:42simply shown up at their CVS and Walgreens
08:46to get a an additional booster shot,
08:50and that that oftentimes the the.
08:58CVS and Walgreens and other groups
09:00will give you a booster if you request
09:04it again if you want to sign up and
09:06make an appointment in advance.
09:08Usually those appointments are
09:10limited to people who are in the
09:12high risk groups and there's a little
09:14questionnaire that you fill out on
09:16their website to indicate that you're
09:18you belong to that high risk group.
09:22So that's really mainly what I wanted
09:25to share with you today about COVID
09:29uhm and and if you have any questions
09:35about anything that I've said,
09:38you're welcome to send me an email.
09:41If you have a if you have.
09:46Would like a copy of the slides.
09:48You can contact Chris Gardner for
09:50a copy of the slides and and.
09:55And so I I again remind you that next
09:59week we have the anti racism taskforce
10:03grand rounds and I'm just really.
10:07Really pleased to to be able to share
10:13with you and with everyone today.
10:17This very special grand rounds in
10:21memory of Kathy Carroll who's been a
10:24part of our department since 1988.
10:27I really want to thank the organizing
10:29committee for today's event.
10:31Ayanna Jordan, Brian Killick,
10:33Stephanie O'Malley, and Syria,
10:35and I particularly want to thank
10:37and acknowledge members of Kathy's
10:40family who've been really also dear
10:43friends of the apartment and who.
10:48Participated and contributed to
10:50yesterday's event and today's grand rounds,
10:54including a Jeff White,
10:56Kate Chivian, Matt Chevy,
10:58and John Carroll,
10:59Natalie White and Carla White.
11:02So thank you everyone and let me pass
11:07the baton to our master of ceremonies.
11:11Thank you.
11:15Thank you John.
11:19I am going to share my screen.
11:27Thank you everyone for
11:28being here this morning.
11:29I want to also say thanks to our
11:32organizing committee who helped
11:33put this together and a special
11:35thanks to Stephanie O'Malley into
11:37to John for giving us the space to
11:40celebrate Kathy's work in her life.
11:44Uhm? Today we are going to focus
11:46on the stage model of behavioral
11:49intervention development for addiction,
11:51which was an organizing framework for both
11:54Kathy's work as well As for the field.
11:58Speakers today will be Doctor Lisa
12:00Onken from the National Institute
12:02on Aging and Doctor Steve Martino,
12:04who's professor of Psychiatry and
12:06Chief of Psychology at the VA.
12:08For those who don't know me,
12:09I'm Brian Killick.
12:10I'm an associate professor
12:12here in the department.
12:14I'm a longtime mentee.
12:15Of Kathy's first,
12:17starting with her as a research
12:19assistant over 20 years ago and
12:22then having her as a mentor during
12:24my early stages of my career,
12:26I will be just providing some
12:29introductory remarks before I pass
12:31things along to our speakers because I
12:33just wanted to provide a little bit of
12:35a background regarding Cathy's career.
12:36For those who might not be
12:38as familiar with her work.
12:40She graduated from Duke University in 1980.
12:44I received her PhD in clinical psychology
12:46from the University of Minnesota in 1988.
12:49And I did learn recently that
12:52while at Duke she was known as
12:55the Brick House Girl of Duke,
12:57which was an interesting piece
12:59of information to learn about
13:01some of Cathy's background from
13:03her earlier days prior to Yale.
13:05UM, after receiving her degree,
13:08she spent the pretty much the
13:10entirety of her career at Yale,
13:12first as an intern at the
13:14Substance Abuse Treatment Unit,
13:15and she has often said that she was
13:19the first psychology intern at statue,
13:22which really helped shape aspects of
13:25her career in terms of identifying
13:27treatments for substance use disorder,
13:30specifying them and trying to
13:32enhance and make them better.
13:33Following a brief.
13:35A stint at Harvard University
13:38as an instructor in 1989,
13:40the rest of her career was spent at Yale
13:43when she joined the faculty in 1990.
13:45Moving up to associate professor in
13:4896 and then in 2001 was promoted
13:50to professor of psychiatry and if I
13:53have this right at the age of 43,
13:56she would have become one of the
13:59youngest female full professors
14:00in the history of the department.
14:03At that time, uh,
14:04those of us who worked with her
14:06and I was just starting with her,
14:08then had a little party for her.
14:12And Kathy was certainly one for
14:14celebrations and having people together.
14:16She definitely didn't really
14:18enjoy having the focus on her.
14:20And you know,
14:20so times like this when cutting the cake,
14:23you often got some awkward pictures,
14:26but she was certainly one to
14:29celebrate everybody else's
14:30accomplishments rather than hers.
14:31And just,
14:32incidentally that figure there in
14:34the background giving the Derek
14:37Zoolander model face is yours truly.
14:39A little basic sankathi some
14:41some 101 just to fill
14:44you in on the her career accomplishments.
14:45I'm not going to go into
14:47too many details of this.
14:48Many of you probably know this,
14:50but for those that don't,
14:51she was a giant in the field of
14:54substance use treatment research.
14:57Which was.
14:59Focused on funding publications,
15:01moving forward,
15:02treatments to improve people's lives.
15:05There are too many accolades and
15:07accomplishments to to mention here,
15:10but just a couple things I
15:11just wanted to highlight.
15:13Just to emphasize the success of
15:15her career in terms of NIH funding.
15:18This is from the NIH reporter
15:21database that provides a snapshot
15:23of all the NIH funding for every
15:27individual who's awarded funding,
15:29and this is.
15:30Or a search for Kathy Carroll at
15:32Yale and you could see here over the
15:34course of her career she was named as
15:37Pi or multiple Pi on 147 projects.
15:40In addition to 34 sub projects,
15:43with funding awards totaling over $100
15:47million in the course of her career,
15:49which is just incredible.
15:52Also from the NIH reporter site you,
15:55this figure provides a little
15:56bit of a snapshot of the types of
15:59topics her research was focused on,
16:01and you could see here on the inner circle.
16:03There's the psychotherapy
16:04development Research Center,
16:05which you'll hear a little
16:06bit about in today's talks.
16:07Kathy was also focused on cognitive
16:09behavioral therapy as a really
16:11influential figure in that area.
16:13Cocaine dependence, substance use,
16:15disorders in general,
16:17and the New England node of
16:19the clinical trials network,
16:20which was she was a copy on.
16:22For many years.
16:25It would be difficult to mention pieces
16:28of Cathy's career without noting the
16:31psychotherapy development Center or the PC.
16:34The PC was a night of fun.
16:37Did P50 Center of Excellence,
16:39which was initially Founded in 1994
16:41by Doctor Brown Spruce Rounsaville.
16:42Here at Yale.
16:44Kathy at that time was scientific
16:46director of the Center,
16:47and she eventually became Pi or the years.
16:50The PDC received continuous
16:52funding from Noida for 25 years,
16:54which was just incredible with the
16:57final year of funding being 2020.
17:01It really served as a hub
17:04of treatment development.
17:05It supported many staff investigators,
17:09launched the careers of dozens of
17:11people with a mission to develop
17:14innovative treatments from just
17:15where they started as good ideas to
17:18places where they became capable
17:20of widespread use as empirically
17:22supported treatments,
17:23and a couple of examples of that are
17:25prize based contingency management,
17:27which was spearheaded by Nancy Petrie.
17:30And Kathy would have played a major
17:32role in that as well as computer
17:34based cognitive behavioral therapy
17:36or CBT for CBT to which Kathy became
17:38more known in the last decade or so.
17:41Treatments that were started as good ideas,
17:43initial development and then
17:46became really more widespread.
17:48If you take a look at her publications,
17:50you'll see that she was a
17:52very prolific writer.
17:53She had around 350 peer reviewed
17:55publications and that number is
17:57continuing to shift because she was
17:59involved in a few papers prior to
18:01her passing that are still coming
18:03out. She had an h-index over 100,
18:06putting her as some of the top
18:09most highly cited researchers,
18:11particularly in the field of substance use.
18:14She had over 40,000 citations her CBT manual,
18:18which was published by Naida.
18:19In the late 90s,
18:21it's been translated into 14
18:22languages and distributed worldwide.
18:25A big aspect of Kathy's career
18:27was also her mentor ship.
18:30If you were lucky enough to
18:31be one of Cathy's men tease,
18:32you can recognize how important and
18:35influential she was into your career.
18:37There are many people that have so
18:39many positive things to say about
18:41Kathy's mentorship and how kind
18:42and generous she was with her time.
18:44These are some quotes,
18:46some of which were in her obituary that
18:49was put out shortly after her passing.
18:53It really emphasizes how much she
18:56dedicated her time to mentoring
18:59those to building them up and
19:01supporting their careers,
19:03and that was really influential for many.
19:07I think one of the, uh.
19:09Things that I.
19:10Most remember about her mentor ship
19:13was that she really liked to shine
19:15a light on other peoples work.
19:17I had been at several conferences
19:19with her where she would be providing
19:22a keynote address or at expert lead
19:24meetings and expert panel where
19:25she was one of the experts and
19:27she would often highlight or talk
19:29about other people's work there.
19:31Those that she was mentoring and
19:32it was just really incredible to
19:34see how she just used her standing
19:36to to help build up others.
19:38But she was so much more than that.
19:41This is a quote from her obituary,
19:43which I think really perfectly
19:45captures her character.
19:46Her tremendous academic and scientific
19:48accomplishments are dwarfed by her kind,
19:50generous, and playful spirit.
19:52She was so down to Earth, so humble, so fun.
19:57Loving and playful.
19:59It was just a joy to to be
20:02around her and to work with her.
20:05I've heard from many people who have said
20:07that the first time they met Kathy Carroll,
20:10they were intimidated to go
20:11up to her and talked to her.
20:13Given her standing in the field,
20:15seeing her name everywhere and
20:17publications are conferences.
20:19And then after meeting her,
20:20realizing just what a down to Earth kind
20:24of regular person she was and so kind and.
20:28Joyful that it was just really great to
20:31be around her and to interact with her.
20:34She really treated everyone like
20:35family and those of us that worked
20:37with her became like a family and many
20:39of us have stuck around for dozens
20:41and dozens of years working with Kathy.
20:44There are so many examples,
20:45too many to count of times where we
20:47all got together for work related
20:50functions or otherwise that were full of joy.
20:53Kathy treated everyone like an
20:55important member of that family, she.
20:58Never boasted on her own accomplishments.
21:01It was always a team effort.
21:03She always built everybody up,
21:06cheered us on.
21:07And it was just wonderful to
21:10work with her and to know her.
21:13I'm going to end my introductory
21:15remarks with just kind of a summary
21:17that Kathy LED with her heart and work
21:19in the community and in her life.
21:23These are some pictures from events that
21:25we would have work functions around.
21:26Holiday times where we would
21:29adopt local families who are
21:31living in transitional housing.
21:34We had children and we would all buy
21:36presents for these families and kids
21:37and have an event where we would
21:39wrap the presents together and it
21:41was a way to kind of get together
21:43and give back to the community.
21:45And Kathy LED all that she was.
21:46It was such a great.
21:48It was a highlight of each year and
21:51these events were so wonderful.
21:53To be a part of these extended
21:55then to other holidays,
21:56Easter making Easter baskets for kids,
21:59school functions and things like that.
22:02Uhm, she will be forever missed and
22:05I think this world would be a better
22:07place if we use her as an example and
22:09all of us just lead with our heart.
22:14Thank you.
22:16I will now pass things over to
22:19this more scientific ask aspects of
22:21our talk and let me introduce our
22:24first speaker, doctor Lisa Onken.
22:29After serving as the chief of the Behavioral
22:32and Integrative Treatment Branch and
22:33the associate Director for treatment at
22:35the National Institute on Drug Abuse,
22:38Lisa Onken joined the National
22:40Institute on Aging and 2015,
22:42where she directs NIH Behavior
22:44Change Intervention Program.
22:45She fosters the development of
22:47maximally potent and scalable
22:49behavioral interventions that are
22:50defined by their principles in
22:52accordance with the NIH stage model,
22:54which was created in collaboration with
22:56colleagues across NIH and Kathy Carroll.
23:01So Lisa, please feel free to share
23:02your screen and I will hand things
23:04over to Doctor Lisa and Ken.
23:18You have to unmute Lisa.
23:22No, it wasn't letting me
23:24unmute for some reason.
23:25Can you hear me now?
23:27Yes, OK, sorry about that
23:30and you can see my screen.
23:35Yes, OK. Good morning everyone, uhm.
23:41I'd like to thank Brian Kulick.
23:45And the organizing committee
23:47for inviting me today.
23:49And for the honor of honoring Kathy Carroll.
23:54I'm really humbled to talk about Kathy's.
23:59Continuing role in
24:00developing the stage model.
24:02As it evolved and how the research he
24:05did brought the stage model to life.
24:13On the yellow website it
24:16says Kathy Carroll, Dr.
24:17Carroll possessed a rare blend of brilliance,
24:20generosity and humility that propelled
24:22a career spanning over 30 years in
24:25addiction treatment research at Yale.
24:27Following a brief strength as instructor
24:30in neurology at Harvard Medical School,
24:32she joined the faculty at Yale in 1989
24:36as assistant professor of psychiatry.
24:40So what this website doesn't tell you is
24:43what Kathy was facing when she joined the
24:46faculty at Yale in 1989 and fully appreciate.
24:53Kathy's contributions and her impact.
24:56I'd like to give you a little bit
24:58of context highlighting some of
25:00the challenges that she was facing.
25:02There were two epidemics going on at the
25:05time, and the first one was with AIDS.
25:09Ah. First identified in the CDC
25:14MRR weekly report.
25:17There were five instances of young,
25:19healthy men with pneumocystis
25:22Carini pneumonia,
25:24which later became understood as.
25:27Ask.
25:28The result of HIV AIDS and by
25:32the late 1980s there were no
25:36effective therapies for AIDS.
25:39There was also the cocaine epidemic.
25:43New York Times stated in 1981 had an
25:47article called Heavy use of cocaine is
25:50linked to surge in deaths and illness.
25:56And in 1984, her cleaver and Frank
25:59Gavin reported there is as yet no
26:03definitive treatment for cocaine abusers.
26:05And that was the case.
26:08When Kathy became assistant professor
26:11in 1989, I can tell you that Kathy and
26:14I started our careers in drug abuse
26:17treatment at a very similar time.
26:19I came tonight in the late 1980s and the
26:23first meeting I ever went to at night.
26:26It was an expert meeting on
26:28cocaine dependence and treatment
26:30of cocaine dependence.
26:31And it consisted of only experts
26:34in the field and it really,
26:37yeah, I've been at NIH over.
26:4230 years now.
26:44And I've never heard such pessimism
26:47expressed that I heard at that meeting.
26:51I've literally heard one person say,
26:54well, maybe this is something
26:56that there is actually no.
26:59We will never find a treatment for
27:01this that maybe maybe this is something
27:04that's going to be intractable.
27:07So this was the climate when Kathy
27:10came and a further say that the
27:14AIDS epidemic affected the cocaine
27:17epidemic and the cocaine epidemic
27:19affected the AIDS epidemic. Uh.
27:22There were. Paradoxically, there were.
27:27There were reports of. People.
27:30Avoiding or steering away from heroin
27:33use because heroin use and injects
27:37drug use was associated with AIDS,
27:40so they transitioned often to
27:43cocaine dependence and not not fully
27:46appreciating that that was spread by.
27:53Spread by.
27:58Sorry.
28:02That cocaine could be transmitted
28:04through sexual behaviors.
28:10And to make things even worse,
28:12there were reports in
28:151989. That cocaine injection was
28:21becoming an increasing problem.
28:25So meanwhile, there were.
28:28Things going on in several fronts.
28:32Kathy was active and the
28:34federal government was active.
28:381988 Naida launched a
28:43medications development program,
28:45setting aside $8 million, which was a.
28:49Big deal at that time.
28:52And 1989, as you know,
28:57Kathy became assistant professor
28:59and the first time I met Kathy,
29:02it was an unexpected kind of thing
29:05because she showed up a meeting at
29:07a meeting she wasn't invited to.
29:10Bruce Rounsaville had been invited
29:11to the meeting and he couldn't come,
29:14and he sent Kathy in his behalf without
29:17without actually telling anyone until
29:19the last minute that Kathy was coming.
29:22So we were, you know,
29:24we had no idea who this Kathy
29:27Carroll person was and dumb.
29:30We found out who this Kathy Carroll
29:34person was in very short order and
29:37after that meeting we realized that she
29:41was an important person to involve in.
29:45Discussions around cocaine
29:47abuse and dependence treatment.
29:54So one of the first meetings that I helped
29:58organized with Jack Blaine was a technical
30:01review on psychotherapy and counseling
30:04in the treatment of drug abuse and the
30:07idea what there was to try and get it.
30:10The methodological problems in psychotherapy
30:13and counseling research and come up with
30:16strategies to deal with those problems
30:19and experts and drug abuse treatment
30:21and experts in behavioral treatment.
30:24Research, many of them very well known
30:28at National Institute of Mental Health,
30:30were invited.
30:31It was not typical to invite not
30:33only an assistant professor,
30:36but a brand spanking new assistant
30:38professor to one of these type meetings.
30:41But as you can see,
30:42Kathy Carroll was one of the
30:44participants at this meeting.
30:49Had the meeting she talked about the
30:52technology model of psychotherapy
30:54research and she followed up the
30:57meeting with a paper resulting from that
31:01presentation asking can a technology
31:04model of psychotherapy research be
31:06applied to cocaine abuse treatment
31:08that she wrote with Bruce Rounsaville?
31:14So the idea of the technology approach
31:17is to specify the treatment variable,
31:20which in this case was psychotherapy or
31:23counseling or behavioral treatment in a
31:25manner analogous to the specification of a
31:28drug formulation and pharmacological trials.
31:34Which. Fast forward a few years later.
31:40Uhm, Neider launched a the behavioral
31:45Therapies development program.
31:48Which was intended to parallel
31:50night's medications development
31:52program and parallel the process
31:55involved in medications development.
31:57With three phases of.
32:01A psychotherapy,
32:02research or behavioral therapy research.
32:08And this announcement.
32:14Paralleled the ideas that came out
32:17of that technical review and other
32:20workshops that we held with the field
32:24advising us as to new directions
32:27in behavioral treatment research.
32:29And I I should also mention that there
32:34were other announcements before this.
32:36There were other meetings before this.
32:38Kathy was heavily involved in.
32:42Many, if not most of those meetings.
32:45The big issue at the time was.
32:49The early issue was to to start funding
32:53what we now call stage one research,
32:56which we first called Phase one research,
33:00which is now a given in the field.
33:03But at the time it was pointed out that
33:06there was a catch 22 that one could not.
33:10Developed new ideas without pilot data,
33:14but in order to have pilot
33:15data you had to have funding,
33:18but you couldn't get the funding.
33:21For the pilot data,
33:23unless you had the pilot data,
33:24so the idea of phase one was an innovation.
33:29And it was brought into the behavioral
33:32Therapist Development program,
33:33which also included an emphasis on what
33:37Kathy called the technology model.
33:461994 as Brian mentioned,
33:48Bruce Rounsaville received funding for
33:52the Psychotherapy Development Research
33:55Center along with Kathy Carroll,
33:58who was a Co investigator and scientific
34:01director and the center parallels
34:05the Behavioral Therapies Development
34:07Program and also talked about three
34:10phases of research at that time.
34:17Behavioral Therapies Development
34:18Program was continued in 1994,
34:21and as you might have gleaned from
34:25from thus far, there was a bit of
34:29medication development envy going on.
34:31I would, I would say the idea was to parallel
34:36the medications development process,
34:38but in 1994 there was a bit of
34:41a split in recognition of pay.
34:44There's actually.
34:45Big differences between medications,
34:48development and behavioral intervention
34:51development and the decision was made
34:54to talk about behavioral intervention
34:57development in terms of stages.
34:59So that's where we first saw, you know,
35:04in a federal program announcement,
35:06the use of stages instead of phases.
35:13So while all of this was going on,
35:17Kathy was busy attending to
35:20important work. Very important work.
35:25She was busy finding a treatment
35:28for cocaine dependence.
35:30Which as you may recall,
35:32only six years before
35:34experts in the field were.
35:37Pessimistic that maybe this was
35:38something we could never find
35:40a treatment for and one of the
35:42reasons they were so pessimistic
35:44was there was no medication for it.
35:46And if there was no medication for it
35:49that could draw people into a clinic
35:51like was the case for heroin addiction.
35:55Uhm, how are we even going to
35:57get cocaine addicts to come in
35:59and do what they call you know
36:01talk therapy or behavior therapy
36:04or psychotherapy or counseling.
36:06But Kathy was busy and by 1994 not
36:10only had she found that cognitive
36:14behavioral had significant effects,
36:17positive effects on the treatment
36:20of cocaine dependence.
36:22She found that these effects
36:24might even be in during.
36:27In fact,
36:28that these effects might even
36:31increase after treatment ended.
36:33So this was six years after the field was,
36:37you know,
36:38almost ready to give up that
36:40anything could be done.
36:41Kathy was showing this.
36:45It was astounding.
36:47I can't even convey.
36:49How meaningful this contribution was
36:53at the time to to really understand it,
36:57you have to understand the
36:58climate at the time,
37:00and I hope I gave you a little taste
37:02of what the climate at the time was.
37:07So. Video website goes on to state. That, uh.
37:18But the depths of her contribution to
37:20the field of addiction are unparalleled,
37:22and these aren't just words.
37:27Her contributions truly were unparalleled.
37:31The website goes on to state,
37:33as Brian mentioned, that CBT has
37:36been translated in over 14 languages.
37:41And among the defining accomplishments
37:43at her career has been broader
37:45recognition of the efficacy,
37:47safety and durability of
37:49behavioral therapies and that she
37:51helped establish the stage model
37:54behavioral therapies development.
37:59Well, she sure did.
38:01And I'm going to try and give
38:04you a sense of how she did that.
38:07In her own words and.
38:12Let me start with some of what she
38:15talked about at the keynote address
38:17at the first annual meeting of
38:20the National Institute on Aging
38:23Roybal Translational Centers of
38:25the Royal Translational Centers,
38:28and this was in the end of October 2020.
38:33Now, the ruble translational centers.
38:35You might be interested to note
38:38were actually modelled around the
38:41psychotherapy development center.
38:42Which was the first center
38:45structured around the stage model,
38:48the ruybal translational centers
38:50are centers funded by the National
38:53Institute on Aging that are
38:56structured around the stage model.
38:58And there are 15 of these centers,
39:01so there is a network of these
39:03centers with a coordinating center.
39:05And Kathy was asked to give the keynote
39:09address because Kathy was the person
39:12who brought the stage model to life,
39:15whose research exemplified the
39:17stage model in its best form so.
39:23I'll give you a sense of some of what
39:27she talked about in that October talks.
39:30And one of the things that she
39:32said that you might find curious
39:34was that we were using the stage
39:37model even before we named it.
39:38The stage model has been a guiding force
39:41for all of our research from the beginning.
39:44So you might ask,
39:45well, how can that be?
39:47How can you be using the model even before?
39:51We named it.
39:54Well.
39:55The model attempts to define critical
39:57steps that are taken by the best
40:01behavioral treatment researchers.
40:03So the model actually evolved
40:05overtime as the field became more
40:08aware of what was necessary to not
40:11only develop a potent intervention,
40:14but to develop an intervention
40:16that might actually end up
40:18being implemented and used.
40:20So Kathy was doing that before
40:23the stage model was. Uhm?
40:27Was named.
40:32So what was she doing?
40:34Well then, what was the model doing?
40:35Well, the model seeks to develop
40:38interventions that are defined
40:40by their principles or by
40:41their mechanisms or by their.
40:43How and why the intervention works,
40:45not just what the intervention is,
40:47but what are the defining
40:50principles of the intervention?
40:52The model and this is what Kathy did.
40:54This is what the model.
40:56Uhm, encourages the goal of the
40:58model is not to just develop
41:01efficacious interventions,
41:02but also to develop interventions
41:04that are implementable that can
41:07actually be used in the real world.
41:10Like I said,
41:11it helps define the critical steps in the
41:14intervention process that are necessary,
41:16but it's completely non prescriptive.
41:18It doesn't tell you what to do.
41:21That has to be done by.
41:25Logically,
41:25figuring out the most important next
41:28steps to get you where you need to
41:32go so one can use the model well.
41:35Or one could use the model poorly.
41:38And Kathy used the model in a very
41:41systematic, logical and pragmatic way.
41:45Her approach to treatment development was
41:49absolutely brilliant and there was no behave.
41:52Better behavioral treatment
41:54researcher than Kathy. So.
41:59Kathy was doing what the model was.
42:03Encouraging and she did it well and
42:07you didn't need to call it the model,
42:09and in order for her to be using the model.
42:14Another quote from her,
42:16a keynote speech,
42:18he's, oh boy,
42:20it's really not linear and she
42:23stressed the importance of often,
42:27you know,
42:27going back to the earlier stages
42:30until you get the work done,
42:32that there may need to be repeated
42:37attempts at come.
42:39Uh, understanding mechanism.
42:40There may need to be repeated attempts
42:44at reformatting the intervention
42:46to make it real world friendly.
42:48One might need to go back to stage
42:51one to develop training materials for
42:54people to use the model correctly and
42:58test those training materials so that
43:00the intervention can be delivered
43:02with fidelity in the Community,
43:05and that's what she meant when she said,
43:08oh boy.
43:08It's really not linear.
43:13She also said, and this this wasn't it.
43:16Come at her talk in October.
43:19This wasn't a commentary.
43:21She wrote that psychotherapies
43:23have similar effect sizes,
43:24does not translate to,
43:26so it doesn't matter what you do,
43:29Kathy understood that it matters what you do,
43:32and she often talked about research
43:36on where clinicians professing to use
43:41specific evidence based treatments.
43:44If Pierik Lee validated treatments
43:47indicated they were doing things such
43:50as CBT and 12 step facilitation.
43:53That the interventions associated
43:55with these therapies were so rare
43:58as to be almost undetectable.
44:01In other words,
44:02the therapists weren't necessarily
44:04doing what they were supposedly saying
44:06they were doing and trained to do.
44:09And that they consistently overestimated
44:12the amount of evidence based
44:14therapies or empirically validated
44:16therapies that they were delivering.
44:19And that often what was happening
44:21was chats as opposed to the
44:24evidence based intervention and
44:26Kathy frequently spoke about chat.
44:31So Kathy understood that the
44:33type of treatment matters and
44:35what a therapist does matters.
44:37And the stage model presumes the
44:40type of treatment matters and
44:42what the therapist does matters.
44:44Kathy said in her keynote address
44:46we did focus on mechanism.
44:49I can't emphasize this more strongly.
44:53And.
44:54She understood that the goal of
44:57treatment development does not end
44:59with defining what a treatment is that
45:02one needs to define a treatment by
45:05the mechanism through which it works,
45:07so this is consistent with the stage model.
45:10This is consistent with.
45:12What Kathy did the way she
45:15conducted her research.
45:18She said in her keynote you have to
45:20continue to your development until
45:22you really have the most potent form
45:24of your intervention that can be
45:26delivered in Community settings again.
45:28Goal of the stage model.
45:33Because according to the model,
45:35potency and efficacy aren't enough.
45:38Treatment development is not complete
45:40until people in the Community can
45:43actually deliver the treatment
45:44with fidelity or the treatment
45:47can be delivered in other ways,
45:49such as computer based CBT is delivered.
45:57She said there's no skipping things
45:58like coming up with training manuals,
46:00what's prescribed,
46:02what's proscribed also completely
46:04consistent with this stage model.
46:07The model emphasizes developing
46:09training materials for people in the
46:11community who will be administering
46:13the treatment to end it and testing
46:16these materials to ensure that there's
46:18actual fidelity of treatment delivery.
46:22And Kathy said in her keynote,
46:24you're not done with an intervention
46:27until you bring it home.
46:29And Kathy did bring it home.
46:33She developed the first in during
46:36treatment for cocaine and she also showed
46:38us ways to successfully deliver it,
46:41which, by the way, at the time,
46:43when the first results came out
46:46for cognitive behavioral therapy,
46:48I heard all sorts of complaints that
46:51this was this treatment was so complex,
46:54so difficult to administer,
46:56so expensive it could never be
46:59delivered in the real world.
47:01Therefore,
47:01maybe we shouldn't have even supported.
47:04It's developments Kathy understood.
47:06You don't throw the baby out with the
47:10bathwater and she figured out a way to
47:13make it deliverable with fidelity in
47:16another form without losing efficacy,
47:20unbelievable accomplishment,
47:21and all the while she was modest,
47:25she was humble. She was unassuming.
47:29You know this page here could go on for.
47:34Multiple pages, I mean she she was empathic.
47:38She was caring.
47:39She cared about people.
47:41She cared about people who were close to her.
47:44I can barely remember a time when we talked.
47:49I called her after she gave a phenomenal
47:53talk in early December to congratulate
47:56her on what a great talk it was and
48:00she she mentioned her to her daughter
48:04and it was just so obvious how.
48:07Proud she was of her.
48:11Daughter and her family,
48:12and that was what she really cared
48:16about and people around her knew
48:18she had her priorities straight.
48:21She was funny. She was ironic.
48:24She had no pretense.
48:25She cared about the truth
48:27in the way she lived,
48:29but she cared about the truth as a true
48:33scientist should care about the truth,
48:35and she didn't mince words.
48:38She spoke the truth very clearly.
48:42She questioned the status quo.
48:45The effect she's had on her minties,
48:47I mean, is. Is more than than evident.
48:53Uhm,
48:53she mentored the net the best
48:56of the next generation of.
48:59Behavioral treatment researchers.
49:03And one could argue that there's
49:04no one who contributed more to
49:07drug abuse treatment then Kathy.
49:08In fact, I would argue that.
49:11No one has and that her brilliance
49:15was absolutely staggering. So.
49:20She brought the stage model to life.
49:24Uhm,
49:25immeasurably improving drug abuse treatment.
49:30And.
49:33She you know she didn't.
49:35She modeled the best of behavioral
49:39treatment research and in doing
49:41so was able to accomplish this.
49:44She didn't stop when she had
49:46an efficacious treatment.
49:47She never stopped when there were
49:50people there who still needed help or
49:53something could still be improved.
49:56And her research accomplishments
49:59I would say are surpassed only by
50:03the absolutely profound influence
50:05and impact she's had on her family,
50:08friends, men, Tees, and.
50:12Drug abusers, people in need.
50:16Thank you for your time.
50:24Thank you very much, Lisa. That was great.
50:28I'm now going to pass things
50:30over to Doctor Steve Martino.
50:34Doctor Martino is a professor of
50:36psychiatry at the Yale School of Medicine
50:38and Chief of the Psychology Service,
50:40the VA, Connecticut healthcare system.
50:42Dr Martino Martino has worked
50:44with Kathy Carroll for 25 years,
50:46serving as the education director
50:48of the Psychotherapy Development
50:49Center for a decade and being
50:50heavily involved with her team in
50:52the New England node of the night,
50:53a clinical trials network over the
50:55same period of time they continue
50:57to collaborate and doctor Martino's
50:59implementation science trials,
51:00which he credits the Doctor Carol's
51:02essential mentorship during his career.
51:04Doctor Martino is best known for his
51:06work studying the implementation of
51:08motivational interviewing and community
51:10treatment and medical settings.
51:12He will speak about Doctor Carol's
51:14contributions to stage four effectiveness
51:15and stage five dissemination
51:17and implementation research in
51:19the addiction treatment fields.
51:20Please welcome Doctor Steve Martino.
51:24Thank you Brian, and thank
51:26you for giving me the honor
51:29of being able to talk about Kathy.
51:32Kathy served a very pivotal,
51:34pivotal role in my career,
51:36and like many others,
51:37you know who are present today.
51:39I am forever grateful for her mentoring,
51:42her generosity,
51:44her professional nudges along the way,
51:47and decades of collaborative research.
51:51So for any of you who've worked with Kathy.
51:55You know that if you want to
51:58get her involvement on a grant,
52:01you had better get your specific aims
52:04and order and there was no green light
52:07to go forward until you got that right.
52:11And so this was it would be especially
52:14true today if I was to tell her I was
52:17going to present some remarks about her.
52:20And so, in preparation for my talk,
52:23I decided that I would send my specific
52:26aims to Kathy for her review and commentary.
52:30So my initial aims were to specify
52:32Doctor Carol professional strengths,
52:34talents and accomplishments to
52:36calculate aim to Kathy Carrales
52:39h-index and compare it to others.
52:42And three to give an academic talk
52:44about Doctor Carol's contributions
52:46to stage four and five a behavioral
52:50intervention development for addictions.
52:52So I sent it up to her and this
52:54is what I got back.
52:56Aim one really, not sure this is needed.
53:02Scratched it out.
53:04Aim to.
53:06See only if it makes some of the
53:09men in the room uncomfortable.
53:12Perhaps something more interesting.
53:14As you know, Kathy had a very
53:17teasing and dry sense of humor,
53:21and often with ironic undertones.
53:25Actually, it's really veils.
53:27The fact that she hates aimed to and and
53:31so aimed three to give an academic talk.
53:34She says this might work if it
53:36relates to what Brian and Lisa
53:38have to say could be too sterile.
53:40Make it fun.
53:43So she always wanted things to fit together.
53:45Synergy was what Kathy was all about,
53:47especially in complex
53:50multi component projects.
53:53So you know I'm going to try to
53:55have fun with you all today,
53:57so I revised my aims and this
53:59is what I came up with.
54:00And of course I had to get
54:02Cathy's approval so.
54:03First aim is to gather attendees
54:06thoughts about Doctor Carolyn,
54:08a feasible acceptable in an engaging manner.
54:11She says OK, if you must, but keep it simple.
54:14Number two to speak about.
54:16Doctor Carol's collaborations that
54:18fostered her remarkably productive career.
54:21She notes I couldn't have done
54:23it without all of you.
54:25And #3 to identify Dr.
54:29Carol's contributions to stage four
54:30and five of the behavioral intervention
54:33development for addictions and the fun times.
54:36Along the way, she says great,
54:39I moved on to stage six transcendence.
54:43Let's talk about a potential
54:46manuscript and I like transcendence.
54:49So as many of you have worked with Kathy,
54:53you know she would often stimulate
54:55some type of conversation so.
54:57I got back in touch and I was like,
54:59well what do you mean by transcendence?
55:02And so she said.
55:05Well,
55:06you you have to sort of think about it
55:11as like Wagner's Tristan and Zelda,
55:15one of her favorite operas.
55:17It's one of the most moving forward
55:20thinking and divine works of art
55:22the Western world has ever known,
55:24and she goes on.
55:26And she says transcendence is when
55:28a behavioral intervention reaches
55:30a state of excelling or expand,
55:32surpassing expectations beyond the usual.
55:36Limits of science.
55:37While true to Kathy Spirit,
55:40it's good to have aspirational goals.
55:43But once again,
55:45Kathy is already ahead of the game and
55:48seems to have already achieved stage 6.
55:54So let's get on with the Ames specific aim.
55:57One to gather attendees thoughts
56:00about Doctor Carolyn, a feasible,
56:02acceptable and engaging manner now
56:05Kathy liked to interact and pull
56:08the best ideas out of everyone,
56:11and so that's what I'd like
56:13to do with you today.
56:15And I'd like you all to think about
56:17a word that comes to mind when you
56:20think about Kathy Carroll and I'd
56:23like you to respond to this poll.
56:25You could either go to you can go to
56:30polleverywhere.com Steve Martino 383.
56:33And just type in the word that comes to mind.
57:11Second
57:36there you have it, and
57:38this can keep going on and
57:39on and on. As others have mentioned,
57:42brilliant, funny.
57:43Kind and caring and generous.
57:46Warm, loving, supportive,
57:48creative, inspirational,
57:50authentic, thoughtful.
57:52Revolutionary, inspiring, dynamic.
57:55All of these things more than all of the
57:58other accomplishments is what people who
58:01knew Kathy knew to be true about her.
58:04This is what Kathy Carroll disseminated,
58:07and this is what we will all remember.
58:14So specific game number 2.
58:18To speak about Doctor Carol's
58:21collaborations that fostered her
58:23remarkably productive career.
58:25These are, as others have mentioned,
58:27Brian mentioned,
58:28or some of her most important collaborators.
58:32And you've heard about the holiday parties,
58:35the Easter baskets that were filled.
58:38Here's the picture of Kathy giving carols
58:42carols to the kids at the Christmas party.
58:47So really, this dissemination of love
58:50of goodwill, charity and kindness is so
58:54evident in what Kathy was all about,
58:57but we need to get back to
58:59the data Kathy always did.
59:01And as you can hear, Kathy,
59:05say, data never lies.
59:08So I'd like just quickly in the chat box.
59:13Anyone want to take a guess?
59:14How many coauthors on peer
59:17reviewed publications?
59:18Do you think Kathy had over
59:20the course of her career?
59:21Just pick a number.
59:27Just type it in the chat box.
59:34Anyone else? Well, I'll tell you if
59:37you took a mean of all that with
59:40the standard deviation and whatnot,
59:41you'd probably get it right.
59:42It was 534 of just your
59:46peer authored manuscripts,
59:48so a lot of people a lot of correct
59:52collaborations over the years.
59:54And Kathy was a disseminator of very
59:57high quality scientific literature.
59:59And actually people read her stuff.
01:00:03Her h-index is Brian mentioned
01:00:06was off the charts.
01:00:08It's the mark of somebody who's
01:00:10really considered out beyond
01:00:12outstanding and innovator.
01:00:14Someone who's making a remarkably
01:00:17important impact on a field.
01:00:20And in case you don't know who all
01:00:23of her collaborators have been,
01:00:25many of you are on this talk on this
01:00:28grand rounds honoring her today.
01:00:30Here's the cascade of collaborators from A-Z.
01:00:33And I'll apologize if I missed someone,
01:00:36but just to give you a sense of the
01:00:39people that she's collaborated with.
01:00:42All over the years.
01:00:51So.
01:00:55Here's where the rubber met the road.
01:00:58Anyone working with Kathy knows
01:01:00about her weekly data meetings.
01:01:02Now weekly I say in quotes because,
01:01:06well, Kathy kind of traveled a lot,
01:01:09and I recall often where people
01:01:11would say are we meeting today?
01:01:13This is Kathy coming in today.
01:01:14You know, we wouldn't know which State City
01:01:17or country she happened to be giving a talk
01:01:20in or presenting at or consulting too.
01:01:22But when those meetings happened
01:01:24that's where the magic happened.
01:01:26And this is a classic picture.
01:01:28Sambol Karen Punky Charlotte Niche,
01:01:31Kathy sort of batting around
01:01:34an idea talking about data.
01:01:36And I want to draw your attention
01:01:39to this stack of papers.
01:01:42This pad this.
01:01:46I don't know what it was actually
01:01:48sometimes and she would write.
01:01:51She would have her To Do List on there
01:01:54and she would scribble on it and
01:01:56cross things out and circle things.
01:01:58And you knew if she circled something twice,
01:02:01it was probably a high priority.
01:02:03But one of the things she had on her list.
01:02:07Part of this was something she affectionately
01:02:10referred to as Blonde and Bishop.
01:02:13Blonde ambition was a list of manuscripts
01:02:16that people had committed to writing,
01:02:20and if you got on that list,
01:02:22your name never came off unless you
01:02:25finished that manuscript and she used
01:02:28the joke about her blonde hair being
01:02:31her secret weapon and how people would
01:02:35often underestimate her because of it.
01:02:37Uhm, if you made blonde ambition
01:02:41she was not underestimating you.
01:02:44And so I'd like to see this
01:02:47tradition continued.
01:02:48I've made a list of manuscripts that
01:02:50need someone to take the lead on and and
01:02:54if any of you feel inclined to do so,
01:02:57please just write it in the chat box that
01:03:00you'd like to write one of these manuscripts.
01:03:03So here we go.
01:03:04Whoops, subtypes of Kathy
01:03:06Carrales men tease the good,
01:03:08the not bad, and then never ugly.
01:03:11Number two,
01:03:12the touch of Midas Kathleen Carroll's
01:03:15contributions to addiction treatment.
01:03:18I don't see anyone signing up yet.
01:03:19All right. Let's try this one.
01:03:21You can't manualized Kathy Carroll,
01:03:24but you can try to live up to
01:03:27her principles with fidelity.
01:03:29I think we got one for that one.
01:03:30OK,
01:03:31let's see Kathy Carroll's enduring
01:03:34effects betwixt and between
01:03:36the personal and professional.
01:03:39Alright. Number five,
01:03:40there is no regression to the mean.
01:03:44Sustaining a rigorous
01:03:46psychosocial research agenda.
01:03:49Alright,
01:03:50last one.
01:03:52Missingness.
01:03:52Is it possible to bridge the
01:03:55gap left by Kathy Carroll using
01:03:59hierarchical linear regression?
01:04:01I'm going to assign that to Cheryl.
01:04:06There you go.
01:04:09So everyone has mentioned
01:04:12that Kathy has been.
01:04:14A wonderful mentor.
01:04:16Very powerful mentor influencing
01:04:18the careers of so many people.
01:04:21This is a quote that I really love.
01:04:23If I have seen further is by standing
01:04:25on the shoulders of giants now when
01:04:28I was looking for an image for this.
01:04:30Lo and behold, when you search for
01:04:33images of shoulders of giants,
01:04:35you pretty much get men as the giants,
01:04:39and I knew that I would never dishonor
01:04:42Kathy by not allowing a picture of a woman
01:04:45as a giant to reflect her accomplishments.
01:04:49And so here's the one I found. And.
01:04:54What I'd like to do is I actually.
01:05:00Wanted to work with sharla little
01:05:02bit on this in order to, uh,
01:05:04calculate the effect of Kathy train
01:05:07Kathy's training effect on the field
01:05:09and all the people she mentored,
01:05:12so we quickly calculated some effect sizes.
01:05:16Cohen's D odds ratio and number needed
01:05:19to treat should have said to train.
01:05:22Cohen's D of 3.0 indicates that 99.9%
01:05:26of people who worked with Kathy
01:05:29have advanced in their careers and
01:05:32odds ratio of 99.9 really reflects.
01:05:35There's a 99.9% likelihood of benefit
01:05:39resulting from those who collaborated
01:05:41with Kathy and number needed to treat
01:05:44of 1 means that every person with whom
01:05:48Kathy collaborated had better career
01:05:50outcomes after this interaction.
01:05:53And So what we then did is we tried
01:05:56to make a composite KC effect and
01:06:00this is what we came up with.
01:06:02It does not compute, it's immeasurable,
01:06:05so we'd all like to thank Kathy for
01:06:09disseminating her expertise and
01:06:11giving us a lift along the way.
01:06:17Alright, specific game 3. To identify Dr.
01:06:22Carol's contributions to stage four
01:06:24and five behavioral intervention
01:06:26development for addictions and
01:06:28the fun times along the way.
01:06:30So let's start off what stage
01:06:32four and what stage five.
01:06:33So stage four is effectiveness research here.
01:06:37The point is really where you're
01:06:39examining behavioral interventions
01:06:41and community settings with
01:06:43community providers and supervisors,
01:06:45and the emphasis is on external validity.
01:06:48You really asking.
01:06:49How well does treatment work
01:06:51in the real world?
01:06:53These are pretty much pragmatic
01:06:55trials that proceed dissemination and
01:06:58implementation and then stage five is
01:07:01dissemination and implementation research.
01:07:03So here you're trying to look at barriers
01:07:07and facilitators of implementing practices.
01:07:09You're looking at how to develop strategies
01:07:14in order to promote the awareness and use
01:07:18of those practices in community settings.
01:07:21And putting those things in place.
01:07:25So before we tackle aim three,
01:07:28I'd like to briefly talk about a
01:07:31few aspects of Kathy's work that
01:07:34are related to these stages.
01:07:37So first,
01:07:37what's in a title?
01:07:39You've heard all of her titles?
01:07:41I'm not going over it again.
01:07:42Kathy would probably be
01:07:44bored to death by now,
01:07:45blah blah,
01:07:46but there are some titles that
01:07:49Kathy really did Cherish and
01:07:52those were of her manuscripts.
01:07:55And so there were a lot of competitive
01:08:01team discussions sometimes and coming
01:08:03up with some of her clever titles.
01:08:07So here are my top 10 + 1
01:08:08'cause it couldn't help myself.
01:08:10Clever titles of Kathy's manuscripts,
01:08:13Blind Man's Bluff effectiveness,
01:08:15and significance of psychotherapy,
01:08:17and psycho pharmacotherapy.
01:08:19Blinding procedures in a clinical trial.
01:08:22Constrained,
01:08:23confounded and confused why we know
01:08:26so little about therapist effects?
01:08:29On beyond urine clinically useful
01:08:31assessment instruments in the
01:08:33treatment of drug dependence.
01:08:35We don't train in vain dissemination.
01:08:38Trial of three strategies of training
01:08:41clinicians and cognitive behavioral therapy.
01:08:44Disulfiram cocaine and alcohol,
01:08:46two outcomes for the price of 1.
01:08:50One small step for manuals,
01:08:52computer assisted training
01:08:54and 12 step facilitation.
01:08:56Making consent more informed preliminary
01:08:59results from a multi multiple choice test.
01:09:03What is usual about treatment as usual data
01:09:06from 2 multi site effectiveness trials?
01:09:10Perhaps it's the dodo bird effect,
01:09:12but the dodo bird verdict
01:09:14that should be extinct.
01:09:16What happens in treatment
01:09:18doesn't stay in treatment.
01:09:20Cocaine abstinence during treatment is
01:09:22associated with fewer problems that
01:09:25follow up and finally lost in translation,
01:09:27moving contingency management
01:09:30and CBT into clinical practice.
01:09:33So dissemination is often
01:09:36about getting people.
01:09:37To read what you have to say
01:09:40and get interested in it.
01:09:41And Kathy was the master of it,
01:09:43especially with their specific games.
01:09:47So.
01:09:47I would have to say that
01:09:51dissemination was in the bloodstream
01:09:54of the psychotherapy development
01:09:56center from the very beginning.
01:09:59Even though the focus was more on stages,
01:10:01one through three,
01:10:03really there was from the getgo this
01:10:05idea how we going to inform people
01:10:08about what we're doing and make
01:10:10it useful for community programs.
01:10:12Now a shout out to Katie Nuro,
01:10:14who was very much part of this
01:10:17early effort to,
01:10:19you know, make manuals that are usable,
01:10:21and then everybody being trained in how
01:10:23to do that and having training packets
01:10:26that would provide video examples of.
01:10:29The treatments and guidelines on how
01:10:32to implement the various treatment.
01:10:35So these are some of those
01:10:37packets that dare I say,
01:10:39a few might remain in the psychotherapy
01:10:42development center and I have
01:10:43to give a shadow to the yellow
01:10:46adherence and competence scale.
01:10:47This was really a very important
01:10:50fidelity general fidelity rating
01:10:52tool used in addiction treatment to
01:10:54capture the fidelity of implementing
01:10:56a lot of the treatments that erodes.
01:10:59Out of the psychotherapy development center.
01:11:04And another aspect of translation
01:11:06that Kathy really jumped on quickly.
01:11:10Dare I say faster than most others is
01:11:13including health economists in her trials,
01:11:16and so she was quick to recognize
01:11:19that if you don't show what the bang
01:11:21for the buck is for the treatments
01:11:23you're trying to get people to use.
01:11:26People like policymakers,
01:11:27state single state authorities,
01:11:30program directors might not
01:11:32be interested and so she.
01:11:34I was very invested in show me the money
01:11:38and I have to say in some ways very
01:11:43much like Jerry Maguire really choosing
01:11:45with whom she worked to produce better,
01:11:48more caring,
01:11:50personal and professional relationships,
01:11:53even if not always easy,
01:11:55always striving for the best outcomes.
01:12:00And another thing that Kathy did in
01:12:02terms of the field for translation
01:12:05is identifying racial and ethnic
01:12:07disparities in treatment outcomes
01:12:09and culturally adapting treatments.
01:12:12This is so important for
01:12:14dissemination and implementation.
01:12:15Even if the treatments were initially
01:12:18shown to work or implemented well,
01:12:21and maybe even cost effective,
01:12:24they may not be so in different,
01:12:27different other types of communities,
01:12:29different communities.
01:12:30And so she was very much interested
01:12:33in this and how long stream of
01:12:36collaborators and projects from a Spanish
01:12:39met project in the clinical trials
01:12:41network or collaborations with Latrice
01:12:43Montgomery and now with Ionic Jordan.
01:12:46And of course, many Paris Michelle, Silva,
01:12:50Louise Onions, Nava and and others.
01:12:56So let's go on stage four
01:13:00effectiveness research.
01:13:01I would say that one of Cathy's major
01:13:03contributions in this area was being one
01:13:07of the original peas in the formation of
01:13:10the night at clinical Trials Network.
01:13:13Kathy led the New England node.
01:13:15She overtime developed important
01:13:19collaborations with her Co P Roger
01:13:24Weiss and then ultimately bringing
01:13:27GAIL D'onofrio into this group.
01:13:30We had a lot of fun in developing
01:13:34this and I really want to underscore
01:13:38the importance of this bidirectional
01:13:41effort to bring researchers.
01:13:43And Community partners community
01:13:46programs to the table and design
01:13:50studies and identify treatments that
01:13:53were perhaps ready for pragmatic
01:13:56trials into to determine their effectiveness.
01:14:01Her big contribution were three
01:14:05motivational interviewing trials.
01:14:08The first was trial.
01:14:09Looking at using MI in an intake
01:14:13process in order to engage.
01:14:15Treatment seeking folks into treatment.
01:14:18A second one was a version of motivational
01:14:22interviewing that included feedback
01:14:24known as motivational enhancement therapy.
01:14:27Sambol led the main outcome paper,
01:14:30which is a very highly cited paper,
01:14:33and.
01:14:35Spanish version of that met trial
01:14:38for monolingual Spanish speaking.
01:14:40People using substances and Kathy was
01:14:44really great at consolidating lessons
01:14:47learned and put out a really nice paper
01:14:50after a decade of the CTN highlighting
01:14:53some of the accomplishments of the CTN,
01:14:55including the need to develop general
01:14:59generalizable training strategy approaches,
01:15:02and again a shout out to Sam Ball on
01:15:04this for all the work he did during
01:15:07that decade and developing training
01:15:08methods that were used within.
01:15:10These these trials,
01:15:12attending the site effects big
01:15:15important contribution that Kathy
01:15:17made characterizing treatment as usual.
01:15:19It's sort of getting into the black
01:15:21box of what that is,
01:15:22how it looks.
01:15:24Highlighting the need for common outcome
01:15:26measures to be used in treatment
01:15:28outcome studies for illicit drug use,
01:15:30and that's been one of the strains
01:15:32of research that she's continued
01:15:34to width and that Brian has been
01:15:36very important in advancing are
01:15:39reaching underserved communities.
01:15:40I've mentioned that already,
01:15:42and building implementation science
01:15:45into the addiction treatment field.
01:15:48Which leads us to the next stage.
01:15:52Stage five implementation
01:15:54and dissemination research.
01:15:55So part of the CTN was to try to get
01:15:58the products that were coming out of
01:16:01the CTN and getting them into practice.
01:16:05So there was something called
01:16:06the blending initiative which was
01:16:08a partnership between Naida and
01:16:10the substance Abuse and Mental
01:16:12Health Services Administration.
01:16:14That's the arm that really is
01:16:17tasked with getting things out
01:16:19into the community and and so.
01:16:21This blending initiative put together
01:16:23these blending teams and out of
01:16:26those teams would be products that
01:16:28would help that hopefully will
01:16:30be useful to the practitioners.
01:16:32And one of those major products that
01:16:34came out of this was something that
01:16:36evolved from those three MI trials,
01:16:38providing a toolkit for supervising
01:16:41people in motivational interviewing
01:16:43which was largely informed by the
01:16:46Yaks Fidelity rating system that
01:16:48became adapted within the My trials.
01:16:54But most importantly,
01:16:56I want to highlight this study
01:16:58that Kathy did with Diane Sholom.
01:17:00Sqas and Kathy was so busy dancing with
01:17:04stages one through three even and four,
01:17:08it's hard to imagine how she would
01:17:10have time to even fit in stage five.
01:17:12And at the time night,
01:17:14it wasn't exactly supportive
01:17:16of it in the way that they are.
01:17:19Maybe more so now of dissemination
01:17:22and implementation.
01:17:23Research, and so Kathy.
01:17:26Actually with others,
01:17:28started a small business which
01:17:32was called the Applied behavioral
01:17:35research and she got small business
01:17:38grants in order to run clinician
01:17:41training trials and so this
01:17:44was one on cognitive behavioral
01:17:46therapy that really highlighted
01:17:48the promise of computer based
01:17:51training as something that could.
01:17:53Potentially be useful in the field for
01:17:56clinicians as well as delivery of CBT
01:18:00and also the importance of feedback
01:18:02and coaching as key components in
01:18:05supervision in order to advance the
01:18:08practice of clinicians to reach at
01:18:11least adequate levels of fidelity.
01:18:14So she was kind of like water
01:18:16rushing over stones like there was no
01:18:17stopping her if she had an idea and
01:18:19she thought it was important she was
01:18:21going to figure out a way to get it done.
01:18:25So I had this idea and this is really
01:18:29an example of Kathy as a barometer.
01:18:33Again,
01:18:33those who knew Kathy is she
01:18:35was always shopping for ideas.
01:18:36She was listening for what was happening
01:18:39in the field and and so in 2004,
01:18:41while I was part of the CTN
01:18:44as part of what I was doing,
01:18:46I was starting my own clinician training
01:18:48research in motivational interviewing.
01:18:50I wanted to do a trial on CBT training,
01:18:54so I presented my ideas to Kathy.
01:18:56And I got what some of you
01:18:58may have experienced,
01:18:59which is that that sort of look
01:19:01she gives you when you know she
01:19:03doesn't really like the idea that
01:19:04you're presenting one eye closed
01:19:06sort of tongue stuck out of the
01:19:08side of her mouth looking at you
01:19:09like she's thinking about it,
01:19:10but you know she doesn't quite like it.
01:19:12And she basically said that CBT already
01:19:15had strong evidence in a variety of
01:19:18areas for different targeted substance uses.
01:19:21But there were so many barriers to.
01:19:25To training clinicians in the approach,
01:19:28it's expensive.
01:19:30It's time consuming.
01:19:31Clinicians are going to
01:19:33drift in their performance.
01:19:35Supervisors are unlikely to listen
01:19:38to or directly observed sessions.
01:19:40Who's going to use the fidelity
01:19:43rating scales anyway.
01:19:45Clinicians are busy and in
01:19:47short supply they turn over.
01:19:49And so let's just say I was a little
01:19:53deflated after the conversation,
01:19:55but what I didn't know is Kathy already
01:19:59had another idea and that was CBT for CBT.
01:20:03Uhm,
01:20:04this was her pride and joy for
01:20:06the last 10 years easily.
01:20:09And it really was a way in which Kathy
01:20:13managed to work across frankly all the
01:20:17stages of psychotherapy development.
01:20:19This was and is an interactive
01:20:24multimedia self guided.
01:20:26Intervention really,
01:20:28presenting different modules
01:20:29and topics of CBT
01:20:32and oh the fun many of us had
01:20:35in creating the characters,
01:20:37writing the scripts,
01:20:39selecting actors for the videos that
01:20:42were shot to be produced for this,
01:20:44and envisioning how all the
01:20:46parts would fit together.
01:20:48And we all worked with Kathy to
01:20:50try to help her envision this
01:20:52dream and share it in that dream.
01:20:55There were versions.
01:20:56Developed for alcohol for mixed drug and
01:21:00alcohol use for methadone maintenance.
01:21:02So there was a module added
01:21:05on HIV prevention.
01:21:06There is primary Spanish speaking versions.
01:21:11There are efforts there for use
01:21:14of this in primary care settings.
01:21:18Work on how to use this within black
01:21:21churches and now an ongoing effort for
01:21:24adapting it for use for chronic pain and.
01:21:27OUD, there are innumerable arced,
01:21:30supporting the efficacy and the
01:21:32durability of the effects of CBT for
01:21:35CBT and there are studies ongoing,
01:21:37as you can imagine,
01:21:39'cause this is Kathy Carroll
01:21:41testing the mechanisms of action
01:21:43and how it might generalize to
01:21:46culturally diverse populations,
01:21:47all true to the NIH stage model.
01:21:51So.
01:21:51What else is there to say about what
01:21:55we've learned for Kathy Carroll when it
01:21:58comes to stage four and stage 5 research?
01:22:02So I want to end by sharing a few
01:22:06pointers that I feel are taken
01:22:09from Kathy Carroll's playbook.
01:22:12The first is,
01:22:14he'll partake.
01:22:16We're all in the process of accepting
01:22:19our loss and Kathy in different ways.
01:22:22And I'd be remiss.
01:22:24And inauthentic not to acknowledge
01:22:27that Kathy had her own share of
01:22:31personal and professional heartaches?
01:22:33But the thing about Kathy was,
01:22:36no matter how despairing things
01:22:38might be in the moment she showed
01:22:41us that heartache can heal.
01:22:43That sense can rise from setbacks
01:22:47and new unexpected opportunities and
01:22:50relationships can propel us forward.
01:22:56And be bold. Kathy Carroll was bold.
01:23:01Especially in this day and age,
01:23:03we need to be bold.
01:23:05Don't settle for mediocrity.
01:23:07Kathy never did.
01:23:09Don't cut scientific quarters corners.
01:23:13I dare you share that with Kathy if you try.
01:23:17Keep the innovation coming.
01:23:21And speak your informed mind.
01:23:24Kathy did this on a.
01:23:28With us all on all of her numerous
01:23:31grants and just for the record,
01:23:33she got funding on nearly every
01:23:35single one of her grants,
01:23:37and almost always from the first submission.
01:23:44Hey have fun. You've heard that
01:23:46theme throughout last night.
01:23:48For those who were present
01:23:50and obviously today.
01:23:51Uhm, Kathy was dedicated to the
01:23:55Christian Community Action organization.
01:23:58She cared about giving to the community
01:24:01where much of her research was conducted.
01:24:04And she had a hell of a lot
01:24:07of fun along the way. So.
01:24:09Please contribute to the funding of
01:24:13Kathy Carol's memorial playground.
01:24:15I have posted the two different sites
01:24:20that you can provide funding to.
01:24:22The playground will serve families
01:24:24and children of New Haven and keep
01:24:28Kathy Carroll's playful spirit alive.
01:24:32Finally.
01:24:34This would be a true Kathy Carol carry on.
01:24:40This is a picture of a lot of the people
01:24:44who have worked with Kathy over the years,
01:24:46taken a few years ago and it indicates
01:24:49the number of years that they had
01:24:51been working with care with Kathy.
01:24:53Check out the longevity.
01:24:55Look at those numbers, folks.
01:24:59It's a tribute to Kathy and the types
01:25:03of relationships and collaborations
01:25:05and loyalty that she built.
01:25:08Blonde ambition it ain't no joke.
01:25:12So Cathy,
01:25:13we carry on in our dedication to the
01:25:18highest quality addiction research
01:25:20channeling you along the way.
01:25:23Striving to make the new stage six of
01:25:27the NIH model transcendence possible.
01:25:31And we'll be in touch about that manuscript.
01:25:35Thank you.
01:25:49Thank you Steve. That was amazing.
01:25:51Sorry to try to compose
01:25:52myself here at the end.
01:25:56Thank you all for sticking with this session.
01:25:59I know we're running a bit long here.
01:26:03My understanding is that the
01:26:04zoom link stays open for awhile.
01:26:06If if people want to share any comments.
01:26:08I so wish we could have done some of
01:26:10this in person to be able to hug each
01:26:13other and share memories and thoughts,
01:26:15but if anyone does feel a
01:26:17need and wants to to share,
01:26:20I open up the floor to additional
01:26:23thoughts or comments.
01:26:49I see lots of things coming in the chat.
01:26:51Everybody so appreciative.
01:26:55This is Ben, just a wonderful tribute.
01:26:59Stevie captured all of that perfectly.
01:27:03And I dare say there isn't much
01:27:04more to be said at the end of that.
01:27:05I think that was a great
01:27:07way to to finish this,
01:27:08as we all try to to carry on.
01:27:12Uhm, so thank you all.
01:27:15Wish you all the best and hopefully
01:27:17we all get to gather together again in
01:27:19person and and share memories of Kathy.
01:27:23Thank you,
01:27:25thank.