Research Efforts in South
Donnie W. Watson, Ph.D., Rick Rawson,
Ph.D., Professor S. Rataemane, M.D.
FRI, Inc.,UCLA ISAP/Medical University of
South Africa/University of Limpopo
R01DA019063-01: The goal of this project is to assess the efficacy of
three (3) training approaches on Republic of South Africa (RSA) clinicians’
ability to adhere to the core elements of a research based model for
individual Cognitive Behavioral Therapy that is adapted for use in RSA.
Thus, 150 RSA clinicians at 30 treatment centers in a 12-session CBT
intervention adapted from the Carroll CBT model will randomized to: 1) An
in-vivo (IV) CBT training and supervision program in which clinicians
receive approximately 84 hours of training and supervision with CBT from
a South African Professional who will be trained in the United States (US)
by an Expert Trainer; 2) A distance learning only (DLO) training and
supervision approach, in which RSA clinicians will receive 84 hours of
training and supervision via a teleconferenced and interactive broadcast
originating in South Africa with a South African Professional who will be
trained in the US by an Expert Trainer; and 3) A self instructional manual
only approach (MO).
Key Personnel
Watson, D.W.
Friends Research Institute
Principal Investigator
Brecht, M.L.
Castro, F.
Arizona State University
Collaborating Scientist
Freese, T.
Collaborating Scientist
Hawken. A.
Morgenstern, J
Mount Sinai School of Medicine
Collaborating Scientist
Obert, J.
Matrix Institute
Collaborating Scientist
Parry, C.
Medical Research Council (RSA)
Collaborating Scientist
Rataemane, S.
Medical University of South Africa
Rawson, R.
UCLA Integrated Substance Programs Co-PI
Crucial Issue/Tech Transfer
our knowledge base remains limited in identifying effective ways to
bridge the gap between research and the use of evidence-based
behavioral treatment in the community
 Lamb et al. (1998) determined that despite the availability of a number
of efficacious behavioral treatments, these established treatments have
not been systematically integrated into community and clinical practice.
Methods for training and supervising community-based providers are
 one of the few studies to systematically examine how CBT knowledge
and skills could be taught, Morgenstern et al. (2001) trained 20
counselors in CBT, while 9 counselors served as a control group . sum
score of the CBT items revealed that this training was successful
(adherence: r = .57, p < .01; skillfulness; r = .71, p < .01). Counselors
rated their enthusiasm for the value of CBT as high and there did not
appear to be substantial conflict between CBT techniques and other
background counseling ideologies.
Specific Aims
The specific aims of this project are: Aim 1- to
develop and pilot test an evidence-based, 12-session
CBT protocol (Carroll, 1998) for use by clinicians in
RSA.; Aim 2- to evaluate, via a randomized clinical
trial, methods for clinician training in the 12 session
CBT intervention to determine whether different
modalities of training result in varying levels of CBT
knowledge and competence in the delivery of CBT.
Aim 3- to calculate the cost of the three training
methods in order to determine the relative efficacy of
the training method vis-à-vis cost.
CBT also has HIV risk reduction session (RSA?)
Background &Significance
Growing body of literature supports the usefulness of
distance learning technologies for training substance
abuse treatment providers in clinical methods.
 These technologies are efficient and cost-effective.
While the use of distance-based delivery systems in
the substance treatment field is in the early stages,
video conferencing, teleconferencing represent viable
cost effective options.
 The transfer of an empirically supported approach
for the treatment of cocaine use disorders to
clinicians in RSA is a timely and important challenge.
 CBT demonstrated effective with US stimulant users
Population (‘97 estimate): 42,327,458
Density (‘97 estimate): 35 people/sq km (90 people/sq mi)
Urban/Rural Breakdown: 60% Urban, 40% Rural
Largest Cities (‘91 census): Cape Town 854,616
Durban 715,669
Johannesburg 712,507
Pretoria 525,583
Largest Metropolitan Areas (‘91 census):
Cape Town 2,350,157
Johannesburg 1,916,063
Durban 1,137,378
Pretoria 1,080,187
Ethnic Groups:
 75.2% Black African - including Zulu, Xhosa,
Tswana, and Sotho
13.6% White - including Afrikaners and British
8.6% Coloured (mixed race)
2.6% Asian – mostly Indian
Official Languages:
 Afrikaans, Tsonga, English, Ndebele,
Sesotho, Sesotho sa Lebowa, Swazi,
Tswana, Venda, Xhosa, Zulu
Other Languages:
 Portuguese, German, Dutch and other
European languages, Gujarati, Hindi, Urdu,
and other Asian languages
 17% Traditional African religions
 16% Dutch Reformed Protestantism
 13% African Christianity
 11% Methodism
 9% Roman Catholicism
 7% Anglicanism
 27% Other, including other Christian
denominations, Hinduism, Islam, and
Provinces (i.e., States):
 Eastern Cape
 Free State
 Gauteng
 KwaZulu-Natal
 Mpumalanga
 Northern Cape
 Limpopo
 Northwest Province
 Western Cape
Alcohol and Cannabis
Mandrax: typically consists of a mixture of
Methaqualone (the active ingredient) and
 Cannabis or cannabis smoked with Mandrax
are the most common primary illicit drugs of
abuse for patients in treatment centers
 Increases observed for Crack Cocaine and
Injection Drug Use (Heroin) and Meth (tik)
 12 ctrs (same as current study) 6 month
period revealed that 1,109 out of 3,968
patients reported cocaine/crack use as part of
their primary presenting complaint (Dec.03)
Research Design
This 5-year study will compare the efficacy and
efficiency of 3 methods of training South African drug
abuse clinician-counselors in a 12-session cognitive
behavioral therapy (CBT) protocol for the treatment of
cocaine dependence. The study participants will be
150 experienced (i.e., at least 3 years of experience)
licensed clinicians who work in 30 South African
National Council on Alcoholism and Drug
Dependence (SANCA) treatment centers in
Johannesburg, Cape town (Gaunteng Province) and
surrounding areas of South Africa (e.g., mental health
nurse professionals, social workers, psychologists).
Eighty percent have BA’s..consistent with
Morgenstern study
Cultural Adaptation of CBT
 Workgroup
will review CBT for cultural
 Clinicians in RSA will have practice
sessions with clients not in study
 Training issues addressed by Jeanne
Design Continued
All of the potential participating clinicians in SANCA centers speak English.
SANCA treatment facilities are located throughout the
9 provinces of South Africa: Gauteng | Kwazulu-Natal
| Eastern Cape | Western Cape |Northern Cape |
Northwest Province | Free State |Mpumalanga |
Northern Province.
Most of the written materials are in English. Most of the patients (70%) speak
English=ample population of English speaking patients for implementation of the
CBT protocol.
The English speaking patients are evenly distributed among racial and ethnic
groups. Manuals and trainings will all be provided in English. IRB may require
translation into one of major dialects
If one mode (manual) is provided in multiple languages, the effects found may
be confounded.
Design continued
The clinicians will be randomized into one of
three training conditions by clinic [i.e., all
clinicians (minimum of 3 per clinic) in a
specific clinic will be randomized into the
same training condition].
 The training conditions will be: 1) in-vivo
training and supervision conducted on site at
the clinic; 2) distance learning training
conducted via teleconference (didactic and
interactive presentations) and conference call
(supervision); and 3) self-study manual
Design continues
 At
the end of the 12 weeks (training
completion) data will be collected to
compare with baseline.
 Follow up data will be collected at 6
months following training completion to
assess sustained training effects.
 The
3 training conditions will be
compared with regard to the relative
changes in CBT-related knowledge,
Dependent variables
The Yale Adherence and Competence Scale: YACS (Corvino et
al., 2000) is a 55-item scale tapping general CBT will be
adapted for use
Domains to be assessed for all clinicians during treatment
sessions (baseline, wk-4, wk-8) will include:
Audiotape from the clinicians in each condition. These tapes are
necessary to monitor clinician adherence/competence by the
independent raters.
Therapist checklist.
Domains to be assessed for all clinicians at completion of the 12
sessions will include:
Post-protocol Audiotape from the clinicians in each condition. A
post-training audiotape is necessary to measure changes in
clinical practice. The independent tape raters also will rate the
post-training audiotape provided on the adherence/competence
rating form.
Therapist checklist.
Clinic Sites
Study Limitations
Adapt CBT core elements that were developed for use with
U.S. clinicians to a population of South African clinicians.
We address this concern by: (1) addressing the cultural
issues with a group to consist of reasoned U.S. and South
Africa Investigators and a cultural adaptation expert to
ensure that our approach is culturally sensitive; (2) forming
a U.S. research team with vast experience in developing
culturally specific therapy manuals in international settings;
(3) having an “expert trainer” who has many years of
training and supervising international groups; (4) choosing
South African clinicians with at least 3 years of experience
with substance abuse treatment and familiarity with core
cognitive behavioral techniques; and (6) collaborating in a
setting country where English is one of the official
language used in the treatment settings by clinicians and
Year One Plan
CBT experienced master trainers from RSA trained in CBT
IRB, US State Department, Pretoria Embassy
The content of the 12 CBT sessions and clinician instructions will be
reviewed by Drs Rataemane, several RSA clinicians together with
Drs Watson, Morgenstern, Rawson and Ms. Obert. Changes in the
12-session NIDA CBT manual will be made to make the materials
relevant and appropriate to RSA clinicians and clients, while
retaining the CBT style and content
Equipment (televisions, computers, fax machines) will be purchased
for study clinics and the research centers at MEDUNSA and Friends
Research. Logistics for television transmission will be arranged with
MEDUNSA staff.
Two independent raters from Friends Research Institute will travel to
the Yale University Psychotherapy Development Center for training
in the Yale Adherence and Competence Scale guidelines.
Lessons Learned and Project Update
(e.g., Domestic and International IRB Issues)

Update on Research Efforts in South Africa