Montana, a large and rural U.S. state, has a motor vehicle fatality rate almost double the national average. For young adults, the alcohol-related motor vehicle fatality rate in the state is almost three times the national average. Yet little research has explored the underlying reasons that young people in rural areas drink and drive. Drawing from the theory of triadic influence (TTI) and a series of qualitative focus group discussions, the current study examined how aspects of the landscape and culture of rural America promote and hinder drinking and driving among young people. In 2015 and 2016, 72 young adults (36 females) aged 18–25 years old (mean age = 20.2) participated in 11 semi-structured focus groups in 8 rural counties in Montana. Discussions were transcribed, and two reviewers independently coded text segments. Themes were identified and an inductive explanatory model was created. The results demonstrated that aspects of the social context (e.g., peer pressure and parental modeling), rural cultural values (e.g., independence, stoicism, and social cohesion), and the legal and physical environment (e.g., minimal police presence, sparse population, and no alternative transportation) promoted drinking and driving. The results also identified salient protective factors in each of these domains. Our findings demonstrate the importance of examining underlying distal determinants of drinking and driving. Furthermore, they suggest that future research and interventions should consider the complex ways in which cultural values and environmental factors intersect to shape the risky health behaviors of rural populations.

<p class="abstract"><strong>Background:</strong> Cognitive behavioral therapy (CBT) features prominently among the first-line treatments for depression. The development of CBT skills is associated with both symptom reductions and reduced risk for relapse, suggesting that improvements in CBT skills might be important to the benefits of CBT. Nonetheless, standard CBT places modest emphasis on the development of these skills.</p><p class="abstract"><strong>Methods:</strong> In this paper, we describe a randomized clinical trial testing the benefits of a variation of CBT that places greater emphasis on teaching patients CBT skills and makes patients' independent use of these skills a central therapeutic goal. Patients in this study (75 per condition) are being randomized to 12 weeks of standard or skill enhanced CBT for depression. The primary outcomes are change in symptoms and change in CBT skills. We will also evaluate the process of change in the treatments.</p><p class="abstract"><strong>Conclusions: </strong>This study has the potential to suggest an approach to enhancing CBT outcomes through greater focus on patients developing and independently using CBT skills. It will also provide an important context for understanding the role that CBT skills play in the therapeutic outcomes of CBT.</p><p class="abstract"><strong>Trial registration:</strong> The trial has been registered in ClinicalTrials.gov. Registration number: NCT04673513; registered on 17 December 2020.</p>

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The therapeutic alliance has been reliably associated with outcome across psychotherapies. We investigated the alliance–outcome relationship in the early sessions of cognitive behavioral therapy of depression using a model that disaggregates within- and between-persons variance while estimating the reciprocal relation between variables. We used this model in a combined data set from two studies totaling 191 patients. In our primary model, we found evidence for a predictive within-patients relationship between alliance and symptoms such that symptoms predicted regressed change in alliance and alliance predicted regressed change in symptoms. In a more conservative detrended model, these relationships were not significant. Given that (a) most of the variability in alliance scores is between patients, (b) the size of the alliance–outcome relationship is modest, and (c) the alliance–outcome relationship is not robust to detrending, our findings suggest that alliance plays at most a small role in improving patient outcomes in cognitive behavioral therapy of depression.