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S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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Drug Matrix cell A4: Interventions; Psychosocial therapies

K Match counselling style to the client (2003). US trial shows that structure and directiveness are key dimensions on which therapies can be matched to client characteristics.

K Visual aids enhance counselling (2009). Node-link maps are flow charts of a patient’s aims and plans which facilitate patient-counsellor communication; in this study they helped methadone patients reduce illegal opiate use and probably also cocaine use.

K Couples therapy improves the lives of both partners (2003). Proven most firmly for alcoholics, this study showed that the benefits of systematically involving a patient’s wife/partner in their treatment extends to the use of an opiate-blocking medication to sustain abstinence from heroin and allied drugs; relative to non-family alternative therapies, there were also improvements in family functioning and other social and legal domains. Similar story for methadone patients (2001).

R Common relationship factors (American Psychological Association, 2011). Introduces reviews based on the understanding that treatment methods are not simply technical interventions, but ways client and therapist relate, so cannot be divorced from the relationship between client and therapist. From here you can find the component reviews and the overall conclusions (2011) reached by the association’s task force.

R Directiveness is a key difference between therapies (2006). The interpersonal style (eg, directive v. patient-led) associated with different therapies is why some work better with some clients than others.

R Reviews of trials of motivational interviewing (Cochrane review, 2011) and cognitive-behavioural therapy (2009) suggest any structured approach grounded in an coherent theory is as good as any other. We have, it was argued, been looking in the wrong direction for therapy’s active ingredients.

R Motivational starts to treatment (2005). Findings review discovers that manualised motivational interviewing is not always better than more directive approaches as a way of engaging clients with treatment.

R Mindfulness meditation takes its place among addiction therapies (2009). Increasingly popular, variants of mindfulness meditation are among the ‘third wave’ of behavioural therapies allying Western and Eastern traditions. This first review of their application to addiction finds them equivalent to other structured therapies, but an important later study (2014) suggests otherwise. See also this more recent review (2014).

R Peer-based addiction recovery (2009). Includes a chapter on the evidence for NA, AA and allied mutual support networks and treatments based on the same principles and networks. See also this review (2004) of how treatment services can promote mutual aid and this synthesis of studies (1999) of approaches based on AA/NA’s 12-steps versus alternative treatments.

R Therapeutic communities certainly work while residents stay (2012). Shortcomings in the original studies prevented a firm conclusion on the lasting benefits of residential communities of patients exerting mutually therapeutic influences, but it was clear that while residents stayed, substance use was significantly reduced.

R Reserve therapeutic communities for most vulnerable patients (2013). Review specific to users of illegal drugs argues therapeutic communities should be reserved for drug addicts with multiple and severe problems who do not do well in outpatient treatment due to the lack of structure and supports, or the fact that they live in high drug use areas.

R Some patients get worse (2005). Reminder that after psychosocial therapy up to 15% of clients end up worse than before; some of the reasons are to do with poor therapy including a weak relationship, failing to assess how clients are doing, being confrontational or critical, low or inappropriate expectations, and lack of challenge.

R Rewards and sanctions for not using drugs (2013). Findings hot topic asks whether we can dispense with counselling and therapy and just punish people or deprive them of rewards when they use substances in ways they and/or we would rather they didn’t, and reward them when they behave as we and/or they would wish? Formalised in to set schedules, these approaches are known as ‘contingency management’.

G NICE-recommended psychosocial interventions ([UK] National Institute for Health and Clinical Excellence [NICE], 2007). UK’s official health advisory body recommends contingency management and behavioural couples therapy.

G Implementing NICE-recommended psychosocial interventions ([English] National Treatment Agency for Substance Misuse, 2010). Report commissioned by England’s national addiction treatment agency from the British Psychological Society; includes protocols for conducting the main psychosocial therapies.

G Expert US consensus on group therapy ([US] Substance Abuse and Mental Health Services Administration, 2005). Consensus guidance on the different types of groups, how to organise and lead them, desirable staff attributes, and staff training and supervision.

G No magic bullet, but treatment based on sound principles (2006). Based on reviews commissioned by the American Psychological Association; reviews evidence and offers in-principle guidance on how to relate to clients and the content of sessions. Argues that these principles “provide a more research-informed and potentially effective approach to treatment than either the application of a one-size-fits-all standard treatment protocol or the use of idiosyncratically selected interventions”.

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For subtopics go to the subject search page or hot topics on contingency management, residential rehabilitation, motivational interviewing, 12-step mutual aid and counselling in methadone treatment.

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What is this cell about? Every treatment involves direct or indirect human interaction, but this cell is about therapies in which interaction is intended to be the main active ingredient. Colloquially referred to as ‘talking therapies’, these are more formally categorised as ‘psychosocial’. They attempt to change how the patient reacts either directly, or via their beliefs and attitudes, how they relate to others, and how others relate to them, in respect of which the biggest change may be the experience of being related to in a caring context centred on your aspirations, needs and welfare. Interventions range from brief advice and counselling to extended therapies based on psychological theories and all-embracing residential communities where clients stay for several months. Elements could include rewards and punishments contingent on client behaviour (contingency management), leading the client to see their substance use as contrary to desired self-images or objectives (as in motivational interviewing), harnessing social influences (as in group and family therapies and community living arrangements), teaching the client what triggers their undesired substance use and how to manage or avoid those triggers (as in cognitive-behavioural therapies), ways to manage thoughts and moods which otherwise might precipitate relapse (as in mindfulness approaches), and more practical elements such as vocational rehabilitation. Whether based on research and theory, religion, morals or experience, belief systems underlie these approaches. Most prominent in the research are the 12 steps of Alcoholics Anonymous and allied fellowships, and the understanding that addiction can be learnt and unlearnt, which underpins major psychological therapies, including those recommended by the UK’s official health advisory body, the National Institute for Health and Clinical Excellence (NICE).

Where should I start? This cell is partly about the relative merits of different therapies, but also about the therapeutic properties they share and how such ‘common factors’ can be made yet more potent. Since these factors have become seen as the major influences, let’s start there, and in particular with the shift to focus on them made by the American Psychological Association (APA). Updating work from 1999, in 2011 their task force analysed the literature to identify what constitutes an effective relationship between therapist and patient. Take a look at the introductory article which lists the component reviews. From there you can access whichever of these reviews most interests you, and the task force’s overall conclusions. Then go back a few years to the guidance offered by another APA task force which integrated these relationship issues with the content of therapy. In both note the stress on collaborative working, and warnings against being confrontational, hostile, pejorative, critical, rejecting, or blaming. Note too that they also cautioned that on issues like this, there are no universal rules; unlike public health approaches, treatment is essentially the treatment of an individual.

Highlighted study One of the most consistent findings on matching therapists with clients is that directive therapists risk a backlash from clients with a short fuse or who resist other people’s attempts to lead the interaction. Conversely, calmer patients or those who welcome direction thrive when given more of a lead. That we found in one of our reviews applies also to substance use clients. Those finding were about the characteristics of therapists, but therapies too differ in the directiveness they require or encourage. What if the same therapists implement these different approaches. Would the same matching finding emerge?

That was answered in the affirmative by the results of a US study at a clinic where cocaine was the dominant drug problem. Read our account and you will see that patients were randomly allocated to therapies designed in some ways to be at opposite poles: one highly structured and directive; the other, less structured and non-directive, the counsellor acting primarily as a sounding board for the patient. How far patients welcomed direction was not directly assessed, but a similar variable was – ‘learned helplessness’. Patients high on this dimension are likely to feel the need to be given direction, while those at the opposite pole are confident in their abilities to do the directing themselves.

Neither approach was preferable overall, but this masked different impacts on different types of clients. As expected, those characterised by learned helplessness did better when the therapy required the counsellor to take the lead, while clients who felt more in control of their lives did better when the less structured therapy allowed them to set the agenda. Depressed clients also did best in the structured therapy and worst when required to take the initiative, again, potentially related to their tolerance for and need for direction.

Apart from the specific findings, the study is a reminder that it would be a mistake to take an ‘It doesn’t matter what you do’ message from reviews and studies which average outcomes across all patients; though it might be true on average, it is not necessarily true for each individual or for different types of patients; treatment is, as we have said, essentially the treatment of an individual.

Issues to think about

Research may have to package; therapy does not. That last comment above brings us to an important point about the nature of research and its links to practice. Researchers often feel they have to tightly control what is being delivered in order to know what caused any improvements, so they manualise interventions and train and supervise therapists to make sure they follow the manual. Our review of motivational interviewing shows this is not necessarily the best way to do therapy, which has to sensitively adapt to where the patient is at in their journey to a commitment to tackle their substance use problems (for more see cell C4).

Similarly, researchers may prefer to deliver interventions according to a set schedule and time period to standardise them, limit costs, equalise time spent with therapists in a comparison therapy, and have a set end date from which the follow-up period can begin. Twelve weeks is the commonest compromise between a manageable research intervention and one which lasts long enough to possibly have the desired impacts. As a result, 12-week treatments have collected an evidence base around them. Yet there is no reason to believe that because 12 weeks is convenient for researchers, it is also how patients should be treated. Some manage well with much less, others will benefit more from longer term care.

Research takes its ideas from practice, standardises and packages that practice, and then tests it. Via recommendations from authorities reliant mainly on research findings, practitioners may then be persuaded that the researchers’ packages – now ‘evidence-based’ – are how they too should do therapy.

Instead, treat research as an aid to developing and reflecting on practice, not a blueprint. This was the approach taken by authorities from the British Psychological Society when they developed their guidance on implementing the main psychosocial therapies recommended by the UK’s official health advisory body, the National Institute for Health and Clinical Excellence (NICE). The authors insisted that though their framework “draws heavily upon treatment manuals, it enables a more comprehensive approach to implementation than a manual alone can provide ... It allows a degree of flexibility and adaptation at the level of the individual service user. Such flexibility may not be present in a particular manual, the development of which may instead be rooted in a specific service in a particular health care setting.”

Are these always the important things to do? Retrieve this guidance from an American Psychological Association task force. Skip to the heading “Treatment factors” on page three of the PDF file. There you will read that research “suggests that a number of specific therapeutic elements are characteristic of effective treatments”. Take a critical look at these suggestions. They include “explicitly helping the client restructure his or her social environment in ways that support change” – or more specifically, abstinence. How feasible is that for the clients you know of? Do they have the resources – psychological, social and material – to replace environments, friendships, even families and intimate partners, conducive to substance use with those conducive to the opposite? Unless they can at least go some way towards this transformation, gains from the radical social re-engineering possible in a contained environment like a residential community remain vulnerable on discharge back to the home environment.

Next up is a “focus on client motivation for change”, possibly through exercises that get the patient to weigh up the pros and cons of changing their substance use. But if (as many will be) patients are already committed to change, maybe it is not such a good idea to encourage them to rehearse the good things about their substance use? On this issue see study 19 in this Findings review. Next is the territory made its own by cognitive-behavioural therapies: “helping the client to develop awareness of repetitive patterns of thinking and behavior that perpetuate substance use ... accompanied by a focus on helping the client learn alternative coping skills.” If this is key, why on average do cognitive-behavioural therapies do no better than other approaches?

Then we learn that “Effective therapies attend to the affective [emotional/mood] experiences of the client, particularly in relation to their substance use.” Yet we know too that a focus on emotions can for some patients be counterproductive. Finally, the task force identified “strong evidence for the role of conditioning in the development and maintenance of substance use disorders,” and argued that “repeated exposure to alcohol- or drug-related situations without using” can weaken these conditioned reactions and bolster the patient’s confidence that they can handle such situations without using drugs. Yet for this so-called ‘cue exposure’ therapy, the UK’s official health advisory body was unable to find a single study which met its quality criteria, leaving it, as far as NICE was concerned, without a research leg to stand on.

These points are made not to criticise the in general very sensible suggestions made by the task force, but to reinforce a point already made; that generalisations are bound sometimes to be misleading in what is essentially an individualised response to an individual set of circumstances never before encountered in precisely the same configuration.

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