EFFECTIVENESS BANK BULLETIN 14 March 2009
EFFECTIVENESS BANK BULLETIN 14 March 2009The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. The Summary is intended to convey the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Human beings don't just react to rewards for abstinence – they interpret them ...
Responsiveness and unfailing optimism aid primary care alcohol treatment ...
Do hedonistic non-conformists make the best British drug workers? ...
Feedback really does make the most of brief motivational counselling ...
Coping skills training and contingency management treatments for marijuana dependence: exploring mechanisms of
behavior change.Litt M.D., Kadden R.M., Kabela-Cormier E. et al.
Addiction: 2008, 103(4), p. 638–648.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Litt at litt@nso.uchc.edu. You could also try this alternative source.
Rare glimpse 'under the hood' of contingency management suggests that unless the patient sees themselves as having actively mastered their dependence and has developed anti-relapse strategies, effects of rewarding abstinence will be short-lived.
Summary Achieving abstinence in the treatment of cannabis dependence has been difficult. To date the most successful
treatments have included combinations of motivational enhancement treatment plus cognitive–behavioural coping skills
training and/or contingency management approaches rewarding abstinence. Although these approaches are theoretically
based, their mechanisms of action have not been explored fully. The purpose of the present study was to explore
mechanisms of behaviour change from a cannabis treatment trial in which cognitive–behavioural and contingency
management approaches were evaluated separately and in combination. A 'dismantling' design was used in the
context of a randomised clinical trial. 240 dependent adult cannabis smokers who responded to advertisements
attended an out-patient treatment research facility located in a university medical centre. They were randomly
assigned to one of four nine-week treatment conditions:
• supportive case management, the control condition used as a benchmark for the other treatments;
• motivational enhancement therapy plus cognitive–behavioural coping skills training;
• standalone contingency management procedures rewarding cannabis abstinence with vouchers for retail goods or
services, with no other therapeutic inputs;
• and a combination of contingency management with the motivational and cognitive–behavioural therapies.
The main outcome measure was total abstinence over the past 90 days based on the patients' own accounts and verified by urinalysis. These measures were recorded every 90 days for the 12 months after treatment ended. Standalone contingency management led to the highest in-treatment abstinence rate, but the lowest in the last six months of the follow-up. Regardless of the treatment, abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence.
Though an exploration of the mechanisms of change in cannabis treatment in general, the study's
innovation
This seems the first study to establish how contingency management works by linking it to psychological and
behavioural changes, and then linking these to abstinence outcomes using a methodology which can tease out potential
causal mechanisms. Inclusion of motivational and cognitive–behavioural approaches in the same study makes it
possible to compare these mechanisms against those of probably the most influential and widespread structured
therapies for substance use problems.
(and the focus for this commentary) was to probe the psychological processes underlying contingency management,
building on previously reported abstinence outcomes
from the same study. The key message is that these procedures do not produce lasting change simply by mechanically
reinforcing the habit of non-use. More important is whether the experience fosters confidence that one can resist
relapse, along with the motivation to transform 'can' in to 'will', and strategies to
effectively implement this resolution. In other words, what the patient makes of their spell on the
contingencies and how they interpret it determines whether it will result in a transient, reward-driven spell
of reduced substance use, or more lasting change. What the patient makes of the contingencies can in turn be
influenced by integrating test results and rewards in to accompanying therapy, leading to greater longer term
success than either on its own.
On the basis of the study, this message can only be considered a tentative working hypothesis. But it is consistent with other studies (1 2 3 4 5) which also found that the in-treatment boost Interestingly, in several studies this boost was deflated somewhat when contingency management was combined with cognitive-behavioural therapy, yet once the rewards ended this combination was at least as or more effective. to abstinence provided by rewards does not persist, leaving contingency management with longer term outcomes at best equivalent to cognitive-behavioural approaches, and sometimes slightly worse. More generally, when rewards end, patients often quickly revert to their previous behaviours. Even during the rewards period, typically impacts are limited to the targeted behaviours and/or the targeted drugs. This is what would be expected if patients interpret the procedures as a chance to do what it takes (and no more) to make some money or win some prizes. In particular, the authors suggest that lasting change is less likely if patients see abstinence as foisted on/enticed out of them by the rewards, rather than something they have shown they can achieve by their own efforts.
Within the study, this hypothesis emerged from an analysis which showed that the way contingency management enhanced cannabis abstinence after treatment, was by having enhanced it during treatment. However, when other variables were taken in to account, the distinct contribution of in-treatment abstinence was relatively weak. More significant were variables contingency management did not directly affect – the individual's growing confidence in their ability to resist cannabis use and their deployment of strategies to help them do so. Each bolstered the other, especially when growing motivation to change gave impetus to the process. These variables were directly impacted by the treatments which included motivational and cognitive–behavioural elements, especially when combined with contingency management.
The
upshot it seems (
chart) was that though it led to the highest
abstinence rates
Both in terms of the average number of days abstinent and the number of patients who remained completely abstinent.
during treatment, by the final follow-up a year later patients subject only to the rewards were least likely to have
sustained abstinence over the past three months. After the
other three
This applied even to the case management option, one deliberately devoid of structured therapeutic content.
treatments, abstinence rates improved, culminating in a final rate of around 20% or more. After standalone
contingency management ended, the abstinence rate rapidly fell to barely more than half the level during
treatment.
This transience did not apply when contingency management was combined with motivational/cognitive-behavioural therapy – in the longer term, the most effective of the options. Contingency management brought these patients in to contact with qualified and specially trained and supervised therapists who melded the urinalysis results and the rewards in to the therapeutic encounter, and who were in a position to influence the patient's interpretation of and response to the contingencies. In contrast, standalone contingency management involved relatively fleeting contact with a research assistant who administered tests and rewards.
When contingency management and cognitive-behavioural therapy have merely run in parallel (1 2 3), no longer term advantage from combining the two has materialised. But when, as in the featured study, therapists have integrated the contingency programme in to their sessions, the combination has proved the most powerful intervention in the longer term.
Though this study breaks new ground, others have also indicated that contingency management may not work in the same way as other therapies. Most relevant is a study which used vouchers to reward drug-free urine tests and consumption of the opiate blocking medication naltrexone to maintain abstinence from opiates after detoxification. As expected, during the 12 weeks of treatment the rewards encouraged patients to take their medication The difference was substantial but fell just short of statistical significance. and stay free of opiate drugs. But this did not presage lasting change. Within 12 weeks of the rewards ending, there was little difference between these patients and those not offered vouchers, by another 12 weeks, virtually none. A clue to the reason came in the observation that across the 12 weeks of treatment, motivation and readiness to change drug use behaviour increased slightly among patients not offered vouchers, but were significantly eroded Tests showed that this was not due to patients who had attained abstinence no longer feeling the need to change. among those rewarded for abstinence.
In other studies, motivation has not been eroded relative to other treatments, but neither has it been enhanced by reinforcing abstinence, indicating that the greater abstinence rates 'bought' by the rewards do not reflect increased motivation to remain abstinent. In one, supplementing motivational and coping skills therapy with rewards actually halved what without the rewards was a substantial increase in confidence in ability to refrain from smoking cannabis.
The potential for contingency management type rewards to erode motivation is well recognised outside the substance misuse sector. An analysis aggregating results from 128 studies found that tangible rewards offered for engaging in, completing, or doing well at a task undermined intrinsic motivation. The effect was greatest when represented by what people actually did after the rewards ended, the equivalent of post-treatment substance use in contingency management studies. However, the same analysis found that it is possible for rewards – and especially verbal recognition – to be given in such a way that they acknowledge the individual's achievements and bolster feelings of mastery rather than of being controlled. In these cases the undermining effect can be reversed and intrinsic motivation enhanced.
Such findings help explain why in several studies (1 2 3) contingent rewards or punishments for engaging in treatment did improve attendance and compliance, but, contrary to the usual pattern, 'engagement' elicited in this way did not improve substance use or other outcomes. It also helps explain why occasionally this does not happen, for example, when rewards are experienced as a non-controlling signal of the individual's own achievements, and are embedded in a caring therapeutic environment which accompanies them with verbal and public recognition. Another exception is a study which achieved greater and more lasting abstinence by rewarding recovery-oriented activities rather than directly rewarding abstinence. In this case the rewards were delivered within a collaborative therapeutic relationship and empowered rather than controlled the patient. With their therapist, they could select activities to be rewarded in line with their own recovery plan and ability to complete the task. The broader findings referred to above also help us understand the oft-reported power of the verbal praise delivered by drug court judges to offenders, precisely the sort of unexpected, non-controlling verbal recognition which the analysts would expect to enhance motivation by reinforcing the offender's sense of control.
Current British trials have absorbed the lessons of this US research and at least one Personal communication from Dr John Marsden of the National Addiction Centre, March 2008. is attempting to extend the substance use reductions gained by contingency management by exploring this experience in accompanying therapy. The trial is also using a newly developed questionnaire Marsden J., Mitcheson L., Stillwell G., Litt M., Shoptaw S. Treatment Incentives Experiences Scale. 2008. to track how patients interpret the contingencies, including whether they attribute their successes to the rewards or to themselves, and impacts on their confidence in their recovery.
Thanks for their comments on this entry in draft to Mark Litt of the University of Connecticut Health Center, John Marsden of the National Addiction Centre in London, and Oswin Baker of the National Treatment Agency for Substance Misuse in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 13 March 2009
Comment on this entry Back to contents list at top of page Give us your feedback on the site (one-minute survey) Open home page and enter e-mail address to be alerted to new studies
Review of treatment for cocaine dependence STUDY 2010
Brief interventions short-change some heavily dependent cannabis users STUDY 2005
Implementing evidence-based psychosocial treatment in specialty substance use disorder care REVIEW 2011
Toward cost-effective initial care for substance-abusing homeless STUDY 2008
Soup kitchen turned into therapeutic setting STUDY 2006
Psychosocial interventions for people with both severe mental illness and substance misuse REVIEW 2008
An intervention for treating alcohol dependence: relating elements of medical management to patient outcomes in primary care.Ernst D.B., Pettinati H.M., Donovan D.M. et al.
Annals of Family Medicine: 2008, 6(5), p. 435–440.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Ernst at dernst@unm.edu. You could also try this alternative source.
In a programme intended to simulate primary care management of alcohol dependence, what made the difference to patients was how far the clinician maintained confident optimism and responded to the patient rather than strictly adhering to the treatment manual.
Summary The purpose of this study was to examine the relationship between treatment outcomes and patient and clinician factors associated with a medical management intervention for the treatment of alcohol dependence. Intended to approximate a primary care approach, the intervention was developed for the COMBINE study, a randomised controlled trial combining two medications (naltrexone and acamprosate) with medical management, with or without specialist psychosocial alcohol therapy.
Overall results of the trial have previously been reported. This report focused on the medical management element of the treatments, examining links between outcomes during the trial and features of the patients and the clinicians and their behaviours, the latter based partly on a sample of audio-recorded sessions rated by observers. In particular, links were examined between
drinking and related problems
Abstinence from alcohol, amount of heavy drinking, and clinical improvement (ie, at most moderate drinking with no related problems).
during treatment and:
• the patients'
attendance
Number of medical management visits; total minutes in treatment.
;
• their alliance or therapeutic relationship with the clinician and satisfaction with treatment;
• and the clinician's adherence to and competence in delivering the manualised medical management protocol.
The analysis found that the more medical management visits a patient attended, but the less total time spent in those visits, the better the outcomes in terms of more drink-free days, reductions in heavy drinking, and a higher likelihood of clinical improvement. It seemed that patients who were doing poorly chose to or were able to attend less regularly, but needed more time at each visit. Patients who were more positive about their alliance with their clinician midway through treatment, or at the end expressed greater satisfaction with their treatment, were abstinent on significantly more days.
Two features of how the clinicians behaved were also associated with better patient outcomes. Those who according to observers most adequately conveyed professionalism, expertise, and confidence in the medical management protocol, yet who also deviated somewhat from strict adherence to that protocol, had patients who drank less often and less heavily. The former factor was also related to overall clinical improvement. Observers commented that these clinicians seemed to convey optimism about recovery even in the face of discouraging news from the patient, and were prepared to respond to issues raised by the patient even if that meant departing from the manual. The authors interpreted these findings as indicating that "some flexibility in delivering medical management, based on good clinical judgment and in conjunction with optimism and hope for recovery, supports better outcomes with the intervention". Their broader conclusion was that medically trained clinicians with little specialised training in alcohol dependence treatment were able to deliver a brief and effective medication management intervention designed to be consistent with primary care practice.
It is important to place these findings in the context of the overall trial (itself previously analysed by Drug and Alcohol Findings). For the trial 1383 alcohol dependent patients were randomly allocated to various abstinence-oriented treatments lasting 16 weeks. The most basic was placebo pills plus nine medical management appointments typically lasting under 20 minutes spent assessing, monitoring and feeding back the medical consequences of the patient's drinking, and promoting adherence to pharmacotherapy. Some of these patients were also allocated to active medications (naltrexone and/or acamprosate) and/or to a sophisticated programme of psychosocial therapy. The key question was how far the extra therapies improved on straightforward medical management with placebo pills. In essence, as long as medical management was bolstered by naltrexone, patients did about as well as they did with additional therapy. Even without active pills, during treatment, 58% of patients receiving basic care achieved a good clinical outcome.
Having discovered that fairly straightforward (if well structured and perhaps more intensive than normal) medical care could be associated with outcomes as good as after state-of-the-art therapy, the featured study set out to unravel the underlying processes. This it did by assessing how much of the difference in outcomes between patients could be accounted for by differences between patients, and how much differences between their clinicians. The analysis found that the patients' behaviour and perceptions of treatment were by far the most significant factors.
Despite features Several of the variables attributed to the patient (attendance; relationship with clinician; satisfaction) could have been influenced by the clinician they were assigned to. Conceivably, this would leave little room for the analysis to find any remaining link with the clinician's skills and approach. Making this less likely still was the fact that in this highly controlled trial, differences between clinicians would have largely been ironed out by the selection, training and supervision procedures, and by that fact that all the clinicians followed the same manual. of the study and analysis which would have obscured this, there was also a small but statistically significant link between the clinician and the outcomes. Patients had better drinking outcomes when their clinicians were characterised (not just with their successful patients, but across their entire caseloads) by unwavering, optimism-instilling confidence in the treatment, allied with flexibility in its application. Importantly, flexibility and optimism had to go together, consistent with the common sense understanding that it is not enough to have confidence in the form of blind faith in the treatment protocol, or to depart from it simply because you lack that faith. The former might lead to disregarding important clues from the patient, missing therapeutic opportunities, and to a damaged therapeutic relationship ('I'm not really being listened to'), the latter to the patient too lacking faith and to an incoherent approach which fails to offer a credible, consistently structured route to recovery.
In general psychotherapy these attributes are well recognised 'common factors' found to account for far more of what makes for good outcomes than the particular brand of therapy. In alcohol therapy too, as long as the approach is explicitly structured in a way which makes theoretical sense, it matters little what particular form it takes. Consistent with the featured study, what is important is being responsive enough to the patient to match your approach to their mood, personality and recovery preferences, even if that means departing from best practice distilled in state-of-the-art manuals.
This is not however a licence to abandon structure altogether. Coherence and structure are important ingredients of good therapy, offering a way to make sense of what may seem chaos and confusion so unstructured that there can be no such thing as a clear route, let alone a route out. For example, in one study of cocaine counselling, a moderate degree of fidelity to the treatment manual led to better outcomes than either following it very diligently or being relatively lax.
Though probably active in every therapeutic encounter, such influences might be more visible in some situations and populations than others. In the featured study, though very heavy Averaging 21 UK units most days. drinkers, the patients were more socially integrated and less severely dependent than some UK alcohol treatment caseloads. They could also only enter the study if they had achieved at least four days without drinking. All were prepared to accept referral to the study or responded to ads soliciting participants. In the cocaine study mentioned above, moderate adherence was most clearly beneficial when a patient had formed a relatively poor relationship with their therapist.
Drug and Alcohol Findings has published a series of articles dedicated to exploring of the impact of some of the common factors which might be important in the treatment of substance use problems.
Thanks for their comments on this entry in draft to Denise Ernst of the Center on Alcoholism, Substance Abuse, and Addiction at the University of New Mexico and to Petra Meier of the University of Sheffield. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 22 March 2009
Comment on this entry Back to contents list at top of page Give us your feedback on the site (one-minute survey) Open home page and enter e-mail address to be alerted to new studies
Relating counselor attributes to client engagement in England STUDY 2009
Gender differences in client-provider relationship as active ingredient in substance abuse treatment STUDY 2010
Adapting psychotherapy to the individual patient: Preferences REVIEW 2011
Adapting psychotherapy to the individual patient: Expectations REVIEW 2011
Medical treatment of alcohol dependence: a systematic review REVIEW 2011
Therapist effectiveness: implications for accountability and patient care STUDY 2011
The impact of worker values on client outcomes within a drug treatment service.Phillips R., Bourne H.
International Journal of Drug Policy: 2008, 19(1), p. 33–41.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Phillips at rosiephillips@drugsandhomeless.org.uk. You could also try this alternative source.
From England, findings suggesting the intriguing but for the moment tentative possibility that non-conformist drug workers who value hedonism and stimulation help socially excluded clients improve most because their values match those of their clients.
Summary Little attention has been paid to understanding the impact of values, attributes and characteristics of drug workers on therapeutic relationships and treatment outcomes. Interaction of values with other variables is considered to be of importance since values play a role in determining attitudes and behaviours. This exploratory study investigated the impact of drug workers' personal values on client outcomes within a drug treatment service.
Eight drug workers and 58 clients were recruited at a UK charity working with problematic drug users who are also socially excluded. Drug workers completed a validated questionnaire to elicit their personal values. These were assessed by asking them to prioritise the importance of 57 attributes such as freedom, pleasure, self-discipline, respect for tradition, honesty, and social justice as "guiding principles" in their lives. Client outcomes were assessed using the Christo Inventory for Substance Misuse Services. The relationship between client outcomes and worker values were analysed using Spearman's rank test of association.
Drug workers prioritising stimulation, self-direction and hedonism value types experienced more positive client outcomes compared with those prioritising security, conformity, benevolence, tradition and universalism types. The value types associated with positive outcomes fall within Schwartz's 'openness to change' superordinate dimension, whereas those related to more negative outcomes fall within the 'conservation' dimension.
The study suggests that drug workers' personal values may have a significant impact on client outcomes in the treatment of substance misuse. Reasons for this finding are explored, as are limitations of this study and suggestions for future research.
As the authors accept, this innovative study is best seen as opening up a potentially important line of enquiry rather than taking us far enough along it to draw conclusions. The most intriguing implication is that workers whose values in some respects match those of their clients are most able to help them, but there are alternative explanations and some methodological concerns.
Among this small sample of British drug workers, the study found that a worker's values were related to improvement in their clients' substance use and social and psychological functioning from intake to treatment exit at least 12 weeks later. The strength of these associations was extraordinary.
Clients improved most when their workers prioritised:
Self-direction: independent thought and action; represented by valuing freedom, self-respect, creativity, independence, choosing your own goals, and curiousity;
Stimulation: represented by valuing an exciting, varied life, and being daring;
Hedonism: represented by valuing pleasure, enjoying life, and self indulgence.
Conversely, outcomes were worse when workers characteristically prioritised:
Conformity: exercising restraint to avoid upset or violating social expectations; represented by valuing politeness, self-discipline, honouring parents and elders, and obedience;
Security: safety, harmony and stability of society, relationships and self; represented by valuing a sense of belonging, social order, national security, reciprocation of favours, family security, health, and cleanliness.
In each case, de-prioritising these values bore an opposite relationship to client improvement. The underlying pattern is that workers characterised by 'openness to change' had better client outcomes, those who conservatively valued stability and established order had worse outcomes. The plausible presumption is that 'openness to change' values also typify users of illegal drugs. No UK study has investigated this directly, but if it were the case, it would fit with the findings of a Norwegian study which was one of the inspirations for the British research. This found that confluence in values between psychotherapists and their clients was associated with (from the patients' points of view) a stronger therapeutic relationship. Across psychotherapy including substance misuse therapy, feelings of empathy and being understood are associated with better outcomes. It could be that these feelings are strongest between like-minded therapists and patients.
However, in Norway, more significant yet were aspects of the therapist's personality, The strongest link was that interpersonally cold therapists were less likely to foster a strong therapeutic relationship. regardless of whether these matched those of their clients. In the featured study too, perhaps workers open to change were also more open to all their clients and better able to adapt to their needs and preferences, and/or were more willing to risk departing from normal or accepted practice to meet those needs. Preparedness to depart from a set treatment protocol has been associated with better substance use outcomes. So too has being responsive enough to the patient to match your approach to their mood, personality and recovery preferences, even if that means departing from state-of-the-art manuals. After being trained in motivational interviewing, in one study addiction counsellors who occasionally violated For example, by confronting clients, warning or directing them, and imposing advice or expressing concern without their permission. the approach's principles had clients who were better engaged and more forthcoming in therapy than more conformist trainees – but only as long as the entire interaction was characterised by socially skilled empathy and caring.
Limitations acknowledged by the authors of the featured study include the small sample of drug workers and the atypical location. A centre in Bath treating socially excluded substance users with complex needs such as homelessness, which itself as an organisation valued attributes similar to those of the more effective workers. Elsewhere and with a different caseload, findings might have been different. Other potentially important unknowns The workers took on a case management role at the centre, so perhaps the advantage conferred by openness to change lay in how well they secured the cooperation of other services, rather than in how well they related to their clients. Neither do we know on what basis clients were allocated to their case managers; maybe, for example, those with the worst prognosis were directed to the more predictable, 'solid' workers. demand caution in interpreting the findings. One concern alluded to in the Norwegian study is that workers might falsely perceive greater improvement in clients whose values are (or are becoming) more like their own. The inventory used to measure improvement in the study has produced similar results when applied by different workers, also the case at the Bath centre when hypothetical clients were rated. But it is completed by the worker and relies on their judgements of the severity of the client's problems. A related possibility is that workers characterised by openness to change also tended to have rosier perspectives on how well their clients were doing.
Despite these cautions, the congruence between this study and the limited amount of allied substance misuse research suggests the findings may reflect a real phenomenon. In psychotherapy generally, similarity of social and intellectual values between therapist and client promotes improvement. If something like this is also the case in substance misuse treatment, it suggests that effective drug workers are as likely to be 'naturals' by virtue of their personalities, values and social skills as to be created by training or recognised by qualifications. It may be possible for such attributes to be recognised in advance by the reactions of relatively untutored observers to how workers say they would behave in different counselling scenarios.
Nothing in this study or in others contradicts the general finding that following a coherent, structured programme which makes sense to the worker and the client is an important therapeutic foundation. But with the relatively unconventional caseloads seen by drug services, being empathic, responsive and independent (or supported) enough to depart from the script when the situation demands is perhaps just as important.
Thanks for their comments on this entry in draft to Rosie Phillips of the Drugs and Homeless Initiative in Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 27 March 2009. First uploaded
Comment on this entry Back to contents list at top of page Give us your feedback on the site (one-minute survey) Open home page and enter e-mail address to be alerted to new studies
Matching resources to needs is key to achieving 'wrap-around' care objectives STUDY 2006
Gender differences in client-provider relationship as active ingredient in substance abuse treatment STUDY 2010
Evidence-based therapy relationships: research conclusions and clinical practices REVIEW 2011
Innovation adoption as facilitated by a change-oriented workplace STUDY 2012
Therapist effectiveness: implications for accountability and patient care STUDY 2011
Relating counselor attributes to client engagement in England STUDY 2009
Client-receptive treatment more important than treatment-receptive clients STUDY 2000
Dismantling motivational interviewing and feedback for college drinkers: a randomized clinical trial.Walters S.T., Vader A.M., Harris T.R.
Journal of Consulting and Clinical Psychology: 2009, 77(1), p. 64–73.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Walters at scott.walters@utsouthwestern.edu.
Brief interventions based on motivational interviewing typically incorporate feedback on the individual's risk and use level compared to the norm, but does this really help? A US college study found it did, the combination leading to greater drinking reductions than either on its own.
Summary Motivational interviewing is a counselling style shown to reduce heavy drinking among college students and in treatment contexts. Most college studies have combined feedback Typically including presentation of information on personal drinking patterns, comparisons with national and/or college drinking norms, risk factors for heavy drinking, and negative consequences experienced as a result of heavy drinking from an assessment of the student's drinking profile with a motivational interviewing style of discussing this information. This study aimed to identify the active ingredients of such an intervention by 'dismantling' it in to these two components.
Students at a US university were
recruited
For their participation, students could receive $20 or an extra psychology course credit at each assessment and for attending the in-person session (if so assigned).
through posters, presentations and direct e-mail invitations. Of an estimated 675 heavy drinkers among those invited, 279 agreed to participate after qualifying for the study by completing screening procedures and admitting to at least one heavy-drinking episode in the past fortnight. They averaged about 27 UK units of alcohol a week. All the students completed an assessment of their drinking and related problems. For a randomly selected 1 in 4, this was the sole 'intervention'. The remainder were randomly allocated to receive: immediate computerised assessment feedback with no further intervention; the same feedback delivered later and discussed face to face during a single-session motivational interview typically lasting under an hour; or a similar motivational interview but without the feedback. The counsellors were specially trained, and supervised with the aid of session videos.
Merely being assessed was followed six months The same measures were also taken at three months. For clarity this account focuses on changes at six months. later by small reductions in a composite measure of drinking intensity and problems and also in the components Consisting of the number of drinks students said they consumed over the past month, an estimate of the highest blood alcohol level reached in their heaviest drinking episode during that period, and reported alcohol-related problems in the past three months. of this measure. Against this benchmark, only the motivational interview incorporating feedback led to significantly greater reductions. For example, after this, on average drinks per week had fallen by an extra 9 UK units. In contrast, when the interview had not incorporated feedback, the extra reduction over and above assessment amounted to just over half a unit. Supplementing assessment with computerised feedback alone was similarly ineffective, leading to no further reduction in drinks per week. Confirming its superiority, when the three active interventions were compared with each other, motivational interviewing incorporating feedback led to the greatest reductions in drinking and (compared to motivational interview without feedback) in drink-related problems, all statistically significantly advantages.
Further analysis suggested that much of the extra impact of the combined intervention was due to correcting the students' over-estimates of how many same-sex students in the USA drank more than they did. On the basis of their work and earlier studies, the authors concluded that feedback-based motivational interviewing appeared to be a robust intervention for reducing drinking among this population.
The message seems to be that among this kind of population (not seeking treatment, but interested enough to participate in a study; moderately heavy socially integrated drinkers), giving individuals 'normative' feedback on how their drinking and risk levels compare to those of their peers is an important but insufficient ingredient. Reinforcing and exploring the implications of this information in the course of a motivational interview gave it greater resonance, seemingly depriving these heavy drinking students of the comforting assumption that they were merely average drinkers. Faced with this identity challenge and/or relieved of presumed social pressure to drink heavily, the tendency was to cut back. Conversely, without feedback to focus and justify the discussion, motivational interviewing was less effective. The interpersonal style and the information content complemented each other.
In this particular study a minor concern is that by chance students allocated to motivational interviewing plus feedback started off being slightly heavier and more problematic drinkers; part of the apparent advantages of this approach may have been due to them reverting naturally to more typical levels. However, the study's verdict has been broadly confirmed by related studies and by reviews of all the available research. This body of work is summarised and selected from below. For details Background notes.
Only one other (smaller and more short-term) analysis has, within the same study, compared assessment feedback alone against motivational interviewing with and without feedback. In line with the featured study, its tentative conclusion was that in respect of drink-related problems, motivational interviewing benefited from assessment feedback. It also found that if it came to a choice between unelaborated feedback and motivational interviewing without feedback, the former more effectively reduced dependence symptoms. In the featured study too, feedback seemed slightly the better option of the two, though neither significantly bettered assessment without any intervention.
Four previous studies contrasted feedback alone with feedback incorporated in a motivational interview. All concerned risky drinkers identified through screening. College samples either volunteered for the studies and received course credits or financial compensation, or were mandated to the intervention for violating alcohol-related college rules. In two studies emergency ward patients were screened. Taken together, these studies (all but one from the USA) suggest impacts are maximised by a motivational interview based partly on feedback from an assessment of the individual's risks and how their drinking compares to national or local norms.
This is not to say that mere feedback is ineffective. As in the featured study, in many previous studies it failed to create statistically significant changes. But when those studies (almost entirely of non-treatment seeking drinkers and mainly of students) were aggregated, a small to medium sized reduction in alcohol consumption was detected.
All these studies left open the question of whether other counselling/information-giving styles might have been just as effective as motivational interviewing. That issue was addressed in three reviews including one which aggregated results from 62 studies evaluating attempts to curb risky drinking among college students. Verdicts were similar, though with some variations. Where they overlapped was in concluding that among the interventions with the strongest research backing were individual, face-to-face discussions which adopted a motivational interviewing style, and which featured personalised feedback on the individual's drinking profile – in particular, 'normative' feedback setting their drinking and/or risks alongside national or local norms.
It should not however be concluded that these are sure-fire ways to curb excessive drinking. It remains unclear whether broader college populations unwilling to volunteer for such studies (sometimes only a minority do) or with a different motivation for accepting such interventions (the normal enticements are cash or course credits) would have reacted in the same ways. And normative feedback is limited by the fact that the most influential comparators are the people socially closest to the individual. For heavy drinkers, commonly their closest friends really are heavy drinkers. There is no misperception to correct. Rather than being a prompt to cut back, confirming that they and their friends drink more than normal may be the kind of distinction they desire. This is one reason why universal norms-based campaigns can fail. Such complications can be more sensitively handled in the individualised and flexible format of a motivational interview.
Thanks for their comments on this entry in draft to Jim McCambridge of the Centre for Research on Drugs and Health Behaviour at the London School of Hygiene & Tropical Medicine. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 05 March 2009
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