Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 20 December 2011

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. 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 prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Patients want to be drug free – but from what and when? ...

CBT pulls some of the right levers but few methadone patients participate ...

Style not content seems key to matching therapy to the patient ...

Large preventive impacts from primary school character development programme ...

What is the role of harm reduction when drug users say they want abstinence?

Neale J., Nettleton S., Pickering L.
International Journal of Drug Policy: 2011, 22, p. 189–193.
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 Neale at jneale@brookes.ac.uk.

A team including one of the researchers responsible for the original finding have queried the interpretation of the highly influential report from a national Scottish study that most drug users starting treatment wanted to become abstinent. On the basis of in-depth interviews, they caution that it is just not that simple.

Summary Starting from the axiom that all research involves questions of meaning, definition and value, and the understanding that knowledge is ultimately subjective, relative and socially constructed, the featured article reviews findings from a paper one of the authors co-authored, which was presumed to indicate that most problem drug users starting treatment in Scotland wanted to become abstinent rather than reduce the harm they experienced from their drug use.

The paper published in 2004 derived from the DORIS study of 1007 drug users starting treatment in Scotland during 2001/02 at community, residential or prison-based drug services offering substitute prescribing for opiate addiction, detoxification, rehabilitation, counselling and/or group work. One of the questions they were asked was: "What changes in your drug use do you hope to achieve by coming to this agency?" In reply they could tick one or more of:
• abstinence/drug free;
• reduced drug use;
• stabilisation;
• safer drug use;
• no goals;
• other goals.

In response to this question, 57% indicated that their sole objective was abstinence. Just 7% each endorsed stabilisation or reduced drug use and under 1% safer drug use as their sole goals. Of the 24% who endorsed several goals, most aspired to abstinence and harm reduction.

These results have been interpreted as meaning that drug users want to be drug free and that therefore services should be abstinence-oriented, ignoring the uncertainties and limitations expressed in the paper. As it made clear, though an aspiration, abstinence may not be realistic for some drug users. Participants may have ticked the responses they thought cast them in the best light. What they meant by "abstinence/drug free" was not explored, so it was impossible to tell whether they meant 'no illicit drugs at all', 'abstinence from my main problem drugs', or abstinence as a distant aspiration rather than a more immediate objective.

The paper did not make the more fundamental point that a different methodological approach might have enabled a better understanding of what drug users really want from treatment. Instead of the quantitative approach used in the DORIS paper – requiring both standardised questions and responses so they can be counted – authors of the featured report drew on in-depth interviews with 30 drug users also starting treatment, but in the south of England. Evenly divided between men and women, a third were starting opiate substitute prescribing treatment on methadone or buprenorphine, a third were detoxifying from illicit or prescribed opiate-type drugs, and a third had recently started residential rehabilitation. In this study conversational prompts and probes encouraged interviewees to expand on what they meant, particularly when the issue of abstinence arose – for example, asking whether this included alcohol or cannabis and how they rated their chances of achieving this goal.

Main findings

As in the Scottish study, many participants did convey a clear desire to stop taking drugs, but they were also frequently unsure they could achieve this. Also, what they meant by abstinence was varied and often not clear cut. Some explained that they never wanted to use heroin or crack again, but would probably always use cannabis, alcohol, ecstasy, or cocaine, especially in some cases if they had to do without their main problem drugs. Others were simply unsure whether they wanted to use drugs other than heroin or crack. Some later clarified that they wanted to be in control of their drug use rather than totally abstinent. Sometimes the aim was to stop using certain drugs now but address others later, and sometimes stopping use was not seen as necessarily forever. Though almost all smoked tobacco, stopping this was rarely mentioned as part of becoming 'drug free'.

Patients being prescribed opiate substitutes hoped to come off these eventually, but some said this would need to done slowly, and/or emphasised the current benefits of the treatment, including subdued cravings, controlled withdrawal symptoms, and less need to commit crime.

Though these were their drug-focused ambitions, their comments also revealed that changing drug use was often not their main priority and/or was intertwined with others. Asked what they wanted from treatment, frequently they began by talking about improving personal relationships, especially with their children – to be a 'good' parent and/or to have their children returned to them. Other similar aspirations included a meaningful relationship with a partner or spouse, developing good friendships, and repairing damaged relationships with family. In particular, they emphasised honest and trusting relationships built around reciprocity and respect. Also they wanted treatment to help them achieve general life goals Such as a 'normal' or 'better' life, 'new start', and a 'sense of purpose and direction'. and psychological wellbeing. Expressed for example as to 'be happy', 'gain confidence', 'develop self-esteem', or to 'find themselves'. Some also hoped treatment would enable them to engage in meaningful activities, Including employment, education, hobbies, and travel. obtain material possessions such as a car or house, markers of an accepted position in society such as a driving licence, address health problems, or to look and feel better.

The authors' conclusions

These findings from a qualitative study investigating abstinence ambitions in depth show how potentially misleading statements such as '57% of drug users approaching drug services want abstinence' can be. In this study (let alone in a more varied and larger sample) it was impossible to quantify the proportion who sought abstinence since this was not uniformly and often not clearly or consistently defined. Reflecting the messy reality of human experiences, behaviours, emotions and feelings, interviewees adopted fluid, contingent and context-specific interpretations of being drug free.

More specifically, when drug users say they want to be 'abstinent', we do not necessarily know what drugs they are talking about. If researchers do not probe for cannabis, alcohol or tobacco, interviewees will probably not think to mention them. Also, does abstinence really mean no drug use at all, or controlled use? And when are individuals talking about being abstinent: now and forever; now but not in the future; or not now but in the future? Those in treatment may want to be free from prescribed opiate substitutes, but may also recognise their benefits for the time being. Sometimes clients do not know what they want in relation to their drugtaking, or might know, but find it difficult to separate this from what they feel they can achieve. A standard survey question, such as that used in the DORIS study, cannot hope to unpick this complexity.

Additionally, drug use per se may not be their focus – changing it may simply be a means (if an important or essential one) to ultimate objectives such as improving relationships, regaining a normal life, or addressing health problems, suggesting that treatment and harm reduction discourses must similarly prioritise these diverse 'wellness' goals.

Findings logo commentary As the featured report points out, the desire for abstinence of most drug treatment starters in Scotland recorded by the DORIS study has been fundamental to critiques of what is seen as the harm reduction orientation of addiction treatment services across the UK. That finding was itself hedged about by the original researchers in ways reflected in the featured report, which establishes the reality of the concern that by abstinence the respondents need not have meant all drugs including legal substitutes, all illicit drugs, abstinence now rather than some time in the future, or an intention to actualise their desires in action. For some Scottish drug users, getting 'clean' means clean of 'dirty' street drugs, not pharmaceutical quality medications. It is also of course equally obscure what the patients in the DORIS study meant by the other options including reduced drug use (of which drugs when?), stabilisation (in what sense?), and safer drug use (of which drugs and in what ways?). It has also not been questioned that whatever they did mean, more preferred to define it as "abstinence/drug free" than in harm reductions terms.

Worth expanding on is a further consideration raised in the featured report – the context-specific nature of their (and any such) responses. Though many thought it "surprising" (as the DORIS report put it) that 57% endorsed only abstinence, given the question and their situations, it would perhaps have been surprising had they not. Instead of a mismatch between patient goals and treatment orientation, the findings can be interpreted as indicating that patients quite sensibly say they hope to get from a treatment service what that service offers rather than what it does not. Details below.

The question – "What changes in your drug use do you hope to achieve by coming to this agency?" – limited the focus of their aspirations to drug use. A question like, "What changes in your life do you hope to achieve by coming to this agency" might have exposed a greater priority for issues like relationships, health housing and welfare benefits. Also the question was specifically about "this agency". For 44%, this was a service Drug-free counselling or group work, detoxification or residential rehabilitation. offering drug-free and/or explicitly abstinence-oriented treatments, and the same proportion were in prison at the time, where abstinence at least most of the time would normally have been the only feasible objective. As commentators on the original article pointed out, in situations where abstinence from illegal drug use is enshrined not just in law but in social and cultural norms, it is to be expected that people seeking access to help reproduce those norms. The fragility of their allegiance to them – or their inability to conform – is indicated by the fact that over the next eight months, 41% sustained even two weeks' of limited abstinence (non-use of drugs other than alcohol or cannabis), and at the end of this period, just 15% to 17% met this criterion.

When the focus was sharpened to methadone programmes, most patients (57%) endorsed goals including reduced, stabilised or safer drug use as well as or instead of abstinence. That left 43% seemingly at odds with their treatment because their sole aim was abstinence. But nearly all these From an earlier paper from the study (Neale J. et al. "Comparing community and prison-based drug treatments." Drugs: Education, Prevention & Policy: 2004, 11(3), p. 213–228) it is known that 24% of the DORIS prison sample were starting methadone treatment. Extrapolated to the relevant DORIS report, these would constitute 39% of the methadone treatment sample. could have been starting methadone in prison, where reduction and abstinence would at that time normally have been Scottish Prison Service. Partnership and coordination. SPS action on drugs. Revised guidance on the management of drug misuse in Scotland's prisons. 2000. See page 43. the only objectives on offer.

Though important, these complications should not obscure the fact that, however the individual defines it, stopping use of some drugs (especially those so problematic that they have driven them to seek help – in the UK, normally heroin and/or cocaine) is a common goal, and that for substitute prescribing patients, it often extends to eventually being free of legal substitutes too. Surveyed in 2007 – but specifically about their long-term goals in respect of drug use – 81% of responding drug treatment clients in England who used heroin wanted to stop doing so; for cocaine, the figure was 73%. But only minorities wanted to cease using cannabis, alcohol or benzodiazepines and 51% methadone. Given the question, fewer would have wanted to stop their methadone right now or in the next weeks or months.

Ambivalence about taking medication in the form of a desire to be free from having to take the pills or concern over their side-effects and efficacy is commonly observed in long-term prescribing, not just for opiate addiction, but for chronic physical and psychiatric conditions. Such is the scale of this problem that it is a major concern for clinicians, leading patients to decide not to take or to prematurely cease or cut down medication, to the possible detriment of their health. That opiate users prescribed methadone or other substitutes share this ambivalence should not be a surprise, especially given the unusual burdens the treatment often entails, such as supervised consumption and daily attendance, the stigma attached to regularly consuming opiate-type drugs (even legally prescribed), and the fact that the treatment marks the patient as an 'addict'.

As formulated by the chair of the Recovery Orientated Drug Treatment Expert Group looking in to these and related issues in England, such findings mandate attention to moving patients towards abstinence, and this should include from legal substitutes, but only "after appropriate careful planning, when they are ready". While confirming the desires of many to be entirely free of the substances which have been dominating and restricting their lives, the featured report should help prevent a partial and unsophisticated understanding of the original DORIS research leading to premature or inappropriate insistence on total abstinence on the grounds that this is what patients want, when their wants are often not so easily encapsulated.

Thanks for their comments on this entry in draft to Joanne Neale of Oxford Brookes University in England, Neil McKeganey and David Liddell of the Scottish Drugs Forum. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 06 December 2011

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How does cognitive behaviour therapy work with opioid-dependent clients? Results of the UKCBTMM study.

Kouimtsidis C., Reynolds M., Coulton S. et al.
Drugs: Education, Prevention and Policy: 2011, early online publication.
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 Kouimtsidis at drckouimtsidis@hotmail.com.

Compromised by an inability to interest enough patients, the only randomised UK trial of cognitive-behavioural therapy for methadone patients was unable to be definitive but did find some signs of benefit and that the therapy had pulled some of the intended psychological levers.

Summary Cognitive approaches to treating substance misuse problems are still relatively new and it is important to understand how they work. Relevant treatment models emphasise the role of: self-efficacy to cope with situations associated with drug use without using; developing skills to cope with these situations as well as skills to generate broader lifestyle changes; and changing patients' expectations of the positives and negatives of using the substance. Successful treatment is theorised to result from a reduction in the extent to which patients expect positive outcomes from substance use, an increase in their negative expectations, and enhanced self-efficacy and coping skills.

The featured study was the first study to directly test this model in the context of substitution treatment for opiate dependence. The findings derive from the UKCBTMM United Kingdom Cognitive Behaviour Therapy Study In Methadone Maintenance Treatment. study, which investigated the effectiveness and cost-effectiveness of cognitive-behavioural therapy for patients in opiate substitute prescribing programmes, itself the first randomised controlled trial of a psychosocial intervention in this setting in the UK.

At several UK treatment centres, the study randomly allocated substitute prescribing patients to keyworking only or keyworking plus cognitive-behavioural therapy, and assessed whether the additional therapy improved outcomes six and 12 months later. Additional therapy was offered weekly for 24 weeks but typically patients attended only four sessions. Therapists and keyworkers were recruited from existing staff and the therapists were trained and supervised in the therapy.

Perhaps because so few patients were eligible for and prepared to join the trial (just 60 did so of 369 who were eligible), though there were outcome gains from the extra therapy, none were statistically significant. Nevertheless, as measured by their effect sizes, A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. In the featured study effect sizes were expected to be about 0.3. the gains were as large as expected in terms of reductions in the severity of addiction and heroin use, and improved compliance with prescribed methadone use. The cost of the extra therapy was more than outweighed by savings in health, social, economic, work, and criminal justice costs. Perhaps because patients had already been in methadone treatment for on average five months, these savings were less than in some other studies, and the difference in cost savings between therapy and non-therapy groups was not statistically significant.

Main findings

However, the featured report was less concerned with whether extra cognitive-behavioural therapy improved the end result of methadone treatment, than with how it might have done so. One way was expected to be by improving how well patients coped with life's problems, a concept measured by a standard questionnaire which assessed different aspects of this ability. Relative to keyworking only, as expected, at six months the therapy was followed by a significant improvement in the degree to which patients positively reappraised problems, and a non-significant improvement in problem solving. Other domains where additional improvements were expected (logical analysis, seeking guidance and seeking alternatives) improved to roughly the same degree regardless of the extra therapy. Six months later (and 12 months after therapy had started) a similar analysis revealed that nearly all the expected mechanisms had improved after cognitive-behavioural therapy but deteriorated without it. The exception was logical analysis, where the reverse pattern was seen. Despite these trends, none of differences between patients who had or had not been offered cognitive-behavioural therapy were statistically significant, so chance variation could not be ruled out.

As expected, the degree to which patients felt confident that they could resist the urge to use drugs ('self-efficacy') increased after cognitive-behavioural therapy but decreased (at six months) or increased less (at 12 months) without this therapy. Patients were also asked about the good and bad consequences they expected from cutting down their heroin use. These measures changed in the opposite to what was expected; patients offered the therapy became relatively less positive and more negative about cutting down. Again, none of these differences between the two groups of patients were statistically significant.

Further analyses not reported here assessed changes among only patients who attended at least one session of their intended psychosocial intervention and related changes to the number of therapy sessions attended.

The authors' conclusions

Though no definite conclusions can be taken from this study, there are indications that the therapy may be effective through at least some of the intended mechanisms, but also that methadone-maintained patients at services as configured in England in the 2000s generally reject the chance for this form of extra therapy.

The fact that few patients were prepared to join the study and that those who did attended few therapy sessions suggest there could be major barriers to implementing cognitive-behavioural therapy in routine practice in the British drug treatment system, perhaps associated with a culture of limited psychological therapy and relatively low expectations of clients' engagement and compliance with treatment.

With such a small sample there is a heightened possibility that real differences made by the therapy will fail to meet conventional criteria for statistical significance and be mistakenly dismissed as chance variation. That this might have happened is suggested by the fact that the relative increase in days free of heroin use after six months was as great as expected. With a larger sample, it might well have also proved statistically significant. Economic analyses also found non-significant but appreciable net social cost-savings. The featured analysis supplements these outcome findings with indications that cognitive-behavioural therapy may have fostered some but not all of the crucial problem-solving skills.

The main seemingly counter-productive finding related to expectations about the pros and cons of reducing heroin use as measured by a scale yet to be validated. Also, more sessions of therapy did not further enhance the presumed psychological mechanisms through which the therapy worked. Nor were these mechanisms significantly related to substance use and other outcomes – again, perhaps due to the small sample size.

Findings logo commentary While appreciating the limits set by sample size, the non-significant trends suggesting that the therapy worked though the intended mechanisms were generally small in size. Of 22 comparisons between the two sets of patients, in only one had a mechanism (positively reappraising life's problems) changed to a statistically significant degree in the expected direction – a result to be expected purely by chance. Together with a few counterproductive trends, these minor changes in the mechanisms thought to be specific to cognitive-behavioural therapy do not suggest it has a special role (that is, over and above other forms of psychological therapy) as a supplement to routine keyworking in the circumstances of the trial. At the same time the findings suggest that extra therapeutic contact did help stabilise patients who were prepared to accept it. Whether this needed to be cognitive-behavioural or a recognised therapy of any kind is impossible to tell from the study. Broader research offers little support for a distinctive role in addiction treatment for cognitive-behavioural approaches, results from which are generally equivalent to other approaches. It also seems that, at least in the mid 2000s, a steep hill remained to be climbed before formal psychological interventions of any kind were routinely and expertly implemented in Britain's methadone clinics. How far that has changed is unclear. Details below.

CBT in methadone treatment

Guidelines from Britain's National Institute for Health and Clinical Excellence (NICE) recommend cognitive-behavioural therapy not as a routine means of further stabilising patients, but to help with lingering anxiety and/or depression among those already stabilised in maintenance treatment. However, the analyses which led NICE to counsel against routine use did not show that cognitive-behavioural therapy was ineffective, just that it was not convincingly more effective than other well structured therapies.

Published in 2007, these guidelines did not have available to them the latest update of an authoritative meta-analytic A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. review conducted for the Cochrane collaboration which combined results from studies comparing structured psychosocial interventions against normal counselling among methadone and other opiate substitution patients. Taking in new studies available up to 2011, it found that overall such interventions had improved neither retention nor outcomes (including opiate use) to a statistically significant degree. In particular, the same was true of the family of behavioural interventions including cognitive-behavioural therapy. Contrary to expectations, this update found contingency management conferred no significant benefits, contradicting both its earlier findings and the NICE guidelines referred to above.

In the Cochrane review, verdicts in respect of cognitive-behavioural therapy rested on three studies, one of which does not appear to have reported substance use outcomes but did find greater improvements in psychological health. Relative to drug counselling alone, so too did a study of male US ex-military personnel starting methadone treatment. A year later, in this study cognitive-behavioural patients had improved more on a much wider range of psychological, social and crime measures, but not in respect of substance use. From methadone plus routine drug counselling only, so complete were the reductions in opiate use that little space was left for additional therapy to further improve outcomes. These two US studies are supplemented by a German study which found that group cognitive-behavioural therapy led to significantly greater post-therapy reductions (at the six-month follow-up) in drug use than routine methadone maintenance alone. The effect was largely due to changes in cocaine use, but there were also minor extra improvements in abstinence from opiate-type drugs and benzodiazepines. What these three studies suggest is that offering extra psychotherapy (not necessarily cognitive-behavioural therapy in particular) improves psychological and social adjustment and perhaps too helps reduce non-opiate substance use, but that methadone maintenance itself as implemented in these studies was such a powerful anti-opiate use intervention that further gains on this front were harder to engineer.

CBT in substance use treatment generally

If in terms of core substance use outcomes, cognitive-behavioural therapy in methadone maintenance does little to improve on routine counselling, this will simply be in line with findings in respect of the therapy's role in treating drug and alcohol problems in general. A review combining results from relevant studies suggested that it remains to be shown that cognitive-behavioural therapies are more effective than other similarly extensive and coherent approaches. Studies which directly tested this proposition often found little or no difference, even when the competing therapy amounted simply to well structured medical care.

The implication is that choice of therapy can be made on the basis of what makes most sense to patient and therapist, availability, cost, and the therapist's training. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects may persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation.

Will CBT help methadone patients leave treatment?

Beyond core substance use outcomes is what in Britain is now a priority issue – whether more intensive therapy, even if it seems to add little to the powerful opiate use reduction effect of methadone treatment, might help people gain sufficient psychological and social stability to leave this treatment, and leave it sooner. In respect of psychotherapy in general and cognitive-behavioural therapy in particular, this remains a live possibility with some support from studies of during and post-treatment changes, though none have directly tested whether these enable patients to more safely leave the shelter of substitute prescribing programmes.

However, from the starting point revealed by the featured study, there seems a long way to go before structured psychosocial interventions of any kind are routine in Britain's methadone services. An earlier report from the study commented that services were overstretched and understaffed and suffered from high staff turnover. Very few staff had been trained in psychological interventions and sometimes even basic individual client keyworking was extremely limited. Difficulties in engaging clients in the study were attributed partly to a low level of psychological interventions in services, which in turn led to low expectations of clients engaging with these interventions. Perhaps too, the authors speculated, some clients were reluctant to become involved in more intensive treatment or to address psychological issues not previously identified in usual clinical care. Most tellingly, the researchers observed "a nihilistic view of psychological intervention and clients' capacity for change among some staff".

In this climate, and with the added burden of research procedures, the small proportion of patients prepared to accept therapy and attend more than a few sessions is likely to be an underestimate of the possible caseload if cognitive-behavioural therapy were well promoted as a part of usual care, especially if elements of the approach were incorporated in keyworking rather than offered as an optional add-on.

In a different set of services probably sampled in the mid-2000s, perfunctory brief encounters focused on dose, prescribing and dispensing arrangements, attendance records, and regulatory and disciplinary issues characterised the keyworking service offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes. However, 'relapse prevention' was the most common therapeutic activity in the sessions, featuring in 44% of the last sessions recalled by the staff, a term often taken to imply cognitive-behavioural approaches. What staff included under this heading was unclear, and the time given to it averaged just seven minutes, but is does suggest that there is a platform which could be built on. Unfortunately the need to do this building to foster recovery and treatment exit has coincided with resource constraints which make widespread training in and implementation of fully fledged therapy programmes seem unlikely.

Thanks for their comments on this entry in draft to Christos Kouimtsidis of the Herts Partnership NHS Foundation Trust in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 December 2011

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Patient reactance as a moderator of the effect of therapist structure on posttreatment alcohol use.

Karno M.P., Longabaugh R., Herbeck D.
Journal of Studies on Alcohol and Drugs: 2009, 70, p. 929–936.
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 Karno at karno@ucla.edu. You could also try this alternative source.

Confirmation from the US Project MATCH alcohol treatment trial that too explicitly imposing structure on therapy risks relatively poor outcomes among patients reluctant to relinquish control and who react against direction – and a further indication that this pattern is not universal, but depends on the context.

Summary In the 1990s, the US Project MATCH study tested whether different types of alcohol-dependent patients would respond better to 12-step based counselling, cognitive-behavioural therapy, or to an approach based on motivational interviewing. It was intended to be a definitive test of this kind of matching of patients to therapies. Few and minor matching effects were found, but researchers at some clinics in the trial were able to use session recordings to probe for a different kind of matching – not of therapies, but of therapeutic (or more broadly, interpersonal) styles.

MATCH therapies were either standalone treatments or 'aftercare' immediately following residential or intensive day care. At one of the clinics in the aftercare arm of the study, patients who seemed Based on ratings of their videoed behaviour in their first therapy session. at least moderately reluctant to relinquish control and who reacted against direction ('reactive' patients) did badly when therapists took the lead in structuring the sessions. Relative to other patient-therapist combinations, in the following year they drank and drank heavily more frequently. For less reactive patients, the degree to which therapists imposed structure was unrelated to subsequent drinking. These results suggested that for patients beyond a certain level of reactance, therapist-led initiation of topics, teaching, and providing information were associated with worse outcomes.

The featured report aimed to test whether these findings would be replicated at another of the MATCH aftercare sites (among 122 patients), and at three of the sites (among in total 125 patients) where MATCH therapies had been provided as standalone treatments. As in the previous study, patients were divided in to high, medium and low reactance based on ratings of their videoed behaviour in their first therapy sessions. Their therapists too were rated on how they behaved with the client across If four sessions had been attended. the first three and final sessions – specifically Another way of imposing structure – asking closed questions – was in this study found unrelated to outcomes, seemingly because it was highly correlated with asking open-ended questions. Omitting this dimension from the analysis of the earlier study did not materially affect the findings from that study. the degree to which they took the lead in structuring sessions by providing information or instruction, or introducing or changing topics.

Main findings

As in the previous study at an aftercare site, at the new aftercare site too, over the following year medium or highly reactive patients drank and drank heavily more often if their therapists had been relatively directive in imposing structure on therapy sessions. Less reactive patients actually did slightly better when therapists imposed structure. No such findings emerged when the therapies were standalone treatments; highly or less reactive patients responded equally well, regardless of whether their therapists explicitly structured sessions. These patterns were consistent across the entire year of the follow-up. Across all patients, they summed to a finding that highly structuring therapists were relatively counterproductive when the therapy was aftercare, but overall had slightly better outcomes when delivering standalone therapies. The structure-reactance interaction did not, however, affect how long patients lasted before lapsing to drinking or relapsing to heavy drinking.

The authors' conclusions

The featured study suggests that when psychosocial therapy for alcoholism follows an intensive treatment episode (that is, plays an aftercare role), the degree to which therapists structure sessions impacts differentially on patients more or less willing to relinquish control and accept direction: the more structure, the less well reactive patients do after therapy. The findings replicate those from another MATCH aftercare site, showing they transcend the particular nature of that clinic, its patients, and its therapists.

This pattern not, however, apply to standalone therapies, and in this role structure was overall beneficial, while in the aftercare role it was overall detrimental. Why this happened is unclear. Perhaps patients starting a new treatment – even those who normally react badly to direction – expect and are receptive to treatment structure. In contrast, patients emerging from intensive treatment in to an aftercare phase may expect a less structured approach; when they find the opposite, those prone to react badly to direction react as expected, and end up drinking more than when treatment meets their expectations.

For therapists in an aftercare or continuing care role, the implications are that generally they should avoid highly structuring therapy in the form of adopting a 'teaching' style, providing information, and controlling which topics are discussed, especially with reactive patients. To avoid this, they may as part of their assessments wish to ask patients to complete one of the validated questionnaires which measure reactance.

It should be remembered, however, that these suggestions emerged from observing how well patients do when therapists happen to be relatively directive or non-directive in the degree to which they structure therapy. A study which deliberately assigned patients to therapists who were directive or not would be in a stronger position to establish whether this was indeed an active ingredient affecting the success of therapy for different types of patients.

Findings logo commentary Across substance use studies, the type of patient-therapist dimensions investigated in the featured study evidence a remarkably consistent pattern. In terms of substance use outcomes, non-directive therapeutic styles work best for clients characterised by anger, defensiveness, or resistance, or who like to take control – the 'reactive' patients of the featured study. In contrast, more structured and directive approaches may profit calmer clients, those who welcome being given a lead, and those already committed to the course of action being directed. While the featured study highlighted the risks of directively imposing structure, other studies have shown that for some patients in some circumstances, being non-directive is counter-productive.

A similar pattern has been observed in psychotherapy in general in an analysis which included data from MATCH: patients who characteristically exhibit low levels of resistance or reactance respond better to directive types of treatment, while patients prone to be reactive or resistant respond best to non-directive treatments. Together with the finding that reactive patients tend to benefit least from therapy, it led the experts to recommend that highly reactive patients should be offered treatment which de-emphasises the therapist's authority and guidance, employs tasks designed to bolster patient control and self-direction, and de-emphasises the use of rigid homework assignments. In general, therapists should avoid counterproductively stimulating the patient's level of resistance.

But as the featured study found, such patterns can be context-specific – in this case, apparent when therapy was aftercare, but not when it was the primary treatment. Patients' expectations of how much structure to expect or how much was appropriate were, the researchers suspected, what made the difference in the two settings. Similarly, a Findings review has cautioned that, for example, non-directiveness from a probation officer to an offender can seem less than genuine, even to the officer, as can biting one's tongue when it would have been natural and caring to be direct about the risks a client faces. In these circumstances, even if being non-directive might generally suit the client's character, following this guideline could adversely affect one of the features of effective therapy – that the therapist comes across as 'genuine'. Outcomes might also be worse if for the sake of not being directive, therapists failed to address the emotional state of highly distressed patients.

The authors of the featured study suggested that standard psychological tests could assess how far clients resist or welcome direction and act as a guide to how tightly therapy should be structured. For their study, these assessments were made by observers on the basis of the first session video, suggesting that the therapist too could observe the patient and adjust accordingly. Feedback from early counselling sessions through recordings assessed by supervisors or peers, or through short 'de-briefing' questionnaires given to the clients, could also be used to assess when there is a mismatch between therapist and client interactional styles.

The degree to which they structure therapy, and directiveness more broadly, is just one dimension which therapists might bear in mind. For more on matching alcohol treatments to patients, see this Findings entry offering an introduction to the topic and a one-click search for relevant Findings analyses.

Last revised 19 December 2011

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Effects of the Positive Action programme on problem behaviours in elementary school students: a matched-pair randomised control trial in Chicago.

Li K-K., Washburn I., DuBois D.L. et al.
Psychology and Health: 2011, 26(2), p. 187–204.
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 Li at ben.li@cityu.edu.hk.

In Hawaii and then the less promising schools of Chicago, a primary school programme aiming to improving school climate and pupil character development had substantial and, in Chicago, lasting preventive impacts – another illustration that focusing on drugs is not always the best way to prevent drug problems.

Summary The Positive Action programme to improve the climate in schools and pupils' social-emotional and character development includes a classroom curriculum, a school climate programme, and a parent and community programme, each working in synergy. The aim is that students become happier and more motivated, teachers freer to focus on teaching instead of classroom control, and head teachers become better leaders. Parents and community members get more involved in education, and schools become more effective.

Positive Action's philosophy is that people feel good about themselves when they adopt positive attitudes and take positive actions like respect, responsibility, self-honesty, self-improvement, a healthy, drug-free lifestyle, and academic achievement; thoughts lead to actions, and those actions lead to feelings about ourselves, which lead to more thoughts, in what can be a negative or a positive spiral.

Throughout the programme, positive actions for the body, mind, and feelings are presented in a framework of six unit concepts, with a seventh for review:
• self-concept: what it is, how it's formed, and why it's important;
• positive actions for your body and mind;
• managing yourself responsibly;
• treating others the way you like to be treated;
• telling yourself the truth;
• improving yourself continually;
• review.

Studies have suggested that the programme enhances academic achievement and school involvement and reduces disciplinary referrals and violence. A four-year trial in Hawaii matched pairs of schools and randomly allocated one of each pair to the programme. By the time pupils were in their fifth grade (age about 10–11) it found significant reductions in self-reported substance use, violence and sexual behaviours in Positive Action schools versus their matched control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. schools.

The featured study aimed to replicate the Hawaii trial using a similar methodology, but among pupils with greater developmental disadvantages – primary school pupils in the publicly funded schools of urban Chicago. Seven matched pairs of schools joined the study and participated during the 2004/05 through 2006/07 academic years. They had been drawn from 483 schools, of which 68 met the study's criteria, including that their pupils were at relatively high risk Pupil roll mostly from poor families and the school has a relatively poor academic achievement record. of problem behaviours. Of these 68, 18 schools agreed to participate in the study on the understanding that they would be matched with another from the 18 and randomly assigned to implement or not the Positive Action programme. Seven pairs of schools could be adequately matched on indicators of pupil achievement, attendance, ethnicity, and family income, pupil and parental involvement, teacher qualifications, and the local crime rate. All 14 schools participated in the study.

Pupils in their third grade aged roughly eight to nine were followed up as they moved through the schools to the fifth grade. Incoming pupils who joined their classes were also included in the study, though for these pupils no baseline data was available (instead it was estimated) and they will not have received the full Positive Action curriculum. Nearly 80% of pupils and parents agreed to the pupils being included in the study. The featured report is based on the roughly 510 who filled in questionnaire surveys on substance use, violence, bullying and disruptive behaviours at the final assessment, It was only that this point that pupils were asked whether they had ever used drugs and their experience of serious violence, it being judged inappropriate to put these questions to younger children. of whom 290 were among the 590 in the study from the start; the remainder were pupils who joined the schools later.

Positive Action schools were offered the standard support package available from the company marketing the programme, including training by the developer, workshops for key players, individual consultations for teachers, and site visits and consultations with school leaders to assess and address obstacles to full and faithful implementation. Additional to this standard package were workshops targeted at the teachers of the pupils in the study to further enhance fidelity of implementation. The version tested in the featured study was intended to comprise over 140 15-minute lessons per grade taught four days a week.

Main findings

Over the three years of the study the quality with which the programme was implemented improved, until by the end of all but one of the seven schools achieved at least a moderate level.

After three years now aged about 10–11, pupils sampled from Positive Action schools were significantly less likely to say they had ever used alcohol or drugs than pupils in control schools. Specifically, they were asked if they had ever smoked a cigarette, drank alcohol, got drunk, used cannabis, or used other more serious drugs. Pupils who admitted to none scored 0, up 5 for those who admitted all five. Across all schools about 35% of pupils had used substances in at least one of these ways, but after taking in to account baseline differences, Including those estimated for pupils who joined the schools after the study started. scores in Positive Action schools were on average 31% lower than in their matched partner schools. Similarly they were respectively 36% and 41% lower for behaviour related to serious violence Including carrying or using a knife and gang affiliation. and for recently having bullied another child. Though 27% lower too for problem behaviours at school such as truanting and theft, this difference was not statistically significant.

There was no evidence that having been exposed to the full programme enhanced its impacts. Of the roughly 500 pupils who contributed analysable final follow-up data, about 280 had been in the schools from the start of the study so were (in the seven relevant schools) exposed to the full Positive Action curriculum. However, in terms of substance use, serious violence and problem behaviour at school, they benefited no more (in fact, non-significantly less) from the programme than pupils not exposed to the full curriculum, and were significantly less likely to have reacted to the programme by reducing the extent to which they had recently bullied other children.

The authors' conclusions

The featured trial in Chicago was the second to find the programme effective in reducing substance use and other problem behaviours among primary school pupils. At 0.27 to 0.41, the magnitude of the impacts expressed as effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. are in the upper range found among such programmes, perhaps partly because the programme is intensive and the pupils, due to their often unpromising situations, were in a relatively good position to benefit.

Among the limitations of the study were the fact that baseline data had to be estimated for about half the pupils. It is also unclear why pupils fully exposed to the programme did not benefit more than those only partially exposed.

Findings logo commentary This study joins a small set which have found sometimes substantial substance use prevention impacts from programmes implemented in the early years of schooling which are not focused on substance use at all, but on overall child development and the prevention of a spiral of deviancy and alienation. A later report from the study yet to be published will focus on substance use and extend the follow-up to US grade eight, roughly age 13–14. By this stage just a fifth of the original grade three pupils were still at the schools. Nevertheless, amalgamating results from new and retained pupils, those in Positive Action schools were 20%–39% less likely to have ever used tobacco, alcohol, or cannabis than those in control schools, and also less likely to have got drunk. As in the featured report, the effects were just as great among the new pupils. The differences extended to the most serious forms of substance use recorded by the study, including having got drunk more than once (9% v. 15%) and used cannabis at least twice (11% v. 16%). Grade eight pupils in Positive Action schools also scored higher on a measure Reflecting prosocial interactions, honesty, self-development, self-control, respect for teachers, and respect for parents. of social-emotional and character development. This measure declined over the years of the study but less steeply in Positive Action schools, an effect which seemed to account for the impacts of the programme on substance use.

Especially given the impacts on incoming pupils, programmes like Positive Action may have a place in the first years of secondary schooling in the UK as well as in primary schools. Such programmes attract because they promise wide-ranging benefits in areas other than substance use such as the prevention of crime and violence and of mental health problems. Beyond specific programmes is the finding that substance use and problems are lower in schools distinguished by the high degree to which they productively engage pupils in their education and/or create a sense of being part of a valued school community – a sense promoted by warm and supportive schools with a caring, inclusive ethos, which emphasise prosocial values, encourage cooperation, show concern for pupils as individuals, allow pupils to participate in decision-making, and offer extracurricular activities.

Methodologically the featured study improved on the previous trial in Hawaii. In particular, It also used two-tailed tests of whether its findings were statistically significant, a procedure which does not in advance effectively deny the possibility of meaningful negative findings. it recruited schools to the study before they knew whether they had been allocated to Positive Action. In the Hawaii study, some schools dropped out on hearing they would be expected to implement the programme, possibly whittling down Positive Action schools to only those particularly willing to devote time to this kind of effort. In Chicago that did not happen, preserving the initial presumption that randomisation led to schools which were equivalent on unmeasured variables like their focus on pupil character development. Unlike the Hawaii study however, it did not provide the raw data from which its findings were derived, leaving it unclear whether more or less serious forms of substance use were most affected and how many pupils (as opposed to the ratio of pupils in Positive Action v. control schools) were prevented from engaging in these behaviours. The later report referred to above remedied this gap. Further methodological considerations below.

In both studies the programme developer was involved in training staff, an advantage which would presumably be hard to sustain if the programme were more widely implemented. Both too are vulnerable to the 'allegiance effect' – the tendency In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers. Such overlaps between developers and researchers are endemic2 in drug prevention research.

1. See articles at the following web addresses:
2. See article at the following web address:
for studies conducted by investigators with a stake in the intervention to produce more positive results, a vulnerability they share with much other prevention research. Both too recruited by definition only schools willing at least in principle to devote considerable time to their pupils' broader development rather than their academic studies. As long as schools self-select for such programmes, this merely reflects the reality that only willing schools would take them on. However, these studies may not be a good indicator of how well the programmes would work if education authorities tried to maximise their coverage by mandating universal implementation.

Unlike in Hawaii, where exposing children to the programme for an additional one or two years appeared to reduce negative behaviours by half, in Chicago being exposed to more of the programme did not enhance its effectiveness. Rather than only limited and short-term implementation being adequate, the authors' favoured explanation is that new pupils rapidly adjusted to changes in the school-wide climate generated over the years of the programme, including the behaviour of pupils and reinforcement of positive behaviours by teachers. Generally in intervention research, a finding that more of an intervention leads to greater impacts is interpreted as further evidence that the intervention is indeed responsible for the changes. That this has not been a consistent finding in respect of Positive Action is puzzling but not altogether surprising given the differences in the Chicago and Hawaii settings. Also, though incoming pupils will have missed out on some of the Positive Action curriculum, they will have become rapidly immersed in the overall climate and behaviour norms and expectations which that curriculum and the other elements of the programme helped to establish.

Thanks for their comments on this entry in draft to Brian Flay of Oregon State University and Adam Fletcher of the London School of Hygiene & Tropical Medicine. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 13 December 2011

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