Alcohol Treatment Matrix cell A2: Interventions; Generic and cross-cutting issues

2020/21 update funded by

Alcohol Change UK web site. Opens new Window

Alcohol Change UK

Previously also funded by

Society for the Study of Addiction web site Society for the Study of Addiction

Developed with

Skills Consortium web site. Opens new window

Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

Includes brief interventions

Drug Treatment Matrix

Effectiveness Bank Drug Treatment Matrix

Includes harm reduction

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Interventions; Generic and cross-cutting issues

Seminal and key studies on aspects of the treatment of problem drinking relevant both to psychosocial and medical approaches. Focuses on ‘common factors’ often sidelined as components of the ‘placebo effect’, but which are actually active ingredients now recognised as at least as important as the particular therapy. See the remaining four cells in row 2 of the matrix for more on generic features of medical and psychosocial therapies.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Shock to the system: handing patients responsibility matches extended treatment (1999). On first page under heading, “The alcohol clinic,” describes the study in London (1977) which questioned the orthodoxy that “alcoholism” requires extensive treatment. After thorough assessment, the extended treatment of the time worked no better than one brief session handing responsibility to a married couple to tackle the husband’s drinking. See also commentary (2015) around four decades later from a study researcher. Trial was broadly replicated (1988; free source at time of writing) at a Scottish alcohol clinic, where extended treatment led to some (but generally not statistically significant) further improvements. For related discussions click here, here and here, and scroll down to highlighted headings.

S Empathy and organisation transform alcohol clinic (1970). Analyses the book which documented a remarkable series of US studies from the late 1950s, showing that an alcohol clinic’s intake and attendance can be transformed by treating even the most unpromising of patients with warmth and respect. It can be thought of as having systematically deployed the ‘common factors’ explained below. For discussion click and scroll down to highlighted heading.

Jerome David Frank

Jerome D. Frank

S Pioneering insight into the ‘common factors’ underlying effective therapies (1991). First published in 1961 and culminating in a third edition in 1991, Jerome D. Frank’s book Persuasion and Healing has afforded an enduring insight into the shared features underlying effective therapies in mental health, including the addictions – features now widely acknowledged as more influential than the distinctive theories and methods of different approaches. For discussions click here and here and scroll down to highlighted headings.

K Treatment entry often the key event (2005). Reanalysis of data from the multi-million dollar US Project MATCH alcohol therapies trial showed treatment entry was associated with major drinking reductions even before treatment had been delivered. For the analysts their findings suggested that “current treatments are not effective”. See also rejoinder (2005) from a MATCH researcher and an informal commentary (2008) for the Effectiveness Bank on this and similar findings. For discussion click and scroll down to highlighted heading.

K Non-residential rehabilitation usually matches residential … but not always (2007). Confirmed that unless there are pressing contraindications, intensive day options deliver outcomes equivalent to residential care. Often of course, there are pressing contraindications. See also this informal Effectiveness Bank review. For related discussion click and scroll down to highlighted heading.

Retention and abstinence outcomes from contracting, prompting and reinforcing aftercare attendance

K Motivating aftercare (2007). Inspiring story of how a US inpatient treatment centre systematically tackled what is widely seen as the greatest weakness of current treatments – the lack of continuing care or aftercare. By applying simple prompts and motivators, the centre substantially improved aftercare attendance and helped sustained abstinence chart. See also later report from same study focusing on substance use patients with mental health problems.

K Remission is the norm among dependent US drinkers; multiple problems mean some take longer to get there (2011). US national survey found that just a third of dependent drinkers remained dependent three years later and three-quarters remitted without treatment. Compared to other dependent drinkers, despite accessing more treatment twice as many of the heaviest drinkers with multiple psychological problems remained dependent. Reanalysis (2013) of same surveys challenges assumptions that progressive neural, lifestyle or psychological changes increasingly lock-in dependence. For discussion click and scroll down to highlighted heading.

R Internationally, remission is the norm (2010). In the general population and in treatment samples, on average studies have found half (or more in recent studies) of all problem substance users were later in remission. Among general population samples, six out of ten who remitted continued to use, but among those whose problems led them to engage in professional treatment, six out of ten remitted by becoming abstinent. For related discussion click and scroll down to highlighted heading.

R Engaging the ‘treatment-resistant’ (2010; free summary). Shock-tactic confrontation and tough-love sanctions by the family and others found less likely to persuade dependent substance users to enter treatment than a ‘community reinforcement’ approach aimed at engaging them in fulfilling activities incompatible with continued use.

R Tailor induction into treatment (2005). When starting treatment or considering this move, some substance users need their motivation bolstered and to explore the options; for others this is not just unnecessary, but counterproductive. For related discussion click and scroll down to highlighted heading.

R Effective ways to relate to clients and patients (American Psychological Association, 2011). Effective ways to relate to psychotherapy clients in general (and by extension, other clients and patients), like forming a therapeutic alliance, being empathic, and appropriately adjusting to the individual – and perhaps even more important, what to avoid. For related discussion click and scroll down to highlighted heading.

R Chronic dependence benefits from long-term, continuing care (2014; free source at time of writing). Synthesis of research built on a previous review (2009) by adding 13 studies to the 20 identified earlier and aggregating all substance use outcomes. Nearly 9 in 10 of the trials were wholly or partly about alcohol use treatment. Found that patients allocated to aftercare/continuing care engaged in slightly but significantly less substance use at follow-up. Related guidelines below. Similar review narrowing in on problem drinkers and the most rigorous studies below. For discussions click here and here and scroll down to highlighted headings.

R Continuing care specifically benefits problem drinkers (2014; free source at time of writing). Focusing on solely alcohol-dependent patients and high quality randomised trials yielded just six trials, across which continuing care generally modestly improved on usual care. Similar review above based on many more studies because it included drug and/or alcohol use patients and less rigorous studies. For discussions click here and here and scroll down to highlighted headings.

R Case management function coordinates and extends care but patient welfare relatively unaffected (2019). In substance use treatment, case management has the intended effects of extending retention and linking patients to services which address their multiple needs, but overall had only minor and non-significant effects on substance use and other indicators of recovery. Related guidance below.

G Official British guidance on how to assess and treat problem drinking (National Institute for Health and Care Excellence, 2011). Recommendations from Britain’s health technology advisers on overall principles and particular interventions. Among the former are that therapeutic staff should aim to build trusting relationships with clients and work in a supportive, empathic and non-judgmental manner.

G Evidence-informed principles of effective substance use treatment (2006; free source at time of writing). Based on reviews commissioned by the American Psychological Association, aims to promote evidence-informed practice integrating factors to do with the therapy, the patient, and their relationship with the clinician, whilst acknowledging that “There is no empirically complete formula to allow clinicians to plan and deliver with complete confidence the right treatment for any incoming client.”

G US guidance on matching patients to an appropriate intensity and type of care (American Society of Addiction Medicine, 2013). From the professional body for US addiction clinicians, the world’s most widely used criteria for deciding what kind of treatment to start with or move on to for different kinds of substance use patients. For related discussion click and scroll down to highlighted heading.

G US evidence-based treatment principles ([US] National Institute on Drug Abuse, 2012). Presents 13 research-based principles of addiction treatment. Seven have been tested against the North American evidence; principles relating to individualising treatment were consistently supported.

G Strategies to promote continuing care (2009; free source at time of writing). Expert US consensus on practical strategies to promote aftercare/continuing care for substance use patients; informed by review listed above.

G Implementing case management (Association of Alcohol and Other Drugs Agencies Northern Territory, 2015). Australian state’s ‘peak’ body for non-governmental drug and alcohol services offers guidance on the widely implemented (but inadequately researched) role of the case manager in coordinating and integrating service delivery. Related review above.

more Search for all relevant Effectiveness Bank analyses or for subtopics go to the subject search or hot topics on promoting recovery through employment, mutual aid and user-involvement, the need for residential care, individualising treatment, and matching alcohol treatments to the patient. See also the collection of analyses relating to the common factors underlying different treatments.

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