Drug Treatment Matrix cell A4: Interventions; Psychosocial therapies

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Interventions; Psychosocial therapies

Seminal and key studies shedding light on the general principles underpinning psychosocial therapies and the effectiveness specific approaches. ’Individualise,’ is the overarching theme … and the consequent dangers of inflexibly following guidelines and research findings.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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K Match counselling style to the client (2003). US trial involving mainly cocaine-using patients shows that structure and directiveness are key dimensions on which therapies can be matched to client characteristics. For related discussions click here, here and here and scroll down to highlighted headings.

K Visual aids enhance counselling (2009). Developed in the USA and popularised in the UK, node-link maps are flow charts of a patient’s aims and plans intended to facilitate patient-counsellor communication; in this study they helped methadone patients reduce illegal opiate use and probably also cocaine use.

K Linkage programme boosted attendance at 12-step groups but not abstinence (2012). Study in London tested the ambition to extend recovery beyond formal treatment by systematically linking patients to mutual aid groups. About 43% were being detoxified from drugs other than alcohol. Group attendance was substantially boosted but not abstinence from the primary problem drug, a pattern seen in similar US studies. See also review (2004) of how treatment services can promote mutual aid.

K Couples therapy improves the lives of both partners (2003). Established most firmly for dependent drinkers, this study showed that the benefits of systematically involving a patient’s wife/partner in their treatment extends to the use of an opiate-blocking medication to sustain abstinence from heroin and allied drugs. Relative to alternative therapies, there were also improvements in family functioning and other social and legal domains. Similar story for methadone patients (2001; free source at time of writing). Note doubts over the probity of the work of lead author in both studies.

R Common core of therapy: effective relationships (American Psychological Association, 2011). Introduces reviews based on the understanding that therapeutic change is generated not only by technical interventions but by the ways clients and therapists relate. From here you can find the component reviews and the overall conclusions (2011) reached by the American Psychological Association’s task force. For discussion click and scroll down to highlighted heading.

R Directiveness is a key difference between therapies (2006). Rather than specific techniques, the interpersonal style (eg, directive v. patient-led) associated with different therapies is why some work better with some clients than others. For related discussions click here, here and here and scroll down to highlighted headings.

R Reviews of trials of motivational interviewing (Cochrane review, 2011) and cognitive-behavioural therapy (2009) suggest any structured approach grounded in a coherent theory is as good as any other, a major plank in the case for prioritising the common factors shared by psychosocial interventions. For related discussions click here, here, here and here and scroll down to highlighted headings.

R Motivational starts to treatment better without the manual (2005). Findings review discovered that motivational interviewing is not always preferable to more directive approaches, and has worked best when the therapist is not constrained to a manual, no matter how expertly drafted – a conclusion confirmed by a synthesis of research findings (2005; free source at time of writing). For related discussions click here and here and scroll down to highlighted headings.

R Mindfulness meditation takes its place among addiction therapies (2009). Variants of mindfulness meditation are among the ‘third wave’ of behavioural therapies allying Western and Eastern traditions. This first review of their application to addiction finds them equivalent to other structured therapies; similar conclusions from a more recent review (2014). Neither could include a later trial (2014) which found mindfulness more effective than group therapy based on the 12 steps and (on some measures only) a cognitive-behavioural relapse prevention programme. For related discussion click and scroll down to highlighted heading.

R Helping each other get better (2009). Monograph from leading authority on peer-based recovery from addiction includes a chapter on the evidence for NA, AA and allied mutual support networks and treatments based on the same principles. See also a review (2004) of how treatment services can promote mutual aid and a synthesis of studies (1999) of approaches based on AA/NA’s 12-steps versus alternative approaches.

R Therapeutic communities certainly work while residents stay (2012). Shortcomings in the original studies prevented a firm conclusion on the lasting benefits of residential rehabilitation houses where residents exert mutually therapeutic influences, but during their stays substance use was significantly reduced. For related discussion related click and scroll down to highlighted heading.

R Reserve therapeutic communities for the most vulnerable patients (2013). Review specific to users of illegal drugs argues that therapeutic communities should be reserved for patients with multiple and severe problems who do not do well in outpatient treatment due to the lack of structure and supports, or due to living in areas where drugs are easily available and widely used.

R Some patients get worse (2005). Reminder that after psychosocial therapy up to 15% of clients end up worse than before. Some of the reasons are thought to be a weak client-therapist relationship, failing to assess how clients are doing, being confrontational or critical, low or inappropriate expectations, and lack of challenge. For discussion click and scroll down to highlighted heading.

R Can rewards and sanctions displace counselling and therapy? (2016). Effectiveness Bank hot topics on contingency management (2016) and drug testing allied with sanctions (2016) ask whether we can dispense with counselling and therapy and just punish people or deprive them of rewards when they use substances in ways they and/or we would rather they didn’t, and reward them when they behave as we and/or they would wish.

R How lasting are the effects of offering prizes for abstinence? (2014). Free source at time of writing. Systematically giving substance use patients a chance to win valuable prizes if they test abstinent offers a lower-cost alternative to other ‘contingency management’ systems which provide rewards each time. Research synthesis shows that in the short term it works, but effects soon fade.

R Psychosocial interventions for stimulant use problems (Cochrane review, 2016). Amalgamation of results of randomised trials of psychosocial therapies for problem use of cocaine, amphetamines or other stimulants, finds them better than basic support but no better than usual treatment, and there was insufficient evidence to distinguish between different therapies.

G NICE-recommended psychosocial interventions ([UK] National Institute for Health and Care Excellence [NICE], 2007). UK’s official health advisory body recommends contingency management and behavioural couples therapy. Implementation advice below. For related discussions click here and here and scroll down to highlighted headings.

G Implementing NICE-recommended psychosocial interventions ([English] National Treatment Agency for Substance Misuse, 2010). Report from the British Psychological Society on how to implement recommendations in guidance above; includes protocols for conducting the main psychosocial therapies. For discussion click and scroll down to highlighted heading.

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

G Principles rather than programmes for how to relate to clients and what to say/do (2006; free source at time of writing). Based on reviews commissioned by the American Psychological Association. Argues that the principles it extracts from research “provide a more research-informed and potentially effective approach to treatment than either the application of a one-size-fits-all standard treatment protocol or the use of idiosyncratically selected interventions”. For discussion click and scroll down to highlighted heading.

more Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. See also hot topics on contingency management, residential rehabilitation, motivational interviewing, 12-step based mutual aid and counselling in methadone treatment.

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