Alcohol Treatment Matrix cell A4: Interventions; Psychosocial therapies

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Interventions; Psychosocial therapies

Key studies on the ‘common factors’ underlying psychosocial therapies for problem drinking and the effectiveness of specific approaches. Explores the famous ‘Dodo bird’ hypothesis that all bona fide therapies are equivalent, examines the legacy of the UK’s most ambitious treatment trial, asks whether therapy can really make things worse, and questions how research amalgamating impacts from many patients can be applied to the treatment of an individual in their individual circumstances.


S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S Confrontation provokes resistance (1993). Among heavy drinkers in the USA, motivational interviewing’s non-confrontational counselling style reduced both resistance to change and drinking itself compared to an explicitly challenging approach. See also the first account (1983) of motivational interviewing and a review (free source at time of writing) of the positive role of subtle forms of ‘confrontation’ in the approach. For discussion click and scroll down to highlighted heading.

Not just encouragement

The member briefly talked to the client about the meeting, its location, provided the client with a ride, met the client before the meeting so that he/she would know someone at the meeting who would answer his/her questions, and reassured the client if he/she felt uncomfortable. [Then] the AA or Al-Anon member made a phone call to the client at his/her home the night of the meeting to remind him/her of the meeting and to inform him/her what time he/she would be by to pick him/her up. The … member then called the therapist the next day to tell him whether the client had made it to the meeting. The client was then encouraged to continue in AA by therapist after the first meeting. The procedure was repeated in the next counseling session.

S Treatment services can radically affect access to mutual aid (1981). Meeting 12-step group members during treatment who encouraged patients to attend 12-step mutual aid meetings and helped them get there ( panel right) meant all attended compared to none just offered the service’s usual information and encouragement. By a toss of a coin, only 20 patients were allocated to these alternative procedures, but this early study convincingly showed that treatment services can radically affect access to mutual aid. Perhaps influential was a lift to the meetings in a “sparsely populated, rural area”.

S Client-centred group therapy works best (1957). For its time methodologically advanced, this US study found a Rogerian, client-centred approach characterised by non-directive, empathic listening generated healthier self-perceptions among alcohol-dependent patients and reduced relapse compared to approaches based on learning theory or psychoanalysis. This approach which underpins motivational interviewing was also tested in the trial listed below. For related discussion click and scroll down to highlighted heading.

K No added value from motivational interviewing (2012). Other than fleetingly and non-significantly, motivational interviewing’s change-prompting strategies did not generate extra drinking reductions among the stable, moderately dependent drinkers recruited to this US trial. If anything, non-directive Rogerian therapy (also tested in study listed above) stripped of motivational interviewing’s ‘active’ ingredients worked best, and a self-change option was almost as effective as both. For discussions click and scroll down to highlighted heading and see “Is Rogerian listening really all that’s needed?” in cell B4; for related discussion click and scroll down to highlighted heading.

K Expected differences between therapies not found in UK (2008). Results of the largest yet UK alcohol treatment trial (dubbed ‘UKATT’) confounded expectations that a motivational approach would best suit unmotivated or hostile clients, and that clients lacking social supports would do best when this was explicitly addressed. Overall too, neither therapy significantly bettered the other. Inspired by US trial listed below. For discussion of this study click here and for related discussion here and scroll down to highlighted headings.

K Definitive US trial confounds ‘matching’ expectations (1999). Project MATCH was a landmark US trial designed as a definitive test of how differences between therapies mean they work best for different types of clients. Instead it confirmed the importance of the ‘common factors’ underlying seemingly distinct approaches; for more see the book (2002) of the project. Inspired the UK trial listed above. For related discussions click here and here and scroll down to highlighted headings.

K In relapse prevention, practice makes (more) perfect (1997 and 2000). In Scotland practising relapse prevention skills rather than just discussing them boosted confidence and helped newly detoxified patients stay sober longer.

K Modest boost to outcomes from adding “state-of the-art” psychological therapy (2008). The large US ‘COMBINE’ trial found that adding psychological therapy to primary care-style medical support plus medications or placebos elevated by 20% the proportion of patients experiencing a “good clinical response” during the year after treatment, though by the end the difference was negligible. Despite over twice the treatment-contact time, psychological therapy plus only basic medical care generated no significant advantages compared to medical support with placebo pills. These findings and similarly good outcomes whatever the therapy have been interpreted (2008, free source at time of writing) as suggesting there is a “robust placebo effect when using medications for alcohol dependence,” or that ‘common factors’ including the healing context, medications, and interactions with medical staff, account for most of the improvements. Further results from the trial in our report (2006) on main findings during and after treatment. For related discussion click and scroll down to highlighted heading.

K 12-step group attendance boosted in London but not abstinence (2012). Tested the ambition to extend recovery beyond formal treatment by systematically linking patients to mutual aid groups. Most patients had just been detoxified from alcohol. Attendance at 12-step groups was substantially boosted but not abstinence from the primary problem drug, a pattern seen in similar US studies. Related review below.

R Active ingredients and common features of four major psychosocial therapies for problem substance use (2007; free source at time of writing). The presumed active ingredients of motivational interviewing and allied therapies, 12-step based treatment, cognitive-behavioural approaches, and contingency management and community reinforcement approaches based on systematic rewards and sanctions usually linked to substance use. Finds that the effective elements they share include: support, structure, and goal direction; rewards for abstinence and rewarding activities that can replace substance use; abstinence-oriented norms and models; and building self-efficacy and coping skills. For related discussion click and scroll down to highlighted heading.

R All bona fide ‘talking therapies’ work equally well (2008). After combining results from relevant alcohol studies, this ingenious analysis found any structured approach grounded in an explicit model as good as any other. We have, it was argued, been looking in the wrong direction for therapy’s active ingredients. Other reviews have delivered similar verdicts on motivational interviewing (Cochrane review, 2011) and cognitive-behavioural therapy (2009). For related discussions click here and here and scroll down to highlighted headings.

R Common core of effective therapy: therapeutic relationships (American Psychological Association, 2018). Introduces and synthesises finding from 16 reviews of the psychotherapy literature based on the understanding that therapeutic change is generated not only by technical interventions, but by the ways clients and therapists relate. Represents the culmination to date of work begun in 1999 which rebalanced the focus on interventions with an appreciation of the power of ‘common factors’ underlying seemingly distinct approaches. From here you can also access the component reviews. For related discussion click and scroll down to highlighted heading.

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). For related discussions click here, here and here and scroll down to highlighted headings.

R Cognitive-behavioural therapies for substance use: what they are and the studies which have tested them (2015). In the UK cognitive-behavioural methods are probably the dominant framework for psychosocial therapy for substance use. This freely available review is particularly useful for its accessible account of what the major subtypes consist of and the studies which have tested them.

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 both 12-step based group therapy and (on some measures only) a cognitive-behavioural relapse prevention programme. Many of the patients were drinkers, though for just 14% was this their sole substance use problem. For related discussion click and scroll down to highlighted heading.

R Weak evidence for extinguishing cue-induced urge to drink (2017). ‘Cue exposure’ therapy tries to rob cues which prompt drinking (like seeing the pub or your favourite beverage) of their urge-provoking power by repeatedly pairing them with non-drinking. Especially in respect of heavy drinking (the most clinically meaningful of the measures), evidence was generally lacking, and in the few available studies often but not always negative. Combining cue exposure with cognitive-behavioural urge-control strategies offered the greatest promise. For related 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 discussion here and for related discussion click here and scroll down to highlighted headings.

R Helping each other get better (2009). Monograph from leading authority on peer-based recovery from addiction includes a chapter on the evidence for AA and allied mutual support networks and treatments based on the same principles.

R Contested vindication for 12-step groups and treatments (Cochrane review, 2020). Finds “high quality evidence that manualized AA/TSF interventions [based on the mutual aid groups and 12 steps of Alcoholics Anonymous] are more effective than other established treatments,” and that manualised or not, they “may be at least as effective as other treatments” – conclusions hotly contested and contrary to those of an earlier review (1999) which found such approaches either no better or worse than other treatments. One of the later review’s authors has also reviewed (2004) how treatment services can promote mutual aid. Related study above.

R If patient is in suitable couple, work with both (2013). Problem substance users in a stable relationship sometimes do better (in terms of substance use and family harmony) when the focus is at least partly shifted to working with the couple to promote sobriety-encouraging interactions. In this review the largest number of studies were of a ‘behavioural’ couples therapy applied to drinking problems. Another review (2011) focused on this approach across substance use, coming to similar conclusions. See also the Effectiveness Bank collection of relevant analyses from our database.

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 No significant advantage for residential treatment – due to severity limits on participants? (2019). Review of studies published 2013 to 2018 found no evidence from rigorous trials that residential treatment generated better outcomes than non-residential for dependent drinkers. Some more positive but still weak evidence from earlier review (2014) across substance use, but none from yet earlier review (1994) focused on alcohol dependence, summarised (paragraph 1.3) in unpublished notes (2002) from Findings. Some evidence across these reviews that more severe cases differentially benefit from residential care. Research is limited by the exclusion of some such cases to ensure that patients can safely be allocated to non-residential care.

R Some patients get worse (2012). Reminder that after psychosocial therapy for substance use problems up to 15% of clients end up worse than before. The client’s social context and psychology are factors but so too are: a poor client-therapist bond; less “involving, supportive, and expressive” services; failing to assess how clients are doing; lack of goal direction and structure; being confrontational or critical, especially in the context of a lack of empathy; not adapting structure, expectations and degree of challenge to the client; provoking emotional arousal in disturbed individuals. For discussion click and scroll down to highlighted heading.

G NICE guidance on treating problem drinking (National Institute for Health and Care Excellence, 2011). Recommendations from England’s gatekeeper to the public provision of healthcare on overall principles for treatment and particular interventions. For related discussions click here, here and here and scroll down to highlighted headings.

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 discussions click here and here and scroll down to highlighted headings.

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, and 12-step based mutual aid.

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