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Interventions; Generic and cross-cutting issues

Seminal and key studies shedding light on aspects of the treatment of problem drinking relevant both to psychosocial and medical approaches.

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). Describes study in London (1977) which questioned the orthodoxy that alcoholism requires intensive treatment. After thorough assessment, a single brief session handing responsibility to the couple to cure the husband’s alcoholism worked as well as the extended treatment of the time. See also commentary (2015) around four decades later from a study researcher dicusssed in bite’s Highlighted study section. The trial was broadly replicated (1988) at a Scottish alcohol clinic, where there was more evidence that extended treatment led to some (but still generally insignificant) further improvements.

S Empathy and organisation transform alcohol clinic (1970). Remarkable series of US studies from the late 1950s proved that an alcohol clinic’s intake and attendance can be transformed by systematically treating patients with warmth and respect. See also slide presentation and video, which end by focusing on the featured studies. Discussion in bite’s Where should I start? section

S Pioneering insight into common factors in therapy (1991). First published in 1961 and culminating in a third edition in 1991, Jerome D. Frank’s book Persuasion and Healing has given us 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 specific theories and methods of different approaches. Discussion in bite’s What are these ‘common factors’? section.

K Treatment entry often the key event (2005). Reanalysis of data from the multi-million dollar US Project MATCH trial showed treatment entry was associated with major drinking reductions even before any or much treatment had been delivered, suggesting to the analysts “current treatments are not effective”. See the rejoinder (2005) from a MATCH researcher, and an informal commentary (2008) from Drug and Alcohol Findings on the implications of this and similar findings. Discussion in bite’s Highlighted study section.

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.

K Motivating aftercare (2007). US inpatient treatment centre systematically applied simple prompts and motivators to substantially improve aftercare attendance and sustain recovery. See also later report from same study.

K Remission is the norm, but some take longer to get there (2011). US national survey found just a third of all formerly dependent drinkers remained dependent three years later, but among the most severely affected drinkers with multiple psychological problems, the proportion was twice as high despite more extensive treatment. Three-quarters of dependent drinker remitted without any treatment. Reanalysis (2013) of same surveys calculates that no matter how long ago someone became dependent, their chances of remission remain the same, challenging assumptions that progressive neural, lifestyle or psychological changes increasingly lock-in dependence.

R 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. After treatment, six out of ten remitted by becoming abstinent, but among general population samples, six out of ten continued to use.

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

R Tailor induction into treatment (2005). When considering or starting treatment some patients need motivation bolstered and options explored, for others this is not just unnecessary, but counterproductive.

R All well-structured 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.

R Effective ways to relate to clients (American Psychological Association, 2011). Effective ways to relate to psychotherapy clients (and by extension, other clients and patients) like forming a therapeutic alliance, being empathic, and appropriately adjusting to the individual. Also, what to avoid.

R Long-term care for chronic conditions (2014; free source at time of writing). Synthesis of research built on a (2009) by adding 13 studies to the 20 identified earlier and aggregating all substance use outcomes reported in the trials. Nearly 9 in 10 of the trials focused exclusively on or included the treatment of alcohol use problems. Finding was that patients allocated effectively at random to aftercare/continuing care engaged in slightly but significantly less substance use at follow-up. Guidelines based on earlier review below. Similar review narrowing in on problem drinkers and most rigorous studies below.

R Continuing care specifically benefits problem drinkers (2014; free source at time of writing). Focused on solely alcohol-dependent patients and high quality randomised trials, the review found just six trials, across which the evaluated continuing care approaches generally modestly improved on usual approaches. Similar review above based on many more studies because included drug and/or alcohol use patients and less rigorous studies.

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 a trusting relationship with clients and work in a supportive, empathic and non-judgmental manner.

G Principles of effective treatment (2006). Based on reviews commissioned by the American Psychological Association, tries to take the therapist as far along the road as possible to evidence-informed practice, 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 with a substance use disorder.”

G US guidance on matching patients to intensity and type of care (American Society of Addiction Medicine, 2013). From the professional body for US addiction clinicians, world’s most widely used criteria for deciding what kind of treatment to start with or move on to for different kinds of patients.

G US evidence-based treatment principles ([US] National Institute on Drug Abuse, 2012). Presents 13 research-based principles of addiction treatment, seven of which have been tested against the North American evidence. Principles relating to individualising treatment were consistently supported. Basis for continuing care guidelines below.

G Strategies to promote continuing care (2009). Expert US consensus on practical strategies to promote aftercare/continuing care based on review listed above.

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

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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What is this cell about? Whether medical or psychosocial, chosen positively or under pressure, patients have to decide to get help and find their way to treatment or get sent there. Decisions must be made about treatment objectives and the form, intensity and duration of care, relationships forged, and attention paid to psychological problems and social circumstances which affect the chances of a sustained end to dependent substance use. Specific medical and psychosocial interventions are respectively covered in cells A3 and A4. This cell is about factors common to both – for example, the very fact that someone or some institution sanctioned by society has identified the patient/client as in need of and deserving help, believes they will benefit, is accepted as an authority in the problem and its solutions, and offers a credible remedy via which they instil confidence and optimism – components often sidelined as the ‘placebo effect’, but which are actually active ingredients in the treatment of behavioural problems.

Across medicine there are calls not just to recognise the power of the ‘placebo effect’, but to deliberately manipulate it in the in the interests of the patient. The flip side is avoiding counterproductive manifestations of common factors, such as negative expectations of the effectiveness of the treatment or its side effects, or interactions with the patient which obstruct engagement with and benefit from treatment. In the treatment of drinking problems and medicine generally, these negatives seem more powerful than the positives. Compounding the complications is that in certain contexts what are normally thought of as beneficial elements may be counterproductive, An example is encouraging unrealistic expectations of a treatment’s benefits or the probability of success, risking when these do not materialise increased distress, pessimism, and a sense of having failed in treatment on top of having ‘failed’ in life by becoming in need of treatment – in particular, on top of the stigma of being unable to control one’s substance use.

This cell is about these generic functions and ‘common factors’, now widely recognised as at least as important as the particular therapy. Also here we touch on the nature of dependence and the nature of the caseload seen in treatment services, helping place those services in the context of the spectrum of dependent substance use in society and the ‘natural’ processes of recovery which treatment seeks to harness and accelerate. Other cells home in on common factors to do specifically with how the practitioner relates to the patient/client and the nature of the treatment service.

Where should I start? Let’s start where the patient journey starts – the decision to seek treatment. Specifically, the remarkable series of studies from the 1950s initiated by Morris Chafetz, later to become the founding director of the US National Institute on Alcohol Abuse and Alcoholism.

‘Skid-row’ alcoholic

‘Skid-row’ alcoholics seen at the emergency department were in crisis, dirty, disturbed and disturbing, and refused treatment. The effect was to evoke hostility and rejection.

Chafetz’s innovations exposed the reasons for the supposedly insoluble problem of engaging the “alienated” alcoholics seen in the emergency department in treatment: it was due not to their intractable refusal to accept they needed help, but to staff hostility and rejection generated by moralising and punitive attitudes.

He also showed that such attitudes were not themselves intractable, setting out to create instead a seamless procedure characterised by always treating ‘alcoholics’ with caring respect. It successfully transformed the emergency episode into the start of a rehabilitation process which involved not just directly interfacing with the patient, but networking to gain the cooperation of other hospital staff and of outside welfare and housing services. A later sub-study of the emergency doctors who made referrals to the alcohol treatment clinic found that tone of voice can betray cold ‘professionalism’ or convey personal concern, and revealed the difference this can make.

For more read the Effectiveness Bank analysis and see this slide presentation and video, which end by focusing on the Chafetz studies.

Highlighted study There is no more fertile alcohol treatment study than the multi-million dollar US Project MATCH trial. What made it so fruitful was the need to explain why the expected findings failed to materialise, despite the unprecedented care with which the ground was prepared. Conceived as a definitive test of the relative benefits of three psychosocial therapies for different patients, it ended by prioritising not how therapies differed, but what they shared – most of all, what the patient brings to treatment.

The findings came as a “surprise” to the study’s eminent researchers, the expectation being that the most highly technical of the therapies – 12 sessions of face-to-face cognitive-behavioural therapy – would prove superior for most of the categories of patients defined for the trial. Yet on the primary measures, “all three treatments yielded virtually identical outcomes ... and few of the matching hypotheses were confirmed.” Even the saving grace that all three manualised and advanced therapies were an improvement on usual approaches was contradicted by a report from one of the MATCH treatment centres. There similar patients recruited into another study which involved only the centre’s usual treatment reduced drinking just as much as those in the MATCH trial – though possibly ‘usual’ treatment at this centre, which housed motivational interviewing’s originator William Miller, was of unusually high quality and well informed by research.

Our concern here, however, is not so much with these overall results (for more see the Effectiveness Bank analysis) as with a re-analysis by MATCH outsiders Robert Cutler and colleague, which attracted a rebuttal from William Miller of, one of MATCH’s principal investigators.

The rebuttal made valid criticisms, but the fundamental question remained: how could it be that on average patients who did not return for therapy or attended only once did almost as well as those who attended all 12 sessions of the longer therapies (cognitive-behavioural and 12-step based) tested in the trial? If treatment is an important active ingredient, shouldn’t there have been a substantial gap? Instead there was on average rapid remission in the first week of intended treatment which was largely sustained after it ended, even if no treatment had been received.

Cutler’s explanation was that in the circumstances of the trial, treatment content and techniques (as opposed to the patient’s motivation and the process of entering treatment and being assessed and monitored) were simply ineffective – an account which would also explain why in MATCH and across alcohol treatment, different therapies result in similar outcomes, as they do for common mental health problems. Contrast this with the MATCH finding that how much patients wanted to change and were ready to do so beforehand was strongly and lastingly linked with how well they did.

In their book on the trial gathering together the many findings, MATCH researchers de-emphasised the ‘distinct effects’ vision on which the study was predicated in favour of what they called “common mechanisms”. These were not treatment techniques at all, but influences such as empathy, an effective working alliance between therapist and client, the latter’s desire to get better and inner resources to overcome alcohol dependence, a supportive social network, and the “provision of a culturally appropriate solution to a socially defined problem”. Similarly, to make sense of his findings Cutler argued that “Enrolling in the trial suggests that the alcoholic has crystallized a decision to reduce or abstain from drinking.” In these formulations, treatment was envisaged not as a ‘technological fix’ specific to a certain malfunction, but as an appropriate-looking door through which patients could pass to actualise their impetus to get better.

Faith healers and witch doctors act in the same way as ‘treatment’ in Western societies

At a conference in London, a senior MATCH investigator speculated that in other cultures faith healers and witch doctors offered such doors in the same way as ‘treatment’ or ‘therapy’ in Western societies. “What may be required even more than the specific components of a therapeutic intervention is the belief on the part of both the patient and the therapist that this particular treatment is likely to be effective,” was how MATCH researchers less picturesquely phrased it in their book on the project.

The “crystallisation” phenomenon of rapid and lasting remission after taking steps to start treatment, but before any or much has been delivered, has a considerable history and keeps getting repeated in studies able to spot it. Contemporary examples can be found in trials of an alcohol dependence pharmacotherapy, which found that substantial minorities of dependent drinkers lastingly remitted to low-risk drinking before taking a single pill.

Then look back at this very different study from 1970s England, which found alcohol-dependent men did as well after a single advice session with their wives as after fully fledged treatment. What did it mean to a researcher on the project? “I concluded ... that ‘treatment’ was less important than those aspects of the process which treatment and advice couples shared: all the negotiations and arguments that must have gone on between husband and wife prior to and after the visit to the general practitioner; the referral to a psychiatric hospital and the wait for the appointment letter; the whole morning spent going over one’s drinking and one’s marriage with a group of expert strangers; the unequivocal advice, delivered in the presence of one’s spouse ... knowing that the hospital was keeping a watching brief and that questions were being asked about your behaviour every month and that you would be asked to account for yourself at the year’s end.”

Finally, step back even further to 1961 and Jerome Frank’s prescient exposition of a common factors theory (discussed below), and marvel at how his ideas predicted the findings described in this section and continue to be offered as explanations.

By the time a problem drinker has decided to enter treatment, most of the therapeutic work has already been done

It seems like by the time many drinkers have decided they have a problem they must do something about, most of the therapeutic work has already been done. And that though for the rest, treatment ‘works’, it is not the therapeutic theories and techniques over which we agonise that matter, but the patient’s resolution to get better and the actions, rituals and relationships involved in doing that through treatment.

Issues to consider and discuss

What is treatment’s primary role? We derived one answer from the Highlighted study – that for people ready and willing to get better, treatment offers a culturally endorsed door for them to pass through – one which also looks ‘right’ to the patient, or which they become convinced leads to a better life. It follows that treatment’s primary role is to make those doors look right, to provide a variety attractive to different beliefs and tastes, and to make them easy to find and easy to pass through – as MATCH researchers put it, “access to treatment may be as important as the type of treatment”. Once would-be patients approach, knock on and seek to pass through those doors, it would seem important to avoid obstructing the process started by the patient by, Simply being available and not doing the wrong thing may be fundamental for example, confrontationally provoking resistance or being judgemental. At their best, treatment services are havens where the more despised and stigmatised in our society find acceptance and understanding.

Simply being available and not doing the wrong thing (of which there is a distinct echo in brief interventions) may be fundamental, but perhaps treatment also has to build motivation, show the route to recovery once the door is passed through, and by ongoing contact, reassure the patient that someone still cares about (and is checking on) how they are doing?

It is in the nature of research trials that participants are not just checked up on, but know they will be, as researchers try to follow them up to assess their progress. Sometimes too, that is a strong feature of the overall intervention package, as in the study from 1970s England which found alcohol-dependent husbands did as well after a single session as after extended treatment. The single-session patients were not entirely left to their own devices: they faced what it is easy to imagine was the bracing prospect of home visits from a social worker who “would call each month to see the wife and collect news of progress”. Just knowing – or thinking – that you are being observed and evaluated changes behaviour. And all structured therapies may be more or less equivalent, but they are all structured – they offer a coherent schema which for patient and therapist makes sense of how the patient got in to a problem with substance use and shows them a navigable way out – something to do to get better, a focus for the motivation.

What else does treatment offer and how does it offer it? If you work in a treatment service, think about what you do, from your manner when you answer the phone and greet newcomers, the look of the service and the appearance of the staff, how you generate hope, offer coherent accounts of the way in and out of addiction, inspire confidence, signify acceptance, monitor how the patient is doing. These are the sorts of things that seem to matter at least as much as the specific techniques which characterise different approaches – the reason why Drug and Alcohol Findings invested in creating the five-part Manners Matter series.

Role different for different people? Perhaps that first issue was based on a false premise – that in fact there is no primary role, but different roles in different situations for different people.

A national US survey suggested that most dependent drinkers have the resources to extricate themselves from a phase not too deeply embedded in their lives, but some are too severely and multiply disturbed to ‘bootstrap’ themselves out of their troubles. Read this Effectiveness Bank analysis and you will see that the Highlighted study tended to exclude the latter. The English seminal study too was limited to men who despite their drinking had sustained a supportive relationship. Typical exclusion criteria employed by alcohol treatment researchers can eliminate the great majority of treatment-seeking drinkers from trials, leaving a relatively stable and committed set with an unusually good prognosis.

Is this why in some trials treatment seemed ‘merely’ to provide a way to actualise the patient’s decision to get better? Other drinkers need much more, such as the 24-hour protection of a residential setting (who they might be is formalised in US guidelines). Some need help to decide whether and how to overcome their dependence, while for others this is counterproductive; they already know, and further cogitation risks obstructing them from getting there.

What are these ‘common factors’? The non-specific, common factors shared by different treatments are mainly what this cell is about, but identifying them is difficult. You cannot, for example, randomly send someone in desperate need of help either to a bona fide treatment service or to a seedy non-clinic staffed by unwelcoming therapists, to see what happens and to confirm that the treatment context is influential. Nevertheless, from the broader psychotherapy literature, we can get a good idea.

The usual starting point is the work of Jerome Frank published first in 1961 and finally in 1991 in an edition co-authored with his daughter. His insistence that “much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than to those that distinguish them from each other” amounted to a revolutionary undermining of the competition for validity between different schools of therapy.

Bruce Wampold’s meta-analytic demonstration of the validity of common factors understanding of therapy included this summary of Frank’s views on what treatment – the attempt “to enhance a person’s feeling of well-being” – consists of: “The first component is that psychotherapy involves an emotionally charged, confiding relationship with a helping person (ie, the therapist). The second component is that the context of the relationship is a healing setting, in which the client presents to a professional who the client believes can provide help and who is entrusted to work on his or her behalf. The third component is that there exists a rationale, conceptual scheme, or myth that provides a plausible explanation for the patient’s symptoms and prescribes a ritual or procedure for resolving them. According to Frank and Frank, the particular rationale needs to be accepted by the client and by the therapist, but need not be ‘true’ … However, it is critical that the rationale for the treatment be consistent with the world view, assumptive base, and attitudes and values of the client or, alternatively, that the therapist assists the client to become in accord with the rationale. Simply stated, the client must believe in the treatment or be lead to believe in it. The final component is a ritual or procedure that requires the active participation of both client and therapist and is based on the rationale (ie, the ritual or procedure is believed to be a viable means of helping the client).”

Wampold was one of the authors who brought elements of this formulation up to date based on research syntheses commissioned by the American Psychological Association, and who co-edited a book also from the American Psychological Association on common factors theory and evidence.

Does this theory break down when it comes to drug-based therapies? Surely these work regardless, as long as the pills are taken? Maybe, but the pills have to be taken and none are so attractive and so effective that therapeutic relationships are irrelevant – as this analysis found. In the treatment of alcohol dependence, active medications generally add little to the improvements seen among patients prescribed a placebo. Something else accounts for the bulk of the improvements, and the prime candidates are the common factors involved in engaging in treatment, even when the ’medication’ is a dummy pill and the psychosocial contact is basic clinical care.

For more see this collection of Effectiveness Bank analyses indexed on ‘common factors’.

Does long-term care/aftercare make a difference? If addiction at least behaves like a chronic relapsing condition, and even if that is only broadly valid for treatment populations, long-term monitoring and care would seem an appropriate and effective treatment strategy. Embedding this perspective into UK health service quality standards, the National Institute for Health and Care Excellence stipulated that even after having achieved abstinence, problem drug using patients should be offered continued treatment or support for at least six months. In support, a synthesis of relevant research (listed above) found that patients allocated effectively at random to systematic aftercare/continuing care versus usual care engaged in slightly but significantly less substance use at follow-up.

That analysis included drug and alcohol use studies. Arguing that dependent drinkers who also use other drugs materially differ from those who do not, another review (listed above; free source at time of writing) focused on solely alcohol-dependent patients. It found just six high quality randomised trials, across which experimental continuing care approaches generally modestly improved on usual approaches. The experimental interventions tended to more proactively and regularly re-contact the patient and to be more active in their interventions, whereas usual care consisted mainly of supportive counselling and promoting Alcoholics Anonymous attendance. Effective interventions also targeted the patient’s family network and sought to improve coordination between different healthcare sectors.

Based partly on these reviews, for more on how to implement longer term care see cell D2.

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