Seminal and key studies shedding light on aspects of the treatment of problem drinking relevant both to psychosocial and medical approaches. The neglected ‘placebo effect’ and the ‘common factors’ studies usually try to eliminate from their analyses emerge as fundamental to the treatment of substance use problems.
S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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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 , and , 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 . For discussion and scroll down to highlighted heading.
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 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 distinctive theories and methods of different approaches. For discussions click and 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 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 and scroll down to highlighted heading.
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 (nearly twice as many patients attended during the last three months of the follow-up) and helped sustained abstinence chart. See also later report from same study focusing on patients with mental health problems.
K Remission is the norm among US dependent drinkers; multiple problems mean some take longer to get there (2011). US national survey found that overall just a third of dependent drinkers remained dependent three years later and three-quarters remitted without treatment. Despite 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 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 warranted professional treatment, six out of ten remitted by becoming abstinent. For related discussion and scroll down to highlighted heading.
R Engaging the ‘treatment-resistant’ (2010; free summary). Shock-tactic confrontation and tough-love sanctions found less likely to persuade dependent substance users in the family 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 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 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 treatment of alcohol use problems. 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 and and scroll down to highlighted headings.
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. For discussions click and and scroll down to highlighted headings.
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 take the clinician as far along the road as possible towards 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 with a substance use disorder.”
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 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 of which 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 .
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? Medical and psychosocial interventions are respectively covered in cells A3 and A4; this cell is about the ‘common factors’ they share. Whatever the treatment, patients have to decide to seek or accept help and access it. At a practical level, 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 chance of sustained remission. At a deeper level, influences include the fact that someone or some institution has identified the patient/client as in need of and deserving help, believes they will benefit, is an accepted authority on 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 widely recognised as at least as important as the particular therapy.
Across medicine there are calls not just to recognise the power of the ‘placebo effect’, but to 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 treatment or its side effects, or interactions with the patient which obstruct engagement with or the effectiveness of treatment. In the treatment of drinking problems and medicine generally, these negatives seem more powerful than the positives. At this level there are few or no universal truths; 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. Even empathy – often lauded as the essence of effective therapy – is not always positive … it all depends.
Also here we touch on the nature of dependence and 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.
Where should I start? The corresponding cell of the Drug Treatment Matrix started at the end – where treatment should be trying to get to. This cell starts where the patient journey usually starts – the decision to seek or accept treatment, investigated in a groundbreaking and frankly inspiring series of studies from the 1950s led by Morris Chafetz, later to become the founding director of the US National Institute on Alcohol Abuse and Alcoholism.
Analysed for the Effectiveness Bank (see listing above), Chafetz’s innovations exposed why the supposedly intractable “alcoholics” seen at Massachusetts General’s emergency department were so hard to divert into treatment at the hospital’s alcohol clinic; it was not fundamentally due to the patient’s rejection of the help they clearly needed, but to the staff’s rejection and hostility, generated by what Chafetz came to see as moralising and punitive attitudes. A later sub-study of the emergency doctors who made referrals to the alcohol clinic revealed that tone of voice can convey cold ‘professionalism’ or personal concern, and the positive link between the latter and whether the doctor’s referrals were followed through.
Dr Chafetz also showed that negative attitudes were not themselves intractable, creating instead a seamless treatment-entry procedure during which patients were listened to and treated with care and respect. It transformed what had almost universally been an isolated episode of emergency care leading nowhere into the start of a rehabilitation process which involved not just working with the patient, but networking to gain the cooperation of other hospital staff and external welfare and housing services. In their willingness to engage with treatment, these supposedly intractable, “alienated men” became more like typical psychiatric patients.
For more on this remarkable story whose lessons seem to need to be continually relearned, read the Effectiveness Bank analysis and see this slide presentation which ends by focusing on the Chafetz studies.
Highlighted study There is no more fertile alcohol treatment study than the multi-million dollar US Project MATCH. Trialled in the early 1990s, its treatments were state-of-the-art and its methodology of unprecedented rigour, but what made it so fruitful was the need to explain why the expected findings nevertheless failed to materialise.
The study emerged from a conviction that alcohol treatments were relatively ineffective overall because the results were averaged across different types of patients, many of whom would be a poor match for any particular therapy. Instead of universally applied scatter-gun therapies, be more discerning, get the match between patient and therapy right, and the result could be a major improvement in outcomes. That was not how it turned out. Conceived as a definitive test of matching different types of patients to three different psychosocial therapies, instead MATCH ended by prioritising not how therapies differ, but what they share – most of all, what the patient brings to treatment.
The findings came as a “surprise” to the study’s eminent researchers. They expected 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”. Worse still, “few of the matching hypotheses were confirmed”; the rationale for the study had proved largely a chimera. 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 MATCH’s clinics.
Our concern here, however, is not so much with the results MATCH intended to gather (for which see the Effectiveness Bank analysis) as with those which emerged from a re-analysis by MATCH outsiders Robert Cutler and colleague, which sparked a rebuttal from William Miller, one of MATCH’s principal investigators. The controversy has been informally explored for the Effectiveness Bank, among the documents listed above.
The rebuttal made valid criticisms, but the fundamental question remained: how could patients who did not return for therapy or attended only once do almost as well on average 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 the intended treatment period which was largely sustained after it ended, even if no treatment had been received. 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 to how well they did.
To make sense of their analyses, Cutler’s team argued that in the circumstances of the trial, treatment content and techniques were simply ineffective – an account which would also explain why in MATCH and across alcohol treatment, different psychosocial therapies result in similar outcomes. In this respect, the treatment of problem drinking resembles the treatment of common mental health problems in general (1, free source at time of writing; 2; 3, free source at time of writing). For Cutler and colleague what mattered was not the therapies, but the patient’s motivation and the process of entering treatment and being assessed and monitored: “Enrolling in the trial suggests that the alcoholic has crystallized a decision to reduce or abstain from drinking.”
By the time in 2002 they came to integrate their many findings in a book, MATCH researchers were also de-emphasising the vision on which the study was predicated in favour of these “common mechanisms” – not treatment techniques at all, but influences such as empathy, an effective working alliance between therapist and client, the client’s desire to get better, the inner resources they can call on to overcome alcohol dependence, a supportive social network, and the “provision of a culturally appropriate solution to a socially defined problem” – in modern Western societies, ‘treatment’.
In these formulations, treatment was envisaged not as a ‘technological fix’ keyed to a matching 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, in 1998 a senior MATCH investigator had 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 the MATCH book more soberly phrased it.
The ‘crystallisation’ phenomenon invoked by Cutler and colleague to explain their findings is marked by rapid and lasting improvement after taking steps to start treatment, but before any or much has been delivered – pattern with a considerable history and which keeps getting repeated in the few studies able to spot it. Unfold the supplementary text for examples.
Finally, step back in time to 1961 and Jerome Frank’s prescient exposition listed above 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 that 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. Though for the rest, treatment may ‘work’, 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. But remember these impressions arise primarily from highly controlled studies which may deliberately or in practice exclude the full range of patients and provide unrealistically homogenous and high quality therapy. Seefor a different perspective.
What is treatment’s primary role? We derived one answer from MATCH and the other studies cited in the “Highlighted study” section above – that for people ready to get better, treatment offers a culturally endorsed door for them to pass through – one which looks ‘right’ to the patient or which they become persuaded leads to a route out of their destructive drinking. It follows that treatment’s primary role is to provide a variety of ‘doors’ which attract and ‘look right’ to patients with different beliefs and preferences, 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”.
But of course, there is more to it. Once would-be patients approach, knock on and seek to pass through those doors, it would then 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 off-puttingly judgemental. At their best, treatment services are havens where the more despised, stigmatised or self-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 (document listed above), deliver a feasible route to recovery once the door is passed through, and by ongoing contact, reassure the patient that someone still cares about them and is checking on how they are doing (1 listed above, free source at time of writing; 2 listed above; 3 listed above, free source at time of writing).
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 assess their progress. Sometimes too, that is a strong feature of the intervention package, as in the study from 1970s England (listed above; see the first page of linked document under the heading, “The alcohol clinic”) 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.
Additionally, all well structured psychosocial therapies may be more or less equally effective, but they are all structured; they offer a coherent schema which for patient and therapist makes sense of how the patient developed a problem with substance use and shows them a navigable way out – something to do to get better, a focus for motivation to act on.
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, to the look of the service and the appearance of the staff, how you generate hope, offer coherent accounts of ways in and out of addiction, inspire confidence, signify acceptance, and 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 the section above was based on a false premise – maybe there is no primary role for treatment, but different roles in different situations for different people.
A national US survey listed above suggested that most dependent drinkers have the resources to extricate themselves from a phase not too deeply embedded in their lives, but also that some are too severely and multiply disadvantaged to lever themselves out of their troubles without support. Read this Effectiveness Bank analysis and you will see that the study highlighted above tended to exclude the these patients. The English seminal study (listed above; see the first page of linked document under the heading, “The alcohol clinic”) was also limited to men who despite their heavy drinking had sustained a relationship supportive enough for their wives to join them in treatment. Typical exclusion criteria in alcohol treatment trials can eliminate the great majority of treatment-seeking drinkers, 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 impetus to get better? Other drinkers need much more, such as the 24-hour protection of a residential setting (document listed above). Who they might be is formalised in US guidelines listed above. 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. These kinds of considerations and findings seem to preclude a unitary role for treatment.
What are these ‘common factors’? Common factors shared by different treatments (the subject of an Effectiveness Bank collection) are mainly what this cell is about, but validating their influence is difficult. You cannot, for example, randomly send someone at risk and in need of help either to a bona fide treatment service or to a seedy non-clinic staffed by unwelcoming therapists, just to see what happens. Nevertheless, from the broader psychotherapy literature, we can get a good idea of what the common factors look like.
The usual starting point is a book by Jerome Frank (listed above) 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 between different schools of therapy.
Bruce Wampold’s meta-analytic demonstration of the validity of a common factors understanding of therapy included this summary of Frank’s views on the fundamentals of ‘treatment’, defined as the attempt “to enhance a person’s feeling of well-being”:
Wampold, a key advocate of common factors theory, was one of the authors who brought (document listed above) 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? As long as the pills are taken, surely these work regardless of any psychosocial common factors? Even if that was true, the pills have to be taken, which means the patient has to have sufficient belief in the treatment and faith in the prescriber to take them. In practice, no pharmacotherapy for behavioural problems is so attractive and so effective that therapeutic relationships can be considered irrelevant – as a study of alcohol treatment 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 ‘therapy’ is basic medical care.
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 essential. 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 substance use research ( ) 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 users of illegal drugs as well as drinkers. Arguing that dependent drinkers who also use other drugs materially differ from those who do not, another review ( ; free source at time of writing) focused on solely alcohol-dependent patients. It found just six high quality randomised trials, across which the evaluated continuing care programmes generally modestly improved on usual approaches. What made the difference? The evaluated programmes tended to more proactively and regularly re-contact patients and to be more active in their interventions, whereas usual care consisted mainly of supportive counselling and promoting attendance at Alcoholics Anonymous meetings. Effective interventions also targeted the patient’s family network and sought to improve coordination between different healthcare sectors.
Based partly on these reviews, cell D2 addresses the issue of how to implement longer term care. But are the studies and reviews cited here strong enough in their support for continuing care to warrant the devotion of resources which could have been used to extend treatment wider if more thinly? Do we owe it to the patients we have to offer appropriately long-term care, even if that closes the door on other would-be patients?