The most important seminal and key studies on the general principles underpinning psychosocial therapies and the effectiveness specific approaches. One of 25 cells in the alcohol matrix. Also highlights the most useful reviews and practice guidelines and offers a customised one-click search for more on the Effectiveness Bank database.
S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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S Confrontation provokes resistance (1993). Among US heavy drinkers motivational interviewing’s non-confrontational style reduced both resistance and drinking compared to an explicitly challenging approach. See also this review (free source at time of writing) of the positive role of subtle forms of ‘confrontation’ in motivational interviewing. Discussion in bite’s Issues section.
S Treatment services can radically affect access to mutual aid (1981). Direct contact with 12-step group members during treatment who then helped patients to meetings created a 100% turn-round in attendance compared to usual encouragement and information. Just 20 patients were allocated to these alternative referral procedures by a toss of a coin, but this early study was a convincing demonstration that treatment services can radically affect access to mutual aid.
S Client-centred group therapy works best (1957). For its time methodologically advanced, this US study found the Rogerian, client-centred approach characterised by non-directive, empathic listening (for which see cell B4) which underpins motivational interviewing generated healthier self-perceptions among alcohol-dependent patients and reduced relapse compared to approaches based on learning theory or psychoanalysis. Discussion in bite’s Where should I start? section.
K No added value from motivational interviewing (2012). Other than fleetingly and non-significantly, motivational interviewing’s change-promoting strategies did not seem to promote extra change among the stable, moderately dependent drinkers recruited to this US trial. If anything, non-directive Rogerian therapy stripped of motivational interviewing’s ‘active’ ingredients worked best, and a ‘self-change’ option was almost as effective as both. Discussion in this cell’s Issues section and also in cell B4.
K Expected differences between therapies not found in UK (2008). Results of the largest yet UK alcohol treatment trial 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. Discussion in bite’s Where should I start? and Highlighted study sections.
K Project MATCH confounds expectations (1999). Landmark US trial designed as a definitive test of matching different types of clients to different therapies instead confirmed the importance of the ‘common factors’ underlying seemingly distinct approaches; for more see the book (2002) of the project. Discussion in bite’s Where should I start? section.
K In relapse prevention, practice makes (more) perfect (1997 and 2000). Practising relapse prevention skills rather than just discussing them boosted confidence and helped newly detoxified Scottish patients stay sober longer.
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 not unusual in similar US studies. Relative to alternatives, treatment based on encouraging AA involvement has generally not further reduced heavy drinking or drink-related consequences. See also this review (2004) of how treatment services can promote mutual aid.
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. See these reviews for similar verdicts on motivational interviewing (2011) and cognitive-behavioural therapy (2009). Discussion in bite’s Where should I start? section.
R Common relationship factors (American Psychological Association, 2011). Introduces reviews based on the understanding that treatment methods are not simply technical interventions, but ways client and therapist relate, so cannot be divorced from the general relationship between client and therapist. From here you can find the component reviews and the overall conclusions (2011) reached by the American Psychological Association’s task force. Discussion in bite’s Where should I start? section.
R Motivational starts to treatment better without the manual (2005). Findings review discovered that motivational interviewing is not always a positive alternative to more directive approaches, and that motivational interviewing has worked best when the therapist is not constrained to a manual. Latter conclusion confirmed by a synthesis (2005) of research findings (free source at time of writing). Discussion in bite’s Issues section (1 2).
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. Discussion in bite’s Where should I start? and Issues sections.
R Peer-based addiction recovery (2009). Includes chapter on the evidence for AA and allied mutual support networks and treatments based on the same principles and networks. 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 treatments.
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. Discussion in bite’s Issues section.
R If patient is in suitable couple, work with both (2011). Problem drinkers in a stable relationship do better when the focus is at least partly shifted to working with the couple to foster sobriety-encouraging interactions.
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.
G NICE guidance on treating problem drinking (National Institute for Health and Care Excellence, 2011). UK’s official health advisory body recommends overall principles and particular interventions. Discussions in bite’s Issues section (1 2).
G Principles for how to relate to counselling/therapy clients and the content of sessions (2006). Free source at time of writing. Based on reviews commissioned by the American Psychological Association. Reviews evidence and offers in-principle guidance on how to relate to clients and the content of sessions. Argues that these principles “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”. Free source available at time of writing. Discussion in bite’s Where should I start? and Issues sections.
more Search for all relevant Effectiveness Bank analyses or for sub-topics go to the subject search page or hot topics on contingency management, residential rehabilitation, motivational interviewing.
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What is this cell about? Every treatment involves direct or indirect human interaction, but this cell is about therapies in which interaction is intended to be the main active ingredient. Colloquially referred to as ‘talking therapies’, these are formally designated ‘psychosocial’ approaches. They attempt to change how the patient behaves either directly, or via their beliefs and attitudes, how they relate to others, and how others relate to them. For an ‘alcoholic’ or ‘addict’, simply being related to and valued in a caring context centred on your aspirations, needs and welfare may be a live-changing experience in itself, but usually there are also specific techniques or strategies derived from different understandings of how dependence arises and how it can be reversed.
Interventions vary in type and in intensity and duration. They range from brief advice and counselling to extended therapies based on psychological theories, and all-embracing residential communities where clients stay for several months.
Techniques and strategies might include: rewards and punishments contingent on client behaviour (contingency management); leading the client to see their substance use as contrary to desired self-images or objectives (as in motivational interviewing); harnessing social influences (as in group and family therapies and community living arrangements); identifying with the client what triggers their undesired substance use and training them how to manage or avoid those triggers (as in cognitive-behavioural therapies); ways to manage thoughts and moods which otherwise might precipitate relapse (as in mindfulness approaches); and more practical elements, such as those intended to upgrade the patient’s employability.
Whether based on research, theory, religion, morals or experience, belief systems underlie these approaches. Most prominent in the research are the 12 steps of Alcoholics Anonymous and allied fellowships, and the understanding that addiction can be learnt and unlearnt, which underpins major psychological therapies, including those recommended by the UK’s official health advisory body, the National Institute for Health and Care Excellence (NICE).
Where should I start? This cell is partly about the relative merits of different psychosocial therapies, but also about the therapeutic properties they share and how such ‘common factors’ can be made more potent. Since these have become seen as the major influences in the treatment of addiction including dependence on alcohol, let’s start there.
Described in cell A2, these cut across the supposedly distinct mechanisms keyed into by approaches at opposite theoretical poles such as cognitive-behavioural therapy and psychoanalysis, turning the spotlight instead on non-specific influences. Thought to be among these are a confiding, emotionally charged relationship with a helping person, a setting in which psychological healing is expected, a plausible explanation for the patient’s symptoms, and a ritual or procedure for resolving them – any convincing ritual will do, as long as in that culture and for that patient it makes sense of the patient’s difficulties and signposts a convincing and feasible way out.
Shift of attention to these factors has partly been prompted by so-called ‘Dodo bird’ findings that different therapies seem to have very similar effects, for which in this cell we repeatedly find evidence (1 2 3). Further evidence of the centrality of common factors has come from findings that therapies stripped down to these factors can work as well as supposedly more active approaches (1 2), and that when there are differences in the effects of different therapies, they are not due to their purportedly distinct active ingredients, but to variations in the degree to which they engage certain common-factor type influences.
A symbolically and practically significant turning point was the refocusing on common factors by the American Psychological Association (APA) via their appropriately named ‘interdivisional task force’. Updating work from 1999, in 2011 the task force analysed the literature to identify what constitutes an effective relationship between therapist and patient. Take a look at our account of the introductory article which lists the component reviews. From there you can access whichever of these reviews most interests you, and the task force’s overall conclusions. Then go back a few years to the guidance offered by another APA task force which integrated these relationship issues with the content of therapy. In both note the stress on collaborative working, and warnings against being confrontational, hostile, pejorative, critical, rejecting, or blaming. Note too that they also cautioned that on issues like this, there are no universal rules; unlike public health approaches, treatment is essentially the treatment of an individual. Based on the same guidance, this maxim is explored below.
Highlighted study For Britain the highlight has to be the £1.5 million UKATT trial, the most ambitious ever in the UK. Implemented in the late ’90s, it was informed by emerging findings from the similar US Project MATCH trial, which found relatively brief therapy based on motivational interviewing as effective as longer and more structured approaches. In response, the UKATT team set out to devise a research-based therapy which would better the standard set by Project MATCH’s motivational intervention. What they came up with was ‘social behaviour and network therapy’. It integrated elements from other approaches and geared them to harnessing the “crucial contribution” of social networks supportive of positive change. A scheduled eight sessions of this more extensive, intensive and comprehensive therapy were compared with three sessions of the basic motivational approach. Unexpectedly, there were no significant differences in effectiveness or cost-effectiveness. Neither did (as had been expected) motivational interviewing particularly help angry patients or those lacking motivation, or the network option particularly benefit patients lacking anti-drinking social support.
Unexpectedly, there were no significant differences in effectiveness
Expectations confounded, the researchers explained the equivalence of the therapies by the equivalence of the training “in a professional and rigorous atmosphere” undergone by the therapists, their expert and regular supervision, and their guidance by a manual with scientific credentials, creating expectations that the approach they had been steeped in would yield good results – expectations, optimism, morale, structure, support, credibility, common factors rather than the distinctions in approach and content which it was thought would prove critical.
On this general point they now agreed with the patients. Asked at follow-up to what factors they attributed any positive changes, general influences not specific to either of the treatment approaches were cited more often than those through which each approach was supposed to distinctively exert its effects. For the researchers these results offered support to the “contextual model of effectiveness of psychosocial treatments, emphasizing such factors as client commitment, therapist allegiance, and the client-therapist alliance ... as opposed to a medical-technical model, which emphasizes specific factors related to mechanisms of change promoted by specific forms of therapy”. Later the lead author gave his personal interpretation of these and other findings: “Treatment research has been asking the wrong questions in the wrong way … the strange thing is how we have persisted with trials of named psychosocial therapeutic techniques despite the evidence that this strategy is largely fruitless. In the psychosocial treatment of addiction there is increasing support for the existence of important change processes that are common to treatments with different names and theoretical rationales.”
Now take a look back at cell A2 where Project MATCH, UKATT’s US progenitor, was the highlighted study. You will see that after two similar trials unprecedented in their combination of size and rigour, some of the most eminent researchers into the treatment of alcohol problems from both sides of the North Atlantic had come to conclusions far distant from the expectations on which their trials were founded. Like UKATT’s researchers, Project MATCH’s team came to emphasise not treatment techniques, 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”.
Can therapy really make things worse? Look back at Where should I start? and the warnings from the American Psychological Association against counsellors being confrontational or negative. Lest you think these overstated, note they are among the reasons why a substantial minority of clients actually get worse after therapy. Avoiding this risk (especially provoking resistance to change) has been embodied most explicitly in motivational interviewing. Its credentials in this respect were seemingly confirmed in a seminal trial. Proofed against counterproductive reactions, appropriate for all levels of severity, generally as effective as other approaches but considerably briefer, motivational interviewing has been seen as a promising standard starting point for substance misuse treatment, one at least unlikely (recalling the first maxim of medicine) to do any harm.
That may be true in the absolute sense, but not in terms of lost opportunities to help patients who would have benefited more from another approach. Sometimes it really is best just to tell patients what they should do or otherwise break motivational interviewing’s ‘rules’ rather than inflexibly follow the manual. Probably the best established ways therapists can both get it right and get it wrong lie along the dimension of directiveness versus non-directiveness, explored in a Findings review listed above.
Sometimes it really is best to tell patients what they should do
They can get it wrong by trying to take charge with patients who react against being led – a clash motivational interviewing aims to avoid – but also by mistakenly adopting an ‘It’s up to you’ stance with patients who need to be given a lead. The perhaps uncomfortable truth seems to be that beyond the obvious, there are no universal rules: some people need to be led, others to lead; some told what to do, others to feel they have come to their own decisions; some need arousing, others soothing – and needs can change as therapy progresses.
So when with all the authority of Britain’s official health standards agency, NICE advises that substance use therapy “should be based on a relevant evidence-based treatment manual”, remember they mean based on, not prescribed in advance no matter who the patient or whatever their needs and preferences at the time.
Research may have to package; therapy does not That last comment above brings us to an important point about the nature of research and its links to practice, one cogently argued in respect of psychosocial therapies in general. To pin down know what caused any improvements, researchers often feel they have to tightly control what is being delivered, so they manualise interventions, and train and supervise therapists to make sure they follow the manual. But (as demonstrated by our review of motivational interviewing (listed above) though this might be the best way to do research, it is not necessarily the best way to do therapy, which has to sensitively adapt to where the patient is at in solidifying their commitment to tackle their substance use problems.
Similarly, researchers may prefer to standardise interventions to a set schedule and time period in order to limit costs, equalise time spent with therapists in a comparison therapy, and have a set end date from which the follow-up period can begin. Twelve weeks is a frequent compromise between a manageable research intervention and one long enough to have a good chance of working. As a result, 12-week treatments have collected an evidence base around them, evidence reflected in NICE’s recommendations. Yet there is no reason to believe that because 12 weeks is convenient for researchers, it is also how patients should be treated. Some manage well with much less, others (see cell D2’s bite) benefit more from longer term care.
What is happening here forms a less than virtuous circle. Research takes its ideas from practice, standardises and packages that practice, and then tests it. Via recommendations from authorities reliant mainly on research findings, practitioners may then be persuaded that the researchers’ packages – now ‘evidence-based’ – are how they too should do therapy. Break this circle by treating research as an aid to reflecting on and developing practice, not a blueprint. In respect to drug misuse rather than alcohol problems, this was the approach taken by authorities from the British Psychological Society when they developed their guidance on implementing the main psychosocial therapies recommended by the UK’s official health advisory body, the National Institute for Health and Care Excellence (NICE). The authors insisted that though their framework “draws heavily upon treatment manuals, it enables a more comprehensive approach to implementation than a manual alone can provide … It allows a degree of flexibility and adaptation at the level of the individual service user. Such flexibility may not be present in a particular manual, the development of which may instead be rooted in a specific service in a particular health care setting.”
Are these always the important things to do? Start this exercise by free of charge downloading guidance listed above from an American Psychological Association task force. Under the heading “Treatment factors” on page three of the PDF file you will read that research “suggests that a number of specific therapeutic elements are characteristic of effective treatments”. Take a critical look at these elements. They include “explicitly helping the client restructure his or her social environment in ways that support change” – or more specifically, change in the form of abstinence. Recall that restructuring the patient’s social network to be more supportive of abstinence or moderate drinking was the main focus of the novel treatment programme developed for the British UKATT trial, our Highlighted study. Look back at that section: how well did it work relative to a more basic motivational treatment? How feasible is social restructuring for the clients you know? Do they have the resources – psychological, social and material – to replace environments, friendships, even families and intimate partners which are conducive to drinking, with those more conducive to non-drinking? An important question, because unless they can, gains from the radical social re-engineering possible in a contained environment like a residential community remain vulnerable on discharge back to the home environment.
Next element is a “focus on client motivation for change” – possibly, suggests the guidance, through ‘decisional balance’ exercises leading them to weigh up the pros and cons of changing their substance use. But if patients are already committed to change (as many will be), maybe it is not such a good idea to encourage them to rehearse the good things about their substance use? On this question, see the alcohol treatment aftercare (study 19) in a Findings review listed above. Of that and two other studies, we commented: “the puzzle is not why the least committed subjects benefited from a motivational approach (this is the expected result), but why the most committed reacted badly … Possibly the explanation is what to the patient may have seemed a backward step to re-examine the pros and cons of whether they really did want to stop using drugs or commit to treatment and aftercare, when they had already decided to do so and started the process.”
A focus on boosting client motivation is above all the province of motivational interviewing, and is thought to be what it adds to non-directive counselling after the style of Carl Rogers. But when these motivation-eliciting enhancements were stripped ( illustration) out, leaving only the bedrock of non-directive, empathic listening, there was no detriment to drinking outcomes; if anything, the reverse. Neither this nor the fully-fledged motivational approach was much better than just telling patients to reduce their drinking on their own. In this study (of which more in cell B4) the patients were relatively stable, moderately dependent drinkers, but the same non-superiority of motivational interviewing has been seen (review listed above) across studies in general.
Next the guidance’s list of “elements … characteristic of effective treatments” moves into the territory of cognitive-behavioural therapies: “helping the client to develop awareness of repetitive patterns of thinking and behavior that perpetuate substance use … accompanied by a focus on helping the client learn alternative coping skills.” If this is a key to effective therapy, why on average do cognitive-behavioural therapies do no better (review listed above) than other approaches?
Then we learn that “Effective therapies attend to the affective [emotional/mood] experiences of the client, particularly in relation to their substance use.” Yet we know too that a focus on emotions can for some patients be counterproductive.
These points are made not to criticise the in-general very sensible suggestions made by the task force, but to reinforce the point that generalisations are bound sometimes to be misleading in what is essentially an individualised response to an individual set of circumstances, never before encountered in precisely the same configuration.
Thanks for their comments on this entry to Jim Orford of the University of Birmingham in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.