Relying on mutual aid groups to supply social support depends on the acceptability and availability of suitable groups, both likely to be greater in much of the United States than in the UK. Attempts are however being made to heighten the profile of and support for mutual aid groups. Potentially influential backing has come from Britain's National Institute for Health and Clinical Excellence (NICE), which recommended that staff in drug services "should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles", and from England's National Treatment Agency for Substance Misuse, which saw "ongoing mutual aid" as one of the components of effective commissioning for recovery. In Scotland, alcohol treatment guidelines recommend that dependent patients should be encouraged to attend Alcoholics Anonymous, "especially if other support for abstinence is lacking".
Many other differences between the featured study and the British UKATT study could account for the difference in outcomes. The therapies compared in the British trial were not the sole treatment; any differential impact may have been overwhelmed by the other components. Also the alternative to the network option was based on motivational interviewing which, though shorter, was possibly a stronger comparator. Not to be ignored is the possibility of chance or at least unaccountable fluctuations in the effectiveness of psychosocial therapies around what in general is an equivalent improvement in the patients.
In contrast to the featured study, an earlier study from the same research team found that supplementing motivational and cognitive–behavioural therapies with contingency management did improve post-treatment abstinence from cannabis, and did not (if anything, the reverse) have a damaging effect on confidence in ability to resist cannabis use and deployment of strategies to do so. In this study, only standalone contingency management had this counterproductive impact. Other studies too have found that cognitive–behavioural therapists seem to be able to productively weave the patient's contingency management experiences in to their work (1 2). A possibly relevant difference was that abstinence was directly rewarded in these studies. In the featured study, emphasising to patients that abstinence was irrelevant to whether they had a chance at the prizes may have diluted what was otherwise a clear focus on not drinking. Introducing a 'policing' element in to the relationship with the therapist, who had to verify the patient's eligibility for the prize draw, may also have been counterproductive.
From this corpus of evidence it is not possible to say that contingency management incentives do undermine motivation and confidence, just that they can do, and that this seems likely to account for the common finding that the gains made while the incentives are in place erode once they have ended. It is also possible to use the patient's experience of the incentive system as productive grist to psychological therapies. Contingency management procedures do not produce lasting change simply by mechanically reinforcing the habit of non-use. More important is whether the experience fosters (or is used to foster) confidence that one can resist relapse, along with the motivation to transform 'can' in to 'will', and strategies to effectively implement this resolution. In other words, what the patient makes of their spell on the contingencies and how they interpret it determines whether it will result in a transient, reward-driven spell of reduced substance use, or more lasting change. What the patient makes of the contingencies can in turn be influenced by how these are integrated in to the accompanying therapy. Such complications demand the caution expressed by Britain's National Institute for Health and Clinical Excellence (NICE), which recommended the introduction of contingency management in to drug services only as part of a phased and carefully evaluated research programme.
Recent reviews (1 2) of how Alcoholics Anonymous works have highlighted mechanisms which it shares with other approaches including self-efficacy, motivation for abstinence and commitment to recovery, coping strategies such as avoiding high-risk situations, clear goals and a coherently structured route for achieving these, abstinence-oriented norms and role models, involvement in alternative rewarding activities, and social support. Particular importance was placed on "perhaps its most potent influence" – social group dynamics in the AA meeting and social support from the broader fellowship. In contrast to these generic mechanisms found in other approaches, there was less support for more AA-specific elements like spirituality, adherence to AA beliefs and philosophy, or following recommended AA practices.
These important social influences have been specifically reviewed. Conclusions were that on the whole AA involvement supports positive changes in social support including support for not drinking, and offers positive social roles to the participant through aiding others. While AA involvement bolsters support via new friendships and acquaintances, existing family and friendship networks are generally unaffected. Abstinence-specific support was found more influential then general support, but this may be because abstinence has generally been the outcome being measured. Both types of support may be influential in helping sustain not just the absence of drinking but the positive well-being of a healthy and sober lifestyle. Abstinence is fostered by AA through social mechanisms which include general friendship quality, weakening of pro-drinking influences, and support for abstinence from friends and especially from AA members. An influential US study cited in the review found that one year after starting treatment, over the past month 37% of patients with no social support for their effort to reduce drinking had sustained abstinence, compared to 52% for those with support only from people not met through AA meetings, and 78% for those with support from people they had met at AA. Taking other factors in to account, non-AA support was not significantly related to abstinence, but AA support was. However, abstinence was the sole drink-related variable related to specifically AA-based support. People deriving at least some support from AA were no more likely to drink less when they did drink, or to experience fewer symptoms of dependence, than people with other sources of support. Also, social support from whatever source was unrelated to the patient's experience of drink-related problems.
The idea that the social network element is important is also supported by findings that dependent drinkers in treatment who lack an abstinence-supportive network gain most from being encouraged to participate in AA.
Of the methodological issues affecting confidence in the featured study's findings or their wider applicability, a major limitation is that the patients were not drinkers seeking treatment in the normal way, but people who responded to the study's ads. Their motivations may have been to do with joining (with accompanying financial compensation) a study rather than simply seeking help. Compared to patients in a major British alcohol treatment trial, who had sought treatment in the normal way, they drank on about the same proportion of days but much less heavily – 16–17 UK units versus nearly 27. About 133gm versus 214gm.
It was not ideal that research assistants who gathered the outcome data knew which treatment the patients had been assigned to, opening up the possibility that somehow their data collection processes favoured some treatments above others. However, this seems unlikely to account for the pattern It is hard to see why they would have expected the addition of contingency management to worsen outcomes. of the findings.
Though in most respects a typical counselling approach, some may consider the case management option a weak comparator, lacking the theoretical basis and research support of approaches like motivational interviewing and cognitive–behavioural therapy. In general the latter has indeed produced slightly better substance use outcomes than alternative therapies. Also, case managers were constrained by instructions to avoid recommending social support interventions or (in the US context, a significant limitation) AA attendance. A less constrained approach might have proved more effective, but would have confused the comparison with the network support treatments.
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