Effective Treatment Modalities

In this section, we shall consider some of the modalities that can be considered effective, as shown by high CESs in the Mesa Grande. Again, the idea is not to describe every single effective treatment for alcohol problems but merely to focus on a few general approaches that are supported by research evidence and can easily be implemented in practice.

Brief Interventions

The highest CES in Table 15.1 is for brief interventions; however, there are a number of important considerations to bear in mind here. First, the category of brief interventions contains two different kinds of activity: very brief interventions given by generalist workers (for example, general medical practitioners) in community settings to excessive drinkers not complaining of an alcohol-related problem and longer brief interventions, better called 'brief treatment', given by alcohol or addiction workers in specialist treatment centres to those who do complain, or have been persuaded to complain, of an alcohol-related problem (Heather, 2003). The existence of the second class of brief interventions makes especially relevant the inclusion of figures for 'clinical populations only' in Table 15.1. It will be seen that nearly half the studies of brief interventions are of this type and that it retains its first-place ranking for cumulative effectiveness. What is not made clear in the Mesa Grande is that, even though it is directed at a clinical population, this sort of brief treatment would normally be offered to clients with less severe problems among those attending specialist treatment centres. Since the brief interventions in the generalist subcategory are by definition aimed at individuals with less severe problems, the direct comparison of brief interventions with other modalities in the Mesa Grande is in a sense misleading because it does not compare like with like.

The above distinction between subcategories of brief intervention was accepted by Moyer et al. (2002) who carried out separate meta-analyses for each. For studies of generalist brief interventions, in which the comparison was with control conditions in non-treatment-seeking samples, small to medium effect sizes were found in favour of brief interventions. At earlier follow-up points, the effect size was increased when individuals with more severe problems were excluded. For studies of specialist brief interventions, where the comparison was with more extended intervention in treatment-seeking samples, there was no evidence that the briefer interventions were less effective. Thus, provided they are used in the right circumstances with the appropriate types of client, the effectiveness of brief interventions is supported by a very large amount of research evidence.

Brief interventions are certainly suitable for those with mild alcohol dependence and/or problems but we do not yet know with any confidence the upper limit of seriousness for the application of brief interventions and therefore which clients should be excluded from brief interventions and offered more intensive treatment. In the meantime it is better to be cautious and restrict brief interventions mainly to those with mild to moderate alcohol problems.

The behaviour change methods used in brief interventions vary considerably. Brief interventions in specialist settings, and sometimes in generalist settings when more time is available (Israel et al., 1996), often represent a condensed version of cognitive-behavioural treatment (see below). Many generalist brief interventions, however, consist of little more than advice, albeit given in sympathetic and constructive terms and preferably tailored to the circumstances of the individual client. Even here, though, practitioners are advised to adhere as far as possible to the six ingredients of effective brief interventions identified by Bien, Miller & Tonigan (1993) and summarised by the acronym FRAMES (see Box 15.1).

Box 15.1 Ingredients of effective brief interventions (from Bien, Miller & Tonigan, 1993)

• Feedback of personal risk or impairment.

• emphasis on personal responsibility for change.

• clear advice to change.

• a menu of alternative change options.

• therapeutic empathy as a counselling style.

• enhancement of self-efficacy or optimism.

Motivational Enhancement

The treatment modality known as 'motivational interviewing' was developed by W.R. Miller (1983) and has been described at greater length by Miller & Rollnick (1991, 2002). The somewhat more general heading in the Mesa Grande of 'motivational enhancement' includes more structured forms of intervention, such as the Drinker's Check-up (Miller, Sovereign & Krege, 1988) and Motivational Enhancement Therapy (MET) as used in Project MATCH (Miller et al., 1992), in which results of assessments are fed back to the client and discussed in a motivational interviewing style. The basic objective of motivational interviewing in all its forms is to elicit from clients an increase in motivation to change behaviour without attempting to impose such an increase on them. The motivational interviewing style owes much to Rogers' (1951) non-directive, client-centred counselling but has been described by its authors as client-centred and directive (Rollnick & Miller, 1995). Motivational interviewing has become extremely popular among practitioners in the alcohol problems field, the addictions field more generally and increasingly in other areas of behaviour change such as exercise, diet and forms of sexual behaviour, where clients experience an ambivalence about giving the behaviour up. Several accounts of the principles and techniques of motivational interviewing are available, including Miller & Rollnick (1991, 2002), Miller et al. (1992) and Rollnick & Allison (2003).

Many of the brief interventions that have been subject to research trials are based on brief forms of motivational interviewing (for example, Bennett, Edwards & Bailey, 2002; Gentilello et al., 1999; Hulse & Tait, 2002; Longabaugh et al., 2001; Marlatt et al., 1998; Monti et al., 1999; Smith et al., 2003; Stein et al., 2002) and this is an increasing tendency. However, these studies are included under the motivational enhancement category in the Mesa Grande rather than under brief interventions. The CES in Table 15.1 is highly positive, both in the clinical population and for alcohol problems of all severities. This occurs despite the fact that few studies of motivational interviewing include quality control of treatment fidelity and it is often not clear whether what was offered to clients conformed to the method as described by its originators (Rollnick & Miller, 1995). A specific use of motivational interviewing is as a preparation for more extended treatment and two randomised studies in the alcohol problems field have shown this application to improve treatment outcome (Bien, Miller & Boroughs, 1993; Brown & Miller, 1993). Motivational interviewing has also been subject to systematic review and formal meta-analysis by Noonan & Moyers (1997) and Dunn, Deroo & Rivara (2001), with positive conclusions.

In findings from Project MATCH (Project MATCH Research Group, 1997b), in the outpatient arm of the trial, clients who were initially high in anger reported more days of abstinence and fewer drinks per drinking day if they had received MET than if they had received CBT. This effect persisted from the one-year to the three-year follow-up point (Project MATCH Research Group, 1998a). This presumably reflects the deliberately non-confrontational nature of MET and high client anger at initial assessment is clearly a positive indicator for the offer of MET, at least as a first step in treatment.

A study in New Zealand (Sellman et al., 2001) showed that four sessions of MET were more effective than four sessions of 'non-directive reflective listening' and to a nonintervention control group, suggesting that it is the specific ingredients of MET rather than any non-specific effects that are responsible for its success.

Community Reinforcement Approach and Related Treatments

Among problem drinkers with severe problems and high dependence - those traditionally labelled 'chronic alcoholics' - one of the most effective treatment modalities is the community reinforcement approach (CRA) and this is reflected in the Mesa Grande where it occupies fourth position. The full CRA consists of a broad range of treatment components, which all have the aim of engineering the client's social environment (including the family and vocational environment) so that sobriety is rewarded and intoxication unrewarded. Although based firmly in the traditional Skinnerian principles of instrumental learning (Bigelow, 2001), the modern form of CRA includes methods to change clients' beliefs and expectations (Smith & Myers, 1995) and several ingredients of the standard cognitive-behavioural approach to treatment (see below).

It is often claimed that the CRA is too expensive to implement in routine practice. This conclusion is challenged by Myers & Miller (2001) who point out that better outcomes from the CRA relative to traditional approaches have been based on treatments of between five and eight sessions, comfortably within the range of intensity of treatments usually offered in the UK and other countries. Even if this is not accepted, however, the principles of the approach (those designed to change the social environment so that sobriety is reinforced and heavy drinking unreinforced) can be applied to the individual case. The CRA has proved especially impressive with socially unstable and isolated clients with a poor prognosis for traditional forms of treatment, including those who have failed in treatment several times in the past.

The CRA was one of the influences on the development of SBNT, the treatment modality that was compared with MET in the UKATT. Other influences were social skills training (Oei & Jackson, 1980), behavioural marital therapy (McCrady et al., 1991) and network therapy (Galanter, 1993). The first two of these obtain high ratings in the Mesa Grande, whereas the third remains unevaluated. More generally, leaving aside the two highest ratings (brief interventions and motivational enhancement), which may apply to modalities more suitable for clients with less severe problems, it is striking that many of the best supported treatments in the Mesa Grande contain a social or at least interpersonal component. This is consistent with evidence mentioned above on the importance of the client's social networks in the response to treatment (Beattie, 2001) and with the way that AA is thought to exert its beneficial effects (by demanding a change in lifestyle and modes of social interaction) (Kaskutas et al., 2002). However, UKATT failed to reveal any overall superiority of SBNT, scheduled for 8 50-minute sessions, over MET of three sessions (UKATT Research Team 2005a). These two forms of treatment showed no differences in their effectiveness in reducing alcohol problems.

Cognitive-behavioural Therapy

There is no single category for CBT in Table 15.1 but several treatment methods usually classified under this more general heading obtain a high CES (behavioural self-control training, behaviour contracting, social skills training and behavioural marital therapy). On the whole, therefore, CBT is strongly supported by the Mesa Grande (see also Parks, Marlatt & Anderson, 2003).

Behavioural self-control training (Hester, 1995) is usually aimed at a goal of moderate use of alcohol rather than total abstinence and, as such, is normally offered to problem drinkers with lower levels of dependence and problems. It is also the approach to treatment that most often forms the basis for the written guidance on how to change drinking behaviour in self-change manuals, another modality well supported by the Mesa Grande. Behavioural contracting (Keane et al., 1984) is a common ingredient of the CBT approach to alcohol problems and aims to ensure that the client's relationships with significant others are helpful to the treatment process rather than unhelpful; it also forms part of the CRA (see above). Social skills training (Monti et al., 1995) focuses on a particular behavioural deficit that is commonly found in problem drinkers but is only one approach to enabling the client to cope with stressful situations without recourse to heavy drinking. Lastly, it should be noted that behavioural marital therapy (O'Farrell, 1993) obtains a high positive CES whereas non-behavioural marital therapy does not. Considered as single entities, a range of other methods commonly associated with the CBT approach, such as 'problem solving', 'functional analysis', 'self-monitoring' and 'relaxation training' are not supported by the Mesa Grande.

In the alcohol problems field, 'cognitive therapy' is regarded as somewhat different from CBT. The former derives from the work of Beck and his colleagues in the substance-abuse field (Beck et al, 1993) and entails an attempt to modify maladaptive cognitions that are thought to underlie the drinking problem, as contrasted with the more performance-based methods of CBT. This distinction is not entirely clear because cognitive therapy often includes role-play, homework assignments and so forth, whereas CBT often includes attention to modifying automatic thoughts and the cognitive restructuring of unhelpful beliefs, but the 10 studies that have explicitly evaluated cognitive therapy resulted in only a modest positive CES in Table 15.1.

'Relapse prevention' is another category needing clarification in the Mesa Grande. In an important sense, relapse prevention is a goal of treatment, one that is an inherent part of the CBT approach in this area, rather than a specific treatment method (Parks, Anderson & Marlatt, 2003). The studies subsumed under the relapse prevention category in Table 15.1, where it has a negative CES, were focussed on various methods for helping clients anticipate and cope with high-risk situations for heavy drinking. Again, in isolation, relapse prevention in this sense appears ineffective. However, as we have seen, the CBT methods with which the relapse prevention goal forms an integral part are heavily endorsed by the Mesa Grande.

Pharmacotherapy

Table 15.1 shows first that several medications that have been successful in the treatment of other disorders (for example, antidepressants - both SSRIs and non-SSRIs, lithium, anxiolytic drugs in general) have not been found to be effective in the alcohol problems field. However, two relatively recently developed drugs, acamprosate (purportedly a GABA agonist) and naltrexone (an opiate antagonist) score in third and sixth place respectively in Table 15.1. The effects of these newer drugs are more specific to alcohol and they are thought to work by reducing craving for alcohol and/or its rewarding properties (Chick, 2003). Even here, however, psychosocial treatment may have an important role to play. Volpicelli et al. (1992) found that a combination of naltrexone and psychotherapy produced better outcome than either alone and O'Malley (1996) reported a similar findings for naltrexone and coping skills therapy. The effects of combining pharmacotherapies and psychosocial treatments for alcohol problems is currently the subject of a large, multi-centred trial (Project COMBINE) in the US. However, an internationally recognised authority on pharmacotherapies in the alcohol field has written: 'At best, these treatments are only an aid to establishing a change in lifestyle' (Chick, 2003, p. 64), thereby endorsing the view that pharmacotherapy remains adjunctive in the treatment of alcohol problems.

A common ingredient of the CRA is the deterrent drug disulfiram, which produces a very unpleasant physiological reaction if alcohol is taken and whose effects can also be understood in terms of operant conditioning principles. Myers & Miller's (2001) conclusion was that disulfiram is not necessary to the effectiveness of the CRA. On the other hand, disulfiram does increase the effectiveness of traditional treatment. The evidence strongly suggests that disulfiram is only effective if compliance with taking medication is based on supervision by a professional or relative in a behavioural contract (Brewer, 1993). If consideration were confined to studies where this 'compliance assurance' method was used, the CES for disulfiram would probably be higher than shown in Table 15.1 and would suggest that drug treatment for alcohol problems must be understood and implemented in a social psychological context.

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