We shall consider first treatment modalities that have been shown by research to be ineffective (as shown by a negative CES in the Mesa Grande) and those for which there is little or no evidence either for or against effectiveness (a CES close to zero in the Mesa Grande). The intention is not to list all treatment modalities fitting this description but to focus on a few prominent examples of modalities that continue to be widely implemented despite the absence of good evidence to support them.
The traditional model of treatment in the alcohol problems field is group therapy. It was the principal type of intervention in the residential alcoholism treatment units that dominated the response to alcohol problems in the UK and in other countries from the pioneering work of Dr Max Glatt in the 1950s to the 1980s (Ettore, 1984, 1988). The conduct of group therapy in this tradition was heavily influenced by the teachings of AA and group therapy of this kind is still widely practised today.
Unfortunately, there is no evidence that group therapy for alcohol problems is effective. This is shown by the low negative CES for 'group process psychotherapy' in Table 15.1, based on three studies. The involvement of groups of people in the treatment process may be an important principle but there is little justification without further research for continued use of group therapy in the traditional way it has been used in the alcohol field.
The inclusion of AA in a section on ineffective treatments needs special justification. This is firstly because AA affiliates would deny that AA is a 'treatment' of any kind but rather a self-help or mutual-aid group outside the formal treatment system. Secondly, because of the anonymity of its affiliates and for other reasons, it has proved extremely difficult to conduct research on the effectiveness of AA. However, the Fellowship does make claims for its own effectiveness, sometimes startling ones, and this issue is therefore one for serious scientific consideration. Thirdly, there can be no doubt that, over the years, AA has helped a huge number of people with alcohol problems and saved many thousands of lives. Nevertheless, the professional in the field has to decide whether a particular client should or should not be encouraged to attend AA, a decision that must be based at least partly on research evidence.
The Mesa Grande in Table 15.1 shows a negative CES for AA. However, this is unfair on AA in one important sense. Because of the difficulties referred to above, it has not been possible to carry out randomised controlled trials of AA's effects among the anonymous, voluntary members it is primarily intended for; the only controlled studies to date have been conducted with individuals mandated by the courts to attend AA or some alternative and there are obvious grounds for suspecting that such individuals might have poorer outcomes in AA than voluntary affiliates. Thus the evidence in the Mesa Grande should be interpreted a providing no support for compulsory attendance at AA as part of court orders or employee assistance programmes.
While on the topic of AA, we may also note the negative CES in Table 15.1 for 'Twelve-step facilitation'. This refers to a one-to-one approach in which the Twelve Steps, the body of principles in which the spiritual message of AA is conveyed, are explained to and discussed with the clients, with attendance at the Fellowship itself the immediate objective (Emrick, 2003). Despite the negative CES, results of Project MATCH were that TSF was as effective as CBT and MET, a finding that supporters of the latter two approaches must have found surprising. Indeed, in the aftercare arm of the project, TSF was slightly but significantly superior to the other two therapies in terms of frequency of abstinence following treatment. In addition, there were three 'matches' favouring TSF:
• in the outpatient arm, clients low in psychiatric severity (those with low psychiatric comorbidity) reported more days abstinence after TSF than after CBT, an effect present at the one-year follow-up but not at the three-year follow-up;
• in the aftercare arm, clients with high alcohol dependence reported more abstinent days with TSF than with CBT at one-year follow-up;
• in the outpatient arm, those individuals with a social network supportive of drinking (those with a lot of heavy drinking friends) did better with TSF than MET, an effect that did not emerge until the three-year follow-up, but the largest matching effect identified in the trial when it did emerge. This last finding is especially interesting in view of accumulating evidence (Beattie, 2001; Kaskutas, Bond & Keith, 2002; Weisner, Matzger & Kasklutas, 2003; Zywiak, Longabaugh & Wirtz, 2002) that clients with heavy drinking social networks tend to show poor treatment outcomes and that intervening in the social network may be an effective component of therapy (Copello et al., 2002).
All the above effects are clearly predicated on attendance at AA meetings and, on a cautionary note, might be affected by the specific cultural context of the US in which AA attendance is popular and AA's influence in the field of alcohol problems very strong. If replicated in other countries, however, the indications are that clients without accompanying psychiatric disorder, with high levels of alcohol dependence or with social networks supportive of drinking, are best suited for referral to AA. Since it is a purely mutual aid organisation AA is also likely to be highly cost-effective.
As is well known, Freud and other early psychoanalysts largely ignored treatment of alcohol dependence and other addictions (Forrest, 1985). Later research suggests that this neglect was justified. The 'psychotherapy' category in Table 15.1 embraces psychotherapeutic methods designed to bring about change by increasing insight into motivations for drinking and revealing underlying psychodynamic processes. It will be seen that this category obtains one of the lowest CESs in the Mesa Grande.
A national census of UK alcohol treatment agencies carried out in 1996 showed that two-thirds of clients being treated for alcohol problems on a particular day were seen in the non-statutory sector (Luce et al.,2000). Depending on the way treatment services are organised, a similar conclusion may apply to other countries. The main approach to helping clients in the non-statutory sector, in the UK at any rate, comes under the heading of 'counselling'. Unfortunately, so little is know about what precisely is covered by counselling in this general sense that it is difficult to arrive at any firm conclusions regarding its effectiveness.
As far as research evidence goes, Table 15.1 reflects the fact that counselling covers a range of different activities. 'General alcoholism counselling', an ill-defined category that presumably includes atheoretical information giving and exhortation, obtains a very low CES, exceeded only by 'educational lectures and films' given in a group format. Unfortunately, both these categories are staples of treatment programmes throughout the world. So too, 'confrontational counselling', based on a misinterpretation of AA principles (Miller & Rollnick, 1991, p. 7) and aimed at breaking down the client's 'denial' and 'resistance', fares badly in the Mesa Grande but, again, is commonly practised, particularly in the US. Against this, 'client-centred counselling' based on the work of Carl Rogers (1951) appears as an effective modality, although not as effective as other approaches in the table to which we now turn.
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