What works?Effective therapies
selected research articles
When what are thought to be effective treatments are compared, it is a common finding that there is no great difference between the two interventions providing that they have been well delivered. The main reason for this is that effective treatments tend to include similar components.
Classic paper ::What are the elements of effective treatment?
Moos R (2007) Theory-based active ingredients of effective treatments for substance use disorders.Drug and Alcohol Dependence 88: 109–121 doi:10.1016/j.drugalcdep.2006.10.010
This is a must read article for anybody interested in the theoretical underpinning of effective interventions which at the same time reviews the available evidence. In an overview of what kind of interventions work the author concludes that, consistent with social control theory, effective treatment appears to be characterised by:
❶ cohesion and support between therapist and service user ❷ moderate, ie flexible, structure ❸ goals oriented toward achieving service user’s personal milestones and objectives.
The quality of the alliance or bonding between service user and therapist or overall program has been consistently associated with treatment outcome.
Theoretical Basis of Cognitive Behavioural Treatments (such as iSBNT)
Better positive communication between all players and monitoring of agreed behaviour change plans.
Planning pleasurable activities without substance use and giving reward for achieving goals.
Reducing the positive experiences from substance use and from being with other drinkers or drug takers.
Increase self-belief and confidence. Develop coping skills for high risk and stressful situations.
Review :: Treatment adherence
Gearing RE, Townsend L, Elkins J, El-Bassel N, and Osterberg L (2014) Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence. Harvard Review of Psychiatry 22: 31-45 DOI: 10.1097/HRP.10.1097/HRP.0000000000000005
Session attendance is more complicated than it might appear. Attendance may be intermittent or suddenly end; an intervention may or may may not have a defined number of sessions; there may be good reason to finish treatment early, namely if the desired goals have been achieved. What goes on within a session is best captured by routine video or audio recordings, which can the be reviewed in supervision or privately by practitioners. There are also several scales, for example the Working Alliance Inventory, which measure opinions about treatment, albeit these may differ between service user and practitioner. Take-home tasks are an important part of psycho-social interventions and it is easy enough to see whether or not tasks have been attempted and completed.
Effective psychosocial interventions have a structure for which there is supportive evidence that the intervention works: it follows that adherence to the structure is important. No single, generally accepted, definition of psychosocial treatment adherence is available, however, three core elements need to be addressed: (1) session attendance (intervention dosage); (2) intra-session involvement (participation within sessions); and (3) inter-session involvement (take-home task completion). Drop-out most often occurs as a ‘no-show’ or after the first few sessions, while sustainable improvement tends to come later
Overcoming drop out depends, in large measure, on the quality of practitioners and how they relate to service users – this is well understood. Other barriers to attendance are simple enough but how to deal with these needs to be thought about: i) ease of access (cost and distance of travel) to an agency and flexibility of appointment times ii) effective communication before and throughout any intervention iii) explanation of the treatment to dispel anxieties (especially of any possible compulsory actions by the agency) iv) awareness of how to encourage at risk demographic groups (young people, economically disadvantaged, ethnic minorities, mental health problems, low expectations for change, child care responsibilities).
Effectiveness is not the only consideration
It is a prerequisite of any treatment offered to the public that it should be effective, but there are other things to think about: Is it practical - are suitably qualified staff available to deliver it and can it be done within necessary time constraints? is it more or less cost-effective than alternatives? Is it acceptable to all stakeholders? Clinical guidelines usually address these issues.
Important study :: What techniques are suggested in guidelines?
Michie S, Whittington C, Hamoudi Z, Zarnani F, Tober G & West R (2012) Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 107: 1431–1440 doi:10.1111/j.1360-0443.2012.03845.x
Behaviour change techniques were identified by trawling through guidelines and treatment manuals and 42 different techniques were agreed upon. The effectiveness of these techniques was then tested against a meta-analysis of RCTs where the target behaviour was heavy rather than dependent drinking. How well the interventions were delivered is not recorded.
The authors conclude that in brief interventions, promoting self-monitoring is associated with improved outcomes. How effective the other promising techniques might be could not be confirmed from the dataset available.
Number of Random Controlled Trials Selecting Particular Behaviour Change Techniques
83% At least one form of motivational technique
67% Information on the consequences of drinking
50% Boost self-efficacy and motivation
28% Provide normative information on other people's drinking
17% Secure immediate commitment to change from service users
Important study :: What does recovery mean?
Thurgood S, Crosby H, Raistrick D, Tober G (2014) Service user, family and friends' views on the meaning of a 'good outcome' of treatment for an addiction problem.Drugs: Education, Prevention and Policy 21: 324-32
24 people with drug and alcohol problems and 12 of their family and friends were asked in six focus groups what 'being better' meant to them. 20 things seen as important to a stable recovery were identified. These were grouped into seven themes: i) abstinence ii) health iii) daily activities iv) relationships v) social circumstances vi) self awareness and vii) wellbeing of family and friends. This first quote really gets to the heart of what needs to change for successful recovery…
❝ Have you got new friends, you know, have you got a social circle of non-drug users - that was one of the main things why I’ve done so well.❞
❝ First of all you had to lose the craving for drink. And then it progressed to getting away from the mental and physical state that you were in when you were drinking. And then it progressed to staying sober and then it progressed to not wanting a drink. And then it progressed to leading a normal sort of life. ❞
❝ Your feelings come back, your emotions and your goals, you know, even your hygiene gets a lot better and that, you take time in yourself, you know, and you make sure all your clothes are ironed, you know, tidying up around yourself, you know, little things like that, stopping smoking dockers out of the ashtray, ‘cos you’ve got money to buy cigs. ❞
❝ I get paid on a Thursday and by the next day I’ve still got money in my pocket, it was all gone on the same day before. ❞
❝ A good social life is moving on from other drinkers. ❞
❝ I still don’t feel like I’ve recovered because I’m still taking an opiate based drug, like I said, I still feel like a drug addict. ❞
Important study :: What do service users think has helped them to change?
Orford J, Hodgson R, Copello A, Wilton S, Slegg G on behalf of the UKATT Research Team (2009) To what factors do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol Treatment Trial. Journal of Substance Abuse Treatment 36: 49–58
The chart shows how many clients thought each of the 12 factors to be important to change - the more the greater its significance. Beliefs about what caused change may not be the reality, nonetheless, therapists should take note of what service users see as important. The dominance of general factors is one reason why different treatments tend to have similar outcomes. Reasons for change are similar to those given for natural recovery.
The reasons given were grouped into social (S), motivational (M) or general (G) factors: S1= involvement with others S2= alternative activities S3= better communication M1= awareness of consequences M2= feedback M3= priorities in life G1= comfortable talking to others G2= keeping occupied G3= commitment G4= detox/medication G5= personal circumstances G6= other.
more for practitioners…
