Effectiveness improves when clients have access to a range of options
Many health disciplines are plagued by a gap between research and practice. Treatments being provided do not always represent the best practices available. This “research-practice gap” is particularly evident with alcohol and drug treatment providers, as the field is less established compared with other primary health sectors, such as mental health.
Despite improvements in education and training in recent years, the addictions workforce in Canada does not have a national professional body or a national set of standards and competencies to guide evidence-based delivery.
In Ontario, addiction counselling is not a regulated profession so virtually anyone can claim to be an addictions counsellor.
Further, Canada currently has no mechanism for knowledge transfer in the addictions field, as compared to the Addiction Technology Transfers Centers in the United States. These centres, established by the Center for Substance Abuse Treatment, which is part of the Substance Abuse and Mental Health Services Administration, have as mandates to identify, document and promote the most innovative and effective treatment strategies. They also help communicate the most successful strategies to substance abuse treatment professionals.
Evidence-based alcohol and drug abuse treatments are derived from the current best-practice evidence and take into consideration a patient’s values and needs.
On a clinical level, these treatments tend to be highly structured. Many clinicians are reluctant to adopt them because they are unwilling to relinquish the freedom to provide treatment as they see fit.
New alcohol and drug abuse treatments must also compete with entrenched, but scientifically unsupported beliefs. For example, current treatment recommendations based on empirical evidence have trouble gaining ground against the commonly held fiction that all alcohol or drug abuse clients require intensive care and lifelong commitment to abstinence.
As a result, the alcohol and drug client is often not presented with a range of treatment options matched to individual need.
The following are summaries of various psychosocial treatment approaches that scientific evidence shows are most effective.
It is important to emphasize that alcohol and other drug use problems encompass a broad range of substances, patterns of use and different degrees of severity. In general, the most intensive, lengthy and expensive services should be reserved for those with the most serious, chronic problems. Many people with less severe problems can benefit from brief treatment or can change on their own. This approach requires systematic screening, assessment and treatment planning.
Cognitive-behavioural treatment: There is reasonably good empirical support for the effectiveness of a number of cognitive-behavioural treatment (CBT) interventions in addressing specific alcohol or other drug use problems. Typically, the highly structured and efficient nature of CBT interventions and their reliance on manuals for guidance ensure treatment quality. Interventions are usually delivered in group settings and can be provided as stand-alone treatments or integrated into a more comprehensive overall treatment infrastructure.
The following brief overview of the conceptual and technical aspects of the “cognitive” and “behavioural” components of this model demonstrates the practical application of the overall approach.
Cognitive component: Cognitive therapy is based on the principle that destructive behaviours, emotions and thoughts can be modified or altered by learning new ways of thinking about oneself and the world. The theory is that thoughts and attitudes create moods and not events themselves: emotions are the way people interpret events.
Some common cognitive techniques include problem-solving, relaxation therapy, showing by example or modelling, changing distorted ways of thinking, challenging incorrect assumptions and replacing destructive thoughts with productive thinking.
Behavioural component: Behaviour therapy is based on the principle that you can replace undesirable behaviours by teaching clients new, more desirable ones. Behaviour therapy focuses on the client’s responsibility for change and the development of an effective, working therapeutic relationship. Some common behavioural techniques are social skills training, modelling, relaxation techniques, and self-management methods such as the rehearsal of new coping strategies.
CBT approaches
When the cognitive and behavioural components are blended into a single approach, treatment sessions are typically offered in a group setting, led by a treatment provider who models the acquisition of thinking and behavioural skills to the participants. Group members are given the opportunity to learn new skills by engaging in interactive exercises, discussion, individual and group work, case studies and role plays. Post-treatment maintenance sessions, ongoing monitoring and after-care help participants with continued behaviour change and new challenges. Emphasis in after-care is placed on assisting participants to learn to cope with high-risk situations, such as negative emotional states or peer pressure, through structured relapse prevention.
Structured relapse prevention: This cognitive-behavioural treatment typically involves about 10 to 12 individual or group sessions followed by maintenance sessions, although the length and intensity of service delivery can vary.
Program participants are taught to recognize and anticipate their high-risk situations for substance use — for example, when out socializing or feeling lonely — and to implement effective coping strategies to either avoid a slip or relapse, or to minimize its impact.
A recent review of the research on relapse prevention suggests that structured relapse prevention is most effective with alcohol problems, when several substances are being abused, and when offered in conjunction with pharmacotherapy. Other behaviour skills training approaches — often part of the treatments described above — have been effective in treating an alcohol or other drug use problem.
Community reinforcement approach: This approach acknowledges the role of a variety of social and environmental events and influences on an alcohol or other drug use problem, and focuses on the development of positive alternative resources in the social environment. The community reinforcement approach puts emphasis on changing important aspects of life, such as work, recreation and family involvement, to promote a lifestyle that is more rewarding than substance abuse.
A specific community reinforcement approach strategy that has been thoroughly researched involves a voucher-based incentive program to promote abstinence. An individual who has submitted substance-free urine samples receives vouchers that can be exchanged for retail items or services. Research suggests that the community reinforcement approach can reduce drinking (especially in combination with disulfiram or Antabuse, a drug that produces an unpleasant reaction to alcohol) and is particularly effective for treating cocaine abuse.
Behavioural marital therapy: This form of therapy is a highly structured series of 15 to 20 sessions for couples and is aimed at reducing substance abuse directly and through restructuring the dysfunctional couple interactions that are thought to reinforce continued alcohol or other drug use. Behavioural marital therapy attempts to engage the family’s support in the change process, and to alter couple and family interactions to reinforce sustained abstinence. There is consistent evidence for the effectiveness of this therapy compared with other family approaches, at least for couples in committed relationships. Improvements in other areas of couple interactions, such as domestic violence, have also been documented.
Brief intervention – motivational interviewing approaches
Brief intervention: Several recent studies have shown that treatment of shorter duration is as effective as that of longer duration.
This is consistent with a shift in public health policy away from the traditional belief that everyone with a substance abuse problem needs extensive treatment, toward a view of alcohol and drug problems as points along a risk continuum ranging from lower to higher severity.
Placing individuals along such a continuum during assessment allows for a cost-effective approach to treatment that reserves the most expensive treatment services for those with the most severe problems.
Motivational interviewing: This is a brief clinical method, lasting one to four sessions, that addresses motivational struggles in behaviour change. The spirit of motivational interviewing is characterized by a counselling style in which a partnership is established between the client and counsellor that honours the client’s perspective and strengths.
Counselling is client-centred, empathetic and built on reflective listening that conveys the counsellor’s acceptance of the client. The client is viewed as possessing the resources and motivation for change and the counsellor’s task is to bring out that motivation in the client. Change comes about by focusing on the differences between current behaviour and important goals and values.
Research supports motivational interviewing as a cost-effective intervention for drinkers and drug users. It has been shown to provide benefits for alcohol and drug problems that are consistently better than no treatment or placebo, and that compare well with much longer, more costly treatment.
Self-help
Self-help and Minnesota model programs: There are a number of very popular treatment approaches that, while not possessing the same degree of empirical support for their effectiveness as the treatments described above, have nevertheless been associated with positive outcomes based on anecdotal reports.
Attendance in self-help support services such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA) is associated with benefits for many individuals, although how it works and the relative effectiveness of these services compared with other types of treatment have yet to be clarified.
AA principles are at the core of a 21- to 28-day residential treatment regime known as the Minnesota model that until recently was the dominant approach to substance abuse treatment. Many publicly funded and private rehabilitation centres in North America use this model to guide clients through AA’s 12-step program and to encourage them to make a lifelong commitment to AA and complete abstinence following treatment. Despite its popularity, few controlled trials have been conducted to determine the effectiveness of the Minnesota model.
Thomas Brown is head of research at Pavillon Foster Addiction Treatment Program in Montreal. Maurice Dongier is researcher at the Douglas Hospital Research Centre and psychiatry professor at McGill University in Montreal. Greg Graves is co-ordinator of best practices and training for the Canadian Centre on Substance Abuse. Greg can be reached at (613) 235-4048 or at www.ccsa.ca.
Despite improvements in education and training in recent years, the addictions workforce in Canada does not have a national professional body or a national set of standards and competencies to guide evidence-based delivery.
In Ontario, addiction counselling is not a regulated profession so virtually anyone can claim to be an addictions counsellor.
Further, Canada currently has no mechanism for knowledge transfer in the addictions field, as compared to the Addiction Technology Transfers Centers in the United States. These centres, established by the Center for Substance Abuse Treatment, which is part of the Substance Abuse and Mental Health Services Administration, have as mandates to identify, document and promote the most innovative and effective treatment strategies. They also help communicate the most successful strategies to substance abuse treatment professionals.
Evidence-based alcohol and drug abuse treatments are derived from the current best-practice evidence and take into consideration a patient’s values and needs.
On a clinical level, these treatments tend to be highly structured. Many clinicians are reluctant to adopt them because they are unwilling to relinquish the freedom to provide treatment as they see fit.
New alcohol and drug abuse treatments must also compete with entrenched, but scientifically unsupported beliefs. For example, current treatment recommendations based on empirical evidence have trouble gaining ground against the commonly held fiction that all alcohol or drug abuse clients require intensive care and lifelong commitment to abstinence.
As a result, the alcohol and drug client is often not presented with a range of treatment options matched to individual need.
The following are summaries of various psychosocial treatment approaches that scientific evidence shows are most effective.
It is important to emphasize that alcohol and other drug use problems encompass a broad range of substances, patterns of use and different degrees of severity. In general, the most intensive, lengthy and expensive services should be reserved for those with the most serious, chronic problems. Many people with less severe problems can benefit from brief treatment or can change on their own. This approach requires systematic screening, assessment and treatment planning.
Cognitive-behavioural treatment: There is reasonably good empirical support for the effectiveness of a number of cognitive-behavioural treatment (CBT) interventions in addressing specific alcohol or other drug use problems. Typically, the highly structured and efficient nature of CBT interventions and their reliance on manuals for guidance ensure treatment quality. Interventions are usually delivered in group settings and can be provided as stand-alone treatments or integrated into a more comprehensive overall treatment infrastructure.
The following brief overview of the conceptual and technical aspects of the “cognitive” and “behavioural” components of this model demonstrates the practical application of the overall approach.
Cognitive component: Cognitive therapy is based on the principle that destructive behaviours, emotions and thoughts can be modified or altered by learning new ways of thinking about oneself and the world. The theory is that thoughts and attitudes create moods and not events themselves: emotions are the way people interpret events.
Some common cognitive techniques include problem-solving, relaxation therapy, showing by example or modelling, changing distorted ways of thinking, challenging incorrect assumptions and replacing destructive thoughts with productive thinking.
Behavioural component: Behaviour therapy is based on the principle that you can replace undesirable behaviours by teaching clients new, more desirable ones. Behaviour therapy focuses on the client’s responsibility for change and the development of an effective, working therapeutic relationship. Some common behavioural techniques are social skills training, modelling, relaxation techniques, and self-management methods such as the rehearsal of new coping strategies.
CBT approaches
When the cognitive and behavioural components are blended into a single approach, treatment sessions are typically offered in a group setting, led by a treatment provider who models the acquisition of thinking and behavioural skills to the participants. Group members are given the opportunity to learn new skills by engaging in interactive exercises, discussion, individual and group work, case studies and role plays. Post-treatment maintenance sessions, ongoing monitoring and after-care help participants with continued behaviour change and new challenges. Emphasis in after-care is placed on assisting participants to learn to cope with high-risk situations, such as negative emotional states or peer pressure, through structured relapse prevention.
Structured relapse prevention: This cognitive-behavioural treatment typically involves about 10 to 12 individual or group sessions followed by maintenance sessions, although the length and intensity of service delivery can vary.
Program participants are taught to recognize and anticipate their high-risk situations for substance use — for example, when out socializing or feeling lonely — and to implement effective coping strategies to either avoid a slip or relapse, or to minimize its impact.
A recent review of the research on relapse prevention suggests that structured relapse prevention is most effective with alcohol problems, when several substances are being abused, and when offered in conjunction with pharmacotherapy. Other behaviour skills training approaches — often part of the treatments described above — have been effective in treating an alcohol or other drug use problem.
Community reinforcement approach: This approach acknowledges the role of a variety of social and environmental events and influences on an alcohol or other drug use problem, and focuses on the development of positive alternative resources in the social environment. The community reinforcement approach puts emphasis on changing important aspects of life, such as work, recreation and family involvement, to promote a lifestyle that is more rewarding than substance abuse.
A specific community reinforcement approach strategy that has been thoroughly researched involves a voucher-based incentive program to promote abstinence. An individual who has submitted substance-free urine samples receives vouchers that can be exchanged for retail items or services. Research suggests that the community reinforcement approach can reduce drinking (especially in combination with disulfiram or Antabuse, a drug that produces an unpleasant reaction to alcohol) and is particularly effective for treating cocaine abuse.
Behavioural marital therapy: This form of therapy is a highly structured series of 15 to 20 sessions for couples and is aimed at reducing substance abuse directly and through restructuring the dysfunctional couple interactions that are thought to reinforce continued alcohol or other drug use. Behavioural marital therapy attempts to engage the family’s support in the change process, and to alter couple and family interactions to reinforce sustained abstinence. There is consistent evidence for the effectiveness of this therapy compared with other family approaches, at least for couples in committed relationships. Improvements in other areas of couple interactions, such as domestic violence, have also been documented.
Brief intervention – motivational interviewing approaches
Brief intervention: Several recent studies have shown that treatment of shorter duration is as effective as that of longer duration.
This is consistent with a shift in public health policy away from the traditional belief that everyone with a substance abuse problem needs extensive treatment, toward a view of alcohol and drug problems as points along a risk continuum ranging from lower to higher severity.
Placing individuals along such a continuum during assessment allows for a cost-effective approach to treatment that reserves the most expensive treatment services for those with the most severe problems.
Motivational interviewing: This is a brief clinical method, lasting one to four sessions, that addresses motivational struggles in behaviour change. The spirit of motivational interviewing is characterized by a counselling style in which a partnership is established between the client and counsellor that honours the client’s perspective and strengths.
Counselling is client-centred, empathetic and built on reflective listening that conveys the counsellor’s acceptance of the client. The client is viewed as possessing the resources and motivation for change and the counsellor’s task is to bring out that motivation in the client. Change comes about by focusing on the differences between current behaviour and important goals and values.
Research supports motivational interviewing as a cost-effective intervention for drinkers and drug users. It has been shown to provide benefits for alcohol and drug problems that are consistently better than no treatment or placebo, and that compare well with much longer, more costly treatment.
Self-help
Self-help and Minnesota model programs: There are a number of very popular treatment approaches that, while not possessing the same degree of empirical support for their effectiveness as the treatments described above, have nevertheless been associated with positive outcomes based on anecdotal reports.
Attendance in self-help support services such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA) is associated with benefits for many individuals, although how it works and the relative effectiveness of these services compared with other types of treatment have yet to be clarified.
AA principles are at the core of a 21- to 28-day residential treatment regime known as the Minnesota model that until recently was the dominant approach to substance abuse treatment. Many publicly funded and private rehabilitation centres in North America use this model to guide clients through AA’s 12-step program and to encourage them to make a lifelong commitment to AA and complete abstinence following treatment. Despite its popularity, few controlled trials have been conducted to determine the effectiveness of the Minnesota model.
Thomas Brown is head of research at Pavillon Foster Addiction Treatment Program in Montreal. Maurice Dongier is researcher at the Douglas Hospital Research Centre and psychiatry professor at McGill University in Montreal. Greg Graves is co-ordinator of best practices and training for the Canadian Centre on Substance Abuse. Greg can be reached at (613) 235-4048 or at www.ccsa.ca.
