Substance-abuse treatment used to bring to mind a no-holds-barred, in-your-face engagement, such as the notoriously confrontational rap groups of the ’70s and ’80s, often led by tough former addicts, or the Johnson intervention, in which family members and close friends came together to overwhelm the abuser’s denial with stories of the harm done and to insist on treatment. It was widely accepted that the best therapists for addicts were former addicts. Many thought intense, confessional, 12-step programs, such as Alcoholics Anonymous (AA), were necessary adjuncts to any treatment. Long-term inpatient treatment, which removes addicts from the stresses of everyday life, was considered the treatment of choice, for those who could afford it, and still is even today.
While treatment approaches to substance abuse have continued to evolve, a clear, new picture of what works in addiction treatment hasn’t emerged. Clinicians and the public continue to rely on a hodgepodge of old and new approaches, unsure what works when. Fortunately, two recent landmark reviews of the research on adult substance-abuse treatment give us a much more coherent picture of what the literature tells us about effective substance-abuse treatment.
Psychologist Rudolf Moos of the Department of Veterans Affairs and Stanford University, widely considered the dean of researchers in substance-abuse disorders, prepared one summary of the research. A panel of experts in substance-abuse treatment and psychotherapy research, including Peter Nathan of the University of Iowa, Barbara McCrady of Rutgers University, and myself, assembled the second. This was part of a larger project to assess principles of change in treating a wide range of clinical problems.
For their reviews, the researchers combed through hundreds of studies to distinguish which assumptions about how to treat substance-abuse disorders are supported by research and which are empirically unfounded. So what, then, do these reviews tell us about what’s effective in the treatment of substance-abuse disorders?
* The core processes of change for overcoming substance-abuse disorders are the same whether addicts participate in psychotherapy self-help programs, or recover without treatment. For instance, Tom, who wants to reduce his drinking on his own, Harry, who’s in AA, and Steve, who’s in outpatient therapy with a therapist who uses Motivational Interviewing, experience more or less the same process of change. Each was initially unwilling to acknowledge his problem with alcohol; each moved through a process of facing the detrimental effects of alcohol, learning more about its dangers, discovering ways to diminish his exposure to situations in which he was likely to drink, and figuring out ways to say “no” when offered drinks. Each was mired in negative cycles with their families around their alcohol use, and each received considerable support from family members when he stopped drinking. All three negotiated these processes that led to their successful recovery.
* Not only are the processes of change the same across groups, so are the stages of change. The research summaries highlight the work by psychologists James Prochaska of the University of Rhode Island and Carlo DiClemente of the University of Maryland, Baltimore, identifying the predictable stages of change. Although research is beginning to show that stages of change apply in other disorders, most of the research has been done in substance-abuse disorders.
In the first stage (precontemplation), addicts typically don’t recognize their problems with substances. In the words of singer Tom Waits, “The piano has been drinking, not me.” In the next stages, they recognize the problem, but aren’t ready to change (contemplation), they take action to try to change (action), and finally they work to maintain the changes they’ve made (maintenance). Clients typically move back and forth among the stages during treatment. The most effective intervention strategies fit the client’s stage of change: giving the client “homework” works best during the action stage, while psychoeducation and insight therapy are appropriate in the “precontemplation” stage.
The stages of change point to the special role motivation has in treating clients with substance-abuse disorders. The research reviews suggest that overcoming an addiction to substances requires greater motivation than do many problems. Motivation is important for another reason, too: in substance-abuse disorders, clients are more often mandated into treatment by judges, employers, or family members than with most other problems, making motivation a key ingredient in treatment. All the therapies demonstrated to be effective for treating substance abuse either explicitly focus on increasing motivation (for example, William Miller’s Motivational Interviewing) or indirectly raise motivation (as in 12-step programs).
* Intense treatment of short duration is less successful than treatment that extends over time with little interruption. In a study of 20,000 Veterans Affairs (VA) patients, Moos and his colleagues found that patients who received care over longer periods stayed sober longer and functioned better than those in treatment for a shorter period of time. The powerful physiological, psychological, and interpersonal effects of addictive substances heighten the likelihood of regressing back into abuse. Longer, more continuous, treatments help overcome the enormous tendency to fall into recidivism.
In a survey of 3,000 VA patients treated for alcoholism, Moos and colleagues found that, no matter what the treatment, only about 20 percent maintained abstinence at a one-year follow-up. All the treatments that have been demonstrated to be effective in reducing substance abuse include a major focus on the maintenance of change. Programs that involve clients over long periods of time, such as AA (which finds a role for individuals in treatment even years after their abuse has ended), are most effective.
* Therapy relationship factors are crucial in treating substance abuse. The research strongly indicates that therapeutic alliances, whether between client and therapist or client and group, are potent curative factors in treatment. When the alliances are strong, clients are likelier to remain in treatment and have better outcomes, both in terms of substance abuse and general functioning. Substance-abuse treatment requires the same strong relationships as any therapy issue.
* Contrary to stereotypes, high levels of confrontation seldom result in better treatment outcomes. William Miller and his associates found that interventions that include listening and restructuring comments elicit positive response from clients, while highly confrontational interventions elicit argumentative responses. A similar pattern emerges over the long term. The multisite Drug Abuse Treatment Outcome Study (DATOS) of more than 2,500 clients found that clients’ ratings of the rapport with their therapists were strongly related to their commitment to treatment. If clients trusted their therapists, they were more likely to engage in treatment in ways that promoted change. There’s no evidence within the research on substance abuse that intense confrontation has positive effects. Furthermore, the research shows that substance-abuse clients who also have personality disorders and/or anger management problems–those often thought of as most in need of a confrontational approach–respond particularly poorly to high levels of confrontation, frequently becoming oppositional or dropping out of treatment.
Research also shows that high levels of confrontation are not as effective in getting clients into treatment as are social support and a quiet, firm attitude toward the substance abuse. In a study comparing methods of engaging unmotivated alcohol abusers, William Miller and his colleagues found that supportive partners who positively reinforced not drinking, increased positive communication, engaged in interests outside the relationship, and encouraged professional treatment had greater positive impact on engagement than the Johnson intervention. Whereas only 22 percent of alcoholics engaged in treatment after the Johnson intervention, 64 percent engaged with the latter approach.
* Social support is critical to overcoming addiction and maintaining change. Addicts with supportive social networks, including family members, are more likely to achieve success. Their success is monumentally affected by those around them. According to Moos, “Formal treatment can be a compelling force for change. But it typically has only an ephemeral influence. In contrast, relatively stable factors in people’s lives, such as informal help and reliable social resources, tend to play a more enduring role.” In therapy, this translates into helping family and friends actively support the changes occurring, through participation in self-help groups as an adjunct to therapy and by helping clients find new support networks that don’t support the substance abuse. Studies by Timothy O’Farrell of Harvard Medical School and William Fals-Stewart of the State University of New York at Buffalo have demonstrated that couples therapy in substance abuse achieves better outcomes with the abuse and improves marital satisfaction.
* Therapists with a personal history of overcoming substance abuse are no more effective than those without such a history. Both groups fared equally well across the treatment studies. However, research does show that patients treated by those with a clear background in treating addictions have better outcomes than those treated by nonspecialists.
* No one substance abuse treatment is more successful than others. Among the effective treatments identified by the research review are motivational enhancement therapies, cognitive-behavioral treatment, and the 12-step treatments based on the philosophy of Alcoholics Anonymous. Effective treatments are directive and active, provide insight into the harmful nature of addiction, help build life skills, and strengthen important relationships. The research shows 12-step programs to be effective, but no more so than other directive approaches to treatment, such as Motivational Interviewing. We have yet to see a nondirective treatment shown to be effective.
Perhaps the most important message from these two research reviews is that the general principles of effective therapy still apply for substance-abuse disorders. When we encounter therapies that rely on radically different principles of change, we need to remain skeptical until they’re demonstrated to be effective, no matter how charismatic the treatment proponents.
Jay Lebow, PhD, is a former contributing editor to the Psychotherapy Networker and clinical professor at Northwestern University. He’s also senior therapist and research consultant at the Family Institute at Northwestern University.