Why consider a collaborative addiction treatment relationship with someone who, by definition, is making very bad decisions? Addicts and alcoholics keep using and drinking and are often irresponsible in other ways. How could they meaningfully contribute to treatment decisions? Don’t they need to be told what to do, and be made to do it long enough for changes to last?
Not necessarily. At Practical Recovery we suggest that 1) supporting recovery is about engaging motivations that are more fundamental than the motivations to use or drink and 2) we best engage these motivations when we collaborate with (rather than confront, direct or “motivate”) our clients. To support this suggestion these articles will 1) review scientific findings about treatment, 2) place treatment in the larger context of recovery, 3) integrate 1 and 2 in order to propose a collaborative approach to treatment, and 4) describe how Practical Recovery, in operation since 1985, uses an entirely collaborative approach. Finally we will consider whether collaborative care is effective.
The Science of Addiction Treatment
The Handbook of Alcoholism Treatment Approaches: Effective Alternatives (3rd ed.), edited by Hester & Miller (Boston: Allyn & Bacon, 2003), may be the best single summary of the science of alcohol treatment. The handbook considers every randomized clinical trial (381 in all) available in the scientific literature through about 2000. Because of the substantial similarities between alcohol, other substance, and activity addiction (e.g., gambling) treatment, this book may also be the best single summary of evidence-based addiction (not just alcohol) treatment. The book lists treatments in order of efficacy, listing 18 which have sufficient support to be considered “evidence-based.” A complete table of treatments can be found here.
These 18 treatments can be grouped as follows. The names of the treatments are taken from the above table, where they are listed in order of efficacy. The groups below are not listed in order of efficacy. The treatments and groups are not entirely distinct. For instance, there are instructional and behavioral components to most treatments.
1) brief motivational counseling (brief interventions, motivational enhancement)
2) medications (naltrexone, acamprosate)
3) behavioral approaches–expanding and rewarding behaviors not associated with substance use: community reinforcement approach, behavioral self-control training, behavior contracting, marital therapy-behavioral,
4) instructional approaches–from a cognitive behavioral perspective (self-change manual, social skills training, cognitive therapy)
5) aversion therapy (nausea, covert sensitization, apneic)
6) miscellaneous (family therapy, case management, acupuncture, client-centered therapy)
What broader themes can be identified here?
The authors, primarily in the concluding sections of chapters 1 and 2, suggest that:
1) Some treatments work better than others, but no one treatment is clearly superior for all individuals. They list 81 treatments that cannot be considered evidence-based (however, not all these treatments have been sufficiently studied).
2) The number of efficacious treatments seems to be increasing (18 in this edition, only 13 in the 2nd edition, published in 1995).
3) There is a range of approaches to treatment, including brief approaches (which are valuable because of the high early dropout rate in addiction treatment).
4) The efficacious treatments hint at underlying mechanisms of change, such as motivation enhancement, the changes produced by medications, an improved capacity to cope, improved relationships and improved environments.
5) Treatment programs should offer a range of treatment options (drawn from treatments that are evidence-based).
6) It is time to discontinue using approaches, such as confrontation, which are not efficacious (“confrontational approaches have one of the most dismal track records in outcome research…with not a single positive study [from 12 studies conducted] (pg. 34).” Unfortunately, however, “the negative correlation between scientific evidence and treatment-as-usual remains striking, and could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy (pg. 41).”
7) Different individuals are likely to respond to different approaches. Unfortunately, research has provided little guidance about how to match individuals to treatment. Some authors have proposed that pre-treatment assessment be conducted by independent evaluators (not affiliated with any treatment program). However, “clients themselves are important resources in choosing from the menu of options. They know a great deal about themselves and their own level of motivation for different approaches to change (pg. 11).”