Best Practices : Substance Abuse Treatment and Rehabilitation

d) Other Treatment Approaches

Brief motivational counselling is based on the work of Carl Rogers (Miller, 1983) and typically involves one to three sessions of motivational feedback and advice based on individualized assessment. The method has been systematically evaluated with drinkers only and Holder et al. identified nine relevant studies. They concluded that there was good evidence for the effectiveness of this approach and it came third when ranked with 23 other modalities. However, Finney and Monahan's index score was negative for this type of treatment (-4) and it came 10th when 24 modalities were ranked on this index. One explanation for these differences is that Finney and Monahan's review took account of the fact that most trials of brief motivational counselling compared this intervention with weak alternatives such as no treatment or waiting list controls, or with treatment for which there was no evidence of effectiveness. Brief motivational counselling appeared less effective when compared with more potent interventions. However, in the large US study, Project MATCH, brief motivational counselling demonstrated a level of effectiveness similar to two more intensive treatments, but the results of Project MATCH were not available at the time that the Finney-Monahan review was published (see section 2).

Education about the effects of alcohol and other drugs is often a component of addiction treatment. However, as indicated by Holder et al., there is no evidence that education per se influences post-treatment behaviours. The Finney-Monahan index score was also quite negative for education (-11). However, education can increase knowledge and change attitudes, and this may be a prerequisite to behaviour change in some types of substance users.

Hypnosis was considered ineffective or unproven by both Holder et al. and by Finney and Monahan.

Residential milieu therapy is defined as an intensive exposure to a therapeutic environment. Under this category, Holder et al. and Finney and Monahan consider halfway house settings, residential treatment using the Minnesota model approach and therapeutic communities. As Holder et al. note, communal residential living is itself a therapeutic milieu, whether or not there is also a structured treatment program. Residential milieu therapy was found to be unproven or ineffective by Holder et al. and by Finney and Monahan.

Minnesota model. As noted by Landry (1995), residential milieu therapy is one component of what has come to be called "traditional" or "Minnesota-model" alcoholism treatment in the United States. Other components of this model include the promotion of a "disease model" of alcoholism and the need for complete abstinence, the 12 steps of AA, use of group therapy and the heavy involvement of "recovering" counsellors. Uncontrolled studies show that participation in these treatment programs is associated with reduced drinking and drug use and other positive outcomes. One controlled study in Finland also showed positive results (Keso and Salaspuro, 1990). However, it has not been convincingly demonstrated that the benefits of this approach are tied to the residential milieu component. Rather, it appears that the residential phase is less important than the provision of a continuum of services, especially continuing care and post-treatment involvement in AA.

Therapeutic community. One form of residential milieu therapy used in the treatment of opiate and other drug users is the therapeutic community. These communities were prevalent in Canada during the 1970s, but many have since been closed. However, there are still several well-established programs in Quebec (Portage and Patriache) and in Ontario (Stonehenge). Many therapeutic communities are rather rigidly run and have a "militaristic" culture that relies heavily on the use of confrontation, but there are many variations (Landry, 1995). Smart (1993) considers evidence for the effectiveness of therapeutic communities to be rather elusive. Although those who complete the required period of residence (one year or more) tend to do well after leaving, dropout rates tend to be very high (up to 90%). Early dropouts usually relapse to drug use, but there is evidence of good outcome for those who stay for at least one third of the required time (Landry, 1995).

Alcoholics Anonymous is not really a treatment for alcoholism but a community resource for those wishing to stop drinking. Uncontrolled studies of AA have shown that people who affiliate with AA tend to stop drinking and find that their lives improve in many respects (Emrick et al. 1993). However, evaluating AA alongside professionally delivered interventions presents problems and perhaps should not be done. AA is not a fixed form of "treatment" and people are free to participate in different ways. Some go a few times and then drop out. Others go more often, but do not actively participate in meetings or "work the program." It is possible that both dropouts and passive participants gain some benefit from the AA experience, but this has not been adequately researched. Only a minority of those ever exposed to AA seem to become full, active members over a long period and consistently "work" all the steps. There is evidence that certain types of people may be more likely to fully affiliate with AA than others (Ogborne and Glaser, 1981; Emrick et al., 1993), but more research is needed and some studies may no longer be relevant given the current range and diversity of AA groups. However, it seems likely that AA would appeal to those who have experienced serious alcohol-related problems and who can accept the need for abstinence and the "alcoholic" label.

When professionals refer clients to AA on the assumption that they will benefit from such referrals, it is reasonable to ask about the outcomes of these referrals and to compare these outcomes with those achieved by other means. Holder et al. identify two studies in which alcoholics were referred to AA by the courts (Ditman et al., 1967 and Brandsma, Maultsby and Walsh, 1980). One study in which subjects in an employee assistance program (EAP) were required to attend AA under threat of job loss has also been reported (Walsh et al., 1991). In no case did the results favour AA and this should discourage courts and employers from mandating AA attendance. However, Project MATCH (1997) included a 12-step facilitation intervention and results showed that those who were encouraged to go to AA did as well as those provided with other interventions. Finney and Monahan did not compute an index score for studies of AA.

There appears to have been no significant research studies of Narcotics Anonymous or other self-help groups for people with substance abuse problems.