Reid K. Hester and William R. Miller, editors
Reviewed by Marty N.
The editors and authors of this Handbook of Alcoholism Treatment Approaches set themselves the task of comparing the variety of treatment approaches in the alcoholism field to see which ones are more effective than others. Toward this end, they excluded studies that consist basically of anecdotal evidence and included only studies that used a control or comparison group -- the same basic method used in all scientific research. They reviewed some 211 published studies meeting this criterion. Their conclusion is one that ought to shake the treatment industry to its foundations: the substance abuse treatment methods that are in the most widespread use today are those for which there is the least scientific evidence of effectiveness. The dominant treatment paradigm has little or no scientific basis and there is much evidence that its most important product is failure. If someone set out to design a system to be as ineffective as possible, it would closely resemble what we have today.
This is an important book worth reading cover to cover. In this review I want first to outline the content of the work, to give the general reader an idea of its findings and arguments. In the second section I will try briefly to draw some lessons from the work for the theory and practice of our alternative self-help recovery organization.
The authors classify the variety of current treatment approaches into eleven broad types. Based on the outcomes of the published controlled studies, they rank these modalities from the most effective to the least effective as follows:
Methods that have consistently positive or mixed but predominantly positive outcome studies: brief intervention; broad-spectrum skills training; marital/family therapy; cognitive-behavioral methods, and aversion therapies.
Methods with equivocal results: Antabuse and psychoactive drugs.
Methods with consistently or predominantly negative outcome studies: Psychotherapies. Confrontational methods.
And finally, lowest on the ladder of scientifically demonstrated effectiveness, the so-called standard methods used almost universally in the US treatment industry. The standard approach used in the US treatment industry is the "Minnesota Model." This "generic" approach consists of the 12 Steps of Alcoholics Anonymous augmented by group psychotherapy, educational lectures and films, and counseling, frequently of a confrontational nature. Controlled studies of this approach almost universally fail to find any advantage over untreated or alternatively treated groups. Yet this approach is unquestionably the foundation of the standard treatment model in the United States.
As the authors note, in the US treatment industry today there is an enormous gap between science and practice. If one had deliberately designed the treatment industry to be as ineffective as possible, one would have created the present system.
The conclusion the authors draw from their survey of different treatment methods is that no one approach -- least of all the dominant Minnesota Model -- is likely to be effective for most alcoholics. The basic assumption of the dominant paradigm, that all alcoholics should be treated the same way, is fundamentally flawed. The authors' objective is to move treatment away from a single model, "operating as if it were the only complete and accurate understanding of alcohol problems and their etiology," toward "a range of effective alternatives." (p. 8). They wish to present the clinician, and thus ultimately the patient, with "a variety of promising tools to use in working with different types of alcohol problems and individuals." (p. 8).
The editors call their strategy "informed eclecticism." Informed eclecticism seeks a position beyond the hollow dogmatism that only one method works, and also beyond the naïve optimism that everything works equally well. The clinician's attitude should be one of openness to a variety of approaches, guided by scientific evidence. Four principles are basic to informed eclecticism:
(1) No single approach to treatment is superior for all individuals. The "state of the art" is not a single method, but "an array of empirically supported treatment options."
(2) Treatment programs should offer a variety of different treatment approaches. The program should have a menu of options.
(3) Different types of people respond best to different approaches.
(4) The art of the clinician lies in matching the right treatment to the right patient the first time around. Doing so increases efficacy, avoids waste, and improves staff morale.
The authors are keenly aware that there are many obstacles in the way of their approach. Existing treatment programs show almost no real variety and alternatives are almost absent. They write that their own community (Albuquerque) has more than 50 different programs, but most of them are "virtual carbon copies of one another." (p. 9). Clear criteria for distinguishing among types of patients and for matching treatment to patient remain to be developed. Irrational motives, economic forces, and institutional inertia often override the patient's best interest. People doing intake and patient evaluation are often the least trained staff members, and frequently have blinding biases toward the particular approach that worked for them.
The client's welfare ought to be the overriding criterion. "It is clear that inappropriately matched clients can be harmed, faring worse than if they had received no treatment at all. Individuals matched to the right treatment the first time can be spared years of needless suffering and impairment. A common concern for those who suffer from alcohol problems should, in the end, be the most persuasive ground for agreement and cooperation toward a comprehensive system of informed eclecticism." (p. 10)
After the groundbreaking introductory chapters, the Hester/Miller handbook settles down and presents what amounts to a training manual for clinicians, from screening methods and intake procedures through the various supported modalities of treatment and ending with post-treatment follow-up and evaluation. Here are some of the highlights that caught my eye.
The chapter on evaluation of alcohol problems by Miller, Westerberg & Waldron examines some of the basic measurement technology used in the treatment industry and finds it wanting. The authors remark that a diagnosis of "alcoholism" was once considered sufficient to commence treatment. But now "a more complex contemporary understanding has evolved" which sees many degrees and shades of alcohol problems. Specific tests have evolved to detect and measure these varieties. However, those instruments that have scientific evidence to support their efficacy are very little used, whereas the tests and checklists in common use have little or no scientific underpinnings.
Like diagnosis, evaluation of program efficacy is rarely done in a conscientious manner, or at all. When outcomes are studied, it is sometimes found that programs believed to be effective actually increase rather than decrease the problem. Outcome studies also torpedoed another cherished belief of the treatment industry, namely that expensive inpatient care is more effective than the much cheaper outpatient treatment (p. 81). Indeed, the editors consistently found an inverse correlation between treatment cost and evidence of efficacy (p. 13).
The authors are too polite to say so but one conclusion that can be drawn from this chapter is that the standard model of alcoholism treatment in this country operates basically with its eyes closed. It knows neither what it is doing nor what it has done.
An outstanding chapter is the contribution of William R. Miller titled "Increasing Motivation for Change." Everyone agrees that client motivation is a key issue in recovery. But there the agreement stops. In the traditional view, motivation or the lack of it ("denial") is rooted in the alcoholic's character structure or personality. Only when that structure is shattered by some disastrous event ("hitting bottom") or when divine intervention removes its defects can motivation to get sober emerge.
Yet in the past 30 years this paradigm has begun to crack. Several findings contributed to undermine it. More alcoholics became sober before landing in the gutter, and the idea arose that it might be possible to "raise the bottom" by appropriate intervention. It was also recognized that the alcoholic's social environment was frequently intertwined with the problem, and that changes in the environment produced changes in motivation. Another nail in the coffin of the "character" paradigm of motivation was the accumulation of negative findings concerning an "alcoholic personality." Finally, studies comparing different treatment styles and personalities found that some counselors were very effective in motivating clients to complete treatment, whereas others "lost" a high proportion of their patients. Studies showed that a small number of staff members in a given center produced the great majority of patient dropouts. The evidence is that patient motivation is not so much a factor of the patient's personality as of the counselor's. The new approach to client motivation is that patient motivation is not found but made. The therapist need not wait for the drinker to "hit bottom" -- or, worse, encourage the patient's descent. The therapist, according to Miller, has many tools available to enhance the client's motivation, and a large part of the professional's skill consists in using them effectively and in a timely manner. Based on hundreds of research studies examining various approaches to enhancing client motivation, Miller identifies six common elements of an effective motivational toolkit. They are:
Personal feedback. Studies showed that drinkers who were given live personal feedback about their drinking situation, even very briefly, did significantly better than those who merely heard lectures or saw films.
Personal responsibility. Because this is such an important element in the self-help process I want to quote the author at some length.
"A second common element in effective motivational intervention is an emphasis on the client's personal responsibility and freedom of choice. Rather than giving restrictive messages (You have to, can't, must, etc.), the counselor acknowledges that ultimately it is up to the client whether or not to change: 'No one can change your drinking for you, or make you change. It's really up to you. You can choose to keep on drinking as you have been. You can choose to make a change. Even if I wanted to, I can't decide this for you.' In addition to being therapeutic, this message is quite simply the truth. A therapist cannot alter the client's ultimate personal responsibility and choice.
"Why is this message helpful in triggering change? A strong and consistent finding in research on motivation is that people are most likely to undertake and persist in an action when they perceive that they have personally chosen to do so. One study, for example, found that a particular alcohol treatment approach was more effective when a client chose it from among alternatives than when it was assigned to the client as his or her only option . […] Perceived freedom of choice also appears to reduce client resistance and dropout [….] When clients are told they have no choice, they tend to resist change. When their freedom of choice is acknowledged, they are freed to choose change." (p. 93).
Advice. A simple and effective method is for the treatment professional, typically a physician, to advise the patient to act.
Real Choice. It is pointless for the therapist to try to mobilize the client's personal responsibility unless there are actually alternatives available for the client to choose from. The counseling methods that work most effectively are those that offer a real choice for the patient to make. The key is to get the client "actively involved in choosing his or her own approach." (p. 94).
Empathy. Studies show that the most effective counselors are those who maintain a client-centered approach. They are felt to be warm, supportive, sympathetic and attentive. Counselors who have these qualities are effective regardless of whether they are themselves persons in recovery. By contrast, counselors with a confrontational, harsh, or punitive style tend to score poorly in long-term outcome studies.
Hope. Motivation ultimately depends on the client's belief that improvement is possible, that is, on the ignition of hope. Fear of negative consequences -- the mainstay of the traditional methods -- is rarely sufficient. There must be a belief that it is within the client's power to change.
Miller and his colleagues have attempted to assemble these elements into a treatment program they call Motivational Interviewing. The basic idea of this approach is to facilitate the client's inner struggle between addiction and recovery and to empower the client's own healthy resources. Toward that end, the counselor encourages the client to select and to construct a personal treatment plan, because research shows the unsurprising fact that "clients tend to be more committed to a plan that they perceive as their own, addressing personal concerns." (p. 95). "[R]esearch suggests that treatments chosen by a client from among alternatives are more likely to be adhered to and effective. The choice process increases the client's perception of personal control and enhances motivation for compliance. … [I]ndividualized strategies lead to increased positive outcomes." (p. 100). Indeed, Miller goes so far as to say: "There is also reason to believe that clients have wisdom about what is most likely to work for them."
An authoritarian approach by the therapist typically backfires. Miller argues persuasively that client "denial" in the treatment setting is unnecessary and is primarily the result of hapless therapy.
A prominent example is the issue whether or not the client must accept the label of "alcoholic." Treatment programs modeled on the first step of Alcoholics Anonymous often begin with a power struggle between client and therapist over acceptance of the "alcoholic" label. Miller says that research finds no strong relationship between self-labeling and outcome. "Many treatment failures are quite willing to accept the label 'alcoholic,' and many people respond favorably to treatment without ever calling themselves alcoholic." (p. 95). The principal outcome of this traditional power struggle is the counterproductive one of mobilizing the client's denial and entrenching resistance. It would appear that the seeds of failure in the standard model treatment program are frequently planted with the very first step.
Closely related to Miller's important chapter on motivation is the chapter on Relapse Prevention by Linda Dimeff and G. Alan Marlatt. This begins with the memorable words: "The most common treatment outcome for alcoholics and addicts is relapse." (p. 176). After everything that has been said before, this should not be surprising. Since the standard paradigm of the treatment industry lacks scientific validation and consists almost entirely of tools and modalities that are demonstrably ineffective if not counterproductive, it would be astonishing if the primary product of the process were anything but failure.
The only dispute is about the magnitude of the debacle. Relapse figures run from about two thirds at 90 days (p. 176) to more than 90 per cent over longer periods (p. 92). The only astonishing thing about these numbers is that there is not more of a public outcry for reform of the industry.
I will not try to summarize the Dimeff/Marlatt Relapse Prevention approach in any detail. The key theme is that clients are most successful at avoiding relapse if they emerge from treatment empowered and equipped to heal themselves, rather than dependent on some outside contingency. In the authors' words, relapse prevention "is most successful when the client confidently acts as his or her own therapist following treatment." (p. 177). The client best avoids relapse when he or she is viewed as the rightful agent of change. Client motivation, largely a function of self-determination in choosing the treatment methods, is key, as is equipping the client "with the necessary skills to act as his or her own future therapist." (p. 178). The approach works best when "tailored to the individual." (192).
There are a number of other chapters that explore treatment alternatives to the standard paradigm. I will not take the space to discuss them here. However, at some point the gist of these chapters should be added to the LifeRing sobriety toolkit (Handbook of Secular Recovery, Ch. IV) and made more widely available to our readership.
What does the Hester/Miller Handbook teach us about the place of the LifeRing S.R. approach in the spectrum of contemporary treatment modalities?
First of all, the book validates the feeling that so many of our members have had, that the standard 12-Step-based treatment programs which they were forced to endure were ineffective at best and counterproductive in many cases. So many who participate in our groups report that they managed to stay sober despite their treatment program, not because of it. The Hester/Miller book supplies evidence and explanations to corroborate the private pain that many felt and still feel from this experience.
Secondly, the publication of this book, and the number and prominence of its contributors, is further evidence that the ruling paradigm is eroding. The editors and authors include a number of prominent and well-placed senior names in university, clinical and government settings, as well as young graduate students joining the ranks (see endnote). The book confirms what the experience of our LifeRing Secular Recovery groups in the San Francisco Bay Area in the past few years has demonstrated. More and more treatment programs exist that really care about what works, that are open-minded, that allow their methods to be influenced by scientific research, and that believe in offering their clients a choice of support groups.
The third conclusion I draw from the Hester/Miller Handbook is that the LifeRing S.R. approach to the central therapeutic issues of recovery is a sound and forward-looking one.
Our own Handbook (Handbook of Secular Recovery, LifeRing Press 1999) advocates an individualized, constructivist approach that maximizes the recovering person's own motivation. We say that each recovering alcoholic has the ability, with group support, to develop a personalized recovery plan that works for that individual. We say that each person has the wisdom to do this. We say that when people develop their own recovery plans, they are more deeply committed to their recovery. We say that when people are encouraged to act as their own therapist, they can more readily modify their program to meet contingencies and they will better resist relapse.
All of these points, which our own Handbook merely asserts in the form of a manifesto, find corroboration in the Hester/Miller Handbook. Published research with controlled trials demonstrates that the cardinal therapeutic principles of the LifeRing S.R. approach are valid and effective ones. Hester and Miller's "enlightened eclecticism" is a good description of the principles of choice and diversity of treatment tools that we so eminently embody.
Reid Hester is director of an alcoholism clinic and a research associate professor at the University of New Mexico. William R. Miller is professor of psychology and psychiatry at the University of New Mexico. Among the contributing authors are prominent academics, clinicians and treatment administrators, including Prof. David Abrams of Brown University, John Allen, chief of the Treatment Research Branch of the National Institute on Alcohol Abuse and Alcoholism, Ned Cooney, director of the VA Medical Center in New Haven, Prof. Richard Frances, the chair of the Council on Addiction Psychiatry of the American Psychiatric Association, Richard K. Fuller, director of Research at the National Institute of Alcohol Abuse and Alcoholism, Prof. G. Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington, Prof. Sheldon I. Miller, chair of the department of psychiatry at Northwestern University Medical School, Lisa Rone, chief resident in psychiatry at Northwestern Memorial Hospital in Chicago, and others.
Quotes from the book:
The negative correlation between scientific evidence and application in standard practice could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy. (p. 33)
There is no tried and true, 'state-of-the-art' treatment of choice for alcohol problems. Rather, the state of the art is an array of empirically supported treatment options.
Controlled studies of group or individual psychotherapy for alcohol problems have yielded negative findings with remarkable consistency, often despite the predictions of investigators [….] Exploratory psychotherapies have accumulated one of the lowest [efficacy scores] of any treatment modality. (p. 27)
Confrontational counseling styles have enjoyed particular popularity in U.S. alcoholism treatment. Yet confrontational approaches have failed to yield a single positive outcome study. (p. 27)
Although Alcoholics Anonymous (AA) is widely recommended by U.S. treatment programs, its efficacy has rarely been studied [….] Only two controlled trials were found in which AA was studied as a distinct alternative, both with offender populations required to attend AA or other conditions, and both finding no beneficial effect.
There are literally hundreds of published instruments for use in assessing alcohol problems. For most of these, even basic psychometric information is lacking … (p. 68)
One's own professional hunches about what works and what doesn't are well known to be fallible. One outcome evaluation, for example, showed that a 'prevention' program, about which both teachers and students were highly enthusiastic, actually increased students' use of drugs. Though we would like to believe that it isn't so, 'therapeutic' interventions similarly can be ineffective or even detrimental. (p. 81)
Fifty years of both psychological […] and longitudinal studies […] have failed to reveal a consistent 'alcoholic personality.' Attempts to derive a set of alcoholic psychometric personality subtypes have yielded profiles similar to those found when subtyping a general population […]. That is, alcoholics appear to be as variable in personality as are nonalcoholics. Studies of character defense mechanisms among alcoholics have yielded a similar picture. Denial and other defense mechanisms have been found to be no more nor less frequent among alcoholics than among people in general. […] There was simply no support for the view that alcoholics in general come into treatment with a consistent set of personality traits and defenses. (p. 90)
Lectures and films about the detrimental effects of alcohol on people, in general, seem to have little or no impact on drinking behavior, either in treatment or in prevention settings. Personal feedback of ways in which alcohol is harming the individual, however, does seem to have a strong motivational effect. (p. 93)
A strong and consistent finding in research on motivation is that people are most likely to undertake and persist in an action when they perceive that they have personally chosen to do so. One study, for example, found that a particular alcohol treatment approach was more effective when a client chose it from among alternatives than when it was assigned to the client as his or her only option . […] Perceived freedom of choice also appears to reduce client resistance and dropout [….] When clients are told they have no choice, they tend to resist change. When their freedom of choice is acknowledged, they are freed to choose change. (p. 93).
There is also reason to believe that clients have wisdom about what is most likely to work for them. (p. 100)
This review appears under the title "Historical Roots and Antecedents of the LifeRing Approach" in Presenting LifeRing Secular Recovery: A Selection of Readings for Treatment Professionals," LifeRing Press 2000.