What’s the Most Successful Treatment for Alcohol Abuse?

By: Garry Cooper, LCSW
 

 

In the1990’s, Project Match, the largest study of alcohol treatments ever conducted, hoped to find out whether 12-step, cognitive behavioral (CBT) or motivational enhancement therapy (MET) worked best, and for whom. Researchers are still digesting the massive amounts of research and arguing (and occasionally despairing) over the methodology, but the most solid conclusion of the $28 million study seems to be that all three treatments had roughly equal, moderate success rates. Project Match did however help break the virtual hegemony of the 12-step approach.

If Project Match gave few definitive answers, it provided many clues, along with tantalizing evidence and suggestions for further research and treatment refinements. In a lively 1999 overview of Match’s treasure trove, Mike Ashton, editor of the British journal Drug and Alcohol Findings, says in the journal’s inaugural issue that the most important accomplishment may have been “to deconstruct alcohol ‘treatment’ into more mundane human virtues – the desire to get better, supportive human relationships, competence, friendly persistence and the provision of a culturally endorsed lifeline for a culturally defined problem.”

Match’s 12-step therapy was adapted from the familiar AA program, but wasn’t the same, a point which many people seized upon to insist that Match did not provide a fair assessment of 12-step’s effectiveness. In 12 weekly sessions, clients were encouraged to accept that they suffered from the disease of alcoholism and to begin working through AA’s twelve steps. They were also encouraged to join AA. As for CBT, the 12 weekly sessions basically helped clients to recognize high risk situations and to avoid them well ahead of time. They were also taught to view drinking as a maladaptive response to life’s problems, to reframe how they viewed their problems, and to reconfigure their thought patterns to avoid pitfalls and orient themselves toward healthier solutions. MET, in four sessions spread out over the 12-week treatment period, focused on helping clients (and their families, who were encouraged to attend the first two sessions) discover their own intrinsic desire to change.

Ashton’s article highlights two significant results from Project Match’s long-term findings, which looked not just at the three treatments over three active 12-week treatment phases but at how well they worked as aftercare treatments over the course of a year. Overall, angry clients responded better to MET, and clients who had strong pro-drinking networks responded better to 12-step. This latter finding, Ashton says, suggests both that dependent people may do better with 12-step, and that 12-step’s effectiveness may be due to the fact that it substitutes an anti-drinking network for a pro-drinking one.

Project Match also shed light on another client characteristic associated with outcome, says Ashton. The client’s readiness to change—what the client brought into treatment—seemed an important predictor. It’s worth nothing that the readiness to change model is an important part of the theoretical basis for MET. That change model, developed by James Prochaska and Carlo DiClemente, describes change as a five part process. In precontemplation, people have not yet considered change. These are the people who seldom show up at therapists’ offices and if they show up for addiction treatment, it’s a safe bet they’re there under court order or some other ultimatum. Next comes contemplation, when people begin to acknowledge they have a problem and start to think about changing. In determination, they consciously decide to take action to change. Following that comes action, which lasts from about three to six months, after which they enter maintenance, in which they consolidate gains and continue putting into action their new thoughts and behaviors. There’s also a sixth phase, relapse, which starts the cycle all over again, beginning with pre-contemplation. So it seems that the alignment of treatment with the contemplation stage is the most propitious scenario for success. MET deliberately focuses on helping clients identify their own motivation for change. A bedrock assumption is that the therapist never challenges the client’s resistance, but instead rolls with it. Challenging resistance hardens it. Only by avoiding confrontation can the therapist help clients identify their own internal motivation for change. Inherent in the MET model is the assumption that the client can best set the terms and agenda for change and define progress. It comes as no surprise then, then MET is more likely than 12-step or even CBT to accept controlled drinking, and not just complete abstention, as a valid treatment goal. As for 12-step, it may be that highly dependent people are least likely to tune into their own motivation for change, and for this reason, the firmer structure of 12-step, and the idea that one is powerless and must give oneself up to a higher power, may supply the necessary support to get clients into contemplation.

It’s important to note that all three treatments had about the same significant success rate of about 30 percent. In the end, it may be that successful treatment of alcoholism relies on some of those same ineffable factors that therapists and researchers have increasingly come to recognize as key ingredients of positive outcome: a therapist/client match characterized by a positive alliance, and frequent feedback from clients to therapists not just about how well or poorly the client is doing but about how the client feels the therapy is working. That 30 percent figure, incidentally, is about the same as the positive effect of placebo in studies of many different therapies and medications for different disorders. Like substance abuse treatment, placebo’s positive effect may well be due to clients’ expectations, clients’ readiness to change, and a supportive environment with steady monitoring.

Resources

Ashton, Mike (1999). Drug and Alcohol Findings, 1(1), “Project match: unseen colossus,”, 15-22. Note: The article is also online at https://www.commed.uchc.edu/match/pubs/PDF/Findings_UnseenColossus.pdf

For more information and articles generated by Project MATCH, see: https://www.commed.uchc.edu/match/

For more information about Motivational Enhancement Therapy, see www.motivationalinterviewing.org or: Miller, W and Rollinck, S (2002). Motivational Interviewing: Preparing people for change, Boston: Guilford