Finer points about new treatment approaches

Alcohol Health & Research World,  Summer, 1991  by Elizabeth D. Huey

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Much attention and help is needed to improve the effectiveness of treatment for alcohol- and drug-addicted patients. Care providers might be struggling less with licensure, accreditation, and third-party payers if there were improvements in long-term treatment outcomes and if the field were less willing to accept notions such as "relapse is a normal part of recovery." In light of these facts, Dr. McCrady's article is timely and valuable. She has examined approaches that have empirical support and that, if considered objectively, might provide the clinician with an expanded repertoire of effective and practical interventions.

"COMPLETE" TREATMENT RESEARCH

The Community Reinforcement Approach (CRA) appears to target patients who have lost major environmental and social supports, presumably as a result of the patients' alcoholism. The program stresses access to reinforcers that remediate these losses. A large portion of patients in private treatment programs are employed and have semistable living environments. These patients would not appear to be good candidates for the CRA because, for them, most of the reinforcers would be irrelevant. The cost of resources needed for private facilities to maintain a CRA program for a small group of patients could be prohibitive. However, public programs that serve larger groups of patients responsive to the reinforcers would be well served if designs similar to the CRA were considered. When limited populations are the subjects of research, it would be helpful distinguish when and where the approach can best be utilized.

The individual use of positive reinforcers along with behavioral contracting can represent an effective approach with virtually any population. For example, the use of disulfiram contracting has been observed to have an effect on treatment; however, as noted by Dr. McCrady, treatment programs tend to utilize disulfiram either routinely or not at all, according to administrative philosophies or clinical beliefs. Procedures related to disulfiram tend to be risk-management policies rather than policies that address the appropriate use and behavioral methods connected with clinical care.

"INTEGRATE-ABLE" TREATMENT APPROACHES

Treatment plans often note the need for communication skills, social skills, or problem-solving skills training, yet do not identify or conceptualize well specific problems. Interventions often consist of little more than talking about change rather than adopting a structured approach to bring about change. Much of the research noted by Dr. McCrady would be considered seriously (or read completely) by only a few of the most sophisticated, academically trained counselors, because the noted research includes concepts and methods anathema to many of the beliefs commonly held.

The effectiveness of a contract such as spouse-observed, daily ingestion of disulfiram may never be acknowledged unless researchers deal with how the spouses manage their own behaviors or "codependency." When research designs or objectives involve decreased or socalled controlled drinking, techniques such as Behavioral Self-Control Training may not be studied or utilized. This is because of counselors' indignation regarding controlled drinking. Many counselors today may not attempt to utilize techniques such as Social Skills Training because they do not know how to implement them. To improve understanding and utilization, it would be helpful if researchers included step-by-step procedures on how to conduct a rehearsal, perform assertiveness training, or implement other methods.

Communication would improve if research and published articles focused on clearly diagnosed alcohol- or or drug-dependent people rather than on people with milder drinking problems, and if studies of different approaches focused on techniques used in the service of abstinence.

TREATMENTS FOR SPECIAL POPULATIONS

Two problems about special populations are worth noting. First, most addiction treatment organizations spend only a small portion of their time on hospital consultations or outpatient assessments of "mild" or circumscribed drinking problems. Practitioners therefore would be interested in information about patients with severer problems, and they would appreciate use of appropriate jargon, such as "patients in early-stage addiction" or "patients with a high bottom."

Second, many people in the treatment field believe that if advice, information, and instructions were all that a patient dependent in the first place. If the patient responds well to these interventions, he or she probably did not need treatment for addiction; if the patient really needs intervention, the methods suggested here will not be enough. Until research helps us to discriminate better between a problem drinker and an alcohol-dependent patient who is identified early in the disease process, these techniques will be utilized only rarely.

SUGGESTIONS

1. As Dr. McCrady noted, better integration of research findings with commonly accepted theoretical approaches and belief systems of clinicians is needed. As in other areas of mental health, the basic theoretical perspective of the clinician need not always change, but it must allow for additional skills that expand on beliefs and support basic tenets. This could be accomplished largely through increased awareness of common beliefs and greater use of language commonly employed in the treatment field. In addition, major gains could be made in linking treatment research with clinical practice if the sensitive issues we have noted here were addressed forthrightly in the discussion of findings and their implications.