Abstract
The purpose of the study is to compare the effectiveness of Motivational Interviewing and Relapse Prevention as treatments for alcohol problems. The most popular forms of less-intensive treatment currently available are based on the set of therapeutic principles and counselling techniques known as motivational interviewing (Miller & Rollnick, 1991; 2002). The Relapse Prevention model is an important component of alcoholism treatment and is based on social-cognitive psychology (Marlatt & Gordon, 1985). Previous research by Carroll (1996) concluded that Relapse Prevention appears to be more effective than no treatment although not necessarily more effective than other active treatments. It has also been found that Relapse Prevention can reduce the severity of relapse episodes if they occur (Carroll 1996). Dunn, DeRoo and Rivara (2001) concluded that there is substantial evidence that MI is an effective substance abuse intervention method. This particular study will be carried out a three treatment sites in Glasgow. At each treatment site there will be 48 participants who will be furthered divided into two groups of 24 (24 in RP and 24 in MI) bringing the total number of participants to 148. To analyse the results a simple t-test will be used.
Alcohol misuse not only affects the health and welfare of individuals themselves but also has a major impact on family relationships, communities and society as a whole. In order to combat this, a small number of major trials of psychosocial treatment in Britain have been carried out (e.g. Edwards & Guthrie, 1967; Edwards & Orford, 1977). Although these earlier studies provided valuable findings, trials of this size have insufficient statistical power to detect small to medium size effects in comparisons of one form of treatment with another. When two or more treatment methods conveying basic care and attention are compared, expected effects are moderate (Mattick & Jarvis, 1993), but remain potentially important when widespread application of treatments over a large number of clients is predicted. Moreover, if treatments differ in costs, the financial implications of even small effect sizes are potentially considerable. The principal reason why many treatment evaluations have small samples and low statistical power is that they are conducted at a single treatment site where, especially after excluding clients who are unsuitable for the trial or unwilling to participate, the collection of a large sample takes an unacceptably long time. In order to overcome this problem multi-centre trials were conducted whereby a suitably large sample could be collected within a reasonable time span. A further advantage of a multi-centre trial was that any findings that emerged could be more easily generalized across different geographical sites and client populations, thus enhancing the possible application to practical clinical settings.
The United Kingdom Alcohol Treatment Trial (UKATT) was to conduct a multi-centre trial of treatment for alcohol problems within the British treatment system. Furthermore, the purpose was find what kinds of clients are especially likely to benefit from either Motivational Enhancement Therapy or from Social Behaviour and Network Therapy. The aim of the trial was to compare the briefer individually-focused intervention of Motivational Enhancement Therapy with two commonly practiced interventions, namely, Cognitive Behavioural Coping Skills and Twelve Step Facilitation with the more rigorous socially focused intervention of Social Behaviour Network Therapy in terms of effectiveness.
Both UKATT treatments produced statistically significant improvements in alcohol consumption, alcohol dependence, alcohol related problems and aspects of general functioning. It is highly unlikely that these changes would have occurred as part of the natural recovery process. The results of the UKATT trial therefore confirmed that MET is an effective form of alcohol treatment. Furthermore, UKATT also found SBNT to be no less effective than MET (UKATT Research TEAM, 2005a).
Considering the findings of UKATT it has been found that two large multi-centre trials of treatment for alcohol problems, one in the UK and one in the USA, have now failed to find statistically significant differences in outcomes between a total of four treatment modalities that are either widely practiced or have firm foundations in theory and research. The findings of UKATT taken with the systematic reviews are consistent with the conclusion that there is a wealth of alternatives (Miller, Andrews, Wilbourne, & Bennett, 1998) available for treatment in specialist services. This does not mean that all treatment methods are effective or that it does not matter what treatment is given but rather it means that there is a range of effective treatments with little research evidence of clear differences in effectiveness between them. At the present state of our research knowledge, it can be deduced that there is no best treatment for alcohol.
The most popular forms of less-intensive treatment currently available are based on the set of therapeutic principles and counselling techniques known as motivational interviewing (Miller & Rollnick, 1991; 2002). Motivational interviewing is closely linked with the stages of change model described by Prochaska and DiClemente (1984). This approach to treatment of alcohol problems fits with the observation that of the people who present to agencies for treatment of alcohol problems many have not yet formed a definite commitment to change. Even when an alcohol misuser seems convinced that change is necessary there is often a lingering attachment to ...
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The most popular forms of less-intensive treatment currently available are based on the set of therapeutic principles and counselling techniques known as motivational interviewing (Miller & Rollnick, 1991; 2002). Motivational interviewing is closely linked with the stages of change model described by Prochaska and DiClemente (1984). This approach to treatment of alcohol problems fits with the observation that of the people who present to agencies for treatment of alcohol problems many have not yet formed a definite commitment to change. Even when an alcohol misuser seems convinced that change is necessary there is often a lingering attachment to heavy drinking and intoxication, and a deep ambivalence towards alcohol. Conflict is an essential part of what is meant by addiction or dependence (Orford, 2001).
Motivational interviewing includes a collection of therapeutic principles, a set of counselling techniques and, more generally, a style of interaction. It is defined by Miller and Rollnick (2002) as a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The guiding principles of the therapist's interaction with the service user to express empathy, develop discrepancy, roll with resistance and support self-efficacy. A basic assumption of motivational interviewing, at least as a standalone treatment, is that once motivated to change service users can succeed in doing so by using their own change resources and without additional training in behaviour change skills.
Five systematic reviews of research on the effectiveness of motivational interviewing (MI) for a range of addictive disorders have been published. Noonan and Moyers (1997) reviewed 11 clinical trials evaluating MI, nine with alcohol misusers and two with drug abusers. Their conclusion was that as most of these studies support MI as a useful clinical intervention. MI appears to be an effective, efficient and adaptive therapeutic style worthy of further development, application and research. Dunn, DeRoo and Rivara (2001) reported a systematic review of MI covering 29 randomised trials over the four behavioural domains of substance abuse, smoking, HIV risk-taking, and diet and exercise. They therefore concluded that there was substantial evidence that MI is an effective substance abuse intervention method when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing entry to and engagement in a more intensive substance abuse treatment.
Burke, Arkowitz and Dunn (2002) began by noting that virtually all published research in this area involves the study of adaptations of MI (AMIs), rather than MI in its relatively pure form. AMIs refer to enclosed versions of MI in which certain methods, such as feedback of assessment results, are used as a shortcut to draw out the service user's reflections on the pros and cons of the behaviour in question, such as a drinker's check-up (Miller, Sovereign and Krege, 1988), motivational enhancement therapy (Miller et al., 1992) and brief motivational interviewing (Rollnick, Heather and Bell, 1992). The reviewing method used by Burke and colleagues was based on the box score method developed by Miller et al. (1995) although this has been criticised by Finney (2000).
However, the earlier review by Burke, Arkowitz and Dunn (2002) was outmoded by later work by Burke, Arkowitz and Menchola (2003) that used quantitative meta-analysis in a technically sophisticated manner. None of the conclusions reached by Burke, Arkowitz and Dunn were overturned by this later review. The authors identified 30 controlled trials that met their inclusion criteria, of which 15 were in the area of alcohol problems. Two trials (Bien, Miller and Boroughs, 1993; Brown and Miller, 1993) looked at AMI as a prelude to treatment among service users at the more severe end of the range of alcohol related problems. Both found clear evidence of the effectiveness of AMI for this specific purpose. Further, thirteen trials considered AMI as a standalone intervention. Clear interpretation of research on AMIs as a standalone intervention from this review is difficult, because this category of studies combines the separate domains of opportunistic intervention in the non-treatment-seeking population and less-intensive treatment in the treatment seeking population. Nevertheless, the evidence suggested MI-based interventions among a diverse range of groups were effective, including those with significant dependence seeking help for established alcohol problems.
The Relapse Prevention model is an important component of alcoholism treatment and is based on social-cognitive psychology (Marlatt & Gordon, 1985). The model incorporates both a conceptual model of relapse and a set of cognitive and behavioural strategies to prevent or limit relapse episodes. Central to the model is the detailed classification of factors or situations that can precipitate or contribute to relapse episodes. These factors fall into two categories, namely immediate determinants which are high risk situations, the person's coping skills, outcome expectancies and the abstinence violation effect. Secondly, there are covert antecedents such as lifestyle, imbalances, urges and craving. The relapse prevention model proposes that high risk situations and the drinker's response to these situations play a central role in the relapse process.
Relapse Prevention Therapy (RPT) was originally designed as a maintenance program for use following the treatment of addictive behaviors although it is also used as a stand-alone treatment program (Marlatt & Gordon, 1985; Parks & Marlatt, 1999). In the most general sense, RPT is a behavioral self-control program designed to teach individuals who are trying to maintain changes in their behavior how to anticipate and cope with the problem of relapse. Relapse refers to a breakdown or failure in a person's attempt to maintain change in any set of behaviors. Like other cognitive-behavioral therapies, RPT combines behavioral and cognitive interventions in an overall approach that emphasizes self-management and rejects labelling clients with traits like alcoholic or drug addict.
Relapse rates, usually measured as any use of a substance after a period of abstinence, are notoriously high. Research has demonstrated that the temporal patterning of the relapse process and circumstances under which relapses occur are similar across addictive behaviors. These commonalties provide clues to a general relapse process. As we conceptualize the relapse process, it involves clients experiencing a sense of perceived control and self-efficacy while maintaining changes gained through quitting or moderating their use. The longer the period of successful abstinence or controlled use, the greater the individual's perception of self-efficacy becomes.
This continues until an individual experiences a high-risk situation that poses a threat to their perceived control, decreases self-efficacy, and eventually increases the probability of relapse. In an analysis of relapse episodes obtained from clients with a variety of addictive behavior problems three high-risk situations were identified that were associated with almost 75% of the relapses reported (Marlatt & Gordon, 1985). They were negative emotional states, interpersonal conflict, and social pressure. If an individual has an effective coping response to deal with a high-risk situation, the probability of relapse decreases significantly. When a person copes effectively with a high-risk situation, he or she is likely to experience an increase in self-efficacy. As the duration of abstinence (or controlled use) increases, an individual has the experience of coping effectively with one high-risk situation after another and the probability of relapse decreases accordingly.
However, if a person has not learned or cannot implement an effective coping response when confronted with a high-risk situation a lapse is likely. Failure to master a high-risk situation is likely to create decreased self-efficacy and a sense of powerlessness. This is followed by positive expectancies for the effects of alcohol or drugs as alternative coping mechanisms. If a slip does occur, an abstinence violation effect (AVE) follows which consists of cognitive dissonance and the attribution of responsibility for the lapse to internal and stable characteristics of the person. The AVE combined with the intoxicating effects of substance use increases the likelihood that a full-blown relapse will occur.
Two reviews of evidence on the effectiveness of relapse prevention (RP) have considered treatment for substance use disorders in general rather than alcohol problems alone. In a narrative review of controlled studies Carroll (1996) included 24 studies that had evaluated an approach defined as RP or were explicitly based on Marlatt and Gordon's (1985) programme. This review reached the conclusion that RP appears to be more effective than no treatment. Although not necessarily more effective than other active treatments, RP can reduce the severity of relapse episodes if they occur. There is some evidence of continued or delayed effects of RP with RP perhaps being more suited to substance users with greater levels of impairment. In a meta-analytic review of 26 studies, Irvin, Bowers, Dunn, and Wang (1999) concluded that RP is effective in reducing substance misuse and improving psychosocial functioning, especially among alcohol misusers and service users with polydrug problems. These authors also noted that RP seems more effective when combined with pharmacological treatments. In considering the accumulated evidence on RP, the Australian review, Shand, Gates, Fawcett and Mattick (2003) made these additional points that Psychosocial RP may have more impact on psychosocial functioning than on reducing substance use. Further, RP can be used successfully with a variety of service users in different contexts, including residential and non-residential settings.
Analysis
The independent variable for this study will be in two categories namely the motivational interviewing group and the relapse prevention group. The dependant variable will be the number of abstinent days recorded. The scores for Relapse Prevention will be added and the mean and standard deviation will be shown for all follow up points. The data for each treatment centre will be calculated independently in order to ascertain the variance between treatment centres. The data from all treatment centres will then be shown as one set of data for the all of the participants assigned to Relapse Prevention. The procedure will then be repeated for participants in the Motivational Interviewing group. The data will be compared along the 4 time points using the unpaired two-group t-test (Two-sample t). This test is very commonly used to compare the means of each group, where the samples in both groups are independent of each other (Robson 1993).
Implications and Limitations
Due to the nature of the research topic there may be a greater drop-rate as a result of the chaotic lifestyles that many alcohol dependant people lead. Collating pre-test information by means of psychometric testing in this instance may affect post-test results by means of sensitizing the sampled population (Nachmias & Nachmias, 1992). This study may lack sample size and statistical power due to the relatively small sample size which may result in the limited generalisability of the findings. A final and probably the most important limitation of this study will be the lack of a no-treatment control group. Ultimately, the possibility exists that any effect may have occurred naturally with no treatment.
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