Interactions between psychotherapy procedures and patient attributes that predict alcohol treatment effectiveness:: A preliminary report
Introduction
Empirical research on the efficacy of psychosocial treatments for alcoholism has been broadly based and has produced decidedly mixed results. On one hand, there has been support for the utility of cognitive–behavioral group therapy (CBT, Oei & Jackson, 1984), self-control training (Connors, Maisto, & Ersner-Hershfield, 1986), behavior therapy (Telch, Hannon, & Telch, 1984), behavioral marital therapy (O'Farrell, 1994), and social skills training (Oei & Jackson, 1980). On the other hand, there is also evidence of the ineffectiveness of each of these treatments. Group CBT has failed to reduce alcohol consumption among repeated drunk driving offenders (Rosenberg & Brian, 1986), behavioral self-control training has failed to induce long-term changes in alcohol use (Rychtarik, Foy, & Scott, 1987), and marital therapy based upon a family systems orientation (Zweben, Pearlman, & Li, 1988), and coping skills training for chronic alcoholics (Walker, Sanchez-Craig, & Bornet, 1982) have both failed to significantly reduce drinking behaviors. As a general rule, moreover, comparisons of different treatment models have failed to reveal large differences, supporting instead the so-called Dodo Bird Verdict that all have won and all must have prizes Luborsky et al., 1975, Wampold et al., 1997.
While methodological inconsistencies (e.g., poor implementation of a given treatment) and/or design flaws may explain some of the discrepant findings about alcoholism treatments, it is also likely that variations in patient responsiveness within treatments masked the effects. The Institute of Medicine (1990) concluded that no single treatment for alcoholism is effective for all patients, and that the effectiveness of a specific treatment is moderated by specific characteristics of each patient or sample.
Analyses of the interactions between patient attributes and treatments have arisen in the field of alcoholism research to address this issue. This body of work, often referred to as patient–treatment matching research, has also produced equivocal findings. In the largest randomized clinical trial of alcoholism treatments to date, Project MATCH Research Group, 1997a, Project MATCH Research Group, 1997b analyzed the effects of 21 patient variables as moderators of treatment effectiveness. Among these variables, only four interacted with treatment modality. Project MATCH (1997a) found that outpatients who were low in global psychiatric severity at pretreatment improved more in the months following a 12-step-based treatment than after CBT (although this difference was no longer present at the 1-year follow-up). Aftercare patients high in alcohol dependence responded better to 12-step than to CBT, and the reverse was found for patients low in alcohol dependence. Further, patients in states of high anger responded better to motivational enhancement therapy than to CBT at both the 1- and 3-year follow-up Project MATCH Research Group, 1997b, Project MATCH Research Group, 1998. The most robust finding in Project MATCH was at the 3-year follow-up, in which patients with a social network that supported drinking did better following 12-step treatment than after a motivational enhancement treatment (Project MATCH, 1998).
In other research, male alcoholics with high levels of sociopathy and psychopathology were shown to improve more from coping skills training than from an interactional group treatment; patients low in sociopathy improved more in response to the interactional group treatment (Litt, Babor, DelBoca, Kadden, & Cooney, 1992). Similar findings were observed among a sample of female alcoholics who received the same treatments as used by Kadden, Cooney, Getter, and Litt (1989) and Litt, Babor, DelBoca, Kadden, and Cooney (1992). The importance of these patient variables in moderating treatment effectiveness was not replicated in Project MATCH (1997b). However, the treatments used by Kadden et al. and Litt et al. differed substantially from Project MATCH both in terms of content and format (i.e., group versus individual).
Additionally, individuals with an external locus of control have been found to respond better to a structured, coping skills training approach than to an interactional treatment (Hartman, Krywonis, & Morrison, 1988). Patients with low education levels, high urges to drink, and high levels of anxiety exhibited a greater reduction in drinking after communication skills training than after cognitive–behavioral mood management training (Rohsenow et al., 1991).
Despite the heuristic value of these findings, the amount of variance accounted for by the interactions of treatment models and patient variables is generally small. There is evidence that unpacking treatment manuals and classifying their interventions into functional groups that represent similar objectives or qualities might improve prediction. In this way, similar procedures from different manuals and theories may be found to share common outcomes. This approach may lay the groundwork for bridging interventions across theoretical boundaries and help to explain the Dodo Bird Verdict of equivalence across theoretically different treatments.
Systematic treatment selection (STS) is a model that attempts to accomplish just this task. STS (Beutler & Clarkin, 1990) proposes that multiple relationships between patient and treatment characteristics may impact an individual's response to psychotherapy. The STS theory postulates that patient characteristics relevant in treatment matching include level of emotional distress, the relative balance of internalizing and externalizing coping style, and psychological reactance level (propensity to resist assistance) Beutler & Clarkin, 1990, Gaw & Beutler, 1995. Corresponding treatment dimensions postulated to be relevant in patient–treatment matching include the therapist's attempts to increase or decrease the patient's level of emotional arousal by focusing on affect, the within-session focus on insight or behavior change, and the directiveness of the therapist's interventions Beutler & Clarkin, 1990, Gaw & Beutler, 1995.
Hypotheses about which treatment works best with which patient along some of these dimensions have been tested empirically among a nonalcoholic population. For example, behaviorally oriented treatment was shown to be superior to insight-oriented treatment for depressed individuals who tended to use an externalizing coping style (Calvert, Beutler, & Crago, 1988). Also, patients high in reactance (i.e., more defensive) were shown to improve more in a nondirective treatment for depression (Beutler et al., 1991).
In the area of alcoholism treatment, the STS theory has not been empirically examined. An evaluation of this theory applied to alcoholism treatment may further explain the interactions between treatments for alcoholism and the alcoholics themselves.
The purpose of the present study was therefore to examine how the effectiveness of alcoholism treatment varies as a function of who the patient is and how the therapist delivers the treatment. This study empirically evaluated multiple aspects of the STS patient and treatment matching theory (Beutler & Clarkin, 1990) that have not been analyzed in alcoholism research. We anticipate that few differences will emerge between the outcomes of CBT and family systems therapy (FST), supporting the Dodo Bird conclusion. Instead, we anticipate that differences in outcomes will be more closely related to dimensions that cut across treatment and that result in fitting particular classes of interventions with patient qualities.
Drawing upon Beutler and Clarkin's (1990) theoretical work, we hypothesized that patients' alcohol use would be predicted by disordinal interactions between: (1) patient emotional distress and the focus on patient affect in treatment, (2) patient coping style and the relative focus on behavioral or insight treatment, and (3) patient psychological reactance and the directiveness of therapist interventions. Hypothesis 1 This predicted optimal drinking outcomes when affect-focused interventions were used with patients low in distress and when non-affect-focused interventions were used with patients high in distress. Hypothesis 2 This predicted optimal drinking outcomes when behavior-focused interventions were used with patients high in externalization and when insight-focused interventions were used with patients low in externalization. Hypothesis 3 This predicted optimal drinking outcomes when directive interventions were used with patients low in reactance and when nondirective interventions were used with patients high in reactance.
Section snippets
Participants
Forty-seven patients who participated in an outpatient couples alcoholism treatment program and that attended at least one session of psychotherapy were the sample for this study. The partners of these patients participated in treatment, but were not a focus of this study. A total of 97 patients (80 men and 17 women) were initially screened for participation in the program. Inclusionary criteria for patients entering the project included a Michigan Alcoholism Screening Test (MAST, Selzer, 1971)
Assumption checks
Several procedures were used to assess for assumption violations. We conducted univariate and multivariate tests of normality and outliers. To evaluate linearity, we examined normal probability plots, partial regression plots, and plots of standardized residuals with predicted scores. Standardized residual plots were used to evaluate homogeneity of variance. We evaluated the homogeneity of regression assumption for the covariates in the models by testing for interactions between the covariates
Discussion
This study demonstrated that alcoholism treatment effectiveness can be predicted by the interaction between baseline patient characteristics and the in-session process of psychotherapy assessed early in treatment. Specifically, the relationships between (1) emotional distress and therapist focus on affect and (2) patient reactance and therapist directiveness were important predictors of alcohol use during the maintenance phase of treatment. Further, these interactions between patient attributes
Acknowledgements
This study was supported in part by National Institute on Alcoholism and Alcohol Abuse grants (RO1 AA12155 and RO1 AA98970) to the first and second authors, respectively. Varda Shoham and Theodore Jacob were Co-PIs on the second grant.
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