Commentary
Declaration of interests None. Keywords Addiction, common factors, eHealth, mHealth, outcome, treatment. JONATHAN B. BRICKER1,2 Cancer Prevention Research Program, Division of Public Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA1 and Department of Psychology, University of Washington, Seattle, Washington, USA.2 E-mail: [email protected] References 1. Miller W. R., Moyers T. B. The forest and the trees: relational and specific factors in addiction treatment. Addiction 2015; 110: 401–413. 2. Strupp H. Specific vs nonspecific factors in psychotherapy and the problem of control. Arch Gen Psychiatry 1970; 23: 393–401. 3. Project MRG. Therapist effects in three treatments for alcohol problems. Psychother Res 1998; 8: 455–74. 4. Horvath A. O., Del Re A. C., Flückiger C., Symonds D. Alliance in individual psychotherapy. Psychotherapy 2011; 48: 9–16. 5. McCambridge J., Day M., Thomas B. A., Strang J. Fidelity to motivational interviewing and subsequent cannabis cessation among adolescents. Addict Behav 2011; 36: 749–54. 6. Vilardaga R., Heffner J. L., Mercer L. D., Bricker J. B. Do counselor techniques predict quitting during smoking cessation treatment? A component analysis of telephone-delivered Acceptance and Commitment Therapy. Behav Res Ther 2014; 61: 89–95. 7. Michie S., Whittington C., Hamoudi Z., Zarnani F., Tober G., West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012; 107: 1431–40. 8. Bricker J., Wyszynski C., Comstock B., Heffner J. L. Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine Tob Res 2013; 15: 1756–64. 9. Xyo I. Estimated US downloads of smoking cessation apps since 2012 [updated 24 March 2014]. Derived from: xyo. net. Accessed March 24, 2014 10. Heffner J., Vilardaga R., Mercer L. D., Kientz J. A., Bricker J. B. Feature-level analysis of an innovative smartphone application for smoking cessation. Am J Drug Alcohol Abuse 2015; 41(1): 68–73.
BRANDING ADDICTION THERAPIES AND REIFIED SPECIFIC FACTORS Forty years of clinical outcome research in addictions have shown us that treatment works, effects are small to moderate and one ‘bona fide’ intervention rarely works better than another. Every 10 years or so, a new brand of behavioral addiction treatment is introduced and, with promise, it becomes the focus of extensive outcome testing. Following a traditional drug development model, this © 2015 Society for the Study of Addiction
415
involves increasing levels of methodological rigor. Behavioral outcome research also includes a successive hierarchy of contrast conditions assumed to control for non-specific therapy effects [1]. Very often, this process continues until the treatment fails in contrast to another specific treatment [2] or, worse yet, in an effectiveness study where the method is pitted against usual care [3–6]. In meta-analyses that do not account for variation in control group magnitude, the end result is a small effect size [7]. The good news is that the field of addiction has a large array of evidence-based treatments for frontline practitioners to choose from. The bad news is that these treatments show moderate and variable effectiveness and may not exceed the benefit derived from existing services. This storyline may be somewhat reductionist, but not to the extent that we do not have to start asking ourselves—why? The monograph entitled: ‘The forest and the trees: relational and specific factors in addiction treatment’ [8] thoughtfully identifies a number of themes in clinical outcome research that challenge a continued reliance upon the traditional efficacy paradigm. Underlying this paradigm is the assumption that an undiscovered specific therapy exists that will surpass the efficacy of all others. This pursuit, again, comes from a drug development model where the possibility of a truly unique pharmacological compound impacting a set of truly unique biological mechanisms is far more plausible. The authors speak to key issues of historical nuisance to randomized clinical trials and present them as empirical opportunities for new directions in outcome research in addictions. One nuisance the authors highlight is small experimental treatment effects in relation to usual care. The dissemination of a new specific therapy to frontline addictions treatment assumes that an undiscovered modality exists that will be superior to services clinicians are currently providing. This might be a fair proposal, if we were confident that the development of such a model were possible or that frontline providers were not already employing many techniques that are evidence-based. Clinical outcome research has been historically disinterested in the strengths, rather than limitations, of community care. A real contribution to future research would be a comprehensive assessment of what actually comprises the ingredients of usual services in both in-patient and out-patient settings. Another nuisance the authors highlight is that of systematic therapist effects, even in the context of a tightly controlled clinical trial. Here, the empirical opportunity would be examining the exact nature of these therapist differences that rise above the experimental treatment effect, in a positive or negative direction. When considering characteristics that make for highly effective therapists, one promising direction would be the study of ‘artful differential responding’. This quality of intuition very probably Addiction, 110, 414–419
416
Commentary
discriminates therapists with successful outcomes on average from those without. Recently, in a test of the technical model of motivational interviewing (MI) with precontemplative non-treatment seekers, the causal process model of MI skills to client language and client language to client outcome held only for highly experienced therapists (Gaume et al., unpublished). It is very probable that these therapists optimized their responses with each passing moment; this kind of decision-making should be the subject of future research. In 1989 Paul Wachtel asked if psychoanalysis was truly different from behavior therapy [9], and in 1994 Barbara McCrady asked if addictive diseases could be treated as addictive habits and if addictive habits could be treated as addictive diseases [10]. The central question here is whether specific therapy ingredients even exist and, if they do, are these ingredients strong enough to surpass the effects of a charismatic and passionate therapist, with high hopes for the client’s potential and with strong skills in relating to others? There is also a set of core behavior change therapy techniques derived from a few established and longstanding treatment traditions [11]. With these conditions in mind, it seems inefficient to commit continued resources to the development of a truly novel (i.e. specific) behavioral addiction treatment.
Declaration of interests None. Keywords Active ingredients, addiction treatment, common factors, mechanisms of behavior change, nonspecific factors, randomized clinical trials, specific factors. MOLLY MAGILL Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, USA. E-mail: [email protected]
References 1. Magill M., Longabaugh R. Efficacy combined with specified ingredients: a new direction for empirically supported addiction treatment. Addiction 2013; 108: 874–81. 2. Imel Z. E., Wampold B. E., Miller S. D., Fleming R. R. Distinctions without a difference: direct comparisons of psychotherapies for alcohol use disorders. Psychol Addict Behav 2008; 22: 533–43. 3. Carroll K. M., Ball S. A., Nich C., Martino S., Frankfurter T. L., Farentinos C. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug Alcohol Depend 2006; 3: 301–12. 4. Hunter S. B., Watkins K. E., Hepner K. A., Paddock S. M., Ewing B. A., Osilla K. C. et al. Treating depression and © 2015 Society for the Study of Addiction
5.
6.
7.
8.
9. 10.
11.
substance use: a randomized controlled trial. J Subst Abuse Treat 2012; 43: 137–51. Morgenstern J., Blanchard K. A., Morgan T. J., Labouvie E., Hayaki J. Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: within treatment and posttreatment findings. J Cons Clin Psychol 2001; 69: 1007–17. Rowan-Szal G. A., Bartholomew N. G., Chatham L. R., Simpson D. D. A combined cognitive and behavioral intervention for cocaine-using methadone clients. J Psychoact Drugs 2005; 37: 75–84. Karlsson P., Bermark A. ‘Compared to what?’ Control group types in Cochrane and Campbell reviews on psychosocial treatments of substance abuse. Addiction 2015; 110: 420– 428. Miller W. R., Moyers T. The forest and the trees: relational and specific factors in addiction treatment. Addiction 2015; 110: 401–413. Watchel P. Psychoanalysis and Behavior Therapy: Towards an Integration. Tucson, AZ: Basic Books; 1989. McCrady B. Alcoholics anonymous and behavior therapy: can habits be treated as diseases? Can diseases be treated as habits? J Cons Clin Psychol 1994; 62: 1159–66. Michie S., Whittington C., Hamoudi Z., Zarnani F., Tober G., West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012; 107: 1431–40.
WHERE IS THE FOREST? The consistent finding that there are no or only small differences in outcome between bona-fide treatment interventions in the addiction field (and also in other neighbouring fields such as psychotherapy in general) is gaining increasing support in the international literature. The paper by Miller & Moyers [1] represents an elaborate and well-articulated piece in that genre. However, while the support for the outcome equivalence paradox (or the Dodo bird verdict) seems to develop into a consensus, the same is not true concerning what the consequences of this situation should entail for the organization of future research on addiction treatment. Babor suggests, with reference to his experiences as one of the leading researchers within Project MATCH [2], that the failure ‘to explain treatment effects also suggest that we focus attention of how to best motivate people to enter treatment, regardless of the therapeutic modality employed’ [3]. The rejection of a continued focus on establishing differences in treatment outcome is turned upside-down in a proposal for more elaborated specificity put forward by Magill & Longabaugh [4], when they write: ‘to the extent that future RCT yield results of no difference the need for specificity as to how the treatment works becomes more compelling’ (p. 876). Miller & Moyers, on their part, state that it seems unlikely that treatment outcome will be improved by searching for better specific ingredients and that future research should focus on therapist, relational and client variables. Although this position seems Addiction, 110, 414–419
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Declaration of interests None. Keywords Addiction, common factors, eHealth, mHealth, outcome, treatment. JONATHAN B. BRICKER1,2 Cancer Prevention Research Program, Division of Public Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA1 and Department of Psychology, University of Washington, Seattle, Washington, USA.2 E-mail: [email protected] References 1. Miller W. R., Moyers T. B. The forest and the trees: relational and specific factors in addiction treatment. Addiction 2015; 110: 401–413. 2. Strupp H. Specific vs nonspecific factors in psychotherapy and the problem of control. Arch Gen Psychiatry 1970; 23: 393–401. 3. Project MRG. Therapist effects in three treatments for alcohol problems. Psychother Res 1998; 8: 455–74. 4. Horvath A. O., Del Re A. C., Flückiger C., Symonds D. Alliance in individual psychotherapy. Psychotherapy 2011; 48: 9–16. 5. McCambridge J., Day M., Thomas B. A., Strang J. Fidelity to motivational interviewing and subsequent cannabis cessation among adolescents. Addict Behav 2011; 36: 749–54. 6. Vilardaga R., Heffner J. L., Mercer L. D., Bricker J. B. Do counselor techniques predict quitting during smoking cessation treatment? A component analysis of telephone-delivered Acceptance and Commitment Therapy. Behav Res Ther 2014; 61: 89–95. 7. Michie S., Whittington C., Hamoudi Z., Zarnani F., Tober G., West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012; 107: 1431–40. 8. Bricker J., Wyszynski C., Comstock B., Heffner J. L. Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine Tob Res 2013; 15: 1756–64. 9. Xyo I. Estimated US downloads of smoking cessation apps since 2012 [updated 24 March 2014]. Derived from: xyo. net. Accessed March 24, 2014 10. Heffner J., Vilardaga R., Mercer L. D., Kientz J. A., Bricker J. B. Feature-level analysis of an innovative smartphone application for smoking cessation. Am J Drug Alcohol Abuse 2015; 41(1): 68–73.
BRANDING ADDICTION THERAPIES AND REIFIED SPECIFIC FACTORS Forty years of clinical outcome research in addictions have shown us that treatment works, effects are small to moderate and one ‘bona fide’ intervention rarely works better than another. Every 10 years or so, a new brand of behavioral addiction treatment is introduced and, with promise, it becomes the focus of extensive outcome testing. Following a traditional drug development model, this © 2015 Society for the Study of Addiction
415
involves increasing levels of methodological rigor. Behavioral outcome research also includes a successive hierarchy of contrast conditions assumed to control for non-specific therapy effects [1]. Very often, this process continues until the treatment fails in contrast to another specific treatment [2] or, worse yet, in an effectiveness study where the method is pitted against usual care [3–6]. In meta-analyses that do not account for variation in control group magnitude, the end result is a small effect size [7]. The good news is that the field of addiction has a large array of evidence-based treatments for frontline practitioners to choose from. The bad news is that these treatments show moderate and variable effectiveness and may not exceed the benefit derived from existing services. This storyline may be somewhat reductionist, but not to the extent that we do not have to start asking ourselves—why? The monograph entitled: ‘The forest and the trees: relational and specific factors in addiction treatment’ [8] thoughtfully identifies a number of themes in clinical outcome research that challenge a continued reliance upon the traditional efficacy paradigm. Underlying this paradigm is the assumption that an undiscovered specific therapy exists that will surpass the efficacy of all others. This pursuit, again, comes from a drug development model where the possibility of a truly unique pharmacological compound impacting a set of truly unique biological mechanisms is far more plausible. The authors speak to key issues of historical nuisance to randomized clinical trials and present them as empirical opportunities for new directions in outcome research in addictions. One nuisance the authors highlight is small experimental treatment effects in relation to usual care. The dissemination of a new specific therapy to frontline addictions treatment assumes that an undiscovered modality exists that will be superior to services clinicians are currently providing. This might be a fair proposal, if we were confident that the development of such a model were possible or that frontline providers were not already employing many techniques that are evidence-based. Clinical outcome research has been historically disinterested in the strengths, rather than limitations, of community care. A real contribution to future research would be a comprehensive assessment of what actually comprises the ingredients of usual services in both in-patient and out-patient settings. Another nuisance the authors highlight is that of systematic therapist effects, even in the context of a tightly controlled clinical trial. Here, the empirical opportunity would be examining the exact nature of these therapist differences that rise above the experimental treatment effect, in a positive or negative direction. When considering characteristics that make for highly effective therapists, one promising direction would be the study of ‘artful differential responding’. This quality of intuition very probably Addiction, 110, 414–419
416
Commentary
discriminates therapists with successful outcomes on average from those without. Recently, in a test of the technical model of motivational interviewing (MI) with precontemplative non-treatment seekers, the causal process model of MI skills to client language and client language to client outcome held only for highly experienced therapists (Gaume et al., unpublished). It is very probable that these therapists optimized their responses with each passing moment; this kind of decision-making should be the subject of future research. In 1989 Paul Wachtel asked if psychoanalysis was truly different from behavior therapy [9], and in 1994 Barbara McCrady asked if addictive diseases could be treated as addictive habits and if addictive habits could be treated as addictive diseases [10]. The central question here is whether specific therapy ingredients even exist and, if they do, are these ingredients strong enough to surpass the effects of a charismatic and passionate therapist, with high hopes for the client’s potential and with strong skills in relating to others? There is also a set of core behavior change therapy techniques derived from a few established and longstanding treatment traditions [11]. With these conditions in mind, it seems inefficient to commit continued resources to the development of a truly novel (i.e. specific) behavioral addiction treatment.
Declaration of interests None. Keywords Active ingredients, addiction treatment, common factors, mechanisms of behavior change, nonspecific factors, randomized clinical trials, specific factors. MOLLY MAGILL Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, USA. E-mail: [email protected]
References 1. Magill M., Longabaugh R. Efficacy combined with specified ingredients: a new direction for empirically supported addiction treatment. Addiction 2013; 108: 874–81. 2. Imel Z. E., Wampold B. E., Miller S. D., Fleming R. R. Distinctions without a difference: direct comparisons of psychotherapies for alcohol use disorders. Psychol Addict Behav 2008; 22: 533–43. 3. Carroll K. M., Ball S. A., Nich C., Martino S., Frankfurter T. L., Farentinos C. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug Alcohol Depend 2006; 3: 301–12. 4. Hunter S. B., Watkins K. E., Hepner K. A., Paddock S. M., Ewing B. A., Osilla K. C. et al. Treating depression and © 2015 Society for the Study of Addiction
5.
6.
7.
8.
9. 10.
11.
substance use: a randomized controlled trial. J Subst Abuse Treat 2012; 43: 137–51. Morgenstern J., Blanchard K. A., Morgan T. J., Labouvie E., Hayaki J. Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: within treatment and posttreatment findings. J Cons Clin Psychol 2001; 69: 1007–17. Rowan-Szal G. A., Bartholomew N. G., Chatham L. R., Simpson D. D. A combined cognitive and behavioral intervention for cocaine-using methadone clients. J Psychoact Drugs 2005; 37: 75–84. Karlsson P., Bermark A. ‘Compared to what?’ Control group types in Cochrane and Campbell reviews on psychosocial treatments of substance abuse. Addiction 2015; 110: 420– 428. Miller W. R., Moyers T. The forest and the trees: relational and specific factors in addiction treatment. Addiction 2015; 110: 401–413. Watchel P. Psychoanalysis and Behavior Therapy: Towards an Integration. Tucson, AZ: Basic Books; 1989. McCrady B. Alcoholics anonymous and behavior therapy: can habits be treated as diseases? Can diseases be treated as habits? J Cons Clin Psychol 1994; 62: 1159–66. Michie S., Whittington C., Hamoudi Z., Zarnani F., Tober G., West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012; 107: 1431–40.
WHERE IS THE FOREST? The consistent finding that there are no or only small differences in outcome between bona-fide treatment interventions in the addiction field (and also in other neighbouring fields such as psychotherapy in general) is gaining increasing support in the international literature. The paper by Miller & Moyers [1] represents an elaborate and well-articulated piece in that genre. However, while the support for the outcome equivalence paradox (or the Dodo bird verdict) seems to develop into a consensus, the same is not true concerning what the consequences of this situation should entail for the organization of future research on addiction treatment. Babor suggests, with reference to his experiences as one of the leading researchers within Project MATCH [2], that the failure ‘to explain treatment effects also suggest that we focus attention of how to best motivate people to enter treatment, regardless of the therapeutic modality employed’ [3]. The rejection of a continued focus on establishing differences in treatment outcome is turned upside-down in a proposal for more elaborated specificity put forward by Magill & Longabaugh [4], when they write: ‘to the extent that future RCT yield results of no difference the need for specificity as to how the treatment works becomes more compelling’ (p. 876). Miller & Moyers, on their part, state that it seems unlikely that treatment outcome will be improved by searching for better specific ingredients and that future research should focus on therapist, relational and client variables. Although this position seems Addiction, 110, 414–419
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
