Mike Ashton, Editor of Drug and Alcohol Findings, has kindly contributed this "Thinkpiece". It's a long post, but very well worth the read.
Project MATCH was the US blockbuster study attempting to find which psychological treatments work best for which types of alcohol-dependent clients. On that score it came up with few answers but at least its multi-million dollar funders could reassure themselves that each of MATCH’s three treatments were encouragingly effective and to roughly the same degree. Now that judgement too has been questioned. A reanalysis of the MATCH data from Robert Cutler and colleagues showed that patients who did not return for a single therapy session did almost as well as those who went through all 12 sessions of the project’s two most extensive therapies.(1) Across the entire study, nearly all the improvement there was going to be in drinking had occurred by week one, before most of the treatment had been delivered. Rather than more treatment leading to less drinking, people who had already controlled their drinking stayed in treatment longer. Another part of this jigsaw is that while which treatment the patients got assigned to made little difference, how much they wanted to change and were ready to do so beforehand had a profound and lasting effect on how well they did, even more so than how severe their drinking problem was.(2) Rather than each treatment being equally effective, it begins to look as if they were equally INeffective.
If that seems unfair, it may well be - there are other explanations for such findings which cannot be excluded. But then consider another reanalysis whose authors include the two Sobells of controlled drinking fame.(3) This time the study concerned at most moderately dependent drinkers who wanted to cut down. They had answered ads for a study which randomly assigned them to one of two mailed self-help programmes. These it seemed were equally effective in leading to modest yet worthwhile reductions in heavy drinking. Yet a closer look showed that most of the reductions had occurred after the subjects had responded to the ad but BEFORE they had received any of the project’s assessment or self-help materials. Rather than these materials leading to change, it seemed that responding to the ads had crystallised the respondents’ resolve to cut back - just as, perhaps, the MATCH patients’ resolve to cut down had been crystallised by their decision to enter one of its treatments.
Such analyses are rare and sidelined into the niches of academic publication. The preferred message is that we have found treatments which work because they embody the right psychological technology to treat a technical, medical disorder of the body and the mind. The car is not working, as long as the technician dutifully uses the right spanner on the right nut and turns it in the direction and by the amount specified in the repair manual, then it will be restored. Despite what Mma Ramotswe’s mechanic husband likes to believe, it matters not at all how the technician talks to the car, whether he loves or loathes it, shows respect or disdain, and the car itself plays no part in the process.
Cutler’s MATCH study and the Sobells’ analysis hint at an entirely different scenario. What matters most is the patient’s desire to get better and their decision to do so via the culturally accepted route of going for ‘treatment’, and beyond certain basics, it matters little what that treatment is. As long as it doesn’t foul up the process started by the patient, they will get better. The main way it can foul things up is not to make one less or one more turn of the spanner than dictated in the manual, but to fail to provide a credible, sympathetic approach which the patient can believe in, which instills optimism and treats them with respect, values them as an individual, is centred on their needs, and treats them as if they at least have the potential to become what they want to be. How the mechanic talks to the car, whether he loves or loathes it, values its idiosyncrasies, makes it believe it can get back on the road, these are what matter. In MATCH this process was visible in the baleful effect of ‘outlier’ therapists who despite its extraordinarily rigorous selection, training and supervision processes, had unusually poor outcomes.(4)
All this is very far from saying that the therapist and the therapy do not matter - they are important, but not in the ways normally thought. To their great credit, the MATCH researchers, after conducting the most technically sophisticated research of the most highly technically specified therapies ever seen in the alcohol treatment field, and with the expectation of finding spanners to match and fix loosened nuts, reached conclusions light years from this starting point. That what their therapists were doing was in essence no different from the faith healers and witch doctors of more ‘primitive’ societies - providing a culturally accepted route to recovery which gave permission to people to activate their pre-existing resolve and resources.(2) Perhaps too, they added somewhat to those resources and perhaps too bolstered that resolve, but these were minor effects.
The practical implications of this kind of thinking are profound and were spelt out in the book which brought together the MATCH findings. There the researchers mused whether instead of distinct ways of working, different therapies work through “common mechanisms, such as empathy, an effective working alliance between the therapist and the client, a desire to get better, the alcoholic’s inner resources to overcome alcohol dependence, a supportive social network, and the provision of a culturally appropriate solution to a socially defined problem ... What may be required even more than the specific components of a therapeutic intervention is the belief on the part of both the patient and the therapist that this particular treatment is likely to be effective.
Another implication of these findings is that access to treatment may be as important as the type of treatment available to people with alcohol problems. If most treatments are similar in their effectiveness, the real value of having an array of treatments available is to promote healthy competition for the wide variety of people who would benefit from any treatment, but who would be more attracted to one because of reputation, convenience, or personal preference.”(5)
A series of articles dedicated to these and allied propositions is being published in Drug and Alcohol Findings under the Manners Matter banner - visit the Findings website for more.
References
1. Cutler R.B. et al. “Are alcoholism treatments effective? The Project MATCH data.” BMC Public Health: 2005, 5:75.
2. Ashton M. “Project MATCH: unseen colossus.” Drug and Alcohol Findings: 1999, 1, p. 15-21.
3. Sobell L. et al. "Responding to an advertisement. A critical event in promoting self?change of drinking behavior.” Poster presented at the 37th Annual Meeting of the Association for the Advancement of Behavior Therapy in 2003.
4. Project MATCH Research Group. “Therapist effects in three treatments for alcohol problems.” Psychotherapy Research: 1998 8, p. 455-474.
5. Babor T.F. and Del Boca F.K. eds. Treatment matching in alcoholism. Cambridge University Press, 200
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