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Robert B Cutler* and David A Fishbain
Corresponding author: Robert B Cutler firstname.lastname@example.org
BMC Public Health 2005, 5:75 doi:10.1186/1471-2458-5-75
(2005-08-22 01:50) Hennepin County Medical Center - Minneapolis
I am a clinical social worker working as a psychotherapist in a partial hospital program
located in an urban medical center that serves a diverse and often indigent clientele.
I have been a psychotherapist working in community mental health settings for 27 years.
Dual diagnosis of mental health and chemical dependency has become the rule rather
than the exception in these treatment settings during my tenure. I have often found
myself in the position of providing aftercare for persons who just completed a twelve
step chemical dependency treatment program. Perhaps even more often, I treat people
who do not appear to fit a classic diagnosis of chemical dependency and in fact seem
to be self-medicating mental health problems.
I was drawn to an article placed in NewScientist.com and was disturbed by what I read.
I found the research manuscript at BioMed Central. While technically the methodology
appears sufficient, this study uses a pretty minimal model of treatment including
weekly sessions for 12 weeks. Then the study draws one conclusion that sounds important,
but is in fact relatively meaningless. Another conclusion of the study is that the
“results suggest that current psychosocial treatments for alcoholism are not
particularly effective.” These results suggest that current psychosocial treatments
for alcoholism are not particularly effective. There is no basis provided to draw
such a sweeping conclusion.
The first conclusion is that the client's commitment to treatment may explain treatment
success better than the treatment itself. In my clinical experience, a client's commitment
to treatment outcomes always has been the most important component in the success
Commitment to treatment is a very complex variable and difficult to measure. This
study assumes the client's self-report and behavior prior and during therapy reflects
that commitment. While that may seem like a reasonable assumption, in my experience,
the willingness of the client to follow through with significant lifestyle changes
after treatment are more meaningful to treatment outcome than the treatment itself.
Such changes usually require a comprehensive aftercare treatment regime to maximize
the possibility of success. Making a decision and commit to follow through takes a
certain amount of self-knowledge and self-discipline. Then successful follow through
requires skills to cope with emotions, crisis and interpersonal relationships. These
skills become the essence of treatment and aftercare.
The conclusion the authors make is based on the assumptions of the research. They
assume that not drinking is the ideal outcome and a sufficient measurement of the
effectiveness of treatment. Traditionally, abstinence is a measurement of success
in alcoholism treatment. However, recent research suggests that some alcoholics can
cut back and improve their quality of life. Apparently aware of this research, the
authors included drinks per day for one of the follow-up measures. That was not a
sufficient measure. The authors used no other measure that might tap some of the more
complex outcomes. A better outcome measure of the effectiveness of treatment is a
comparison of quality of life of the client before and after treatment.
Then the authors conclude that the treatments they used in the study were roughly
equivalent to each other and to no treatment. This seems like a reasonable conclusion
from the data. The problem is that the conclusion has very little value. The treatment
they describe is merely the skeleton of what it takes to provide quality treatment
and without the necessary aftercare regime. This research follows the clients treated
in weekly sessions for 12 weeks. A more reasonable treatment model might include daily
sessions for two or three weeks followed by 6 to 12 weeks of aftercare in the form
of weekly session. In my experience, this minimal effort at treatment is certainly
not what it takes to provide successful alcoholism treatment. So they have measured
the effectiveness of an inadequate treatment and concluded it was little better than
doing nothing at all! No surprises here.
There is no documentation that they were taught the skills of putting their lives
back together, those skills they would need to make the choice not to drink and follow
through possible. Then there was no follow up on the clients' quality of life after
treatment through the follow up period. Did they have and keep a job? Did they have
successful relationships? Did they manage life without requiring hospitalization or
further treatment? What sorts of difficulties and successes did they experience during
the follow-up period? What was their quality of life before treatment?
In my experience, people drink to manage what they feel about what has been missing
in their lives. Therefore, once the client stops drinking, they need treatment on
how to live their lives without alcohol. The research treatment appeared to teach
clients how to not drink, not how to live after treatment. Then they checked with
clients for 15 months after treatment to find out if they were still not drinking
or how much they were drinking. Not surprisingly, the outcomes were not very good.
The real shame is that many people without scientific training in critically reading
research are going to see this article in NewScientist.com and may conclude that CD
treatment is useless. That is a real tragedy. Fortunately, CD and MH treatment is
much more comprehensive in Minnesota than that which was offered to the clients in
the study. People generally are treated for their symptoms and offered an opportunity
to learn how to better live their lives. And outcomes, in my experience, are much
This was interesting research with some useful results. One result suggests people
who never attend treatment by dropping out before attending may well prove to be a
sufficient comparison group. Those that dropped out of treatment after one session
had the worst outcomes and might be best treated as a separate comparison group.
Also the authors suggested developing instruments for measuring client's motivations,
opportunities, beliefs and hopes and that they are critical issues in treatment. Finding
ways to measure them would likely be fruitful. And how they interact with the treatment
environment may also suggest better treatments and identify what characteristics of
clients most likely to benefit from treatment. While I don’t agree that future
research may shift away from treatment components, as evidenced by the inadequate
treatment regime used in the study, I do agree that patient characteristics and quality
of life may well predict treatment outcome. I would add that outcome is likely better
measured by quality of life measures before and after treatment than any other measure.
Because I am a treatment clinician who has considerable experience in treatment settings,
I have a significant personal and professional investment in believing at least some
treatment is effective.
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