UKAT: U. K. ALCOHOL TREATMENT TRIAL

Everyone has a view about the nature and remedy of Addiction disorders, most likely because so many of these behaviors are visible in the public domain. Moreover they are common, so everyone knows someone who has one. As a result, things done in the name of treatment are sometimes based in science and sometimes they have more to do with folklore.

BACKGROUND

Many treatments of drinking problems have been presented over the years, some have endured due to the scientific evidence for their efficacy, but many have endured because of their popularity and in spite of the paucity of evidence for their effectiveness. A handbook of treatments shown to be effective, with ratings of their effectiveness from clinical trials as well as clinical descriptions of the method of their delivery was published during the nineties (Miller and Ilester, 1995): following on front this a large study was conducted in the U.S., which aimed to answer the question of whether one treatment was better than another for certain sorts of people (for example those who were socially stable, mentally ill, committed to entering treatment). Three treatments were compared in the attempt to answer this question and one of these involved encouraging clients to enter Twelve Step recovery programs in the form of Alcoholics Anonymous. The other two treatments were individually based cognitive and behavioral programs, the one focusing on behavior change and the other focusing on motivational change. All were found to be equally good at helping people with Alcohol dependence and problems to give up or reduce their drinking (Project MATC11, 1997).

In the U.K., treatment for problem drinking and dependence has taken a somewhat different course: the twelve step approach to recovery, while practiced in Alcoholics Anonymous, is not the most common form of or basis for treatment. Most treatment agencies in the U.K. are provided by the state and based in the cognitive behavioral approach. Moreover, the pursuit of moderation drinking goals for those with mild to moderate levels of alcohol dependence and an absence of alcohol related physical harm is common. Controlled drinking practice is prescribed for a minority of patients in most treatment agencies. A further consideration leading up to the present study was the growing recognition of the central role of the social network in supporting change in people with alcohol and drug problems. It has increasingly become common practice in the U.K. to recruit family members and significant others in the process of treatment (Orford, 1994).

In light of these considerations, the Medical Research Council in Britain agreed to fund a multi-center study of treatments for drinking problems. The Principal Investigators, a mixture of National Health Service and University based clinicians and researchers have collaboratively designed and implemented the study. Results will be available in the year 2002.

DESIGN

The UKATT study compares two treatments to determine their relative effectiveness: Motivational Enhancement Therapy, adapted from the treatment studied in Project MATCH (Miller et al. 1992), is treatment which targets the motivation of the individual for drinking and for stopping or reducing drinking. Using feedback of objectives tests which are run as part of the assessment procedure, the therapist uses specific techniques which have been shown to enhance client motivation for change. The content of sessions is discussion of the negative consequences of continuing to drink in a harmful fashion and of the benefits of change. The treatment with which MET is compared is Social Behavior and Network Therapy whose focus is network support for change. Treatment sessions concentrate on the recruitment of social network whose members are than encouraged to modify their coping responses, improve lines of communication with the client, assist in the development of a relapse prevention program including identification of alternative activities and further sources of support. This treatment is adapted from a number of sources, primarily the Community Reinforcement Approach (Hunt and Azrin 1973) and Network Therapy (Galanter 1993). Both treatment protocols are specified in manual form and supervision of therapy, conducted by telephone and simultaneous viewing of videos, is designed to ensure manual adherence.

Clients for the study are recruited at the participating clinical centers, which are a combination of National Health Service and counseling agencies for the treatment of alcohol dependence. The clinical sites are in three different parts of the country: Yorkshire, South Wales, and the Midlands. The goal is to include as many as possible of the clients normally treated in these agencies and therefore the exclusion criteria have been kept to a minimum. People with active mental health problems or with addiction to a different treatment. Those younger than sixteen are not included: they have to be seen with a responsible adult other than the therapist and this would interfere with the individual nature of one of the treatments. Homeless people are not excluded provided that they can demonstrate that they have contact with someone in the community and are deemed possible to trace after treatment is complete, at three months and at one year. This requirement tends to exclude only those who are rootless and not in regular contact with any other agency. Also excluded are those who have already been treated as part of the study, the goal is to identify the effects of a single dose of the treatment rather than repeated doses.

Once they have been accepted for the study, clients are given a battery of tests and questionnaires designed to measure their drinking, related psychological and physical health, their use of health and other social services, their social networks, the extent to which there is drinking in these, their daily activities and whether these involve, their motivational stage of change and readiness for treatment. Clients are than randomly assigned to one of the two treatments which commences forthwith. Where there is a preliminary requirement for medically supervised withdrawal from alcohol or the need for another physical or social intervention, the above assessment will be deferred until this has been achieved.

An important goal of the study is to be pragmatic in order that the findings are relevant to the average treatment agency in the U.K. Relevance would mean that the treatments could be offered as the standard treatments for alcohol dependence and problem drinking by those staff normally recruited to work in such agencies. Therapists for the study are therefore existing employees at the clinical sites participating in the study. They are invited to express an interest in becoming a study therapist and to submit a resume and video recording of their practice for selection. If deemed suitable they are also randomly allocated to be trained in one or the other treatment. They are unable to select the treatment that they will be delivering in the study. The purpose of this procedure is to address the question of whether it is the case that any therapist with the above qualifications can be taught to deliver these treatments.

The therapists normally have professional qualifications in nursing, medicine, social work, occupational therapy or counseling and at least two years experience working with clients with drinking problems. They attend a three-day introduction to the therapy to which they have been assigned and this takes place at the national training center in Leeds in Yorkshire. Thereafter they are required to practice and demonstrate competence by objective pre-determined criteria with at least two cases before proceeding to offer treatments in the study.

All therapy sessions are video recorded for the purpose of supervision, standardization of the delivery of treatment and evaluation of the extent to which these things have occurred.

OUTCOMES

The effectiveness of the two treatments is judged on the basis of the amount and frequency of drinking, the level of dependence and alcohol related problems in the study clients at three months and at twelve months. Measures of quality of life, economic activity, psychiatric morbidity and adjustment are also used to assess the value of the treatments.

Qualitative data on the process of therapy and the perceptions of the client and therapist of the active ingredients of the treatments are collected through a number of instruments administered at the end of the therapy sessions and the quality of the deliver of the treatment is separately assessed through independent ratings of therapist performance as demonstrated in the video recordings or practice. Integrity of the treatments as well as individual variations between therapists are identified through this method off evaluation.

CLINICAL IMPLICATIONS

There is an increasing demand for time limited treatments of alcohol dependence, for standardization and transparency of practice. While it is well recognized that there are therapist behaviors which are associated with improved outcomes in clients and these behaviors are often expressed in rather individual ways, it is also recognized that too often the question of the duration and nature of treatment is based upon the personal preference of the therapist and therefore subject to a variety of overt and convert influences. That therapists with a wide variety of backgrounds and different working practices can be taught to adhere to a manual and to deliver treatments in line with protocols has been demonstrated during this trial. How effective their interventions will be revealed in the results.

BIBLIOGRAPHY

Galanter, M. (1993). Network therapy for alcohol and drug Abuse: A new approach in practice. New York: Basic Books Inc.

Hester, R. K., and Miller, W. R. (eds.). (1995). Handbook of alcoholism treatment approaches: Effective alternatives. Needham Heights, MS: Allyn and Bacon.

Hunt, G. and Azrin, N. (1973). The community reinforcement approach to alcoholism. Behaviour Research and Therapy, 11, 91-104.

Miller, W. R., Zweben, A., Di Cleente, C. C. and Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATC11 Monograph Series No. 2. Rockville, MD: NIAAA.

Oxford, J. (1994). Empowering family and friends: a new approach to the prevention of alcohol and drug problems. Drug and Alcohol Review, 13, 417-429.

Project MATC11 Research Group. (1997). Matching alcoholism treatments to client heterogencity: Post treatment drinking outcomes. Journal of Studies of Alcohol, 58, 7-29.

Gillian Tober