K. Initiate Addiction-Focused Psychosocial Therapy

OBJECTIVE

Initiate addiction-focused psychosocial treatment that will help the patient establish early remission and prevent relapse to substance use.

ANNOTATION

1. Indicate to the patient and significant others that treatment is more effective than no treatment.

2. Respect patient preference for the initial psychosocial intervention approach, since no single intervention has emerged as the treatment of choice.

3. Consider addiction-focused psychosocial interventions with the most consistent empirical support, several of which have been developed into published treatment manuals:

§ Behavioral marital therapy

§ Cognitive-behavioral coping skills training

§ Community reinforcement and other contingency-based approaches

§ Individual and group drug counseling

§ Motivational enhancement

§ Twelve-Step facilitation training

4. Emphasize that the most consistent predictor of successful outcome is retention in formal treatment or community support.

5. Promote active involvement in Twelve-Step programs (e.g., Alcoholics Anonymous and Narcotics Anonymous) that have been helpful to many and are widely available.

6. Use effective strategies for referral to mutual help programs in the community, addressing patient preferences and prior experiences.

§ Ask whether the patient has ever attended a self-help meeting.

§ Explore the patient's attitude and concerns about attending meetings.

§ Discuss the possible benefits.

§ Describe the range of meetings that are available.

§ Refer the patient to a specific meeting, at a specific time, date, and location.

§ Follow-up regarding meeting attendance and experience.

DISCUSSION

Available qualitative and quantitative reviews consistently conclude that psychosocial treatment is more effective than no treatment (Gerstein & Harwood, 1990; IOM, 1990) and where indicated, pharmacotherapy with psychosocial treatment is more effective than pharmacotherapy alone (Carroll & Schottenfeld, 1997; Crits-Cristoph & Siqueland, 1996). However, of the many approaches empirically evaluated, no psychosocial treatment modality has emerged as the treatment of choice.

The most consistent evidence of effectiveness is found for modalities that prepare patients to prevent relapse in their everyday lives (Finney & Moos, 1998). The modalities consistently validated in clinical trials include motivational enhancement, social skills training, community reinforcement and other contingency-based approaches, and behavioral marital therapy (Carroll & Schottenfeld, 1997; Finney & Moos, 1998; Miller, 1995).

While no randomized clinical trial has compared the effectiveness of Alcoholics Anonymous per se with other treatments, treatment guided by Twelve-Step principles has shown outcome results comparable to those of cognitive-behavioral interventions (Humpreys, 1999; Ouimette et al., 1997; Project MATCH Research Group, 1997; Tonigan et al., 1996). In addition, Twelve Step meetings are the most widely available community support for recovery.

Therapist relational styles that are less confrontational and more empathic are associated with improved treatment outcome, independent of therapist training, therapeutic orientation, experience, or type of treatment (Hser, 1995; Najavits & Weiss, 1994).

EVIDENCE TABLE

	Recommendations	Sources of Evidence	QE	R
1	Indicate to the patient that treatment is effective.	Gerstein & Harwood, 1990 IOM, 1990	I	A
2	Respect patient preference for the initial psychosocial intervention approach.	Carroll & Schottenfeld, 1997 Crits-Cristoph & Siqueland, 1996 Finney & Moos, 1998	I	A
3	Consider behavioral marital therapy.	Stanton & Shadish, 1997 O'Farrell, 1993	I	A
4	Consider cognitive-behavioral coping skills training.	Beck et al., 1993 Carroll, 1998 Kadden et al., 1992 Monti et al., 1989	I	A
5	Consider community reinforcement and other contingency-based approaches.	Budney & Higgins, 1998 Meyers & Smith, 1995 Silverman et al., 1996	I	A
6	Consider individual and group drug counseling.	Mercer & Woody, 1999	I	A
7	Consider motivational enhancement.	Miller et al., 1992	I	A
8	Consider Twelve-Step facilitation training.	Nowinski et al., 1992 Ouimette et al., 1997 Tonigan et al., 1996	I	A
9	Emphasize retention in formal treatment or community support.	Finney & Moos, 1998 Simpson, 1997	I	A
10	Promote active involvement in Twelve-Step programs.	Humphreys, 1999	II-2	A

QE = Quality of Evidence; R = Recommendation (See Introduction)