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5 Does Treatment Work?
A potential hazard of framing simple questions is that they may evoke simplistic
answers. The committee has nevertheless entitled this chapter Does Treatment Work?"
because "this question is put to us by patients, legislators, referring physicians, social
planners, and many others" (Gottheil, 1985~. Some have chosen to answer the question as
it stands, usually with an unqualified affirmative. The committee, however, concurs with
the opinion of Sanchez-Craig (1986) that Moth the question and its answer are exceedingly
~ . ~ ~ ~ . , ~ . ~ ~ ~ ~ ~ ~ . . . ~ ~ ~ ~ ~^ ~ ~ ~ ~ ~
complex" and believes that a more helpful and productive answer Will be tortncomlng it tne
question is reframed.
Reframing the Question
An examination of several problems inherent in the usual form of this question is
instructive and can guide the reframing process. As it stands, the question seems to imply
that there is a single or unitary phenomenon that is to be dealt with; however, as discussed
in Chapter 1, alcohol problems are multiple and diverse. The question also focuses only
on the problems themselves and not on the individuals who manifest them. It appears to
overlook the reality of the current therapeutic effort, which consists of many treatments
rather than a single standardized form of treatment (see Chapter 3~.
In addition, the question seems to imply a "one-shot approach to the treatment
of alcohol problems, in which a single episode of treatment is the exclusive focus of
attention. Some individuals may achieve lasting positive results from such an episode, but
for others a satisfactory outcome hinges on many episodes of treatment, often of different
kinds and often delivered over an extended period of time. As a useful (albeit limited)
analogy, some forms of cancer may be effectively dealt with by a single treatment episode,
but other cancers may require repeated episodes of care, as well as combinations or
sequences of several treatments (surgery, radiation, and chemotherapy).
The simple form of the question Does treatment work?" also places too much
weight on treatment; it does not put the treatment process into an appropriate perspective.
As has been particularly emphasized in the work of Rudolf Moos and his associates
(Cronkhite and Moos, 1978, 1980; Moos et al., 1982; Moos et al., 1990), treatment is only
one of many factors that contribute to outcome. Among the others are the characteristics
of the individual who manifests the problem, the characteristics of the problem itself, and
the characteristics of the individual's posttreatment experiences.
~ ~ For example, the
probability of a positive outcome in a psychotic, homeless individual presenting for
treatment with delirium tremens is likely to be lower than that for a mildly anxious, socially
stable individual presenting in a sober state without withdrawal symptoms, even assuming
that each person receives appropriate treatment.
Finally, there is an implication in the question that there may be a uniform
criterion for "working," that is, some absolute standard for outcome. In a very general
sense, one could say that such goals as ~health" or "increased well-being" or "reduction or
elimination of alcohol consumption" represent such standards. Clinicians, however, are
aware of the need for flexible goals adapted to individual circumstances. A goal of no
further episodes of delirium tremens in the first individual mentioned in the preceding
paragraph would represent a major achievement for him but would be totally irrelevant for
the second individual.
For these as well as other reasons, the question as it stands requires elaboration.
Reframing questions of this kind is an approach that has been taken in other areas of
142
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DOES TREATMENT WORK?
143
therapeutics such as psychotherapy, in which the simple question "Does psychotherapy
work?" has given rise to similar problems (Kiesler, 1966; Paul, 1967~. Here, the expanded
question may be framed as follows: Which kinds of individuals, with what kinds of alcohol
problems, are likely to respond to what kinds of treatments by achieving what kinds of
goals when delivered by which kinds of practitioners? (Cf. Pattison et al., 1977.)
Answering the Reframed Question: Methods
If there has been a tendency to frame and to respond in a simplistic manner to
questions regarding whether treatment works, there has also been a similar tendency in
operation with respect to choosing the appropriate method for making such determinations.
To wit: to determine whether treatment works, one conducts a randomized controlled trial
(RCI~).
The Randomized Controlled Trial
The RCT has an important and even crucial role to play in the overall process of
examining the results of treatment. Nevertheless, it is only a partial role; realistically, the
RCP should be seen as only one of a number of methods for exploring the results of treat-
ment. Given the complexity of treatment, such a perspective should not be surprising, but
there has been a tendency to view the RCI as the "gold standards for all judgments
regarding treatment outcome. Perhaps it should be viewed more as a bronze standard, that
is, as a significant part of an alloy that has other important constituents as well.
In a randomized controlled trial, individuals who manifest the target problem are
randomly assigned either to the treatment method being studied or to a control
(no-treatment) or comparison (other-treatment) condition or conditions. A number of
methods may be used for implementing random assignment, such as tables of random
numbers, the drawing of lots, or even the flipping of a coin; what is crucial is that every
subject in the study have an equal probability of being assigned to each group in the study.
The purpose of the random assignment is to make any differences between the treatment
groupies) and the control or comparison groupies) chance differences rather than systematic
differences. Outcome is then determined for all groups. Because there are no systematic
differences relevant to outcome between the groups (because of the randomization
procedure), and because one group has received the treatment being examined and the
other (or others) has not, differences in outcome beyond what might be expected by chance
alone can with some confidence be attributed to the effects of the treatment.
This methodology can be used to address a wide variety of issues that arise in
treatment. In one study, for example, individuals seen at a treatment center without access
to inpatient beds were referred elsewhere when it seemed indicated but were invited to
return following their inpatient experience. Because many did not do so, it was felt that
Ha personal letter expressing concern for the patient's well-being and repeating our
invitation for further assistance" might increase the rate of return. To test this idea, half
of the next 100 patients were selected at random to receive such a letter. Of the group
that received the letter, 50 percent returned; only 31 percent of those who did not receive
the letter returned. Because this result was well beyond what could have been expected on
the basis of chance, it was concluded that the letter was effective in promoting further
contact with the program (Koumans and Muller, 1965~.
Although this example seems both straightforward and useful, RCEs have not been
widely utilized in clinical treatment programs. Furthermore, when they have been used, it
has often been to examine only the outcome of treatment rather than to examine other
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144 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
issues. The reasons for such restricted use of what is clearly a broadly applicable
methodology have not been systematically studied. They seem to lie partly in the method
itself but, significantly, in the social ecology of treatment and research as well.
Even though taking therapeutic action with respect to a given problem and
observing the effects of that action would seem to be closely related activities-perhaps even
two aspects of the same activity they are not always perceived as such. The activities of
clinicians and researchers have sometimes been viewed as antagonistic: clinicians treat, and
researchers observe. The pathways to becoming a clinician and to becoming a researcher
have in like manner been perceived as sharply divergent. One becomes a clinician, it is
sometimes argued, through experience; one becomes a researcher through study. Treatment
is a practical discipline; research is an academic discipline. The clinician's knowledge is
intuitive; the researcher's knowledge is experimental. Although these dichotomies may be
artificial and exaggerated, and the activities involved may in fact be complementary (cf.
Blackburn, 1971), with few exceptions the gulf between clinician and researcher is a
regrettable reality in the treatment of alcohol problems (cf. Kalb and Propper, 1976; Cook,
1985~.
Differing Cultures have grown up around the treatment of alcohol problems on
the one hand and research on such problems on the other. These cultures shape the
actions of those who are part of them. The RCI' is part of the culture of research; it is
not part of the culture of treatment. Regrettably, it seems a common perspective that
RCls are carried out by researchers and not by clinicians. The committee believes these
cultural differences have much to do with the relative absence of RCEs from clinical
settings in the field of alcohol treatment.
Yet there are also practical reasons for the absence of RCIs from the clinical
setting. The conduct of such trials involves the exercise of a level of methodological
sophistication that is beyond the capability of many clinical treatment programs. That no
treatment at all might be as effective as the treatment they offer is understandably not a
proposition most clinical programs will readily entertain; in addition, because most do not
offer alternative interventions (cf. Glaser et al., 1978), comparison studies often are not
feasible. There is evidence that many persons who seek treatment do not understand the
process of random assignment, even when it has been extensively explained (Appelbaum et
al., 1983~. At the same time there is evidence that those who volunteer for random
assignment to treatment have a systematically poorer prognosis than those who decline to
volunteer (Longabaugh and Lewis, 1988~.
Deeply felt ethical concerns may make it difficult for clinicians to entertain the
possibility of referral to controlled trials. Clinicians are sought out for their informed
opinions as to what kind of treatment might be best for a particular individual. As they
often have definite opinions on such questions, whether substantiated by well-controlled
studies or not, they may feel remiss if they do not provide their personal view, albeit in a
highly qualified form, when it is ur~entlv solicited. A medical ethicist has commented on
this problem:
One could readily concede that the preference of a physician' unsupported
by adequate scientific evidence, is relatively unreliable, but one might
nevertheless insist that patients are entitled to know of such preferences
(accompanied by appropriate warnings as to their merely intuitive nature).
For a physician to withhold such information would be to violate his
patient's right to the best possible care. (Schafer, 1982:723)
Under these circumstances, referral to a trial in which treatment is selected by chance alone
is quite unlikely to ensue (cf. Marquis, 1983; Angell, 1984; Taylor et al., 1984~.
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DOES TREATMENT WORK?
145
There is a further problem regarding the generalizability of results from RCTs.
Although the subjects of controlled trials can certainly be individuals who are enrolled in
standard treatment programs (as in the example given above), in many instances they tend
to be highly selected. This selectivity is often introduced with the intent of making the
results of the study more clear-cut and understandable. It nevertheless involves a distortion
of the usual clinical situation that may limit the applicability of the study.
For example, researchers with the Cardiovascular Disease Databank at Duke
University Medical Center, which contains information on all patients with suspected
coronary artery disease seen at the center, compared the characteristics of their patients
with the eligibility criteria of three large randomized trials of coronary bypass surgery.
They found that (respectively) only 13 percent, 8 percent, and 4 percent of their patients
met these criteria. The researchers concluded that "the results of these RCEs. . .apply
directly to only a small fraction of the patients with coronary disease, and it is uncertain
whether one can extrapolate from the results in a highly selected subgroup to the general
population of patients" (Hlatky et al., 1984:377~.
Even in instances in which such selection is not a problem, generalization may still
be difficult. The RCT has proven to be an indispensable method of documenting the
effectiveness of drugs and procedures in general medicine. Such procedures, however, and
especially such medications are highly likely to be uniform across different treatment
settings. Treatments of the sort generally used to deal with alcohol problems are much
less likely to be uniform.
Without special efforts of the kind that are becoming
increasingly common in most areas of behavioral research (see Chapter 11), such interven-
tions as group therapy, individual psychotherapy, and even Alcoholics Anonymous meet-
ings are likely to be highly variable from one setting to the next. Although the
comparability of medications cannot be taken for granted (Koch-Weser, 1974), two standard
doses of, for example, insulin, are much more likely to be comparable than two sessions
of "usual" group therapy.
Thus, there are difficulties in the application of RCIs to clinical treatment
programs. Some of these problems have to do with the inherent attributes of the
methodology itself, such as its complexity and the difficulties experienced by persons
seeking treatment in understanding the concept of randomization. Many other problems
have to do with factors external to the methodology, such as the way in which it tends to
be used. The committee regrets that RCIs are not more frequently utilized in clinical
settings to explore critical issues, and it favors efforts to assist in the more frequent
deployment of this methodology. But it views these efforts as necessarily long-term and
believes that, in the shorter term, alternative methodologies that avoid some of the
problems noted above (although they may be subject to other difficulties) could usefully be
broadly deployed in clinical treatment programs as an important complement to RCIs.
Defining some of the terms employed in discussing the results of treatment may
be a useful way of placing the RCI in perspective. Among the more prominent are
efficacy and effectiveness. E~`ca~ refers to the probability of benefit to individuals in a
defined population from a treatment provided for a given problem under ideal conditions
of use (modified from Lohr et al., 1988~. A test of efficacy answers the question "Can
treatment work?" Effectiveness reflects the probability of benefit when the treatment is
applied under ordinary conditions by the average therapist to a typical individual requiring
treatment (modified from Lohr et al., 1988~. A test of effectiveness answers the question
nDoCs treatment work?"
In terms of methodology the RCI is the method that can most convincingly
demonstrate either efficacy or effectiveness. It has in general been used to demonstrate
efficacy, which is another way of saying that it has tended to be used in research settings
by academically trained clinical researchers. Although it could be used by clinicians in
clinical settings to demonstrate effectiveness, and the committee would strongly support
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146 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
its use in this manner, there are many difficulties in the way (see above) that are not likely
to be readily resolved. An alternative course is to deploy a methodology in treatment settings
that, ergot as powerful as the RCT, nevertheless provides data that am useful in themselves, that
speak to the issue of effecfiven~ess, awl that complemera what can be Earned from RCTs conducted
in other setting
As will be discussed further in Chapter 12, systematic monitoring of the outcome
of treatment is such a method. To know that a high percentage of individuals who pass
through a particular treatment program subsequently achieve a positive outcome is
knowledge worth having for its own sake. Because in the usual outcome monitoring study
there is no identical comparison group, this type of study does not prove that the good
results observed were due to the treatment provided, although it does suggest that the
program me be effective. However, if randomized controlled trials have suggested that the
method of treatment being provided is effective, a greater level of confidence can be
entertained that the treatment provided in the program monitored is eff~caciou~that it may
have been a significant factor in producing the positive outcomes that were observed.
Although outcome monitoring is a far less complex methodology than the conduct
of RCTs, it has not been widely used in examining the treatment of alcohol problems.
There are, however, signs that this is changing, both in the public sector (e.g., the state of
Minnesota requires all publicly funded programs to participate in some form of outcome
monitoring) and in the private sector (e.g., the Chemical Abuse/Addictions Treatment
Outcome Registry, or CATOR, an outcome-monitoring service, is increasingly subscribed
to by private treatment programs). The committee applauds such efforts and considers the
broad application of outcome monitoring to be both feasible and desirable. (See Chapter
12 for a more detailed discussion.) If coupled with a more general use of RCIs in research
settings (IOM, 1989), regular outcome monitoring in clinical settings would represent a
highly significant advance in the treatment of alcohol problems.
The Role of Quality Assurance
For a convincing demonstration of efficacy or effectiveness to occur, mechanisms
should be in place to assure "truth in packaging that the treatment allegedly being
delivered is actually being delivered and that it is being delivered appropriately.
Accomplishing this assurance involves such activities as the selection, training, and
monitoring of treatment staff. (These activities and others like them are part and parcel
of RCIs, but the term quaky assurance is usually applied only to realistic treatment
situations.)
The necessity for quality assurance activities arises from long experience. Not all
alcohol treatment programs succeed in providing what they claim to be providing (Moffett
et al., 1975~. Programs vary. Key staff leave; new staff are hired. Various staff differ
considerably in background, training, orientation, personal characteristics, and so forth. In
the absence of quality assurance mechanisms the treatment activities of individual staff
members may evolve in differing and idiosyncratic therapeutic directions. The need for
quality assurance is not unique to the treatment of alcohol problems but is common to all
therapeutic situations (cf. Eddy and Billings, 1988; Lohr et al., 1988; Roper et al., 1988~.
Other Methods
In addition to the RCI and outcome monitoring, there are other methods that can
yield useful and important information regarding the impact of treatment on persons with
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DOES TREATMENT WORK?
147
problems. The individual case study is an example. Surveys of consumer satisfaction are
another. In recent years much attention has been given to quasi-experimental methods of
studying treatment. In short, many methods are available that can add to our
understanding of the results of treatment, and they may all be required to fully comprehend
so complex an undertaking. A single method, by itself, will not suffice.
Answering the Reframed Question: Results
Workers in the alcohol treatment field have done yeoman service in attempting to
answer questions of treatment efficacy and effectiveness. One estimate is that more than
600 treatment outcome studies have been completed, about half of which have been
completed in the 1980s; among these there have been approximately 200 comparative clini-
cal trials, about two-thirds of which have employed random assignment (Miller, 1988; IOM,
1989~. In addition to these original studies, the subject has been repeatedly reviewed over
the last four decades (cf. Bowman and Jellinek, 1941; Voegtlin and Lemere, 1942; Hill
and Blane, 1967; Pattison, 1974; Baekeland et al., 1975; Emrick, 1975; Clare, 1976;
Baekeland, 1977; Emrick, 1979; Diesenhaus, 1982; Miller and Hester, 1986; Annis, 1987;
IOM, 1989~. This body of work represents a commendable and important effort.
What conclusions can be drawn? As with any large and diverse body of
information, the data admit of differing interpretations. During the course of the present
study the assembly and analysis of information on treatment efficacy and effectiveness was
undertaken jointly by this committee and IOM's Committee to Identify Research
Opportunities for the Prevention and Treatment of Alcohol-Related Problems. The results
appear as part of this second committee's report (IOM, 1989~. The relevant chapter of
that report is reproduced here as Appendix B for the convenience of the reader.
Many of the conclusions noted in the appended material are directly applicable to
the work of this committee; a few are specifically responsive to our sister committee's
charge and are therefore beyond the purview of this group. Other conclusions have been
modified to reflect accurately the particular views of the committee for the present study.
Its somewhat modified conclusions, which are supported by the material and the citations
to be found in the appendix, are as follows:
1. There is no single treatment approach that is effective for all persons with alcohol
problems. A number of different treatment methods show promise in particular groups.
Reason for optimism in the treatment of alcohol problems lies in the range of promising
alternatives that are available, each of which may be optimal for different types of
individuals.
For example, a series of studies on heterodox eous treatment populations has shown rho
overall advar~tage in terms of outcome for residential or inpatient treatment over outpatient
treatment. Each treatment setting may be most appropriate for particular persons. Specifi-
cally, nonhospital residential care may be most appropriate for individuals who are socially
unstable (i.e., who are homeless, unemployed, etc.) but who do not have coexisting acute
medical or severe psychiatric problems. Inpatient hospital care may be most appropriate
for persons with coexisting acute medical or severe psychiatric problems, regardless of their
level of social stability. Outpatient care may be indicated for socially stable individuals who
do not have coexisting acute medical or severe psychiatric problems.
2. The provision of appropriate, specific treatment modalities can substantially improve
outcome. A variety of specific treatment methods for alcohol problems has been associated
with increased improvement, relative to no treatment or alternative treatments, in
controlled studies.
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48 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
3. Brief ir~erventior~s car' be quite effective compared with no treatment, and they can
be quite cost-effective compared with more intensive Moment. For some people with alcohol
problems, relatively minimal interventions have been shown to be significantly more
effective than no intervention and on a cost-effectiveness basis may compare favorably with
more intensive treatment (see Chapter 9~. The low cost and simple nature of brief
interventions render them accessible to a broad range of persons with alcohol problems
who might otherwise not receive treatment.
4. Treatment of other life problems related to drinking can improve outcome ir' persons
with alcohol problems. Posttreatment problems and experiences have been shown to be
important determinants of outcome. Social skills training, marital and family therapy,
antidepressant medication, stress management training, and the community reinforcement
approach all show promise for promoting and prolonging favorable outcome. Such
broad-spectrum strategies seem to affect outcome by helping to resolve other significant life
problems that, if left untreated, could precipitate relapse.
5. Therapist characteristics are determinants of outcome. Treatment is not offered by
neutral agents. Therapist skills and attributes can be important factors in influencing
treatment outcome. The interaction of therapist variables with treatment variables and with
variables of the individuals manifesting alcohol problems, as well as the more direct effects
(main effects) of therapist characteristics, has been shown to account for a substantial
amount of variance in motivation, drop-out, compliance, and outcome.
6. Outcomes are determined in part by treatment process factors, posttreatmer~t
adjustment factors, the characteristic of individuals seeking treatment, the characteristics of their
problems, and the irzleractior~s among these factors. Individual difference variables that are
non~necitic (e.~.. resistance to treatment) or specific to particular approaches (edit., the
r ~ D ~ ~ ~ ~ , ~ ~ A,
establlsnment of a conoltloneo aversion response) nave oeen snown lo prealcl Irealmen~
outcome. Recent research on pretreatment matching likewise indicates that responses to
a particular treatment may depend on the personal and problem characteristics of those
seeking treatment.
7. People who are treated for alcohol problems achieve a continuum of outcomes with
respect to drinking behavior and alcohol problems and follow different courses of outcome.
Drinking behavior following treatment ranges from an increase in drinking, to no change
in drinking, to a reduction in drinking but with continuing problems, to problem-free
drinking, to total abstinence. Alcohol problems may increase or decrease following
treatment. Some treated individuals show initial improvement with subsequent
deterioration (nfadersn). Others show a gradual increase in improvement (nsleepersn). Still
others oscillate between outcomes (e.g., between abstinence and problem-free drinking or
between abstinence and problem drinking).
8. Those who significant, reduce their level of alcohol consumption or who become
totally abstinent usually enjoy improvement in other life areas, particulars as the period of reduced
consumption becomes more extended. Treatment for alcohol problems thus wisely emphasizes
the importance of significantly reducing or eliminating alcohol consumption.
The committee views these conclusions as somewhat tentative but highly
encouraging. They are tentative both because additional replications of completed studies
are needed and because many treatment methods have not been evaluated under a range
of circumstances-for example, with many different kinds of persons. Moreover, new
treatment methods are constantly being developed, and various combinations and sequences
of treatment methods require exploration. There is no foreseeable end to the need for
information regarding the impact of treatment. Its investigation is part and parcel of the
provision of treatment (see Chapter 12~.
The conclusions are viewed as highb encouraging because they suggest that treating people
with alcohol problems is an endeavor that can produce very positive results. Although it is not
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DOES TREATMENT WORK?
149
realistic to expect outstanding results in every instance, some such results will occur, and
most persons can be helped in some way. The conclusions contain many important
indications of improvements that might be made in current treatment practices. These
suggestions will be dealt with in more detail in the balance of this report.
Summary and Conclusions
The simplistic question "Does treatment work?" needs to be reframed. In its
stark, albeit common, form, it does not reflect accurately the complexities of the
therapeutic situation or current understanding of the results of treatment research. A
preferable version of the question is the following: Which kinds of individuals, with what
kinds of alcohol problems, are likely to respond to what kinds of treatments by achieving
what kinds of goals when delivered by which kinds of practitioners?
The ongoing effort to provide appropriate answers to this reframed question
requires the deployment of a variety of investigative methods. Although the randomized
controlled trial ARCH has many advantages and should be more broadly used to answer
questions of clinical relevance, it has disadvantages that tend to limit its widespread
application in clinical treatment settings. Alternative methodologies, if less powerful in
terms of the demonstration of treatment efficacy, may nevertheless be more widely
applicable and can provide information to complement that derived from RCIs.
Based on treatment research efforts to date, which should be continued and
extended, the committee believes that some necessarily tentative but highly encouraging
conclusions may be drawn. Although no single treatment has been identified as effective
for all persons with alcohol problems, a variety of specific treatment methods has been
associated with positive outcomes in some groups of persons seeking treatment. Brief
interventions have been shown to be effective compared with no treatment and compared
with more complex treatments.
Although it is important to approach alcohol problems directly, dealing with other
life problems can also contribute to positive outcomes. Treatment outcomes are affected
by a multiplicity of factors, both within the treatment situation (e.g., the skills and
attributes of therapists) and outside the treatment situation (e.g., the posttreatment
experiences of the individuals. A significant, extended reduction or elimination of alcohol
consumption is usually associated with improvement in other areas of living; as in the treat-
ment of other human problems, however, a varieW of outcomes is to be expected.
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Representative terms from entire chapter:
treatment programs
