by Michael D. Anestis, M.S.
Late last week, a comment by "Jan" in the comments section of an article on the UPPS-P Impulsive Behavior Scale got me thinking about today's topic. She asked if individuals respond differently to different treatments for alcohol use disorders (AUDs) depending either upon their drinking motive or their respective level of positive or negative urgency. The short answer to this question is frustrating: nobody knows because we do not have that precise data. Rather than leave it at that, however, it seemed to me like this comment justified a more thorough look into what we do know about matching clients to particular treatments for AUDs.
By far the most comprehensive effort to answer this question has been Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a multi-site study in which participants were randomly assigned to one of three treatment approaches: cognitive behavioral coping skills therapy (CBT; Kadden et al., 1992), motivational enhancement therapy (MET; Miller et al., 1992), or twelve step facilitation therapy (TSF; Nowinski, Baker, & Carroll, 1992). The phrase "random assignment" refers a process by which participants are assigned to a condition (a type of therapy in this case) arbitrarily rather than basing that assignment on preference, severity of presenting problem, or any other variable. By using random assignment, the authors vastly increase the likelihood that there are no meaningful differences between the groups on variables that could effect the outcome.
Participants took part in one of two parallel studies, one utilizing outpatient clients seeking treatment for AUDs, and the other utilizing a sample of individuals in aftercare following inpatient or outpatient treatment. The researchers who designed Project MATCH had several hypotheses, but they were primarily interested in answering two questions:
- Does one of the three treatment approaches utilized in this study stand out as producing greater effects?
- Are there specific variables that can be used to determine whether an individual would benefit more from one treatment approach rather than another?
Jan's comment was most directly related to the second question, although the first question is an important consideration as well, because if one treatment is significantly better than the other two in general, there is less likelihood that individual difference variables would differentially predict treatment response across therapeutic approaches. The Project MATCH results and subsequent answers to these questions were both surprising and controversial. The authors found that all three treatments were equally effective, although individuals in TSF improved more on a variety of secondary variables (Finney & Moos, 2002). Additionally, they did not find robust evidence supporting the notion that particular patient variables would provide information regarding the best treatment approach for particular individuals (Project MATCH Research Group, 1997).
The variables utilized as the focus of the matching hypothesis were as follows:
- Severity of alcohol involvement
- Cognitive impairment
- Client conceptual level
- Biological sex
- Meaning seeking
- Motivational readiness to change
- Psychiatric severity
- Social support for drinking versus abstinence
- Psychopathy
- Typology
- Anger
- Antisocial personality
- Assertion of autonomy
- Psychiatric diagnosis
- Prior engagement in Alcoholics Anonymous (AA)
- Religiosity
- Self-efficacy
- Social functioning
These variables were chosen based upon a review of prior studies that indicated their potential utility in matching clients to particular treatments. As mentioned above, these variables did not prove useful in determining who was most likely to respond to which treatment. The authors themselves noted several reasons why this might have occurred, and to answer Jan's comment, I would like to discuss some of those reasons.
First, it is entirely possible that either the treatments or matching variables chosen by the Project MATCH Research Group are not ideal for matching clients. Personally, I think this is, for the most part, a highly probable idea. By no fault of the authors, neither drinking motives nor positive and negative urgency were the subject of much if any research at the time that this project was conducted. As such, they were not included in the study and no data is available to determine if why an individual drinks influences the manner in which he or she will respond to a particular treatment. This is not to say that these variables certainly will predict differential treatment response, but it seems like a possibility that justifies further investigation.
Another potential explanation for these findings is that, despite its efforts to understand the utility of matching clients to particular treatments, Project MATCH did not actually match clients to treatments. As mentioned earlier, random assignment was utilized in an effort to ensure minimal risk of between group differences resulting in spurious findings. A noble methodological approach in general, in this case random assignment meant that clients were not actually matched to the therapies that were hypothesized to be the most likely to help them. Comparing a matched sample to a sample randomly assigned to treatment would better serve to answer this question.
As mentioned by Heather (1999) in one of a series of commentaries on Project MATCH published in the journal Addiction, participants in all three conditions attended AA meetings, including those assigned to the TSF treatment condition, which was based on AA. As such, participants in the TSF condition - who demonstrated greater benefit on secondary variables - actually received, on average, a greater dose of their assigned treatment than did individuals in either the CBT condition or the MET condition. Given that one of the reported findings for this project is that the greater the number of sessions attended, the greater the effect of the treatment, this seems to potentially serve as a confounding problem that obscures the favorable findings for TSF.
Two others problems with Project MATCH were mentioned by Heather (1999), although he did not believe that they were necessarily as problematic as others believe them to be. First, abstinence was the sole outcome variable utilized in the study. In other words, moderation goals, which are particularly prominent in MET, were not considered in assessing the efficacy of the treatment. The presumption that abstinence alone is the marker for efficacy is subject to debate that is beyond the scope of this particular article. Additionally, Heather (1999) noted that there was no control group utilized in this study. Without a waitlist or treatment as usual control group, there is no way to determine the degree to which any of the three treatment approaches actually exhibited an impact above and beyond the effects of what would happen with any other approach or even the lack of any approach whatsoever. This is not to say that it is likely that the findings were spurious in this sense, but rather it points out that we simply can not determine how this sample compares to others, as we have no easy metric with which to compare them.
So, bringing this back to the central focus of this article, what can we conclude about matching clients to particular treatments for AUDs based upon specific variables? This deserves a two-part answer. First, the data we do have does not support the matching hypothesis. Second, we do not have data that examines whether drinking motives or positive or negative urgency might impact the degree to which an individual responds to a particular treatment. Personally, I believe that individual difference variables such as negative urgency and drinking motives could serve as informative tools for determining treatment response, but until such data exists, my opinion on that is not a useful guide. Hopefully, investigations into the use of treatments such as dialectical behavior therapy (DBT; Linehan, 1993) will be conducted in a manner that allows for treatment matching hypotheses to be tested, but until then, we are unfortunately left guessing regarding the answer to Jan's thought provoking question.
If you would like to learn more about the treatment methods utilized in Project MATCH, or treatment methods that are similar, we recommend the following products, all of which are available through our online store:
Books: Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence
;
Motivational Interviewing, Second Edition: Preparing People for Change
Kindle: Motivational Interviewing, Second Edition: Preparing People for Change
DVD: Motivational Interviewing with William R. Miller (Individual Version)
; Handbook of Cognitive-Behavioral Therapies, Second Edition
; Cognitive Therapy of Substance Abuse
Kindle:Cognitive Therapy in Clinical Practice
; Alcoholics Anonymous - Big Book 4th Edition
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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