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11
PAllt;NT-TREATMENT MATCHING AND OUTCOME IMPROVEMENT
IN ALCOHOL REHABILITATION
In the decade since the Institute of Medicine last reviewed the state of research on the
treatment of alcohol problems (IOM, 1980), there has been a substantial amount of work
on patient-treatment matching. Perhaps most important has been the recognition that
matching patients and treatments is a sophisticated idea with as yet untapped possibilities
for improving the effectiveness and efficiency of treatment. In particular, as a result of the
work of Glaser (1980), Skinner (1981), and more recently Finney and Moos (1986), it has
become accepted that (a) Matching studies are among the most conceptually,
methodologically, and practically complicated of all forms of treatment evaluation research;
and (b) appropriate studies of patient-treatment matching can be accomplished only after
careful specification of patient and treatment characteristics.
In addition to making conceptual progress, researchers have investigated basic patient
characteristics that are generally predictive of outcome across a variety of treatments.
Treatment methods have begun to be specified more clearly and to be applied in the
manner specified. There has also been progress in the development and utilization of
designs appropriate to the study of patient and treatment characteristics that have sufficient
power to obsene real effects and in the use of statistical treatments that can adequately
assess the complexity of various interactions.
Advances in matching over the past decade have occurred primarily in methodological
development, patient measurement, and treatment measurement. In the first part of this
chapter, progress in each of these areas is summarized, and general suggestions for research
opportunities are presented. Review articles by Miller and Hester (1986b), Annis (1987),
and Longabaugh (1986) have been particularly helpful, and the reader is encouraged to use
these sources for additional information and references.
ADVANCES IN PATIENT-TREA1~MENT MATCHING RESEARCH, 1978-1988
The developments of the past decade provide a basis for an expectation of additional
progress in the matching area. First, after a review of the concepts, methods, and results
of existing studies, the committee suggests more focused designs and clearer evaluation
questions tailored to the treatments being studied. In the second section of this chapter,
the committee discusses potential areas of progress and identifies specific research
opportunities.
Advances in Research Methodology
The past decade has seen the increased deployment of rigorous, experimental designs to
assess treatment efficac y as well as the development of new and more sophisticated
statistical procedures to analyze multiply determined outcomes.
Many patient-treatment matching studies from the 1960s through the late 1970s were
retrospective examinations of variables that had been generated at the time of admission
to treatment from data taken from patients admitted to two or more different programs or
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treatments. They were generally analyzed by using a series of t-tests, chi-squares, or simple
correlations.
Some of the recent progress in method development is due to the practice developed
during the past 10 years of analyzing multiple outcome measures (e.g., amount, duration,
and frequency of alcohol consumption; employment; social adjustment; medical services
utilization) rather than abstinence or nonabstinence alone when evaluating alcoholism
treatment efficacy. This practice has led to the recognition that outcome is not
unidimensional and that many aspects of the patient's posttreatment condition (e.g.,
employment situation or family, psychiatric, and medical status) can have a direct bearing
on the likelihood of relapse. The earlier concentration by clinicians and researchers on a
unidimensional outcome tended to obscure the complexity of the treatment process and the
factors that accounted for treatment failure. The more recent development of measuring
multiple outcomes has encouraged researchers to give more thought to determining
reasonable goals and expectations from venous types of treatments and deciding what types
of patients could be expected to show change in each. This trend has resulted in more
rigorous designs with better specification of treatments and the patients who should
undertake them, as well as testable hypotheses regarding outcome.
Another development that has facilitated matching and is also related to the practice of
evaluating multiple outcome measures is the use of multivariate statistics. Current reports
rarely contain only two-by-two chi-square distributions of abstinent and nonabstinent
frequencies in two treatment programs. It is now recognized (Skinner, 1981; Finney and
Moos, 1986) that the number and complexity of the interactions among patient
pretreatment characteristics, during-treatment factors, and posttreatment environmental
factors cannot be characterized without the sophisticated use of multivariate statistical
procedures. The introduction of new statistical procedures has also increased the rigor of
measurement, the sophistication of the designs used, and the specificity of the hypotheses
tested.
Much progress in our understanding of matching has come from the use of more rigorous
methodologies and experimental designs. This usage should be encouraged. However,
because randomized controlled trials are not appropriate or possible for all evaluation and
treatment matching studies in all clinical settings, it is necessary to develop a range of
rigorous, quasi-experimental designs.
There have been few evaluations of patient treatment matching strategies outside of public
or institutional settings that treat mainly lower socioeconomic strata patients. Given the
importance of social supports and stability in determining outcome across a varieW of
treatments, it may be that some of the conclusions reached to date apply to only a limited
segment of the patient population. In addition, what some researchers have seen as
resistance to evaluation on the part of clinics and clinicians may be the result of ethical
and financial pressures. Many private clinics that might have liked to participate in
evaluations may have been prevented because of design limitations.
Three matching strategies that have been developed within recent years are discussed below.
1. Ewing (1977) proposed a Cafeteria matching strategy in which patients are offered
several alternatives and are permitted to select among them. The major limitation of this
strategy is that the attractiveness of a treatment is assessed along with its efficacy, and
attractiveness has been shown to be a major factor in determining retention in treatment
and acceptance of treatment goals (Luborslgr et al., 1984; Miller, 1985~.
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- ~
2. Feedback designs employ early findings to generate testable hypotheses that in turn
generate self~orrecting further hypotheses (Glaser, 1980; McLellan et al., 1980, 1983a,b).
Patients are evaluated pre- and posttreatment within a multiprogram network, with no
modification of standard patient-program assignments. Data are analyze, and
patient-program Statistical hunches are developed on the basis of retrospective data. In
the second stage of the project, patients are assigned, based on the launches, to the
programs that may be best for them. Data are again analyzed, and ~matched" patients are
compared with ~mismatched. patients. Limitations include the influence of the self-selection
process, the need for adequate variability in program characteristics, and the need for a
relatively stable treatment network.
3. Experiments can be designed to test the addition of a critical treatment element to
the usual treatment. This strategy can be effective in cases in which there is a minimum
standard treatment available. Because no patient is denied the standard treatment and
because participation in this type of study can lead to extra care, these designs are often
well accepted by both patients and treatment staff. The limitations of this design concern
the sample sizes that can reasonably be generated and the types of treatments for which
this design can be used.
-
All three of these designs may allow matching research to be done in settings, treatments,
and populations that have not previously been studied. They may also permit the research
findings generated thus far to be more easily translated into clinical practice.
The following are opportunities for research on methodology development:
· Euang's cafeteria matching strategy should be reexamined.
· Statistical models of clinical decision making should be employed. The clinical
decision-making process of senior, experienced-clinicians can be modeled mathematically
by using discriminant function or path analyses. Studies should be performed to examine
the data that are used in making treatment assignment decisions (Miller and Hester, 1986b).
· Experiments designed to test the addition of a critical element to the usual treatment
should be attempted.
· Studies should be performed using feedback designs.
Advances in Patient Measurement
During the past decade there has been greater recognition of the full range of problems
commonly seen among alcoholics who present for treatment. As discussed in Chapter 8,
a number of measurement instruments have been developed to assess these problems, both
at the time of admission, when such instruments serve as predictors of treatment outcome,
and at follow-up points, when they function as outcome criteria. The social, psychological,
and economic problems of alcohol-dependent patients may contribute to relapse and
therefore should be targets for intervention during alcohol treatment (Finney and Moos,
1986~. This realization has broadened the scope and complexity of treatment evaluations.
Several groups have used developments in patient measurement to search for generic
patient variables that may be broadly predictive of outcome across several different types
and settings of treatment. This rapidly progressing area of research has been reviewed by
Longabaugh (1986), Miller and Hester (1986b), and Annis (1987~. Four types of
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measurement appear to be generally predictive of treatment outcome as evidenced by
replication in more than one treatment setting and in more than one type of patient
population:
1. Social stabilitY/socia1 supports. Fewer supports result in worse treatment response
generally but especially in the case of outpatient treatment. This factor appears to be a
major generic predictor (McLellan et al., 1983a; Longabaugh and Beattie, 1985~.
2. Psychiatric diagnosis including severity/number, duration, and intensity of symptoms.
Greater severity indicates generally worse treatment response, especially for outpatient
treatments. This measure of overall impairment, irrespective of diagnosis, has been a good
predictor across a variety of outcome domains and patient populations (McLellan et al.,
1983a,b; Cooney et al., 1987; Rounsaville et al., 1987; Babor et al., 1988~. Specific
diagnoses (e.g., major or intermittent depressive disorders, panic attacks) have been the
symptom patterns usually associated with greater overall severity of psychiatric illness among
alcohol-abusing patient populations. These diagnostic entities have received a great deal
of attention as predictors of outcome. The differentiation of primary and secondary
psychiatric disorders in alcoholics has been emphasized by Schuckit (1984) as a predictor
of treatment outcome. As new and more specific treatments develop for psychiatric
disorders, these treatments are being provided to patients with concomitant alcohol
problems.
3. Severity of alcohol use/severity of alcohol dependence syndrome. Greater severity
means worse treatment response generally and, especially for outpatients, more rapid return
to drinking and drinking problems. This variable has probably been the best predictor of
posttreatment alcohol consumption and alcohol-related problems, although it has been
somewhat less effective as a predictor of adjustment in other areas such as employment,
medical health, or family relations (Orford, Openheimer, and Edwards, 1976; Polich, Armor,
and Braiker, 1980; Lyons et al., 1982; Babor et al., 1988~.
4. Antisocial personality (ASP) disorder. The presence of ASP is generally indicative
of poor treatment response across all modalities with the possible exception of enforced
disulfiram treatment (Schuckit, 1984; Stabenau and Hesselbrock, 1984; Hesselbrock, Meyer,
and Keener, 1985; Powell et al., 1985~.
Other patient variables have been related to treatment outcome in general, but they have
not been examined extensively. These variables include a family history of alcoholism,
particularly in a f~rst-degree relative (Schuckit, 1985) and cognitive or
information-processing problems (Walker et al., 1983~. There is also a large literature on
the use of personality tests such as the Minnesota Multiphasic Personality Inventory
(MMPI) to develop topologies of clients that would be differentially responsive to
treatment; however, thus far no group within these topologies has emerged that has a clear
relationship to treatment response. New and promising approaches to the subtyping of
patients based on combinations of personality traits, drinking history, and familial variables
have been developed by Morey, Skinner, and Blashfield (1984), Zucker (1987), and
Cloninger (1987~. To the extent that these topologies are found in the future actually to
represent homogeneous groups of alcoholics, it will be more efficient to match treatments
to patient types defined by multiple characteristics than to patient types defined by
individual traits or characteristics.
Although it is encouraging that there has been a great deal of replication of these generic
"patient predictor findings," all of which appear to be conceptually sensible and potentially
useful clinically, more research should be done on the following areas of patient
measurement:
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· Parametric work is needed to determine the strength of these variables across a
variety of patient mixes and treatment types.
· The extent to which robust predictors cova~y, especially in selected segments of the
population, should be examined. For example, it is possible that a high level of alcohol
dependency, ASP, and a history of familial alcoholism may occur together, especially in
chronic male alcoholics.
· The American Psychiatric Assomation's revised edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III-R) differs in major ways from DSM-III,
and it will be important to determine whether the differences in classification affect patient
outcome across a range of treatments.
· With the exception of ASP, there has been very little evidence that the presence of
a specific psychiatric disorder is predictive of treatment outcome. Global symptom severity
has been more predictive than specific diagnosis. Specific treatments must be developed
to address the specific needs of certain diagnostic groups (e.g., depressed alcoholics,
alcoholics with panic disorder) before matching can become optimal.
· Additional work is needed to better define and describe the dimensions of ASP
(including impulsiveness, learning disorder, childhood aggression, relationship problems, and
criminal activity) to determine the particular factors responsible for the observed resistance
to treatment for alcohol problems.
· Motivation for change is widely viewed as an important predictor of response tO
treatment, but there has been little indication that this quality can be measured either
reliably or validly. A clear definition of motivation and a means of measuring it would be
valuable. Work reported by Prochaska and DiClemente (1983) that describes a method for
measuring "readiness for change" should be extended.
ADVANCES IN TREATMENT MEASUREMENT
New treatment models have been developed during the past several years, including the
relapse prevention model (Gorski and Miller, 1982; Marlatt and Gordon, 1985) and brief
interventions (Sanchez-Craig and Walker, 1982; Sanchez-Craig, 1984; Miller, 1985~. There
have also been wider use of standard treatments in different settings and experimentation
with outpatient detoxification and rehabilitation (Longabaugh et al., 1983; Hayashida et al.,
1989~. In addition, manual-directed relapse prevention efforts (Marlatt and Gordon, 1985)
and self-help treatments (Sanchez-Craig, 1984; Heather, 1986; Miller, 1986) have been
developed and implemented. These new models are welcome developments for a variety
of reasons. The manuals are an important source of training in theory and practice for
clinicians and promote the standardized delivery of treatment. They are also valuable for
researchers, enabling the derivation of better measures of treatment goals and processes.
Although there has been progress in treatment process standardization, other areas still
require work. New treatments are needed for specific segments of the population such
as the cocaine-alcohol-dependent patient, the antisocial personality alcoholic, the alcoholic
schizophrenic, and the medical patient with an alcohol-related disorder (e.g., alcohol
cardiomyopathy, alcohol hypertension).
· .
These new treatments should be conceptually
related to the specific problems of the target populations and should use manuals for
guidance tO ensure the accuracy of treatment application.
It should be noted that patient-treatment matching can occur only when there are clearly
different treatments. Many treatments are minor variants in practice. There is no evidence
at this time that any single process or approach will work for every patient, and newer
methods may succeed where older ones have not. As much attention should be paid to
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developing instruments that measure characteristics of treatments as has been paid to the
development of instruments that measure characteristics of patients.
Although it is frequently said that patient characteristics account for more variability in
outcome than do treatment characteristics, this perception could be a function of the lack
of available treatment measures (Glaser, 1980~. The development of treatment manuals for
specific therapies has promoted cnterion-based measures of the extent to which treatments
are actually delivered as intended, the quantity of treatment provided to a patient, and
ratings of its quality. Moreover, evaluation research using these manual~erived process
measures has begun (Luborsly et al., 1984~. Instruments are now needed to assess the
nature and amount of various treatment components across a range of treatment programs
and across various stages of the treatment process. This assessment would provide some
indication of which training components are most effective as well as suggestions about how
to train therapists and improve the delivery of these components. The lack of such
instruments has handicapped the study of matching and the accurate evaluation of
treatment efficacy.
The following questions represent opportunities for research on treatment measurement:
· What is treatment supposed to do? Many insurance companies and treatment
funding agencies have reduced to 28 days the amount of time for which they will reimburse
alcohol rehabilitation (formerly, they reimbursed from 90 to 120 days). Have the goals of
treatment changed to reflect these time constraints? Are the goals of rehabilitation clearly
different from detoxification, or do they complement each other?
· Have patients reached the established goals of treatment by the time they are
discharged or released? There are few studies evaluating progress during the course of
treatment (as opposed to outcome measures on the completion of treatment).
· How much entreatments does it take to produce a given level of change for a specified
number of patients? It is necessary to develop a more quantified estimate of treatment
effects so that more informed decisions can be made regarding how much treatment is
necessary and in turn how much treatment should be compensated by insurance companies.
· Does the achievement of during-treatment goals relate to posttreatment success?
The-work by Finney, Moos, and Mewborn (1980) showing the importance of the
posttreatment environment has led to new studies. However, even this excellent research
lacks the specificity of measurement necessary to determine if the "treatments has been
applied in the intended manner and to an adequate extent.
· What are the "active ingredients" of treatment? Treatment programs offer many
services or interventions. In a study by McLachlan and Stein (1982), patients received a
standard treatment package of medical consultation, disulfiram or calcium carbimide, group
psychotherapy, education, relaxation training, nutritional counseling, physiotherapy, physical
training/exercise, and individual planning for an alcohol-free life-style. Are all of these
necessary? Are they all associated with outcome? What are the essential or Active
ingredients? Investigators have been attempting to match people to treatment settings
(inpatient and outpatient) or treatment programs without knowing which factors are
responsible for observed patient changes.
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RESEARCH ON PATIENT-TREATMENT MATCHING:
PERSPECTIVES AND OPPORTUNITIES
Given the advances of the last decade in the areas of methodology development and patient
measurement, what can be expected in the future in the area of matching research? The
analysis of more discrete and better defined stages of the rehabilitation process offers the
greatest Dotential for progress in refining the process of treatment selection and the
provision or specific treatment components during rehabilitation. It can also help to
improve the services offered in the posttreatment environment. Just as each of these
stages of the rehabilitation process takes place in a different context and requires the
patient to set different goals, the clinical possibilities for patient-treatment matching and
the potential for matching research will also be different.
cat ~
~ ~ c'
.
In the remainder of this section the committee examines the potential for matching
research in each of four areas that correspond to typical treatment situations: (1) matching
before treatment starts, (2) matching at the initiation of treatment, (3) matching during the
treatment process, and (4) matching following the rehabilitation intervention. Critical
commentary is provided regarding the matching research conducted to date, along with
suggestions for future methods to be applied and examples of specific types of studies that
could be performed.
Matching Before Treatment Starts: Special Populations and Self-Selection
Ideally, the outcome evaluation researcher would like to examine the effects of a
representative treatment program, technique, or modality on randomly selected patient
samples that proportionally represent the total patient population. However, the
population of ~alcohol-problemed" individuals is not completely represented by the patients
who present for treatment. Moreover, because the nature of the treatment program,
including its location, cost, referral network, charter, and preferred modalities, will
determine in large part the types of patients who seek treatment, the sample of patients
evaluated at a specific treatment program will not be representative of the population of
treatment-seeking individuals. Therefore, all outcome studies done to date reflect
imperfectly applied treatments in nonrepresentative, generally self-selected patient samples;
most often these samples comprise the most severely impaired patients.
Designers of treatment programs have recognized and utilized patient self-selection in their
marketing strategies and in their clinical attempts to develop programs tailored to the
individual needs of the patient. This process, which can be termed "solicited self-selection,"
is sensible in that it is not likely that the effects of even conceptually identical and
comparably applied treatments would be similar, for example, for both a sample of older,
male, lower-socioeconomic, chronic alcoholic veterans treated in a Veterans Administration
hospital and a sample of adolescent, middle-class girls referred to treatment at a private
facility.
It is apparent that a form of matching takes place prior to the initiation of treatment
through the process of specialization as well as the selective marketing and referral of
seemingly appropriate patients. This type of marketing has encouraged the development
of special programs for special populations such as adolescents, Native Americans, women,
abused women, adult children of alcoholics (ACOAs), homeless men, and many others.
These specialized programs are by far the most extensive matching work carried out in
this country, yet little more than descriptive information is available about outcomes.
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Special populations are important for patient-treatment matching (particularly at the level
of treatment entry), but they have been difficult to study. It is not easy to discern who
constitutes a special population. In a recent seminal report by Saxe and coworkers (1983),
the special populations discussed are elderly people, adolescents, women, blacks, Hispanics,
Native Americans, drunk drivers, and public inebriates/skid row alcoholics. The problems
associated with evaluating treatment options for these groups are numerous and obvious.
The three major definitional problems are that (1) these groups have substantial internal
variability (e.g., Hispanics include Puerto Ricans, Mexicans, Cubans, etch; (2) these groups
are not mutually exclusive (e.g., ~ member of the black special population may be elderly,
Hispanic, a skid row woman, and convicted of drunk driving); and (3) they are not
exhaustive (i.e. more recent designations have added pregnant, physically handicapped, and
psychiatrically ill alcoholics to the groups already mentioned).
The matching research that has been done in this area has attempted to determine whether
differential outcomes are seen among these groups when they are treated in the same
program. To date, the modest amount of research that has been completed has shown no
clear indication that these group designations are associated with different outcomes among
those patients who have entered treatment (Westermeyer, 1982; Blum, 1987; Blume, 1986~.
It is quite clear, however, that members of these groups do not enter available "mainstream"
treatments in proportions that are representative of the alcohol problems within those
groups. For this reason, the major efforts in this area related to patient-treatment
matching have been in the development of tailored programs designed and operated by and
for selected special population groups. The goal of these efforts has been to attract more
alcohol-impaired individuals from these groups into treatment.
Although there has been a marked increase in the number of programs available, it is not
yet clear that proportionally more members of these groups have been attracted to
treatment or that greater proportions of special populations enter special programs rather
than traditional programs.
When these programs have offered attractions that were
specifically directed toward their target populations (e.g., child care for women's programs,
special access for handicapped programs), it is not clear whether or to what extent the
actual treatment provided within these programs differed from more mainstream types of
treatment or whether they were associated with differential opportunities.
These facts of clinical life do not imply that research in this area is impossible. Matching
or the prediction of outcome studies can be performed simultaneously with ongoing
treatments as long as the questions addressed and the methodologies employed are suitable
in the treatment context. The following questions represent opportunities for research on
programs designed with specialized segments of the patient population in mind:
· Do patients with the "right" patient profile stay longer, show more improvement, and
remain improved longer than patients with the "wrong" profile?
· Is greater demographic and socioeconomic homogeneity among patients associated
with better retention in a specific treatment? How much and what types of diversity can
a patient population tolerate and still maintain cohesiveness? This is a particularly relevant
question for those treating the increasing numbers of cocaine and alcohol abuse patients
who present for treatment at traditional ~alcohol-only" programs. Can these patients be
treated along with alcohol-only patients? Are treatment goals and methods compatible for
these two types of patients? Can women be treated as effectively in mixed male and female
settings as in specialized women's facilities? Similar questions could be asked with respect
to adolescent alcoholics as well as other significant subgroups in the total patient
population.
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· Do similar treatment strategies and components (e.g., group therapy, education,
Alcoholics Anonymous, disul£iram) have qualitatively similar effects on outcome among
programs with different patient profiles?
Matching at the Initiation of Treatment: Levels of Treatment Intensity
There are several different levels of treatment intensity offered in most areas:
(a) advice/self-help; (b) brief interventions (usually fewer than five counselor appointments
lasting about a week); (c) outpatient care (usually one to three hours per day, three to five
days per week); (d) partial hospitalization (usually six to eight hours per day);
(e) residential inpatient (nonmedical inpatient setting); and (f) medical inpatient (in a
specialized unit in a general or psychiatric hospital).
There now exist a body of valid, replicated data on patient factors in treatment matching
and enough understanding of the various levels of treatment that the development of more
carefully staged designs is possible. Staged or hierarchical designs refer to the tailoring of
matching hypotheses to the treatment goals and patient populations appropriate for
different levels of treatment structure (e.g., no treatment, brief treatment, outpatient,
inpatient). New work in this area should build on conclusions from previous studies that
are sensible and have been replicated. The work of many investigators has been reviewed
by Sanchez-Craig (1984) and by Miller and Hester (1986a). These efforts indicate that
individuals with less severe and shorter periods of problem drinking, better social supports,
and fewer medical or psychological problems can improve without intensive treatment.
The following are opportunities for research on matching at treatment initiation:
· Studies of matching to different levels of treatment intensity should attempt to select
patients with approximately the same level of problems and social supports. The results
of such studies might then permit a better understanding of the patient factors within the
clinically appropriate group that are associated with outcomes from each level of treatment
intensity.
· Studies of matching within each level of treatment intensity are needed to evaluate
the treatment components (e.g., group therapy, individual therapy, medication, education)
and patient characteristics in the clinically appropriate group that are associated with
favorable outcome.
· Models of patient assignment to different levels of treatment intensity (e.g., Hoffman
et al., 1987) should be evaluated in a series of controlled trials at various sites and with
various segments of the patient population.
Matching During the Treatment Process: Role of Treatment Components
There is a fairly discrete set of treatment components that is provided, or at least offered,
to most alcohol-dependent patients in treatment, regardless of the treatment modality or
setting. These components include (a) group therapy (usually focused on issues of
treatment need and denial); (b) individual therapy (usually personal counseling on
relationship problems and crises); (c) alcohol or substance abuse education; (d) attendance
at Alcoholics Anonymous (AA) meetings; and (e) antidipsotropic medications (usually
disulfiram).
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Although some research has been conducted to examine matching in treatment settings
(e.g., inpatient versus outpatient) and among programs, there has been little matching work
done on treatment components (e.g., medication, therapy, education) and even less on
therapist or counselor technique. Studies in these areas are potentially important in that
the failure to find evidence of differences in efficacy as a result of matching to different
programs or settings may be due to the similarity of the therapeutic methods employed
in these treatment venues. As has already been emphasized, there is a need for more
detailed measurement of the treatment process, as well as a need to identify the active
ingredients of treatment. If the active ingredients are identified at the process level and
if they are applied fairly similarly across treatment settings and programs, then it would not
be surprising if there were not much evidence of differential outcomes from Patient-setting
or Patient-program matching.
The following are opportunities for research on matching during treatment:
· Random patient assignment methods in controlled experimental trials can be used
most effectively used in studies within a treatment setting or program to investigate the
value of different combinations of treatment components or the addition of a specific
component to the usual treatment. The study by Woody et al. (1984, 1985) of
psychotherapy as an adjunct to standard counseling is an example of an approach that can
provide clear data on the value of specific treatment components.
· Each of the standard treatment components now used in rehabilitation programs
(education, the Twelve Steps, group therapy, etc.) should be evaluated for its contribution
to outcome by comparison with programs that have all other aspects of the treatment
except the target component.
Matching Following the Rehabilitation Intervention:
Role of the Posttreatment Environment
The work of Finney, Moos, and Mewborn (1980) has shown that the posttreatment
environment can profoundly influence the overall outcome for treated alcohol abusers. In
the past, the posttreatment environment of patients depended on the patient's personal
resources because most programs concentrated on primary treatment and the funds needed
to develop individually tailored posttreatment programs were not available. Continuing
treatment options offered to patients who had completed primary care were generally
restricted to AA meetings and possibly a weekly or monthly continuing care meeting at the
primary care site.
Because of recently shortened periods of reimbursed care for primary rehabilitation and
some new financial incentives to provide outpatient treatment, clinical programs are now
devoting more time to the development of posttreatment continuing care programs and
have attempted to bring the family of a patient into the continuing treatment process.
The availability of these services provides an opportunity for patient-treatment matching
research following the period of primary rehabilitation.
The following are opportunities for research on patient-treatment matching following
primary rehabilitation:
· Comparative studies of AA treatment, relapse prevention, individual therapy, or
family therapy following the completion of primary rehabilitation might be initiated in a
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variety of treatment settings and patient populations. Do these interventions add anything
beyond primary treatment? What types of patients benefit most from each of these
treatments? Idealtr, this research should involve parametric studies that investigate the
optimum duration and intensity of treatments and should include measures of
cost -effectiveness.
· Comparative studies of different posttreatment environments (e.g., halfway houses,
quarter-way houses, family treatment centers) should be conducted to determine the overall
efficacy of these environments and the types of patients best suited to them.
· Comparative studies of family treatments that are independent of the rest of the
patient's treatment program could be used to evaluate the contributions of various forms
of family education to the posttreatment adjustment of the patient. For example, during
the course of the patient's rehabilitation, families could be assigned to Al-Anon, family
therapy, alcohol education, or individual counseling. It should then be determined whether
these interventions add anything beyond primary treatment for the affected patient and
whether these different approaches can be matched with specific types of families.
PATIENT-TREATMENT MATCHING: SOME CONCLUSIONS
AND RESEARCH RECOMMENDATIONS
Work to date on patient-treatment matching leads to three conclusions, which are
recapitulated here.
1. Patient factors appear to be more predictive of outcome from treatment than are
treatment process factors. Techniques for measuring patient characteristics have shown
major development in breadth, reliability, and validity over the past decade. In contrast,
treatment processes have been almost unstudied, and there are no available instruments
for reliable and valid treatment measurement. The broader range of treatments now
available and under development may reveal more potent treatment process factors if
treatment is actually provided in an appropriate manner and for an adequate length of
time.
2. Of the patient variables that have been studied, psychosocial factors have been
shown to be the most important predictors of outcome for different treatment intensities
(e.g., inpatient, partial hospitalization, outpatient care). Patients with better social and
economic support and fewer psychiatric problems do well in most treatments and seem to
benefit equally from inpatient or outpatient interventions. Lower socioeconomic strata
patients and those having more serious psychiatric problems do less well in treatment
generally and fare particularly poorly in outpatient care. Such patient factors as the
severity of alcohol dependence, family history of alcoholism, and presence of antisocial
personality disorder have been generally predictive of poorer outcomes front all treatments
but are not differentially predictive of response to specific treatments.
3. There have been very few studies in which patients were matched to different
treatment components (e.g., group therapy, individual therapy, medication, relapse
prevention) Within a given level of treatment intensity. There are at this time no clear
predictors of differential outcomes from any of these components.
Work on patient-treatment matching offers the potential for significant, practical advances.
To achieve this potential, the committee makes the three following recommendations:
1. There is a need for a more specific focusing of matching questions (Longabaugh,
1986; Annis, 1987~. Efforts should be made to study well-defined treatments that have
clear therapeutic goals for specific segments of the patient population. Matching studies
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OCR for page 242
that employ appropriate designs should be considered at each level of the rehabilitation
process. At the levels of referral to the treatment program (primary care) and
posttreatment environment (aftercare), experimental designs that employ random patient
assignment and nonexperimental designs such as a cafeteria approach (Ewing, 1977) or a
feedback system (Glaser, 1980) should be considered. When assigning patients to treatment
components or treatment providers within a specific program or environment, experimental
designs with random patient assignment are preferable to evaluate the differential efficacy
of components of approximately equal attractiveness and comparable intensity.
2. More innovative interventions are needed, as well as programs designed to address
specific treatment problems of different groups in the population (e.g., the psychiatrically
ill alcoholic, the antisocial alcoholic, the cocaine- and alcohol~ependent patient). Similarly,
there is a need to continue evaluation and patient-treatment matching work with recently
developed treatments for problem drinkers (Sanchez-Craig, 1984; Miller 1985), for relapse
prevention (Gorski and Miller, 1982; Marlatt and Gordon, 1985), and for community
reinforcement (Azrin et al., 1982~. As discussed in Skinner (1981), it is difficult to study
the optimum matching of patients and treatments when there is so little variability in the
philosophy, duration, or basic therapeutic components of most treatments.
3. Reliable, valid, practical, and generalizable instruments are needed to measure the
types, amounts, and duration of alcohol treatment interventions a patient receives during
the course of rehabilitation. These measurements are important both for training therapists
and for evaluating of treatment efficacy. If treatments are not applied in an appropriate
manner, then it is unreasonable to think that they will work. We do not always know
whether a specific intervention (e.g., group therapy for denial), much less a multi-senrice
treatment program, is practiced in the manner originally intended. We do not always know
the extent to which different individuals in a single treatment receive the same types,
amounts, or duration of treatment components. The often repeated claim that patient
factors account for more outcome variation than treatment factors may be simply a function
of the unavailability of treatment measurement instruments or the close association between
certain client characteristics (e.g., age, marital status, antisocial personality) and the
posttreatment environments to which these individuals typically return. The ability to
characterize a treatment intervention or program as well as it is now possible to
characterize patients should substantially enhance our ability to predict outcomes and
assign (match) patients to optimal treatments.
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Representative terms from entire chapter:
treatment process
