Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 11--Matching
Chapter 11--Matching
Pages 279-312
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From page 279... ...
Anonymous In Chapter 5 of this report the principal conclusion drawn from a review of the available evidence on the efficacy of treatment was that there was no single treatment approach that was effective for all persons with alcohol problems. The chapter went on to state that "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.H Research data corroborating these conclusions are extensively reviewed in Appendix B
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From page 280... ...
A retrospective analysis of outcome results from this randomized controlled trial indicated a significant difference in the effect of treatment depending on the self-image of the individual. Persons who entered treatment with a positive self-image achieved outcomes that were significantly better than those of control subjects who were not treated; however, those who entered treatment with a negative self-image did significantly worse than controls.
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From page 281... ...
Beyond studies that investigate ways in which researchers and treatment personnel may attempt to match patients to treatment programs are studies suggesting that patients may be attempting to match themselves to the most appropriate treatments. For example, there is evidence that patients entering treatment expect to be matched.
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From page 282... ...
Persons with high severity did poorly in both inpatient and outpatient treatment; those with low severity did well in both; and those with intermediate severity had outcomes that were sensitive to careful matching to either setting. Following inpatient treatment, those high in global psychopathology and sociopathy did better in a relapse prevention group; those high in neuropsychological impairment did better in interactional group psychotherapy.
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From page 283... ...
did best in intensive treatment; nongamma alcoholics did best with simple advice. Females did better in treatment programs that had a medical orientation; males with less severe problems did best in programs with a rehabilitation orientation.
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From page 284... ...
Matching can be carried out by treatment programs themselves. Indeed, this practice may be advisable because matches elected by individuals seeking treatment may speak more to the attractiveness of the treatment than to its probable efficacy and because their judgment may be constrained by the pressures of the problems for which they are seeking relief.
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From page 285... ...
To date, there is some evidence that utilization management is an effective cost-containment strategy (Feldstein et al., 1988~; evidence that superior or even equivalent therapeutic results have been produced is not available. A program tested in the Clinical Institute of Ontario's Addiction Research Foundation, the Core-Shell Treatment Program, attempted to match all individuals seeking treatment for alcohol and drug problems to the most appropriate treatment (cf.
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From page 286... ...
286 Iz o tr w tc (J _ r?
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From page 287... ...
Hence, the committee discusses the remaining kinds of specifications in the following pages: those of treatments and of matching guidelines in this chapter and that of outcome in the next. Specification of Treatment If individuals seeking treatment are to be matched to particular treatments, there must be detailed knowledge of the treatments that are to be provided.
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From page 288... ...
For example, if most treatment programs offer only a small complement of interventions, and if they engage in careful matching, they are likely to find it necessary to refer a large number of persons to programs that provide alternative interventions. But how are they to know whether these other programs constitute a better match in terms of the treatments they offer?
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From page 289... ...
2~. The criteria in the appendix are for the admission of adults to what are termed Levels of care." For each such level (e.g., mutual/self-help, low intensity outpatient treatment, intensive outpatient treatment, etc.)
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From page 290... ...
I want to learn haw to spend free time out of my home in the community. FIGURE 11-2 Treatment Goals Inventory for the Core-Shell Treatment Program (Glaser and Skinner, 1981:312313~.
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From page 291... ...
Treatment programs differ on these beliefs; some assign the responsibility for developing alcohol problems and for dealing with them to the person seeking treatment, and others do not (Brickman et al., 1982~. Accordingly, one can systematically assess such beliefs in both potential clients and potential treatment programs prior to treatment and take them into account in the matching process.
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From page 292... ...
To be eligible for outpatient marital therapy, four assignment rules must be satisfied. The person seeking treatment must have selected a marital therapy goal statement as one of their top five goals on the treatment goals inventory; must have scored within the dissatisfaction range on the marital satisfaction scale; must have a reasonable level of social support on the social stability scale to support an outpatient intervention; and must have a spouse who is willing to participate.
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From page 293... ...
For these and other reasons, research should perhaps be viewed as an important but not an exclusive source of matching guidelines, and the need to evaluate and possibly modify research guidelines when they are applied to particular programs should be accepted as a fact of clinical life. Data-driven Selection In Chapter 10 the development of a clinical data base was discussed as a way to provide guidelines for matching to various interventions.
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From page 294... ...
Eventually, the committee believes, a highly effective set of matching guidelines can evolve. Some Treatment Controversies as Matching Problems In addition to being a method for the potential improvement of treatment outcomes, matching is a perspective that may help to resolve controversies that arise from time to time in the treatment of alcohol problems.
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From page 295... ...
One is the issue of inpatient versus outpatient treatment. discussed in the previous chapter.
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From page 296... ...
To summarize, matching is not only a useful technique for enhancing the effectiveness of treatment but casts new light on at least some treatment controversies. Two such controversies are those that have been presented as "inpatient versus outpatient treatments and Controlled drinking versus abstinence." A matching perspective, considered in the context of the broad spectrum of alcohol problems and of those who manifest such problems, moots the adversarial nature of these controversies.
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From page 297... ...
Pp. 170-182 in Handbook of Alcoholism Treatment Approaches: Effective Alternatives, R
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From page 298... ...
1976. The social climate of alcoholism treatment programs.
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From page 299... ...
1987. The Cleveland Admission, Discharge, and Transfer Criteria: Model for Chemical Dependency Treatment Programs.
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From page 300... ...
1971. Outpatient treatment of alcoholics: Effects of status, stability, and nature of treatment.
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From page 301... ...
1973. Population variation among alcoholism treatment facilities.
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From page 302... ...
1956. Comparative study of treatment methods for chronic alcoholism: The alcoholism research project at Winter VA Hospital.
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From page 303... ...
It is assumed that clinical parameters and standards of care, no economic policies, are the driving force for the appropriate treatment placement. The criteria are designed to place individuals into an appropriately intensive treatment level in accordance with appropriate standards of clinical practice.
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From page 304... ...
A Brief Description of Treatment Level Acute alcohol and/or drug intoxication and/or withdrawal potential; Physical complications; Psychiatric complications; Life areas impairments; Treatment acceptance/resistance; Loss of control/relapse crisis; Recovery environment.
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From page 305... ...
Sufficient environmental stability to indicate safe and adequate living conditions and support of recovery goals. LEVEL II: LOW INTENSITY OUTPATIENT TREATMENT Brief Description of Treatment Level Low Intensity Outpatient Treatment is the provision of outpatient services by appropriately trained professionals.
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From page 306... ...
c. Significant anxiety, guilt, and/or depression, if present, are related to chemical dependency problems rather than another psychiatric condition; Mental state is sufficiently stable to permit participation in the outpatient treatment program; Sufficient comprehension to understand the materials presented.
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From page 307... ...
c. Sufficiently supportive psychosocial environment for low intensity outpatient treatment (e.g., significant others in agreement with recovery efforts; supportive work or legal coercion)
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From page 308... ...
Brief Description of Typical Patient Admission to this level of care requires at least one of the following: a significant likelihood of the development of a withdrawal syndrome; previous history of having failed at attempts at outpatient withdrawal; the presence of a medical condition serious enough to warrant inpatient management; the presence of isolated medical symptoms of concern; external mandates for inpatient treatment; a recent history of inability to function without some externally applied behavioral controls; and significant denial of the severity of his/her own addiction. In addition, high motivation for a multifaceted intensive inpatient treatment program does not preclude admission to an inpatient setting provided other criteria are met.
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From page 309... ...
preclude participation in outpatient treatment services; Danger of physical, sexual, and /or severe emotional attack or victimization in his/her current environment will make recovery unlikely without removing the individual from the environment; The patient is employed in an occupation where his/her continued employment could jeopardize public or personal safety in the event that he/she resumed use as a consequence of treatment failure. ADULT DISCHARGE & TRANSFER CRITERIA These Discharge & Transfer Criteria are measured along several dimensions of patient participation Dimension 1 (Acceptance/Awareness)
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From page 310... ...
Transfer to a Lower Level of Care In general, transfer to a lower level of care is warranted if all of the following apply: 4. There is sufficient improvement across all the transfer criteria dimensions; There is sufficient progress in all appropriate dimensions; There is sufficient resolution of problems; Lower intensity services will continue to positively impact remaining problem areas; Such services are available and can be provided while maintaining the continuity of care.
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From page 311... ...
LEVEL II: LOW INTENSITY OUTPATIENT TREATMENT All of the following must be present for a patient to be transferred from Outpatient Treatment to a lesser level of care.
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From page 312... ...
6. Environmental Support Patient's social system and significant others are supportive of recovery to the extent that the patient can adhere to a self-directed treatment plan without substantial risk or reactivating hisser addiction.
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