Reprinted from "Self-Management" issue of Visions Journal, 2003, 1 (18), pp. 29-30
Problems involving alcohol are common, and take on a variety of forms. Numerous interventions for alcohol problems have been devised over the years, and the evidence supporting different treatments varies. Since 1980, Miller and colleagues have published a series of increasingly rigourous, systematic reviews of the alcohol treatment literature.
In their latest review,1 a total of 381 studies were identified, representing 99 different treatment modalities and involving over 75,000 clients. A number of the findings are provocative. For example, the majority of treatments for alcohol problems have little or no evidence of effectiveness. More troubling, the treatments with the strongest evidence are the ones that are least available in practice, and the most commonly available forms of treatment are those with the least scientific support. In the authors’ words:
The negative correlation between scientific evidence and treatment-as-usual remains striking, and could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy.
But there is also good news. Specifically, a number of treatments have repeatedly been found effective, presenting a range of evidence- based options that benefit clients. The most effective therapies include motivational enhancement, bibliotherapy (reading- or workbook-based interventions), and other forms of brief intervention. In general, brief interventions place considerable emphasis on self-directed change, with minimal input from professionals.
Thus far, the evidence supporting brief interventions for alcohol problems is considerably stronger than the evidence for all other forms of treatment to date. Brief interventions have been used effectively for several target groups including youth, hazardous drinkers, dependent problem-drinkers, and clients who have not responded to other forms of treatment.
The effectiveness of brief interventions is good news for several reasons. First, there is growing recognition that many problems with alcohol do not involve severe dependence. Many people who would not be considered alcoholics will nevertheless experience adverse impacts due to drinking. Brief interventions can be employed effectively with a broad range of clients, including high-risk drinkers. Second, brief interventions can be used in the context of a stepped care approach. Rather than providing intensive treatment for all clients, stepped care approaches proceed gradually, beginning with less intensive forms of treatment, increasing the intensity only as needed. If the client responds to the less intensive step, then no additional resources are required. This ties in with a third benefit of brief interventions: cost-effectiveness. Brief interventions present a rare opportunity in the current context of health reform: they are both more effective than typical treatment and they are considerably less expensive. A fourth benefit relates to the fact that many people with alcohol problems will drop out of treatment. Brief interventions allow providers to make a positive impact in one or two sessions, stimulating changes and increasing the likelihood that the client will return for additional treatment if necessary.
So if brief interventions are cost-effective, useful with a broad range of alcohol problems and have abundant empirical support, then why aren’t they offered in practice? And what types of reforms might help ensure that the most effective alcohol treatments are routinely available to people who need them? In many areas of health care, coverage by health care plans is reserved for treatments that reflect evidence-based practice. This is only now becoming true with respect to treatment of alcohol problems.
Many jurisdictions are currently working to better integrate the treatment of alcohol problems with other relevant health services, including mental health and primary health care. These reforms have the effect of broadening the base of practitioners who encounter alcohol problems and can provide care. For many health professionals, brief interventions will be appealing — first because they work, and second because they can be introduced through an existing treatment relationship and do not necessarily require referral to a specialist. Clients and family members can also facilitate change by inquiring about treatment alternatives and the probability of success associated with different options.
Brief interventions are not a cure-all. However, they represent a currently-neglected component of treatment for alcohol problems, and warrant much greater attention by all parties concerned with the welfare of problem drinkers. They also deserve consideration as the first step in a menu of evidence-based alternatives from which problem drinkers may benefit.
About the authorJulian is a full-time member in the Department of Psychiatry at the University of British Columbia. His research interests include telehealth and collaborative care, as well as innovations in the education and development of health professionals. Dr. Somers has also conducted research in the areas of addictions, motivation for change, and child and adolescent mental health
- Hester, R.K. & Miller, W.R. (2003). Handbook of alcoholism treatment approaches: Effective alternatives. 3rd ed. Boston: Allyn & Bacon. (p. 41).