Blending Addiction Science and Practice: Evidence-Based Treatment and Prevention in Diverse Populations and Settings

Transcription

1 William R. Miller, Ph.D. The University of New Mexico Have you noticed: that in multisite trials (like CTN) of treatments that are already evidence-based even under highly controlled, supervised, manual guided delivery conditions the expected main effects are often quite small? and that efficacy often varies by therapist and by site? In practice, EBTs are not homogeneous entities This even happens with pharmacotherapies Project MATCH COMBINE Study Intake 4 Months 16 Months CBT MET TSF CBI + Placebo Naltrexone, No CBI Placebo, No CBI CBI + Naltrexone and Psychiatry, University of New Mexico Page 1 of 15

2 MI = 3 Sessions vs. SBNT = 8 Sessions TREATMENT TESTED 004 MET 005 MI 013 MET 021 MET 009 Smoking cess. 011 Tele calls 015 Seeking Safety 006 Incentives 007 Incentives PRIMARY OUTCOME Drug use & retention days - nsd Use: nsd 5 vs. 4 sessions p<.05 Retention nsd (pregnant users) Drug use & retention nsd Cessation nsd by 13 weeks Retention nsd; PTSD symptoms & drug use nsd 8.6 vs 5.2 sessions abstinent p< vs 2.3 sessions abstinent p <.001 The specific effect size for manual-guided EBT is typically small Even small effects may be clinically meaningful With large multisite samples, statistical significance can be found for small effects, but do clinicians care? and Psychiatry, University of New Mexico Page 2 of 15

3 Clinically significant improvement = large enough to be interested in learning a new treatment method. Approximately 10 point increase in % doing well doubling or halving of continuous measures or Miller, W. R., & Manuel, J. K. (2008). How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review, 27, Learning More from Clinical Trials Where are the bigger effects? and Psychiatry, University of New Mexico Page 3 of 15

4 Azrin 1973 Azrin 1976 Azrin 1982 % Days Abstinent Traditional CRA % Days Abstinent Psychologists tested patients in three different treatment programs They identified patients with particularly high alcoholism recovery potential (HARP) HARP vs. non-harp patients did not differ from each other on prior treatment history or severity of alcoholism and Psychiatry, University of New Mexico Page 4 of 15

5 More motivated for counseling More punctual in meeting appointments Showing greater self-control Neater and more attractive in appearance More cooperative Trying harder to stay sober Showing better recovery Higher rates of abstinence Longer spans of abstinence Fewer slips More employment HARPs had been selected at random. and Psychiatry, University of New Mexico Page 5 of 15

6 Average 12-Month Drinking Outcomes for 8,389 Clients Survival 98.5% Percent Days Abstinent: 81.4% Percent Continuous Abstinence 24.1% Average Reduction in Consumption 87.0% Overall outcomes were fairly similar for treatment as usual (RAND, VAST, RREP), pharmacotherapy trials (lithium, disulfiram), and controlled trials of psychosocial treatments (MATCH) Miller, W. R., Walters, S. T., & Bennett, M. E. (2001). How effective is alcoholism treatment? Journal of Studies on Alcohol, 62, Percent Days Abstinent MATCH Pre Months 1 3 Months 4 6 Westerberg, V. S., Miller, W. R., & Tonigan, J. S. (2000). Comparison of outcomes for clients in randomized versus open trials of treatment for alcohol use disorders. Journal of Studies on Alcohol, 61, and Psychiatry, University of New Mexico Page 6 of 15

7 Percent Days Abstinent MATCH TAU Pre Months 1 3 Months 4 6 Westerberg, V. S., Miller, W. R., & Tonigan, J. S. (2000). Comparison of outcomes for clients in randomized versus open trials of treatment for alcohol use disorders. Journal of Studies on Alcohol, 61, Supportive-Expressive Therapy: 3 Counselors provement Percentage of Imp Drug Use Employment Psychiatric Effect Size Luborsky, McLellan, Woody, O Brien & Auerbach, 1985 Archives of General Psychiatry 42: Two drug treatment counselors resigned Their 62 cases were assigned randomly to the four remaining counselors There were dramatic differences in client outcomes. McLellan et al., 1988 Journal of Nervous and Mental Disease, 176, and Psychiatry, University of New Mexico Page 7 of 15

8 % Positive Urines Methadone Dose % Employed % Arrested McLellan et al. (1988). Journal of Nervous and Mental Disease, 176, All Clients got the same manual-guided treatment in the NIAAA COMBINE Study Mean PDA Baseline Mean PDA Week 4 Mean PDA Week 26 Mean PDA Week 52 Mean PDA Week 68 Much emphasis is given to common factors as an alternative to EBTs So-called common factors may or may not be all that common in practice If they exert a large effect, they should not be hard to observe Nonspecific just means that they have not yet been adequately specified and tested Why not both.. and? and Psychiatry, University of New Mexico Page 8 of 15

9 Miller, Benefield & Tonigan (1993) JCCP 61: Confront (r =.65) 42% Miller, Benefield & Tonigan (1993) JCCP 61: Accurate empathy is a well-specified, learnable, reliably measurable therapist skill the ability to understand and reflect clients meaning Originally defined and studied by Carl Rogers It is not identification with your client and Psychiatry, University of New Mexico Page 9 of 15

10 Were delivering the same manual-guided behavior therapy (self-control training) Were trained both in behavior therapy and accurate empathy Had sessions independently d observed and rated by three supervisors, including the Truax & Carkhuff scale for accurate empathy Were then rank-ordered (1-9) for empathic skill while delivering behavior therapy And when we examined 6-month client outcomes Miller, Taylor & West (1980) JCCP 48: and Psychiatry, University of New Mexico Page 10 of 15

11 6 months 12 months 24 months r =.82 r =.71 r =.51 67% 52% 26% Miller & Baca (1983) Behavior Therapy 14: Patients in treatment for alcoholism were randomly assigned to counselors with: LOW levels of empathy and related skills MEDIUM levels of empathy and related skills or HIGH levels of empathy and related skills What percentage of patients relapsed? Valle (1981) J Studies on Alcohol 42: and Psychiatry, University of New Mexico Page 11 of 15

12 20 minutes in ER One handwritten letter One telephone call % Attending AA Systematic Encouragement Systematic Encouragement Standard Procedures Hire Empathic Therapists! It is an evidence-based practice to hire staff based on and to train staff in empathic skill 12-month drinking outcome determined by therapist factors (random assignment designs) There s some beef! Miller, Taylor & West 1980 Valle 1981 Miller et al., % 42% Relapse Empathy Empathy Confronting ( ) and Psychiatry, University of New Mexico Page 12 of 15

13 OR THE BOARDS and Psychiatry, University of New Mexico Page 13 of 15

14 and some of them are influenced by the therapist There are some specific treatment effects generally supported by clinical trials They are often relatively small compared to Therapist effects Client effects and social context Overall impact of treatment And perhaps for these reasons they vary across sites These larger nonspecifics (e.g., empathy) need to be specified, tested, and trained as EBTs Treatment-as-usual is a high standard to beat Re-training staff in EBTs can be challenging and expensive Specific treatment effect size often shrinks with dissemination into clinical practice Therapist belief/enthusiasm blif/ i / style matters Testable question: Is it cost effective to re-train staff in an EBT? In any event, it makes sense to train the next generation of addiction professionals in EBTs from the very beginning and Psychiatry, University of New Mexico Page 14 of 15

15 What is it about the therapists who are delivering the treatment that affects outcome? What is it about the treatment that really matters? Understanding the underlying mechanisms of efficacy of treatments and therapists will help us to know: Whom to hire What is essential in training What to focus on in fidelity monitoring What can be changed in adaptations and Psychiatry, University of New Mexico Page 15 of 15