Common factors in reducing drinking
The UKATT (United Kingdom Alcohol Treatment Trial) is one of the largest psychotherapy studies in history (n=742) and you probably haven’t heard of it. It compared two treatments: motivational enhancement therapy (MET: basically, 3 sessions of motivational interviewing) and social behaviour network therapy (SBNT: 8 sessions of a therapy aiming to help individuals build and strengthen relationships with others and other activities that would reinforce reduced drinking). There was famously no significant difference between the drinking outcomes of both groups. However, in this week’s article, Gaume and colleagues (2018) re-analysed the data to see whether any specific therapist behaviours were predictive of better outcomes, regardless of which treatment the client received.
The authors developed a 20-item rating scale that measured how often and how well therapists engaged in behaviours that were characteristic of each treatment. Independent observers used the scale to rate therapist behaviour in sessions randomly drawn from both conditions. In other words, a therapist supposed to be delivering MET was rated both on how often she engaged MET-adherent tasks such as focusing on ambivalence and discussed commitment to drinking goals, and SBNT-specific tasks such as discussing alternative activities to drinking and stressing the importance of social support in changing. The authors then performed a mediation analysis to see whether – irrespective of the actual condition clients received – MET- or SBNT-consistent therapist behaviours explained drinking outcomes.
The results weren’t the first of their kind, but it is important to keep remembering the principles they embody:
Although MET (compared to SBNT) sessions were associated with increased frequency of MET-consistent behaviours, they were not associated with increased quality of MET behaviours. This is akin to therapists in the wild not getting a performance boost just because they claim allegiance to a ‘brand’ of therapy: merely using the language and practices of a well-known therapy doesn’t ensure that you are executing it well.
Quality of MET behaviours significantly predicted drinking outcomes (higher percentage of abstinent days and lower amounts of alcohol on drinking days). There was a trend toward frequency of MET behaviours also predicting percentage of days abstinent but there was more variability in this effect. Regardless of which condition therapists were assigned to, the better they executed motivational interviewing-consistent behaviours, the bigger the reductions in client drinking. SBNT behaviours were not related to drinking outcomes.
The authors then looked at which specific MET behaviours did the heavy lifting.
What worked was being good at generic counselling skills (empathy and reflective listening) and prompting the client to set, and commit to pursuing, specific drinking goals.
Take Home
When the client’s problem is a behaviour that they are ambivalent about changing, focus on: reflective listening, accurate empathy, evoking inner tension by focusing their attention on the gap between how things are and how they would like them to be, and then eliciting specific behaviour change goals and specific intentions to carry them out.
Adherence to a protocol is not the same as being competent in it. Benchmark your results against the literature. If your results don’t match those of others who are doing what you think you’re doing, get some supervision that involves an expert observing you and giving you feedback. Describing what you do in therapy is not the same as what you do in therapy.
The therapy you think you’re doing may work through mechanisms that you’re not even paying attention to if the model you follow doesn’t focus on them. Common factors aren’t everything, but they’re robust. It’s wise to make sure that whatever you think you’re doing, you make sure you perform the behaviours common to most schools of therapy, to the best of your ability.
Go to https://psycnet.apa.org/record/2018-08981-001 for the original article.
References
Gaume, J., Heather, N., Tober, G., & McCambridge, J. (2018). A mediation analysis of treatment processes in the UK Alcohol Treatment Trial. Journal of Consulting and Clinical Psychology, 86(4), 321-329. http://dx.doi.org/10.1037/ccp0000287