RESEARCHUPDATE BUTLER CENTER FOR RESEARCH JUNE 2010 Research Update is published by the Butler Center for Research to share significant scientific findings from the field of addiction treatment research. Project MATCH: A Study of HAZELDEN BETTY FORD FOUNDATION EXPERIENCE Alcoholism Treatment Approaches The Hazelden Foundation, established in 1949, pioneered an approach to alcoholism treatment that incorporates the philosophy of Alcoholics Anonymous into the treatment Most issues of Research Update discuss current findings from multiple research studies. experience. In order to standardize the components and However, because of its major contribution to the understanding of addiction treatment and recovery, this Research Update focuses exclusively on one study—Project MATCH. delivery of that therapeutic treatment modality for the purposes of Project MATCH, Hazelden provided expert consultation in the development of the manual on Twelve Background and Rationale Step Facilitation (TSF).10 Hazelden’s treatment, in practice, It was long observed and acknowledged that no single treatment regimen worked best for all utilizes elements of CBT and MET approaches as well. alcoholic patients. Many studies of alcoholism treatment suggested that different treatment approaches (types of treatment and levels of care) might be more effective than others for certain types of patients.1,2 This basic notion is known as “patient matching,” or finding the best CONTROVERSIES & QUESTIONS type of treatment for a particular type of patient. The release of Project MATCH findings sparked a flurry of methodological and other discussions, applause, and In order to test that hypothesis and examine the nature and strength of associations between criticism. On the one hand, the study was criticized for various treatment and patient “matches,” the National Institute on Alcohol Abuse and Alcoholism using the Randomized Controlled Clinical Trial (RCT) as the initiated Project MATCH—Matching Alcoholism Treatment to Client Heterogeneity. Generally basis for its design rather than testing a predetermined set speaking, the goal was to determine what type of treatment worked best with what type of patient by conducting a large-scale, multi-site, statistically rigorous, randomized, clinical of matching rules. On the other hand, Project MATCH was research study, the results of which would have important implications for clinical practice.3 lauded as a rigorous test of the utility of patient/treatment matching. Of most concern, however, has been the danger of misinterpreting the results of the study. Study Design Project MATCH conducted two independent treatment matching studies using the following Question: Isn’t Twelve Step Facilitation the same as client groups: Alcoholics Anonymous? 1. 952 outpatients at five sites, and No. Twelve Step Facilitation is not the same as Alcoholics 2. 774 aftercare patients at five sites, who had recently completed an episode of inpatient or Anonymous (AA) or a referral to AA. It refers to a intensive day hospital treatment. therapeutic approach wherein a series of one-to-one counseling sessions occur between a therapist and For both the outpatient and aftercare group, the same randomization techniques, data collection patient, that address the basics of alcoholism as a instruments, treatment protocols, and follow-up procedures were used. Patients were enrolled chronic, long-term disease. The sessions also cover the into the study over a two-year period. basic philosophy of AA (particularly the first five steps), All patients were randomly assigned to one of three treatment approaches: and address the spirituality component of recovery. The patient is encouraged to participate in AA. TYPE OF TREATMENT GOAL OF TREATMENT DESCRIPTION FREQUENCY CBT Learn skills to achieve and Coping and drink-refusal skills taught by 12 weekly sessions HOW TO USE THIS INFORMATION (Cognitive Behavioral maintain sobriety therapist to handle states and situations Therapy) known to precipitate relapse Clinicians in alcohol treatment settings can apply these findings regarding anger, psychiatric severity, alcohol TSF Acceptance of the disease of Patients introduced by therapist to the 12 weekly sessions (Twelve Step Facilitation) alcoholism and loss of control first steps of Alcoholics Anonymous and dependence, and social support networks for drinking, in over drinking encouraged to attend meetings order to better assess patients upon entry into treatment. Clinicians can also examine the manuals, counselor training, MET Mobilize the person’s own Therapist applies motivational psychology 4 sessions in 12 weeks (Motivational commitment and motivation to examine effect of drinking on patient’s and patient assessment components dictated by the Enhancement Therapy) to change life, and develop and implement a plan to Project MATCH study as a general approach to treatment stop drinking that works well. Ten client characteristics examined were based on the literature: severity of alcohol involvement, cognitive impairment, conceptual level, gender, meaning seeking, motivation, psychiatric severity, social support for drinking versus support for abstinence, sociopathy, and alcoholic typology. For each treatment approach, a detailed, written manual was developed. It was accompanied by therapist training, supervision, and certification. The three treatment approaches were: 1. Cognitive Behavioral Therapy (CBT), 2. Twelve Step Facilitation (TSF), and 3. Motivational Enhancement Therapy (MET).4 < CONTINUED NEXT PAGE < CONTINUED FROM FRONT Project MATCH Study Results—Few “Matches” Found Outcomes were measured in terms of percent of days abstinent (PDD) and drinks per drinking References day (DDD). There were no significant differences across treatment approaches during and after treatment; patients in all treatment groups reported considerable reduction in drinking.5, 6 1. Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. National Academy Press. Washington, D.C. Generally speaking, clients with higher alcohol problem severity at intake did better at three 2. Del Boca, Frances K., and Mattson, Margaret E. (1994). years follow-up than clients with lower severity. (Severity was measured by alcohol involvement, Developments in alcoholism treatment research: Patient-treatment matching. Alcohol. Vol. 11. No. 6. alcohol dependence, and type of alcoholic).7 Subsequent analyses also revealed that patients 3. Project MATCH Research Group. (1993). Project MATCH: Rationale with higher anger levels had better outcomes with MET than the other two therapies.7 At and methods for a multisite clinical trial matching patients to months 37–39 another match appeared: clients who had a social network that supported alcoholism treatment. Alcoholism: Clinical and Experimental their drinking before they received treatment had better outcomes with TSF than MET.7 This Research. Vol. 17. No. 6. difference is explained, in part, by the higher AA involvement of TSF clients.8 4. Donovan, Dennis M., Kadden, Ronald M., DiClemente, Carlo C., Carroll, Kathleen M., Longabaugh, Richard, Zweben, Allen, and Rychtarik, Robert. (1994). Issues in the selection and development of therapies in alcoholism treatment matching research. Journal of Post treatment Drinking Outcomes Studies on Alcohol. Supplement No. 12. Patients in all three treatment groups reported significant reductions in drinking during the one 5. Project MATCH Research Group. (1998). Matching alcoholism year, post treatment follow-up period. Differences across treatment groups were not significant, treatments to client heterogeneity: treatment main effects and matching effects on drinking during treatment. Journal of Studies although TSF showed a slight advantage.6 on Alcohol. Vol. 59. At three years follow-up, however, a significantly higher abstinence rate was found with TSF 6. Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment clients. Among TSF clients 36% were abstinent, compared with 27% of MET and 24% of CBT drinking outcomes. Journal of Studies on Alcohol. Vol. 58. clients (p< 0.007).7 7. Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three year drinking outcomes. Alcoholism: Clinical and Experimental Research. Implications for the Delivery of Treatment Vol. 22. No. 6. Project MATCH remains the largest behavioral intervention trial conducted on alcoholism to 8. Longabaugh, Richard, Wirtz, Phillip W., Zweben, Allen, and Stout, Robert L. (1998). Network support for drinking, Alcoholics date. The main implication of Project MATCH findings is that all three treatment approaches Anonymous and long-term matching effects. Addiction. Vol. 93. are effective in the treatment of alcoholism: TSF, CBT and MET.6 The fact that few patient- No. 9. treatment matches resulted in modestly improved treatment outcomes suggests that a 9. Commentaries (1999). Comments on Project MATCH: matching major overhaul is unwarranted in the manner and extent of treatment triaging based on client alcohol treatment to client heterogeneity. Addiction. Vol. 94. No. 1. characteristics. 10. Carroll, Kathleen M., Kadden, Ronald M., Donovan, Dennis M., Zweben, Allen, and Rounsaville, Bruce J. (1994). Implementing treatment Project MATCH was the first scientifically rigorous demonstration of the effectiveness of TSF, a and protecting the validity of the independent variable in treatment matching studies. Journal of Studies on Alcohol. Supplement No. 12. widespread, but previously untested approach to alcoholism treatment. Finally, contrary to the popular belief that treatment for alcoholism is not very effective, Project MATCH found that up to one half of patients were abstinent or had significantly reduced their drinking one and three years after treatment.9 Further, the reductions in drinking were greater for the sample of patients who entered Project MATCH after completion of a residential program (not simply treated on an outpatient basis). This raises the possibility that a prolonged period of abstinence enhances long-term success and brings into question, according to Enoch Gordis, M.D., Director of the National Institute on Alcohol Abuse and Alcoholism, whether the best interests of many alcoholic patients are being best served by managed-care organizations’ replacement of residential treatment services in favor of outpatient settings.9 BUTLER CENTER FOR RESEARCH JUNE 2010 HazeldenBettyFord.org The Butler Center for Research informs and improves recovery services and produces research that benefits the field of addiction treatment. We are dedicated to conducting clinical research, collaborating with external researchers, and communicating scientific findings. Patricia Owen, Ph.D., If you have questions, or would like to request copies of Research Update, please former Director call 800-257-7800, ext. 4405, email [email protected], or write BC 4, P.O. Box 11, Center City, MN 55012-0011. 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