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An important ingredient of the motivational model is client choice. Emphasis is placed on obtaining client agreement about the severity of drinking problems and the kinds of strategies to be used for changing the drinking behavior. To this end, clients are offered a variety of options-including doing nothing. Client commitment can be enhanced by facilitating the belief that there is "a way out" of the problem and by enabling the individual to "do something" about it.
In practice, MET is structured in two phases. Motivational approaches are at least as effective as more intensive or conventional strategies Bien et al. No significant differences were found among the three MATCH treatments in total health care costs in the post-treatment period. The cost savings associated with MET may place pressure on health care or managed care providers to adopt such methods in settings where individuals with alcohol problems are typically seen.
Treatment mismatching is a source of treatment failure and client drop-out. Many treatment modalities are founded on the assumption that the client is ready to take action, ignoring all other stages of the change cycle precontemplation, contemplation, preparation, and maintenance. Treatment mismatching occurs when treatments offered are inconsistent with the client's stage of readiness. It also occurs when more treatment is given than a client wants or when barriers to treatment are ignored.
Treatment matching allows for varied responses to be matched to client readiness. For example, in response to precontemplation processes, an intervention can increase awareness and raise doubts about the problematic behavior. In response to contemplation, the interventions are designed to help tip the decisional balance toward action and away from inaction. In preparation, intervention should involve the negotiation of a concrete and workable plan for change. Action interventions, the ones with which we are generally most familiar, assist the client in behavior change through achieving a series of small, progressive steps toward a goal.
Maintenance interventions are critical in that they help to prevent relapse and help support ongoing lifestyle change.
Subjects in the highest third of the anger variable treated in MET had an average of For angry clients, a non-confrontational approach such as MET may work more effectively to defuse anger or resistance than modalities that are typically more directive. Cognitive Behavioral Therapy CBT is based on principles of social learning theory, indicating that the problem behaviors are determined by factors in the social environment. As such, the behaviors can be "unlearned" in the same ways that they were first acquired and are now maintained. CBT focuses on learning alternative coping strategies, rather than alcohol use, to deal with potentially high-risk situations.
A functional analysis is conducted to determine target areas for intervention. A wide range of goals are identified and prioritized, and a sequence of interventions is employed to achieve them. Interventions might include assertiveness training, mood management, job seeking skills, anger control, communication training, and planning of leisure-time activities. Opportunities are provided to practice skills inside and outside the sessions i.
To build the individual's confidence, easily attainable "quick win" goals are given priority in the treatment plan.
Typical objectives associated with CBT include social skills training, reduced psychiatric symptoms, anger reduction, social support, and job finding. CBT has demonstrated efficacy when it is delivered as part of a comprehensive treatment program, rather than as a stand-alone approach. Longabaugh and Morgenstern reviewed the CBT outcome literature and concluded that CBT was more effective than other treatments when it was delivered within the context of a program to change an individuals' social environment.
The latter involved creating alternative lifestyles that would be incompatible with drinking. For example, an individual might choose to regularly attend church services with family members, find stable employment, focus on healthy nutrition, save money, and so on.
Those with more alcohol dependence symptoms fared better in TSF. These differences were observed across a number of outcomes pertaining to drinking and health care costs Project MATCH, ; Holder et al. This also has not been confirmed by subsequent research. RET involves a variety of different, but related approaches, all aimed at increasing social support for abstinence, buttressing motivational readiness, improving interactional patterns that promote and reinforce sobriety, and establishing and maintaining emotional ties with members of the social network.
Although there are conceptual differences among these approaches systems theory versus social learning theory versus Alcoholics Anonymous philosophy , each involves the promotion and active involvement of a supportive significant other in treatment. The SSO could be a child, parent, friend, clergyman, or member of a self-help group e. Toward this end, methods are used to enhance communication patterns that reinforce social support for sobriety. More specifically, RET can help to: With regard to mutual help i.
RET enables the individual to obtain ongoing social support for abstinence. This is an important ingredient of change, especially for those whose natural social networks are not supportive of abstinence. Interestingly, RET has been used effectively to enhance clients' abilities to cope effectively with drinking problems, even if they are unwilling to seek help themselves Miller, et al. RET Goals and Objectives: Some of the common goals and objectives associated with RET include: It is important to note that effective SSO involved therapy requires that both drinking and relationship issues be addressed during the course of treatment.
Interventions that include minimal SSO-involvement i. Ideal candidates for SSO's are those who are: Long-term results demonstrate the advantages of RET approaches over individual-focused alcohol therapy in terms of increasing length of stay Zweben et al. Both factors are associated with sustaining sobriety. In summary, RET studies show superior results over control groups on a number of outcome measures including drinking, marital stability, motivation, and compliance.
Concerning mutual help, it is often unclear whether it is AA attendance or AA participation e. Both were found to be positively related to abstinence Tonigan, et al, in press. These findings offer additional support for mutual help involvement. This may be why some researchers suggest that all clients be routinely encouraged not required to attend mutual help groups, especially those clients who lack a support system for abstinence Westerberg, A major limitation of treatments employed in clinical studies has been the necessity to maintain the purity or integrity of the treatment model.
Greater emphasis has been placed on adhering to the integrity of the particular treatment i. Unlike "real world" clinical settings, no attempt is made to integrate components of different models to address client problems. In other words, a person in a CBT skill building program would not have motivation enhancement, while a person in MET would not acquire skills training. The models described here are "pure" models, but the clients are not, and the process in reality is far more eclectic.
This means that individuals might have had the ability to improve their coping capacities in CBT, but did not have the requisite motivation to use them. In short, the MATCH treatment outcomes were limited by the need to reduce similarities across the three modalities. At the same time, traditional alcoholism treatment programs have not been responsive to the diverse needs and capacities of the broad spectrum of clients seen in these clinical settings Tucker, The "one size fits all" approach has often been the primary method of treating individuals with alcohol problems.
However, the evidence suggests that to best serve individuals with alcohol problems, a repertoire of interventions should be developed, tailored to the differential needs and capacities of a heterogeneous client population, and delivered in a manner that is responsive to the complex problems or issues confronting this group Tucker, A phase model of matching may be the means by which this is accomplished-see below.
The fact that few matching hypotheses were supported, and that some contrasts were in the direction opposite of what was predicted, suggest that current matching theory is under specified. A more adequate theory should specify the circumstances and conditions under which matching effects might appear. Thus, higher order a priori matching hypotheses await testing. Based on the findings emerging from Project MATCH, it is conceivable that individuals with a profile of high self-efficacy, high motivational readiness for change, and high social support for drinking would benefit most from CBT, whereas those with low self-efficacy, low motivational readiness for change and high support for drinking would benefit most from TSF.
Use of a Phase Model of Matching Evidence has shown that individuals vary in patterns of alcohol use and related consequences over the course of relapse and recovery Babor, Longabaugh, Zweben, Fuller, Stout, Anton, et al. Some individuals are able to sustain long periods of abstinence, while others may move in and out of sobriety over a lifetime. Some individuals may continue to experience serious negative consequences, despite achieving abstinence, while others may demonstrate major improvements in various areas of life following abstinence.
In this model, a broad array of assessment measures is employed. They deal with individual, interactional, and situational factors. These measures are examined in terms of how alcohol use might be directly or indirectly associated with these different areas. For example, is marital conflict a precipitant or consequence of excessive alcohol use? Can we expect an improvement in the marital relationship to be followed by a reduction of alcohol use or vice versa?
Decisions about the kinds of strategies to be employed are based on an understanding of how these individual, interactional, and contextual variables interact with the treatment variables to produce good treatment outcomes. For those clients whose environments were highly supportive of drinking, positive change in treatment was predicated on consequent changes occurring outside of treatment-namely, AA involvement.
MATCH treatments may have helped to initiate change, but AA participation was necessary to maintain or consolidate its benefits Longabaugh, et al. Thus, in "phase model" terminology, symptom improvement i. In sum, a phase model might offer us some guidance to determine what kinds of strategies might address special problems linked with the drinking, and how best to deliver these strategies to maximize treatment benefits.
Nevertheless, phase model matching requires an ongoing, dynamic process of assessment to work. The benefits of naltrexone for abstinence have been linked with a sustained period of abstinence and in preventing a "slipup" or "set-back" from turning into a full-blown relapse. In the same study, the likelihood of returning to heavy drinking following an initial drink was lower for individuals who received 50 mg daily of naltrexone than for placebo treated clients O'Malley, Jaffe, Chang, Rode, Schottenfeld, Meyer, et al.
However, these benefits did not persist beyond the four-month follow-up after the 12 weeks of active treatment O'Malley, et al. This raises important questions about how to extend the benefits of naltrexone so that: Another promising medication, acamprosate , is a glutamate antagonistic that addresses the negative effects of protracted withdrawal. Acamprosate has been shown to be effective in a multi-center, randomized control trial conducted in Europe.
This large scale clinical trial more than 4, patients combined acamprosate with routine psychosocial treatment cf. Ten of the eleven treatment centers involved with the trial demonstrated superior results of acamprosate compared with the control group Soyka, This translates into a 2-to-1 abstinence enhancement rate.
Similar results were detected in the U. However, enthusiasm for these findings is tempered by several limitations. The empirical literature on alcohol use disorders suggests that no single treatment has been proven to be superior. Instead, it should be remembered that treatment options each have associated advantages and disadvantages. This module has examined several promising approaches to the treatment of alcohol use disorders.
An additional strategy that warrants examination is the combination of approaches to maximize benefits and treatment efficacy. Both clinical experience and research evidence remind us of the benefits gained by integrating pharmacotherapy and psychosocial interventions for the treatment of alcohol problems. Evidence suggests that combining a medication with a moderate intensity psychosocial intervention may produce outcomes beyond those generated by each of the these approaches alone Carroll, In a recent study, O'Malley and colleagues demonstrated the advantages of combining naltrexone with cognitive behavioral therapy.
In an earlier trial O'Malley, et al. These treatment responders were randomized to one of two conditions over a six-month period: Subjects who had received primary care counseling brief advice and support during the earlier study, and were placed on the placebo, drank more often and had more heavy drinking days than did the naltrexone-treated subjects.
However, it is interesting to note that subjects who received CBT in the earlier study were able to maintain treatment gains throughout the six-month period, regardless of whether they were assigned to a placebo or naltrexone condition. Thus, medications such as acamprosate and naltrexone have the potential for reducing the unpleasant effects of craving during the first three months of treatment-a particularly vulnerable period for alcohol dependent clients-thus culminating in a sustained period of abstinence.
This can help practitioners to work more successfully at increasing motivational readiness, enhancing self-efficacy, and mobilizing appropriate individual and social coping resources. Social work practitioners need to gain familiarity with these new medications, along with the state-of-the-art techniques for motivational interviewing, cognitive behavioral treatment, and relationship enhancement therapies in order to better serve their alcohol dependent patients.
Knowledge of these pharmacological and psychosocial methods should be integrated into the curricula offered by schools of social work, along with recent evidence demonstrating their utility with individuals who have alcohol use disorders. Finally, it is important to address non-treatment as an option. This module has focused on various types of interventions designed to enhance motivation and treat alcohol use disorders. However, some clients do make changes without participation in professional intervention. However, the term "spontaneous remission" is something of a misnomer, as it fails to convey the depth and breadth of the intensive effort required to make lasting behavior changes.
For those who do enter into formal treatment endeavors, it is possible that the most effective treatment is simply to facilitate natural change processes by: The effect of general practitioners' advice to heavy drinking men. British Journal of Addiction, 87, Inventory of drinking situations: Situational confidence questionnaire SCQ Biological assessment of alcohol consumption.
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Marlatt Eds Changing addictive behavior: Bridging clinical and public health strategies pp. A controlled trial of treatment and advice. Journal of Studies on Alcohol, 38, Attempted referral as intervention for problem drinking in the general hospital. What is currently known? Shchedrin Pieces from the Ballet Konyok. Visions of Africa Series. An Artistic Evening of Viktoria.
MariusCichyRodion Shchedrin - piano Rec. The last two pieces - Moresque and Cancion arabe,. Ludmil Angelov piano began performing as duo in Albeniz are parts of four pieces for piano , where motifs from his ballet The Little Hump-Backed Horse. Double Concerto Romantic Offering for piano , cello and orchestra Marc-Andre Hamelin is a superb advocate for all three.