It can therefore form the basis of measuring performance and treatment fidelity in clinical trials, in treatment audit and in routine supervision of practice. A valid and reliable method of evaluating the delivery of manual-based psychosocial treatments for alcohol dependence and misuse. Download pdf. Share: Share Tweet. Tagged with. Research and development grants Treatment and recovery Types of treatment.
References and further reading
Rapid Evidence Review: The relationship between alcohol and mental health problems. A further subsidiary null hypothesis was included to investigate the possibility of therapist effects on treatment outcome. Most of the variation stemmed from a few therapists whose clients showed poorer outcomes. However, the project selected therapists on the basis of their previous experience in, and enthusiasm for, each of the three treatments.
Hence, they could not test whether therapist characteristics were associated with better than average outcomes in one treatment but not in another. This will enable us to test whether some therapist characteristics lead to better outcomes in one treatment than in the other.
Alex Copello (Author of Social Behaviour and Network Therapy for Alcohol Problems)
Before describing the design of the trial in any detail, we list some general principles that informed the development of UKATT and determined the kind of trial we wished to carry out. First and most obviously, we decided to conduct a pragmatic , rather than an explanatory , trial Schwartz and Lellouch, The crucial aspect of this distinction for the present purposes is that explanatory trials are concerned primarily with understanding , whereas pragmatic trials are aimed primarily at decision. UKATT is not an explanatory trial because treatment intensity 3 vs 8 sessions and treatment type motivational vs social are confounded in the design.
To decide this issue, one would need to conduct a further study that included a treatment consisting either of eight sessions of MET or three sessions of SBNT. Furthermore, in the sense that MET is, or will become, the usual form of treatment that any other treatment must improve on to be considered for routine clinical application, MET serves as a control condition to evaluate the effectiveness of SBNT, thus removing the problem of a design confound.
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Lastly, the inclusion in UKATT of a strong element of economic evaluation further emphasizes the pragmatic nature of the trial. A related distinction to the above, but with somewhat different implications, is that between efficacy and effectiveness trials see, e. Flay, ; Holder et al.
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In these terms, Project MATCH, with its 8 h of pretreatment assessment, five follow-up interviews in the first year after treatment and its use of specially selected and highly trained therapists, was an efficacy trial. It has been claimed that each of the above factors could have blunted potential differences between the treatments studied, with the result that main effects of treatment or client by treatment interactions were made difficult to detect see Heather, ; Orford, If true, this would render the findings of the trial, so this criticism runs, largely irrelevant to routine clinical practice.
So too, the exclusion from the MATCH trial of certain types of client, mainly those who showed dependence on illicit or prescribed drugs, could not name a locator person or were suffering from acute psychosis, reduced the generalizability of the project's findings to real world clinical settings. Although there are reasons for believing that these criticisms of Project MATCH are misplaced or exaggerated Heather, , we made an early decision to design a trial with, as far as possible without sacrificing internal validity, high generalizability to the real world of treatment in the UK. Thus, initial assessment is reduced as much as is compatible with the need to collect information on crucial variables; initial assessment is condensed into one 3-h session; and the next occasion on which the client visits the treatment centre is to begin UKATT treatment.
Only two follow-up assessments are scheduled during the first year after treatment. Exclusion criteria were limited so as to include as many clients as possible who would normally receive treatment at British specialist centres, again without compromising the viability of the trial. Trial therapists are not employed by UKATT but are selected from treatment staff employed by the treatment services in which the research is taking place.
Screening and identification of potential clients for the trial is carried out by clinical staff in conjunction with routine assessment procedures in place in the treatment centres. These aspects of the attempt to increase external validity will be specified in more detail below. Staff are selected for the delivery of a UKATT treatment by the submission of a curriculum vitae and a video-recording of practice demonstrating motivational interviewing skills and the ability to work with two or more clients simultaneously.
Evidence of 2 years practice in the addictions field or of substantial experience of working with addiction problems, coupled with demonstrable therapeutic ability, are normally required for therapists to be accepted as trainees. Successful candidates attend a 3-day standardized introduction to the trial and its procedures and training in the treatment type to which they have been randomly assigned.
Skills training includes role play and feedback. This intensive introduction takes place at the Trial Training Centre at the Leeds Addiction Unit and is delivered by the principal investigator PI responsible for training together with one or more specialists in the treatment being delivered and the supervisor for that treatment. The PI ensures the standardization of training during the three introductory days and the subsequent period of training practice. Following the 3 days at the Training Centre, trainees are required to complete treatments with at least two clients before being assessed for competence to practise in the trial.
These training sessions are video-recorded and a copy sent to the Training Centre where they are supervised by simultaneous viewing of the recording and telephone contact between supervisor and therapist. Only the therapist is seen on video. Competence is assessed in line with the procedures for examining skills that are validated for addiction practice modules by the University of Leeds.
On successful acquisition of competence, therapists are able to treat clients randomized to trial treatments. All sessions continue to be video-recorded and copies are sent to the Training Centre. Once competent, therapists have one-third of their sessions supervised in the manner described above in order to prevent drift from the manual protocols for each treatment. The Training Centre supervisors one for each treatment are themselves supervised by the PI responsible for training to ensure standardization of the supervision and their own adherence to manual protocols.
Both supervisors are practitioner-trainers who are required to practise the treatments they supervise.
Supervision of day-to-day problems and adherence to trial procedures outside the delivery of the treatment itself are ensured by the Clinical Manager at each site. The main focus of UKATT is a comparison of outcomes between two forms of treatment for alcohol problems and possible matching effects, but there is also a commitment to examining treatment process. This is done by both quantitative and qualitative methods.
All clients in the trial are given a semi-structured interview lasting approximately 20 min at initial assessment and at both follow-up points. The semi-structured interview has been designed to collect data for qualitative analysis, which it is hoped will illuminate the statistical findings.
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The initial assessment interview focuses on the client's reasons for seeking treatment and the follow-up interview focuses on perceptions of change during the treatment period. Interviews are tape recorded, with the client's consent, to permit qualitative analysis. Independently of the training and supervision process, the delivery of treatment is rated using a manual by a research assistant who is separately supervised. These data will also be related to treatment outcome in the analysis.
There are few data on the cost-effectiveness of different alcohol treatments and most published studies have used retrospective data or authors' estimates rather than prospective data Godfrey, The costs being considered include: the direct costs of the two therapies for each agency; any other services consumed as a direct result of the two UKATT therapies; and costs incurred by clients. The principal individual outcome measure will be changes in drinking.
Such calculations allow the results from this evaluation to be put in context of other healthcare procedures. Treatment may also have a number of other consequences that reduce costs to the rest of society. There is considerable research into the potential for treatment to reduce future healthcare costs Potamianos et al. Crime costs, especially those related to public order, may be reduced after treatment and workplace productivity increased. All costs and consequences are being considered whoever bears them: publicly funded agencies; individual drinkers and their families; or the rest of society.
Motivational Interviewing and Behaviour Change in Addiction Treatment
The social focus of SBNT may have a greater impact on these consequences as well as on individual outcomes. The detailed costing work alongside the potential savings to the public sector will be used to investigate the financial implications of implementing the results of the trial.
A brief screening of potential candidates for the trial is carried out by clinical staff from among referrals to treatment centres taking part in the trial. The purpose of screening is to eliminate clients who are clearly unsuitable for the trial and to identify those likely to meet exclusion criteria. Screeners are supplied with guidance notes that describe and discuss inclusion and exclusion criteria and they also receive special training in screening requirements from UKATT researchers. In cases where there is doubt as to eligibility, screeners are requested to make a referral to the UKATT research staff.
The objective of this interview, which is carried out by UKATT research personnel following referral by clinical staff, is to establish eligibility for the trial and willingness to participate, leading to the signing of informed consent and entry to the trial. An additional requirement is that alcohol is the client's main problem for which help is sought. It is also necessary that the client has drunk alcohol within the last 3 months. In cases of doubt about inclusion or exclusion criteria, the over-riding principle determining whether a client should be admitted to the trial is whether or not the client would be offered treatment under normal circumstances at the treatment centre in question.