COMMENTARIES

Commentaries on Miller & Moyers (2015) CLIMBING ABOVE THE FOREST AND THE TREES: THREE FUTURE DIRECTIONS IN ADDICTION TREATMENT RESEARCH * Miller & Moyers have revived a debate, dating back more than four decades, about the importance of specific versus non-specific factors in addiction treatment and psychotherapy writ large [1]. They conclude, quite correctly, that the two are inseparable. I fully agree that clinical research has focused on specific treatment content, to the neglect of the relational and programmatic contexts of treatment delivery. I agree that the field of behavioral intervention research needs to move beyond a hyper-focus on standardized empirically supported treatments. However, as therapist factors overall account for only 3–7% of the variance in client outcomes [2,3], will studying the therapeutic context be sufficient to boost the effects of addiction treatments? Instead, perhaps the way beyond this long-held debate is to focus upon [1] specific techniques predicting outcomes, [2] stand-alone technologies and [3] broadening the focus to include cost-effectiveness.

Value of studying treatment techniques Few studies have linked therapist techniques with treatment outcomes, even though they have great potential to boost effect sizes [4]. Recently, my colleagues and I conducted the first study of therapist techniques predicting smoking. We found that therapists’ techniques to promote awareness and observation of smoking cues, without acting on them by smoking, predicted 42–52% lower odds of smoking at the next counseling session [5]. The implication is that focusing upon and refining intervention techniques aimed at awareness and observation have the potential for boosting the effect sizes of smoking cessation intervention and, perhaps, addiction treatments overall. Indeed, there is a growing literature on the study of taxonomies of behavior change techniques which has recently shown specific techniques that predict reductions in alcohol consumption [6]. Moving beyond the therapist: new technologies Therapists themselves may be a confound that, at least partly, accounts for the ‘effect’ of specific techniques. Our answer for addressing that confound is to study the therapy platforms that take the therapist out of the

equation. Technology-delivered interventions offer a convenient method to do that. Stand-alone technologies such as websites and smartphone applications (apps) are increasingly becoming a primary method for intervening on addictive behaviors, including alcohol and tobacco at low cost. Technologies address a critical problem that traditional therapist-delivered interventions are unlikely to ever address adequately: reach the people who need addiction treatment the most. For example, in the United States alone, the Smokefree.gov website reaches nearly 2 million people each year and has 10% quit rates—which are more than double the effect of quitting on one’s own [7]. Moreover, smartphone apps for smoking cessation reached 3.2 million people in the United States alone during 2012–13 [8]. Conveniently, such technologies provide precise methods for studying the role of specific therapy techniques in addiction treatment outcomes. For example, in our analysis of our SmartQuit apps for smoking cessation, we found that tracking practice of therapy skills, viewing a quit plan and tracking instances of letting one’s urge pass (without smoking) were associated prospectively with a higher odds of quitting [9]. Such analysis illustrates the value of technology for focusing upon specific techniques that, if shown promising, can be used in interventions —delivered either with or without a therapist.

Too much focus on treatment effect sizes: cost effectiveness is key Finally, I would argue that the focus on the factors (whether specific or non-specific) that predict outcomes is too narrow. Cost-effectiveness needs to be a new focus. Metrics such as the cost per successful outcome (e.g. abstinence), health-care savings and life years gained need to be taken into account. Beyond effect sizes, these are the hard data that payers (e.g. insurance companies, governments) and health-care administrators need in order to decide to spend precious time and resources to adopt a new treatment. Cost-effectiveness analysis can indicate [1] whether a therapy might yield the same outcomes as another therapy but cost less to implement, or [2] whether a therapist is equally effective as another therapist but costs less to employ. In sum, I am glad to see Miller & Moyers revitalize the debate over specific versus non-specific factors in psychotherapy. The way out of this long-held debate is to climb above it.

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This work was performed at the Fred Hutchinson Cancer Research Center, Seattle, WA.

© 2015 Society for the Study of Addiction

Addiction, 110, 414–419

Commentary

Declaration of interests None. Keywords Addiction, common factors, eHealth, mHealth, outcome, treatment. JONATHAN B. BRICKER1,2 Cancer Prevention Research Program, Division of Public Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA1 and Department of Psychology, University of Washington, Seattle, Washington, USA.2 E-mail: [email protected] References 1. Miller W. R., Moyers T. B. The forest and the trees: relational and specific factors in addiction treatment. Addiction 2015; 110: 401–413. 2. Strupp H. Specific vs nonspecific factors in psychotherapy and the problem of control. Arch Gen Psychiatry 1970; 23: 393–401. 3. Project MRG. Therapist effects in three treatments for alcohol problems. Psychother Res 1998; 8: 455–74. 4. Horvath A. O., Del Re A. C., Flückiger C., Symonds D. Alliance in individual psychotherapy. Psychotherapy 2011; 48: 9–16. 5. McCambridge J., Day M., Thomas B. A., Strang J. Fidelity to motivational interviewing and subsequent cannabis cessation among adolescents. Addict Behav 2011; 36: 749–54. 6. Vilardaga R., Heffner J. L., Mercer L. D., Bricker J. B. Do counselor techniques predict quitting during smoking cessation treatment? A component analysis of telephone-delivered Acceptance and Commitment Therapy. Behav Res Ther 2014; 61: 89–95. 7. Michie S., Whittington C., Hamoudi Z., Zarnani F., Tober G., West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012; 107: 1431–40. 8. Bricker J., Wyszynski C., Comstock B., Heffner J. L. Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine Tob Res 2013; 15: 1756–64. 9. Xyo I. Estimated US downloads of smoking cessation apps since 2012 [updated 24 March 2014]. Derived from: xyo. net. Accessed March 24, 2014 10. Heffner J., Vilardaga R., Mercer L. D., Kientz J. A., Bricker J. B. Feature-level analysis of an innovative smartphone application for smoking cessation. Am J Drug Alcohol Abuse 2015; 41(1): 68–73.

BRANDING ADDICTION THERAPIES AND REIFIED SPECIFIC FACTORS Forty years of clinical outcome research in addictions have shown us that treatment works, effects are small to moderate and one ‘bona fide’ intervention rarely works better than another. Every 10 years or so, a new brand of behavioral addiction treatment is introduced and, with promise, it becomes the focus of extensive outcome testing. Following a traditional drug development model, this © 2015 Society for the Study of Addiction

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involves increasing levels of methodological rigor. Behavioral outcome research also includes a successive hierarchy of contrast conditions assumed to control for non-specific therapy effects [1]. Very often, this process continues until the treatment fails in contrast to another specific treatment [2] or, worse yet, in an effectiveness study where the method is pitted against usual care [3–6]. In meta-analyses that do not account for variation in control group magnitude, the end result is a small effect size [7]. The good news is that the field of addiction has a large array of evidence-based treatments for frontline practitioners to choose from. The bad news is that these treatments show moderate and variable effectiveness and may not exceed the benefit derived from existing services. This storyline may be somewhat reductionist, but not to the extent that we do not have to start asking ourselves—why? The monograph entitled: ‘The forest and the trees: relational and specific factors in addiction treatment’ [8] thoughtfully identifies a number of themes in clinical outcome research that challenge a continued reliance upon the traditional efficacy paradigm. Underlying this paradigm is the assumption that an undiscovered specific therapy exists that will surpass the efficacy of all others. This pursuit, again, comes from a drug development model where the possibility of a truly unique pharmacological compound impacting a set of truly unique biological mechanisms is far more plausible. The authors speak to key issues of historical nuisance to randomized clinical trials and present them as empirical opportunities for new directions in outcome research in addictions. One nuisance the authors highlight is small experimental treatment effects in relation to usual care. The dissemination of a new specific therapy to frontline addictions treatment assumes that an undiscovered modality exists that will be superior to services clinicians are currently providing. This might be a fair proposal, if we were confident that the development of such a model were possible or that frontline providers were not already employing many techniques that are evidence-based. Clinical outcome research has been historically disinterested in the strengths, rather than limitations, of community care. A real contribution to future research would be a comprehensive assessment of what actually comprises the ingredients of usual services in both in-patient and out-patient settings. Another nuisance the authors highlight is that of systematic therapist effects, even in the context of a tightly controlled clinical trial. Here, the empirical opportunity would be examining the exact nature of these therapist differences that rise above the experimental treatment effect, in a positive or negative direction. When considering characteristics that make for highly effective therapists, one promising direction would be the study of ‘artful differential responding’. This quality of intuition very probably Addiction, 110, 414–419

Climbing above the forest and the trees: three future directions in addiction treatment research.

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