Why don’t evidence-based treatments always work as well in
the community as they do in the lab? There are several reasons.
One is that the mix of patients is more variable in the
community. “When you’re implementing a treatment that was
shown to be effective in a rigorously controlled trial, and then
you implement it in a clinical setting, you get a different patient
mix, sometimes under different environmental conditions — so
you will get variable results,” says Kelly.
Another is that the people providing the treatment may be
different as well. Licensing regulations for addiction counselors
vary tremendously by state. According to the CASA Columbia
report, 14 states do not require all addiction counselors to
be certified, six states don’t have any minimum educational
requirement for licensure and 14 require only a high-school
diploma or GED. Only one state requires a master’s degree.
That means that the people providing front-line addiction
treatment often don’t have the background and expertise to do
so effectively, says Alan Budney, PhD, an addiction researcher at
“The typical training ground for substance abuse providers is
workshops,” he says. “They may learn a little bit about cognitive
behavioral therapy or motivational interviewing, and may try to
do a little. But those things take a lot of training to do well.”
Kelly agrees. “If you go around the country and ask
programs what they’re doing, they’ll say, ‘Yes, we’re doing
that.’ But if you look at what they’re actually doing, it doesn’t
resemble the treatments that are found in the original trials.”
For Kelly, the solution to this problem is to work from the bottom
up rather than the top down. He believes that treatment systems
and funding agencies should invest in a network of measurement
and reporting. Clinical treatment programs that receive federal
funding would be required to report their patients’ response to
treatment or ‘during-treatment outcomes’ in a standard way.
Then, researchers could identify underperforming programs, as
well as spot clinical innovators and more effective programs and
find out what they’re doing right.
“This has been done in other fields, like cystic fibrosis for
example,” he says. “It’s ‘measurement-based practice,’ rather
than ‘evidence-based practice.’ But really, it is evidence-based.”
Another perspective comes from Sarah Feldstein Ewing,
PhD, a clinical psychologist at the University of New Mexico
Center for Alcoholism, Substance Abuse, and Addiction. She
and Tammy Chung, PhD, a psychologist at the University of
Pittsburgh Medical Center, co-edited the June special issue of the
journal Psychology of Addictive Behaviors, which focuses on using
neuroimaging to examine the brain basis of addiction treatment.
The idea, she says, is that if researchers can figure out the neural
mechanisms that underlie these therapies, they can learn what
makes them work and how to apply them more effectively.
In her research, for example, she’s used fMRI to examine
the brains of teenagers who have received motivational
interviewing treatment for marijuana abuse. She found that
getting clients to engage in “change talk” — making statements
like, “I need to back off my marijuana use, it’s causing problems
with my family” — increased activation in brain areas related to
introspection and contemplation.
Such research is just taking off, Feldstein Ewing says, but the
goal is to eventually gain a better understanding of what makes
behavioral addiction treatments work.
“I’m hoping this research will eventually point to the active
ingredients in treatment,” she says.
Psychologist researchers like Feldstein Ewing, Sigmon, Kelly,
Budney and others are on the front lines of figuring out how to
design effective addiction treatment.
But engaging the field more broadly in addiction treatment
is crucial to improving outcomes, experts say. Right now, not
all psychologists are properly trained to recognize the signs of
addiction, and given the size of the addiction problem, they
should be, many say.
“I know that when I was getting my degree at NYU,
Join David Sheff at APA’s 2013
there were no courses, none at all, in addiction,” says CASA
Columbia’s Jon Morgenstern, PhD. “When I was teaching at
Rutgers, it was a very small part of the curriculum.”
It’s a problem that David Sheff ran into personally. At one
point early in his son’s meth addiction, he took him to a well-
respected psychologist. “In restrospect, my son was on meth
at the time. We were sitting in a room with this esteemed
psychologist, and the guy didn’t know. It wasn’t his fault, but he
hadn’t been trained to recognize it.”
It’s a problem that’s rampant in the medical profession,
Annual Convention in Honolulu
David Sheff will speak
about his new book “Clean:
Overcoming Addiction and
Ending America’s Greatest
Tragedy” at APA’s 2013
Annual Convention in
Honolulu, on Friday, Aug. 2,
from 10–10: 50 a.m. He aims
to bring his personal account
of America’s failing addiction
treatment system to people
who can help change it.
“A lot of the psychologists in the room are
going to know more than me about addiction,”
he says. “But I lived the disastrous treatment
system. I hope that I can humanize the problems
that are out there, and the need.”