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Substance Abuse Treatment Modalities: Literature Review

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Confrontation/Encounter Techniques

The impetus for a confrontational style of substance abuse treatment stems from the assumption that substance abusers as a group tend to deny or fail to recognize the reality of their problems and that it is therapeutic to confront them with reality. Although approaches vary, the usual procedures include a forceful and factual presentation of evidence that the individual has a substance abuse problem, refutation of the client's protestations to the contrary, and application of any available leverage or contingencies to persuade or coerce the individual to accept his/her substance problem (Miller & Hester, 1986).

Reviews of the treatment literature have revealed an absence of controlled evaluations examining the effectiveness of a confrontational style of treatment (Eliany & Rush, 1992; Miller & Hester, 1986). Although not as generalizeable, results of less rigorous studies have found that confrontation as a treatment intervention often produces poorer treatment outcomes. For example, Lieberman et al. (1973) reported that a hostile-confrontational style of group leadership was associated with more negative outcomes than other leadership styles. Likewise, research on motivation for change does not support an exhortatory or argumentative style as optimal for inspiring behaviour change (Miller, 1983).

There is very limited investigations of outcome based on a confrontational style of treatment. Swenson and Clay (1980) screened subjects to determine social or problem drinker classification and then assigned randomly to one of two conditions: (1) a short-term program emphasizing small group interaction and confrontation to develop personal awareness, and (2) a minimal exposure home study educational learning guide. Results indicated that the short-term treatment intervention had no more effect than minimal exposure in improving the quality of social or problem drinkers' life situations. The authors called into question the utility of confrontation as a more intrusive mode of treatment, given the equivocal results of the less intrusive home based study course.

There exists only one study that has examined the impact of a confrontational substance abuse treatment program for federal offenders. Annis and Chan (1983) compared the effectiveness of a confrontational style of treatment by randomly assigning 100 adult offenders to an intensive eight-week group therapy program and 50 to routine institutional care. Offenders in the confrontational program performed equally well compared to those who did not participate in any substance abuse treatment. However, offenders who were classified high in self-image showed greater improvement in the group therapy program (i.e., fewer reconvictions, and lower reconvicted offence severity), while offenders who were low in self-image did more poorly in group therapy than under regular institutional care.

In summary, confrontation as a style of intervention does not appear to be effective in changing substance-abusing behaviour. In different treatment settings, confrontation has not been demonstrated to be effective beyond that of minimal or no-treatment conditions. The results highlight Miller and Hester's (1986) conclusions in that confrontational approaches must be undertaken with care because of the potential for precipitating dropout, negative emotional states, lowered self-esteem, and proximal relapse. The current research suggests that confrontation as a treatment technique has little therapeutic utility.

References for Confrontation/Encounter Techniques:

Annis, H. M., & Chan, D. (1983), “The differential treatment model: Empirical evidence from a personality typology of adult offenders”, Criminal Justice and Behaviour, 10(2), 159-173.

Eliany, M., & Rush, B. (1992), The effectiveness of prevention and treatment programs for alcohol and other drug problems: A review of evaluation studies, (Unpublished report). Ottawa: Health and Welfare Canada.

Lieberman, M. A., Yalom, I. D., Miles, M. B. (1973), Encounter groups: First facts, New York: Basic Books.

Miller, W. R. (1983), “Motivational interviewing with problem drinkers”, Behavioural Psychotherapy, 11, 147-172.

Miller, W. R., & Hester, R. K. (1986), “The effectiveness of alcoholism treatment: What research reveals”, In W.R. Miller & N. Heather (Eds.), Treating addictive behaviours: Processes of change, New York: Plenum Press.

Swenson, P. R., & Clay, T. R. (1980), “Effects of short-term rehabilitation on alcohol consumption and drinking-related behaviour: An eight month follow-up study of drunken drivers”, International Journal of the Addictions, 15, 821-838.