Wasted research on dropouts
What makes a patient drop out from addiction treatment? It turns out scientists have been looking for the answer in the wrong place.
"We have to stop thinking that there is a defect in the patient which makes him or her drop out from treatment”, says Hanne H. Brorson.Photo illustration: Colourbox
The Norwegian government has been very vocal about its plans to achieve better quality in the treatment of substance abuse. An important part of successful addiction treatment is to prevent dropout. The number of patients who drop out is high, but those who manage to stay and finish the treatment, do much better on average than those who drop out. There is no shortage of studies on dropout. So why has all this research not helped more patients finish their addiction treatment?
Hanne H. Brorson and colleagues at the Institute of Psychology have surveyed 20 years' worth of studies on addiction treatment dropout. The bad news is that a lot of the research on droput has been a waste.
«Our most important finding is that over the last 20 years, research on droput from treatment has looked almost exclusively on demographic variables – age, sex, education, marital status et cetera. But when you look for reasons for dropout among these factors, you find, with few exceptions, nothing. This research may have been carried out at the expense of research into factors that could actually be significant,» she says.
Almost none of the studies Brorson and her colleagues have surveyed, has looked into whether the patients drop out from treatment as a result of something about the therapist or the treatment regime. The good news is that there's a good chance that precisely these things will turn out to be the crucial factors, and in contrast to the patient's age or sex, we can actually do something about the treatment regime.
Time to study treatment
«Something which looks promising, but on which we don't have much research, is what psychologists call alliance. It can be compared to having a good teacher. Perhaps you remember a teacher that you liked particularly well. You liked the teachers' method of teaching, or the teacher had the ability to convey the importance of the subject, or you got the impression that the teacher had your best interest at heart. There's a good chance that you paid extra attention in this teachers' classes, and that you learned something from them. It's the same in treatment. It's rather interesting that alliance has been the focus of a lot of research when it comes to other patient groups, while for patients in addiction treatment, researchers have instead looked at motivation for treatment. The difference is, of course, that a lack of motivation can be pinned on the patient, while a lack of alliance also involves the therapist,» Brorson says.
The treatment regime itself is another obvious candidate for more research. Could there be something about the treatment which increases the risk of patient dropout? General psychological research has shown that patient satisfaction is the most important factor in successful treatment, and much more important than the therapist's opinion.
The patient knows best
«Therapists in general are very bad at identifying which patients will benefit from the treatment, and which will not. It's a kind of blindness on our part, and it is difficult to improve when you can't spot your mistakes. But it turns out that if therapists are told that the treatment isn't going too well, then they are very good at coming up with alternative approaches which lead to a better outcome. But this depends on a systematic monitoring of the patients' satisfaction with their treatment. This is done as a matter of course for other patient groups, but not patients who are treated for addiction,» says Brorson.
She herself is currently involved in exactly this kind of treatment research. Once a week the patients in her study get access to a computer or an Ipad and use it to answer questions about their condition. What symptoms do they have, what are their relationships with themselves and others, how do they cope with their day-to-day life? Statistical methods are then used to find out if the patients are doing better or worse than before.
«Part of the reason why we do this, is that a successful treatment has certain characteristics, for instance a great deal of change early in the treatment course. If the questions reveal that the patients' treatment differs from this, that gives us a reason to change the treatment,» she says.
Health or morality?
Brorson wonders whether part of the reason why research on substance abusers has been different from research on other patient groups, might be that substance abuse has only recently been defined as a public health issue. Traditionally, it has been seen as a moral and social problem, and as such, something that the patient alone is responsible for.
Admittedly, Brorson's survey shows that some patient characteristics could help explain treatment dropout. There is a slight correlation between young age and dropout, and a substantially stronger correlation between suffering from certain types of personality disorders or cognitive deficiencies, and dropping out. These conditions could all lead to difficulties with concentration, impulsivity and difficulties with forethought and long-term planning. The last two conditions may also lead to trouble with understanding and remembering new information. All of these abilities are crucial in successful addiction treatment.
«And if you suffer from these kinds of problems, it is not very surprising if you drop out from treatment,» Brorson claims.
Learn from other patient groups
The fourth and last dropout risk factor that has been revealed in the survey, is lack of alliance, as already mentioned. The good news is that if any of these factors are present, the treatment can be adjusted to meet the patients' needs.
«It should be possible to get inspiration from other therapy situations where cognitive dysfunction is part of the picture, for instance rehabilitation after brain injury. Traditionally, addiction treatment has tended to be very focused on the addiction itself, and not so much on the other things that people with personality disorders and cognitive deficiencies may struggle with. Also, addiction treatment tends to be very controlling, but young patients who are in a process of severance from their closest family, cope badly with being under constant control. In this case, research has shown that offering support and information, and using less controlling methods, lead to more patients completing their treatment,» Brorson says.
Not a patient-defect
The conclusion is that there are multiple possible ways to achieve the good addiction treatment that the minister of health, Bent Høie, wishes for – but only if one stops spending money and resources on research that leads nowhere.
«I think a change of perspective is needed. We have to stop thinking that there is a defect in the patient which makes him or her drop out from treatment, and rather look at the interaction between the patient and the treatment,» Brorson says.
Brorson, Hanne Helene; Arnevik, Espen Kristian; Rand-Hendriksen, Kim & Duckert, Fanny (2013). Drop-out from addiction treatment: A systematic review of risk factors.Clinical Psychology Review. doi:10.1016/j.cpr.2013.07.007