We’ve been seeing a lot of claims about the comparative effectiveness of AA or 12 step facilitation (TSF) versus motivational interviewing (MI) or motivational enhancement therapy (MET), most recently here. That AA/TSF is superstitious voodoo and MI/MET is rational, evidence-based and effective. (Interestingly, the author of the piece used an appeal to authority argument by invoking Bill Miller, one of the developers of MI. Keith Humphreys points out that, “the Miller work is cited to say things he doesn’t believe”.)
Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold.
At any rate, a new study on MET just popped up in my feed reader. It included a very positive conclusion.
CONCLUSION: Motivational enhancement therapy (MET) appears to increase the percentage of days abstinent in patients with chronic hepatitis C, alcohol use disorders and ongoing alcohol use.
What was that conclusion based on?
FINDINGS: At baseline, subjects in MET had 34.98% days abstinent which increased to 73.15% at 6-months compared to 34.63% and 59.49% for the control condition. Multi-level models examined changes in alcohol consumption between MET and control groups. Results showed a significant increase in percent days abstinent overall [F(1,120.4)=28.0, p<.001] and a significant group by time effect [F(1,119.9)=5.23, p=.024] with the MET group showing a greater increase in percent days abstinent at 6 months compared with the education control condition.
So far, so good. Right? MET resulted in more days without drinking. It’s not total abstinence, but it’s movement in the right direction. That’s a good thing, right?
Oh, wait. There’s more.
There were no significant differences between groups for drinks per week.
If I understand correctly, that sounds like the MET group drank more when they drank.
The MET group appears to have gone from 19.5 drinking days per month with an average of 7.8 drinks per drinking day, to 8 drinking days per month with an average of 8.3 drinks per drinking day.
The control group appears to have gone from 19.5 drinking days per month with an average of 8.5 drinks per drinking day, to 12 drinking days per month with an average of average 7.8 drinks per drinking day.
Even if you accept drink counting as a good way to measure outcomes, that positive conclusion seems a little less positive, doesn’t it? And, when these authors argue AA or TSF don’t work, but MI or MET do, what does “works” mean?
This isn’t to say that MI isn’t useful, just that you should be suspicious when you see these comparative claims.
So, why do we see this over an over again? I imagine there are a lot of reasons. However, I heard something on the radio last week that might shed some light on on the persistence of these assertions and my sense that we’re caught up in a battle of the culture wars. I hesitate to bring this up, because I don’t want to nourish arguments that AA is religion (I’m an agnostic.), but last weeks’ episode of On Being was on science/religion debates. One of the guests said the following:
Dr. Bradley Correct. There’s another factor that you are alluding to here which is — is that not only is there a science and religion issue going on here, but there is also a power struggle going on, too. This is very much tied up with issues of power. Um, if you go back to the 19th century and look at the writings of people like T. H. Huxley, and, uh, Andrew Dickson White, um, these folks, um, saw so much of the formative influences in culture as coming from religion and they wanted to switch the locus of the power to shape culture to scientists.
And so it became a power struggle. And you see it on the Christian side as well. There are communities that, uh, that kind of want to stay closed, and one way is to make sure that people don’t talk too much to people who think differently themselves. And to create fear and suspicion and I think that’s a lot of what’s going on as well. So you’ve got all these power dynamics outside of the science and religion…
Has addiction treatment become an arena for these power dynamics? A struggle for the locus of power to shape culture?