These ar some exerpts of the article, not the entire article itself. I didn't know if it was posted anywhere else, I think this is good to present as evidence.
Confrontation in Addiction Treatment Feature Articles - Treatment Strategies or Protocols
Written by William R. Miller, PhD and William White, MA
Thursday, 04 October 2007 ..............................
Destructive RehabsEarly claims of the superior effectiveness of confrontation and counterclaims that it was ineffective and potentially harmful relied primarily on statement of opinion buttressed by anecdotes. With the emergence of more science-grounded treatment approaches in the 1980s and 1990s came studies that began to tip the scales of this debate. Two recent reports, however, suggest that confrontation still has its proponents. A 2001 study on staff attitudes toward addiction treatment found that 46 percent of those surveyed agreed that “confrontation should be used more” (Forman, Bavasso & Woody, 2001); and a 2004 ethnographic survey of adolescent addiction treatment in the United States commonly encountered programs that were “explicitly designed to demean and humiliate” (Currie, 2004).
Scientific evidence on confrontation As the preceding history reflects, the use of confrontation in addiction treatment was based not in science, but in a confluence of cultural factors and personalities. It was primarily an American phenomenon, with very limited diffusion to other nations. We turn now to a review of relevant science on the outcomes of confrontational therapies and their conceptual underpinnings.
Efficacy of confrontational counselingSome of the first data on the effects of confrontational counseling came not from substance abuse treatment, but from research on the more general outcomes of encounter groups. Few differences or beneficial effects were found across a range of different encounter group styles. There was one style of group leader, however, who stood out from all the rest, and did so by producing an uncommonly high level of harmful outcomes: the aggressive confrontational leader.
The clearest evidence, however, regarding the efficacy of a treatment (or lack thereof) comes from random zed clinical trials, a number of which have specifically focused on confrontational therapies. The earliest of these was conducted in an inpatient alcoholism treatment facility near Bergen, Norway, where 46 patients were randomly assigned to receive or not receive an intensive “encounter group” experience in addition to treatment as usual. Contrary to prediction, no significant difference was observed in drinking outcomes at six months, with the control group showing a slightly higher abstinence rate.
In the first U.S. randomized trial, which was conducted in Mississippi (P.M. Miller, Hersen, Eisler & Hemphill, 1973), confrontational group therapy was used as a comparison group in a study of aversion therapy. Men in inpatient treatment for alcoholism.showed no better outcomes when assigned to confrontational therapy, versus electric shock aversion therapy.
Another randomized trial compared behavioral group therapy with a confrontational group designed to trigger insight . The dropout rate was four times higher from the confrontational group, and even among treatment completers there was no significant difference in outcomes, with the direction favoring the behavioral group. In a small study, MacDonough similarly compared outcomes for alcoholism patients on a behavioral (token economy) ward versus those in intensive confrontational therapy. Contrary to prediction, the improvement rates were 50 percent and 0 percent, respectively. A randomized trial in Australia found no outcome differences between those treated by a seven-week “didactic, confrontational approach” versus a minimal intervention consisting of a single session of advice.
In a Canadian study, 100 adult offenders with substance use disorders were randomly assigned to routine institutional treatment or an intensive eight-week confrontational group therapy. Overall, the added confrontational therapy group produced no better outcomes than those of the control group receiving institutional treatment as usual. There was evidence, however, that offenders with low self-esteem were differentially harmed by the confrontational therapy, showing higher rates of recidivism when placed in this treatment.
A quasi-experimental study compared outcomes for inpatients receiving “a combination of persuasion, health education and gentle confrontation” versus a group of patients referred elsewhere (primarily to medical care) because admissions to the inpatient unit were temporarily closed. No significant differences in drinking outcomes were reported, but treated patients had significantly more rehospitalizations than did referred patients. A nonsignificant trend indicated more deaths in the referred group.
Two inpatient alcohol treatment programs were compared in a randomized clinical trial with 137 older patients treated at a Veterans Affairs Medical Center in Dallas, Texas (Kashner, Rodell, Ogden, Guggenheim & Darson, 1992). One was run by empathic staff and emphasized the development of self-esteem. The comparison traditional care program emphasized confrontation of patients with past failures and current problems. At 12-month follow-up, those treated in former program showed an abstinence rate more than double that for patients treated in the confrontational program.
Two reports evaluated a 15-hour “DWI therapy workshop” that used “confrontation to develop personal awareness” (Swenson & Clay, 1980; Swenson, Struckman-Johnson, Ellingstad, Clay & Nichols, 1981). Over 18 months of follow-up, there were no significant differences in outcomes for offenders randomly assigned to the DWI therapy workshop, as compared with an untreated control group given home-study alcohol education materials.
Another clinical trial directly compared confrontational versus client-centered counseling styles. Problem drinkers were randomly assigned to one of these two therapeutic styles, both of which were delivered by the same counselors. Those assigned to the client-centered condition showed larger reduction in alcohol use (69 percent vs. 41 percent), although with a small sample this difference was not statistically significant. Because the same counselors delivered both styles and differed in their skillfulness in doing so, the authors analyzed audiotapes of counseling sessions to study what was actually done in counseling. They discovered that a single therapist response predicted how much clients were drinking a year later ( r = .65): the more the counselor confronted, the more the client drank.
DiscussionReviewing four decades of treatment outcome research, we found no persuasive evidence for a therapeutic effect of confrontational interventions with substance use disorders. This was not for lack of studies. A large body of trials found no therapeutic effect relative to control or comparison treatment conditions, often contrary to the researchers’ expectations. Several have reported harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism. This pattern is consistent across a variety of confrontational techniques tested. In sum, there is not and never has been a scientific evidence base for the use of confrontational therapies.
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