An article from University of Oslo
Wasted research on rehab dropouts
What makes someone drop out from addiction treatment? It turns out scientists have been looking for the answer in the wrong place.
University of Oslo
An important part of successful addiction treatment is to prevent dropouts.
The number of those who don’t finish their treatment is high, and there is no shortage of studies on the subject.
Hanne H. Brorson and colleagues at the Institute of Psychology at the University of Oslo have surveyed 20 years' worth of studies on addiction treatment dropout.
Their aim was to find out why all this research have not helped more patients finish their addiction treatment.
Looking at the wrong variables
“Our most important finding is that, over the last 20 years, research on droputs from treatment has looked almost exclusively on demographic variables – age, sex, education, marital status et cetera,” Brorson says.
“But when you look for reasons for dropping out 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.
Therapist and treatment
Almost none of the studies Brorson and her colleagues have surveyed has looked into whether the patients drop out from treatment of reasons related to the therapist or the treatment regime.
“Something we don't have much research on is what psychologists call alliance,” she says.
The researcher compares the phenomenon to having a good teacher that one likes particularly well.
“There's a good chance that you would pay extra attention in this teachers' classes, and that you would learn something from them. The same mechanisms are in play between therapist and patient during treatment,” Brorson says.
She thinks it’s 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 points out.
The treatment regime itself is another obvious candidate for more research.
The patient knows best
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.
“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,” she adds.
However, for the therapists to know exactly how the therapy is going, they need a systematic monitoring of the patients' satisfaction with their treatment. This is currently being done for other patient groups, but not for patients who are treated for addiction.
Answers questions once a week
Brorson is 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 pattern, we have reasons to change the treatment,” she says.
Finally defined as a public health issue
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 dropping out – and a substantially stronger correlation between suffering from certain types of personality disorders or cognitive deficiencies and dropping out.
These conditions could lead to difficulties with concentration, impulsivity and difficulties with forethought and long-term planning.
“If you suffer from these kinds of problems, it is not very surprising if you drop out from treatment,” Brorson claims.
Not a defect in the patient
The researcher believes 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,” she says.
Furthermore, she believes addiction treatment tends to be very controlling, and that 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,” she says.
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 concludes.
- Drop-out from addiction treatment: A systematic review of risk factors, Clinical Psychology Review, 33:8, December 2013, Pages 1010–1024,