Effective Treatment: Doing the Right Thing in the Right Way Terrence D Walton, MSW, ICADC

Treatment Morality Modal Temperance Model Concept Disease Anonymous Alcoholics

EBT Manuals Best Practice Outcomes Science

OUT Anecdotes Instincts IN Efficacy Outcomes Evidence

Process Practice Effective Treatment

Process Full Continuum of Care Adequate Duration Sufficient Intensity Stage of Recovery-based Design Policies & Procedures Team Interactions Evaluation

Practice Culturally-appropriate evidenced based treatment practices Practitioners trained and coached in manual-guided delivery Services dominated by those that have been rigorously tested

Sources of Information Good Drug Courts Alcohol Treatment Better DUI Courts DUI Offender Offender treatment means DUI offender Treatment

Sources of Information More Drug Courts Alcohol Treatment Less DUI Courts DUI Offender Offender treatment means DUI offender Treatment

Four Big Alcohol Studies Randomized Controlled Trials Project MATCH COMBINE Study UK Alcohol Treatment Trials Mesa Grande Project (361 clinical trials analyzed) Project Matching Alcohol Treatment to Client Heterogeneity (Project MATCH) – 1726 participants Combining Medications and Behavioral Interventions for Alcoholism (The COMBINE Study) The first three studies were major randomized controlled trials of alcohol treatment. Smaller studies indicate that many of the findings are transferrable to drug addictions. The fourth study-Mesa Grande project-is meta-analysis-i.e. a study examining other studies. It represents a summary of all of the relevant studies of treatment effectiveness. The reference handout provides information on all four of the studies. Project MATCH was a multisite clinical trial designed to test a series of a priori hypotheses on how patient-treatment interactions relate to outcome. Two independent but parallel matching studies were conducted, one with clients recruited from outpatient settings, the other with patients receiving aftercare treatment following inpatient care. Patients were randomly assigned to Twelve-Step Facilitation, Cognitive-Behavioral Coping Skills, or Motivational Enhancement Therapy. Subjects were followed at 3-month intervals for 1 year following completion of the 12-week treatment period and were evaluated for changes in drinking patterns, functional status/quality of life, and treatment services utilization. Interaction effects with selected patient characteristics were studied. Project MATCH was designed to provide a rigorous test of the utility of patient-treatment matching in general and has important implications for clinical practice (Project MATCH Research Group, 1993, p. 1130). Project MATCH Research Group. (1993). Project MATCH: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 17, 1130-1145. Project MATCH began in 1989 and was sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The project was an 8-year, multi site, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The programs were administered by psychotherapists and, although twelve-step methods were incorporated into the therapy, actual AA meetings were not included.[1][2] Three types of treatment were investigated: Cognitive Behavioral Coping Skills Therapy, focusing on correcting poor self-esteem and distorted, negative, and self-defeating thinking.[3][4] Motivational Enhancement Therapy, which helps clients to become aware of and build on personal strengths that can help improve readiness to quit.[5] Twelve-Step Facilitation Therapy administered as an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation.[1] The study concluded that patient-treatment matching is not necessary in alcoholism treatment because the three techniques are equal in effectiveness. The largest clinical trial ever conducted for alcoholism treatment methods was Project MATCH, a collaborative study involving nine clinical sites, a coordinating center, and NIAAA. CASAA was one of the nine performance sites. 1,726 clients were randomly assigned to (1) 12 sessions of Twelve-Step Facilitation Therapy, (2) 4 sessions of Motivational Enhancement Therapy, or (3) 12 sessions of Cognitive-Behavioral Skills Training. Five sites treated outpatients, and five treated patients in aftercare following intensive treatment. An excellent summary of the entire study is provided by Babor & Del Boca (2003). Overall, the three treatments yielded substantial and statistically equivalent outcomes through follow-up periods as long as 3 years (Project MATCH Research Group, 1997a, 1998a). The principal purpose of the study, however, was to determine which clients responded best to which treatments. Four such effects were found. Clients who entered treatment with a high level of state/trait anger fared best in Motivational Enhancement Therapy through the three years of follow-up (PMRG 1997b, 1998a; Waldron et al., 2001). Those whose social support systems favored continued drinking rather than abstinence benefitted most from Twelve-Step facilitation. Outpatients with less concomitant psychopathology likewise fared better in Twelve-Step facilitation than in Cognitive-Behavior therapy. Finally, the Twelve-Step treatment was more beneficial for aftercare patients with high levels of alcohol dependence, whereas those with lower levels of dependence fared better in Cognitive-Behavior Therapy (Babor & Del Boca, 1993). A research design paper demonstrated that it is not necessary to conduct prospective matching studies in which patients are intentionally matched vs. mismatched to treatments. Such a design is, under most conditions, equivalent to a normal randomized clinical trial. This means that matching analyses of the kind used in Project MATCH can be conducted with ordinary clinical trials, as long as adequate measures are included to characterize clients, and a prior hypotheses are stated (Miller & Cooney, 1994). Within Project MATCH, the Albuquerque site was particularly active in examining effects of ethnicity (Arroyo et al., in press), AA involvement (Connors et al., 2001a; Tonigan et al., 2000, 2001a), spirituality (Connors et al., 2001b; Tonigan et al., 2001b), motivation (Miller & Tonigan, 2001), therapist effects (Project MATCH Research Group, 1998d), severity of alcohol problems (Rychtarik et al., 2001), and client anger (Waldron et al., 2001) on treatment outcomes

www.nrepp.samhsa.gov. A Big Resource National Registry of Evidenced-based Programs and Practices: www.nrepp.samhsa.gov. Teacher should go to this site at this point and walk participants through how to use it. Teacher should familiarize him or herself with the site in advance so that they navigate it smoothly for the participants. Includes hundreds of approaches that were submitted for expert review and each was rated and determined whether it could be registered as an evidence based practice. Information regarding the intervention, as well as the nature and strength of the evidence supporting it is outlined. Not all evidence-based practices are included in this registry, but it is appropriate starting point when looking for EBP. The best way to know if you are using evidenced-based approaches is if you find them in NREPP and see that that intervention achieved the outcomes in which you are interested on a population demographically similar to yours.

Other Evidence Based Practices Behavioral Couples Therapy (BCT) Not well tested in an offender population Brief Interventions (5 or fewer sessions) Not appropriate for an addicted DUI offender Project Matching Alcohol Treatment to Client Heterogeneity (Project MATCH) Combining Medications and Behavioral Interventions for Alcoholism (The COMBINE Study)

Not Evidence Based Generic Counseling AOD Education Confrontational Interventions Psychodynamic Therapy Solution-focused Therapy Mindfulness-based Stress Reduction Acupuncture Emphasize that the first three items are among the more common approaches to substance-related treatment. However there is little evidence that they are effective with our population. AOD education as it is typically delivered—i.e.—focusing on the dangers of alcohol and other drug use has not been found effective for prevention or treatment. AOD education is an important part of a comprehensive program and is included as a part of most cognitive behavior and relapse prevention approaches. However to be effective such education should focus on helping participants to understand the dynamics of their condition and how to manage it. The bottom three have shown some results in a few small studies, but have yet to demonstrate that they are replicable when subjected to rigorous scientific study.

Goals of Cognitive Behavioral Therapy (CBT) Approaches Analyzes thoughts, feelings, and actions (behavior) Thoughts drive emotions Emotions drive behavior Identify thinking patterns and stop thinking “errors” from leading to emotional reactions that produce problem behaviors. Did you ever have one of those situations where you thought something happened, reacted to what you thought had happened, and done something based on that feeling, and then had to apologize for the misunderstanding. You get a call to come to the boss’s office. You think “I’m in trouble…I’m going to get fired”, Now your emotions kick in and you get scared, or angry, or whatever. Before you go you tell a co-worker that the company stinks and you hate your boss. Then you go into the office and get a certificate for being employee of the month. Automatically thinking that you are in trouble is faulty thinking which resulted in you making a bad decision. Many addicted individuals are driven by faulty thinking patterns. By identifying the patterns and stopping the faulty thinking (remember the famous line about what happens when you “assume” something [You make an ass out of “u” and me], the persons emotional state will improve and they will not behave in self destructive ways. Cognitive-Behavioral Therapy (CBT) Approaches The use of cognitive behavioral models has been recognized as a critical factor in reducing recidivism for offenders. A research review of meta-analyses found that cognitive behavioral approaches consistently appear to be among the most effective treatment therapy for substance abusers (Taxman, 1999). CBT approaches suggest that unless offenders’ faulty thinking is addressed, there is a reduced likelihood of long-term change. Research has shown that the use of cognitive interventions can enhance outcomes by up to 50% (MacKenzie, 2001) However, even today, only about 30 to 50 % of treatment programs for offenders report having a cognitive-behavioral component as part of the therapeutic intervention. The three main cognitive models now utilized by criminal justice agencies are Reasoning and Rehabilitation (R&R), Thinking for a Change and Moral Reconation Therapy (MRT®). MRT is used as a primary treatment component in the Anchorage, Alaska DWI Court. An outcome study found the comparison group had a significantly lower recidivism rate for the DWI Court group (25% in 2001 and 0% in 2002) than the comparison group which had a recidivism rate of 63%. These outcomes are particularly interesting considering that 83% of the comparison group had on average one prior DUI conviction per person while 92% of the treated DWI Court group had on average four prior DUI convictions per person (DeLong, 2003)

Show Me the Manuals! Key Question You heard Tom Cruise ask “show me the money” in Jerry McGuire. We must ask “show me the manuals” This is the key question to be asked of providers—”May I see your treatment manuals?” These should be specific to a particular intervention and include both background/theoretical information and session by session outline of how the intervention is to be structured and delivered.

Be Skeptical Nearly every evidenced based intervention is manual-based. However not every intervention that is manual-based is evidenced based. Emphasize this point so that participants aren’t fooled into believing that just because an intervention has been manualized that this necessarily evidenced based. We also want them to be suspect of an intervention that isn’t manualized and suspect of any provider who claims to use evidenced based practices, but cant produce manuals.

Motivational Approaches To increase and maintain the person’s motivation to change his or her life Motivate those who don’t want to change Help increase the motivation of the people who aren’t sure Help the motivated maintain their readiness to change Motivational Approaches Many people are not motivated for making a change, many are motivated for a while and then lose their motivation (think of trying to stay on a diet, or quit smoking, or keep your desk neat). Many treatment approaches used to believe that for treatment to work, the patient had to be motivated already. This usually happened when somebody hit bottom. If they weren’t ready, they were told they hadn’t hit their bottom yet. Now we recognize that the role of treatment can (and should) be to help people with their motivation. ADDITIONAL NOTES It was once assumed that motivation to change was a prerequisite that the client had to develop independently prior to enrolling in treatment. Without motivation, there was a belief that counseling would be ineffective. Motivational approaches essentially turn this notion upside down. Current theory is that most individuals enter treatment under some sort of duress, resulting in resistance, or, at best, ambivalence regarding any change in behavior. Motivational approaches focus on ways to engage substance users in considering, initiating and continuing substance abuse treatment while stopping their use of alcohol and other drugs. (SAMSHA, 1999). Motivational approaches involve linking a therapeutic style – called “motivational interviewing” with a transtheoretical stages-of-change model. MI is a style of interacting with the client –more of a discussion than an interview. MI emphasizes providing feedback, assigning responsibility for change to the client, providing advice, and providing a menu of counseling options. Importantly, MI is an empathic rather than confrontational approach with a goal of creating self-efficacy – a sense on the part of the client that change is possible and achievable (Miller, 2003). The transtheoretical model of change defines the processes involved in natural recovery and self-directed change, a movement from pre-contemplation regarding change, through contemplation, preparation, action, and maintenance (Prochaska and DiClemente, 1984). These “stages of change” related to stopping substance use can be engaged and continued by enhancing motivation. (SAMHSA, 1999)

Motivational Interviewing: Preparing People for Change William Miller & Stephen Rollnick (2002) Addiction and Change: How Addictions Develop and Addicted People Recover Carlo C. DiClemente (2003)

Assessing Readiness to Change Pre-Contemplation Contemplation Preparation Action Maintenance

Medication-Assisted Treatment To provide relief from withdrawal symptoms To prevent drugs from working (antagonist) To reduce craving To provide replacement (agonist) To provide aversive reactions

Medication-Assisted Treatment Naltrexone – Interrupts actions of alcohol and opiates; reduces cravings (Vivitrol) Acamprosate – reduction of alcohol cravings Disulfiram/Antabuse – produces adverse reaction with alcohol use Acamprosate – recently approved for use with alcohol treatment. Works by blocking the release of GABA. Doesn’t interfere with opiate receptors so can be used with an individual on methadone maintenance. Naltrexone used for many years as an antagonist for both opiates and alcohol. Works by binding with receptor site and keeps the opiate or alcohol from working. Antabuse – around a long time – makes person sick if they drink alcohol - some significant health risks is not used properly with careful attention to diet, other medications, mouthwash, skin products with alcohol, etc. Works by interfering with the normal metabolizing of alcohol by inhibiting the enzyme aldehyde dehydrogenase. Evidence regarding the effectivenes sof antabuse is mixed. These are the only drugs approved by the FDA for the treatment of substance related disorders.

Medication-Assisted Treatment Methadone – Opiate addiction – reduces craving, mediates withdrawal symptoms, helps restore normal functioning (agonist) Buprenorphine (Subuxone) – similar to methadone, may be prescribed by an MD with special training (partial agonist) Driving while using a legally prescribed medication, including methadone taken according to doctor’s orders, can still trigger a DUI charge in all 50 states Acamprosate – recently approved for use with alcohol treatment. Works by blocking the release of GABA. Doesn’t interfere with opiate receptors so can be used with an individual on methadone maintenance. Naltrexone used for many years as an antagonist for both opiates and alcohol. Works by binding with receptor site and keeps the opiate or alcohol from working. Antabuse – around a long time – makes person sick if they drink alcohol - some significant health risks is not used properly with careful attention to diet, other medications, mouthwash, skin products with alcohol, etc. Works by interfering with the normal metabolizing of alcohol by inhibiting the enzyme aldehyde dehydrogenase. Evidence regarding the effectivenes sof antabuse is mixed. These are the only drugs approved by the FDA for the treatment of substance related disorders.

Combining Medications and Behavioral Interventions for Alcoholism Finding: Naltrexone in combination with medication management sessions delivered by health professionals was at least as effective as psychosocial interventions Side note: Pathology of multiple DUI offenders will likely require psychosocial interventions in addition to medications The Combine Study

Shaffer HJ, Nelson SE, LaPlante DA, LaBrie RA, Albanese MJ, Caro G Shaffer HJ, Nelson SE, LaPlante DA, LaBrie RA, Albanese MJ, Caro G. The epidemiology of psychiatric disorders among repeat DUI offenders accepting a treatment sentencing option Journal of Consulting and Clinical Psychology. 2007;75(5):795-804.

92.9% with bipolar disorder 68.4% with depression 100.0% with OCD Those Missed 92.9% with bipolar disorder 68.4% with depression 100.0% with OCD Repeat DUI offenders represent a population of individuals who are at high risk for co-occurring psychiatric disorders (Lapham, C'De Baca, McMillan, & Lapidus, 2006). However, in a variety of clinical settings, such as addiction treatment facilities and DUI offender programs, offenders often do not undergo comprehensive screening for psychiatric disorders (Nelson et al., 2007; Shaffer et al., 2007). This week, the DRAM reviews a study that evaluated the extent to which repeat DUI offenders are diagnosed with comorbid psychiatric disorders during mandatory treatment (McMillan et al., 2008). Method The sample consisted of 233 repeat DUI offenders (86% male, Mage= 38.5, 72% White) scheduled to undergo mandatory alcohol treatment at seven licensed facilities. The investigators assessed their sample with a battery of surveys, using the following measures: The Composite International Diagnostic Interview (CIDI; Robins, Helzer, Ratcliff, & Seyfried, 1982)—assesses whether respondents meet diagnostic criteria for a range of mental health disorders. The investigators used the CIDI to assess disorders occurring within the past 12 months. The Treatment Abstraction Form (Timken, 2001)—gathers data from treatment charts of persons convicted of DUI and sentenced to mandatory treatment, including mentions of alcohol or drug use disorders in an offenders’ medical records as well as any psychiatric comorbidity identified during the treatment process. Results 92.9% of participants with bipolar disorder, 68.4% of those with depression, and 100.0% of those with OCD went undiagnosed for these disorders during treatment. The CIDI identified just over 10% of the sample as qualifying for a drug use disorder. Participants were overdiagnosed as having drug use disorders during treatment. Treatment records identified more than 25% as having drug use disorders; approximately 24.6% (adjusted) of defendants who were not identified as having a drug use disorder on the CIDI were diagnosed with such during treatment. The CIDI is a valid and reliable instrument for assessing mental health disorders in general populations; however, its validity has not been assessed in repeat DUI populations. There is no gold standard for diagnosis, and the CIDI “diagnosis” is a proxy just as are real-time clinician impressions for a patient’s “actual” mental health status. Absent a gold standard, we cannot determine whether the clinician or the CIDI are correct. The CIDI was administered prior to treatment admission, and the records analyzed to determine disorders recognized during treatment included observations made later (i.e., during treatment), as well as records that potentially pre-dated CIDI administration. Therefore, mental health status might have been different at the time of each assessment. It is possible that the treatment programs’ patient records were not consistently maintained or accurately reflected clinicians’ diagnoses. Clinicians might have diagnosed patients consistently with the CIDI, but the diagnosis not properly recorded. Programs might not have had an alternative diagnosis record keeping system, but nevertheless made some diagnoses that were in line with the CIDI

Does Program include: Blended Screening and Assessment Approaches? Education on Co-Occurring Disorders? Medication Monitoring and Management Sessions? Heavy Utilization of Positive Reinforcement and Flexible Application of Graduated Sanctions? Mental Health Specialists? Agreements with Community Mental Health Services Agencies?

Twelve Step Groups

What About Alcoholics Anonymous? What about coerced AA participation? There are two critical reasons to be careful when mandating 12 step group participation Legal precedent indicates clearly that if participants or potential participants object to 12 step participation because of it’s religious content, secular alternatives must be made available. (This is discussed in an earlier presentation during the Operational Tune up Training). It is only objections made on religious grounds that must be accommodated. There is scant evidence that mandated AA/NA is effective and some evidence that has found that it isn’t effective. Coerced AA attendance has not been proven effective. In fact, the few studies that have examined coerced participation have found it to be ineffective. Most of the AA-related studies analyzed in the Mesa Grande Project included primarily individuals who were mandated to attend AA by court order. (These are the studies where AA participation fared especially poorly.) While coerced treatment has been found effective in other studies, evidence does not yet indicate the same for mandated Alcoholics Anonymous attendance. Miller, W. R., & Wilbourne, P. L. (2002). Mesa grande: A methodological analysis of clinical trials for alcohol use disorders. Addiction, 97(3), 265-277. Speiglman, R. (2006) Mandated AA attendance for recidivist drinking drivers: policy issues. Addiction 92 (9), 1133-1136. Alcoholics Anonymous (AA) is the most ubiquitous form of self-help group available worldwide. Project MATCH found AA attendance predicted a better long-term outcome, particularly in those lacking a non-drinking support network (Project MATCH, 1998). However, a meta-analysis of randomized and non-randomized trials showed that attending AA resulted in worse outcomes than comparator treatments or no treatment (Kownacki and Shadish, 1999). Critically, this result was heavily influenced by trials in which patients were mandated to attend AA. In light of this, Slattery et al. (2003) gave a strong recommendation that patients should be introduced to AA, and encouraged to attend, but not mandated to attend. Kownacki R, Shadish W (1999) Does Alcoholics Anonymous work? The results from a meta-analysis of controlled experiments. Substance Use Misuse 34: 1897–1916 Slattery J, Chick J, Cochrane M, Godfrey C, Kohli H, Macpherson K, Parott S, Quinn S, Single A, Tochel C, Watson H (2003) Prevention of relapse in alcohol dependence. Health Technology Assessment Alcoholics Anonymous Involvement and Positive Alcohol-Related Outcomes: Cause, Consequence, or Just a Correlate? A Prospective 2-Year Study of 2,319 Alcohol-Dependent Men John McKellar, Eric Stewart, and Keith Humphreys Journal of Consulting and Clinical Psychology In the public domain 2003, Vol. 71, No. 2, 302–308  A positive correlation between Alcoholics Anonymous (AA) involvement and better alcohol-related outcomes has been identified in research studies, but whether this correlation reflects a causal relationship remains a subject of meaningful debate The present study evaluated the question of whether AA affiliation appears causally related to positive alcohol-related outcomes in a sample of 2,319 male alcohol-dependent patients. An initial structural equation model indicated that 1-year posttreatment levels of AA affiliation predicted lower alcohol-related problems at 2-year follow-up, whereas level of alcohol-related problems at 1-year did not predict AA affiliation at 2-year follow-up. Additional models found that these effects were not attributable to motivation or psychopathology. The findings are consistent with the hypothesis that AA participation has a positive effect on alcohol-related outcomes.

What About Alcoholics Anonymous? “Attendance” versus “Involvement” (active participation) Coerced AA attendance has not been proven effective. In fact, the few studies that have examined coerced participation have found it to be ineffective. Most of the AA-related studies analyzed in the Mesa Grande Project included primarily individuals who were mandated to attend AA by court order. (These are the studies where AA participation fared especially poorly.) While coerced treatment has been found effective in other studies, evidence does not yet indicate the same for mandated Alcoholics Anonymous attendance. Miller, W. R., & Wilbourne, P. L. (2002). Mesa grande: A methodological analysis of clinical trials for alcohol use disorders. Addiction, 97(3), 265-277. Speiglman, R. (2006) Mandated AA attendance for recidivist drinking drivers: policy issues. Addiction 92 (9), 1133-1136. Journal of Substance Abuse Treatment, Vol. 12, No. 4, pp. 241-246, 1995, Does Alcoholics Anonymous Involvement Predict Treatment Outcome? HENRY A. MONTGOMERY, PhD, WILLIAM R. MILLER, PhD, AND J. SCOTT TONIGAN, PhD Our findings suggest, therefore, that it is the extent of involvement or active participation in AA processes, rather than mere attendance at AA meetings, that is associated with more favorable outcomes after treatment. This is consistent with the finding from controlled trials that mandated or coerced attendance at AA meetings is not associated with differentially improved outcomes (e.g.,Brandsma et al., 1980; Ditman et al., 1967). AA was designed to operate by a process of attraction and voluntary affiliation, never by coercion (Alcoholics Anonymous, 1976; Miller & Kurtz, 1994). It appears that those who choose to become involved in the 12-Step processes of AA following treatment do experience more favorable outcomes. We recommend, therefore, that those who wish to study the impact of AA on outcomes should measure not only physical attendance at meetings, but the extent to which individuals are "working the steps" of Alcoholics Anonymous.  

What About Alcoholics Anonymous? Seek Alternatives to Mandating AA Programs that incorporate Alcoholics Anonymous or other mutual aid groups should consider incorporating Twelve Step Facilitation (TSF) into their treatment component. Alternatives to mandating AA attendance may need to be adopted such as providing incentives for participation in AA, as opposed to mandating it; determining which participants are most amenable to and/or suitable for AA; and offering choices that include other types of mutual support programming in addition to AA or other 12-step groups. Also, there is solid legal precedent establishing that programs must not penalize or deny participation to individuals who refuse to attend 12-step groups because of religious content (e.g. prayers, references to “God” in 12 steps). For such individuals, comparable secular alternatives must be offered. Smart recovery is a secular alternative that has a few in-person meetings and many telephone: www.smartrecovery.org

Using Support Groups in Therapy “The 12 Step Facilitation Therapy Manual” Offer choice (types, spiritual & secular) Be selective regarding approved groups Try to match demographics, lifestyles, and level of substance involvement www.smartrecovery.org Self-help or mutual aid approaches refer to those situations in which alcoholics seek help from others people experiencing the same problem. Drug Courts, whose program rules universally require abstinence from the use of alcohol and illicit drugs, typically recommend that clients participate in self help/mutual aid programs that reinforce that philosophy. The approaches most often attended include Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, Women for Sobriety, and SMART Recovery. It should be noted that AA, NA and CA are widely available, however Women for Sobriety and SMART Recovery both have fewer than 350 groups nationwide ( McGrady et al, 2003). Manualized treatment approaches designed to integrate 12 step principles into primary treatment have been developed and utilized successfully in treatment. The 12 Step Facilitation Therapy Manual (Nowinski, Baker & Carroll, 1994) was found to be an effective treatment approach with individuals both intentionally and unintentionally matched in NIAAA’s Project MATCH. Nowinski et al’s manual focuses on Alcoholics Anonymous’ first four steps. The experience of drug courts is that self help/mutual aid group attendance appears to be enhanced when clients are offered choice, both in the types of groups approved by the court and also choice in the types of 12-step (AA, CA, NA) offered in the community. Clients report a greater level of acceptance when attending meetings where there is a good match in terms of drug of choice (i.e. alcoholics attending AA rather than NA or CA meetings) and also in the demographics of the client and the group (i.e. young people, women, etc.)

Next Steps Identify and adopt evidence-based practices Incorporate medication-assisted treatment Utilize alcoholics anonymous and provide secular alternatives for those with religious-based objections Treat the hard, core alcohol-dependent impaired driver Modify (lessen) treatment requirements if treating non-addicted participants in DWI Court. Stay abreast of latest DUI Court treatment-related research findings