EFFECTIVENESS BANK BULLETIN 9 April 2008
EFFECTIVENESS BANK BULLETIN 9 April 2008
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Style not content key to matching patients to therapeutic approaches ...
Still hard to find reasons for matching patients to therapies ...
Helping drug treatment patients find work pays (some) dividends in Scotland ...
Substance-focused initiatives not only way schools help prevent risky substance use ...
A painstaking series of analyses has demonstrated that matching (or at least, not mismatching) therapeutic styles to patients’ predispositions substantially improves outcomes. Based on data from one of the Project MATCH clinics, the research is all the more significant since the parent study generally failed to find such effects from matching patients to therapies. In this major US study, how the therapist related to the patient mattered more than which therapy they practised.
FINDINGS Project MATCH tested whether different types of alcohol-dependent patients would respond better to 12-step based counselling, cognitive-behavioural therapy, or to an approach based on motivational interviewing. Providence was one of the study’s clinics. Unlike the parent study, here videos of counselling sessions directly revealed how patients and therapists related to each other.
The latest analysis of the Providence data1 first divided patients in to high, medium and low on each of three dimensions: their tendency to react angrily, how depressed they felt, and the degree to which in their first therapy session they seemed reluctant to relinquish control and reacted against direction (‘reactance’).
Based on up to four videoed sessions, next step was to rate their therapists' approaches as high, medium or low on three dimensions expected to suit different patients. Highly depressed patients were expected to do best when therapists avoided focusing on painful emotional material. Angry patients would it was thought do best when therapists avoided confronting them (for example, by interpreting resistance rather than ‘rolling with it’) while calmer patients would benefit from a degree of confrontation. Highly reactive patients were expected to do best in non-confrontational therapy and when therapists avoided taking the lead in structuring the session.
These favoured combinations of patients and therapeutic styles were considered ‘matched’, contradictory combinations, ‘mismatched’, and the remaining neutral combinations, ‘unmatched’. The expectation was that therapists whose approach matched their patients would avoid counterproductive provocation of the emotionally vulnerable or volatile, while productively provoking those who needed it.
Compared to neutral combinations, some matched combinations (avoiding emotional material with depressed patients; not taking the lead with reactive patients) did indeed lead to significantly less drinking in the following year, reflected in average days abstinent and the proportion of patients substantially improved to the point where they were drinking no more than one day in 20. Rather than dramatic gains, matching optimised already good outcomes.
The effects of being mismatched were more substantial and apparent across all the combinations expected to be detrimental. For example, while around half the unmatched patients substantially improved, for mismatched patients proportions ranged from about 1 in 10 to about a third. Though (perhaps due to small numbers) not always statistically significant, multiple matches were cumulatively beneficial, multiple mismatches cumulatively detrimental. At its peak, when patients were matched on two of the patient-type/therapeutic style combinations, all (but there were just four) substantially improved; mismatched on two, just 1 in 5 did so.
IN CONTEXT The tested combinations were derived from earlier analyses of the same
patients LINKS.
These found motivational interviewing
worked relatively well with
angry patients because therapists were less
directive than when they were training patients in cognitive-behavioural
techniques.2 In this US context (where the
approach is second nature to many patients), 12-step therapists too
had been relatively non-directive and also did well with angry patients. Despite their tendency
to obstruct, given a
non-directive therapeutic style, ‘reactive’
patients did as well as the more cooperative.3
But when
therapists attempted to be directive either in the structure of the sessions or their content, these patients went on to drink more.4 Patients
prone to anger (not the same as the autonomy-striving of reactive patients)
reacted badly only to the more overtly confrontational styles of therapists who
imposed content in the form, for example, of un-asked for interpretations and
challenges. But without this provocation, less highly strung patients actually
ended up drinking more than their angry peers. Patients with
clinically elevated depressive symptoms later drank
less when the
therapist avoided focusing on painful emotional material, more when the
therapist did the reverse.5 Similar findings have emerged from studies of different therapies and
different kinds of patients.6 7 8 9
PRACTICE IMPLICATIONS Cumulatively this evidence is strong enough to support a non-directive therapeutic style with clients whose anger or defensiveness would otherwise lead to a counter-productive reaction, but to be more structured and directive with clients who welcome being given a lead. The Providence studies also suggest that depressed mood is an indication to avoid emotionally painful material. Ability to sense these signals and adjust accordingly could be one way empathic and socially skilled therapists improve outcomes. Some of these adjustments could be formalised on the basis of an initial assessment of the patient or their behaviour in early counselling sessions. Clinical supervision could then be used to encourage a more suitable therapeutic style or to revise client allocation. However, the complexity of multiple and potentially contradictory patient-style matches may defeat attempts to codify the practice of skilled therapists. For example, in one study, the biggest influence on drinking outcomes was not directiveness, but whether therapists addressed the emotional states of highly distressed patients.6 Had they failed to do so for fear of being too directive, they might have done more harm than good.
1 FEATURED STUDY Karno M.P. et al. Does matching matter? Examining matches and mismatches between patient attributes and therapy techniques in alcoholism treatment. Addiction: 2007, 102(4), p. 587–596.
2 Karno M.P. et al. What do we know? Process analysis and the search for a better understanding of Project MATCH’s anger-by-treatment matching effect. Journal of Studies on Alcohol: 2004, 65(4), p. 501–512.
3 Karno M.P. et al. Less directiveness by therapists improves drinking outcomes of reactant clients in alcoholism treatment. Journal of Consulting and Clinical Psychology: 2005, 73(2), p. 262–267.
4 Karno M.P. et al. An examination of how therapist directiveness interacts with patient anger and reactance to predict alcohol use. Journal of Studies on Alcohol: 2005, 66(6), p. 825–832.
5 Karno M.P. et al. Patient depressive symptoms and therapist focus on emotional material: a new look at Project MATCH. Journal of Studies on Alcohol: 2003, 64(5), p. 607–615.
6 Karno M.P. et al. Interactions between psychotherapy procedures and patient attributes that predict alcohol treatment effectiveness: a preliminary report. Addictive Behaviors: 2002, 27, p. 779–797.
7 Gottheil E. et al. Effectiveness of high versus low structure individual counseling for substance abuse. American Journal on Addictions: 2002, 11, p. 279–290.
8 Thornton C.C. et al. High- and low-structure treatments for substance dependence: role of learned helplessness. American Journal of Drug and Alcohol Abuse: 2003, 29(3), p. 567–584.
9 Thornton C. et al. Coping styles and response to high versus low-structure individual counseling for substance abuse. American Journal on Addictions: 2003, 12, p. 29–42.
LINKS
Still hard to find reasons for matching patients to therapies |
Project MATCH: unseen colossus |
My way or yours? | Nuggets
14.1
9.3 | Nuggette
12.5
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After finding no overall difference in effectiveness between the two therapies it tested, the UK Alcohol Treatment Trial (UKATT) has now also found no differences for different types of patients.1 The results confounded expectations that an approach based on motivational interviewing would be preferable for the least motivated or most hostile, while bolstering supportive social networks would be particularly important for patients lacking these to begin with.
FINDINGS The trial recruited 742 patients seeking treatment for alcohol problems at seven specialist treatment services in England and Wales. They were randomly allocated either to three sessions of motivational enhancement therapy or eight of social behaviour and network therapy, each spread over eight to 12 weeks. The former was a familiar elaboration of motivational interviewing, the latter a novel therapy integrating cognitive-behavioural, community reinforcement and other elements with the aim of building social networks supportive of positive change in the patient’s drinking. If possible the patient’s associates were directly involved in the process.
Twelve months after therapy started, 85% of surviving participants (12 had died) were re-interviewed. Across both therapies, alcohol consumption over the past three months had fallen by 45%.2 There had also been significant improvements in the severity of alcohol dependence, alcohol-related problems, and psychological health, and savings in health and social care costs.3
The featured study1 tested whether at either the three-month or the twelve-month follow-ups, certain types of patients had responded better to one therapy than the other in terms of drinking reductions (days abstinent, amount consumed when drinking), alcohol dependence, or alcohol-related problems. It was expected that the non-confrontational style of motivational interviewing would defuse the hostility of patients prone to react angrily, and help those relatively devoid of motivation find reasons to curb their drinking. The network option was expected to particularly help patients with poor family relationships or few regularly seen associates who were not also heavy drinkers. Also tested was whether a patient’s mental health or severity of dependence would affect relative responses to the therapies.
Just two of these tests for ‘matching’ achieved the conventional level of statistical significance. Both findings were the opposite to what was expected and (along with near misses) were dismissed as chance outcomes from among the 130 tests.
IN CONTEXT UKATT derived its hypotheses partly from the US Project MATCH study, which also found its therapies roughly equivalent and few and only minor
matching effects. Together these methodologically advanced studies strongly question whether it is worth trying to match alcohol patients to different outpatient psychosocial therapies. However, alternative analyses have found statistically and
clinically significant matching effects from Project MATCH and might yet do so
from UKATT. Some have been based not on which therapy was delivered, but on the
whether the therapist’s interpersonal style matched that of the patient4 entry in this bulletin. Another
tailored its analysis to a model of
relapse (and its opposite) as often sudden, wholesale transitions capable of
being precipitated in vulnerable individuals by minor changes in circumstances
or psychological state.5
Results like these mean that the possibility of matching patients to interventions cannot yet be dismissed. Studies might have produced negative results because they mistakenly assumed it was important to match to the specific therapy rather than to non-specific, cross-cutting features such as the interpersonal style of the therapist, or because their analytic model mistakenly assumed that relapse and recovery are incremental rather than often precipitous.
In another paper UKATT found just such processes at work as the patients it studied improved.6 Asked what they thought had helped, their answers commonly revealed revelatory moments which precipitated wholesale transitions in how they saw drinking and drink and in their determination to change. Others described how an understanding listener and learning new facts made a difference. The catalysts for change often preceded treatment entry, and patients saw themselves as responsible for the changes they had made using the treatments, accounts which might partly explain why these changes were equivalent across the therapies. Such processes might also explain why in Project MATCH not only were the therapies equivalent, but it seemed to make little difference to drinking outcomes whether they were attended or completed.7
Patients highlighted not just the therapies tested in UKATT, but preceding, subsequent and parallel interventions, including other treatments and facilities available at the same clinics and contact with the UKATT team itself. Their accounts question the implicit assumption that all the savings in health and social care costs could be attributed to the UKATT therapies, an assumption which yielded a ratio of £5 savings for every £1 spent.3
PRACTICE IMPLICATIONS On the basis of their own work and that of Project MATCH, the UKATT researchers suggested that therapies such as those tested could be chosen on grounds other than relative effectiveness, including cost, availability of therapists, clinical judgement, and patient preference. One strategy would be to offer the cheaper and more widely available motivational interviewing first and monitor patients to see if they required further or different therapy.
For the generality of patients of the kind recruited to treatment trials, that seems an evidence-based and efficient strategy, but perhaps not one that should be universally applied. Implemented inflexibly with unsuitable patients, motivational interviewing can be counter-productive. This may have happened in Project MATCH.5 Patients who began treatment drinking heavily and lacked confidence in their ability to resist drink reacted poorly to motivational interviewing. They drank on far fewer days after cognitive-behavioural therapy. As in other studies, perhaps these patients floundered without structure, direction and concrete anti-relapse guidance.8 Sometimes patients do much better when left to go through treatment in the normal way or given simple advice, particularly those already committed to a recovery goal and strategy or who respond counter-productively to the assessment feedback often featured in motivational interviews.9 Reactions during the session itself can indicate that this is happening. Sufficiently sensitive and skilled therapists encouraged to adapt to these signals may avoid bad reactions, but in other circumstances the risk is that patients who could have done well from the start will be sent on less positive trajectory.
Thanks to Dr George Christo of the Barnet Drug & Alcohol Service and to UKATT researchers Nick Heather, Gillian Tober and Jim Orford for comments on this entry in draft. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 FEATURED STUDY UKATT Research Team. UK Alcohol Treatment Trial: client-treatment matching effects. Addiction: 2008, 103(2), p. 228–238.
2 UKATT Research Team. Effectiveness of treatment for alcohol problems: findings of the randomised UK alcohol treatment trial (UKATT). British Medical Journal: 2005, 331.
3 UKATT Research Team. Cost effectiveness of treatment for alcohol problems: findings of the randomised UK alcohol treatment trial (UKATT). British Medical Journal: 2005, 331.
4 Karno M.P. et al. Does matching matter? Examining matches and mismatches between patient attributes and therapy techniques in alcoholism treatment. Addiction: 2007, 102(4), p. 587–596.
5 Witkiewitz K. et al. Nonnormality and divergence in posttreatment alcohol use: reexamining the Project MATCH data ‘another way’. Journal of Abnormal Psychology: 2007, 116, p. 378–94. For an informal analysis of this work see: Ashton M. Catastrophe. Unpublished, 2007.
6 Orford J. et al. The clients’ perspective on change during treatment for an alcohol problem: qualitative analysis of follow-up interviews in the UK Alcohol Treatment Trial. Addiction: 2005, 101, p. 60–68.
7 Cutler R.B. et al. Are alcoholism treatments effective? The Project MATCH data. BMC Public Health: 2005, 5:75. For an informal analysis of this work see: Ashton M. It makes you think ... MATCH - the untold story. Unpublished, 2007.
8 Ashton M. My way or yours? Drug and Alcohol Findings: 2005, 15, p. 22–29.
9 Ashton M. The motivational hallo. Drug and Alcohol Findings: 2005, 13, p. 23–30.
LINKS
Style not content key to matching patients to therapeutic approaches |
Nugget 14.6 |
My way or yours? |
The motivational hallo |
Project MATCH: unseen colossus |
It makes you think ... MATCH - the untold story |
Catastrophe
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Patients in Scotland who received employment-related support as part of their addiction treatment package were three times more likely later to find work. The findings suggest that such support does improve the employment prospects of at least a minority of patients, lending weight to the current UK policy emphasis on the provision of these services.
FINDINGS The figures derived from the Drug Outcome Research in Scotland study (DORIS). In 2001 this sampled 1033 patients starting treatment in different modalities and observed what happened as they went through the normal treatment process. Though using many other drugs, most saw their main problem as heroin.
33 months later the 695 who could be reinterviewed were asked about their legal paid employment; casual and cash-in-hand work was disregarded.1 Just 1 in 10 were working but a fifth had worked between their previous interview 17 months earlier and the 33-month interview (the employment assessment window). An omnibus analysis of 25 factors which might have influenced this outcome found that having been helped by the initial treatment agency to find work or gain employment-related skills or education was the one most closely related to employment. After taking in to account the other factors, patients who recalled They had been asked about this at an earlier interview eight months after treatment had started, establishing that the help had preceded (so could have contributed to) employment. such help2 were over three times more likely later to have worked than those who did not.
The only other variables significantly related to employment were age, severity of dependence in the three months preceding the employment assessment window (highly dependent patients half as likely to have worked), and whether patients had committed crimes in the three months before the final interview (those who had were half as likely to have worked).
Equally important was what was not related to employment. These factors included employment-related help from agencies other then the initial treatment service, the treatment modality (prison-based, residential rehabilitation, or methadone prescribing), and whether the patient had altogether avoided heroin in the three months leading up to the employment assessment window.
Faced with these surprising negative results, the researchers tested whether these influences might have been obscured by the other factors simultaneously taken in to account. An analysis which did not compensate for other factors found that preceding In the three months preceding the employment assessment window. abstinence3 from illegal drugs other than cannabis was significantly related to employment: 27% who had been abstinent later worked, 18% who had not. Further such analyses established that patients who had started the study in residential rehabilitation were over twice as likely to have received employment-related help, yet were not significantly more likely to have found work – 29% had done so, but so had 20% in methadone services or other non-residential treatments. Outside prison, the biggest gap in receipt of help was between residential rehabilitation (38%) and methadone services (13%), but this 25% gap converted to just a 9% gap in the attainment of employment.
IN CONTEXT These findings suggest that receipt of employment help is an important influence on later employment, that the treatment modality is less influential, and that whether treatment eliminates heroin use is less important than whether it reduces dependence and the crime that often comes with it. The fact that similar help from outside agencies did not enter the frame possibly indicates that on-site help from familiar and trusted faces is most likely to be acted on, or that external help was sought only after prompting from the treatment service. The link between employment and abstinence from illegal drugs other than cannabis makes sense, but was not tested in an analysis which took other influences in to account. As a result, it remains unclear whether abstinence was in itself influential. When abstinence from the sample’s main problem drug (heroin) was tested in this way, it fell out of the frame.
Several features of the study hinder interpretation of its findings. The most important is that it observed normal treatment processes rather than deliberately allocating patients to receive or not receive employment-related help. This makes it impossible to be sure that the help actually caused the elevated employment rates it was associated with. Patients’ pre-treatment employment assets and their desire and belief in their ability to work were not included in the analyses. As in other studies,4 5 6 these might have been the decisive influences over whether they found work and perhaps too over whether they sought help, creating a spurious relationship However, this seems unlikely to have been the full story. On starting treatment 4% of the non-prison sample were currently employed; 33 months later, about 10% who could be reinterviewed were. between the two.7 Significantly more residential rehabilitation patients received employment help yet this did not result in a significant advantage in employment, suggesting that employment prospects are heavily influenced by other factors.
A high hurdle was set: paid, ‘on the books’ employment. In one US study an intensive employment intervention for methadone patients significantly increased access to paid employment overall, but formal employment remained rare.5 Finally, an analysis based on whether patients had been offered help – rather than whether they recalled receiving it – might have been more relevant to service provision and produced a different impression of how available help was and how effective it had been.6
PRACTICE IMPLICATIONS Despite the doubts, the findings are compatible with the proposition that providing employment-related help during treatment means more patients later solidify their recovery through work, strengthening the case for services to take the initiative in helping patients on this journey. In this light it is worrying that just 17% of patients said they had received this support (more may have been offered it6), raising the issue of how many more might have found work with appropriate help. However, converting this help in to success in a tough job market would not have been easy. Even those who overcame their dependence would often have been held back by the stigma of drug use and criminal histories, lack of qualifications, poor health, underdeveloped work discipline, lack of confidence, and a benefit system which makes entering the job market financially risky. Attaining competitive employment may require a long-term, supportive and incremental introduction to work, and employers willing to take what to many will seem an unnecessary risk.8 Barriers like these probably account for the general failure of treatment itself, or vocational interventions during treatment, to increase entry to competitive employment.4 5 6 But this general failure masks positive studies, some showing that people previously considered unemployable can be helped to find work.9 Innovative schemes which actually provide work during treatment rather than just helping patients find it in the job market have also proved feasible.
Thanks for their comments on this entry in draft to Mick Bloor of the Centre for Drug Misuse Research at the University of Glasgow, coordinator of the DORIS project. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 FEATURED STUDY McIntosh J. et al. Drug treatment and the achievement of paid employment. Addiction Research & Theory: 2008, 16(1), p. 37–45.
2 They had been asked about this at an earlier interview eight months after treatment had started, establishing that the help had preceded (so could have contributed to) employment.
3 In the three months preceding the employment assessment window.
4 Magura S. et al. The effectiveness of vocational services for substance users in treatment. Substance Use & Misuse: 2004, 39(13–14), p. 2165–2213.
5 Magura S. et al. An innovative job placement model for unemployed methadone patients: a randomized clinical trial. Substance Use & Misuse: 2007, 42, p. 811–828.
6 Dunlap L.J. et al. Do treatment services for drug users in outpatient drug-free treatment programs affect employment and crime? Substance Use & Misuse: 2007, 42(7), p. 1161–1185.
7 However, this seems unlikely to have been the full story. On starting treatment 4% of the non-prison sample were currently employed; 33 months later, about 10% who could be reinterviewed were.8
8 Kemp P. et al. Employability and problem drug users. Critical Social Policy: 2005, 25(1), p. 28–46.
9 South N. et al. Idle hands. Drug and Alcohol Findings: 2001, 6, p. 24–31.
LINKS
Concern over abstinence outcomes in Scotland’s treatment services |
Idle hands |
Nuggets 14.10 11.5
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Surveys in the West Midlands indicate that schools which engage pupils in their school and their education also protect them against risky forms of substance use, offering a way to prevent substance misuse by focusing on core educational and social virtues.
FINDINGS Two of the reports derived from the 1995–6 West Midlands Young People’s Lifestyle Survey of nearly 26,000 pupils in grades 7, 9 and 11 (ages 11 to 16) in 166 secondary schools who completed an anonymous health and lifestyle questionnaire. The latest was concerned with drinking and use of illegal drugs.1 For the purposes of the study, pupils who admitted drinking at least 10 UK units of alcohol (80g) a week were designated heavy drinkers. Since adolescent drinkers normally consume once or twice a week, they might also be considered ‘binge’ drinkers. Grade 7 pupils (aged 11–12) who drank alcohol at least monthly were considered early initiators. The survey also asked about regular use of one or more of seven illegal drugs, including cannabis.
At issue was whether in a school the proportions of pupils in these categories would be related to four school performance indicators: the proportion of pupils who achieved five good grades in the GCSE exams at the end of compulsory schooling; the truancy rate; and the degree to which on both measures each school exceeded or fell below the rate expected for schools with a similar pupil mix – indices of ‘added value’. These two indices tended to co-vary so could be combined in to a single index thought to reflect Supporting its validity as an index of lack of commitment to the school, the truancy index co-varied with two other such indices: the rate of authorised absence and the proportion of pupils who failed to secure qualifications virtually all could achieve had they tried. the degree to which schools productively engaged pupils in their education.2 The better the engagement, the more pupils were expected to absorb the school’s norms regarding substance use.
After adjusting for differences between schools in the profiles of their pupils, only the added value measure was significantly related The only other statistically significant relationship in the adjusted analysis was between good exam results and fewer pupils engaging in heavy drinking. to all three substance use measures.3 In each case, the more added value, the fewer pupils used substances. Compared to schools at the bottom end of the scale, in schools towards the top the proportions of early or heavy drinkers were both 7% less and of regular users of illicit drugs, 4% less. Given the relative rarity of these forms of substance use, these figures represent substantial proportional reductions. An earlier report based on the same survey had found a similar relationship with the proportion of pupils who smoked at least a cigarette a week, down by 6% in high versus low added value schools.4
A third report from the same area followed up roughly 7000 pupils initially aged 13–14 for two years.5 The data derived from 52 schools evaluating an anti-smoking intervention. That was ineffective, but school culture reflected by the added value index seemed to curb the uptake of smoking and to restrain consumption among pupils who started the study as smokers. All else being equal, compared to a school at the bottom of the added value scale, by the end of the study a school towards the top would have 7% fewer pupils (18% versus 25%) who smoked at least weekly.
IN CONTEXT These findings echo an earlier report from the Glasgow area where over 2000 pupils were followed up from 1994 when they were ending primary school (age 11) to their last year of compulsory schooling (age 15) in 43 randomly selected secondary schools.6 Differences between schools in the proportions of pupils at age 13 or 15 who regularly drank, were smokers, or had used illegal drugs, could not be accounted for by a battery of pupil, family and social background measures (including substance-related experiences at primary school and parental smoking and drinking) nor by the neighbourhoods the schools drew their pupils from. It was, it seemed, something about the schools which produced the differences. For all three forms of substance use and at both ages, the school’s influence was at least partly accounted for by the degree to which its pupils felt disengaged from school and from education and by how many teachers they felt they got along with.
In both areas the greatest influences on levels of substance use in a school were usually the social backgrounds and characteristics of its pupils. Still it seemed that schools could make a worthwhile contribution to mitigating or promoting these influences simply by being good schools which engaged and forged positive relationships with their pupils. Also in both, the relative influence of the school diminished as pupils aged. This might have been an artefact of what was measured. Though worryingly atypical at an earlier age, by school-leaving age the assessed substance use patterns would have been more normative. Had the reports been able to titrate their measures to pupils’ ages, they might have found that the school retained its influence.
Despite attempts to eliminate alternative explanations, the major doubt over the reports is whether school culture reflected in the commitment of the pupils was actually instrumental in determining levels of atypical substance use. If it was, then changing the culture to bolster commitment can be expected to curb use. On the other hand, it could be (for example) that good schools attract families whose children are less at risk, or that both culture and substance use reflect some other factor, such as unmeasured quirks of the neighbourhood. In these cases, enhancing school culture would not impact on substance use.
Doubts are allayed by the consistency of the findings and by their
compatibility with closely allied findings on pupils’ ‘connectedness’ to school
– the sense of being part of a valued school community click here for details. Mainly US studies have linked higher connectedness to healthy
development, including avoidance of early and risky substance use.7 Connectedness is higher in warm and supportive schools with a caring, inclusive ethos, which emphasise prosocial values, encourage cooperation, show concern for pupils as individuals, allow pupils to participate in decision-making and offer extracurricular activities. Attempts to foster pupil development and school bonding by creating this kind
of climate have sometimes worked, but some schools have been unable to take
these interventions on board.
A few studies have also directly tested whether such efforts reduce substance use. The results have at best been inconclusively promising. This could be because the greatest impact is on particularly deviant forms of drug use, frowned on by most pupils as well as by the school, rather than age-typical substance use experimentation. Also, the improvement levers open to researchers fall far short of those available to authorities which can replace staff, inject resources and mandate compliance. This may be partly why findings are muddied by a suspicion that schools able to implement school climate interventions were already on a positive trajectory.
PRACTICE IMPLICATIONS Because they are all-pervasive, school culture improvements might justify themselves on a multiplicity of grounds including academic achievement and crime prevention as well as substance use, and may seem a better bet for schools than diverting resources to dedicated drug prevention activities with their patchy track record. The evidence is strong that schools which (as in the featured studies) develop supportive, engaging and inclusive cultures, and which offer opportunities to participate in school decision-making and extracurricular activities, create better outcomes across many domains, including non-normative substance use.7 As well as facilitating bonding, such schools are likely to make it easier for pupils to seek and receive the support they need. However, these studies document the impacts of normal school development processes. Doubts remain over whether an add-on intervention to improve school culture can be implemented and effective unless these processes have already created fertile ground. The lessons seem to be to attend to the basics through school management, training, pastoral and administrative procedures which foster and demonstrate a caring, cooperative and participative ethos and concern for pupils as individuals, then perhaps to seek to optimise these virtues through targeted interventions.
Thanks for their comments on this entry in draft to Patrick West and Lyndal Bond of the MRC Social & Public Health Sciences Unit and Chris Bonell and Adam Fletcher of the London School of Hygiene & Tropical Medicine. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 FEATURED STUDY Bisset S. et al. School culture as an influencing factor on youth substance use. Journal of Epidemiology and Community Health: 2007, 61, p. 485–490.
2 Supporting its validity as an index of lack of commitment to the school, the truancy index co-varied with two other such indices: the rate of authorised absence and the proportion of pupils who failed to secure qualifications virtually all could achieve had they tried.4
3 The only other statistically significant relationship in the adjusted analysis was between good exam results and fewer pupils engaging in heavy drinking.
4 FEATURED STUDY Aveyard P. et al. The influence of school culture on smoking among pupils. Social Science & Medicine: 2004, 58(9), p. 1767–1780.
5 FEATURED STUDY Markham W.A. et al. Value-added education and smoking uptake in schools: a cohort study. Addiction: 2008, 103(1), p. 155–161.
6 West P. et al. School effects on pupils’ health behaviours: evidence in support of the health promoting school. Research Papers in Education: 2004, 19, p. 261–291.
7 Fletcher A. et al. School effects on young people's drug use: a systematic review of intervention and observational studies. Journal of Adolescent Health: 2008, 42(3), p. 209–220.
LINKS
Background notes for In Context section |
Nugget 13.9 |
Nuggette 11.5
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