Psychology and Brief Interventions

British Journal of Addiction (1989) 84, 357-370

Psychology and Brief Interventions

NICK HEATHER

National Drug & Alcohol Research Centre^ University of New South Wales, Australia

SummaryIn this article, a discussion of the definition and description of brief interventions is followed by broad reviewsof their effectiveness in the cigarette smoking and alcohol fields. It is then argued that brief interventionsshould not be Justified only in terms of early intervention; that there is at present insufficient evidence towarrant the abandonment of conventional outpatient treatment for clinic attenders; and that the relativecontribution of motivational and active behaviour-change components of brief interventions is an importantarea for research.

IntroductionIn addressing the topic of psychology and briefinterventions in the field of addictions, this article isnot primarily concerned with the psychologicalprinciples or techniques that are employed in theseinterventions. This will not be a 'how-to-do-it'guide to this area—but see Heather (1989). Instead,the opportunity will be taken to review, in broadterms, the evidence for the effectiveness of briefinterventions in the cigarette smoking and excessivedrinking areas, paying more attention to smokingthan is sometimes the case in reviews of this topic.Some conceptual and methodological problemsfollowing on from this evidence will then bediscussed.

To anticipate a general conclusion of the article,there will be an attempt to show that enthusiasm forbrief interventions has been in some ways mis-placed, especially in the alcohol field. It is not, ofcourse, denied that they are of great potentialimportance in the overall response to problems ofaddiction but there needs to be a greater awarenessof the panicular implications for practice of the

This nnicle is based on a paper read ai ihe Joint Symposium ol'the Society for the Study of Addiction and the British PsychologicalSociety on 'Psycholi^- and Addiction', held at Cardiff, November26-27, 1987.

accumulated evidence on brief interventions and.Indeed, a re-appraisal of the major goals underlyingtheir use.

The main justification for including this materialunder the title of 'Psychology and Brief Interven-tions' is that, in recent years, psychologists havebeen the main professional group involved in theapplication of brief interventions, especially in thearea of alcohol problems. It is hoped that aclarification of some conceptual and methodologicalproblems may enable the future contribution ofpsychologists in this area of work to proceed on amore logical basis. Moreover, during this anicle,there will be reference to research issues which needattention and which psychologists are ideally placedto investigate.

There is also a need to justify the restriction ofattention here to just alcohol and tobacco. Theapplication of brief interventions to the area ofillegal drug use has been interestingly explored byBiihringer (1987), but no research results are yetavailable. Similarly, Allcock & Dickerson (1986) inAustralia have produced a self-help manual forcompulsive gamblers and are examining its effect-iveness but, again, no results are yet to hand. Otherexamples of the exploration of brief interventionsoutside the alcohol and smoking areas could doubt

357

Nick Heather

less be found, but a review of this work must awaitanother occasion.

Definition and DescriptionThe task of arriving at a clear definition of briefinter^'entions is similar to that of defining the lengthof a piece of string! Any proposed definition is sureto be arbitrary. In fact, for the purposes of thisdiscussion, there is no point in attempting a hardand fast definition—in terms, for example, of amaximum amount of specialist time which qualifiesas 'brief. The cost-effectiveness of each particularintervention strategy must be assessed in compari-son with other forms of intervention, both 'minimal'and 'intensive', which may be applied. The generalcharacteristics of brief interventions—that theyinvolve a lesser degree of specialist time than isnormally the case in treatment, that they oftenincorporate the efforts of primary level or non-specialist workers, that they are typically aimed atlarger numbers of clients than are reached byconventional treatment methods—are by now wellunderstood (Heather, 1986).

Contrary to some usages, self-help manuals willbe included here within the category of briefinterventions. Indeed, one might argue that the mostinteresting difference between brief and more ex-tended inter^'entions is that the former utilize theself-management capacities of clients to compensatefor the work normally done by the therapist in moreconventional treatment. Thus, from this point ofview, self-help programmes are not merely a type ofbrief inter\'ention but their purest representation.However, it is possible that brief inter\'entionsincorporating some degree of personal contact withchange agents are relatively more effective thanself-help procedures alone (see Heather, 1986).Whether this is in fact the case and, if so, underwhat particular conditions of personal contact, is animportant question for research.

Although the actual methods and procedures usedin brief interventions var>' widely, one distinction itmay be useful to make is between simple advice toclients and what might best be called condensedcognitive-behavioural treatment for addictive dis-orders. This sort of distinction was recently made bySanchez-Craig (1987). Simple advice has beenmainly used by psychiatrists interested in briefinter\*entions (e.g. Edwards & Orford, 1977; Chicket ai, 1985j 1988), while condensed behaviouraltreatment has been explored mainly by psycho-logists (e.g. Miller « a/., 1980, 1981; Robertson et

ai, 1986; Heather et al, 1986, 1987a,b; Sancbez-Craig et ai, 1987). The distinction is blurredbecause 'simple advice' sometimes involves self-monitoring and other elements of a behaviouralapproach, while there is often an ingredient ofadvice and plain exhortation in brief cognitive-behavioural programmes.

As we shall see, the relative contribution ofmotivational and behaviour-change components ofbrief interventions is an issue of some topicalinterest. For the present, we may note thai oneobvious question to which research could be ad-dressed is whether or not the relatively complextechnology of the self-management approach isnecessary for change to occur or whether simpleadvice, given in 'constructive and sympatheticterms' (Orford & Edwards, 1977), is sufficient. Theanswer lo this question should take the form of a listof circumstances and/or client characteristics whichfavour simple advice and another which suggests theneed for a more formal self-management approach.A further research issue concerns the question,which elements of the self-management package, ifany, are essential to its effectiveness.

Cigarette SmokingCigarette smoking is the addictive behaviour inwhich brief inter\'entions have had the greatestdegree of success. Research studies in the smokingarea (e.g. Russell et al., 1979; 1983) provideexamplars with which other studies of brief inter-vention should be compared and will usually sufferin the comparison.

Because cigarette smoking has generally escapedbeing thought of as a disease and because, therefore,there is not a long tradition of intensive treatmentfor smoking, there has been less controversy aboutthe alleged effectiveness of brief interventions andless resistance to their application than in thealcohol field. Moreover, general practitioners, whoconstitute the main mode of delivery of briefinterventions for smoking, seem more prepared toengage in this kind of work than in brief inter\'en-tions for excessive alcohol consumption. Finally,smokers are easy to identify, outcome is relativelyeasy to measure and large samples of clients areusually available.

The seminal piece of research was Russell et a/.'s(1979) study of the effects of general practitioners'advice against smoking. Two thousand one hundredand thirty-eight smokers attending their GPs in fivegroup practices in the London area were allocated to

Psychology and Brief Interventions 359

one of four groups; a non-intervention control; aquestionnaire-only control; a group given simpleadvice by the GP to stop smoking; and a groupadvised to stop smoking, given a leafiet to help themand warned that they would be followed up. Theproportions in these four groups which had stoppedsmoking during the first month and were still notsmoking 1 year later were 0.3%, 1.6%, 3.3% and5.1%. The authors estimated that, if all GPs in theUnited Kingdom adopted the simple advice plusleaflet routine, the yield would exceed half a millionsmokers a year, a target that could not be matchedby increasing the number of special withdrawalclinics to 10,000.

Since Russell et al.'s (1979) study appeared, afunher six controlled trials of GF's advice tosmokers have been published (Wilson et ai, 1982;Stewart & Rosser, 1982; Russell et ai, 1983;Jamrozik et al., 1984; Fagerstrom, 1984; Richmondet al., 1985; 1986). Each of these studies investi-gated the effects of adding to simple advice invarious ways, in order to increase the effectivenessof GP intervention.

Unfortunately, it is difficult to make directcomparisons between these studies owing to differ-ent follow-up intervals, different criteria for absti-nence (depending on the length of abstinencerequired and the extent to which self-repons ofquitting were confirmed by biochemical measures,etc.), different methods for estimating abstinencerates (depending mainly on whether or not thoselost to follow-up were regarded as failures or simplydiscounted in the analysis), and criteria for entry toihe trial (all smokers or only those thought to bewell-motivated to stop). Nevertheless, the results ofthis research effort are collated in Table 1. Thisgives two outcome measures: the percentage ofsubjects not currently smoking at the follow-uppoint; and the percentage not smoking at anycontact point during the foltow-up period andpresumed to have been continuously abstinentduring that period (long-term abstinence). Alsogiven in Table I are significance levels for relevantcomparisons and the method used lo validate self-reports of non-smoking, if any, together with theestimated 'deception rate' calculated from thisvalidation procedure. This rate did not differsignificantly between the groups being compared inany of the studies under review.

The evaluations of brief interventions recentlyreported by Folsom & Grimm (1987) and by Janz etal. (1987) have not been included in Table 1because of follow-up of 6 months or less. Moreover,

the Janz et al. study was conducted in a hospitaloutpatient setting rather than in general practice.

Stewart & Rosser (1982) were the only investiga-tors not to find a superiority of GP's advice over acontrol condition. Six hundred and ninety-onesmokers were randomly assigned to a questionnaire-only control group, to a group given simple adviceby the GP or to a group given advice plus a leaflet.At 12 month follow-up, the abstinence rates in thesethree groups were U.7%, 10.5% and 12.8% respec-tively, with no significant differences emerging. It isnot clear why no effect of advice was obtained inthis study, Also in Canada, Wilson et ai (1982)arranged for 206 mainly middle-class smokers toreceive a 3- to 5-minute counselling session fromtheir GP. They were then randomly assigned to agroup that received up to three funher counsellingsessions within the next 6 months or to a controlgroup that received no further attention to smoking.Outcome was assessed from patients' reports 6-14months after entry into the trial and it was foundthat 12% of patients in the control group hadstopped smoking compared with 23% in the experi-mental group (p<0.05). Despite problems incomparing the outcome measures in this study withthose from other research, it does at least raise thepossibility that a greater investment of GP time incounselling might be worthwhile.

In another study by Russell and his colleagues(1983), it was found that, by adding nicotinechewing gum to the brief intervention, the I yearabstinence rate for subjects who had also beenabstinent at 4 months follow-up could be increasedto 8.8%, which was clearly superior to rates of 4.1%and 3.9% respectively in an advice plus bookletgroup and a non-intervention control. The figure of8.8% here should be compared with that of 5.1% forsustained abstinence found in the group givenadvice, a leaflet and a warning of follow-up inRussell et a/.'s previous (1979) study.

Fagerstrom (1984) made an independent assess-ment of the added benefits of nicotine chewing gumand of a long, as opposed to a short, therapeuticfollow-up in which patients were educated andcounselled about their smoking by the physician. Hefound that the best outcome was observed in thegroup receiving chewing gum and long follow-up,with a 1 year abstinence rate of 27%. Of the twofactors, the chewing gum was the more influential inincreasing success rates. The relatively high absti-nence rates in this study should be treated withcaution, however, because subjects were selected forinclusion on the basis of being sufficiently moti-

360 Nick Heather

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vated to stop and a direct comparison with resultsfrom studies looking at unselected smokers istherefore difficult.

Jamrozik et ai (1984) also investigated theeffects of simple, verbal and written advice but thistime compared it with the added procedure of ademonstration of exhaled carbon monoxide and alsoadvice plus the offer of further help from a healthvisitor. A non-intervention control group was alsoused. At 1 year follow-up, 11% of the control groupclaimed to have stopped smoking compared with15% in the group receiving advice alone, 17% in thegroup given the added demonstration of exhaledcarbon monoxide and 13% in the group given theadded offer of help from a health visitor. Theauthors themselves warn that their observed self-reported quitting rates may have been exaggerated,but claim that this does not affect their conclusionsabout the relative effectiveness of the differentprocedures. There was an interesting suggestion thatthe exhaled carbon monoxide procedure was parti-cularly effective with individuals from lower socialclass groups who are usually thought to be lessamenable to treatment and advice to stop smoking.

In Australia, Richmond et al. (1986) allocated200 smokers to a non-intervention control group ora treatment programme, described as 'intensive',which involved an educational consultation and fourfollow-up visits following an initial visit. At 3-yearfoiiow-up, 36% of patients were abstinent in thetreatment group compared with 8% in the controlgroup. In this study, all losses to follow-up wereregarded as failures and all self-reports were con-firmed either by biochemical assay or collateralinformation. The impressive rate of success ob-served 3 years after treatment is sufficiently betterthan other reports to warrant a replication, espe-cially in view of the apparent absence of anyevidence of deception in self-reports. However,these results, together with those of Wilson et al.(1982), certainly raise the possibility that a moreintensive approach from GPs may be cost-effectivecompared with the type of brief interventionpioneered by Russell and his colleagues.

Clearly, however, the intervention used by Rich-mond et al. is intensive only in relative terms; it isstill a great deal more economical of time and effortthan specialist stop-smoking clinics. This line ofresearch has suggested the hypothesis that interven-tion by GPs is the best way of proceeding for thegreat majority of smokers. However, it is possiblethat there may be a significant minority, probablythose with a high level of dependence or showing

unusual personal or environmental characteristics,who need attention in specialist clinics or on-siteworkplace clinics. Several other modes of interven-tion exist using, for example, pharmacists or healthvisitors, and GP interventions must eventually becompared with each of these. In wider terms, waysmust be found to compare the cost-effectiveness ofGP interventions with smoking cessation pro-grammes initiated through the media (Cummings etai, 1987) and mass media campaigns in general(Flay, 1987).

A remaining question is precisely how minimal orintensive should GP interventions be for optimalresults. The main alternative to increasing theamount of GP involvement is the use of nicotinechewing gum combined with very brief intervention.This comparison is the focus of a further study byRichmond and her colleagues which is nearingcompletion. These investigators also intend to enlistthe aid of an economist in making a formal estimateof the cost-effectiveness of the different GP-administered procedures.

Before leaving the smoking area, it should bepointed out that the effectiveness of brief interven-tions has been examined for patients who havealready contracted smoking-related diseases in anattempt to improve prognosis, Williams (1969)found that, following simple advice to stop, between18% and 23% of patients attending a chest clinicclaimed to have given up for 6 months. Burt et ai(1974) found that, for patients recovering frommyocardial infarction, firm advice reinforced withwritten advice and home visits by a communitynurse gave a 62% abstinence rate at 12 monthfollow-up. However, iii a report by the ResearchCommittee of the British Thoracic Society (1983),it was found that adding a booklet, nicotine chewinggum or placebo chewing gum to advice did notincrease the confirmed quit rates of patients attend-ing a hospital or chest clinic with smoking-relateddiseases. The average rate was only 9.7%. Thisresearch topic clearly requires more attention.

AlcoholThere is no intention to review here the results ofresearch on brief interventions in the alcohol area,since this has been done several times before (e.g.Babor et ai, 1986, 1987; Saunders & Aasland,1987). Instead, a few general observations will bemade before moving on to develop some argumentswhich are especially relevant to the way briefinterventions for excessive drinking are deployed.

362 Nick Heather

As is now well-known, interest in brief interven-tions for alcohol problems was stimulated, amongstother things, by Emrick's (1975) review of treat-ment outcome research and then by Orford &Edwards' (1977) controlled trial of treatment versusadvice. Despite the deserved amount of attentionthe latter has received and despite Edwards &Orford's (1977) specific recommendation of'a plaintreatment for alcoholism', it is not clear that actualtreatment practices in Britain or elsewhere havebeen much infiuenced by this research. It would befascinating to see the results of a survey oftreatment agencies asking whether the averagelength of their treatment had been affected by thisevidence.

The situation with regard to controlled drinkingtreatment is different. Interest in brief controlleddrinking interventions was mainly stimulated by thework of William R. Miller and his co-workers on theeffects of self-help manuals compared with regularbehavioural treatment (Miller, 1978; Miller &Taylor, 1980; Miller et ai, 1980, 1981; Miller &Baca, 1983). This area of work has also beenpursued by Heather and his colleages in Dundee(Heather, 1986; Heather et a/., 1986, 1987a,b;Robertson & Heather, 1982; Robertson etal., 1986;Baldwin & Heather, 1987). Research evaluationsand practical implementations of brief interventionshave been far more numerous than in the area ofabstinence treatment, probably because they weredirected mainly at those with 'early' problems andalso because there was a far less stable tradition ofintensive treatment to provide resistance to thenotion of brief intervention.

As is also well-known, there have been severalresearch evaluations of brief interventions in thecommunity with very interesting and promisingresults. Chief among these is the work of the Malmogroup led by Hans Kristenson (Kristenson et al.,1982, 1983; Trell et al., 1984). The research ofChick et al. (1985) on the effects of simple advicewith excessive drinkers identified on general hospi-tal wards has also attracted much interest. Evidencefor the effectiveness of self-help manuals withoutany therapist contact is less secure at present(Heather et ai, 1986,1987) but work on this topic isproceeding in Dundee, as is a project exploring someof the implications of Chick's work in generalhospitals.

Perhaps the most active area of research atpresent is on the effectiveness of brief interventionsin general practice or other primary care settings. A

controlled trial of the Scottish Health EducationGroups's DRAMS Scheme (Heather, 1987;Heather et ai, 1987) produced inconclusive results,owing partly, it must be said, to a failure to attractthe necessary co-operation in the project fromgeneral practitioners. However, a controlled trial ofa brief intervention in general practice in London(see Wallace & Haines, 1985) has been completed,although no details are available yet. Meanwhile,work in this area is proceeding in Wales (Rollnick,1987), Sweden (Romelsjo, 1987), Holland (VanLimbeek & Walburg, 1987), Australia (Wodak,1988) and, no doubt, in several other places aswell.

One other point is worth making before movingon. A recent article by Rowland et ai (1987)commented on the difficulties involved in persuad-ing junior medical staff to incorporate a few briefscreening questions on alcohol consumption, takingonly 1 or 2 minutes to complete, into the medicalhistories they take from patients. The articleconcluded: "This study showed that questioningpatients about their drinking habits was not per-ceived by doctors as a priority. Many patients whodrink to excess therefore remain unidentified and amajor reducible cause of disease and death isignored" (p. 96). We have had a similar experiencein Dundee. Moreover, the problems encountered inpersuading general practitioners to become involvedin brief interventions for excessive drinkers havealready been mentioned and there is now a sizeableliterature on this topic (e.g. Strong, 1980; Thom &Tellez, 1986; Clement, 1986). Lest it should beconcluded that the problem is confined to themedical profession, difficulties encountered in Dun-dee in persuading magistrates to refer young offen-ders with obvious alcohol problems to a specially-tailored intervention and of persuading social work-ers to take over the delivery of this interventionshould also be mentioned.

It may not be too much of an exaggeration to saythat the main obstacle to the successful implementa-tion of brief interventions in the alcohol field isovercoming the reluctance to co-operate with pro-jected interventions on the part of relevant profes-sions, rather than the problem of persuading clients,when we do get access to them, to change theirdrinking behaviour. At the very least, practicalresearch should be directed urgently to the dis-covery of the best ways of persuading generalpractitioners, physicians, social workers, etc. tobecome involved in this work.


Not Just *Early* InterventionsAn important issue concerns the eventual aim, orguiding principle, which should lie behind the use ofbrief interventions, In the area of alcohol problems,their justification is often expressed solely in termsof early recognition and intervention (Skinner &Holt, 1983; Babor et al, 1986). It is pointed out thattreatment of alcohol problems is relatively ineffec-tive once people have reached an advanced stage ofdependencei hence the need for early identificationof those with mild problems and, in view of thesuperior prognosis for those at early stages ofdependence, the potential benefits of effectiveintervention. However, while no-one would seri-ously deny that early intervention is a mostimportant aim, it would be a mistake to think of theadvantages of brief interventions only in theseterms.

First, there is good evidence that many of thosewho develop alcohol problems early in life grow outof them with increasing maturity. For example, inFillmore's (1974) 20-year follow-up of collegestudents, only 29% of those defined as problemdrinkers between the ages of 16 and 25 years couldalso be so defined 20 years later, nearly all theremainder having become non-problem drinkers.More than half the 110 'core-city' alcohol abusersfollowed-up over a 33-year period by Vaillant &Milofsky (1982), alcohol abusers who would nor-mally be thought of as having a poor prognosis, hadbecome abstainers or social drinkers by age 47 yearswithout the benefit of any formal treatment. It isnow nearly 20 years since an increasing divergencebetween prevalence and incidence after about theage of 40 years led Drew (1968) to describealcoholism as a 'self-limiting disease'. More gener-ally, evidence on 'spontaneous remission' fromalcohol problems (Tuchfeld, 1976; Saunders &Kershaw, 1979) has been one factor leading to arejection of the view that alcohol problems inevit-ably or even usually deteriorate over time. It iscurious that this well-accepted evidence should nothave had more impact on discussions of the majorgoals of brief interventions. Clearly, there is everyjustification for intervening early on behalf of theminority who may not recover unaided but, at thesame time, the evidence surely demands the postula-tion of a wider rationale for brief interventions ingeneral.

It would appear that the basic distinction betweenalcohol dependence and alcohol-related disabilities(Edwards et ai, 1977) has been forgotten here.These two domains are conceptually and empirically

separate. They may be positively correlated but thedegree of correlation varies according to the samplestudied. Among younger men, for example, depend-ence and disabilities show less correlation (Fillmore& Midanik, 1984) than among clinical samples ofolder subjects. At this point, it may be useful to referonce again to Thorley's (1980) 'three-balls' modelof alcohol problems (see Fig. 1), which must now berivalling Glatt's 'slippery slope' as the most familiarartefact in the alcohol field.

Regular excessiveconsumption

Intoxication Dependence

Figure 1, Three aspects of alcohol consumption which cancause problems. (Adapted from Thorley, 1980, p. 1817.)

The point is that problems due to intoxication andthose due to excessive consumption do not neces-sarily involve significant degrees of alcohol depend-ence and there is therefore no inherent reason whythey should get worse over time. For example, in thedomain of problems caused by intoxication, drunk-enness by young adult males does not necessarilylead on to increasing levels of alcohol dependenceand the majority of those who drink in this way growout of this type of problem when they acquiregreater responsibilities. Nevertheless, acute intoxi-cation often causes considerable damage to people'slives. For example, while preparing a secondaryprevention programme aimed at excessive drinkingamong university students, Marlatt (1987) notedthat two students on the campus concerned hadfallen to their deaths during drinking parties withinthe previous year. Accidents apart, arrests for public

364 Nick Heather

drunkenness, alcohol-related assaults or drink-driv-ing offences are serious matters for the personconcerned, as well as for society at large, in thedomain of problems caused by regular, excessiveconsumption, we know that those showing alcohol-related organic conditions do not always show a highdegree of dependence. For example, Wodak et al.(1983) found that only 18% of patients withalcoholic liver disease could be classified as severelyalcohol dependent on the SADQ. There may be aneed to intervene early here, before liver damage hasbecome irreversible, but this is not in the interests ofpreventing the development of more severe levels ofalcohol dependence, as often seems to be implicitwhen early intervention in this area is beingdiscussed. The main point is that the problems weare concerned with here are worthy of attention intheir own right, not merely as precursors of moreserious problems in the future.

It is presumably because smoking is not usuallyregarded as a disease that the appeal to earlyintervention is not made in the cigarette smokingarea. Its use in the alcohol field is another illustra-tion of how the assumptions of the disease way ofthinking continue unacknowledged to influence ourapproach to this subject.

The alternative justification for brief interven-tions is that they mark an expansion of ourconception of what counts as an alcohol problem—ashift away from a narrow preoccupation withproblems of severe dependence to the entire rangeof problems caused by alcohol. The argument forthe necessity of this shift is now very familiar and,indeed, was first made by Jellinek (1960). This iswhy it is curious that it does not seem to havepermeated most discussions of brief intervention.However, an important corollary of the argument,which was not anticipated by Jellinek, is that theburden of the national response to alcohol problemsshould also shift —away from the clinic and thespecialist worker to the wider community settingwhere it would form part of the natural environmentof the excessive drinker. Furthermore, at the sametime that brief intervention is not merely earlyintervention, neither is it merely in the interests of'secondary prevention'. Rather, it is in many wayscloser to the primary preventive aim of reducing percapita alcohol consumption by producing a wide-spread change in the norms surrounding drinkingbehaviour. Thus, the eventual goal of brief interven-tions—that of reducing the drinking of large num-bers of the population, combined with a change inthe public awareness of alcohol consumption—is

more fundamental than is implied by an appeal to'early intervention'.

*Proving the Nul! Hypothesis*A methodological problem in this field concernsstudies in which a brief intervention is comparedwith a more intensive intervention, normally con-ventional treatment for the addictive disorder inquestion. The methodological problem appliesmostly in the alcohol area but is potentiallyapplicable to other addictive behaviours. The highlyinfluential study by Orford & Edwards (1977) andthe series of studies by William Miller and hiscolleagues on controlled drinking treatments are ofthis type. The typical finding, and the one which hasdone most to encourage interest in brief interven-tions, is that the intensive and minimal groups donot differ on any important outcome measure atfollow-up. It is therefore concluded that the twoforms of intervention are equal in effectiveness and,by implication, that the minimal intervention ismore cost-effective.

The problem consists in the fact that thisinterpretation is quite erroneous and is an exampleof a classic error in the logic of hypothesis testing,known as 'proving' the null hypothesis. The point is,of course, that the null hypothesis of no differencebetween groups cannot be proved. If an experimentfails to find any significant differences between twosample groups, it cannot be concluded that theexperiment provides evidence that the populationsfrom which the samples are drawn do not differ; allthat can be legitimately concluded is that theexperiment provides no evidence that they do differ,a quite different deduction. One implication of thisis that, if the experiment were repeated, perhapswith a larger or more representative sample, asignificant difference might emerge.

That this error is in fact made in the briefinterventions literature can be economically illus-trated by quoting from a recent article in the BritishJournal of Addiction. Skutle & Berg (1987) com-pared four conditions for training controlled drink-ing in 'early-stage' problem drinkers: a bibliotherapygroup and three types of therapist-directed training.All groups showed significant reductions in alcoholconsumption from intake to follow-up but nosignificant between-group effects were found. Indiscussing how these findings replicate previousresults from the Miller research group, the authorswrite: "This indicates no differences in effective-ness between the minimal bibliotherapy and the


three more extensive programs" (p. 499). Thisinterpretation is especially worrying in view of thesmall sample sizes in this study (w= 12) and the factthat, from inspection of Fig. 1 in Skutle & Berg'sresults, it would seem that the bibliotherapy groupshowed a smaller relative reduction in consumptionthan the more intensively treated groups. Thus alarger sample may well have shown a significanteffect. (It should be stressed that this example of theerror is but one of several which could have beenchosen.)

As this suggests, the problem becomes parti-cularly acute when some measure of improvement ishigher at foUow-up, although not significantly so, inthe intensive than in the minimal group. This makesthe conclusion of equal effectiveness for the briefintervention especially dubious. In fact, this situa-tion is quite common in the literature. For example,in the study by Miller & Taylor (1980), a groupreceiving a self-help manual only was comparedwith one given behavioural self-control training(BSCT) by an individual therapist, another givenBSCT plus relaxation training and another givengroup therapy which included relaxation trainingand instruction in self-control procedures. At 12months follow-up, the success rates for these groupswere, respectively: 75%; 40%; 75%; 89%. Thusbibliography produced rates of effectiveness higherthan one type of intensive treatment, equal to asecond, but lower than a third, without any of therelevant differences reaching statistical significance.But it is possible that further sampling would haveshown the group therapy procedure to be statistic-ally superior, especially since we are again dealingwith small samples sizes (« = 9-12). Thus, if it is infact the case that there has been an erroneous failureto reject the null hypothesis because of small samplesizes, it is likely that the direction of the realdifference between groups is in favour of moreintensive interventions. One solution to the problemis to conduct a meta-analysis of the relevant dataand determine the power of the test of the nullhypothesis which combining the data would produce(Glass et ai, 1981). This is now proceeding at thisresearch centre.

The argument is strengthened by the fact that, inat least one study, a superiority of intensive overminimal treatment has been found. Robertson et ai(1986) randomly assigned 37 problem drinkers withlow or moderate alcohol dependence to a groupreceiving an average of about nine sessions ofindividually-tailored cognitive-behavioural treat-ment directed at a controlled drinking goal or to two

or three sessions only of assessment and advice. Atfollow-up a mean of 15 months after intake, theintensive group showed a significantly greaterreduction in consumption and also a significantlygreater increase in days of abstinence in the previousmonth. The significant different in consumptiondisappeared if three atypical individuals, whoshowed large increases in consumption, were ex-cluded from the minimal group, but the significantdifference in days of abstinence remained.

Why this study should have shown a differencebetween intensive and minimal groups when severalothers have not is unclear. One possibility issuggested by the incidental finding of Miller et ai(1980) that clients seen by controlled drinkingcounsellors high on empathy did better than thosegiven a self-help manual, whereas clients seen bycounsellors low on empathy did worse. Overall, theresults evened out to show no difference betweenthe bibliotherapy and counselled groups. It may bethat the therapists in the Robertson et ai study (whodid not include the author) were especially empathicor skilful and were likely to produce favourableresults, suggesting if true that brief interventionsshould only be used when the alternative is poorcounsellors or therapists. Whatever the reason forthe discrepancy, it should at least make us hesitatebefore concluding that intensive show no superiorityto brief interventions aimed at a controlled drinkinggoal.

A similar point can be made with respect toOrford & Edwards' (1977) study of 100 married,male alcoholics given conventional abstinence-ori-ented treatment or a single session of advice. It wasquickly pointed out in reactions to this research thatthe lack of significant differences between groups inone year outcome might disguise an interaction inthe data, such that more severely dependent clientsdid relatively better with intensive treatment whilethe reverse was true for the less dependent (Tuch-feld, 1977). Indeed, this interpretation appeared tobe borne out by the second-year follow-up results(Orford et a/., 1976). Moreover, it has also beenremarked that the lack of significant differencesnoted might only apply to clients of relatively highsocial stability of the type studied by Orford &Edwards, since such individuals are likely to im-prove with any kind of attention, including minimaladvice (Kissin, 1977).

This last suggestion is supported by the restUts ofa recently completed study by Chick et al. (1988)which was based on Orford & Edwards' design butwith a few important modifications. Following a

366 Nick Heather

comprehensive client and informant assessment,152 attenders at an alcohol problems clinic wererandomly assigned to receive extended inpatient oroutpatient treatment or alternatively one session ofadvice. Unlike Orford & Edwards' sample, however,this included women and unmarried clients. At 2-year follow-up, there was no difference betweenextended treatment and advice in terms of abstin-ence rates or in employment or marital status, butthe extended group showed evidence of less alcohol-related damage in the period since intake. Interest-ingly, this study supported, in a controlled trial, thesuggestion originally made by Emrick (1975) in hiscompendious review of the outcome literature thatextended treatment does not affect the likelihood ofsuccessful abstinence but may reduce the amount ofharm caused by drinking.

The main conclusion to be drawn from thisdiscussion is that there is insufficient evidence tojustify the inference frequently made that intensivetreatment for individuals attending specialist treat-ment centres is no better than brief treatment oradvice. On the contrary, there are several groundsfor suspecting that intensive treatment is superiorfor this client group. This conclusion may becompletely unsurprising to treatment providers inthe field who have always 'known', despite what theevidence appeared to suggest, that treatment didimprove their clients' chances of recovery. How-ever, it may be surprising to researchers and to thosewho see little of value in specialist treatment.

At first sight, this conclusion appears to be atodds with a growing consensus in the field, asexemplified by Miller & Hester's (1986a) recentreview, that intensive treatment for alcohol prob-lems should be abandoned. However, there is nointention here to suggest that inpatient treatmentshows any superiority to outpatient treatment; thishas been shown fairly conclusively by Miller &Hester, among others, to be false and, in any event,is irrelevant to the present argument. It should benoted, though, that Miller & Hester write that"findings on intensity of outpatient care are lessconsistent" (p. 156). Thus it is still possible that, forexample, outpatient cognitive-behavioural con-trolled drinking therapy produces superior results tobrief assessment and advice, as was indeed theunexpected finding of Robertson et al.'s (1986)study. As Robertson et al. point out, however, eventhis limited conclusion is complicated by thepossibility that some types of client are more suitedto intensive approaches and some to briefer inter-ventions and that accurate matching of clients to

intensity of treatment, on variables yet to bedetennined by research, would improve overallsuccess rates (cf. Miller & Hester, 1986b).

At this point, the cost-effectiveness argument islikely to be raised: intensive outpatient treatmentmay be better than simple advice but not much, sothat on a cost-effectiveness basis brief interventionis the best policy. One arguable view here is that,when problem drinkers are actively seeking help,cost-effectiveness becomes irrelevant. We are ethic-ally bound to offer clients the best available help.And the interpretation of the literature in thepresent article suggests that this is still intensiveoutpatient treatment, irrespective of the level ofseriousness of problems or how 'early' they arethought to be.

This conclusion does not, of course, affect thejustification for brief interventions in the commu-nity. Here several studies have shown such inter-ventions to be superior to control conditions (Kris-tenson et ai, I983i Chick et ai, 1985; Heather et ai,1986, 1987). Thus the evidence shows that briefinterventions are effective and should be used forthose individuals who are not actively seeking helpat specialist agencies. This justification is, again,independent of level of seriousness, although mostrecipients of community-based brief interventionswill obviously have problems of a less severevariety. Moreover, when potential clients are notactively seeking help, then the cost-effectivenesskind of argument does become relevant and it isethically legitimate to ask what is the least expensiveway of reaching the greatest number of smokers orexcessive drinkers, etc.

Contemplation or Action?It is often said that the study of alcohol problemshas much to offer the study of other addictivebehaviours. This is why it is unusual to suggest that,in relation to some aspects of brief interventions, thealcohol area can learn from research into cigarettesmoking.

In studies of smoking cessation, it is relativelyeasy to disentangle motivational factors from thoseto do with skill in giving up. For example, in theoriginal study by Russell et al. (1979), changes inmotivation and intention to stop smoking weremeasured immediately after advice was given. Thisenabled the authors to conclude that the beneficialeffect of advice was achieved by motivating morepeople to try to stop smoking, rather than byincreasing the success rate among those who did try.


In the later (1983) study, in which nicotine gum wasadded to brief advice, the conclusion was that thebeneficial effect was more prolonged; it motivatedmore smokers to try to give up, but also increasedthe success rate among those who tried to stop andreduced the relapse rate among those who did stop.It is possible that the latter benefits were mainly aresult of the chewing gum rather than the advice.

Clear distinctions of this sort are much harder tomake in the alcohol field, especially when the goal isreduced drinking and it is difficult to tell whether agenuine attempt to cut down consumption has beenmade. Nevertheless, the future development of briefinterventions must take these factors into account.In the language of Prochaska & diClemente (1986),it must distinguish between the Contemplation stageof change and the Action and Maintenance stages.This introduces another artifact which is rapidlybecoming very familiar, Prochaska & diClemente'smodel of the stages of change in the addictivebehaviours, illustrated here by a reduced drinkinggoal for problem drinkers (see Fig. 2).

Exit - Long termReduction in Drinking

Enter -Problem Drinking

Figure 2. A model of the change process for a problemdrinker aiming at reduced alcohol consumption. (Adapted

from Prochaska &- diClemente, 1986, p. 6.J

The Stages of change model is the basis for arevision of the DRAMS Scheme for general practi-tioners which Robertson & Heather are developingin conjunction with the Scottish Health EducationGroup (see Heather, 1988). An attempt will bemade to assess where patients have reached in themodel of change described in Fig. 2 and theintervention offered them will be adjusted to this,with separate materials, GP and nurse interventionprocedures for those in Contemplation, Action andMaintenance stages. Patients will move through the

stages until, hopefully, successful maintenance ofreduced dnnking has been achieved.

Apart from any added effectiveness this will bringto brief GP interventions, it may also allow theseparate effects of components of the intervention,directed at the different stages, to be assessed. Forexample, one hypothesis which could be tested isthat, in 'opportunistic' interventions of this kind—in other words, in interventions where the potentialclient is not actively seeking help but must bepersuaded of the need for it—an increase in themotivation to change is all that is needed for change,at any rate initial change, to take place. Thisassumes that, if the level of dependence is low, theAction stage is relatively easy to negotiate and thatall the technology of the Action stage—self-moni-toring, functional analysis, rule-setting, self-rein-forcement, etc.—is irrelevant (cf. Rollnick, 1987).This hypothesis is being proposed because it repre-sents a clear starting point in the task of attemptingto explain why brief interventions work when theydo and what kinds of intervention are best suited towhat kinds of situation. If the hypothesis wereconfirmed, however, this would obviously haveconsiderable implications for the design of briefinterventions in future. For example, they couldthen focus on the motivational procedures recentlydescribed and applied by W. R. Miller (1983, 1987,1989i Miller er a/., 1988).

ConclusionsThis article has commented on issues concernedwith the definition and description of brief interven-tions. Evidence for the effectiveness of brief inter-ventions in the cigarette smoking field was reviewedand the current situation with respect to the alcoholproblems field was briefly summarized. Remainingconclusions will be confined to the three argumentsabout brief interventions, and how they are bestimplemented, that have been developed in thisarticle.

(1) Although they are undoubtedly important,early intervention and secondary prevention shouldnot be regarded as the only aims of brief interven-tions. Instead, brief interventions should be directedat consequences of additive disorders which areproblems in their own right, and should be viewed aspart of an expansion of the definition of whatconstitutes a problem and of a general move awayfrom the specialist agency.

(2) There is insufficient evidence to justify theabandonment of conventional outpatient treatment,

368 Nick Heather

and its replacement by brief intervention, for clientsactively seeking help from specialist agencies, as-suming that it is desired to offer these clients thebest available help. The present evidence justifiesthe use of brief interventions only in communitysettings for those who do not wish to attendspecialist agencies or are not actively seeking help.

(3) For those not actively seeking help, therelative contributions of motivational and behav-iour-change components of brief interventionsshould be assessed in research. One hypothesis isthat, for maximal effectiveness, brief interventionsshould be directed primarily towards increasingmotivation to change.

AcknowledgementI am very grateful to Steven Rollnick who read thepaper in my absence at the Cardiff meeting.

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Psychology and Brief Interventions