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S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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S Intractable ‘alcoholics’ became normal patients (1970). Remarkable series of US studies from the late 1950s transformed ‘skid row alcoholics’ from patients who virtually never attended for treatment after being seen in the emergency department to normal attendees; secret was not to change them, but how they were treated by staff, replacing hostility with warmth and respect. See also slide presentation and video, which end by focusing on the featured studies.
S Some counsellors inspire retention, others rapid drop-out (1976). Trainee alcohol counsellors at a US alcohol treatment clinic varied widely in their records of retaining patients; professional and personal experience of alcoholism did not account for the variation.
S Therapy-related social skills of counsellors strongly related to patient relapse (1981). US study at an inpatient alcohol unit found strong links between the empathy, genuineness, respect, and concreteness exhibited by counsellors in response to written cameos of typical patient/family comments and how many of their patients had relapsed two years after leaving chart. Related study below. Discussion in bite’s Highlighted study section.
K Rapport-generating counsellors improve retention (2002). Replication at a Finnish alcohol clinic of above US study found that in an outpatient setting, greater initial counsellor and client rapport was followed by more patients completing treatment, and that responses to the US cameos predicted which counsellors would on these measures be most effective.
K Reinforcing ‘change talk’ helps curb problem drinking (2009). Micro-analysis of tapes of motivational interviewing sessions in the US Project MATCH trial led to the appealingly simple and plausible conclusions that “What therapists reflect back, they will hear more of”, and that promoting talk about change promotes change itself. However, the study was not designed to establish causality.
K Can therapists be too accommodating? (2009). Rarely has counselling been so deeply analysed as in this US study which found that some counsellors generate relationships with clients which feed through to better outcomes – but also that the ‘best’ relationship builders are not on average the most effective. Discussion in bite’s Issues section.
R Some therapists are just better than others (2012). Ingenious analysis finds that across therapies for behavioural and mental health problems the contribution of the therapist to the creation of a strong alliance and resultant improvement in outcomes is greater than that of the patients: “These results suggest that some therapists develop stronger alliances with their patients (irrespective of diagnosis) and that these therapists’ patients do better at the conclusion of therapy.”
R Therapist effects more important than specific treatments (2014). In substance use treatment, “one of the best indicators of clients’ retention and outcome is the particular counselor to whom they happen to be assigned,” was this essay’s assessment of the evidence. Among the reasons were therapist expectancy of good outcomes, allegiance to the treatment approach they are providing, interpersonal skills including ( below) empathy, and how competently they provide the therapy. A free downloadable copy may be available.
R Select and evaluate clinicians based on ‘track records’ (2000). After exploring the evidence for just about every way you could think of to identify the most effective substance use clinicians, concludes that “past assumptions that levels of training, experience, or other simple therapist variables” would work are mistaken, and that there is no substitute for monitoring actual performance. Free copy may be available. See bite’s Where should I start? section.
R Complexity demands socially skilled and flexible therapists (2016). From Drug and Alcohol Findings, an issue-focused essay on the role of staff in brief interventions and addiction treatment, emphasising that the complexity of interacting variables which therapists have to respond to belies easy, uniform answers.
R Authoritative, evidence-based assessment of how best to relate to therapy clients (American Psychological Association, 2011). Effective ways to relate to therapy clients (including those with substance use problems) common to different therapeutic traditions, like forming a therapeutic alliance, demonstrating empathy, and adjusting to the individual. Also what to avoid (of which more in bite’s Issues section), like confrontation, negativity about the client, and inflexible adherence to one method.
R Relationship factors in treating substance use disorders (2006). Chapter in book on principles of therapeutic change written for the American Psychological Association; covers therapeutic alliance and family/peer support.
R Directiveness is a key dimension of therapeutic style (2006). We all know people who bristle when we take the lead, others who gladly take a back seat. In substance use treatment too, the interaction of therapist ‘directiveness’ with client preferences seems the most consistently influential dimension of interpersonal style. Discussion in bite’s Issues section.
R Is low therapist empathy toxic? (2012). That was the title of a review which synthesised findings on the relationship between therapist empathy ratings and substance use outcomes. It found that “empathy may exert a larger effect in addiction treatment than has been generally true in psychotherapy, accounting in some studies for a majority of variance in client outcomes.” A free downloadable copy may be available. Discussion in bite’s Issues section.
G Official British guidance on how to assess and treat problem drinking (National Institute for Health and Care Excellence, 2011). Recommendations from Britain’s health technology advisers on overall principles and particular interventions. Among the former are that therapeutic staff should aim to build a trusting relationship with clients and work in a supportive, empathic and non-judgmental manner.
G Principles of substance use treatment (2006). Integrates reviews and guidance commissioned by the American Psychological Association (APA), in particular on relationship factors in relevant chapter of APA book. For clinicians, says “Development of an effective therapeutic alliance is crucial” and inter alia recommends accurate empathy, respect for client’s experience, avoiding confrontational struggles, titrating confrontation to client’s “reactance”, and providing goal direction and a moderate level of structure for the therapy. Free download may be available.
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What is this cell about? Whether medical or psychosocial, chosen positively or under pressure, among the ‘common factors’ affecting treatment’s success is the nature of the patient’s relationships with referral and treatment staff. (Common factors are dealt with more generally in cell A2.) Relationships affect whether people want to enter and stay in treatment, and through these and also directly, the degree to which treatment helps them overcome their drinking problems. Relationships emerge partly from the patient, but of most interest is the therapist’s contribution, because this is what can be changed by recruitment, training and experience. The interpersonal style and other features of treatment staff are much less commonly researched than the nature of the intervention, and many studies try to eliminate these influences in order to focus on the specific content of the intervention. This risks eliminating what matters, in order to focus on what generally (1 2) does not.
Where should I start? This freely available review comprehensively maps the ways practitioners of all kinds – medical, counsellors and therapists – might affect the quality and impact of substance use treatment. Later studies can be used to update the conclusions but generally they remain robust, including the fact that while clinicians vary greatly in their effectiveness, what accounts for this is hard to pin down.
In substance use therapy, it is the relationship-building qualities that matter
One thing we do know from this review and from later work is that formal quality indicators like years of experience and professional training and qualifications, usually bear no relation to performance; in substance use therapy and therapy for behavioural and mental health problems more generally, it is the relationship-building qualities that matter. Published in 2000, the reviewers’ conclusions remain broadly supported: “The easiest clinician variables to measure are, unfortunately, some of the least relevant to quality of service delivery (eg, gender, race, age, training, years experience). Variables with much more relevance to quality care include empathy, ability to establish an alliance, emotional reactions to patients, professional demeanor and recordkeeping, ability to enforce clinic rules and make appropriate referrals to further care, beliefs about substance use disorder topics, etc.”
With – in the counsellor role – no formal badges predictive of effectiveness, the reviewers emphasised that there is no substitute for evaluating clinicians based on how they perform with clients. However, this need not entirely be a ‘suck it and see’ experience, with clients as the guinea pigs. Using realistic therapy cameos, staff recruitment and evaluation procedures can get close enough to eliciting how the clinician would react to real clients to make this a worthwhile predictor of their actual performance; more in Highlighted study section below.
Highlighted study A US study from the 1970s illustrates how older studies can have particular value. Notable for its large sample and random assignment of patients to counsellors, it also predated the trend to test treatments so highly standardised and delivered by therapists so highly selected, trained and supervised, that the impact of counsellor quality (if assessed at all) is minimised. Modern studies would probably have eliminated the least competent of the counsellors or subjected them to further training and supervision until they met quality standards. Aided by the wide range of competence seen in everyday practice, the study was able to find a strong link between ratings of the empathy, genuineness, respect, and concreteness exhibited by counsellors in their written responses to written cameos of typical patient/family comments, and how many of their patients had relapsed two years after leaving inpatient treatment.
Contained as they were in an inpatient unit, where patients complete treatment more often than outpatients or perhaps leave for reasons other than their relationships with their counsellors, the study found no link with how long patients stayed in treatment. Over two decades later, a similar study was conducted in Finland but with outpatients, and found that the same ratings of the counsellor’s interpersonal therapeutic skills were this time related to treatment completion. The intervening variable accounting for why some therapists’ patients more often completed appeared to be the degree of ‘rapport’ generated between therapists and clients. Therapists who on average experienced more rapport tended to have clients who felt the same and who more often completed treatment, a proportion which for different therapists ranged from under 40% to nearly 90%.
Isn’t it just a matter of being nice? Not, it seems, from an unusually deep analysis of data from five US outpatient counselling centres. How would you account for the key finding – that substance use reductions were best sustained by clients of counsellors rated about average in terms of their clients’ experiences of working with them? Counsellors who had been relatively poor at striking up a close alliance had worse outcomes, but so too did those who had been especially good.
Counsellors poor at striking up a close alliance had worse outcomes, but so too did those especially good
Note that in this study counsellors were generally very good at generating positive relationships; it was only towards the very top of this range that outcomes started to worsen. Look at the questionnaire on which this finding was based. Imagine the working style of a therapist, nearly all of whose clients ticked all those boxes (some are reverse scored). Perhaps at these levels, therapists were too ‘nice’ or focused too much on the client’s comfort, failing to develop change-promoting “discrepancy” when needed, perhaps not willing to generate some discomfort by highlighting how the patient’s actions contradict their self-image and values. Perhaps too they seemed less than ‘genuine’ to their clients – an important quality which sometimes means making interventions which contravene therapeutic ideals. But remember that while the very top of this scale may not be ideal, you don’t have to slip very far down before things start getting worse again; this is no carte blanche for neglecting alliance-building.
Lest we think this study a one-off, similar findings have emerged in general psychotherapy/counselling, and also in brief alcohol interventions for risky drinkers identified through screening, findings highlighted in cell B1 of the Alcohol Treatment Matrix.
Don’t tell me what to do! There is a corollary to the issue discussed above – the impact of the opposite (in therapeutic terms) of being ‘nice’. On this front, in cell A2 we theorised that once would-be patients approach, knock on and seek to pass through doors to treatment, doing the right things help, but what is critical is to avoid obstructing the process started by the patient by, for example, confrontationally provoking resistance or being judgemental.
How destructive the ‘wrong’ response by a counsellor can be has been most clearly demonstrated among risky drinkers intercepted by screening programmes. The impact of brief interventions to moderate their drinking can it seems be scuppered by just one or two instances of practitioners expressing the non-collaborative stance of someone who knows best, and is therefore in a position to confront, warn, direct, or advise the drinker. In medicine generally, comments patients see as ‘invalidating’, like being dismissed or not taken seriously, have a detrimental impact thought to be greater than the positive impact of validating comments.
The American Psychological Association has provided us with a handy list of what not to do in therapy. It starts with the opposite of what to do, like not expressing accurate empathy. It moves on to confrontation, hostile, pejorative, critical, rejecting, or blaming comments or behaviour, assuming (without checking) that thing are going well, and centring on your own perspective rather than that of the client. But it ends with “inflexibly and excessively structuring treatment” and “using an identical therapy relationship (or treatment method) for all clients”. The implication is that all the previous ‘rules’ might sometimes need to be broken to tailor therapy appropriately.
Directiveness is one example. Probably the most well-evidenced way to obstruct the progress of substance use patients is to ‘direct’ through advice and warnings when the client is likely to react against being ‘told what to do’ – the classic counterproductive reaction which leads patients to dig in their heels, a reaction motivational interviewing was designed to circumvent.
Sometimes, however, being directive is good, and failing to direct the client is a mistake. Take a look at this Findings review. Think about your own relationships. As the review says, in principle things are no different in therapy. Some people, sometimes, and in some situations, expect and need direction, other times it will be resisted. Such complications are why we have socially skilled therapists who can react appropriately, and are almost certainly among the reasons why counselling outcomes can be worse when the therapist is tightly constrained by a manual.
What kind of people do we need to handle these complexities and how can we identify or foster them? One answer can be found in the Highlighted study section.
Empathy: communicating understanding Another obstructing influence is failure to show you understand the client. Among people in treatment for substance use, low empathy has been theorised to be “toxic” by two researchers with an unparalleled record in analysing how motivational interventions work. More empathy helps, but the lack of it is powerful too: “Outlier therapists with outstandingly poor client outcomes are often found in addiction treatment studies. Available evidence links implicates low empathic skill as a marker of this outlier status.”
The type of empathy they were talking about was “accurate empathy”, identified in Carl Rogers’ classic formulation as one of the six “necessary and sufficient conditions” for psychotherapy clients to get better (more on these conditions in cell B4). It combines understanding the client and communicating this, yet retaining emotional distance: “To sense the client’s anger, fear, or confusion as if it were your own, yet without your own anger, fear, or confusion getting bound up in it ... When the client’s world is this clear to the therapist, and he moves about in it freely, then he can both communicate his understanding of what is clearly known to the client and can also voice meanings in the client’s experience of which the client is scarcely aware.” Invert this definition and it is easy to see how the opposite can be destructive, explicitly failing to validate the client’s experience as understandable rather than an aberration.
But again, rules are occasionally there to be broken. Usually being explicitly empathic is good, but the truly empathic clinician knows when this is just going to rub the patient up the wrong way.