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S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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S Alcoholics can learn moderate drinking (1973). Not the first, but the most incendiary paper to challenge the then orthodoxy that abstinence must be the only treatment goal for dependent drinkers. See also second- (1976) and third-year (1978) follow-up results. This refutation (1982) based on a 10-year follow-up was itself refuted (1984) point by point by the original authors.
S The abstinent alcoholic (1962). Classic description of the patient who has sustained abstinence but is nevertheless unhappy, unfulfilled and/or nervously hanging on – in this study from Connecticut alcohol clinics in the 1950s, they were the majority among the non-drinkers.
S Choose the right people (1981). US study showed that responses to written counselling scenarios could be used to assess the interpersonal skills Empathy, genuineness, respect and 'concreteness' – the ability to be specific and direct in expression of feelings and experiences. of alcohol counsellors, which were strongly linked to their patients' post-treatment relapse, research with implications for counsellor recruitment later replicated/extended in Finland (2002).
S Target-setting and feedback to counsellors can improve client engagement (1991). Client participation was improved by setting targets plus feedback to counsellors against those targets, while retention was promoted by seeing the same key worker in residential and follow-on non-residential phases of treatment. See p. 211 (numbered 204) of linked PDF.
K Best for British patients to choose abstinence goal? (2010). Data from Britain’s largest alcohol treatment trial sheds light on whether services should offer moderation as well as abstinence goals to dependent clients. ‘Let the patient choose’ seems the implication.
K Applicants can be screened for empathy (2005). Research project saved on training by using responses to simulated clients to screen applicant therapists for "accurate empathy". Free copy may be available. Could help services employ people with the hard-to-teach (2006) ability to form good relationships with users.
K Coaching helps counsellors learn to motivate (2004). Client responses to trainees improved only when motivational interviewing workshops had been reinforced by continued expert coaching and feedback on performance. See also this Findings analysis of a later report from the same study.
K Ensuring high quality therapy (2005). UK alcohol therapy research project offers a comprehensive model for recruitment, training and supervision.
K Tell clinic counsellors how their clients are doing (2012). To maximally improve outcomes feedback needs to identify which individuals are doing poorly and recommend remedial actions. The same system has been found beneficial (2011) in psychotherapy generally.
K Leaders set context for training to be implemented (2012). Whether counsellors initiate training-based practice improvements is strongly influenced by the ethos and support emanating from an organisation’s leadership, especially how far it fosters professional development.
R Offer moderation as well as abstinence as a treatment goal (2013). Concludes that dependent drinkers can cut down, that psychosocial treatments based on this goal are probably just as effective as abstinence-oriented approaches, and that allowing patients a choice improves outcomes.
R Workshop training not enough (2005). Retaining psychosocial therapy skills after this popular training format requires follow-up consultation, supervision or feedback.
R The importance of supervision (2011). Systematic and expert continuing supervision emerged as a key to newly introduced psychosocial treatments improving practice and outcomes.
R Implementation lessons from clinical trials (2007). Research shows importance of therapist selection and post-training supervision and the pitfalls of assuming researched interventions will translate to routine practice.
G UK goal choice guidance ([UK] Department of Health and National Treatment Agency for Substance Misuse, 2006). Guidance on models of care for problem drinkers stressed that whatever their goals it should not exclude them from support or treatment, but saw abstinence as the preferred objective for many moderately or severely dependent drinkers.
G Clinical supervision and professional development of counsellors ([US] Substance Abuse and Mental Health Services Administration, 2009).
G Skills and abilities of clinical supervisors ([US] Substance Abuse and Mental Health Services Administration, 2007).
G Group therapy ([US] Substance Abuse and Mental Health Services Administration, 2005). US consensus guidance on the different types of groups, how to organise and lead them, desirable staff attributes, and staff training and supervision.
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What is this cell about? Every treatment involves direct or indirect human interaction, but this cell is about ‘psychosocial’ therapies in which interaction is intended to be the main ingredient. These range in form from brief advice and counselling to extended therapies based on psychological theories, and all-embracing residential communities where clients stay for months. The content and approach of therapy and the qualities of the staff matter of course, but so too do the management functions of selecting, training and managing staff, and managing the intervention programme, including how a service decides treatment goals and which patients are offered which therapies. In highly controlled studies, it may be possible to divorce the impact of interventions from the management of the service delivering them, but in everyday practice, whether interventions get adopted and adequately implemented, and whether staff are able to develop and maintain appropriate attitudes and knowledge, depend on management and supervision.
Where should I start? Where so much starts – at the top. The leader’s influence was explored in unusual detail by the research stable (the Institute of Behavioral Research at the Texas Christian University) behind the investigation of British treatment services highlighted in cell D2. This fertile source also conducted this cell’s starting point study, which seemed to confirm that even ‘bottom-up’ improvements initiated by counsellors are strongly influenced by the ethos and support (especially for open thinking) emanating from managers; without specifically initiating improvements, leadership influences cascade down to staff. Their British study suggests that these too are the kind of services that best engage patients. The qualities they investigated among leaders included setting an example, encouraging new ways of looking at the work, and providing well defined performance goals and objectives. Can you recognise this picture in your own service – even if only by the absence of these influences from the top?
Highlighted study Human beings build brains and lives based on feedback loops. Without these we know neither how we are doing nor how to improve or correct it. In substance use treatment, systematising feedback was tried in a simple but effective way in the late ‘80s. More sophisticated systems benefit general psychotherapy patients by giving therapists feedback on who is doing less well than expected, and clues to why this might be the case based on an assessment of the therapist-client relationship. Gains are greater still if feedback is supplemented by guidance on how to get patients back on track. The underlying assumption that the relationship affects progress has (see cell B4) some validity in alcohol problem treatment. Our highlighted study is an adaptation of the same system at three US services. It gave substance use counsellors feedback on why individuals might be lagging due to poor therapeutic relationships, motivation, social support, or stressful events. Read the analysis, and you will see that these patients ended up drinking no more than initially more promising patients. How feedback helped ‘rescue’ them is unclear. The analysis offers several ideas; try reading it perhaps with colleagues and discuss which makes most sense, and whether some such system might be incorporated in the services you work at or know of.
Is coaching the right model for producing good counsellors and therapists? Getting the right people is critical was a message of cell C2 and more evidence can be found in this cell’s seminal and key studies. But as a manager, you have to make the most of the staff you have or can find. What then? Even if it worked, handing staff an expert manual and telling them to follow it would be undesirable. Sending your counsellors away on a course is often a waste without post-workshop feedback (see Highlighted study) on performance and/or expert coaching. More generally, systematic and expert supervision is needed before newly introduced psychosocial approaches improve practice and outcomes. William Miller’s research on the motivational interviewing approach he originated includes this demonstration that performance feedback and expert coaching are both needed for workshop training to impact on patients. Have a look at the original article (link is to a freely available copy). Note that in passing it confirms the importance of having the right trainees to begin with. Then that even with the right trainees, post-workshop competence boosts did not last without follow-up feedback and/or coaching. Finally the crunch finding: patient responses improved only when trainees were offered continuing expert coaching and when this included an opportunity to discuss feedback on how their work with clients compared with that expected of an expert. Look at the detail of what was entailed. It can be likened to a sports coach reviewing with the players a video of the last game, reinforcing the good points, pointing out where they fell short of expectations, getting them to practice how they could have done it better, and checking later with another video that the lessons have been absorbed. As a manager, do you have to take a deep breath and accept this is the intensity and extensity of input needed to really make a difference?
Should dependent drinkers always be advised to try for abstinence? Should dependent drinkers always be advised to try for abstinence? Hardly a bite-sized issue; its centrality to alcohol dependence and its treatment makes it difficult to ignore but also demands extended coverage, so we offer a two-tier introduction. For a more bite-size chunk read just the next two paragraphs. For more (recommended) unfold and dip in to the extra text.
Not so long ago the issue was not just about advice, but whether alcoholics should be denied treatment until deterioration forced them to accept the need to stop drinking altogether and forever. The debates go back decades, but abstinence has recently returned to prominence as an essential component of influential visions of ‘recovery’. This is how we have summed up the evidence: “Treatment programmes for dependent drinkers should not be predicated on either abstinence or controlled drinking goals but offer both. Nor does the literature offer much support for requiring or imposing goals in the face of the patient’s wishes. In general it seems that (perhaps especially after a little time in treatment) patients themselves gravitate towards what for them are feasible and suitable goals, without services having to risk alienating them by insisting on a currently unfavoured goal”. Another reason for not insisting on abstinence is that non-drinking does not always equate with ‘recovery’ as often defined. The recovery agenda encourages us to value outcomes other than (non-)drinking which reflect the quality of life of the individual and their integration in society. This classic paper from the 1960s reminds us that this can mean classifying some abstinent ex-patients as not really recovered. Without their favourite sedative and the friends and social activities that went with it, most in this study were living an empty and/or unhappy life.
For more on the controlled drinking controversy see this US account and if you can this British perspective (turn to chapter four of the book). See also this cell’s relevant seminal study, key study (the background notes are particularly informative) and review. Armed with these (and if you wish the extra text), reflect on questions such as: Should very heavily dependent drinkers always be advised to try for abstinence? Is this because of their dependence, or lack of supports in their lives like a marriage and a job and worth keeping? Are there exceptions? Should it (albeit after advice) be the patient’s choice – in practice, must it be the patient’s choice? Is shared decision-making the best way to engage patients, or have they a right to expect direction from a professional expert? Should the process model what we want patients to become – independent and in control of their lives? Or accept that for the moment they are neither? How strongly should the clinician advocate for their choice? What of less dependent drinkers and/or those with more supports in their lives? Would recommending abstinence drive them away from interventions? Or is at least a period without drink the best way to break any heavy-drinking habit? And what do your answers say about the nature of alcohol dependence? More on this issue ....