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The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Seminal studies of the impact of alcohol counsellor skills and support

These seminal studies were added to the Effectiveness Bank as part of a project identify key workforce development studies for the UK Substance Misuse Skills Consortium. Still challenging and thought-provoking, they have stood the test of time and remain major landmarks in the relatively scarce literature about what makes some alcohol counsellors, therapists and treatment services more effective than others.

'Treatment-resistant' skid-row alcoholics react to organised empathy ...

Training little use if it falls on stony organisational ground ...

Socially skilled counsellors reduce relapse rate ...

Motivate rather than confront ...

Frontiers of alcoholism.

Chafetz M.E., Blane H.T., Hill M.J. eds.
New York: Science House, 1970.
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Later to become founding director of the US National Institute on Alcohol Abuse and Alcoholism, in the late 1950s Dr Morris Chafetz of the Massachusetts General Hospital conducted a remarkable series of studies which proved that an alcohol clinic's intake and performance can be transformed by the simple application of empathy and organisation.

Summary This account is adapted from the Findings review The power of the welcoming reminder. Apart from the featured book, it drew on the preceding journal articles dealing with the impacts of the 'treatment catalyst' teams and the doctor's tone of voice, and the chapter "Increasing motivation for change" in the 1995 edition of the Handbook of alcoholism treatment approaches.

Much of what we know today about how to engage dependent drinkers in treatment was prefigured in a remarkable series of studies begun in the late 1950s at the alcohol clinic of Massachusetts General Hospital. It was run by Morris Chafetz, later to become founding director of the US National Institute on Alcohol Abuse and Alcoholism.

Dr Chafetz showed that not only can a service's performance be improved, it can be transformed by the simple application of empathy and organisation. He suspected that alcoholics' notoriously poor acceptance of and response to treatment reflected the dismissive or hostile attitudes of those around them, including clinical staff. If these attitudes were replaced with optimism and respect, then many more patients might embrace the help they needed – exactly what happened.

Why won't they come?

‘Skid-row’ alcoholic

‘Skid-row’ alcoholics seen at the emergency department were in crisis, dirty, disturbed and disturbing, and refused treatment. The effect was to evoke hostility and rejection.

Work started with the observation that virtually none of the alcoholics referred to the clinic from the hospital's emergency service actually attended. A micro-analysis of the referral process revealed that it entailed seeing perhaps a dozen individuals and numerous delays and opportunities to be baulked by the system. Staff attitudes did not engender determination to overcome the obstacles. Typically these 'Skid Row' alcoholics were in crisis (the reason for emergency admission), dirty, disturbed and disturbing, and often dragged in by the police. The effect was to evoke outright hostility and rejection on top of underlying moralising and punitive attitudes.

Chafetz's team set out to create instead a welcoming and seamless procedure which established the emergency episode as the start of rehabilitation. It involved not just directly interfacing with the patient, but networking to gain the cooperation of other hospital staff and of outside welfare and housing services. Effectively Chafetz pioneered a case management approach intended to see that the alcoholic got coordinated, holistic and continuing care.

Because we are doing the wrong things

In practice they established 'treatment catalyst' teams to reach out from the alcohol clinic: a psychiatrist on 24-hour call to immediately see patients in the emergency room, and a social worker who worked with the patient, their family and outside services. By being welcoming, respectful and concerned and by continuing to care for the patient throughout, they sought to convey that they were the patient's own personal doctor and social worker. They also tried to avoid the patient being treated poorly by other staff. Rather than the insight-oriented psychotherapy then in vogue, they stressed practical actions responsive to the patient's expressed needs, such as help with housing, money, getting a meal and a shave.

‘Treatment catalyst’ teams transformed clinic attendance.

‘Treatment catalyst’ teams transformed clinic attendance.

Alternate male alcoholic patients were assigned either to normal emergency procedures or additionally to one of the treatment teams, 100 in each group. Nearly two-thirds (65%) of the treatment catalyst patients made an initial visit to the alcohol clinic compared to 5% of normal procedure patients. Forty-two of the patients seen by the teams made five or more visits compared to just one of the normal procedure patients – and he was a former clinic patient. The supposedly insoluble problem of engaging these "alienated men" was exposed as due not to their intractability, In a later study the alcoholic clinic's psychiatrists took on the screening role at the emergency service. The result was to identify and refer to the clinic a less socially isolated group of patients, but they too attended far more often if the catalyst teams started the process in the emergency department: 62% made an initial visit versus 21%; 27% versus none made five or more visits. but to that of an inappropriate clinical response.

In a crisis, respond – simple!

Another way the clinic came in contact with potential patients was through phone calls from the alcoholic or their family, usually during a domestic crisis. The response was typical of services then and perhaps of many now. A secretary noted basic details then mailed out an appointment for several weeks hence, by which time the moment and the motivation had passed. Instead Chafetz's team tried initiating same-day social work contact with the family, if necessary in person at the their home. After assessment, therapy and practical intervention were made immediately available. Throughout, the same social worker maintained contact.

On a quasi-random basis, callers were allocated to this approach or to normal procedures. Initial attendance tripled from 21% to 62% of patients and from 13% to 38% of their relatives. In nearly 30% of cases both came together compared to none under normal procedures. None of the usual-procedure patients returned at least five times over the next six months compared to 27% of the immediate-response patients.

Keep them coming

Patients were now coming for intake but still many did not return, particularly those (the most inebriated and debilitated) who after assessment had first to be sent to an inpatient unit to 'dry out'. The clinic's first attempt to retrieve them was a handwritten letter sent the day after their assessment. It expressed personalised concern ('I am concerned about you.') and equally personalised desire that the individual would return, when the service would be "glad to work with you". It was sent to 50 randomly selected patients; another 50 were handled as usual.

Impact of handwritten post-assessment letter

The impact was striking: 25 returned, all but five sober, and 19 the day they were discharged from the unit; without the letter, 16 returned, just two without delay and most after having resumed drinking chart. Replacing the letter with a phone call to the unit had a similar impact. Within a week of discharge, 22 of the 50 called patients returned for outpatient care but just four of the 50 who were not called.

It's the way you say it

The next experiment was based on the belief that alcoholics are sensitised to hints of rejection in what a doctor says and how they say it. The doctors concerned were nine of the emergency doctors involved the year before in the earlier studies. The issue was whether emotion betrayed months later in response to the question, "What has been your experience with alcoholics?" would predict how many of their patients had followed through on a referral to the alcohol clinic. Ratings were made of the unaltered tape recording, of one filtered to obscure the words but leave emotional tone, and of a transcript.

As expected, ratings were related to referral success only when the treatment catalyst teams had not intervened to override the doctors' influence. Also not unexpectedly (all the patients had been men), the only significant relationships derived from male raters. The more anxious the doctor sounded and (in filtered speech) the less angry, the more of their referrals had been successful. The correlations were substantial and statistically significant. Just missing significance was a trend for more matter-of-fact and 'professional' sounding doctors to have a lower success rate. Assuming that 'anxiety' was a proxy for concern, it seemed that the more a doctor showed personal (rather than 'coldly professional') concern for a patient's welfare, and evidenced this in tone as well as words, the more likely the patient was to treat this as the start of a therapeutic relationship which they wished to continue.

Last revised 23 April 2013. First uploaded 04 April 2013

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REVIEW 2004 The power of the welcoming reminder

STUDY 2010 What process research tells us about brief intervention efficacy

MATRIX CELL 2014 Drug Matrix cell D2: Organisational functioning: Generic and cross-cutting issues

STUDY 2010 Gender differences in client–provider relationship as active ingredient in substance abuse treatment

MATRIX CELL 2014 Drug Matrix cell B2: Practitioners: Generic and cross-cutting issues

REVIEW 2011 Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

REVIEW 2010 A meta-analysis of motivational interviewing: twenty-five years of empirical studies

MATRIX CELL 2016 Alcohol Matrix cell A2: Interventions; Generic and cross-cutting issues

STUDY 2012 Does active referral by a doctor or 12-step peer improve 12-step meeting attendance? Results from a pilot randomised control trial

STUDY 2011 Transitioning opioid-dependent patients from detoxification to long-term treatment: efficacy of intensive role induction

The attitudes of helping agents toward the alcoholic client: the influence of experience, support, training and self-esteem.

Cartwright A.K.J.
British Journal of Addiction: 1980, 75(4), p. 413–431.

Seminal English study which turned the spotlight on organisational factors in the development of a positive attitude to working with problem drinkers, in particular the availability of experience in working with these patients and the support of experienced colleagues. Without these the effects of training are less and less well sustained.

Summary Previous studies have concluded that the major determinants of therapeutic attitudes towards alcoholic clients are the helper's previous experience in working with such clients and the availability of support from colleagues in times of difficulty. Support and experience appear necessary conditions for the development of positive therapeutic attitudes. Other factors, such as formal education in alcohol and alcohol-related problems, personality, and type of working environment, affected attitudes only it seemed when found in conjunction with experience or support.

To further test this model data was obtained from 109 staff who attended a week-long basic summer school on alcoholism in England in 1977, plus 49 who attended a one-week residential course on alcohol counselling and 29 involved in a one-week course in research methods as applied to alcoholism services. Many trainees came from specialist alcoholism treatment agencies. They completed questionnaires just before their courses, at the end of the courses, and six months later. Of the 187 trainees, 115 completed and returned all three questionnaires.

Main findings

Before the basic summer school, questionnaire responses showed that the degree of commitment and positivity trainees felt to working with problem drinkers was related to the degree of support for such work from other colleagues and the amount of experience they'd had in such work. Six months later, only trainees who felt they had gained more support and more experience than they'd had before the course had also deepened their commitment to working with problem drinkers, largely it seemed due to what had happened after they had returned to work. Other trainees had increased their commitment during the course but this had fallen back after returning to work. Changes in commitment were independently related to changes in support and experience; both these factors appeared to have an impact. The conclusion was that formal training alone is of limited value in changing therapeutic attitudes unless combined with opportunities to gain support and experience on return to work.

A further analysis pooled data from all the trainees, not just those at the basic summer school. Again, before the courses the degree of commitment and positivity trainees felt to working with problem drinkers was related to the degree of support for such work from other colleagues and the amount of experience they'd had in such work. However, these relationships were weaker among trainees with low general self-esteem. Between pre-course and six-month follow-up, increases in support, experience and self-esteem were all related to increases in commitment to working with problem drinkers.

At both the pre-course point and at the six-month follow-up, support and experience appeared critical in another way. Only when these were high, were high self-esteem and having been highly trained in alcohol problems related to a stronger commitment to working with problem drinkers. Without support and experience, even highly trained staff and those enjoying high self-esteem were still relatively negative about working with problem drinkers.

These factors seemed to account for the stronger therapeutic commitment of staff who had worked in specialist alcohol services and even higher commitment of those now working in these services. It was it seems their greater access to clinical support from colleagues, to more problem drinkers to work with, and to specialist training, which generated greater commitment to this work. Outside these services it is extremely difficult for staff to gain access such support experience and training.

The authors' conclusions

The most important determinants of positive therapeutic attitudes towards the alcoholic client are to be found in the staff member's experience and support; the effect of factors such as alcohol education and self-esteem is contingent on these variables. Further, staff who specialise in working with alcoholic clients have more positive therapeutic attitudes because they have greater access to experience, support and training than those working in non-specialist settings. As staff develop more positive attitudes under the influence of support and experience, they become more willing to work with drinking clients.

Given these findings, it seems that developing more positive attitudes among non-specialist staff requires access to experience and support. This will be difficult to provide given that few experienced colleagues are able to offer support.

Findings logo commentary This work turned the spotlight on organisational factors in the development of a positive attitude to working with problem drinkers, in particular the availability of experience in working with these patients and the support of experienced colleagues. Without these the effects of training are less and less well sustained.

The featured study was followed in 1986 by a study of the same set of processes which also examined other organisational factors. It tested whether the impacts of role support, experience, education and self-esteem on attitudes to working with drinkers were themselves contingent on 'constraints' in the work environment such as time pressures, case priorities, departmental policy, and opportunities for involvement in alcohol-related work. If these were unfavourable they might it was thought impede the development of a positive attitude to working with problem drinking patients, even if the other factors were favourable.

This idea was tested not on specialist alcohol workers but on 24 community psychiatric nurses and 24 social workers working in the south west of England. The results were consistent with the theory, indicating that social workers expressed significantly less positive therapeutic attitudes towards drinkers than nurses because their more constraining work environments meant they were less likely to take advantage of training and educational opportunities and less likely to develop supportive contacts. Social workers agreed significantly more often than nurses that: the policy of their departments governed the sorts of problems they could respond to; they received little or no encouragement from their seniors to get involved in alcohol problems; within their department, the general feeling was that they hadn't the right to interfere in people's drinking choices; only a few, if any, of their colleagues had had success in dealing with these problems; these problems had to affect others than the drinker to justify their involvement; being occupied with statutory cases meant they had little scope for getting involved in alcohol problems; and they would not have the time to put to use any knowledge about these problems. In this environment, it was concluded, role support and training per se would have little effect on their rejection of anything but a minimal therapeutic role with problem drinkers.

Among other spin-offs from the featured study was a test published in 1993 of whether the processes identified in the featured article could be influenced by training geared to this purpose. Trainees and comparison workers were non-alcohol specialist medical and social work staff in England. They were trained by alcohol treatment specialists on the premise that problem drinking could be understood within the context of an individual's life experiences rather than as a biologically driven disease process. However, most of the two days were spent in discussing the difficulties, uncertainties, and negative feelings trainees experienced in their work with problem drinkers, exploring why individuals begin to drink heavily and have difficulty resolving this problem, and developing basic assessment and counselling skills, and skills most appropriate to the agency in which they worked and their role within it. The aim was to develop therapeutic attitudes and skills which would enable non-specialist workers to form more effective therapeutic alliances with this client group.

A month later it seemed that training had bolstered feelings that trainees would be supported in their work with drinkers. Directly and via this link it had also bolstered feelings that this was an appropriate role and one they could fulfil. This in turn deepened their commitment to working with problem drinkers, which other studies have shown mean they are more likely to develop good therapeutic relationships. However, these mechanisms were most apparent among trainees who even before training felt working with problem drinkers was an appropriate role for them and one they could fulfil. The results were said to raise questions about the effectiveness of skills- and knowledge-based training when not backed up by provision of support. In the study, the effect of the training would have been negligible if it had not been able to improve feelings of being supported. But even then it could not overcome pre-existing and continuing feelings that working with drinkers was not one's business in the environment within which one worked.

Last revised 06 April 2013. First uploaded 06 April 2013

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STUDY 2011 Therapist effectiveness: implications for accountability and patient care

REVIEW 2011 Integration of treatment innovation planning and implementation: strategic process models and organizational challenges

STUDY 2012 Innovation adoption as facilitated by a change-oriented workplace

REVIEW 2005 The motivational hallo

REVIEW 2010 Assessing user perceptions of staff training requirements in the substance use workforce: a review of the literature

STUDY 2012 Implementation issues in an innovative rural substance misuser treatment program

REVIEW 2004 The power of the welcoming reminder

STUDY 2006 Matching resources to needs is key to achieving 'wrap-around' care objectives

STUDY 2013 Screening and brief intervention for alcohol and other drug use in primary care: associations between organizational climate and practice

REVIEW 2011 Implementing evidence-based psychosocial treatment in specialty substance use disorder care

Interpersonal functioning of alcoholism counselors and treatment outcome.

Valle S.K.,
Journal of Studies on Alcohol: 1981, 42(9), p. 783–790.
Unable to obtain a copy by clicking title? Try this alternative source.

Seminal US study which found that the therapy-related social skills of alcohol counsellors were strongly related to how many of their patients relapsed in the two years after leaving inpatient treatment.

Summary At a US hospital-based alcoholism treatment unit 247 inpatients admitted for the first time were randomly assigned to one of eight counsellors. Six of the counsellors were men. All eight were recovered alcoholics who had attended a school of alcohol studies or had equivalent training experience. Most patients were men, nearly all were employed, and about two thirds married.

The scenarios

I wish everybody would stop talking to me about drinking. So I have a few too many drinks once in a while. If my wife would stop nagging me about the bills and the kids and everything else, I wouldn't have to drink. If she would just shut up.

Please tell me what to do to get my sister to stop drinking. I have tried everything but nothing works. What am I going to do?

I know I love him, why, I remember when we would spend all weekend together fishing or building something in the backyard. But he's not like that any more and when I see him on the streets, I try to avoid him. Even my friends are making jokes about him. Mom says he's sick, but if he's sick, why isn't he in the hospital? I just don't know what to say to him, or how I should feel. After all, he is my father.

Lately, it seems we're always leaving parties early and I find myself worrying about what my wife will do or say instead of enjoying my friends. Then we talk about it the next day and she always says she doesn't remember. She's really been acting strange lately ... and I wonder, well, do you think she could have a drinking problem? I know she's not an alcoholic because she can go without a drink for weeks, but when she does drink, well ...

I can't do it, I can't stay sober. No matter how hard I try, I can only get a few weeks together. I might just as well admit I'm a no good bum.

Reproduced from: Saarnio P. et al. "Rating therapists who treat substance abusers." International Social Work: 2002, 45(2), p. 167–183.

Treatment over an average 12-day stay consisted of individual and group counselling, lectures, Alcoholics Anonymous meetings, psychological evaluation, recreational therapy, and daily consultations with doctors. Counsellors were the primary therapists, responsible for coordinating all services for patients and had the most contact with them.

The counsellors were asked to submit written responses to several written scenarios intended to approximate actual interactions between counsellors and their patients or their patients' relatives panel. Two trained raters then scored these responses for the degree to which they exhibited:
Empathy: ability to respond to the feelings and reasons for the feelings the patient is experiencing in a manner which communicates understanding.
Genuineness: degree of sincerity manifested in the helping relationship; extent to which counsellor exemplifies a manner free of roles and not 'phony'.
Respect for the client: also known as positive regard; the ability to convey to patients that they are persons of worth, best communicated through warmth and understanding; crucial in establishing a basis for empathy.
Concreteness: ability to be specific and direct in expression of feelings and experiences; serves to ensure the counsellor's responses stay on target and are accurate in terms of the patient's feelings and experiences.

Scores on these four dimensions were combined to arrive at a rating of each counsellor's overall level of interpersonal functioning. At the lowest level the counsellor did not respond helpfully either or both of the content of the patient's communication or its emotional tone; medium level counsellors responded accurately to both; higher level counsellors did this and more, offering perceptive personalised responses and at the highest level also personalised treatment goals and plans. This tripartite grading of counsellors was then related to their patients' progress in the six months to two years after they had left the unit, assessed for all patients via hospital records and by a survey of patients at the final follow-up, to which two thirds responded.

Main findings

The level of interpersonal functioning of the eight counsellors stretched across the range from low to high. In general, the higher it was, the fewer of their patients were known from hospital records to have relapsed, and the less extended and fewer the relapses.

Relapse rate related to interpersonal functioning of counsellor

For example, over the entire two years ( chart) 17% of the patients of low functioning counsellors were known to have relapsed at least twice compared to just 3% of those of high functioning counsellors. Corresponding figures for any relapse were 38% and 18%, and for cumulative days in relapse eight versus two days. On all these measures the progress of patients of medium functioning counsellors was intermediate, meaning the relapse indicators improved as patients had been assigned to increasingly well functioning counsellors.

However, this pattern did not hold for patients' accounts of whether they had drunk at all over the two years. Again the worst figure was for the patients of low functioning counsellors, 79% of whom had drunk. But at 51% the best figure was for the medium functioning counsellors. In between at 64% were the high functioning counsellors.

Of the battery of 22 measures of the quality of personal and work life and of drinking and alcohol-related adverse consequences completed by patients two years after leaving treatment, it was only the percentage who had at some time drank after leaving treatment which differed to a statistically significant degree depending on their counsellors' functioning. Neither was retention in the initial treatment related to counsellor functioning.

The authors' conclusions

The findings suggest that the better the interpersonal skills of alcoholism counsellors, the better the drinking outcomes for their patients. These results have implications for the process of determining what constitutes an effective alcoholism counsellor and in turn for the certification of counsellors. They indicate that one measure of counselling quality – interpersonal skills – is quite strongly related to treatment outcome, so may prove worthy of consideration as a criterion for certification of individual counsellors and accreditation of counsellor training programmes. Emphasising quality by assessing the interpersonal skills of counsellors and providing related training is one way to improve the quality of alcoholism services.

Findings logo commentary Such studies stand in contrast to generally negative findings on the relationship between how their clients do and clinicians' professional background characteristics, such as years experience and training and whether they are themselves former problem substance users. When their impacts are allowed to emerge, studies commonly find that clinicians make a big difference to outcomes, but rarely are these differences related to the 'hard' variables of qualifications or sex/race match with patients. Though rarely studied, social skills, and whether the counsellor's way of relating to other people suits the patients, are more promising potential causes of differences in counsellor performance.

Considered notable for its large sample size and random assignment of patients to counsellors, the featured study also had the benefit of predating 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, though not always entirely ironed out. In many such studies the lowest level of competence scored by the featured study would have led those counsellors to be eliminated from the study or subject to further training and supervision until they conformed to the study's quality standard, in order that the interventions being tested were delivered as intended.

In this way studies have risked eliminating what matters (the quality of the therapeutic relationship) in order to highlight what often matters not at all (the type of psychosocial therapy). The featured study instead took 'run of the mill' counsellors not subject to special training or supervision and tested what happens when the variation in patients is eliminated by randomly allocating them to the counsellors. This study design exposed the variation in counsellor/therapist effectiveness obscured in more highly controlled studies. It validates the (when these questions are asked in studies) common attribution by patients/clients of part of the impetus for their recovery to their therapist's qualities and how they related to them, and the common understanding of staff and patients that some practitioners are highly regarded whereas others are avoided.

With just two counsellors each in two of the skill categories the study's results were vulnerable to the particular characteristics of those individuals. It would also have benefited from a more detailed account of how it was decided that someone had relapsed and the duration of that relapse. It seems this was decided by their return to the clinic for further treatment, yet this may reflect willingness to return in response to a relapse rather than the frequency of relapse. It seems possible that people who found their counsellor sympathetic and non-judgemental would be more willing to admit to them that things had gone wrong and seek further help from the same source, while others who had also relapsed might not seek help or go elsewhere.

Arguing against this, however, is the puzzling reversal in the proportion who had drunk at all, at its lowest not among patients of the 'best' counsellors, but of the intermediate ones. It meant that of the patients who had drank, just 29% who had seen the most skilled counsellors were known to have relapsed compared to 48% each of those who had seen either medium or less skilled counsellors. This pattern does not suggest patients of the higher rating counsellors were more willing to come back, rather that they were more able to drink without major problems.

Another conundrum is why retention was not improved by the higher rating counsellors. Typically patients who feel positive and comfortable about their therapists stay longer in treatment than other patients, even if they fare no better in terms of substance use. In the featured study the reverse was the case. One explanation may be the inpatient setting. The constraints on mainly married and employed men on how long they could stay away from home and work, the atmosphere at the unit, and its environment, were possibly the determining factors, overwhelming any impact of the counsellor.

Replication in Finland

Over two decades later a similar study was conducted in Finland where four counsellors were rated (this time by social workers and social work students not trained in the rating method) on the same dimensions used by the featured study and using the same written scenarios. Counsellors tended to rate high or low on all four dimensions and (as with the trained raters in the featured study) the raters largely agreed in their assessments. The Finnish study was conducted at an outpatient substance misuse clinic, and this time the ratings were related to retention.

Over five scheduled sessions, patients attending the service for the first time who dropped out of treatment were compared with those who had stayed or left by mutual agreement. In this study there was less variation between the professional therapists than between the ex-alcoholics in the US study; all scored as high functioning according to the US study's cut-off point. Nevertheless 63% of one therapist's clients dropped out ranging down to just 11% for another. This variation was largely predictable from the ratings made of their interpersonal skills. It was also predictable from the post-session ratings therapists and clients made of their 'rapport' with the other; when client and therapist agreed that their rapport was good (that is, in the top half of the distribution) only a fifth of clients dropped out; when both saw it as poor, half did so.

Last revised 11 April 2013. First uploaded 11 April 2013

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STUDY 2003 How to identify retention-enhancing alcohol counsellors

STUDY 2011 Therapist effectiveness: implications for accountability and patient care

STUDY 2010 Gender differences in client–provider relationship as active ingredient in substance abuse treatment

STUDY 2012 A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

STUDY 2010 A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers

STUDY 2010 Computer-assisted cognitive rehabilitation for the treatment of patients with substance use disorders: a randomized clinical trial

DOCUMENT 2013 Sometimes best to break the rules

REVIEW 2009 Peer-based addiction recovery support: history, theory, practice, and scientific evaluation

STUDY 2005 How does motivational interviewing work? Therapist skill predicts client involvement within motivational interviewing sessions

REVIEW 2011 Integration of treatment innovation planning and implementation: strategic process models and organizational challenges

Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles.

Miller W.R., Benefield R.G., Tonigan, J.S.
Journal of Consulting and Clinical Psychology: 1993, 61, p. 455–461.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Miller at wrmiller@unm.edu. You could also try this alternative source.

Probably more than any other, this seminal study heightened the profile of the therapist's interpersonal style in substance use counselling, seeming to confirm that by not provoking resistance, the non-confrontational style mandated by motivational interviewing reduced drinking compared to the then more typical blunt and challenging approach.

Summary This account is adapted from the Findings review The motivational hello.

Motivational interviewing was developed as counselling style which would avoid resistance-provoking confrontation and instead 'non-directively' stimulate and take advantage of the client's own ambivalence to bolster motivation to change. The very first trials were conducted by the co-originator William Miller's research team based at Albuquerque in New Mexico. While they had the unique benefits of his expert tuition and oversight, at this stage there was no manual for them to follow.

The first two tests of motivational interviewing were as a standalone brief intervention combined with the Drinker's Check-up, a two-hour battery of tests of alcohol use and related physical and social problems. In the first study, heavy drinkers responded to ads offering the check-up, which was followed a week later by a single session feeding back the results in a motivational interviewing style. Two-thirds had their check-ups without delay while a randomly selected third had to wait six weeks. Over this period there seemed Clients were not actually assessed at the beginning of the waiting period, but measures taken at the end were similar to the pre-intervention measures of the groups immediately given the check-up, suggesting nil change. no change in their drinking, while in the six weeks following feedback alcohol consumption fell by 27%, a reduction sustained for at least 18 months. However, about two-thirds Unimproved symptomatic plus improved symptomatic as a fraction of those for whom there was data at six weeks and 18 months. were still drinking heavily and experiencing alcohol-related problems. During this time a third of the sample had sought further help when few had done so before.

These outcomes suggested that motivational feedback was often insufficient in itself, but could serve as a useful motivator of change and treatment entry in this type of population – drinkers a long way from seeing themselves as alcoholics (most saw themselves as 'social drinkers') but concerned enough to respond to the offer of a check-up. After years of alcohol problems, it seemed the offer of a 'check-up' had enabled them to take a first step towards seeking help without violating their self-image as non-alcoholics.

The next (and the featured) study was similar, except that feedback was provided in one of two styles. One was the empathic motivational interviewing style, the other the supposedly counterproductive style this aimed to improve on: explicitly directive, confronting client resistance, arguing when they minimised their problems, and (when the cap fitted) telling them they were alcoholics. Again, feedback was followed by substantial reductions in drinking not seen in those who had to wait six weeks.

As expected, giving feedback in the empathic style did result in greater reductions in drinking, but the effects were small and failed to reach conventional levels of statistical significance. One reason may have been that, though they did differ in the intended ways, analysis of audiotaped sessions revealed considerable overlap between the two styles, which were delivered by the same therapists. For example, confrontation was practically absent in the motivational style and noticeable in the directive, yet even here it was rare. Perhaps understandable, given that all but one of the therapists was a psychology student and they were faced by experienced drinkers averaging 40 years of age. Conversely, though there was more 'restructuring' in the motivational sessions, this core technique was rarely deployed compared to simple listening or 'teaching', responses not characteristic of motivational interviewing.

Only when the researchers focused on how therapists and clients had actually behaved did significant findings emerge. The more the therapist had confronted (arguing, showing disbelief, being negative about the client), the more the client drank a year There remains the mystery of why this relationship was apparent at the 12-month follow-up but not at the six-week follow-up. This could be related to the fact that only at 12 months were 'collaterals' (wives, husbands or other people close to the patient) interviewed as well as the clients. Perhaps this led to greater honesty in the clients' responses. later. The same was true of 'resistant' client behaviours like interrupting the therapist, arguing, avoiding therapeutic interactions, or being negative about their need to change or prospects for changing. These relationships were very strong and highly statistically significant. During sessions these behaviours seemed to feed off each other resulting in them being highly correlated. In general, client resistance behaviours were strongly correlated with therapist confrontational responses, while positive, self-motivational client responses were related to therapist listening and restructuring.

There was also a statistically significant indication that the motivational style was most effective with drinkers who did not believe their own or other people’s frequent heavy drinking was a manifestation of the disease of alcoholism, but rather that is was more like a bad habit. This effect was absent for the directive counselling style.

Findings logo commentary Despite their strength, what the relationships between actual client and therapist behaviour and later drinking meant is unclear, because there was no way to pin down what was cause and what effect. For motivational interviewing, the favoured interpretation is that when therapists confronted, clients were provoked in to hitting back or withdrawing, rare but powerfully counterproductive interactions. In this scenario, by adopting motivational interviewing's non-confrontational style, therapists would avoid provocation and improve outcomes.

But the causal chain could have been the other way round: perhaps clients who were always going to resist change argued and interrupted more, provoking therapists to argue back. We know this can happen from a British study which used actors to mimic either highly resistant smokers angry about being referred for counselling, or more contrite ones keen to reverse a relapse. The former provoked counsellors into non-motivational-style responses including unilateral agenda-setting, confrontation, and closed-end questions, all related to poorer outcomes with this kind of resistant patient.

Whether the Albuquerque therapists were also provoked by resistant clients is unclear. Arguing against is the fact that therapist and client behaviours were changed by the assigned therapist style – they were not simply determined by whether the client was difficult to begin with. From the client, the motivational style elicited twice as many statements acknowledging their problems and fewer resistant behaviour such as arguing, interrupting and introducing irrelevant topics. And though not possible in this study, some key studies of the impact of therapist behaviours have been able to eliminate the possibility that were simply reacting to the clients (1 2 3 4).

Conceivably, a combination of both processes – therapist influencing client and the reverse – explained the results in Albuquerque. Whatever the truth, probably more than any other, this study heightened the profile of the therapist's interpersonal style in substance misuse research, seeming to confirm that the style mandated by motivational interviewing was preferable to confrontation.

In this early study we also have an indication that certain types of patients are best suited to a motivational style – those whose views of ‘alcoholism’ chimed more with its non-directive approach. It seems understandable that clients convinced they were instead talking about a disease process would not be put off by – in fact, would probably expect – medical-type directiveness in diagnosis and remedy from an expert in this disease, just as they would if they went to a doctor with a physical complaint. The ‘It’s up to you – what do you think?’ stance of motivational interviewing might well feel inappropriate to the urgency and danger of a progressive disease which required specific responses. Other studies have investigated and corroborated similar matching effects.

Last revised 17 September 2015. First uploaded 28 March 2013

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