Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 22 May 2013

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.


These additions to the Effectiveness Bank show that practice improvements initiated by counsellors are strongly influenced by workplace context, that very good relationship-builders may not be the most effective counsellors, and that long-term effectiveness is improved by monitoring former clients. Lastly, a trial of an alternative to benzodiazepines for alcohol withdrawal was marred by seizures.

Leaders and service ethos set context for training to affect treatment practice ...

Can therapists be too good? ...

Benefits of post-treatment check-ups extend to four years ...

Anticonvulsants yet to better benzodiazepines for alcohol withdrawal ...

Innovation adoption as facilitated by a change-oriented workplace.

Becan J.E., Knight D.K., Flynn P.M.
Journal of Substance Abuse Treatment: 2012, 42, p. 179–190.
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 Becan at j.r.edwards@tcu.edu. You could also try this alternative source.

Message from this large US study is that 'bottom-up' practice improvements in treatment services initiated by counsellors are still strongly influenced by the climate-setting and support offered by an organisation's leadership and ethos, especially how far they foster professional development.

Summary Although innovations may be initiated or mandated by leadership to improve clinical practice, the decision to implement a new intervention in client care is often determined by the individual counsellor. The main focus of this study was on 'bottom-up adoption', the degree to which individuals in an organisation choose to try an innovation, not the degree to which leaders mandate it. In turn this perspective focuses attention on how leaders and organisations foster staff commitment to practice improvements.

In investigating these issues, the study was guided by an influential model of the processes involved in the planning and adoption of innovations developed by Texas Christian University's Institute of Behavioral Research, which has researched these processes in the UK as well as the USA and other countries.

The study was conducted in nine US states and derived its data from 421 counselling staff at 71 outpatient drug-free programmes, a subset of the 92 where more than one staff member had completed a survey on how they saw the treatment environment at their centre. It aimed to tease out what makes counsellors more or less likely to adopt and spread innovations in the treatment of substance use problems, a 'propensity to innovate' tapped by questions such as how often they had adopted new ways of working as a result of training workshops, how often they had encouraged other counsellors to use new ideas they had adopted, and how well clients respond to new ideas and materials.

Other questions looked for qualities in the counsellor which might have influenced their propensity to innovate, such as feeling they influence others in their workplace, flexibly adapt to work demands, feel it is important to and take steps to foster their professional development, and are confident of their abilities.

The study hypothesised that it was by bolstering such qualities in their staff that leaders foster their adoption of new practices, so another set of questions asked about their programme director's leadership qualities such as setting an example, encouraging new ways of looking at the work, and providing well defined performance goals and objectives. It was also expected that the positive influence of these leadership virtues on staff would be greatest when the climate of the organisation as a whole was conducive to change, tapped by questions about the climate at their centre in respect of the clarity and nature of its mission, cohesion among the staff, delegation of authority over their work to staff, adequacy of communications, staff stress, and how receptive the organisation is to change.

In assessing interrelationships between these variables the study adjusted as needed for any influence In the event, all except certification were related to propensity to innovate, such that more experience, having a master's degree, and a higher caseload were related to a stronger propensity. of differing staff experience levels, qualifications, professional certification status, and caseloads, and the possible clustering of similar views among staff at the same centre.

Main findings

The raw figures showed that all the hypothesised influences on the counsellors' propensities to innovate were indeed related to this propensity. It was also clear that treatment centres differed, tending to generate similar views among staff working there which differed from those elsewhere.

The first link in the proposed causal chain was established when it was found that counsellors keen on professional growth, who feel confident, adapt to new work pressures, and feel they influence others, were indeed more likely These relationships were not significantly different in different centres, ie, they did not depend on where the counsellor worked. to say they tried innovations from training.

Positive leadership qualities also seemed to bolster the propensity of their staff to innovate, a finding which paved the way for establishing whether leadership might exert its effect by affecting the counsellors. On this issue there was evidence that positive leadership did indeed affect counsellors' propensity to innovate by making them keener on professional development. Leadership also partially worked by fostering the other staff attributes of confidence, feeling influential, and feeling that one adapted well to new work pressures.

Lastly was the issue of whether these links depended on the types of organisation the programme director was leading and in which their counsellors worked. In respect of whether it was part of a larger conglomerate or had been approved by accreditation bodies, the answer was no. Instead what seemed influential was how staff saw their workplace in respect of strength of mission, staff cohesion, communications, professional autonomy, not being stressful, and receptiveness to change. The more they perceived these virtues in their workplace, the more influence they felt they had on other staff and the more they valued and practised their own professional development. To the point where leadership qualities were no longer related to professional development, suggesting that organisational climate was the decisive factor. Together leadership and organisational climate accounted for most of the variation between staff in different services in their commitment to professional development and their feelings of being influential. They seemed independent influences on staff; the impact of the leader did not depend on the organisation's climate, nor did the impact of climate depend on leadership.

The authors' conclusions

Findings suggest that organisations, funding agencies, and policy initiatives which promote leadership development, facilitate a climate receptive to change, and foster innovative thinking among staff, are better positioned to promote new treatment methods among clinicians. Results were consistent with the idea that the propensity of staff to adopt new methods is strengthened by:
• an innovative organisation with creative leadership; and
• change-oriented staff attributes (ie, confidence, influence on others, professional development, and adaptability), and
• that each strengthens the change-promoting impact of the other.

In other words, leaders do have a cascading impact on their staff in ways other than through mandate, findings which highlight the importance of training leaders to be supportive of innovation and to construct an environment which bolsters open thinking among staff.

More detailed findings suggest that strong, positive leaders are not in themselves enough to maximise innovation adoption; they need to instil confidence among their employees in their own abilities, a desire to influence organisational improvement, and adaptability to new work objectives. Most of all, it seems essential that leaders use their influence (including support of new interventions and establishing a clear and forward-thinking mission) to promote a commitment to professional development among their staff, without which even the best leaders will find staff less amenable to initiating change.

How the organisation is perceived is also influential. When the climate is seen as receptive to change as well as when there is supportive and innovative leadership, counsellors perceive more opportunities for professional development. Also, counsellors working in conducive environments feel they have more influence on others in their workplace and are more confident and prepared to adapt, so can adopt and spread new practices.

The study does however have some limitations. All the influences it tested were assessed at the same time and within the same assessment, precluding the establishment of whether proposed causes actually did come before their hypothesised effects, and it sampled only non-residential services. There was no information of what types of evidence-based practices were implemented by staff.

Findings logo commentary With the benefit of a large and diverse (but entirely non-residential) set of organisations to draw its data from, and a well worked out model of change to help make sense of that data, from the featured study emerges a persuasive set of often mutually reinforcing links between organisational climate, leadership, and staff attitudes, which interact to influence whether staff feel they have the motivation, 'permission', and confidence to initiate practice changes for themselves and promote these to their colleagues, and perhaps too the clarity of mission to sense what direction change should take. However, these variables were all assessed on the basis of the accounts given by counsellors rather than independently verified; more below on this methodological limitation.

All main variables tested by the study were assessed on the basis of the accounts given by counsellors in response to research surveys. There was, for example, no independent verification of whether when they said they had adopted new ways of working and encouraged others to do the same, they actually had, nor whether they truly were as adaptable and keen on professional development as they claimed, nor that their perceptions of their services and programme directors were valid. This leaves the study vulnerable to a 'halo effect' – staff who rate themselves highly on one variable also rating themselves highly on another and seeing their leaders and organisations through the same possibly rose-tinted spectacles. Arguing that this is not the entire explanation of the findings, is that in most cases ratings from staff at the same service were more similar to each other than to those of staff elsewhere, and that the strength of the relationships varied to the degree that some were (when other factors had been taken to account) not statistically significant; there was more to the findings than just the degree of rosiness of each individual's spectacles as they completed the survey.

Evidence that the kind of organisations which in the featured study fostered innovation adoption by their staff are also found engaging by clients comes from a British study by the originators of the model on which the featured study was based. They used some of the same questionnaires to investigate 44 substance use treatment services in and around Manchester, Birmingham, and Wolverhampton. Each took a 'snapshot' of their clients using the US centre's CEST (Client Evaluation of Self and Treatment) forms for the clients, which asked them to rate themselves on statements representing their motivation and readiness for treatment, psychological and social functioning, and engagement with treatment. At the same time, counsellors at the services completed ORC (Organizational Readiness for Change) forms also used in the featured study, assessing their perceptions of the service they worked for and of their own professional functioning and needs. This work, which represents the most wide-ranging investigation of the organisational health of British treatment services to date, found clients engaged best when services fostered communication, participation and trust among staff, had a clear mission, but were open to new ideas and practices.

Such findings should come as no surprise, because studies of the implementation of new treatment practices have highlighted the degree of commitment needed by the whole organisation if an initial training experience is actually to result in the desired changes at the clinical front line. For this to happen care has to be taken that the innovation fits with the organisation's and its clients' needs, and that training is reinforced by ongoing supervision and coaching, if possible based on feedback from taped sessions, and opportunities to discuss implementation barriers.

Studies are lacking on whether it is possible deliberately to engineer a conducive climate and leadership along the dimensions measured by the featured study in ways which improve treatment engagement or outcomes. Such studies are rare probably because change along dimensions like mutual trust among staff, or willingness to listen to their suggestions, cannot simply be introduced by researchers and then studied. However, at least one study has shown that feedback of scores from the ORC organisational health scale used in the featured study can motivate less well functioning agencies to engage in an improvement programme. Agencies which scored as less open Lower scores on cohesion, communication, and openness to change were associated with a higher likelihood of further work in making improvements in the area(s) identified in an assessment and training workshop designed to improve organisational functioning. to change and staff suggestions – the ones which would normally be least likely to engage in a change process – were the ones most likely to commit to change The study was unable to report whether they actually followed through on this commitment. when faced with the evidence of their shortcomings.

For more on leadership and organisational health in treatment services see this Findings hot topic.

Last revised 17 May 2013. First uploaded 14 May 2013

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Top 10 most closely related documents on this site. For more try a subject or free text search

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

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

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

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

STUDY 2008 Replication and sustainability of improved access and retention within the Network for the Improvement of Addiction Treatment

REVIEW 1999 Barriers to implementing effective correctional drug treatment programs

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

DOCUMENT 2013 Sometimes best to break the rules

The alliance in motivational enhancement therapy and counseling as usual for substance use problems.

Crits-Christoph P., Gallop R., Temes C.M. et al.
Journal of Consulting and Clinical Psychology: 2009, 77(6), p. 1125–1135.
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 Crits-Christoph at crits@mail.med.upenn.edu. You could also try this alternative source.

Rarely has counselling been so deeply analysed as in this US study of mainly alcohol and cocaine dependent patients. The far-reaching implications are 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.

Summary A working relationship or 'therapeutic alliance' between patient and counsellor is expected to be particularly important for motivational interviewing, which seeks to engender change built on empathy, listening, respect and other features of a collaborative and supportive relationship. The featured report sought to determine whether this was the case in comparison to usual US substance use counselling. It carefully teased out variation between therapists in the extent to which they fostered an alliance across all their patients, versus variation between patients seeing the same therapist. If the former was substantial it would mean some therapists were better at generating collaborative working in their patients, which might be related to how well those patients did in controlling their substance use. One reason alliance might vary is the extent to which therapists embodied the supposedly relationship-building motivational style, another issue investigated by the report. First this account summarises the earlier findings (small text) from the study which set the context for the analysis made in the featured report.

The report drew its data from a study conducted in 2001–2004 at five US treatment centres The centres were collaborators in research–practice partnerships in the US National Institute on Drug Abuse Clinical Trials Network. offering outpatient counselling. In all 35 therapists at the centres who volunteered Most did. to join the study were allocated at random to implement two forms of individual counselling, an addition to the group counselling at the centres. Both individual approaches occupied three sessions over the first four weeks of what was on average a 10-week treatment episode. One simply replicated usual one-to-one counselling at the centres, for which the counsellors received no special training or supervision as part of the study. The other replaced this with sessions based on a manualised form of motivational interviewing, for which the counsellors had been specially trained, tested to ensure at least adequate/average delivery of the approach, and supervised via taped sessions to ensure they remained on track.

Of the 461 patients in the trial, about 60% each were assessed as problem (mainly dependent) drinkers or cocaine users. Typically they were single men in their 30s and half were in full time employment. The severity of their substance use was assessed during the 16 weeks after they started treatment.

A report on the main outcomes found that while seeing the counsellors, both sets of patients substantially reduced use of their main problem substance, but this was sustained over the next 12 weeks only after motivational counselling – an effect due to the 40% of patients with a primary alcohol problem; others did about as well regardless of the approach used for individual counselling. The report also found clinics differed in how well their patients did and how much was gained or not by implementing motivational interviewing, but after this had been taken in to account no significant differences could be attributed to individual therapists. However, this analysis included just 20 of the 35 therapists, two from each approach at each of the five centres. With so few at each clinic it seems possible that individuals at some clinics actually were more effective than those at others, but that this was associated with where they worked in such a way that its impact was obscured when both factors were included in the same analysis. Another report on the same study found that patients of motivational counsellors In respect of motivation changes, the same was true to a lesser degree of the counsellors who implemented usual counselling. who more often and more skilfully implemented the approach expressed greater increases in motivation to change during counselling sessions and were less likely to test positive for illegal drugs during the four weeks they were individually counselled. However, other measures of substance use were not related to the counsellor behaviours assessed by the study.

The featured report assessed how much of these impacts could be attributed to the therapeutic alliance. It drew its data from 30 of the 35 therapists and 319 of the 461 patients, the ones who had attended their first counselling session and who after the second reported how they saw their alliance with their counsellor. In respect of substance use, the analysis further narrowed down to 257 patients who completed at least one of the required research interviews.

Main findings

The Helping Alliance Questionnaire: patient version

Patients indicate their agreement with each question ranging from strongly disagree to strongly agree

1. I feel I can depend upon the therapist.
2. I feel the therapist understands me.
3. I feel the therapist wants me to achieve my goals.
4. At times I distrust the therapist's judgment.
5. I feel I am working together with the therapist in a joint effort.
6. I believe we have similar ideas about the nature of my problems.
7. I generally respect the therapist's views about me.
8. The procedures used in my therapy are not well suited to my needs.
9. I like the therapist as a person.
10. In most sessions, the therapist and I find a way to work on my problems together.
11. The therapist relates to me in ways that slow up the progress of the therapy.
12. A good relationship has formed with my therapist.
13. The therapist appears to be experienced in helping people.
14. I want very much to work out my problems.
15. The therapist and I have meaningful exchanges.
16. The therapist and I sometimes have unprofitable exchanges.
17. From time to time, we both talk about the same important events in my past.
18. I believe the therapist likes me as a person.
19. At times the therapist seems distant.

Click here to download the questionnaire.

The first and surprising finding was that as rated by the patients ( figure), their working relationships were on average Also motivational and usual counsellors varied to roughly the same significant degree in the average ratings of their patients. very good with the counsellors regardless of whether they had been assigned to motivational counselling. After this, how well patients did during the rest of their time with the counsellors (ie, weeks three and four of treatment) was unrelated to these ratings, but an effect did emerge in weeks four to 16, even though patients were no longer being seen individually. Across this period the average trend in how often a counsellor's patients used their primary substance was significantly related to how far that counsellor had (as assessed up to 12 weeks earlier) generated a positive alliance across their patients. This relationship was, however, not straightforward. Best results were seen among patients seen by counsellors who scored about average (for this set of counsellors, still very high) on their patients' experience of working with them; these patients sustained the substance use reductions they had achieved while seeing the counsellors. But among other patients, on average the gains they had made eroded, and this was the case both when their counsellors had been particularly good at generating a positive alliance, and when they had been particularly poor.

In contrast to differences between counsellors, differences between patients of a particular counsellor in how positively they saw their relationship were unrelated to that patient's substance use trends; patients who felt they had an extremely good relationship did as well as those who thought it not so good. Other interesting 'negative' findings were that relationships between alliance and substance use were similar regardless of the type of counselling, and that the alliance as rated by the counsellor did not vary much on average between counsellors, and was unrelated to trends in their patients' substance use

Next the study investigated what might have caused a counsellor to generate on average better or worse alliance scores across their patients. Across all their recorded sessions, how competently each on average used motivational skills was unrelated to how their patients felt about working with them, but the more extensively they used these techniques and skills, Assessed skills were:
Open-ended questions
Reflective statements
Fostering collaboration
Motivational interviewing style
Client-centred problem discussion and feedback
Pros, cons, and ambivalence
Heightening discrepancies
Motivation for change
Change planning
the better their patients as a whole rated them, and this was particularly the case for the motivational counsellors. But this did not account for the relationship between alliance and substance use trends; no matter how often counsellors used motivational skills, their alliance scores had a similar relationship to substance trends in their patients. Something else generating the alliance, not just the use of the assessed motivational techniques, accounted for its apparent influence on outcomes.

The authors' conclusions

Unexpectedly, training and supervising counsellors in motivational interviewing did not lead to more positive relationships with their patients, despite the approach's stress on empathy, acceptance, positive regard, and clear discussion about goals, and even though these and other such interactions were indeed elevated among the motivational counsellors. One conclusion is that forming a positive alliance is not unique to motivational-style counselling. Counsellors never trained in motivational interviewing can generate very positive alliances, in this study perhaps because typically they were highly experienced and used client-centred counselling skills to a fairly high degree, enough perhaps to match the alliance-generating impact of explicitly motivational counselling.

For any given counsellor, how positively each of their patients felt about them was unrelated to that patient's substance use. However, patients seen by counsellors who typically generated (relative to the average in this study) relatively high or low alliance scores were less likely to sustain their initial substance use reductions, and this was the case for both motivational and treatment-as-usual counsellors. Similar findings have also emerged in general psychotherapy/counselling.

These findings suggest that in so far as the alliance influences desired improvements in the patients, it is not to do with how well an individual therapist and patient get along. Instead therapists differ perhaps in skill levels, interpersonal styles, abilities to learn and implement alliance-fostering techniques, or to identify and repair alliance ruptures, differences which mean they tend to form relatively good or poor relationships with their patients, in turn affecting whether they make the desired changes in their lives.

This pattern of findings justifies efforts to train therapists and counsellors to enhance alliance with their patients, and/or to select therapists with the right personalities and skills, which may to a degree not be teachable. Training does not it seems have to explicitly be based on motivational principles.

The findings also seem to confirm the truism that patients can often initiate abstinence on entering treatment, and that where the quality of treatment has an impact is in sustaining those gains and dealing with lapse and relapse. This was the phase during which an earlier report on the study found a motivational approach more effective than usual counselling, and during which in the featured report each counsellor's ability to generate an alliance among their patients appeared to exert an influence. However, generating especially positive alliances was not necessarily a good thing; as with counsellors who generated relatively poor alliances, patients of these counsellors had poorer outcomes.

One way counsellors apparently enhanced their patients' alliance ratings was by using more of the skills and techniques which characterise motivational interviewing. However, these were not the driving force which made a high alliance counterproductive. Therapists can engage in these types of interactions without fearing 'over-use' will damage their patients' prospects.

It should be remembered that these implications derive from a just a few studies. In the featured study, results might have been different had the counselling programme been a typical length rather than just three sessions, if the alliance had been assessed later in therapy when the relationship had developed further, or if it had been rated from sessions recordings. The same counsellors led group therapy sessions which might have included their patients, and many remained in treatment during all or part of the period during which their substance use was measured, meaning the results are complicated by the impact of continuing treatment. Just 56% of the patients could be included in the outcome analysis; had more been able to be included, results might have differed. Only the motivational therapists were specially trained and supervised, so the impact of the motivational content is confounded with any impact from receiving extra training and supervision, whatever the content. Patients were not randomly assigned to counsellors, so the possibility cannot be excluded that the clinics allocated certain types of patients to certain counsellors.

Findings logo commentary The featured study seems to confirm the intuitive assumption that how well a counsellor relates to their clients has an impact on how well the client does – that in the words of a Findings hot topic entry, treatment staff matter.

This assumption is supported by evidence from psychotherapy trials in general, in respect of which a comprehensive meta-analytic review commissioned by the American Psychological Association concluded that whether seen from the patient's or the therapist's perspective, the more solid the working relationship, the better the outcomes. Though it accounts for a relatively modest proportion of variance in treatment outcomes, the reviewers saw the alliance-outcome relationship as one of the strongest predictors of treatment success. As in the featured study, they also found evidence that therapists varied in the degree to which they foster an alliance with their clients, suggesting that alliance development is a skill and/or capacity therapists can develop.

In substance use treatment the picture is less clear. A review published in 2005 found that therapeutic alliance early in treatment was more consistently related to engagement and retention than to substance use outcomes, especially when those outcomes were assessed at times distant from the assessment of the alliance.

A study of motivational interviewing training sheds further light on what it is about counsellors which generates retention/outcome-enhancing alliances. Many studies recruit skilled therapists and then train and supervise them to ensure competence, partly eliminating the normal variability in competence, but this study randomly allocated an unusually diverse (in terms of initial proficiency) set of addiction counsellors and clinicians to different motivational interviewing training regimens and then tested their performance with clients. It found that client engagement was unrelated to the frequency with which the therapist made statements compatible (such as open questions) or incompatible (such as warning) with the specific techniques recommended in motivational interviewing, but was strongly related to embodying the overall spirit of the approach and to more general social skills including empathy, warmth, supporting the client's autonomy, and coming across as 'genuine', an amalgam of seeming open, honest and trustworthy. In the featured study too, the skills and techniques exhibited by motivational and non-motivational counsellors partly determined client engagement, and to the same degree in both sets of therapists.

The featured study's supposition that to some extent these personal attributes cannot be trained is supported by another study of motivational interviewing training, the findings of which suggested that when it comes to choosing addiction and mental health therapists, choosing the 'right' people who have not been trained in motivational interviewing would be better than choosing the 'wrong' people who have been trained; the former not only started at a higher level, but were more able to benefit from and retain training.

Some puzzling findings

Of the thought-provoking findings thrown up by the featured study, most notable was that the patients of counsellors who generated unusually high alliance ratings did less well than those of average counsellors. An earlier psychotherapy study found a similar relationship. The authors surmised that patients with an unrealistic idealisation of their therapists may later feel disappointed, or that a very high alliance rating signifies an excessive need for attachment indicative of a poor prognosis. Neither explanation fits the data from the featured study, because under both scenarios there should have been a relationship between outcomes and the alliance levels of each individual patient seeing the same therapist.

Another possibility is that such counsellors also generated feelings of being reliant on their support; when individual sessions ended, reliance may have rebounded to a feeling of now being devoid of needed support, with a consequent rebound in substance use. At the other end, counsellors with relatively poor alliance scores from their patients may have developed relationships too weak to support a determination not to relapse and strategies to avoid it.

A further possibility is that rather than what might be thought as the perfect stable-normal personality profile for a therapist, workers whose imperfections and deviancies to an extent match those of their drugtaking clients are most able to help them, even if this means their clients see them as less than ideal. These were the implications of a study in England set in a drug service for marginalised clients which found that drug workers who prioritised stimulation, self-direction and hedonism experienced more positive client outcomes than those prioritising security, conformity, benevolence, and tradition. A similar picture emerged from a US study of ex-addict methadone counsellors published in 1974, which found that "deviant" personalities who shared the insecurities and edginess of their patients and had a suspicious outlook on life had patients who engaged better and used drugs less.

The featured study's findings may have been dependent on the generally high alliance-generating competence of the counsellors. Had there been a greater range and on average lower competence, it seems possible that there would have been a simpler finding: that the more a therapist generated good alliances, the better the outcomes for their patients.

Another puzzling finding was that though over the following 12 weeks motivational counselling promoted desistance from the main drug the client was using, it did not do so to any greater extent the more competently and skilfully it had been delivered, as would have been expected if motivational interviewing was the active ingredient. It seems more likely that factors common both to motivational approaches and effective substance use counselling were the main ingredients. These were perhaps present to a greater degree among the motivational therapists, possibly due to their specific training, but also possibly due to the opportunities they had to learn from feedback on their performance with patients and the optimism and morale-boost associated with learning a new approach and receiving extensive attention from trainers and supervisors.

Also it seems contradictory that some therapists were characterised by alliance levels (ie, about average) among their patients which were associated with the best substance use outcomes, yet there was no significant relationship between which counsellor a patient saw and how well they fared on the same measure. On the face of it one would expect the impact of a counsellor's alliance-generating abilities to be reflected in the progress of their caseload.

Thanks for their comments on this entry to Paul Crits-Christoph of the Center for Psychotherapy Research at the University of Pennsylvania Medical School in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 22 May 2013. First uploaded 10 May 2013

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2011 Therapist effectiveness: implications for accountability and patient care

DOCUMENT 2013 Sometimes best to break the rules

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

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

REVIEW 2006 My way or yours?

REVIEW 2005 The motivational hallo

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

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

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

Four-year outcomes from the Early Re-Intervention (ERI) experiment using recovery management checkups (RMCs).

Dennis M.L., Scott C.K.
Drug and Alcohol Dependence: 2012, 121(1–2), p. 10–17.
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 Dennis at mdennis@chestnut.org. You could also try this alternative source.

Chicago studies have shown that quarterly check-ups on former patients can identify need and pave the way for treatment re-entry. Though extra substance use/problem reductions were modest, these remained significant four years after the patients started treatment. Issue for the UK: how does this square with the stress on lasting treatment exit?

Summary Post-treatment check-ups are one attempt to address the fact that rapid relapse is typical after short-term treatment of severe addiction, especially when complicated by social and psychiatric problems. Instead of leaving it to the patient to seek further help, check-ups assume that regular, proactive, long-term monitoring and early re-intervention will improve long-term outcomes by facilitating early detection of relapse and reducing time to treatment re-entry.

Over four years, the featured report documents outcomes from a post-treatment check-up and (if needed) treatment re-engagement protocol previously reported on up to two years after treatment entry. The two-year report was able to assess whether over the same time period promising results from an earlier version of the check-ups could be improved on by taking on board the lessons of that initial evaluation.

The trial of the earlier version had recruited 448 people referred by a central assessment unit in Chicago for treatment at a centre specialising in substance users who are new mothers or mothers-to-be, homeless, or mentally ill. Three months later when most had left initial treatment they were randomly assigned to 21 months of quarterly recovery management check-ups, or to a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group re-assessed according to the same schedule.

Questions put by researchers to both groups were designed to identify clients not already in treatment or custody, but who needed to return to treatment, indicated by a positive response to at least one of six questions 1 During the past 90 days, have you used alcohol, marijuana, cocaine, or other drugs on 13 or more days?
2 During the past 90 days, have you gotten drunk or been high for most of one or more days?
3 During the past 90 days, has your alcohol or drug use caused you not to meet your responsibilities at work/school/home on one or more days?
4 During the past month, has your substance use caused you any problems?
5 During the past week, have you had withdrawal symptoms when you tried to stop, cut down, or control your use?
6 Do you feel that you need to return to treatment?
probing for a return to regular, 'binge', or problem substance use, and whether the client themselves felt in need. For the control group, this was where the interviews ended; except rarely in an emergency, no attempt was made to re-connect them with treatment. During check-up interviews, instead the researcher immediately referred 'in-need' patients to a 'linkage manager' whose role was to motivate Using motivational interviewing principles and feedback on the client's problems. treatment re-entry and to offer practical assistance. As intended, the check-ups improved treatment re-entry rates, but results were far from perfect. For example, just a third of the people encouraged to return to treatment actually did so, the intervention did not improve retention once in treatment, and benefits did not become statistically significant until the end of the two-year follow-up.

For the study behind the featured report, this earlier study was replicated with 446 patients Somewhat fewer were diagnosed as dependent or had recent psychological problems, but generally they were quite similar to the initial set. recruited in the same way at the same centre. As before, typically they were dependent on cocaine Though large minorities also or instead were dependent on alcohol or opioids. and most had serious mental health or behavioural problems. Just under half were women, 80% black, three quarters out of work, and about a quarter homeless. Eight in ten were referred to residential programmes, and (judging from the earlier trial) the remainder probably mainly to intensive outpatient programmes, in both cases usually lasting under three months.

They were subject to the same check-ups, except for three modifications suggested by the earlier study. To facilitate identification of treatment need, researchers countered the tendency of a small minority to deny drug use by reminding them of previous assessments and urine test results, and probing inconsistencies. To facilitate treatment entry, from the start there was a requirement to provide transport to treatment intake and initial sessions. To facilitate retention, linkage managers now maintained contact with patients in treatment, and treatment staff gave the managers a chance to intervene beforehand with patients about to leave prematurely. Either of their own volition or because staff were going to discharge them.

As detailed in this analysis of results up to two years after treatment entry, the modifications enhanced treatment access by increasing the proportion of former patients identified as in need of treatment and also the proportion (now practically all) who agreed to see the linkage manager. However, the modifications made virtually no difference to the proportion of in-need participants who agreed to attend a treatment intake assessment, though more completed it and started and engaged with treatment and did so more quickly. By the end of two years, in both studies the check-ups had led to about 10% fewer people Down from 44% to 34% in study 1 and from 57% to 46% in study 2. still being assessed as in need of treatment. Only in the second study was there an impact on substance use: a slight increase in days abstinent from on average 68% in the control group to 76%, and a further slight reduction in an already quite low index of substance abuse, dependence or related problems.

Main findings

Having established that at least over the first two years the modified procedures further improved treatment re-entry rates and modestly improved substance use outcomes, the featured report focused on whether the protocol had remained preferable to merely assessing patients (the control group) over a further two years, four years in all. Nearly all the patients completed at least two of the quarterly research re-assessments and could be included in the analysis of treatment re-entry. Around 90% were assessed as at some stage in need of returning to treatment; again, nearly all could be included in an analysis of the time it took them at re-enter.

Compared to the control group, 19% more check-up patients (70% v. 51%) returned to treatment at some point after the first check-up point, they returned nearly twice as often (average of 1.9 v. 1 times), spent 42% more days in treatment (112 v. 79 days), and nearly twice as often engaged in outpatient treatment for at least a week or residential for at least a fortnight (2 v. 1.2 times). Those assessed as in need of returning to treatment did so much more quickly (13 v. 45 months) if they had been assigned to the check-ups. Check-up patients were also much more likely to return sooner than control patients after a range of severity and other variables had been taken in to account, and of these variables, being assigned to check-ups was the only significant influence. While access to treatment was enhanced by the check-ups, it remained far from universal; on just a fifth of occasions did being identified as in need of treatment result in engagement in treatment.

Enhanced access to treatment seems to have fed through to reduced substance use and problems. Check-up patients were less often assessed as in need of treatment (7.6 v. 8.9 of the 16 quarterly check-ups), stayed in need for a shorter time (5.9 v. 7.5 quarters in a row), reported fewer substance-related problems, Relating to the past month, weekly use, hiding using, complaints about use, symptoms of abuse or dependence, and substance-induced health or mental health problems. and spent more days not drinking or using drugs (out of 1350 days, 1026 v. 932).

By the last three months of the four-year follow-up, check-up patients had used substances and/or used heavily or experienced problems related to that use on fewer days than control group participants (0.10 v. 0.13 on a scale of 0–1), they had more often been abstinent (70 v. 63 of 90 days), and over the final month of the follow-up they also experienced fewer (1.4 v. 2.3 on a scale of 0–16) problems Weekly use, hiding using, complaints about use, symptoms of abuse or dependence, and substance-induced health or mental health problems. related to substance use.

The authors' conclusions

Findings confirm that we are one step closer to effectively responding to addiction as a chronic illness. Recovery management check-ups were associated with reduced time to treatment readmission, more treatment, and reduced substance use and related problems. They offer a proactive approach to help substance abusers learn to identify their symptoms, resolve their ambivalence about their substance use, and support their choice to assume personal responsibility for the management of their long-term recovery.

The findings also demonstrate the need for such an approach; at some point during the study, 90% of the participants were in need of further treatment. High follow-up rates also show that quarterly monitoring is acceptable to patients and they can manage this despite often chaotic and highly mobile lifestyles.

It should be remembered however that the results derive from a mainly African American urban sample seen at one centre and with multiple problems. Implementing recovery management check-ups is also labour-intensive and financial considerations may be an obstacle. While the check-ups helped many and effects cumulated over time, each subsequent check-up reaped diminishing returns, and there was a subgroup of people for whom they may not have been the optimal intervention.

Findings logo commentary The featured report is the latest from a well-constructed set of studies conducted most notably by the featured research team in Chicago and by another team in Philadelphia. Both attempted to make a feasible reality of the common understanding of addiction (at least of the kind experienced by people who seek treatment from public services) as a chronic condition.

Among dependent drinkers in Philadelphia, low readiness and/or motivation for curbing substance use, and lack of positive social support to do so, were markers of the need for more intensive continuing care. Additional markers were co-dependence on cocaine and poor outcomes or self-help attendance during initial treatment. Similarly, the featured study found hints Most severity markers made no statistically significant difference to the impact of the check-ups. that patients more entrenched in crime and violence and who had started drug use early in life benefited most from the recovery check-ups. The other side of the coin is that less vulnerable patients do as well with no or only minimal continuing care. However, these are not hard and fast rules. Securely identifying who is and is not at risk means keeping a check on how patients are actually doing after they leave treatment. A panel of experts convened by the US Betty Ford Institute saw such checks as the key component of continuing care and the one with the greatest evidence of effectiveness.

The featured Chicago studies sampled people with multiple problems and little stake in conventional society, the kind most likely to repeatedly relapse and need continuing care. Their primary substance use problem (cocaine) ruled out maintenance prescribing as a major long-term anti-relapse strategy. Check-ups helped re-engage patients with treatment, especially when for the second study assessment, transport and treatment engagement procedures had been improved, but the gains in respect of substance use or problems seem modest.

Presumably check-ups work best when there are adequate services for patients to re-engage with. In the face of the problems posed by these caseloads, brief episodes of resumed care focused on substance use perhaps for some missed the mark. Repeated access to episodic drug treatment is in these circumstances more a sign of the intractability of the patient's situation than a way to lastingly resolve it, perhaps why success in encouraging treatment re-uptake was not matched by a similar degree of success in curbing substance use problems. Another reading of the results is that for many the check-ups were unnecessary; even without them, by the end of the four years of the study levels of substance use and related problems were low. Below some further considerations in respect of the study's methodology and context.

How well the criteria for 'need for treatment' identified people normally considered in need is questionable. They would have included someone who had spent just one day drunk in the past three months and never used any other drugs. Such patients may justifiably have seen themselves as not really in need, possibly why most did not re-engage with treatment.

Also questionable is whether in routine, real-world use, the check-ups would work as well as they did. As the authors acknowledged, such gains as there were resulted from specially trained staff using a standardised and supervised protocol; a substantial investment was required to reach required standards. While the patient was still in the initial treatment, the studies paved for the way for later follow-ups by verifying potential contact points and carefully preparing the patient, their nominated associates, and the agencies they were likely to be in touch with, so they would respond to later re-contact attempts. Also the interventions took place during visits when research data was collected, for which these poor participants were financially reimbursed; presumably Because they were offered (presumably) in order to increase attendance. fewer would have attended without these incentives.

On the other hand, it could be that routinised check-ups would be more successful if familiar faces from the initial treatment agency were involved, and there was no burden of completing research assessments. Also, regular re-assessment of the control group participants may have raised their awareness of need for treatment, narrowing the gap with the check-up patients.

It is unclear whether the reduction in treatment need was due to remission of substance use problems, or because more recovery check-up patients were already in treatment, so could not be assessed as needing to return.

Other ways to keep in contact

A review of continuing care and aftercare studies found that most recorded clear and statistically significant advantages for continuing care versus no care or only standard care. Provided the interventions were capable of keeping patients engaged, longer durations of continuing care seemed more consistently beneficial. These longer interventions all involved 'taking the treatment to the patient' rather than relying on them visiting a clinic.

In particular, studies have shown that proactively re-contacting former patients can transform aftercare attendance, that re-contacts can in themselves be therapeutic, even without leading to a return to treatment, and that such work can be done by a service's routine staff. Approaches which evidence individualised concern for the patient work best, probably because they convey active caring rather than a bureaucratic reminder-mill. The more socially excluded and damaged the caseload, the more active and personal the follow-ups need to be, and the greater the help needed to re-establish aftercare contact.

Case management is a more common form of continuing care than featured study's check-ups, one which typically also tries to orchestrate multiple sources of help for multiply problematic caseloads. Despite some successes with US welfare applicants, like the check-ups, in general these interventions raise service access more noticeably than they improve substance use.

Another approach is to encourage all former patients to return for aftercare whether they need it or not, and to make it easier for them to do so by adopting a welcoming, personal approach and implementing systematic reminders. Especially among the more psychologically vulnerable patients, this proved effective in another US study.

UK policy stresses lasting treatment exit, not return

The check-up system in the featured report was intended to move (in a way feasible for patients and services) towards matching the chronicity of the vulnerability of patients with an equally long-term support system. Though advocated by the researchers in the name of 'recovery' from addiction, in Britain policy based on the same overarching concept is less encouraging of treatment contact than in the pre-recovery era when guidance stressed the need for aftercare following residential rehabilitation and for continued post-detoxification treatment. However, on the ground long-term continuing care or aftercare was patchy and post-residential care plans relied mainly on mutual aid groups. With the encouragement of national caseload and retention targets, opiate substitute prescribing based largely on oral methadone was the mainstay of longer term care.

From the late 2000s, in theory the recovery vision and associated understandings of addiction extended the horizon beyond treatment episodes restricted in space (as at a clinic) and time to the world within which the patient lives and must fully return after treatment, and their entire life course, but at the same time the resources to commission services and forge those extended links became more restricted. New commissioning guidance continued to mention "aftercare support services" but as a "supplement" to mutual aid groups and recovery networks, on which the greater stress was placed along with "planned exits" from treatment.

Policy levers reinforced the new stress on treatment completion and exit and at the same time tried to ensure this had represented lasting recovery by stipulating that the patient not return to treatment within six months or a year. A six-month non-return criterion was built in to the public health indicators by which local authorities (now responsible for addiction treatment) are held to account. It was also intended to determine part of the financial allocation to local areas for addiction treatment, though it now seems that will not happen. Pointing the way to the probable future, nationally agreed criteria for pilot payment-by-results schemes place a premium not on long-term contact, but on discharging dependence-free patients who then are not seen in treatment again for at least a year, one of a set of criteria services will find difficult to ignore because their financial survival depends on how well they do against these yardsticks. Gone entirely are the retention targets of previous years.

The probable intention was to encourage agencies and commissioners to offer the "recovery support interventions" provided for in the definitions used to record treatment entry and exit in England. These include the check-ups of the featured study and do not count as continuing treatment. Other interventions too can count as "recovery support" rather than "structured treatment", to the extent that a patient can be considered discharged yet be in regular contact with the treatment service, receiving the same types of interventions as before, for the same purpose, at the same location and with the same staff. But if before six months or a year these cross the unclear line to treatment re-entry, the service and/or the area stand to lose some of the credit and some of the money they would have gained from ensuring the patient stayed out of treatment, seemingly contrary to the featured study's stress on regularly checking treatment need and (if needed) getting patients back as soon as possible.

Thanks for their comments on this entry in draft to Michael L. Dennis of Chestnut Health Systems in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 15 May 2013. First uploaded 08 May 2013

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An open trial of gabapentin in acute alcohol withdrawal using an oral loading protocol.

Bonnet U., Hamzavi-Abedi R., Specka M. et al.
Alcohol and Alcoholism: 2010, 45(2), p. 143–145.
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 Bonnet at udo.bonnet@lvr.de. You could also try this alternative source.

Drawbacks of the favoured benzodiazepine drugs used to ameliorate alcohol withdrawal have led to trials of anticonvulsants, but this German trial found one promising anticonvulsant effective only among less severe cases, and even then some seemingly doing well later developed epileptic seizures, one of the most severe consequences of alcohol withdrawal.

Summary Benzodiazepines (and in some European countries, clomethiazole) are the pharmacological treatments of choice in the management of the alcohol withdrawal syndrome. To avoid their propensity for dependence and other drawbacks of these drugs, novel anticonvulsants have been studied, of which gabapentin seems promising both due to its pharmacological profile and some animal studies and reports involving human subjects. But the only published placebo-controlled human clinical trial did not find gabapentin superior to placebo as an adjunct to clomethiazole. In that trial moderate gabapentin initial doses around 400mg (increased to 1600mg in the first 24 hours) did not ameliorate the severity of withdrawal.

Given this finding, the featured study instead tried a higher initial gabapentin dose of 800mg, which can be expected to show effects within two to three hours. The study involved 10 women and 27 men admitted to a German hospital for treatment of severe alcohol withdrawal, defined as scoring at least 15 points on the Clinical Index of Alcohol Withdrawal-Revised scale, a standard way of assessing withdrawal severity. They were selected to be free of other substance use disorders (except smoking) and not using certain medications.

Patients who within two hours responded well to the initial 800mg of gabapentin (the 'early responders'), identified by withdrawal severity remitting to under 15 points, were given further doses totalling 3200mg in the first 24 hours. Further doses were given on the following days until on day four the dose started to be reduced.

Patients who after two hours had not responded well to the initial 800mg were switched to the unit's usual regimen based on clomethiazole or clonazepam.

Main findings

Of the 37 patients, 27 were classified as early responders. In the first two hours their withdrawal severity fell from on average 17 points to eight. However, over the next 36 hours two experienced seizures and another worsening withdrawal symptoms and were switched to clonazepam, meaning that only 24 completed the study as 'responders'. The early responders averaged nearly 11 days' inpatient treatment.

The other 10 patients averaged at the start 20 points on the withdrawal severity scale, which despite the initial gabapentin dose deteriorated to nearly 22 points within two hours. The two patients with initially the most severe withdrawal symptoms were both among them. They averaged about a fortnight in hospital. They differed from the responders by: having initially more severe withdrawal symptoms, probably accounting for their longer treatment; and by significantly more severe initial symptoms of anxiety and depression. Their heart rates and blood pressures also tended to be higher and they smoked more cigarettes. However, they did not significantly differ from the early responders in terms of their drinking histories, number of alcohol-associated consequences, laboratory results and ECG changes.

With the exception of the two seizures, no other serious adverse events were recorded.

The authors' conclusions

In this study patients who did not respond to gabapentin were characterised by more severe withdrawal symptoms exceeding 20 points and more severe symptoms of anxiety and depression. It seems therefore that the evaluated gabapentin regimen is helpful only for less severe and less complicated acute alcohol withdrawal. Similar conclusions have drawn from other trials. However, its utility even among these patients is compromised by the fact that two who at first seemed to be doing well on gabapentin later developed epileptic seizures.

Findings logo commentary The two seizures are a major concern, because benzodiazepines became the mainstay of alcohol withdrawal treatment to avoid these and other serious consequences. These drugs made seizures largely avoidable, and any change in treatment which resurrects this threat to patient welfare is on those grounds a step backwards. The featured study's authors speculate that in this study they happened but not in a previous study, because the waiting period before further medication was two hours rather than one. It could also be that this was a chance finding somewhat out of line with other alcohol withdrawal studies, on which more below.

As well as benzodiazepines, British guidelines recommend considering not gabapentin but another anticonvulsant, carbamazepine, and also chlormethiazole (Heminevrin), a drug with anticonvulsant and sedating properties. The experts did so after reviewing studies across which there were no significant differences between these agents in the incidence of alcohol withdrawal seizures and other adverse effects, or in their abilities to ameliorate withdrawal symptoms. The guidelines also recognise the reasons why attention has turned to gabapentin and other alternatives to benzodiazepines – that the latter have attractions for people dependent on alcohol due to their tranquillising and sedating properties which risk abuse and dependence.

A review conducted for the Cochrane collaboration which evaluated the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal found them not significantly better than placebos, though possibly better at preventing seizures, and no better than alternative medications, except perhaps in respect of ameliorating withdrawal symptoms.

Another Cochrane review focused on benzodiazepines for alcohol withdrawal found these drugs definitely prevent seizures compared to a placebo, and compared to other drugs tended non-significantly to be better at preventing or controlling seizures and delirium, severe life threatening side-effects, treatment drop-out, and drop-out due to side effects. In relation specifically to anticonvulsants, there were no significant differences, but benzodiazepines tended to result in greater improvements in the doctor's global assessment of the patient's wellbeing, but also an increased risk of alcohol withdrawal seizures. The latter possibility rested on two trials, one of which compared carbamazepine against oxazepam and the other chlormethiazole against alprazolam. Each recorded no seizures among the anticonvulsant patients but one among the respectively 29 and 46 patients administered benzodiazepines.

Last revised 21 May 2013. First uploaded 15 May 2013

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