Hot topics for September/October 2016
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If considered at all, addiction treatment research generally dismisses the impact of the therapist as ‘noise in the system’ to be eliminated in order to focus on the therapy. In the light of what we now know – and have done for many years – they are eliminating what matters in order to focus on what generally does not, an investigative gaze misdirected not just in substance use but also across psychosocial therapies for mental health problems. To help redress the balance, this hot topic focuses on the recruitment and development of the workforce, and on the influence of how they treat patients in the ordinary sense of the word ‘treat’.
Influentially formulated by Carl Rogers in the mid-1950s, the centrality of the relation between therapist and client has long been acknowledged, but became overshadowed by a mechanistic ethos which sought to legitimise psychosocial therapies by analogy with interventions based on ‘hard science’ like pharmacology. The implicit model was that if the remedy keyed adequately into the disorder, and was administered as intended and in a sufficient ‘dose’, it had the potential to unlock the cure – whoever administered it, with whatever attitude to the patient, whether they were caring or cold, and regardless of the context.
That this was a misguided vision has been suggested by studies which found therapists varied greatly in their performance (1 2 3 4 5). Even in studies designed for other purposes or which actively sought to eliminate it from the analysis, the influence of the therapist and how they relate to substance using clients has forced its way to the surface. In 2000 reviewers commented: “This finding has emerged repeatedly in a variety of studies, although, paradoxically, this result was rarely the intent of the studies. It is a finding that has been called ‘surprising’ and ‘serendipitous’. Yet to most front-line clinicians, program administrators, and patients, this result would seem obvious; it is widely known that some practitioners are highly regarded whereas others are avoided.”
In this respect, substance use research is catching up with findings from general psychotherapy, where client-therapist relations have been endorsed in reviews commissioned by the American Psychological Association as the root of several of the common factors which affect outcomes across different therapies. Techniques such as motivational or cognitive-behavioural exercises can be seen not as active ingredients in themselves, but as vehicles for communicating what to many substance use clients will be the revelation that someone sees them as worth devoting time and attention to and is optimistic about what they can become, offering a credible schema of how they got into trouble with substances, and how they find a way out.
This hot topic focuses on the impact of the ‘proximal’ client experience face-to-face with their carer, but we should acknowledge that this encounter is merely the sharp end of all the organisational influences on how that counsellor feels they should and can behave and on how the client interprets the encounter. Oranisational context is the subject of another hot topic, which describes a classic series of British studies which though focused on the therapeutic alliance – the core of the client-carer encounter – found this depended on the workplace environment, including whether it engendered the feeling in the carer that tackling drinking was a legitimate role supported by their organisation. The studies turned the focus on the messages staff receive about the organisation’s priorities as expressed in its policies, resource allocation, and the perceptions induced in staff about whether working with drinkers is a valued and worthwhile use of their time.
Among the documents retrieved by the GO-button search are some of our own Manners Matter series devoted to the roles played in treatment by sensitivity, helpfulness, and the systematic implementation of a personal, welcoming response. But such generalisations cannot mechanistically determine treatment at the individual level, where there are no hard and fast formulas for success, and the patient is the greater part of the equation. Treatment is or should be an individualised and collaborative venture whose pattern is worked out between client and patient rather than directly transferred from research. Across psychotherapy, evidence is strongly in favour of patients and therapists collaboratively agreeing goals and how they will go about reaching them. Paradoxically, collaboration can sometimes mean adopting the role of an expert telling the patient what they should do. While researching Manners Matter, we discovered solid research support for therapists matching how directive they are to the patient’s inclination to be led or to take the lead. My way or yours? related these findings to everyday experience: “As in life outside the consulting room, neither back seat nor driving seat is invariably the preferred position – it all depends. Any given mixture of taking versus ceding the lead will be right for some companions at some times, wrong for others.”
However, many more dimensions are involved than directiveness, and they interact. For example, in one of the studies we reviewed,
The complexity of interacting influences demands socially skilled therapists who can react appropriately
the biggest influence on drinking outcomes was not directiveness, but whether therapists addressed the emotional state of highly distressed patients. Had they avoided doing so for fear of being over-directive, they might have done more harm than good. Then there is the possibility that adopting an interpersonal style which does not come naturally or contradicts the realities of the situation will violate another tenet of effective therapy – being and seeming genuine. It all means there are no set recipes for success, rather broad principles and multiple influences whose complex interactions change depending on the context, underscoring the importance of socially skilled, empathic, and client-centred staff capable of and willing to react appropriately and incorporate patient preferences in treatment decisions.
Given this complexity, it is no surprise that while research has shown outcomes differ for different therapists, distilling the essence of what makes a therapist better or worse has been difficult. It might, for example, be thought that those more competent in the therapy or who more conscientiously implement its prescribed style and techniques would prove more effective. Then the route to effective therapy would be clear – select, train and supervise to make sure therapists do what they are supposed to do well, and do lots of it. But that route was confounded by a synthesis of studies of psychosocial therapies which had assessed therapist competence in and adherence to the therapy and related this to outcomes: “The most striking result is that variability in neither adherence nor competence was found to be related to patient outcome and indeed that the aggregate estimates of their effects were very close to zero.” Among the substance use studies in particular there was a near-zero relationship between adherence to the therapy and outcomes, and a slight and non-significant negative one for competence. Similarly, in substance use studies, outcomes can be worse when therapists are trained and tightly supervised to ensure they implement the therapy manual.
Just too good!
The authors of the research synthesis referred to above advanced several possible reasons for their findings. One was that therapists in research studies are often selected, trained and supervised to ensure they are all good at the therapy, leaving little scope for different degrees of goodness to affect outcomes. Then too, therapists may ease off when patients are doing well, and intensify therapy implementation when they are not, creating spurious relationships in the ‘wrong’ direction. But the most interesting reason why higher competence and adherence does not necessarily generate better outcomes is that something happens when therapists are very, very good at the therapy, which makes them less effective than their peers who are (as usually assessed by trained observers) merely good or very good.
This puzzling result can it seems happen in brief alcohol interventions for risky drinkers identified through screening. It emerged in a Swiss study which set out to reveal the impact of the counsellors by deliberately recruiting 18 who differed widely in professional status, clinical experience, and experience of motivational interviewing, the basis for the intervention. Left to their own widely differing devices, they also delivered interventions which while modestly effective in reducing drinking and overall of good quality, varied widely around this average. The advanced motivational interviewing skill of complex reflections – reflecting back the client’s comment but in a way which adds or alters meaning – seemed to make sessions more effective in reducing drinking. But in surprising contrast, simply accreting more of the other responses considered compatible with motivational interviewing actually seemed counterproductive. The study is discussed further in cell B1 of the Alcohol Treatment Matrix.
Similarly, therapists who act in ways which generates a very close alliance with their clients can weaken outcomes. An unusually penetrating analysis of motivational counselling at US substance use services found that substance use reductions were best sustained by clients of counsellors rated about average in terms of their clients’ experiences of working with them. Counsellors who had been relatively poor at striking up a close alliance had worse outcomes, but so too did those who had been especially good. Similar findings have emerged in general psychotherapy/counselling. Note that in the US study counsellors were generally very good at generating positive relationships, so it was only towards the very top of this range that outcomes started to worsen. As discussed in cell B2 of the Alcohol Treatment Matrix, perhaps at these levels therapists were too ‘nice’ or focused too much on the client’s comfort, failing to develop change-promoting “discrepancy”, even if highlighting how the patient’s actions contradict their self-image and values causes discomfort.
Given this complexity, it seems more understandable that a review published in 2005 found that therapeutic alliance early in substance use treatment was more consistently related to engagement and retention than to longer term substance use. It is important, however, to remind ourselves that patients get more out of treatment than what we choose to judge as success; even if a very close relationship with a counsellor does not further reduce substance use, it might foster other psychological and social benefits valued by the client – the reasons why they tend to stay longer.
Some easy answers
Among this complexity and paradox, there are some findings supportive of simple relationship-builders familiar from our everyday lives. For example, counselling clients in Canada rated the extent to which their counsellors had exhibited 15 behaviours thought to affect the client-therapist bond. They were not esoteric counselling skills, but simple things like maintaining eye contact and not fidgeting. Researchers then related these ratings to the degree to which the same client reported a strong working alliance with the counsellor. Once inter-relationships between the behaviours had been adjusted for, three stood out as predicting the strength of the alliance: making encouraging comments; making positive comments about the client; and greeting the client with a smile – all of which the researchers said “may be interpreted as behaviours that communicate a sense of positive regard or liking towards the client”.
Working out what the findings mean is hampered by a common inability in such research to be able to pin down which side of the related variables was chicken and which egg. For example, did greeting with a smile help generate a strong alliance, or did counsellors smile more at some clients because they already had a good relationship – or a mixture of both? However, face validity and general psychotherapy research persuasively suggests such behaviours are not just an epiphenomenon of a good relationship, but help generate it and improve outcomes.
Given expectations that this would be the case, it is worth noting that assigning therapists of the same race or sex as the patient does not provide a simple shortcut to good therapeutic relationships, though it may help in other ways. To narrow in on these studies run this search. One of the hits will be these unpublished notes on relevant studies.
Rather than stolid conservatism, ‘openness to change’ has emerged as an overarching feature of good addiction treatment services and staff – receptiveness to new ideas, new ways of working, and to developing skills and knowledge. The most wide-ranging investigation ever of the organisational health of British drug and alcohol treatment services found that staff working in an atmosphere of support, respect, and concern for their development, tended to have clients who also felt understood, respected, supported and helped. Most striking were the roles of openness to change and openness to the drivers of change in the form of staff who suggest innovations (facilitated by an environment which encourages open communication) and training and educational inputs. The study serves as a reminder that no matter how good the counsellor, they will not be able to maximally flourish – and neither will their patients – unless they are appropriately supported by the organisation within which they work.
Also from the UK, another study threw up the intriguing possibility that non-conformist drug workers who value hedonism and stimulation help marginalised drug users most because their values match those of their clients – in some ways the opposite to what one might expect. Again, the underlying pattern in the findings was that workers who conservatively valued stability and established order had worse outcomes, while those characterised by openness to change had better client outcomes. The plausible presumption is that ‘openness to change’ values also typified their clients – users of illegal drugs.
Non-conformist drug workers who valued hedonism and stimulation helped marginalised drug users most
Not too much should be made of this small one-off study, especially since the client outcomes were rated by the workers themselves: they might falsely perceive greater improvement in clients whose values are (or are becoming) more like their own. But despite its limitations, the congruence between the British findings and the limited amount of allied substance misuse research suggests the findings may reflect a real phenomenon.
In particular, findings from the British study resonate with those of a Norwegian study which was one of its inspirations. This found that confluence in values between psychotherapists and their clients was associated with (from the patient’s point of view) a stronger therapeutic relationship. Across psychotherapy including substance misuse therapy, feelings of empathy and being understood are associated with better outcomes. It could be that these feelings are strongest between like-minded therapists and patients.
In Norway, more significant yet were aspects of the therapist’s personality, regardless of whether these matched those of their clients. In the British study too, perhaps workers open to change were also more open to all their clients and better able to adapt to their needs and preferences, and/or were more willing to risk departing from normal or accepted practice to meet those needs. Preparedness to depart from a set treatment protocol has been associated with better substance use outcomes. So too has being responsive enough to the patient to match your approach to their mood, personality and recovery preferences, even if that means departing from state-of-the-art manuals. After being trained in motivational interviewing, in one study addiction counsellors who occasionally violated the approach’s principles had clients who were better engaged and more forthcoming in therapy than more conformist trainees – but only as long as the entire interaction was characterised by socially skilled empathy and caring.
These findings are also reminiscent of a US study of ex-addict methadone counsellors published in 1974, which found that rather than the ‘perfect’ profile of a stable psychologically healthy therapist, “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 importance of the counsellor stretches even to very brief encounters with risky drinkers and drugtakers identified in general medical services or other settings. This finding emerged from one of the deepest and most painstaking analyses ever undertaken of what makes for a successful brief intervention. Set in a Swiss emergency department, it focused on five counsellors with similar qualifications and experience and uniform preparatory training, who nevertheless ended up at one extreme with patients who on average drank nine UK units fewer a week, at the other, 18 units more. What partly accounted for this was how far the counsellor was actually able to deliver the intervention in the intended motivational style – not in minute or tick-box detail, but in a broad-brush and consistent manner.
Central to this style was reflective listening, also found in another study to be a key skill in motivational brief interventions. It may seem straightforward – instruct your counsellors to selectively reflect back the client’s comments – but it is in fact difficult to do consistently, going against the grain of much human interaction and the hierarchical relationship inherent in therapist-client and doctor-patient encounters.
The “Practitioners” columns of our alcohol and drug treatment matrices provide a shortcut to significant seminal and contemporary studies on the influence of the practitioner. In these we sought to redress the relative neglect of getting the right staff to begin with, rather than the more commonly studied training route to effectiveness.
Among the highlighted studies is this seminal US trial from the 1970s. Notable for its large sample and random assignment of patients to counsellors, it also predated the trend to test treatments so highly standardised, and delivered by counsellors so highly selected, trained and supervised, that the impact of counsellor quality (if assessed at all) is minimised. With a set of counsellors who exhibited the wide variation seen in everyday practice, the study was able to find a strong link between the avoidance of post-treatment relapse and ratings by research staff of the empathy, genuineness, respect, and concreteness shown by the counsellors in their responses to counselling scenarios.
In this study patients were contained in an inpatient setting, likely to be why there was no relationship between retention and ratings of the counsellors. Over two decades later a similar study conducted in Finland with outpatients found that the same ratings were indeed related to how long patients stayed in treatment.
Across psychotherapy, similarity of social and intellectual values between therapist and client has been found to promote improvement. If ( above) something like this is also the case in substance misuse treatment, it suggests that effective drug workers are as likely to be ‘naturals’ by virtue of their personalities, values and social skills, as to be created by training or identified by their qualifications. It may be possible for such attributes to be recognised in advance by the reactions of relatively untutored observers to how workers say they would behave in different counselling scenarios.
An argument for focusing on recruiting the right staff also emerged from a a training study featured in the drug matrix. It found that recruiting the ‘right’ therapists who had not been trained in motivational interviewing would have been better than choosing the ‘wrong’ ones who had been trained. Not only did the former start from a higher level, they went on to absorb and retain more of what they had learnt.
But that study was of just a workshop training session, an experience which might impart theory and techniques but would be unlikely to alter attitudes or develop the stance and flexibility needed to conduct effective therapy. Conceivably, more extended training or training supplemented by feedback and expert coaching could develop not just skills in the particular therapy, but also empathy, social skills and other generic attributes of an effective therapist, even among people who seemed less promising trainees. This could be why therapy training has been found to improve client outcomes only when accompanied by ongoing expert coaching.
Running this search takes you straight to all our workforce-related analyses, an under-examined but (as when asked, patients and clients often testify) critical dimension of treatment effectiveness.
Thanks for their comments on this entry to David Skidmore based in England, former probation officer, addiction counsellor and regional manager with the National Treatment Agency for Substance Misuse. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 31 August 2016. First uploaded 01 March 2010
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Said to have “conquered the addiction treatment field”, motivational interviewing was first formally documented in 1983 when William Miller noted that many drinkers resist treatment because they reject stigmatisation as an ‘addict’ or ‘alcoholic’ and the loss of control implied by being a patient. ‘Bill’ Miller developed an approach which explicitly avoided these and other deterrent interactions, instead amplifying aspects of the client’s ambivalence towards their substance use to nudge them in a seemingly non-directive (but actually directive) manner towards finding their own reasons to cut back.
A key shift was from seeing motivation to change substance use as a fixed characteristic, to seeing it as an interpersonal process that could be affected through therapy. Anyone taking this reformulation seriously could no longer dismiss the addict as unwilling to change; the onus shifted to the counsellor’s ability to elicit motivation by highlighting discrepancies between the client’s substance use and their valued goals and beliefs.
An initial randomised trial from Bill Miller’s team published in 1993 ended by seeming to vindicate the approach for problem drinkers, but the findings were disappointing. Clients allocated to the empathic motivational interviewing style did further curb their drinking compared to those allocated to an explicitly directive, confrontational approach, but effects were small and failed to reach conventional levels of statistical significance.
What rescued the approach was when (with the aid of audiotapes of counselling sessions) the researchers focused on how counsellors actually behaved rather than how they were meant to. The more the counsellor had confronted (arguing, showing disbelief, being negative about the client), the more the client drank a year later. Drinking was also elevated to the degree that the client had exhibited ‘resistant’ 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, but (see our commentary) the way they were generated meant they lacked the reassurance of a playing field levelled by randomisation.
Bill Miller’s 1993 study exemplified a key strength of the approach for practice – and a major headache for researchers who need to pin down whether what they are evaluating really is motivational interviewing. A counselling style rather than a counselling programme, motivational interviewing’s originators did codify broad principles, and some associated techniques (like decisional balance – pros versus cons – exercises) became commonly applied, but it remains a fluid approach heavily dependent on the skill of the counsellor and adaptable to many different situations. No attempt was made to license it as a defined product controlled by its owners. For researchers and reviewers, this posed the difficulty of deciding whether in any particular study the adaptations went so far that the counselling no longer embodied the (as it came to be called) ‘spirit’ of motivational interviewing, or whether counsellors had actually been unable to sustain what to many is an unnatural stance.
Handing staff an expert manual and ensuring they follow it undermines the approach
That leads to another key characteristic of motivational interviewing: that it is best learnt by being coached over time via expert feedback and guidance, much as a sports coach might review with the players a video of the last game, reinforcing the good points, pointing out where they fell short, getting them to practise how they could have done it better, then checking a later video to see if the tips had been absorbed. Quick fixes are at best suboptimal and for patients may be useless. Handing staff an expert manual and ensuring they follow it undermines the approach ( below), and the typical one-off workshop needs to be supplemented by performance feedback and expert coaching before substance use patients feel the benefit, a finding supported by a synthesis of research on the impact of motivational interviewing training on clinicians’ behaviour.
Not predicated on a motivated, treatment-seeking client, and defined broadly in terms of spirit and principles, motivational interviewing’s great advantage is its wide applicability. Targets range from risky but as yet non-problematic drinkers or drugtakers identified by screening programmes, to established addicts who recognise they need help, but welcome being afforded the dignity of self-definition and self-control. It is, however, important to separate out these applications. The motivational state of people who decide they have a drinking problem and seek treatment is likely to be very different from that of people intercepted while (for example) visiting their GPs for something else entirely.
Appropriate comparators also differ. For people seeking intervention, the key issue is whether motivational interventions are preferable to other treatments. When all relevant studies are amalgamated, the answer seems to be, not much, but they do usually take less time. A similar message emerged from the most definitive trials in the USA and in Britain, which also generally failed to find the expected ‘matches’ between different types of patients and different types of therapies, including therapies based on motivational interviewing.
For people identified through screening, the main issue is whether having a motivational intervention ‘seek them’ is better than nothing. Across relevant studies, usually it is better, but that depends to a surprising degree on who is doing the motivating, a finding which emerged from studies as different as one in London involving cannabis-using students, and one in Switzerland involving heavy-drinking emergency patients. In both cases, how far counsellors embodied the spirit of motivational interviewing in their comments and tone, and in particular the skill of ‘reflective listening’, were among the factors which made a difference.
Also assessed by reviewers is whether brief alcohol interventions based on motivational interviewing reduce drinking more than other approaches. The first problem for the review was the relative paucity of studies in which motivational interviewing was not a basis for the intervention – 12 out of 52, a sign of how far the approach has pervaded research. Key finding was that whether motivational interviewing was the basis made no statistically significant difference to an intervention’s impact on drinking. In fact, when it came to quantities consumed, non-motivational brief advice had a slight edge. For frequency of drinking, the position was reversed, motivational interventions having a slightly greater impact. Overall, there was little support for motivational interviewing comprising an important active ingredient of brief interventions, in the absence of which their impacts are significantly weakened.
The review’s findings are in line with those from the English SIPS brief intervention studies conducted in GPs’ surgeries, emergency departments and probation offices. In all three settings, relatively unsophisticated and brief advice was no less effective than longer interventions which drew on motivational interviewing.
Motivational interviewing was built on Carl Rogers’ classic formulation of the six “necessary and sufficient conditions” for psychotherapy clients to get better, including communicating genuineness, unconditional positive regard, and empathic understanding of clients in need of help to get their actions, thoughts and self-perceptions in line. What Bill Miller added to this foundation was directive strategies and techniques geared to moving the client in the desired direction, including: sharpening their perception that how they actually behave is not how they wish to; generating client statements indicative of a desire, intention and ability to move in this direction; and securing a commitment to do so – the last two categories constituting ‘change talk’, for motivational interviewing, the crucial precursor of actual change. During this process, resistance to change is also expected to wilt as it finds no grist in the form of confrontation or other therapist behaviours incompatible with motivational interviewing, and as the client finds reasons not to resist.
Motivational interviewing’s record was explored in our reviews of the approach as a preparation for addiction treatment and of findings on matching counselling styles to the client. We discovered it has worked best when therapists have not been tightly constrained to work to a manual, findings later confirmed by a synthesis of outcomes from relevant research. Unexpectedly, we also found that motivational interviewing can actually be counterproductive among patients who welcome explicit direction or who are already committed to a way out of their substance use problems.
The implication is that sometimes it really is best just to tell patients what they should do or otherwise break motivational interviewing’s ‘rules’ rather than inflexibly following the manual. One explanation is that the quality of seeming genuine, long recognised as one of the keys to effective therapy, can suffer from drilling in techniques and in withholding normal caring responses in order to adhere 100% to motivational principles. In certain circumstances, avoiding explicitly directive advice and warnings can seem as uncaring and unnatural as suggesting to a pedestrian heading blindly towards a pit that they consider the pros and cons of stepping forward, but in the end it is up to them; the natural and caring response is to shout, ‘Stop!’
In 2016 a systematic review investigated whether motivational interviewing’s proposed mechanisms had been supported by research, breaking this down into the influence of the Rogerian qualities of empathy and embodying the spirit of motivational interviewing, versus using the approach’s more interventionist or directive techniques like selectively reflecting back the client’s comments, open questions, offering affirmations and support, and emphasising client control. Of the 37 studies found for the review, 29 were of drinking or drug use. In some the approach had been the basis for a brief intervention for risky substance users identified through screening, in others, a component of treatment for problem/dependent users.
The review found that using motivational interviewing techniques was fairly consistently related to the generation of change talk, and change talk was fairly consistently related to actual change – the expected causal chain. But using these techniques more often did not consistently have the desired results, such as greater reductions in substance use. Unlike motivational techniques, greater levels either of empathy or of embodying the spirit of motivational interviewing did not consistently generate change talk. But like the techniques, the relationship to outcomes was inconsistent, though stronger when both qualities were enhanced rather than one or the other.
Overall, the studies included in the review seemed to suggest that talk about change can be elicited by motivational techniques, among which selectively reflecting back the client’s comments is the most consistently effective, but that increasing use of these techniques or greater adherence to the spirit of the approach are often unrelated to final outcomes.
Key ‘mechanism’ studies
Such reviews are, however, no substitute for definitive studies, and for motivational interviewing, the most definitive was a rare randomised trial of its distinct and supposedly active ingredients. Though a small study and partially contradicted by a predecessor, the findings cast doubt on whether motivational interviewing’s distinct mechanisms really are active ingredients, turning the spotlight (at least among treatment-seeking, stable, and not very dependent drinkers) on the patient’s own impetus to change. It also seemed that change talk did not cause change, but was a sign of the impetus to change, a sign elicited by motivational techniques.
Recruiting mainly via ads, the trial had netted 89 generally stable, moderately dependent drinkers, who were aiming to cut down on their drinking rather than stop altogether. At random they were allocated either to fully-fledged motivational interviewing combining its Rogerian spirit with directive techniques, to just the non-directive or Rogerian elements, or to a self-change option in which participants were told to try to change on their own over the next eight weeks, after which they would be offered treatment. Self-change participants were told some people could cut down without professional support, and that monitoring their drinking and being interviewed for research purposes might help.
Generally, the directive elements made no further difference to the drinking reductions achieved by the patients, and neither version of motivational interviewing led to significantly greater reductions in drinking than the self-change option. However, fully-fledged motivational interviewing may have accelerated those reductions. Confusingly, a previous similar study had found the directive elements augmented the intervention’s impact on frequent heavy drinking. The supplementary text in our commentary explored possible reasons for the discrepancy.
For non-treatment seekers identified through screening and offered a brief alcohol intervention, the definitive studies are a series (highlighted in cell B1 of the Alcohol Treatment Matrix) which capitalised on the fact that at age 20 Swiss men are assessed for fitness to be conscripted into the army. One of the studies set out to reveal the impact of the counsellors rather than the intervention by recruiting 18 who differed widely in professional status, clinical experience, and experience of motivational interviewing. Left to their own widely differing devices, best results came from the more experienced counsellors, those who were more confident of their motivational interviewing abilities and of the efficacy of the approach, and/or who were rated as especially proficient. On average, it could not be shown that counsellors and sessions outside these upper ranges were any better at reducing risky drinking than no counselling at all.
Saying lots of the ‘right’ things matters little, but just one ‘wrong’ comment can be destructive
That much was perhaps not unexpected, but it was the details in this study which were thought-provoking. Experience was important, but only because it was associated with better motivational interviewing skills, an amalgam of demonstrating acceptance of and empathy with the client and embodying the collaborative spirit of the approach. So-called ‘complex reflections’ – the times when the counsellor reflected back the client’s feelings or comments, but with a spin which extended or deepened their meaning – seemed particularly important. When these formed a relatively small portion of all the reflections whether simple or complex, the brief intervention made no difference to drinking; when a larger portion, drinking was reduced.
In surprising contrast, simply accreting more of the other responses considered compatible with motivational interviewing actually seemed counterproductive. It seemed that frequent interjections by the counsellor which conveyed support, affirmation, straightforwardly reflected back the client’s comments, and so on, were fine, but when these became very, very frequent, something was happening to make the session ineffective.
The other side of the equation was counsellor comments incompatible with motivational interviewing. These were very uncommon – usually one or none per session – but when they happened, that session was no more effective at moderating drinking than no counselling at all.
In cell B1 of the Alcohol Treatment Matrix, these and other findings led us to ask, “Is it what you don’t do that matters?” Generalising across the studies listed in the cell, it seemed that that saying lots of the ‘right’ things in a brief motivational intervention matters little, while just one lapse to the ‘wrong’ sort of comment can be destructive.
Our commentary on another Swiss study which corroborated some of these findings explored the implications of these and other studies of how motivational interviewing works. One implication was confirmed by a US training study: that recruiting clinicians who have not been trained in motivational interviewing, but take to it naturally, will net you more competent therapists than trying to turn round less promising recruits through training. Not only were the promising recruits better to begin with, they also gained most from the training.
Choose your search
Taking to heart the distinction made above between applying motivational interviewing to treatment seekers versus non-seekers, we offer different search strategies for finding more information in the Effectiveness Bank. To narrow in on treatment-seekers run this search; for non-treatment seekers identified through screening, run this search. For both, run this omnibus search.
Last revised 30 August 2016. First uploaded 01 November 2010
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Though the term has a long history associated especially with 12-step-based approaches, the modern ‘recovery’ era in Britain can be dated to its forefronting by governments in Scotland and England in May 2008, presented as a new dawn ( Scottish strategy cover) which would reinvigorate treatment services stuck in the rut of preventing harm and crime rather than redeeming and regenerating lives. With reference especially to England and the UK government, this hot topic reminds us of the roots of the recovery era in the desire to contain public spending, queries interpretations which demand more of former problem substance users than many less disadvantaged citizens manage to achieve, and asks what in theory and in practice this all means for treatment services. The underlying theme is that in an “age of austerity”, the ambitious rhetoric was not matched by the “intensive support over long periods of time needed to become drug free” and – notwithstanding genuine advocacy in the interests of a better future for patients – instead at a political level helped legitimise the withdrawal of support as long-term treatment became stigmatised as impeding recovery.
The discovery of recovery
Recovery is at the heart of the treatment themes in Britain’s national drug policies, featuring in the titles of both the English and the Scottish strategies (The Road to Recovery), while the Welsh strategy committed the nation to “focus our efforts on helping substance misusers to improve their health and maintain their recovery”.
What these strategies meant by ‘recovery’ was not spelt out, but the broad themes were clear: some of the most marginal, damaged and unconventional of people were to become variously abstinent from illegal drugs and/or free of dependence and (as Scotland’s strategy put it) “active and contributing member[s] of society”. In his foreword to the Scottish strategy, minister for community safety Fergus Ewing first equated recovery with the “desire of people who use drugs to become drug free” before explaining that The Road to Recovery was meant to lead toward “sustainable economic growth ... Reducing problem drug use will get more people back to work; revitalise some of our most deprived communities; and allow significant public investment to be redirected.”
Scotland’s ambition echoed those of the government in England dating back to the mid-2000s for more drug users to leave treatment, come off benefits, and get back to work – and become an economic asset rather than a drain.
At first under Gordon Brown’s Labour government, for England this ambition verged on the brutal, the UK drug strategy released in February 2008 seeming to threaten drug users on benefits with penury if they failed to “move successfully through treatment and into employment”. The backdrop was the credit-crunch crisis dating from August 2007 which in April 2009 was followed by a promise by Conservative Party leader and later prime minister David Cameron to usher in an “age of austerity” to cut the budget deficit.
Though transition out of treatment and into employment was close to what later became ‘recovery’, of the six times that word was mentioned in the 2008 strategy, all but one referred to recovering financial assets from drug dealers, not recovery from addiction. South of the Scottish border, ‘recovery’ had yet to be discovered, but already preparations must have been underway to make it the dominant theme in the Scottish strategy released in May 2008. That month too, in England the initial stress on reintegration through employment enforced by withdrawal of benefits had in senior government circles morphed in to a more appealing label: “recovery”.
In this Labour was not just catching up with Scotland but also with the Conservative opposition. In July 2007 David Cameron’s “New Conservatives” had released the fruits of their addictions policy think-tank. In contrast to Labour’s strategy, “recovery” was the banner for its overarching philosophy. “Towards Recovery” was the heading of the section on policy reform, and for treatment in particular, “The ultimate goal ... should be recovery and rehabilitation through abstinence,” requiring a “radical reform” away from substituting legal for illegal drugs and “facing the fact that abstinence is the most effective method”. Not much survived of what would have been the expensive shift to residential rehabilitation services and the structural reforms the report saw as needed to pursue recovery, but recovery itself and the associated abstinence objective and denigration of maintenance prescribing became embedded in Conservative thinking, and with the advent of David Cameron’s government in 2010, in national policy.
But the strands later to be woven into recovery had been gathering several years earlier, prompted by the felt need from the mid-2000s to make economies in addiction treatment services and to contain public spending,
In an “age of austerity”, the ambitious rhetoric was not matched by intensive support
especially the welfare benefits on which these services’ patients overwhelmingly relied. Though total funding was increasing, in England since at least 2002 per patient funding had been falling (1 2) when in 2005 an “effectiveness” strategy developed by the National Treatment Agency for Substance Misuse complained of the “lack of emphasis on progression through the treatment system” leading to “insufficient attention ... to planning for exit”. Foreseeing a time when funding would be less available, the agency’s board was told that “Moving people through and out of treatment” will create space for new entrants “without having continually to expand capacity”.
Opposing the previous stress on retention – the yardstick on which services were then being judged – this new emphasis on treatment exit was given an unwelcome boost when in 2007 the crime-reduction justification for investing in treatment was challenged by the BBC on the grounds that treatment should be about getting people off drugs. There was no gainsaying the seemingly incriminating fact that in England in 2006/07 just 3% of patients were recorded as having completed treatment for drug problems and left drug-free. It was the shock of that challenge and the economising turn away from retention to treatment exit which fed through to Labour’s 2008 national drug policy. Announcement of a three-year standstill in central treatment funding until 2011 – a real-terms cut at a time when the caseload was expected to rise further – focused attention on squaring the circle by getting more patients to leave as well as enter treatment.
By then firmly linked to the term ‘recovery’, in 2014 the emphasis on treatment exit remained in government circles, eliciting a robust defence from the Advisory Council on the Misuse of Drugs of long-term opioid substitution therapy for heroin users. The following year the Conservative Party’s election manifesto made it clear that the council’s message had been rejected, continuing in the name of “full recovery” to condemn “routine maintenance of people’s addictions with substitute drugs”.
We all want ‘recovery’ – but what is it?
Do experts and the people on the ground envisage recovery in the same way? Not all, and the definition of recovery has been so contested and so crucial that special commissions have been set up to try to reach a consensus. Most influentially for the UK, in 2008 the non-governmental UK Drug Policy Commission brought 16 experts together to thrash it out. They couldn’t agree what being recovered was, but did agree that getting recovered is “characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.” Their brief report expanded on each element of the definition, explaining that that by “control” they meant “comfortable and sustained freedom from compulsion to use” – the traditional treatment goal of sustainably ending addictive patterns of substance use. But that was, they said, not enough: recovery is not just about ending pathology, but about gaining “positive benefits ... a satisfying and meaningful life”.
Of as much importance was what was not in their definition. Abstinence was missing, and so too was leaving treatment, a rejection of government ambitions to move patients through and out of treatment as a step to getting (back) into work. The commission’s 16 accepted the work objective, but in a softer formulation which allowed for other routes to a meaningful and productive life.
About gaining “positive benefits ... a satisfying and meaningful life”
Though there was a passing nod to the social determinants of getting into and out of trouble with substance use, it has been seen as not enough to rescue their report from placing the responsibility for and control over their recovery at the door of the individual substance user – and, by extension, the responsibility (or blame) for non-recovery. In contrast, the recovery capital concept ( below) directs attention to the supports made accessible by the wider society. Rather differently too, in Scotland a government-commissioned working group placed the social and cultural environment at the heart of its recommendations about reorienting alcohol treatment to recovery. For these experts, “A shift from an individual and substance based understanding to one that has its base in social networks” meant that “families, peer groups or other significant social networks should be an important part of any planned intervention.” Extending further still from the individual patient, services would need to “Develop ‘whole population’ approaches that create environments which discourage alcohol and drug misuse and encourage positive health behaviour change.”
No one has more authority than US recovery guru William White to say what it entails. In 2008 his definitive monograph said adopting recovery as an objective meant a shift in treatment from isolated bouts of professional care forced by a problem which has become intolerably severe or attracted attention, to on the one hand, intervening before things have descended to this point, and on the other, locating treatment as often merely the first step to extended “recovery maintenance”. In this vision, the focus shifts to systems around the clinic within which the patient must eventually reshape their life in community with others who have done or are trying to do the same, secured by ties to family, community, and work. Arguably, it is this aspect of the recovery vision which most productively redirects our attention. At the same however, it also redirects the challenge from changing what to a degree can be controlled by treatment services – the intra-clinic environment – to an external environment more intractably unfriendly to their patients.
When in order to measure recovery Dr White had to pin down what it was, he saw it as “an enduring lifestyle marked by: 1) the resolution of alcohol and other drug problems, 2) the progressive achievement of global (physical, emotional, relational) health, and 3) citizenship (life meaning and purpose, self-development, social stability, social contribution, elimination of threats to public safety).” But writing six years later he reflected the fact that defining ‘recovery’ remained a contested work in progress, in which for individuals who may be included or excluded from its ambit, “The personal stakes are high”.
Counsels of perfection or of necessity?
Though expressed as a process of ‘moving towards’, the implication that recovering from addiction entails developing lives more fulfilling than many who never had these problems was well represented by a definition from the US agency for substance ‘abuse’ and mental health. It saw recovery as “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” In there were: “Making informed, healthy choices that support physical and emotional wellbeing”; “A stable and safe place to live”; “Meaningful daily activities ... and the independence, income and resources to participate in society”; and “Relationships and social networks that provide support, friendship, love, and hope”. Explaining its vision, the agency said, “Recovery encompasses an individual’s whole life, including mind, body, spirit, and community”.
Former problem substance users surveyed in the USA, nearly all of whom were now abstaining from drink and/or drugs after treatment, also saw recovery as entailing desirable qualities beyond not being dependent, including: making a contribution to society; ability to experience inner peace; growth and development; being someone people can count on; gaining inner strength; and taking responsibility for the things you can change (1 2). Deleted by the researchers as “extraneous” or counsels of “perfection”, nevertheless the respondents also overwhelmingly endorsed items such as, “Living in a way that is consistent with what I feel and think”, “Appreciating the positive things in my life”, and “Making sense of where I’ve been and who I am today”.
Though a critic who wants to open up recovery to non-abstainers and who sees “perfection” and “giving back” to the community as requiring too much, still Maia Szalavitz includes being “socially and occupationally healthy in a stable way” and “functional work and social relationships” in her definition of recovery.
Rejected were the “superhuman” requirements demanded by prevailing formulations
If collectively these definitions sound like having to become more worthy and better balanced than many who have never got deeply into trouble with substance use, that’s also how it seemed to a sample of problem drug and alcohol users in and out of treatment in England – representatives of the people who it is hoped will achieve recovery. When in 2014 they were asked what recovery consisted of, none of the drug-focused criteria identified by senior treatment staff gained widespread endorsement. Instead, participants “repeatedly argued that recovery meant ‘being normal’ and ‘living life like everyone else’.” The route to ‘normality’ entailed neither being like each other nor like other people, but was an individual itinerary, and would be diverted, limited and shaped by the usual human frailties and faults. Rejected were the “superhuman” requirements which seemed demanded by prevailing formulations.
In a substance-using society, abstinence from psychoactive substances might be seen as just such a requirement. Though insisting on abstinence as a prerequisite for other people’s recovery is in Britain commonly rejected, that should not blind us to the fact that for many problem drug users and drinkers, abstinence is the prime component of their own visions of recovery. But at the same time, they may embrace seemingly contradictory components like safer or reduced drug use.
Imbued with conventional ideas about what constitutes a good and worthwhile life, current conceptualisations of recovery were criticised by Kari Lancaster, an Australian drugs researcher, as based on “neoliberal assumptions about work, productivity and what it means to live a ‘contributing life’ which fail to take into account the differences in the normative and social contexts of people’s lives.” In other words, there are more ways of being worthwhile than are envisioned by middle-England (or middle-Australia) perspectives. Another concern was that these definitions imply that “people who use drugs who are not ‘in recovery’ always already exist somehow outside of community and cannot live meaningful and fulfilled lives.” The first limitation will exclude many from the dignity of recovery, the second, from the dignity of meaningful and fulfilled lives – exemplifying William White’s reminder that in defining recovery, the personal stakes are high.
Some perspective can be gained on these issues by shifting ground from dependence on illegal drugs, or ‘alcoholism’ of the kind treated at specialist services, to dependent smoking. Would we say someone who has sustainably stopped smoking or who smokes only once in a while, but hasn’t found a job, is still on benefits, maybe even offending, and who remains at a loss for meaning in life, has failed to recover from their addiction? Imperfect they may be, but only in ways they share with many people who have never been addicted, and perhaps too in ways not entirely under their control, like employment, housing and family relationships.
But for socially unacceptable addictions to illegal drugs and drinking of the kind that drives one to seek professional help, perhaps there are good reasons why these wider issues intrude. By the time you have narrowed down to the minority who try drugs like heroin and cocaine, the very few who become regular users, those of the former who become clinically dependent, and then the subset of those who want to stop but can’t without treatment, then you have selected a highly atypical and usually multiply and deeply troubled population – the caseload of drug addiction treatment services. Dependent drinkers of the kind seen at specialist services are also disproportionately the most severely affected. Multiply comorbid, over typically long histories these more intractable ‘addicts’ have grooved into a dependence from which they have few levers left to extricate themselves – and perhaps few reasons to do so, having already lost jobs, families, homes, self-respect and the respect of others.
Having defined the desired ‘recovery’ outcome as far as we can, now we can work backwards to what that means for treatment. Logic dictates it should determine how to assess success and the inputs needed to achieve it. Whether counsels of perfection or counsels of necessity, prevailing conceptualisations imply that treatment services will need to gear up with integrated access to vocational experts, family re-unification inputs, artistic and creative opportunities, and whatever else for their patients is needed to move towards a meaningful and productive life which leads them to welcome, and be welcomed by, mainstream society.
Potentially that transforms addiction treatment into an endeavour of daunting proportions, involving not just the overcoming of substance use problems, but the bolstering of the patient’s ‘recovery capital’, seen in the UK and in the USA as a key task for recovery-oriented treatment systems.
‘Recovery capital’ refers to the “breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from [alcohol and other drug] problems”. According to the social scientists who coined the term, these include: being able to rely on the support of acquaintances and friends; financial stability and capital; the knowledge, skills, qualifications, health, mental health, and other traits essential for optimal negotiation of daily life; and the ability to divorce oneself from subcultural norms which promote substance use and instead embrace “the prosocial norms of the dominant culture”. Set against these on the negative side of the equation are physical and mental ill-health and the impact of being imprisoned. It is immediately apparent that positive capital is often in very short supply among the multiply damaged and disadvantaged caseloads of public sector treatment services, while negative capital is common.
The concept’s originators warned that it had “Major implications for treatment providers and policymakers.” Aware of these implications, some argue that inputs related to non-drug focused elements like wellbeing and social reintegration are not essential components of the treatment of addiction, but the business of other welfare, employment and health services. The UK group which defined recovery did not let treatment off so lightly. Their definition was, they said, about “the goals of treatment and rehabilitation ... that could be applied to all individuals tackling problems with substance misuse, and all services helping them.”
Hopes for reconciling limited resources with expanded ambitions were pinned on a change of heart among services (and especially prescribing-based services) to supplement or replace a ‘keep them safe’ mentality with more risktaking, optimism and dynamism, and in the capacity of dependent drug users and ex-users themselves to bootstrap their ways to recovery via mutual aid, along the way challenging the stigma which impedes recovery and leads those in recovery to hide from view.
Recovery’s great utility is its elasticity, allowing it to act as an unarguably desirable objective under which disparate stakeholders can unite, even if in practice they interpret it differently, a role it plays in UK national strategies. But this also means it is too nebulous a concept to be used as a target or yardstick in itself. For these purposes, recovery has to be broken down into components and then into concrete, observable events which signify those components, entailing the risk that what for some stakeholder is its core meaning will be lost in translation.
Arguably that was the case when it came to making recovery objectives concrete enough to be used for the payment-by-results funding of English services. Among the criteria, recovery as envisaged in the national strategies was notably lacking. Employment and whether the patient was active in and contributing to society were put aside in favour of more readily measured and achieved elements, like feeling OK and not offending. It was perhaps a recognition that implementing the transformational vision in the strategies would be a stretch in an era where conventional routes to a normal life through employment and stable housing were shrinking or remained in short supply, and the resources to elevate patients from near the bottom rungs of society to at least near the average were being stripped back.
Individualisation seems another way the criteria are at variance with understandings of recovery. When money hinges on the achievement of objectives, these have to be consistent, concrete and prescriptive about what they expect from treatment services, clashing with the insistence of recovery advocates and patients themselves that recovery is a highly personal journey with no ‘right’ or ‘best’ way. In theory local schemes could create a space for the patient’s ambitions in their payment criteria, but this is not a required element or one included in the national criteria, nor one which sits easily within a system predicated on observable outcomes the public and their representatives recognise and are willing to pay for. Instead schemes pre-set what counts as success without reference to what the individual patient wants, and in a way services cannot afford to ignore.
Achieving recovery partially boils down to terminating care and not rapidly readmitting patients
Practicalities if nothing else mean the schemes often specify in-treatment and treatment exit measures rather than post-treatment recovery indicators, and the post-treatment indicators are confined to routinely collected criminal justice and treatment records which bear a loose relationship to treatment success. Though introduced in the name of recovery, the national framework for the schemes places a premium on drug-free discharges of patients who then are not seen in treatment and other records for at least a year – on the face of it, at odds with the continuing contact presupposed by the recovery vision and by understanding of the chronic nature of treated addiction. The same limitations apply to the national public health objectives for England against which local authorities are held to account, which have also adopted treatment exit and non-return as their sole recovery-related criterion. Via these mechanisms, in practice being seem to achieve recovery objectives partially boils down for treatment services to terminating care and not rapidly readmitting former patients.
A fundamental problem for services is that just as their remit is being extended to encompass recovery and the building of recovery capital, the resources available are being cut, in some areas, dramatically. As explained above, this conjunction is, however, no accident, but flows from the roots of recovery in the imperative (as seen by national UK governments) to save money both on addiction treatment and on welfare and other benefits. What became known as ‘austerity’ both drove the cuts and created the ground on which recovery grew as a positive and appealing way to call for more patients to leave and not re-enter treatment, support themselves and their families, get a job, and contribute to the economy.
Transferred to local authorities facing deep funding cuts, it is not just that addiction treatment services themselves are feeling the pinch, but also that the wider supports needed to pursue a recovery agenda are weakening. Surveyed in 2014, 88% of responding services dealing with people suffering multiple problems including addiction felt “welfare changes had a negative effect on their clients’ overall wellbeing, and 86% on their mental health”. About as many said their clients’ housing prospects had worsened and three-quarters that welfare ‘reforms’ were leading to ill health due to poor nutrition. In the addiction sector, these adverse effects of government policy on welfare and housing would erode the recovery capital seen by the same government as promoting the recovery objective they say should be the treatment mission.
By the former head of the National Treatment Agency for Substance Misuse, in 2014 we were reassured that despite the rhetoric, at national policy level the recovery agenda had not swept away support for approaches which had helped keep drug users alive and prevent drug-related crime. Crime-prevention does remain seen as a key treatment outcome, one which will tend to mitigate interpretations of ‘recovery’ that entail time-limiting treatment and relegating maintenance prescribing to a niche role. On maintaining the record of saving lives, the figures are not reassuring, the UK experiencing a substantial increase in drug-related deaths since 2012.
How far on the ground services have retained their previous focus or re-oriented to recovery – and what those which have reoriented meant by that – is unclear. In respect of drinking, in 2014 Alcohol Concern published the results of its audit of the priority given to alcohol in local plans across England. Almost entirely missing from the alcohol sections of the plans were a focus on recovery and the associated mechanisms of peer support, mutual aid and an asset-based approach. On the drugs side, writing in 2012 the campaigning organisation The Alliance had gained the impression that “in a number of areas across the country providers and commissioners seem to be struggling to interpret ‘the recovery agenda’ as anything other than service rationing, coerced reduction and detoxification and a new reliance on unfunded self-help groups to provide post-detox support.” Whether this impression was due to the situations of the people who contact The Alliance for help or respond to their surveys, or reflects a general picture, is impossible to say, but reports of methadone maintenance being curtailed in the name of recovery are common.
Alex Boyt, a drug service user coordinator in London, is closer to the ground than many commentators and researchers. Prompted by a steep rise in drug-related deaths in England, in 2014 he asked, “Is the recovery agenda killing people?” His answer was, “You have to think in places it probably is.” Reasons were that “People who used to be held by the treatment system are now confronted by goals for integrating into society the moment they make it through the door ... usually with an implied or overt requirement that prescribing is dependent on engaging. When successful completions (often code for getting off your script) became the focus, one of our local service managers said ‘we have to get them in and out before we get to know them’.” If this is the case, it would cast a worrying shadow over the claim in the Conservative Party’s 2015 election manifesto to have “reformed drug treatment so that abstinence and full recovery is the goal, instead of the routine maintenance of people’s addictions with substitute drugs.” One side of that equation – curtailing treatment – may be happening, but perhaps not recompensed by widespread gains in the achievement of “full recovery”.
There are also stories of whole-system reorganisation prompted by the policy turn towards recovery which truly do seem to embody the best of a recovery orientation. An example comes from Scotland where a wholesale redesign of services in East Renfrewshire to orient the system towards recovery was based on client and worker views and evidence on local provision and outcomes. Published in 2013, the plan predated the withdrawal announced early in 2016 of £15.4 million from the central pot for funding drug and alcohol services in Scotland.
Among the issues raised by the recovery agenda are the fundamental one of whether we accept repeated and widespread post-treatment relapse as a sign of the intractability (or as US guidelines have it, the persistence of drug-induced brain dysfunction) of addiction, or a sign that treatment, commissioners and planners have failed truly to embrace the changes needed to reorientate to recovery. If treatment does make these changes, how many fewer patients will we be able to afford to treat, and will that be counterbalanced by greater success in closing the revolving door of treatment re-entry due to relapse? Is it simply beyond the reach of any feasible treatment service, even with partner services, to create environmental changes of the magnitude required to make recovery (as commonly conceptualised) the norm, such as the changes which led to rapid, widespread and lasting remission from heroin dependence among US Vietnam War returnees? Must we set our sights lower, and ameliorate while we seek usually only slightly to accelerate the normal processes of remission (tracked in these studies: 1 2 3 4) – or could that prove a self-fulfilling lack of ambition, too close to the ‘parking’ accusation levelled at methadone services in the name of recovery?
This omnibus search gathers together all the analyses on our site assigned the keyword ‘recovery’ as an objective or outcome of drug or alcohol treatment. Instead run this search to restrict the hits to studies conducted in the UK and/or to UK-originated documents.
Last revised 12 September 2016. First uploaded 01 September 2011
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