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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. The summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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

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

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

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

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

Main findings

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

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

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

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

The authors' conclusions

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

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

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

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

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

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

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

Last revised 06 April 2013. First uploaded 06 April 2013

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