Alcohol Treatment Matrix cell B4: Practitioners; Psychosocial therapies

2020/21 update funded by

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Previously also funded by

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Practitioners; Psychosocial therapies

Key studies on the impact of the practitioner in psychosocial therapies for alcohol dependence. Structured around Carl Rogers’ classic account of the prerequisites of effective psychotherapy.


S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

S Fundamentals of effective therapy: genuineness, positive regard and empathy (1957; free source at time of writing). In psychosocial counselling and therapy, no paper has had more influence than Carl Rogers’ formulation of the “necessary and sufficient conditions” for clients to get better, the foundation of arguably all effective substance use counselling. See also commentaries (1 2) on his work. Direct test of his theory listed below. For discussions click here and here and scroll down to highlighted headings.

S Counsellors’ relationship style affects patients’ relapse rate (1981). US study found a strong link between higher levels of empathy, genuineness, respect, and concreteness exhibited by alcohol clinic counsellors and a reduced risk of their patients relapsing after treatment. For discussion click and scroll down to highlighted heading.

S Empathy makes the difference (1980). Big differences in therapy content and duration did not affect the progress of US heavy drinkers. What seemed to for at least two years (1983) after treatment was the degree to which their therapists displayed “accurate empathy”. See also this assessment of the impact of empathy in psychotherapy generally (2018). For discussion click and scroll down to highlighted heading.

K Therapist effects emerge even when subdued by stringent controls (1999). Despite exhaustive selection, training and supervision, some therapists in the landmark US Project MATCH alcohol treatment trial had on average worse outcomes (1998) than their peers, and there was enough variation (1997) in the therapeutic relationship for this to influence engagement and later drinking. Session recordings exposed reasons for variation, including the match between the therapist’s directiveness (2009) and whether the client reacts against direction, subject of a review below. Project MATCH was the “Highlighted study” in cell A2. Sub-study from the same trial below.

K Reinforcing talk about changing drinking really does seem to promote change (2009). Micro-analysis of tapes of motivational interviewing sessions from the US Project MATCH alcohol treatment trial led to the appealingly simple and plausible conclusions that “What therapists reflect back, they will hear more of”, and that promoting talk about change promotes change itself. However, the study was not designed to establish causality. Other results from the same trial above.

K Combine authenticity with social skills in motivational interviewing (2005). US study suggests that the quality of seeming ‘genuine’ can suffer if training mandates withholding natural responses, but also that departing from these mandates is risky unless done by a socially skilled therapist. See also an essay (2013) from Drug and Alcohol Findings based on this and other studies, arguing that ‘by the book’ is not always best way to do therapy. For discussion click and scroll down to highlighted heading.

K Adding strategies targeting change did not improve on non-directive listening (2012). Supplementing ‘Rogerian’ (paper on his theory listed above) non-directive listening with motivational interviewing techniques directed at reducing drinking did not further help (if anything, the reverse) US heavy drinkers cut back, contradicting a similar earlier study (2001). For discussion click and scroll down to highlighted heading and also see “Are these always the important things to do?” in cell A4.

K Can therapists be too accommodating? (2009). Rarely has counselling been so deeply analysed as in this US study involving mainly alcohol- and cocaine-dependent patients. Expected finding was that some counsellors generate good working relationships with clients which feed through to better outcomes; less expected was that the very ‘best’ relationship builders were not on average the most effective. For related discussion see “Isn’t it just a matter of being nice?” in cell B2.

K Largest UK alcohol treatment trial finds client–therapist relationship related to post-therapy drinking (2015). Offshoot of the UKATT study (main results highlighted in cell A4) comparing therapy based on motivational interviewing with one focused on reconstructing social networks. Primary issue for this sub-study was whether a better client–therapist working relationship was associated with a greater subsequent chance of remission. Overall it was, but significantly only when the relationship was assessed by client rather than therapist – and when the treatments were considered separately, only for motivational rather than network therapy. For discussion click and scroll down to passage highlighted below.

R Common core of effective therapy: therapeutic relationships (American Psychological Association, 2018). Includes, but not specific to, substance use. Introduces, cites and synthesises finding from 16 reviews (also analysed for the Effectiveness Bank) of the psychotherapy literature based on the understanding that therapeutic change is generated not only by technical interventions, but by the ways therapists relate to clients, like forming a therapeutic alliance (related review below), being empathic (related study above), and appropriately adjusting to the individual (related review below). Still valuable is an earlier version (2011) of this article which integrated findings on how to adapt therapy to the individual client (work listed below) and on counterproductive behaviours like being confrontational. See also a broader practice-oriented interpretation (2014) of the research from same lead author which draw on these reviews.

R Therapists who form good therapeutic relationships have better outcomes (American Psychological Association, 2018). One of the (see above) US American Psychological Association task force reviews. Supports the argument that “a good working relationship is an important determinant of treatment success, and that nurturing, maintaining, and as needed, re-establishing such a relationship, are core tasks not just in psychosocial therapies, but in treatment generally”. Earlier an advanced synthesis of research findings (2012; free source at time of writing) from some of the same authors had confirmed that some therapists consistently develop stronger relationships and have better outcomes.

R Adapt to the client (American Psychological Association, 2011). Includes but is not specific to substance use. US American Psychological Association task force whose overall report is listed above judged that adapting psychotherapy to the client’s reactance/resistance, preferences, culture, and religion/spirituality demonstrably improves effectiveness. Related review below.

R Some clients like to lead, others to be led (2006). How directive the therapist is during treatment is one of the strongest and most consistent influences on outcomes. There is no ‘right’ degree of directiveness; it all depends on how the client reacts. Related review above.

G Addiction counselling competencies ([US] Substance Abuse and Mental Health Services Administration, 2008). Includes competencies associated with positive outcomes and the knowledge, skills, and attitudes all substance use counsellors should have. First step is to “Establish a helping relationship with the client characterized by warmth, respect, genuineness, concreteness, and empathy.”

G What makes a good group therapist? ([US] Substance Abuse and Mental Health Services Administration, 2005). US consensus guidance on the different types of groups, how to organise and lead them, desirable staff attributes, and staff training and supervision.

G What makes a good case manager? ([US] Substance Abuse and Mental Health Services Administration, 1998). US consensus guidance including the staff skills, knowledge and attitudes needed to fulfil the case management role orchestrating the range of services which may be needed to promote lasting recovery and broader life improvements.

more Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. Also see hot topics on treatment staff and matching alcohol treatments to the patient.

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