Alcohol Treatment Matrix cell C4: Management/supervision; Psychosocial therapies

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Management/supervision; Psychosocial therapies

Seminal and key studies on management and supervision in psychosocial therapies. Focus is on evidence of the need for post-training ‘coaching’ and for letting therapists know how their clients are doing – especially when they are doing badly.

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 No need to insist on abstinence; patients can choose their (non-)drinking goals (1973). Not the first but the most incendiary paper to challenge the then orthodoxy that abstinence must be the only treatment goal for dependent drinkers. See also second- (1976) and third-year (1978) follow-up results. A refutation (1982) based on a 10-year follow-up was itself refuted (1984) by the original authors. Related contemporary UK study, review and guidance below. Discussion in cell C2.

S Key management task: recruiting the right people (1981). US study showed that responses to written counselling scenarios could be used to assess the interpersonal skills of alcohol counsellors, which were strongly linked to their patients’ post-treatment relapse. Study was later replicated/extended in Finland (2002). Related study and review below. For discussion see cell C2.

S Target-setting and feedback to counsellors improves client engagement (1991; alternative source; article starts on page 204 as printed). Client engagement in non-residential counselling and therapy was improved by setting engagement targets plus feedback to counsellors against those targets, while retention was promoted by seeing the same key worker in residential and follow-on non-residential phases of treatment. Related study and guidance below. For discussion click and scroll down to highlighted heading.

K No clear advantage in UK from choosing abstinent versus non-abstinent treatment goals (2010). Britain’s largest alcohol treatment trial (known as UKATT) primarily aimed to compare social network and motivational therapies, but also shed light on whether services should offer moderation as well as abstinence goals to dependent patients. With no clear lasting advantage for either on drink-related measures, ‘Let the patient choose’ seems the implication of the findings. More from UKATT below and in cell A4. Related seminal study above and review and guidance below. Discussion in cell C2.

K Screening applicant therapists for empathy saves on training (2005; free source at time of writing). The research team behind the large US COMBINE alcohol treatment trial (of which more on its medical treatments in cell A3 and psychosocial in cell A4) saved on training by using responses to simulated clients to screen candidate therapists for “accurate empathy”. Same method could help services spot people with the hard-to-teach (2006) ability to form good relationships with clients. Related study above and review below. Discussion of empathy in cell B2 and of staff recruitment in cell C2.

K Gaining competence in cognitive-behavioural therapy requires more than just studying the manual (2005; free source at time of writing). After being told to ‘read the manual’ and practice its guidance on cognitive-behavioural therapy (and doing so for on average nine hours), just 15% of substance use counsellors and clinicians who volunteered for this US study were acceptably competent. Adding web-based training comparing performance in role-plays to the ideal helped, but greater and more consistent gains were made by adding a training seminar subsequently reinforced by expert coaching based on taped sessions with real clients. Counsellors with personal experience of problem substance use (presumed likely to be 12-step adherents and least familiar with formal therapies) benefited most from the addition of coaching. Related motivational interviewing study and reviews (1 2) below. For discussion click and scroll down to highlighted heading.

K Coaching helps counsellors learn to motivate (2004; free source at time of writing; if not already a member you may need first to join Academia; there is a free membership option). How clients responded to trainees during counselling sessions improved only when motivational interviewing workshops had been reinforced by expert coaching and feedback on performance. See also report from the same study suggesting that the important quality of seeming genuine can suffer if training mandates withholding natural responses. Related cognitive-behavioural study above and reviews (1 2 3) below. For discussion click and scroll down to highlighted heading.

K Seven coaching sessions needed before UK therapists competent (2005). The UKATT trial compared social network and motivational therapies for alcohol-dependent patients, in the process developing comprehensive models for recruitment, training and supervision. One lesson was that “supervision after initial training was critical in the acquisition of competence”. Despite often being conducted by phone, it added substantially to training costs. More from UKATT above and in cell A4. Related review below. For discussion click and scroll down to highlighted heading.

K Assess how well clients are doing and tell their counsellors (2012). To maximally improve outcomes feedback to counsellors needs to identify which of their clients are doing poorly and recommend remedial actions. The same feedback system has been found beneficial across psychotherapy (1; 2; 3, free source at time of writing). Related study above and guidance below. For discussion click and scroll down to highlighted heading.

K Leaders set the context for training to be implemented (2012). Whether substance use counsellors initiate and spread training-based practice improvements is strongly influenced by the ethos and support stemming from an organisation’s leadership, especially the degree to which it fosters professional development. Similar findings in review below. For discussion click and scroll down to highlighted heading.

Walk in our shoes

K Take a walk in the client’s shoes (2008). When senior staff role-played the process of becoming a new client it helped halve waiting times and extend retention at substance use counselling and residential services. See also report on an extension (2012) to the programme and an account (2007; free source at time of writing) of the ‘walk-through’ procedure. Discussion in cell C2.

K No lasting benefit from therapist input supplementing computerised programme (2019; free source at time of writing). In Sweden whether therapists supplemented an internet-based treatment programme with personal support via messaging two to three times a week did not significantly alter drinking outcomes six months after the trial started, though there were signs that the support did help while it lasted. Both treatments were superior to merely being placed on the waiting list for the programme.

R Offer moderation as well as abstinence as a treatment goal (2013). Concludes that dependent drinkers can drink more moderately, that psychosocial treatments based on this goal are probably just as effective as abstinence-oriented approaches, and that allowing patients a choice improves outcomes. Related seminal study and UK study above and guidance below. Discussion in cell C2.

R One-off workshop training is not enough (2005). Review spanning basic counselling and more complex psychosocial therapies in the treatment of problem substance use found that retaining skills after workshop training requires follow-up consultation, supervision or feedback. Also, “ Studies which compared trainees’ perceptions with observers’ ratings of their interactions with clients uniformly found trainees overestimated their skills.” Related studies (1 2 3) above and reviews (1 2 3) below. For discussion click and scroll down to highlighted heading.

R Motivational interviewing training works best with post-workshop coaching (2013). Synthesis of findings on training clinicians (broadly defined and not limited to those working with problem substance use) in motivational interviewing finds it does develop competence, especially when supplemented by coaching/supervision based on feeding back trainees’ actual performance. Given motivated trainees, initial training can be via books or videos rather than face-to-face workshops. Related review and studies (1 2) above and reviews (1 2) below. For discussion click and scroll down to highlighted heading.

R Sustaining motivational interviewing skills after training (2014; free source at time of writing). Studies mainly but not only of substance use treatment show that retaining competence in motivational interviewing after training requires follow-up feedback and/or coaching – at least three to four sessions over a six-month period. Just offering these is not enough; trainees have to attend. Related studies (1 2) and reviews (1 2) above and review below. For discussion click and scroll down to highlighted heading.

R The importance of supervision (2011). Systematic and expert continuing supervision emerged as a key to newly introduced psychosocial treatments actually improving practice and outcomes in specialist substance use treatment settings. Implementation was more likely if supported or mandated by agency leaders or supervisors. Despite best efforts, “what was striking was that trainees whose attitudes to treatment were not conducive to adopting a motivational approach benefited relatively little even from the extended training and supervision”. In respect of motivational interviewing, studies were available which showed that the accounts of treatment providers and therapists themselves bore little relation to how well therapists actually conducted new interventions. Related studies (1 2 3 4 5) and reviews (1 2 3) above. For discussions click here and here scroll down to highlighted headings.

R Let motivational counsellors adapt to the client (2005). Effectiveness Bank review and a synthesis of the research (2005) find inflexible manualisation of motivational approaches associated with worse outcomes. For related discussion click and scroll down to highlighted heading.

R Implementation lessons from trials of psychosocial therapies (2007; free source at time of writing). This single review covers many of the issues management faces in trying to implement evidence-based practice. Concludes that research has demonstrated the importance of therapist selection and post-training supervision, and the pitfalls of assuming researched interventions will translate into routine practice and of relying on a therapist’s own assessment of their competence. Ten years later and focusing on cognitive-behavioural approaches, the same lead author effectively updated (2017; free source at time of writing) aspects of the earlier essay. For discussion of this review click here and for a related discussion here, then scroll down to highlighted headings.

G UK guidance on choosing treatment goal ([UK] Department of Health and National Treatment Agency for Substance Misuse, 2006). Guidance on models of care for problem drinkers stressed that whatever their goals it should not exclude them from support or treatment, but saw abstinence as the preferred objective for many moderately or severely dependent drinkers. Related seminal study, contemporary UK study, and review above. Related discussion in cell C2

G Clinical supervision and professional development of substance use counsellors ([US] Substance Abuse and Mental Health Services Administration, 2009). Intended be the focus of a series of six or so meetings in which the contents would be reviewed, discussed, and in other ways used as an educational and training vehicle for the improvement of clinical supervision skills. Related guidance below. For related discussion click and scroll down to highlighted heading.

G Skills and abilities for clinical supervision ([US] Substance Abuse and Mental Health Services Administration, 2012). Competencies needed for effective clinical supervision in substance use disorder treatment. Includes a step-by-step guide to implementing comprehensive supervisory training and workforce development. See also US checklist of competencies (2017; described here) for people with personal experience of substance use problems engaged in supervising people with similar experience who are supporting patients or clients. Related guidance above. For related discussions click here and here and scroll down to highlighted headings.

G How to use client progress measures in counsellor supervision (2014; free source at time of writing). Thoughtful suggestions on how clinical supervision of therapists and counsellors can promote staff development by incorporating discussion of measures of how well their clients are progressing. Not specific to substance use but applicable across therapy and counselling. Related seminal and key studies above.

G Staff selection, training and supervision for group substance use therapy ([US] Substance Abuse and Mental Health Services Administration, 2005). Consensus guidance on the different types of groups, how to organise and lead them, desirable staff attributes, and staff training and supervision. Related guidance below.

G Training and supervising addiction counsellors to deliver group cognitive-behavioural therapy (2013; free source at time of writing). Based on experience in US addiction treatment settings in developing and evaluating group cognitive-behavioural therapy programmes for depression and substance use. Related guidance above.

more Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. See also hot topics on individualising treatment, staffing treatment services, holistic service delivery, matching treatment to the patient, and whether dependent drinkers should always be encouraged or required to try for abstinence.

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