At the front line the practitioner is to the patient the face of treatment. They can matter enormously – not so much in their formal credentials, but their manner with patients. Tour seminal and key studies which probe the heart of addiction treatment: relationships. See the remaining four cells in row 2 of the matrix for more on generic features of medical and psychosocial therapies.
S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text
S ‘Intractable alcoholics’ transformed into normal patients (1970). Remarkable series of studies from the late 1950s saw US ‘skid row alcoholics’ elevated from virtually never engaging with alcohol treatment after emergency care to engagement patterns more typical of psychiatric patients. The strategy was not to try to directly change the patients, but to radically change how they were treated by staff, replacing hostility with warmth and respect. More on these studies in cell B3 (seminal study “It’s the way you say it”) and towards the end of a slide presentation on the matrices.
S Some counsellors inspire retention, others rapid drop-out (1976). Trainee alcohol counsellors at a US alcohol treatment clinic varied widely in their records of retaining patients; professional and personal experience of alcoholism did not account for the variation. For related discussion and scroll down to highlighted heading.
S Therapy-related social skills of counsellors strongly related to post-treatment relapse (1981). US study at an inpatient alcohol unit found strong links between how many of their patients later relapsed and the empathy, genuineness, respect and ‘concreteness’ exhibited by their counsellors in response to brief written cameos of typical patient/family scenarios chart. Related study below. For discussions click and here and scroll down to highlighted headings.
K Rapport-generating counsellors improve retention (2002). Replication at a Finnish outpatient alcohol clinic of US study listed above found that greater initial counsellor and client rapport was followed by more patients completing treatment, and that responses to the US cameos predicted which counsellors would on these measures be most effective. For discussion and scroll down to highlighted heading.
K Can therapists be too accommodating? (2009). Rarely has counselling been so deeply analysed as in this US study which found that some counsellors generate relationships with clients which feed through to better outcomes – but also that the ‘best’ relationship builders are not on average the most effective. For discussion and scroll down to highlighted heading.
R Some therapists are just better than others (2012; free source at time of writing). Ingenious analysis finds that across behavioural and mental health problems, the therapist’s contribution to the creation of a strong client–therapist alliance and resultant improvement in outcomes exceeds that of the patient, suggesting that “some therapists develop stronger alliances with their patients (irrespective of diagnosis) and that these therapists’ patients do better at the conclusion of therapy”.
R Select and evaluate clinicians based on their ‘track records’ (2000; free source at time of writing). After exploring the evidence for just about every way you could think of to identify the most effective substance use clinicians, concludes that “assumptions that levels of training, experience, or other simple therapist variables” would act as quality markers are mistaken, and that there is no substitute for monitoring actual performance. Related review below. For discussion and scroll down to highlighted heading.
R Clinician effects more important than specific treatments (2014; free source at time of writing). In substance use treatment, “one of the best indicators of clients’ retention and outcome is the particular counselor to whom they happen to be assigned,” was this essay’s assessment of the evidence. Among the reasons were the clinician’s expectations of good outcomes, allegiance to the treatment approach, and interpersonal skills (including empathy; related review below). Related review above. For discussion and scroll down to highlighted heading.
R Complexity demands socially skilled and flexible clinicians (2016). Essay from Drug and Alcohol Findings emphasises that the complexity of the interacting patient characteristics clinicians have to respond to means there are no reliably effective, standardised ways of responding to any particular characteristic or need. There is no substitute for sensitivity, flexibility and social skills.
R Authoritative, evidence-based assessment of how best to relate to clients (American Psychological Association, 2011). Effective ways to relate to clients (including those with substance use problems) common to different therapeutic traditions, like forming a therapeutic alliance, demonstrating empathy (related review below), and adjusting to the individual. Also what to avoid, like confrontation, negativity about the client, and inflexible adherence to one method. For discussion click and scroll down to highlighted heading.
R Directiveness is a key dimension of therapeutic style (2006). We all know people who bristle when someone else tries to take the lead, others who gladly take a back seat. In substance use treatment too, the interaction of the ‘directiveness’ of the clinician with client preferences has emerged as the most consistently influential interpersonal factor. For discussion click and scroll down to highlighted heading.
R Is low therapist empathy toxic? (2012; free source at the time of writing). That was this review’s title question, answered in the affirmative after amalgamating findings on the relationship between counsellor empathy and substance use outcomes. It also concluded that “empathy may exert a larger effect in addiction treatment than has been generally true in psychotherapy, accounting in some studies for a majority of variance in client outcomes”. For discussion click and scroll down to highlighted heading.
G Official British guidance on how to assess and treat problem drinking (National Institute for Health and Care Excellence, 2011). Recommendations from Britain’s health technology advisers on overall principles and particular interventions. Among the former are that therapeutic staff should aim to build a trusting relationship with clients and work in a supportive, empathic and non-judgmental manner.
G Principles of substance use treatment (2006; free source at time of writing). Journal article which integrates reviews and guidance commissioned by the American Psychological Association (APA), including the relationship factors reviewed in the relevant chapter of an APA book (2006). For clinicians, asserts that “Development of an effective therapeutic alliance is crucial” and recommends accurate empathy (related review above), respect for the client’s experience, avoiding confrontational struggles, titrating confrontation to the client’s “reactance” to such tactics (related review above), and providing goal direction and a moderate level of structure for the therapy.