Alcohol Treatment Matrix cell B5: Practitioners; Safeguarding the community

2020/21 update funded by

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Practitioners; Safeguarding the community

Key studies on the impact of the treatment practitioner on safeguarding the community, families and children, and their influence in criminal justice contexts. Explores whether exceptional abilities are needed to forge productive therapeutic relationships in these situations, and invites you to ‘stress test’ a proposed universal rule: The trickier the situation, the more the worker matters.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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K Relationship with therapist seems more important for offenders than other clients (2008). At a Canadian substance use rehabilitation centre, seeing their therapist as understanding and involved was related to whether patients under criminal justice supervision/pressure completed treatment, and the relationship was stronger than for other clients. Alcohol was the most common problem use substance. For discussion click and scroll down to highlighted heading.

K Client-centred supervision motivates UK offenders ([UK] Ministry of Justice, 2014). Survey of offenders who started community sentences in 2009 to 2010 in England and Wales found they generally had good relationships with their offender manager. Nearly three-quarters with an identified alcohol-related need had discussed this with their offender manager; of these, just over half found the discussions “very useful”, the highest of all the identified needs. Offender managers who holistically addressed offenders’ multiple needs seemed to motivate them to make positive changes in their lives. For related discussion click and scroll down to highlighted heading.

K ‘Not my job’ perception and lack of confidence impede assessment of domestic violence (2016). Interviews with stakeholders suggest that staff in substance use treatment services in England often lack the skills or confidence to ask patients about their intimate relationships and violence between partners, and they may not see making these enquiries as part of their job. Guidelines arising from the research below. For related discussion click and scroll down to highlighted heading.

K Mothers in Wales see staff support as critical to child welfare and keeping families together (Welsh Assembly Government, 2008). Evaluation of a Welsh service which worked intensively over a few weeks with problem substance-using parents (their problems mainly involved alcohol) on the drink of proceedings which could lead to their children being removed from the home. See also later evaluation (2012) of the same service. In both reports, mothers powerfully testified to the impact of individual staff. For discussion click and scroll down to highlighted heading.

R Supervising offenders is about the quality of the relationship (2002). Download is the whole issue of the journal. The featured article starts on page 16, numbered 14. It reviews evidence on how to plan and implement crime-reduction programmes for substance-using and other offenders, including desired skills and attributes for supervision staff. Highlights the importance of the quality of contacts with offenders. Associated supervision manual below. For discussions click here and here and scroll down to highlighted headings.

R Best practice in working with substance users in the criminal justice system (Australian Government, 2005). Includes desired/required working styles and attitudes and understandings among treatment and criminal justice staff.

R Can motivational interviewing work in criminal justice settings? (2005). Asks whether the contradictions of at the same time helping and punishing, controlling and being client-centred (‘motivational arm-twisting’), undermine motivational interviewing’s ethos and effectiveness. For discussions click here and here and scroll down to highlighted headings.

G Manual for research-based offender supervision (2005). How probation and other supervision staff can motivate behaviour change and manage offenders’ behaviour instead of merely monitoring it, drafted by a team led by the author of a review listed above. For discussions click here and here and scroll down to highlighted headings.

G Working with men who physically abuse their partners (2015). Based partly on research in England, key capabilities (knowledge, attitude and values, ethical practice, skills and reflection and professional development) for staff treating the substance use problems of men who commit intimate partner violence. Associated study from same project above.

more Retrieve all relevant Effectiveness Bank analyses or search more specifically at the subject search page. See also hot topic on the influence of treatment staff.

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What is this cell about? Whether treatment is chosen positively or under pressure, we learnt from cell A4 that among the ‘common factors’ affecting its success is patients’ relationships with treatment practitioners. This cell explores research on the client-worker relationship, and on workers’ attributes which affect their clients’ progress, narrowing in on when treatment has been offered or imposed not because it has been sought by the client, but because it is thought that treating their substance use problems could reduce offending, protect their children, or otherwise benefit the community – some of the trickiest situations (see final section below) in which establish a productive rapport.

Across psychotherapy the interpersonal style and other features of staff are now seen as at least as important as the intervention, but remain far less commonly researched. In the expectation that the influences exerted by practitioners in these settings may not differ too much from those elsewhere, for more studies we can refer you back to the other cells dealing with practitioner influences: cell B1 for brief interventions, B2 for treatment in general, B3 for medical treatments, and cell B4 for psychosocial therapies.

Where should I start? With an excellent and freely available review listed above from a respected US researcher on the supervision and treatment of substance using offenders. Faye Taxman’s review offers a clue to why research is lacking on the quality of the relationship between practitioner and offender. Despite being able to cite 25 studies of offender supervision, she notes that “Very few … discussed the … qualitative nature of the contacts that occur in the supervision setting … The relationship … between the offender and the agent is presumed to be the basis for the offender to change due to the controls that the agent places on the offender and the attention to supervision objectives” (emphasis added). According to this conventional understanding, whether the probation or parole officer forms a good relationship with the offender is irrelevant; what matters is how consistently they adhere to supervision objectives and pull legal levers underpinned by sanctions. Research has followed these lines, focusing on the number and frequency of contacts and caseload size as proxies for the ability to exert control. Suggesting something important is missing, these ‘hard’ statistics have generally been found unrelated to re-offending.

Professor Taxman advances a different perspective: “Like in the therapeutic setting, the degree of rapport between the offender and agent is an important component for the supervision process to achieve better outcomes … contacts must have a function that exceeds the mere exchange of information. The contact is more of an engagement process that is designed to achieve desired outcomes.” Those outcomes are not merely suppressing offending during supervision, but more lastingly “improving compliance with general societal norms including the conditions of release”. For more on this alternative vision, see the supervision manual (listed above) drafted by a team led by Professor Taxman.

Issues to consider and discuss

Are the practitioner’s therapeutic skills really unimportant? Research may be sparse, but what we do have supports Professor Taxman’s contention (section above) that the influence of the practitioner is not unimportant in criminal justice settings, just relatively neglected. The implication of a study listed above at a Canadian substance use rehabilitation centre is that feeling understood and that the therapist is actively involved in helping you are actually more important when the patient is under criminal justice supervision or pressure, than when they are not. A possibly related finding was that compared to other patients, criminal justice patients were “less committed, more resistant and displayed more negative attitudes in treatment” – not surprising, since most entered treatment under criminal justice supervision or while awaiting charges, their trials, or sentencing, pressures which might have made them enter treatment against their wishes. Reading slightly between the lines, unless this distancing from treatment (‘I’m only here because I have to be’) was countered by a feeling that the therapist is, after all, ‘on my side’, drop-out was particularly likely among the criminal justice clients.

The glue of the supervision process is the manner of being between offender and agent

Therapists in the Canadian study described above were treatment staff rather than criminal justice officials supervising the offender. But for these officials too, Professor Taxman was convinced (review listed above) that “The glue of the [supervision] process is deportment or the manner of being between the offender and the agent. The contact is the key because it is the means to focus the purpose of supervision and it allows the offender and agent to develop a rapport … an important component for the supervision process to achieve better outcomes.”

The “deportment” she recommended was that systematised by motivational interviewing – empathy, avoiding arguments, rolling with resistance, highlighting where their undesired behaviour contradicts the offender’s ambitions and self-image, and bolstering confidence that they can change for the better. In criminal justice contexts the therapist skills needed to maintain and communicate this counselling style might be even more important than usual. Self-initiated clients are already well on the way to a collaborative stance. When the patient has sought treatment much of the work of therapy has already been done. Treatment has to do more of the engaging and motivating when the ‘client’ is not there because they want to be, when for them you may represent an oppressive authority, and when in reality you and/or your employers have a responsibility to exert control over them – and treatment’s frontline is the encounter between patient and practitioner.

The starting point review put it this way: “agencies have tried to achieve two purposes – enforcer and social worker – and have found the polar nature of the two tasks often conflicting”. The same conflict was highlighted by the title (Motivational arm twisting: contradiction in terms?) of an Effectiveness Bank review listed above of motivational interviewing with clients coerced into treatment. The implications of these potentially conflicting roles are explored further in the final two sections below.

Best to split therapy and supervision? The preceding discussion raises another issue – whether therapy/support should be divorced from the criminal justice supervision process to make it easier for treatment staff to sustain an effectively therapeutic attitude. Listed above, our own review of motivational interviewing with clients coerced into treatment saw it this way: “the approach can work – given that substance use is an appropriate focus, that the patients have the resources to make positive changes, the therapist can remain true to motivational principles, and the patients feel safe to open up to their therapist”. With legally coerced treatment populations, elements are often missing from this constellation, especially the ability genuinely to adopt a motivational stance and to offer confidentiality to the client. Working in these ways seems to require insulating therapists from criminal justice supervision and freeing them (with obvious exceptions if the offender or others are at serious risk) from the obligation to report back to legal authorities, and making sure patients know this is the case.

Partly because they acknowledge the difficulty of combining a therapist with a supervisor role, several probation services in the UK have introduced peer mentors as a large component of their drug and alcohol work, offering support outside the context of a controlling relationship. Peer mentors typically meet-and-greet offenders in a treatment setting, talk about their own experiences, and co-run groups. An example can be seen in the English midlands, where a peer mentor has explained that taking on this role helps offenders to open up, and has helped her cope without drinking.

A young man being supervised by the London Probation Trust explained why such arrangements may not be seen the same way by the offender art the receiving end:

“You’re aware that your probation officer can recall you … you need to conduct yourself in a certain way. If you think the mentoring programme is linked to probation you’ll behave the same around the mentor … you’ll put up barriers rather than just open up, because you’ll think whatever you say to him or her they’ll go back and report to probation. When [mentor] first saw me, he said he’s not probation, he’s not the police, he don’t get involved with them, he’s nothing to do with them. But he also [explained] to me if he had information or I told him I’m going to harm myself, I’m going to hurt someone else or do this or that or break my licence conditions, he has to go and tell them.”

How far is it realistic to insulate support and therapy from criminal justice supervision. Won’t someone working for criminal justice authorities always be seen by offenders as suspect, despite lacking formal powers? Even were such separation possible, is it desirable?

The trickier the situation, the more the worker matters Issues discussed above tempt the formulation of a general rule: The greater the formal power a clinician/therapist/counsellor has over a patient’s life, the weaker their informal influence through therapy. A corollary is that engineering collaborative therapy in a formal control context requires exceptional abilities. Combine the two propositions and express the product in everyday language gives the title of this section: “The trickier the situation, the more the worker matters.”

The situations discussed above relate to the counselling of offenders under criminal justice supervision. Also seen as ‘tricky’ is broaching certain forms of criminality, unacceptable or risky behaviour in substance use treatment services outside the criminal justice context – intimate and stigmatised issues, the very raising of which might be seen as jeopardising the relationship with the client. The more formal power over a patient’s life, the less informal power through collaborative therapy An example is the possibility that the patient has been abusive or violent towards their partner, seen as difficult (document listed above) to broach and beyond their remit and competency by staff in English substance misuse services and also in mental health services, where “enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional”.

Perhaps trickiest of all is forging a therapeutic relationship with parents whose substance use and other behaviours might seriously threaten their children’s welfare. The Scottish Government among others has emphasised that no matter what the context, “The welfare of the child is always paramount.” In a substance use treatment context, take this to heart and it means you cannot as a clinician focus exclusively on being there for the client. The children-first perspective requires you to ask uncomfortable questions not to do with the patient’s welfare, but that of any children, and to stand ready at all times act against the patient’s wishes if that’s what it takes to prevent serious harm to a child.

Like juggling balls with a magnetic tendency to interfere with each other’s flight

No wonder substance use treatment workers commonly sideline the whole issue of children in order “to avoid any perceived potential conflicts of interest or a need to make child protection notifications, which could jeopardise their working relationship with clients”. The situation becomes trickier in the extreme when you know a child is at risk, the client knows you know, and you are acting at the behest of services which could take the child away from the parent – a bit like not just juggling several balls at once, but balls with a magnetic tendency to interfere with each other’s flight. Only an expert juggler with exceptional reflexes and coordination could manage.

Reverting to therapy language, this was one of the key findings in the evaluations (1, listed above; 2, listed above; discussed in cell A5) of the Option 2 service in Wales which worked with problem substance using parents at imminent risk of losing custody of their children. Guidance based on the evaluation reports stressed that delivering such services “which rely on highly skilled direct work with families – is very challenging. It is easy to set-up a service that looks like Option 2. It is much more difficult to ensure that the service actually received by families is of … high quality … Doing so requires recruiting exceptional staff, providing very high levels of clinical supervision and training and ensuring that staff have the time to devote to delivering high quality work for families.”

Options 2 clients appreciated directness

One of the evaluation reports highlights the following quote from an interview with a client, illustrating that the worker whilst friendly could also be firm and communicate difficult issues when required.

“[Option 2 worker] told them that if they messed up now, the boys might get taken into care. The interviewee said that that was a good thing about [Option 2 worker]: [Option 2 worker] was really friendly but [Option 2 worker] ‘got to the point if [Option 2 worker] needed to’. [Option 2 worker] was ‘straight’, ‘blatant and honest’ and she found that really helpful.”

The two evaluation reports (available via our analyses: 1 2) revealed in the mothers’ own words the difference they felt was made by the quality of the worker and of their work. Common themes were good listening skills, showing that they cared – including going the ‘extra mile’ and sticking with people through difficult changes – and being honest about concerns and problems. That last theme alludes to the tricky business of ‘laying down the law’ in such a way that it strengthens the relationship with the parent rather than damaging it. The panel right taken from one of the evaluation reports listed above illustrates this point. The essence of what in this context makes a good worker was also distilled by the researchers into the box on page 55 of the original report.

How difficult it is to meld support with control became apparent when an attempt was made (free source at the time of writing) to disseminate Option 2’s methods to generic child protection services. The aim was to train child and family social workers in London to use Option 2’s motivational interviewing counselling style when working on child protection cases involving problem-drinking parents. Trainees made progress, but it was patchy. Part of what stood in the way was the tension between the client-centred stance of motivational interviewing and the need in serious child protection cases to be clear about what is required of the parents, and if necessary to confront certain behaviours. More skilled workers felt able to combine these, but they were in the minority.

The proposed rule seems plausible and has some evidence to support it. Now let’s subject it to an imaginary ‘stress-test’, bearing in mind the cautions in cell A4 that in psychosocial therapy, rules followed regardless of the situation are potentially counterproductive, and universally applicable rules are hard to find. Is it really the case that when a counsellor or therapist has formal power over the client, making therapeutic progress becomes trickier and requires exceptional abilities? Could they not use this formal power to persuade the client to undertake recovery-promoting activities that would otherwise be refused, like insulating against temptation by taking a drug which makes drinking a nasty rather than a nice experience (look back at the references to disulfiram treatment in cell A5)? Contrary to the supposed rule, could it be that having formal power mean there is less need to be an expert therapist? Is formal power only a complicating factor when the therapeutic relationship between clinician and client is the main treatment mechanism rather than a powerful medication? Well maybe, but take a look at cell B3’s findings on the influence of practitioners in medical treatment. If despite these questions, we really have hit on a general rule, are there exceptions?

Thanks for their comments on an earlier version of this entry to Russell Webster, a qualified probation officer working in London as an independent consultant specialising in the fields of substance misuse and crime. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

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