Alcohol 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

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S No need to insist on abstinence; patients can choose goal (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. This refutation (1982) based on a 10-year follow-up was itself refuted (1984) by the original authors. Discussion in cell C2. Related contemporary UK study, review and guidance below.

S Recruit the right people to be counsellors (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. Discussion in cell C2.

K Similar degree of success in UK from choosing abstinent or non-abstinent treatment goals (2010). UKATT was Britain’s largest alcohol treatment trial. Main aim was to compare social network and motivational therapies, but it also shed light on whether services should offer moderation as well as abstinence goals to dependent clients. ‘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.

K Screening applicant therapists for empathy saves on training (2005). Research project saved on training by using responses to simulated clients to screen applicant therapists for “accurate empathy”. Free source at time of writing. Study’s screening 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 ‘Read the manual’ not enough to develop competence in cognitive-behavioural therapy (2005; free source at time of writing). After being told to read the manual just 15% of substance use counsellors and clinicians were acceptably competent. Web-based training comparing role-play responses to the ideal helped but greater and more consistent gains in competence were made after a training seminar followed by expert coaching based on taped sessions with real clients. Related motivational interviewing study and reviews (1 2) below. Discussion in bite’s Issues section.

K Coaching helps counsellors learn to motivate (2004; free source at time of writing). Client responses to trainees improved only when motivational interviewing workshops had been reinforced by continued expert coaching and feedback on performance. See also this Effectiveness Bank analysis of a later report (2005) from the same study. Related cognitive-behavioural study above and reviews (1 2 3) below. Discussion in bite’s Issues section.

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”. More from UKATT above and in cell A4. Related discussion in bite’s Issues section.

K Assess and tell counsellors how their clients are doing (2012). To maximally improve outcomes, feedback should identify which individuals are doing poorly and recommend remedial actions. The same system has been found beneficial (1 2 3) in psychotherapy generally. Related guidance below. Discussion in bite’s Issues section.

K Leaders set the context for training to be implemented (2012). Whether substance use counsellors adopt 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. Discussion in bite’s Where should I start? section.

K Walk in their 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 this extension (2012) to the programme and this account (2007; free source at time of writing) of the “walk-through” procedure. Discussion in cell C2.

R Offer moderation as well as abstinence as a treatment goal (2013). Concludes that dependent drinkers can cut down, 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). Retaining psychosocial therapy skills after this popular training format requires follow-up consultation, supervision or feedback, and trainees’ self-assessments cannot be relied on to assess their progress. Related studies (1 2 3) above. Related reviews (1 2) below. Discussion in bite’s Issues section.

R Motivational interviewing training works best with post-workshop coaching (2013). Synthesis of findings on training clinicians (broadly defined and including but not limited to 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. Discussion in bite’s Issues section.

R Sustaining motivational interviewing skills after training (2014; free source at time of writing). Retaining motivational interviewing competence 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 for competence to be retained. Related studies (1 2) and reviews (1 2) above and review below. Discussion in bite’s Issues section.

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 treatments. Related studies (1 2) and reviews (1 2 3) above and discussion in bite’s Issues section. Implementation was more likely if supported or mandated by agency leaders or supervisors; related study above and discussion in bite’s Where should I start? section. Trainees whose attitudes were not conducive to a motivational approach benefited relatively little even from extended training and supervision; related studies (1 2) above.

R Let motivational counsellors adapt to client (2005). Effectiveness Bank review and a synthesis of the research (2005; free source at time of writing) find inflexible manualisation of motivational approaches associated with worse outcomes.

R Implementation lessons from trials of psychosocial therapies (2007; free source at time of writing). Research shows importance of therapist selection and post-training supervision, and the pitfalls of assuming researched interventions will translate into routine practice and of relying on the therapist’s self-assessment of their competence. Related discussion in bite’s Issues section.

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.

G Clinical supervision and professional development of counsellors ([US] Substance Abuse and Mental Health Services Administration, 2009). Related discussion in bite’s Issues section.

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

G Skills and abilities needed for clinical supervision ([US] Substance Abuse and Mental Health Services Administration, 2007). See also US checklist of competencies (2017; described here) for people with personal experience of substance use problems who are supervising peer supporters with similar experience. Related discussions in bite’s Issues sections (1 2) below.

G Staff selection, training and supervision for group 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 How to train and supervise addiction counsellors to deliver group cognitive-behavioural therapy (2013; free source at time of writing). Based on experience in developing and evaluating group cognitive-behavioural therapy programmes for depression and substance use for use in addiction treatment settings. Related guidance above.

more Search for all relevant Effectiveness Bank analyses or for sub-topics go to the subject search page. See also hot topic on individualising treatment.

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What is this cell about? About managing services which deliver psychosocial therapies for the treatment of alcohol dependence. Every treatment has psychosocial dimensions and involves interaction between human beings, even those based on medication or delivered via computers. However, this cell is about approaches in which interaction is intended to be the main active ingredient, the psychosocial approaches which are the mainstays of specialist alcohol treatment in Britain. These range in form from brief advice and counselling to extended outpatient therapies and all-embracing residential communities where clients stay for months.

The content and rationale of these therapies and the qualities of the staff delivering them matter of course, but so too do the management functions of selecting, training and managing staff, and managing the intervention programme, including how a service decides treatment goals and which patients are offered which therapies. In highly controlled studies, it may be possible to divorce the impact of interventions from the management of the service delivering them, but in everyday practice, whether interventions get adopted and adequately implemented, and whether staff are able to develop, maintain and improve competence, depend on management and supervision. These functions are the focus of the current cell.

Where should I start? Where so much starts – at the top. The leader’s influence was explored in unusual detail by the research stable (the Institute of Behavioral Research at the Texas Christian University) behind the investigation of the organisational health of British treatment services discussed in cell D2. The same fertile source also conducted this cell’s starting point study. It seemed to confirm that even ‘bottom-up’ improvements initiated by counsellors are strongly influenced by the ethos and support emanating from managers, implying that even when they do not themselves initiate improvements, leadership influences cascade down to staff. Qualities investigated among leaders included setting an example, encouraging new ways of looking at the work, and providing well defined performance goals and objectives.

These extracts from our summary of the study make the point: “leaders … have a cascading impact on their staff in ways other than through mandate, Leaders have a cascading impact on their staff in ways other than through mandate findings which highlight the importance of training leaders to be supportive of innovation and to construct an environment which bolsters open thinking among staff … Most of all, it seems essential that leaders use their influence (including support of new interventions and establishing a clear and forward-thinking mission) to promote a commitment to professional development among their staff, without which even the best leaders will find staff less amenable to initiating change.”

Completing the chain, the organisational health study from cell D2 suggested that services with leaders like these are the kind of services which best engage patients. It found clear relationships between the ‘micro’ level of the degree to which patients engaged with treatment, and ‘macro’ organisational features such as team working and mutual trust, whether the service fostered open communication between staff, was receptive to staff ideas and concerns, and had a clear mission and programme.

Issues to consider and discuss

Is coaching the right model for producing good counsellors and therapists? Getting the right people is critical was a message of cell C2, and more evidence can be found among this cell’s seminal and key studies and reviews. Were it looked for, it’s a fair bet that as a by-product, other studies focused on the impact of training would also have registered the importance of where clinicians start from to where they end up after training.

But as a manager, you have to make the most of the staff you have or can find. What then? Even if it worked, handing staff an expert manual and telling them to follow it would be ineffective or even counterproductive (see documents listed above). One of the best established findings in the development of the substance use workforce is that sending counsellors away on a course is often a waste without post-workshop feedback to the trainee on their performance with clients, ideally allied with expert coaching (1 2 3 4 4); more on feedback below). Beyond substance use too and among medical staff generally, really getting to grips with motivational interviewing requires a similar commitment. Without this, even after (2012; free source at time of writing) two days of training in motivational interviewing for substance use, competencies rapidly revert towards pre-training levels.

Let’s pin down what these generalities might mean in practice through two studies, one from the USA, the other the UK. William Miller’s research on the motivational interviewing approach he originated includes an influential demonstration that performance feedback and expert coaching are both needed for workshop training to impact on patients. The subjects were an unusually diverse (in terms of initial proficiency) set of addiction counsellors and clinicians who applied for training in motivational interviewing. Finally, the crunch finding: patients responded only when trainees had expert coaching and feedback Take a look at the original article (link is to a freely available copy) and at the Effectiveness Bank analysis of a later report derived from the same study. Note in passing that the study confirmed the importance of having the right trainees to begin with. Then it showed that even with the right trainees, post-workshop competence boosts did not persist without follow-up feedback and/or coaching. Finally, the crunch finding: the responses of the patients themselves – what the whole process was about – improved only when trainees were offered continuing expert coaching and when this included an opportunity to discuss feedback on how their work with clients compared to that expected of an expert.

Look at the detail of what coaching entailed. It can be likened to a sports coach reviewing with the players a video of the last game, reinforcing the good points, pointing out where they fell short of expectations, getting them to practice how they could have done it better, and checking later with another video that the lessons had been absorbed. For motivational interviewing in particular, it seems that at least three to four sessions over a six-month period are required, though much may depend on the quality of those sessions and probably too on the openness to learning and experiences of the trainees. Resources also need to be put into evaluating therapist competence. Generally and specifically in respect of motivational interviewing (1 2), substance use therapists’ own assessments of their competence are near useless compared to ratings made by observers.

In Britain the need for training programmes to include coaching based on work with clients was confirmed as a by-product of the UKATT alcohol treatment trial. Despite initial extensive training, on average it took about seven supervision sessions before therapists achieved the study’s competence standards in its motivational and social network therapies. During supervision, videos of the therapist conducting a session with a client were viewed simultaneously by the trainee and by an expert in the therapy, who communicated by phone or face-to-face. The experience led to this conclusion: “supervision after initial training was critical in the acquisition of competence. Not only did we believe that supervision ensured that therapists adhered to treatment protocols over time, but also that it underpinned understanding of the treatment and its purpose. Provision of both technical support and time was essential. Manuals do not provide these. Indeed they were less likely to be followed without these elements.”

Though there is some evidence, it is (see our analysis of a review listed above) by no means clear that greater competence in a therapy is consistently associated with better patient substance use outcomes, suggesting there is a need directly to assess how well patients are doing. That is also the case across psychosocial therapy for diverse mental health and other problems. Amalgamated findings from 36 studies relating recovery to the degree to which therapists adhered to the intended therapy and their competence in delivering it led to the “striking result … that variability in neither adherence nor competence was found to be related to patient outcome and indeed that the aggregate estimates of their effects were very close to zero.” One of the possible explanations is that sticking very closely to a therapy somehow leads to worse outcomes – a finding reminiscent of cell B2’s discussion of a study which found substance use reductions were best sustained by clients not of the ’best’ counsellors, but of those rated about average in terms of their clients’ experiences of working with them.

Do you have to take a deep breath, and accept this is the intensity and extensity of input needed to really make a difference?

Such findings mean management is critical to staff development and ultimately to client progress. Without this being mandated/expected and supported by the service’s management, practitioners tend not to engage with ongoing coaching and clinical supervision – and unless they do, competence gained through training will be lost. Managements also need to set up systems to assess therapist competence and client progress; they cannot rely on the self-assessments of the practitioners. All that transforms training into an extended workforce development programme, and the ‘done that’ boxes cannot be ticked until the trainee has demonstrated competence, preferably through objective ratings of session recordings and measures of how well clients are doing.

As a manager, do you have to take a deep breath, and accept this is the intensity and extensity of input needed to really make a difference to clients? Is this realistic? Teleconferenceing and phone-based supervision may be adequate, but are still labour-intensive. Is there a better use for limited resources? If we believe that (as per cell B4’s bite) relationship quality is the essence of psychosocial treatment, perhaps we also have to accept that this cannot be acquired quickly and easily through didactic teaching or from a manual. Though motivational interviewing has been most studied, that was also the message from a study of training substance use counsellors and clinicians in cognitive-behavioural therapy. Incidentally, the study also indicated that counsellors who were former substance users (presumed likely to be 12-step adherents and least familiar with formal therapies) benefited most from being coached rather than just being told to read the manual.

Let therapists know how (especially how badly) clients are doing Human beings build brains and lives based on feedback loops. Without these we know neither how we are doing nor how to improve or correct it. In substance use treatment, clinical supervision based on session recordings (section above) are a tried and tested way to provide feedback and correctives, but perhaps some of this can also be built into routine systems.

In substance use treatment, systematising feedback to therapists was tried (article starts on page number 204 as printed) in a simple but effective way in the late 1980s. More sophisticated systems benefit psychotherapy patients generally by giving therapists feedback on who is doing less well than expected, and clues to why this might be the case based on an assessment of the therapist-client relationship. Gains are greater still if feedback is supplemented by guidance on how to get patients back on track. The underlying assumption that the relationship of the therapist or counsellor to the client affects their progress has (see cell B4 of both the drug and alcohol matrices) some research support in the treatment of problem substance use. Before moving on to the application of these sophisticated feedback systems in substance use, unfold Unfold supplementary text the supplementary text to appreciate why supplying objective feedback is important.

That sets the background for a study (listed above) published in 2012 which adapted the same feedback system tried in the late 1980s. At three US substance use services, counsellors were given feedback on why individual clients might be lagging due to poor therapeutic relationships, flagging motivation, weak or the wrong kind of social support, or stressful events. The feedback derived from the patients’ answers to a computerised questionnaire on their psychiatric wellbeing and functioning and substance use, assessments made just before each counselling session and immediately fed back to the therapist.

Read our analysis, and you will see that patients doing less well than expected ended up drinking no more than initially more promising patients (the same was true of drug use). How feedback to the therapist helped ‘rescue’ these ‘off track’ patients is unclear. Illuminated by the fact that a different feedback system had previously failed to make a difference, the analysis (see section headed “Why the difference?”) offered several ideas. Most favourable to the revised system was that identifying individuals doing poorly, giving concrete feedback on their substance use to their counsellors, and offering guidance on how to respond, made it easier for counsellors to do the job to which they were committed – helping problem substance users get better. But in the ‘small print’ of the analysis you will find alternative explanations. You might wish to discuss with colleagues which make most sense. If you favour the explanation that the system did indeed have the desired impacts, it might be worth considering whether it or something like it could be incorporated in services you are familiar with.

In passing, note that feedback is also important for managers. One way of getting it is the ‘walk-through’ procedure trialled trialled in the USA, listed above and discussed in cell C2, entailing senior staff taking on the roles of patients in their service and seeing how it feels.

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