Drug Treatment Matrix cell B2: Practitioners; Generic and cross-cutting issues

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Society for the Study of Addiction web site

Society for the Study of Addiction

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Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

Includes brief interventions

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Effectiveness Bank Drug Treatment Matrix

Includes harm reduction

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Practitioners; Generic and cross-cutting issues

At the front line the practitioner is to the patient the face of addiction treatment. Key research shows they can matter enormously – not so much in their formal qualifications, but in their manner with the patients. Probe with us the heart of addiction treatment: relationships.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S What makes some therapists more successful? (1985). A by-product of a randomised trial of different therapies, instead this study ended up highlighting the “dramatic” difference made by the therapist, some on average achieving little (or on some measures, negative) change among methadone patients, while others generated consistent and substantial improvements across substance use, psychological and social outcomes. Based on ratings made by their peers and other assessments, the impression was that skilled therapists most interested in helping patients and who formed warm, supportive relationships generated greater improvements.

K Best drug workers are non-conformist hedonists – like their clients? (2008). Findings of a small study in an English drug service for marginalised clients suggests that workers whose values and preferences deviate from the norm in the same direction as their clients are most able to help them. Findings are tentative, but similar to those from a US study (1974) of ex-addict methadone counsellors. For discussion click here and scroll down to highlighted heading.

K Client-receptive treatment more important than treatment-receptive clients (1999). Engagement and substance use outcomes at US drug counselling services were more strongly associated with how well counsellors related to their mainly stimulant-using clients than to the clients’ pre-treatment motivation.

K Clients who feel positive about their counsellors stay longer and feel better (2002). US study which benefited from a large and varied sample of counsellors working in residential and counselling/day centres found that favourable perceptions of one’s counsellor were significantly related to how long patients stayed in treatment. A year after the initial research assessments there were also significant relationships with psychiatric health, but not with the severity of drug problems and only modestly with alcohol problems. For discussion click here and scroll down to highlighted heading.

Simplified treatment process models for men and women

K Strong therapeutic relationships mean patients get more of the services they need (2010). How does a close working relationship with your keyworker improve drug use outcomes after treatment? According to this analysis based on over 3000 US clients, mainly by meaning they got more of the ‘wrap-around’ services they needed. Good relationships also extended retention, but once the sexes were analysed separately, retention was unrelated to post-treatment drug use diagram. For discussion click here 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 takes the lead, others who gladly take a back seat. In substance use treatment research too, the interaction of therapist ‘directiveness’ with client preferences has emerged as the most consistently influential dimension of interpersonal style. For discussion click here 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 contribution of the therapist to the creation of a strong alliance and resultant improvement in outcomes exceeds that of the patient: “These results suggest 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 Good therapeutic relationships mean patients stay longer (2005; free source at time of writing). The therapeutic relationship between patient and worker early in treatment was more consistently related to engagement and retention than to substance use outcomes, especially when those outcomes were assessed at times distant from the assessment of the alliance. For discussion click here and scroll down to highlighted heading.

R Select and evaluate clinicians based on ‘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. For discussion click here and scroll down to highlighted heading.

R Therapist 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 therapist expectancy of good outcomes, allegiance to the treatment approach they are providing, interpersonal skills including empathy (see document below), and how competently they provide the therapy. For discussion click here and scroll down to highlighted heading.

R Authoritative, evidence-based assessment of how best to relate to therapy clients (American Psychological Association, 2011). Effective ways to relate to therapy clients (including those with substance use problems) common to different therapeutic traditions, like forming a therapeutic alliance, demonstrating empathy (see document below), and adjusting to the individual. Also what to avoid, like confrontation, negativity about the client, and inflexible adherence to one method. For discussions click here and here and scroll down to highlighted headings.

R Is low therapist empathy toxic? (2012; free source at the time of writing). “Is low therapist empathy toxic?” was the title and the question answered in the affirmative by a review which synthesised findings on the relationship between ratings of a therapist’s empathy and substance use outcomes. It found 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.

R Complexity demands socially skilled and flexible therapists (2016). Essay from Drug and Alcohol Findings on the role of staff in brief interventions and addiction treatment. Emphasises that the complexity of the interacting variables which therapists have to respond to means there are no reliably effective, standardised ways of responding to a particular characteristic or need. For discussion click and scroll down to highlighted heading.

G Principles of substance use treatment (2006; free source at time of writing). Integrates reviews and guidance commissioned by the American Psychological Association (APA), in particular on relationship factors in relevant chapter of an APA book (2006). For clinicians, asserts that “Development of an effective therapeutic alliance is crucial” and recommends accurate empathy, respect for client’s experience, avoiding confrontational struggles, titrating confrontation to the client’s “reactance” to such tactics, and providing goal direction and a moderate level of structure for the therapy.

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

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