Drug Treatment Matrix cell B4: Practitioners; Psychosocial therapies

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Practitioners; Psychosocial therapies

Seminal and key studies on the impact of the practitioner in psychosocial therapies. Takes Carl Rogers’s seminal theories as its starting point and guides you through the complexities which obscure the impact of client-worker relationships despite their patent important to the clients.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S Fundamentals of effective therapy: genuineness, positive regard and empathy (1957; free source at time of writing). In psychosocial counselling and therapy, no paper has had more influence than Carl Rogers’ formulation of the “necessary and sufficient conditions” for clients to get better, the foundation of arguably all effective substance use counselling. See also commentaries (1 2) on his work. For discussion click and scroll down to highlighted heading.

S Connection with counsellor promotes client progress (1997). Findings at a US treatment service for “for indigent drug users” led researchers to argue that “providing the opportunity to develop appropriate relationships may be one of most important contributions made by treatment”. Psychologically healthy patients forged better initial relationships with their counsellors, but across all patients better relationships were followed by greater improvements in psychological health. For related discussion click and scroll down to highlighted heading.

K Treat manuals as guides, not scripts (2006). Especially when the therapeutic relationship is not going well, counsellors should be prepared to depart from the counselling ’script’ without altogether abandoning it. That implication came from a national US study (1999) of cocaine dependence treatment, which also found typical drug counselling at least as effective as psychological therapies. For discussion click 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 involving mainly alcohol- and cocaine-dependent patients. Expected finding was that some counsellors generate relationships with clients which feed through to better outcomes; less expected was that the very ‘best’ relationship builders were not on average the most effective. For discussion click and scroll down to highlighted heading.

K Authenticity and social skills in motivational interviewing (2005). US study suggests that the quality of seeming ‘genuine’ can suffer if training mandates withholding natural responses, but also that departing from these mandates is risky unless done by a socially skilled therapist. See also an essay (2013) from Drug and Alcohol Findings based on this and other studies, arguing that ‘by the book’ is not always best way to do therapy. For discussion click and scroll down to highlighted heading.

R Common core of effective therapy: therapeutic relationships (American Psychological Association, 2018). Includes but not specific to substance use. Introduces and synthesises finding from 16 reviews of the psychotherapy literature based on the understanding that therapeutic change is generated not only by technical interventions, but by the ways therapists relate to clients, like forming a therapeutic alliance (related review below), being empathic, and appropriately adjusting to the individual (related review below). Still valuable is an earlier version (2011) of this article which additionally integrated findings on how to adapt therapy to the individual client and on counterproductive behaviours like being confrontational. Drawing on this work see also a broader practice-oriented interpretation (2014) of the research from same lead author.

R Therapists who form good therapeutic relationships have better outcomes (American Psychological Association, 2018). One of the (see above) US American Psychological Association task force reviews. Supports the argument that “a good working relationship is an important determinant of treatment success, and that nurturing, maintaining, and as needed, re-establishing such a relationship, are core tasks not just in psychosocial therapies, but in treatment generally”. Earlier an advanced synthesis of research findings (2012; free source at time of writing) from some of the same authors had confirmed that some therapists consistently develop stronger relationships and have better outcomes.

R Adapt to the client (American Psychological Association, 2011). Includes but not specific to substance use. US American Psychological Association task force (their overall report is listed above) judged that adapting psychotherapy to the client’s reactance/resistance, preferences, culture, and religion/spirituality demonstrably improves effectiveness.

R Some clients like to lead, others to be led (2006). How directive the therapist is during treatment is one of the strongest and most consistent influences on outcomes. There is no ‘right’ degree of directiveness; it all depends on how the client reacts.

R Strong therapeutic relationships mean patients stay longer (2005). Among samples mainly being treated for problems with illegal drugs, the therapeutic relationship between patient and worker early in treatment was more consistently related to engagement and retention than to substance use, especially when use was assessed at times distant from the assessment of the alliance. See this study (2002) for an example of the review’s findings. For discussion click and scroll down to highlighted heading.

G Implementing NICE-recommended psychosocial interventions ([English] National Treatment Agency for Substance Misuse, 2010). Report from the British Psychological Society on how to implement recommendations in guidance from the UK’s National Institute for Health and Care Excellence on treating drug misuse; includes competencies and attributes of therapists.

G Addiction counselling competencies ([US] Substance Abuse and Mental Health Services Administration, 2008). Includes competencies associated with positive outcomes and the knowledge, skills, and attitudes all substance use counsellors should have. First step is to “Establish a helping relationship with the client characterized by warmth, respect, genuineness, concreteness, and empathy.”

G What makes a good group therapist? ([US] Substance Abuse and Mental Health Services Administration, 2005). US consensus guidance on the different types of groups, how to organise and lead them, desirable staff attributes, and staff training and supervision.

G What makes a good case manager? ([US] Substance Abuse and Mental Health Services Administration, 1998). US consensus guidance including the staff skills, knowledge and attitudes needed to fulfil the key case management role orchestrating the range of services often needed to promote lasting full recovery.

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

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What is this cell about? Every treatment involves direct or indirect human interaction, but this cell is about treatments in which interaction is intended to be the main active ingredient – ‘psychosocial’, or more colloquially, ‘talking’ therapies. They attempt to change the patient’s behaviour directly by ‘shaping’ it through rewards and sanctions, or indirectly via their beliefs and attitudes, how they relate to others, and how others relate to them. Interventions vary in type, intensity and duration; see cell A4 for more on these variations.

Of course, what is done in therapy matters, but as long as this is a well structured, bona fide treatment which ‘makes sense’, the ‘common factors’ shared by different therapies seem more critical to their success. For the patient, the main embodiment of these factors is how the therapist relates to them, the influence of which is apparent in substance use treatment generally and in respect of medical treatments. Unsurprisingly, the evidence is stronger still when the structured enactment of that relationship is the treatment. In this cell we focus on the client-worker relationship, and on whether some therapists are more successful because they more strongly forge the right kind of relationships – ‘therapeutic’ relationships.

Where should I start? With arguably the most fertile source for practice and research in psychosocial therapy for substance use problems – Carl Rogers’ classic formulation listed above (free source at time of writing) of the “necessary and sufficient conditions” for therapeutic progress: the communication of genuineness; unconditional positive regard – no ‘ifs’ or ‘buts’ qualifying the therapist’s acceptance of the patient; and accurately empathic understanding of clients in need of help to align their actions, thoughts and self-perceptions. The ‘seminal’ credentials of this paper are indicated by its being reprinted 50 years later (the version listed above), and by the fact that throughout the matrices (including practically every entry in the current cell) you will find these qualities continue to emerge as significant in engaging problem substance users in effective treatment.

Introduction to Carl Rogers’ “The necessary and sufficient conditions of therapeutic personality change”. Text reads: For many years I have been engaged in psychotherapy with individuals in distress. In recent years I have found myself increasingly concerned with the process of abstracting from that experience the general principles which appear to be involved in it. I have endeavoured to discover any orderliness, any unity which seems to inhere in the subtle, complex tissue of interpersonal relationship in which I have so constantly been immersed in therapeutic work. One of the current products of this concern is an attempt to state, in formal terms, a theory of psychotherapy, of personality, and of interpersonal relationships which will encompass and contain the phenomena of my experience. What I wish to do in this paper is to take one very small segment of that theory, spell it out more completely, and explore its meaning and usefulness.

Introduction to Carl Rogers’ seminal paper, “The necessary and sufficient conditions of therapeutic personality change”

Despite his focus on the universals of relating to clients, Rogers did not dismiss specific techniques like offering interpretations of the roots of the client’s feelings and behaviour, exercises weighing up the pros and cons of change, analysing what triggers unwanted behaviour, and training in social and self-control skills. In his schema, these were not active ingredients in themselves, but also not trivial, because it is partly through such techniques that relational qualities like positive regard are communicated – and communicating these was seen as one of the essentials of effective therapy. From the problem drinkers investigated in a seminal British study highlighted in cell B3 of the Alcohol Treatment Matrix, and from the comments of drug and alcohol treatment clients in eight European countries, we know that these qualities – especially unconditional positive regard – are also what substance use patients seek in a helper, and that they promote access to and retention in treatment. Across psychotherapy, they have (review listed above) stood the test of time, increasingly being acknowledged rather than becoming overtaken by alternative theories.

An obituary records that Rogers’ theories emerged from an iconoclastic figure who “did not care about appearances, roles, class, credentials, or positions, and [who] doubted every authority including his own,” and from someone (for his time) distinctively devoted to subjecting theory to scientific tests of validity in practice. Produced in 1965 as training aids, you can see this figure in therapeutic action in the (within psychotherapy circles) legendary ‘Gloria’ videos of his encounter with a psychotherapy client, who was also filmed being treated by two other leading therapists of the time. See these accounts (1 2) for more on the videos and their importance in the history of psychotherapy.

Carl Rogers’ insights were further specified and translated into practice, among which in 1967 was Charles Truax and his colleague’s influential book, Toward Effective Counseling and Psychotherapy: Training and Practice. Based on work undertaken with Rogers himself, it argued that “genuineness or authenticity is most basic to a relationship”, a quality explored below under the heading, “Being genuine sometimes means breaking the ‘rules’”. According to Truax’s book, having established this foundation, the therapist or counsellor communicates warmth and respect for the client and proceeds to the work of therapy via their “moment to moment empathic grasp of the meaning and significance of the client’s world”. The understanding of ‘genuineness’ in the book entails “openness to experience” rather than defensively retreating behind a facade or role, among which for therapists is that of the ‘technical expert’ in their profession.

In various guises openness to experience later emerged as a quality underlying effective practitioners and effective organisations in addiction treatment. That finding seems also to extend to the therapists engaged by the UK’s drive launched in 2008 to improve access to mental health care; unfold Unfold supplementary text the supplementary text to read about the study.

Motivational interviewing is the guise in which Carl Rogers’ insights will be most familiar to addiction therapists. A direct inheritor of his person-centred focus, it differs in the therapists’ “intentional and strategic use of questions, reflections, affirmations, and summaries to strengthen the client’s own motivations for change” – though these strategies do not necessarily augment outcomes.

Highlighted study Decades of searching have failed to find a recognised drug-based treatment for dependence on cocaine, and no specific psychosocial therapy has been constructed which can fill the therapeutic gap. That leaves standard counselling focused on drug use as the dominant response, one the definitive national US evaluation found at least as effective as sophisticated psychological therapies.

Derived from the same evaluation, our highlighted study listed above went on to explore what it was which made the manualised counselling programme more or less effective. Read our analysis and you will see that its large sample enabled it to probe for complex patterns in the results, which lumped together generated the misleading impression that for drug use outcomes, neither the client-counsellor relationship nor the counsellor’s flexibility in implementing the programme mattered.

Both did matter, but not in a linear ‘more is best’ manner. Improvements in drug problems were greatest when counsellors had stuck moderately well to the manual, and worse to roughly the same degree when they had either been unusually diligent or unusually lax in implementing the intended programme. This pattern was most marked when patients reported a relatively weak relationship with the therapist. When relationships were good, patients tended to do well regardless; moderate adherence to the manual’s programme was still best, but outcomes suffered less from the extremes.

What sense can we make of these findings? First, we cannot dismiss the possibility that despite statistical significance, they are anomalous or chance findings. But the large sample, the care taken over the analysis, concordance with other findings (see Is it best to busk it? in cell B2’s bite), and the fact that the findings ‘make sense’, argue for them to be taken seriously.

What sense they could make was explained by the authors: “Very high levels of adherence might reflect a lack of flexibility on the part of the therapist in responding to patients’ needs, whereas very low levels might reflect an inability to translate a therapeutic model or theory into practice as prescribed … practicing in a way that is responsive to the clinical situation may, on occasion, require a deviation from a treatment manual even while maintaining overall adherence.” This flexibility – or to put it another way, being patient-centred as opposed to programme-centred – seemed especially important when patient and counsellor had not rapidly forged a good working relationship. In turn, another US study suggests this could be due to the more psychologically weak and distressed patients (anxiety, depression, and self-esteem were assessed) being unable to rapidly form a trusting and open emotional connection with the counsellor within which they can receive the help on offer. These patients might particularly benefit from attention to their needs, even if that means departing from the prescribed programme.

Remember though that the highlighted study’s finding emerged from highly selected, experienced and trained counsellors, who could presumably exercise discretion wisely. Interpreting these and other findings, we saw the evidence “converging on the proposition that outcomes improve when skilled therapists are able and willing to depart from manualised regimens no matter how expertly these have been drafted, so long as a coherent structure is retained for the therapy which makes sense to the client”.

Being genuine sometimes means breaking the rules Imagine yourself as a psychosocial therapist influenced (as most in the substance use field will directly or indirectly have been) by the Rogerian principles outlined in a previous section and their elaboration into motivational interviewing. You know you are not supposed to insist clients ‘must do’ something, even less to warn of the consequences if they don’t, and still less to express disapproval of their choices, but biting your tongue just doesn’t feel right – doesn’t feel like you are being you. Yet you also know you are supposed to be you – to be “genuine” as Rogers put it, not put on an act. There seems a conflict between these demands, all of which Carl Rogers and/or motivational interviewing’s theorists saw as keys to effective therapy. What should you do?

Avoiding warnings can seem as uncaring and unnatural as suggesting to this pedestrian heading towards a pit that they consider the pros and cons of proceeding, but in the end it is up to them; the natural and caring response is to shout, ‘Stop.’

Avoiding warnings can seem as uncaring and unnatural as suggesting to this pedestrian heading towards a pit that they consider the pros and cons of proceeding, but in the end it is up to them; the natural and caring response is to shout, ‘Stop.’

For guidance, turn to a study listed above of the training of addiction counsellors and clinicians, the implications of which are most easily absorbed from a brief, informal account by Drug and Alcohol Findings. Read at least this.

Are you convinced by our interpretation that (in the context of a caring relationship and a socially skilled therapist) “warning and directive advice which conveys and comes from concern for [the patient’s] welfare and respect for [them] as an equal” can be beneficial, and that withholding such comments can make you feel and sound less than genuine? Was it naive to reassure counsellors that “Everyone knows the difference between warning, advice and concern which conveys and comes from care and respect for one as an equal, and that which comes from and conveys accusation, denigration, and an attempt to exert control.” Is this clear departure from a Rogerian stance and motivational interviewing’s ‘rules’ too risky, easily seeming to the patient to represent a degeneration into negativity and confrontation? If so, we know from a review listed above that the results are often counterproductive.

At this stage, it might help to remind yourself of the ‘small print’ of the study: that only when the counsellor was relatively socially skilled did ‘breaking the rules’ in these ways enhance the effect their skills had on client engagement. Like a skilled barber with a cut-throat razor, they were able turn what could have been inadvertently harmful into something which could help get the job done by strengthening the therapeutic relationship.

Isn’t it just a matter of being nice? Not, it seems, from a penetrating analysis listed above of data from five US outpatient counselling centres. How would you account for the key finding – that substance use reductions were best sustained by clients of counsellors rated about average in terms of their clients’ experiences of working with them? Counsellors who had been relatively poor at generating a close ‘helping alliance’ from the client’s perspective had worse outcomes, but so too did those who had been especially good.

Counsellors poor at striking up a close alliance had worse outcomes, but so too did those especially good

Note that in this study counsellors were generally pretty good at generating positive relationships; it was only towards the very top of this range that outcomes started to worsen. Look at the questionnaire on which this finding was based. Imagine the working style of a therapist, nearly all of whose clients ticked all those boxes (some are reverse scored). Perhaps at these levels, therapists were focusing too much on being ‘nice’ or on the client’s comfort, failing to develop ‘discrepancy’ when needed – unwilling to generate change-promoting discomfort by highlighting how the patient’s actions contradict their self-image and values. Perhaps too, they seemed less than ‘genuine’ to their clients – an important quality which sometimes means (section above) making interventions which contravene guidance and theory. But remember that while generating scores at the very top of the helping alliance scale may not be ideal, you don’t have to slip very far down before outcomes start getting worse again; this is no carte blanche for neglecting alliance-building.

Lest we think this study a one-off, similar findings have emerged in general psychotherapy/counselling, and also in brief alcohol interventions for risky drinkers identified through screening, findings highlighted in cell B1 of the Alcohol Treatment Matrix.

If therapists are influential, why don’t more studies register their effects? Across psychotherapy more effective therapists “generally form better alliances with their patients and have better facilitative interpersonal skills, and provide an emotionally activating relationship”. But in the substance use field we find a clash between frequent reports from patients that a particular therapist, counsellor or keyworker was the catalyst for their recovery, and trials which often find no significant signs that helpers differ in effectiveness. Are these trials missing something “obvious” (free source at the time of writing) to patients and clients and patently observable in normal practice? With random allocation to people trained or selected to be bad versus good therapists ruled out on ethical grounds, proving therapists have an impact on substance use outcomes and establishing the reasons are not straightforward. Looking into these difficulties offers a case study of the limitations of usual scientific methods, ill-suited in this case for establishing that what seems obviously valid and important, really is.

One limitation is that therapist effects are often obscured by the control researchers exercise over trials, including over therapists. Data on these effects is commonly gathered as a by-product of a trial designed to evaluate an intervention, not the interventionists. To test whether a psychosocial intervention can work, it has to be given a good chance to succeed. Usually that means selecting highly competent therapists and/or training them to meet the study’s standard for delivering the intervention. Anything less risks alienating patients to the point that many disengage from therapy and from the study, leaving researchers with a partly untreated, small and probably unrepresentative follow-up sample, exposed to a sub-optimal implementation of the programme. No surprise then that whichever therapist patients have been assigned to, on average they improve to roughly the same degree. The surprise is that sometimes therapist effects nevertheless emerge, even in the most highly controlled of studies.

Where therapists do appear to have made a difference to client outcomes, a strong candidate for how this happens is via the relationships they establish with clients. At this point, disentangling what caused what becomes a major obstacle to verifying therapist effects; rather than relationships causing therapeutic progress, it could be that patients who are in any event going to do well – or are already doing well when the relationship is assessed – form stronger relationships with their therapists and vice versa, each tending to be more appreciative of the other when their goals are being achieved. However, across psychotherapy there is evidence (free source at time of writing) that more is going on than a good relationship merely being a by-product of a good prognosis – that relationships do actually account for part of the difference in how well clients do.

Establishing a link between the client-worker relationship and outcomes may also (if findings on the treatment of depression apply) require an unusually large study and unusually complete monitoring of those relationships, offering sufficient assessments for a reliable average to be computed. It is also critical to take these measures early in therapy before the relationship begins to reflect rather than promote client progress.

Then there are complexities which confound simple analyses. For example, usually researchers test whether the stronger the relationship, the better the outcomes. But what if the association between the two is not linear, but ‘curved’ – relatively weak and very strong relationships both being associated with poorer outcomes? In this scenario, linear analyses might fail to find an association even if there really was one. If that seems fanciful, look back at the previous section, “Isn’t it just a matter of being nice?”, and the evidence that there may well be a curve in the association between relationships and outcomes.

A further complexity is that therapeutic relationships matter more in some circumstances and for some people than others. If this is the case, rather than casting doubt on the existence of relationship effects, inconsistent findings are only to be expected. An example emerged from a large and careful study of the US national drug treatment system, which suggested that relationships matter more for clients and patients with prior experience of treatment than those for whom this is a new experience. Explore the intriguing implications of this study by clicking on the eye-opener icon Unfold supplementary text.

Then there is how we assess the client–therapist relationship. The varied measures usually largely reflect the degree to which client and therapist collaborate in the work of therapy – they are ‘task-oriented’. In turn this collaboration is based partly on how they get on simply as human beings encountering each other as they might in ‘real life’ outside the clinic or consulting room. A major component of this so-called ‘real relationship’ is how genuine you feel the other person is being, seemingly important in therapy generally and in substance use treatment in particular (see section above). Another component is seeing and reacting to the other person as they really are. Reflecting the concept’s psychoanalytic roots, this is contrasted to seeing them as an unreal projection of your own unresolved inner conflicts, but it could also be that one’s insight is obstructed by in effect seeing them not as an individual, but as an embodiment of the standard clients envisaged in therapy manuals, failing to realise that a departure from those manuals may be called for; a relevant study formed the basis for the “Highlighted study” section above. If components of the ‘real relationship’ were given greater prominence, might this more rounded assessment of the client–therapist relationship emerge more strongly as an influence on outcomes?

The research has been like probing for signs of the ‘big bang’ with a toy telescope pointed at the ground

Relationships are complex and their impacts on treatment outcomes not straightforward. Searching for proof of these impacts using methodologies designed for the simplicity of testing intervention versus no/alternative intervention, and in studies where relationships are not the main interest, might be likened to probing for signs of the ‘big bang’ origins of the universe with a toy telescope pointed at the ground. You might not see any signs, but that doesn’t mean the ‘big bang’ was a trivial event without consequences. Perhaps this is why a review of research on the therapeutic alliance in the treatment of problem drug use (listed above) found client-worker relationships only inconsistently related to substance use outcomes. The same review found relationships were more consistently associated with engagement and retention in treatment, suggesting a less sanguine interpretation of the findings (advanced in cell B2) that better relationships make clients want to stick around but do not make them better – though of course, for some treatments (especially those based on medications), ‘sticking around’ is often vital to their effectiveness.

Search back through your experiences as a patient, client, therapist, counsellor, keyworker, adviser or advised, supporter or supported, and use these experiences as a prism through which to assess the adequacy of the research. If somebody did have a profound effect on you, or you had that effect on someone else, how might this have been demonstrated – how could it have been proved to scientific standards?

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