Drug Treatment 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. Findings challenge managers to invest in the post-training ‘coaching’ needed to make a difference for patients, and to set up systems alerting therapists to how well 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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K Coaching helps counsellors learn to motivate (2004; for free source at time of writing run this Google Scholar search and in the result click on the PDF link to the right). Client responses to trainees improved only when motivational interviewing workshops had been reinforced by continued expert coaching and feedback on performance. See also report (2005) from the same study suggesting that the important quality of seeming genuine can suffer if training mandates unnaturally withholding normal responses. Related cognitive-behavioural study and reviews (1 2 3 4) below. For discussion click and scroll down to highlighted heading.

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. For discussion click and scroll down to highlighted heading.

K Put your best people up front (2000). Interactive exercises and games and induction by senior staff helped new residential rehabilitation residents engage with the programme. Study is numbered 3 in the downloaded document.

K Assess and tell counsellors how their clients are doing (2012). To maximally improve outcomes feedback needs to identify which individuals are doing poorly and recommend remedial actions. The same system has been found beneficial (1 2 3; free source at time of writing) in psychotherapy generally. Related guidance below. For discussion click and scroll down to highlighted heading.

Walk in our shoes

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 report on an extension (2012) to the programme and an account (2007; free source at time of writing) of the ‘walk-through’ procedure. Discussion in cell C2. For related discussion click and scroll down to highlighted heading.

K Don’t make counsellors stick to the manual no matter what (2006). Findings from a US study of cocaine dependence treatment suggest that – especially when the therapeutic relationship is not going well – counsellors should feel free to depart from the counselling ’script’ without altogether abandoning it. Data came from a national study (1999) which found drug counselling at least as effective as psychological therapies. Related review below.

K Screening applicant therapists for empathy saves on training (2005; free source at time of writing). About alcohol treatment but applicable to other substance use problems. Research project saved on training by using responses to simulated clients to screen candidate therapists for “accurate empathy”. Same method could help services spot people with the hard-to-teach (2006) ability to form good relationships with clients. See Alcohol Treatment Matrix for related discussions of empathy and of staff recruitment.

K You don’t develop competence in cognitive-behavioural therapy just by reading the manual (2005; free source at time of writing). After being told to‘read the manual’ just 15% of substance use counsellors and clinicians who volunteered for this US study were acceptably competent. Web-based training comparing role-plays to the ideal helped, but greater and more consistent gains were made after a training seminar was reinforced by expert coaching based on taped sessions with real clients. 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 being told to read the manual. Related motivational interviewing study above and reviews (1 2 3 4) below. For discussion click and scroll down to highlighted heading.

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. This single review covers many of the issues management faces in trying to implement evidence-based practice. Ten years later and focusing on cognitive-behavioural approaches only, the same lead author effectively updated (2017; free source at time of writing) aspects of the earlier essay. For discussion click and scroll down to highlighted heading.

R Let motivational counsellors adapt to the client (2005). Effectiveness Bank review and a synthesis of the research (2005) find inflexible manualisation of motivational approaches associated with worse outcomes. Related study above. For discussion click and scroll down to highlighted heading.

R One-off workshop training is not enough (2005). After this popular training format, retaining psychosocial therapy skills in addiction treatment requires follow-up consultation, supervision or feedback, and trainees’ self-assessments cannot be relied on to assess their progress. Related studies (1 2) above and reviews (1 2 3) below. For discussion click and scroll down to highlighted heading.

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 treatment settings. However, not all trainees ‘get it’: “what was striking was that trainees whose attitudes to treatment were not conducive to adopting a motivational approach benefited relatively little even from the extended training and supervision”. Related studies (1 2) above and reviews above and below (1 2). For discussion click and scroll down to highlighted heading.

R Motivational interviewing training works best with post-workshop coaching (2013). Synthesis of findings on training clinicians (broadly defined and not limited to those working with problem 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 studies (1 2) and reviews (1 2) above and review below. For discussion click and scroll down to highlighted heading.

R No short-cut to sustaining motivational interviewing skills after training (2014; free source at time of writing). Studies mainly but not only of substance use treatment show that retaining competence in motivational interviewing 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. Related studies (1 2) and reviews (1 2 3) above. For discussion click and scroll down to highlighted heading.

G Implementing NICE-recommended psychosocial interventions ([UK] National Treatment Agency for Substance Misuse, 2010). Commissioned from British Psychological Society. Includes generic and specific competencies and training/supervision methods for the main therapies recommended by the UK’s health intervention assessor.

G Clinical supervision and professional development of substance use counsellors ([US] Substance Abuse and Mental Health Services Administration, 2009). Guidance on supervision methods and models, cultural competence, ethical and legal issues, and performance monitoring, plus an implementation guide for managers. Web page also gives access to the literature review on which the advice was based, plus updates to 2012.

G Skills and abilities for clinical supervision ([US] Substance Abuse and Mental Health Services Administration, 2012). Competencies needed for effective clinical supervision in substance use disorder treatment, including a step-by-step guide to implementing comprehensive supervisory training and workforce development. See also US checklist of competencies (2017; described here) for people with personal experience of substance use problems engaged in supervising people with similar experience who are supporting patients or clients.

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

G Staff selection, training and supervision for group therapy ([US] Substance Abuse and Mental Health Services Administration, 2005). Consensus US 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 Training and supervising addiction counsellors to deliver group cognitive-behavioural therapy (2013; free source at time of writing). Based on experience in US addiction treatment settings in developing and evaluating group cognitive-behavioural therapy programmes for depression and substance use. Related guidance above.

more Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. See also hot topics on individualising treatment, staffing, treatment services, and holistic service delivery.

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What is this cell about? Every treatment involves direct or indirect human interaction, but this cell is about the management of treatments in which interaction is intended to be the main active ingredient – ‘psychosocial’ or ‘talking’ therapies. Based on varied understandings of how dependence arises and how it can be overcome or ameliorated, they attempt to change how the patient behaves via their beliefs and attitudes, how they relate to others, and how others relate to them, or directly by ‘shaping’ behaviour through rewards and sanctions. Programmes range in form from brief advice and counselling to extended outpatient therapies and all-embracing residential communities where clients stay for months.

Differences between psychosocial therapies have been tested and contested and occupied the lion’s share of research time, but as long as it is a well structured, bona fide treatment which ‘makes sense’ to patient and therapist, the ‘common factors’ shared by supposedly distinct therapies (on which see see cell A4) seem more critical to their success.

The content and approach 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 types of 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? With an essay listed above which touched many of the bases found scattered among other listed reviews and studies. It was led by Kathleen Carroll, a US clinical psychologist and researcher who has done much to advance understanding of psychosocial treatments in the addictions. Now a Professor of Psychiatry at Yale, she teamed up with Bruce Rounsaville, another eminent researcher, to stand back to take a broad view over what is known about whether and how interventions supported by research (termed “empirically supported therapies”) find their way into practice. Think of it as two researchers who have spent working lives generating Think of it as two researchers bravely questioning what it’s all been for empirically supported therapies bravely questioning what it’s all been for. Based on a lecture delivered in 2005, the article is relatively easy reading, and there is a free source. Here we pick out some main themes relating to this cell’s agenda.

Their starting point was, “Now that we have all these [empirically supported therapies], what should we do with them? … What do we need to know about [their] efficacy, value, and transferability … into clinical practice?” The problem was that despite there being many evidenced therapies, “the majority of treatment programs in the United States remain grounded in traditional counseling models that have largely not been evaluated rigorously [and] many … persist in their use of interventions and strategies that have been demonstrated to be ineffective … and even some that may be harmful to some populations”; training and monitoring of the performance of clinicians was also lacking or rudimentary – all features identifiable in the UK.

Despite its advances, research too is lacking, leaving questions of intense interest to clinicians unanswered: Are these therapies really any better than my routine practice? Which should I use for which type of client? What do I do when they fail? As they interpret the research we do have, for this expert duo the practice implications are that in non-residential settings, broadly applicable and feasible starting points for treatment are motivational interviewing or cognitive-behavioural therapy or an amalgam of both, to be followed by more intensive and costly interventions if “objective benchmarking outcomes (retention, urine toxicology screen results)” indicate the need.

Unlike medications that can be delivered anywhere in pure form, new behavioural treatments can be disseminated only through training

Identified as the main bottleneck in disseminating therapies was that “Unlike … approved medications that can be manufactured in bulk and delivered in pure form anywhere in the world, new behavioral treatments can be disseminated only through training therapist after therapist, with the hope that they will remain in practice and stay motivated to deliver the treatment.” This effort is hampered by there being “no system or standards for ensuring that empirically supported behavioral therapies are delivered with even minimal levels of adherence or competence.” The standard training approach of brief workshops “has been shown to be of limited effectiveness in imparting key skills and competence to experienced clinicians”. Training plus performance-based supervision and feedback does better, but is expensive, time-consuming, and removes clinical staff from their day-jobs for several days. ‘Train the trainer’ models may prove more feasible; a key clinical leader is thoroughly trained not only in the therapy, but also in how to train other clinicians and to monitor and supervise their implementation of the approach. The “surprisingly positive” performance of computer-based training in trials suggest this too may be a more feasible option.

But they acknowledged that even with adequate training, we cannot assume that everyone is able to achieve competence in every approach. If basic skills are lacking, “it is not clear how [these] should be taught, or even whether they can be taught”. A reasonable starting point might be to require clinicians to demonstrate competence in at least one evidenced therapy, and to be exposed to newly emerging therapies as needed and as dictated by the clinical populations with whom they work.

Once acquired, maintaining competence was judged likely to require ongoing monitoring of a clinician’s implementation of a given therapy plus ongoing supervision and support from clinicians trained and experienced in the approach. Here another yawning gap emerges in the implementation infrastructure: “clinical supervision based on objective standards or systems is virtually nonexistent in the United States,” and given the “high rate of turnover of clinicians in substance abuse treatment programs, extensive training, certification and supervision procedures may not be seen as cost-effective”.

If blanket training of clinicians in multiple therapies is unrealistic, an alternative is first to teach basic principles and strategies shared by effective therapies, and then for trainees to master implementations of these in the form of particular therapies validated by research and needed for their work or which appeal to the clinician. Again, experience suggests to the two experts that this strategy may not work; anywhere near ‘mastery’ and consistently competent delivery of a therapy is rarely achieved in normal practice. In turn this raises the issue of whether findings from research for which therapists are highly selected, trained and monitored would transfer to normal practice. On the other hand, faithful implementation of a therapy does not necessarily generate the best outcomes: “while therapist skill and adherence to manual guidelines have been linked to outcomes for several treatments, in other areas the findings have been more mixed or even negative”.

A more novel alternative strategy would be to dispense with the face-to-face therapist altogether and deliver treatments directly to patients via computer, standardising quality, enhancing convenience and lowering costs. In 2005 the two essayists were optimistic: “Computer-assisted therapies potentially also offer more consistent delivery of interventions to patients, particularly for comparatively complex approaches such as [cognitive-behavioural therapy] where clinician fidelity and skill in implementing the treatment tends to be variable.” Ten years later and focusing on cognitive-behavioural approaches only, the same lead author effectively updated aspects of the earlier review in a freely available essay listed above. This time technology was the major theme, and the earlier optimism was yet more apparent: “The studies reviewed above suggest that technology-based [cognitive-behavioural therapy] interventions, provided that they are carefully constructed, developed to be as engaging as possible, and rigorously evaluated in methodologically sound clinical trials, have tremendous potential as a dissemination strategy to reach the majority of individuals with substance use problems who do not receive care due to issues of access, stigma, costs, concerns about confidentiality, and many more.” However, “promising” results were somewhat undermined by the “variable” methodological quality of studies in what remained a “young field”. Whether technology really is the way forward is still to be seen – an issue we investigated in a hot topic devoted to computerised therapies.

Highlighted study An organisation’s leader does literally set the lead, and we can expect that to extend to the implementation of evidence-based and effective practice. Expecting is one thing, demonstrating it to scientific standards is another. Fortunately, 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 highlighted in cell D2. The same fertile source also conducted this cell’s highlighted study listed above. Its findings were consistent with the picture that the ethos and support stemming from managers strongly influenced the degree to which counsellors were willing to initiate the adoption of new ways of working and encourage their colleagues also to develop. In other words, even when leaders do not themselves initiate improvements, their influence cascades down to staff. Qualities investigated among managers included setting an example, encouraging new ways of looking at the work, and providing well defined performance goals and objectives. These seemed to exert their effects by helping construct what the counsellors saw as a conducive organisational environment, characterised by strength of mission, staff cohesion, good communications, professional autonomy, not being stressful, and receptiveness to change.

Extracts from our summary encapsulate the implications of the findings: “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 listed in 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 nurturing good counsellors and therapists? In the Alcohol Treatment Matrix we explored the importance of getting the right people in the first place – a neglected issue also in drug treatment, on which further evidence can be found in this cell (1 2). But as a manager, you have to make the most of the staff you have or can find. What then? At this stage we are forced to accept a difficult conclusion: really developing your workforce demands considerable and continual effort; shortcuts typically fail. Let’s explore the evidence.

Even if it worked, handing staff an expert manual and telling them to follow it would be ineffective (study listed above) and possibly even a target='_blank' title='Effectiveness Bank analysis: The motivational hallo. Opens new window' href='http://findings.org.uk/PHP/dl.php?f=Ashton_M_33.pdf&s=eb&sf=mx'>counterproductive (review listed above). Worse still, one of the best established findings in the development of the substance use workforce among others 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 5; more on feedback in the section below).

Of different therapies, acquiring competence in motivational interviewing has been most thoroughly examined. Beyond substance use (review listed above) and among clinical staff generally, really getting to grips with motivational interviewing requires post-training coaching. Without this, even after (2012; free source at time of writing) two days of training, 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. From the USA, William Miller’s research on the motivational interviewing approach he originated includes an influential demonstration (listed above) 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 (you can use the instructions in the listing above to find a free copy) and at the Effectiveness Bank analysis of a later report 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 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. The responses assessed were so-called ‘change talk’ indicative of a commitment to reducing substance use, and resistance, indicative of the opposite – close to what the whole process was about, but not actual measures of substance use.

Look too at the detail of what in this study ‘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 better, and checking later with another video that the lessons had been absorbed. For motivational interviewing in particular, the study suggests 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 experience of the trainees. Resources also need to be put into evaluating therapist competence. Generally (study listed above) and specifically in respect of motivational interviewing (1; 2, listed above), 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.”

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

Though there is some evidence, it is (see our analysis of a review listed above) by no means clear that ‘better marks’ on one’s implementation of a therapy are consistently associated with better patient substance use outcomes. To more validly assess clinician effectiveness, we need directly to assess how well their patients progress. That is also the case across psychosocial therapy for diverse mental health and other problems: amalgamated findings from 36 studies relating patient progress 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 those 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; the implications are discussed in cell B4.

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 (review listed above), competence gained through training will be lost. Management also needs to set up systems to assess therapist competence which go beyond their self-assessments, and ideally to assess effectiveness by tracking how well their clients progress in terms of the intended outcomes, not just how well counselling sessions go. 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 client substance use and/or related problems.

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? Teleconferencing and phone-based supervision may be adequate, but are still labour-intensive. Is there a better use for limited resources? If we believe (as suggested in cell B4) that 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 listed above 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.

Where would we be without feedback? The short answer is, we would not know! To build brains and lives, human beings rely on feedback loops (an entertaining account makes this point in the context of generating good and bad habits). Without these, we know neither where we have got to in our attempts to progress nor how to improve or correct these. In substance use treatment, clinical supervision based on session recordings are a tried and tested way to provide feedback and correctives (see section above), but perhaps some of this can also be built into routine systems.

In substance use treatment, systematising feedback to therapists was tried in a simple but effective way in the late 1980s. More sophisticated systems benefit psychotherapy patients (see articles listed above) 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 client–therapist relationship. Gains are greater still if feedback is supplemented by guidance on how to get patients back on track. The underlying assumption that the client–therapist relationship affects client 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 examining the results of an important study listed above. Published in 2012, it 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 patients’ answers to a computerised questionnaire on their substance use and psychiatric wellbeing and functioning, assessments made just before each counselling session and immediately fed back to the therapist.

Read our analysis of the study and you will see that patients at first doing less well than expected ended up using substances no more than initially more promising patients. 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 makes 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 the services you know.

Walk in our shoes

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

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