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Practitioners; Psychosocial therapies

The talker in the talking route to recovery: seminal and key studies on the impact of the practitioner in psychosocial therapies for alcohol dependence.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text

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 much substance use counselling. Link is to a free 50-year anniversary reprint. See also commentaries (1 2). Discussion in bite’s Where should I start? and Issues sections.

S Counsellors’ relationship style affects patients’ relapse rate (1981). US study found a strong link between higher levels of empathy, genuineness, respect, and concreteness exhibited by alcohol clinic counsellors and a reduced risk of their patients’ relapsing after treatment. Discussion in bite’s Highlighted study section.

S Empathy makes the difference (1980). Big differences in therapy content and duration did not affect the progress of US heavy drinkers. What seemed to for at least two years (1983) after treatment was the degree to which their therapists displayed “accurate empathy”. See also this assessment of the impact of empathy in psychotherapy generally (2011). Discussion in bite’s Highlighted study section.

K Therapist effects emerge even in one of the most highly controlled studies ever (1999). Despite exhaustive selection, training and supervision, some therapists in the US Project MATCH alcohol treatment trial had on average worse outcomes (1998) than their peers and there was enough variation in the therapeutic relationship (1997) for this to influence engagement and later drinking. Session recordings exposed reasons for variation including the match between the therapist’s directiveness (2009) (see review below) and whether the client reacts against direction. Project MATCH was the Highlighted study in cell A2.

K Reinforcing ‘change talk’ helps curb problem drinking (2009). Micro-analysis of tapes of motivational interviewing sessions from the US Project MATCH alcohol treatment trial led to the appealingly simple and plausible conclusions that “What therapists reflect back, they will hear more of”, and that promoting talk about change promotes change itself. However, the study was not designed to establish causality.

K Social skills matter in motivational interviewing (2005). Link is to the Effectiveness Bank analysis; there is also a free source for the original paper. 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 this essay (2013) based on the same and other studies arguing that ‘by the book’ is not always best way to do therapy. Discussion in bite’s Issues section.

K Rogerian non-directive listening was all these patients needed (2012). Link is to the Effectiveness Bank analysis; there is also a free source for the original paper. Adding motivational interviewing techniques directed at reducing drinking did not improve on (if anything, the reverse) ‘Rogerian’ non-directive listening in helping US heavy drinkers cut back – not the case in a similar earlier study (2001). Discussion in this bite’s Issues section and also in cell A4.

K Counselling is a relationship business (2009). Penetrating study involving mainly alcohol- and cocaine-dependent patients found that some counsellors generated relationships with clients which fed through to better outcomes – but also that the ‘best’ relationship-builders were not on average the most effective. Discussion in cell B2.

R Effective ways to relate to clients (2011). US American Psychological Association task force reviews evidence and offers guidance on outcome-promoting qualities in relating to psychotherapy clients, like forming a therapeutic alliance (see below), being empathic, and appropriately adjusting to the individual (see below). Also offers guidance on outcome-harming qualities like being confrontational. Includes but not specific to substance use. See also this later (2014) and broader practice-oriented interpretation from same lead author, drawing on the task force’s work.

R Therapists who form good therapeutic relationships have better outcomes (2011). One of the (see above) US American Psychological Association task force reviews. In substance use treatment and psychosocial therapy generally, a strong working relationship between therapist and client is “one of the strongest and most robust predictors of treatment success”. An advanced analysis (2012; free source at time of writing) confirmed that some therapists consistently develop stronger relationships and have better outcomes.

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

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

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 analyses or for subtopics go to the subject search page. Also see hot topics on treatment staff and matching alcohol treatments to the patient.

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