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Alcohol Treatment Matrix cell B3 Matrix cell logo

Practitioners; Medical treatment

The most important seminal and key studies and reviews shedding light on the impact of the practitioner in medical interventions and treatment for alcohol problems in medical settings.

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 Commitment to working with problem drinkers affects engagement (1996). See also related paper from same study (1996). At an English alcohol treatment clinic assessment workers differed greatly in how many of their patients went on to engage with treatment; how committed they were to working with a client (‘therapeutic commitment’) affected both therapeutic relationships and engagement. Later studies (1980) from the same team found therapeutic commitment depended on workplace support for dealing with drink problems. Discussion in bite’s Highlighted study and Issues sections.

S It’s the way you say it (1970). Final step of a remarkable series of studies from the late 1950s found that the warmth and concern a doctor expressed towards alcoholics in general was strongly related to whether at a US emergency department a year before their patients had followed through on the same doctor’s referral to the hospital’s alcohol treatment clinic. Discussion in bite’s Highlighted study and Issues sections.

K Doctor’s optimism and flexibility improve outcomes (2008). In the arms of the US COMBINE alcohol treatment trial which evaluated medical care with medications but without psychosocial therapy, what made the difference to patients’ drinking and clinical progress seemed to be how far the clinician maintained confident optimism and responded to the patient rather than strictly adhering to a treatment manual. Discussion in bite’s Issues section.

K Patients do best when they feel GPs know them and communicate well (2007). Free source at time of writing. US patients referred to primary care after detoxification reduced alcohol problems most when they saw doctors they trusted, they felt knew them as a whole person, and who probed/communicated thoroughly and well. Discussion in bite’s Issues section.

R Clinicians’ impact on treatment quality (2000). Free source at the time of writing. Impacts on retention and outcome related to professional characteristics, recovery status, adherence to protocols, countertransference, alliance, personality, beliefs about treatment, and professional practice issues. Concludes that “clinicians’ actual record of work with patients (eg., retention and outcome within their caseload) varies greatly between clinicians. Moreover, past assumptions that levels of training, experience, or other simple therapist variables could account for such differences does not hold.” Discussion in bite’s Where should I start? section.

G What UK doctors should do and be able to do ([UK] Royal College of Psychiatrists and Royal College of General Practitioners, 2012). Guidance from UK professional associations for GPs and for psychiatrists on the competencies, training and qualifications expected of doctors involved in caring for substance users, from generalists such as doctors in emergency departments to general practitioners and addiction specialists.

G What UK specialist addiction doctors should do and be able to do ([UK] Public Health England, Royal College of Psychiatrists and Royal College of General Practitioners, 2014). Guidance from body overseeing addiction treatment in England and from professional associations for GPs and for psychiatrists on the “essential functions which can usually only be carried out by addiction specialist doctors”, and the importance of retaining their expertise in the sector.

G What US specialist addiction doctors should do and be able to do ([US] American Society of Addiction Medicine, 2014). Consensus guidelines from the US professional association for doctors specialising in treating addiction on what they are expected to do and the standards they should meet at stages in the addiction care process from assessment to aftercare.

more This search retrieves all relevant analyses.
For subtopics go to the subject search page and hot topic on treatment staff.

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What is this cell about? About the treatment of alcohol dependence in a medical context and/or involving medical care, typically by GPs or at alcohol treatment or psychiatric units in hospitals. Clinical staff are responsible for medications, so the centrality of these to an intervention distinguishes it most clearly as medical. But drugs are never all there is to medical care, and are prescribed in a relapse-prevention role to only a minority of patients in Britain. Even when they are prescribed, the clinician-patient relationship influences whether the drugs are taken and is also a therapeutic – or possibly anti-therapeutic – influence in its own right. Apparent also in the studies set in hospital treatment units listed in cell B2, how clinicians relate to patients affects whether they enter and engage in treatment. Through these mechanisms and perhaps also directly, relationships ultimately affect the degree to which treatment helps overcome drinking problems.

Pinning down the impact of these influences is however much harder than pinning down the impacts of medications or other specific interventions. To set the scene for randomised trials, researchers can ensure some patients get treatment x, and others treatment y or no treatment at all. The relationship-forming qualities of treatment staff are less easily controlled. Rather than deliberately allocating patients to workers known to differ along these dimensions, studies often have to rely on an association between outcomes and relationship quality or staff attributes observed in everyday practice, or as a by-product of a trial organised for another purpose. Usually the most that can be said is that the findings are consistent with these qualities affecting outcomes, not that they actually did affect outcomes. Usually such research designs cannot eliminate the possibilities that clinicians are reacting to the patient’s progress rather than causing it, that patients differed from the start, or that the clinician’s behaviour and the patient’s progress are both related to other factors.

However, difficulty in demonstrating to scientific standards that something is true, does not mean it is untrue. Observations and patient feedback testifying to the role of the clinician-patient relationship are persuasive, if not clinching, evidence.

Where should I start? With this freely available review which systematically runs through evidence on the possible reasons why patients do better with one clinician than another. The reviewers comment that such effects often emerge from studies not designed to find them, sometimes being strong enough to surface through the study’s attempt to eliminate ‘extraneous’ influences. Relative neglect by research is contrasted with the everyday experience of front-line clinicians, managers and patients, for whom it is “obvious … that some practitioners are highly regarded whereas others are avoided”. The reviewed research reveals that “clinicians typically account for more [of the difference] in patient outcomes than do differences between active treatments or patients’ baseline characteristics”.

If clinicians are important, the next question is, why? What does not account for their impacts are professional characteristics, including qualifications and whether they are themselves ex-addicts. According to the reviewers, instead the most consistent factor has been the clinician’s ability to build a positive relationship with patients, one best identified in practice: “Select and evaluate clinicians based on their ‘track record’ … assumptions that levels of training, experience, or other simple therapist variables could account for such differences does not hold. Selecting and evaluating clinicians based on how they actually perform, using standardised measures, is rarely done but is an effort that could greatly improve the quality of care.”

Highlighted study Mount Zeehan alcohol treatment unit in Kent was the site for a seminal British study of patients starting treatment in 1990/91 and the nurses who assessed them. Though the six nurses were all experienced and well trained and supported, at one extreme fewer than a fifth of the patients they assessed went on to engage with treatment, at the other extreme, over three-quarters. Whether a patient engaged with treatment was strongly related to how the nurse felt about them. Comprehensively assessed as their ‘therapeutic commitment’ to the patient, in fact responses to just two of the 24 questions asked of assessors after their assessments were sufficient to predict the engagement of over two-thirds of the clients. If workers agreed with, “I like this client,” but disagreed with, “The best I can offer to this client is referral to somebody else,” patients were highly likely to engage. In turn the worker’s commitment to the client was related to their experiences of the assessment: “There is a strong sense that clients experience committed interviewers as interpersonally warm and less committed ones as interpersonally cold.”

Alan Cartwright argued that the patient was actually assessing the assessor

Interpreting this data in the light of patients’ comments, Alan Cartwright and colleagues argued that the patient was actually assessing the worker, and that their main concern was, “How does the worker see me? Does the worker like me? Do they accept me? Are they critical of me?” Arriving at the clinic in a fragile state with low self-esteem, their sensors were tuned to recognise signs of rejection. When rejection was sensed, they tended to reject back by not engaging with treatment. Though these specialist workers could be expected to be committed to working with alcoholics in general, still about a third of their clients did not feel sufficiently accepted or understood. What seemed to be happening was that some workers were more able than others to maintain a sense of commitment when clients were resistant or ‘difficult’. Even in the face of a client seemingly rejecting their efforts, they could continue to convey warmth, acceptance and understanding, and convince the client that they still genuinely wanted to work with them.

There is a striking parallel with the implications of the US COMBINE study that the clinician’s ability to credibly convey optimism even in the face of discouraging news from the patient helped reduce later drinking. The themes of interpersonal warmth and patients “sensitized to rejection” were also central to a seminal study from the USA. It found emergency doctors’ responses to the question, “What has been your experience with alcoholics?” were closely related to how many of their alcoholic patients had a year before followed through on a referral to the treatment clinic. Though a year later, the more a doctor evidenced personal (rather than coldly professional) concern in tone as well as words, the more likely their former patients had been to treat the emergency unit encounter as the start of a relationship they wished to continue.

Issues to consider and discuss

How much is down to workplace leadership and context? The studies highlighted above revealed the influence of the relationship style of the doctors and nurses – how they ‘treated’ patients in the colloquial sense of the word, their “therapeutic commitment” to the individual. Later Alan Cartwright and colleagues found that as a general predisposition, commitment itself was not (or not just) an inherent quality of the practitioner or generated by their interaction with patients, but was influenced by management and workplace culture.

Their earlier study had been set in a specialist alcohol treatment unit, so all the clinicians had a workplace supportive of working with drinkers. With no variation in workplace environment, each individual clinician’s therapeutic commitment to each client emerged as the overriding influence on their engagement with treatment. But the later studies involved practitioners working in a range of specialist and non-specialist settings. Now it became clear that therapeutic commitment itself depended on whether the workplace engendered the feeling that dealing with drink problems was a legitimate and supported role.

Context also determined whether differences between clinicians could emerge as influential in a US seminal study. Cell A2’s bite described how a new management transformed attendance at the alcohol treatment unit at Massachusetts General Hospital by deploying specialist staff trained to show unwavering respect and warmth to alcoholic patients seen in the hospital’s emergency department. In the follow-up study described above, only among patients not allocated to this new regimen were the attitudes to alcoholics expressed by emergency doctors related to whether their patients had accepted a referral to the alcohol treatment unit. Among the other patients, it seemed that the innovations introduced by a new-broom management had overshadowed the doctors’ influence.

What are the attributes of effective clinicians? First thing to say is that to a degree effectiveness can be generated and sustained (see above), not just found as a natural quality. But we know too that no matter how rigorous the training or how supportive the workplace, substantial differences can remain in how well clinicians promote substance use reductions and other desired outcomes. What accounts for these differences was the subject of the review we picked as our starting point. It highlighted the clinician’s ability to build a positive relationship with patients as the factor most consistently found to relate to outcome differences, and advised that this be identified via the clinician’s performance with actual patients.

How clinicians relate to patients is central to the ‘placebo effect’ and the ‘common factors’ found to account for most of the impacts of addiction treatment. In cell A3’s bite it was argued that even when medications are prescribed, “The placebo effect is the main active ingredient,” and that this effect is driven partly by the how the clinician relates to the patient.

An example emerged in the US COMBINE trial of medical care allied with pharmacotherapy. The substudy which found these effects was confined to the arms of the trial in which patients were not also offered psychotherapy, leaving the clinician as the main source of psychosocial support. An analysis of recorded consultations with patients highlighted the clinician’s ability to instil confidence in the treatment, and especially their ability to credibly convey optimism about recovery even in the face of discouraging news from the patient. Allied (and only when allied) with a flexible approach to delivering the medical care programme, patients seen by these clinicians less often drank at all and less often drank heavily.

Already noted is the parallel between these findings and the implications of a seminal British study – that during patient assessments at an alcohol clinic, what made the difference to whether patients engaged with the treatment on offer was whether workers maintained acceptance, warmth, understanding and optimism when clients were resistant to changing their drinking.

In the US COMBINE study the conclusion was that “some flexibility in delivering Medical Management, based on good clinical judgment and in conjunction with optimism and hope for recovery, supports better outcomes”. In line with other findings, the clinician’s level of professional training bore no relationship to outcomes. Relationship factors also emerged in another US study, but this time based on the patient’s perceptions rather than observations. For more on this study unfold the supplementary text Unfold supplementary text.

While we have focused so far on the positive, it is perhaps even more clear that negative behaviour from clinicians has a destructive impact. In cell A2 we theorised that once would-be patients seek to pass through the doors to treatment, doing the right things help, but what is critical is to avoid obstructing the process started by the patient by, for example, confrontationally provoking resistance or being judgemental. Such impacts have been demonstrated most clearly among risky drinkers intercepted by screening programmes. The impact of brief interventions to moderate their drinking can it seems be scuppered by just one or two instances of practitioners expressing the non-collaborative stance of someone who knows best, and is therefore in a position to confront, warn, direct, or advise the drinker. Those findings may not be duplicated in treatment studies where the patient has implicitly given permission for the clinician to ‘treat’ them, but in medicine generally, comments patients see as ‘invalidating’, like being dismissed or not taken seriously, have a detrimental impact thought to be greater than the positive impact of validating comments.

By now you may be thinking, but surely for doctors and nurses, technical knowledge too is critical? A patient may not die (or not immediately – they might in the longer run if deterred from treatment) from being cold-shouldered, but they could die if mistakes are made in prescribing medications. Indeed, British and US guidelines focus on these technical aspects, largely (but not entirely) ignoring relationship quality and the instilling of hope and confidence in patients. One possible explanation for the dominance of relationship factors in research is that trials cannot afford to endanger participants by allowing technically sub-standard doctors and nurses to treat them. Typically clinicians are highly selected and well-trained and supervised. What remains is variation in what is less easily controlled by researchers – how the clinicians relate to their patients.

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