Alcohol Matrix cell B4: Practitioners; Psychosocial therapies

2020/21 update funded by

Alcohol Change UK web site. Opens new Window

Alcohol Change UK

Previously also funded by

Society for the Study of Addiction web site Society for the Study of Addiction

Developed with

Skills Consortium web site. Opens new window

Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

Includes brief interventions

Drug Treatment Matrix

Effectiveness Bank Drug Treatment Matrix

Includes harm reduction

About the matrices

Effectiveness Bank matrices

Articles, slides, and video


Send email for updates

Effectiveness bank home page. Opens new window Matrix cell

Alcohol Treatment Matrix cell B4 Matrix cell logo

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.

Matrix Bite Open Matrix Bite guide to this cell Open Matrix Bite guide and commentary

Close Matrix Bite guide and commentary Close Matrix Bite Close Matrix Bite guide and commentary

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

What is this cell about? Every treatment involves direct or indirect human interaction, but this cell is about ‘psychosocial’ therapies in which interaction is intended to be the main active ingredient. These range in form from brief advice and counselling to extended outpatient therapies and all-embracing residential communities where clients stay for months. In their content and techniques therapies also differ, varying for example from the deep probing of psychoanalysis to the more skills-based cognitive-behavioural approaches. 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 cell A4) seem more critical to their success.

For patients and researchers, how the therapist relates to the client is the main embodiment of the common factors shared by therapies and the most salient way they affect engagement and outcomes. We have seen this generally across treatment and in respect of medical treatments. Unsurprisingly, the evidence is strongest for psychosocial therapies, when the structured enactment of the therapist-client relationship is the treatment, forcing attention to it even in studies designed to minimise such influences. In this cell we focus on client-worker relationships, and on whether some therapists are more successful because they more strongly forge the right kind of relationships – ‘therapeutic’ relationships. Before moving into that territory, a reminder that therapists and counsellors typically work in organisations which limit or enhance their ability to maximise client progress, an issue explored earlier in this matrix in the context of the influence of practitioners in medically-based treatments. The same issue will emerge in this cell from a study (described in the supplementary text towards the end of this ‘bite’) which identified significant relationships between abstinence and the characteristics of the treatment organisation, but not (once organisational factors links had been taken into account) between abstinence and the client-worker relationship.

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 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 get their actions, thoughts and self-perceptions in line. The ‘seminal’ credentials of this paper are indicated by its being reprinted 50 years later (the version listed), and by the fact throughout the matrices (including practically every entry in the current cell) you will find these qualities continue to emerge as significant in engaging problem drinkers 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 endeavored 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 Highlighted study in cell B3 and from the comments of 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. Across psychotherapy more broadly they have stood the test of time and their significance has increasingly been acknowledged.

You can see Rogers in action in the (within psychotherapy circles) legendary ‘Gloria’ videos of his encounter with a psychotherapy client who was also filmed in sessions with two other leading therapists of the time, produced in 1965 as training aids. See these accounts (1 2) for more on the videos and their importance in the history of psychotherapy.

Carl Rogers’s insights have been further specified and translated into practice, among which in 1967 was the influential book, Toward Effective Counseling and Psychotherapy: Training and Practice. Based on work with Carl Rogers, it argued that “genuineness or authenticity is most basic to a relationship”, a quality explored below. 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. Since then, in various guises openness to experience has emerged as a quality underlying effective practitioners and effective organisations; for more see the supplementary text towards the end of this ‘bite’.

Highlighted study The case for empathic, responsive and socially skilled therapists who build strong relationships hardly seems to need to be argued or researched, any more than (as a famous article put it) the case for strapping on a parachute before leaping from a plane. But in fact, though counsellors and therapists undoubtedly differ on these dimensions, the evidence that as a result their patients do better or worse is far from consistent below. At least part of the reason could be methodological issues; though this would be the ideal randomised trial format, it would be unethical to deliberately and at random allocate vulnerable and troubled people to non-empathic, phony, hostile and incompetent versus better counsellors, just to see what happens.

However, you can randomly allocate clients to different therapists, some of whom will happen to be better than others. Go back in time to an era when trials were less tightly controlled, and you might find the wide variation in therapist competence probably seen even today in the ‘real world’ beyond controlled trials. Such a study would effectively (since these qualities tend to go together) randomly allocate patients to counsellors with high versus low levels of empathy, understanding, and warmth. That’s what a seminal US study (listed above) did, and it remains the most convincing test of the effect of these qualities on drinkers seeking treatment in the normal way. As noted in cell B2, the study found a strong link between the empathy, genuineness, respect, and ‘concreteness’ of counsellors – seemingly an amalgam of good communication and accurate empathy – and a reduced risk of their patients relapsing after treatment. Here we can add that these are the very qualities Carl Rogers expected (section above) to be positively related to patient improvement. If you read our analysis of the study, you will see that it cannot be said on its own to settle the issue of the impact of Rogerian qualities on substance use problems – but with others, it makes a persuasive case.

Among these other studies is another seminal work which randomly allocated clients to therapists, whose degree of “accurate empathy“ was rated by observers behind one-way mirrors. The study was led by Bill Miller, originator of motivational interviewing, the main contemporary inheritor of Rogers’s legacy. Conducted in the pre-motivational interviewing era, it was intended as a trial of alcohol therapies differing in intensity and in the breadth of issues addressed, all benchmarked against self-help. ‘No significant difference’ was the conclusion, but the “surprised” researchers stumbled across a “serendipitous finding” which drew their attention in a very different direction, helping to found motivational interviewing. While huge differences in the extent and content of therapy made no difference to drinking, the style in which the therapies were delivered was strongly related to drinking: across their admittedly small caseloads, the greater the average degree of accurate empathy exhibited by therapists over the eight months of the study, the more likely their clients were to have improved in their drinking by the end. The range was from 100% improvement among clients of the most empathic therapist to 25% among the least, a variation in effectiveness which would have been ironed out in studies with more selected and sifted therapists.

Issues to consider and discuss

Is Rogerian listening really all that’s needed? Read Carl Rogers’ paper and our comments on it above and you will see that he never said empathic and accepting listening was all that was needed to maximise client progress. Nevertheless, at least two studies have tested this interpretation of his model by adding extra elements to a Rogerian approach to see if they improve outcomes. The extra elements were those which transform the non-directive Rogerian approach into directive (but not explicitly directive) motivational interviewing. Though motivational interviewing “rests explicitly in Carl Roger’s approach”, it sharpens it into a goal-directed strategy which “presupposes that the therapist prefers one outcome over another” and tries to get to that outcome by “responding preferentially to language that indicates a desire, ability, reason, need, or commitment from the client” to make the desired changes. In different ways, both the studies below stripped out these directive elements to see whether they really did make a difference. See what you make of them.

First take a look at our analysis of the most recent of the studies; there is also a free source for the original paper. If anything, basic Rogerian reflective listening bettered motivational interviewing Conducted in the USA, it found that adding the directive elements of motivational interviewing to Rogerian reflective listening did not improve drinking outcomes. Research staff gave all the patients feedback on their assessment results, categorising their drinking by degree of severity from low risk in stages up to possible physical dependence. For some this was followed by an instruction to try to change their drinking on their own, after which they were left to their own devices, never having seen a therapist. The remainder were allocated to four therapy sessions of either motivational interviewing or Rogerian reflective listening – effectively, motivational interviewing stripped of its more directive techniques intended to provoke a commitment to reduced drinking. The result was unexpected: improvements all round, but no significant differences on any of the measures of drinking or its consequences. On each measure, if anything Rogerian reflective listening bettered motivational interviewing. In this study the patients were relatively stable, moderately dependent drinkers. To join the study they had to be aiming for moderation rather than abstinence, socially stable, and not severely mentally ill or seriously involved with other drugs. Typically they were in their 30s and 40s, employed, well educated and had never been treated for drinking problems. If the study’s version of non-directive listening was all that was needed, that was the case for a caseload much less severe than typical in public sector treatment services.

About a decade before, a similar sample had been recruited in New Zealand for a similar study, but one which found the opposite to the US study: frequent heavy drinking was further significantly reduced when motivational interviewing techniques were added to non-directive listening. Without motivational interviewing’s directive elements, around 64% of patients engaged in this pattern of drinking over the six-month follow-up; with these elements, just 43%. The study also found that non-directive listening was no better than doing nothing except the basics provided to every patient – feedback on the extent of their (excessive) drinking over the past six months, diagnosis of the severity of their drinking, and advice to cut down to within national guidelines.

Why the difference? See if you can get a copy of the earlier article (we were unable to find a free web-available version) and compare the two studies. Note that the earlier study’s non-directive listening was very non-directive – to the point that if patients wanted to talk about the weather, that was fine. Here’s how the researchers described this, perhaps to both patients and therapists, strange ‘therapy’: it “consisted of nonstrategic reflective listening ... in which subjects were invited to talk about anything they wanted, not necessarily issues related to drinking. The direction of content throughout the treatment was intentionally left for subjects to determine. [Non-directive listening] was Rogerian counseling cut back, restricting therapist responses to the barest minimum (ie, nondirective reflective listening while maintaining rapport) and retaining the same therapeutic stance irrespective of the content being offered by the subject.”

In everyday language, no matter what the patient said or how they behaved, their distress or their elation, the therapist acted as a friendly, absorbent, but essentially unresponsive sounding board. It might have puzzled and disappointed patients who (unlike in the later study, which used ads to solicit participants) had all gone to a specialist substance use clinic seeking help with what was diagnosed as dependent drinking. Recall the conclusion to which Project MATCH researchers were driven, that treatment is a “culturally appropriate solution to a socially defined problem”. Could it be that such a stance violated patients’ culturally shaped expectations of what ‘treatment’ should look like? Perhaps too, the limitations placed on non-directive listening stopped therapists communicating empathy and acceptance, one of Carl Rogers’s essentials for effective therapy, and forced them to respond to patients in an unnatural way. If that was the case, the effect would probably have been to undermine perceptions of the therapist as being genuine – another quality of effective therapy below.

Does being genuine sometimes mean breaking the rules? As a psychosocial therapist influenced (perhaps indirectly) by motivational interviewing and Rogerian therapy, 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. You also know you are supposed to be you – to be ‘genuine’, not put on an act. There seems a conflict between these demands, all of which Carl Rogers saw (see Where should I start? above) as essential to effective therapy. What should you do?

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

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

For guidance, turn to this study (free source at time of writing) of the training of addiction counsellors and clinicians, the implications of which are perhaps most easily absorbed from this brief, informal account. Read at least this.

Are you convinced by the conclusion 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 artificially eliminating these sorts of 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 such a 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 (see cell A4) 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 wielding a cut-throat razor, they were able turn what could have been inadvertently harmful into something which added an extra sheen to the therapeutic relationship.

If therapists are influential, why don’t more studies register their effects? In the modern era, therapist effects are more often obscured than highlighted by the control researchers exercise over trials, including the counsellors and therapists. With random allocation to what are designed to be bad versus good therapists out of the question ( Highlighted study above), proving therapists have an impact on substance use outcomes and why they have that impact is not straightforward. It may also (if findings on the treatment of depression apply) require an unusually large study and unusually complete monitoring of client-therapist relationships, offering sufficient assessments for a reliable average to be computed and also taking these measures early in the therapeutic programme, before the relationship begins to reflect rather than promote client progress.

In practice, evidence for therapist effects has often been gathered as a by-product of a study whose main aim was to evaluate an intervention, not the interventionists. To show 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, without alienating patients to the point that many disengage from therapy and from the study. No surprise, then, that often patients do about as well whichever therapist they have been assigned to; the surprise is that sometimes therapist effects nevertheless emerge, even in the most highly controlled studies.

In the supplementary text (click to unfold Unfold supplementary text) we offer examples of modern-day studies. They illustrate the difficulties of finding therapist effects and even more so of pinning these down to what the better therapists are doing which makes them better, but they also show these effects can be found and are related to patients’ substance use outcomes, and more so, to their engagement with therapy and satisfaction with the therapist. Among the findings, you will come across that same “openness to experience” which became seen in the 1960s as the foundation of effective therapy and counselling.

Thanks for their comments on this entry to David Skidmore based in England, former probation officer, addiction counsellor and regional manager with the National Treatment Agency for Substance Misuse. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Close Matrix Bite guide and commentary Close Matrix Bite Close Matrix Bite guide and commentary