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Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

Includes brief interventions

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Effectiveness Bank Drug Treatment Matrix

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Management/supervision; Generic and cross-cutting issues

Key studies on management and supervision across psychosocial and medical treatments of problem drinking. Highlights that “Manners Matter”, focuses on staff recruitment, queries the ubiquitous stages of change model, and details the fascinating history of the most controversial issue in alcohol treatment: whether to insist dependent drinkers try for abstinence. See the rest of row 2 of the matrix for more on features common to psychosocial and medical treatments.


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 The abstinent alcoholic (1962). Classic description of the patient who has sustained abstinence after treatment but is still unhappy, unfulfilled and/or nervously hanging on – in other words, not really ‘recovered’. They formed the majority of patients seen at US alcohol clinics in the 1950s who were not drinking at follow-up. Related study and review below. For related discussion click and scroll down to highlighted heading.

S Alcoholics can learn to moderate their drinking (1973). Not the first, but the most incendiary paper to challenge the orthodoxy that abstinence must be the only treatment goal for dependent drinkers. See also second- (1976) and third-year (1978) follow-up results. This refutation (1982) based on a 10-year follow-up was itself refuted (1984) by the original authors. Related study above and review below. For discussion click and scroll down to highlighted heading.

‘Skid-row’ alcoholic

Clinic manager transformed response of patients dismissed as intractably treatment-resistant.

S Organised caring transforms alcohol clinic (1970). Remarkable series of US studies from the late 1950s proved that fresh management can transform an alcohol clinic’s intake and attendance – in this case by listening to previously dismissed ‘skid-row alcoholics’, being responsive to their needs, and systematically yet caringly keeping in touch. See also a slide presentation which ends by focusing on the studies.

S Relapse-preventing social skills of counsellors can be identified in advance (1981). US study at an inpatient alcohol unit found strong links between the interpersonal qualities and skills exhibited by counsellors in response to typical patient/family scenarios and how many of their patients later relapsed. Related study below. For discussion click and scroll down to highlighted heading.

K Identifying rapport-generating counsellors (2002). Responses to written counselling scenarios identified which counsellors would best generate retention-enhancing rapport at a Finnish outpatient alcohol clinic. Partial replication of US study above. For discussion click and scroll down to highlighted heading.

K First get the staffing right (2004). US study suggests that recruiting the ‘right’ clinicians who have not been trained in appropriate ways to relate to patients is preferable to choosing the ‘wrong’ ones who have been trained, and the former gain most from training. For discussion click and scroll down to highlighted heading.

K Try walking in their shoes (2008). When senior staff role-played becoming a new client (a ‘walk-through’) at their own US substance use services, the resulting enlightenment helped halve waiting times and extend retention. See also this extension (2012) to the programme and an account (2007; free source at time of writing) of the walk-through procedure. Walk-throughs are a key element in the NIATx quality improvement model; see document and web site listed below. For discussion click and scroll down to highlighted heading.

K “You cannot treat an empty chair” (2013; free source at the time of writing). Title is from a report of how 67 US substance use outpatient clinics used the NIATx quality improvement model (see web site below) to reduce ‘no-shows’ through sensitively-handled reminder calls, cutting waiting times, increasing capacity (eg, extra hours), and psychosocial interventions such as motivational interviewing to bolster engagement. Related document above.

K Systematically link assessments to services (2005). In Philadelphia automatically linking problems identified at treatment intake to relevant local services transformed assessments from clinically redundant paperwork into a practical route to the ‘wrap-around’ care advocated to deepen and extend recovery. For discussion click and scroll down to highlighted heading.

R How to generate evidence-informed practice ([Australian] National Centre for Education and Training on Addiction, 2008). Though they found few studies on substance use treatment, reviewers extracted valuable lessons from health services on how to implement research-based innovations to improve treatment practice. One of a package of three reviews and a presentation from Australia’s national centre devoted to these issues.

R Care enough to be personal but also to be systematic and persistent (2004). In seemingly mundane tasks like appointment-reminders and checking how former patients are doing, individualised and welcoming communications characterise retention-enhancing services. Systematising such procedures embeds ‘caring’ in routine pracctice. For discussion click and scroll down to highlighted heading.

R Cycle of change model poor guide to intervention (2001). Its simplicity is beguiling, but can services trust Prochaska and DiClemente’s ubiquitous model to guide them in matching interventions to a client’s ‘stage of change’? This thorough but easy-reading review found little evidence to support this popular strategy. Since it was written not much has changed. For discussion click and scroll down to highlighted heading.

R Offer moderation as well as abstinence as a treatment goal (2013). Concludes that dependent drinkers can cut down, that treatments based on this goal are probably just as effective as abstinence-oriented approaches, and that allowing patients a choice improves outcomes. Related studies (1 2) above and review below. For related discussion click and scroll down to highlighted heading.

R Tentative support for matching treatment to patient preferences (2016). The first review to evaluate shared decision-making and matching substance use treatment to patient preferences found some evidence that greater patient involvement has no negatives and can improve outcomes. Related review above. For related discussion click and scroll down to highlighted heading.

R Involving former problem substance users in promoting recovery (2014). For such a widely implemented and recommended adjunct to formal treatment, the revelation from this review is how little evidence there is for involving former substance users in promoting recovery – a lack which may simply reflect the paucity of adequate research. However, on balance the evidence we do have is positive. Related UK and US supervision guidelines below.

R G Train for skills not programmes (2010; free source at time of writing). “Shift the focus of dissemination efforts from manualized psychosocial interventions to specific skill sets … broadly applicable and easily learned by clinicians,” is a core recommendation in this thoughtful US essay on integrating evidence-based practices into real-world clinical settings. Also makes a stab at what those skills should be in order to target key therapeutic goals.

G English inspectorate’s criteria for quality in substance use services ([English] Care Quality Commission (CQC), accessed 2020). Official inspector of health and social care services in England asks five key questions of specialist NHS and independent substance use services. One (“Is it well-led?”) assesses management through questions such as, “Is the culture centred on the needs and experience of people who use services?” More on what “well-led” means in appendices to prior consultation. Standards based on the CQC’s requirements listed below.

G English drug services define their own quality standards (2016). From the English addictions treatment sector, standards developed after consultation and piloting to help services assess how they support clients into and through recovery and the quality of vital aspects of their organisations. Can act as a checklist for managers as well as services and commissioners. Consists of: standards for non-residential services (2016); implementation guide (2016) for these standards; and standards for residential rehabilitation (2016). Based partly on CQC requirements listed above.

G Criteria for quality in substance use treatment in Scotland (Convention of Scottish Local Authorities and Scottish Government, 2014). Developed to ensure anyone looking to address their problem drug and/or alcohol use receives high-quality treatment and support that assists long-term, sustained recovery and keeps them safe from harm. Can act as a quality-assurance checklist for service managers.

G UK staff development toolkit ([English] National Treatment Agency for Substance Misuse, 2006). From the former central authority for substance use treatment in England, guidance including recruitment, training, staff development, appraisals, supervision, and exit interviews. For related discussion click and scroll down to highlighted heading.

G Managing peer supporters ([UK] Substance Misuse Skills Consortium, 2015). Guidance from (no longer operational) government-supported skills body for the substance use sector on how to manage (ex-)problem substance users who support other users through and out of treatment. Related review above and US guidelines below.

G Supervising peer supporters (2017). US checklist and training curriculum for developing and evaluating a service’s competence to supervise (ex-)substance users whose role is to promote recovery among the service’s patients. Related review and UK guidelines above.

G Assessing whether the workforce has the required knowledge, skills and ability (NHS Health Scotland, 2009). Desired competencies and assessing the training needs of Scotland’s substance use workforce at all levels, from specialists to generic workers who may deal with substance use only peripherally.

G Improving efficiency and capacity means more patients can be helped ([US] NIATx, accessed 2020). Web-based service supported by US government offers practical strategies to improve management of substance use treatment services. Objectives include reducing waiting times and the number of ‘no-shows’ (example above) and increasing admissions and retention (example above). For related discussion click and scroll down to highlighted heading.

G Managing non-residential programmes ([US] Substance Abuse and Mental Health Services Administration, 2006). US expert consensus on managing outpatient, counselling and day-care substance use services, including strategies to meet “the challenges facing executives”.

G Clinical supervision and professional development of substance use counsellors ([US] Substance Abuse and Mental Health Services Administration, 2009). US expert consensus on monitoring staff performance and supervision methods and models, including how these can address cultural, ethical and legal issues, plus an implementation guide for administrators.

G Workforce development aid for managers ([Australian] National Centre for Education and Training on Addiction, 2005). Evidence-based strategies to address priority workforce development issues such as supervision, team building and performance appraisal, plus resources to help managers implement the strategies. Endorsed by the Australian government.

G Implementing change ([US] Substance Abuse and Mental Health Services Administration, 2009). Guide for managers on how to assess an organisation’s capacity to identify priorities, implement changes, evaluate progress, and sustain effective programmes, and how to implement these programmes. Substantially draws on a broader review (2005).

more Search for all relevant Effectiveness Bank analyses or for sub-topics go to the subject search page or hot topics on why some treatment services are more effective than others, controlled drinking as a treatment goal, matching alcohol treatments to the patient, matching interventions to the client’s ‘stage of change’, and individualising treatment. See also a reading list (2013) from a leading US analyst intended to help treatment services develop recovery-oriented programmes, and a resource list (2014) from the UK’s Substance Misuse Skills Consortium to (among other topics) help managers recruit and supervise staff, manage organisational change, and foster effective team working.

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