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Phillips R., Bourne H.
International Journal of Drug Policy: 2008, 19(1), p. 33–41.
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From England, findings suggesting the intriguing but for the moment tentative possibility that non-conformist drug workers who value hedonism and stimulation help socially excluded clients improve most because their values match those of their clients.
Summary Little attention has been paid to understanding the impact of values, attributes and characteristics of drug workers on therapeutic relationships and treatment outcomes. Interaction of values with other variables is considered to be of importance since values play a role in determining attitudes and behaviours. This exploratory study investigated the impact of drug workers' personal values on client outcomes within a drug treatment service.
Eight drug workers and 58 clients were recruited at a UK charity working with problematic drug users who are also socially excluded. Drug workers completed a validated questionnaire to elicit their personal values. These were assessed by asking them to prioritise the importance of 57 attributes such as freedom, pleasure, self-discipline, respect for tradition, honesty, and social justice as "guiding principles" in their lives. Client outcomes were assessed using the Christo Inventory for Substance Misuse Services. The relationship between client outcomes and worker values were analysed using Spearman's rank test of association.
Drug workers prioritising stimulation, self-direction and hedonism value types experienced more positive client outcomes compared with those prioritising security, conformity, benevolence, tradition and universalism types. The value types associated with positive outcomes fall within Schwartz's 'openness to change' superordinate dimension, whereas those related to more negative outcomes fall within the 'conservation' dimension.
The study suggests that drug workers' personal values may have a significant impact on client outcomes in the treatment of substance misuse. Reasons for this finding are explored, as are limitations of this study and suggestions for future research.
commentary As the authors accept, this innovative study is best seen as opening up a potentially important line of enquiry rather than taking us far enough along it to draw conclusions. The most intriguing implication is that rather than what might be thought as the perfect stable-normal personality profile for a therapist, workers whose values and preferences deviate from the norm in the same direction as those of their drugtaking clients are most able to help them. However, this speculation is tentative; the findings are subject to alternative explanations and reliance on them is weakened some methodological concerns.
Among this small sample of British drug workers, the study found that a worker's values were related to improvement in their clients' substance use and social and psychological functioning from intake to treatment exit at least 12 weeks later. The strength of these associations was extraordinary.
Clients improved most when their workers prioritised:
Self-direction: independent thought and action; represented by valuing freedom, self-respect, creativity, independence, choosing your own goals, and curiousity;
Stimulation: represented by valuing an exciting, varied life, and being daring;
Hedonism: represented by valuing pleasure, enjoying life, and self indulgence.
Conversely, outcomes were worse when workers characteristically prioritised:
Conformity: exercising restraint to avoid upset or violating social expectations; represented by valuing politeness, self-discipline, honouring parents and elders, and obedience;
Security: safety, harmony and stability of society, relationships and self; represented by valuing a sense of belonging, social order, national security, reciprocation of favours, family security, health, and cleanliness.
In each case, de-prioritising these values bore an opposite relationship to client improvement. The underlying pattern is that workers characterised by 'openness to change' had better client outcomes, those who conservatively valued stability and established order had worse outcomes. The plausible presumption is that 'openness to change' values also typify users of illegal drugs. No UK study has investigated this directly, but if it were the case, it would fit with the findings of a Norwegian study which was one of the inspirations for the British research. This found that confluence in values between psychotherapists and their clients was associated with (from the patients' points of view) a stronger therapeutic relationship. Across psychotherapy including substance misuse therapy, feelings of empathy and being understood are associated with better outcomes. It could be that these feelings are strongest between like-minded therapists and patients.
However, in Norway, more significant yet were aspects of the therapist's personality, The strongest link was that interpersonally cold therapists were less likely to foster a strong therapeutic relationship. regardless of whether these matched those of their clients. In the featured study too, perhaps workers open to change were also more open to all their clients and better able to adapt to their needs and preferences, and/or were more willing to risk departing from normal or accepted practice to meet those needs. Preparedness to depart from a set treatment protocol has been associated with better substance use outcomes. So too has being responsive enough to the patient to match your approach to their mood, personality and recovery preferences, even if that means departing from state-of-the-art manuals. After being trained in motivational interviewing, in one study addiction counsellors who occasionally violated For example, by confronting clients, warning or directing them, and imposing advice or expressing concern without their permission. the approach's principles had clients who were better engaged and more forthcoming in therapy than more conformist trainees – but only as long as the entire interaction was characterised by socially skilled empathy and caring.
The featured study's findings are also reminiscent of a US study of ex-addict methadone counsellors published in 1974, which found that rather than the 'perfect' profile of a stable psychologically healthy therapist, "deviant" personalities who shared the insecurities and edginess of their patients and had a suspicious outlook on life had patients who engaged better and used drugs less.
Limitations acknowledged by the authors of the featured study include the small sample of drug workers and the atypical location. A centre in Bath treating socially excluded substance users with complex needs such as homelessness, which itself as an organisation valued attributes similar to those of the more effective workers. Elsewhere and with a different caseload, findings might have been different. Other potentially important unknowns The workers took on a case management role at the centre, so perhaps the advantage conferred by openness to change lay in how well they secured the cooperation of other services, rather than in how well they related to their clients. Neither do we know on what basis clients were allocated to their case managers; maybe, for example, those with the worst prognosis were directed to the more predictable, 'solid' workers. demand caution in interpreting the findings. One concern alluded to in the Norwegian study is that workers might falsely perceive greater improvement in clients whose values are (or are becoming) more like their own. The inventory used to measure improvement in the study has produced similar results when applied by different workers, also the case at the Bath centre when hypothetical clients were rated. But it is completed by the worker and relies on their judgements of the severity of the client's problems. A related possibility is that workers characterised by openness to change also tended to have rosier perspectives on how well their clients were doing.
Despite these cautions, the congruence between this study and the limited amount of allied substance misuse research suggests the findings may reflect a real phenomenon. In psychotherapy generally, similarity of social and intellectual values between therapist and client promotes improvement. If something like this is also the case in substance misuse treatment, it suggests that effective drug workers are as likely to be 'naturals' by virtue of their personalities, values and social skills as to be created by training or recognised by qualifications. It may be possible for such attributes to be recognised in advance by the reactions of relatively untutored observers to how workers say they would behave in different counselling scenarios.
Nothing in this study or in others contradicts the general finding that following a coherent, structured programme which makes sense to the worker and the client is an important therapeutic foundation. But with the relatively unconventional caseloads seen by drug services, being empathic, responsive and independent (or supported) enough to depart from the script when the situation demands is perhaps just as important.
Thanks for their comments on this entry in draft to Rosie Phillips of the Drugs and Homeless Initiative in Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 22 May 2013. First uploaded 02 March 2009
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DOCUMENT 2013 Sometimes best to break the rules