Effective people research
selected articles
How therapists behave makes all the difference to treatment outcomes
Research into what makes an effective practitioner has produced remarkably consistent findings. Perhaps most important is that the way practitioners deliver a treatment makes a bigger difference than the treatment itself. This is not to say that the treatment choice is unimportant, but being friendly, respectful and having an understanding of addiction problems is crucial to engaging people in treatment. This classic research says it all…
Classic study :: How do you engage people in treatment?
Chafetz ME, Blane HT, Abram HS, Golner J, Lacy E, McCourt WF, Clark E and Meyers W (1962) Establishing treatment relations with alcoholics. Journal of Nervous and Mental Disease 134: 395-409
The researchers looked at what happened when people with alcohol problems attending an Emergency Room were seen by the regular staff compared to staff from an alcohol agency. The first chart shows 65% of those seen by specialist alcohol staff attended the alcohol service for an initial appointment compared to 5.4% of those seen by ER staff. The second chart shows those making contact of any kind after the Emergency Room encounter.
It is all about being nice, being optimistic and showing expertise that gives confidence that you can help.
Review :: Treatment adherence
Gearing RE, Townsend L, Elkins J, El-Bassel N, and Osterberg L (2014) Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence. Harvard Review of Psychiatry 22: 31-45 DOI: 10.1097/HRP.10.1097/HRP.0000000000000005
Effective psychosocial interventions have a structure for which there is supportive evidence that the intervention works: it follows that adherence to the structure is important. No single, generally accepted, definition of psychosocial treatment adherence is available, however, three core elements need to be addressed: (1) session attendance (intervention dosage); (2) intra-session involvement (participation within sessions); and (3) inter-session involvement (take-home task completion). Drop-out most often occurs as a ‘no-show’ or after the first few sessions, while sustainable improvement tends to come later.
Session attendance is more complicated than it might appear. Attendance may be intermittent or suddenly end; an intervention may or may may not have a defined number of sessions; there may be good reason to finish treatment early, namely if the desired goals have been achieved. What goes on within a session is best captured by routine video or audio recordings, which can the be reviewed in supervision or privately by practitioners. There are also several scales, for example the Working Alliance Inventory, which measure opinions about treatment, albeit these may differ between service user and practitioner. Take-home tasks are an important part of psycho-social interventions and it is easy enough to see whether or not tasks have been attempted and completed.
Overcoming drop out depends, in large measure, on the quality of practitioners and how they relate to service users – this is well understood. Other barriers to attendance are simple enough but how to deal with these needs to be thought about: i) ease of access (cost and distance of travel) to an agency and flexibility of appointment times ii) effective communication before and throughout any intervention iii) explanation of the treatment to dispel anxieties (especially of any possible compulsory actions by the agency) iv) awareness of how to encourage at risk demographic groups (young people, economically disadvantaged, ethnic minorities, mental health problems, low expectations for change, child care responsibilities).
Not all therapists are equal
The next question is whether practitioners are born effective or learn to be effective. The answer is some of each and better questions are how much can be learned and what to do with practitioners who are not very good in spite of their best efforts.
Treatment outcomes vary quite markedly between therapists and there is no reason to suppose that this is not the case in most services. A strong clinical governance programme is perhaps the way to minimise variation. The next study is important because it was designed specifically to look at therapist effectiveness rather than the treatment they were delivering…
The effectiveness of nine well qualified and experienced therapists was judged against a collection of outcome measures: Addiction Severity Index (ASI) (drug use, employment, legal status, psychiatric status), Beck Depression Inventory, a symptom checklist (SCL90) and a neuroticism scale. Outcomes were averaged across each practitioner’s caseload. The chart shows how variable the practitioners prove to be in helping people to get better - notice that the ninth practitioner consistently made people worse.
Note that measures of practitioners’ personal qualities, interest in helping, psychological health and skill correlated with their Helping Alliance Questionnaire score (r=0.74), which in turn correlated across all outcomes (r=0.65) and with adherence to treatment manuals (r=0.44). In other words all these things have an impact on outcome.
Landmark study :: Are all therapists equally effective?
Luborsky L, McLellan T, Woody GE, O'Brien CP and Auerbach A (1985) Therapist Success and Its Determinants. Archives of General Psychiatry 42: 602-611
Service users want a ‘normal’ relationship with a knowledgeable practitioner
The Royal College of Psychiatrists has been proactive in looking at the effectiveness of its members. A study, How to Introduce Yourself , was interesting in showing, what some might see as the obvious, that when you meet a service user it is not enough to tell them your name; they also want to know what your role is and what the treatment session will involve, but they do not want to know anything personal about you.
The next study is about what service users think are important characteristics for their psychiatrist. We are not aware of any similar studies about addiction practitioners, but think it likely there would be many similarities…
Important study :: What sort of practitioner do service users want?
Laugharne R, Priebe S, Chevalier A, Paton C, Sharma RK, O’Kelly A and Richards G (2021) The sociocultural and behavioural characteristics that patients want in psychiatrists: cross-sectional survey of patients’ views. British Journal of Psychiatry Bulletin 45: 158–163 doi:10.1192/bjb.2020.115
This study asked 132 service users of mental health services what sociocultural characteristics they see as important in their psychiatrist. If repeated with addiction practitioners the results may be different, but they may well be very similar.
The four top ranking characteristics are not unique to any one profession or any given role, with the exception of having up to date medical knowledge (ranked 2nd most important), the characteristics are generic. 79% of service users wanted a practitioner who had been qualified for some time, meaning was experienced, and 73% wanted someone 40-55yrs. Otherwise the large majority rated gender, religion, social background or marital status low in importance. About a quarter of women expressed a preference to see a female or a (smaller number) male psychiatrist.
It is important that services strive to meet the preferences of all service users not just the majority, however large that might be.
Alexander LB, Barber JP, Luborsky L, Crits-Cristoph P and Auerbach A (1993) On What Bases Do Patients Choose Their Therapists? Journal of Psychotherapy Practice and Research 2: 135-146
Necessarily based on an artificial situation, this study is worth noting. Forty participants chose one of two therapists with whom they had two treatment sessions. The researchers conclude that the choice was made on the strength of their working alliance and liking for each other rather than demographic characteristics. It was noted that, from a psychological perspective, people like to have choices but not to make them.