❝ empathy is rarely seen in a fully fledged form ❞

Carl Rogers


Whatever the role a practitioner may have, there are things that they can do for the better, and things that are for the worse.

How important are practitioners?

The way that practitioners behave makes a difference to treatment outcomes - for good or bad. The research evidence is consistent and well developed. The story starts back in the 1960s when so-called humanist approaches to treatment emerged. Carl Rogers was an influential American psychologist who developed the idea of person centered therapy.

Carl Rogers on Empathy (14.06) remains one of the key lessons for all practitioners to absorb and to apply in their practice. Showing empathy is repeatedly found to be an important characteristic of effective therapists.

Around the same time a group of researchers led by Morris Chafetz in Massachusetts set out to understand the nature of alcoholism and improve the treatment available. They further found that improving understanding of the nature of excessive alcohol use would enable practitioners to demonstrate respect for their clients. They called one of the chapters in their book: Making Alcohol Use and Problems Respectable. Their title focuses our attention on recognising that shame is not a feeling likely to result in help seeking, that alcohol problems are widespread, that their causes or origins are as likely to be social as they are to be individual and psychological, and that we have some idea of how people can be helped to improve their lives in every way. It is worth reading the detail of these studies because of their contemporary relevance. Busy A&E department staff in the main just wish that people with alcohol problems were not there and unsurprisingly often give them just this message. Of course these principles are true for all drugs not just alcohol.

How do you engage people with services?
Key point :: it is important to have dedicated addiction staff
This groundbreaking work observed that people with alcohol problems were reluctant to go to alcoholism treatment clinics and set out with a rather simple proposal in their attempt to change this. Treating people with concern and respect quickly improved the numbers who turned up at the alcohol treatment clinic following an attendance at the local emergency room.

Rather than services constantly improving it seems to be the case that the lessons from the 1960s have to be learned over and over again. No doubt there are multiple reasons for this including the absence of a career structure in the addiction field and the repeated recommissioning of services. Carl Rogers and Maurice Chafetz have given us some principles that are both timeless and applicable to all practitioners. Research on the effectiveness of practitioners who are therapists is extensive - here is a landmark study as an example…

How effective are therapists?
Key point :: therapists are varied in their effectiveness
This study was conducted in a methadone clinic and the findings are consistent with other similar studies. Therapists varied significantly in their delivery of effective treatment across a range of outcome measures - many were very good but a few actually made things worse. These differences held up for different interventions.

Once it was observed that therapists vary in their effectiveness the next question was in what way? Quite a bit is known about this albeit that the evidence has come together piecemeal. The ability of therapists to form a therapeutic relationship, also referred to as a working or helping alliance with service users is the key. The better this relationship the more likely that good outcomes will follow. If you have an illness or a problem of some kind you want to know that the person helping you to deal with it understands what is going on, knows what to do about it, and is generally agreeable. So it is with addiction problems. This is what we know about the characteristics of effective therapists:

Practitioner qualities

  • Empathic

  • Experienced over a number of years

  • Authoritative in their field

  • Psychologically stable

  • Interested in academic enrichment and disinterested in personal enrichment

Practitioner behaviours

  • Active listening and reflection

  • Shows genuineness, respect and direction

  • Adherent to treatment modality (with flexible use of treatment manual)

The therapeutic relationship seems to be all important. We know that practitioners with certain qualities are likely to build positive relationships but so can other people. For example, people in recovery who may not have the ideal practitioner characteristics can, nonetheless, build positive relationships and be effective counsellors. The explanation is that people who have had similar experiences have a natural affinity and basis for mutual trust. Mutual aid groups such as SMART, AA and NA depend on this kind of therapeutic relationship which is also supported in some way by a 'manual' - the 12 steps for example.