Therapist Factors

This chapter has focussed on research into the effectiveness of different treatment modalities in the response to alcohol-related problems, with some attention to issues of intensity, setting and implications for cost-effectiveness. What has not yet been covered is research on the non-specific features of treatment that are common to all modalities and delivery settings -chiefly characteristics of therapists and their interactions with clients that are associated with the variance in treatment outcome. There are grounds for believing that these therapist and interactional factors are nearly as important to treatment success as differences between treatment modalities based on psychological or therapeutic theories - some would say more important (Luborsky et al., 1986).

The factor of this kind that has received most attention in the alcohol field is therapist empathy. Miller, Taylor & West (1980) reported that behavioural self-control training on a one-to-one basis was no more effective than a self-help manual without therapist contact. However, when the authors examined differences between therapists more closely, they found that clients of therapists rated as most empathic fared better than those given a self-help manual, whereas clients of those rated least empathic did worse. Therapist empathy accounted for two-thirds of the variance in outcome of treatment at various follow-up points. Valle (1981) reported similar findings from a study of client-centred counselling for alcohol problems. A further remarkable finding was reported by Miller, Benefield & Tonigan (1993) who showed that half the variance in treatment outcome could be predicted by the degree to which the therapist had confronted the client, in many ways the opposite of empathy, during treatment sessions.

The issue of therapist factors was explored in Project MATCH (1998b) but this analysis was limited by the fact that therapists were selected by their preferences for each of the three modalities studied. This may be the reason why no clear picture emerged of therapist characteristics or skills associated with better outcome. However, in all three of the treatments under study, at least one 'outlier' therapist produced results much worse that the remainder.

One other feature of Project MATCH findings deserves comment in this section on non-specific factors. Whatever method of accounting is used, this project produced highly successful outcomes of treatment and these outcomes were associated with highly trained therapists delivering standardised treatment manuals written by some of the best clinicians and researchers in the field in the US (Kadden et al., 1992; Miller et al., 1992; Nowinski, Baker & Carroll, 1992). Thus the issue of professional training for alcohol therapists, and the degree to which the success of treatment as a whole can be improved by better training and greater quality control, is an important one for any treatment system. With regard to manualised treatments, it is not known whether this produces better treatment than allowing therapists more flexibility in the conduct of treatment but this is an issue clearly in need of research attention.

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