“Something is rotten in the state of Denmark,” muses one of Shakespeare’s characters in “Hamlet.” And after a round of bad press lately – the hard-hitting, June 26 exposé by “Sunday Night With Megyn Kelly” a case in point – it would be easy to size up all addiction treatment in similar terms, however misguided.
What such stories sadly overlook, and often at the expense of the millions of Americans whose lives hang in the balance because of substance abuse, is that treatment can be the best hope of recovery. We now know, for example, thanks to ongoing research in the field, that there is such a thing as “clinical excellence” in treating addiction. This article, as the first in a three-part series devoted to the theme, will explore three key building blocks of progress in addiction treatment that anyone in the world of recovery – be they a client needing treatment, a family member, clinician or referring professional – can benefit from knowing:
1. “Therapeutic Alliance” is the clinical term that is meant to describe the level of trust, working rapport and mutual connection between a client and their primary therapist. Research has revealed that the quality of this client-clinician relationship is of paramount importance – so much so, in fact, that the therapeutic alliance is reportedly the single biggest, clinician-influenced predictor of positive treatment outcomes.
Strikingly too, the therapeutic alliance proved to be an even bigger influence on positive treatment outcomes than the particular modality (or type of psychotherapy) itself. For example, cognitive behavioral therapy (CBT) and motivational interviewing (MI) are evidence-based therapies for substance use disorders (SUDs), meaning that in multiple clinical trials these two interventions have been associated with better treatment outcomes. Yet regardless of which of these two modalities was used, therapeutic alliance reportedly emerged as a bigger determinant of treatment progress.
If the strength of therapeutic alliance is such a vital component of successful addiction treatment, how, then, is it created for clients – and then measured and evaluated with a view to improving recovery outcomes in real time? The use of standardized measures of therapeutic alliance is one way; so are ongoing trainings for clinical staff in how to strengthen and evaluate therapeutic alliance; and finding the best fit of therapist for each incoming client is another way. (Upon admission to treatment, the use of certain evidence based assessment tools can facilitate a good client-therapist match.)
But the regular evaluation of clinical staff according to measures of therapeutic alliance is also critically important. For more on this next building block of progress in addiction treatment, read on.
2. Clinical Supervision might seem like a no brainer – especially when treatment outcomes for substance abuse are necessarily a source of concern – but sadly; they are not yet the norm in the field of addiction treatment. A recent article in The Atlantic, titled “What Your Therapist Doesn’t Know,” draws attention to this current gap between, on the one hand, the recognition that the therapeutic relationship (a.k.a. “therapeutic alliance”) is vital to a client’s treatment progress, and, on the other, a lamentable scarcity of performance feedback that can cue therapists in to how they are doing with respect to the effectiveness of their interventions, including therapeutic alliance.
But it’s precisely this kind of performance feedback that is so critical to improving treatment outcomes, as the same article in The Atlantic, written by a practicing therapist, reiterates. The author, citing studies showing how feedback-informed treatment (FIT) is associated with better client outcomes, shares the story of two of his own clients: one, a heroin addict whom he calls “Grace,” progressed in therapy for a time only to relapse and tragically die from an overdose; but the other client, “June,” experienced a much happier outcome, one that the author attributes to performance feedback and metrics.
When metrics revealed June was not progressing in treatment, the author (her therapist) sought out performance feedback from a seasoned therapist. Together they viewed a video of a recent therapy session, reflecting on what clinician-directed improvements could be made to better serve June’s needs. (And in this case, the counsel to her therapist was that he “get out of the authority role, approach June as an equal partner, and help her acknowledge her pain and anxiety…”) That approach is reportedly “what may have saved June’s life.”
Clinical supervision therefore works best when the following elements are in place:
• “Feedback-informed treatment” that provides clinicians with performance feedback and the opportunity to adjust their interventions accordingly and in real time
• The regular observation and evaluation of actual clinical sessions (via videotaped recordings)
• The over-arching goal of delivering the very best clinician driven treatment outcome possible in each client’s case
• A formal and disciplined working alliance between a clinician and a more experienced clinical supervisor
3. Outcomes Tracking is another critical but oft-overlooked building block of progress in addiction treatment – yet the data for recovery outcomes at treatment centers can often be sparse at best, for various reasons. Sometimes, the systems for collecting and evaluating this data are not in place, or a commitment to tracking outcomes isn’t there; sometimes marketing interests can get in the way of an impartial process of data collection. Whatever the reason, one direct consequence can be that the quality and effectiveness of treatment suffers.
Here, too, however, there are certain evidenced best practices for tracking and evaluating outcomes. For starters, investing in an independent third party that collects and analyzes data on client outcomes is one such practice. Another is employing evidence-based measurement tools for tracking and optimizing treatment outcomes. Any data retrieved by these efforts should then be the basis for future clinical research and efforts to improve treatment outcomes, providing a feedback loop that helps providers continually monitor and improve clients’ treatment experience and their prospects of long-term recovery.
In summary, therapeutic alliance, clinical supervision and outcomes tracking are three building blocks of progress in addiction treatment that, in the 21st century, define clinical excellence in treating addiction. While there is no iron-clad, one-size-fits-all guarantee of a successful recovery from drug and alcohol addiction—no matter how far research takes us, it’s hard to imagine a scenario in which this prospect could ever be real—these three findings from emerging science can be fresh footholds of hope for anyone suffering from addiction, and for all those who love and care for them.
Anna Ciulla has been passionately helping clients with substance use and
co-occurring disorders to heal, using solution-focused, strengths based
care, for nearly twenty years. In her role of directing client care services
at Beach House Center for Recovery, she uses a spiritual perspective and
strongly believes in the power of a culture of connection for both clients
and staff. https://www.beachhouserehabcenter.com