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Influenced by the evidence

July 28, 2009
by Mark Sanders, LCSW, CADC
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Addiction counselors can be effective without a wholesale adoption of evidence-based approaches

Fifty percent of chemically dependent clients leave treatment prematurely. Fifteen percent of chemically dependent clients are administratively discharged, and the great majority of the rest who relapse do so within the first 90 days after leaving treatment.1 These relapse rates have resulted in a call for a treatment paradigm shift, and thus the movement toward evidence-based practices.2
Yet the main challenge in making this transition lies in the fact that evidence-based practices are difficult to implement for many reasons, including:

Cost. In order to prove fidelity to a model, agencies need to be fortunate enough to receive a large research grant, have a university affiliation, hire research teams to formulate questions, decide the nature of the studies (i.e., randomized, double-blind, etc.), conduct the trials, make comparisons with control groups, analyze data, and hire utilization review teams.3 This is costly.
Locating clients. With relapse rates being extremely high, many chemically dependent clients are difficult to locate for the purpose of studying results, for reasons involving cell phone disconnections, evictions, arrests, homelessness and spontaneous relocations, among other factors.
Limited direct observation. Many supervisors report that they rarely have the opportunity to directly observe counselors working with clients. It is difficult to implement an evidence-based practice without direct observation and feedback from supervisors.4
Evidence-based practices vs. reality. Most evidence-based practices are individualized approaches.4 Addiction counselors do a great deal of their work in groups. This makes it difficult to utilize evidence-based practices.
Natural resistance to change. Some counselors have utilized their clinical approaches for so many years that they could do their work blindfolded. New approaches can be threatening to their comfort level, causing them to resist adopting them.5
Expert approach to implementation. Many organizations introduce evidence-based practices by bringing in experts to teach the models to counselors. This is often met with resistance, as some counselors believe that the experts do not live in the real world.3,5
Ignoring grief. As organizations move toward evidence-based practices, counselors will naturally have grief reactions. Ignoring this grief can lead to anger and resistance to adopting new approaches.5
Lack of buy-in from the top. Some agencies attempt to implement evidence-based practices by sending counselors to training without identifying the strategies to be used at the organizational level to ensure that information gained in training will be adopted. Training is not enough to ensure adoption—there needs to be buy-in from the top of the organization as well.3

What can be accomplished
While evidence-based practices are difficult to administer, it is still possible for counselors to be influenced by the evidence. Suggestions include:

Listen more than you talk. The research from many evidence-based practices indicates that there is a relationship between increased verbalization among clients and outcomes. Specifically, outcomes are better when the client talks more than the therapist does.4,6,7
Invite solutions from clients and partner with them. Clients feel a greater satisfaction in counseling when there is a partnership between them and their counselors. This will increase the chances that they will return for future sessions.6,8
Minimize confrontation. While heavy confrontation is an important part of the addiction field’s historic path, studies reveal that heavy confrontation increases client dropout rates. Some studies indicate that for some clients, the more heavily they are confronted the more heavily they drink.6
Spend time in the beginning engaging your client in treatment. Research reveals that client engagement may be a more important determinant of client outcomes than the specific evidence-based practice that is used.8
Increase individual counseling sessions. As a field, we have historically done a great deal of group therapy, as it is time- and cost-effective. As stated earlier, most evidence-based practices are individualized approaches.
Work with families. Studies show that various types of family therapy increase recovery rates; these include family systems therapy, structural family therapy, network therapy and behavioral couples therapy.4,9
Work with couples. Behavioral couples therapy has proven to increase client attendance in continuous care, reduce the length of relapses, and increase recovery rates.4,9
Provide 90 days of continuous recovery support. Most relapses occur in this window.1,10
Make assertive linkages into 12-Step and other communities of recovery. Handing clients a list of 12-Step meetings and simply encouraging them to go is not nearly as effective as assertively linking them into the program, such as by educating them about 12-Step, using volunteer escorts, suggesting tasks for the meetings, etc.11,12

Managers’ role
There are ways in which managers and supervisors can help counselors be influenced by evidence-based practices. These include: