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Three patients with drinking problems talk about their care providers:
I remember when I first met that doctor. She seemed friendly but when I tried to con her, she laughed and told me to get my priorities right. Typical alcoholic thinking – just told myself that she didn’t understand, and I didn’t bother to turn up for the next appointment. What happened next? I get a letter, not one of those form-letters that hospitals send out, but a personal letter from this doctor saying something like, “I know it’s difficult. I don’t want to push you into anything, but I’ll be in the clinic on Friday afternoon if you want to talk about things further.” So I went back to tell her she didn’t understand!
That social worker was the first guy in years who seemed to really believe in me, after all my screw ups and all my broken promises. At first I was able to stop drinking simply because I didn’t want to let him down, didn’t want to prove that he was wrong for having confidence in me. When I went back to the drink I was so ashamed that I could barely face him. But he didn’t condemn me, he just said that we would figure out together how it happened and try to get back on track.
I don’t know why it didn’t work, because everyone told me how smart a psychiatrist he was and they were right. He had more awards and degrees and books in his office than I have hairs on my head. But whenever I tried to tell him how I really felt, he either contradicted me or changed the subject. Even though I was drinking less, and I guess that’s to his credit, I left most of our psychotherapy sessions feeling 2 inches tall. And then I stopped going. All I have now is my AA [Alcoholics Anonymous] sponsor, who didn’t even go to university and isn’t any smarter than I am. But he “gets me,” and he treats me with respect, and that’s what I need.
The previous chapters have described how to assess a patient, formulate the case, set a treatment goal, and conduct any needed detoxification. After all this preliminary work, the time has come for treatment to begin in earnest. Yet we cannot jump directly into specific clinical techniques without first discussing their essential context: the therapeutic relationship.
Human beings are not machines who passively allow repairs by a tool-wielding expert. They are active parties in the change process, which is pursued in alliance with a clinician who is also a human being. Attention should therefore be given to the subtle and important range of happenings that occur whenever patient and clinician interact – the what, when, and how of what is felt and said and done between them. Otherwise, we are at risk of throwing out as packaging an essential content of the parcel.
The characteristics of a high-quality therapeutic relationship
The relationship between patient and clinician is fundamental both to what can be achieved in any one therapeutic session and to what changes can be won over time (Luborsky et al., 1985). It begins to be built at the first moment of contact, is developed during the assessment interview (or interviews), is vital to the effectiveness of the initial counselling and goal-setting, and continues thereafter as an important component of treatment (Edwards, 1996). “What is said” matters, but it cannot be abstracted from the feelings between the two people who are doing the saying and the listening. Take, for instance, the following remarks by a clinician that might be necessary at a certain point in an individual’s treatment:
You know that l believe you can stop drinking and make sense of your life, but things can’t usefully just drag on. You’ve been coming up here regularly to talk about your problems for the last 6 months, and we are both aware that you’re now becoming badly caught up in this business of, “I’ll start tomorrow … the day after.” Here’s a challenge. Instead of us meeting next week as usual, I propose that you come back in a month’s time and show me that by then you have stopped these binges and started instead to do some of those things with your family that you have been talking about. I want you to show yourself that you can succeed, and that will be a great feeling. It’s time to make a start. You can make a start.
That same form of words may have three different types of impact. The impact may be negative, with the patient reinforced in their sense of hopelessness. The second alternative is for the patient in effect not to hear what is said because no words spoken within a meaningless relationship can matter: if they bother to come back in a month’s time, it will be with nothing having changed. Last, there is the possibility that the challenge is taken and used as a turning point, but this outcome can only be expected when the relationship positively matters. At worst, the word “relationship” is devalued into a catch-phrase of professional jargon, and yet every now and then one senses again the intensely important reality of what is being talked about.
Working with drinking problems requires an awareness of how relationships are made and used, but there is little that is unique to alcohol problems in this regard (Levin & Weiss, 1994). Certain characteristics of clinicians account for between 10–50 percent of treatment outcome variance. More effective clinicians are empathic, supportive, and also goal-directed (Najavits & Weiss, 1994; Raistrick, Heather, & Godfrey, 2006). Being goal-directed bears special comment in that the successful professional is not the mushy stereotype of the clinician who approves of everything and sets no limits or change-targets in treatment. Rather, effective clinicians both take the work of change seriously while maintaining an attitude of respect and support toward the patient. The way in which clinicians interact with patients may be at least as important as the specific approach used (Carroll, 2001; Connors et al., 2000).
The qualities of the therapeutic relationship that should be aimed for are summarized in Table 12.1. All of them overlap to some degree but will be discussed separately because they each merit attention.
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Alliance in pursuit of a common goal
Rivers of ink have been spilt in the psychotherapy literature regarding whether one theoretical orientation is superior to all others. Yet, regardless of whether treatment is psychodynamic, cognitive, or behavioural in nature, the strength of the alliance between the clinician and patient will be a significant determinant of success (Luborsky et al., 1985). To put it bluntly, even the most skillfully applied treatment techniques will be ineffective if, fundamentally, the clinician and patient are working against each other.
Clear formulation of the case, clearly articulated to the patient is critical for building the alliance from the start of treatment (see Chapter 11). So, too, is the negotiation of treatment goals. Some differences regarding goals is tolerable: for example, if the patient is 80 percent sure that a moderate drinking goal is best and the clinician is only 60 percent sure, they can proceed together toward that goal in good faith, with one or both potentially revising their view as treatment moves along. But if the clinician believes, for example, that treatment is about changing drinking behaviour and thereby improving the patient’s marriage, whereas the patient believes treatment is about getting his or her spouse to stop complaining about the drinking – which will go on as before – treatment is quite possibly a lost cause from the start.
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