The Alcohol Treatment Matrix is concerned with the treatment of alcohol-related problems among adults (another deals with drug-related problems). It maps the treatment universe and for each sub-territory (a cell) lists the most important UK-relevant research and guidance. Across the top, columns move from specific interventions through how their impacts are affected by the widening contexts of practitioners, management, the organisation, and whole local area treatment systems. Down the rows are the major intervention types implemented at these levels. Inside each cell is our pick of the most important documents relevant to the impact of that intervention type at that contextual level. 

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What is cell B2 about?

Whether medical or psychosocial, chosen positively or under pressure, among the ‘common factors’ affecting treatment’s success is the patient’s relationships with referral and treatment staff. Relationships affect whether people want to start treatment after initial contact (for an example see document listed above), whether they stay (free source at time of writing), and the services they receive. Via these mechanisms and also directly (document listed above), ultimately relationships can affect the degree to which treatment helps patients overcome their problems with drinking and improve their lives.

Relationships emerge partly from the patient, but of most interest is the clinician’s contribution, because this is what can be manipulated by (among other methods) recruitment procedures, training, and experience. The interpersonal style and other features of treatment staff are much less commonly researched than the nature of the intervention, and studies commonly try to eliminate these influences (which can still break through despite the researchers’ best efforts) in order to focus on the specific content of the intervention. In doing so they risk eliminating what matters (document listed above) in order to focus on what generally matters little or not at all (1 2).

Though this is the general picture, the nature of the research from which it emerges demands caution. Relative neglect of relationship issues means that associations between clinicians’ behaviour or characteristics and retention or outcomes often emerge from studies intended to investigate interventions, not interventionists. Without randomly allocating patients to different clinical styles, it is usually impossible to be sure that these associations represent causal effects. Additionally, publicly- or insurance-funded treatment services are the typical locus for research. There are reasons to believe that while in these services relationships with clinicians are from the patient’s point of view the key ‘quality’ dimension, in fee-paying services perceptions of quality are more about getting the outcomes paid for, structured therapeutic programmes, and what is seen as ‘professionalism’.

In this cell the focus is on therapist-related factors; common factors more generally are dealt with in cell A2. A closely related concept is the ‘placebo effect’ – the way common factors can generate improvements in patients even though the treatment has no specific active ingredients. How the therapist relates to the client is an important component. Even in medication-based treatment of physical as well as mental complaints, the physician’s enthusiasm for and confidence in the therapy can potentiate improvements in response to a medication or placebo. These effects are, however, complex and not uniform, sometimes (for example) emerging only when the enthusiastic role adopted by the doctor matches their real attitudes and expectations and those of the patients, and sometimes (free source at the time of writing) only when the doctor conveys warmth or the environment reinforces their competence – and in this randomised study of physical reactions to a placebo ‘treatment’ for an induced allergic skin reaction, maximally when both were present. You can find more on this study and on placebo effects in general in the corresponding cell (open the supplementary text in paragraph beginning “From outside substance use treatment… ”) of the Drug Treatment Matrix.