Welcome to this edition of “Research to Practice,” which covers two items. The first adds additional support to the importance of the counseling relationship, and the second is about timing your counseling strategies.

More counselor-client relationship data

In the June 2003 issue of Counselor, we reviewed the importance of the counselor-client relationship in relation to outcome. Additional research supporting that finding was recently published (Kasarabada, et al., 2002). The researchers wanted to know if clients’ favorable perceptions toward their counselors contributed to favorable outcome. If yes, then improving the counselor-client relationship would be important. The research team found that certain outcome parameters were partly related to the clients’ perception of their counselors. This finding was based on a project in which a group of clients (n=511, 225 males, 286 females) from 19 different programs were surveyed, while in treatment, on a number of counselor aspects (e.g., empathy and directiveness). One year later, the clients were contacted to see how they were doing. Results showed that clients who perceived their counselor as positive stayed longer in treatment, and had better psychiatric composite scores. Interestingly, there was only a limited relationship between the positive perception and severity of alcohol use, and no relationship to the follow-up drug severity. Those clients who did lower their drug use rated themselves as more responsible and had rated their counselors on a higher level of immediacy. These findings were especially related to counselor empathy, attractiveness, and directiveness.

Research-to-practice key: If you are able to develop a good counseling relationship with your client, that client may well improve his/her psychological well-being following treatment. In addition, clients tend to stay in treatment longer, allowing you to work on a variety of issues such as relapse potential and overall recovery skills. Moreover, if clients view themselves as responsible for their recovery and have a positive view of their counselors, the drug use will also decrease, this research suggests. With clients staying longer in treatment, you have the ability to develop this attitude even more. This key is no stranger to most responsible addiction program philosophies. However, this is just one small piece of the counseling pie. It is not meant to be the final word.

The “try it yourself” section: For the adventurous, it is again time for a simple experiment. The question to address would be something such as: Is counselor empathy related to lower Addiction Severity Index (ASI) scores? Find a copy of the ASI, and administer it to a sample of clients (try to get 25 or more clients for this experiment). Run that sample through you program. Around the discharge date, ask each client in the sample to rate his or her counselor’s empathy (use a Likert scale). Keep those scores someplace, and wait a few months. Then find as many clients from this group as you can and ask them to retake the ASI. There should be a positive correlation between lower post-treatment client ASI scores and the higher client perception of counselor empathy. As always, I would be interested in your findings.

Timing counseling interventions
We don’t often see research about timing counseling interventions, i.e., adjusting your counseling strategy to the client situation. However, one such timing issue has been out there for a few years — under the guise of the transtheoretical stages of change (Prochaska & DiClemente, 1982). Most practitioners have heard of the stages of change:

1. Precontemplation: The client isn’t aware that change is contemplated or even needed.

2. Contemplation: The client begins to realize there is a problem, and thinks about doing something.

3. Preparation: The client has made a decision to change and is now willing to do something about it.

4. Action: The client actually does something to deal with the problem. It is at this stage actual steps are taken to adjust old behaviors into new ones.

5. Maintenance: New behaviors are sustained and eventually blended into a new life style.
   A cursory glance at these stages suggests that the counselor needs to administer a different counseling strategy for each stage of change. Simply, the counselor needs to adjust or time interventions based on the client’s stage.

Bad timing or using interventions that are not conducive to a particular stage of change is going to result in non-compliance or resistance (Taleff, 1997). For example, if you expect a client to be ready to make major changes the day he or she walks into your office, your goals are unrealistic. Not long ago, some treatment centers demanded just that. If the clients weren’t ready to do significant behavioral change on the day of admission, they were summarily kicked out and tagged as still in denial.

Research-to-practice key: What are the optimal interventions for various stages of change? DiClemente (2003) recommended some broad counseling tasks for each stage, and we added other research-based strategies that fit the various stages. They are:

1. Precontemplation: Since the client doesn’t think there is a problem, which precludes the need for change:

• Take modest first steps, like helping the client keep appointments, or encouraging the client to simply talk, or working through the anger, shame, fear that often accompanies this stage.

• Develop that professional relationship!

• Try to get the client to be concerned about the problem, increase his or her awareness, and envision the possibility of change. This generally means administering carefully planned educational strategies.

2. Contemplation: Now that the client thinks there may be a problem, and even thinks about doing something, consider:

• Analyzing the pros and cons of the current behavior.

• Offering hope.

• Getting in touch with core values that can promote change.

• Offering encouragement.

• Beginning discussions about what all the changes would look like, move on to the steps of decision-making.

• Sustaining the professional relationship.

• Encouraging the client to talk with someone who’s been through what they are going through.

3. Preparation: Now that the client has made a decision to change and is willing to do something about it:

• Begin to make real change plans (each client will need his or her own special plan, but focus on cues, triggers).

• Make the plan with the client, not for the client.

• Shift from educational and consciousness-raising approaches to skill-building approaches.

• Enlist support of family, friends, and others.

• Offer encouragement where appropriate.

• Keep the professional relationship firm but warm.

• Schedule a few peer-support meetings (e.g., AA, NA, SMART, SOS, WFS) in the plan.

4. Action: The client is now doing something to change old behaviors into new ones. So:

• Take small first steps.

• Understand (not criticize) failure and adjust the plan accordingly.

• Keep the encouragement going.

• Reward real progress.

• Try out a few peer-support meetings (e.g., AA, NA, SMAET, SOS, WFS).

• Try a mix of cognitive-behavioral coping strategies.

5. Maintenance: At this stage, new behaviors are being sustained and combined into a new lifestyle. Consider:

• Reinforcing what works.

• Cutting back on formal therapy.

• Using the best support groups or systems.

• Creating a working relapse-prevention plan.

The caveat remains that these are suggestions and will need to be tweaked for each client.

The “try it yourself” section: If you haven’t already adjusted your counseling strategies to what stage of change represents each of your clients, try a little research project. First, establish a baseline of client compliance with treatment. This can be as simple as creating a compliance Likert scale for each client and noting how each client is doing following a session. This will be the dependent variable, or the thing you want to change. Do nothing different for a few weeks to a full month.

Then start adjusting your counseling to the stage of change for each client. This will be the independent variable, or the thing that may change the dependent variable. Note your clients’ compliance on the Likert scale for another few weeks to a month. Finally, compare the two results. Try to match the two groups of clients as closely as you can. Note that this experiment is not rigorous, so your results are to be viewed with some caution.
As usual, I would be interested in your results.

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai’i at Manoa. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
DiClemente, C.C. (2003). Addiction and change: How addictions develop and addicted people recover. New York: Guilford.
Kasarabada, N. D., Hser, Y.I.., Boles, S.M., & Huand. Y.C. (2002). Do patient’s perceptions of their counselors influence outcomes of drug treatment? Journal of Substance Abuse Treatment, 23 (4), 327-334.
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Journal of Counseling and Clinical Psychology, 51, 390-395.
Taleff, M.J. (1997). A handbook to assess and treat resistance in chemical dependency. Dubuque, IA: Kendall/Hunt.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2003, v.4, n.5, pp. 66-67.

One person has commented on this article.

 1. Untitled
Mark MacDonald, Unregistered

The high outcomes of our patients are directly related to their attendance of outside support meetings,AA,NA,AV, etc.

Waiting until the patient is in the Preperation Stage of Change would set our outcomes back to an unacceptable level. The outside support meetings are attending with our counselors. This process is started immediately after detox. The patients may not understand what they see or hear, yet all make valuable "new friends" and contacts for long-term absyinence and "Emotional Recovery".

 Posted 2007-06-17 07:23:18

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