Attention to Clinician Processes

Techniques per se are inert; they come alive in the person of the therapist. Indeed, research shows that for patients with substance abuse in particular, the effectiveness of treatment is determined as much or more by the therapist as by theoretical orientation or patient characteristics (Luborsky et al., 1986; McLellan, Woody, Luborsky, & Goehl, 1988; Najavits, Crits-Christoph, & Dierberger, 2000; Najavits & Weiss, 1994b). Even separating a treatment into content and process may be an artificial distinction (Strupp & Binder, 1984). The therapist represents the form the treatment takes and can magnify or diminish its impact. And the more severe the patients, the more negative therapist processes are likely (Imhof, 1991; Imhof et al., 1983).

Therapist processes emphasized in this treatment include building an alliance; having compassion for patients’ experience; using the various coping skills in one’s own life (i.e., not asking the patient to do things that one cannot do oneself); giving patients control whenever possible (as loss of control is inherent in trauma and substance abuse); modeling what it means to try hard by meeting the patient more than halfway (e.g., “heroically” doing anything possible within professional bounds to help the patient get better); and obtaining feedback from patients about their genuine reactions to the treatment.

The flip side of such positive therapist processes is negative countertransference, including harsh confrontation; sadism; inability to hold patients accountable, due to misguided sympathy; becoming victim to patients’ abusiveness; power struggles; and, in group treatment, allowing a patient to be
scapegoated. As Herman (1992) has suggested, therapists may unwittingly repeat the roles of trauma—victim, perpetrator, or bystander. Attention is also directed to what might be termed “the paradox of countertransference” in PTSD and substance abuse. That is, PTSD and substance abuse appear to evoke opposite countertransference reactions, and it is difficult for therapists to balance these. PTSD tends to evoke sympathy and identification with patients’ vulnerability, which if taken too far may lead to excessive support and overindulgence rather than encouraging accountability and growth. Substance abuse tends to evoke concern and anxiety over patients’ substance use, which, if extreme, becomes harsh judgment and confrontation.
Therapists typically land too much on one or the other side of these opposites. Thus the goal is for the therapist to integrate praise and accountability, which are viewed as the two central processes in the treatment.

Therapist processes in this treatment are addressed through several features in each topic: a therapist “Orientation” that provides background about the topic and discussion of countertransference issues; a “Tough Cases” segment that presents typical treatment challenges for the therapist to rehearse; and an “End-of-Session Questionnaire” that obtains patient feedback about each session.

In addition, despite its highly structured approach, the treatment is designed to adapt flexibly to therapist preferences. For example, some therapists enjoy using CBT forms in sessions, while others dislike them; they are provided but always optional. Many topics have multiple subtopics from which to choose; and instead of a strict protocol, various ways to address the material are suggested. There is no required order of topics, and there are a variety
of formats in which to conduct the treatment. In short, respect for therapists’ individual styles and support for their very difficult role are emphasized throughout.