Therapist discourse in manualised therapy for alcohol addictions

In the context of the rising agenda of evidence based practice, the use of treatment manuals is now common in psychotherapeutic treatments for addiction and other mental health issues. There is debate amongst clinicians and researchers regarding the trade-off between the costs and benefits of manuals; and differing opinions regarding the importance of treatment fidelity. One concern that clinicians often raise is the effect that manuals have on clinical judgement and responsivity, and one benefit that researchers raise is the standardisation of treatment. The purpose of this study was to consider how therapists enact the delivery of manualised through analysing the discourses used. Particular attention was given to how therapists attempted to facilitate behaviour change using both adherent and non-adherent techniques, and how therapists addressed the expression of client emotions. Two types of manualised alcohol addiction therapy sessions were investigated in this study; Motivational Enhancement Therapy, and Social Behaviour and Network Therapy, both taken from the large scale UK Alcohol Treatment Trial (UKATT research team, 2005). A discursive psychology informed analysis was conducted, spanning nineteen therapy sessions with six therapist-client dyads. The interpretative repertoires that therapists used to promote behaviour change were: therapist actions are responsible for enabling change, clients are responsible for changing their own behaviour, and therapeutic alliance is required for change. These were enacted through the following discursive practices: being paternalistic, being critical, persuading, lecturing, using humour, being collaborative, acting as benevolent expert and constructing oneself as a powerful expert. Therapists managed adherence to the manuals and responsivity to the clients in differing ways; at times prioritising one over the other, at other times attending to both, and at other times attending to neither. Therapists responded to clients’ expression of emotions in a variety of ways categorised under two themes of acknowledging and avoiding. The analysis highlighted the variability of therapist responses within both manualised therapies, which is discussed in further detail. The clinical implications, opportunities for further research, and limitations of the study are discussed.