From Chapter1, Identifying, assessing and treating concurrent disorders: The client-counsellor relationship in Treating Concurrent Disorders: A Guide for Counsellors (©2005 CAMH)
Most texts that discuss ways to identify, assess and treat concurrent disorders concentrate on methods, techniques, tools and instruments. The interpersonal dimensions of working in this area are given, at best, a passing nod. This is understandable: cooccurring substance use and mental health problems are complex and diverse, with patterns of illness and recovery that are dynamic and elusive. To be as helpful as possible, the counsellor needs many resources to understand the client’s problems. When clients present with complex problems and histories, the clinician’s first consideration tends to be, “What tools will help me screen for substance use and mental health problems and, then, assess comprehensively?”
However, if one is preoccupied with technique, it is easy to forget that the fundamental task for the counsellor is to work with the client and the other people who can play an important role in producing healthy outcomes. This chapter addresses the role of the client–counsellor relationship, serving as a background for the following chapter, which discusses instruments and techniques.
Note: The term client can be used here to refer not only to the narrow description of someone with a diagnosis of a substance use disorder or mental illness, but also to the broader set of people who are affected by substance use and mental health problems, including people who are not formally involved in the health care system. The term also extends to those who are affected by other people’s mental health and substance use problems. While the context for a counsellor’s involvement with this wide range of people varies, the helping role applies, no matter what the situation.
Evidence of the importance of the client–counsellor relationship
Evidence suggests that the client–counsellor relationship has more influence on engagement and improved outcomes than the methods, tools and instruments we employ (Hubble et al., 1999). Clients coming into treatment facilities for assessment indicate that the warmth and welcoming attitudes of the staff—rather than client perceptions of the staff ’s skills—are the most important factor in making clients want to return to use the service (Health Canada, 2002).
In a cross-cultural meta-analysis of therapy outcome literature, Asay and Lambert (1999) report that the single most important factor that the counsellor can influence is the therapeutic relationship; this relationship explains 30 per cent of the variance in treatment outcome. Technique and method, which counsellors tend to focus on in their training, was only half as powerful, accounting for just 15 per cent of the outcome variance in therapy. The other factor that the therapist can influence, expectancy (the belief that things will improve or be adequately addressed), accounted for 15 per cent of the variance—the same as technique and method. That leaves 40 per cent of the variance to extratherapeutic factors relating to the client’s personal strengths and weaknesses, social supports and environmental resources.
Too often, clinicians have assumed that clients with severe, persistent substance use and mental health problems are too compromised to benefit from the therapeutic relationship in the way healthier clients are. We are now seeing that the opposite is true.Where clients face overwhelming challenges, a respectful, continuing, supportive relationship with a health care provider not only helps people to get through hard times, but also to accomplish positive change.
Identifying, assessing and treating concurrent disorders: The client–counsellor relationship