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1. Principal investigator: Title of project: Site of research: Duration of project: 2. Background

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origins of the between-therapist variation in substance abuse treatment effectiveness;Site of research: School of Social Sciences and Humanities, University of Tampere, Finland; Duration of project: 48 months.

2. Background

The effects of various treatments on outcome have been studied extensively in both

psychotherapy and substance abuse treatment (Lambert & Ogles, 2004; Raistrick, Heather, & Godfrey, 2006). According to meta-analytic reviews, there is little evidence that specific treatments differ in their effectiveness (Imel, Wampold, Miller, & Fleming, 2008; Wampold, 2001).

The investigation of between-therapist variation in effectiveness has been relatively rare in the substance abuse field (Najavits, Crits-Christoph, & Dierberger, 2000; Staines, Cleland, & Blankertz, 2006). It has been more common in psychotherapy research (Ackerman & Hilsenroth, 2003; Beutler et al., 2004). In both of these the therapist has proved to be an important factor.

The mean proportion of psychotherapy outcome variance explained by the therapist has been about 8% (Wampold, 2006). Research on substance abuse treatment also supports these findings: the therapist has been found to explain 4-12% of outcome variance, depending on treatment type and dependent variable used (Project MATCH Research Group, 1998). A recent study demonstrated that as many as one in six therapists ended up with clients whose substance use disorders were significantly worse than when they started treatment (Kraus, Gastonguay, Boswell, Nordberg, & Hayes, 2011).

In psychotherapy research naturalistic studies have been conducted on between-therapist variation in effectiveness (Lutz, Leon, Martinovich, Lyons, & Stiles, 2007;

Wampold & Brown, 2005). However, studies on therapist effects in the substance abuse field have rarely been based on an approach with no selection of clients and therapists (Carroll, 2001). These studies have mostly been unintentional by-products of clinical trials. The results of these studies are likely to have limited generalizability to everyday practice.

Another important therapist-related factor is the working alliance between client and therapist. The alliance serves as an infrastructure on which other therapeutic functions rely. Therefore the alliance is in a crucial position with respect to outcome (Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Horvath & Bedi, 2002). There is evidence that between-therapist variation in the alliance is related to treatment effectiveness

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Further, client satisfaction with treatment has been found to contribute to outcome. In a study by Donovan, Kadden, DiClemente, and Carroll (2002), higher levels of client

satisfaction were associated with higher levels of treatment attendance and greater reductions in drinking during treatment. Despite the potential importance of client satisfaction in

substance abuse treatment, relatively little research has investigated this topic. * * *

Our own studies on the subject can be divided into three entities. In the first stage the vignette task developed by Valle (1981) was translated into Finnish and piloted in outpatient substance abuse treatment in order to investigate between-therapist (N= 4) variation in interpersonal functioning (Saarnio & Mäntysaari, 2002). The vignette task proved

psychometrically sound in our circumstances. Next we conducted a pilot study to test if the vignette task would predict between-therapist (N = 4) differences in the client (N = 66) dropping out of outpatient treatment (Saarnio, 2002). It emerged that the better the therapist’s social skills were, the fewer clients dropped out of treatment.

In the second stage we investigated differences in therapists’ (N = 162) personality traits and interpersonal functioning (Saarnio, 2011a; 2011b). The sample size was greater than in the first stage and it was gathered from several inpatient institutions (N = 17). In addition to a personality test the vignette task was used again. The findings indicated that there were considerable differences between therapists not only in social skills but also in those personality traits assumed important for effective treatment.

In the third stage a multisite (N= 7) naturalistic study was conducted on between-therapist (N = 33) variation in outpatient treatment effectiveness and client satisfaction (N = 327) (Artkoski & Saarnio, in press; Knuuttila, Kuusisto, & Saarnio, 2011). This was

apparently the largest sample size so far in Finnish research on substance abuse treatment. The findings indicated that there was significant between-therapist variation in treatment effectiveness and client satisfaction. However, we were unable to explain the reasons for this with the research design used.

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The research so far – our own and that of others – has demonstrated that there are considerable differences between therapists on the one hand in interpersonal functioning and personality traits and on the other in treatment effectiveness. It is surprising that very little research has been conducted on the connections between therapist’s characteristics and treatment effectiveness – only a few pilot studies (Saarnio, 2002; Valle, 1981). However, studies in both research areas have habitually stressed a need for this.

Thus it remains a mystery to what extent the therapist’s characteristics account for treatment effectiveness. To solve this problem requires a study in which these two aspects are combined using a sufficiently large sample size. It is moreover necessary to incorporate into the study those methods which are known to be useful and those which are new to this field. 3. Objectives

The purpose of the study can be divided into two parts: 1) finding an explanation for between-therapist variation in treatment effectiveness, 2) further developing methods for the

investigation of therapist characteristics.

The study will bring together four different research perspectives and methods: 1) personality research, 2) research on social skills and nonverbal reasoning, 3) psychotherapy research, 4) research on substance abuse treatment. Briefly described, our approach can be illustrated by the proverb “The colour of the cat doesn’t matter if only it is a good mouse catcher”.

4. Research methods, materials and ethical issues

Those participating in the study will be clients and therapists from several outpatient treatment units, with approximate number of cases about 500 and 40, respectively. The

implementation of the study will adhere to naturalistic principles, that is, clients and therapists will not be selected and treatment will be arranged with the units’ everyday practices. The study arrangements will moreover be planned in such a way as to cause as little burden to participants as possible.

Therapists will be studied using five different tests: 1) PK5 Personality Inventory (PK5, 2007), 2) the Adult Autism Spectrum Quotient (Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley, 2001), 3) the Reading the Mind in the Eyes Test (Baron-Cohen,

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Wheelwright, & Hill, 2001), 4) the vignette task for interpersonal functioning (Valle, 1981), 5) a task for therapist attitudes towards clients, to be developed specifically for this study.

In the selection of the tests attention was paid on the one hand to their theoretical coherence and on the other the strength of the empirical evidence. The personality test is based on the Five-Factor Model (FFM) (Goldberg, 1993). Underlying the tests of social skills and nonverbal reasoning is the Theory of Mind (TOM) (Premack & Woodruff, 1978). The vignette task for its part is based on Rogers’ (1965) conception of psychotherapy. The task for therapist attitudes towards clients will be built on the principles of motivational interviewing (MI) (Miller & Rose, 2009). MI is a style of client-centred counselling developed to facilitate change in addictive behaviours. We shall also draw on our own earlier research on MI

(Saarnio, 2011c).

Given the amount of time available, treatment follow-up is not a realistic option. The focus of the project will therefore be on aspects within treatment. There will be a total of four dependent variables: 1) the working alliance between client and therapist, 2) client’s

satisfaction with therapist, 3) client’s hopefulness regarding the future, 4) dropping out of treatment. Demographic information on clients and therapists will be collected by a questionnaire, which will also contain client items on substance use and therapist items on professional activities. In addition, client’s self-efficacy and readiness to change will be checked by questionnaires.

Both clients and therapists will participate in the study on a voluntary basis to be ascertained through written consent. Tentative consent for the study has already been received from the A-Clinic Foundation, which maintains a large share of outpatient treatment units here. The research plan is to be processed later by the ethics committee of the Foundation. 5. Implementation: timetable, budget and distribution of work

The project is to be implemented in four stages: 1) preparation for data collection and studying the most recent contributions to the research literature (1 September 2013 – 28 February 2014), 2) data collection and finalizing analysis plan (1 March 2014 – 28 February 2015), 3) data analysis and start of writing up (1 March 2015 – 28 February 2016), 4)

completion of publications and presentation of findings in domestic and international forums (1 March 2016 – 31 August 2017). Finally, the data will be stored in the Finnish Social Science Data Archive (FSD).

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The total costs of the project amount to 920,721 Euros. The share of the University of Tampere will be 30 per cent (276,216 Euros) and of the Academy of Finland 70 per cent (644,505). The total costs of personnel will be 839,221 Euros to be divided between a postgraduate student (36 months), a postdoctoral researcher (48 months) and a research assistant (18 months). The indirect employee costs amount to 53 per cent and the overheads 77 per cent. The table below provides further details.

Salaries 2013 2014 2015 2016 2017 Total

Salaries 14 954 96 435 86 517 81 181 30 805 309 892

Indirect employee costs 7 926 51 111 45 854 43 026 16 327 164 244

Overheads 17 618 113 610 101 926 95 639 36 292 36 5085 2013 2014 2015 2016 2017 Total Other costs 9 600 28 450 16 550 14 400 12 500 81 500 2013 2014 2015 2016 2017 Total Total costs 50 098 289 606 250 847 234 246 95 924 920 721 2013 2014 2015 2016 2017 Total University of Tampere 15 029 86 882 75 254 70 274 28 777 276 216 2013 2014 2015 2016 2017 Total Academy of Finland 35 069 202 724 175 593 163 972 67 147 644 505

Other costs will accrue from expert consultation, travel, per diem allowances, test materials and final seminar to the amount of 81,500 Euros. The task of the raters is to evaluate the responses to the vignette task (7,500 Euros). A translator will check and, if necessary, translate project publications into foreign languages (14,000 Euros). Advice from a statistician will be required during the data analysis because given the time available learning the most complicated statistical methods is not reasonable (5,000 Euros). The decidedly high level of expenses for travel and per diem allowances (50,000 Euros) is necessary because the implementation of a multisite study necessitates repeated visits by research personnel to the treatment units. The other travel expenses will cover attendance at foreign conferences where the project findings will be presented. The rest of other costs are

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intended to cover test materials, the expenses of arranging a final seminar and making of posters (5,000 Euros).

6. Researchers, research environment and mobility

The project researchers will be: 1) Petri Mäkelä, M.Soc.Sci., postgraduate student, 2) Katja Kuusisto, Ph.D., postdoctoral researcher*. Mr. Mäkelä is a specialist in MI. He has

considerable experience of practical substance abuse treatment. Dr. Kuusisto for her part is experienced in the research on substance abuse treatment. Her doctoral dissertation on recovery routes from alcoholism was accepted in 2010, in addition to which she has been a researcher on the Academy funded project “Effectiveness of substance abuse treatment in light of common factors” led by the present applicant.

The location of the project is the University of Tampere School of Social Sciences and Humanities. Here there are also co-operation partners on which the project can, if necessary, rely for assistance: Emerita Professor Anja Koski-Jännes (motivational interviewing, working alliance) and Professor Jari Hietanen (nonverbal reasoning, social skills).

The international dimension of the project is to be found both in its envisaged publications and conference presentations and also through established researcher contacts. Research on this subject is very scarce in Finland. So the basic nature of the project is inevitably international. In addition, therapist effects in substance abuse treatment appear largely the same throughout the world.

7. Researcher training

In keeping with the regulations, the tasks of the postgraduate student and the postdoctoral researcher will also include 80 hours of teaching per academic year for each. This teaching will be offered to undergraduates and postgraduates. The researchers are also involved in the University of Tampere interdisciplinary addiction research seminar, which is under the direction of the present applicant.

* Dr. Kuusisto has also submitted an application for the Academy’s postdoctoral researcher post. Her research plan is entitled “The client's viewpoint on the effectiveness of substance abuse treatment”. These two plans are totally different from each other.

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8. Expected results

This project has been planned to be just the size that it needs to be. So what really are the reasons for between-therapist variation in treatment effectiveness? We have excellent prospects for taking the project to a successful conclusion and solving this mystery. Valuable knowledge about research methods will also be generated. The findings will be significant both nationally and internationally and for the research on substance abuse treatment and its practice. International co-operation is the more important because our research group is the only one here of the subject area.

The objective regarding publications is to produce peer-reviewed articles for international journals and a doctoral dissertation in monograph format. A review article on the findings will also be made for a Finnish scientific journal. The main responsibility for writing the articles rests with Dr. Kuusisto and Professor Saarnio. The articles will address both research objectives described before. The emphasis in Mr. Mäkelä’s doctoral

dissertation will be on therapist’s attitudes towards clients. * * *

The following is likely an appropriate epilogue to this research plan: “The quality of clinical services would benefit more from a research paradigm that emphasizes ‘empirically supported psychotherapy practice’ than one focused on ‘empirically supported treatments’. We take an even stronger stance and believe that emphasizing ‘empirically supported therapists’ may prove even more beneficial to client outcomes.” (Okiishi, Lambert, Nielsen, & Ogles, 2003)

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9. Bibliography

Ackerman, S., & Hilsenroth, M. (2003). A review of therapist characteristics and

techniques positively impacting the therapeutic alliance.Clinical Psychology Review,23, 1-33.

Artkoski, T., & Saarnio, P. (in press). Therapist effects in substance abuse treatment: A naturalistic study.Journal of Substance Use.

Baron-Cohen, S., Wheelwright, S., & Hill, J. (2001). The ‘Reading the Mind in the Eyes’ Test revised version: A study with normal adults, and adults with Asperger Syndrome or high-functioning autism.Journal of Child Psychology and Psychiatry,42, 241-252. Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J. & Clubley, E. (2001). The Autism Spectrum Quotient (AQ): Evidence from Asperger Syndrome/high functioning autism, males and females, scientists and mathematicians.Journal of Autism and Developmental Disorders,31, 5-17.

Beutler, L., Malik, M., Alimohamed, S., Harwood, T., Talebi, H., Noble, S., et al. (2004). Therapist variables. In M. Lambert (Ed.),Handbook of psychotherapy and behavior change (pp. 227-306). New York: Wiley.

Carroll, K. (2001). Constrained, confounded and confused: Why we really know so little about therapists in treatment outcome research.Addiction,96, 203-206.

Connors, G., Carroll, K., DiClemente, C., Longabaugh, R., & Donovan, D. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology,65, 588-598.

Crits-Christoph, P., Hamilton, J., Ring-Kurtz, S., Gallop, R., McClure, B., Kulaga, A., et al. (2011). Program, counselor, and patient variability in the alliance: A multilevel study of the alliance in relation to substance use outcomes.Journal of Substance Abuse Treatment,40, 405-413.

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Del Re, A., Flückiger, C., Horvath, A., Symonds, D., & Wampold, B. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis.Clinical Psychology Review,32, 642-649.

Donovan, D., Kadden, R., DiClemente, C., & Carroll, K. (2002). Client satisfaction with three therapies in the treatment of alcohol dependence: Results from Project MATCH. American Journal on Addictions,11, 291-307.

Goldberg, L. (1993). The structure of phenotypic personality traits.American Psychologist, 48, 26-34.

Horvath, A., & Bedi, R. (2002). The alliance. In J. Norcross (Ed.),Psychotherapy

relationships that work. Therapist contributions and responsiveness to patients (pp. 37-69). Oxford: OUP.

Imel, Z., Wampold, B., Miller, S., & Fleming, R. (2008). Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders.Psychology of Addictive Behaviors,22, 533-543.

Knuuttila, V., Kuusisto, K., & Saarnio, P. (2011). Client characteristics and therapist style: A combined analysis of impact on retention and effectiveness in outpatient substance abuse treatment.Nordic Studies on Alcohol and Drugs,28, 321-338.

Kraus, D., Gastonguay, L., Boswell, J., Nordberg, S., & Hayes, J. (2011). Therapist

effectiveness: Implications for accountability and patient care.Psychotherapy Research,21, 267-276.

Lambert, M., & Ogles, B. (2004). The efficacy and effectiveness of psychotherapy. In M. Lambert (Ed.),Handbook of psychotherapy and behavior change(pp. 139-193). New York: Wiley.

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Lutz, W., Leon, S., Martinovich, Z., Lyons, J., & Stiles, W. (2007). Therapist effects in outpatient psychotherapy: A three-level growth curve approach.Journal of Counseling Psychology,54, 32-39.

Miller, W., & Rose, G. (2009). Toward a theory of motivational interviewing.American Psychologist,64, 527-537.

Najavits, L., Crits-Christoph, P., & Dierberger, A. (2000). Clinicians impact on the quality of substance use disorder treatment.Substance Use & Misuse,35, 2161–2190.

Okiishi, J., Lambert, M., Nielsen, S., & Ogles, B. (2003). Waiting for supershrink: An empirical analysis of therapist effects.Clinical Psychology and Psychotherapy,10, 361-373.

PK5 (2007). PK5-persoonallisuustestin käsikirja [Manual of the PK5 Personality Inventory]. Helsinki: Psykologien Kustannus.

Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a theory of mind?The Behavioral and Brain Sciences,4, 515–526.

Project MATCH Research Group (1998). Therapist effects in three treatments for alcohol problems. Psychotherapy Research,8, 455-474.

Raistrick, D., Heather, N., & Godfrey, C. (2006).Review of the effectiveness of treatment for alcohol problems. London: NTA (National Treatment Agency for Substance Misuse). Rogers, C. (1965).Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton Mifflin.

Saarnio, P. (2002). Factors associated with dropping out from outpatient treatment of alcohol-other drug abuse.Alcoholism Treatment Quarterly,20, 17-33.

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Saarnio, P. (2011a). Therapists’ big five personality traits and interpersonal functioning in the substance abuse field: A cluster-analytic study.Journal of Substance Use,16, 348-358.

Saarnio, P. (2011b). The relationship between general therapeutic orientation, big five personality traits and interpersonal functioning in substance abuse therapists: An explorative study.Addictive Disorders & Their Treatment,10, 29-36.

Saarnio, P. (2011c). Therapist’s preference on motivational interviewing and its

relationship to interpersonal functioning and personality traits.Counselling Psychology Quarterly,24, 171-180.

Saarnio, P., & Mäntysaari, M. (2002). Rating therapists who treat substance abusers. International Social Work,45, 167-183.

Staines, G., Cleland, C., & Blankertz, L. (2006). Counselor confounds in evaluations of vocational rehabilitation methods in substance dependency treatment.Evaluation Review, 30, 139-170.

Valle, S. (1981). Interpersonal functioning of alcoholism counselors and treatment outcome.Journal of Studies on Alcohol,42, 783-790.

Wampold, B. (2001).The great psychotherapy debate. Models, methods and findings. Mahwah, NJ: Lawrence Erlbaum.

Wampold, B. (2006).The psychotherapist. In J. Norcross, L. Beutler & R. Levant (Eds.), Evidence-based practices in mental health(pp. 200-208). Washington, DC: APA. Wampold, B., & Brown, G. (2005). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care.Journal of Consulting and Clinical Psychology,73, 914-923.

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