Psychotherapists' Experience with In-Session Use of Routine Outcome Monitoring: A Qualitative Meta-analysis

Routine outcome monitoring (ROM) has become an increasingly utilized tool in therapeutic practice that has the potential to improve therapy outcomes. This study aimed to synthesize the findings of existing qualitative studies investigating how clinicians use ROM in their work with clients. A systematic search of qualitative studies on clinicians' experience with the use of ROM in mental health services was conducted via PsycInfo, PsycArticles, Medline, Web of Science, and Scopus databases. Qualitative meta-analysis was used to synthesize the finding of the primary studies. Forty-seven studies met the inclusion criteria. The analysis resulted in 21 meta-categories organized into six clusters, namely (1) obtaining clinically relevant information, (2) adapting treatment, (3) facilitating communication, (4) enhancing the therapeutic relationship, (5) facilitating change in clients, and (6) personalized usage of ROM. The meta-analysis revealed that clinicians utilized ROM in diverse ways, including both informational and communicational functions. From the clinicians' perspective, ROM was an element that, on the one hand, introduced additional structure and standardization in treatment and, on the other hand, allowed for greater flexibility and tailoring of treatment.

Staying with the silence: Silence as affording care in online alcohol and other drug counselling

As the name 'talk therapy' suggests, a key aim of alcohol and other drug counselling, psychotherapy and other talk therapies is to discuss issues, concerns and feelings with a health professional. Implicit here is the therapeutic value of talking through issues with a trained professional. But as with all interactions, therapeutic encounters involve silences and pauses as key aspects of the communicative process. Despite their ubiquity in the therapeutic encounter, research tends to either dismiss silences as inconsequential or as having undesirable effects, such as generating awkwardness or even disengagement from treatment. Drawing on Latour's (2002) concept of 'affordance' and a qualitative study of an Australian alcohol and other drug counselling service, we explore the varied functions of silences in online text-based counselling sessions. For clients, these include the role of silence in affording opportunities to engage in other everyday practices, such as socialising, caregiving or working - practices that can generate comfort and reduce distress, which in turn may support the therapeutic encounter. Similarly, for counsellors, temporal silences provide opportunities to confer with other counsellors and provide tailored care. However, protracted silences can raise concerns about the safety and wellbeing of clients who do not respond promptly or who exit encounters unexpectedly. Similarly, the sudden cessation of online care encounters (often associated with technical difficulties) can leave clients feeling frustrated and confused. In tracking these diverse affordances of silence, we draw attention to its generative potential in care encounters. We conclude by exploring the implications of our analysis for conceptions of care that underpin alcohol and other drug treatment.

Addressing alcohol and other drug use among young people from migrant and ethnic minority backgrounds: Perspectives of service providers in Melbourne, Australia

Young people from migrant and ethnic minority backgrounds are recognised as emerging priority populations for reducing alcohol and other drug (AOD)-related harms in Australia. Limited research has investigated how service providers address AOD challenges in migrant communities. In this qualitative study, we interviewed 15 service providers from AOD, migrant support, community and other health services in a diverse region of Melbourne. Interviews explored the challenges that service providers faced and the strategies they implemented to engage with young migrants in relation to AOD use. Thematic analysis was used to generate four themes: stigma as a barrier to service delivery, intergenerational differences between young people and parents, the need for outreach and establishing trust and understanding over time. Service providers believed that stigma prevented many young people from migrant backgrounds having open conversations about their AOD use with family members and professionals. Participants perceived that some parents had less AOD-related knowledge and lower English language proficiency than their children creating challenges for effective communication. Service providers recognised the importance of engaging with young people in settings where they felt comfortable rather than expecting them to approach their service. Participants also acknowledged the need to invest time in establishing trust and understanding with young migrants so they could facilitate conversations about AOD use as relationships evolved. Although service providers had a strong understanding of young people's needs, they found it challenging to build relationships in the context of funding and time constraints. Our results indicate the need for long-term funding and timelines that enable service providers to build strong relationships with young migrants, their families and their broader cultural communities to facilitate access to AOD support.

When the Brain Leaves the Scanner and Enters the Clinic

Addiction neuroscience promises to uncover the neural basis of addiction by mapping changes in the “diseased brains” of people with “drug addictions.” It hopes to offer revolutionary treatments for addiction and reduce the stigma experienced by those seeking treatment for a medical, rather than moral, condition. While the promises of addiction neuroscience have received considerable attention, relatively few studies have examined how neuroscientific discourses and promises play out in drug treatment settings. Instead of asking how neuroscience might measure or treat a preexisting addiction “problem,” we draw on poststructuralist ideas to trace how neuroscientific discourses produce addiction as a certain type of “problem” and the effects of these particular problematizations. Based on interviews with a range of different types of treatment providers working in Victoria, Australia, we discuss three themes that reveal neuroscientific discourses at work: (1) constituting pathological subjects, (2) neuroplasticity and “recovery,” and (3) the alleviation of guilt and shame via references to the “diseased brain.” On the basis of our analysis, we argue that dominant neuroscientific discourses produce patients as pathologized subjects, requiring medical treatment. We also contend that the intersection of neuroscientific and recovery discourses enacts “recovery” in terms of brain “recovery” through references to neuroplasticity. Further, when neuroscientific and moral discourses intersect, addicted subjects are absolved from the guilt associated with immoral behavior emerging from a “hijacked brain.” We conclude by emphasizing the need for future critical work to explore the complex ways in which neuroscientific discourses operate in localized care ecologies.

Making visible the politics and ethics of alcohol policy research

Although research on alcohol policy has produced a huge international literature, alcohol research and policy itself-its cultural assumptions, methods, politics and ethics-has rarely been subject to critical analysis. In this article, I provide an appreciative review of an exception to this trend: Joseph Gusfield's 1981 classic, The Culture of Public Problems: Drinking-Driving and the Symbolic Order. I first outline Gusfield's argument that the 'problem of drinking-driving' is constructed as a 'drama of individualism' centring on the 'killer drunk'. The 'culture' of drinking-driving research and policy emphasizes alcohol as the problem and locates the source of car accidents in the moral failings of the individual motorist, rather than in social institutions or physical environments. For Gusfield, this construction of the problem is the outcome of political and ethical choices rather than of 'objective' conditions. In the second part of the article, I highlight the book's remarkable foresight in anticipating later trends in critical policy analysis, and argue that it should be regarded as a sociological classic and as required reading for those working in alcohol and indeed other drug policy research. I conclude by arguing that The Culture of Public Problems remains relevant to those working in alcohol and other drug policy research, although the reasons for its relevance differ depending on readers' theoretical commitments.

"What constitutes a 'problem'?" Producing 'alcohol problems' through online counselling encounters

Typically, health policy, practice and research views alcohol and other drug (AOD) 'problems' as objective things waiting to be detected, diagnosed and treated. However, this approach to policy development and treatment downplays the role of clinical practices, tools, discourses, and systems in shaping how AOD use is constituted as a 'problem'. For instance, people might present to AOD treatment with multiple psycho-social concerns, but usually only a singular AOD-associated 'problem' is considered serviceable. As the assumed nature of 'the serviceable problem' influences what treatment responses people receive, and how they may come to be enacted as 'addicted' or 'normal' subjects, it is important to subject clinical practices of problem formulation to critical analysis. Given that the reach of AOD treatment has expanded via the online medium, in this article we examine how 'problems' are produced in online alcohol counselling encounters involving people aged 55 and over. Drawing on poststructural approaches to problematisation, we not only trace how and what 'problems' are produced, but also what effects these give rise to. We discuss three approaches to problem formulation: (1) Addiction discourses at work; (2) Moving between concerns and alcohol 'problems'; (3) Making 'problems' complex and multiple. On the basis of this analysis, we argue that online AOD counselling does not just respond to pre-existing 'AOD problems'. Rather, through the social and clinical practices of formulation at work in clinical encounters, online counselling also produces them. Thus, given a different set of circumstances, practices and relations, 'problems' might be defined or emerge differently-perhaps not as 'problems' at all or perhaps as different kinds of concerns. We conclude by highlighting the need for a critical reflexivity in AOD treatment and policy in order to open up possibilities for different ways of engaging with, and responding to, people's needs in their complexity.