Common Factors in Psychotherapy 12
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Transcript of Common Factors in Psychotherapy 12
Working Alliance &Common Factors in Therapy:
Old and New Challenges.
International Family Therapy Festival
(Accademia di Psicotherapia della Famiglia)
Roma, Italia02-xi-02
Dr JOHN BARLETTASenior Lecturer of CounsellingAUSTRALIAN CATHOLIC
UNIVERSITY
Download this presentation:
Web-Site:www.mcauley.acu.edu.au/staff/johnb/subjects.html
E-Mail:[email protected]
AIMS for this presentation:
• Review stages of client readiness for change.• Examine client and therapist characteristics
that facilitate positive outcomes.• Explore common curative factors responsible
for quality outcomes in therapy. • Provide an overview of the working alliance as
a powerful dynamic construct.
Outcomes of Therapy:
CHANGE - Growth & Development
• Thoughts, Feelings, Behaviours• Plans, Expectations, Hopes, Goals
Motivational Readiness& Stages of Change:
Pre-contemplation (no intentions)
Contemplation (considering)
Preparation (some commitment)
Action (new behaviours)
Maintenance (working consistently over time)
Termination (self-efficacy, 100% confidence)
(Prochaska, DiClementi, Norcross, 1992 )
Readiness & Stage of Change: “CUSTOMER”
GREEN LIGHT
• Able to identify goal (agree)• Views self as part of solution (explore)• Willing to take steps (encourage)• A “doer”
Homework: Assign doing tasks. (BTC, 1993; deShazer; Prochaska & DiClemente)
Other Stages of Change:
“Complainant”: AMBER LIGHT
“Visitor”: RED LIGHT
“How do therapists move such clients?”
Client Characteristics related to Positive Outcomes: (Weiner,
1998)
• Client motivated, and hopes to change, and expects that intervention will help accomplish the change.
• Client is a likable person with good capacity for expressing and reflecting on their experiences.
• Reasonably intact personality.
Therapist Characteristics &Bond development: (Pope,
1998)
10 most significant attributes
Empathy, Acceptance,Genuineness, Sensitivity,Flexibility, Open-mindedness,Emotional Stability, Confidence,Interest in people, Fairness.
Trend in therapy:
There has been a move from theoretical views (opinions) to empirically and
clinically based issues of client change.
What Theory Works Best? Outcome Research: Efficacy!
• Comprehensively proven that therapeutic interventions do have a positive impact
• 25-50 years of research: Failure to establish any one school/theory/model is superior to any other (Smith, Glass, & Miller, 1980)
• “Everyone has won and all must have prizes!” • Shared core/common features that are curative
• Not IF it works or WHAT works, but HOW it works…
(Lambert, 1992)
Four Common Curative Factors: • Client Factors (remission, inner strengths, goal
directedness, motivation, personal agency, fortuitous events, social support, faith) 40%
• Expectancy/Placebo/Hope (credibility) 15%• Techniques/Models (questions, feedback, reframing,
interpretation, modelling, info) 15%• Therapeutic Relationship Factors
(empathy, warmth, respect, genuineness, acceptance, encouragement of risk-taking) 30%
Outcomes in Education: (Hattie, 1992)
WHAT MAKES THE DIFFERENCE ?
• Cognitive development
• Quality of instruction
• Reinforcement (feedback)
Common Characteristics of “Proven” Therapies (O'Donohue et al,
2000)APA "empirically valid" therapies:
• Involved skill building rather than insight or catharsis;
• Had a specific focus rather than a general one;
• Included regular, ongoing assessment of progress;
• Relatively brief in duration (20 visits or less).
Understanding the Working Alliance: (Bordin,
1980)
• Integrates both the relational and technical aspects of therapy
• Strongly associated with outcome across all forms of treatment and intervention
Working Alliance: Components
Three-stage model:• Bond• Goals• Tasks(applicable across theoretical approaches)
The alliance is contracted.
Characteristics:
• Strength of alliance is predictive• Strength of alliance fluctuates throughout
relationship (ruptures and repairs)• Early Vs. late scores as a marker of success• Strength of early alliance allows strains and
ruptures to be addressed
Phases:
• Phase one occurs in the initial session/s (Bond phase)
• Phase two begins as therapist starts addressing client issues (Work phase)
• Phase two is characterized by one or more strains and ruptures
• Direct therapist focus on ruptures can repair the alliance
Ensuring a Positive Therapeutic Alliance: (Miller, Duncan, & Hubble,
1997)
• Accommodating therapy to motivational level and readiness for change,
• Accommodating therapy to client’s goals and ideas about intervention,
• Accommodating the core conditions to fit the client’s definition of those variables.
Client Behaviours that Strain the Alliance:
Overt and indirect expression of negative feelings toward the therapist or the process
Disagreement about the goals or tasks Over-compliance or avoidance manoeuvres ‘Self’-enhancing communication that is
based in power conflicts (e.g., boasting) Non-responsiveness or continued lateness
Clients’ perceptions of non-alliance minded Therapists :
critical, hostile non-attentive non-empathic forgetful, suspicious belief that the therapist is not clear about
their expectations and goals
Non-alliance minded Therapists create negative client reactions
negative feelings about themselvesguiltanger at the Therapista sense of abandonment
Non-alliance mindedTherapists’ views/behaviours:
On-going general disagreement with the client
Acceptance of, or not addressing, client negative behaviours
Power struggles over goals and tasks Technical mistakes; either being too
assertive/directive; too non-directive; changing techniques; inadequate support
Non-alliance minded Therapists' views/behaviours:
Failure in empathyTriangulation, collusionCounter-transferenceCounterproductive roles:
“rescuer” or “fixer”Therapist’s personal issues
Correcting Alliance Ruptures:
Therapist’s ability to continually monitor and openly attend to the status of the alliance, directly influences clients’ willingness to confront their own (dysfunctional) relational patterns (model)
Support for, & work with, clients’ perception of the challenges and relationship
Strengthening the Alliance:
• Client’s interpersonal and cognitive style• The impact of interventions on the alliance• Therapist sensitivity to the status of the
alliance• Formative experience and attachment style• Client and Therapist perceptions of the
alliance
Developing an Alliance Framework:
• Bond– empathy, warmth, trust, genuineness– managing client anxiety– self-observation and awareness
• Goals– Client and Therapist collaboration, and the short-,
medium-, and long-term goals for the relationship and intervention
Developing an Alliance Framework:
• Tasks– process of the intervention and the impact on the
relationship– agreement on the appropriateness of interventions or
steps and plans
• Sensitivity to the status of the alliance– Assessing here-and-now issues and pressures in the
relationship– Intervening to address problems
Summary: The trend of outcome research has challenged and improved
therapy. There are no meaningful differences among helping models and
theories. Common curative factors are a powerful and useful trans-
theoretical way of understanding client change. An appraisal of the client’s stage of change will facilitate the
choice of therapeutic interventions used. There are specific client and Therapist variables that mediate
change. Clients and Therapists contribute to the development of a
positive working alliance.
Summary: The alliance, which is necessary but not sufficient, is formed
early and has a well-established link to outcomes. Therapists and clients perceive the working relationship
differently and attending to clients’ perceptions of the alliance is relevant to therapeutic efficacy.
Strains and ruptures are typical and represent normal development of the alliance.
Monitoring the client’s level of satisfaction and perception of the relationship allows the Therapist to repair strains and ruptures.
Pre-existing dispositional characteristics of client and Therapist influence the quality of the alliance.
Research-What works in Therapy
http://www.talkingcure.com
Institute for the Study of Therapeutic Change
andPartners for Change
Thank you, Grazie.
THE END,La Fine.
Appreciation
I am indebted toAustralian Catholic University for funding provided via the
International Conference Travel Grants Scheme which has enabled me to attend this conference to
present this paper.
Acknowledgement
I want to express appreciation to Matt Bambling(Psychiatry Dept, University of Queensland) for professional training/supervision and the
“alliance” notes that comprise the latter part of this presentation.