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

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Web-Site:www.mcauley.acu.edu.au/staff/johnb/subjects.html

E-Mail:J.Barletta@mcauley.acu.edu.au

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.