Training Systems Therapists to

Match Theory to Client Variables:

A Framework for Integration and Alliance

Jill C. Morris, PhD, LMHC, LMFTRelationships Consultants International, Inc.October 27, 2013 European Family Therapy Association Istanbul, Turkey

Agenda and Objectives  Learning Objectives:

Participants will gain in-depth knowledge of Common Factors research

Participants will understand how integrating multiple theories and techniques while maintaining a clear therapeutic framework also helps build therapeutic alliance.

Participants will be able to adapt their supervisory style to help trainees develop clinical decision making skills by incorporating client factors and informal theories

Trainee’sPredicament

Integration: The Clinician’s Dilemma

ODraws from a wide range of resources

OOpportunities for “therapeutic fit” increase

ODecreases clinician boredom and burnout

OConvoluted case conceptualization

OLack of clarity and/or purpose

OClient’s and clinician’s sense of hope may be impaired

Saul Rosenzweig, M.D.

“Some Implicit Common Factors in Diverse Methods of Psychotherapy”

1936

The Dodo Bird Verdict

“Everybody has won, and all must

have prizes.”

“ . . . Similarities rather than differences between models account for most of the change that clients experience across therapies” Miller, Hubble & Duncan, 1995

Common Factors

40%

30%

15%

15%

Lambert 1992

Client/Extratherapeutic Factors Patient-Therapist RelationshipModel/TechniquePlacebo/Hope/Expectancy

Common FactorsWampold 2001

Client and Ex-tra-therapeutic Factors

Therapeutic al-liance

Model

87%

Client & External Factors

GenderEthnicityAgeCareerPersonalityPreferencesCultureReligionLife ExperiencesResiliencyInterestsResources

BirthsDeathsAccidentsDisabilityJob lossFinancial shiftsNatural disastersMarriagesDivorcesExternal systemsHealth issuesOther events

Client/Trainee Theory

ProblemWhat, Who, When, WHY

ChangeWhat, Who, When, HOW

Client/Trainee FactorsBeliefs about

Therapy Therapist listens

Client talks

Therapist gives advice Client follows advice

Therapist interacts Client collaborates

Therapist “fixes” Client is passive

Style & Resources Concrete Goal Oriented Storyteller/Metaphoric Perceived Resources

Financial Social Internal/Intrapsychic

Supervisor/Trainee Factors

Beliefs about Therapy

Therapist listens Client talks

Therapist gives advice Client follows advice

Therapist interacts Client collaborates

Therapist “fixes” Client is passive

Style & Resources Concrete Goal Oriented Storyteller/Metaphoric Perceived Resources

Life & Clinical Experience

Theoretical Knowledge Flexibility/Adaptability

Client/Trainee/SupervisorFeedback Loop

RECIPROCAL INFLUENCE

Client

Trainee

Supervisor

“You are multidimensional – you are already many things to many people (friend, partner, parent,

sibling). Use your complexity to fit

clients” Duncan & Sparks (2004)

Trainee Experience

Supervisor Experience

Client Beliefs about

Therapeutic Process

Client Beliefs about

Problem/Change

Client Characteristics and Resources

                   

   

Therapist Beliefs about

Therapeutic Process

Therapist Beliefs about

Problem/Change

Therapist Characteristics and Resources

Case Example #1

Ashley

Robert

7

David

George

5 1

Laura

• Ashley’s not listening• Ashley is resistant to

authority• Sibling Rivalry• Spousal relationship

stressed• Organizational problems at

work• Family was not running as

smoothly as they expected

• Did not want Ashley pathologized

• Responsible and achievement-oriented

Theories/Techniques(Solution-Focused/Milan)

• Joining with customer• Exploring existing

resources/beliefs• Circular Questioning • Reframing (unintentional

positive reinforcement)• Positive connotation

(linguistic shift)• Miracle Question• Deframing• Task Assignment

Case Example #2

Ted SaraSara

• Sara’s alcohol/drug use

• “Manic-Depressive”• Too much “thinking

time”

• Wants “Objective Opinion”

• Artistic• Self-Help oriented

Theories/Techniques(Bowen Family Systems/Strategic Family

Therapy/SFT)• Therapist’s dilemma – “objective opinion”:

Genogram• Therapeutic Double Bind• Recontextualizing• Thinking/Feeling• Individuality/Togetherness• Systemic Psychoeducation• Miracle Question

• Parent/Child • Family• Dx: unwanted• Clear goals• IP-present• Gender: non-

issue

• Adult/Marital• Individual• Dx: self-

established• Vague goals• IP-absent• Gender: relevant

DIFFERENCES

SIMILARITIESEither

• We have a sick kid •Commit to a troubled relationship Or

• We’re lousy parents •Dismiss love and give up hope

Web ResourcesOutcome Rating Scale (ORS) and Session Rating Scale (SRS) are available at www.talkingcure.com

http://www.personal.kent.edu/~dfresco/CRM_Readings/Duncan_dodo_2002.pdf

The Legacy of Saul Rosenzweig: The Profundityof the Dodo Bird

ReferencesDuncan, B. L., Solovey, A. D., & Rusk, G.S. (1992) Changing the rules: A client-directed approach to therapy. New York: Guilford.

Duncan, B. L. & Sparks, J. A. (2004) Heroic clients, heroic agencies: Partners for change- a manual for client-directed outcome-informed therapy and effective, accountable, and just services. E-Book: ISTC Press.

Lambert, M.J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J.C. Norcross & M.R. Goldfreid (Eds.) Handbook of psychotherapy Integration. (pp. 94-129). New York: Basic Books.

Miller, S. Hubble, M., & Duncan, B. (1995, March/April). No more bells and whistles. The Family Therapy Networker, pp. 52-58, 62-63

Robinson, B. (2009). When therapist variable and the client’s theory of change meet. Psychotherapy in Australia, 15 (4), 60-65.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, N.J.: Erlbaum

http://ctiv.alexanderstreet.com.ezproxylocal.library.nova.edu/view/1778986/play/true/