Working Alliance & Common Factors in Therapy: Old and New

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Working Alliance Common Factors in Therapy
Old and New Challenges.

• International Family Therapy Festival
• (Accademia di Psicotherapia della Famiglia)
• Roma, Italia
• 02-xi-02
• Dr JOHN BARLETTA
• Senior Lecturer of Counselling
• AUSTRALIAN CATHOLIC UNIVERSITY

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• Web-Site
• www.mcauley.acu.edu.au/staff/johnb/subjects.html
• E-Mail
• J.Barletta_at_mcauley.acu.edu.au

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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.

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Outcomes of Therapy

• CHANGE - Growth Development
• Thoughts, Feelings, Behaviours
• Plans, Expectations, Hopes, Goals

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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 )

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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)

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Other Stages of Change

• Complainant AMBER LIGHT
• Visitor RED LIGHT
• How do therapists move such clients?

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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.

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Therapist Characteristics Bond development
(Pope, 1998)

• 10 most significant attributes
• Empathy, Acceptance,
• Genuineness, Sensitivity,
• Flexibility, Open-mindedness,
• Emotional Stability, Confidence,
• Interest in people, Fairness.

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Trend in therapy

• There has been a move from theoretical views
  (opinions) to empirically and clinically based
  issues of client change.

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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

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(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

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Outcomes in Education (Hattie, 1992)

• WHAT MAKES THE DIFFERENCE ?
• Cognitive development
• Quality of instruction
• Reinforcement (feedback)

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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).

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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

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Working Alliance Components

• Three-stage model
• Bond
• Goals
• Tasks
• (applicable across theoretical approaches)
• The alliance is contracted.

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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

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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

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Ensuring a Positive Therapeutic
Alliance (Miller, Duncan, Hubble, 1997)

• Accommodating therapy to motivational level and
  readiness for change,
• Accommodating therapy to clients goals and ideas
  about intervention,
• Accommodating the core conditions to fit the
  clients definition of those variables.

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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

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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

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Non-alliance minded Therapists create negative
client reactions

• negative feelings about themselves
• guilt
• anger at the Therapist
• a sense of abandonment

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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

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Non-alliance minded Therapists'
views/behaviours

• Failure in empathy
• Triangulation, collusion
• Counter-transference
• Counterproductive roles
• rescuer or fixer
• Therapists personal issues

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Correcting Alliance Ruptures

• Therapists 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

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Strengthening the Alliance

• Clients 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

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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

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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

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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 clients 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.

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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 clients 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.

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Research-What works in Therapy

• http//www.talkingcure.com
• Institute for the
• Study of Therapeutic Change
• and
• Partners for Change

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Thank you, Grazie.

• THE END,
• La Fine.

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Appreciation

• I am indebted to
• Australian Catholic University
• for funding provided via the
• International Conference Travel Grants Scheme
  which has enabled me to attend this conference to
  present this paper.

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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.