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AIMS for this presentation:

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.

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  1. 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.

  2. Outcomes of Therapy: CHANGE- Growth & Development • Thoughts, Feelings, Behaviours • Plans, Expectations, Hopes, Goals

  3. 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 )

  4. 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)

  5. Other Stages of Change: “Complainant”: AMBER LIGHT “Visitor”: RED LIGHT “How do therapists move such clients?”

  6. 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.

  7. Therapist Characteristics &Bond development: (Pope, 1998) 10 most significant attributes Empathy, Acceptance, Genuineness, Sensitivity, Flexibility, Open-mindedness, Emotional Stability, Confidence, Interest in people, Fairness.

  8. Trend in therapy: There has been a move from theoretical views (opinions) to empirically and clinically based issues of client change.

  9. 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…

  10. (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%

  11. Outcomes in Education: (Hattie, 1992) WHAT MAKES THE DIFFERENCE ? • Cognitive development • Quality of instruction • Reinforcement (feedback)

  12. 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; • Relativelybrief in duration (20 visits or less).

  13. 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

  14. Working Alliance: Components Three-stage model: • Bond • Goals • Tasks (applicable across theoretical approaches) The alliance is contracted.

  15. 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

  16. 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

  17. 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.

  18. 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

  19. 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

  20. Non-alliance minded Therapists create negative client reactions • negative feelings about themselves • guilt • anger at the Therapist • a sense of abandonment

  21. 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

  22. Non-alliance minded Therapists' views/behaviours: • Failure in empathy • Triangulation, collusion • Counter-transference • Counterproductive roles: “rescuer” or “fixer” • Therapist’s personal issues

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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.

  28. Summary: • The alliance, which is necessarybut notsufficient,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.

  29. Research-What works in Therapy http://www.talkingcure.com Institute for the Study of Therapeutic Change and Partners for Change

  30. Thank you, Grazie. THE END, La Fine.

  31. 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.

  32. 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.

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