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@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 clients goals
and ideas about intervention,
Accommodating the core conditions to fit
the clients 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 themselves
guilt
anger at the Therapist
a sense of abandonment

Non-alliance minded
Therapists 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 empathy
Triangulation, collusion
Counter-transference
Counterproductive roles:
rescuer or fixer
Therapists personal issues

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
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
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 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.
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.

Research-What works in Therapy

http://www.talkingcure.com

Institute for the
Study of Therapeutic Change
and
Partners for Change
Thank you, Grazie.

THE END,
La Fine.
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.



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.