Therapeutic Alliance-2024.pptx

Therapeutic Alliance Dr. Ian Grey UAEU Review Remember we are focused on the question of how psychotherapy work or what influences the outcome of a psychotherapeutic process (success or fail) Three important variables The type of psychotherapy (more on this later) The type of therapist (characterist...

Therapeutic Alliance Dr. Ian Grey UAEU Review Remember we are focused on the question of how psychotherapy work or what influences the outcome of a psychotherapeutic process (success or fail) Three important variables The type of psychotherapy (more on this later) The type of therapist (characteristics) The type of client (more on this later) Last Class We discussed therapist characteristics Today we discuss the type of relationship needed to make therapy effective Think about the word relationship for a moment. Many people think of therapy is something that is delivered/given Relationship In Therapy Two Types of Research in Psychotherapy Outcome research analyses the results of the therapy (does it work?)….yes about 75% of people benefit (if done right) Process research investigates the various aspects of the therapeutic process, which can also be measured during the course of therapy regardless of outcome This process is what takes place between, and within, the client and therapist during the course of their interaction Important Distinction Research on psychotherapy outcomes is divided into two important things Research on psychotherapy outcomes is divided into two important things 1. Specific Factors (things specific to the type of psychotherapy such as the theory, approach to change, techniques etc) 2. Non-Specific Factors (personal characteristics of the therapist and the positive feelings that arise in the patient) Non-Specific (Meaning Across Therapies) Feelings which can lead to the creation of a positive therapeutic climate from an emotional and interpersonal perspective There are CONDITIONS necessary for therapy to work….. Trust, acceptance, warmth, positivity, etc (discussed some of these last week) but also the relationship between therapist and client Basic Fact Every form of therapy requires an interpersonal relationship, with the goal of helping a client heal or relieve distress. Therefore, understanding this particular relationship is something that anyone in a helping position should seek to do. This type of relationship has several names (therapeutic relationship, therapeutic alliance, working alliance) In Simple Terms: Two Questions 1 Therapist characteristics are important so how important is the relationship between the therapist and the client (not patient)? 2 What are the elements of a sucessful therapeutic relationship BETWEEN a therapist and a client? In Simple Terms And yes this can be identified. And its important to identify these elements so they can be explicitly trained and developed in future psychotherapists. Yes it is non-specific but that does not mean its mystical/ ‫رو?حان?ية‬ Simple Equation Therapy + Client + Relationship between T and C = Outcome The basic finding of 50 years of research is that if there is a negative relationship then the outcome of therapy will almost certainly be negative Phases of Psychotherapy Research First phase, between the 1950s and 1970s, when research focused on the outcome of psychotherapy Second phase between the 1960s and 1980s in which there was a growing interest for research into the relationship between process and outcome Third phase from the 1970s onward, in which interest shifted to the therapeutic process and the desire for a greater understanding of the “micro-processes” involved in therapy Basic Early Idea If the client is convinced of the therapist’s competence and feels safe, this will give the latter the necessary influence to bring about changes in the client. Two Phases of Relationship The first, found in the early phases of therapy, was based on the client’s perception of the therapist as supportive The second type, more typical of later phases in the therapy, represented the collaborative relationship between client and therapist to overcome the client’s problems – a sharing of responsibility in working to achieve the goals of the therapy and a sense of connection. But Yes that’s all correct but moving from phase 1 to phase 2 is mediated by a critical issue in psychotherapy To understand this, you must be aware of the general structure of psychotherapy (basically what happens across different types of psychotherapy) General Structure of Psychotherapy 1 Psychotherapy begins with some discussion of a person's background and the concerns that led him or her to seek help. 2 This typically involves assessment and the quality of these vary Should result in a psychological picture of the client. This is called a formulation…not a diagnosis General Structure of Psychotherapy 3 Following this initial assessment, the client and therapist come to an agreement, called the treatment contract. The treatment contract specifies the goals of treatment, treatment procedures, and a regular schedule for the time, place and duration of their treatment sessions. Sometimes this treatment contract is written down explicitly, but more often it is discussed between client and therapist. General Structure of Psychotherapy 4 Therapy lasts for whatever length of time 5 Therapy ends Critical Issue Moving from phase 1 to phase 2 is dependent upon the ‘treatment contract’ or the plan for therapy (what it will involve) This is not as easy as you think. Before therapy begins the psychologist must provide an explanation of the clients difficulties that (a) are grounded in psychology and (b) make sense to the client This explanation is the basis for any subsequent treatment selection Take a Simple Example Some one has a phobia and they want help. The explanation obviously includes an explanation of how the phobia developed and also what keeps the phobia going (avoidance-fear conditioning) Treatment must be logically based on this explanation and will include some variation of systematic desensitization (exposure to the feared object resulting in habitutation). Implication The therapist must have a lot of skill in formulating the clients difficulties from a psychological perspective AND Have a lot of skill in helping the client understand and ACCEPT and type of intervention that may help and work effectively with what are called client expectancies…. Client Expectancies Every single client will always have some expectancy of what is is involved in psychotherapy. These may be accurate but they may also be inaccurate. …..anticipatory beliefs that clients bring to treatment and can encompass beliefs about procedures, outcomes, therapists, or any other facet of the intervention and its delivery” Role Expectancies Examples of role expectancies include: expecting that a therapist will give advice; or expecting that the client (or caregiver) and the therapist will collaborate in therapy (i.e., the client or caregiver will have an active —not passive—role in therapy). Expectancies in the UAE remain unknown. Outcome Expectancies Outcome expectancies can be defined as, “Expectations that therapy will lead to change” and how Again we have no data on these in the UAE So How Important is This Relationship? Consider this statement Research examining outcomes of psychotherapy and counseling have found that only 15% of treatment success can be attributed to the type of therapy or the techniques administered (Hubble, Duncan, & Miller, 1999). The best predictor of outcome is the quality of the relationship Outcomes of Psychotherapy Research Rigorous review and analysis of controlled studies on psychotherapy outcomes. Conclusion: much more variance resides with the clinician than with the treatments. How does therapy work? Lambert (1992) estimates 40% of clients change due to motivation or severity of the problem 30% to quality of therapeutic relationship 15% to expectancy (placebo) effects, and 15% to a specific technique. (specific therapy) Key Point Between 30-40% of the outcomes of psychotherapy are attributable to the quality of the therapeutic alliance More The relationship will influence outcome, not because it is healing in its own right …….but as a critical ingredient which enables the client to accept, follow, and believe in the treatment. What are the Ingedients of Therapeutic Alliance? Three Components:  Tasks: Behaviors and processes within the therapy session that constitute the actual work of therapy  Bonds: Connection, The positive interpersonal attachment between therapist and client of mutual trust, confidence, and acceptance  Goals: Objectives of therapy that both client and therapist endorse What the Ingredients of Therapeutic Alliance? TA Implication If you want to be a really good therapist, this means that you have to work to develop therapeutic alliance You might wonder where to actually start? There is one simple way but it requires the therapist being ‘open’ You Should Practice Measuring Alliance “During the session I felt… (5-point scale: Agree to Do Not Agree )...confident that the therapist and I were working well together (task oriented)...that we talked about the things that were important to me (goal oriented)...like the therapist understood me …that the therapist was honest and sincere (bond oriented) Does Measuring Alliance Work? Alliance Results: Measuring Makes A Difference 1.2 Highly effective range Effect Size 1 0.8 0.6 Effective Range 0.4 0.2 0 Alliance items completed No items alliance at start at start of treatment of treament (n=1192) (n=1924) Alliance Results: Improvement Related to Effectiveness 1.20 Highly effective range Effect Size 1.00 0.80 Effective Range 0.60 0.40 0.20 0.00 Alliance Change for Worse No Change Alliance Change for Better Conclusion Knowing about therapeutic alliance is not enough…..you must actively seek feedback on this and ideally very frequently and especially at the beginning Its difficult for young therapists to do this and especially difficult is they (a) self identify as the expert, (b) think therapy is something that is given to the client, (c) think of the person as a ‘patient’ What are the effective characteristics of good therapists? APA-Wampold Paper (see Blackboard) 14 qualities of effective therapists Interpersonal skills Clients feel understood Can form a working alliance Provide an acceptable account of difficulties Provide a treatment plan consistent with this Is convincing and influential Monitors client in an authentic way Is flexible and can adjust Does not avoid difficult material APA-Wampold Paper (see Blackboard) 14 qualities of effective therapists Communicates hope and optimism Are aware of clients characteristics and context Are aware of their own psychological processes (know thy self) Are aware of best research evidence related to the problem Seeks to continually improve