Relianceontheallianceslides

www.heartandsoulofchange.com 7/22/2010 Reliance on the Alliance The Soul of Change Barry Duncan, Psy.D. www.heartandsoulofchange.com 954.721.2981 www.whatsrighwithyou.com barrylduncan@comcast.net 1

www.heartandsoulofchange.com 7/22/2010 The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “Everybody has won and all must have prizes.” Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215. TDCRP The Alliance •Considered most sophisticated comparative clinical trial ever: •CBT, IPT, Drug, Placebo •No difference in outcome •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. 2

www.heartandsoulofchange.com 7/22/2010 Project MATCH The Alliance •CBT, 12-step, & Motivational 12- Interviewing •NO difference in outcome •The client’s rating of the alliance the best predictor of: Treatment participation; Drinking behavior during Anton, S. et al., (2006). Combined treatment; pharmaceutical and behavioral interventions for alcohol Drinking at 12-month FU 12- dependence.. JAMA, 295, 203-217. COMBINE…same thing Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29. Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK. Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98. The Dodo Also Rules Family Therapy Cannabis Youth Treatment Project •600 Adolescents marijuana users: •Significant co-morbidity (3-12 problems). co- (3- •Two arms (dose, type) and one of three types of treatment in each arm: •Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support Network (12 wks)+MET+CBT; •Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). Approach accounted for 0% of the variance in outcome. Ratings of the alliance predicted: Premature drop-out; Substance abuse and dependency drop- symptoms post-treatment, and cannabis use at 3 and 6 month follow-up. post- follow- 3

www.heartandsoulofchange.com 7/22/2010 Implication of the Dodo Bird Verdict All 400 approaches work because: Of factors common to all therapies So what are the factors? Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association 4

www.heartandsoulofchange.com 7/22/2010 Therapist Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo bested bottom third giving meds; clients of best therapists improve 50% more & dropped out 50% less; meds useful for clients of more effective therapists, not for less. What accounts for the Wampold, B., & Brown, J. (2006). Estimating variability in variability? outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. Therapists Variables that Predict Change Therapists with the best results:  Emphasize the relationship; are better at the alliance across clients  Alliance predicts change Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; Vocisano et al. (2004). Therapist variables that predict symptom change in psychotherapy with chronically depressed outpatients. Psychotherapy, 41(3), 255-265. over and above early Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical change Psychology. 5

www.heartandsoulofchange.com 7/22/2010 Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38- 38-54% • Agreement on tasks Seven Times the Impact of Model/Technique…Accounts for Most of Therapist Variance Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass 6

www.heartandsoulofchange.com 7/22/2010 The Therapeutic Alliance The Alliance Goals, Means or Meaning Methods: or Theory of Purpose Change Client’s View of the Relationship The Alliance: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline-- recall TDCRP, MATCH, CYT.  Clients rarely report negative reactions before deciding to terminate.  Same holds true for youth and family therapy 7

www.heartandsoulofchange.com 7/22/2010 Disentangling the Alliance-Outcome Correlation Anker, Owen, Duncan, & Alliance Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology Alliance score at session 3 predicts outcome over and above the effects of early symptom change Translating Research into Practice •How have traditional theories and models minimized the role of the alliance and client engagement? •How can research showing the importance of the therapeutic alliance and client engagement be utilized? 8

www.heartandsoulofchange.com 7/22/2010 Research into Practice The Alliance •Increasingly, the relationship is viewed as merely “setting the stage” for the “real” treatment: •Confronting distorted thoughts; •Recovering forgotten memories; •Asking special questions; •Tapping on or waving fingers in front of the face…but the data say: •The alliance deserves far more RESPECT… Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA. Reliance on the Alliance • Be friendly, responsive, and flexible (like a first date); stay close to client’s experience. • Empathy and Positive Regard: Validate. Legitimize the client’s concerns/basic worth and the importance of their struggle. • Work on client’s goals period. • Fit the client’s theory of change. 9

www.heartandsoulofchange.com 7/22/2010 Empathy Carl Rogers Was On To Something  Empathy. A meta-analysis of 47 studies: r of .26 between therapist empathy and psychotherapy outcome, translating to ES of .32.  ES of model and technique differences is but .20; Client’s perception of empathy more powerful than any technique you can ever wield. Empathy Plus Positive Regard Equals Validation  Positive Regard: warm acceptance of client w/o conditions.  When outcome & positive regard were both rated by clients, 88% of studies found sig. relationship. Critical that clients think we view them positively.  Appreciation: appreciation of people in general, their struggles, and of their humanity and innate goodness… 10

www.heartandsoulofchange.com 7/22/2010 Reliance on the Alliance • Be friendly, responsive, and flexible (like a first date); stay close to client’s experience. • Empathy and Positive Regard: Validate. Legitimize the client’s concerns/basic worth and the importance of their struggle. • Work on client’s goals period. • Fit the client’s theory of change. The Client’s Theory of Change Pre- Pre-existing beliefs about the problem and change Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. New York: Guilford. 11

www.heartandsoulofchange.com 7/22/2010 The Client’s Theory of Change: Empirical Findings In the TDCRP, congruence between the clients TOC and tx resulted in: Stronger therapeutic alliances; Longer duration in treatment; and Improved treatment outcomes. Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451. The Alliance and Model/Technique Not Disembodied Parts  Alliance dependent on delivery of some “treatment;” bond, goals, and tasks  Technique is an activity; the alliance characterizes the activity, the purpose of the activity—to engage the client in the work 12

www.heartandsoulofchange.com 7/22/2010 Plurality Pays Off Differential Efficacy with Current Client  Q: Does it resonate; does it fit client preferences; can both get behind it?  Alliance skills: explore client ideas, discuss options, collaboratively plan, and negotiate changes if benefit not forthcoming.  Alliance in action. Litmus test: whether it engages client in purposive work. Attitude Important Alliance is Central Filter  Is what I am doing and saying now building or risking the alliance?  Doesn’t mean you can’t challenge but rather that you have to earn the right and, consider the alliance consequences 13

www.heartandsoulofchange.com 7/22/2010 Alliance As An Overarching Framework The Alliance is the Soul  Transcends any beh & is a property of all—from tech. to scheduling appt  Purpose is to engage in purposive work  Have to earn it each & every time; alliance is our craft; practice elevates to art The Alliance Bottom Line  The Alliance Matters— Big Time  TDCRP: alliance accounted for up to 21% of the variance,  Real-time Feedback about the Alliance Critical to Success 14

www.heartandsoulofchange.com 7/22/2010 The Alliance The of Change Alliance feedback enables a fit between client expectations, preferences, and services Does not leave the alliance to chance—applying over 1000 studies showing the relationship of the alliance to positive outcomes Becoming Better Isn’t It Good, Norwegian Wood  Feedback v TAU; Both persons reliable or sig. change— 50.5% v. 22.6%; ES: .50; 4 xs # of clin. sig. change  FU: TAU-34.2% v. 18.4% Feedback Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a sep./divorce rate naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704. 15

www.heartandsoulofchange.com 7/22/2010 Reese, Norsworthy, & Rowlands (2009) First Independent Study  N=148: Feedback group doubled controls (10.4 Reese, R., Norsworthy, L., & vs. 5.1 pts); ES: .48  Like Norway study, Rowlands, S. (2009). Does a continuous feedback model clients, regardless of risk improve psychotherapy outcomes? Psychotherapy,46, 418-431. status, benefit from continuous feedback  And the replication study now in press 16

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