TherapeuticWork

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Barry's dad had a stalwart response to any complaint he ever made about doing any job. “Why do you think they call it work?” Hold that thought while we discuss the alliance. Although often ignored, the fact of the matter is that the alliance is our most powerful ally and represents the most influence that we can have over outcome. The alliance is an all-encompassing framework for psychotherapyundefinedit transcends any specific therapist behavior and is a property of all aspects of providing services. In short, it calls for your utmost attention and best clinical skills in each and every client encounterundefinedthe alliance requires your conscious, proactive efforts to engage the client in purposive work. It’s not always easy. In fact, it’s hard work. And you thought that “therapeutic work” only applied to clients.

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TherapeuticWork

  1. 1. www.heartandsoulofchange.com 3/28/2011 Therapeutic Work It’s Not Just for Clients Anymore Barry Duncan, Psy.D. www.heartandsoulofchange.com Psy.D. 954.721.2981 www.whatsrighwithyou.com barrylduncan@comcast.net 1
  2. 2. www.heartandsoulofchange.com 3/28/2011 My Dad Had A Stalwart Response to any Complaint I ever Made  About any job. w Whether it was painting or roofing a house, working in a tire factory, studying for a test, or working in my practice, his response was consistent: “Why do you think they call it work?” Hold that thought while we discuss the alliance. 2
  3. 3. www.heartandsoulofchange.com 3/28/2011 Although Often Ignored The Fact Is that the Alliance  Represents the most influence that we can have over outcome. Do not underestimate its power or its endurance—don’t give the alliance short shrift!  I know this is challenging—you believe in it but it’s hard not to take it for granted when it gets such little press compared to models and techniques. How often, for example, is the alliance discussed in client conferences? 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. 3
  4. 4. www.heartandsoulofchange.com 3/28/2011 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). No Difference! Approach accounted for 0% of the variance in outcome. Alliance predicted: Premature drop-out; Substance abuse symptoms post- drop- post- treatment, and cannabis use at 3 and 6 month follow-up. follow- 4
  5. 5. www.heartandsoulofchange.com 3/28/2011 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) 30-?% 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 Wampold, B., & Brown, J. (2006). Estimating variability in for the variability? outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. 5
  6. 6. www.heartandsoulofchange.com 3/28/2011 Therapists Variables that Predict Change Therapists with the best results:  Are better at the alliance across clients; alliance ability accounts for Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, therapist 75(6), 842-852.; Owen, Duncan, Anker, & Sparks (2011). Therapist variability in couple therapy. Manuscript submitted for publication. differences 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) 30-?% 6
  7. 7. www.heartandsoulofchange.com 3/28/2011 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 The Therapeutic Alliance The Alliance Goals, Means or Meaning Methods: or Theory of Purpose Change Client’s View of the Relationship 7
  8. 8. www.heartandsoulofchange.com 3/28/2011 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. Across modalities and populations Project MATCH What about the mandated clients? •No difference in outcome between voluntary and mandated clients. •The only reliable predictor? •The Alliance Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7- 29. 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. 8
  9. 9. www.heartandsoulofchange.com 3/28/2011 Model Maniacs (I Mean Proponents) Dis the Alliance by saying… Findings are only correlational, even though there are over 1000 reported associations… Don’t know anything about the direction of the correlation—the chicken or the egg: does change cause high alliance ratings or does a high alliance cause change Only 6 studies have looked at the issue and they are split down the middle on findings Disentangling the Alliance-Outcome Correlation Anker, Owen, Duncan, & Alliance Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology, 78, 635–645 Alliance score at session 3 predicts outcome over and above the effects of early symptom change 9
  10. 10. www.heartandsoulofchange.com 3/28/2011 Research into Practice The Alliance Not the anesthesia to surgery. Not the stuff you do until the real therapy. Intervention is not therapy. Better case for the alliance being the therapy. Deserves RESPECT Norcross, J. (2010). The Therapeutic Relationship. In B. Duncan et al. (eds.). The Heart and Soul of Change. Washington, D.C.: 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. 10
  11. 11. www.heartandsoulofchange.com 3/28/2011 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…Lisbeth 11
  12. 12. www.heartandsoulofchange.com 3/28/2011 My Task, Your Task You Know It Ain’t Easy  Gotta try and understand the anger; gotta figure out a way for it all to make sense (validation)  Gotta find stuff about the client to like, to appreciate  Gotta work on her goals, and get her involved in purposeful work The Rubber Hose of Doubt and the Bright Light of Blame You are the problem! You are to blame!  Validation doesn’t mean you agree with what the client has done; means that you acknowledge the rest of the story!  Puts client’s actions in a context that legitimizes him/her as a human being. No wonder…  Clears a path for change because it diffuses self doubt and dissipates self loathing…Lisbeth 12
  13. 13. www.heartandsoulofchange.com 3/28/2011 But I Can’t Validate That! Yes You Can  Abuse! No wonder you were trying to establish parental control—the kid was over the top…not agreeing with the abuse but the intent of the behavior.  Crime! No wonder you wound up robbing that store. You believed the lies about the life people told you, and you didn’t have much of a family life or anything else good going on. 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. 13
  14. 14. www.heartandsoulofchange.com 3/28/2011 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. 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. 14
  15. 15. www.heartandsoulofchange.com 3/28/2011 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. Preferences Meta-Analysis of 35 Studies  Clients matched to preferred conditions were less likely to drop out & improved more.  Type of preference (role, therapist, or tx) not sig.  Results underscore centrality of incorporating client preferences Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165. 15
  16. 16. www.heartandsoulofchange.com 3/28/2011 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 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 16
  17. 17. www.heartandsoulofchange.com 3/28/2011 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 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 17
  18. 18. www.heartandsoulofchange.com 3/28/2011 40 Years of Data say… •Client’s rating of the alliance the best predictor of engagement and outcome. outcome. •Client’s subjective experience of change early in the process the best predictor of success for any particular pairing. Quickest Way Prevent Drop Out Clients drop out for 2 reasons: therapy is not helping (monitor outcome) & alliance problems—not engaged or turned on. Direct way to improve effectiveness is to keep people engaged in therapy. Gotta measure the alliance 18
  19. 19. www.heartandsoulofchange.com 3/28/2011 The Session Rating Scale Measuring the Alliance •Give at the end •Score in cm to of session; the nearest mm; •Each line 10 cm •Discuss with in length; client anytime total score falls •Reliable, valid, below 36 feasible The Session Rating Scale Traditionally  Told us with their feet  Will let us know on SRS before telling/bolting.  Takes work for candor.  Disparity in power & socio- economic, ethnic, or racial diff., can make it tough. When was the last time you told your physician, “Youre making a big mistake"? 19
  20. 20. www.heartandsoulofchange.com 3/28/2011 Alliance Patterns But Don’t Stress It’s Okay  Keep encouraging client to let you know…  Have to KNOW: No bad news. Not a measure of competence or anything negative about you or the client. Gift from the client that helps you to be better.  Unless you really want it, you are unlikely to get it.  You won’t get it from everyone. 20
  21. 21. www.heartandsoulofchange.com 3/28/2011 The SRS Graceful Acceptance  And a willingness to be flexible usually turn things around.  Clients reporting alliance problems more likely for success. Lower scores on the SRS should be celebrated.  If clients are comfortable enough to express something isn’t right, then you are doing something great…example The Session Rating Scale Problems and Challenges  No Bad News on the SRS  It’s where you wind up that counts  Use SRS to BUILD or Maintain Alliance 21

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