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
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)
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
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
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.