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 client‟s goals
and ideas about intervention,
• Accommodating the core conditions to fit
the client‟s 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”
Therapist‟s personal issues

Correcting Alliance Ruptures:

 Therapist‟s 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:

• Client‟s 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 client‟s 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 client‟s 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.