Good morning. Here for Symposium on Therapeutic Relationships hope you are too. Lets get started. -I d like to tell you about plans for today -And introduce you to the team. 1
The Team: 1. Joshua: Therapeutic Relationship & Treatment Outcome (Clinical Psychologist/Supervisor, The Psychology Centre, Hamilton) 2. Gerard: Therapeutic Relationship in Action (Lead Psychologist for Mental Health & Addictions, Waikato DHB) 3. Juanita: Therapeutic Relationship and Offenders (Principal Psychologist, Department of Corrections, Hamilton) 4. Kirsty: Therapeutic Relationship Children, Adolescents & Families. (Clinical Advisor with Casa) Plans: - full program in 4 quarters. - Brief Q&A following each individual talk. - Realize people may enter/leave, we will keep moving with the talk. - We have a lot to cover in a short time, so we will be moving fast! Goals: 1. Understand the current state of research on Therapeutic Relationships 2. How to apply this to everyday and specific practice. 3. In an evidence-based manner. 2
What kind of a talk is this going to be??? Well, it starts with a story - Last year at the Society Conference in Auckland - and over a bottle of wine - I was having dinner with two friends - We got to discussing treatment as psychology nerds do - And got on the topic of Therapy Relationships - how vital they are - how little they are really talked about - and how did we learn about and how do we teach these things - We thought it would be great to talk about these things at conference - So, here we are! 3
Plans for this talk: - Background/History: Might be aware of some of this, but it helps to explain how we got to where we are. - Definitions - What does the data say particularly related to outcome? - What does the future hold? 4
We aren t just solitary trees on a hill are we? We relate, but we do this in different ways. There are several different definitions of therapy relationships and alliance, but for today s purposes: Therapeutic Relationship: Broad term the relationship in total. Therapeutic Alliance / Working Alliance: Quality & strength of collaborative relationship between client and therapist. Agreement of therapy goals, consensus on treatment tasks, & relationship bond. WE will not be too fussed with this today (click) 5
Biases/Assumptions/Where I m coming from 1. Although we might have different ideas about how the work of therapy gets done 2. We re all basically interested in the same thing 3. Helping people improve in some way. Psychotherapy helps people it works We know that the average client is better off than 75% of people receiving no treatment. Smith & Glass 1977 Meta-Analysis of psychotherapy outcome studies. (American Psychologist, 32, 752-760). **We are agents of change and ethically obligated to function in this way, so it probably helps to be thinking this way 6
In his article in The American Journal of Orthopsychiatry, Saul Rosenzweig had this to say (click) He Concludes: 1. Therapist needs effective personality 2. Needs to consistently adhere to a system of treatment concepts that he has mastered. 3. Which are adapted to the unique client. 4. It becomes little consequence what particular method is used. 5. Notes: in certain types of mental disturbances certain kinds of therapy are indicated as compared with certain others. When was he saying things like this??? (click) 1936!!! 7
So for me, this begs the question, (click) Did Rosenzweig have a crystal ball???? (click) 8
Or have we spent too much time barking up the wrong tree??? 9
Saul Rosenzweig: begins his 1936 paper with the following quote: - At last the Dodo said, Everybody has won and all must have prizes - Coined the phrase Common Factors It does seem as though he knew what he was talking about. Smith & Glass 1977 Meta-Analysis of psychotherapy outcome studies. (American Psychologist, 32, 752-760). - Found little evidence for any difference between therapy types. Others: - Refined & confirmed by Shapiro & Shapiro 1982. - Wampold 1997 & 2001 - Luborsky et al 2002 meta-analysis of 17 meta-analyses - On and on and on - Latchford & Green2012 for review. 10
SO IF TECHNIQUES ARE OF LIMITED IMPORTANCE, WHAT DOES MATTER??? What do the numbers say??? 11
Depends on who you ask But depending on which study is sited, the amount of change attributable to the alliance is 5 to 7 times greater than that of specific models or techniques. (Horvath & Symonds 1991, Martin et al 2000, Wampold 2001). SO WE KNOW THAT THE ALLIANCE IS MORE IMPORTANT THAN THE TECHNIQUES 12
But, what is accounting for outcome? - All treatment factors combined accounted for only 13% of the variance in final outcome. - Client-Related and extra-therapeutic Factors explained 87% of variance. SO, WE HAVE LIMITED RANGE WITH WHICH TO WORK/INFLUENCE **Wampold 2001. A meta-analysis of outcome studies comparing bona fide psychotherapies: empirically, all must have prizes. Psychological Bulletin, 122, 203-215. **Lambert 1992. Psychotherapy outcome research; implications for integrative and eclectic psychotherapists, in Handbook of Psychotherapy Integration, Norcross & Goldfield eds, basic Books, New York. similar findings: 13
How about Therapeutic Alliance and Outcome??? Horvath, et al. 2011. - An analysis of 200 research reports - Involving 190 independent data sources - Comprising 14,000 txs Found: Overall Effect Size of.275 - In the authors words, relatively modest But the best we have to work with??? 14
More Therapeutic Alliance and Outcome??? 2011 study found that therapy alliance scores (click) at the 3 rd session accounted for (click) 4.7% of the variance. BUT!!! Average of sessions 3 through 9 explained (click) 14.7% So initial rating might be a bit deceiving, we have to work at this therapy alliance thing Most studies indicate that of the therapeutic factors that relate to change, the alliance accounts for the most variance 15
The other side of the coin: 2013 review of 44 studies completed between 2000 and 2011. They found: - Therapeutic Alliance, Client Satisfaction and Pre-therapy preparation influenced drop out. They concluded: - To reduce dropout, therapists need enhanced skills in building and repairing the therapeutic relationship. But how do we build the Alliance??? 16
We ve been told for a long time that Therapeutic Relationship was the key factor, haven t we??? Examples of various texts that draw attention to this topic. CBT, IPT, Obj-Rel, Mot Int., etc., etc. They all refer to the topic, but don t really explain. - Anywhere from a few paragraphs to a few pages - They all just seem to refer to it or maybe mention Rogers, but that s about it - However, the more modern the text, the more emphasis. (Stuart & Robinson IPT, A Clinician s Guide, 2012) page 34: a good therapeutic alliance is absolutely essential in IPT, and the burden to create one is on the therapist! without establishing a productive therapeutic alliance, none of the IPT techniques and strategies will be effective. The therapist should also constantly remember that the quality of the alliance is the primary predictor of psychotherapy outcome. for this reason in IPT particular attention must be paid to all of the non-specific elements of therapy: warmth, empathy, affective attunement, positive regard all of the elements described by Rogers and Truaz as necessary to bring about 17
psychotherapeutic change. 17
This notion started gaining steam in the 2000 s 2005: This Special issue is based on the notion that what matters most in psychotherapeutic treatments is the interplay of techniques and the therapeutic relationship. - Intro + 9 articles.. 2011: 11 articles, ranging from overall, what works, to children, families, couples, group and Empathy, collaboration, positive regard, congruence etc.. 18
Then: The APA, Division 29 Task Force made recommendations that practitioners be encouraged to make the creation and cultivation of a therapy relationship a primary aim in the treatment of patients and that training programs in psychotherapy be encouraged to provide explicit and competency-based training in the effective elements of the therapy relationship. (2002 from Crits-Christoph paper). The Task Force: 1. Identified elements of effective therapy relationships 2. Identify effective methods of tailoring therapy to individual clients. Some of the specific of this will be covered by Gerard in a moment. 19
What s on the horizon Consumer Movement (click) - what do clients want from therapy - what works best for different people - and how do we know if they ve achieved it? Highlighted in certain healthcare systems certainly in vogue in the UK. Special Section in the journal Psychotherapy in 2013 that you might want to review: - Clients perceptions of change and therapy 20
What else is on the horizon? (click) Therapist Variables: 2005 Wampold: variance of outcomes due to therapists is 8% to 9% Which is larger than variance accounted for by treatments 0% to 1 % And Therapeutic Alliance 5% Note: The superiority of empirically supported treatment to placebo was (0 to 4%) Baldwin et al 2007: Better therapists form better alliances with a range of clients leading to better outcomes. What are these factors??? No one knows yet. We know it is not these: - Age - Gender - Years of experience - Professional discipline - Degree - Training 21
- Theoretical orientation - Amount of supervision - Personal therapy - Specific or general competence - Use of evidence-based methods (Beutler et al 2004, Miller, Hubble & Duncan 2007). 21
You can hear an awful lot just by listening. Yogi Bera If we listen in the correct way Clients evaluations of the alliance are better predictors of outcome than therapists (Bachelor & Horvath 1999; Busseri & Tyler 2004; Zuroff et al. 2000). Gelso et al. 2012 Clients ratings of the real relationship at the 1 st session, 1 st quarter of treatment and overall related to outcome, therapist ratings did not. We need methods for checking in and assessing our work with clients The Therapeutic Relationship Not just assuming we know what is happening. - Various rating forms - Specific discussion - Collaboration/Obtaining Feedback on Goals/Progress. - I ll turn it over to the others to dig into the how s and what s of this in general and with different client populations 22
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Empathy: the therapists sensitive ability and willingness to understand clients thoughts, feelings and struggles from their point of view. Alliance: The quality and strength of the collaborative relationship between client and therapist. Cohesion: (In groups). Like TA in individual work. The forces that cause members to stay in the group. Goal Consensus: agreement on Treatment goals and considerations Collaboration: mutual involvement of participants in the helping relationship. 25
Positive Regard: Warm acceptance of the Client s experience without conditions. Congruence/Genuineness: therapists personal integration into the relationship and the therapists capacity to communicate themselves to the client as appropriate. Feedback: Descriptive or evaluative information provided to clients about their behaviour or the effects of it. Repair of Alliance Ruptures: awareness of and ability to effectively mend breakdowns in collaborative relationship. Self-Disclosure: practitioner self-revelations. Management of Counter-Transference: managing personal reactions to the client. Quality of Relational Interpretations: doing a good job of bringing client concerns into awareness. 26
These all seem fairly obvious The bigger issue is: - How? - When? - With Which clients? 27