the alliance is crucial. what are the implications?

the alliance is crucial.the alliance is crucial.what are the what are the implications?implications?

James Hawkins, Independent James Hawkins, Independent PracticePractice

EdinburghEdinburgh

key points of this talkkey points of this talk

therapeutic alliance seems as therapeutic alliance seems as important as type of therapy important as type of therapy in determining outcome in determining outcome

cbt training, assessment & cpd cbt training, assessment & cpd often undervalue allianceoften undervalue alliance

amongst many wide-ranging amongst many wide-ranging implications, experiential implications, experiential interpersonal groups are worth interpersonal groups are worth considering for training & cpdconsidering for training & cpd

Gary LarsonThe Far Side. Gallery

3

psychotherapy is successfulpsychotherapy is successful

many meta-analyses and even meta-meta-many meta-analyses and even meta-meta-analysis show an effect size of approx 0.8analysis show an effect size of approx 0.8

0.8 a ‘strong’ effect size in the social sciences0.8 a ‘strong’ effect size in the social sciences this makes psychotherapy more potent than this makes psychotherapy more potent than

many well established EBM procedures includ-many well established EBM procedures includ-ing (for example) almost all interventions in ing (for example) almost all interventions in asthma, geriatric medicine and cardiologyasthma, geriatric medicine and cardiology

combating helplessness, hopelessness & fear

Wampold, B. E. (2007). "Psychotherapy: the humanistic (and effective) treatment." Am Psychol

62(8): 855-73.

bona fide psychotherapies bona fide psychotherapies seem pretty much equally seem pretty much equally

effective effective Benish, S., et al. (2008). Benish, S., et al. (2008). The relative efficacy of bona fide psych-The relative efficacy of bona fide psych-

otherapies for treating post-traumatic stress disorder: a meta-otherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons.analysis of direct comparisons. Clin Psychol RevClin Psychol Rev 28(5): 746-58. 28(5): 746-58.

Spielmans, G., et al. (2007). Spielmans, G., et al. (2007). What are the active ingredients in What are the active ingredients in cognitive and behavioral psychotherapy for anxious & depressed cognitive and behavioral psychotherapy for anxious & depressed children? A meta-analytic review.children? A meta-analytic review. Clin Psychol RevClin Psychol Rev 27(5): 642- 27(5): 642-54.54.

Wampold BE, Minami T, et al. Wampold BE, Minami T, et al. A meta-(re)analysis of the effects A meta-(re)analysis of the effects of cognitive therapy versus 'other therapies' for depression. of cognitive therapy versus 'other therapies' for depression. J Affect Disord 2002; 68(2-3): 159-65.J Affect Disord 2002; 68(2-3): 159-65.

Casacalenda N, Perry JC, et al. Casacalenda N, Perry JC, et al. Remission in major depressive Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. and control conditions. Am J Psychiatry 2002; 159(8): 1354-60. Am J Psychiatry 2002; 159(8): 1354-60.

Westen D. & Morrison K. Westen D. & Morrison K. A multidimensional meta-analysis of A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety treatments for depression, panic, and generalized anxiety disorder: an empirical examination of the status of empirically disorder: an empirical examination of the status of empirically supported therapies.supported therapies. J Consult Clin Psychol 2001; 69(6): 875- J Consult Clin Psychol 2001; 69(6): 875-99.99.

this is partly explained by this is partly explained by alliancealliance

Baldwin, S. A., B. E. Wampold, et al. (2007). Untangling the alliance-outcome correlation: exploring the relative importance of therapist and patient variability in the alliance. J Consult Clin Psychol 75(6): 842-52.

Kim, D.-M., B. E. Wampold, et al. (2006). Therapist effects in psychotherapy: A random-effects modeling of the NIMH Treatment of Depression Collaborative Research Program data. Psychotherapy Research 16(2): 161-172

Wampold, B. E. (2006). The psychotherapist. Evidence based practices in mental health: Debate and dialogue on the fundamental questions J. C. Norcross, L. E. Beutler and R. F. Levant (eds). Washington, DC, APA: 200-208.

there is considerable evidence that the therapeutic alliance may be more important than the form of psychotherapy in deciding

therapeutic outcome

the therapist may be more important than the therapy

extensive research on extensive research on alliancealliance

Baldwin, S. A., B. E. Wampold, et al. (2007). "Untangling the alliance-outcome Baldwin, S. A., B. E. Wampold, et al. (2007). "Untangling the alliance-outcome correlation: exploring the relative importance of therapist and patient variability correlation: exploring the relative importance of therapist and patient variability in the alliance." in the alliance." J Consult Clin PsycholJ Consult Clin Psychol 7575(6): 842-52.(6): 842-52.

Lutz, W., S. C. Leon, et al. (2007). "Therapist Effects in Outpatient Lutz, W., S. C. Leon, et al. (2007). "Therapist Effects in Outpatient Psychotherapy: A Three-Level Growth Curve Approach." Psychotherapy: A Three-Level Growth Curve Approach." Journal Counseling Journal Counseling PsychologyPsychology 5454(1): 32-39(1): 32-39

Kim, D.-M., B. E. Wampold, et al. (2006). "Therapist effects in psychotherapy: A Kim, D.-M., B. E. Wampold, et al. (2006). "Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. ." Depression Collaborative Research Program data. ." Psychother ResPsychother Res 1616(2): 161-(2): 161-172.172.

Zuroff, D. C. and S. J. Blatt (2006). "The therapeutic relationship in the brief Zuroff, D. C. and S. J. Blatt (2006). "The therapeutic relationship in the brief treatment of depression: contributions to clinical improvement and enhanced treatment of depression: contributions to clinical improvement and enhanced adaptive capacities." adaptive capacities." J Consult Clin PsycholJ Consult Clin Psychol 7474(1): 130-40.(1): 130-40.

Black, S., G. Hardy, et al. (2005). "Self-reported attachment styles and Black, S., G. Hardy, et al. (2005). "Self-reported attachment styles and therapeutic orientation of therapists and their relationship with reported general therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy." alliance quality and problems in therapy." Psychol PsychotherPsychol Psychother 7878(Pt 3): 363-77.(Pt 3): 363-77.

Wampold, B. E. and G. S. Brown (2005). "Estimating variability in outcomes Wampold, B. E. and G. S. Brown (2005). "Estimating variability in outcomes attributable to therapists: a naturalistic study of outcomes in managed care." attributable to therapists: a naturalistic study of outcomes in managed care." J J Consult Clin PsycholConsult Clin Psychol 7373(5): 914-23.(5): 914-23.

extensive research on extensive research on alliancealliance

Trepka, C., A. Rees, et al. (2004). "Therapist Competence and Outcome of Trepka, C., A. Rees, et al. (2004). "Therapist Competence and Outcome of Cognitive Therapy for Depression." Cognitive Therapy for Depression." Cognitive Therapy and ResearchCognitive Therapy and Research 2828(2): (2): 143-157143-157

Hardy, G., K. Bonsall, et al. (2003). A review and critical analysis of studies Hardy, G., K. Bonsall, et al. (2003). A review and critical analysis of studies assessing the nature and quality of patient-therapist interactions in the assessing the nature and quality of patient-therapist interactions in the treatment of patients with mental health problems. treatment of patients with mental health problems. BABCP Annual Conference BABCP Annual Conference Abstracts: Page 57Abstracts: Page 57. York.. York.

Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression Klein, D. N., J. E. Schwartz, et al. (2003). "Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics." treatment: controlling for prior change and patient characteristics." J Consult J Consult Clin PsycholClin Psychol 7171(6): 997-1006.(6): 997-1006.

Meyer, B., P. A. Pilkonis, et al. (2002). "Treatment expectancies, patient Meyer, B., P. A. Pilkonis, et al. (2002). "Treatment expectancies, patient alliance, and outcome: further analyses from the National Institute of Mental alliance, and outcome: further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program." Health Treatment of Depression Collaborative Research Program." J Consult J Consult Clin PsycholClin Psychol 7070(4): 1051-5.(4): 1051-5.

Waddington, L. (2002). "The therapy relationship in cognitive therapy: a Waddington, L. (2002). "The therapy relationship in cognitive therapy: a review." review." Behavioural and Cognitive PsychotherapyBehavioural and Cognitive Psychotherapy 3030: 179-191.: 179-191.

Andrusyna, T. P., T. Z. Tang, et al. (2001). "The factor structure of the working Andrusyna, T. P., T. Z. Tang, et al. (2001). "The factor structure of the working alliance inventory in cognitive-behavioral therapy." alliance inventory in cognitive-behavioral therapy." J Psychother Pract ResJ Psychother Pract Res 1010(3): 173-8.(3): 173-8.

... a cognitive therapy ... a cognitive therapy exampleexample

randomly selected therapy session from randomly selected therapy session from each of 30 courses of cognitive therapyeach of 30 courses of cognitive therapy

rated for technical competence (CTS) and rated for technical competence (CTS) and for therapeutic alliance (ARM, CALPAS)for therapeutic alliance (ARM, CALPAS)

higher scores were associated with higher scores were associated with greater BDI improvementgreater BDI improvement

alliance was more strongly related to alliance was more strongly related to improvement than competence wasimprovement than competence was

Trepka, C., A. Rees, et al. (2004). "Therapist Competence and Outcome of Trepka, C., A. Rees, et al. (2004). "Therapist Competence and Outcome of Cognitive Therapy for Depression." Cognitive Therapy for Depression." Cognitive Therapy and ResearchCognitive Therapy and Research 2828(2): (2):

143-157143-157

what is meant by ‘alliance’?what is meant by ‘alliance’?

Andrusyna, T. P., T. Z. Tang, et al. (2001). "The factor structure of the Andrusyna, T. P., T. Z. Tang, et al. (2001). "The factor structure of the working alliance inventory in cognitive-behavioral therapy." working alliance inventory in cognitive-behavioral therapy." J Psychother J Psychother

Pract ResPract Res 1010(3): 173-8.(3): 173-8.

Factor analysis of the alliance in CBT (measured by the WAI) highlights two largely independent factors - the relationship between therapist and client (Relationship) and the client's agreement with and confidence in the therapist and CBT

(Agreement/Confidence)

“Alliance describes the degree to which the therapy dyad is engaged in collaborative, purposive work . . . alliance and technique occupy different conceptual levels and

cannot be considered to be two different types of activity in therapy. Technique is an activity, alliance is a way to

characterize activity”Hatcher, R. L. & A. W. Barends (2006 ). "How a Return to Theory Could Help Alliance Research." Psychotherapy: Theory, Research, Practice, Training.

43(3): 292-299.

two great alliance light two great alliance light sourcessources

pessimismhopelessnesscynicism criticismhelplessness

caringrespectawarenessempathygenuineness

self-centerednessdominationcoldnessinsensitivityphoniness

optimismhopeconfidencechoicefreedom





In God’s kitchen

more attention to alliance more attention to alliance factors?factors?

basic CBT training – for example in the basic CBT training – for example in the South of Scotland – the great majority of South of Scotland – the great majority of the course focuses on the application of the course focuses on the application of cognitive therapy techniques for different cognitive therapy techniques for different psychological disorders. Our ability to psychological disorders. Our ability to create, maintain and resuscitate a good create, maintain and resuscitate a good therapeutic alliance was largely assumed.therapeutic alliance was largely assumed.

ongoing CBT training - look at this BABCP ongoing CBT training - look at this BABCP annual conference programme – out of the annual conference programme – out of the 100’s of presentations, there are hardly any 100’s of presentations, there are hardly any at all on the therapeutic allianceat all on the therapeutic alliance

... and with CBT research too... and with CBT research toosuch a high proportion of CBT research is directed at improving our understanding

and interventions for different psychological disorders

“Tell me what techniques you’re using that work and we’ll figure out later why they’re cognitive”

Aaron Beck as remembered by Mary Anne Layden, Durham ‘98

improved alliance is powerfully associated with “what works” – it makes great sense

for CBT researchers to look more thoroughly at this area





Drive, George, drive! This one’s got a coat hanger!

personal experiencepersonal experience I have been involved in peer experiential I have been involved in peer experiential

interpersonal groups since the 1970’sinterpersonal groups since the 1970’s I sent a simple questionnaire to 46 I sent a simple questionnaire to 46

(health professionals) colleagues who I (health professionals) colleagues who I have been in these groups with since have been in these groups with since the early 1990’sthe early 1990’s

I asked them 3 questions about their I asked them 3 questions about their experience of these groupsexperience of these groups45 responded: 18 doctors; 3 nurses; 3

psychol-ogists; 9 psychotherapists/counsellors; 11 others

e.g. clergy & complementary practitioners

case seriescase seriesQu.1:Qu.1: Please give a number somewhere Please give a number somewhere

between 0 and 10 to indicate approximately between 0 and 10 to indicate approximately how helpful you feel these groups have been how helpful you feel these groups have been for you as a health professional, where 0 for you as a health professional, where 0 stands for “not helpful at all” right up to 10 stands for “not helpful at all” right up to 10 which stands for “very helpful indeed”. which stands for “very helpful indeed”.

mean response (0 to 10) =

8.48.4

findingsfindings

1 12 2

6

10

6

16

1

02468

10121416

num

ber

of p

eopl

e

0 1 2 3 4 5 6 7 8 9 10 11

helpfulness

how helpful for you as a health professional?

0 = not helpful at all; 10 = very helpful indeed

key areaskey areasQu.2:Qu.2: If you feel coming to the groups has been helpful for If you feel coming to the groups has been helpful for

you as a health professional, please put beside each of the you as a health professional, please put beside each of the following options a number from 1 to 5, where 1 indicates following options a number from 1 to 5, where 1 indicates this area has been most helpful for you, 2 indicates the this area has been most helpful for you, 2 indicates the second most helpful area, and so on.second most helpful area, and so on. a.)a.) Learning more about Learning more about emotions. emotions. 44 b.)b.) Learning more about myself and how/why I Learning more about myself and how/why I react the way I do. react the way I do. 22 c.)c.) Feeling more comfortable & Feeling more comfortable & accepting of myself. accepting of myself. 11 d.)d.) Feeling more ready to be honest & direct with others. Feeling more ready to be honest & direct with others. 33 e.)e.) Other area (please state) _______________ Other area (please state) _______________

spr collaborative research spr collaborative research networknetwork

The vast majority of mental health professionals, independent of professional discipline, have undergone personal treatment, typically on several (2-3) occasions.

78% relate that therapy has been a strong positive influence on their own professional development.

Multiple studies consistently demonstrate that the enduring lesson taken by practicing clinicians from their own treatment concerns the importance of the thera-peutic relationship and the centrality of nurturing inter-personal skills.

Geller, J.D., Norcross, J.C. & Orlinksky, D.E. (eds). The psychotherapist’s own psychotherapy: patient and clinician perspectives. OUP, 2005

a study of about 8,500 psychotherapists across 25 countries

other commentsother commentsQu.3:Qu.3: Are there any other comments you would Are there any other comments you would

like to make about the helpfulness of groups like to make about the helpfulness of groups like these for health professionals themselves? like these for health professionals themselves?

While conventional training puts great emphasis on Knowledge, Skills and to an extent Attitudes, there is very little about self understanding or self knowledge. This is hugely important in both consultations with patients and working with colleagues.

An oasis where I can really risk being me - not always easy but a step that sends ripples through the rest of my personal and professional life.

Make them compulsory! No health pro. then need be without one.

Everybody needs a good network.... qualities necessary in health care are those which the groups

help develop: authenticity, inner solidity ... , directness, ... kindness.

other commentsother commentsQu.3:Qu.3: ... any other comments ... (cont.) ... any other comments ... (cont.)

The crossover between personal development and professional development has been a highlight of these groups.

Experiential group work has the potential to be very powerful indeed in supporting and challenging new understanding and behaviour. The critical factors I believe are the culture of the group and the sensitivity & authen-ticity with which it is facilitated - whether that be peer or with leader.

I think in the group we can uncover aspects of ourselves that we might not normally discover and this can only be a good thing as so much of the time we hide behind our professional defences and shy away from our vulner-abilities and in doing so I believe must be less helpful to our clients.

Developing meaningful trusting friendships which provide ongoing support and encouragement

Also a wonderful bi-product has been the enrichment of non-work relationships especially with wife, children, parents and siblings.


Listening with the heart.Communicating with clarity and honesty really helpful. As a health care practitioner I feel the most helpful thing has been

feeling held by the group in a loving and challenging and safe environment. I can't underestimate this. I am able to hold, support, love and challenge my clients more effectively because of that I have received in the group. There is more of me to give from and a greater enthusiasm for my work.

Witnessing other people's responses to and ways of supporting individuals in the group offers valuable learning.

Support, friendship, insight & inspiration ... where no subject is censored!

I also feel more confident about taking emotional risks , e.g. knowing how much of me I'm prepared to show in a consultation.

Anything that promotes this depth of contact/understanding with oneself and a bunch of others is inevitably beneficial with all personal interactions.


The experience of these groups has allowed me to develop my ability to express myself ... in ways that are simultaneously emotionally and logically congruent. I have learned a lot of ‘emotional intelligence’.

... a rare and invaluable opportunity for honest exchange and feedback from peers as well as support, in both professional and personal respects. This more personal and experiential aspect of the group is for me the 'core' of what we do together, and something I feel strongly is an important if not essential part of working as a healthcare professional, certainly in psychological fields ... in the CMHT I work with, long periods off sick due to stress and burnout are unfortunately common, and I wonder if more opportunities for personal experiential work could help prevent this. In fact, the more I think about it, the more precious and rare an opportunity these groups seem!





references/copy of presentation: [email protected]/copy of presentation: [email protected]

to be uncertain is to be uncomfortable

to be certain is to be merely ridiculous

Goethedisagreements between scientists of

good intention are merely truth in the making

Andrews

shared goals … & more shared goals … & more research!research!

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the alliance is crucial. what are the implications?