the alliance is crucial. what are the implications

1
the alliance is crucial.what are the
implications?

• James Hawkins, Independent Practice
• Edinburgh

2
key points of this talk

• therapeutic alliance seems as important as type
  of therapy in determining outcome
• cbt training, assessment cpd often undervalue
  alliance
• amongst many wide-ranging implications,
  experiential interpersonal groups are worth
  considering for training cpd

Gary Larson The Far Side. Gallery 3
3
psychotherapy is successful
combating helplessness, hopelessness fear

• many meta-analyses and even meta-meta-analysis
  show an effect size of approx 0.8
• 0.8 a strong effect size in the social sciences
• this makes psychotherapy more potent than many
  well established EBM procedures includ-ing (for
  example) almost all interventions in asthma,
  geriatric medicine and cardiology

Wampold, B. E. (2007). "Psychotherapy the
humanistic (and effective) treatment." Am Psychol
62(8) 855-73.
4
bona fide psychotherapies seem pretty much
equally effective

• Benish, S., et al. (2008). The relative efficacy
  of bona fide psych-otherapies for treating
  post-traumatic stress disorder a meta-analysis
  of direct comparisons. Clin Psychol Rev 28(5)
  746-58.
• Spielmans, G., et al. (2007). What are the active
  ingredients in cognitive and behavioral
  psychotherapy for anxious depressed children? A
  meta-analytic review. Clin Psychol Rev 27(5)
  642-54.
• Wampold BE, Minami T, et al. A meta-(re)analysis
  of the effects of cognitive therapy
  versus 'other therapies' for depression. J Affect
  Disord 2002 68(2-3) 159-65.
• Casacalenda N, Perry JC, et al. Remission in
  major depressive disorder a comparison of
  pharmacotherapy, psychotherapy, and control
  conditions. Am J Psychiatry 2002 159(8)
  1354-60.
• Westen D. Morrison K. A multidimensional
  meta-analysis of treatments for depression,
  panic, and generalized anxiety disorder an
  empirical examination of the status of
  empirically supported therapies. J Consult Clin
  Psychol 2001 69(6) 875-99.

5
this is partly explained by alliance
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

• 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.

6
extensive research on alliance

• 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.
• Lutz, W., S. C. Leon, et al. (2007). "Therapist
  Effects in Outpatient Psychotherapy A
  Three-Level Growth Curve Approach." Journal
  Counseling Psychology 54(1) 32-39
• 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 Depression
  Collaborative Research Program data. ."
  Psychother Res 16(2) 161-172.
• Zuroff, D. C. and S. J. Blatt (2006). "The
  therapeutic relationship in the brief treatment
  of depression contributions to clinical
  improvement and enhanced adaptive capacities." J
  Consult Clin Psychol 74(1) 130-40.
• Black, S., G. Hardy, et al. (2005).
  "Self-reported attachment styles and therapeutic
  orientation of therapists and their relationship
  with reported general alliance quality and
  problems in therapy." Psychol Psychother 78(Pt
  3) 363-77.
• Wampold, B. E. and G. S. Brown (2005).
  "Estimating variability in outcomes attributable
  to therapists a naturalistic study of outcomes
  in managed care." J Consult Clin Psychol 73(5)
  914-23.

7
extensive research on alliance

• Trepka, C., A. Rees, et al. (2004). "Therapist
  Competence and Outcome of Cognitive Therapy for
  Depression." Cognitive Therapy and Research
  28(2) 143-157
• 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 treatment of patients with
  mental health problems. BABCP Annual Conference
  Abstracts Page 57. York.
• Klein, D. N., J. E. Schwartz, et al. (2003).
  "Therapeutic alliance in depression treatment
  controlling for prior change and patient
  characteristics." J Consult Clin Psychol 71(6)
  997-1006.
• Meyer, B., P. A. Pilkonis, et al. (2002).
  "Treatment expectancies, patient alliance, and
  outcome further analyses from the National
  Institute of Mental Health Treatment of
  Depression Collaborative Research Program." J
  Consult Clin Psychol 70(4) 1051-5.
• Waddington, L. (2002). "The therapy relationship
  in cognitive therapy a review." Behavioural and
  Cognitive Psychotherapy 30 179-191.
• Andrusyna, T. P., T. Z. Tang, et al. (2001). "The
  factor structure of the working alliance
  inventory in cognitive-behavioral therapy." J
  Psychother Pract Res 10(3) 173-8.

8
... a cognitive therapy example

• randomly selected therapy session from each of 30
  courses of cognitive therapy
• rated for technical competence (CTS) and for
  therapeutic alliance (ARM, CALPAS)
• higher scores were associated with greater BDI
  improvement
• alliance was more strongly related to improvement
  than competence was

Trepka, C., A. Rees, et al. (2004). "Therapist
Competence and Outcome of Cognitive Therapy for
Depression." Cognitive Therapy and Research
28(2) 143-157
9
what is meant by alliance?
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)
Andrusyna, T. P., T. Z. Tang, et al. (2001). "The
factor structure of the working alliance
inventory in cognitive-behavioral therapy." J
Psychother Pract Res 10(3) 173-8.
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.
10
two great alliance light sources
pessimism hopelessness cynicism
criticism helplessness
optimism hope confidence choice freedom
caring respect awareness empathy genuineness
self-centeredness domination coldness insensitivit
y phoniness
11
key points of this talk

• therapeutic alliance seems as important as type
  of therapy in determining outcome
• cbt training, assessment cpd often undervalue
  alliance
• amongst many wide-ranging implications,
  experiential interpersonal groups are worth
  considering for training cpd

In Gods kitchen
12
more attention to alliance factors?

• basic CBT training for example in the South of
  Scotland the great majority of the course
  focuses on the application of cognitive therapy
  techniques for different psychological disorders.
  Our ability to create, maintain and resuscitate
  a good therapeutic alliance was largely assumed.
• ongoing CBT training - look at this BABCP annual
  conference programme out of the 100s of
  presentations, there are hardly any at all on the
  therapeutic alliance

13
... and with CBT research too
such a high proportion of CBT research is
directed at improving our understanding and
interventions for different psychological
disorders
Tell me what techniques youre using that work
and well figure out later why theyre
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
14
key points of this talk

• therapeutic alliance seems as important as type
  of therapy in determining outcome
• cbt training, assessment cpd often undervalue
  alliance
• amongst many wide-ranging implications,
  experiential interpersonal groups are worth
  considering for training cpd

Drive, George, drive! This ones got a
coat hanger!
15
personal experience

• I have been involved in peer experiential
  interpersonal groups since the 1970s
• I sent a simple questionnaire to 46 (health
  professionals) colleagues who I have been in
  these groups with since the early 1990s
• I asked them 3 questions about their experience
  of these groups

45 responded 18 doctors 3 nurses 3
psychol-ogists 9 psychotherapists/counsellors
11 others e.g. clergy complementary
practitioners
16
case series

• Qu.1 Please give a number somewhere between 0
  and 10 to indicate approximately how helpful you
  feel these groups have been for you as a health
  professional, where 0 stands for not helpful at
  all right up to 10 which stands for very
  helpful indeed.     

mean response (0 to 10) 8.4
17
findings
0 not helpful at all 10 very helpful indeed
18
key areas
Qu.2 If you feel coming to the groups has been
helpful for you as a health professional, please
put beside each of the following options a number
from 1 to 5, where 1 indicates this area has been
most helpful for you, 2 indicates the second most
helpful area, and so on.

a.) Learning more about emotions.
4 b.) Learning more
about myself and how/why I react the way I do.
2
c.) Feeling more comfortable
accepting of myself. 1 d.) Feeling more
ready to be honest direct with others.
3
e.) Other area (please state)
_______________
19
spr collaborative research network
a study of about 8,500 psychotherapists across 25
countries

• 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 psychotherapists own psychotherapy
patient and clinician perspectives. OUP, 2005
20
other comments

• Qu.3 Are there any other comments you would like
  to make about the helpfulness of groups 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.

21
other comments

• Qu.3 ... 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.

22
other comments

• Qu.3 ... any other comments ... (cont.)

• 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.

23
other comments

• Qu.3 ... any other comments ... (cont.)

• 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! 

24
key points of this talk

• therapeutic alliance seems as important as type
  of therapy in determining outcome
• cbt training, assessment cpd often undervalue
  alliance
• amongst many wide-ranging implications,
  experiential interpersonal groups are worth
  considering for training cpd

references/copy of presentation
jh_at_goodmedicine.org.uk
25
shared goals more research!
to be uncertain is to be uncomfortable to be
certain is to be merely ridiculous
Goethe
disagreements between scientists of good
intention are merely truth in the making
Andrews