Therapeutic Alliance and ReED:

1
Therapeutic Alliance and Re-ED

• What have we learned about building positive
  relationships with youth?

2
Definition of Alliance

• Working relationship between youth and the
  teacher/counselor that is based on
• Perception of an emotional bond
• Agreement on goals of treatment
• Agreement on tasks to reach goals
• Perception of openness truthfulness of the
  relationship
• (Doucette Bickman, 2001)

3
Why is it important?

• The importance of TA cuts across all
  psychotherapy approaches (behavioral,
  psychodynamic, social learning, cognitive)
• TA is considered necessary to effect change in
  most approaches
• Therapists, counselors believe TA to be the
  single most important factor in therapy

4
How does alliance work?

• Form of attachment
• Transference and modeling
• Social influence
• Model of positive interpersonal relations
• Intervention strategytherapeutic effects of
  attention

5
PR has been conducting research in alliance since
1999

• Collaboration between Pressley Ridge and
  Vanderbilt University
• Research conducted at the dayschool, Ohiopyle and
  in Delaware treatment foster care program
• Both youth and TCs were asked about alliance

6
When asked what makes a favorable relationship
with a TC, YOUTH at the dayschool and at Ohiopyle
said that TCs should be

• Good listeners
• Honesty and integrity
• Mature
• Fair
• Patient
• Confident

• Committed
• Self control
• Caring
• Sense of humor
• Authenticity
• Hold youth accountable
• Respectful

7
Focus group

• Commitment Caring
• Some chiefs, even though you sit there and
  disrespect them, they keep coming back and keep
  coming back. They keep trying to get you in the
  right head, because most of the chiefs, they care
  about us. They talk to us and stuff. We can tell
  them anything. Some chiefs, they wont give
  up on us.

8
Focus Group

• Self-Control maturity
• If they cant control theyself, how are we going
  to control ourself?
• f you try to push your chief -- like to get in a
  conflict with you, and hes already self-aware,
  he knows what buttons you can push get him mad.
  Hes got to be more mature.
• Authenticity
• If you get a chief trying to be something that
  hes not,
• then hes not helping us out at all.

9
Focus Group

• Patience and commitment
• He lets me know what Im doing right and lets
  me know when Im doing wrong.
• Like, when Im doing wrong, he keeps telling me
  Im doing wrong. I wont want to hear it, but he
  
• wont keep giving up. He will keep trying and
  keep trying.
• Why do you think that is?
• Because he says he sees something in me and
  that I could be something, and he dont want to
  give up on me.

10
Focus Group

• Accountability
• A really good relationship is keeping the
  youth accountable, because if you get a chief
  that is lax and lets you do whatever you want,
  like lets you -- during one project lets you sit
  down, hes not being a chief. If he keeps up the
  high standards and do what he got to do, that
  helps you get out of the program more quicker and
  learn in the communityIf he holds you
  accountable, hes doing his job . Sometimes you
  dont like whenever they hold you accountable,
  but then when youre looking at -- when youre
  looking at it in the long run, you see -- you see
  how it helped you out.

11
When asked what makes a favorable relationship
with youth, TCs at the dayschool and at Ohiopyle
said the TC should be

• Good listener
• Honest
• Committed
• Patient
• Self confident
• Consistency
• Self-control
• Caring
• Sense of humor
• Flexibility
• Respectful

12
Focus Group

• Commitment Consistency
• I just think that being here every day, and even
  know they are calling you everything in the book,
  you keep coming back and still trying. You know,
  youre not leaving.
• You just keep saying the same thing, until
  finally they realize they are not going to shake
  you. They realize that they are not going to
  come to a dead end or until this person finally
  snaps the way everybody else has done --Before
  they finally realize, Wait a minute. These
  people --theyre not going anywhere--They are
  here for me.

13
Focus Group

• Self-control
• You have to be calm in their reaction to their
  behaviors. There has to be a sense of calmCalm
  and composed
• Sense of humor
• A sense of humor, especially when things are
  terrible Enjoying the kids.

14
Focus Groups

• Flexibility
• There might be situations Ive seen where
  theres a conflict between the student and the
  teacher, and the teacher cant relent on giving
  them a little space and knowing when to say
  something or saying -- trying to say as little as
  possible to give them -- so youre not
  overwhelming them or providing more stimulation
  for more anger or agitation. Not being a
  control freak.
• Being flexible You have to know when
  to be -- to stick to
• your guns, and you have to know when to be
  flexible.

15
Focus Groups

• Listening
• Your willingness to listen, no matter what the
  situation. You are always giving them the
  benefit of the doubt.
• Respect
• If you dont treat a kid with respect, therefore
  they wont show respect.

16
Youth and TC perceptions

• Youth report having positive relationships with
  TCs (higher than average score)
• Youth do differentiate between TCs they report
  higher alliance with some TCs than with others
• Across all services (dayschool, TFC, ohiopyle)
  TCs see the relationship as more positive than
  the youth

17
Youth factors affecting TA

• Timing--Early TA ratings by youth are stronger
  indicators of the quality of the relationship
  (e.g. window of opportunity)
• History of abuse--Youth who had experienced
  sexual and physical abuse have TA profiles that
  show overly high alliance (unreasonably high
  ratings) and significant resistance to
  intervention

18
Youth factors affecting TA

• Social competence
• Youth social competence is associated with
  alliancealliance increases, social competence
  increases
• Alcohol and drug use is associated with more
  resistance and poor alliance

19
Youth factors affecting TA

• Resistance to treatment associates with lower
  alliance. However, over time, youth alliance
  will increase.

20
TC factors affecting TA

• Using a measure of personality (16 PF) the
  relationship between TC personality and youth
  reported TA was examined.
• High impression management associated with low
  youth alliance (r.636)
• Tendency to manipulate in order to create
  impression that things are going well
• High openness to change associated with high
  youth alliance (r.320)
• Innovative, inclined to change if things are not
  working well

21
TC factors affecting TA

• Consistency of alliance across time is associated
  with 16PF emotional stability
• Youth report stable alliance for TCs with high
  average and high emotional stability
• Comfort with personal disclosure associated with
  alliance
• TCs who were highly private had lower alliance
  ratings from youth

22
TC factors affecting TA

• Resistance to treatment also associates with
  Teacher/Counselor personality
• Youth report high resistance when
  Teacher/Counselors have
• High dominance (forceful, tendency to think
  others are wrong)
• Rule Consciousness (rule bound, inflexible,
  dogmatic)
• Private (personally guarded)
• Perfectionism (difficulty dealing with
  unpredictable events)

23
Personality Profiles for High Alliance, Low
Resistance

• High emotional stability (stable and consistent
  responses predictable, not emotionally reactive,
  able to manage negative events without losing
  cool, controls self in difficult situations)
• High openness to change (innovative, thinks about
  new ways to improve things, will change the
  situation if status quo is not satisfactory
• High appropriate self-disclosure

24
Personality Profiles for High Resistance, Low
Alliance

• High dominance (forceful, vocal about opinions,
  tendency to subjugate others and regard them as
  wrong or mistaken)
• High rule consciousness (rule-bound, inflexible,
  self righteous and dogmatic)
• High degree of private ness (personally guarded,
  no self-disclosure)
• High Perfectionism (comfortable only in highly
  organized environments, difficulty dealing with
  unpredictability or ambiguity)
• High impression management (tendency to
  manipulate in order to create an impression that
  things are going well e.g. phoniness)

25
Summary of Personality Findings

• More personality profiles to rule out (rather
  than rule in).
• Personality is only one part of the picture
• Context is very important under the right
  conditions, someone who would not have the
  personality profile for high alliance, could
  actually become at TC who is good at fostering
  alliance

26
Summary of Personality Findings

• What are the right conditions or context??
• Supervision
• Observation and coaching
• Training
• An environment in which the TCs supervisor
  actively tries to build alliance with the TC
• An environment in which the TC feels that there
  is a bond between him/herself and the supervisor,
  agreement on what the TCs role is, a sense of
  competence, agreement on the tasks of the role
  and a perception that the relationship is an
  honest and open one!

27
Building Alliance
28
Teaching vs. Compliance

• A compliance orientation increases resistance.
  How do you hold youth accountable in a way that
  encourages teaching and re-education" rather
  than compliance to external rules?
• What are the signals that compliance rather than
  learning is being fostered?

29
TCs Role with Goal

Implementation

• Know your kids Individual Service Plan.
• Know your kids individual goals.
• Know your kids beliefs and values and what he
  expects from his treatment in a residential
  setting
• Know situations where goal progress can be
  reinforced and reinforce it.
• Know the situations in which flexibility around
  goals and tasks is called for.

30
Importance of Goals

• What should be the youths role in choosing
  goals?
• How do you discuss goals in order to have
  understanding and agreement rather than
  compliance?
• How do you let the youth lead in goal?
• How do you reach agreement on the tasks of the
  goals?
• How do you assess his/her expectations and values
  about what treatment is?

31
Listening

• Listening is not agreementyou can listen and
  acknowledge feelings but not agree
• Find opportunities to listen to the youth such as
  trail talk or walking back to the cottage,
  driving in the van etc. Sometimes these moments
  that are not therapy times are the most
  opportune times for listening
• How can we be better listeners?

32
Ask

• Dont assume that the youth feels the same way
  about your relationship
• Check in on the status
• Ask him/her how you can help foster the
  relationship

33
Consistency

• Be consistent and fair in applying rules
• Hold everyone accountable to the same degree
• Be consistent in your own moods and
  responsesknow what triggers you respond to

34
Commitment

• Youth and TCs identified that being committed
  was critical
• How do you stay committed in the face of extreme
  resistance?
• How do you support staff to stay the course and
  remain committed in the fact of extreme
  resistance?

35
Humor

• Some forms of humor are not appropriatesarcasm,
  irony, making others the target of jokes
• Think of ways humor can be effectively used.

36

• But most of all, a teacher/counselor is a decent
  adult educated, well trained able to give and
  receive affection, to live relaxed and to be
  firm a person of hope, quiet confidence and
  joy one who has committed himself to children
  and to the proposition that children who are
  disturbed can be helped by the process of
  re-education
• Nicholas Hobbs