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the alliance is crucial. what are the implications?

the alliance is crucial. what are the implications?. James Hawkins, Independent Practice Edinburgh. key points of this talk. therapeutic alliance seems as important as type of therapy in determining outcome cbt training, assessment & cpd often undervalue alliance

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the alliance is crucial. what are the implications?

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  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 Psychol62(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 Psychol75(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 Research16(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 Psychol75(6): 842-52. • Lutz, W., S. C. Leon, et al. (2007). "Therapist Effects in Outpatient Psychotherapy: A Three-Level Growth Curve Approach." Journal Counseling Psychology54(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 Res16(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 Psychol74(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 Psychother78(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 Psychol73(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 Research28(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 Psychol71(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 Psychol70(4): 1051-5. • Waddington, L. (2002). "The therapy relationship in cognitive therapy: a review." Behavioural and Cognitive Psychotherapy30: 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 Res10(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 Research28(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 Res10(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 optimism hope confidence choice freedom pessimism hopelessness cynicism criticism helplessness self-centeredness domination coldness insensitivity phoniness caring respect awareness empathy genuineness

  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 God’s 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 100’s 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 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

  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 one’s got a coat hanger!

  15. personal experience • I have been involved in peer experiential interpersonal groups since the 1970’s • I sent a simple questionnaire to 46 (health professionals) colleagues who I have been in these groups with since the early 1990’s • 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. 4b.) Learning more about myself and how/why I react the way I do. 2c.) Feeling more comfortable & accepting of myself. 1d.) Feeling more ready to be honest & direct with others. 3e.) 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 psychotherapist’s 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@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

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