Tag Archives: Working Alliance

Evidence-Based Relationship Factors in Counseling and Psychotherapy

The medical model of psychotherapy . . . has led us to accept a view of clients as inert and passive objects on whom we operate and whom we medicate. Gene V. Glass, in The Great Psychotherapy Debate, 2001, p. ix

John and Max Seattle

In a 1957 publication in the Journal of Consulting Psychology, Carl Rogers boldly declared:

  1. No psychotherapy techniques or methods are needed to achieve psychotherapeutic change.
  2. Diagnostic knowledge is “for the most part, a colossal waste of time” (1957, p. 102).

Let’s pause for a moment and reflect on what Rogers was saying.

**PAUSE HERE FOR SERIOUS REFLECTION**

If diagnosis is a waste of time and therapy techniques are unnecessary, then what can counselors or therapists do to produce positive outcomes? Here’s what Rogers said:

All that is necessary and sufficient for change to occur in psychotherapy is a certain type of relationship between psychotherapist and client.

Rogers’s revolutionary statements refocused counseling and psychotherapy. Until Rogers, therapy was primarily about theoretically based methods, techniques, and interventions. After Rogers, writers and practitioners began debating whether the relationship between client and therapist—not the methods and techniques employed—might be producing positive therapy outcomes.

This debate continues today. Wampold (2001) has called it “the great psychotherapy debate.” This debate has been boiled down to a dichotomy captured by the question: “Do treatments cure disorders or do relationships heal people?” (Norcross & Lambert, p. 3).

Keep in mind that like lots of things on planet Earth, the techniques vs. relationship debate promotes a false dichotomy. IMHO, most “rational” professionals understand that therapy relationships and techniques are BOTH important to positive outcomes. Seriously, how could it be otherwise?

But there is a positive outcome from this debate. Various researchers around the world started focusing on how to define specific relationship factors that contribute to counseling outcomes. Previously, these relationship factors were lumped into a category called “common factors.” Common factors were viewed as the main reason why all therapy approaches tend to produce approximately equal positive outcomes.

Flowing from research on common factors, one of the most fascinating and important movements in counseling and psychotherapy is now called, “Evidence-based relationships” (Norcross, 2011). As it turns out, there’s a large body of existing and accumulating research to help us clearly identify what’s relationally therapeutic.

In the attached link, you’ll find the powerpoint slides that Kim Parrow and I developed for a supervisor training yesterday, at the University of Montana. Our goal was to describe, demonstrate, and discuss 10 specific and observable relationship factors that contribute to positive counseling outcomes. We call them Evidence-Based Relationship Factors (EBRFs). They include:

  1. Congruence
  2. Unconditional positive regard
  3. Empathic understanding
  4. WA1: Emotional bond
  5. WA2: Goal consensus – Focus on strengths
  6. WA3: Task collaboration
  7. Rupture and repair
  8. Countertransference (management)
  9. Progress monitoring (feedback)
  10. Culture and Cultural Humility

The link at the bottom of this post will take you to our powerpoint slides. Also, for more information, you can always check out various theories textbooks, including Counseling and Psychotherapy Theories in Context and Practice (from which this blog was adapted). https://www.amazon.com/Counseling-Psychotherapy-Theories-Practice-Resource/dp/1119084202/ref=sr_1_1?ie=UTF8&qid=1504292029&sr=8-1&keywords=counseling+and+psychotherapy+theories+in+context+and+practice

EBRFs for Supervisors 2017 FIN

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Five Recommendations for Developing a Positive Working Alliance

The working alliance is one of the most robust predictors of positive counseling and psychotherapy outcomes. This excerpt, from the forthcoming 6th edition of Clinical Interviewing, describes five recommendations. You can always email me directly if you have questions about these resources I post. Have an excellent Wednesday evening.

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Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using Bordin’s (1979) model, alliance-building strategies focus on (a) collaborative goal setting; (b) engaging clients in mutual therapy-related tasks; and (c) development of a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:

  1. Initial interviews and early sessions are especially important to alliance-building. Many clients will be naïve about psychotherapy. This makes role inductions essential. Here’s a cognitive-behavioral therapy (CBT) example:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

  1. Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan helps build the alliance. In CBT this includes making a problem list (J. Beck, 2011).

Clinician:     What brings you to counseling and how can I be of help?

Client:         I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Clinician:     Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we say, “Find ways to help you start feeling more up?”

Client:         Sounds good to me.

  1. Engaging in collaborative goal-setting to achieve goal consensus is central to alliance-building. In CBT this involves transforming the “problem list” into a set of mutual treatment goals.

Clinician:     So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:         Totally. It would be amazing to tackle those successfully.

Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (TP) for moving from problems to goals. The TP includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here’s an example of a “Devil’s Advocacy” technique where the clinician takes on the client’s negative thoughts and then has the client respond (Newman, 2013). You’ll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:

Clinician:     You said you want a romantic relationship, but then you start thinking it’s too painful and pointless. Let’s try a technique where I take on your negative thinking and you respond with a reasonable counter argument. Would you try this with me?

Client:         Sure. I can try.

Clinician:     Excellent. Here we go: “It’s pointless to pursue a romantic relationship because they always come to a painful end.”

Client:         That’s possible, but it’s also possible to have some good times along the way toward the painful end.

Clinician:     [Smiles, breaks from role, and says] . . . That’s the best come-back ever.

  1. Soliciting feedback from clients from the first session on to monitor the quality and direction of the working alliance contributes to the alliance. Although you can use an instrument for this, you can also ask directly:

We’ve been talking for 20 minutes and so I want to check in with you on how you’re feeling about our time together so far. How are you doing with this process?

  1. Making sure you’re able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance (Linehan, 1993). Here’s an excerpt from an initial session with an 18-year-old male where the clinician accepted the client’s aggressive message and transformed it into a relational issue:

Clinician:     I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:         You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Clinician:     Thanks for telling me that. I’d never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you’ll just tell me, and I’ll stop.