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
 amongst many wide-ranging
implications, experiential
interpersonal groups are worth
considering for training & cpd
Gary Larson
The Far Side. Gallery 3
psychotherapy is successful
combating helplessness, hopelessness & fear
 many meta-analyses and even meta-metaanalysis 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 including (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.
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 metaanalysis 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.
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.
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.
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.
... 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
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.
two great alliance light sources
optimism
hope
confidence
choice
freedom
self-centeredness
domination
coldness
insensitivity
phoniness
pessimism
hopelessness
cynicism
criticism
helplessness
caring
respect
awareness
empathy
genuineness
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
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
... 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
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!
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 psychologists; 9 psychotherapists/counsellors; 11 others
e.g. clergy & complementary practitioners
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
findings
number of people
how helpful for you as a health professional?
16
14
12
10
8
6
4
2
0
16
10
6
6
1
0
1
2
3
1
4
2
5
2
6
1
7
8
9 10 11
helpfulness
0 = not helpful at all; 10 = very helpful indeed
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) _______________
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 therapeutic relationship and the centrality of nurturing interpersonal skills.
Geller, J.D., Norcross, J.C. & Orlinksky, D.E. (eds). The psychotherapist’s own
psychotherapy: patient and clinician perspectives. OUP, 2005
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.
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 & authenticity 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 vulnerabilities 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.
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.
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!
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
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