Week 10 Flashcards
How many psychotherapy clients show benefit?
About 75–80% of patients who enter psychotherapy show benefit.
What factors account for success (and
failure)?
the patient, the treatment method, the psychotherapist, the context, and the relationship between the therapist and the patient
Norcross (2011) Psychotherapy relationships that work. NY: Oxford University Press.
The therapy relationship makes substantial and
consistent contributions to patient success.
• The therapy relationship accounts for why clients
improve as much as the treatment method.
• Practice guidelines should address therapist qualities
and behaviours that promote the therapy relationship.
According to Narcoss 2011 Practitioners should routinely:
monitor patients’ responses to the therapy relationship.
• Efforts to promulgate evidence-based practices without including the relationship are incomplete and potentially misleading.
• The relationship acts in concert with treatment methods, patient characteristics and practitioner qualities in determining effectiveness.
• Adapting or tailoring the relationship to several patient
characteristics enhances effectiveness.
Key Elements of the Therapy Relationship (Norcross, 2010
Therapeutic Alliance Cohesion in Group Therapy Empathy Goal Consensus and Collaboration Positive Regard and Affirmation Congruence/Genuineness Collecting Client Feedback Repairing Alliance Ruptures Managing Countertransference Adapting the Relationship to the Individual Patient
Therapeutic Alliance
“The alliance is an emergent quality of partnership and mutual collaboration between therapist and client.” (Norcross (2010), p5)
Therapeutic alliance in youth is more
complicated
The development of a good alliance is essential for the
success of psychotherapy.
The ability of the therapist to bridge the client’s needs, expectations, and abilities into a therapeutic plan is important in building the alliance.
Because the therapist and client often judge the quality of the alliance differently, active monitoring of the alliance throughout therapy is recommended.
Responding nondefensively to a client’s hostility or negativity is critical to establishing and maintaining a strong alliance.
best predictor of outcome
Clients’ evaluation of the quality of the alliance is the best predictor of outcome
Group Cohesion
Cohesion describes therapeutic relationships in group psychotherapy and has two dimensions: relationship
structure and relationship quality
Structure in group cohesion
Structure refers to the direction of the relationship.
Vertical cohesion:
group member’s perception of leader’s competence, genuineness, and warmth. Horizontal cohesion: group member’s relationship with other group members and with the group as a whole
The quality in group cohesion
The quality is defined by how members feel with their leader and with other members (positive bond), by the tasks and goals of the group (positive work), and also the empathic failure with the leader and conflict in the group (negative relationship)
Is cohesion associated with outcomes?
Cohesion is reliably associated with outcomes. All group leaders should foster cohesion in its multiple manifestations.
Group leaders emphasising member interaction give higher cohesion-outcome links.
Cohesion is strongest when a group lasts more than 12 sessions and is composed of 5 to 9 members.
Younger members experience the largest outcome changes when cohesion is present within their groups.
Empathy
Carl Rogers (1980, p85) defined empathy as “the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view. … It means sensing meanings of which he or she is scarcely aware”
what makes an empathic therapist?
Psychotherapists should make efforts to understand clients’ experiences and demonstrate this understanding through their responses.
Empathic therapists do not parrot clients’ words back; instead they understand overall goals.
Empathic responses can include straightforward responses that convey understanding of client experience, but also responses that validate the client’s perspective, or bring the client’s experience to life, or that aim at what is implicit.
Therapists should not assume that the client feels understood by their efforts at empathy.
Research has shown empathy to be inseparable from the other relational conditions
Goal Consensus and Collaboration
Therapists and clients outline the conditions of their work
together.
Agreement about the nature of the problem for which the client is seeking help, goals for treatment, and the way that the two parties will work together to achieve these goals are the essence of goal consensus.
To help clients fulfill mutually agreed-upon treatment goals, mental health service providers and consumers must function as a team.
Collaboration represents the active process of their cooperation in this endeavor
Begin problem-solving only after agreeing on
treatment goals and the ways to reach them.
Listen to what clients say and formulate
interventions with their input and understanding.
Include clients’ contributions throughout psychotherapy by requesting their feedback, insights, reflections, and elaborations.
Clients need to recognize the importance they play
in achieving goal consensus and collaboration.
Positive Regard and Affirmation
Carl Rogers (1951) believed clients should be treated in a consistently warm, supportive, highly regarding manner
Positive regard is strongly indicated in practice.
May be especially useful wherein a nonminority therapist is working with a racial/ethnic minority client.
Therapists should ensure that their positive feelings toward their clients are communicated to them.
Therapists can monitor their expressed level of positive regard and adjust it as a function of the needs of particular patients and specific clinical situations.
Congruence/Genuineness Two facets:
Two facets:
Intrapersonal - mindful genuineness on the part of the therapist. (even if you don’t like them you can genuinely want to help them)
Interpersonal - therapist’s capacity to conscientiously communicate his or her experience with the client to the client.
Congruence/Genuineness involves:
Congruence involves acceptance of and receptivity to the client as well as a willingness to use this information in conversation.
Congruence must be developed by discipline, practice, and effort, with active and engaged listening.
Congruence may be modeled through self-disclosure as well as sharing of thoughts and feelings, opinions, pointed questions, and feedback regarding client behavior.
Effective therapists will modify and tailor their
congruence style according to client characteristics .
A congruent therapist communicates acceptance and
the possibility of engaging in a genuine relationship.
Collecting Client Feedback
Systematic monitoring of client mental health through the use of standardised scales can improve psychotherapy
effectiveness.
Research showed when feedback was provided:
rates of patient deterioration were cut in half
rates of positive responding were several times greater
Employ real-time client feedback to compensate for therapist’s limited ability to accurately detect client deterioration.
Practitioners and clients can share their impressions
about the progress of treatment and the therapy relationship.
Beware of clients understating or overstating their problems and the possibility of inaccurate ratings on feedback systems.
Consider sharing progress with clients.
Consider using electronic versions of feedback systems that expedite and ease practical difficulties.
Repairing Alliance RupturesManaging Countertransference
Ruptures in the therapeutic alliance are episodes of tension or breakdown in the collaborative relationship between the client and therapist. Exploring and repairing alliance ruptures when they occur is important.
The presence of alliance rupture-repair episodes
over the course of treatment is positively related to
psychotherapy success.
Therapists should be attuned to ruptures and to take the initiative in exploring what is transpiring and repairing them.
It can be helpful for patients to express negative feelings about the treatment to the therapist should they emerge.
When ruptures occur, it is important for therapists to respond in an empathic and nondefensive fashion.
Managing Countertransference
Countertransference (CT) is a psychotherapist’s internal and external reactions to a client that are influenced by the therapist’s personal vulnerabilities and unresolved conflicts
Psychotherapists acting out of their CT can be
harmful
Because CT management seems to promote successful treatment, therapists are urged to manage internal CT reactions.
Therapists are encouraged to resolve their personal conflicts through personal therapy, clinical supervision, or both.
Patients probably benefit from psychotherapists who help them learn about the interpersonal reactions that they evoke in others
Adapting the Relationship to the Individual
Goal is to increase treatment effectiveness by tailoring it to the unique individual and his/her singular situation
Treatment should be tailored to each of the
following client characteristics:
- Reactance Level
- Stages of Change
- Preferences
- Culture
- Coping Style
- Religion/spirituality
- Patient expectations
- Patient attachment style
Things to be mindful of with clients.
Demonstrably Effective
• Reactance Level (might be more reactive than others, might be better suited to a less structured session. Less reactive might need more structure)
• Preferences (gender, ethnicity, sexuality of therapist etc)
• Culture
• Religion / Spirituality (when it comes to spirituality related outcomes, this is important. Adapting therapy style is important.)
Probably Effective
• Stages of Change (adapt therapy according to stages of change)
• Coping Style (externalizing coping style might be more symptom focused.)
Promising
• Patient Expectations
• Patient Attachment Style
Effective Psychotherapists
Therapy efficacy is also dependent on the
abilities of the psychotherapist.
Specifically skills, interpersonal abilities, professionalism, ongoing training and supervision.
A therapy is just a framework – it is the therapist that makes it truly effective.
Effective Psychotherapists subjective vs objective characteristics
you have things like age and sex which are objective and things like personality which are subjective, and these interact in different ways differently for cross-sectional environments and for therapy specific environments.
Effectiveness Skills
Interpersonal Trustworthy Collaborative Adaptive Structured Confident Evaluative Flexible Inspiring Sensitivity Self-Insight Knowledgeable Ongoing Training
Effectiveness Skills:
Interpersonal
Having a sophisticated range of interpersonal
skills
Able to express themselves clearly and intelligibly
Able to relate to a wide range of people
Show warmth, acceptance and empathy
Able to focus on the client, and not themselves
Client should feel understood, valued and respected
Effectiveness Skills: Trustworthy
Therapist presents as trustworthy
Therapists communicate, either verbally or non-verbally, that they have clients best interests foremost.
Clear about limitations includingconfidentiality, efficacy, duration, cost and competency.
Clients should feel the therapist can be trusted with sensitive information.
Effectiveness Skills: Collaborative
Willing to establish a therapeutic alliance
Client feels they are working together with the therapist as a team.
Goals are meaningful to the client.
Clients are “on board” and aware of the purpose of specific exercises
Effectiveness Skills: Adaptive
Can explain symptoms and can adapt as
circumstances change
Able to discuss symptoms with regard to diagnoses.
Able to give evidence-based information and refer to specific bodies of information
Shouldn’t be overly scientific unless clearly explained in a language appropriate to client,
Client should feel as though therapists actions are grounded in an advanced understanding.
Effectiveness Skills: Structured
Commitment to developing a consistent
and acceptable treatment plan
First conduct an assessment then develop a treatment plan collaboratively with client
Review throughout the course of therapy
Client should feel as though there is a reason for a specific treatment plan
Effectiveness Skills: Confident
Communicates confidence about the course of therapy (and flexibility if goals are not being met)
Therapist needs to show confidence in the therapy and communicate this to the client
Therapist also needs to communicate that they are competent in the therapy
Client should not feel as though they are being “experimented” on!
Effectiveness Skills: Evaluative
Attention to the progress of therapy and communication of this interest to the client.
Effective therapists “check in” with the clients to ascertain how they feel therapy is progressing
They also act on behalf of the client by registering and evaluating verbal and non verbal communications
Client should feel as though if the therapy is going of track, that the therapist is aware and flexible
Effectiveness Skills: Flexible
Flexibility in adapting treatment to the
particular client’s characteristics.
No single therapy suits every client
An effective therapist considers this and uses multiple therapeutic techniques as required
Therapist also invites feedback from client about what works and what doesn’t
Clients should feel the therapy is tailored to them rather than “fitting in” with a therapy
Effectiveness Skills: Inspiring
Therapist creates inspiration of hope and optimism about clients chances of improvement.
Maintain balance between optimism and reality – some psychological conditions take longer to treat
Any optimism should be tempered with the reality that most clients experience a relapse in symptoms
Client should feel that improvement is possible and that the therapist is on-side if a relapse occurs
Effectiveness Skills: cultural Sensitivity
Sensitivity toward client’s cultural background.
Effective therapists are respectful of, and consider the cultural norms relevant to their clients identity
Effective therapists incorporate these norms and reinforce adaptive aspects of people’s cultural identity
Therapists may respectfully point out where disparate values lie, but acknowledge and reinforce the clients own cultural norms
Effectiveness Skills: Self-Insight
Possession of self-insight:
Effective therapists are aware when their own problems impinge upon their efficacy
Effective therapists work to address these issues, either through own therapy and/or supervision
Effective therapists do not become complicit in maladaptive behaviours or thoughts that mirror their own
Client should not feel like they are the therapist!
Effectiveness Skills:
Knowledgeable
Reliance on the best research evidence.
Effective therapists never stop learning, inquiring, and trying to improve their knowledge
They keep abreast of new evidence, treatments, psychopharmacology, and diagnostic criteria
Client should feel as though therapist is operating under evidence-based practice
Effectiveness Skills: Ongoing
Training
Involvement in continued training and
education.
Usually in the form of CPD but an effective therapist goes beyond minimum requirements
They actively seek out further training and identify gaps in own knowledge
They realise that while you will never know everything, you can maximise your clients progress through increasing own knowledge
