Common Factor? A behavioural perspective on the therapeutic - - PowerPoint PPT Presentation

Common Factor? A behavioural perspective on the therapeutic relationship

David Gillanders Academic Director, Doctoral Programme in Clinical Psychology University of Edinburgh

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The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

• I can confirm that I have received no sponsorship or

financial aid or other relations that could be relevant to this meeting

• As a peer reviewed ACT trainer I do receive free

books from New Harbinger

DISCLOSURE OF INTERESTS

The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

• To see a full catalogue of ACT related books go to

www.newharbinger.com

(Other publishers are available)

DISCLOSURE OF INTERESTS

WE HUMANS CANT HELP COMPARING…

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The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

• Saul Rosenzweig, 1936

– “Implicit common factors” – The Dodo Bird Verdict

• Jerome Frank, 1975

– Provide for a need to be heard / accepted – Provide a rationale that explains the situation

COMPARING THERAPIES

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• Bruce Wampold -

– “bona fide and non bona fide treatments” – Trained therapist – Face to face contact, individualised treatment – Psychologically valid components

• For typical outpatient depression studies, there are

no differences between theoretical approach

COMPARING THERAPIES

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• Luborsky et al., 2002
• Meta analyses of meta analyses: 17 metanalyses,
• Adult patients with common problems (depression,

anxiety, OCD, ‘neuroses’)

• CT, BT, CBT, REBT, Dynamic Psychotherapy

COMPARING THERAPIES

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• Average mean difference in effect size between

active comparisons

• Cohen’s d = .20, and non significant
• Differences between treatments are small

COMPARING THERAPIES

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• Robust critiques from several authors:
• Same studies used multiple times
• Active and control comparisons lumped together
• Active treatment and pharmacotherapy confounded

in some dynamic therapies

• Collapsing different problems together and different

severities of patients

IT’S CONTROVERSIAL

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• Lack of specification of procedures, therapies that

are quite different put together in the same category

IT’S CONTROVERSIAL

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• …differences among competently conducted psychotherapies may be

small for some problems (e.g., adult depression) but quite striking for

• thers (e.g., agoraphobia). Even within the category of behavior

therapy, clear differences emerge. For example, in four separate studies, exposure and response prevention (ERP) for OCD was compared to progressive muscle relaxation training. In all studies, ERP was significantly superior to the other treatment. As a clinician, should I conclude that I can safely ignore these findings and base my treatment on relaxation because, overall, if I were to average all possible differences between psychotherapies for all possible problems, the average difference would be small? Obviously not.” Chambless, 2002, Clin. Psych. Sci & Prac, 9: 13-16

IT’S CONTROVERSIAL

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“If we accept the Dodo bird verdict then it follows that regardless of the nature of your psychological problem, seek any form of therapy. This is absurd and not even the strongest advocates of the common factors hypothesis actually dispense this advice”

Rachman & Wilson, 1985”

IT’S CONTROVERSIAL

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LIKE MIXING PAINT…

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• Common factor advocates feel misrepresented in

these critiques

• Other sources of variance in outcomes – not just the

specific treatment package but significant therapist variability

Messer & Wampold, 2002,

• Clin. Psych. Sci & Prac, 9: 21-25.

MISUNDERSTANDINGS

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• Seeking to redress the balance
• A misinterpretation of the EST field: more

concern about what is delivered rather than how it is delivered

• An emphasis on therapist rather than therapy

factors

MISUNDERSTANDINGS

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• “In the common factor or contextual model, the

purpose of specific ingredients is to construct a coherent treatment that therapists believe in, and this provides a convincing rationale to clients. Furthermore, these ingredients cannot be studied independently of the healing context and atmosphere in which they occur.”

Messer & Wampold, 2002,

• Clin. Psych. Sci & Prac, 9: 21-25.

MISUNDERSTANDINGS

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• “In the common factor or contextual model, the

purpose of specific ingredients is to construct a coherent treatment that therapists believe in, and this provides a convincing rationale to clients. Furthermore, these ingredients cannot be studied independently of the healing context and atmosphere in which they occur.”

Messer & Wampold, 2002,

• Clin. Psych. Sci & Prac, 9: 21-25.

MISUNDERSTANDINGS

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• “In the common factor or contextual model, the

purpose of specific ingredients is to construct a coherent treatment that therapists believe in, and this provides a convincing rationale to clients. Furthermore, these ingredients cannot be

studied independently of the healing context and atmosphere in which they occur.”

Messer & Wampold, 2002,

• Clin. Psych. Sci & Prac, 9: 21-25.

MISUNDERSTANDINGS

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• The relationship is the common contextual factor

across all therapies

• It is that aspect of the context that has greatest

influence on outcomes

• The specific techniques are also a feature of the

context though one that has relatively less influence

Messer & Wampold, 2002,

• Clin. Psych. Sci & Prac, 9: 21-25.

AXIOMS

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• Metaanalysis of the correlation between relationship

and outcome

• Overall correlation between relationship and
• utcome r = .275 (95% CI = .25 - .30), p<.0001
• High variability: range of r = .18 to .42

Horvath et al., 2011, Psychotherapy, 48, (1), 9-16.

HOW POWERFUL IS THE RELATIONSHIP?

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• This amounts to around 7.5% of the variance in

treatment outcome

• Correlation is not moderated by how the alliance is

measured, from whose perspective it is evaluated, when it is assessed, the way the outcome is evaluated, or the type of therapy involved.

Horvath et al., 2011, Psychotherapy, 48, (1), 9-16.

HOW POWERFUL IS THE RELATIONSHIP?

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Flückiger et al., 2012, Journal of Couns. Psych.,59, (1), 10 – 17.

HOW POWERFUL IS THE RELATIONSHIP?

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• RCT of 112 people for Bulimia Nervosa
• Alliance high throughout treatment (89% of max)
• Alliance did not predict outcome or drop out
• Alliance not correlated with initial severity of BN,

interpersonal problems or depression and anxiety

• Best predictor of outcome was severity of BN at mid

treatment

(Raykos et al., 2014, BRAT, 57, 65 – 71)

NECESSARY BUT NOT SUFFICIENT

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COMPARISON OF CONTRIBUTION OF METHOD AND ALLIANCE

Effect Sizes for Common Factors and Specific Ingredients

Factor Number of studies Number of patients Effect size Cohen’s d % of variability in outcomes Common factors Alliancea 190 2,630 .57 7.5 Empathya 59 3,599 .63 9.0 Goal consensus/collaborationa 15 1,302 .72 11.5 Positive regard/affirmationa 18 1,067 .56 7.3 Congruence/genuinenessa 16 863 .49 5.7 Therapistsb 46 14,519 .46 5.0 Specific ingredients Differences between treatmentsc 295 5,900 .20 1.0 Specific ingredients (dismantling)d 30 871 .01 0.0 Adherence to protocole 28 1,334 .04 0.1 Rated competence in delivering particular treatmente 18 633 .14 0.5

a Norcross and Lambert (2011). b Baldwin and Imel, 2013. c Wampold et al. (1997); confirmed by various

• ther meta-analyses for specific disorders.

d Bell et al., 2013 (targeted variables); see also Ahn and Wampold

(2001).

e Webb, DeRubeis, and Barber (2010).

Laska, Gurman & Wampold, 2014, Psychotherapy, 51, 467 - 481

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“The common factors approach asserts that (a) most therapists achieve commendable and desirable outcomes (b) improvement will flow from managing outcomes (c) any variable shown to influence outcome is scientifically important (d) data-gathering efforts should focus on changing any therapist behaviours that influence outcome.”

Laska, Gurman & Wampold, 2014, Psychotherapy, 51, 467 - 481

RAPPROCHEMENT

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“Patients are still assigned to “psychotherapy” as if it were a uniform homogeneous treatment, and to psychotherapy with different therapists as if therapist differences were irrelevant . . . If psychotherapy research is to advance, it must first begin to identify and measure these therapist variables so relevant to eventual outcome (personality characteristics, technique factors, relationship variables, role expectancies, and the like) (pp. 112–113).” Keisler, 1966, Psychol. Bull.

SYNTHESIS

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• Non specific versus non specified factors
• False dichotomy between the EST and the CF

approach

• Some specific factors are common and some

common factors are specifiable

Weinberger, 2014, Psychotherapy, 51, (4), 514-518

SYNTHESIS

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SYNTHESIS

Unspecified factors that could contribute to all treatments, including EST’s So called specific factors that that may be common across treatments Expectancy Exposure Attribution for treatment gains Mastery Relationship Understanding / Awareness Remoralisation

Weinberger, 2014, Psychotherapy, 51, (4), 514-518

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Any effective psychotherapy is characterized by (a) an emotionally charged bond between the therapist and patient, (b) a confiding healing setting in which therapy takes place (c) a therapist who provides a psychologically derived and culturally embedded explanation for emotional distress, (d) an explanation that is adaptive (i.e., provides viable and believable

• ptions for overcoming specific difficulties) and is accepted by the

patient, and (e) a set of procedures or rituals engaged by the patient and therapist that leads the patient to enact something that is positive, helpful, or adaptive”

Laska, Gurman & Wampold, 2014, Psychotherapy, 51, p. 469

IDEAS ABOUT THE RELATIONSHIP

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Bordin, 1979

THREE ASPECTS OF RELATIONSHIP

Alliance Bond Goals Tasks

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HOW DO ALLIANCE FACTORS AND SPECIFIC FACTORS INTERACT?

Alliance Specific Factors / Procedures Outcome

Bond Goals Tasks

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• Multi site psychotherapy process study in Norway
• 227 patients with mix of axis I & II problems
• 70 different therapists
• Ratings of alliance by therapist and patient at session

3, 12, 20 and 40

• Therapists also rated aspects of in session burden,

anxiety, challenge as well as flow, engagement,

Nissen-Lie, et al., (2014). Clin. Psychol. & Psychoth., 22, 317-327

INFLUENCES ON THE ALLIANCE

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• Used growth curve modelling to see what

influenced the developing alliance over time, controlling for patients level of relational difficulty

• Therapist sense of flow contributes only to therapist

rated alliance.

• Patient ratings of alliance is negatively impacted by

– lack of empathy / irritation with client – professional self doubt / low self efficacy – therapists that feel anxious

Nissen-Lie, et al., (2014). Clin. Psychol. & Psychoth., 22, 317-327

INFLUENCES ON THE ALLIANCE

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• RCT with 50 Cluster C PD patients
• STDP and CT
• Relationship of bond to outcome and what therapist

behaviours influence bond

• 4 therapist behaviours influenced the patients ratings
• f bond

Ulvenes et al., (2012), Psychotherapy, 49, (3), 291=302

DIFFERENT PROCESSES FOR DIFFERENT THERAPIES

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• 1. Therapist draws attention to patient’s nonverbal

behaviour, e.g. body posture, gestures, tone of voice

• 2. Therapist is sensitive to the patient’s feelings,

attuned to the patient; empathic

• 3. Therapist is responsive and affectively involved (vs.

distant, aloof)

• 4. Therapist comments on changes in patient’s mood
• r affect that occur during the hour

Ulvenes et al., (2012), Psychotherapy, 49, (3), 291=302

THERAPIST INFLUENCES ON BOND

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• Surprisingly, therapist avoidance of affect led

patients to rate bond higher (Cluster C patients), but bond did not predict outcome

• Results were different for the two treatments.

STDP: focus on affect = impaired bond but better

• utcome

CT: avoidance of affect = improved bond and better outcome

RESULTS

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POSSIBLE RELATIONSHIPS

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Ackerman & Hilsenroth (2003), Clin. Psychol. Review, 23, 1-33.

WHAT CONTRIBUTES TO BETTER ALLIANCES?

therapist Characteristics consistency, therapist interested and engaged, non verbal gestures of engagement (e.g. eye contact, leaning forward) verbal behaviours (e.g. self disclosure) sensitivity to patient’s emotions therapist’s own attachment security greater training and experience = related to task and goal but not bond therapist expectation of optimism warmth, friendly, accepting and affirming,

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Ackerman & Hilsenroth (2003), Clin. Psychol. Review, 23, 1-33.

WHAT CONTRIBUTES TO BETTER ALLIANCES?

therapist behaviours / techniques exploration of emotive personal themes communicating hope to achieve goals noting progress towards goals referring to shared therapy experiences conveying a feeling of working together communicating confidence in the patient’s use of new strategies therapist showing understanding and connectedness

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• CBT-p trial, 48 patients rated 11 therapists at

session 3 on empathy, genuineness, positive regard, competence and convincingness

• After the 5th session ratings of alliance and bond

were taken

• Genuineness and ratings of competence significantly

predicted both alliance and bond

Jung et al., (2015). B. J. of Clin. Psych., (54), 34-48

CULTIVATING POWERFUL ALLIANCES

“Learn your theories well but put them aside when you confront the mystery

• f the living soul.” Carl Jung (1875 – 1961)

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CULTIVATING POWERFUL ALLIANCES

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• Topical review
• Five strategies for cultivating therapeutic

relationship in BPD

– cultivate emotional awareness – structure treatment – be responsive – supervision / team involvement – explore ruptures

McMain et al., (2015). J. of Psychoth. Integration, (25), 20-29.

CULTIVATING POWERFUL ALLIANCES

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• Self practice and self reflection by experienced

cognitive therapists (mean of 17 years experience)

• A small study using single case methods (n =7)
• Following a self practice cognitive therapy

workbook led to improvements in CT technical skill and empathy

Davis et al., (2015). Clin. Psychol. & Psychother., 22, 176-184

WHAT CAN HELP US TO DEVELOP EMPATHY AND SKILL?

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SELF PRACTICE - SKILLS

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50 55 60 65 70 75 80

Pre baseline Start of self practice End of self practice 4 week follow up Average client Most difficult client

SELF PRACTICE - EMPATHY

increase relative to baseline (overall), F(1,6) = 6.03, p=.049, η2 = .501

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BENEFITS OF SELF PRACTICE

Gale & Schroeder, (2014). Psychol & Psychoth.87, 373- 392

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• Therapists that can be authentically themselves
• That can structure sessions
• That can talk about the therapy itself
• Can mend ruptures
• That can be both validating and change focussed
• That can find agreement about the goals and tasks
• That are reliably consistent
• That apply their strategies to themselves

SUMMARY…

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• What therapist behaviours, in what contexts lead to

powerful therapeutic relationships?

• What contingencies and contexts increase the

probability of those behaviours in a therapists’ repertoire?

• What is the relationship between those therapist

behaviours, the therapy relationship and change?

TRANSLATING THE QUESTION INTO CONCRETE BEHAVIOURAL TERMS

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“To the extent that therapists can allow themselves to be who they really are with a client, a more powerful and unforgettable relationship is created in therapy.”

Tsai, Callaghan & Kohlenberg, (2013). Psychotherapy, 50, 3, 366-370.

FUNCTIONAL ANALYTIC PSYCHOTHERAPY

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• A behavioural relational approach to psychotherapy
• Client interpersonal behaviour can be categorised

into functional classes, and will occur in therapy

• CRB 1 = Problematic interpersonal interactions
• CRB 2 = More effective interpersonal responding

FUNCTIONAL ANALYTIC PSYCHOTHERAPY

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• 1. Watch for CRB’s
• 2. Evoke CRB’s
• 3. Provide natural reinforcing responses to CRB 2’s
• 4. Observe if reinforcement actually occurs
• 5. Use behavioural interpretation and encourage

generalisation outside of therapy

Kohlenberg & Tsai, 1991.

5 RULES OF FAP

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Awareness Courage Therapeutic Love

AWARENESS, COURAGE & LOVE

Watch out for the function of client behaviour (CRB1 & CRB2) Evoke CRB1 and shape CRB 2 responding Naturally reinforce CRB2

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Awareness Courage Therapeutic Love

AWARENESS, COURAGE & LOVE

Watch out for the function of client behaviour (CRB1 & CRB2) Evoke CRB1 and shape CRB 2 responding Naturally reinforce CRB2 Client who habitually subjugates his own needs

• self sacrificing
• passive aggressive
• self loathing

“I’m not sure I can even change, I don’t think I have what it takes to follow through, I might just be wasting your time” “I hear how ready you are to give up

• n our work and I

feel sad about it, and I sense that you are feeling that too. What do you most need from me as we sit with this? “Even just hearing you say that helps, to know that you care” “I do hear you, and I do care. How else might I best support you in working on this together?”

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HOW DO WE KNOW ACL IS HELPFUL?

• Single case design
• 25 yr old woman
• Depression and interpersonal

distress

• Baseline, CT then FAP
• CRB1 and 2 increase in FAP
• More relationship focus and

shaping in the FAP phase

• More CRB2 occurs in FAP phase
• Time lagged effects show that

CRB2 occurs following relationship focussed work

Busch, Kanter et al., (2009).

• Behav. Therp.(40), 280 – 290.

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• Responding to closeness building questions
• Evoke only versus evoke and respond with love
• Depth of disclosure rated from recording by blind assessors
• Self reported sense of connection to the RA measured pre,

post, 48 hours and 2 weeks later.

Haworth, Kanter, Tsai, et al., (2015). JCBS

EVIDENCE FOR MECHANISM

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Haworth, Kanter, Tsai, et al., (2015). JCBS

DEPTH OF DISCLOSURE OVER SESSION

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1 2 3 4 5 6 Pre Post 48 Hours 2 weeks Control Evoke Evoke & Respond

SENSE OF CONNECTEDNESS

Time x Condition interaction, F(6,74) = 9.29, p<.001, ηG2 = .059,

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• 8 weeks of online FAP group
• 2 hours per week, 8 trainees per group
• Develop FAP conceptualisations
• Practice ACL
• Homework assignments
• n = 16

Kanter, Tsai, Holman & Koerner, (2013). Psychotherapy, 50, 2, 248-255.

CAN WE TRAIN THESE BEHAVIOURS?

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• Significant increases in self-awareness, awareness of

client, courage/risk taking, therapeutic love/reinforcement, values, self-disclosure, behaviourism competence/attitudes, and in-session focus.

• Significant improvements in FAP relevant responses

to vignettes

• Effect sizes were medium to large

Kanter, Tsai, Holman & Koerner, (2013). Psychotherapy, 50, 2, 248-255.

ONLINE FAP TRAINING GROUPS

how to build a powerful, transformative relationship

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The University of Edinburgh is a charitable body, registered in Scotland, with registration number SC005336 www.ed.ac.uk

• Being present
• Monitoring self and other
• Tracking micro phenomena
• Accurate experiencing:

– “Labelling is the death of experiencing”

• Sensitivity and attunement to the other
• Not getting hooked into your own responding
• Slowing down

AWARENESS

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• Notice when ‘the rules’ show up
• Track function both of the client’s and your own

behaviour

AWARENESS

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• Putting the client’s growth first
• Resolute in being of service
• Fostering your own willingness to do hard things in

the service of your client’s growth

• Zone of proximal development
• Confidence

“Con fides”

• Courage

“Coeur – age”

• Explore affective material, if it is functional to do so

COURAGE

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• Pop the bubble – be humorous
• Functional self disclosure

– to show togetherness – to show normality – to model (openness, defusion, commitment, willingness etc) – to show genuine caring / being moved – to foster trust – to encourage client disclosure

COURAGE

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• Be genuine
• Try not to hide behind therapy rules and roles
• Model, instigate & reinforce
• Gentle persistence is as courageous as a bold move

COURAGE

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• Speak from a genuine, heartfelt place
• Let clients matter to you and let them know they

matter

• Use your caring presence deliberately to shape the

client’s behaviour towards the things that they want

• Validate struggling / Validate effort
• Validate anything that is different from the usual

problematic repertoire

THERAPEUTIC LOVE

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• “If you love somebody, set them free…”
• Let distant clients experience attachment
• Let dependent clients experience attachment and

work towards independence

• Help people ask for what they need and find ways of

getting it from their natural environment

THERAPEUTIC LOVE

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• Look after your own needs first
• In the service of others, look after your own

boundaries

• You are the tool – keep yourself sharpened, well

looked after, well maintained.

THERAPEUTIC LOVE

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• In the moment self soothing
• Supportive self talk
• As an on-going quality of

self maintenance, self support

SELF CARE

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THREADS OF YOUR LIFE