Therapeutic alliance is one of the most frequently discussed topics in psychotherapy literature and its importance is broadly acknowledged. But what about the consequences of this acknowledgment? How does the robust evidence of the critical importance of alliance affect what we call evidence based treatment?
In one of my previous posts I mentioned a Japanese swordsman Miyamoto Musashi, who lived in the 17th century. In feudal Japan, Musashi belonged to the caste of free people. For many years he did not serve anyone, but at the age of 32 he voluntarily entered the service of one of the Shoguns and pledged allegiance to his family.
As I wrote, this story may be a good metaphor of professional development of a clinician. We all start our education as free people with free minds, searching only for inspiration and wisdom. But at some point of our professional path we must decide whom we want to serve, who we want to pledge our allegiance to: a certain theoretical approach, our clients or something/someone else.
This choice is unavoidable, because – as the Bible says – “you can’t serve two masters” (Matthew 6:24), and it will impact the rest of our career.
The fact that we can’t serve two masters is not only a biblical metaphor and it does not only have an ethical dimension. Actually, there is some interesting research on the consequences of our therapeutic allegiance.
Protocol or relationship?
As you perhaps know, in serious clinical trials therapists’ adherence to the protocol is always rated. And so is the level of competence in delivering the tested treatment. This sounds logical, because if we are to judge the value of an intervention branded as “X”, we must be sure that it was the “X” that was delivered during the trial and that the therapists had sufficient skills. Then, we can be sure that a possible failure is not to be blamed on insufficient competence or the lack of adherence in those who delivered the treatment, but on the treatment itself. As a bi-product, such studies provide us with valuable data showing the impact of single therapists’ adherence and competence on their results.
A meta-analysis of 36 such studies showed that neither the therapist’s adherence to protocol nor the level of treatment-specific competence play any significant role in determining clinical outcomes. In other words: it doesn’t matter how well you are trained in a particular treatment nor how much your intervention resembles the “ideal” version of the treatment. It’s something else that counts.
Another study goes even further and shows that the more flexible (non-adherent) therapists are in applying specific protocols and techniques, the better outcomes they achieve. Being a purist does not work out in the field of psychotherapy. It looks like being bad as “X”-therapist makes you good as a therapist. Unbelievable! How is this paradox possible?
Well, as someone who teaches psychotherapy I always differentiate between (1) general therapeutic skills (applicable across approaches) and (2) approach-specific skills. The above-mentioned studies concern (2) approach-specific skills only. So, don’t jump to far-reaching conclusions. The research does not show that psychotherapy training is a waste of time, but it shows that training in general therapeutic skills is essential and more important for success.
If you expected that such results would revolutionize psychotherapy training, you couldn’t be more wrong. No, during workshops on “X-for-something” you will learn how to deliver a “correct X” and not how to be efficient in treating this “something”. They are usually based on the assumptions that (1) higher fidelity to “X” leads to higher therapeutic efficiency and (2) if you have poor “X”-skills then this must be the cause of your failures.
The majority of clinicians seem to have realized already that these assumptions are false. As research shows, they deliver eclectic interventions. However, the fact that adherence to treatment has detrimental impact on results is a phenomenon that needs some conceptual explanation.
Actually, there is a contextual model of psychotherapy, developed by Wampold and Zimel, that predicts such paradoxical results. The authors have actually pointed out that rigid adherence to a protocol can harm outcomes because it may be detrimental for the therapeutic alliance.
Alliance – an agent of change or just a facilitator
Oops! Did I use the magic word “alliance” again? Well, the proponents of pure treatments admit that alliance is important, and yet …. unimportant. It means, that the alliance only facilitates specific processes of change but is not an agent of change in itself. So far, research seems to show the opposite.
There are two main arguments typically used against looking at alliance as an active agent of change across approaches: (1) it’s a poorly defined/operationalized concept and (2) we don’t know how (i.e. through what mechanisms) it might work. Let’s have a look at both arguments:
Therapeutic alliance is defined quite precisely as a relationship between a therapist and a client that consists of three components: (1) the bond, (2) the agreement about the goals of therapy, and (3) the agreement about the tasks of therapy.
Even if you have never heard of any measurement of alliance, it’s not difficult to figure out that something like the “level of agreement” is easy to measure. What concerns the quality of the emotional bond, it is not different from the quality of any positive human relationship: reciprocal positive feelings, mutual affirmation, trust and respect. In other words: the interpersonal climate of emotional safeness that allows partners to take risk of being honest and to open to honesty.
Well, how and why may the alliance have a healing effect?
Hmm, to begin with, how and why do you think a mutual agreement about the goals and tasks may impact the client’s motivation and the sense of empowerment in own healing process? Is the correlation between agreement and engagement psychologically inexplicable, or can we find theories that explain the “causal” character of the link between both variables? Well, do your own research on the topic…
Now, let’s have a look at a possibly healing role of a close relationship, the “emotional bond”. Is it really so hard to understand and explain? Since Bowlby published his first work on attachment, the neuroscience of human relationships has advanced and our understanding of the “social brain” has deepened.
The impact of social connectedness on mental and physical health is well researched and commonly understood, both from biological and psychosocial points of view. Finally, the well-known, potentially lethal consequences of loneliness, cast some light on the healing power of positive inter-human relationships.
Therapeutic alliance in Emotional Safeness Therapy
Emotional Safeness Therapy views the therapeutic relationship not as a mere facilitator of change, but as an active agent of change. It is thought to directly contribute to the therapy outcomes through a synergy of neuro-affective, cognitive and behavioral processes, well researched and described in literature. Thus, in EST, the quality of the therapeutic relationship is prioritized over other elements of therapy and must never be sacrificed for adherence to protocols. That’s why systematic and structured feedback on the quality of therapeutic relationship is an inherent part of the treatment and is viewed as a core strategy of change.
How about the EST protocol then? Well, there’s evidence that no protocol is evidence based, since clients get better when therapists don’t follow protocols. Actually, when I was writing this post, a new systematic review has been published showing that manualized treatments are not more effective than non-manualized treatments.
Having said that, let’s take a look at the EST model. Awareness, Safeness, Connectedness and Empowerment – no therapy would explicitly neglect these qualities of psychological functioning. There are many ways of enhancing them and no single approach has a monopoly. But there are also ways of delivering any therapy that can undermine those qualities. So, although the EST has its own technical repertoire and explanatory models, the approach requires from the therapist extreme flexibility and sensibility to the client. When therapists are fixed on protocols, it’s easy to lose sight of the purpose.
Building the context of change in EST
So, how do we build the interpersonal context of change in Emotional Safeness Therapy? There are three core elements of the therapeutic relationship in EST: mutual respect, validation and safeness. Respect implies that the client’s goals and expectations are always taken seriously and viewed as legitimate, even if unachievable.
That’s why we dropped the strategy of “creative hopelessness” used in the traditional ACT. Even if the client wants to “forget some memories” or “control some thoughts”, these goals are viewed as legitimate. The clients’ goals are never wrong, neither are their intentions. These goals just lie sometimes beyond our reach. However, instead of labeling them as “control agenda”, the EST therapist invites the client to a common exploration of their meaning and to an open reflection on how the specific, time- and space-limited therapeutic situation might be helpful for the client.
EST was co-created by clients and is always delivered as a common project of the team consisting of a client and a therapist. There are no leaders and no consumers in this dyad. There are only partners who share both goals and the responsibility for their achievement.
Therapists on a bus
Steven Hayes created a beautiful metaphor of self-defeating thoughts, which are compared to annoying passengers that try to change the direction in which the client drives the bus of own life. They stop yelling at the driver only when the bus starts moving in the direction of their choice. Well, without continuous and systematic work on the quality of the therapeutic relationship, the therapist may easily become yet another of these passengers.
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