Strategies for doing What Works in Therapy

Recently I was discussing the high rates of relationship breakdowns and depression with a therapist colleague. We covered many issues, including the challenge of being an effective therapist and how best to do that.

As a therapist I support clients to negotiate and deal with the plethora of emotional pains, suffering, relationship breakdowns and depression symptoms they come with. At this time the emerging reflection and questions for me are how to engage with clients, facilitate a trusting therapeutic alliance and deliver effective therapy outcomes for the client so that I truly help to make a difference.

The question of how to do to therapy that works has led me to review the work of Miller, Duncan and Hubble, whose current research and books on this subject are enlightening. In their books ‘The Heart and Soul of Change’ and ‘The Heroic Client’, they challenge the role of therapists as the experts who do therapy to fix clients. They question the adherence to medical models for the delivery of therapy on the basis that it isn’t necessarily effective. The humanistic approach they offer instead recognises and honours the roles and contribution clients rightly have in determining and informing their therapy and identifying opportunities for real change. Who better to advise and inform about what processes and therapy outcomes suit them best?

Miller et al provide a paradigm shift from current models of client care where the client is the problem or diagnosis in needing of fixing, to one in which the client and therapist for a collaborative alliance to join in fixing the problem. In other words the client isn’t the problem, the problem is the problem.

I am pleased to offer a brief synopses from their work, in the hope that it may provoke you, entice you to explore it further, be curious and who knows, even find the courage to become bold enough to question your own effectiveness. Finally I will provide some links for further research and reading on the subject, which Miller et al generously offer on their website.

Briefly here are some strategies to consider.

Form an Alliance with the client to Work on the Problem

Therapy isn’t about fixing people; rather it is about working on problems and finding solutions. The research shows that it is more effective to form an alliance with the client in which they are enabled and assisted to fix or alleviate their problem/s. Rather than have the therapist and client pull in two different directions, which happens when there is a misfit in the alliance, the combined effort of an effective therapeutic alliance is more likely to lead to a solution.

The development of a poor alliance between clients and therapists is a major reason for clients dropping out of therapy.

Forming a positive alliance between the client and therapist is one of the best predictors of success of outcomes in individual therapy, group work and relationship counselling. Next to what the client brings to therapy, the client’s perceptions of the therapeutic relationships are responsible for most of the gains resulting from therapy.

Relationships account for 30% of successful outcome. (Asay & Lambert, 1999)

Be Informed about Client Outcomes

If the therapy isn’t working and the client isn’t getting better outcomes, then stop doing what isn’t working and do something different. Easier said than done you might say. What is required is reliable methods to detect when the therapy or counselling is off track early rather than later. Then corrective steps can be taken at an early stage to more appropriately meet the needs of the client. Consider also:

Client-directed therapy requires that we therapists give up our notion of ‘expertness, a proposition that is difficult to assimilate after the years of training that we have endured in order to achieve our status ... humility is required to become a client-directed therapist because of the benefits that clients will experience by participating in a healing practice that recognises their wisdom and respects their understanding of themselves (Duncan et al, p.xi)

So isn’t it enough that we have health services and professionals to help clients achieve these outcomes? The simple answer is no!

Many human services providers confuse the act of building and resourcing service structures with the delivery and achievement of effective client services and outcomes. They are not the one and same thing. The service structure, accreditation processes, manuals and professional degrees do not guarantee effective client outcomes.

Surprisingly, not all therapists provide effective therapy. Current research describes how therapists who have been in practice for more years often tend to be the least effective. These therapists were shown to be unaware of how ineffective they were, and in fact considered that they were truly helpful therapists. (Hiatt and Hargrave (1995) cited in Duncan, Miller & Sparks).

With inadequate processes process to evaluate their effectiveness such therapists remain uninformed about their practice, and clients continue to suffer from ineffective therapy, or drop out. It is possible that many of these clients are labelled as resistant and difficult rather than the recipients of unhelpful therapy.

Help is at hand. Miller et al have designed a number of useful client self-reporting and peer rating tools which are obtainable from their website at www.talkingcure.com . These tools provide some direction and information about how to become more informed about client outcomes, and can be easily downloaded and used.

Develop Effective Client Alliances

Next to what clients bring to therapy; their perceptions of the therapeutic relationship are responsible for most of the therapy gains. As no therapist is effective for every client it is important to include options such as referrals to other therapists or professionals who may be more appropriate for the client to work with when this action is needed. Of course prevention is better than cure, and the effort to consider ways to develop and maintain the alliance is a preferable option from a cost effectiveness point of view and the clients wellbeing.

A quality alliance will keep the client informed about the process, ascertain their needs and invite them to monitor and own the process. It is useful to identify up front how the client will express when they are dissatisfied with the progress or content of the therapy and / or need to be referred to another practitioner. This alerts them to the prospect that this may happen, normalises the situation if and when it happens, and provides early understanding about how sensitive issues such as these will be raised. It may alert the client to the fact that their input and opinions are vital components of the therapy process.

Strategies described by Duncan et al for a therapist to develop an effective alliance include commonsense measures such as:

• Being likeable, friendly, and responsive
• Carefully monitoring the client’s reaction to comments, explanations, interpretations, questions and suggestions
• Being flexible: doing whatever it takes to engage the client.
• Validating the client. Legitimising the client’s concerns and highlighting the importance of the client’s struggle.

Therapy that is a mutually agreed process rather than an imposed treatment is less likely to create resistance, and more likely to be implemented.

Find out what they need to be successful

To elicit what would be helpful for the client may be as simple as having the conversation and mutually agreeing to a plan. This may include:

• I’d like to tell you about how I work, so you can understand what I do
• What would you like from the sessions?
• I want to provide you with effective therapy, and I would like your feedback to make sure that I am on track
• How will you let me know when I’m on track and being helpful to you?
• How will you let me know when I’m off track?

The important message from the research of Miller et al. (1999b) confirms that clients not therapists make therapy work. Therapists need only to take direction from their clients, follow their leads, adopt their world view, goals and ideas about the problem; and acknowledge their experiences with, and inclinations about the change process that is needed.

In practice, this has the potential to be a more relaxed and enjoyable process for the therapist. Rather than being responsible for the outcomes there is opportunity to loosen the reins and watch as the client takes them up, and hopefully does the work. After all, in order to fix the problem, the client does need to do the work.

I hope this brief snippet has been of some interest and benefit, and if you require further information you might follow up this link and take a look at what 40 years of research says about effective clinical practice.

Be the most "up-to-date" practitioner on your block. Read the latest research on "what works" in clear, uncomplicated, and non-statistical language. www.talkingcure.com