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Emotion-focused therapy workshop series (second post): client processes and therapist-client conflict

So yesterday was a day seminar on Emotion-focused therapy (EFT) with Robert Elliott.  I wrote yesterday about my excitement over starting this sequence of monthly workshops - there are another five due over January to May next year.  Well how did the day go?

There were twenty two participants (including four who had flown over specially from Portugal and some from England), an assistant, and Robert. We were in a room at Glasgow's Strathclyde University Jordanhill Campus. OK. It will do as a container for the learning that hopefully will flow! I'm particularly doing this course because I want to brush up on my skills with methods like two chair & empty chair dialogue techniques. However the morning was mostly taken up with looking at Client processes and Process markers. We were referred too to chapter four "Client microprocesses: what process-experiential therapists listen for" in the book "Learning emotion-focused therapy" by Robert, Jeanne Watson, Rhonda Goldman & Leslie Greenberg. Interesting stuff on body language, emotion cues of various kinds, "modes of client engagement". We took the information into a role play where we were asked to explore and move through simple mindfulness of current state, to "experiential search" similar to focusing, to active expression bringing in body movement, to interpersonal contact involving relating to the others in one's small group. Interesting, fun, a good way of beginning to meet other members of the course.

The afternoon topic was more immediately engaging for me ... "conflict" in the therapeutic relationship. I think this is very important territory that, as therapists, we tend not to pay enough attention to. Jeremy Safran & colleagues have published an important overview of the area this year in their paper "Repairing alliance ruptures", where they write "In this article, we review the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted. The first reviewed studies examining the relation between rupture-repair episodes and treatment outcome ... The second meta-analysis reviewed the research examining the impact on treatment outcome of training therapists in the use of alliance rupture intervention principles ... Both meta-analyses provided promising evidence regarding the relevance of alliance rupture-repair processes to therapeutic outcome. The limitations of the research reviewed are discussed as well as practice implications for repairing the inevitable alliance ruptures in psychotherapy."  This article is available in free full text from Safran's university web page, which also lists a number of other full text articles that are very relevant to this area. 

In digging around this topic after the seminar, I was intrigued to see Hill & Knox's paper "Processing the therapeutic relationship" is listed by the Psychotherapy Research journal as their most read article.  Happily it too is available in free full text.  The abstract states "The authors propose that if therapists and clients process their therapeutic relationship (i.e., directly address in the here and now feelings about each other and about the inevitable problems that emerge in the therapy relationship), feelings will be expressed and accepted, problems will be resolved, the relationship will be enhanced, and clients will transfer their learning to other relationships outside of therapy. The authors review theories supporting the idea of processing the therapeutic relationship, discuss the relevant empirical literature in this area, and provide their conceptualization of the construct of processing the therapeutic relationship based on the theory and empirical findings. Finally, they discuss methodological concerns and suggest implications for clinical practice, training, and further research."

And this is the kind of territory we looked at in the EFT seminar, discussing a variety of "alliance difficulty markers" - both involving confrontation and, sometimes more trickily, client withdrawal.  Robert made the interesting & helpful suggestion to "Watch out for hiding behind empathy" and encouraged us to really meet clients authentically in these conflict/withdrawal difficulties ... allowing ourselves to take the situation seriously and to let us feel & connect emotionally.  We explored a conflict resolution dialogue in further small group role play.  A personal comment I would make here is that 'ruptures' and 'micro-ruptures' in our own close relationships (involving both family and friends) can provide a rich 'practice ground' for working with interpersonal difficulties in the therapeutic relationship (and vice-versa). 

My main gripe with this interesting and enjoyable seminar was the lack of any discussion about more methodical session-by-session tracking of alliance & outcome problems.  I've written quite extensively about this in the last few months.  This exploration was triggered by hearing Michael Lambert talk back in July on "What shall we do about the fact that there are supershrinks and pseudoshrinks?".  The points he was making in his presentation have been worryingly enlarged on in the recent Kraus et al paper "Therapist effectiveness: Implications for accountability and patient care" with its abstract reading "Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of "effective" and "harmful" therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d = - 0.91 to - 1.49) while effective therapists demonstrated large, positive treatment effect sizes (d = 1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training." 

I totally agree with the plea to integrate outcome (and alliance) measurement into routine care and training.  Without clear feedback human beings are often very poor at knowing how successful they actually are. This tendency to misperception applies to nearly all of us. Michael Lambert has commented that "90% of therapists interviewed thought they were in the top 25% of effective therapists when compared with their peers ... and no therapist rated themselves as below average in effectiveness."  We know that interpersonal skills are of major importance here - see, for example, Tim Anderson et al's paper "Therapist effects: facilitative interpersonal skills as a predictor of therapist success".  However trainings, like yesterday's EFT seminar, I believe should also encourage methods of tracking our daily therapeutic practice.  Whipple & Lambert have written about this recently in their paper "Outcome measures for practice" and I am a fan of the freely downloadable Outcome & Session Rating Scales.  For more on these measures, see my posts "On becoming a better therapist", "Client-directed, outcome-informed therapy" and "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent and potentially dangerous".  See too the recently published book by Barkham & colleagues "Developing & delivering practice-based evidence"

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