If, in psychotherapy, everyone seems to have won and everyone received prizes, what might the essential ingredient in this success be? Research suggests that the therapeutic alliance is the critical factor in successful therapy. This paper explores the process and outcome of the logical extension of this finding--Mutual Alliance Therapy.Psychotherapeutic methods are proliferating, and a professional eclecticism which incorporates them is also on the rise. In an attempt to filter out the active ingredients in psychotherapy from its inert stylistic embellishments, professionals in the field have been examining the ways psychotherapy is conducted and the results it produces. The consensus of what the latest methods of process research has revealed belies the postulates of most traditional training in psychotherapy.
It is the feeling of alliance between the therapist and the patient, as perceived by the patient, not the therapist, that is most predictive of a good therapeutic outcome (Horvath, 1993, Luborsky, 1994).Disregarding the important variable of individual therapist differences, this single factor is more important than the therapist's theoretical orientation, his or her training, personal analysis, or the length of time that the patient attends therapy. Is there some sense of alliance perceived by those who comprise the placebo groups often used in psychotherapy outcome studies? Might this account for the significant benefits attributed to the placebo effect? What is revealed if we observe the therapeutic alliance outside of the confines of therapy?
Healing alliance is naturally sought after by distressed individuals. Dr. Frank Riessman, Director of the National Self-help Clearing House in New York, has pointed out that the benefit accrued to an individual through being understood is a powerful dimension of self-help mutual aid, because of the potential for experiential understanding. Many people benefit from self-help groups or other kindred spirits who rise to the occasion of their needs.
The placebo group, used to control for the effects of psychotherapy in experiments, is often comprised of people on waiting lists for therapy, or those seeing non-professional helpers such as religious counselors, friends and self-help groups who are not offering formal therapy, but do tend to their needs. Like people in therapy they experience increased hopefulness, and alliance. The placebo has often been called a misnomer because it is actually comprised of the effective human ingredients available for solace. These natural virtues may indeed be the generic penicillin for neurosis. It may be the magic elixir in the placebo, human love, guided by intelligent attention that helps to cure the two thirds of the people who get better with or without the benefit of formal psychotherapy.
Learning From the Time-honored Placebo
Meta-analysis, a new approach to interpreting a body of treatment effectiveness research, arose in 1977 (Smith, et al.). With this procedure, the results of individual studies are systematically sampled, surveyed, weighted and coded into a database, that is then analyzed, as if it was a single study, in order to provide cumulative figures representing the totality of known data. Increasingly sophisticated meta-analyses have culminated in a new conceptual vehicle, the meta-meta-analysis by Lipsey & Wilson (1993). Using this procedure, they have examined and weighted 302 meta-analyses, which, in turn, include thousands of studies on the effectiveness of psychotherapy. Cumulatively, they clearly demonstrate the healing power of the placebo. This is all the more reason that the common effective ingredients to all schools of psychotherapy some of which are shared by the placebo are a legitimate area for study.
Meta Meta on the Wall: Which treatment Is the Finest of Them All?
Hans Strupp, Ph.D., one of the leading researchers in the field of psychotherapy, has prominently exemplified the power of a consoling relationship with a good person who does not have either the benefit or the possible encumbrance of professional training in psychotherapy. Strupp thinks that growth is promoted by nonspecific factors such as understanding, trust, and warmth, which are not the exclusive province of any single therapeutic school of thought. By and large, he feels that all prominent therapeutic approaches have been shown to be equally effective. Although they may not all be alike, there is no proof that one is better than the other across the board. (However, there is evidence that behavior therapies are superior for target symptoms such as tics, phobia and bed-wetting (Eysenck, 1993). Strupp observed that,
Therapeutic Professors or Professional Therapists?
"The art of psychotherapy may consist largely of judicious and sensitive applications of a given technique, delicate decisions on when to press a point or when to be patient, when to be warm and understanding or when to be remote. The therapist structures the situation in bold relief so that the patient is forced to renounce the helping relationship or undergo change."Strupp's now classic Vanderbilt study (1979) links the therapist's technical skills and the qualities inherent in a good human relationship to outcome in time-limited individual psychotherapy. In this study, Strupp worked with male college students who exhibited high levels of depression, anxiety, and social introversion. One group of 15 was treated by highly experienced psychotherapists. Another group of depressed, obsessional, anxious men was treated by "nice guy" college professors chosen for their ability to form understanding relationships.
Strupp's now classic Vanderbilt study (1979) links the therapist's technical skills and the qualities inherent in a good human relationship to outcome in time-limited individual psychotherapy. In this study, Strupp worked with male college students who exhibited high levels of depression, anxiety, and social introversion. One group of 15 was treated by highly experienced psychotherapists. Another group of depressed, obsessional, anxious men was treated by "nice guy" college professors chosen for their ability to form understanding relationships.
Each student participated in therapy sessions once or twice a week over a period of three to four months for a total of 25 hours. Strupp used multiple measures of assessment, such as patient, clinician, and therapist ratings of fundamental change, change in test scores, and change in specific target complaints. In addition, he followed up one year later, when the initial gains shown in many studies have long since dissipated. The results of this investigation were consistent and straight-forward. On the average, the patients who consulted with college professors showed as much improvement as the patients treated by experienced professional psychotherapists. The greatest degree of change occurred during the treatment period, but the gains still held one year after the study began. The experimenters concluded that positive change was generally attributable to the healing effects of a benign human relationship.
In a recent conversation Strupp told me that he thought he had tipped the balance in favor of the professors who had more in common with the client-students than the professionals did in his original Vanderbilt study. This is perhaps the point on which we may build on a naturally occurring phenomenon, friendship. How would we fare if we found a partner with whom we might relate and formed a mutual therapeutic alliance? If the therapist reading this article tries to channel a natural relationship into a therapeutic venture, using the same focus of attention and intent that he or she might bring forth in the ideal therapist/client relationship, would he benefit? Since alliance (as judged by the client) is the currently acknowledged most powerful force in effective psychotherapy (Luborsky, 1994, Strupp, 1993), the challenge of finding a potential therapeutic partner is worth the considerable risk and effort it entails.
One may wonder why this sort of mutual alliance is not already the provenance of friendship. It may well be, but a survey of one's relationships may leave a great deal of room for constructive improvement. Should this work for us, might it not also help a wistful client who might be strengthened by the structure and benevolent intent of such a plan?
In a surprisingly neglected, but remarkable study the powerful effect of increased peer-alliance, with professional guidance, has already been demonstrated in a cost-effective manner. This series of studies on peer alliance which yielded extraordinary results, even ten years after the experiments were over, has unfortunately not reached many psychotherapy practicioners or the psychotherapy training institutes that form them. These experiments were conducted by the late Dr. Irving Janis and Dr. David Hoffman (1970, 1982) at Yale University. Paired-off patients with similar challenges who were part of a once-a-week counseling program were instructed to agree to talk about their progress on a daily basis with an assigned peer who was also in the program. They agreed on goals and the means to get there. Even 10 years later the advantage gained by a short term of peer support was still maintained in proportion to the amount of peer contact that they had! The daily conversations had a significant lead over the once-a-week talkers who, in turn, did better than those that just had the once-a-week professional counseling, but were without peer-pairing. Salutary effects this long-lasting have rarely been demonstrated, even though research into the effective ingredients in psychotherapy by such organizations as the Welcome Trust, the Economic and Social research Council in the U.K. and the National Institute of Mental Health in the U.S. represent an investment of over 100,000,000 pounds in the last 10 years.
What if we increase the alliance?
If we ask the right questions such as "What can we do to increase the therapeutic alliances in our lives and thereby improve our effectiveness and well-being?", interesting answers begin to reveal themselves.
Since psychotherapy research tells us that the engendering of hope is therapeutic, and the number of therapy sessions is unrelated to psychotherapy outcome, and the therapist's training is also unrelated to outcome, the question of what qualities in a relationship might make one hopeful becomes the focus of our attention.
Shall we then engage in an anecdotal experiment? Suppose each of us who has the strength and motivation selects another with whom we form an intentional therapeutic alliance? This selection must be made with care and consideration because it involves a mutual commitment, beyond the normal demands of polite behavior. When the going gets rough we will want to find a time and place to confront our partner or be confronted, with the intention of creating greater understanding and compassion. Because this is not easy, the selection of our chosen other must be made carefully, maybe even with a short trial period. The amount of contact should be pre-arranged as it is in psychotherapy. Although therapeutically allied partners who participated in experiments done at Yale initially committed only to time-limited, regular contact, afterwards, some participants maintained their ongoing relationship in a less formal way for several additional weeks. Whether or not they chose to continue active contact, the benefits of the alliance have demonstrably endured for more than ten years are occurrence in the social sciences. Clearly, not all patients or even all therapists are appropriate candidates for Mutual Alliance Therapy. But for those with sufficient ego strength and a therapeutic intention the prospects are promising.
On October 2, 1993 at the University of Auckland in New Zealand I initiated the first Mutual Alliance Therapy Workshop. This anecdotal experiment was based on research-supported evidence that an increased alliance will increase the long-lasting beneficial effects of therapy. Since that event, the participants, however dissimilar their goals, have been talking to each other daily about their adherence to the course of action each one custom designed, with the help of the group, to meet their own objectives. Surprisingly, there were more men than women attending the workshop. They have committed to do this every day, by phone, for six months. Less dedicated inquirers were asked not to come. So far the results have been encouraging. I participated as well. A prominent financial counselor is gratified to be helping a professional psychologist to resolve her issues of whether to live independently, as she had been, or to see how she might co-exist in some kind of harmony with her husband. This is what she has done, with the added support of her financial-counselor ally. She thinks this has worked really well, and the leaderless group will soon meet again (at no charge to anyone). The financial consultant, a very intelligent and responsible, but cautions man, was completely amazed at his therapeutic effectiveness. In addition to business goals he's now adding weight-loss to his agenda. As for me, I lost 12 pounds in the first seven weeks (still off at the time of this writing) while my partner got control of his cholesterol intake and stopped eating candy (a previously elusive goal). A woman business consultant who is also a veteran psychotherapy patient, lightened her dependence on professionals, and reports that she has been launched from a dream world into the world of reality. A working couple who had lost touch with each other because of their preoccupation with demanding independent careers and 5 children are now talking to each other again on a daily basis, even though this had to be scheduled at 6:30 AM. And the stories of life's everyday victories go on. Reportedly, a leader-guided approach with monthly group meetings might increase the power of this method of mutual help. The great distance prevented this but a one year follow-up meeting will be scheduled in Auckland, New Zealand.
Mutual Alliance Therapy: An Experiment in Structured Friendship?
While these gains may sound minor in comparison with solutions to the more serious problems clients present in the consulting room, they seem to me a step in the right direction for those able to avail themselves of a constructive mutual relationship with another human being. Many of us are absorbed in the business of earning a living or lost in consumerism, zonked out on routinized television, or living in an alcoholic haze. A therapeutic alliance can provide a heartfelt readjustment in a society in which we are normally alienated from our feelings and from each other.
Will these preliminary results prove to be enduring? Only controlled research now in the planning stage will be able to provide definitive answers. Nevertheless, cumulative research results have given researchers good reason to explore the long-term results of therapeutic alliances.
Having a mutually congenial thing-to-do helps to buttress the evolving relationship against the stresses inherent in most mutual commitments, and it holds us steady when the fear of the other's betrayal or disinterest comes to the fore. It was an initial, partially successful therapeutic alliance of this sort in which I co-authored a book with the late R.D. Laing, that encouraged me to explore other manifestations of therapeutic alliances. Even without a mutual project, a commitment of daily phone calls in which partners discuss their compliance to mutually-agreed-upon tasks and goals, will do the job, if one is guided by the right intentions and equipped with the capacity to listen attentively, so that one hears the other's intent behind the words.
Smith, M.L., & Glass, G.V. Meta-analysis of psychotherapy outcome studies. American Psychologist, 1977, 752-760
Eysenck. H.J (1993) Forty years on: The outcome problem in psychotherapy revisited, in Handbook of effective psychotherapy ed. by Thomas Giles, 1993 New York: Plenum
Horvath, A.O., & Greenberg, L.S., (1993) The working alliance: Theory research and practice, New York: Wiley
Janis, I. (1983) Short-term counseling, New Haven: Yale University Press
Lipsey, M.W. & Wilson D.B.(1993) The Efficacy of Psychological, Educational, and Behavioral Treatment, American Psychologist, (December) 1181-209
Luborsky, L. Update (1994) in R. Russell (1981,1994) Report on effective psychotherapy: Legislative testimony, Lake Placid, New York: Hillgarth Press
Miller, N.E., Luborsky, L., Barber, J.P. & Docherty, J.P. (1993) Psychodynamic treatment research, New York: Basic Books
Russell, R. & Laing, R.D., (1992) R. D. Laing & me: lessons in love, Lake Placid, N.Y.: Hillgarth Press
Strupp, H.H. (1979) Specific versus non-specific factors in psychotherapy. Archives of General Psychiatry, 1125-36
Strupp, H.H. (1994) in Report on effective psychotherapy: Legislative testimony with 1994 Update), Lake Placid, New York: Hillgarth Press
For more about Mutual Alliance Therapy click here For more about RD Laing & Me: Lessons in Love click here.
Roberta Russell is the author of R.D. Laing & Me: Lessons in Love with R.D. Laing (1992) Hillgarth Press and the author of Report on Effective Psychotherapy: Legislative Testimony with 1994 Update (1981, 1994) Hillgarth Press.
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