Alliance Is The Key! Using Client Feedback To Teach You About Family Therapy
By Dr Mark Scholes
Clinical Psychologist and Clinical Family Therapist
My two primary passions in therapy are thinking and working in Systemic ways with clients, and learning from my clients regarding what type of therapy they need from me. My first passion is honing my knowledge and skills in having a clear framework and process to help guide me with clients. This focus is orientated towards the therapeutic maps I use to guide my work with clients and provide me with the confidence and clarity in my direction in therapy. Research on the Common Factors to all therapies tells us that having a clear therapeutic allegiance to any model provides clients with trust and confidence in the therapy process (Hubble, Duncan & Miller, 1999). My therapeutic bias for Systemic Theories provides my clients with a trust that I know what is happening for them (theory of the problem) and ways to move through it (theory of change).
The various models of Family/Systemic Therapy offer a variety of ways of understanding and influencing individuals and families to change and grow. From adjusting the structure of a family, to changing the meaning around a symptom, to re-building relationships, to moving between past, present, and future possibilities. This way of working for the Systemic Therapist offers the freedom to work with anyone in a system, working with groupings of people, and be able to provide conceptualisations and ideas for influencing complex dynamics within any family or workplace system. What Family Therapy can give you and your clients is a smorgasbord of understandings and options that keep things moving forward in therapy. For example, I have had many parents with a teenage child with a diagnosis of Autism and ADHD come to see me after many years of doing individual therapy, and experience great benefit when we start a process of family sessions.
"In the early stages of learning Family Therapy, it can certainly feel overwhelming for students to learn the various approaches and can easily sway us into a state of chaos, giving us the feeling of being lost and anxiously uncertain"
The freedom and flexibility inherent in Contemporary Family Therapy is a great benefit for therapists as it helps us adapt to our client’s needs. However, in the early stages of learning Family Therapy, it can certainly feel overwhelming for students to learn the various approaches and can easily sway us into a state of chaos, giving us the feeling of being lost and anxiously uncertain. I can admit to experiencing many times like this, and wondering what systemic theory or concept I needed to be drawing upon in any given moment with clients. Over time, and after much reflection, it becomes more automatic (like riding a bike), and realising that with the aid of Equifinality (i.e., there are many different paths that can lead to the same therapeutic outcome), I need to trust myself to make a decision and see what happens next.
I have also seen Family Therapists become rigidly trapped in their own worldview. For example, therapists only working with whole family groupings, refusing to work with a child alone to not reinforce the Identified Patient status, and talking about the “real” problem of the marriage rather than the child concern. When we become too rigid in our approach, it is like an enmeshed relationship to our worldview at the cost of the client. I am not ashamed to admit that I have also been in this space, and I think it is a natural consequence of falling in love with Family Therapy at the beginning, and seeing it as the answer to all of our clients’ struggles.
Developmentally, it is inevitable that we swing between chaos and rigidity in our attempt to immerse ourselves in our preferred therapeutic approaches and practice with our clients. Like learning any new skill, we need to learn the right way before we can learn to break the rules and take more risks for our client’s sake. Life is complex and any idea that we learn in a theory has an opposite truth. So, it appears that we therapists go through our own experiences of swinging between rigidity and chaos in ordering therapy, similar to that of our clients. There is an inevitable isomorphic process (parallel process) between clients and therapists as we are trying to make sense of the never-ending messiness of real life. Our ability to find a middle ground between rigidity and chaos is powerfully modelling the same to our clients. A structure/path + flexibility to adapt is the key. But how do we work towards this?
"The messy challenge is that we are trying to learn and master our preferred approaches AND be flexible and adaptive to our clients at the same time"
The messy challenge is that we are trying to learn and master our preferred approaches AND be flexible and adaptive to our clients at the same time. They call it Clinical Practice for a good reason! We are practicing on our clients all the time. Like learning any new skill from reading and writing, to driving, we work hard at learning it at the beginning and then get comfortable and go on auto-pilot, which leads to a risk of plateauing and not developing further. Research on therapeutic outcomes shows that therapists in general don’t get better over time, but as a professional group we plateau in our outcomes (please refer to Scott D Miller’s presentation outlining the research - https://www.youtube.com/watch?v=pI8Hww1xjK4). So, what does the research tell us about how to avoid plateauing in therapy and continuing to develop and improve clinical outcomes? Unfortunately, the research does not say that continual professional development or supervision is the key, although they can potentially help if used wisely.
The answer...Alliance, Alliance Alliance!!!
The research has clearly shown that the therapeutic alliance is the single most strongest predictor of clinical outcomes (please refer to this book for a summary - Hubble, Duncan & Miller, 1999). Clients come to therapy with their own worldview and needs, and require us to be flexible and adaptive in our therapeutic approach. The growing number of psychological therapies suggests that we need to develop an individualised approach for every client that comes through the door. I am not suggesting we need to learn every therapy approach possible, but that the key to developing as a therapist is in engaging clients in a collaborative therapeutic alliance. This is no easy task, as we need to connect with a variety of people of all ages, genders, cultures, etc. However, when was the last workshop you attended on therapeutic alliance/engagement? In fact, when did you see a workshop come up on this topic? Just like when we learned to read and write as a child, we are expecting to know this skill and not need further development in this area.
The Therapeutic Alliance Model as Bordin (1979; 1983) described it involves the therapist and client developing a strong emotional bond, agreed-upon goals, and agreed-upon tasks in therapy. When we have an alignment with the client on all three variables it can be like magic! But we also face many times of divergence and need to have the flexibility to prioritise our client’s needs more than our preferred approach. Bill Robinson wrote an interesting article on the interaction between a client’s theory of change and a therapist’s theory of change, and ways of prioritizing and working within our client’s theory of change (Robinson, 2009). Scott D Miller and colleagues have spent their working career summarizing the research on therapeutic models and clinical outcomes and writing about the common factors that create change across all models of therapy (Hubble, Duncan & Miller, 1999). A good therapy approach is like a good cake - a mix of good therapy engagement skills, having expectancy and hope (the good old placebo effect is real!), a clear structure, a theory of the problem, and a theory of change, and feedback from clients. When all of these ingredients mix well together, therapy can taste as good as a well-made cake.
"When all of these ingredients mix well together, therapy can taste as good as a well-made cake"
The research is clear that eliciting feedback from clients and adjusting therapy in response has a significant impact on the clinical outcome (Miller, Hubble, Chow & Seidel, 2015). Scott D Miller developed a process called Feedback Informed Treatment (FIT) to assist therapists to improve in this area, as the research does not show therapists are naturally good at this skill. It is likely that we therapists are so busy trying to remember how to “DO” therapy, that we can lose sight of the client and not dare to change our therapy process when it is not meeting the needs of our clients. Scott D Miller also transferred the term Deliberate Practice over from the literature on expert performers in different fields to help therapists think more about how they can become better therapists (Miller, Hubble & Duncan, 2008). It seems clear to me that therapists are juggling many aspects of therapy at the same time – improving their ability to connect and engage a variety of people of all ages and types, become clearer in the ways of working with clients by developing a theory of the problem and change, and integrating feedback from clients to adjust their therapy process. No wonder we can never stop learning as therapists. This is a life-long journey!
There is a lot of flexibility and creativity that comes from working within a systemic framework, and many choice points. One of the common questions I hear from people in the early stages of practicing family therapy is how to choose which approach, when, and with whom at any given point in time. FIT involves learning from clients about what is working well in therapy and what needs to be adjusted to improve the therapeutic alliance and ultimately, clinical outcome. Daryl Chow (2016) defined 3 different types of knowledge we acquire – content knowledge, process knowledge, and conditional knowledge. Content knowledge is centered upon WHAT we learn (e.g., theories, treatment methods, clinical presentations). Process knowledge is about HOW we learn (e.g., conducting an effective first session, using a miracle question, etc). Conditional knowledge is about knowing WHEN to do WHAT in any given moment with clients.
I believe that Conditional knowledge is developed when we work on improving our ability to read our client's nonverbal and verbal feedback, suggesting whether we are on the right track or not. Just like effective parents, being sensitive and responsive to our clients helps us read signals from clients to suggest if what we are doing is working for them or not (see Stiles & Horvath, 2017 for further information). There is a set of skills involved in eliciting feedback from clients regarding the therapeutic alliance and clinical outcome. There is also a set of skills in using this feedback to modify your treatment approach to better suit the clients’ needs (see Rousmaniere, Goodyear, Miller, & Wampold, 2017 for further information).
So, how do we get better at asking for feedback from clients, and learning how to use this information to adjust our therapy accordingly? This is not an easy task. Have you ever been unhappy with your meal at a restaurant and not been honest to the waiter when they ask you how the meal was? Maybe the waiter didn’t sound like they genuinely wanted to know. Maybe you didn’t feel like being negative when you were trying to have a good time. Therapy is not so different. It takes a lot for the therapist to create a culture of feedback in order to warm clients up to the importance of honesty.
"It takes a lot for the therapist to create a culture of feedback in order to warm clients up to the importance of honesty"
So, how can you integrate FIT into your Family Therapy sessions? There are simple and brief forms, the Outcome Rating Scale and Session Rating Scale that take only 2 mins to complete and score, and are administered in every session. I have found these forms valuable in continuing to review my work on a regular basis (see https://www.scottdmiller.com/ to access the forms for free!). I have learned a lot about my clients and what works and what doesn’t as a result. When I have family sessions, I have tended to modify this to sometimes use a family scaling question, in which everyone rates how their family is functioning from 0-10. At the end of the session, I review how the session was for everyone and ask them to rate the session from 0-10.
The challenge as a therapist is to create a culture of feedback that not only reviews what was helpful, but also draws out any areas of the session that were not useful and missing in order to adjust things for the follow-up session. Although there are always some people that can be brutally honest in giving feedback, it is not typical and easy to get an honest answer from people. It takes great skill to avoid asking for feedback in the vein of getting reassurance or validation, rather than encouraging any constructive/negative feedback that will allow you to grow as a therapist.
The balancing act between maintaining integrity over my systemic practice AND adjusting my practice to my client’s needs is always a work in progress in developing therapeutic wisdom or as Daryl Chow put it, Conditional Knowledge. I wish you well on this exciting and challenging journey of therapeutic and self-discovery.
- Mark Scholes
Bordin, E. S. (1979). The generalizablity of the psychoanalytic concept of the workingalliance. Psychotherapy: theory, Research and Practice, 16, 252–260.
Bordin, E. S. (1983). A Working Alliance Based Model of Supervision. The Counseling Psychologist 11(1): 35-42.
Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999). The heart & soul of change: What works in therapy. Washington, DC: American Psychological Association.
Miller, S.D., Hubble, M. & Duncan, B. (2008). Supershrinks: What is the secret of their success? Psychotherapy in Australia. Vol 14. No 4. Aug
Miller, S.D, Hubble, M.A, Chow, D. & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy. Dec;52(4):449-57
Robinson, B. (2009). When therapist variables and the client’s theory of change meet. Psychotherapy in Australia. Vol 15. No. 4. Aug
Rousmaniere, T., Goodyear, R. K., Miller, S. D., & Wampold, B. E. (Eds.). (2017). The cycle of excellence: Using deliberate practice to improve supervision and training. Wiley-Blackwell. https://doi.org/10.1002/9781119165590
Stiles, W. B., & Horvath, A. O. (2017). Appropriate responsiveness as a contribution to therapist effects. In L. G. Castonguay & C. E. Hill (Eds.), How and why are some therapists better than others?: Understanding therapist effects (pp. 71–84). American Psychological Association. https://doi.org/10.1037/0000034-005
Mark is a part of the teaching team at The QLD Institute of Family Therapy and runs his own private practice on the Gold Coast.
This article is educational in nature. Please check the Scott Miller website to see if you are eligible to use the measures for free.