How psychotherapy works

I like this post by Dr. Barry Duncan. It was addressed to the heroicagencies listserve on  It is addressed to therapists.   (TOC – theory of change )

Bordin (1979) classically defined the alliance with three interacting elements: 1) a relational bond between you and the client—the client’s perception of your empathy, respect, and genuineness; 2) agreement on the goals of therapy; and 3) agreement on the tasks of therapy, which included all the accompanying details including topics of conversation, frequency of meetings, handling cancellations, payment, etc.


Although everything in therapy can be conceptualized as part of the alliance in that each and everything we do is designed to engage the client in purposive work to accomplish client goals, the client’s TOC is best thought of as a component of the alliance, drawing the therapist’s attention to the negotiation of tasks process.


This is probably our biggest alliance blind spot. After all, we’re supposed to be the experts, right. We know what approach is the right one. I hope you are hearing warning bells, red alerts, and “danger, danger.”The beauty of collaboratively setting the tasks of therapy is that we not only ensure the alliance is on track with an approach that resonates with everyone involved, but this process also provides a continual impetus to broaden our theoretical horizons.


In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique (Hatcher & Barends, 2006). If a technique or a task, in other words, fails to engage the client in purposive work, it is not working properly and a change is needed.  The alliance and technique are not disembodied parts. Think of it this way: Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity (Hatcher & Barends, 2006). Although it is possible for a strong relationship to develop between you and the client, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend. 


So you can’t have a good alliance without some agreement about how therapy is going to address the issues at hand. You can’t have purposeful work without collaboration about what that work will entail. Here is where the incredible variety of models and techniques pays off. While there is no differential efficacy among approaches in general, there is differential efficacy among approaches with the client in your office now. The question is: does it resonate or not? Does it fit client preferences? Does its application help or hinder the alliance? Is it something that both you and the client can get behind? You matter here too. If you don’t believe in the potential restorative or healing power of any selected approach—i.e., don’t have allegiance to it—then not much good will come of it. Can you get on board with the client’s notions about how he or she can be helped? Or perhaps some idiosyncratic blend of client ideas, yours, and theoretical/technical ones might ultimately be just the ticket. Your alliance skills are truly at play here: your interpersonal ability to explore the client’s ideas, discuss options, collaboratively form a plan, and negotiate any changes when benefit to the client is not forthcoming. Technique, its selection and application, in other words, are instances of the alliance in action.


TOC: The issue of resonance and the agreement about tasks—finding a framework for therapy that both you and the client can believe in—is why it makes a lot of sense to ask clients about their ideas about how to proceed, or at the very least getting client approval of any intervention plan. Traditionally, such a process has not been the case—the search has been for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—the search for ideas that promote change by validating the client’s view of what is helpful—the client’s theory of change (Duncan et al., 1992; Duncan & Moynihan, 1994; Duncan & Miller, 2000). Not surprisingly, Frank and Frank (1991) said it best: “Ideally, therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem’’ (p. xv).


Recall the TDCRP. Clients’ perceptions of treatment fit or match with their beliefs about the origin of their depression and what would be helpful (psychotherapy or medication), contributed to early engagement, continuation in therapy, and the development of a positive alliance (Elkin et al., 1999). Additional empirical support for matching the client’s theory of change is provided in the attribution, expectancy, acceptability literatures (see Duncan & Miller, 2000 for a review), as well as the emerging area of client preferences which indicates that providing clients’ preferred treatments, not surprisingly, results in increased engagement and stronger alliances (Arnkoff et al., 2002; Iacoviello et al., 2007; Leykin et al., 2007).


Asking about the client’s theories or preferences does not preclude your ideas, suggestions, models, methods, or mean in any way that you do not contribute. Instead, it speaks to the more collaborative aspects of formulating a plan, with the degree and intensity of your input determined by the client’s expectations of your role. And unequivocally, some therapists are better at forming alliances than others (the alliance accounts for most of the variance between therapists), and negotiation of the tasks of therapy is integral to alliance. Securing an agreement about the tasks is all but guaranteed when a given therapy framework—explanation or solution—implements, fits, or complements the client’s ideas and beliefs. The SRS can help us not only focus on this issue but also catch when we are missing the mark.


Bottom Line:  Agreement about the tasks of therapy is a critical component of the alliance. The application of any agreed upon explanation or technique represents the alliance in action. The litmus test of any chosen rationale or ritual is whether or not it engages the client in purposive work and ultimately reflects a change on the ORS. Asking the client about his or her ideas or preferences regarding the tasks (TOC) is a way to help us with the alliance.






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