webinar 4: how to develop therapeutic relationships online dr simone rodda [email protected]...
TRANSCRIPT
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What we will cover Definitions of therapeutic
alliance Alliance can be established
online Methods to establish alliance
online Correcting ruptures in alliance
online Where to next?
Therapeutic alliance: working alliance
Working alliance (Bordin, 1979) includes a focus on the ‘here and now’. It requires participation from the client and therapist
Task Items
1.As a result of these sessions I am clearer as to how I might be able to change
2.What I am doing in therapy gives me new ways of looking at my problem
3.I feel that the things I do in therapy will help me to accomplish the changes that I want
4.I believe the way we are working with my problem is correct
Task Items
1.As a result of these sessions I am clearer as to how I might be able to change
2.What I am doing in therapy gives me new ways of looking at my problem
3.I feel that the things I do in therapy will help me to accomplish the changes that I want
4.I believe the way we are working with my problem is correct
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Development of a positive bond
1.I believe my therapist likes me
2.My therapist and I respect each other
3.I feel that my therapist appreciates me
4.I feel my therapist cares about me even when I do things that he/she does not approve of
Development of a positive bond
1.I believe my therapist likes me
2.My therapist and I respect each other
3.I feel that my therapist appreciates me
4.I feel my therapist cares about me even when I do things that he/she does not approve of
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Agreement about the goals of treatment
1.My therapist and I collaborate on setting goals for my therapy
2.My therapist and I are working towards mutually agreed upon goals
3.My therapist and I agree on what is important for me to work on
4.My therapist and I have established a good understanding of the kind of changes that would be good for me
Agreement about the goals of treatment
1.My therapist and I collaborate on setting goals for my therapy
2.My therapist and I are working towards mutually agreed upon goals
3.My therapist and I agree on what is important for me to work on
4.My therapist and I have established a good understanding of the kind of changes that would be good for me
When is therapeutic alliance more about the relationship or more about the work?
Alliance in online and telephone counselling sessions equivalent to face-to-face settings, however, alliance higher in telephone than online
– Main outcome general functioning and distress Found client-counsellor collaboration (i.e., tasks and goals of a session)
was a better predictor of change in distress than client ratings of mutual liking (i.e., bond).
Indicative of the online single session modality where less time is spent on rapport building and more time is spent on clarifying the presenting issue and constructing solutions
King, Bambling, Reid, and Thomas (2006)
Clients do not need another explanation of their behavior, the origins of their problems, and the solutions they ought to pursue. Instead, clients need a therapeutic experience. One of our concerns is that the way some professionals use e-mail does not create such an experience for the client. Although it may provide interesting advice and information, it does not create a ‘‘therapeutic space’’; that is, a supportive, safe, and empathic relationship in which a client can explore issues, feelings, and alternatives related to their concerns
Murphy et al., 2008
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There is evidence for online therapeutic alliance (Sucala et al., 2012)Systematic review found 11 online studies that had examined alliance. This found online alliance was equivalent to face-to-face therapy and also that online alliance was related to client outcomes
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Skilled helper model: Attending
The online counselling environmentClient and counsellor:Can not be seen Relies on typing speed and familiarity with technologyMay have a feeling of being rushedMay forget or not attend a sessionCould experience issues around consent, privacy & securityMore spontaneity–less guarded or censoredSometimes have difficulty conveying emotions??
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Experiences of clients (chat and email) Greater control of what is
disclosed
Take it at their own speed
Less embarrassment & help client find their voice
Can read back over what has been written
Integrate goals, strategies and progress into everyday routine
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Clients will recommend online counselling to others when there is a good relationshipIn a national study of gamblers accessing online counselling, access to helpful professional support as well as the development of a therapeutic alliance was a reason to recommend online counselling
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Client written clues Writing is less formal Capitals are used for strong
emotion Trailer dots are used to present
hesitation, pause or indicator of thinking (for the client this might indicate a change in topic immediately after)
Change in style can indicate change in emotion (e.g., grammar, punctuation, over emphasis)
Use of symbols and phrases to communicate feelings about issues, irony, abstraction, and humour.
Very fast disclosure of information
I was doing fine getting my bills paid and getting my studies done. And then I thought that it wouldn’t hurt to just put a few dollars in and then before I knew it I had lost it all. I was so upset that I just COULDN’T tell me partner!!!!! she… she would be SOOOOOO disappointmmed and sure to leave…..anyway could you give me the number for self-exclusion at least I won’t be able to get in
I was doing fine getting my bills paid and getting my studies done. And then I thought that it wouldn’t hurt to just put a few dollars in and then before I knew it I had lost it all. I was so upset that I just COULDN’T tell me partner!!!!! she… she would be SOOOOOO disappointmmed and sure to leave…..anyway could you give me the number for self-exclusion at least I won’t be able to get in
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Initial pleasantries very briefClients feel they have established a rapport early on, before the counsellor does. We see a reversal of the usual order of counselling (Urbis, 2003)
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Establishing online rapportWrite less formally and brieferUse simple language and explain things simplyUse emotional bracketingDescribe your own physical, intellectual or emotional state while writing.Avoid misunderstanding by regularly checking inChange pacing to make a pointYou cannot ask a string of questions and receive a string of answers online. People respond best to one question at a time.
”Wow things have really changed for you since our last session (big smile on my face).”
I know it can be really tricky to really understand how gambling works (I’m even scratching my head right now!).
But I’m wondering where you are at with it….
Ok
We are really getting to the heart of the problem now
Just take it slow. If you could take a breath for a moment and wait for me to type again…
That’s great…
..can you tell me how you are going now..
”Wow things have really changed for you since our last session (big smile on my face).”
I know it can be really tricky to really understand how gambling works (I’m even scratching my head right now!).
But I’m wondering where you are at with it….
Ok
We are really getting to the heart of the problem now
Just take it slow. If you could take a breath for a moment and wait for me to type again…
That’s great…
..can you tell me how you are going now..
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The only thing I hate about the online thing is the typing, because a lot of the answers that I submit are actually shortened because I don’t want to take the time out to type it. And when I am taking the time, she’ll ask another question. So it’s just jumbled. Because if you pause to type out your response, she’s just thinking that it’s quiet. So, she’ll ask a question to keep the conversation flowing, but I’m actually trying to type a response and then I have to type another response.
Haberstroch, et al., 2007
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social presence or telepresence, The moment-by-moment awareness of the co-presence of another person. When social presence is established there is a sense of awareness and engagement that one person feels when communicating via technology with another person.
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Therapeutic alliance: when things go wrong
Overt expression of negative sentiment
– Expression of negative feelings towards the therapist (no good) Indirect communication of negative sentiments or hostility
– Odd or sarcastic questioning (i.e., are you a computer, are you using drop down lists, how many people are you speaking to)
Disagreement about the goals or tasks of therapy
– Request strategies but reject the advice or not be ready to implement them
Adapted for online from Safran et al., 1990
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Therapeutic alliance: when things go wrong
Compliance
– Accept referral, talk to someone else agreed to (but no evidence of change talk or commitment language)
Avoidance manoeuvres
– Have you ever had a problem, silence, ignore questions– Gambling or drinking during the session– Coming late to appointment, failing to attend
Self-esteem—enhancing operations
– Presenting a positive image (possessions, good job)– Discussing problem is a theoretical way
Non-responsiveness to intervention
– Not implementing intervention
Adapted for online from Safran et al., 199018
Common counsellor experiences that can cause therapeutic distance
Frustration
Feelings of helplessness or inadequacy
Belief the client is not really trying
Concern about complexity
Worry that the client will get disconnected or will disconnect
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Therapeutic alliance: resolving the problem Attend to ruptures in the alliance
– Always be ready for ruptures and be aware of their indicators– Avoid confrontation in the first place – be ready to work from where
the client is at (i.e., readiness, screening information)– Agree on the tasks and goals of the session at the start of every
session– Get a sense of where the client is physically and emotionally at the
start of the session
Adapted for online from Safran et al., 1990
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Identification of distress in online sessionsAsk directly about distress
The lack of accompanying non-verbal cues when communicating in text creates a risk of missing serious issues or suicidality.
If you suspect your client is crying but are unsure, you should gently ask, “your words sound very sad and I am wondering whether you are crying?’
Respond directly to distress
On a scale of 1 to 10, 1 being not distressed at all and 10 being very distressed, where would you be right now?
Apply and teach distress management techniques
Use ASIST guidelines
Therapeutic alliance: resolving the problem Awareness of one's own feelings
– Useful barometer of how the session is going (empathy=safe)– If unaware, can come across as punitive (e.g., frustration, anger)– Use drop down menus sparingly– Convey emotions that otherwise would be non-verbal– Focus on the Here and Now for you and your client– Delays in responding feel like a lifetime. Be physically, mentally and
emotionally present
Adapted for online from Safran et al., 1990
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Therapeutic alliance: resolving the problem Accept responsibility for the rapport
– Important component in resolving an alliance rupture consists of the therapist acknowledging his or her role in the interaction
– “Me against you” versus “teamwork” and “our problem”– “I feel like we are having a bit of a struggle at the moment and I’m not
sure what is going on. Are you experiencing this too?”
Adapted for online from Safran et al., 1990
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‘It [acknowledging miscommunication] often marks a turning point in the counselling because it allows the counsellor to apologise, back track, seek clarification, provide an explanation, and seek more client feedback’
Bambling et al, 2008
Presentation title 24
Online practice elements
Session rating scale (Duncan & Miller, 2003)26
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Many practitioners in this study spoke about their feelings of apprehension when they first started training or thinking about doing online counselling/support because they were unfamiliar with how to phrase sentences in order to convey a warm tone. Their clients, on the other hand, seemed to communicate comfortably and naturally online.
Callahan & Inckle, 2012
Summary of session Create a therapeutic space by fostering trust, warmth, mutual liking and empathy.
Establish goals (e.g., abstinence) and complete tasks (e.g., how to respond to urges).
Learn to notice cues online (e.g., capitalisation, dots, grammar, symbols)
Be prepared to get going right away
Use emotional bracketing & immediate descriptors
Limit questioning, write briefly and often
Develop your own style to create social presence
Understand indicators for therapeutic ruptures (silence, sarcasm)
Be aware and express your thoughts and feelings overtly (I am smiling)
Be part of the rapport solution not an observer (responsibility)
Use therapeutic alliance measures regularly
Practice.. Practice…Practice…
Webinar seriesRemote counselling skills
Further resources Cavanagh, K. (2010). Turn on, tune in and (don’t) drop out: engagement, adherence, attrition, and
alliance with internet-based interventions. Oxford guide to low intensity CBT interventions, 227-233
Reynolds, D. A. J., Stiles, W. B., Bailer, A. J., & Hughes, M. R. (2013). Impact of Exchanges and Client–Therapist Alliance in Online-Text Psychotherapy. Cyberpsychology, Behavior, and Social Networking, 16, 370-377.
Leibert, T., Archer, J. J., Munson, J., & York, G. (2006). An exploratory study of clients perceptions of internet counseling and the therapeutic alliance. Journal of Mental Health Counseling, 28(1), 69-83
Murphy, L & Mitchell, D. (2008). When writing helps to heal: email as therapy. British Journal of Counselling, 26: 21-31
Reynolds, D. J., Stiles, W. B., & Grohol, J. M. (2006). An investigation of session impact and alliance in internet based psychotherapy: Primliminary results. Counselling and Psychotherapy and Research, 6(3), 164-168
Sucala et al (2012). The Therapeutic Relationship in E-Therapy for MentalHealth: A Systematic Review. Journal of Medical Internet Research, 14.