Monday, 13 October 2008

How Clients Make Therapy Work

For those of you who did not read your Drink and Drugs News, to let you know that my latest Background Briefing focused on a very interesting book, 'How Clients Make Therapy Work: The Process of Active Self-Healing' by Arthur C. Bohart and Karen Tallman. 

You are going to hear a lot more about this book in my Briefings over the coming months - and on this blog. For now, I leave you with the text of my Briefing, if you have not clicked through to the DDN pdf document with my ugly mugshot!

In my last Background Briefing, I focused on two William White books that are classics in the field. In this Briefing, I describe another classic. Whilst this book focuses on mental health and psychotherapy, the ideas it contains are of direct relevance to recovery from addiction and the treatment process.
‘How Clients Make Therapy Work: The Process of Active Self-Healing’ by Arthur C. Bohart and Karen Tallman
The authors of this book argue that the most important factor in making psychotherapy work is the active, creative involvement of the client. Clients are viewed as possessing self-healing capacities and resources that are responsible for the resolution of problems and for change in everyday life – and in any form of psychotherapy.
Clients, like all people, have a built-in capacity for learning and creative problem solving, which can help them overcome problems in their lives. The capacity for creative problem solving can be enhanced or supported – or limited or distorted – by the person’s internal resources, and interpersonal and physical environments.
Their capacity for creative problem solving can also be limited by low self-esteem, feelings of discouragement, and a lack of hope.
Most people cope, survive and grow with challenges in their everyday lives without the help of a therapist.
Clients come for help with their ‘problems’ when their self-healing capacities or resources are inaccessible or blocked. Therapy is most effective when it makes use of these self-healing capacities and resources.
The most important thing that the therapist can do to be helpful is to find ways of supporting, stimulating, and energising client investment and involvement in the therapeutic process. The second most important thing is to stimulate client learning and creative problem solving.
The authors of this book view the therapist as a coach, collaborator and teacher who frees up the client’s innate tendency to heal.
The therapist may use one of the major theoretical frameworks (e.g. cognitive-behavioural or psychodynamic), but the way their help is used will ultimately be determined by the client.
Clients know the intimate details of their problems and the intimate ecological connections that are created by their problems, and they have a sense of the factors that create the problems.
They also have a much more intimate sense of what is possible in their life space than does the therapist.
Clients actively translate the lessons and experiences of therapy into their life contexts. Therapists cannot expect a one-to-one translation of their technique and ‘teachings’ into client behaviour. Clients use their own idiosyncratic uses and understandings of whatever they have learned in therapy to help them deal with their problems.
This model of the client as a self-healer is in contrast to the medical model, which still dominates psychotherapy. In the medical-like ‘treatment’ model, the therapist is analogous to a physician.
He or she is an expert on the nature of the client’s problems and on how to help alleviate these problems. He or she forms a diagnosis and then prescribes treatment, which consists of applying interventions appropriate to that diagnosis. These interventions cause change to the client, thereby alleviating the symptoms.
In their book, Bohart and Tallman provide a wealth of research evidence supporting the idea that the active efforts of clients are responsible for making psychotherapy work. They contrast their views with the medical model.
They emphasise the fact that differences in effectiveness between different therapeutic approaches have only infrequently been found. The self-healing tendency of the client usually overrides differences in technique or theoretical approach.
The authors describe the assumptions about clients, problems and change that underlie the self-healing model, and why clients come to therapy. They view therapy as a form of education and describe different ways therapy promotes self-healing.
They particularly examine how the provision of a basic empathic relationship can be helpful. Therapy is also viewed as a meeting of minds.
This book is essential reading for anyone working in the substance use treatment field. If you have any doubts about the relevance of this book, I remind you of a quote from the excellent book by Tom Waller and Daphne Rumball, “Treating Drinkers & Drug Users in the Community” (2004):
‘Other people, however skilled they may be, never make a drinker of drug user better. It is always the client who does the work. Helping professionals can make assessments, point the way, offer suggestions, provide interventions tailored to meet a client’s needs, give appropriate counselling, and do what they can to improve the client’s environment, but success, when it comes, always belongs to the client, never to the professional worker.’
So think about this the next time you meet one of your clients. And think about the following excellent quote from Bohart and Tallman’s seminal book:
‘The client is a creative, active being, capable of generating his or her own solutions to personal problems if given the proper learning climate… therapy is the process of trying to create a better problem-solving climate rather than one of trying to fix the person.’


Anonymous said...

The development of self-efficacy is essential if recovery is to happen and there are a variety of techniques we can employ to help the client find this. Motivational interviewing is a powerful tool in this regard.

As a doctor, I have some concerns about throwing the baby out with the bathwater as far as the medical model is concerned. Many clients have co-occurring mental and physical health issues needing diagnosis and treatment. Where I work we assess nutritional, dental, bood-borne virus, immunisation, sexual health, mental health status. All clients get a thorough physical examination. I don't think we've ever treated anyone who has not had an unmet medical need secondary to their addiction. Our treatment services are encumbered with a medical language still. We make a diagnosis of substance dependence based on ICD or DSM classification. We 'treat' people. The neuroscience shows clear evidence of brain disorder and structural changes.

There is a wealth of evidence now to show higher function impairment, low drive, anhedonia and reduced capacity to make healthy choices in addiction. We need to bear this in mind when supporting clients. In the intial stages many will need boundaries and structure, some of which they may not choose for themselves and here the balance is between 'do what you choose' and 'here's what works'. This can be a difficult tension.

I fully agree that we need to enable, support and mentor the client to the point where healthy choices, self-efficacy and empowerment are second nature. Abandoning all the elements of the medical approach would not serve our clients well I fear, although I don't think that's what you are advocating!

David Clark said...

I agree whole-heartedly with the sentiments in this blog Dr Dave. This is a great response!!

Anonymous said...

I wholeheartedly agree with the philosophy on which the book is based, and also the comments of ‘dr dave’.

It is an approach that is integral to ‘The Process of Change’, which has more than withstood the test of time; an approach which I refer to as treating the addicted rather than the addiction.

I intend no criticism when I say that apart from the knowledge of addiction and the clearer understanding of it’s effects on the addicted, which science has revealed over the past 15 years or so, there is nothing new in the philosophy which can be traced back to the beliefs of AA and NA, and which regards addiction as a condition affecting mind, body and spirit. Without addressing all three within the framework of Prochaska and DiClemente’s work, we are failing those who seek our help, insofar as helping them to recognise that within the limitations of the mental, physical and spiritual harm that addiction has inflicted, their condition is healed with their own inner resources.

It is my firm belief that the process of healing and recovery begins at the moment my client accepts that he/she is the only one with the power,the authority, and the responsibility to permit the necessary changes.

Sadly, there is no room for such an approach has no place in either ideological or political agendas.