This post explores the relationship between the concept of the therapeutic working alliance and the principles of 'recovery', primarily relating to substance use but also to mental health.
Recovery has been identified as a primary goal for behavioural healthcare, although with reference to substance use, the concept of ‘recovery’ has historically been somewhat difficult to define. In these posts, Davidson’s 'Recovery Principles' as described in ‘Recovery — Concepts and Application’ (Davidson, 2008), will be explored through the lens of the therapeutic working alliance discussed extensively in earlier posts. The ‘recovery agenda’ in the substance use field has emerged in parallel with an equivalent in the mental health field that recognises that medical treatment has its place, but is not sufficient in isolation. The development of recovery-based services has also placed emphasis on the ‘people skills’ that staff possess as much as their formal qualifications, and promotes ways of relating to service users which the service users themselves say help their recovery, such as active listening and respect for choice (Davidson, 2008). Similarly, the Munro Review into Child Protection found that social work clients most desired productive and helping relationships with social workers who listened to them about their needs and responded to them. The treatment relationship, based on empathy, respect and collaboration, therefore has a central role in recovery.
Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.
Emerging definitions within the field of substance use also emphasise that recovery is more than just the removal of potentially destructive drug or alcohol use from an otherwise unchanged life (McLellan and White, 2012). Many contemporary definitions suggest that it involves a radical reconstruction of the relationship that problematic substance users have with drugs and alcohol; improvements in health and social functioning; and improvements in the substance user’s relationship with, and contribution to, the wider community (McLellan and White, 2012). This is built on the belief that ‘recovery from substance use’ is not only possible, but that recovery is associated with personal growth and development, and not merely the resolution of symptoms and a cessation of substance use (Best et al., 2009).
It is important to note that within the substance use field there are different views on the necessity for abstinence to experience ‘recovery’. This may reflect differing views on whether recovery is ‘in substance use’ or ‘from substance use’. It may also reflect a moral viewpoint that perceives substance use as ‘the problem’, rather than the problems being those pertaining to the causes and consequences of substance use. Alternatively, it may reflect the politicisation of the ‘recovery’ and ‘substance use’ debates where ‘recovery’ is contrasted with ‘harm reduction’ and maintenance prescribing, and where they are misleadingly portrayed as polar opposites. The Betty Ford Institute Consensus Panel describes abstinence as “the cardinal feature of a recovery lifestyle”, whereas the United Kingdom Drug Policy Commission (UKDPC) Recovery Consensus Group proposed that recovery requires control over use and a freedom from compulsion to use. However, the UKDPC acknowledges that for many people:
Recovery will require abstinence from the problem substance or all substances, but for others it may mean abstinence supported by prescribed medication or consistently moderate use of some substances.
(UKDPC, 2008: 5)
Importantly, it should be recognised that not all clients will want, or will be able, to achieve treatment-free abstinence, at least in the short-term. However, all services should enable clients to experience ‘social recovery’ where they achieve effective independent living and engage in a range of meaningful activities (Best et al., 2010). This is important because too great a focus on ‘abstinence’, certainly early in treatment, could be detrimental to the formation of a therapeutic working alliance if the client does not perceive this as an attractive or realistic goal.
Hope, Expectancy and Self-Efficacy
Hope is central to recovery and can be enhanced by each person seeing how they can have more active control over their lives (‘agency’) and by seeing how others have found a way forward.
The importance for people experiencing problematic substance use of seeing others succeed in making and maintaining change and achieving the things that they want in their own lives, is often known as ‘visible recovery’. Best and Lubman (2012) suggest that recovery is predicted by exposure to recovery role models, a process that they describe as the ‘social contagion’ of recovery. Recovery role models, especially those who are interacted with in a supportive way, such as through recovery support groups like SMART Recovery or as drug workers, serve as examples and instil hope and confidence in change. Beliefs can be strengthened by seeing others’ abilities to achieve the goals that we want. However, the reverse is true and that people’s self-belief can be diminished by seeing others fail.
Beck et al. (1974) identify hopelessness as a fundamental symptom of depression and other psychopathological conditions, and describe it as implicated in a variety of conditions including problematic substance use. It makes sense then that hope should be posited as the antithesisof hopelessness. Hope includes having a sense that change is possible. Hanna (2002:93) includes ‘hope for change’ as one of the seven client-specific change characteristics or precursors to change, and identifies it as “the realistic expectation that the future will be positive”. Similarly, Snyder and colleagues propose that hope is a construct involving “an overall perception that goals can be met” (Snyder et al., 1991).
This definition of ‘hope’ shares similarities with Bordin’s alliance dimension relating to the setting of goals and the tasks necessary to meet those goals. This reinforces the view that part of a practitioner’s role in developing effective alliances is to help clients to identify goals and the processes and actions (pathways) required to meet them and in doing so enhance their motivation to change.
If psychotherapy cannot help an individual to explore that which makes life worth living, what motivation does the individual have to participate in the arduous work of treatment?
(Cheavens et al., 2006: 136)
By talking about treatment in a positive way and describing how treatment can help their clients overcome problems, practitioners can arouse client hope that positive change will follow. They should therefore express confidence that treatment will have positive benefits for the client. Snyder et al. (1991) talk in terms of ‘expectancies for goal attainment’ and also describe how individuals who report higher levels of hope also report higher levels of self-esteem, are more goal orientated and have a lower propensity towards negative self-thoughts. Hanna (2002) refers to hope as a catalyst for other precursors to change as it can reduce anxiety and increase confidence in a person's ability to cope and in confronting problems. In this way hope can be seen to share many similarities with the concept of ‘expectancy’ or ‘self-efficacy’.
Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness
Best (2010) suggests that assessment approaches concentrating on the flaws and troubles of an individual, and which merely list their shortcomings, can lead to a therapeutic relationship founded on illness, failure and powerlessness, which is insidious and can permeate all other aspects of the person’s treatment journey. Practitioners therefore need to re-cast the assessment process in order to promote hope and emphasise the client’s skills. This approach mirrors the field of ‘positive psychology’ focusing on people’s strengths and potentials, rather than on the more traditional psychological problem-focused ‘fixing’ framework, and allows not only the alleviation of immediate symptoms, but builds strengths and promotes longer term satisfaction.
As mentioned earlier, the collaborative role of practitioners needs to include instilling hope and confidence of positive outcomes in their clients, as practitioners who hold pessimistic views about their clients’ chances of success present further barriers to the delivery of effective treatment (Best and Lubman, 2012). Lack of belief is easily transmitted from practitioner to client, and can create self-fulfilling prophecies. Conversely, workers who encourage and communicate confidence in their clients’ ability to achieve change strengthen their commitment to change.
Larsen and Stege (2012) propose that the experience of being in a therapeutic and supportive relationship can offer a sense of hope, and that a crucial aspect of hope is embedded within the therapeutic relationship itself where the relationship offers understanding and acceptance. They acknowledge that many perceive the counselling relationship and ‘hope’ as separate factors contributing to change, but question the usefulness of this distinction and suggest that both are fundamental to change and that “a strong counseling relationship is considered … to be the bedrock of client hope” (Larsen and Stege, 2012: 51).
Self-management is encouraged and facilitated. The processes of self-management are similar, but what works may be very different for each individual. No ‘one size fits all’.
(Davidson, 2008: 1)
In practice, Davidson (2008) suggests that this means that individuals are allowed and supported to define their own goals. The role of practitioners, therefore, is to help clients to identify these goals and achieve them in ways that are meaningful and acceptable to them. This principle bears a strong relation to the ‘goal’ and ‘task’ elements of Bordin’s (1979) three-component theory.
Fundamentally, there should be a move away from solutions defined and imposed by professionals without reference to service user need (Davidson, 2008). Irrespective of the definition of recovery, the principles should be about client choice and empowerment, together with a recognition that “recovery is a fundamentally social process that is lived and experienced outside the walls of specialist treatment services” (Best et al., 2010: 8). Thus, in relation to service delivery “a number of factors are coalescing … which suggest recovery-oriented services and initiatives should be more personalised and offer a better balance between medical and psychosocial interventions” (Paylor et al., 2012: 79). Self-management is not only about clients taking more responsibility for their own treatment, but also about a change in the dynamics of the relationship between drug (and mental health) workers and their clients.
The helping relationship between clinicians and patients moves away from being expert/patient to being ‘coaches’ or ‘partners’ on a journey of discovery. Clinicians are there to be “on tap, not on top”.
It has been suggested that the working alliance and the therapeutic relationship are not the same thing, rather that the alliance is a way of looking at the relationship through a lens of goal-directed work and asking whether the relationship promotes collaborative working with improved outcomes, or whether it could detract from the work (Hatcher, 2010). Similarly, Davidson (2008) suggests that as the relationship between practitioners and their clients moves away from one of expert–patient to one of partners on a journey, treatment is viewed through ‘recovery glasses’ to see whether it empowers people or takes power away from them.
Best et al. (2009) describe how the recovery agenda is not just about addressing the stigma and social exclusion experienced by problematic substance users and about empowering drug users, but that it also challenges the status of drug workers as ‘professionals’. They suggest that the dichotomy of ‘patient’ and ‘professional’ is not only using the wrong language, but creating the wrong relationship, and that drug workers need to learn new skills to support new roles.
In the mental health field, the Improving Access to Psychological Therapies (IAPT) programme was established in 2008 with the intention of enabling more people to access NICE-approved psychological therapies for common mental health problems such as anxiety and depression (NHS, 2010). As part of this, the role of Psychological Wellbeing Practitioners (PWPs) was developed to provide people with low intensity interventions, and can be likened to a coaching role such as athletics coach or personal fitness trainer, where the coach devises a plan, monitors progress and provides encouragement, motivating the client rather than doing the work for them (NHS, 2010). This reflects Davidson’s (2008) suggestion about how clinicians should be ‘on tap, not on top’. PWPs take a collaborative approach, focus on self-guided help and are:
Explicitly educated and skilled in ‘common’ as well as ‘specific’ therapeutic factors, so they know how to establish, develop and maintain therapeutic alliances with patients, [and] are able to respond to and deal with real or potential ruptures in the alliance.
(NHS, 2010: 5)
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BECK, A. T., WEISSMAN, A., LESTER, D. & TREXLER, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42, (6), 861-865.
BEST, D., BULLOCH, T., JONES, V., TUNNAH, C. & SIMPSON, D. D. (2010). Time to Change. Drink and Drug News, 19th July 2010.
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CHEAVENS, J. S., FELDMAN, D. B., WOODWARD, J. T. & SNYDER, C. R. (2006). Hope in Cognitive Psychotherapies: On Working With Client Strength. Journal of Cognitive Psychotherapy, 20, (2), 135-145.
DAVIDSON, L. (2008). Recovery - Concepts and Application. Devon Recovery Group. Available: https://recoverydevon.co.uk/?mdocs-file=2657
HANNA, F. J. (2002). Therapy with difficult clients: Using the precursor model to awaken change. Washington DC, American Psychological Association.
HATCHER, R. L. (2010). Alliance Theory and Measurement. In: MURAN, J. C. & BARBER, J. P. (eds.) The Therapeutic Alliance: An Evidenced-Based Guide to Practice. (pp. 7-28). New York: The Guilford Press.
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About Hugh Asher
Hugh is an author, practitioner, trainer, researcher and consultant.
He keeps rare breed sheep and cows.
He also shares his house with the world’s largest puppy, called Charlie.
Although he was told from a young age that “Life isn’t fair” he has refused
His vision for a better world involves giving people the skills and