Research and dissemination.

Therapeutic Relational Professionalism

A Description of Different Approaches to Alliance Formation between Psychotherapist and Client

Prepared by:

Jette Gørtz Smestad. Cand.psych. Aut

1. Introduction…………………………………………………………………………………….1

2. Alliance Formation based on the Contextual Paradigm ..............................................42.1 The Miller Group's Contribution to the Development of Alliance Formation

in Psychotherapy ....................................................................................................4

3. Alliance Formation based on the Relational and Contextual Perspective…………...6 3.1 Systemic Theory and Therapy’s Contribution to the Development of Alliance

Formation in Psychotherapy…………………………………………………………...6

4. Alliance Formation based on the Narrative Perspective……………………………....10 4.1 Narrative Theory and Therapy’s Contribution to the Development of Alliance

Formation in Psychotherapy………………………………………………………….11

5. Conclusion.................................................................................................................... 14

6. Literatura………………………………………………………………………………………..16

1. Introduction

The starting point of this project is a preoccupation of which factors that has an effect in the meeting between psychotherapist and client in psychotherapy. As early as in 1936, Saul Rosenzweig made a conclusion about the effects of various psychotherapies based on

relatively few studies. He concluded that all forms of psychotherapy work equally well and made a parallel to the “Dodo bird verdict” (From Lewis Carroll:" Alice In Wonderland "):"Everybody has won all must have prizes ". (Andersen, 2003, p. 65).

In connection to the Dodo hypothesis the question have been asked (Henry, 1998, p.128; Wampold, 1997, p.167; Hougaard, 2009, p.211), why the controlled efficacy research use a lot of resources on documenting that different methods have approximately the same effect? An answer to this could be that differences between various methods have been found for some medical conditions (Chamb & Ollendick, 2110) , but when recent scientific studies have focused on measuring the effects of psychotherapeutic treatment of some conditions like anxiety or depression, usually the basis for it has been a specific form of psychotherapy for example cognitive behavioral therapy. Today cognitive behavioral therapy is the most studied form of therapy and therefore has come to appear as the most effective.

Most recent systematic reviews have concluded, however, that the differences in the effect of psychotherapy have shown no differences or been small or of moderate practical value (Hubble, Duncan and Miller, 2002, p. 6; Hougaard, 2009 p. 98). This has been interpreted by many researchers as if all forms of psychotherapy work equally well, and that it is not the specific theoretical considerations, the type of therapy or method that constitute the effective factors in psychotherapy, but the so-called "non-specific factors" (Hougaard, 2009, p.117; Andersen & Holme, 2002, p.13; Andersen, 2003, p. 65). Wampold has reviewed the research results of the effect of treatment, and according to this, the effective factors in psychotherapy are the following: (Note 1)

These results show that the psychotherapist’s behavior in therapy is regarded crucial to the effect of therapy (Hougaard, 2009, p. 291; Hubble et al., 2002; Jørgensen, 2001, p. 455; Jørgensen 2002, p 12). Moreover, it is considered beneficial for the effect of psychotherapy, if the psychotherapist focuses more on his or her skills to form and maintain positive therapeutic alliances with clients rather than solely focusing on learning the theory, methods and techniques. This does not mean, however, that theories, methods and techniques are not valuable just that they should not be the only or primary focus of concern.

In the article: "To sider af terapeut-klient-forholdet” (Eng: Two Sides of the Therapist-Client-Relationship), Torben Nielsen (2011, p.18) writes that it appears as if a good relationship

between psychotherapist and client as well as specific methods play a significant role in the outcome of a psychological treatment.

A group of expert researchers (Webb et al., 2011) in the field of cognitive behavioral therapy has investigated the role of the psychotherapist-client relationship in relation to the outcome of cognitive behavioral therapy for depressed people. Basically, the group was of the opinion that one should consider two sides of the therapist-client relationship. One side is called the cooperative relationship and regards how well therapist and client can agree to cooperate progressively in relation to the goals they have set together for the therapeutic work and furthermore which methods should be applied to achieve this goal. The other side is called sympathy relationship and regards how much warmth, sympathy and understanding they both experience in their mutual interaction. With this assumption the research team conducted two studies of cognitive-behavioral therapeutic treatment for depression. The studies showed two things:

1. The cooperative relationship had at the beginning of the therapy great subsequent impact on how well the therapy worked during the treatment. This was not the case for the sympathy relationship.

2. The more progress had happened through the course of therapy, the higher was the client's sympathy for the therapist at the end of therapy. For the sympathetic relationship it rather seems to be an effect than a cause of an effective therapy.(Webb et al., 2011, p. 282)

The conclusion of this study is that agreement on goals and methods as well as the client's sympathy for the therapist are essential elements in relation to what works in psychotherapy.

The focus of my project is the therapist-client relationship. Especially the therapeutic alliance consisting of sympathy and consensus in regards to the goal of the therapy, the method and the technique. The Miller Group has contributed with thoughts in relation to the importance of the client´s assessment of both the progress in therapy and of the quality of the therapeutic relationship. The starting point of this project is therefore the work and thoughts of the Miller Group that concerns the factors, which they describe as being important in the formation of the therapeutic alliance. In addition, this project will focus on how systemic and narrative theory and therapy, which are the theories and therapies I work with daily in my clinic, describe and implement formation of therapeutic alliance defined as cooperative relationship and as sympathetic relationship. Based on this, the research question is as follows:

How do systemic and narrative theory and therapy describe the factors, which the Miller Group describes as being important in the alliance formation?

To answer the research question, the starting point of the literature search has been partly the main body of literature in the area of systemic and narrative theory and therapy, which was obligatory in my further training as psychotherapist in 2010 and 2011 at Inpraxis (Denmark), and partly the main literature from the Miller Group. Besides books, I have been searching in the recognized Danish Psychological Magazine of Psychology, the Danish Royal Bibliotheca via the Danish Royal Library and in the databases: APA PsychNet, Psykinfo and GoogleScholar.

Keywords: Dodo, what works in psychotherapy, therapeutic alliance, ORS and SRS, systemic theory and therapy, narrative theory and therapy.

2. Alliance Formation Based on the Contextual Paradigm The Miller Group (Duncan, Miller and Sparks, 2000; Hubble, Duncan and Miller., 2002) has been very interested in questions concerning what works in psychotherapy. They have found evidence that the likelihood of increasing the effectiveness of therapy is greater when therapy is consistent with the client's theory of change processes. The client is not the star but the Director of the therapy. The client is the “engine” of change. (Duncan et al., 2000, p. 67). The Miller Group has encouraged therapists to make the client the primary agent of change, and they have suggested that the client's assessment of progress in therapy and his or her assessment of the quality of the therapeutic relationship should be in focus and lead the therapist. According to this the group has been concerned with the development of documentation in relation to evidence. Today evidence is very important, because the requirement of evidence in psychotherapy has become more and more prevalent, particularly to ensuring the quality of the psychotherapeutic work (Bargmann and Jensby, 2012 p. 8).

The method introduced by the Miller Group has a dual function consisting in being a method of alliance formation, but also a method for documenting efficacy of psychotherapy. Both areas are important and will influence each other. The effect of the psychotherapy will depend on the cooperative relationship - which in the beginning of the therapy is of great subsequent influence for how well the therapy works – and on the client's sympathy for the therapist - the sympathetic relationship. It has been found that progress through the therapy seems to add to the sympathetic relationship, so it is higher at the end of the therapy and therefore tends to be a consequence of rather than a cause of effective therapy (Webb et al 2011, p.282).

The focus of this project is, however, factors related to the alliance formation. Which is why the Miller Group’s description of the effect of psychotherapy will only be included in connection to the description of formation of alliance.

2.1 The Miller Group's Contribution to the Development of Alliance Formation in PsychotherapyTo document whether the therapy works, the Miller Group has developed a method: "Client-directed, outcome-informed therapy," which focuses on how the client finds the therapy "works". Via schedules the client makes assessments by reference to whether the therapy has resulted in recovery and an assessment of the therapeutic alliance. Subsequently the ratings are used to adapt the therapy to the client’s needs.

In order to continuously measure these factors in therapy, the Miller Group has developed a measuring instrument in the form of two tables. One schema Outcome Rating Scale (ORS) measures the client's benefits from the theory; the second schema Session Rating Scale (SRS) measures the client's assessment of the alliance. ORS scores at the beginning of the therapy session, SRS scores at the end of the session.

Outcome Rating Scale-form consists of 4 elements which in research have proven to be the points of the client's life, which are influenced by therapy. (Henley and Miller, 2012. p.9),

- Individual well-being- Close relationships (family and close friends)

- Social (school, work and friends)- General well-being

According to the Miller Group the schema is useful to statistical calculation and makes it possible for the therapist to get an idea of how many sessions he or she should expect to spend on creating the first therapeutic change. Thus the schema has a dual function partly as practice research and partly as therapeutic tool (Bargmann and Jensby, 2012 p.12 ), and makes it possible for the therapist early in the process to become aware of whether it is the right issues the therapy deals with and whether the therapy moves in the desired direction. This insight allows for changing the therapeutic process and also allows for early in the process to terminate any infertile therapy and refer the client to other treatments.

The consideration and assessment of the curve takes place in interaction between therapist and client, and it is in the dialogue the determining of the curve is to be understood as well as the identification of, whether the therapy should continue or be terminated. This ensures a higher degree of understanding of the curve in interaction with the client's experience of change/development rather than an understanding based solely on the therapist's statistical understanding. The understanding of ORS curve and the use of it shall ensure that the therapy is "Client-directed" - guided by the client's wishes, thoughts and opinions.

The use of ORS and the dialogue between therapist and client names as the dialogical component (Andersen (2003, p. 270) - can thus engage the client because it makes it visible that the client has a major responsibility as to whether the therapy works and a responsibility regarding decisions, such as whether therapy should be adjusted, end or continue as it takes. Furthermore, the dialogue helps to open up the exploration of the client's understanding of change. Questions open up as: perhaps the client doesn’t think that change must happen at the same rate as the therapist thinks? Perhaps the client sees other elements of the therapy as progress than the therapist does? Thus the curve becomes a starting point for a conversation and serves to that therapist and client can reflect on the therapeutic process together, which also opens up to a higher level of understanding of the client's experience of change/development. Dialogue on ORS curve can thus be a central and essential part of the therapeutic conversation and often lead right into the heart of some of the key themes for the client such as motivation, feeling stuck in his/her situation, relationships with significant others, and work-related problems. (Andersen, 2003, p. 271)

The Miller Group does not operate with phrases such as agreement about goals and methods which are elements of the cooperative relationship. They believe that therapy should be guided by the client's wishes, thoughts and opinions, that is be consistent with the client's theory of change. This increases the probability of the efficiency of the therapy, and according to Webb et al. (2011) the efficiency will have an impact on the client's sympathy for the therapist and thus an impact on the formation of the alliance and the therapeutic relationship. The second table developed by the Miller Group is dealing specifically with the relationship between therapist and client.

The second table: Session Rating Scale consists of four points:- Relationship- Goals and topics- Approach or method- Overall

With this schema the client is given the opportunity to comment and express whether the therapist in the session offers a satisfactory alliance. If the client evaluates the alliance negatively this is taken up in dialogue immediately and furthermore with the opportunity to talk about it in more detail in the next session - to get the opportunity to learn more about what changes the client could wish for. This enables the therapist early in therapy to correct the therapeutic alliance.

It is important that the conversations dealing with these issues takes place in an appreciative way, so the client will come to understand, that his criticism is a help and a valuable tool for the therapist to become a better therapist. For some clients, it may be difficult to answer the questions, particularly in the first sessions; it may be difficult to have the courage to answer honestly. A context with an open and secure atmosphere may be helpful for the client. Furthermore, it can be helpful if the therapist underlines clearly that an evaluation, positive or negative, is helpful for the therapist in an effort to improve the therapeutic alliance. (Andersen and Holme, 2002, pr. 14; Andersen, 2003, p. 269)

3. Alliance Formation Based on the Relational and Contextual Perspective

Systemic theory is based on the meta-theoretical basis of social constructionism. It is a basic theory on how change can happen and on what is needed for people to change. Social constructionism sees reality as a social construct. Especially our language and the way we talk about things and the world are seen as important factors in the construction of reality. This means that our stories and problems are created and developed through the language we use in social interaction with others, and that the truth as such does not exist, but can be dissolved partly through therapy. It also causes therapist’s presumed expertise to be just one among numerous possible perceptions.

The central aspects of systemic therapy is that, which is created between the actors in an interaction and that the therapist uses the language to create changes in reality. An understanding of the context and the conscious use of this knowledge is crucial to create meaning and thus change. (Haaland, 2007, p.36/38)

Over the years there has been a development from classic systemic therapy, which among other things operated with an approximate objective observer, towards a systemic therapy with a focus on the social context and culture (Rasmussen, 2012, p .27). Furthermore, there has been a shift away from the formation of hypotheses made exclusively by the therapist system and towards "dialogical hypotheses" in stead. This means that the most important thing in therapy is how the therapist and client together develop a language which is rooted in the both therapist’s and the client's experiences, understandings, knowledge and skills. (Torsteinsson, 2012, p. 291)

In my daily work I practice this newer understanding of systemic therapy. Below I will therefore describe the newer systemic understanding of how changes are made and how systemic theory relates to the formation of the therapeutic alliance related to the cooperative relationship as well as the sympathy relationship.

3.2 Systemic Theory and Therapy’s Contribution to the Development of Alliance Formation in Psychotherapy. According to systemic theory communication will always take place within a context and thus provide a framework for our understanding of the information exchanged. Our interpretations, our way of understanding information and our construction of stories

depends on the context. Systemic theory has thus the relational and the contextual perspective as well.

In systemic therapy the therapeutic process starts by talking about the client's description and definition of the problem and what the client thinks about it. The therapist will not define the problem and steer the conversation towards the therapist’s prior understanding of the problem. Furthermore it is necessary that the description of the problem is considered fluent and has a workable character implying that all involved parties can understand the description. The actual work does not consist in achieving a goal, a specific content or outcome or moving in a certain direction. The work consists in a process that evolves to open up rather than close down or limit - and to mobilize rather than immobilize. (Anderson and Goolishian, 1988, p.388).

The goal of the systemic therapist is to participate in a conversation that loosens up so that fixed meanings and behaviors can broaden, shift and change (Anderson and Goolishian, 1988, p 381). In the conversation and the dialogue all meanings, understandings and interpretations are negotiable and tentative. The constant exploration of the many descriptions of the problem and of its systemic causes makes it possible for the client and the therapist to co-evolve the “not-yet-said” and thereby co-create and co-develop new themes, new narratives and new stories. (Anderson and Goolishian, 1988, p 381/383/384).

To facilitate the conversation to move toward large-scale production of new information, understanding, interpretation and hence new stories, the systemic therapist uses queries, where the concept of appreciation is of utmost importance. Appreciation has always been closely associated with systemic theory and method. In systemic therapy the therapist is not considered to be an expert and therefore is not in a position to predict, instruct or control a specific change in a client. Instead the therapist interfere (Note 2) the client´s realizations and mental understandings to create change. This is done with a special kind of appreciation containing more than accommodating and accept. In the systemic theory the concept also consists of active linguistic appreciation, emphasis and articulation of the resources of the client system, skills and stories.

Systemic theory has several ways of using the language to highlight and give voice to the client´s resources and capabilities such as these become visible through the client´s story during the therapy. One way is the use of appreciative questions; another is the use of positive reformulations and "retelling" of the client´s existing, dominant and dysfunctional understanding. The purpose is to create new understandings and new meaning in order of creating new stories that will allow the client new possibilities, hope and positive self-esteem. The function of appreciation is thus partly to elicit positive emotions such as hope, values and self-awareness and partly to create a possible conceptual framework, a context in which the formation of new meaning can occur (Søholm and Juhl, p.11,).

To stimulate reflection, new perspectives and new hypotheses a special interview technique is needed (Søholm and Juhl, p.15). One element in this interview is Circularity, which involves switching from a preoccupation with the problem of etiology in a linear causal way to having a curiosity related to the meaning associated with the circularity of the client´s problem Circular questions do not examine the problem. They explore the relationships, connections and correspondences with differences and patterns in the various explanations and descriptions that the problem consists of, and this exploration takes place with a curiosity that opens up new possibilities, new understandings and thus therapeutic development.

In systemic thinking of communication and the concept of appreciation it is very important; that the therapist, in the receiving position, understands what the client says and does. This is very basic regard to appreciation: "How can I /the therapist understand what underlies what the client says and does"? It is important that the therapist understands what the client says and does in a sense is "logical" according to a given set of premises and values. This understanding will enable the therapist to create a foundation on which it is possible to meet the client and thus establish more constructive conversations as well as cooperation.

According to Thorkild Olsen (2008, p.4) appreciation in systemic theory is both a philosophical concept and a practical method consisting of minimum two main directions. One direction is appreciative inquiry based on the insight that it is through language that we create the reality in which the therapist will be able to focus on what makes sense and on what works, on hopeful dreams and desires and on the client´s resources and competence.

The second direction consists of a more existential approach to appreciation, and stresses that human beings only can grow if we have access to the appreciation of our lives. Appreciation of this understanding means to be seen, and it is therefore essential for the therapist to see the client (as a significant other). Seeing the client is basis to create the foundation for change. (Olsen, 2008, p.4).

The therapist's role in the therapy is thus extremely important and in this context, domain theory is a very useful tool. Domain theory was originally formulated by the Chilean philosopher and biologist Humberto Maturana and later developed by Cechin, Long, Little and Cronen. Domain theory includes all systems and points out that in all communication systems, in principle, there are three basic domains (contextual factors). The domain theory is thus a context clarifying model in which human acts of speech are classified into three domains which are inter-related and thought of as the domains where the acts of language unfold.

The first domain is called "production domain" or "domain of action. When we speak from this domain, we speak related to that part of the world where we are governed by laws, norms and rules (society affects our behavior). This is where the framework for our work is set and where from responsibility is placed. It is here views are broken: “who was the right / wrong”? It is here decisions are taken – What is a right/wrong solution? - , and tasks are resolved. This is where we act. In this domain the understanding is linear and Uni-verse.

The second domain is called the "personal domain" or "aesthetic domain". Here is the personal, private background - the experiences from life and upbringing. It is here the moral / ethical values, ideals, religion, cultural background, perceptions of beauty and harmony has its place. It is her we take personal positions. Thorkild Olsen (2008, p.5) also call this domain "My-verse" - as it is a place from which I relate myself to the production domain in terms of, what I do or do not like, which is connected with personal well-being and self-esteem. There is also uni-verse in this domain but not in relation to right and wrong. This is an aesthetic dimension based on criteria such as beautiful / ugly, ok / not ok. Appreciation – described as an existential relation- is related here, but the more appreciation you get, the more you are seen, the less are you centered in your personal domain, because appreciation make it possible to face the world and open up and be flexible.

The third domain is named the “reflection domain”. In this domain it is possible to be in an observer position for itself. It is the room for reflections and dreams. Here is multi-verse: many versions of reality and many different truths and perspectives and different ways of viewing the world. Here multiple explanations of various phenomena exist and various

viewpoints are considered equally valid. Disagreements are welcome here and no decisions are taken. As a way of understanding the therapist uses the circular form, thinks out loud and listens attentively. The systemic ideas, models and methods are used with the intention either to establish better decisions or production in the production domain or to provide space for personal reflections in relation to one’s own actions or attitudes. The dialogue in this domain may occur slowly, but experience has shown that the time needed to move in this domain can be tremendously effective. (Olsen, 2008, p.5).When the domain is handled professionally; it can lead to better quality of communication, understood as a move away from fixation towards opening up possibilities instead.

In real life it is not possible to identify the domains apart, they always exist simultaneously. One of the domains will, however, emerge as a key to what is going on. In psychotherapy, the domain theory can be used as a tool that provides concepts for investigating which linguistic domain the client is in at any given time. This insight is very useful for the therapist in order of performing professionally in the therapeutic context. (Søholm and Juhl, p. 8). When communication in therapy takes place in for example the reflection domain, more creative ideas, more combinations and multiple viewpoints can lead to the possibility of a greater overview, a greater understanding and knowledge of relations and to appropriate action. (Strand, 2003 p.740)

Based on the above, it can be said, that to apply systemic method you need an understanding of the concept of appreciation and the concept of context, and that the concept of context reflects that systemic theory is primarily a communication perspective. This implies that a text can only be understood in its con-text. For the therapist it means opportunities in relation to "reading" the context, that is, to clarify the context and constantly ask for it or make up hypotheses about it. Another thing in connection to context is the ability to “set the context”, that is, make the context common, which is significant, because the more common and obvious the context is, the more possible it is for everyone to attend and contribute appropriately. Both of these roads are the ultimate keys in working with conversations. (Olsen, 2008, p.5)

The research question of this project was: “How do systemic and narrative theory and therapy describe the factors which the Miller group describes as being important in the alliance formation?" To answer this question it can be said, that systemic theory and therapy has no defined categories which the therapist can take advantage of in practical therapeutic work or in measuring of effect. The therapeutic work does not consist in achieving goals, in specific content, outcome or movement in a particular direction. The theory and therapy is more preoccupied with change, alterations and how change happens. In the therapy no distinction is made between cooperative relationship and sympathy relationship; the focus is on co-development, which includes elements of both types of relationships and which in turn partly influence one another and also is one other´s condition. This is expressed in the concepts of dialogue, appreciation and context.

In systemic therapy the client's definition and description of the problem is recognized as well as what the client in this regard would wish. The recognition invites to cooperation and dialogue in which the language is a breeding ground for changes and alterations. In relation to development, appreciation is fundamental, as the approach to appreciation - to be seen, and to understand that what the client says and does is "logical" from a given set of premises and values - is the foundation on which it is possible to meet the client, and it’s from this foundation the conversations and the co-development can be constructed.

Because the therapist does not possess expert knowledge, the dialogue will invite to cooperation. The therapist's knowledge is just one among many others, and thus do not rank above the clients knowledge, but is a contribution in the Multi-verse, a contribution to opening up, to creating new understandings, new meanings and new stories. The dialogue is not possible without appreciation - the cooperative relationship and the sympathy relationship go hand in hand.

The domain theory - the context clarifying model – can be used by the therapist in regard to recommended courses of action, for example in relation to how the therapist can invite the client to move towards the reflective domain by offering more appreciation, which can open up to openness and flexibility.

In systemic therapy no measure is made to clarify whether the client thinks the conversations are about the right issues, whether the therapy is moving in the right direction, or whether the therapist provides a satisfactory alliance. However many systemic therapists will ask the client about these things regularly:"Are we talking about the right things?", “The things we are talking about, do they make sense to you?”,"How does it make sense?" In addition having a feedback function related to the therapy, these questions also offer the client space to express new meanings, understandings and perspectives. Hereby, it sometimes becomes visible, that change and alteration may appear in different ways, than the therapist had in mind. On the other hand if the client does not feel that the conversations have included the right topics, the questions can invite to a dialogue about what more the client could need. These questions do not directly open up a dialogue about the therapeutic alliance. Often this kind of issue will not even be articulated in this type of therapy. However, sometimes these questions do open up discussions concerning whether the client thinks that the therapist offers a satisfactory alliance. If the client evaluates the alliance negatively, this is taken up in dialogue to learn more about what changes the client could possibly wish for. This dialogue also provides the therapist the opportunity of rectifying the therapeutic alliance that might have come awry from the start or perhaps have moved on to an unhelpful place, where the client does not feel seen. In this respect, the therapist will be able to invite to a dialogue both by reading and setting the con-text.

4 Allliance Formation based on the Narrative Perspective.One of the founders of narrative theory and method is the Australian Michael White. Just as systemic theory the narrative theory rests on the meta-theoretical basis of social constructionism and is a basic theory within the frame of reference of how change can happen and what can be done to help people change (Wermer and Mortensen, 2009, p 127). The method is based on post-structuralism, which debates the idea of deeper underlying truths that can be identified by science.

In the narrative approach the key element is the notion of people seeking to create meaning and coherence in their lives. To create meaning, our experience is tied together into stories, and the stories create the framework for our experience and organize and give a pattern to the experience. Thereby our stories create structures, make a whole, coherence and meaning for us. We live our stories, and the story of the story is guiding for individuals. (Haaland, 2007, p.40).

The main idea behind the narrative method is that a man can tell countless kinds of stories about his life, and that therapist and client together can create alternative stories about the client’s life. This provides a new perspective on the client's past, present and future. In

narrative therapy the therapist is not the more knowledgeable, but the person responsible. The person who takes on the task of listening and asking questions, which allows the client to move in increasing progression from something that is well known and familiar, to something which is possible to know and do (Svarer, 2012, p 222; White 2010, p. 267)

4.1. Narrativ Theory and Therapy’s Contribution to the Development of Alliance Formation in Psychotherapy In narrative therapy, it is important for the therapist to work on creating a context in which it will be possible for the client to deconstruct the problem story, so that there is room for richer and alternative descriptions and narratives by which the client's favorite story, that is the story that is consistent with the person's values, intentions and beliefs, may be more accessible. The focus in narrative therapy is on promoting a conversation form that helps to build a community where the client's abilities, knowledge and desires are appreciated, as narrative therapies have shown that an appreciative perspective, focusing on what works, on strengths, resources and dreams of the individual is mediating a positive development (Epston, 2000, s17; White, 2006, s. 179).

One of the key ideas behind narrative therapy is also that when people are given the opportunity to define their own condition in words, which express their own experience, people are at the same time given the opportunity to define their own world; they are given the opportunity to name their problem and tell their own story, and thus they become agents in their own lives. (Holmgreen, 2007, p.14).

In the meeting with the client, one of White's key points is, that the therapist must deal openly and allowing the concrete situation to dictate the form of the therapy. Thus sometimes challenges, difficulties, dilemmas and deadlock is related to the issue of the therapist's position, which in turn is related to questions about the therapist's influence, the therapists understanding of how change is created and the therapist’s understanding of power and discourses. In this context, it may be helpful for the therapist to navigate the conversation related to what White described as possible positions. In conversations humans continuously position themselves and the other through the language and the actions that we use. Knowledge, awareness and attention to these positions in the therapy allow the therapist to invite and challenge the professional considerations in relation to own position and ways of working. (Wermer and Mortensen, 2009, p.129/130).

The four modes in possible positions are:

Centered Position of Influence. In this position the therapist's knowledge and experience is raised above the client’s more local knowledge and experience. The therapist is the expert on the client’s life and work situation. The therapist's knowledge is then going to provide the frame of reference for understanding the problem that the client presents. The result of this can be, that the client is separated from his own sensations and experiences of his life (Morgan, 2011, p. 63; Wermer and Mortensen, p.130).On the other hand, centering may be useful and not oppressive, if e.g. the therapist, after having asked for and negotiated for permission, is capable of formulating own experiences and ideas related to and in extending of a joint exploration of the client's doubts and dilemmas, for then explicitly to ask for the client's perception of the usefulness of the experiences (Wermer and Mortensen, 2009, p.133)

Centered Position without Influence. In this position the therapist constantly incorporates the things that have been told into his own a priori frame of reference. It can also be that the therapist quickly forms an assumption of what the client thinks of a particular word or phrase and therefore does not investigate the use of these, or that the therapist is so

preoccupied with his own method and therefore "misses" what the client asks help for or think might be helpful to explore (Wermer and Mortensen, 2009, p.135).The reasons for this may be that some of what the client is talking about is something the therapist knows from his own either personal or professional life, whereby the therapist quickly makes a conclusion about what is important for the client. This causes the therapist to direct the conversation through questions related to his own conceptual framework. If a conversation most of the time occurs in this position the result may be, that the client does not feel that the conversation is about something meaningful, but that the talked is about something completely wrong.

Decentralized Position without Influence. In this position, the therapist will be on hold and will not directly or indirectly attempt to influence the direction of the therapy. Instead, the therapist will focus on the client's wishes and the client's perception of the situation without contributing to the development of new stories or other angles to the presented situation and problems. According to Werner and Mortensen (2009, p.137) the therapist’s inactivity can end up confirming and supporting the client’s in advance given stories and versions of how things work. On the other hand, if the client is very stuck in the problem, it can be helpful, if the therapist for a while consciously is in this position, since the client may only be ready to deal with dreams and resources, when he or she has had a chance to talk about the problem and its consequences.

A Decentered Position of Influence. The client is here considered as the expert of his own life, and therefore the client's knowledge, skills, preferences and desires are in the center of the therapy. The therapist does not set the agenda but gets influence by listening and asking carefully structured questions, by structuring interrelated connections and by reacting in a way so that the client's skills, knowledge and aspirations for the future will be more nuanced and more richly described and thus can be activated in relation to the current problems. (Morgan, 2011, p.74). By listening and asking questions this way, the therapist tries to bring the alternative and preferred stories and knowledge forward. To be decentered with influence is the therapists preferred position in narrative practice and according to Morgan (2011, p.87) this position foster cooperation with the client, and this particular form of cooperation maintains the focus that the client is the expert in his own life.

In therapy the theory of the possible positions can be extremely helpful for the therapist, thus the knowledge and awareness of positions makes it possible for the therapist through the conversation to put himself in a meta position, a position of being "not knowing" but investigative to the client's expressed frustration, concerns, fears, desires, dreams, perspectives, etc. All of which could generate some room for reflection (Morgan, 2011, p. 72; Wermer and Mortensen, 2009, p. 138). The therapist deliberately uses his influence to create contexts where favorite stories about the client's identity are to be made more robust, which in turn will impact on the development and changes on the behavioral level. To help these conversations narrative therapists have developed many practices, such as White’s map of narrative therapy practice, naming the problem, externalization and conceptualization, which among other things are meant to create a distance to the problem and thus invite the promotion of the client's sense of identity and personal agency / capacity.

By working in accordance to the basic premise that change cannot be created through induction, one of the therapist's options for change is to look at himself and e.g. look at the various positions he holds in a particular therapy session to challenge his professionalism in relation to his own position and ways of working usefully. Such a focus would make visible

what the therapist actually does in the actual therapy session and also, the possible effects of this and the possible consequences.

The research question was: How do systemic and narrative theory and therapy describe the factors which the Miller group describes as being important in the alliance formation? Among other things can be said, that they have many similarities. Narrative theory and therapy has no categories, which the therapist can use in the practical therapeutic work or in measuring the effect. The therapeutic works consist not in achieving goals, specific content, outcome or in moving in a certain direction, but is more concerned with the question of how change and alterations can happen. In narrative therapy there is no distinction between cooperative relationship and sympathy relationship. The focus is on promoting a conversation form that helps to build a community where the client's abilities, knowledge and wishes are appreciated, since the assumption is that an appreciative perspective, focusing on what works, the strengths, resources and dreams of the individual, is mediating a positive development. In this understanding the term community also includes elements of cooperative relationship and sympathetic relationship as well.

In narrative therapy the client sets the agenda himself. It is the client who describes and defines the problem, and it is the client’s knowledge, skills, preferences and desires which are in the center of the therapy. By having knowledge of and by paying attention to the possible positions in therapy, it becomes possible for the therapist through the conversation to put himself in a meta position. When the therapist thus finds himself in the position decentered with influence, where the therapist does not consider himself to be in possession of expertise of the client's life and problems, it enables him to be "not knowing", but rather listening and exploratory in regard to the client's problems as well as his or her wishes and dreams, etc., and thus make room for reflection. In addition, it also will cause an invitation to partnership where the client and therapist jointly converse in a way that allows the client to develop fuller and alternative stories. Thus it also applies to narrative therapy that language invites to cooperation and dialogue as well as creating a breeding ground for changes and alterations.

The theory of the possible positions thus contains a description of how change is stimulated by the ways the therapist listens and asks questions, structures and reacts in ways that stimulate change and alterations. The therapist's conscious efforts to use his influence to create contexts, where the favorite stories about the client's identity are made more robust, is what stimulates developments and changes on the behavioral level. Moreover, this particular way for the therapist to be present in the therapy results in an invitation to cooperation, which means to build a community that in turn is mediating a positive development. So, when the narrative therapist is in the preferred position of being decentered with influence, then the cooperative relationship and sympathy relationship goes hand in hand.

In narrative therapy there is no measuring in relation to whether the client thinks the conversation is including the right topics, whether the therapy is moving in the right direction, or whether the therapist provides a satisfactory alliance. Many narrative therapists will continually ask the same kinds of questions as described for the systemic therapists. These questions have a feedback function in relation to the therapy, but at the same time, they also offer space to express new opinions, stories and perspectives. The questions do not directly lead to a dialogue about the therapeutic alliance, and therefore maybe it is more random, whether the client's assessment of the alliance is articulated. In cases where it appears, that the client is not completely satisfied or perhaps even unhappy with the alliance, or where the client might have some specific requests to the therapist, the

narrative therapist, by positioning himself decentered with influence and by listening and asking questions, maybe can help the client to formulate these things and then the therapist and the client can talk about this and jointly work on it.

4. Conclusion

The research question of this projectis: How do systemic and narrative theory and therapy describe the factors, which the Miller Group describes as being important in the alliance formation?

Systemic theory and therapy's preoccupation with how change and alteration occurs is focused on co-development, which includes elements of cooperative relationship and sympathetic relationship as well. This therapy uses a specific form of appreaciation which invite to cooperation and dialogue, and it is in the dialogue that the client can express whether there have been changes and alterations as well as relate to the therapeutic relationship.There is no set procedure for this in systemic therapy, so it will depend greatly on the individual therapist, but also of the individual client, whether this is a theme in the therapy or not. You could say that dialogue causes that the possibility of this is present, but it may not explicitly be expressed in the individual session or process.

The same can be said of Narrative theory and therapy. The focus here is to encourage a conversation form that helps to build cooperation containing an appreciative perspective, a perspective that is considered to be mediating a positive development. In systemic as well as in narrative therapy there are no described categories, which the therapist may use in the practical therapeutic work or to measure the effect. These theories and therapies are more concerned with how the client describes himself and defines the problem. As I see it, using the Miller Group’s ORS schema at the beginning of a conversation does not deprive the client the opportunity of describing and defining his problem. It is my experience that some clients might find it helpful to be presented to the four elements. It can be helpful in order of remembering to tell other things than what the client just had in mind. Furthermore it can be a help to clients, who are experiencing confusion resulting in not knowing where to start the presentation of their problem/problems or who find it difficult to verbalize their problem/problems. It can also be helpful for the therapist and enable him to invite to a dialogue concerning issues that might not otherwise become visible. The schema additionally, via the score, provides a measure of the client's experience of the degree of impact. This is perhaps articulated in systemic and narrative therapy, but it is not necessarily continuously made visible in the therapy. In systemic and narrative therapy change and alterations are described through the language, which does not necessarily exclude talking about the size of a change and alteration, which can be an eye opener and very helpful for many clients, and it is also what the ORS-table measures and displays visually to both the client and the therapist.

Regarding the SRS schema and its elements, it can be said, that if the client scores low on the table, it is a feedback message to the therapist saying that therapy has not offered what the client thinks he needs. The therapist can then invite the client to make suggestions about methods, themes or ways to be met, which would be more helpful for the client. Focus here is on what can be done differently in therapy, so that the therapy is more fitting with the client's needs. As described, many systemic and narrative therapists will (with appropriate intervals) ask whether the conversation makes sense to the client, just as most

systemic and narrative therapists together with the clients will evaluate the session at the end of this. Although the client may not think the session has been helpful, many systemic and narrative therapists may probably still consider whether some changes have happened due to the dialogue in the session. Neither party will be the same, both will have changed.This understanding implies that even if the client does not immediately believe that there has been a change, something new to the client may still have been said during the therapy session. This approach and focus can help to raise the client’s awareness of the fact that a change indeed has happened.

Finally, it can be said that in relation to cooperative relationship and sympathetic relationship, both systemic theory and therapy and narrative theory and therapy offer some constructive and useful suggestions to therapeutic approaches - due to their understanding of contextual challenges, the domain theory and the theory of positioning in conversation.

Thus, the domain theory as well as the theory of positions can be a helpful analytical tool for the therapist in the specific therapeutic situations. Partly in relation to the development of change in the client, and partly in relation to any specific challenges the therapist may experience in specific situations with a client. A focus on the domain theory as well as the theory of positions will then enable the therapist to navigate on two levels in the specific therapy session. One level is the concrete level dealing with specific questions and the responses to these. The other level is the meta level dealing with for example challenges in communication, perhaps because of the therapist’s possible attempt (for various reasons) to bring the client to a certain domain/an interpretation/a subject etc.This can be something the client does not want or is not able to handle, and it can be a sign of disagreement about goals and methods. Insight into and the using of domain theory as well as the theory of positions can strengthen the therapist's interpersonal skills, alliance skills and conversational skills and thus strengthen the therapist's skills in relation to the formation, maintenance and development of a collaborative relationship. Therefore it is of almost importance, that therapists continuously work to master these skills (Miller, 2013 (a), s. 23; Miller, 2013 (b), p.36).

In this regard, Bargmann (2013, p.141) points to differences in therapist’s alliance skills as a way of explaining the differences between the most effective and the less effective therapists:

"Clients treated by the most effective therapists get better up to 50% more often and drop out 50% less than clients who are treated by less effective therapists." (Bargmann, 2013, p. 141; Wampold et al., 2005; Bargmann et al., 2012)

In order to develop a collaborative relationship and (equally important) to continuously develop as a therapist, it's not just about getting better "technical" and e.g. practicing various questions, but also about having a deep sense of what is helpful in relation to a specific problem experienced by the therapist in relation to specific clients. In this respect, all three theories presented in this project may be extremely useful to the professional therapist as work and analysis tools.

Literature:

Andersen, Susanne Østervig (2003). “Udviklingen af den terapeutiske alliance – indførelsen af ”den dialogiske komponent””. Fokus på familien 31

Andersen, Susanne & Holme Mogens (2002). ”Med klienten ved roret”. Psykolognyt nr. 21/

Anderson, H., & and Goolishian, H.A (1988). “Human systems as linguistic systems: Preliminary and Evolving ideas for clinical theory”. Family Process, 27, p 371-393.

Bargman, Susanne & Jensby, Tang, Laura (2012): “Hvordan kan vi dokumentere, at det vi laver virker?” Systemic narrative Forum. # 4

Bargmann, Susanne (2013). “ Familieterapiens fremtid – terapeuten mellem evidenskrav og udvikling”. Fokus på familien, 2, 2013

http://www.susannebargmann.dk/uploads/7/3/2/0/732009/handouts_nykbing_sj_fit_oplg.pdf

Chambless, D. L. & Ollendick, T. (2001). ”Empirically supported Psychological Intervention: Controversies and Evidence”. Annual review of Psychology, 52, 685-716

Duncan, B.L, Miller, S.D., & Sparks, J. A. (2000).The Herioc Client. San Francisco: Jossey-Bass. 4.Printing

Epston, D. (2000). ”Jag är er en björn!” In White, M & Epston, D.: Narrativ terapi- en introduction. Mareld. Sverige. Kapitel 1.

Henley, R.C.A, Miller, S.D (2012).” Possible Applications of Psychotherapy Outcome Research to Traditional Chinese Medicine”. Journal of Complementary and Integrative Medicine. Volume 7, Issue 1 Article 18.

Henry, W. P. (1998). “Science, Politics, and the Politics of Science. The use and misuse of empirically validated treatment research “.Psycholotherapy Receach. Volume 8, Issue 2, 126-140)

Hougaard, E. Psychotherapy (2009). Psykoterapi. Teori og Forskning. Dansk Psykologisk Forlag., 2. Udgave, 3. Oplag

Hubble, M.A., Duncan, B.L, Miller, S.D. (2002). The Heart & Soul of Change. American Psychological Association. Washington, DC, sixth printing 2002

Haaland, K.R. (2007). Løft og narrative I professionelle samtaler .Akademisk Forlag

Holmgreen, Allan (2007): ”Forord” in: White, Michael: Kort over narrative landskaber. Hans Reitzels Forlag. 1. Udgave, 3. Oplag.P.9 -18

Jørgensen, C.R. (2001). “Skal effektforskningen fortsat primært fokusere på tekniske faktorer? Håndtering af terapeutfaktorer i effektforskningen 2.” Matric. Nordisk Tidsskrift for Psykoterapi nr. 17.4. P. 453 - 476

Jørgensen, C.R. (2002). ”Behandlingsrelationen i centrum”. Psykolog Nyt nr. 16. P 10 -15

Miller, S & Hubble, M. (2013). “Vejen til mestring”. PSYCHOTHERAPY Networker MAY / JUNE 2011. Systemisk Narrative Forum.2013/2. P.20 – 25 (a)

Miller, S. & Hubble, M. (2013). “Vejen til mestring”. 2. Del. PSYCHOTHERAPY NETWORKER MAY/JUNE 2011. Systemisk Narrativt Forum. Sommer 2013/3. P.32-37 (b)

Morgan, Alice: (2011): ”Terapeutens position i arbejdet med familier og deres børn”. In: White, M.& Morgan, A: (2011): Narrativ terapi med børn og deres familier. Akademisk Forlag, København. 1. Udgave, 3. Oplag

Nielsen, T. (2011). “To sider af terapeut-klient-forholdet”. PsykologNyt nr. 20, P 17 – 18

Olsen, Thorkild (2008). “Systemisk Metode – Et stærkt perspektiv på forandringer og samtaler”. Villa Venire A/S. Avis Venire, 3. Udgave. December p.1/4/5

Rasmussen, S. A. (2012). “ Magtens øje: En Kafkask process”. Fokus på Familien. Nordisk Tidsskrift for Familie- og Relasjonsarbeid. Årgang 40 Nr. 4, p. 327)

Strand, H. (2003): Konsultativt arbejde. Psykologisk Pædagogisk Rådgivning. 6

Svarer, Trine (2012). ”Tilbage til livet”. Fokus på familien. Nordisk Tidsskrift for Familie-og relationsarbeid. Universitetsforlaget. Årgang 40. nr. 3, 218 -237

Søholm, TM & Juhl, A.: Den systemiske terapeut. Attractor kurser. www.attractor.dk

Torsteinsson, Vigdis Wie Torsteinsson (2012). ”Kommentar til artikkelen ”Underbygging av praksisbasert kunnskap”. Av Sissel Reichelt og Jan Skjerve”. Fokus på Familien. Nordisk Tidskrift for Familie- og relationsarbeid. Årgang 40 Nr.4, p. 288

Wampold, B. E. (1997). “Methodological problems in Identifying Efficacious Psychotherapies”. Psychotherapy Reseach, Volume 7, 21 -43 Wampold, B. E., & Brown, G. S. (2005). ”Estimating Therapist variability: A Naturalistic study of outcomes in managed care”. Journal of Consulting and Clinical Psychology, 73, 914-923

Webb, Christian A.; DeRubeis, Robert J.; Amsterdam, Jay D., Shelton, Richard C.; Hollon, Steven D.; Dimidjian, Sona. (2011). “Two aspects of the therapeutic alliance: Differential relations with depressive symptom change”. Journal of Consulting and Clinical Psychology, Vol 79 (3), Jun, 279-283.

Werner, A. og Mortensen, A (2009). “Narrativ inspireret supervision”. I Syv fortællinger om narrativ praksis. Red: Anne Sofie Møller Sparre og Katrine Dall Jørgensen. Psykologisk Forlag.

White, Michael. (2006): Narrativ Praksis. Hans Reitzels Forlag, 1. Udgave, 1. Oplag

White, Michael (2010): Kort over narrative landskaber. Hans Reitzels Forlag. 1 Udgave, 3 Oplag

Notes:

1. http://www.susannebargmann.dk/uploads/7/3/2/0/732009/handouts_nykbing_sj_fit_oplg.pdf slide p.10; Wampold, B. (2001). The Great Psychotherapy Debate. New York: Lawrence Erlbaum.

2. The key concept disturbance is mainly treated by the famous Milan Group (Cecchin, Boscolo, Prata&Selvini-Palazzoli), the terms of which has contributed to the understanding of the therapist's role, eg in relation to "disrupt" the client's awareness and mental perceptions. (Søholm and Juhl s. 14)