Reliance on the Alliance, Part 4: The Client’s Theory of Change

Ideally, therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem. – Jerome Frank

As I noted in the previous blog post, agreement with the client about the tasks of therapy represents our biggest alliance blind spot. The of agreement about tasks—finding a framework for therapy that both you and the client can believe in—is why it makes a lot of sense to ask clients about their ideas on how to proceed, or at the very least getting client approval of any intervention plan. Such a process has not been highly regarded in traditional psychotherapy—the search has been instead for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—searching for ideas that promote change by validating the client’s view of what is helpful, the client’s theory of change. I first discussed the client’s theory of change way back in 1992 in the book, Changing the Rules, an idea that I found most useful for building strong alliances and honoring client perspectives (Duncan, Solovey, & Rusk, 1992).

Why Explore Client Ideas

Exploring client ideas has several advantages: It puts the client center stage in the conversation; It enlists the client’s participation; It helps ensure the client’s positive experience of you; and It structures the conversation and directs the change process. Here are some tips:

· The client’s theory of change unfolds from a conversation structured by your curiosity about the client’s ideas, attitudes, and speculations about change.

· Honoring the client’s theory occurs when you follow, encourage, and implement the client’s ideas for change or when you select a technique or procedure that fits clients’ beliefs about their problem(s) and the change process.

· Learning the client’s theory is like starting a journey in an unknown territory. Trust clients to show the way on their own map. Unfolding the client’s map reveals not only the desired destination, but also what paths may be followed to get there. Explore the landscape and cross the terrain of the client’s theory of change; vantage points along the way will reveal the client’s own routes of restoration. In that endeavor, clients will show trails never thought to exist.

To learn clients’ theories, adopt their views in their terms with a very strong bias in their favor. Explore the client’s thoughts, feelings, and attitudes about the nature of the problem as well as any ideas about how you might best address the client’s goals.

· Make direct inquiries about the client’s ideas about change:

What ideas do you have about what needs to happen for improvement to occur?

Many times, people have a pretty good hunch about not only what is causing a problem, but also what will resolve it. Do you have a theory of how change is going to happen here?

· Listen for or inquire about the client’s usual method of, or experience with, change:

How does change usually happen?

What causes change to occur?

What does the client do to initiate change?

What do others do to initiate/facilitate change?

What events usually precede/occur during/follow the change?

· Discuss prior solutions as a way of learning the client’s theory of change. Exploring solution attempts enables you to hear the client’s evaluation of previous attempts and their fit with what the client believes to be helpful. Inquiring about prior solutions, therefore, allows you to hear the client’s frank appraisal of how change can occur.

What have you tried to help the problem/situation so far? Did it help? How did it help? Why didn’t it help?

· Find out what your role is in the change process: How does the client view your part in the change process? Clients want different things. Some want a sounding board, some want a confidant, some want to brainstorm and problem solve, some want advice, some want an expert to tell them what to do. Explore the client’s preferences about your role by asking:

How do you see me fitting into what you would like to see happen?

How can I be of most help to you now?

What role do you see me playing in your endeavor to change this situation?

Let me make sure I am getting this right. Are you looking for suggestions from me about that situation?

Asking about the client’s theories or preferences does not preclude your ideas, suggestions, models, methods, or in any way mean that you do not contribute. Instead, it speaks to the more collaborative aspects of formulating a plan, with the degree and intensity of your input determined by the client’s expectations of your role. Securing an agreement about the tasks is all but guaranteed when a given therapy framework—explanation or solution—implements, fits, or complements the client’s ideas and beliefs. Once again, the Session Rating Scale can help us not only to focus on this issue but also to catch ourselves when we are missing the mark.

Bottom Line: Agreement about the tasks of therapy is a critical component of the alliance. The application of any agreed-upon explanation or technique represents the alliance in action. The litmus test of any chosen rationale or ritual is whether it engages the client in purposive work and makes a meaningful difference determined by the client. Exploring the client’s theory of change can help secure a strong alliance.

Read more about the alliance in On Becoming a Better Therapist or a chapter, “The Person of the Therapist.” Watch a brief video about the alliance.