Allegiance: A powerful force in therapy

We all want to be effective in our work. There’s nothing more satisfying than when a client gets over their problem. What would it be like to believe that is possible with all clients? Well, it turns out that believing is seeing.

Allegiance is the degree to which the person delivering the treatment believes that the treatment is efficacious. It turns out that in therapy, allegiance has a  large impact on outcome. (effect size up to .65) (1)

In therapy, unlike medicine, the protocol and its specific effects are not that important, but the degree to which the therapist believes that what they do will work is crucial. Allegiance effects account for as much as 70% of treatment effects.(1). Adherence to treatment manual without attention to the client, on the other hand may actually make things worse.

This is another weird phenomenon of therapy that is sorely missing a scientific explanation.

We don’t need to wait for an explanation, however, to use the power of this phenomenon in our work. The trouble is though, that we also know from outcome research that the model is not the thing that creates effectiveness. The 400+ different models are all as good as each other but only account for up to 1% of outcome variability.

How can we use the power of allegiance while still acknowledging how small a role the model plays in effectiveness? It’s hard for me to believe in a model when it only accounts for 1% of the variability in outcomes.(1)

Believing in ourselves might seem like a good idea. Therapists effects exceed treatment effects, accounting for 3-7% of outcome variance. Who we are is more important than what we do. But, wait, therein lies another weird phenomenon. Professional self doubt seems to correlate with effectiveness. The new, fresh student filled with enthusiasm and hope and knowing that they don’t know, is more often more effective than the seasoned therapists who knows that they know. Supershrinks also doubt themselves more.  Scott Miller says it more clearly than I can here.

So that leaves the client. I choose to believe in the client.

Milton H Erickson said that “a baby doesn’t know it can walk, but you do”. You watch that baby learn to walk with a solid belief that they will succeed, and you don’t realise how powerful the mood of your knowing is for that baby to walk into. He was atheoretical in his approach to therapy, but one of the most spectacular things about him and his work was his unwavering belief in the client.

Some years ago a talented student I was working with rang me up in tears because she had failed an oral exam. The protocol was that she could do it again the following day. She needed calming before we could do anything useful, so I grappled for a distraction. I told her a story. The night before I had had a dream that our newly installed gas hot water stopped working mid shower, and I had a bizarre phone call trying to get the old electric one put back in. I woke and thought, “what a weird dream”. Half an hour later my son yelled out from the shower that the hot water had gone off. I said “Oh my god I dreamed that happened”. My husband rang the gas man who was just around the corner so he came straight over. It turned out that someone walking down our street had reached into our front yard and turned the gas meter off. Easily fixed and kind of funny. The student said to me “For god’s sake Gabrielle, why can’t you dream something useful?!” We both laughed. The next morning I texted her that I had dreamed that she passed her exam. She said when she read the text she had a wonderful feeling of confidence. She went into the exam feeling invincible and performed outstandingly.

We’ve all heard stories of faith healing, or shamanic healing, and the power of belief. Conversely, pointing the bone, in Australian Aboriginal culture causes the death of the recipient. We’ve all had clients believe they have an incurable mental illness proclaimed by a well intended, if ill informed psychiatrist, and we must first work to dispel this myth.

When we get resigned, we start to believe that a client can’t get better and we throw away one of the most powerful aspects of what we do. Once we understand the power of belief we can use it for the good of the client. One of the ways that I notice I can restore my faith in the client is to ask what they like to do. Resources and resourcefulness appear, often in surprising ways.

What do you do to restore allegiance when your faith wavers? Please leave a comment.

1. Wampold, B. E. (2001) The Great Psychotherapy Debate: Models, methods and findings. Mahwa, NJ: Erbaum

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