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Tools for Transforming Training

September 1, 2009
by Lori Ashcraft, PhD and William A. Anthony, PhD
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The importance of relationships

We're about to tell you some things we learned while attending an interesting workshop that was offered at this year's United States Psychiatric Rehabilitation Association (USPRA) conference. But first let's set the stage by giving you a little background on workshop attendance in general.

Early on Lori used to show up early for conference workshops. She wanted to be sure to get a good seat near the front. She would stay for the entire presentation even if the content wasn't what she had hoped for or, worse yet, was really boring (hey, it happens). You can imagine how challenging this was for her, given her inability to sit still for very long and her rather short attention span.

Out of desperation, she came up with a new approach that accommodates her squirminess. She still shows up a little early but for a different reason—now she wants to make sure she gets a good seat in the back of the room. This way if the content isn't what she was hoping for, she can slip out without disturbing anyone and step into another workshop. Her excuse for this unorthodox behavior, she says, has to do with her age. She figures she has only so many workshops left in her, and she can't afford to use them up on those that don't match her expectations.

But the workshop we're about to tell you about is causing Lori to seriously reconsider her strategy. As usual, she sat in the back of a workshop presented by Dr. Bob Bohanske, Chief of Clinical Services and Clinical Training at Southwest Behavioral Health Services in Phoenix, Arizona. Lori walked into the room just as Dr Bob was fiddling with the Powerpoint (a prerequisite for most presentations) and up came a slide that was a real attention grabber. Too bad she wasn't sitting in the front.

Dr. Bob's first slide began with these three bullets:

  • Building good relationships (an alliance) with the people we serve accounts for 9% of success or at least the variance we can account for in outcomes

  • Talking to people about using their strengths (what the person brings to the relationship, including their hopes and expectations) accounts for 87% of success or variance in outcomes

  • The modality (no matter which one you choose) accounts for about 1% of successful outcomes (the remaining 3% is accounted for by overlap).

He followed the three bullets with this question:

“If the relationship we develop with people accounts for so much in achieving successful outcomes, and talking to people about their strengths accounts for over 80% of successful outcomes, and the modality accounts for 1% of successful outcomes, why don't we spend more time teaching staff how to form positive relationships that focus on people's strengths, and stop wasting so much of our time teaching various modalities?”

What a concept!

Indeed, this is a very profound question. Think about all the time our behavioral health staff spends in school, plus all the money spent for this, and all the years concentrating on various treatment modalities. Turns out, that may just be a distraction from the most effective interventions: building strong relationships and a focusing on the person's strengths.

As we pondered Dr. Bob's question, we started asking ourselves how this may have happened-why would we get side-tracked from tried and true interventions like “relationships” and “focus on strengths” and instead focus on modalities?

Well, maybe because it's easier. Ask your training department what they think about this. Is it easier to train staff about modalities than it is to teach them how to create strengths-based relationships?

How do you teach people about developing “relationships” anyway? Right now, pretend you're standing in front of a group of behavioral health staff who think they already know all there is to know about relationships and you're pretty sure they don't. How would you start? What would tell them about developing strength-based relationships? What will you do when they roll their eyes? See what we mean? It's not like reciting a formula, or expounding on the techniques and steps involved in using various modalities.

The development of healing relationships moves us from our head to our heart; from science to art. Tricky business! Relationships require a more profound investment-we can't fall back on the techniques and rules and roles that various modalities require. We must be present; we must be real; we must be willing to risk caring about someone who could disappoint us. We can't take cover behind the usual hiding places of “professional distance” and “boundaries” and “dual relationships.” Don't get us wrong, we know there is a place for these, but in order to form positive relationships based on strengths, we can't hide behind them or use them as an excuse to protect ourselves.

Real therapeutic relationships can be challenging, but they are definitely worth it because, as Dr. Bob points out, they work.

OK, so the relationship thing is a challenge-but why would we avoid placing an emphasis on strengths? That seems harmless enough: low-risk, non-invasive, and painless, isn't it? So why not just go there? Well once again, we aren't really sure, but we have some ideas, and here's one: If a program hasn't yet embraced recovery principles and practices, staff may not be seeing much hope for recovery in the people they are serving, so to talk about strengths may seem insincere. In cases like this we often hear staff say they don't want to give people false hope or set them up for failure. If this is the mindset, staff is less likely to talk about strengths and more likely to see their role as that of caretaking and controlling.