Overcoming alliance barriers in complex cases: the Newcastle Complexity Model

Abstract This model proposes that clinical complexity is defined with respect to treatment complications, not just client characteristics. In complex cases, there are significant barriers in the working alliance between the client and the therapist, and this limits the gains the client can receive. In any course of therapy, client, therapist, healthcare and contextual factors interact to facilitate or complicate the therapeutic process. Each participant has facilitative factors that are therapy-enabling, and complexity factors that challenge the therapeutic process. Some clients have multiple complexity factors and it is helpful to specify them and try to mitigate them. However, identifying clients as complex cases can overlook facilitative factors and take attention away from therapist and service variables. Overcoming alliance barriers relies on bringing attention to them, reflecting on the various factors that influence them, and communicating explicitly about them in supervision and therapy. Practical applications are explored for clients, therapists and services using a case example to illustrate the key points.