PSY343 - 8. Therapeutic Relationship Flashcards
The Search for Common Factors
Comparisons of different forms of psychotherapy consistently result in nonsignificant differences, + contextual + relationship factors often mediate or moderate outcomes
The Search for Common Factors
Dodo Bird Verdict: there is little or no substantial difference between bona fide therapies with regard to client outcomes
effectiveness of all psychotherapies is due, in part, to factors common to all treatments over and above treatment approach
What is the Therapeutic Relationship?
Freud (1912): positive relationship betw analyst + patient based in reality of their work together (i.e., separate from transference countertransference)
each approach has own way of conceptualizing relationship
above and beyond - something meaningful taking place
What is the Therapeutic Relationship?
Rogers (1957): empathic bond betw patient + therapist is necessary and sufficient for promoting therapeutic change
highlight it as curative factor
capable of helping selves only if facilitative relationship exists
What is the Therapeutic Relationship?
direct relationship betw relationship + client improvement
empathy, genuineness, congruence, unconditional positive regard
What is the Therapeutic Relationship?
Bordin (1979): extent to which client + therapist able to maintain a strong affective relational bond as they collaborate on the tasks + goals of treatment.
What is the Therapeutic Relationship?
bordin: broke it apart into alliance - 3 parts: goals, tasks, bonds
goals: agreement of goals - symptom reduction
tasks: steps to take to achieve goal - CBT(thought records)
What is the Therapeutic Relationship?
Gelso (2011): real relationship: genuineness (intent to avoid deception, including self-deception) + realism (realistic experiences + perceptions of each other)
relationship broader than alliance
one but not all of components of relationship
What is the Therapeutic Relationship?
tripartite model: counter-transference/transference relationship (unconscious unresolved material)
alliance - agreement
genuineness: intent to avoid deception
realism: perceive other in way that actually fits reality (real relationship - 2 ppl in a room)
Psychotherapy Relationships That Work (Norcross, 2011)
Sponsored by the APA Division of Clinical Psychology
+ Psychotherapy
Task Force reviewed 20+ meta-analyses, rated the
evidence + made recommendations for practice,
training, and research
Psychotherapy Relationships That Work (Norcross, 2011)
empirically supported therapeutic relationships
Identified relationship variables that contribute to
therapeutic change and outcome
Elements of the Therapy Relationship
Demonstrably effective: elements that had strong evidence for successful outcomes
• Alliance
• Empathy
• Collecting client feedback
Elements of the Therapy Relationship
Probably effective: enough evidence, but not definitive
• Goal consensus/collaboration
• Positive regard/affirmation/support
Elements of the Therapy Relationship
Promising but insufficient research to judge
• Congruence/genuineness
• Managing countertransference
• Repairing alliance ruptures
Alliance
therapeutic relationship is made up of several interconnected elements (e.g., empathy, responsiveness, creating a safe environment) + alliance is one aspect
Alliance
alliance represents emergent quality of partnership + mutual collaboration between therapist = client
not same as relationship - construct that measure agreement on goals, tasks, bonds
Alliance
Bordin’s construct: alliance built on positive emotional bond betw therapist + client, their ability to agree on the goals of treatment, + establishment of a mutual consensus on tasks that form the substance of the specific therapy
Alliance
more robust finding
technical factors of therapy can only be understood in relational context in which they are applied
Reviewed 190 studies, > 14,000 patients
The overall effect size was r = .275 (d= .57), p
Alliance in Individual Therapy (Horvath, Del Re, Fluckiger, & Symonds, 2011)
working alliance inventory - therapist, client + observer rating
client perception provided best prediction
alliance is low, prognostically know therapy is in trouble - predicting a trajectory
Alliance in Individual Therapy (Horvath, Del Re, Fluckiger, & Symonds, 2011)
differences in the strength of alliance-outcome relationship depending on who (client, therapist, or observer) rates alliance and outcome; client judgment provides best prediction
Alliance in Individual Therapy (Horvath, Del Re, Fluckiger, & Symonds, 2011)
Alliance assessment early in treatment (sessions 3-5) provides reliable prognosis of both treatment drop-out + treatment outcome
Conclusion: Alliance is one of the best predictors of outcome across a range of treatments, diagnoses
Alliance
Therapist contributions to alliance predict outcome more so than patients contribution.
some therapists better at creating alliance and better predictor of outcome
Alliance
look across (comparing to other therapists) or within therapist (across clients) individual’s clients rating of therapist isn’t as predictive of outcome as general rating of therapist
Alliance
Therapists who are on average better able to form better
alliances with their patients have better outcomes
Clients who are able to form a better alliance with a
given therapist do not have better outcomes than clients
with poorer alliances with the same therapist
Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)
Definition: Therapist’s sensitive ability to understand client’s thoughts, feelings, + struggles from client’s view
Reviewed 57 studies, 3,599 clients
Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)
empathic therapists understand moment to moment experiences + goals
straightforward response - forward, agreement
Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)
validating stance - what makes sense about relationship, evocative language
therapists should not assume understanding or mind reader
overall effect size was r = .30 (d= .62), p
Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)
but get feedback to see if empathy is there
being able to form strong alliance requires empathy*
constructs are not seperate, most cases interdependent*
Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)
Conclusions: important for therapists to make efforts to understand their clients’ experiences + demonstrate understanding through responses that address client’s perceived needs
Collecting Client Feedback (Lambert & Shimokawa, 2011)
Definition: Systematic monitoring of client mental health vital signs through use of standardized scales
Collecting Client Feedback (Lambert & Shimokawa, 2011)
overall effect size was r = .23 (d= .48), p
scales: clinician is doing + sharing with client information from client of what is working increases ability to respond to that info
Collecting Client Feedback (Lambert & Shimokawa, 2011)
don’t always intervene in time to save therapy
checking in regularly to solve problems as quickly as possible
OQ45, Treatment Outcome Package
Collecting Client Feedback (Lambert & Shimokawa, 2011)
Conclusions: Employing real-time client feedback can compensate for therapist’s limited ability to accurately detect client deterioration in therapy, and increase therapist’s ability to intervene accordingly.
Goal Consensus/Collaboration (Tryon & Winograd, 2011)
Definition: Agreement about nature of problem for which the client is seeking help, goals for treatment, + way that client + therapist will work together to achieve these goals
Goal Consensus/Collaboration (Tryon & Winograd, 2011)
Collaboration: active process of cooperation in this endeavour
goal consensus + collaboration similar constructs
Goal Consensus/Collaboration (Tryon & Winograd, 2011)
no therapy should begin unless both agree to goals
rarely should push own agenda
form goals around input from clients
Collecting Client Feedback (Lambert & Shimokawa, 2011)
Goal Consensus:
overall effect size was r = .34 (d= .72), p
Collaboration:
The overall effect size was r = .33 (d= .70), p
Goal Consensus/Collaboration (Tryon & Winograd, 2011)
Conclusions: Treatment should begin only once client + therapist agreement on goals + ways of achieving these goals has been established
Positive Regard/Affirmation (Farber & Doolin, 2011)
Definition: extent to which therapist finds him or herself experiencing warm acceptance of each aspect of client’s experience. no conditions of acceptance (acceptance or nonpossessive warmth)
Positive Regard/Affirmation (Farber & Doolin, 2011)
overall effect size was r = .27 (d= .55), p
Rogers
went against what traditional analysts believed: you had to be blank slate - risk of interfering transference
Positive Regard/Affirmation (Farber & Doolin, 2011)
Conclusions: Therapists should ensure positive feelings towards clients are communicated (appropriately) to them; there is no evidence to support withholding positive regard in therapy
Congruence/Genuineness (Kolden, Klein, Wang, & Austin, 2011)
Definition: personal characteristic of therapist (i.e., therapist is authentically him or herself), + experiential quality of therapy relationship (i.e., therapist’s capacity to communicate his or her experience with client to the client)
overall effect size was r = .24 (d= .XX), p small to medium effect
Congruence/Genuineness (Kolden, Klein, Wang, & Austin, 2011)
Conclusions: Therapists should strive for genuineness with clients, which includes awareness of thoughts, feelings, attitudes + develop skills for effectively communicating their experiences to their clients (e.g., appropriate self disclosure).
Congruence/Genuineness (Kolden, Klein, Wang, & Austin, 2011)
less robust
appropriate self-disclosure: most do not advocate self-disclosure - only DBT so far
not same thing as acting from place of countertransference
Managing Countertransference (Hayes, Gelso, & Hummel, 2011)
Definition: psychotherapist’s internal + external reactions to client influenced by therapist’s personal vulnerabilities + unresolved conflicts
Managing Countertransference (Hayes, Gelso, & Hummel, 2011)
exists in every therapeutic relationship
natural part of being therapist
how it gets managed affects it
Managing Countertransference (Hayes, Gelso, & Hummel, 2011)
CT: Reviewed 27 studies, 1152 clients
overall effect size was r = -.16 (d= 1.0), p => small effect
CT management and outcome: Reviewed 7 studies
overall effect size was r = .56 (d= 1.0), p => large effect
Managing Countertransference (Hayes, Gelso, & Hummel, 2011)
can be therapy destroying
managing it through self awareness, therapy, can increase alliance
client can trust in therapist
unconscious insight on self + client
Managing Countertransference (Hayes, Gelso, & Hummel, 2011)
Conclusions: Acting out CT reactions can be harmful Therapists should manage internal CT reactions in ways that prevent them from manifesting them behaviourally in session (through personal therapy, supervision, or both)
Alliance Rupture and Repair
Alliance ruptures: episodes of tension or breakdown in collaborative relationship between therapist + client
Alliance Rupture and Repair
Clients often have negative feelings about therapy or therapeutic relationship that they are reluctant to broach for fear of therapist’s reactions
Alliance ruptures: clinically significant events that can lead to premature termination or treatment failure.
Alliance Rupture and Repair
Exploring + addressing ruptures when they occur can be an important element contributing to positive treatment outcomes
alliance: dynamic process that changes and is renegotiated constantly
Alliance Rupture and Repair
transtheoretical phenomenon relevant for all clinicians
rare + diff to tell therapist that they are having problems - may fear punishment, afraid of confrontation, power
Alliance Rupture and Repair
differential that takes power out of clients’ hand (therapists opinion has more strength), don’t have access to therapeutic process (thinks therapist knows best)
can lead to small tensions or big breakdown
even best therapists may not be aware
Alliance Ruptures
Safran &Muran (2000) identify two types of ruptures:
Withdrawal ruptures – Client deals with difficulties or
misunderstandings in relationship by falling silent, offering minimal responses, shifting topics, or becoming overly compliant - disengaging with process
Alliance Ruptures
Confrontation ruptures – Client directly expresses anger,
resentment, or dissatisfaction with therapist of some aspect of treatment, often in a blaming or demanding fashion - moves toward conflict
Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)
overall effect size was r = .24 (d= .50), p=> medium effect
often measured at intervals - draw lines betw those
rupture-repair episodes positively related to good outcome
how alliance gets negotiated over time + letting negotiation predict outcome
Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)
V-shape: unresolved rupture that predicts poor outcome
rupture + repair leads to good process
markers of ruptures + resolution
Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)
code videos across one session and across multiple sessions
rupture: disengagement
repair: do you wanna talk about why you’re feeling distant
can be more distal resolutions
Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)
Unresolved ruptures: associated with deterioration in alliance + may lead to poor outcome or patient dropout
Conclusion: important for therapists to be attuned to ruptures in relationship + explore what is transpiring during ruptures in an attempt to resolve them
What Doesn’t Work in the Therapy Relationship?
Confrontations: clients made to face attitudes + shortcomings, way they are perceived, + consequences of their behaviours
risky and sometimes helpful
often ineffective confrontations - risky at best - become defensive, emotions go up
What Doesn’t Work in the Therapy Relationship?
Negative process: comments or behaviors hostile, pejorative, critical, rejecting, or blaming - really bad for outcomes
What Doesn’t Work in the Therapy Relationship?
Therapist centricity: privileging therapist’s perspective on therapy relationship over client’s perspective
problem thinking in neglecting client’s perceptions
What Doesn’t Work in the Therapy Relationship?
Rigidity: inflexibility + excessively structuring treatment
makes you less responsive + relationship suffers
What Doesn’t Work in the Therapy Relationship?
Flexibility without Fidelity: being overly flexible + ignoring research evidence or adapting treatments in ways that markedly deviate from its established effectiveness
What Doesn’t Work in the Therapy Relationship?
fine balance using effective practices
we have to be attentive to all components of this dynamic relationship which matters and predicts outcome
