PSY343 - 8. Therapeutic Relationship

Question 1

The Search for Common Factors

Answer 1

Comparisons of different forms of psychotherapy consistently result in nonsignificant differences, + contextual + relationship factors often mediate or moderate outcomes

Question 2

The Search for Common Factors

Answer 2

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

Question 3

What is the Therapeutic Relationship?

Answer 3

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

Question 4

What is the Therapeutic Relationship?

Answer 4

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

Question 5

What is the Therapeutic Relationship?

Answer 5

direct relationship betw relationship + client improvement

empathy, genuineness, congruence, unconditional positive regard

Question 6

What is the Therapeutic Relationship?

Answer 6

Bordin (1979): extent to which client + therapist able to maintain a strong affective relational bond as they collaborate on the tasks + goals of treatment.

Question 7

What is the Therapeutic Relationship?

Answer 7

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)

Question 8

What is the Therapeutic Relationship?

Answer 8

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

Question 9

What is the Therapeutic Relationship?

Answer 9

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)

Question 10

Psychotherapy Relationships That Work (Norcross, 2011)

Answer 10

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

Question 11

Psychotherapy Relationships That Work (Norcross, 2011)

Answer 11

empirically supported therapeutic relationships
Identified relationship variables that contribute to
therapeutic change and outcome

Question 12

Elements of the Therapy Relationship

Answer 12

Demonstrably effective: elements that had strong evidence for successful outcomes
• Alliance
• Empathy
• Collecting client feedback

Question 13

Elements of the Therapy Relationship

Answer 13

Probably effective: enough evidence, but not definitive
• Goal consensus/collaboration
• Positive regard/affirmation/support

Question 14

Elements of the Therapy Relationship

Answer 14

Promising but insufficient research to judge
• Congruence/genuineness
• Managing countertransference
• Repairing alliance ruptures

Question 15

Alliance

Answer 15

therapeutic relationship is made up of several interconnected elements (e.g., empathy, responsiveness, creating a safe environment) + alliance is one aspect

Question 16

Alliance

Answer 16

alliance represents emergent quality of partnership + mutual collaboration between therapist = client
not same as relationship - construct that measure agreement on goals, tasks, bonds

Question 17

Alliance

Answer 17

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

Question 18

Alliance

Answer 18

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

Question 19

Alliance in Individual Therapy (Horvath, Del Re, Fluckiger, & Symonds, 2011)

Answer 19

working alliance inventory - therapist, client + observer rating
client perception provided best prediction
alliance is low, prognostically know therapy is in trouble - predicting a trajectory

Question 20

Alliance in Individual Therapy (Horvath, Del Re, Fluckiger, & Symonds, 2011)

Answer 20

differences in the strength of alliance-outcome relationship depending on who (client, therapist, or observer) rates alliance and outcome; client judgment provides best prediction

Question 21

Alliance in Individual Therapy (Horvath, Del Re, Fluckiger, & Symonds, 2011)

Answer 21

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

Question 22

Alliance

Answer 22

Therapist contributions to alliance predict outcome more so than patients contribution.
some therapists better at creating alliance and better predictor of outcome

Question 23

Alliance

Answer 23

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

Question 24

Alliance

Answer 24

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

Question 25

Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)

Answer 25

Definition: Therapist’s sensitive ability to understand client’s thoughts, feelings, + struggles from client’s view Reviewed 57 studies, 3,599 clients

Question 26

Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)

Answer 26

empathic therapists understand moment to moment experiences + goals straightforward response - forward, agreement

Question 27

Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)

Answer 27

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

Question 28

Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)

Answer 28

but get feedback to see if empathy is there being able to form strong alliance requires empathy* constructs are not seperate, most cases interdependent*

Question 29

Empathy (Elliott, Bohart, Watson, & Greenberg, 2011)

Answer 29

Conclusions: important for therapists to make efforts to understand their clients’ experiences + demonstrate understanding through responses that address client’s perceived needs

Question 30

Collecting Client Feedback (Lambert & Shimokawa, 2011)

Answer 30

Definition: Systematic monitoring of client mental health vital signs through use of standardized scales

Question 31

Collecting Client Feedback (Lambert & Shimokawa, 2011)

Answer 31

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

Question 32

Collecting Client Feedback (Lambert & Shimokawa, 2011)

Answer 32

don’t always intervene in time to save therapy checking in regularly to solve problems as quickly as possible OQ45, Treatment Outcome Package

Question 33

Collecting Client Feedback (Lambert & Shimokawa, 2011)

Answer 33

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.

Question 34

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

Answer 34

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

Question 35

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

Answer 35

Collaboration: active process of cooperation in this endeavour goal consensus + collaboration similar constructs

Question 36

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

Answer 36

no therapy should begin unless both agree to goals rarely should push own agenda form goals around input from clients

Question 37

Collecting Client Feedback (Lambert & Shimokawa, 2011)

Answer 37

Goal Consensus: overall effect size was r = .34 (d= .72), p Collaboration: The overall effect size was r = .33 (d= .70), p

Question 38

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

Answer 38

Conclusions: Treatment should begin only once client + therapist agreement on goals + ways of achieving these goals has been established

Question 39

Positive Regard/Affirmation (Farber & Doolin, 2011)

Answer 39

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)

Question 40

Positive Regard/Affirmation (Farber & Doolin, 2011)

Answer 40

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

Question 41

Positive Regard/Affirmation (Farber & Doolin, 2011)

Answer 41

Conclusions: Therapists should ensure positive feelings towards clients are communicated (appropriately) to them; there is no evidence to support withholding positive regard in therapy

Question 42

Congruence/Genuineness (Kolden, Klein, Wang, & Austin, 2011)

Answer 42

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

Question 43

Congruence/Genuineness (Kolden, Klein, Wang, & Austin, 2011)

Answer 43

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).

Question 44

Congruence/Genuineness (Kolden, Klein, Wang, & Austin, 2011)

Answer 44

less robust appropriate self-disclosure: most do not advocate self-disclosure - only DBT so far not same thing as acting from place of countertransference

Question 45

Managing Countertransference (Hayes, Gelso, & Hummel, 2011)

Answer 45

Definition: psychotherapist’s internal + external reactions to client influenced by therapist’s personal vulnerabilities + unresolved conflicts

Question 46

Managing Countertransference (Hayes, Gelso, & Hummel, 2011)

Answer 46

exists in every therapeutic relationship natural part of being therapist how it gets managed affects it

Question 47

Managing Countertransference (Hayes, Gelso, & Hummel, 2011)

Answer 47

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

Question 48

Managing Countertransference (Hayes, Gelso, & Hummel, 2011)

Answer 48

can be therapy destroying managing it through self awareness, therapy, can increase alliance client can trust in therapist unconscious insight on self + client

Question 49

Managing Countertransference (Hayes, Gelso, & Hummel, 2011)

Answer 49

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)

Question 50

Alliance Rupture and Repair

Answer 50

Alliance ruptures: episodes of tension or breakdown in collaborative relationship between therapist + client

Question 51

Alliance Rupture and Repair

Answer 51

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.

Question 52

Alliance Rupture and Repair

Answer 52

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

Question 53

Alliance Rupture and Repair

Answer 53

transtheoretical phenomenon relevant for all clinicians | rare + diff to tell therapist that they are having problems - may fear punishment, afraid of confrontation, power

Question 54

Alliance Rupture and Repair

Answer 54

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

Question 55

Alliance Ruptures

Answer 55

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

Question 56

Alliance Ruptures

Answer 56

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

Question 57

Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)

Answer 57

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

Question 58

Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)

Answer 58

V-shape: unresolved rupture that predicts poor outcome rupture + repair leads to good process markers of ruptures + resolution

Question 59

Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)

Answer 59

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

Question 60

Alliance Rupture and Repair (Safran, Muran, & Eubanks-Carter, 2011)

Answer 60

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

Question 61

What Doesn’t Work in the Therapy Relationship?

Answer 61

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

Question 62

What Doesn’t Work in the Therapy Relationship?

Answer 62

Negative process: comments or behaviors hostile, pejorative, critical, rejecting, or blaming - really bad for outcomes

Question 63

What Doesn’t Work in the Therapy Relationship?

Answer 63

Therapist centricity: privileging therapist’s perspective on therapy relationship over client’s perspective problem thinking in neglecting client’s perceptions

Question 64

What Doesn’t Work in the Therapy Relationship?

Answer 64

Rigidity: inflexibility + excessively structuring treatment | makes you less responsive + relationship suffers

Question 65

What Doesn’t Work in the Therapy Relationship?

Answer 65

Flexibility without Fidelity: being overly flexible + ignoring research evidence or adapting treatments in ways that markedly deviate from its established effectiveness

Question 66

What Doesn’t Work in the Therapy Relationship?

Answer 66

fine balance using effective practices | we have to be attentive to all components of this dynamic relationship which matters and predicts outcome