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PSY343 > PSY343 - 8. Therapeutic Relationship > Flashcards

PSY343 - 8. Therapeutic Relationship Flashcards

1
Q

The Search for Common Factors

A

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

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2
Q

The Search for Common Factors

A

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

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3
Q

What is the Therapeutic Relationship?

A

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

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4
Q

What is the Therapeutic Relationship?

A

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

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5
Q

What is the Therapeutic Relationship?

A

direct relationship betw relationship + client improvement

empathy, genuineness, congruence, unconditional positive regard

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6
Q

What is the Therapeutic Relationship?

A

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

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7
Q

What is the Therapeutic Relationship?

A

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)

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8
Q

What is the Therapeutic Relationship?

A

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

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9
Q

What is the Therapeutic Relationship?

A

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)

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10
Q

Psychotherapy Relationships That Work (Norcross, 2011)

A

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

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11
Q

Psychotherapy Relationships That Work (Norcross, 2011)

A

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

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12
Q

Elements of the Therapy Relationship

A

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

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13
Q

Elements of the Therapy Relationship

A

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

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14
Q

Elements of the Therapy Relationship

A

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

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15
Q

Alliance

A

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

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16
Q

Alliance

A

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

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17
Q

Alliance

A

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

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18
Q

Alliance

A

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

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19
Q

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

A

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

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20
Q

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

A

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

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21
Q

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

A

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

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22
Q

Alliance

A

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

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23
Q

Alliance

A 
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
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24
Q

Alliance

A

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

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25
Q

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

A

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

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26
Q

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

A

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

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27
Q

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

A

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

28
Q

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

A

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

29
Q

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

A

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

30
Q

Collecting Client Feedback (Lambert & Shimokawa, 2011)

A

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

31
Q

Collecting Client Feedback (Lambert & Shimokawa, 2011)

A

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

32
Q

Collecting Client Feedback (Lambert & Shimokawa, 2011)

A

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

33
Q

Collecting Client Feedback (Lambert & Shimokawa, 2011)

A

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.

34
Q

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

A

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

35
Q

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

A

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

36
Q

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

A

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

37
Q

Collecting Client Feedback (Lambert & Shimokawa, 2011)

A

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

38
Q

Goal Consensus/Collaboration (Tryon & Winograd, 2011)

A

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

39
Q

Positive Regard/Affirmation (Farber & Doolin, 2011)

A

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)

40
Q

Positive Regard/Affirmation (Farber & Doolin, 2011)

A

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

41
Q

Positive Regard/Affirmation (Farber & Doolin, 2011)

A

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

42
Q

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

A

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

43
Q

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

A

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).

44
Q

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

A

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

45
Q

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

A

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

46
Q

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

A

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

47
Q

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

A

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

48
Q

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

A

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

49
Q

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

A

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)

50
Q

Alliance Rupture and Repair

A

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

51
Q

Alliance Rupture and Repair

A

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.

52
Q

Alliance Rupture and Repair

A

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

53
Q

Alliance Rupture and Repair

A

transtheoretical phenomenon relevant for all clinicians

rare + diff to tell therapist that they are having problems - may fear punishment, afraid of confrontation, power

54
Q

Alliance Rupture and Repair

A

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

55
Q

Alliance Ruptures

A

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

56
Q

Alliance Ruptures

A

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

57
Q

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

A

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

58
Q

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

A

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

59
Q

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

A

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

60
Q

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

A

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

61
Q

What Doesn’t Work in the Therapy Relationship?

A

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

62
Q

What Doesn’t Work in the Therapy Relationship?

A

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

63
Q

What Doesn’t Work in the Therapy Relationship?

A

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

64
Q

What Doesn’t Work in the Therapy Relationship?

A

Rigidity: inflexibility + excessively structuring treatment

makes you less responsive + relationship suffers

65
Q

What Doesn’t Work in the Therapy Relationship?

A

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

66
Q

What Doesn’t Work in the Therapy Relationship?

A

fine balance using effective practices

we have to be attentive to all components of this dynamic relationship which matters and predicts outcome

PSY343 (11 decks)

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