Week 10 Flashcards
How many psychotherapy clients show benefit?
About 75–80% of patients who enter psychotherapy show benefit.
What factors account for success (and
failure)?
the patient, the treatment method, the psychotherapist, the context, and the relationship between the therapist and the patient
Norcross (2011) Psychotherapy relationships that work. NY: Oxford University Press.
The therapy relationship makes substantial and
consistent contributions to patient success.
• The therapy relationship accounts for why clients
improve as much as the treatment method.
• Practice guidelines should address therapist qualities
and behaviours that promote the therapy relationship.
According to Narcoss 2011 Practitioners should routinely:
monitor patients’ responses to the therapy relationship.
• Efforts to promulgate evidence-based practices without including the relationship are incomplete and potentially misleading.
• The relationship acts in concert with treatment methods, patient characteristics and practitioner qualities in determining effectiveness.
• Adapting or tailoring the relationship to several patient
characteristics enhances effectiveness.
Key Elements of the Therapy Relationship (Norcross, 2010
Therapeutic Alliance Cohesion in Group Therapy Empathy Goal Consensus and Collaboration Positive Regard and Affirmation Congruence/Genuineness Collecting Client Feedback Repairing Alliance Ruptures Managing Countertransference Adapting the Relationship to the Individual Patient
Therapeutic Alliance
“The alliance is an emergent quality of partnership and mutual collaboration between therapist and client.” (Norcross (2010), p5)
Therapeutic alliance in youth is more
complicated
The development of a good alliance is essential for the
success of psychotherapy.
The ability of the therapist to bridge the client’s needs, expectations, and abilities into a therapeutic plan is important in building the alliance.
Because the therapist and client often judge the quality of the alliance differently, active monitoring of the alliance throughout therapy is recommended.
Responding nondefensively to a client’s hostility or negativity is critical to establishing and maintaining a strong alliance.
best predictor of outcome
Clients’ evaluation of the quality of the alliance is the best predictor of outcome
Group Cohesion
Cohesion describes therapeutic relationships in group psychotherapy and has two dimensions: relationship
structure and relationship quality
Structure in group cohesion
Structure refers to the direction of the relationship.
Vertical cohesion:
group member’s perception of leader’s competence, genuineness, and warmth. Horizontal cohesion: group member’s relationship with other group members and with the group as a whole
The quality in group cohesion
The quality is defined by how members feel with their leader and with other members (positive bond), by the tasks and goals of the group (positive work), and also the empathic failure with the leader and conflict in the group (negative relationship)
Is cohesion associated with outcomes?
Cohesion is reliably associated with outcomes. All group leaders should foster cohesion in its multiple manifestations.
Group leaders emphasising member interaction give higher cohesion-outcome links.
Cohesion is strongest when a group lasts more than 12 sessions and is composed of 5 to 9 members.
Younger members experience the largest outcome changes when cohesion is present within their groups.
Empathy
Carl Rogers (1980, p85) defined empathy as “the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view. … It means sensing meanings of which he or she is scarcely aware”
what makes an empathic therapist?
Psychotherapists should make efforts to understand clients’ experiences and demonstrate this understanding through their responses.
Empathic therapists do not parrot clients’ words back; instead they understand overall goals.
Empathic responses can include straightforward responses that convey understanding of client experience, but also responses that validate the client’s perspective, or bring the client’s experience to life, or that aim at what is implicit.
Therapists should not assume that the client feels understood by their efforts at empathy.
Research has shown empathy to be inseparable from the other relational conditions
Goal Consensus and Collaboration
Therapists and clients outline the conditions of their work
together.
Agreement about the nature of the problem for which the client is seeking help, goals for treatment, and the way that the two parties will work together to achieve these goals are the essence of goal consensus.
To help clients fulfill mutually agreed-upon treatment goals, mental health service providers and consumers must function as a team.
Collaboration represents the active process of their cooperation in this endeavor
Begin problem-solving only after agreeing on
treatment goals and the ways to reach them.
Listen to what clients say and formulate
interventions with their input and understanding.
Include clients’ contributions throughout psychotherapy by requesting their feedback, insights, reflections, and elaborations.
Clients need to recognize the importance they play
in achieving goal consensus and collaboration.
Positive Regard and Affirmation
Carl Rogers (1951) believed clients should be treated in a consistently warm, supportive, highly regarding manner
Positive regard is strongly indicated in practice.
May be especially useful wherein a nonminority therapist is working with a racial/ethnic minority client.
Therapists should ensure that their positive feelings toward their clients are communicated to them.
Therapists can monitor their expressed level of positive regard and adjust it as a function of the needs of particular patients and specific clinical situations.
Congruence/Genuineness Two facets:
Two facets:
Intrapersonal - mindful genuineness on the part of the therapist. (even if you don’t like them you can genuinely want to help them)
Interpersonal - therapist’s capacity to conscientiously communicate his or her experience with the client to the client.
Congruence/Genuineness involves:
Congruence involves acceptance of and receptivity to the client as well as a willingness to use this information in conversation.
Congruence must be developed by discipline, practice, and effort, with active and engaged listening.
Congruence may be modeled through self-disclosure as well as sharing of thoughts and feelings, opinions, pointed questions, and feedback regarding client behavior.
Effective therapists will modify and tailor their
congruence style according to client characteristics .
A congruent therapist communicates acceptance and
the possibility of engaging in a genuine relationship.
Collecting Client Feedback
Systematic monitoring of client mental health through the use of standardised scales can improve psychotherapy
effectiveness.
Research showed when feedback was provided:
rates of patient deterioration were cut in half
rates of positive responding were several times greater
Employ real-time client feedback to compensate for therapist’s limited ability to accurately detect client deterioration.
Practitioners and clients can share their impressions
about the progress of treatment and the therapy relationship.
Beware of clients understating or overstating their problems and the possibility of inaccurate ratings on feedback systems.
Consider sharing progress with clients.
Consider using electronic versions of feedback systems that expedite and ease practical difficulties.
Repairing Alliance RupturesManaging Countertransference
Ruptures in the therapeutic alliance are episodes of tension or breakdown in the collaborative relationship between the client and therapist. Exploring and repairing alliance ruptures when they occur is important.
The presence of alliance rupture-repair episodes
over the course of treatment is positively related to
psychotherapy success.
Therapists should be attuned to ruptures and to take the initiative in exploring what is transpiring and repairing them.
It can be helpful for patients to express negative feelings about the treatment to the therapist should they emerge.
When ruptures occur, it is important for therapists to respond in an empathic and nondefensive fashion.
Managing Countertransference
Countertransference (CT) is a psychotherapist’s internal and external reactions to a client that are influenced by the therapist’s personal vulnerabilities and unresolved conflicts
Psychotherapists acting out of their CT can be
harmful
Because CT management seems to promote successful treatment, therapists are urged to manage internal CT reactions.
Therapists are encouraged to resolve their personal conflicts through personal therapy, clinical supervision, or both.
Patients probably benefit from psychotherapists who help them learn about the interpersonal reactions that they evoke in others
Adapting the Relationship to the Individual
Goal is to increase treatment effectiveness by tailoring it to the unique individual and his/her singular situation
Treatment should be tailored to each of the
following client characteristics:
- Reactance Level
- Stages of Change
- Preferences
- Culture
- Coping Style
- Religion/spirituality
- Patient expectations
- Patient attachment style
Things to be mindful of with clients.
Demonstrably Effective
• Reactance Level (might be more reactive than others, might be better suited to a less structured session. Less reactive might need more structure)
• Preferences (gender, ethnicity, sexuality of therapist etc)
• Culture
• Religion / Spirituality (when it comes to spirituality related outcomes, this is important. Adapting therapy style is important.)
Probably Effective
• Stages of Change (adapt therapy according to stages of change)
• Coping Style (externalizing coping style might be more symptom focused.)
Promising
• Patient Expectations
• Patient Attachment Style