Therapeutic relationship in therapy

therapeutic relationship in therapy

The crucial nature of the therapeutic alliance is not a new idea. Four of the six items directly addressed the client-therapist relationship. It comes as no surprise to any experienced therapist that the therapeutic alliance – that felt bond between therapist and client – is the most powerful factor in the. The therapeutic relationship is unique in that for many clients, it is the first The client-therapist relationship is essential to establishing a.

But even so, the power of the alliance is often far stronger than many realize, and the most effective therapists are those who focus specifically on building the alliance. Research shows that many clients make an improvement between making the telephone call to book the first session, and the actual first session Wampold, By the time they arrive in the therapy room and meet the therapist for the first time, they are often feeling better, more empowered.

However once in the therapy room there are many factors that can help build empathy and accord, as the smart therapist knows, and equally, many factors that can undermine it. But while the therapeutic alliance is a common factor across all therapies, it is more than the bond between therapist and client.

The therapist needs to be experienced and intuitive enough to critically formulate and apply judgment, and help the patient define and reach their goals in therapy. Not that experience itself is necessarily the key to a powerful and effective alliance — in fact in some studies e. Castonguay et al, it has been shown that as some therapists became more technically able, paradoxically they can became less effective therapeutically. So we know that the effect and outcome of therapy depends on more than the skills and training of the therapist, and their technical competence.

We know that positive alliances tend to be fostered by the therapist being warm, understanding and empathetic. The internal consistency of the Client Initiative scale was low 0. Some aspects of the alliance as measured by the ARM was correlated with psychotherapy outcome Stiles et al. Kim alliance scale KAS Kim et al.

Therapeutic Relationship - Interview with VGCT

The scale comprises the three dimension of the alliance originally proposed by Bordin plus a fourth dimension: The KAS is a self report measure consisting of item 8 collaboration item, 11 communication item, 5 integration item, and 6 empowerment item each of one rated on a four-point scale. The alphas for the four dimensions ranged from 0.

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Highly correlated with the ARM. The scale has not been used in outcome research.

therapeutic relationship in therapy

Open in a separate window Any attempt to measure something as complex as therapeutic alliance involves a series of conceptual and methodological shortcomings, which have probably hindered the development of research in this field. Single-case research is one method used to investigate this theoretical construct, but implies some methodological drawbacks regarding the simultaneous treatment of several factors, the need for an adequate number of repeated measurements, and the generalizability of results.

Meta-analysis is a possible research strategy that can be used to obtain the combined results of studies on the same topic. However, it is important to remember that meta-analysis is more valid when the effect being investigated is quite specific. According to Migoneanother hindrance is the so-called Rashomon effect named after the film by Akira Kurosawa: Di Nuovo et al.

Though designed by independent research teams, there is often good correlation between the scales used to rate the therapeutic alliance, which reveal that these instruments tend to assess the same underlying process Martin et al.

None of their findings suggest that any one instrument was a stronger predictor of outcome than the others, in relation to the type of therapy being considered. It is interesting to note that although almost all of these scales were originally designed to examine the perspective of only one member of the patient—therapist—observer triad, they were later extended or modified to rate perspectives that were not previously considered.

The number of items included in the scales varies considerably between 6 and itemsas do the dimensions of the alliance investigated e. According to Martin et al. Different approaches for the evaluation of alliance coexist in group psychotherapy.

One of them is derived from individual psychotherapy. Although a comparison between different treatment modalities is a topic beyond the scope of this paper, it is worth noting that in the late s, some authors Marmar et al. However, subsequently, Raue et al. This latter study compared 57 clients, diagnosed with major depression and receiving either psychodynamic—interpersonal or cognitive—behavioral therapy: They argue that these findings could reflect the effort in cognitive—behavioral therapy to give clients positive experiences and to emphasize positive coping strategies.

Understanding the Therapeutic Alliance - Psychotherapy Treatment And Psychotherapist Information

A more recent comparison was suggested by Spinhoven et al. Results obtained by evaluating alliance through WAI-Client and WAI-therapist after 3, 15, and 33 months, showed clear alliance differences between treatments, suggesting that the quality of the alliance was affected by the nature of the treatment. Schema-focused therapy, with its emphasis on a nurturing and supportive attitude of therapist and the aim of developing mutual trust and positive regard, produced a better alliance according to the ratings of both therapists and patients.

Ratings by therapists during early treatment, in particular, were predictive of dropout, whereas growth of the therapeutic alliance as experienced by patients during the first part of therapy, was seen to predict subsequent symptom reduction.

Phases of the Alliance during the Therapeutic Process and the Relationship with the Outcome There is much debate on the role of the therapeutic alliance during the psychotherapeutic process. It may in fact be a simple effect of the temporal progression of the therapy rather than an important causal factor. On the basis of this hypothesis, we would expect a development in the alliance to be characterized by a linear growth pattern over the course of the therapy, and alliance ratings obtained in the early phases to be weaker predictors of outcome than those obtained toward the end of the therapy.

However, according to the findings of numerous researchers, this is not the case. Horvath and Marx describe the course of the alliance in successful therapies as a sequence of developments, breaches, and repairs. According to Horvath and Symondsthe extent of the relationship between alliance and outcome was not a direct function of time: The results of these studies have led researchers to consider the existence of two important phases in the alliance. The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session.

During the first phase, adequate levels of collaboration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of confidence in the procedures that constitute the framework of the therapy.

The deterioration in the relationship must be repaired if the therapy is to be successful. This model implies that the alliance can be damaged at various times during the course of therapy and for different reasons.

The effect on therapy differs, depending on when the difficulty arises. In this case, the patient may prematurely terminate the therapy contract. According to Safran and Segalmany therapies are characterized by at least one or more ruptures in the alliance during the course of treatment.

Randeau and Wampold analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies. Although some studies are based on a very limited number of cases, the results appear consistent: While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used static measures of alliance.

There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: Few studies have analyzed alliance at different stages in the treatment process. According to the results proposed by Traceythe more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction high—low—high over the course of treatment. When the outcome was worse, the curvilinear pattern was weaker.

Kivlighan and Shaughnessy use the hierarchical linear modeling method an analysis technique for studying the process of change in studies where measurements are repeated to analyses the development of the alliance in a large number of cases. According to their findings, some dyads presented the high—low—high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment.

Understanding the Therapeutic Alliance

In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development. Kivlighan and Shaughnessy distinguish three patterns of therapeutic alliance development: They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pattern, in that this appeared to be correlated with the best therapeutic outcomes.

In further studies of this development pattern, Stiles et al. Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative. No significant correlation was observed between any of the four patterns and the therapeutic outcome. However, the authors observed a cycle of therapeutic alliance rupture—repair events in all cases: On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes.

In particular, Stiles et al. The results of the study by De Roten et al. According to De Roten et al. De Roten et al. According to Castonguay et al. This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon. Discussion and Conclusion According to their meta-analysis based on the results of 24 studies, Horvath and Symonds demonstrate the existence of a moderate but reliable association between good therapeutic alliance and positive therapeutic outcome.

More recent meta-analyses of studies examining the linkage between alliance and outcomes in both adult and youth psychotherapy Martin et al. Thus, it is not by chance that in their meta-analysis, Horvath and Luborsky conclude that two main aspects of the alliance were measured by several scales regardless of the theoretical frameworks and the therapeutic models: This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants.

In a helpful contribution, Hentschel points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: The use of neutral observers or the creation of counterintuitive studies is therefore recommended.

From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. The development of a dynamic vision of the concept of therapeutic alliance is also apparent.

therapeutic relationship in therapy

The work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in Research aimed at analyzing the components that make up the alliance continues to flourish and develop.

Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: Attention has recently turned toward the role of the therapeutic alliance in the various phases of therapy and the relationship between alliance and outcome.

So far, few studies have regarded long-term psychotherapy involving many counseling sessions. This topic, along with a more detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects. Equally important, in our opinion, will be the findings of studies regarding drop-out and therapeutic alliance ruptures, which must necessarily consider the differences between that perceived by the patient and that perceived by the therapist.

Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Acknowledgments The authors thank Mauro Adenzato for his valuable comments and suggestions to an earlier version of this article.

A Research Handbook, eds Greenberg L. Guilford Press;— Bibring E. On the theory of the results of psychoanalysis.