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Moecke DP, Camp PG. Social support from the physiotherapist and the therapeutic relationship in physiotherapy: bridging theory to practice. Physiother Theory Pract 2024:1-11. [PMID: 38949505 DOI: 10.1080/09593985.2024.2372687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND/PURPOSE Therapeutic relationship and social support are critical components in physiotherapy that shape patient outcomes. However, defining these constructs, discerning their similarities and differences, and measuring them pose challenges. This article aims to facilitate scientific and clinical advancement on social support and the therapeutic relationship in physiotherapy by (a) providing conceptual clarity, (b) discussing measurement tools, and (c) offering practical recommendations for the deliberate incorporation of these constructs in clinical practice. METHODS This is a perspective paper drawing on examples from existing research. KEY RESULTS Assessing the nature and strength of social support and promoting naturally occurring social support networks are practical ways for physiotherapists to foster social support in physiotherapy clinical practice. Physiotherapists can offer direct support, facilitate the development of an individual's social skills, and promote participation in group activities. To strengthen the therapeutic relationship, it is important to maintain good communication, foster connectedness with the patient, demonstrate professional skills, and adopt a reflective practice. Physiotherapists are encouraged to establish clear roles and responsibilities, prioritize individualized patient-centered care, and involve patients in shared decision-making, ensuring congruence in goals and expectations. Willingness to dedicate time and energy within and beyond direct patient-therapist interactions can foster connections. Moreover, using the body - which is the main point of contact with patients - and physical touch can help physiotherapists to connect with patients. Finally, physiotherapists must be prepared to address and mend any conflicts which can impact the relationship's trajectory. CONCLUSION Social support and therapeutic relationships are complementary aspects of one's health care, and it is crucial to purposefully account for both in physiotherapy practice to optimize person-centered care and rehabilitation outcomes.
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Affiliation(s)
- Débora Petry Moecke
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Sciences Graduate Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pat G Camp
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
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Tramonti F, Saviozzi V, Ferrante B, Saliani S, Galeazzi E, Vatteroni S, Genovesi I, Di Vecchio I, Možina M. Life, complexity, and psychotherapy: A systemic perspective on the elusive construct of extra-therapeutic factors. J Eval Clin Pract 2024. [PMID: 38837307 DOI: 10.1111/jep.14039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 06/07/2024]
Abstract
STUDY AIMS Despite being mentioned in well-known models of psychotherapeutic change, the concept of extra-therapeutic factors seems to have left the scene across time, eaten away by the progressive refinement of the construct of common factors. Aim of the present study is to better understanding the historical evolution of the concept of extra-therapeutic factors and its importance for psychotherapy today. METHODS This is a position paper based on a literature review on extra-therapeutic factors and psychotherapy outcome and process. DISCUSSION There is growing evidence of the decisive role of clients' and therapists' characteristics, as well as of the importance of therapeutic alliances and relationships in promoting change. Within this context, the concept of extra-therapeutic factors still deserves proper attention, rather than being relegated to a residual and vanishing category. CONCLUSION A renewed interest on extra-therapeutic factors could reinvigorate the debate over the relationship between psychotherapy and life contexts and conditions. In terms of complexity and systems thinking nothing, a priori, really falls outside the realm of psychotherapy and, in turn, psychotherapy is not a practice that could be abstracted from the context in which it is practiced or from clients' and therapists' lives.
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Affiliation(s)
| | | | - Benedetta Ferrante
- Istituto di Psicoterapia Relazionale, Pisa, Italy
- Institute of Clinical Physiology of the Italian National Research Council (IFC-CNR), Pisa, Italy
| | | | | | | | | | | | - Miran Možina
- Sigmund Freud University Ljubljana, Ljubljana, Slovenia
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Warren JS, Bullock M, Top DN, Salazar GC. Self-efficacy, motivation, social support, and alliance as predictors of youth psychotherapy outcomes in usual care. Psychother Res 2024:1-13. [PMID: 38735039 DOI: 10.1080/10503307.2024.2349996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/24/2024] [Indexed: 05/14/2024] Open
Abstract
OBJECTIVE We examined how youth self-efficacy, motivation for treatment, social support, and therapeutic alliance relate to psychotherapy outcomes of patients receiving services at outpatient community clinics. We hypothesized that (1) these variables would increase throughout the course of therapy, (2) baseline scores would predict initial ratings of distress, (3) baseline scores would predict the rate of change in symptoms throughout treatment, and (4) changes in these variables would be associated with symptom change over the course of treatment. METHOD Participants included 150 adolescents at community outpatient treatment centers. Data was collected prior to beginning treatment, and every three weeks afterward until termination. We used hierarchical linear modeling (HLM) to address our hypotheses. RESULTS We found that (1) youth ratings of self-efficacy, social support, and motivation increased throughout treatment, (2) initial self-efficacy and social support were associated with initial levels of distress, (3) ratings of youth self-efficacy at intake predicted its rate of change over therapy, and (4) changes in all variables during therapy were related to lower distress at termination. DISCUSSION Results suggest that these variables may affect the trajectory and course of treatment in community-based treatment settings. These results may have implications for treatment planning to maximize treatment effectiveness.
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Affiliation(s)
- Jared S Warren
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Mariah Bullock
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - D Nicholas Top
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Gus C Salazar
- Department of Psychology, Brigham Young University, Provo, UT, USA
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Solomonov N, Victoria LW, Lyons K, Phan DK, Alexopoulos GS, Gunning FM, Flückiger C. Social reward processing in depressed and healthy individuals across the lifespan: A systematic review and a preliminary coordinate-based meta-analysis of fMRI studies. Behav Brain Res 2023; 454:114632. [PMID: 37598904 PMCID: PMC10557626 DOI: 10.1016/j.bbr.2023.114632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Social rewards (e.g., social feedback, praise, and social interactions) are fundamental to social learning and relationships across the life span. Exposure to social rewards is linked to activation in key brain regions, that are impaired in major depression. This is the first summary of neuroimaging literature on social reward processing in depressed and healthy individuals. METHOD We screened 409 studies and identified 25 investigating task-based fMRI activation during exposure to social stimuli in depressed and healthy populations across the lifespan. We conducted a systematic review followed by an Activation Likelihood Estimation (ALE) analysis of three main contrasts: a) positive social feedback vs. neutral stimuli; b) negative social feedback vs. neutral stimuli; c) positive vs. negative social feedback. We also compared activation patterns in depressed versus healthy controls. RESULTS Systematic review revealed that social rewards elicit increased activation in subcortical reward regions (NAcc, amygdala, ventral striatum, thalamus) in healthy and depressed individuals; and decreased activation in prefrontal reward regions (medial prefrontal cortex, orbitofrontal cortex) among depressed persons. Our meta-analysis showed, in both depressed and healthy individuals, increased cluster activation of the putamen and caudate in response to negative social stimuli vs. positive stimuli. We also found increased cluster activation in the inferior frontal gyrus (IFG) and the medial frontal gyrus (MFG) in healthy controls vs. depressed individuals, in response to negative social stimuli. CONCLUSIONS Processing of social stimuli elicits activation of key brain regions involved in affective and social information processing. Interventions for depression can increase social reward responsivity to improve outcomes.
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Affiliation(s)
- Nili Solomonov
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medicine, White Plains, NY, USA.
| | - Lindsay W Victoria
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medicine, White Plains, NY, USA
| | - Krystalle Lyons
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medicine, White Plains, NY, USA
| | - Dustin K Phan
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medicine, White Plains, NY, USA; University of Kassel, Germany
| | - George S Alexopoulos
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medicine, White Plains, NY, USA
| | - Faith M Gunning
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medicine, White Plains, NY, USA
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Wampold BE, Flückiger C. The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry 2023; 22:25-41. [PMID: 36640398 PMCID: PMC9840508 DOI: 10.1002/wps.21035] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 01/15/2023] Open
Abstract
The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.
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Affiliation(s)
- Bruce E Wampold
- Modum Bad Psychiatric Center, Vikersund, Norway
- University of Wisconsin-Madison, Madison, WI, USA
| | - Christoph Flückiger
- Department of Psychology, University of Zürich, Zürich, Switzerland
- Department of Psychology, University of Kassel, Kassel, Germany
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Moggia D, Schwartz B, Rubel JA, Zimmermann D, Kästel B, Lutz W. Is it me, is it you or is it both of US? Applying the social relations model to disentangle the components of the therapeutic bond. Psychother Res 2023; 33:30-44. [PMID: 36215730 DOI: 10.1080/10503307.2022.2126334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE The study investigated the contribution of therapists and patients to the therapeutic bond and their associations (at the within and between levels) to treatment outcome. On this aim, the social relations model (SRM, aimed to analyze dyadic interpersonal data) was implemented. METHOD A novel design for individual psychotherapy studies was adopted, a many-with-many asymmetrical block dyadic design, in which several patients interact with several therapists. Hierarchical linear models were computed to study through variance partitioning the different components of the SRM and their association to treatment outcome. RESULTS All SRM components (with significant effects at therapist- and patient- within and between levels) resulted in significant contributions to the bond. However, only components at the within- and between-therapist, and within-patient levels resulted in significant associations with outcome. CONCLUSION Given the dyadic nature of the bond, our results support not only studying and offering clinical training on interpersonal therapeutic skills but also on constant monitoring and feedback of the relationship at the more idiosyncratic level.
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Gómez Penedo JM, Flückiger C. Therapists' perceptions of interpersonally challenging patients in generalized anxiety disorder. Psychother Res 2023; 33:45-56. [PMID: 35446230 DOI: 10.1080/10503307.2022.2062268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE This study explores in cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) to what degree therapists' perceptions of their patients as interpersonally challenging (IC) is explained by the therapist or patient effects, if baseline patients' characteristics predict IC, and if IC is related to outcome. METHOD Eighty patients diagnosed with GAD and treated by 20 therapists with 16 sessions of CBT were randomized to two different implementation conditions. Patients completed baseline measures of depression, anxiety, interpersonal problems, and interpersonal strengths. The therapists completed a single-item assessing IC session-by-session. As an outcome, patients completed a worry measure at baseline, session 5, session 10, and posttreatment. RESULTS Multilevel models showed meaningful therapist effects, explaining 18% of IC variance. Interpersonal strengths were the only baseline predictor significantly and negatively associated with IC during treatment. Structural equation models showed significant negative IC effects on subsequent patient worry during therapy. CONCLUSIONS IC might represent a risk factor for psychotherapy outcome. Patient interpersonal strengths at baseline may buffer therapists perceiving their patients as ICs. The therapist effects on IC suggest that CBT clinicians treating GAD might benefit from identifying cases that are interpersonally challenging for them and reflecting about what might trigger that perception.
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Affiliation(s)
- Juan Martín Gómez Penedo
- Department of Psychology, University of Zürich & Facultad de Psicología, Universidad de Buenos Aires (CONICET), Buenos Aires, Argentina
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Law R, Ravitz P, Pain C, Fonagy P. Interpersonal Psychotherapy and Mentalizing-Synergies in Clinical Practice. Am J Psychother 2022; 75:44-50. [PMID: 35232220 DOI: 10.1176/appi.psychotherapy.20210024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Interpersonal psychotherapy (IPT) is an evidence-supported, relationally focused treatment for people living with depression and other psychiatric disorders in the context of stressful life events. Mentalizing, also relationally focused, promotes the ability to perceive, understand, and interpret human behavior in terms of intentional mental states of others or oneself, in order to support social leaning. IPT and mentalization-based treatments (MBT) both seek to improve interpersonal effectiveness, albeit with different emphases in the therapeutic process, with IPT promoting interpersonal problem solving and MBT promoting understanding of the obstacles to this outcome. In this article, the authors propose that the central intentions of IPT and mentalizing are essentially linked and complementary; understanding others and oneself in relationships facilitates interpersonal problem resolution and symptomatic recovery and enhances resilience. The clinical synergies of IPT and mentalizing are elaborated and illustrated through a case example of treatment for a socially isolated woman with depression and interpersonal sensitivities.
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Affiliation(s)
- Roslyn Law
- Anna Freud Centre London (Law, Fonagy); Faculty of Medicine, Department of Psychiatry, Sinai Health System and University of Toronto, Toronto (Ravitz, Pain); Division of Psychology and Language Sciences University College London, London (Fonagy)
| | - Paula Ravitz
- Anna Freud Centre London (Law, Fonagy); Faculty of Medicine, Department of Psychiatry, Sinai Health System and University of Toronto, Toronto (Ravitz, Pain); Division of Psychology and Language Sciences University College London, London (Fonagy)
| | - Clare Pain
- Anna Freud Centre London (Law, Fonagy); Faculty of Medicine, Department of Psychiatry, Sinai Health System and University of Toronto, Toronto (Ravitz, Pain); Division of Psychology and Language Sciences University College London, London (Fonagy)
| | - Peter Fonagy
- Anna Freud Centre London (Law, Fonagy); Faculty of Medicine, Department of Psychiatry, Sinai Health System and University of Toronto, Toronto (Ravitz, Pain); Division of Psychology and Language Sciences University College London, London (Fonagy)
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Chen S, Liao F, Murphy D, Joseph S. Measurement Invariance of the English, Chinese, and Spanish Versions of the Barrett-Lennard Relationship Inventory. MEASUREMENT AND EVALUATION IN COUNSELING AND DEVELOPMENT 2021. [DOI: 10.1080/07481756.2021.1955212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Shun Chen
- University of Nottingham, Nottingham, United Kingdom
| | - Faith Liao
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan
- Graduate Institute of Humanities in Medicine, Taipei Medical University, Taipei, Taiwan
| | - David Murphy
- University of Nottingham, Nottingham, United Kingdom
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Wampold BE. Healing in a Social Context: The Importance of Clinician and Patient Relationship. FRONTIERS IN PAIN RESEARCH 2021; 2:684768. [PMID: 35295467 PMCID: PMC8915743 DOI: 10.3389/fpain.2021.684768] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022] Open
Abstract
When a patient presents to a health provider, the course of the disorder is composed of three effects: natural effects, specific effects, and contextual effects. Part of the contextual effect is due to the relationship between the healer and the patient. Social healing appears to be present in eusocial species and particularly well-developed in humans. Evidence for the importance of the relationship in healing is found in placebo studies, including placebo analgesics, medicine, and psychotherapy. Although the theory for how the relationship is therapeutic is not well-developed, four possible mechanisms are discussed. The implications for health care and the treatment of pain are discussed.
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Affiliation(s)
- Bruce E. Wampold
- Modum Bad Psychiatric Center, Research Institute, Vikersund, Norway
- Department of Counseling Psychology, University of Wisconsin-Madison, Madison, WI, United States
- *Correspondence: Bruce E. Wampold
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