Therapist actions that address initially poor therapeutic alliances in psychotherapy

Interpersonal guilt and the working alliance in psychotherapy: The moderating role of childhood experience

Interpersonal guilt often encompasses pathogenic beliefs that imply omnipotent responsibility for others and concerns about abandoning, humiliating or threatening others. This study sought to examine how interpersonal guilt may influence patients' and therapists' ratings of early working alliance and the potential moderating effect of perceived adverse parenting in childhood. Ninety-five patients and their 19 therapists in an outpatient psychotherapy clinic rated their early working alliance after the first and the fifth session in treatment. We conducted separate moderation analyses for patient and therapist-reported working alliance and controlled for psychological distress at baseline. Results suggest that perceived adverse parenting in childhood significantly moderated the effect of interpersonal guilt on the working alliance in such a way that for patients reporting very low levels of perceived adverse experiences, the interpersonal guilt beliefs had a positive effect on working alliance, whereas for those with very high levels of perceived adverse experiences, interpersonal guilt had a negative effect on working alliance. This same pattern of moderation was found for patient- and therapist-reported working alliance at session 1 and therapist-reported working alliance at session 5. Thus, although the effect of interpersonal guilt on the working alliance depends somewhat on the perspective of the working alliance rating (patient or therapist), it mainly depends on developmental experiences of the patient.

Effects of Therapist Feedback on the Therapeutic Alliance and Alcohol Use Outcomes in the Outpatient Treatment of Alcohol Use Disorder

BACKGROUND

It is widely accepted that the therapeutic alliance (TA) is a mediator of psychotherapy effects, but evidence is sparse that the TA is an actual mechanism of behavior change. The purpose of this study was to provide the first systematic evidence regarding the TA as a mechanism of change in the treatment of alcohol use disorder (AUD).

METHODS

Participants were 155 adult men and women presenting for individual outpatient treatment of AUD. Each was randomly assigned to 1 of 6 experienced therapists, who did or did not receive over 3 study phases postsession participant feedback on his/her ratings of the TA. All participants received a 12-session version of cognitive behavioral therapy for AUD. Participants rated the TA by use of the California Psychotherapy Alliance Scale (CALPAS) and reported their daily alcohol consumption between sessions and for 1 year posttreatment by use of the timeline followback interview. Multilevel statistical models that partitioned within- and between-participant effects and between-therapist effects were run to test the effects of feedback condition on the alliance and alcohol use, and the effects of the alliance on alcohol use.

RESULTS

The study's main hypotheses that feedback causes an enhanced therapeutic alliance and that the alliance is associated with better alcohol use outcomes were not supported.

CONCLUSIONS

Several methodological and substantive reasons for the pattern of findings are suggested, as well as directions for future research that would advance study of the TA as a mechanism of change in psychotherapy and in studying therapist effects on outcomes in general.

What Defense Mechanisms Do Therapists Interpret In-Session?

One of the key technical guidelines outlined by psychodynamic theorists and clinicians is for therapists to interpret a patient's most prominent defenses (Greenson, 1967; Langs, 1973). However, a debate exists about what constitutes a patient's most prominent defense and which defenses therapists actually choose to interpret in-session. This study aimed to shed light on this debate by examining 35 psychotherapy sessions (18 high alliance and 17 low alliance dyads) of individuals in therapy at a university counselling center. The analysis focused on comparing the patients' most prominent defenses and the range of defenses they utilized, and the therapists' most prominent interpretation level as well as the range of interpretation level. Paired sample t-tests showed no significant mean difference between sessions with low and high alliance scores in patient defense levels (e.g., frequency and range) and therapist interpretation levels (e.g., frequency and range). Significant differences were found between the range of patient defense levels and the range of therapist interpretation levels. Correlational analyses showed no significant relationship between patient defense levels and therapist interpretation levels on both the frequency and range levels. Clinical implications of these results, and directions for future research are discussed.

Sexual Offenders' Perceptions of the Client-Therapist Relationship: The Role of Risk

The therapeutic alliance has been shown to be integral to treatment outcomes even in forensic settings. There is still a relative dearth of research examining factors related to the formation of the therapeutic alliance in sex offender treatment specifically. Using a sample of 202 incarcerated male sexual offenders participating in sex offender treatment, this study examined whether perceptions of the client-therapist relationship from the perspective of male sexual offenders varied by risk for sexual and general recidivism. Overall, we found a significant negative relationship between risk for sexual recidivism and bond formation. However, when therapist subscale scores on the Working Alliance Inventory were considered by therapist gender, higher risk sexual offenders perceived poorer bonds with their female therapists, relative to their male therapists. Findings are discussed as they pertain to therapeutic relationships and responsivity issues in sex offender treatment.

Defensive functioning and psychopathology: a study with the REM-71

OBJECTIVES

The aim of the present study is to explore the association between defensive functioning (as assessed through the REM-71) and psychiatric symptoms in a large sample from the community, and the moderating role of age and gender on that association. Furthermore, we explored the concurrent validity of REM-71 as compared with "caseness" (SCL-90-R).

METHODS

The REM-71 was administered together with SCL-90-R to a community sample of 1,060 Italian high-school and university students (mean age=19.01±3.85 years; 66.7% females).

RESULTS

Factor 1 defenses were by far the primary contributors to the predictor synthetic variable (i.e. association between defenses and psychopathology). Gender proved to moderate the association between immature defenses and symptoms. Using ROC analysis, we derived a cut-off score for Factor 1 defenses.

CONCLUSIONS

Our results support the adoption of the REM-71 as a useful instrument for the assessment of defensive array and psychopathological liability in adolescents and adults.

How does addressing patient's defenses help to repair alliance ruptures in psychodynamic psychotherapy?: An exploratory study

Interpreting or addressing defenses is an important aspect of psychoanalytic technique. Previous research has shown that therapist addressing defenses (TADs) can produce a positive effect on alliance. The potential value of TADs during the process of alliance rupture and resolution has not yet been documented. We selected patients (n = 17) undertaking a short-term dynamic psychotherapy in which the therapeutic alliance, measured with the Helping Alliance Questionnaire and monitored after each session, showed a pattern of rupture and resolution. Two control sessions (5 and 15) were also selected. Presence of TADs was examined in each therapist interpretation. Compared with control sessions, rupture sessions were characterized by fewer TADs and especially fewer TADs addressing specifically intermediate-essentially neurotic-defenses. Resolution sessions were characterized by more TADs addressing specifically intermediate defenses. This confirms the link between therapist technique and alliance process in psychodynamic psychotherapy.

Change in defense mechanisms during short-term dynamic and cognitive therapy in patients with cluster C personality disorders

The aims of this study were to examine whether a change in overall defensive functioning during treatment a) would predict change in symptom distress during the course of treatment and follow-up and b) would be greater in short-term dynamic therapy than in cognitive therapy. Patients (N = 50) who met criteria for cluster C personality disorders were randomized to 40 weekly sessions of short-term dynamic therapy or cognitive therapy. Video recordings of a pretreatment interview and therapy session 36 were evaluated using the Defense Mechanisms Rating Scales. Symptom distress was measured using the revised version of Symptom Checklist-90. Change in overall defensive functioning during treatment predicted change in symptom distress from pretreatment to 2 years after treatment. Both treatment groups showed significant changes in defensive functioning toward greater adaptability but without any significant differences between the short-term dynamic therapy and cognitive therapy groups in a sample of patients with cluster C personality disorders.

Therapeutic alliance: a concept for the childbearing season

This analysis was conducted to describe the concept of therapeutic alliance and its appropriateness for health-care provider-client interactions during the childbearing season. The concept has been defined in other disciplines. A universal definition suggested a merging of efforts directed toward health. A simple and concise definition evolved, which is applicable to the childbearing season as well as to health-care encounters across the life span. This definition states: Therapeutic alliance is a process within a health-care provider-client interaction that is initiated by an identified need for positive client health-care behaviors, whereby both parties work together toward this goal with consideration of the client's current health status and developmental stage within the life span.

Processing the therapeutic relationship

The authors propose that if therapists and clients process their therapeutic relationship (i.e., directly address in the here and now feelings about each other and about the inevitable problems that emerge in the therapy relationship), feelings will be expressed and accepted, problems will be resolved, the relationship will be enhanced, and clients will transfer their learning to other relationships outside of therapy. The authors review theories supporting the idea of processing the therapeutic relationship, discuss the relevant empirical literature in this area, and provide their conceptualization of the construct of processing the therapeutic relationship based on the theory and empirical findings. Finally, they discuss methodological concerns and suggest implications for clinical practice, training, and further research.

Therapist technique and patient defensive functioning in ultra-brief psychodynamic psychotherapy: a Lag sequential analysis

This study examined the association between therapist interventions, including interpretations, and patient defensive functioning. The first session of 32 (n = 32) Brief Psychodynamic Interventions were rated for therapist interventions and patient defensive functioning. Lag sequential analysis was used to determine if (a) there are organized sequences of therapist interventions; (b) there are predictable sequences in the patients' level of defensive functioning; (c) there are sequences of therapist interventions leading to change in the patients' defensive functioning; and (d) there are levels of patient defensive functioning leading to organized therapist response. Results suggested that there are organized sequences in the therapists' interventions and that patient in-session defensive functioning is relatively stable. However, no chain of therapist interventions led to a predictable response in the patients' defensive functioning or vice versa.

EARLY WITHDRAWAL FROM MENTAL HEALTH TREATMENT: IMPLICATIONS FOR PSYCHOTHERAPY PRACTICE

Despite more than 50 years of research on client attrition from therapy, obstacles to the delivery and success of treatments remain poorly understood, and effective methods to engage and retain clients in therapy are lacking. This article offers a review of the literature on attrition, highlighting the methodological challenges in effectively addressing the complex nature of this problem. Current interventions for reducing attrition are reviewed, and recommendations for implementing these interventions into psychotherapy practice are discussed.

How to address patients' defences: a pilot study of the accuracy of defence interpretations and alliance

This pilot study examined the accuracy of therapist defence interpretations (TAD) in high-alliance patients (N = 7) and low-alliance patients (N = 8). TAD accuracy was assessed in the two subgroups by comparing for each case the patient's most frequent defensive level with the most frequent defensive level addressed by the therapist when making defence interpretations. Results show that in high-alliance patient-therapist dyads, the therapists tend to address accurate or higher (more mature) defensive level than patients most frequent level. On the other hand, the therapists address lower (more immature) defensive level in low-alliance dyads. These results are discussed along with possible ways to better assess TAD accuracy.

What is Interpersonal Behavior? A Post-Cartesian Approach to Problematic Interpersonal Patterns and Psychotherapy Process

Most efforts to learn about interpersonal behavior reflect a shared set of key commitments. These commitments, in turn, reflect the Cartesian framework with its split between person and world. Guided by the recent work of certain developmental psychologists interested in social interaction (e.g., Fogel, 1993 ; Kaye, 1985 ) and by an alternative philosophical perspective that regards the person's involvement in practical activities as fundamental ( Heidegger, 1962 ; Merleau-Ponty, 1962 ; Wittgenstein, 1958 ), the author maps out the participatory model of interpersonal behavior. According to this model, interpersonal behaviors are viewed as a person's contributions to doing something with other people. The author considers the model's implications for research by clinical psychologists on problematic behavior patterns in adults and psychotherapy process. The author also considers implications of rejecting the Cartesian framework for methodological concerns about the role of interpretation in research on interpersonal behavior.

Empirical studies of defense style: relationships with psychopathology and change

The Defense Style Questionnaire (DSQ) is a widely used self-report measure of empirically derived groupings of defense mechanisms ranked on an adaptive hierarchy. A review of published studies indicates strong evidence that adaptiveness of defense style correlates with mental health and that some diagnoses are correlated with specific defense patterns-for example, borderline personality disorder with greater use of both maladaptive and image-distorting defenses and less use of adaptive defenses. For other diagnoses, the pattern of defenses is less clear but often reinforces theoretical formulations. Defense styles become more adaptive with improvement in symptoms, but intermediate defenses tend to be stable (traitlike) over time. Defenses are sometimes predictive of the quality of the therapeutic alliance. Although one might speculate that assessment of defenses can be useful in planning treatment, there are no studies supporting this hypothesis.

The therapeutic relationship in the treatment of severe mental illness: a review of methods and findings

AIMS

To review the methods and findings from studies of the therapeutic relationship (TR) in the treatment of severe mental illness.

METHOD

A literature search was conducted to identify all studies that used an operationalised measurement of the TR in the treatment of severe mental illness.

RESULTS

Fifteen scales--the majority of which were developed for psychotherapy--and the expressed emotion index have been used. Most scales have acceptable internal, inter-rater and test-retest reliability. As none of the scales has been used in more than five studies, no single scale is widely established in psychiatric research. A more positive relationship consistently predicts a better short- and long-term outcome. It appears that a large global factor accounts for the greatest proportion of the variance in the therapeutic relationship.

CONCLUSIONS

The therapeutic relationship is a reliable predictor of patient outcome in mainstream psychiatric care. Valid assessments may need to take account of different, specific aspects of the relationship in psychiatric settings such as greater heterogeneity of treatment components and goals, increased variability of setting and the statutory responsibility of the clinician. Methodological progress may require conceptual work to ensure valid assessments of this central element of treatment.

Alliance and dropout in family therapy for adolescents with behavior problems: individual and systemic effects

This study examined the relationship between alliance and retention in family therapy. Alliance was examined at the individual (parent and adolescent) and family levels (within-family differences). Participants were 34 families who received functional family therapy for the treatment of adolescent (aged 12-18 years) behavior problems. Families were classified as treatment dropouts (n=14) or completers (n=20). Videotapes of the first sessions were rated to identify parent and adolescent alliances with the therapist. Results demonstrated that individual parent and adolescent alliances did not predict retention. However, as hypothesized, dropout cases had significantly higher unbalanced alliances (parent minus adolescent) than did completer cases. These findings highlight the importance of alliances in functional family therapy and suggest that how the alliance operates in conjoint family therapy may be a function of systemic rather than of individual processes.

The early impact of therapeutic alliance in brief psychodynamic psychotherapy

INTRODUCTION

Therapeutic alliance is a key component of the psychotherapeutic process. This study estimated the impact of the therapeutic alliance as measured by CALPAS-P in an individual brief psychodynamic psychotherapy program.

METHODS

To study the impact of the therapeutic alliance patients in psychotherapy answered to the CALPAS-P at the first and third session and to the Self-report Questionnaire (SRQ-20), to the Beck Depression Inventory (BDI) and to the Hamilton Anxiety Scale at the beginning and at the end of psychotherapy.

RESULTS

The study of the impact of the therapeutic alliance in brief psychodynamic psychotherapy showed that higher TUI scores in the first session were significantly associated to the improvement on the BDI. Patients with best scores in the working alliance, measured at the third PWC session had also significant symptomatic changes.

DISCUSSION

The study of the impact of the therapeutic alliance in brief psychotherapy indicated that patients who perceived that their therapists had the best capability to understand and to be involved in their issues had best results in reducing depressive symptoms and patients with higher capability to form the working alliance reached the best psychotherapy outcomes.

A pilot study of defenses in adults with personality disorders entering psychotherapy

This study examined defensive functioning in adults entering open-ended dynamic psychotherapy and determined whether defenses predict retention at 1 year. Beginning at about the fifth session, 14 adults with personality and or depressive disorders entering open-ended dynamic psychotherapy had five therapy sessions audiotaped. The sessions were rated according to the Defense Mechanism Rating Scales, quantitative method. Interrater reliability of overall defensive functioning (ODF) and the number of defenses used per session were intraclass R = .85 and .83, respectively, whereas that of seven defense levels yielded a median of .625 (range .52 to .80). Stability of ODF across the five sessions was intraclass R = .48. The 11 subjects with personality disorders (PDs) used predominantly lower immature (49.3%) and neurotic (40.8%) level defenses. Subjects with borderline PD had significantly lower ODF than those with other PD types. Higher ODF was associated with remaining in treatment at 1 year, although this was confounded with a higher frequency of weekly sessions. Quantitative assessment of defenses demonstrated fair to excellent reliability and indicated that in the short term approximately half of defensive functioning reflects a stable repertoire, whereas the remaining variation may be due to occasion and error. PDs and especially BPD are characterized by a predominance of lower defenses. Higher defensive functioning was associated with twice-weekly sessions and retention in therapy at 1 year. In therapy, adjusting technique to the patient's defenses may improve retention and outcome.

Alliance and technique in short-term dynamic therapy

We review existing studies on the extent to which the alliance and techniques predict the outcome of short-term dynamic psychotherapy (STDP). Although the alliance has been found to relate to outcome in diverse psychotherapies, evidence for its role in STDP is more inconsistent. Studies of technique factors have provided support for the relation of competence with exploratory interventions to outcome. Less support for the role of specific transference interpretations was found. Little empirical support exists for the notion that the technical factors are most potent in the context of a positive alliance, although adequate studies of this interaction are scarce. Similarly, adequate studies that attempt to tease apart the extent to which technical factors influence the alliance, and vice versa, are also rare. Despite the methodological limitations of research in this area, the fact that there are some consistent findings relating techniques to outcome suggests that nonspecific relationship factors do not by themselves account for the changes found over the course of STDP. Moreover, such findings encourage additional efficacy and process research on STDP. Some suggestions for future research are presented.

The psychological characteristics of patients suffering from anorexia nervosa and the nurse's role in creating a therapeutic relationship

This paper reviews research on the psychological characteristics of patients suffering from anorexia nervosa and that examining the therapeutic relationship. The former research suggests that anorexic patients possess a psychological profile characterized by: a phobia of weight gain and fear of loss of control; alexithymia and lack of introceptive awareness; mistrust of self and others; cognitive dysfunction; low self-esteem; and often the presence of starvation-induced depression. The latter strongly suggests that in order for a relationship to be therapeutic it needs to be characterized by: empathy; positive regard and acceptance; warmth; commitment; trust; genuineness; and be non-judgemental. The implications of these research findings regarding the nurse's role in forming a therapeutic relationship with anorexic patients is then discussed. It is seen that it is vital that nurses receive adequate education before working with such patients, and that their knowledge is regularly updated. Nurses should receive regular clinical supervision and support, in order to ensure that they are able to provide therapeutic care for such patients.

Preserving families at risk of child abuse and neglect: the role of the helping alliance

Family preservation services are increasingly employed to decrease the use of foster care and preserve maltreating families at high risk of child placement. First studies of family preservation services appeared to support their effectiveness in achieving these goals. However, questions are raised increasingly about their effectiveness, particularly with those families whose functioning is impaired by psychopathology and substance abuse. The time has come to seek fuller understanding of family preservation services and their differential successes. In this paper, we draw on current research in the field of psychotherapy--specifically on studies of the helping alliance and its relationship to treatment outcome--to purpose a new look at family preservation services and to inform of treatment of high-risk families.

Treatment of posttraumatic stress disorder: a review

This article analyzes the literature on the treatment of posttraumatic stress disorder (PTSD). It briefly exposes the theoretical basis for each treatment modality and extensively examines pharmacological, behavioral, cognitive, and psychodynamic therapies, as well as group and family therapies, hypnosis, inpatient treatment, and rehabilitation. Articles were identified by scanning Medline and PsychLit for all papers in English reporting treatment of PTSD. Anecdotal case reports were, then, excluded. Eighty one articles were identified and categorized as either biological or psychological, with the latter category further divided into behavioral, cognitive, psychodynamic, and other treatment modalities. Information regarding the type of trauma, the sample studied, the treatment method, and the results of the treatment has been extracted from each article and is presented briefly. A synthesis of findings in each area is provided. Most studies explored a single treatment modality (e.g., pharmacological, behavioral). The cumulated evidence from these studies suggests that several treatment protocols reduce PTSD symptoms and improve the patient's quality of life. The magnitude of the results, however, is often limited, and remission is rarely achieved. Given the shortcoming of unidimensional treatment of PTSD, it is suggested that combining biological, psychological, and psychosocial treatment may yield better results. It is further argued that rehabilitative goals should replace curative techniques in those patients with chronic PTSD. A framework for identifying targets for each treatment modality is presented.

The relationship of counselor and peer alliance to drug use and HIV risk behaviors in a six-month methadone detoxification program

The purpose of this study was to examine the relationship of treatment outcomes in opioid detoxification to levels of counselor and peer alliance. Forty-one subjects were recruited from a larger, 180-day study of psychosocial treatment. Beginning at day 90, subjects completed monthly measures of alliance. Outcome measures included treatment retention, drug use and self-reported HIV risk. Measures of alliance were found to be internally consistent and moderately stable over time. During the final 30 days of the methadone taper, higher levels of both types of alliance were associated with less use of illicit opioids. Alliance with counselor was associated with less frequent needle sharing. For subjects who could be located for 30-day follow-up, greater alliance with peers was associated with more frequent HIV (sexual) risk behaviors. Results suggest that treatment outcome may be improved through approaches that address a patient's alliance with both counselor and peers.

Psychology of comorbid posttraumatic stress disorder and substance abuse: lessons from combat veterans

This article provides important phenomenological observations, conceptual models, research findings, theoretical ideas, and psychotherapeutic techniques that are proving useful in working with combat veterans who display both PTSD and substance abuse disorders. Some of the clinical challenges of treating patients displaying a complicated trauma response are explored, such as the phenomena of patient and therapist dichotomous thinking, a "tuned-out" patient style, and difficulty establishing or maintaining therapeutic alliance. A clinically useful model (cocomplication model) is presented that views PTSD and substance abuse as tending mutually to impede resolution of one another, so that over time the patient may never achieve significant resolution of either problem. An overview of historical and current models of PTSD is then presented in order to provide a context for understanding ways that pretrauma variables might help determine the nature, persistence, and severity of adverse psychological reactions to overwhelming stress. Pathogenic beliefs developed in response to childhood mistreatment, abuse, or neglect are capable of mediating responses to later trauma. Once reinforced in combat or by other trauma, such beliefs may become particularly tenacious and compelling. Pathogenic beliefs incompatible with recovery from the trauma response and from addiction are reviewed. Testing for safety among traumatized populations is discussed and treatment suggestions are provided to avoid confirmation of pathogenic beliefs. A clinical case is provided that illustrates the application of these concepts to formulation and treatment.

Formulation: a multiperspective model

This paper presents a model of formulation that can be used by psychiatrists and other mental health professionals. A review of the literature indicates a need for a more comprehensive approach that can accommodate a variety of perspectives, suggest treatment and can be easily recalled. These issues are addressed by the multiperspective grid presented in this paper.

The relationship of patient difficulty to therapist performance in interpersonal psychotherapy of depression

The efficacy of Interpersonal Psychotherapy (IPT) in the treatment of ambulatory major depression was demonstrated in the recently completed NIMH Treatment of Depression Collaborative Research Program (Elkin et al. 1986). Factors which enhance or impede the administration of the treatment delimit effective patient care and should therefore be understood. This report examines the relationship of pretreatment patient attitudes and in-treatment patient difficulty to the ability of therapists to competently conduct IPT, using data from a training program in IPT. The hypothesis was that the patient's ability and willingness to establish a relationship and undertake the task demands of therapy would influence the therapist's ability to administer treatment. Patient difficulty was found to be strongly related to both therapists' and supervisors' judgements of therapist performance during IPT sessions: when patients were more difficult, therapists were judged to have performed more poorly. Patients' preexisting negative expectations about the potential outcome of treatment were associated with patient difficulty and poorer therapist performance, while the level of presenting symptomatology was not. Thus, it appears that the patient's ability to engage in a productive therapeutic relationship rather than the severity of his presenting problems influenced the therapist's ability to competently perform IPT. The findings regarding the relationship of patient difficulty to ratings of therapist performance suggest that patient difficulty should be taken into account in assessing therapist competence, whether for studies of therapeutic efficacy or for clinical supervision and training in general.