Clinician level factors of empathy and listening skills predicted outcomes strongly in studies of .. The them is, "The Psychotherapy Relationship: What Works?. Keywords: alliance measures, evaluation of psychotherapeutic process, . the patient to believe in the therapist's ability to help him/her and the. Although the psychotherapeutic relationship is influenced by general .. time outside of the actual therapy practicing various therapy skills (8).
Read More 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 process of emotional and psychological healing. There are hundreds of studies that show that a purposeful collaborative relationship between a therapist and the patient correlates with positive therapeutic progress. The most important aspect of effective therapy requires the patient and the therapist work collaboratively.
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.The Therapy Relationship – Key Ideas in Therapy (1/3)
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. A score on a 5- HAcsa HArand a 6- HAq point rating scale is assigned to a series of items grouped into sub-scales according to the type of alliance being considered. For each scale, the alliance score is the sum of the subscale ratings.
In the VPPS rating is performed on a segment of the therapy, using a five-point scale to measure 80 items. In the VTAS tapes of treatment sessions are rated using a six-point scale to measure 44 items. The VTAS has demonstrated solid inter-rater reliability, internal consistency, and convergent validity with other alliance measures Krupnick et al. Toronto scales Marziali, ; Marziali et al. Specific focus on the affective aspects of the alliance. Each item is rated on a six-point scale. Tracey and Kokotovic have developed a shortened version of these scales.
The WAI is a self-report scale consisting of 36 item each of one rated on a seven-point scale. The shorter version consists of 12 item. Several studies have demonstrated the predictive validity of this instrument in a variety of treatments Horvath, ; Horvath and Greenberg, ; Howard et al. California scales Gaston and Marmar, ; Marmar et al. The former derives from the TARS and focuses on the affective and attitudinal aspects of the alliance rather than on specific therapeutic interventions.
Each item is rated on a seven-point scale. The TSR is a item structured-response instrument. Most of the item are scored in a binary fashion or on a 0—2 scale. Adequate internal consistency and inter-rater reliability Elvins and Green, ; Kolden, Therapeutic bond scales TBS Saunders et al.
This instrument consists of 50 item belonging to the following dimensions: Altogether, these subscales provide a Global Bond scale.
Each item is rated on a point scale. All three scales and the Global Bond scale are related to patient ratings of session quality Martin et al. The report is filled in by the therapist and consists of six items rated on a five-point scale. Patients also respond to 12 items that rate the level of therapist collaboration.
Alliance as measured by the PSR has been shown to be correlated with outcome in patients with severe and enduring mental illness such as schizophrenia Elvins and Green, ; Svensson and Hansson, The ARM was intended to describe components of the alliance in language designed to be acceptable within a wide range of theoretical orientations and was developed during the Second Sheffield Psychotherapy Project, a randomized comparison of cognitive—behavioural therapy and psychodynamic—interpersonal therapy for depression.
The ARM assesses five dimensions of the alliance: The ARM has five scales comprising 28 items rated on parallel forms by patients and therapists using a seven-point scale. 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.
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. Highly correlated with the ARM. The scale has not been used in outcome research.
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.
Understanding the Therapeutic Alliance - Psychotherapy Treatment And Psychotherapist Information
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.
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.
Therapeutic relationship - Wikipedia
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. 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.