Therapeutic alliance and progress in couple therapy: multiple perspectives

Therapeutic alliance research in couple therapy using multiple perspectives and longitudinal data has been sparse. This study used structural equation modelling to explore relationships between changes in alliance and in progress from clients' and therapists' perspective in a fairly large sample of couples (N=195) during the initial stage of therapy at an on‐campus training clinic. Self‐rated alliance was measured after sessions 2 through 4 with the Working Alliance Inventory. There was very little change in alliance over the early sessions of therapy, and changes in alliance did not always account for changes in relationship satisfaction. Husbands' perceptions of satisfaction and alliance seem to play an important role in the dynamics of the therapeutic process. Findings suggest a reciprocal relationship between perceptions of alliance and progress in therapy when combining perceptions of therapists and couple clients. Clinical implications and future research are discussed.     

The formation of the therapeutic alliance in couple therapy

This study examines the predictive validity of several clinical variables--including marital distress, individual symptomatology, and family-of-origin experiences--on the formation of the alliance in couple therapy. Eighty people who were treated with a naturalistic course of integrative conjoint psychotherapy at a large midwestern outpatient clinic were assessed on the clinical variables before session 1. They also completed ratings of the therapeutic alliance after sessions 1 and 8. Individual symptomatology did not predict alliance formation at either treatment stage. Higher levels of marital distress predicted poorer alliances to treatment between partners at session 1. Marital distress also predicted therapeutic alliance quality for men and women at session 8. Family-of-origin distress predicted alliance quality for men at session 1, and for women at session 8. Family-of-origin distress for men and women predicted split alliances early in treatment, and marital distress predicted split alliances for women at session 8. Clinical implications for the assessment and treatment of couples are discussed.     

Reflections on the early stages of the Oedipus complex: The parental couple in relation to psychoanalytic work

The author refers to the parental couple as it appears in relation to the Oedipus complex at the various levels of development and psychical maturation. A 'pathological' Oedipus situation is differentiated from a 'normal' one. Accordingly the author distinguishes the primitive Oedipal fantasies about the parental couple represented in the myth by the parents of Thebes and the parents of Corinth (and the influence that these can have on the psychoanalytic work), from a couple who have reached truly creative functioning. Furthermore, it is pointed out how elements are activated in the therapist's mind: emotional qualities of a feminine maternal and masculine paternal kind that either collaborate in containing and promoting the psychoanalytic process and psychic development of the patient or else fail in this task.     

Factorial and construct validity of the revised short form integrative psychotherapy alliance scales for family, couple, and individual therapy

The Integrative Psychotherapy Alliance model brought an interpersonal and systemic perspective to bear on theory, research, and practice on the psychotherapeutic alliance. Questions have been raised about the independence of the theoretical factors in the model and their operationalization in the Individual, Couple, and Family Therapy Alliance Scales. This paper presents results of a confirmatory factor analysis of the scales that delineated at least three distinct interpersonal factors as well as shorter versions of the three scales to facilitate their use in research and practice. The paper also presents the results of a study testing each factor's association with client retention and progress over the first eight sessions in individual and couple therapy. At least two of the interpersonal factors were uniquely associated with progress in individual and couple functioning. Implications of the results for theory, research, practice, and training in individual, couple, and family therapy are elaborated.     

Developing the couple perspective in parenting support: evaluation of a service initiative for vulnerable families

The importance of the relationship between parents is frequently underestimated by those designing and developing services to support parents in bringing up their children. Instead, the primary focus of recent family support initiatives in the United Kingdom has been on improving parenting skills. This article describes the outcomes of a project designed to maximize the effectiveness of parenting support to vulnerable families through sensitizing the workforce of a community‐based adult mental health agency to take account of the parental couple in providing postnatal support groups, parenting workshops and relationship counselling. Evaluating outcomes from these services suggests that a couple orientation adds significant value to the effectiveness of parenting support.     

Influence of expressed emotion and perceived criticism on cognitive-behavioral therapy for social phobia

This study examined significant others' expressed emotion (EE) and a closely related construct, perceived criticism, as predictors of cognitive-behavioral therapy outcome in a sample of 40 patients with social phobia (social anxiety disorder). Patients enrolled in group therapy for social phobia completed pre- and post-treatment questionnaire measures of perceived criticism and anxious and depressive symptoms. Designated significant others were assessed for the components of high EE (criticism, hostility and emotional overinvolvement) using the Camberwell Family Interview. It was hypothesized that these high-EE components and patients' perceived criticism would be associated with poorer treatment outcome, and results ran counter to these expectations. Controlling for initial social phobia severity, lower levels of perceived criticism predicted treatment dropout. There was also a nonsignificant trend for participants with a significant other rated as high in emotional overinvolvement to show less change on a composite symptom measure. Findings from this study suggest that close relationships impact the outcome of cognitive-behavioral interventions for social phobia.     

Program for advanced studies in integrative psychotherapy: Family,couple, and individual therapy (an interdisciplinary program)

This article describes briefly an advanced program in integrative marital and family therapy and individual psychotherapy established at the Hebrew University of Jersusalem in 1993–94 and its first two years of successful operation.     

The Role of Theory and Research in the Practice of Cognitive-Behavioral Couple Therapy: If You Build It,They Will Come

Cognitive-behavioral couple therapy (CBCT), while empirically validated and highly efficacious, does not always have positive results for couples. One factor that may limit the efficacy of this intervention is the way in which therapists are trained to provide this type of therapy. More specifically, there is a need for therapists to gain a solid foundation in CBCT theory in order to maximize treatment results. This paper presents an argument for why an understanding of theory is necessary for therapists in treating couples. Then, this paper presents our training model and how we integrate theory into our training of both graduate student therapists and more experienced clinicians. We take the stance that “if you build it, they will come.”     

从指南看冠心病降脂治疗的现状及分析

层出不穷的试验研究和不断更新的指南使人们对冠心病防治的认识不断加深,但指南的实施和普及却不理想,大多数冠心病患者并未真正受益于降脂治疗。现就NCEP-ATP指南的更新和目前冠心病患者降脂治疗的现状、主要影响因素(患者的依从性、医务工作者的医疗质量、药物有效性以及效价比与经济条件)及可能的改善措施做一综述。     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

Narcissism, solitude, friendship: notes on the therapeutic alliance in the context of the Freud-Jung relationship

This paper deals with friendship and therapeutic alliance as a transformation of the libidinal love that structures the Oedipal complex. The author considers the relationship between Jung and Freud as a formidable test that may shed light on their personalities and on the relevance of the Oedipal complex for both of them and for their particular theories and practices. The author discusses the possibility that the Oedipal complex may be seen under a finalistic frame of reference and discusses which implicit goals it may express. Such a goal has not been reached by either Freud nor Jung, but might be the key to underline and recognize the fundamental importance of the 'therapeutic alliance' within the analytical situation, seen as a potential relationship between the selves of the patient and of the analyst springing from a transformation of libidinal love into 'friendship' as it was described by Friedrich Nietzsche.     

Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb

Studies in academic research centres with selected patients have shown that several cognitive behaviour therapies are effective in the treatment of PTSD following traumas affecting individuals or small groups. Little information is available on the extent to which these positive findings will generalize to more routine clinical settings with less selected patients or to a trauma that affects a whole community. The present study addresses these generalization issues. A consecutive series of 91 patients with PTSD resulting from a car bomb which exploded in the centre of Omagh, Northern Ireland in August 1998 were treated with cognitive therapy, along lines advocated by Ehlers and Clark (2000). There were no major exclusion criteria and 53% of patients had an additional axis I disorder (comorbidity). Therapists were NHS staff with heavy caseloads and modest prior training in CBT for PTSD. A brief training in specialist procedures for PTSD was provided. Patients received an average of eight treatment sessions. Significant and substantial improvements in PTSD were observed. Degree of improvement was comparable to that in previously reported research trials. Comorbidity was not associated with poorer outcome, perhaps because comorbid patients were given more sessions of treatment (average 10 vs 5 sessions). Patients who were physically injured improved less than those who were not physically injured. Overall, the results indicate that the positive findings obtained in research settings generalize well to a frontline, non-selective service.     

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

ABSTRACT

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.     

Definitional and Research Issues in the Common Factors Approach to Psychotherapy Integration: Misconceptions, Clarifications, and Proposals

This paper focuses on two common misconceptions of common factors in therapy. The first misconception entails the confusion between common factors and therapeutic factors, and thus the inappropriate and misleading use of the term therapeutic common factors in various situations. The second misconception is the mixing of commonalities of different kinds and levels in proposed lists and studies of common factors. These areas are discussed and clarified, and recommendations designed to facilitate conceptual and methodological improvements relative to each misconception are offered. The selection of best levels and kinds of common factors to be studied are further explored (i.e., the study of client change events and antecedent therapist behaviors across different therapies), and specific proposals for their research are outlined.     

Lexical stress,frequency, and stress neighbourhood effects in the early stages of Italian reading development

We examined the development of stress assignment in reading Italian aloud. We investigated frequency effects as a marker of the use of item-specific lexical knowledge in assigning stress together with stress dominance and stress neighbourhood (the number of words sharing both stress and ending) as markers of distributional information regarding properties of the lexicon extracted from spoken language. We tested second- and fourth-graders in a reading-aloud experiment including high- and low-frequency words and nonwords. Results show that despite the regularity of orthography–phonology mappings in Italian and the predominant use of phonological recoding procedures, item-specific lexical knowledge is also used, even by beginning readers. The frequency effect was significant and did not increase with age, while stress errors on low-frequency words decreased with increasing grade. Stress neighbourhood increasingly affected stress assignment on nonwords with older children. Taken together, our findings show that both item-specific knowledge and general information about stress distribution are relevant in children's reading, suggesting the simultaneous use of both lexical and sublexical information. Moreover, as the reading system develops, and knowledge about the relative distribution of stress neighbourhood increases, larger grain-size units are also exploited.     

Prevention, solution-focused therapy, and the illusion of mental disorders

Therapy theorists' criticism of the lack of specific mechanisms in the prevention of mental disorders is examined from the perspective of solution-focused therapy (SFT), which argues that solutions can be unrelated to problems, and that it is not even necessary to know what a problem is in order to solve it. It is suggested that the shift of attention from problems to solutions in SFT offers a conceptual framework within which the criticism is not relevant, and from which theorists of therapy and prevention can share a common outlook. This outlook involves a focus on encouraging productive, useful, positive behavior, with a corresponding deemphasis on an skepticism about current conceptualizations of mental disorders.