Is Therapeutic Alliance Influenced by a Feminist Approach to Therapy?

Although the feminist critique of marriage and family therapy has been a significant part of the literature for many years, its impact has been blunted by two criticisms. The first suggests that the feminist critique lacks empirical support. The second suggests that the feminist critique promotes an alliance with women clients at the expense of men. The first criticism has been addressed in recent years. The present study examined the relationship between feminist principles and therapeutic alliance. Results suggest that feminist principles actually enhance therapeutic relationship for men clients but has no effect on therapeutic relationship for women clients.of the Marriage and Family Therapy Program     

Cultural ruptures in short‐term therapy: Working alliance as a mediator between clients' perceptions of microaggressions and therapy outcomes

Aim: To determine whether or not clients' perceptions of microaggressions varied based on their own and the therapist's race/ethnicity and whether or not they would be negatively related to the effectiveness of therapy and if the working alliance would mediate this effect. Method: The study utilised a cross‐sectional, retrospective, methodology. Clients were recruited from a large university counselling centre in the United States (N=232 clients and 29 therapists). Results: Neither clients' race/ethnicity, therapists’ race/ethnicity, nor client‐therapist ethnic matching predicted perceptions of microaggressions. Clients' ratings of microaggressions were negatively associated with their psychological wellbeing; however, this effect was mediated by clients' ratings of the working alliance. Implications: Therapists should take into account the cultural messages they may be conveying to both white and racial/ethnic minority clients. Therapists should develop strategies that are consistent with a general therapeutic approach that promotes discussions about culture with their clients and, most importantly, should attend to the therapeutic relationship.     

What Does the Alliance Predict in Group Interventions for Early Psychosis?

The therapeutic alliance is considered an essential component of any clinical or psychological intervention. The therapeutic alliance can however change over time, and therefore it is relevant to determine if the alliance and its variations are related to clinical outcomes. The present study had three objectives: (1) determine the impact of the alliance measured by the client and the therapist, on clinical and psychosocial outcomes of individuals with early psychosis receiving group interventions; (2) measure the concordance between the client and the therapists’ ratings of the alliance; and (3) determine the best predictor of the client’s alliance in our sample. A total of 36 individuals with early psychosis who participated in group interventions for symptom management answered the WAI three times, and so did the group therapists. Outcomes included measures of insight, symptoms (total, positive and negative), and self-esteem. Attendance and group participation were also measured. Results suggest that the overall client’s alliance predicted total symptoms and self-esteem at post-therapy, whereas both clients’ and therapists’ ratings predicted group attendance and participation. Greater variations in the alliance overtime for the clients were somewhat linked to worse negative symptoms at post-therapy. Alliance ratings were generally high and fairly concordant between therapists and clients. Only the baseline measure of capacity for attachment, predicted the client’s overall alliance scores. Clinical implications are discussed.     

Modèle systémique de l'alliance thérapeutique

This article presents Pinsof's (1995) systemic model of therapeutic alliance. Pinsof's systemic model of alliance sees the therapy as an interaction between the systems of the client and those of the therapist. This model is composed of two primary dimensions: an interpersonal system dimension and a content dimension. The first focus on four levels of the alliance between and within the therapist and patient systems. The dimension of content includes three qualities of alliance that cut across the four interpersonal dimensions. We studied the notion of alliance profiles, institutional alliance and the notion of split alliance because the alliance is born and evolutes inside the interaction between the systems of the client and those of the therapist. Thus clients develop an alliance not only with their own therapist but also with the systems in which the therapist operate.     

Building Alliances with (In)Voluntary Clients: A Study Focused on Therapists’ Observable Behaviors

This study aimed to compare therapists’ observable behaviors to promote alliances with involuntary and voluntary clients during brief family therapy. The therapists’ contributions to fostering alliances were rated in sessions 1 and 4 using videotapes of 29 families who were observed in brief therapy. Using the System for Observing Family Therapy Alliances, trained raters searched for specific therapist behaviors that contributed to or detracted from the four alliance dimensions: engagement in the therapeutic process, an emotional connection with the therapist, safety within the therapeutic system, and a shared sense of purpose within the family. The results showed that when working with involuntary clients, therapists presented more behaviors to foster the clients’ engagement and to promote a shared sense of purpose within the family. However, in the fourth session, the therapists in both groups contributed to the alliance in similar ways. The results are discussed in terms of (a) the therapists’ alliance‐building behaviors, (b) the specificities of each client group, and (c) the implications for clinical practice, training, and research.     

Client crying in the context of family therapy: an exploratory study

This study explores the crying episodes of twenty‐eight clients treated at a family therapy service in a community centre. The crying episodes were associated with some significant elements: the time of appearance, the content and triggering factor, the interpersonal context of sessions and the emotions clients had for the therapist, as well as the therapy's outcome (end of treatment and the satisfaction of clients). Crying was much more frequent during the first session. It occurred more frequently when there was another family member present. The proportion of clients who cried during the treatment was significantly higher for clients who completed it successfully. Clients who cried perceived the therapist, in all cases, as a kind person who never got annoyed with them. Crying could be considered a type of behaviour that helps the therapist to create a safe context and foster the therapeutic alliance.     

The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

The therapeutic alliance in adolescent substance abuse treatment: a one-with-many analysis

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes.     

Honoring Protective Responses: Reframing Resistance in Therapy Using Polyvagal Theory

Therapists often conceptualize resistance as client behaviors that impede progress; this perspective threatens the therapeutic alliance, especially in couple and family therapy where increased resistance and multiple alliances are present. Polyvagal theory reframes and normalizes resistant behaviors as preconscious, protective responses emerging from our autonomic nervous system. The theory also explains how humans reciprocate safety cues to connect with each other; therapists can use concepts of polyvagal theory to manage their own emotional regulation and foster safety and connection in therapy. Polyvagal concepts deepen our understanding of protective behaviors presenting in couple and family therapy; therapists can help couple and family clients to recognize protective behaviors in their own relationships and facilitate safer connection and engagement. Clinical implications are presented: psychoeducation can help clients normalize and understand their protective processes; therapist presence and immediacy acknowledges and normalizes protective behaviors as they arise; therapist and client self-regulation skills support connection; therapist genuineness is a precondition to client safety; and understanding of polyvagal theory enhances assessment of conflict and enactments in couple and family therapy.

     

The facilitative interpersonal skills method: Difficult psychotherapy moments and appropriate therapist responsiveness

The Facilitative Interpersonal Skills (FIS) task is a performance test of therapists’ use of common relational skills (e.g. empathy, building expectations). The FIS method includes (a) materials that simulate difficult client moments on video, which are used to collect therapists’ responses to these situations; and (b) independent ratings of these responses. Many of the FIS items are informed by psychotherapy processes that have been linked to outcome and facilitative conditions that have been reframed as individual therapist skills (e.g. alliance bond capacity). Overall, the FIS has predicted psychotherapy outcome. A single study is described in which FIS predicted the therapist effect using multilevel modelling of a large sample of clients who were nested within therapists. We also summarise two additional outcome studies that used experimental designs. One future direction is to better understand how therapists form responses to these difficult moments. We conclude that forming an optimal therapeutic response during challenging, emergent in‐session situations involves responsiveness (Stiles et al., 1998), or finding a response that fits the clients’ needs within any moment.     

Fostering Client Creativity in Family Therapy: A Process Research Study

Creativity has been shown to enhance problem solving, and to increase flexibility and adaptability—qualities associated with positive therapeutic outcomes. Literature related to therapist and/or client creativity is primarily anecdotal. Empirical literature addressing how therapists can facilitate the creativity of their clients in family therapy is scarce. In this study, the researchers used process methodology to code the behavior of therapists and clients in 31 videotaped family therapy sessions. Results show a significant positive correlation between interventions that induce positive affect and the creative client behaviors of optimism and playfulness.     

Comparing Alliance in Two Cognitive-Behavioural Therapies for Adolescents With ADHD Using a Randomized Controlled Trial

Alliance is defined as the client-therapist bond and their ability to collaborate on therapeutic activities. Treatment for adolescents with ADHD is rarely studied in terms of alliance. In this study, two cognitive-behavioral treatments (CBT; one structured treatment aimed at planning skills and one less-structured solution-focused treatment, both delivered in the style of Motivational Interviewing) were compared with regard to alliance and alliance-outcome association. The influence of therapist competence on this alliance-outcome association was also evaluated. The alliance between 69 adolescents diagnosed with ADHD and their therapists was measured early in treatment, using the Therapy Process Observational Coding System for Child Psychotherapy–Alliance scale. Observer-rated therapist competence was measured using the Motivational Interviewing Treatment Integrity scale (version 3.1.1.). Outcome variables were the adolescents’ reduction in planning problems and ADHD symptoms. The alliance, and, more specifically, collaboration on therapeutic activities, was significantly higher for the more structured CBT (p = .04; moderate effect size). Alliance was not related to outcome in the more structured CBT, while the alliance was positively related to the reduction in planning problems in the less structured CBT. Finally, alliance was a significant mediator between therapist competence and treatment outcome for the less-structured CBT. The clarity and structure of CBT may help facilitate alliance formation for adolescents with ADHD who often have difficulty implementing structure themselves. Therapists may need to invest more in alliance formation in less structured CBT as the alliance affects outcome. Moreover, enhancing therapist competence in less structured CBT may help improve outcomes in less structured CBT, as therapist competence may impact outcome through alliance.     

Real relationship,working alliance,transference/countertransference and outcome in time-limited counseling and psychotherapy

Six client/therapist dyads (three therapists each working with two clients) were studied to determine how the real relationship unfolds over the course of time-limited treatment and how this unfolding relates to the development of the client/therapist working alliance, client transference, and therapist countertransference. We also examined how these indices of the relationship fluctuate as a function of treatment outcome. Results indicate that in general for all six dyads, therapists’ and clients’ ratings of the real relationship and working alliance were strong throughout treatment. However, patterns of real relationship and working alliance over the course of treatment varied between dyads categorized as more vs. less successful. Therapists’ countertransference was low, as was client transference, but differences in ratings were evident when the dyads were classified by outcome.     

Do motivational interviewing behaviors predict reductions in partner aggression for men and women?

Motivational interviewing is a directive, non-confrontational intervention to promote behavior change. The current study examined therapist behaviors during a successful brief motivational interviewing intervention for physically aggressive college dating couples (Woodin & O'Leary, 2010). Forty-five minute motivational interviews with each partner were videotaped and coded using the Motivational Interviewing Treatment Integrity scale (MITI; Moyers, Martin, Manuel, & Miller, 2003). Hierarchical modeling analyses demonstrated that therapist behaviors consistent with motivational interviewing competency predicted significantly greater reductions in physical aggression perpetration following the intervention. Specifically, greater reflection to question ratios by the therapists predicted reductions in aggression for both men and women, greater percentages of open versus closed questions predicted aggression reductions for women, and there was a trend for greater levels of global therapist empathy to predict aggression reductions for women. These findings provide evidence that motivational interviewing seems to have an effect on behavior change through therapist behaviors consistent with the theoretical underpinnings of motivational interviewing.     

Collaboration and a Self-Help Orientation in Therapy with Suicidal Clients

Working with suicidal clients historically has placed a heavy burden of responsibility on the therapist for a successful outcome. This orientation generally has left clinicians feeling stressed and in need of controlling their clients' behavior; clients, in turn, often have developed unrealistic expectations of therapy or resistance of the therapist's interventions. In this context, the chance for a potentially valuable collaboration between client and therapist is often lost. This paper builds on previous work that has introduced the notion of a collaborative working relationship with suicidal clients. It is argued that the therapeutic process ideally should not only utilize the therapist's knowledge and skills in treating suicidal clients, but also cultivate self-efficacy by encouraging the client to adopt a self-help orientation to therapy. Several general principles of a collaborative/self-help orientation to working with suicidal clients are discussed and a variety of specific therapeutic strategies consistent with this orientation are described.     

Phone coaching in Dialectical Behavior Therapy: frequency and relationship to client variables

Telephone coaching is a treatment mode in Dialectical Behavior Therapy (DBT) that is designed to help clients generalize skills, prevent suicidal behaviors, and repair therapeutic ruptures. To date, phone coaching has received scant empirical investigation. The aims of this study were to (1) describe patterns in frequency of telephone calls and text messaging in DBT and (2) investigate whether demographic factors, baseline severity, suicidal behaviors, and therapeutic alliance are associated with phone and text frequency. Participants were 51 adults (35 treatment completers) with borderline personality disorder (BPD) in a six-month comprehensive DBT treatment program. Phone coaching frequency was documented by therapist weekly session notes. The average number of contacts per month was 2.55 (SD = 4.49). Four of the 35 treatment completers comprised 56% of the contacts. Having a recent history of suicidal behaviors, degree of severity at baseline, or the strength of the therapeutic alliance was not associated with phone coaching use. However, lower income was significantly associated with a higher frequency of phone coaching use. These preliminary results can help clinicians and administrators make informed decisions on how to better provide phone coaching and clarify the degree of effort involved in providing this service to clients with BPD.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

Valuing clients' perspective and the effects on the therapeutic alliance: a randomized controlled study of an adjunctive instruction

The patterns of growth and development of the therapeutic alliance over the course of therapy have been of continued interest to psychotherapy researchers. The purpose of this study was to investigate whether a simple institutional metacommunication intervention with clients had an effect on the development of the alliance. This adjunctive instruction involved inviting therapy clients to take a proactive role in their treatment by encouraging feedback to their therapist about various aspects of the therapy process. In this randomized controlled study (N = 94), clients were assigned to 1 of 2 conditions: (a) an institutional adjunctive instruction condition in which patients were contacted by clinic personnel at the beginning of the remediation phase (Session 5) and encouraged to take a proactive role in their treatment and (b) a control condition that contained no institutional adjunctive instruction. Between-condition differences in the alliance were tested, controlling for baseline influences and the early therapeutic alliance. Clients' postsession reports from Sessions 1 to 24 indicated that the adjunctive instruction increased the alliance over the course of therapy vis-à-vis the control condition. The adjunctive instruction appeared to have fostered clients' evaluation of their therapists' interest in their welfare. The results indicate that interventions, even brief or subtle, can produce lasting benefits in the alliance when targeted at specific psychological processes. Systematic metacommunication from the institutional level appeared to reinforce clients' therapeutic alliance with their therapists in individual treatment.