Personality Assessment in Today's Health Care Environment: Therapeutic Alliance and Patient Satisfaction

This autobiography traces my professional and, to a lesser extent, personal life through my career as a forensic and correctional psychologist. As an only child living in the country and later attending boarding schools from the fifth grade through high school, I learned to be self-reliant and independent. These traits led me to join an archaeological expedition to Oaxaca when I was 18, which fostered my interest in anthropology and then psychology at Amherst. I survived the clinical training program at the University of California at Berkeley and while still in graduate school obtained a staff position at the Alameda County Probation Department Guidance Clinic where I began my interrelated research paths on clinical assessment and the dynamics of aggression, paths I continued as an assistant professor at the University of Texas (1964–1967) and as an associate to full professor at the Florida State University (1967–2003). My major research contributions have been the (a) delineation of the overcontrolled and undercontrolled assaultive syndromes; (b) development of the MMPI–2 (Butcher, Dahlstrom, Graham, Tellegen, &; Kaemmer, 1989 Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A. and Kaemmer, B. 1989. MMPI-2: Minnesota Multiphasic Personality Inventory–2: Manual for administration and scoring, Minneapolis: University of Minnesota Press.  [Google Scholar]) Overcontrolled Hostility (O–H) Scale; (c) formulation of the “Algebra of Aggression,” a theoretical framework for evaluating and understanding aggressive behavior; (d) exploration of how gender roles interact with dominance in leadership assumption; (e) empirical demonstration of the adverse effects of population density on adjustment in correctional institutions; and (f) development and validation of a classification system for adult criminal offenders based on the MMPI–2.     

VA Puget Sound Telemental Health Service to rural veterans: a growing program

The VA Puget Sound Health Care System Telemental Health program connects veterans with psychologists, psychiatrists, and social workers via live clinical video teleconferencing. Providers deliver care to veterans in rural Veteran Affairs medical centers, community-based outpatient clinics and residences, and thus, increase access to specialty mental health care for rural and medically underserved veteran communities.     

The Therapeutic Alliance in Multicultural Practice

Abstract

The therapeutic relationship rests on both an emotional bond with the therapist and a rational, “working” connection. Both dimensions of the alliance have relevance for multicultural clinical work. There have been many contributions to multicultural practice that emphasize either cognitive or emotional levels of the alliance. This paper uses both empirical studies and clinical papers to synthesize both the emotional and the rational perspectives on the multicultural alliance. Examples are drawn from literature, published case examples, and the author's own clinical practice.     

The Play Relationship and the Therapeutic Alliance

Abstract

This article examines the function of play in normal development and within the treatment relationship in both child and adult psychotherapy. Noting its developmental function and the natural role that play has as a mode of communication with children, the author emphasizes the centrality of play in the construction of the therapeutic alliance. The therapeutic alliance is characterized here as a libidinal attachment, a new object relationship through which developmental experiences involving play may be revivified and, ultimately, may lead to the forging of more enduring and successful adaptations. Two detailed clinical vignettes furnish illustrations of the ways in which play themes and scenarios develop in therapy, and how their association to the therapeutic alliance and transference relationship may be understood and interpreted.     

The Therapeutic Alliance: Implications for Therapeutic Process and Therapeutic Goals

Interest in the importance of the therapeutic alliance to the psychotherapeutic process has recently grown across theoretical domains. Through a case example the author demonstrates that in some cases a familiar pattern of relating with the therapist may be more important for the client in terms of treatment success than positive regard early in treatment. Also, charting shifts in the quality of the relationship rather than quantitative changes in the alliance may help the therapist navigate the recursive emergent properties of relationship, goals of treatment and choice and timing of interventions. Finally, the author suggests that the therapist’s internalization of the client may represent a significant leap in the relationship, and help reduce some of the “sloppiness” that is inherent in the therapeutic process.     

Research Developments on the Therapeutic Alliance in Psychodynamic Psychotherapy

Research on psychotherapy in general, and psychodynamic therapy in particular, has consistently found that the quality of the alliance predicts the outcome of treatment. Little empirical support exists for the notion that the alliance sets the stage for techniques to be most effective, although adequate studies of this interaction between techniques and alliance are scarce. Research suggests that that the alliance is influenced in part by preexisting patient characteristics and in part by the quality of therapist interventions. Limitations of the empirical literature on the alliance are presented and some suggestions for future research are given.     

Pretreatment Correlates of the Therapeutic Alliance in the Chronically Depressed

We examined the relationship between patient characteristics and the working alliance in a multisite trial for chronic depression. Patients treated with the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), alone (n = 169) or combined with nefazodone (n = 198), completed the Working Alliance Inventory during the 2nd week of treatment. Within the CBASP alone group, a history of drug abuse/dependence, lower peak social adjustment over the past five years, and lower current social adjustment predicted a significantly poorer alliance. Within the combination group, male gender and a distancing coping style predicted a significantly poorer alliance. Results should be interpreted with caution since they did not replicate across treatment groups, and the number of significant findings were not much greater than chance expectations.     

The Perceived Relative Strength of the Therapeutic Alliance

ABSTRACT

The association between the perceived relative strength of the therapeutic alliance in couples therapy and psychotherapeutic outcome was investigated. The perceived relative strength of the couples therapeutic alliance was classified into three categories: a balancedalliance (an individual perceives his/her own alliance and the partner's alliance as approximately equal in strength), a positively biasedor blessedalliance (an individual perceives his/her alliance as stronger than the perception of the partner's alliance) and a negatively biasedor just biasedalliance (an individual perceives his/her alliance as weaker than the perception of the partner's alliance). The impact of a consensus or non-consensus within each partner about the perceived relative strength of the alliance on outcome was also investigated. The Alliance Inventory for Couples was used as a measure of the alliance and outcome was assessed with the Family Environment Scale and the Marital Satisfaction Scale. No statistically reliable relation was found between perceived relative strength of the alliance and improved outcome. Consensus was also not predictive of outcome. These findings failed to confirm previous theoretical propositions and empirical research. Possible reasons for discrepancies between the current findings and previous research are provided. The distinction between perceived strength and strength based upon independent self-report measures; and the designation of biased, blessed and balanced alliances merit future research.     

Implementation of Universal Behavioral Health Screening in a University Health Setting

Universal screening at university health centers can facilitate early identification and treatment of behavioral health problems common among college students. This article describes the (a) process of implementing behavioral health screening at a university health center and (b) results of universal screening for depression, suicidal ideation, alcohol misuse, tobacco use, and sleep problems. We discuss the decision points involved in screening, including what to screen for, whom to screen, how to implement the screening measure, and how to deal with patients who screen positive. During the Spring and Fall 2010 academic semesters, 4,126 screening questionnaires were completed by students (62 % female) accessing a university health center. Each semester, 9–13 % of students screened positive for depression, 2.5–3 % for suicidal ideation, and 33–38 % for alcohol misuse, while 10 % wanted help with smoking cessation and 12–13 % with sleep problems. The results suggest that behavioral health screening in a university health center can help identify students with behavioral health concerns to increase access to care.     

Influence of Therapist Behaviors on Therapeutic Alliance

A number of recent studies have investigated the relationship between therapist and client gender and conversation in marriage and family therapy. There has also been recent empirical investigation of therapeutic alliance and its influence on therapy outcome in marriage and family therapy. However, there has been limited investigation of the influence of interactional patterns on therapeutic alliance. It seems probable that therapy conversation (which seems to be influenced by gender) will influence therapeutic alliance and subsequent outcome.     

Empty Depth,Empty Breadth,and the Forging of a Therapeutic Alliance

This paper describes a case in which analyst and analysand became interlocked in battles that drew out the 'mad' parts of each other. It explores how the extreme conflict may have actually been an integral part of what has become a truly therapeutic process for both. Theoretically, the dialectical movement of becoming through contradiction is used to help explicate how mutually destructive enactments were necessary building blocks of genuine intimacy.     

Implementing a Virtual Health Telemedicine Program in a Community Setting

Aurora Health Care in eastern Wisconsin has a clinical genetics program driven by genetic counselors in the cancer/adult and prenatal genetics settings. In 2015, the workforce shortage of genetic counselors left us with 4 open positions for genetic counselors that we were unable to fill. We explored many models of alternative service delivery, and determined virtual health (VH) via telemedicine to be the best option for our system. Historically, telemedicine technologies have been used to provide access to healthcare services to patients in remote areas. We, however, were struggling to find genetics counselors to staff both our remote clinics and urban clinics. To solve this problem, we recruited genetic counselors from across the country to work remotely from their current home or home office utilizing VH to staff our clinics. We then created clinical workflows and an implementation process of virtual health for 9 prenatal and cancer clinics across the eastern Wisconsin footprint of our healthcare system over the course of 12 months. Here we provide our experience and process in establishing a VH program in order to help other institutions that have been affected by the workforce shortage of clinical genetics professionals.     

The Facilitation and Maintenance of the Therapeutic Alliance in Family Therapy

The formation and maintenance of the therapeutic alliance in family therapy involves complexities pertaining to the stabilizing tendency of family systems, and the necessity for negotiation of the goals and tasks of therapy with and among multiple individuals (i.e., the family members) in a context of systemic reciprocity and mutual influence. This article explores the complexities associated with the establishment and maintenance of the therapeutic alliance in family therapy. Alliance stances are presented as clinical applications designed to assist therapists in working with split alliances, establishing within family collaboration, and in negotiating homeostatic processes.     

The Association Between Therapeutic Alliance and Treatment Outcomes in a Group Triple P Intervention

A growing literature has examined the association between therapeutic alliance and treatment outcomes in child therapy. Few studies, however, have specifically investigated the role of therapeutic alliance within evidence-based parenting programs for children with externalizing behavioural difficulties. The current study prospectively collected measures of therapeutic alliance for 117 families completing a Triple P parenting program in a community children’s mental health center. Higher levels of mother and father rated therapeutic alliance were associated with greater gains in parenting skills and parental sense of competence. Parental rated therapeutic alliance was also associated with greater improvements in child conduct problems for mothers, but not fathers. However, therapist ratings of therapeutic alliance had limited associations with treatment improvement. The implications of the findings for clinical practice are discussed.     

The Development and Role of the Therapeutic Alliance in Supportive Psychotherapy with Adolescents

The formation of a therapeutic alliance is considered a central issue in therapy, and particularly crucial and challenging in work with adolescents. The relational and technical components of the therapeutic alliance were examined from the perspective of the adolescent client. 40 emotionally disturbed adolescent girls, aged 13 to 16 years, received brief supportive psychotherapy in the school setting. The alliance was assessed at sessions 3, 6 and 9, and outcome was evaluated on measures of internalizing problems, self-esteem, adjustment and client satisfaction. The results indicated the stability of the alliance between sessions 3 and 6, followed by significant linear increases between sessions 6 and 9. The strength of the alliance was most consistently related to reductions in internalising problems and client estimates of change. The implications for training and clinical practice with adolescent clients are discussed and future research avenues outlined.     

Revisiting Bordin's Theory on the Therapeutic Alliance: Implications for Family Therapy

Because of the belief that relationships are a major contributor to problems as well as the avenue for bringing about change, the alliance between therapists and clients is important in family therapy. Writings and ideas on the therapeutic alliance from psychoanalytic theory were used by Edward Bordin to develop a working theory in 1979, and later adapted to the field of family therapy. However, the adaptation did not account for many variables unique and important to family therapy. This article describes the therapeutic alliance and the necessity of creating a theory of therapeutic alliance that accounts for family therapy concepts. Future ideas for scholarship are presented.     

Shifting from Treatment Plans to Action Plans: Solidifying the Therapeutic Alliance

This article summarizes the evolution of my theoretical orientation and treatment intervention style over the past thirty-something years. It discusses the pathways taken, influences felt, and experiences that have contributed to my expanding mindset and current therapeutic modus operandi, progressing from past to present. As to what will be in the future, that is difficult to predict as the metamorphosis keeps happening, although some components remain essential ingredients and provide grounding and balance. Que será, será sums up the future succinctly.     

The Effect of Tomm's Therapeutic Questioning Styles on Therapeutic Alliance: A Clinical Analog Study

10 suggests that circular and reflexive questions tend to elicit feelings of freedom/acceptance whereas lineal and strategic questions usually trigger feelings of judgment/constraint. Employing an analog methodology, each of Tomm's four questioning styles was portrayed in the form of a 5-minute videotaped intake scenario. Forty family triads with a mother, father, and adolescent son were randomly assigned to one of four experimental conditions with ten families each. Each condition involved viewing one of four questioning style scenarios. All participants (N = 120 individuals — 40 mothers, 40 fathers, and 40 adolescent sons) completed the Family Therapy Alliance Scale (FTAS; 9 ) and a validity-check instrument. The results indicated that circular and reflexive questioning styles elicited significantly higher (p < .001 ) alliance scores on the FTAS than did either lineal or strategic questions. Implications for the use of different types of questions in family therapy are discussed.