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.     

REBT in a Therapeutic Community: REBTC

Long-term residential treatment--therapeutic communities--have some empirical support for efficacy but historically have been viewed as insulated and alien to the world of research. A therapeutic community with Rational Emotive Behavior Therapy as the core of its philosophy and practice is described, and follow-up results are presented. The argument is made that therapeutic communities may be particularly well suited to treatment of people with dual diagnoses.     

Humanness: A Therapeutic Variable

Since attempts by adherents to various psychotherapeutic orientations have failed to demonstrate the efficacy of any one of them, this paper tries to explicate the single variable—humanness—that seems to underlie all therapeutic approaches, and may account for the positive results obtained by all approaches. Many investigators have emphasized the importance of a positive relationship as a factor in counseling; but an influential force, behavior modification therapy, has attempted to once again place the role of technique in the spotlight. Their results have not been striking. A second aim, therefore, of this paper is to offer a critique of this position in the light of humanistic and research considerations. The implications of a technique-oriented therapeutic approach are also discussed. A plea is entered for emphasis being placed on, and an investigation of, the role of humanness as the most important variable in the counseling process.     

The rapid-smoking technique: Therapeutic effectiveness

The study examined the effectiveness of the rapid-smoking technique in terms of two measures of outcome—post-treatment abstinence rate and reduction in smoking achieved by non-abstinent subjects. A total of 75 volunteers (40 men and 35 women) participated in treatment and were randomly allocated to one of four conditions—rapid-smoking alone; rapid-smoking and relaxation training; rapid-smoking, relaxation and contingency contracting; or contingent rapid-smoking. No significant differences between treatment conditions were obtained. For the total sample, abstinence was achieved by 64% of the subjects immediately post-treatment but the probability of remaining abstinent 12 months later was only 0.33. Immediately post-treatment the non-abstinent subjects reduced their rate of cigarette consumption to 34.2% (SD = 29.3) of baseline smoking but by 12 months average consumption had increased to 82.4% (SD = 28.3) of baseline. It is concluded that rapid-smoking gives rise to substantial short-term changes in smoking behaviour but these effects are not sustained.     

Maintaining Therapeutic boundaries: The Motive Is Therapeutic Effectiveness,not defensive Practice

In his article "How Certain Boundaries and Ethics Diminish Therapeutic Effectiveness," Lazarus asserts that many clinicians are adhering to strict therapeutic boundaries and ethics in a fear-driven effort to avoid unwarranted malpractice claims. Although I agree that maintenance of conventional therapeutic boundaries is apt to minimize malpractice claims in most cases, I believe that is because such boundaries are critical to protect patients' welfare and thereby promote effective treatment. My reasoning, discussed next, revolves around the following premises: 1. For many, if not most, types of patient problems and patient populations, boundaries and the personal meaning of the therapeutic boundaries are an arena in which critical emotional issues are manifested and worked through. 2. Clear, consistent boundaries provide a structure and safety for many patients that is a curative factor in itself. 3. Patients' reactions to alterations in usual therapeutic boundaries are often unpredictable ahead of time (even if requested by the patient) and typically complex, ambivalent, and heavily colored by transferential meaning. 4. Because alterations in therapeutic boundaries typically add a new therapist role or activity that involves potential gratification of personal needs of the therapist, objectivity in evaluating such a change may be compromised by the inherent self-interest. 5. Consistent, clear boundaries need have no impact on therapist warmth and empathy.     

Beginnings and endings: Therapeutic opportunities in educational settings

This paper is based on its author's experience of working in a Counselling Service with both school and university students. She shows how developmental disturbances in the students' educational lives tended to resonate with developmental disturbances in their earlier lives. She draws on the material from seven students to illustrate her thesis.     

Therapeutic factors in group psychotherapy: A contemporary view

This paper reviews the two major approaches to the assessment of therapeutic factors in therapy groups: 1) questionnaires administered at termination, and 2) postsession Critical Incident reports. The major categories will be discussed, and a new study utilizing Critical Incident methodology reported which replicates previous results. Suitable studies will be reanalyzed from the standpoint of the change in therapeutic factors over time as a group develops. It is recommended that the Critical Incident methodology be further refined and used in preference to the questionnaire approach.     

Transformations in Therapeutic Practice

In her training of therapists, Virginia Satir sought to change the way her trainees perceived themselves, their clients, and the therapeutic endeavor. The change she sought was a movement from hierarchical models of therapy where clients were diagnosed in terms of paradigms of how they ought to be to an organic model where the therapist attempts to understand the client by entering the client's internal context. Contemporary training in the Satir model attempts to bring about the same change. Research indicates that the trainers are succeeding.     

Prepared phobias and obsessions: Therapeutic outcome

Sixty-nine phobic and eighty-two obsessional patients, treated at the Maudsley Hospital, were rated for ‘preparedness’, the evolutionary significance of the content and behaviour of the disorder. Reliable ratings (r = 0.78 and 0.90) of the dangerousness of the object or situation to pretechnological man indicated that the content of the large majority of the phobias and obsessions are judged as evolutionarily significant. Degree of preparedness, however, did not predict outcome of therapy, suddenness of onset of the disorder, severity of impairment, intensiveness of the treatment received, or age of onset. Nor was there any significant relationship between preparedness and certain other variables in the obsessional sample: stimulus generalization, effect on life style, impaired reproductive capacity and abnormal personality. The implications of these findings for the hypothesis that human phobias and obsessions are prepared, and for the clinical usefulness of the concept of preparedness, are discussed.     

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.     

Measuring Responsiveness in the Therapeutic Relationship: A Patient Perspective

This article reports results from a three-country study of patient perceptions of physician responsiveness. Based on existing research in the medical and social-psychological literatures, we theorized that patients' perceptions of physician responsiveness to their needs would be an important component of the patient–physician relationship and that this construct could be distinguished reliably from more global assessments of patient satisfaction. We then developed a new measure designed to assess these perceptions from the patients' point of view. This measure was administered to large samples of patients in the United States, the United Kingdom, and Canada. Results supported our hypotheses. Patient perception of physician responsiveness significantly predicted both patient satisfaction and subjective health-related problems, over and above effects attributable to general satisfaction. We also noted the absence of significant differences across the three cultures or sex, suggesting that the process we identify has considerable generality. We also describe a short version of our measure that researchers may find useful in a variety of research or clinical settings.     

Therapeutic Document in Group Counseling: An Active Change Agent

In this article, the authors provide a therapeutic document model using language as an active change agent. The practice of the therapeutic letter has demonstrated substantial power in narrative therapy to foster client change. No literature, however, has applied this construct in group counseling. Grounded in social constructionism, re-authoring therapy and the power of written language, this model transforms the usually time-consuming and frequently nontherapeutic client documentation into a functional intervention. As a competency-based intervention, this model provides counselors with principles and procedures to enhance clients' self-agency and expedite the change process in group counseling.     

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.