When the Tree Falls and No One Hears It: On Being Dropped and Learning to Hold

This case study focuses on a student therapist’s reflections upon a premature termination that occurred in her work with an adolescent male patient. The therapeutic process is traced back to the beginning of treatment, and the article delineates the extent in which the patient’s early interpersonal experiences influenced the development of the therapeutic alliance. The author addresses several themes that evolved throughout the treatment, including the patient’s experience of unpredictability and instability and his inconsistent understanding of time, and the ways in which these experiences ultimately influenced the treatment’s ending. The article describes the therapist’s development as a clinician over the course of the treatment, focusing on the various experiences that helped her consolidate a dynamic understanding of the holding environment.     

Der ausreichend gute Therapeut

Psychotherapists show a great variation in their ability to achieve positive outcomes in therapy. Specifically, they vary in terms of their ability to identify and repair ruptures in the therapeutic alliance. Alliance ruptures are a frequent phenomenon but often go undetected; however, repairing alliance ruptures represents a great opportunity to improve the psychotherapy process and therapy outcome. Empirical research suggests that patient feedback should be included in the psychotherapy process to be able to detect alliance ruptures better. From a psychodynamic point of view, a “sufficiently good” therapist is a therapist who can acknowledge the countertransference-based limitations in evaluating the therapeutic alliance with patients and the need to use feedback in order to detect and repair inevitable alliance ruptures. The consequences for research, practice and psychotherapy training are considered.     

The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder

The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.     

Critique of the "therapeutic ego split"

The technical relevance of the concept of a therapeutic ego split is rigorously examined. In the author's view, the distinction between a neurotic transference and a non-neurotic working alliance serves the therapist as a defense against anxiety rather than as a clarification of his intricate involvement with the patient.     

Sociopolitical Enactments as Arenas of Mutual Vulnerability: Psychotherapeutic Experiences During the War Between Israel and Gaza in the Summer of 2014

The understanding that sociopolitical, cultural, and socioeconomic spheres always play a part in psychotherapeutic endeavors forms a central aspect of the relational premise. Nevertheless, the literature rarely relates to psychotherapeutic interactions in which patient–therapist exchanges involve sociopolitical disputes or discussions. The main thesis of this paper suggests that the sociopolitical context in which the psychotherapeutic process takes place tend to serve as an arena of mutual vulnerability (Aron & Starr, 2013) between patient and therapist out of which Sociopolitical Enactments characterized by a curative potential tend to emerge, especially during times of war and horror. Two very different Sociopolitical Enactments that took place with patients in Tel Aviv during the war between Israel and Gaza in August 2014 are presented, followed by a literature review and conceptualization of Sociopolitical Enactments as arenas of mutual vulnerability that explicitly or implicitly facilitate working through processes of traumatic self-states, challenge binaries, and open up ways for inquiring power relations in the therapeutic alliance and beyond.     

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.     

Clinical Mutual Attunement and the Development of Therapeutic Process: A Preliminary Study

Despite the identification of many factors that play a central role in the development of the psychotherapy process, there is still a lack of evidence about the basic relational mechanisms that pave the way to its working. In this pilot study, we focus on nonverbal microprocessual attunement as the basic mechanism grounding the displacing of discrete factors in shaping the clinical process. Two single sessions of two short-term psychodynamic treatments, selected respectively from a good- and a poor-outcome treatment, have been coded in terms of patient and therapist speech rate, coordination in ruptures, resolution of the therapeutic alliance, and patient's displayed thinking processes. Two dynamic structural equation models focusing on clinical attunement as a factor able to activate the interplay of the assessed clinical dimensions have been theoretically designed and tested in both cases. The driven theoretical structural equation models fit the data, suggesting a different role of nonverbal attunement as a moderating factor. The obtained results are consistent with the hypothesis claiming that a good-outcome psychotherapy session is characterized by a mechanism of clinical attunement that enforces the therapist–patient relationship and promotes the integration of formal thinking processes that affect emotional and cognitive domains.     

“I’ve got you under my skin”: Relational therapists’ experiences of patients who occupy their inner world

The aim of this study was to conduct an in-depth exploration of therapists’ experiences of patients who affect them more than others and occupy their inner world beyond the context of therapy sessions. A phenomenological analysis was performed on semi-structured interviews with five relational therapists. All the therapists had a strong experience of a particular patient getting “under their skin.” In all these cases, the patient was a traumatized woman. The distinctive characteristic of the phenomenon was a sense of blurred or too permeable boundaries between the therapist and the patient. This was associated with fear and anxiety, but also with feelings of love. The therapists’ reactions to having a patient “under their skin” varied from resistance to symbiotic relatedness. The therapists’ ideas of their professional role influenced how the experience of carrying the patient’s suffering was interpreted. The phenomenon of the patient’s presence in the therapist’s representational world might be interpreted as a distinct countertransference phenomenon when working in a more “thin boundary” manner with particular cases. The therapists’ ability to effectively manage their vulnerabilities, activated in the countertransference, seems to be crucial for therapeutic progress. Implications for research, clinical practice, and training are discussed.     

Cultural function and psychological transformation in psychoanalysis and psychoanalytic psychotherapy

Cultural experience of silence and individual vicissitudes between talking and being silent infl uence the way individuals form an alliance and pursue the analytic process. This is of relevance both for the patient and for the psychoanalyst/therapist. The author describes a patient, whose silent phase occurred in the fi fth and sixth year of intensive psychoanalytic psychotherapy. She suggests that a) the silence functioned as a protection of a space for the core self and promoted inner transformation and psychologicaldevelopment;b)thesilenceinvolvedatransference-countertransference matrix with projective identifi cations of the patient's internalized mother- and father-related objects that caused a tenuous balance between maintaining and erasing the relationship between the patient and the author; c) the silence phase was highly infl uenced by the author's own cultural background and what she brought into the relationship of tolerance of being silent in the presence of another, and understanding of the many complex functions of silence. During the silent phase the patient moved from simply describing and naming her affects and inner experiences or expressing them as somatic processes, to being able to internally access and verbally convey her own affects and experiences in the therapeutic alliance. This process involved both affect desomatization, affect differentiation, and affect verbalization.     

Understanding the psychological processes of the racial match effect in Asian Americans

Some studies on mental health outcomes research have found that when clients and therapists are ethnically or racially matched, this tends to be related to greater satisfaction and better outcomes. However, the precise underlying mechanism for the match effect has not been extensively examined. In this experimental study, we tested the effect of racial match on critical counseling processes (i.e., therapist credibility and the working alliance) using a sample of 171 Asian American respondents. We also examined Asian ethnic identification as a potential moderator of the racial match effect. Structural equation modeling analyses indicated that racially matched individuals perceived greater experiential similarity with the therapist than nonmatched individuals, and experiential similarity was positively associated with therapist credibility. Although racial match did not predict attitudinal similarity, attitudinal similarity was strongly related to the working alliance and therapist credibility. Counseling implications are discussed.     

Revenge of the fathers Incest and the male therapist

Abstract

This paper argues that the socio-psychological foundation of incestuous relations between father and daughter resides in the primordial rivalry between father and son and is a manifestation of the property relations existing between them throughout the period of patriarchy. After an attempt to trace this rivalry along a path through Western civilization by summarizing evidence from both religious and mythological sources, I introduce it into our own times by using two case illustrations from my own clinical work. Here I claim that when a male counsellor/therapist engages a sexually abused female patient he, at the same time, encounters the incestuous father in a potentially rivalrous struggle over the patient. For genuine healing to take place in the patient, the counsellor/therapist must form an alliance with the father and utilize his hidden value in enhancing his own therapeutic capability.

I began by stating that particular clinical complexities exist when male therapists engage with female clients who have been the victims of paternal incest. I then postulated the idea that the socio-psychological foundation of such relationships is the primordial rivalry between father and son and is in fact a particular manifestation of the property relations existing between them. I then traced this father/son rivalry along its path down through Western civilization via Jerusalem and the Judaic/Christian religions, and Athens with its early creation myth, and the somewhat later myth of Oedipus. I then pursued the course of its influence to our own times, to the incestuous father/daughter relationship, and, using examples from my own clinical work, I attempted to show how this father/son rivalry survives as a powerfully pervasive influence in the clinical relationship between the female patient who has experienced paternal incest and her male therapist.     

Love in the therapeutic alliance

Volumes have been written about the patient's love for the therapist, but there has been relatively little discussion of the therapist's love for the patient. In an attempt to create a theoretical and technical space for discussing the appropriateness and role of love in the therapeutic relationship, a revised concept of the therapeutic alliance is applied to provide technical guidelines and understanding of two kinds of love between patient and therapist, corresponding to two systems of self-esteem regulation: an open, reality-oriented system and a closed, sadomasochistic system organized according to omnipotent beliefs. Examples of the role of love through the phases of treatment illustrate the interrelationship of love and the accomplishment of therapeutic alliance tasks.     

The dynamics of empirically derived factors in the therapeutic relationship

The therapeutic relationship is the source of major concepts in psychoanalytic clinical theory. Such concepts as resistance, transference, countertransference, and the alliance are fundamental, even though there may be shifts in meaning between theoretical schools and clinical contexts. In the clinical psychoanalytic literature, disagreement exists over the nature of the alliance and its essential components. Empirical studies using reliable patient, therapist, and observer scales to assess the alliance demonstrate a correlation with psychotherapeutic gains. In the study reported here, thirteen patients were followed for 6 to 33 months of psychodynamic psychotherapy, during which time their views of the therapeutic relationship were assessed, and several experiential measures taken, all on a weekly basis. Statistical analyses reveal that the therapeutic relationship, as reflected in the patients' weekly responses to the St. Louis Therapeutic Relationship Rating Scale, has four distinct components: therapeutic alliance, resistance, transference love, and negative transference. On a week-by-week basis, the therapeutic alliance was the strongest predictor of improvement in patient-reported general adjustment, as reflected in such areas as self-esteem, positive affect, social relations, work productivity, satisfaction, and optimism. Time plots of the variables show the typical time course for the components of the therapeutic relationship, as well as for improvement on the experiential variables. Results indicate that the therapeutic alliance, transference, and resistance are central components of the psychotherapeutic relationship, which in turn predict the ongoing life experience of the patient.     

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.     

Developing the Working Alliance in Marital Therapy; A Psychodynamic Perspective

A good working alliance in marital therapy is one in which the partners are actively collaborating with their therapist to work through conflicts. The therapist begins to develop the alliance by setting the frame of therapy and helping the couple understand the guidelines of treatment. The partners gradually identify with and emulate the therapist's working style and use of self as a reflective instrument. The working alliance can be weakened by empathic failures and strengthened by increased feelings of trust in the therapist and the process of treatment This paper looks at the development of the working alliance in marital therapy from a psychodynamic perspective. A clinical illustration is included.     

Cultural tensions in strategic marital therapy

Whether the elements of a good marital relationship are universal is the question addressed in this case study of therapy with a couple who were culturally different from the therapist. The conflicts between the therapeutic strategies, which were based on a strategic therapy model, and the customs of the couple from a foreign culture, made it difficult to evaluate whether the therapist was on target with interventions. On one hand, therapists need to guard against being misled into believing that customs are cultural imperatives which never can be changed. On the other hand, they need to be aware of the impact and possible ramifications of challenging long-held, culturally-based beliefs and behaviors. The following case study details the dilemmas faced by a therapist working with an Asian-Indian couple who presented themselves as being bound by their cultural background and heritage.Grateful acknowledgement is made by the author to Etienne Phipps, PhD, whose comments give direction and substance to all my work.     

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.     

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.     

An Indicator of Suicidal Ideation on the Rorschach Test

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn &; Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher &; Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.