The therapeutic alliance–A conceptual analysis

The role and function of the therapeutic alliance in psychotherapy has increasingly been the focus of clinicians' and researchers' interests over the last decade. Alliance concepts have, however, been criticized for lack of conceptual clarity. The paper presents a generic model as a heuristic means for clarifying the conceptual meaning of the therapeutic alliance. The model distinguishes between the personal relationship aspect, and the collaborative, task-related aspect of the alliance, with therapist, patient, and common contributions to each of these aspects. The model is compared to other alliance conceptualizations, and its implications for alliance theory and research are discussed. A content analysis of four widely used alliance scales in relation to the model shows the scales to represent conceptually different, yet overlapping constructs. It is argued that the componential nature of the therapeutic alliance will render difficult any interpretation of findings regarding the relationship between alliance and outcome in traditional process-outcome research. More complex research strategies guided by theory are called for, if the therapeutic alliance should remain a vital field of research.     

Reconsidering the ‘heresy’ of using treatment manuals

Some argue that the medical model and the experimental design that underlies the use of treatment manuals to prove the efficacy of a psychotherapeutic treatment clashes with the theoretical basis of family therapy. From the point of view of the empirically supported treatments (ESTs) movement, treatment manuals are the operationalization of the independent variable in a clinical trial; the therapist is only part of the procedure and the therapeutic relationship is a confounding variable. Applying that logic to the practice of family therapy might be considered a heresy. This article argues that paradoxically, this heresy has a lot to offer the practice of family therapy. Research is the best way to answer questions like ‘how does family therapy work?’ ‘What makes ‘good therapy’ good?’ ‘Do therapists do what they say they do'? This article recommends an alternative framework for integrating ESTs into practice by proposing empirically informed guides to practice which, being less formulaic, encourage process‐outcome research, are coherent with the systemic model and do not constrain the therapist's creativity. Such guidelines allow therapists to use manuals flexibly so that they deepen the understanding of the process of therapy. We encourage you to listen to the JFT Editor, Mark Rivett, as he interviews the author on Manuals in the Practice and Research of Family Therapy. Available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467‐6427/homepage/jft_podcast_series.htm .     

The Evolution of Mindfulness‐based Cognitive Therapy

Metcalf and Dimidjian (this issue) present a timely review of the evolving evidence base and mechanisms of mindfulness‐based cognitive therapy (MBCT). The present commentary extends the discussion on the current evidence base for MBCT based on findings from recent meta‐analytic reviews in this field which attest to the promising outcome for mindfulness‐based therapies, particularly for depressed populations. However, the specific effects of MBCT as applied to anxiety, health and developmental populations is still very much in its infancy. The second objective of this commentary extends discussion on the transdiagnostic applications of MBCT versus traditional cognitive behavioural therapy (CBT). It is recommended that with the continuing expansion of MBCT, the effects of this therapeutic approach needs to be evaluated against other empirically supported therapies, including traditional CBT.     

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.     

Evidence‐based practice: Accounting for the importance of the therapeutic relationship in UK National Health Service therapy provision

It is argued that different models of therapy result in broadly similar outcomes and that the therapeutic relationship is the most important factor in relation to outcome. This paper presents some of the main findings from over 30 years of psychotherapy research. We discuss these findings in relation to current provision of therapy within the UK National Health Service (NHS) and express our fears that despite a culture of evidence‐based practice, this evidence is in danger of being ignored. We conclude by discussing some of the implications and challenges that this evidence presents to therapy researchers, policy makers, trainers and practitioners.     

Commentary on ‘The arms of the chimeras’ by Béatrice Ithier

In this Commentary I will first of all summarise my understanding of the proposal set out by Béatrice Ithier concerning her concept of the ‘chimera’. The main part of my essay will focus on Ithier's claim that her concept of the chimera could be described as a ‘mental squiggle’ because it corresponds to Winnicott's work illustrated in his book ‘Therapeutic Consultations’ (1971). At the core of Ithier's chimera is the notion of a traumatic link between analyst and patient, which is the reason she enlists the work of Winnicott. I will argue, however, that Ithier's claim is based on a misperception of the theory that underpins Winnicott's therapeutic consultations because, different from Ithier's clinical examples of work with traumatised patients, Winnicott is careful to select cases who are from an ‘average expectable environment’ i.e. a good enough family. Moreover, Winnicott does not refer to any traumatic affinity with his patients, or to experiencing a quasi‐hallucinatory state of mind during the course of the consultations. These aspects are not incorporated into his theory. In contrast (to the concept Ithier attempts to advance), Winnicott's squiggle game constitutes an application of psychoanalysis intended as a diagnostic consultation. In that sense Winnicott's therapeutic consultations are comparable with the ordinary everyday work between analyst and analysand in a psychoanalytic treatment. My Commentary concludes with a question concerning the distinction between the ordinary countertransference in working with patients who are thinking symbolically in contrast to an extraordinary countertransference that I suggest is more likely to arise with patients who are traumatised and thus functioning at a borderline or psychotic level.     

Experiences of Altruism in the Therapeutic Relationship: Perspectives of Counselors‐in‐Training and Their Clients

The purpose of this phenomenological investigation was to explore experiences of altruism in the therapeutic relationship to better understand how counselors‐in‐training (CITs) and their clients mutually perceived the construct in sessions. Findings from interviews with clients (n = 14) included emotional–relational characteristics and cognitive–behavioral aspects of altruism by their counselors. Findings from interviews with CITs (n = 10) included explorations of the role of altruism in counseling, overall experiences of altruism in counseling sessions, and experiences of altruism with specific clients. Implications for practice and research are discussed.     

Three modes of psychotherapy and their requisite core skills

The field of psychotherapy suffers from the lack of an integrative meta‐perspective on the large variety of existing psychotherapies and on the therapeutic skills involved. In the present paper, it is suggested that the development of a more comprehensive view of this field may be facilitated if we differentiate between three modes of psychotherapy, which require different therapeutic core skills: (a) an educational mode, which requires teaching skills; (b) a reparative mode, which requires analytic‐conceptualising skills to identify some kind of disordered functioning, in combination with specific relational‐technical skills to repair this dysfunction; and (c) a developmental mode, which involves engaging in a therapeutic relationship with patients to facilitate their personal growth, and which requires non‐directivity skills. In addition, some therapeutic skills (e.g., awareness and communication skills) may be more or less important in all modes of treatment. Concrete manifestations of the three different modes of psychotherapy are discussed in terms of five different theoretical perspectives on psychotherapy: the common factors, the humanistic‐experiential mindfulness cognitive‐behavioural (CBT) and psychodynamic perspective. The common factors model is criticised as being insufficient in several respects. Finally, it is argued that if personal therapeutic skills are essential to the effects of psychotherapy, then empirical research on psychotherapy needs to be re‐oriented towards a person‐oriented study of therapist skills in action, in the context of a study of the interaction between therapist and patient.     

The sandwich model: The ‘music and dance’ of therapeutic action

My premise is that a ‘layered’ approach is necessary to understand the process of exchanges that result in therapeutic change. I imagine these processes occurring in three layers – although the number of domains in which change is taking place is actually infinite – such as in a sandwich. The top layer, or top slice of bread of the sandwich, represents a broad view of the change process; it is non‐linear and includes the feature of uncertainty, a general principle of dynamic systems theory. The middle layer, or the meat of the sandwich, is explained by theories that are immediately and clinically useful to a therapist, such as psychoanalytic theories. These are primarily linear theories and use language and symbols to ‘tell a story of what happened’. The bottom layer, or bottom slice of bread of the sandwich, is the micro‐process; this layer includes the moment‐to‐moment patterns of coordinated rhythms that both communicate meaning and provide the essential scaffold for all higher‐level change processes. The micro‐process also requires a non‐linear theory to make sense of its variability and emergent properties. Taking a bite out of the sandwich will include a ‘polysemic bundle of communicative behaviors’ (Harrison and Tronick, 2011). I will illustrate the ‘sandwich model’ with the clinical case of the analytic treatment of a 5 year‐old boy.     

Use of Trauma‐Informed Care With Incarcerated Offenders

Regardless of preexisting trauma history, offenders regularly experience traumatic events while incarcerated. Current therapeutic approaches focus on coping skills and behavioral responses. The authors recommend integrating the use of trauma‐informed care to address the deeper emotional responses tied to trauma.     

Patient-targeted googling by psychological therapists: A narrative review of the literature and ethical implications

Background

“Patient-Targeted Googling” (PTG) refers to a healthcare professional using the Internet to discover information about a patient. The present review explores PTG by psychological therapists. The review focused on the prevalence of PTG, how often consent is sought from the patient, and the motivations for and consequences of PTG.

Method

A narrative literature review of published PTG studies was undertaken. Potentially eligible studies were identified by searching PsycINFO, PsycARTICLES, Psychology and Behavioural Sciences Collection, and MEDLINE. Results were screened for suitability for inclusion in the sample (n = 9). All studies were appraised for quality using a structured tool developed for this review.

Results

PTG prevalence rates ranged from 20% to 98%, with rates of non-consent ranging from 60% to 84%. Motivations for PTG included curiosity, to gather new information and to verify existing information. Consequences of PTG included enhancing the therapist's sense of safety and causing harm to the therapeutic relationship.

Discussion

Current literature on PTG is limited and focussed largely in the United States. This review revealed no published PTG studies including UK-based psychological therapists, as well as issues in defining and operationalising PTG. Further research is needed to understand the prevalence of PTG by UK-based psychological therapists, as well as the motivations behind, and consequences of, PTG. This evidence base will inform the development of PTG professional guidelines and training, neither of which currently exist for therapists practising in the UK. Both would be timely given the increasing move of the therapeutic frame to the online environment due to the COVID-19 pandemic.     

The Use of Touch in Counseling: An Ethical Decision‐Making Model

Although some counselors have advocated for the limited use of touch in counseling, others have argued that touch has no place within the counseling relationship. Despite the controversy, the use of touch has been shown to have a number of therapeutic benefits; however, there are few ethical decision‐making models that are appropriate for considering the use of touch in counseling. The authors discuss the controversy surrounding the use of touch and the benefits/contraindications of touch. The 5 ethical principles of counseling are also examined; a new ordering of the principles is presented as a useful ethical decision‐making model when considering the use of touch in counseling.     

Therapeutic outcomes in the Welsh Government's school‐based counselling strategy: An evaluation

Aims: The purpose of this study was to evaluate the outcomes of school‐based counselling, as delivered in the Welsh Government's School‐based Counselling Strategy, for reducing psychological distress in young people aged 11–18. Method: The study used a quantitative cohort design, comparing levels of distress on either the Young Person's CORE (YP‐CORE) or the Strengths and Difficulties Questionnaire (SDQ) from baseline to endpoint. Data were available on 3613 episodes of counselling, across 42 datasets. Meta‐analytical procedures were used to identify the mean effect size and predictors of outcomes. Results: Within each dataset, counselling was associated with significant reductions in psychological distress, with a mean effect size (d) of 0.93(95% CI = 0.89–0.97) using a fixed effects model and 1.09 (95% CI = 0.97–1.22) using a random effects model. Datasets using the YP‐CORE had larger effect sizes than those using the SDQ, and datasets with more complete response rates had lower outcomes than those with poorer response rates. Conclusion: The results confirm that school‐based counselling, as delivered in the UK, is associated with significant reductions in psychological distress, comparable to adult counselling and psychotherapy services.     

A Therapeutic Model of Self‐Forgiveness With Intervention Strategies for Counselors

Self‐forgiveness is associated with psychological and relational well‐being and may be a worthwhile treatment goal for clients who have hurt others. The authors utilized theoretical and empirical literature to describe a 4‐component therapeutic model of self‐forgiveness—responsibility, remorse, restoration, and renewal—and offer suggestions for promoting each component with clients. Finally, the authors explore potential contraindications and the applicability of self‐forgiveness for military veterans, clients in substance abuse treatment, and clients convicted of a crime.     

Towards an Italian model of therapeutic community

In this paper the author reflects on research undertaken by the Association Myth and Reality in the context of the psychiatric reforms in Italy which resulted in the closure of the asylums and the organisation, over the last 20?years, of a network of services in the community. These include thousands of residential units operating on a rehabilitative model. The focus of this paper is on the concept of the therapeutic community as a dynamic evolutionary path, individually tailored to people with different diagnoses and different ages – e.g. psychosis; borderline; adolescents and children. The therapeutic – and more specifically the environmental – factors are presented here. This includes the aesthetics of living and the sensory/emotional climate in relation to the care of the self and protection, regulation and safety, transitional playful climate, everyday life and the sharing implicit in relationships. The emotional climate is a fundamental component that transverses and intersects all the other factors. Treatment is central to the group with its potential for containment and dynamism in relation to relationships, cohesion, belonging, integration of the self in the community and connections with social networks outside the group aimed at reintegration into society of the resident as a citizen. A system of evaluation through peer reviews between therapeutic communities in Italy is being built in order to continuously improve the quality of service delivery.