Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families

Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents’ and youths’ perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.     

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.     

医联体中实施老年患者中期照护模式的实践探索

对中期照护的定义、市场需求和国内实施难度进行了介绍。介绍了苏北人民医院医联体内开展中期照护的相关背景、基础条件、评估指标、医保结算、绩效分配及专家补贴方式。对在医联体联合病房内开展中期照护前后的情况进行比较,如对是否进行中期照护的急性肩袖损伤老年患者术后康复效果进行比较,苏北医院平均住院日及患者非计划再入院率,患者和工作人员的满意度,数据都有明显优化。说明在医联体联合病房内开展中期照护模式较适合术后需要康复的老年患者,应提升卫生院工作质量,加快三级医院运营效率,促进分级诊疗进一步推进。     

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.     

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1–3 and one session from Sessions 4–7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18–0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.     

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.     

心理咨询中工作同盟的发展模式与咨询效果

为了探索工作同盟在咨询过程中的发展模式, 采用Stiles等(2004)提出的4个变化特征参数(shape-of-change parameters)对30个个案的工作同盟在咨询过程中的发展变化进行描述。聚类分析的结果显示有3类工作同盟的发展模式, 分别是线性增长、线性下降和二次增长模式。不过, 3种发展模式、4个变化特征参数及同盟的破裂?修复片段对咨询效果均没有影响。比较咨询效果不同的当事人在工作同盟发展模式上的差异, 发现同一个发展模式对于不同的个案可能有着不同的含义, 咨询师在早期对同盟关系的处理与调控对咨询效果有着重要的影响。     

The Influence of Trauma Symptoms on the Therapeutic Alliance Across Treatment

The authors examined the influence of early phase dissociation, interpersonal problems, and retraumatization on the therapeutic alliance at early, middle, and later treatment phases. Participants were 84 female survivors of child abuse (ages 18 to 60 years, 53.6% Caucasian) who were receiving counseling at a university training clinic. Master’s- and doctoral-level students provided counseling using integrated relationship and trauma-based cognitive behavior therapy. Treatment followed a 3-phase model. The authors used structural equation models to test the hypothesis. In the early and later phases, fewer interpersonal problems significantly predicted a stronger alliance. In the middle phase, fewer interpersonal problems, less dissociation, and more revictimization significantly predicted a stronger alliance. Tasks, goals, and bond contributed significantly to the alliance in each of the 3 phases. Interpersonal problems were consistently the strongest predictor across the 3 phases, whereas tasks consistently made the greatest contribution to the therapeutic alliance across all 3 phases.     

Curriculum Evaluation and Assessment of Multicultural Genetic Counselor Education

Multicultural competence in genetic counseling integrates racial-cultural knowledge, awareness, and skills into clinical interventions and research practices. Researchers and educators often cite racial-cultural factors as obstacles for visible racial-cultural people seeking help. However, the professional's unfamiliarity of how his or her own racial-cultural group affiliations are influenced by the history of discrimination and oppression coupled with their lack of self-understanding of racial-cultural issues for him- or herself has also limited the effectiveness of genetic counseling. The purpose of this study is to evaluate the effectiveness of the Handbook of Cross-Cultural Genetic Counseling, a multicultural curriculum developed for genetic counselor education for increasing multicultural counseling competence. The multicultural curriculum was evaluated for its effectiveness of increasing multicultural counseling competence using a nonequivalent control group design. A participant's multicultural counseling competence was hypothesized to increase after being taught the curriculum. The curriculum was effective for increasing multicultural counseling competence. Additionally, achieved multicultural counseling competence was not influenced by when the curriculum was taught. Trend analyses measuring the longitudinal impact of the curriculum on multicultural competence were significant. Implications of the results are discussed.     

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.     

Multicultural Education and Perceived Multicultural Competency of School Counselors

A national survey of practicing school counselors (N = 755) revealed significant differences between participants’ perceived multicultural competence based on the type of multicultural training received. Participants who took infused multicultural coursework had significantly higher mean scores in multicultural awareness, knowledge, and skills than participants who reported taking a single multicultural course. Una encuesta nacional de consejeros escolares en activo (N = 755) reveló diferencias significativas en la competencia multicultural percibida de los participantes según el tipo de capacitación multicultural recibida. Los participantes que tomaron cursos que incluían contenidos multiculturales obtuvieron puntajes medios significativamente más altos en consciencia, conocimientos y habilidades multiculturales que aquellos participantes que indicaron haber tomado un único curso multicultural.     

Measuring Multicultural Training Reactance: Initial Instrument Psychometrics

Resistant behaviors in multicultural courses are a common dilemma within counselor education. On the basis of psychological reactance theory (J. W. Brehm, 1966), the authors created a multicultural training reactance scale to measure the construct. Exploratory factor analysis and initial reliability and validity data are presented, followed by suggestions that address course reactions. Los comportamientos resistentes en los cursos multiculturales son un dilema frecuente en la educación de consejeros. Basándose en la teoría de reactancia psicológica (J. W. Brehm, 1966), los autores crearon una escala de reactancia en la capacitación multicultural para medir el constructo. Se presenta un análisis factorial exploratorio, así como datos iniciales de fiabilidad y validez, seguidos por sugerencias que abordan las reacciones al curso.     

多元文化经历促进创造力

大量实证研究支持了多元文化经历促进创造力这一假设。深度参与两种不一致的文化活动是多元文化经历提升创造力的前提条件; 在融合过程中, 双重认同者获得的交替、整合和包含等认知技能, 促进了个体的创造性表现。未来可以采用更具多样性的样本以扩展研究的外部效度, 考察认知评价、趋近动机、积极情绪的中介作用, 并加强国内对此领域的研究。     

Democratic Patriotism and Multicultural Education

Debate about multicultural education in the USAhas been marked by anxieties about thestability of a nation that is both increasinglyculturally diverse and increasingly resistantto coercive assimilative practices. Apolitically and morally persuasivemulticulturalism must seek to dispel ratherthan evade these anxieties. One educationalvenue in which they must be addressed ishistory teaching. The possibility ofcultivating democratic patriotism in theteaching of a genuinely multicultural Americanhistory is discussed.     

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.     

Examining Perceived Multicultural Counseling Competence and Negative Attitudes Toward the Arab American Population

The purpose of this quantitative study was to investigate the relationship between professional counselors’ general multicultural competence and negative attitudes held toward Arab Americans. Participants (N = 124) completed a survey, and a series of correlational, stepwise, and multiple regression analyses was conducted. Results indicated that counselors displayed higher levels of multicultural awareness than of multicultural knowledge. Furthermore, general multicultural awareness and specific knowledge of Arabs related significantly to negative attitudes held toward Arabs. El propósito de este estudio cuantitativo fue investigar la relación entre la competencia multicultural general de consejeros profesionales y las actitudes negativas mantenidas hacia personas estadounidenses de origen árabe. Los participantes (N = 124) completaron una encuesta, y se llevó a cabo una serie de análisis correlacionales, por pasos y de regresión múltiple. Los resultados indicaron que los consejeros mostraron niveles de conciencia multicultural mayores que los niveles de conocimiento multicultural. Además, la conciencia multicultural general y el conocimiento específico acerca de las personas árabes estuvieron significativamente relacionados con actitudes negativas mantenidas hacia personas árabes.     

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.     

Multicultural training practices in community psychology programs

Surveyed the directors of 56 community psychology graduate programs to assess multicultural training practices and attitudes. Although most program directors agreed that multicultural training is important in their mission to educate students, less than half the programs (48%) required their students to take any relevant course work and only half of the programs surveyed had any faculty who were members of an ethnic minority group and one third had only one such faculty member. Furthermore, less than half the programs had a combination of training opportunities in place to integrate classroom, research, and field experiences relevant to multicultural issues. Finally, only 23% of program directors believed their training programs were successful for most students, suggesting the need to improve training.     

A Career Developmental Perspective on the Therapeutic Alliance: Implications for Counseling

This review explores the role played by childhood emotional maltreatment (CEM) in selecting a career in the field of mental health and the potential positive and deleterious effects of these career‐choice motives on the therapeutic alliance. The reviewed findings support the assumption that CEM may serve as a precursor for career choice of professions in the mental health field. Implications are suggested for the counselor/therapist–client relationship, also known as the therapeutic alliance, as well as for career counseling.     

The Relationship Between Mindfulness and Multicultural Counseling Competence

The authors examined the association between multicultural counseling competence (MCC) and mindfulness. Previous authors have maintained a conceptual link between MCC and mindfulness; however, this is the first empirical analysis of the relationship between MCC and mindfulness. Results revealed that, after race/ethnicity, multicultural course completion, and empathy were controlled, components of mindfulness were correlated with multicultural awareness and multicultural knowledge. These results have implications for counselor education, counseling practice, and future research.