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.     

Satisfaction et confort au travail. L’apport de la démarche implicative

A large body of research has investigated the psycho-organizational variables predicting satisfaction at work, but few studies have so far examined variables in the field of environmental psychology. Our study aims first to identify the impact of variables evaluating comfort at work (satisfaction with the work environment, attachment to the workplace) by comparing them with organizational variables known to be related to job satisfaction, and then to rank the relationships between these variables in a pseudo- implication sequence, based on statistical implicative analysis. The study involved 105 bank employees and confirms our theoretical model, showing that job satisfaction can be explained implicatively by the three other variables [(Comfort/Functionality => Control/privacy) => Workplace attachment] => job satisfaction.     

What is happening in the world of therapeutic communities?

This overview of the contributions to the special edition illustrates something of how the collection of papers reflects the marginal nature of therapeutic communities, and makes parallels as to how they are forever struggling to survive, yet generate a passion of ideas and intellectual resilience that no project-managed health service can extinguish. It briefly describes the theoretical and geographical terrain covered, and signals how the cross-disciplinary incorporation of congruent ideas can be added to the traditional bedrock of therapeutic community practice. It ends by stating the context of the new, and seemingly successful, organization which assembled these contributions into its inaugural conference – and suggests that the journey could, and ultimate should, go further.     

Discomfort in the community. The place of psyche: Between zōē and bios

In this paper, the author considers the treatment of people diagnosed with a psychosis or borderline personality disorder in therapeutic communities from a psychoanalytic perspective, with a particular focus on the work of Jacques Lacan and of André Green. He discusses two key questions. First, how are these patients to recover life? – not just in the biological sense but in terms of subjectivity. Secondly, is it ever really possible to build relationships with them? In relation to this second question, the author emphasizes the importance of the training and supervision of practitioners, as well as their own analysis. Therapeutic communities, above all, he argues, can provide structure and security in a society which is increasingly fragmented and unstable.     

Therapeutic Relationship

This article addresses the important role of the therapeutic relationship in cognitive-behavioral therapy (CBT). As has been noted from the inception of CBT, there are critical features of both the therapist and the relationship that optimize the likelihood of therapeutic success, and this article briefly describes these features. It is further argued that a successful therapeutic relationship in CBT is not static but is flexible and adaptive both across and within clients, as their needs and concerns vary. A positive therapeutic relationship is viewed within CBT as a necessary but insufficient condition for change, as the relationship serves as a foundation upon which interventions are scaffolded, but that the client’s response to various interventions itself shapes the interactions between therapist and client. Finally, it is argued that the key therapeutic ingredients of CBT are largely teachable, and the article provides several suggestions to promote an effective therapeutic relationship in CBT.     

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.     

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.     

Converting a Freudian analysis into a Jungian one: obsession,addiction, and an answer from Job

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive‐compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle‐aged obsessional academic who had been treated for nearly twenty years in a ‘classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super‐ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis.     

ANALYTIC MIND USE AND INTERPSYCHIC COMMUNICATION: DRIVING FORCE IN ANALYTIC TECHNIQUE,PATHWAY TO UNCONSCIOUS MENTAL LIFE

Developed from established psychoanalytic knowledge among different psychoanalytic cultures concerning unconscious interpsychic communication, analysts' use of their receptive mental experience—their analytic mind use, including the somatic, unconscious, and less accessible derivatives—represents a significant investigative road to patients' unconscious mental life, particularly with poorly symbolized mental states. The author expands upon this tradition, exploring what happens when patients unconsciously experience and identify with the analyst's psychic functioning. The technical implications of the analyst's “instrument” are described, including the analyst's ego regression, creation of inner space, taking mind as object, bearing uncertainty and intense affect, and self‐analysis. Brief case vignettes illustrate the structure and obstacles to this work.     

Client as expert: A Delphi poll of clients’ subjective experience of therapeutic alliance formation variables

This study extends prior research that identified client-derived variables believed to contribute to therapeutic alliance development. Forty-two clients participated in a three-round-modified Delphi poll in which the subjective importance of 74 client-derived, common alliance formation variables was rated using a six-point scale. Participants consensually identified 23 variables as highly important, five as moderately important and three as low in importance to the formation of a strong alliance. Variables related to validation and asking about parts of the client’s life other than the presenting concern were considered as most important by at least one-third of the sample. Limitations of the study are presented and implications for theory, measurement, practice and future research are briefly discussed.