How a strong therapeutic alliance can lead to real change the specific type of treatment,” and that “the therapy relationship accounts for why clients improve (or . Though “dual relationships” are typically frowned upon by the mental health community, therapy clients typically need a close, trusted friend. The authors propose that if therapists and clients process their therapeutic relationship (i.e., directly address in the here and now feelings about.
As we know, money can either cut or cure. It can be gift and weapon, benefit and burden, source of security or wellspring of misery, and all things in between.
Psychotherapy Relationship and Money: Strange Bedfellows?
I can remember feeling confused and anxious about the payment early on in my time on the couch as a young cash-strapped, insecurity-riddled musician, and later as a slowly-getting-my-act-together grad student on a Ramen budget. My first therapist, a Doctor of Psychology, was a tall, handsome, dapper dresser. His being a doctor with a prominent office locale made it easy to project all sorts of ungodly wealth and highbrow leanings onto him. Lacking in assertiveness, nursing a broken heart, and clinically depressed at the time, I never raised my feelings about the money.
In fairness to my young neurotic self, neither did he that I recall, even in response to my consistent and rather bold no-show, no-call habit. Most of that was my insidious fear and shame.
But I believe I was also trying to communicate something about how odd it felt to pay him to…to what? But was I paying him to care? What exactly was I paying for? All of this gnawed at me all the way through.
Maybe my Doc was as uncomfortable discussing the financial exchange as I was. He might have perceived no connection between my no-showing, my palpable shame, and my conflicts about the money. I quit my first therapy experience about six months in. The take-away though was the absolutely genuine caring and concern I felt from him — my first taste of what really matters in therapy.
I was far off still from getting better, but feeling better was a must. There will, however, always be asterisks in my time with him, as one of the most symbolic, meaning-laden aspects of the therapy process went unacknowledged.
Light in the dark The person who became my mentor is a therapist I began seeing years later during graduate school. From the get-go there was an easy warmth, an accepting nature, and an unassuming confidence about him.
I also quickly picked up an implied appreciation and deep wisdom about the complexity of the monetary aspect of therapy. What I really wanted from him, of course, was approval that I would be good at doing what he does, as if he could know based on one meeting.
His later reaching out and gently reminding me that his door was always open really touched me. That thoughtfulness made it difficult to resist getting started for much longer, though I still managed to hold off for a few more months.
Many people, many therapists, are uncomfortable discussing money let alone the meaning of the exchange of currency in psychotherapy. I know a few who set up their practices to compartmentalize the payment away from a face-to-face interaction, some employing third-party systems to isolate it entirely. Technology makes that easy, and perhaps easier still to justify. However, it is important to remember that meta-analysis is more valid when the effect being investigated is quite specific. According to Migoneanother hindrance is the so-called Rashomon effect named after the film by Akira Kurosawa: Di Nuovo et al.
Though designed by independent research teams, there is often good correlation between the scales used to rate the therapeutic alliance, which reveal that these instruments tend to assess the same underlying process Martin et al.
None of their findings suggest that any one instrument was a stronger predictor of outcome than the others, in relation to the type of therapy being considered. It is interesting to note that although almost all of these scales were originally designed to examine the perspective of only one member of the patient—therapist—observer triad, they were later extended or modified to rate perspectives that were not previously considered.
The number of items included in the scales varies considerably between 6 and itemsas do the dimensions of the alliance investigated e. According to Martin et al. Different approaches for the evaluation of alliance coexist in group psychotherapy. One of them is derived from individual psychotherapy. Although a comparison between different treatment modalities is a topic beyond the scope of this paper, it is worth noting that in the late s, some authors Marmar et al.
However, subsequently, Raue et al. This latter study compared 57 clients, diagnosed with major depression and receiving either psychodynamic—interpersonal or cognitive—behavioral therapy: They argue that these findings could reflect the effort in cognitive—behavioral therapy to give clients positive experiences and to emphasize positive coping strategies.
A more recent comparison was suggested by Spinhoven et al. Results obtained by evaluating alliance through WAI-Client and WAI-therapist after 3, 15, and 33 months, showed clear alliance differences between treatments, suggesting that the quality of the alliance was affected by the nature of the treatment.
Schema-focused therapy, with its emphasis on a nurturing and supportive attitude of therapist and the aim of developing mutual trust and positive regard, produced a better alliance according to the ratings of both therapists and patients. Ratings by therapists during early treatment, in particular, were predictive of dropout, whereas growth of the therapeutic alliance as experienced by patients during the first part of therapy, was seen to predict subsequent symptom reduction.
Phases of the Alliance during the Therapeutic Process and the Relationship with the Outcome There is much debate on the role of the therapeutic alliance during the psychotherapeutic process. It may in fact be a simple effect of the temporal progression of the therapy rather than an important causal factor.
On the basis of this hypothesis, we would expect a development in the alliance to be characterized by a linear growth pattern over the course of the therapy, and alliance ratings obtained in the early phases to be weaker predictors of outcome than those obtained toward the end of the therapy. However, according to the findings of numerous researchers, this is not the case. Horvath and Marx describe the course of the alliance in successful therapies as a sequence of developments, breaches, and repairs.
According to Horvath and Symondsthe extent of the relationship between alliance and outcome was not a direct function of time: The results of these studies have led researchers to consider the existence of two important phases in the alliance.
The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session. During the first phase, adequate levels of collaboration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of confidence in the procedures that constitute the framework of the therapy.
The deterioration in the relationship must be repaired if the therapy is to be successful. This model implies that the alliance can be damaged at various times during the course of therapy and for different reasons.
The effect on therapy differs, depending on when the difficulty arises. In this case, the patient may prematurely terminate the therapy contract. According to Safran and Segalmany therapies are characterized by at least one or more ruptures in the alliance during the course of treatment. Randeau and Wampold analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies.
Although some studies are based on a very limited number of cases, the results appear consistent: While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used static measures of alliance.
There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: Few studies have analyzed alliance at different stages in the treatment process. According to the results proposed by Traceythe more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction high—low—high over the course of treatment.
When the outcome was worse, the curvilinear pattern was weaker. Kivlighan and Shaughnessy use the hierarchical linear modeling method an analysis technique for studying the process of change in studies where measurements are repeated to analyses the development of the alliance in a large number of cases.
Psychotherapy Relationship and Money: Strange Bedfellows? – PsychologyTomorrowMagazine
According to their findings, some dyads presented the high—low—high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment. In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development.
Kivlighan and Shaughnessy distinguish three patterns of therapeutic alliance development: They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pattern, in that this appeared to be correlated with the best therapeutic outcomes. In further studies of this development pattern, Stiles et al. Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative.Robert T. Muller - Trauma and the Avoidant Client II: The Therapy Relationship
No significant correlation was observed between any of the four patterns and the therapeutic outcome. However, the authors observed a cycle of therapeutic alliance rupture—repair events in all cases: On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes.
In particular, Stiles et al. The results of the study by De Roten et al.
According to De Roten et al. De Roten et al. According to Castonguay et al. This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon.
Discussion and Conclusion According to their meta-analysis based on the results of 24 studies, Horvath and Symonds demonstrate the existence of a moderate but reliable association between good therapeutic alliance and positive therapeutic outcome.
More recent meta-analyses of studies examining the linkage between alliance and outcomes in both adult and youth psychotherapy Martin et al. Thus, it is not by chance that in their meta-analysis, Horvath and Luborsky conclude that two main aspects of the alliance were measured by several scales regardless of the theoretical frameworks and the therapeutic models: This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants.
In a helpful contribution, Hentschel points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: The use of neutral observers or the creation of counterintuitive studies is therefore recommended.
From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. The development of a dynamic vision of the concept of therapeutic alliance is also apparent. The work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in Research aimed at analyzing the components that make up the alliance continues to flourish and develop.
Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: Attention has recently turned toward the role of the therapeutic alliance in the various phases of therapy and the relationship between alliance and outcome.
So far, few studies have regarded long-term psychotherapy involving many counseling sessions. This topic, along with a more detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects. Equally important, in our opinion, will be the findings of studies regarding drop-out and therapeutic alliance ruptures, which must necessarily consider the differences between that perceived by the patient and that perceived by the therapist.
Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgments The authors thank Mauro Adenzato for his valuable comments and suggestions to an earlier version of this article. A Research Handbook, eds Greenberg L. Guilford Press;— Bibring E. On the theory of the results of psychoanalysis. The generalizability of the psychoanalytic concept of the working alliance. Clinical Applications of Attachment Theory. Routledge and Kegan Paul Budman S. Cohesion, alliance and outcome in group psychotherapy.
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