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Abstract

Originally a psychodynamic concept, the therapeutic relationship (also therapeutic alliance, helping alliance or simply alliance) has become a pan-theoretical model for the professional relationship between a therapist and his or her client (Kivlighan, 1995). With the development of this concept in the latter half of the 20th century, psychotherapeutic theory and practice saw a paradigm shift away from strict adherence to technique with little room for responsive, individual behavior from the therapist and toward the "authentic" human relationship at the core of therapy. This meant that more consideration was given to the idea of mutual influence from patient and therapist to the success of therapy (Safran & Muran, 2006). This article aims to provide a comprehensive overview of the complex and shifting research on the therapeutic relationship to promote a greater understanding of the concept.
... It is an oblivious occasion, the realization and mindfulness of which may be at the center of psychodynamic and explanatory treatments (Aggarwal, 2020;McCluskey and O'Toole, 2019). Transference may be a central occasion which decides the relationship between the client and the mental health clinician/practioner in each psychotherapeutic experience (Kanani and Regehr, 2003;McCluskey and O'Toole, 2019;Parth et al., 2017). In any case in which psychodynamic or classical psychoanalytic interventions are concerned, there is continuously an oblivious transference. ...
... The client feels frail and powerless, talks discreetly, and is unknowingly looking for maternal security-somebody who "gets" them and who can do everything for them. In the event that their unhappiness is related to early misfortune encountered in their childhood, as is frequently the case, their oblivious transference serves the craving to re-establish the circumstance some time to remind them of the painful events they have experienced (Parth et al., 2017;Veach et al., 2018). This may be related to idealizing trust, regarding the meaning of the transference perspectives to the mental health clinicians/practioners. ...
... Countertransference in a broader sense is the full subliminal enthusiastic reaction of the individual giving treatment and a mental health clinician/practioner group to the behavior of a client, which incorporates their responses and states of mind coming about from the transference (Gait and Halewood, 2019;Greenberg, 2016). That is, in a simpler sense, countertransference is the complementary response of the mental health clinician/practioner, which ought, moreover, which should be explained in a broader sense, including all the enthusiastic responses given by the client (Aggarwal, 2020;McCluskey and O'Toole, 2019;Parth et al., 2017). ...
... Health care professionals' reactions of countertransference have received sustained attention as an important aspect of the therapeutic relationship (15)(16)(17)(18). First presented by Sigmund Freud, the term and classical definition of countertransference referred to the therapist's unconscious reactions to a patient's transference (19). ...
... Because a clear definition of countertransference has yet to be developed (18), we borrowed heavily from the totalistic view and defined countertransference for our study as all of the emotional responses and reactions that a healthcare professional may have toward a patient, shaped by the professional's learned beliefs, lived experience, and schemas as well as the transference materials presented by the patient. That definition incorporates the professional's reactions, both conscious and unconscious, to both transference and non-transference materials presented by the patient, reactions that may manifest as affective, cognitive, somatic, and/or behavioral responses. ...
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Introduction As a part of the therapeutic relationship, a significant, well-established predictor of outcomes in psychiatric healthcare, healthcare professionals' emotional reactions to patients may affect treatment outcomes. Aim The aim of our study was to explore and describe healthcare professionals' experiences with managing countertransference using skills from a training program on self-guided imagery in meditation (SIM). Method Following an exploratory descriptive design, we conducted qualitative interviews with 10 healthcare professionals who care for patients with mental illness and subjected the collected data to thematic content analysis. Results Participants reported that SIM had helped them to manage countertransference and had prompted changes that we categorized into three themes: managing personal vulnerability, setting clearer boundaries, and practicing self-care. Conclusion The results suggest that by cultivating wellbeing and dealing with unresolved inner conflicts, SIM can help healthcare professionals to manage countertransference.
... Therapeutic ruptures can manifest as withdrawal, in which the patient moves away from the work of treatment by missing appointments, or confrontation, in which the patient expresses anger or dissatisfaction with the therapist or attempts to pressure or control the therapist (Eubanks et al., 2018). Recognizing risk for a rupture in the relationship and knowing how to repair ruptures are important skills for therapists to learn and can be highly important to successful outcomes of treatment (Parth et al., 2017). ...
Chapter
Therapeutic alliance plays a key role in understanding and addressing treatment resistance in depression, both for psychotherapeutic and pharmacologic interventions. By considering the shared goals, agreed-upon tasks, and trusting bond between therapist and patient, it is possible to identify factors contributing to reduced treatment response. Regardless of the treatment modality, a stronger therapeutic alliance is associated with greater symptom improvement. Interventions that focus on the patient first, acknowledge and manage transference, and help the patient make meaning and work toward understanding and healing enhance therapeutic alliance. These concepts and techniques are equally important whether treatment is done in person or via telehealth or using other technology-based interventions.
... Introduced by Sigmund Freud (1912Freud ( /2001 in the context of psychoanalytic treatment, it is a foundational concept in many forms of psychotherapy. Transference refers to a phenomenon where a patient redirects emotions, feelings, or wishes that were originally directed toward other people in their life onto the therapist (Goldstein and Goldberg, 2004;Parth et al., 2017). Transference can manifest, for example, in a patient's speech, demeanor, attitude, or patterns of behavior (Fink, 2007). ...
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AI-enabled virtual and robot therapy is increasingly being integrated into psychotherapeutic practice, supporting a host of emotional, cognitive, and social processes in the therapeutic encounter. Given the speed of research and development trajectories of AI-enabled applications in psychotherapy and the practice of mental healthcare, it is likely that therapeutic chatbots, avatars, and socially assistive devices will soon translate into clinical applications much more broadly. While AI applications offer many potential opportunities for psychotherapy, they also raise important ethical, social, and clinical questions that have not yet been adequately considered for clinical practice. In this article, we begin to address one of these considerations: the role of transference in the psychotherapeutic relationship. Drawing on Karen Barad’s conceptual approach to theorizing human–non-human relations, we show that the concept of transference is necessarily reconfigured within AI-human psychotherapeutic encounters. This has implications for understanding how AI-driven technologies introduce changes in the field of traditional psychotherapy and other forms of mental healthcare and how this may change clinical psychotherapeutic practice and AI development alike. As more AI-enabled apps and platforms for psychotherapy are developed, it becomes necessary to re-think AI-human interaction as more nuanced and richer than a simple exchange of information between human and nonhuman actors alone.
... Die therapeutische Beziehung ("alliance") entspricht nach moderner Konzeption einer "authentischen" menschlichen Beziehung und stellt den Kern der Psychotherapie und psychotherapeutischen Medizin dar [4,5]. Die bisherige Evidenz weist darauf hin, dass klinische Erfahrung und berufliches Training nicht direkt zu einer Verbesserung der Arzt/ Therapeut-Patient Beziehung ("working alliance") beitragen [6][7][8][9]. ...
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Zusammenfassung Die Wichtigkeit einer tragenden Arzt/Therapeut-Patient-Beziehung konnte als der wesentliche Faktor für den Therapieerfolg herausgearbeitet werden. Mit zunehmender klinischer Erfahrung verbessert sich die Fähigkeit von Behandlern, auch in komplexeren klinischen Situationen akkurate diagnostische und therapeutische Entscheidungen zu treffen. Bisher konnte zwar kein direkter Einfluss der klinischen Erfahrung auf die therapeutische Allianz nachgewiesen werden, allerdings wird deutlich, dass sich Interventionstechnik und damit Interaktionen bei erfahrenen Ärzten/Therapeuten basierend auf intuitiven Prozessen verändern. Konstruktive Interaktionsprozesse bilden das Fundament einer stabilen Arzt/Therapeut-Patient-Beziehung. Analysen nonverbaler Interaktionsaspekte zeigten, dass sich die Bearbeitung sogenannter negativer Spitzenaffekte in der Therapie günstig auf die therapeutische Beziehung und auf den Therapieerfolg auswirken.
... Σε συνέχεια του έργου του Freud (1958Freud ( /1912) για τη μεταβίβαση, οι Brumberg και Gumz (2012) υποστηρίζουν ότι η ερμηνεία της μεταβίβασης συνιστά βασική θεραπευτική τεχνική και σημαντικό ειδικό μηχανισμό θεραπευτικής αλλαγής στην ψυχοδυναμική συμβουλευτική και θεραπεία. «Η περίπτωση της Ντόρας» (Freud, 1963), το έργο εκείνο στο οποίο εισάγεται ο όρος της μεταβίβασης για πρώτη φορά, αποκαλύπτει ότι η κατανόηση της μεταβίβασης εξαρτάται σημαντικά από τη διαρκή συσχέτιση ανάμεσα σε όσα συνιστούν το περιεχόμενο και σε εκείνα που χαρακτηρίζουν τη δομή της θεραπευτικής σχέσης, υποδηλώνοντας έτσι ότι η μεταβίβαση εκτυλίσσεται μέσα σε ένα διαπροσωπικό, διϋποκειμενικό πλαίσιο (King, 2006;Parth et al., 2017). Όπως αναφέρουν χαρακτηριστικά οι Freedman και Berzofsky (1995), η μεταβίβαση πηγάζει από την ίδια επικοινωνιακή συνιστώσα του ονείρου. ...
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In the psychodynamic approach, the therapeutic relationship stands at the core of the therapeutic process and constitutes a key factor of the effectiveness of treatment. As such, highlighting the psychodynamic components associated with the therapeutic relationship can help reinforce the role of counseling and clinical psychologists, by offering a broader understanding of the various dynamic interactions in clinical work. Specifically, the present paper delineates particular aspects of the therapeutic relationship (e.g. therapeutic alliance, transference, countertransference, real relationship) that should be taken into account in counseling and psychotherapy as essential components of the therapeutic relationship. Current empirical data are presented to demonstrate the importance of these parameters for the therapeutic process and outcome. Emphasis is also placed on the conditions that need to be fulfilled in order to ensure a relationship of therapeutic value, such as the importance of the therapeutic framework and the role of the psychologists / psychotherapists in dealing with enactments. Finally, the benefits of using the potential of the therapeutic relationship in clinical practice are highlighted, for improving both someone’s relationship with oneself and with others.
... These reactions include "personal countertransference," unconscious hostile and/or erotic feelings toward patients that interfere with objectivity and limit therapists' effectiveness. Later interpretations expanded to include all of a therapist's reactions to his or her patients (2,3). Countertransference may now refer HIGHLIGHTS • Cognitive and affective biases, stemming in part from intuitive, fast-thinking processes, can contribute to illogical thinking, affect medical decision making, and adversely affect the conduct of psychotherapy. ...
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Objective: Cognitive and affective biases are essentially connected to heuristic shortcuts in thinking. These biases ordinarily function outside of conscious awareness and potentially affect clinical assessment, reasoning, and decision making in general medicine. However, little consideration has been given to how they may affect clinicians in the conduct of psychotherapy. This article aims to illustrate how such biases may affect assessment, formulation, and conduct of psychotherapy; describe strategies to mitigate these influences; and draw attention to the need for systematic research in this area. Methods: Cognitive and affective biases potentially influencing clinical assessment, reasoning, and decision making in medicine were identified in a selective literature review. The authors drew from their experiences as psychotherapists and psychotherapy supervisors to consider how key biases may influence psychotherapists' conduct of psychotherapy sessions. Results: The authors reached consensus in selecting illustrative biases pertinent to psychotherapy. Included biases related to anchoring, ascertainment, availability, base-rate neglect, commission, confirmation, framing, fundamental attribution error, omission, overconfidence, premature closure, sunk costs, and visceral reactions. Vignettes based on the authors' combined experiences are provided to illustrate how these biases could influence the conduct of psychotherapy. Conclusions: Cognitive and affective biases are likely to play important roles in psychotherapy. Clinicians may reduce the potentially deleterious effects of biases by using a variety of mitigating strategies, including education about biases, reflective review, supervision, and feedback. How extensively these biases appear among psychotherapists and across types of psychotherapy and how their adverse effects may be most effectively alleviated to minimize harm deserve systematic study.
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Objective: This study aimed to develop the Therapist Self-Efficacy Scale (T-SES), and test its validity in a sample of Italian mental health therapists, to assess their professional self-efficacy concerning their practice of eTherapy in a synchronous video-based setting. Methods: A sample of 322 Italian mental health professionals (37.6% psychologists, 62.4% psychotherapists; Mage = 38.48, SD = 8.509) completed an online survey. Results: The T-SES showed a clear, one-factor structure with good psychometric properties. Significant associations were found with insight orientation, general self-efficacy, self-esteem, and personality traits of openness, conscientiousness, and agreeableness. The results showed no differences between psychologists and psychotherapists, or differences based on years of experience. Conclusion: The T-SES is an agile and versatile self-report measure for mental health professionals to assess their self-efficacy concerning their therapeutic activity, which can provide information for tailoring training for eTherapy.
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Despite a large amount of research on the impact and consequences to the individual targeted for workplace bullying, there is relatively little written about the treatment of the targets of workplace bullying. What has been written has described case studies and discussed treatment processes such as listening, validation and coping strategies. There has been more description of working with a perpetrator of workplace bullying; however, this has been from a coaching perspective rather than a counselling perspective. To our knowledge, the role of a counselling professional in providing counselling to the target and perpetrator of workplace bullying has not been fully explored. This chapter examines the roles of counselling professionals in working with both the target and the perpetrator of workplace bullying, first through the lens of the broad counselling approach and then specifically through the “contextual model” of psychotherapy developed by Wampold (e.g. 2015). We explore the workplace bullying counsellor’s roles with the target and perpetrator in developing therapeutic relationships, the creation of real relationships, issues of transference and countertransference, establishing expectations and providing an approach that teaches health-promoting behaviours. We examine these roles through a review of the extant literature and the authors’ counselling experiences. Finally, the chapter explores the importance and need for a consistent and nurturing practice of self-care.
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Um dem Gegenstandsbereich der Psychotherapie in der Psychiatrie gerecht zu werden, gilt es die Subjektivität des Menschen zu betonen. Seit über 100 Jahren gilt die Zielsetzung der ersten psychotherapeutischen Tradition, der Psychoanalyse, sich nicht nur als therapeutische Methode zu verstehen, sondern auch in ihrer kulturtheoretischen Dimension, und sich vor allem in ihrer gesellschaftskritischen Aufgabenstellung immer wieder zu Wort zu melden. In diesem Zusammenhang gilt es sich mit der Tatsache auseinanderzusetzen, dass gerade die Psychotherapie durch die Inklusion von geistes- und sozialwissenschaftlichen Forschungsfragen das naturwissenschaftliche Forschungsparadigma erweitert und ergänzt. Aus diesem Grund gestaltete die AG Ambulante Psychotherapie der Österreichischen Gesellschaft für Psychiatrie, Psychosomatik und Psychotherapie (ÖGPP) angesichts des Tagungstitels der ÖGPP-Jahrestagung 2015 „Psychiatrie in der Medizin“ in Gmunden einen Workshop zum Thema Psychotherapie in der Medizin und lud zur Diskussion ein. Wir stellten eine Literaturanalyse vor: Anhand von Thomas Bernhards Aussagen über „Die Medizin“, „Das Patiententum“, „Die Mediziner“ und „Der Medizinbetrieb“ wurde eine Abhandlung über das Subjektive im Menschen gezeigt, wobei diese Auseinandersetzung als Diskussions-Start diente, in der versucht wurde, den medizinischen Diskurs wieder gezielt mit geisteswissenschaftlichen Diskursformen zusammenzubringen. Eine Auseinandersetzung als eine Übung, die nun schon beinahe vergessen worden war – und, um der Klage, dass über Ökonomie, Spezialisierung und Effizienzsteigerung, die Rolle der Ärztin/des Arztes als „Wesen an sich“ in der Gesellschaft, nicht mehr befriedigend reflektiert werden kann. Um Thomas Bernhards Reflexionen und Anwürfe dem Leser näherzubringen und für die Aufnahme und Reflexion der Gedankengänge Offenheit zu erhalten, wurde auf folgende Werke Thomas Bernhards fokussiert: „Ein Kind“, „Die Kälte“, „Der Atem“ und „Frost“. Die Diskussion fokussiert Versorgungsaspekte (Karin Matuszak-Luss), gesellschaftliche Aspekte (August Ruhs), die Berufspolitik (Bettina Fink), die Ausbildung (Henriette Löffler-Stastka) und Aspekte der Kooperation (Reinhold Glehr). Im Folgenden werden Thomas Bernhards Positionen sowie deren mögliche Bedeutung für unser Fachgebiet der Psychiatrie als Anregung zur Reflexion erläutert.
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The aim of this study is to explore the relationship between level of personality organization and type of personality disorder as assessed with the categories in the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006) and the emotional responses of treating clinicians. We asked 148 Italian clinicians to assess 1 of their adult patients in treatment for personality disorders with the Psychodiagnostic Chart (PDC; Gordon & Bornstein, 2012) and the Personality Diagnostic Prototype (PDP; Gazzillo, Lingiardi, & Del Corno, 2012) and to complete the Therapist Response Questionnaire (TRQ; Betan, Heim, Zittel-Conklin, & Westen, 2005). The patients’ level of overall personality pathology was positively associated with helpless and overwhelmed responses in clinicians and negatively associated with positive emotional responses. A parental and disengaged response was associated with the depressive, anxious, and dependent personality disorders; an exclusively parental response with the phobic personality disorder; and a parental and criticized response with narcissistic disorder. Dissociative disorder evoked a helpless and parental response in the treating clinicians whereas somatizing disorder elicited a disengaged reaction. An overwhelmed and disengaged response was associated with sadistic and masochistic personality disorders, with the latter also associated with a parental and hostile/criticized reaction; an exclusively overwhelmed response with psychopathic patients; and a helpless response with paranoid patients. Finally, patients with histrionic personality disorder evoked an overwhelmed and sexualized response in their clinicians whereas there was no specific emotional reaction associated with the schizoid and the obsessive-compulsive disorders. Clinical implications of these findings were discussed.
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The purpose of this review is to provide a comprehensive and critical examination of the empirical literature about the relation between patient personality and therapist countertransference. The therapist's countertransference can play a crucial role in psychotherapy outcomes, especially in the treatment of personality disorders. The therapist's emotional responses to patients can accomplish the following: inform the clinician about the patient's personality, impact therapy outcome, influence patient resistance and elaboration, mediate the influence of the therapist's interventions and influence therapeutic alliance. In the last years, several studies have empirically demonstrated the presence of a specific pattern of therapist responses that are related to different patient personality disorders. Other works showed how the effects of the therapist's technique depend on the emotional context in which they are delivered and in particular countertransference experiences. Moreover, researchers suggest that the therapist's emotional responses occur across all kinds of therapy and are independent of the therapist's theoretical preferences.
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This article outlines some of the main features of a research program on ruptures in the therapeutic alliance and reports some of the major findings to date. A rupture in the therapeutic alliance is a deterioration in the quality of the relationship between patient and therapist; it is an interpersonal marker that indicates a critical opportunity for exploring and understanding the processes that maintain a maladaptive interpersonal schema. Following the task-analytic research paradigm, a preliminary model of the resolution process was developed and then tested and revised with 2 different data sets. A series of lag 1 sequential analyses were used to confirm the hypothesized sequences of events within resolution sessions and to demonstrate a difference between resolution and nonresolution sessions. This article describes the evolution of a model of rupture resolution and then discusses its implications for treatment development and evaluation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Objective: The aim of this study was to examine the relationship between therapists' emotional responses and patients' personality disorders and level of psychological functioning. Method: A random national sample of psychiatrists and clinical psychologists (N=203) completed the Therapist Response Questionnaire to identify patterns of therapists' emotional response, and the Shedler-Westen Assessment Procedure-200 to assess personality disorders and level of psychological functioning in a randomly selected patient currently in their care and with whom they had worked for a minimum of eight sessions and a maximum of 6 months (one session per week). Results: There were several significant relationships between therapists' responses and patients' personality pathology. Paranoid and antisocial personality disorders were associated with criticized/mistreated countertransference, and borderline personality disorder was related to helpless/inadequate, overwhelmed/disorganized, and special/overinvolved countertransference. Disengaged countertransference was associated with schizotypal and narcissistic personality disorders and negatively associated with dependent and histrionic personality disorders. Schizoid personality disorder was associated with helpless/inadequate responses. Positive countertransference was associated with avoidant personality disorder, which was also related to both parental/protective and special/overinvolved therapist responses. Obsessive-compulsive personality disorder was negatively associated with special/overinvolved therapist responses. In general, therapists' responses were characterized by stronger negative feelings when working with lower-functioning patients. Conclusions: Patients' specific personality pathologies are associated with consistent emotional responses, which suggests that clinicians can make diagnostic and therapeutic use of their responses to patients.
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Tallies were made of outcomes of all reasonably controlled comparisons of psychotherapies with each other and with other treatments. For comparisons of psychotherapy with each other, most studies found insignificant differences in proportions of patients who improved (though most patients benefited). This "tie score effect" did not apply to psychotherapies vs psychopharmacotherapies compared singly—psychopharmacotherapies did better. Combined treatments often did better than single treatments. Among the comparisons, only two specially beneficial matches between type of patient and type of treatment were found. Our explanations for the usual tie score effect emphasize the common components among psychotherapies, especially the helping relationship with a therapist. However, we believe the research does not justify the conclusion that we should randomly assign patients to treatments—research results are usually based on amount of improvement; "amount" may not disclose differences in quality of improvement from each treatment.
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Abstract The development and empirical examination of a tripartite model of the therapeutic relationship over nearly three decades are described. The model asserts that all therapeutic relationships, to varying degrees, consist of a real relationship, a working alliance, and a transference-countertransference configuration. Research testing propositions about how each of these components is related to treatment process and outcome, and to each other, is presented. Many propositions have been supported, but some have been disconfirmed. Although the tripartite, or perhaps a quadripartite, model appears to be empirically and theoretically viable, continued research and theoretical development will serve to refine the model further. The development and testing of additional models that unpack the global concept of the therapeutic relationship would also be useful.
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Recent decades have witnessed an extraordinary amount of conceptual and empirical work on attachment theory in psychology and psychotherapy. Attachment theory is discussed in the present article as a way of understanding and fostering therapeutic work with 2 other key relationship constructs that have been theorized to be elements of all psychotherapies: client transference and the real relationship existing between the therapist and patient. Fundamental features of attachment, transference, and the real relationship are summarized. Particular emphasis is given to the role of the therapist as a secure base and a safe haven within the real relationship, and to the patient's internal working model as it relates to transference. A case of long-term psychodynamic psychotherapy conducted by the first author is presented to illuminate the 3 main constructs. The case demonstrates both the usefulness of attachment theory and the fact that any single theory cannot explain all of the complex features of a given treatment.