Therapeutic Alliance - Science topic

Hello Leandro,

The vague answer is, more cases is generally better than fewer cases. There are two reasons:

1. The factor model you seek must, ideally, be capable of providing good estimates for the (12*11/2 =) 66 unique observed relationships among your 12 variables (here, item scores). That's a lot to ask of 61 cases.

2. In general, the smaller the N of cases, the more volatile are the observed relationships among the variables from sample to sample. Hence, the less likely that your sample data will accurately represent the correlations that may exist in the population. As these correlations are what the EFA is intended to account for, if they are incorrect then you likely will identify a factor model that does not generalize well to the population. The literature is full of studies in which one set of authors using a small or modest sample claims their EFA shows "different" results than those from another set of authors, even if ostensibly drawing from the same population.

Can you still proceed? Yes, of course--the numbers won't leap up from your data file and protest! However, do be mindful that: (a) guidelines such as "at least 100 cases" and "10-20 cases per variable" for EFA abound; and (b) you likely would want to characterize your results as tentative or exploratory, rather than as a definitive solution to the question of the true factor structure.

Good luck with your work.

.

these two articles are intresting

best wishes Susana Couto

Dear all, many thanks for your contributions. What concerns me most in these days, is the dilemma we have to solve between infection control and therapeutic alliance. On one hand mental health services are part of the entire (public) health system that works in order to contain or to mitigate the virus spread. On the other hand, I have the impression that we haven't got a real solution for how to conduct person-centered care given the restrictions in daily life and in psychiatric settings. And we have to be aware that this situation will probably last for months, if not years according to the latest simulation study

In addition, I hear from across Europe that service users now try to avoid mental health care services and institutions. By not having sufficiently staffed and equipped outreach resources, there is a risk that service users become abandoned at home while being isolated, lonely and suffering from anxiety. Inpatient care, however, is not an adequate alternative at the moment, I guess. There you will face restrictive environments and, more importantly, a higher risk of becoming infected. New data from EU countries show that about fifty percent of deaths happen in care homes, especially care homes for the elderly.

Once the virus is inside the institution, you have a real problem. And a lot of hospitals and care homes have already been closed due to high infection rates of both, service users and staff.

Any ideas for possible solutions?

Best,

Dirk

I have come across these resources:

Yes, there isn't conclusive evidence to support the efficacy of CBT for Anorexia Nervosa. In general, CBT, family-based treatment, and interpersonal therapy for eating disorders.

These articles may interest you:

These researchers are here on RG. Discuss the topic with these experts:

Revisiting Bordin's Theory on the Therapeutic Alliance: Implications for Family Therapy

Mojgan:

To give you a general sense of the study, here is the summary from the grant:

Over 1 million Canadians use psychotherapy each year to alleviate their mental health problems. Psychotherapy is highly efficacious, and several therapeutic approaches are equally effective (cognitive, interpersonal, psychodynamic) for common disorders (depression, anxiety). Common therapy factors like establishing a therapeutic alliance are related to positive patient outcomes. However, there is a well-documented gap between practice and research in psychotherapy. To address this gap, we developed the Psychotherapy Practice Research Network (PPRNet; www.pprnet.ca) to engage therapists and researchers in practice-based patient-oriented research. PPRNet initiated a deliberative priority setting process in which over 1000 therapists ranked their top research priorities that included: (1) identifying and repairing therapeutic alliance tensions, and (2) professional development. This proposal is the next step of this collaborative process. Therapeutic alliance is one of the most researched and important therapist practices that is robustly related to patient outcomes across all psychotherapy modalities. Tensions in the alliance (breakdowns in the collaborative relationship between patient and therapist) are reliably associated with poor patient outcomes. OBJECTIVE: to evaluate the effectiveness of professional development training designed to improve therapists’ skills to detect and repair alliance tensions. OUTPUTS: (1) training will increase therapist competence to detect and repair alliance tensions; and (2) increased therapist competence will improve patient mental health outcomes. HYPOTHESES: compared to therapists in the control condition who receive no intervention, therapists who do receive the professional development intervention will: (1) show greater competence in detecting and repairing alliance tensions; (2) have patients who experience better outcomes; (3) report greater self-efficacy in detecting and repairing alliance tensions; and (4) have greater increase in patient and therapist reported alliance during psychotherapy. This study will use a cluster randomized trial design, with patients clustered within therapists. Therapists will be assigned to study condition with 1-1 allocation to compare: (1) therapists (n = 40) who receive a professional development intervention to identify and repair alliance tensions to (2) therapists (n = 40) who do not receive the intervention. Therapists will each recruit 7 new patients that will be seen for at least 6 psychotherapy sessions (N = 560 patients). Therapists’ competence in identifying and repairing alliance tensions will be assessed by reliable trained blind judges using a valid observer-based rating system to assess audio recordings of the psychotherapy sessions. Patient outcomes will be assessed by patient and therapist self-report at baseline, post-study period, and at follow-up. Knowledge translation will be informed by qualitative analysis of post-study interviews with therapists, and knowledge dissemination will be facilitated by our existing network of therapists. Our team represents Canada’s leaders in psychotherapy research and training. Co-applicants developed the evidence-based learning modules to identify and repair alliance tensions. Research to improve practicing therapists’ ability to identify and repair therapeutic alliance ruptures will result in better mental health outcomes for the many Canadians who seek psychotherapy each year.

As for the actual therapist training, here is a summary:

The professional development

intervention is an educational program constructed on evidence-based methods, which was developed

and published by members of our team (Ravitz & Leszcz). The intervention teaches therapists to

make the most of psychotherapeutic relationships, including: methods to successfully form an alliance,

using meta-communication, mentalizing, and identifying and repairing alliance tensions. Alliance

tensions may be detected when there is a disagreement on tasks or goals of psychotherapy or there is a

strain in the relational bond between therapist and patient. Interventions to repair tensions include:

repeating the therapeutic rationale, changing tasks or goals, clarifying misunderstandings, or exploring

relational themes.

The professional development consists of case-based descriptions and DVDs

with role plays by experts and standardized patients. These are state of the art methods of education

practice based on quality evidence and recommendations from systematic Cochrane Reviews. We

will conduct 2 separate 2-day workshops for therapists randomized to this condition. The workshops

will occur prior to therapists recruiting patients. Following the workshop and after the therapists enroll

their first patient, the therapist will attend monthly 2-hour virtual or face to face supervision meetings

with up to 10 therapists at a time and led by one of the trainers. Therapists will end supervision when their patients complete the trial (if necessary,

number of supervisions attended may be controlled in the analyses). Independent reliable trained judges

will rate audio recordings of each psychotherapy session for alliance tensions and repairs. These

ratings will be used by the supervisor/trainer to focus the supervision meetings, to provide feedback to

therapists, and to ensure adherence/fidelity to the model.

I hope this gives you the information you were seeking.

Best wishes,

John

Nexhmedin Morina, thank you for your help.

2018 free paper:

Adolesc Health Med Ther. 2018; 9: 199–210.

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Jean Marc Guilé,1,2,3 Laure Boissel,1,2 Stéphanie Alaux-Cantin,1,2 and Sébastien Garny de La Rivière1

What a fabulous question Gary. Sorry I don't know the answer.

I have to admit that I have not undestood everything claimed by you in your question. The problem of the presentation of BPD symptoms in older patient is interesting and I would like to give you some hints:

- I dont think that you can find BPD symptoms in a patient that never showed signifiants psychiatric symptoms, someway suggesting a Personality Disorder. A personality disorder has a longtime history.

- there is a consensus that BPD sympotms can become milder in old age.

- It can happen in my opinion that a personality disorder like BPD can adapt himself very well under certains conditions of his life and show a severe maladjustment symptomatology in other circumstances.

Fonagy et al are busy investigating CBT and Dit (Dynamic Interpersonal Therapy) in a blended condition vis à vis with a classical treatment. You could contact Patrick Luyten who invited me to engage in this research later this year. He'll know if there is already research on the issue.

I recommend the following articles:

Franzini, L. R. (2001). Humor in therapy: The case for training therapists in its uses and risks. The Journal of general psychology, 128(2), 170-193.

Dziegielewski, S. F. (2003). Humor: An essential communication tool in therapy. International Journal of Mental Health, 32(3), 74-90.

Sultanoff, S. M. (2013). Integrating humor into psychotherapy: Research, theory, and the necessary conditions for the presence of therapeutic humor in helping relationships. The humanistic psychologist, 41(4), 388.

Scott, C. V., Hyer, L. A., & McKenzie, L. C. (2015). The healing power of laughter: The applicability of humor as a psychotherapy technique with depressed and anxious older adults. Social Work in Mental Health, 13(1), 48-60.

Yonatan-Leus, R., Tishby, O., Shefler, G., & Wiseman, H. (2017). Therapists’ honesty, humor styles, playfulness, and creativity as outcome predictors: A retrospective study of the therapist effect. Psychotherapy Research, 1-10.

Fox, L. E. (2016). The Use of Humor in Family Therapy: Rationale and Applications. Journal of Family Psychotherapy, 27(1), 67-78.

Look for the source who said about peace before Troyan War. Paris theft Helen on Feast after the Alliance.

If you are interested in the patient-therapist relationship, that should be the focus. It places or emphasises the dynamic relationship between "the two frightened people in the room" (Wilfred Bion.) I am from a psychoanalytic background and thus will perceive this question in a very different way. Since the relationship is the single most important factor in psychotherapy, regardless of whether it is CBT, psychoanalytic, etc we look at the moment-by-moment happenings in a session.

We would begin with a single case study which would be repeated again and again in order to build up clinical knowledge of what takes place between the patient and therapist and only after multiple studies can we begin to generalise. The work of RD Hinshelwood would be very important here. Hinshelwood is a British Kleinian whose work has included single case studies as a viable format.

You might also enquire into the work of Lester Lubosky and Paul Crits-Christoph who deveoped a "manualised" system which might be helpful to you. I know the Menniger Clinic has done a great deal of work through Lubosky's ideas - although there are those who are critical because of the assumptions he makes - we all make assumptions!

I am somewhat puzzled by your reference to "resistance" and "challenging". All patients are challenging in one way or another. Similarly, therapists are also challenging to the patient! We (I) do not necessarily respond in the same way to all patients; it is dependent on my understanding of the patient.

It is also the question of how you understand "resistance." There are many reasons for "resistance" in a patient, including defence mechanisms which require the therapist to understand. This is especially important because in some patients, breaking down a resistance too soon could lead to a "break-down." That is, either the patient's vulnerability is too overwhelming; or the break-down in the relationship itself.  Understanding the meaning of "resistance"or how you define resistance is therefore important. I am uncertain as to what you mean; and it can also seem to be something that is objectively problematic, rather than a normal part the therapeutic relationship. Can "resistance" be objectively described? Can the therapist aslo be "resistant"? I think that is also possible.

I am concerned about how human relationships can be "generalised" in such a way that we forget that the therapist is not objective in a way that scientific methodology is objective. To give an example, in the UK, which is where I was trained, psychoanalytic or psychodynamic models have to be "manualised" else there is no NHS (National Health Service) funding. Some very accomplished psychoanalysts like Prof. Peter Fonagy and Prof. Alessandra Lemma etc have developed "manualised" versions of "mentalisation" and also developed "Dynamic Internpersonal Psychotherapy (DIT) which means than non-psychoanalytic clinicians or even non-therapists eg nurses can follow a manualised format. It was done on the basis that preserving psychodynamic therapy in the NHS is better than nothing.

Nevertheless, the idea we can or should manualise or generalise involves philosophical questions as well. There will always be natural incompatibilities between patient and therapist, but the question is whether both parties are sufficiently committed to work at the relationship. It has been my experience that working through these "break-downs" are far more important and can lead to the patient (and therapist) really gaining insight into their relationships outside the consulting room. Since the concept of transference is crucial, these working-throughs in therapy are taken "outside" by the patient.

For me, understanding why is there an impasse is vitally important. The patient could be "diagnosed" as being "resistant" but I believe it is far more complex. Another question that comes to mind is how do you recognise and isolate "resistance"?

Sorry if this is unhelpful to you, but I am fascinated by your study.

Kind regards,

Ros

:

";

Hi Maureen,

The individual (or group) psychotherapy intervention for the treatment of depression with the strongest empirical evidence is called Behavioral Activation; this is the "active ingredient" in Cognitive Behavioral Therapy. If you review the scientific literature, you will find it is as effective as medications at treating depression and more effective at preventing relapse. FYI, while there are undoubtedly cases where it makes sense to consider a purely biological source of depression (e.g., thyroid or brain disease) and to treat the underlying medical condition accordingly, there are compelling reasons to question the medical model of depression as simply reflecting a neurotransmitter imbalance (you can read more in the link below). Also, it may be worth considering that "having" everything doesn't necessarily result in fulfillment; for many (all?) people greater satisfaction is to be found in what you are "giving" through purposeful activity guided by personal values (check out the literature on Acceptance and Commitment Therapy, which combines behavioral activation, mindfulness practice, and values clarification to treat depression).

Warm regards,

Paul

Dear Mendel,

The following resources may help:

In my training of students, we use many strong elements from David Burns' TEAM model and the second element of TEAM after Testing, is Empathy. We work on that continuously as they interview patients and practice active listening.  The mantra that we focus on and repeat over and over again is "Let the Ego Go".  You can't truly show empathy for another if you are, often in the background, focused on yourself, your anxieties, trying to look professional, etc. Learning to Let the Ego Go, and to free yourself up to actually show emotion, the echo of the patient's emotion, is the key, I think. When I watch videos of their interviews, we emphasize this issue in both personal and group supervision.  I think in-depth discussions and exercises where they have to think about their own reasons for going into counseling that are often NOT discussed such as feeling superior and wanting to "help" others, or trying to fix their own problems, or because they feel proud and have been told repeatedly that they are good listeners, etc. is also really important.  Burns has a great list of Self-Defeating Beliefs that we also use as part of this discussion of letting the ego go.  We also talk about countertransference reactions and how the natural tendency is to back away or avoid strong emotions, especially negative emotions like guilt, shame, pain, sorrow -- but that professionals, just like firefighters rushing into a burning building, learn to move toward the emotion, not away from it.  

There's a really interesting approach by Italian authors: Colli, A., Tanzili, A., Dimaggio, G., Lingiardi, V. (2014). Patient Personality and Therapist Response: An Empirical Investigation. American Journal of Psychiatry, 171(1), 102-108

Hi John, I know a text by Derrida referring to French philosopher Montaigne:

Derrida, J.; Montaigne, M. de (2000): Über die Freundschaft, Frankfurt (Suhrkamp).

However, I do not know if it is available in English. It's worth reading!

What I know, then, is:

Greenwood, Alice (1998): Accommodating Friends: Niceness, Meanness, and Discourse Norms, in: Hoyle, Susan M. / Adger, Carolyn Temple (Hrsg.). Kids talk. Strategic language use in later childhood, New York, Oxford University Press, S. 68–81.

Schofield, W. (1964): Psychotherapy, the Purchase of Friendship, Englewood Cliffs (Prentice Hall).

Shechtman, Z. (1991): Small Group Therapy and Preadolescent Same-Sex Friendship, in: Int. J. Group Psychotherapy 41, S. 227–243.

Shechtman, Z. (1994): Group Counseling/Psychotherapy as a School Intervention to Enhance Close Friendships in Preadolescence, in: Int. J. Group Psychotherapy 44, S. 377–391.

Tannen, Deborah (2005): Conversational style. Analyzing talk among friends, New York (Oxford University Press).

Traverso, Véronique (2009): The dilemmas of third-party complaints in conversation between friends, in: Journal of Pragmatics 41, S. 2385–2399.

This is a mixture of psychotherapeutic essays and research on friendship. I hope it makes some use for you.

Best

Michael

Chris

Not quite clear what you are looking for but I will tell you what I know. First, regarding “agency.” Are you interested in clients’ experience of agency? Or in the fact that they act agentically? They could act agentically without explicitly perceiving or experiencing themselves as being agentic. For instance, I have considered David Rennie’s qualitative studies as having demonstrated client agency in terms of action (so did David). But there was no explicit attempt to measure or even to ask clients if they were feeling agentic at the time. Second, I’m not sure if you mean something different by self-agency from agency per se.

            I’ve summarized evidence suggesting that clients act agentically in therapy. Most of it is qualitative and does not explicitly link to outcome, although I think you can infer a link. I will attach two chapters that summarize evidence. Both are page proofs so probably you shouldn’t quote directly, but the content is the same as is what is in the final chapters. The Bohart & Wade chapter is in the recent Handbook of Psychotherapy and Behavior Change. The Bohart & Tallman is in M. Cooper, J. C. Watson, & D. Hölldampf (Eds.), Person-centered and experiential therapy work: A review of the research on counseling, psychotherapy and related practices (pp. 91-133). Ross-on-Wye: PCCS Books.

            As far as the experience of agency, there is less. One study I know of is Hoener, Stiles, Luka, & Gordon, (2012). That is cited in both chapters, although mis-cited in Bohart & Tallman (2010) as “Hoerner” (I mis-spelled her name; it is Hoener, and in that chapter it is her conference presentation that is cited).

Art

My  experience is somewhat tangential using an adapted CST as part of a feedback system that used different outcome measures but used the ASC routinely.

I am convinced that the overall clinical setting and the mindset of clinicians and managers are vital variables here as is the patient population. I think that in the UK, at least there has been a drift away from clinical psychologists seeing themselves individually as active researchers but this does not mean that they have necessarily become good users of research even such eminently practical research as exemplified by Mike's work. Furthermore there has been a cultural dilution with the advent of psychological therapists without a scientific background.

While our forthcoming paper (Lucock et al.) and indeed the Pychotherapy Research Special issue (2016?) should give you some hard data, my belief is that the way ahead is more about developing cultures (where therapists are receptive to feedback and accept that when things are not going well they need to stop think and go in another direction) [I have just been moving my rather large van in a rather confined space!] rather than systems. Systems are great but they can only function in the right culture. lambert himself spoke on this at SPR Barcelona but I am not sure how much the negative data gets published.

If the CST is to work it probably needs to be an interactive device that pulls and pushes the therapist into changing direction trying new tactics getting help and advice and using other resources. Of course good supervision or the combination of CST supervision and outcome data could do this. We also need therapists who are prepared to carry on working when they are out of their comfort zone and statistically are more likely to produce less results than if they abandon the client and move onto someone else who is easier to work with. ie a system that rewards persistence and flexibility.

You're welcome.  Let me know if you need anything more as I (& know others who) have some experience with many of these measures.

Thank you, Adriano, for your thoughtful comments, & best wishes for the new year, Chris

Hello John,

check these out:

Also, these two reviews could be of help:

Edit:

I've just found one more. It's in French though, but has an extended English abstract:

Not much in the form of research.  Good chapters on the therapeutic relationship in DBT & ACT in the edited book The Therapeutic Relationship in the Cognitive Behavioral Therapies (Gilbert & Leahy, 2007).  Our own research (funded by NIMH) includes investigating the impact of mindfulness training for therapists on the interpersonal process in a CBT for PDs (I posted a recent presentation of preliminary results on my profile page, more to come),

Hi Juergen, Thanks for your useful clarifications. I agree, I think that the distinction that Jacques is posing is between the quality of the therapeutic relationship as important in promoting a process of change or the relationship itself as integral to that change. So one might think that a good alliance between therapist and patient/client would encourage trust, understanding and identification. These qualities might lead the patient to be more open to accept suggestions by the therapist or to be motivated to undertake exercises or study. However, in my work I'm more interested in the way that entering into the relationship itself becomes part of the mechanism of change.

Winnicott has written usefully about this. In 'Fear of breakdown' he describes how the patient's difficulties arise from a fear that something will happen that will destrroy his or her sense of self. In order to prevent this catastrophe, the patient will adopt various defensive strategies to isolate and repudiate the feared thoughts. Winnicott's insight is that this breakdown has in fact already occured. The individual as an infant experienced that catastrophe in the form of a failure of his or her environment to respond in sufficient time to their need. At that time the infant lacked the ability to deal with the failure. A defensive structure was then established, what WInnicott calls a False Self, which lays a pattern for future living and relating.

Winnicott suggests that optimally the patient will experience a similar and inevitable failure in the therapeutic relationship. (As no relationship can be perfect.) However, this time the patient as an adult, and with a facilitative therapist, can re-experience that earlier trauma and grow beyond the earlier defensive structures. An earlier relationship contained a trauma that could not be experienced, was frozen or sealed off and because it was thus timeless, continued to have a limiting effect upon the individual's capacity to relate and to fully live. Re-experiencing, even mildly, in the safer setting of the therapeutic relationship enables that experience to enter into time and then to become past.

So the relationship with the therapist itself is a vehicle for change, not a useful attribute to increase the effectiveness of other tools.

And I totally agree with you, Juergan, that we exist within a social nexus. It is not useful to think of ourselves as existing outside of relationships. Within psychoanalysis there are useful models to describes these processes, projective identification being a major insight into the way inwhich we shape eachother and are shaped by others. Winnicott, again, has useful things to say about this - for example, his statement that there is no such thing as an infant, rather there is always an infant/mother, from which the infant emerges. More recently Christopher Bollas has described the ways in which we use our environment of people, physical objects, ideas to construct our 'character', in the sense of a character in our personal story.

Regards

Geoff

Reading is nice, but a good supervision will be more important...