Client attachment to therapist: Relation to client personality and symptomatology, and their contributions to the therapeutic alliance

This study examined the relation of client attachment to the therapist to diverse facets of the therapeutic alliance, client personality, and psychopathological symptoms, as well as the relative importance of therapeutic attachments, personality, and symptomatology in predicting the alliance. Eighty clients in ongoing therapy completed measures of client attachment to therapist (CATS), personality (6FPQ), psychopathological symptoms (BSI), and therapeutic alliance (WAI-Short, CALPAS, HAQ). Secure and Avoidant-Fearful attachment to the therapist correlated positively and negatively, respectively, with total and subscale alliance scores. Preoccupied-Merger therapeutic attachment was unrelated to the alliance. Exploratory analyses suggested however that the relationship between Preoccupied-Merger attachment and the alliance was moderated by the extent to which clients were distressed. Clients' therapeutic attachments were unrelated to basic personality dimensions. Preoccupied-Merger attachment to the therapist correlated significantly with several symptom dimensions. Clients' therapeutic attachments emerged as superior and more consistent predictors, relative to client personality and symptomatology, of the therapeutic alliance.     

French adaptation and validation of the helping alliance questionnaires for child, parents, and therapist.

OBJECTIVES: To adapt the Helping Alliance Questionnaires for Child and Parents (HAQ-CP) into French and to assess their validity and reproducibility for use with the child, parent, and therapist. METHOD: First, the 3 US versions of the questionnaires were translated into French by 3 French-English bilingual translators (who were native speakers), and the translations were then discussed by an expert committee to ensure that the concept explored within the French context was efficiently targeted. Second, the psychometric properties of the French version were investigated in a cross-sectional, multicentre study. The questionnaires were completed by 148 children and adolescents, aged 9 years or older and with various conditions, who were followed in 3 university hospital outpatient clinics and 2 ambulatory psychiatry units, and also by their parents and therapists. RESULTS: The instruments were quick and easy to administer, and acceptability was good. All 3 versions proved unidimensional in factorial analysis (80% of variance was explained) with high internal construct validity (Cronbach's alpha = 0.8). Reproducibility was satisfactory (intraclass correlation coefficients were as follows: child, 0.84; parent, 0.84; and therapist, 0.87). Concordance of the 3 alliance assessments was moderate. CONCLUSION: This work provides child psychiatrists with a valid measure of the therapeutic alliance. Its predictive value, while recognized in adults, remains to be demonstrated in children.     

Predictive validity of patient and therapist attachment and introject styles

This study assessed introject and attachment styles of patients and therapists, and the match of these styles in patient/therapist dyads, to determine their relation to various psychotherapy process and outcome measures. The INTREX was used to measure introject style (affiliation and autonomy) and the Relationship Scale Questionaire to measure attachment style (secure, fearful, preoccupied, dismissing). Therapists with more affiliative (self-loving) and secure styles achieve better outcome results compared to therapists with less affiliative (self-hating) and insecure styles. Further, the greater the difference in introject and attachment styles within the patient/therapist dyad, the better the outcome.     

Psychotherapy engagers versus non-engagers: Differences in alliance,therapist verbal response modes,and client attachment

Abstract

For each of four therapists, we studied two clients who did not return after intake (non-engagers) and two clients who continued for at least eight sessions of psychodynamic psychotherapy (engagers), for a total of 16 cases yielding 3877 therapist verbal response units. Engagers and non-engagers did not differ in terms of working alliance measured after the intake session. In terms of therapist verbal response modes for non-engagers compared to engagers, therapists used more approval-reassurance in the beginning third of intake sessions, and more reflections of feeling but less information about the helping process in the last third of intake sessions. Non-engagers had higher pre-intake attachment anxiety than engagers. Implications for practice and research are discussed.     

The therapist in child sexual abuse: the context of helping

Professional response to childhood sexual abuse has evolved through three stages: (1) discovery of the problem, (2) identification of abuse victims and support for disclosure, and (3) emphasis on forensic issues. The importance of treating victims and offenders is emphasized, as opposed to overinvestment in the validation and prosecution of abuse allegations.     

The magnitude of client and therapist working alliance ratings

Researchers studying the working alliance frequently comment that clients and therapists tend to rate the alliance highly. The authors conducted this study to determine the accuracy of these comments by examining of the magnitude of adult client and therapist working alliance ratings in 63 refereed articles published between 1990 and 2007. The authors wondered if clients and therapists generally tend to use just the higher points of rating scales for measures of working alliance. The 63 articles used 9 different measures of the working alliance and provided working alliance ratings by 6,441 clients and 6,359 therapists. Results indicate that clients tend to use only the top 20% of rating points and therapists tend to use only the top 30% of rating points on alliance measures. Implications of the findings include the possibility that clients and therapists do not differentiate among lower rating points on the scales, tend to rate the alliance according to a social desirability or dissonance-reducing response set, or provide ratings that accurately reflect the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Exploring the helping relationship between the schizophrenic client and rehabilitation therapist

This paper argues that the enhanced efficacy of current rehabilitation strategies compared to insight-oriented therapies for schizophrenic clients cannot be understood in terms of differences in technique alone. Rather, the relationship that develops between rehabilitation therapist and schizophrenic client may represent a potent therapeutic ingredient warranting further study. The concept of therapeutic alliance is examined as a means toward understanding the mechanisms underlying successful rehabilitation.     

New roles for new-professional mental health workers: Training the patient advocate,the integrator,and the therapist

This article describes the conceptualization, development, and implementation of a Veterans Administration neuropsychiatric hospital-based human services worker (new-professional) training program. The program involves an experientially heterogeneous group of 16 trainees whose practical and academic training will he centered around the veteran psychiatric patient and the community with which he is in contact. Four principal roles of this new professional are emphasized: (1) patient advocate, (2) longitudinal contact person for patients from hospital admission to posthospitalization community adjustment, (3) integrator of the patient's ongoing treatment process and experiences, and (4) cross-disciplinary worker who under supervision relieves existing professionals of the less specialized portions of their workload.He formerly was Coordinator, Human Services Worker Training Program, Brentwood Veterans Administration Hospital, Los Angeles, California.This program is supported by the Education Service, Veterans Administration Central Office, Washington, D.C.     

Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact

Thirty volunteer clients of trainee therapists nominated an incident that was critical in the development of their therapeutic relationship. Clients completed the Client Attachment to Therapist Scale (CATS), the Experiences in Close Relationships Scale (ECRS), and the Session Impacts Scale (SIS). Clients reported an increase in attachment security with their therapists, along with perceptions of support and relief and increasing exploration following the relationship building incident. While clients' avoidant attachment was unrelated to attachment to the therapist prior to the incidents, in subsequent sessions avoidance was related to a change in secure attachment to therapist. Finally, client attachment to therapist but not general attachment was significantly related to in-session exploration. Findings are discussed in light of attachment theory and convergence with findings from the field of social psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Therapeutic alliance and multiple psychotherapy in the context of therapist rotation: Experiences with OLITA

Despite a long tradition of client-centered approaches in addiction therapy, these approaches have not been broadly applied until the 90s of the last century, since treatment programs were predominantly based on behavior therapy. However, due to dissemination of and research on motivational interviewing (MI) over the last 20 years, client-centered therapy has become increasingly accepted in routine care of patients with substance use disorders. Originally, W. R. Miller and S. Rollnick did not establish MI as a brief intervention. Nevertheless, research on MI has mainly been performed within the context of brief interventions. As a consequence, empirically supported client-centered interventions that are based on long-term treatment are largely missing in addiction therapy. OLITA, the Outpatient Long-term Intensive Therapy for Alcoholics, may be one of few exceptions. OLITA is a comprehensive long-term treatment program that is fully compatible with the principles of MI and that combines elements of client-centered and behavior therapy. This review article presents a synopsis of the published literature on OLITA, focusing on aspects of therapeutic alliance and multiple psychotherapy. After a short introduction of the therapy program, we delineate how client-centered therapy is integrated in the context of therapist rotation. The most important data on process–outcome research in OLITA are summarized. Our results suggest that the therapeutic alliance is a major treatment factor that is strongly associated with the eight treatment processes of the TOPPS (Therapy Orientation by Process Prediction Score) that, in turn, is highly predictive of long-term alcohol abstinence. Based on experience of clinical care and training of OLITA therapists, we show in the practical part of this article how to implement therapist rotation and multiple psychotherapy, as well as how to apply communication and interaction skills to build a successful working alliance.     

Relationships among patient and therapist ratings of therapeutic alliance and patient assessments of therapeutic process: a study of cognitive therapy with long-term mentally ill patients.

The therapeutic alliance as rated by therapists and patients was assessed every 5 weeks throughout the treatment period in an in-patient treatment program for schizophrenic and other long-term mentally ill patients. The patients (N = 26) also assessed perceived curative factors (Curative Factors Questionnaire) and made therapy session evaluations (Session Evaluation Questionnaire). The most important patient rated factors showing a relationship with therapist-rated alliance were in the initial phase of treatment depth in the therapy sessions, in the working phase the experience of involvement in the treatment, and in the discharge phase perceived helpfulness of encouragement and reassurance. The investigation of curative factors, session evaluations, and alliance as rated by patients showed a relationship in the initial phase between alliance and encouragement, reassurance and awareness, in the working phase between alliance and depth in sessions and "talking to someone who understands," and in the discharge phase between alliance and self-understanding and problem solution.     

The therapist and the patient: coping with noncompliance.

In the mental health clinic, the psychotherapist must cope with a multitude of diagnostic and therapeutic challenges. Extensive efforts are expended in reaching a diagnosis and a decision regarding treatment. Despite these efforts, the patient may fail to comply with the recommendations for treatment. Noncompliance has a wide variety of manifestations. One of the major reasons for noncompliance concerns the relationship between the patient and the physician, forcing the therapist to take an active part. Manifestations of noncompliance usually arouse countertransference reactions in therapists, who feel that this behavior exemplifies a lack of trust in them and in the corpus of knowledge they represent. Unique to the therapist's work in the mental health clinic is the need that sometimes arises to begin intervention before a basis for treatment has been established or an initial treatment contract achieved. In certain cases, observation is the only psychotherapeutic intervention possible. Much time may elapse until a therapeutic contract is established, and sometimes it is not established at all.     

Neuroanalysis of therapeutic alliance in the symptomatically anxious: the physiological connection revealed between therapist and client

This study was an attempt to establish neurophysiological correlates, particularly brain activity, during high therapeutic alliance (TA) between client and therapist. The aim was to assess electroencephalography (EEG) activity in clients with symptomatic anxiety during high TA using skin conductance resonance measurements from both client and therapist. Thirty clients, aged 43.8 +/- 11.5 years (males: n=15 females: n=15), underwent six, weekly, 1-hour sessions (180 hours of repeated measures). The EEG activity was measured from the prefrontal, temporal, parietal and occipital sites during the sessions. State and trait anxiety, Working Alliance Inventory (WAI) and heart rate measures were obtained before and after each session. Prefrontal, parietal and occipital sites were associated with TA. Anxiety and heart rate were found to decrease after therapy, and for both the client and the therapist, the WAI score increased significantly in later sessions. The results are discussed from the perspective of further understanding the neurophysiological associations to TA.     

Psychotherapy as civics: the patient therapist as citizens

The field of psychotherapy has failed to live up to its promise to be a force in the continued development of democracy by aligning itself with medicine and psychiatry. Psychotherapists must recognize that those with whom they work and disseminate information to are inevitably citizens and that they are redefining citizens as mental patients. By utilizing psychiatric diagnoses, which are in effect, moral labels, psychotherapy unwittingly helps create authoritarian political structures by convincing their patients and the public that they are essentially inferior and can do nothing to change that condition. A series of recommendations are made that suggest ways for psychotherapy to free itself from institutional psychiatry and medicine and build its own "house."     

Alexithymia and therapist reactions to the patient: expression of positive emotion as a mediator

This study examined patient's expression of emotion as a mediator of the relationship between patient alexithymia and therapist reactions to the patient. We analyzed data from 107 psychiatric outpatients who participated in a randomized controlled trial of two forms of group therapy for complicated grief. Patient alexithymia was assessed using the Toronto Alexithymia Scale-20. Patient's expression of emotion was assessed via sociometric ratings provided by other group members. Therapist reactions to the patient were assessed via therapist's ratings of each member in the group. Patient's expression of positive emotion met all the requirements for being considered a mediator. The findings indicated that the higher the level of alexithymia (specifically, greater difficulty communicating feelings and greater tendency to engage in externally oriented thinking), the less expression of positive emotion by the patient, and the more negative the therapist's reactions to the patient. The mediation provided by expression of positive emotion accounted for over half of the direct effect of alexithymia on therapist reactions to the patient. Future work needs to consider whether a therapist's awareness of a patient's limited capacity to express positive emotions and the negative influence that this can have on his/her reactions to his/her patients can help improve the therapeutic experience with alexithymic patients.     

Burden of Alzheimer's disease: helping the patient and caregiver.

The burden associated with caring for a patient with dementia is well documented. There are many conflicting data on the factors that cause caregiver burden. Historically, studies in this area have tended to focus on deficits in the patient and the burden and distress they cause the caregiver. More recently, it has been acknowledged that caregivers' own characteristics may play a major role in determining how burdensome and stressful they find their role. These characteristics include such things as gender, availability of support systems, and relationship to patient, as well as the way the caregiver perceives the patient's symptoms (whether illness related or deliberate) and his or her attitude and behavior toward the patient. Understanding the origins of caregiver burden has broad implications both in terms of the well-being of caregivers and the quality of support that patients receive. The Manchester Carer's Project, which is described here, seeks to identify the origins and management of caregiver burden.     

Reflections on gifts in the therapeutic setting: the gift from patient to therapist

Since Freud's time, psychoanalytically oriented therapists have been wary of accepting gifts from patients, although they have done so in some circumstances within the sanctum of their offices. After providing a working definition of the word "gift" for the purposes of this clinical discussion, the article reviews the relevant literature on the subject. The author presents clinical material in which he describes how gifts were presented by patients within the context of their treatment processes. The article concludes with the author's attempt to define some of the variables that affect the response of the therapist to a patient's gift, and expounds on those variables in terms of their influence on technique.     

Ability to form an alliance with the therapist: a possible marker of prognosis for patients with antisocial personality disorder

Antisocial personality disorder is generally perceived to be refractory to treatment, particularly psychotherapy. In this study, the ability of 48 patients with this disorder to form a working relationship with a psychotherapist or drug counselor was examined in relation to outcome of 24 weeks of treatment evaluated at 7-month follow-up. Some antisocial patients were able to form working relationships with their therapists, and there was a significant association between the ability to form such a relationship and treatment outcome. Measures of this ability, such as the Helping Alliance Questionnaire, may help identify antisocial patients who can benefit from psychotherapy.