Therapeutic relationship

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The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client.

Contents

In psychoanalysis the therapeutic relationship has been theorized to consist of three parts: the working alliance, transference/countertransference, and the real relationship. [1] [2] [3] Evidence on each component's unique contribution to the outcome has been gathered, as well as evidence on the interaction between components. [4] In contrast to a social relationship, the focus of the therapeutic relationship is on the client's needs and goals. [5]

Therapeutic Alliance / Working Alliance

The therapeutic alliance, or the working alliance may be defined as the joining of a client's reasonable side with a therapist's working or analyzing side. [6] Bordin [7] conceptualized the working alliance as consisting of three parts: tasks, goals and bond. Tasks are what the therapist and client agree need to be done to reach the client's goals. Goals are what the client hopes to gain from therapy, based on their presenting concerns. The bond forms from trust and confidence that the tasks will bring the client closer to their goals.

Research on the working alliance suggests that it is a strong predictor of psychotherapy or counseling client outcome. [8] Also, the way in which the working alliance unfolds has been found to be related to client outcomes. Generally, an alliance that experiences a rupture that is repaired is related to better outcomes than an alliance with no ruptures, or an alliance with a rupture that is not repaired. Also, in successful cases of brief therapy, the working alliance has been found to follow a high-low-high pattern over the course of the therapy. [9] Therapeutic alliance has been found to be effective in treating adolescents with PTSD, with the strongest alliances were associated with the greatest improvement in PTSD symptoms.[ citation needed ] Regardless of other treatment procedures, studies have shown that the degree to which traumatized adolescents feel a connection with their therapist greatly affects how well they do during treatment. [10]

Necessary and sufficient conditions

In the Humanistic approach, Carl Rogers identified a number of necessary and sufficient conditions that are required for therapeutic change to take place. Rogers stated that there are six necessary and sufficient conditions required for therapeutic change:[ citation needed ]

  1. Therapist–client psychological contact: A relationship between client and therapist must exist, and it must be a relationship in which each person's perception of the other is important.
  2. Client incongruence: That incongruence exists between the client's experience and awareness.
  3. Therapist congruence, or genuineness: The therapist is congruent within the therapeutic relationship. The therapist is deeply involved, they are not 'acting' and they can draw on their own experiences (self-disclosure) to facilitate the relationship.
  4. Therapist unconditional positive regard: The therapist accepts the client unconditionally, without judgment, disapproval or approval. This facilitates increased self-regard in the client, as they can begin to become aware of experiences in which their view of self-worth was distorted or denied.
  5. Therapist empathic understanding: The therapist experiences an empathic understanding of the client's internal frame of reference. Accurate empathy on the part of the therapist helps the client believe the therapist's unconditional regard for them.
  6. Client perception: That the client perceives, to at least a minimal degree, the therapist's unconditional positive regard and empathic understanding.

Transference and Counter-Transference

The concept of therapeutic relationship was described by Freud (1912) as "friendly affectionate feeling" in the form of a positive transference. However, transferences, or more correctly here, the therapist's 'counter-transferences' can also be negative. Today transference (from the client) and counter-transference (from the therapist), is understood as subconsciously associating a person in the present, with a person from a past relationship. For example, you meet a new client who reminds you of a former lover. This would be a counter-transference, in that the therapist is responding to the client with thoughts and feelings attached to a person in a past relationship. Ideally, the therapeutic relationship will start with a positive transference for the therapy to have a good chance of effecting positive therapeutic change.

Operationalization and Measurement

Several scales have been developed to assess the patient-professional relationship in therapy, including the Working Alliance Inventory (WAI), [11] the Barrett-Lennard Relationship Inventory, [12] and the California Psychotherapy Alliance Scales (CALPAS). [13] The Scale To Assess Relationships (STAR) was specifically developed to measure the therapeutic relationship in community psychiatry, or within care in the community settings. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Psychotherapy</span> Clinically applied psychology for desired behavior change

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.

<span class="mw-page-title-main">Counseling psychology</span> Counseling theory

Counseling psychology is a psychological specialty that encompasses research and applied work in several broad domains: counseling process and outcome; supervision and training; career development and counseling; and prevention and health.

Integrative psychotherapy is the integration of elements from different schools of psychotherapy in the treatment of a client. Integrative psychotherapy may also refer to the psychotherapeutic process of integrating the personality: uniting the "affective, cognitive, behavioral, and physiological systems within a person".

Person-centered therapy, also known as person-centered psychotherapy, person-centered counseling, client-centered therapy and Rogerian psychotherapy, is a form of psychotherapy developed by psychologist Carl Rogers beginning in the 1940s and extending into the 1980s. Person-centered therapy seeks to facilitate a client's self-actualizing tendency, "an inbuilt proclivity toward growth and fulfillment", via acceptance, therapist congruence (genuineness), and empathic understanding.

Countertransference is defined as redirection of a psychotherapist's feelings toward a client – or, more generally, as a therapist's emotional entanglement with a client.

Unconditional positive regard, a concept initially developed by Stanley Standal in 1954, later expanded and popularized by the humanistic psychologist Carl Rogers in 1956, is the basic acceptance and support of a person regardless of what the person says or does, especially in the context of client-centred therapy. Rogers wrote:

For me it expresses the primary theme of my whole professional life, as that theme has been clarified through experience, interaction with others, and research. This theme has been utilized and found effective in many different areas until the broad label 'a person-centred approach' seems the most descriptive. The central hypothesis of this approach can be briefly stated. It is that the individual has within him or her self vast resources for self-understanding, for altering her or his self-concept, attitudes, and self-directed behaviour—and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided.

Transference is a phenomenon within psychotherapy in which the "feelings, attitudes, or desires" a person had about one thing are unconsciously projected onto the here-and-now Other. It usually concerns feelings from a primary relationship during childhood. At times, this transference can be considered inappropriate. Transference was first described by Sigmund Freud, the founder of psychoanalysis, who considered it an important part of psychoanalytic treatment.

<span class="mw-page-title-main">Psychodynamic psychotherapy</span> Form of psychoanalysis and/or depth psychology

Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of psychological therapy. Its primary focus is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies.

Psychological resistance, also known as psychological resistance to change, is the phenomenon often encountered in clinical practice in which patients either directly or indirectly exhibit paradoxical opposing behaviors in presumably a clinically initiated push and pull of a change process. In other words, the concept of psychological resistance is that patients are likely to resist physician suggestions to change behavior or accept certain treatments regardless of whether that change will improve their condition. It impedes the development of authentic, reciprocally nurturing experiences in a clinical setting. It is established that the common source of resistances and defenses is shame. This and similar negative attitudes may be the result of social stigmatization of a particular condition, such as psychological insulin resistance towards treatment of diabetes.

A therapeuticalliance, or working alliance, is a partnership between a patient and his or her therapist that allows them to achieve goals through agreed-upon tasks.

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true. It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications. Along with cognitive behavioral therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice for depression.

<span class="mw-page-title-main">History of psychotherapy</span>

Although modern, scientific psychology is often dated from the 1879 opening of the first psychological clinic by Wilhelm Wundt, attempts to create methods for assessing and treating mental distress existed long before. The earliest recorded approaches were a combination of religious, magical and/or medical perspectives. Early examples of such psychological thinkers included Patañjali, Padmasambhava, Rhazes, Avicenna and Rumi.

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

Common factors theory, a theory guiding some research in clinical psychology and counseling psychology, proposes that different approaches and evidence-based practices in psychotherapy and counseling share common factors that account for much of the effectiveness of a psychological treatment. This is in contrast to the view that the effectiveness of psychotherapy and counseling is best explained by specific or unique factors that are suited to treatment of particular problems.

<span class="mw-page-title-main">Insight-oriented psychotherapy</span>

Insight-oriented psychotherapy is a category of psychotherapies that rely on conversation between the therapist and the client. It involves developing the patient's understanding of past and present experiences, how they are related to each other and the effect they have on the patient's interpersonal relationships, emotions and symptoms. Insight-oriented psychotherapy can be an intensive process, wherein the client must spend multiple days per week with the therapist.

Body-centred countertransference involves a psychotherapist's experiencing the physical state of the patient in a clinical context. Also known as somatic countertransference, it can incorporate the therapist's gut feelings, as well as changes to breathing, to heart rate and to tension in muscles.

"Acting in" is a psychological term which has been given various meanings over the years, but which is most generally used in opposition to acting out to cover conflicts which are brought to life inside therapy, as opposed to outside.

Paradox psychology is a counter-intuitive approach that is primarily geared toward addressing treatment resistance. The method of paradoxical interventions (pdxi) is more focused, rapid, and effective than Motivational Interviewing. In addressing resistance, the method seeks to influence the clients' underlying attitude and perception by providing laser beam attention on strengthening the attachment-alliance. This is counter-intuitive to traditional methods since change is usually directed toward various aspects of behavior, emotions, and thinking. As it turns out, the better therapy is able to strengthen the alliance, the more these aspects of behavior will change.

Parallel process is a phenomenon noted in clinical supervision by therapist and supervisor, whereby the therapist recreates, or parallels, the client's problems by way of relating to the supervisor. The client's transference and the therapist's countertransference thus re-appear in the mirror of the therapist/supervisor relationship.

References

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  3. Gelso, C.J. & Carter, J. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296-306.
  4. Gelso, C.J. & Samstag, L.W. (2008). A Tripartite Model of the Therapeutic Relationship. Handbook of Counseling Psychology (4th ed.). (pp. 267-280).
  5. http://www.ohsu.edu/xd/outreach/occyshn/training-education/upload/DevelopingTheraputicRelationships_Ch10.pdf [ dead link ]
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