The Therapeutic Relationship

Innovative Investigations

Hadas Wiseman, Orya Tishby

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317513698
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

The therapeutic relationship has been recognized by psychotherapy researchers and clinicians alike as playing a central role in the process and outcome of psychotherapy. This book presents innovative investigations of the therapeutic relationship focusing on various relationship mechanisms as they relate to changing processes and outcomes. A variety of perspectives on the therapeutic relationship are provided through different research methods, including quantitative and qualitative methods, and divergence in psychotherapy orientations, including psychodynamic, interpersonal, cognitive-behavioural therapy, emotion-focused process experiential therapy, narrative therapy, and attachment-based family therapy.

The chapters, written by leading psychotherapy researchers, present cutting-edge empirical studies that apply innovative methods in order to: study process-outcome links; explore in session processes that address the question of how the therapeutic relationship heals; examine the contributions of clients and therapists to the therapeutic relationship; and suggest practical implications for training therapists in psychotherapy relationships that work. Research on the therapeutic relationship has been identified as a natural arena for bridging the gap between research and clinical practice, and will be of particular interest to practicing clinicians. This book was originally published as a special issue of Psychotherapy Research.

The therapeutic relationship: Multiple lenses and innovations

HADAS WISEMAN & ORYA TISHBY

In 2005, Psychotherapy Research marked 15 years of publication with a special issue, “The Therapeutic Relationship” (Volume 15, Issues 1–2). The challenges lying ahead were outlined in Horvath’s (2005) introduction to the issue, and these and other challenges have been put forward during the last decade in other joint efforts published in special sections of other journals and in edited books devoted to the therapeutic relationship. They include prominent publications such as the special section of Psychotherapy: Research, Theory, Practice, Training that was devoted to the working alliance (Samstag, 2006), Muran and Barber’s (2010) The Therapeutic Alliance: An Evidence-Based Guide to Practice, and Norcross’s (2002, 2011) Psychotherapy Relationships that Work (which appeared both in book form and in a special issue of Psychotherapy). The latter presents the work of the contributors of the APA Interdivision Task Force on Evidence-Based Relationships and their conclusions and recommendations for research and practice (Norcross & Lambert, 2011; Norcross & Wampold, 2011). Research on the therapeutic relationship continues to develop and this special section is devoted to providing “multiple lenses” on some of the important and exciting new directions in research on the therapeutic relationship. The articles present an array of empirical studies in which the contributors offer innovative ways of studying various relationship mechanisms as they relate to change processes and outcomes.

The joint initiative for this special section originated during the course of a research workshop held in Jerusalem in the summer of 2010. As an extension of our collaboration in a psychotherapy research project (University of Haifa and the Hebrew University of Jerusalem), we had received support to gather leading psychotherapy researchers and clinicians to take part in a research workshop on a topic related to our ongoing research project (Wiseman & Tishby, 2011). We entitled the workshop Multiple Lenses on the Therapeutic Relationship. Its aims were to focus on research and clinical practice on the therapeutic relationship—past, present, and future—to paraphrase Castonguay, Constantino, and Holtforth (2006), where we were, where we are, and where should we go. The key speakers addressed theoretical underpinnings, client-therapist relationship processes and experiences, client and therapist variables, techniques versus the relationship and outcome, and implications for training therapists. The original work presented at this workshop by the key speakers formed the basis for the papers in this special section. Given our intention to bring together researchers from a variety of psychotherapy orientations and research methodologies, we have added two additional research groups to the contributors of the special section.¹ Thus, we set out to provide a panorama of cutting-edge studies on the therapeutic relationship that are intended to demonstrate and suggest promising pathways for future research.

Going back to the challenges for the next generation of research on the therapeutic relationship, we wish to highlight five: First, the theoretical-conceptual challenge of clarifying the construct of the therapeutic relationship and defining and refining new constructs and various specific components of the relationship; second, the methodological challenge of how best to measure the relationship and study process-outcome questions such as whether the therapeutic relationship is curative in itself; third, the change process challenge, entailing understanding the function of the relationship in the change process and its development over time at different phases of therapy; four, the client and therapist contributions challenge, concerning how the participants influence the kind of relationship that is formed between them; and five, the training challenge, consisting of the development of successful training programs for therapists regarding the development and management of their relationships with their clients (Castonguay et al., 2006; Crits-Christoph, Crits-Christoph, & Connolly, 2010; Horvath, 2006; Sharpless, Muran, & Barber, 2010).

Multiple Lenses and Innovations

The studies in this special section offer multiple lenses on how to tackle the above challenges by addressing one or more of these key issues, which are, to some extent, naturally intertwined. For example, suggesting new constructs is embedded in the development of new measures and methods for studying them. Similarly, efforts directed at understanding change mechanisms involve client and therapist contributions and training therapists to facilitate processes of change in the therapeutic relationship. Although the studies by no means encompass all the landscape or even most of it, each suggests new ways of studying the therapeutic relationship and the alliance. We found that the studies can be broadly divided into three groups according to the key issues they each tackle in their unique way: (a) methodological innovations, with an emphasis on process-outcome questions; (b) change processes and micro-processes, focusing on the question of how the therapeutic relationship heals; and (c) client and therapist contributions to the therapeutic relationship and the study of special populations of clients. All the articles offer (to a greater or lesser extent) implications for training therapists in psychotherapy relationships that work.

Process-Outcome Questions

The first group of studies includes methodological innovations, with an emphasis on process-outcome questions, especially the predictive validity of the alliance. These include questions about the causal role of the alliance and about variability in alliance patterns and their impact on change.

DeRubeis and colleagues (DeRubeis, Gelfand, German, Fournier, & Forand, 2014) set out to investigate an almost “truism” in the psychotherapy research literature, which they refer to as the “variance accounted for” approach to characterizing the sources of change in psychotherapy. They re-examine the pie chart that summarizes the percentage of explained variance in psychotherapy outcome as a function of therapeutic factors: 30% attributed to common factors, including the therapeutic alliance; 15% attributed to techniques; 40% attributed to patient extra-therapeutic change; and 15% attributed to expectancy (Lambert, 1992; Lambert & Barely, 2002). They suggest an alternative conceptualization for research based on the elements of psychotherapeutic processes, taking into account variability in patients and therapists. Using a set of sophisticated simulations, the authors show that in the typical psychotherapy study we cannot really expect process-outcome correlations beyond .25 or .30. They propose the concept of patient “response patterns” and therapy “quality” to test these ideas and suggest that we need to consider the “variability among patients in the degree to which the quality of therapy provided to them will affect their outcomes”. They offer some implications of these new ideas in order to facilitate progress in process-outcome research.

The Barber and colleagues study (Barber et al., 2014) addresses the alliance-outcome correlation question by directly testing whether the alliance has a causal role in change or whether the alliance itself is merely a reflection of prior symptom change (for recent reviews of the equivocal evidence, see Barber, Muran, McCarthy, & Keefe, 2013, and Crits-Christoph, Connolly Gibson, & Mukherjee, 2013). In order to disentangle early alliance from early symptom improvement, they examine the predictive value of alliance both with and without accounting for early change in depressive symptoms. Using sophisticated statistical analysis of the temporal sequence of alliance and symptoms, they show that after controlling for prior symptom improvement, early alliance predicted subsequent depression change. As we will indicate later in their article, Barber et al. also address a client variable, namely, client expectations as they relate to symptom change.

Another related alliance-outcome question that goes beyond previous studies asks how the alliance develops over time in different phases of psychotherapy (e.g., Stiles, 2004). It has been shown that the alliance is particularly predictive of outcome when assessed early in treatment (usually once in the third or fifth session), but that in order to understand patterns of alliance development, there is a need to measure alliance throughout treatment. Weiss, Kivity, and Huppert (2014) therefore examine in their preliminary study of CBT for panic disorders, session-by-session alliance client ratings taken before and after each session in relation to session-by-session change in anxiety sensitivity and treatment outcome. This led them to the identification of three types of alliance patterns: “sawtooth,” sudden gains, and stabilization. They found the sawtooth pattern, defined as “within-session improvements followed by decline between sessions” (identified in 63% of 19 patients), to be related to less symptom reduction between sessions.

In-Session Process and “How” Questions

The second group of studies focuses on specifying in-session therapeutic relationship processes exploring the “how” questions, such as how the therapeutic relationship heals. To advance our understanding of these processes, we need to develop concepts and new ways to measure diverse aspects of the relationship. Each article in this group offers a different lens for looking at in-session processes using different units of analysis, ranging from micro-processes to events.

Muntigl and Horvath (2014) suggest a new set of questions about client-therapist relational processes, such as how therapists gain clients’ enthusiastic participation in the tasks of treatment; how the actual deterioration or breakdown (rupture) of the close alignment between therapist and client dynamically unfolds in the session; and how therapists interact with their clients to effectively re-negotiate their affiliation and re-align themselves with the client, re-build a sense of joint purpose, and resume productive work. To address these questions in their article, Muntigl and Horvath present an innovative application of conversational analysis to track at a micro-level the turn-by-turn therapist-patient dialogical interactions (verbal and nonverbal) in which relational disaffiliation occurs and, subsequently, successful re-affiliation (repair) is or is not achieved. In their study, the intensive conversational analysis is demonstrated using cases drawn from the York I Depression Study identified as less successful, in which two severely depressed female clients were seen by two therapists in Emotion-Focused Process Experiential Therapy.

Another innovative method for studying moment-to-moment client-therapist collaboration applied to session transcripts is the Therapeutic Collaboration Coding System (TCCS.) In Ribeiro and colleagues’ article (Ribeiro et al., 2014), they apply the TCCS in the context of ambivalence events in the analysis of client-therapist interaction in a relatively poor-outcome case of narrative psychotherapy. The ambivalence events are conceptualized using the identification of Innovative Moments (IM) and Return to the Problem (RPM) markers. The authors shed light on client resistance in terms of ambivalence; their theory-based case study of poor outcomes offers a way to integrate the study of resistance with that of therapeutic collaboration.

Safran et al. (2014) take their ongoing programmatic research on alliance ruptures and resolution and Alliance Focused Training (AFT) a step further in a research design aimed at evaluating the additive effect of AFT to CBT for personality disorders (cluster C). In this multiple baseline design, all therapists began treating a case with CBT while receiving CBT supervision, and then at session 8 or session 16 they switched from CBT supervision to an AFT protocol designed to enhance therapists’ abilities to detect and work constructively with alliance ruptures and negative therapeutic process. The rationale for this methodology is that “every therapeutic dyad is unique, and their style of mutual responsiveness will vary at different points in time”, thus, rather than testing differences between patient-therapist dyads, within-dyads differences were tested, allowing the researcher to control for patient and therapist individual differences as well as differences specific to each dyad. The impact of AFT was tested in relation to theory-driven hypotheses on shifts in patient and therapist interpersonal process using SASB and therapists’ awareness of internal experience on the Experiencing scale. The findings support the value of training therapists to improve their ability to work constructively with weakened alliances and negative therapeutic processes.

Hill and colleagues’ (Hill et al., 2014) article focuses on immediacy events, a specific type of event in the client-therapist relational work, and how they affect client and therapist evaluations of process and outcome. Immediacy is defined as “a discussion of the therapeutic relationship, by both the therapist and client in the here-and-now, involving more than social chitchat”. The frequency and consequences of immediacy events were studied in 16 cases of psychodynamic-interpersonal psychotherapy, applying a mixed quantitative-qualitative method. The associations between the use of immediacy and self-reports of session process and outcome, as well as judges’ consensus qualitative ratings of the events (depth, appropriateness, resolution, and quality) and clients’ post-therapy interviews about their experiences with immediacy were all applied to shed light on this relational event. The use of immediacy calls for specificity in its use with different types of clients, as demonstrated in two cases that differed in their attachment style, which we also refer to below in relation to client-contribution questions.

Watson, Steckley, and McMullen’s (2014) article focuses on therapist empathy, which is considered a specific element of the relationship that has been found to have an effect size for empathy-outcome similar to that found for alliance-outcome (Elliott, Bohart, Watson, & Greenberg, 2011). How empathy facilitates client change in psychotherapy is investigated in Watson et al.’s study through data derived from a RCT comparing EFT-PE and CBT in the treatment of depression. The client’s perceived therapist empathy was found to have a direct effect on client outcome and indirect effects as a mediator of changes in interpersonal (improvement of attachment insecurity) and intrapersonal (decreases in negative self-treatment) functioning at the end of therapy. This study makes use of comprehensive assessment in its relian...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Citation Information
• Notes on Contributors
• 1. Introduction: The therapeutic relationship: Multiple lenses and innovations
• 2. Understanding processes of change: How some patients reveal more than others—and some groups of therapists less—about what matters in psychotherapy
• 3. The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder
• 4. How does the therapeutic alliance develop throughout cognitive behavioural therapy for panic disorder? Sawtooth patterns, sudden gains, and stabilization
• 5. The therapeutic relationship in action: How therapists and clients co-manage relational disaffiliation
• 6. Therapeutic collaboration and resistance: Describing the nature and quality of the therapeutic relationship within ambivalence events using the Therapeutic Collaboration Coding System
• 7. Investigating the impact of alliance-focused training on interpersonal process and therapists’ capacity for experiential reflection
• 8. To be or not to be immediate with clients: The use and perceived effects of immediacy in psychodynamic/interpersonal psychotherapy
• 9. The role of empathy in promoting change
• 10. Client attachment, attachment to the therapist and client-therapist attachment match: How do they relate to change in psychodynamic psychotherapy?
• 11. Types of countertransference dynamics: An exploration of their impact on the client-therapist relationship
• 12. Client disclosure and therapist response in psychotherapy with women with a history of childhood sexual abuse
• 13. Good versus poor therapeutic alliances with non-accepting parents of same-sex oriented adolescents and young adults: A qualitative study
• Index