determining successful outcomes of psychotherapy. relationship built, and the collaboration between therapist and client as, “one of the keys, quality of the therapeutic alliance is predictive of positive treatment outcome (Black, . only is the relationship important to the therapy process, but another component of the. Importance and Implications of Client Choice. 6. Implications for . client and therapist and positive outcome (Ross, ) Indicated that at best otily a weak positive relationship existed. Rather than being determine the match. Attempts to. In the second phase the therapist begins the therapy to deal with important issues. of client and therapist session satisfaction be correlated with positive outcomes.
When she spoke of her mother and father, she recalled how she has never experienced her mother not drinking alcohol. However, through the timeline, she was able to speak about hopes for her future and a possible career in drama. I noted how her posture and voice changed to being upright and more assertive, revealing an uplifted mood when speaking about drama. In fact, I felt that I did most of the talking in the session, as Noluthando would not answer questions in more than a few words. How would you describe yourself?
Is there anyone that you like to talk to? It may be quite difficult for you to be here, because in therapy you will do a lot of the talking. This is the reason I want to come here. I want to overcome that. Maybe that can be a goal in therapy, something we can work and challenge together? Yes quiet short laugh. I felt that it would possibly take time for her to develop trust with me as she has difficulty with trust in her other relationships. In the second session, I noted that by me being more practical in the session by working on a timeline together, allowed more information to be shared between Noluthando and myself.
This could be because the focus appeared to not be on her but rather on the task. I reflected on how difficult it was for Noluthando to openly communicate and how I could try to create a space in therapy where she could begin to open up more. This would entail moving at a pace, which would be comfortable for her. I felt that she might have difficulty speaking in the session because of the emotional content, as shown in the transcript below.
It sounds like quite a few people in your family do not get along. What is that like for you? It is hard, silence because now you have to choose between family members. What do you think of your family not getting along? He is not open to talking about it. How often is your mother drunk?
I felt that the collaborative relationship in CBT may help her to feel responsible for therapy and may assist in her working together with me. Belsher and Wilkes believe collaboration in CBT to be one of the key therapeutic principles when working with adolescents.
I was concerned that the techniques of CBT may break down communication in therapy and that the therapeutic relationship may not develop. Strunk and DeRubeis describe how the techniques of CBT may be experienced as boring and not age appropriate, by younger people, and I did not want her to have this experience. The Development of the Therapeutic Relationship: It was hoped that by doing this it may relieve some of the anxiety she may have been experiencing in sessions so that she may open up similar to the previous session with the timeline.
Whilst drawing, she spoke about her father and how she learnt of his HIV positive status by reading about it in some notes he had made, which she had come across by accident. She related how difficult it was for her as she did not know who to speak to about the information that she had learnt about her father.
She described her father as not wanting to talk about his feelings. She described a family that does not communicate with one another.
Although I experienced Noluthando finding the session difficult, I found her to open up more than the initial two sessions.
Noluthando completed the BDI in this session and her score increased from 16 points to 19 points. I was concerned about this and reflected about it after the session and discussed it with my supervisor. I thought that perhaps she under reports her experiences and feelings as, in this particular session, she shared how she often smiles even though she is not okay on the inside. Before the session ended, I provided her with an automatic thought record to start recording her thoughts.
Thought records provide the client with the task of responding and challenging negative automatic thoughts in writing and the therapist can then help the client to find a more balanced or alternative thought. I felt that perhaps she would not be accepting of completing the thought record on her own, and was interested to see if she would bring it with her to the following session.
Session 4 [ TOP ] Noluthando started the session by saying she was very stressed about the examinations that she was presently busy with at school. That day, she had written her theoretical drama exam and was anxious about her performance, as she felt she had not done well. This allowed us to explore what she often reported, on her BDI, as feeling like a failure. Noluthando reported how she feels like a failure not only in her studies, but also when her father beats her mother and she does not stand up for her.
She said that being a failure is what she really believes about herself and may represent her core belief. A core belief is described by Westbrook et al. We challenged this belief about being a failure by referring to how she has performed at school despite difficult circumstances. I also provided a space for her to reflect on what may happen if she did stand up for her mother when her father became violent.
This was not easy for her and she became somewhat disassociated in the session when talking about the feeling and thoughts of being a failure. In the session, I provided psycho-education about CBT and the hot cross bun that looks at five aspects of life that are interconnected, namely: Noluthando and I applied this to her belief of failure at school, and she then later said that she would like to try this in future sessions.
The session closed with her speaking about a play that she was involved with as part of a school project, in which she was acting the part of a man who is a husband who fights with his wife. I reflected on how this role may be difficult for her to act and how it is similar to her own life story with her father who abuses her mother. Both Noluthando and I felt it was sad. Noluthando forgot her thought record form as she was busy with studying and said that she would bring it with her the following week.
In lieu of her being busy with examinations, I did not challenge her on not completing the thought record as I felt it to be inappropriate at the time and may close communication down between us. On reflection of her not completing her thought record, a possible explanation could be that due to the thought record only being introduced at the end of the session, it may have provided too little time to demonstrate its use effectively.
However, she seemed to understand the thought record homework without any further explanation in the session, and therefore, her not completing her homework may have been a preoccupation with her examinations, which seemed appropriate due to her grade level and number of subjects she was writing at the time. Further Discovery and Process [ TOP ] The significance of Sessions 3 and 4 was the beginning of the development of the therapeutic relationship.
In Session 3, I found that our relationship was developing and Noluthando was beginning to open up. I felt that perhaps as she was beginning to develop a relationship with me, she may have felt more able and willing to disclose how she was feeling and, therefore, was able to report how she often smiles even when she is not feeling okay.
This was aided by the drawing that she completed, as it provided a space for her to communicate in an indirect way, as revealed in the below transcript. Like when I went home on the weekend, long pausewas it Monday, no Tuesday pause, silence and mumbled voice I got home and my mother and father were arguing about the chicken. They were both so angry strained voice and he just slapped her. I had to help carry her by her feet to the room. I thought she had taken the chicken. When my mother does something wrong she will cry and then stop.
Otherwise she cries and will talk about it. This time silentshe cried and went to the neighbours afterwards.
In Session 4, I felt that the therapeutic relationship was growing and that Noluthando was becoming more communicative in the therapy setting. This was revealed by her being able to talk about her feelings and thoughts of failure. She opened up about feeling like a failure when she experiences her father abusing her mother and she takes no action, as revealed in the below transcript.
One of the things I have noticed is how you mark past failures on the questionnaire BDI in every session. Can you tell me a bit about this? You feel as though you could have done something?What is Transference In Therapy? - Kati Morton
I could cover her and then my father would stop very quiet and mumbled voice. Although I experienced Noluthando as being more communicative, I was aware that she was battling with this but was trying. I felt this because I could hear in her voice how emotional she was and yet how she did not avoid talking about the issue. In regard to her not completing the thought record, I felt uncertain of being more assertive with her not completing the homework exercise and battled with this.
Intuitively, I decided not to follow up on the homework in a confrontational manner, as I felt that doing so may break down any relationship that had developed. I felt a pull between following CBT techniques strictly and focusing on the relationship. I wondered whether CBT was necessarily the best choice for my client, as, although Noluthando understood CBT and how it was applicable to how her thoughts were impacting on her depression, I was unsure of the fit between myself, the techniques and the client.
Leahy describes how through the experience of the training of CBT, often emphasis is placed on technique and little attention is given to the therapeutic relationship, resulting in a misconception of the therapeutic relationship not needing much attention in CBT. I felt the need for emphasis to be on the therapeutic relationship so that communication could be opened between us.
A Change and Progress: Sessions 5 to 9 [ TOP ] Session 5 [ TOP ] Noluthando arrived 20 minutes late for her session as she reported that she was trying to help someone find a museum in the area. She was quite out of breath when she arrived for the session and was very apologetic. Noluthando was starting holidays and this was to be the last session for a number of weeks because of the long break due to the Soccer World Cup.
She wanted to during the time away from therapy work on her own and to do her own therapy. She wanted to work on her thought records she had completed the thought record homework from the previous session and reflecting. She reported that she was trying to pick up weight, was sleeping a bit better, and was feeling excited about the Soccer World Cup. Her BDI score reduced markedly to a score of 10 points.
‘The Relationship is the Therapy.’ - Acorn Therapy - counselling and complementary therapies
The score could be attributed to positive changes she was trying to make in her own life by trying to eat more and being more active in her daily life helping a stranger, etc. Session 6 [ TOP ] Six weeks later extended school holidays due to Soccer World CupNoluthando displayed herself in a very introverted manner, she appeared down and her speech was soft, and almost inaudible.
Her mother moved out of the house and moved to a different town during the holiday and Noluthando reported not knowing why this had happened. I experienced her as being very closed off. I wondered if not hearing the bad referred to the fighting that she witnesses between her mother and her father. However, I battled to question this as Noluthando was very uncommunicative.
When asking her how she felt about being at school, she said that she felt neither good nor bad about it. This further revealed to me how she was attempting to prevent herself from feeling anything and provided understanding regarding why she was quiet, as she was blocking herself from feeling anything.
She did reveal feeling positive about a play she would be auditioning for in the following week. I felt that although there was a closing down in communication, there was new insight gained into how she was trying to cope with difficult life issues and her use of suppression as a defence against hurtful feelings.
Various outcomes were measured, including pain, disability, quality of life, depression, adherence, and satisfaction with treatment. The alliance was most commonly measured with the Working Alliance Inventory, which was rated by both patient and therapist during the third or fourth treatment session. The results indicate that the alliance is positively associated with: Limitations Among homogenous studies, there were insufficient reported data to allow pooling of results.
Conclusions From this review, the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings; however, more research is needed to determine the strength of this association. The relationship between patient and therapist traditionally has been viewed as an important determinant of treatment outcome and is considered central to the therapeutic process. The construct of the alliance in therapeutic situations is derived from theories of transference first outlined by Freud in and refers to the sense of collaboration, warmth, and support between the client and therapist.
Using this definition, researchers began to measure the alliance in clinical practice and formally assess its impact on treatment outcomes. The majority of this evaluation has been conducted in psychology, counseling, or general medicine settings, where the intervention is typically centered on a one-to-one interaction between the patient and the treating physician or therapist.
Elvins and Green 13 recently conducted an extensive review to investigate the conceptualization and measurement of the alliance. They identified a broad consensus as to the key concepts of the alliance among the various measures, but no single unifying alliance model or a single measure that comprehensively addressed all of the key concepts. It would appear from the previous research that the alliance is positively associated with treatment outcome and could potentially be used as a predictor of treatment outcome in psychotherapy and general medicine settings.
However, the degree to which the alliance relates to outcome in other treatment settings is not clear. Physical rehabilitation, like psychotherapy and general medicine, includes a high level of patient-clinician interaction; however, the characteristics of the patient population, as well as the intervention, are arguably different.
It is plausible, therefore, that the relationship between the alliance and the outcome seen in psychotherapy or general medicine settings is not transferable to physical rehabilitation settings. It is thus of great importance to determine whether the alliance of rehabilitation therapists is similar to that of psychotherapists and general practitioners and whether this alliance influences outcome in the physical rehabilitation setting.
To our knowledge, there has been no systematic review of the primary research in this area. Based on a large dataset of people with severe mental illnesses receiving services at four different mental health clinics, the study addresses the following questions: Participants and Procedures The cross-sectional study was a secondary data analysis using data from a study related to mental health disparities, which was conducted from to The disparities study consecutively recruited participants who were enrolled in services at four community mental health clinics.
Participants completed structured interviews, which focused on service use, treatment process and outcomes. The data source for this study was the baseline interview for the disparities study, which was completed by all participants. Institutional Review Board approval from the University of Pennsylvania was obtained for the study. Measures Gender, race, diagnosis and length of time in services and with psychiatrist were measured by demographic and clinical questions from the baseline interview.
Severity of illness was measured by the Colorado Symptom Index CSI [ 31 ], which is specifically used to assess symptoms related to mania and psychosis. The CSI has demonstrated good reliability and validity [ 32 ]. The scale has 10 items, with responses ranging from 1 to 5. Scale scores were based on an averaging of all items, with total scores ranging from 1 to 5, with higher scores representing a greater severity of illness. Choice was operationalized as patient perception of patient centeredness and patient perception of consultation tasks.
Patient perception of patient centeredness was measured by the Patient Perception of Patient Centeredness Scale [ 33 ].
The validity of the item scale was established through significant correlations with patient health outcomes. The scale has a reliability of 0. The scale has 14 items, with responses ranging from 1 to 4. Scale scores were based on averaging all items, with total scores ranging from 1 to 4, with higher scores representing greater perception of patient centeredness.
Patient perception of consultation tasks was measured by the Patient Perception of Consultation Tasks Scale, which was developed for the disparities study. The scale has 7 items, with responses ranging from 1 to 6.
Scale scores were based on averaging all items, with total scores ranging from 1 to 6, with higher scores representing greater perceived consultation. Therapeutic alliance was used to measure the service user-psychiatrist relationship from the service user perspective. Coefficient alphas for the WAI-S three subscales have ranged from 0. The scale has 12 items, with responses ranging from 1 to 7.
Scale scores were based on averaging all items, with total scores ranging from 1 to 7, with higher scores representing a more positive working alliance. Outcomes were operationalized as recovery, quality of life and perceived outcomes. Recovery was measured by the Recovery Assessment Scale—Short Form, which assesses the subjective aspects of recovery.
The scale has established reliability and validity [ 37 ]. The scale has 20 items, with responses ranging from 1 to 5. Scale scores were based on averaging all items, with total scores ranging from 1 to 5, with higher scores representing greater recovery.