Therapeutic relationship

The therapeutic relationship (also therapeutic alliance, the helping alliance, or the working alliance) 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.

Research

While much early work on this variable was generated from a psychodynamic perspective, researchers from other orientations have since investigated this area. It has been found to predict treatment adherence (compliance) and concordance and outcome across a range of client/patient diagnoses and treatment settings. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings.[1] Informal coercion is common, and may be unintentional on the part of the therapist.[2]

In the humanistic approach, Carl Rogers identified a number of necessary and sufficient conditions that are required for therapeutic change to take place. These include the three core conditions: congruence, unconditional positive regard and empathy.

Components

In psychoanalysis, the therapeutic relationship has been theorized to consist of three parts: the working alliance, transference/countertransference, and the real relationship.[3][4][5] Evidence on each component's unique contribution to the outcome has been gathered, as well as evidence on the interaction between components.[6] In contrast to a social relationship, the focus of the therapeutic relationship is on the client's needs and goals.[7]

Transference

The concept of therapeutic relationship was described by Freud (1912) as "friendly affectionate feeling" in the form of positive transference.

Working alliance

Also known as the therapeutic alliance, working alliance is not to be confused with the therapeutic relationship, of which it is theorized to be a component.

The working alliance may be defined as the joining of a client's reasonable side with a therapist's working or analyzing side.[8] Bordin[9] 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.[10] 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.[11] Therapeutic alliance has been found to be effective in treating adolescents suffering from PTSD, with the strongest alliances were associated with the greatest improvement in PTSD symptoms. 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.[12]

Operationalization and measurement

Several scales have been developed to assess the patient-professional relationship in therapy, including the Working Alliance Inventory (WAI),[13] the Barrett-Lennard Relationship Inventory,[14] and the California Psychotherapy Alliance Scales (CALPAS).[15] The Scale To Assess Relationships (STAR) was specifically developed to measure the therapeutic relationship in community psychiatry, or within care in the community settings.[16]

See also

References
  1. Orlinsky, D. E., Ronnestad, M. H., Willutski, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In M. J. Lambert (Ed.) Handbook of psychotherapy and behavior change (5th Ed.). New York: John Wiley & Sons.
  2. Hotzy, Florian; Jaeger, Matthias (12 December 2016). "Clinical Relevance of Informal Coercion in Psychiatric Treatment—A Systematic Review". Frontiers in Psychiatry. 7: 197. doi:10.3389/fpsyt.2016.00197. PMC 5149520. PMID 28018248.
  3. Greenson, R.R. (1967) The technique and practice of psychoanalysis. (Vol.1). New York: International Universities Press.
  4. Gelso, C.J. & Carter, J. (1985). The relationship in counseling and psychotherapy: Components, consequences, and theoretical antecedents. Counseling Psychologist, 13, 155-243.
  5. Gelso, C.J. & Carter, J. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296-306.
  6. Gelso, C.J. & Samstag, L.W. (2008). A Tripartite Model of the Therapeutic Relationship. Handbook of Counseling Psychology (4th ed.). (pp. 267-280).
  7. http://www.ohsu.edu/xd/outreach/occyshn/training-education/upload/DevelopingTheraputicRelationships_Ch10.pdf
  8. Gelso, C.J. and Hayes, J.A. (1998). The Psychotherapy Relationship: Theory, Research, and Practice. (p. 22-46): John Wiley & Sons: New York.
  9. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252-260.
  10. Ardito, R. B., & Rabellino, D. (2011). Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2. DOI:10.3389/fpsyg.2011.00270.
  11. Stiles, W.B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., Rees, A. & Barkham, M. (2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped). Journal of Counseling Psychology, 51, 81-92.
  12. Capaldi S, Asnaani A, Zandberg LJ, Carpenter JK, Foa EB. Therapeutic alliance during prolonged exposure versus client-centered therapy for adolescent Posttraumatic Stress Disorder. Journal of Clinical Psychology. 2016 Oct;72(10):1026-36
  13. Horvath, A. O., Greenberg, L. (1986). The development of the Working Alliance Inventory: A research handbook. In L. Greenberg and W. Pinsoff (Eds.) Psychotherapeutic Processes: A Research Handbook, New York: Guilford Press.
  14. Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in therapeutic change. Psychological Monographs: General and Applied, 76, 1-33.
  15. Gaston L., Marmar, C. R. (1991). Manual for the California Psychotherapy Alliance Scales - CALPAS Unpublished manuscript. Department of Psychiatry McGill University, Montreal, Canada.
    • McGuire-Snieckus, R., McCabe, R, Catty, J., Hansson, L., and Priebe, S. (2007). A new scale to assess the therapeutic relationship in community mental health care: STAR. Psychological Medicine, 37, 85-95.
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