Relational Psychotherapy Research Articles

The ongoing debate about expertise in psychotherapy – what would Bernie Neville say?

ABSTRACT In response to the ongoing and unresolved debate about expertise in psychotherapy, and in the context of this special issue, this article contends that Bernie Neville would argue that expertise in psychotherapy is more likely to be indicated by the quality of the therapeutic relationship than by the therapist’s specific methods or techniques. His teaching and research in education and psychotherapy was firmly grounded in humanistic-existential theory with a strong Rogerian orientation. Creativity was a hallmark of his work in education; for example, he deployed the myths of the ancient Greek gods to encourage students and practitioners to critically analyze and imaginatively understand being in the world. In this article, I also point to how the gods informed his thinking in relation to humanistic-existential themes concerning the precariousness of existence, to evidence-based psychotherapy relationships, and to the ‘Master Therapist’ model whereby the quest for expertise in psychotherapy is typically a dynamic process beset with paradox and ambiguity.

The effects of cultural humility on therapeutic alliance and psychotherapy outcomes: A systematic review and meta‐analysis

AbstractAimThe present review and meta‐analysis sought to synthesise previous findings of studies examining the correlation between therapist cultural humility, the quality of the therapeutic alliance and psychotherapy outcomes.Materials and MethodsThree databases were searched for relevant citations, yielding 548 records for review. After the systematic review of these articles, a final sample of 13 citations was submitted for coding and analysis. A random‐effects meta‐regression model was used to synthesise correlations collected from the final sample of studies. Heterogeneity was assessed using Cochran's Q, I2 and τ2. Publication bias was assessed using contour‐enhanced funnel plots and Egger's test for asymmetry.ResultsThere was a statistically significant, positive correlation between cultural humility and alliance quality (r = .66, 95% CI = [0.64, 0.68]). Similarly, a smaller, yet still statistically significant and positive association between cultural humility and psychotherapy outcomes was also found (r = .39, 95% CI = [0.36, 0.42]). Moderators related to client race, gender and lesbian, gay and bisexual (LGB) status were also examined though nonsignificant.ConclusionSuch results suggest that therapist cultural humility is an important part of a strong working relationship and eventual positive outcomes in psychotherapy regardless of race, gender or LGB status. Thus, efforts should be made to foster cultural humility among therapists.

The family alliance as a facilitator of therapeutic change in systemic relational psychotherapy for borderline personality disorder: A case study.

Managing the Therapeutic Alliance is often complex when it comes to the treatment of borderline personality disorder (BPD), but the alliance is crucial for the success of the therapy. Combined individual and family interventions have been shown to be very useful in treating of these cases. This study has two objectives. First, to describe how the family therapeutic alliance facilitates therapeutic change through family psychotherapy for families with a member diagnosed with BPD. Second, to analyze how the therapeutic change achieved through combined individual and family systemic relational psychotherapy affects the individual functioning of the patient with BPD. This single case study used the System of Observation of Family Therapy Alliances (SOFTA-o) to analyze the therapeutic alliance, along with two semi-structured clinical interviews, one at the beginning and one at the end of therapy. Results show a dynamic and positive evolution of the therapeutic alliance throughout the therapeutic process and how this alliance facilitated therapeutic change, both reducing the symptomatology of the patient with BPD and improving family communication and functioning. Results contribute to highlighting the importance of including family therapy as an intervention unit in protocols for patients with BPD.

The alliance–outcome relationship in individual psychotherapy for early psychosis: a secondary analysis of a randomized clinical trial

ABSTRACT Background Studies of the alliance–outcome relationship in psychosocial treatments for early psychosis are limited both in number and design, with few utilizing subjective measures as outcomes, multiple alliance timepoints or existing benchmarks to distinguish high or low levels of the alliance. We addressed these gaps in the context of a pilot randomized controlled psychotherapy trial for early psychosis. Methods Twenty-eight clients with early psychosis completed alliance ratings at mid-treatment (4.5 months) and post-treatment (9 months). We tested the alliance–outcome relationship through change scores between mid- and post-treatment and the use of a pre-defined benchmark to distinguish high versus low mid-treatment alliance. We also examined baseline differences between levels of the alliance. Outcomes included objective and subjective targets. Results Change in the alliance did not predict any outcomes at post-treatment. Clients with high mid-treatment alliance had lower perceived stress and higher psychological well-being at post-treatment. At baseline, clients with high alliance had lower negative symptoms and loneliness as well as higher community functioning and well-being. Discussion Use of an empirical alliance benchmark may help identify early psychosis clients who need additional support in alliance formation as well as facilitate positive psychotherapy outcomes

A systematic review on the role of therapist characteristics in the treatment of eating disorders.

Treating patients with eating disorders can be challenging for therapists, as it requires the establishment of a strong therapeutic relationship. According to the literature, therapist characteristics may influence intervention outcomes. The aim of this systematic review was to identify and synthesize existing literature on therapist interpersonal characteristics that could affect psychotherapy relationship or outcomes in the context of eating disorder treatment from both patients' and therapists' perspectives. We conducted a systematic search using electronic databases and included both qualitative and quantitative studies from 1980 until July 2023. Out of the 1230 studies screened, 38 papers met the inclusion criteria and were included in the systematic review. The results indicate that patients reported therapist's warmth, empathic understanding, a supportive attitude, expertise in eating disorders, and self-disclosure as positive characteristics. Conversely, a lack of empathy, a judgmental attitude, and insufficient expertise were reported as therapist negative characteristics, which could have a detrimental impact on treatment outcome. Few studies have reported therapist's perceptions of their own personal characteristics which could have an impact on treatment. Therapists reported that empathy and supportiveness, optimism, and previous eating disorder experience were positive characteristics. Conversely, clinician anxiety, a judgmental attitude, and a lack of objectivity were reported as negative characteristics that therapists felt could hinder treatment. This systematic review offers initial evidence on the personal characteristics of therapists that may affect the treatment process and outcomes when working with patients with eating disorders.

A tripartite model of the psychotherapy relationship: Interrelations among its components and their unfolding across sessions.

The tripartite model of the therapy relationship, which includes the working alliance, real relationship, and transference-countertransference configuration, has been a useful way to conceptualize the complexity of the connection between a therapist and a client. However, little research has focused on the interrelationships between these three components over time. This study sought to replicate the findings of Bhatia and Gelso (2018) by examining the between-person relationships among each of the three elements averaged across all sessions. Additionally, we extended earlier work by examining the within-person relationship between the working alliance, the real relationship, and transference-countertransference with themselves as well as with each of the other elements across sessions. Using 5,931 sessions across 142 clients and 36 therapists, we examined time-ordered associations among the cocreated working alliance, cocreated real relationship, and the therapist-rated transference-countertransference configuration using latent variable dynamic structural equation modeling. Results replicated the findings of Bhatia and Gelso (2018), demonstrating that in one session, the working alliance and the real relationship were positively related, and both the working alliance and the real relationship were negatively related to the transference-countertransference configuration. Regarding the interrelations over time, the findings revealed that the working alliance in the previous session had a significant and positive relationship with real relationship in the current session, and the real relationship in the previous session was related to reduced transference-countertransference in the current session. These findings provide support for complex interrelations among the components over time. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The therapy relationship, digital interventions, and their interaction

This article serves as an introduction to a special section devoted to the psychotherapy relationship and digital interventions. The nature of the therapy relationship is explored, and the question is raised as to whether machines can have relationships with their users. Finally, an overview and synthesis of the articles in the special section is provided.

Tackling poor mental health and self-harming tendencies among students: Indicative evidence of the effectiveness of a novel partnership-based approach to intervention

Poor mental health and self-harm are becoming increasingly common in student populations. Strategic partnerships between universities and NHS mental health services can ensure that students have access to appropriate support. The current paper reports on a pilot service evaluation of a brief therapy service for students who have recently self-harmed, namely University-Community Outpatient Psychotherapy Engagement (U-COPE) service. The aim of the pilot evaluation was to ascertain the efficacy of the U-COPE service as well as offer insights around partnership working between university and NHS mental health services in relation to the design, implementation, and delivery of the U-COPE service. Students completed measures of psychological distress before and after the intervention, as well as across the four therapy sessions. There was a reduction in psychological distress between assessment and discharge. Psychological distress also reduced significantly between the first and final therapy session. Most students (93%) continued their programme of study from the year in which they had accessed the U-COPE service to their next year of study. The provision of brief, relational psychotherapy to students presenting with self-harm related difficulties is a novel approach to intervention. The success of this approach illustrates how multiple organisations play a role in supporting student mental health, bringing a blend of diverse skills and expertise together. Although the U-COPE service shows promise as a brief intervention for students who self-harm, these findings should be treated with caution due to the small sample size. Further investigation of this brief intervention is warranted to ascertain whether U-COPE has a long-term impact on difficulties and distress-related behaviours.

Enhancing Psychotherapy Outcomes by Encouraging Patients to Regularly Self-Monitor, Reflect on, and Share Their Affective Responses Toward Their Therapist: Protocol for a Randomized Controlled Trial.

The quality of the therapeutic relationship is pivotal in determining psychotherapy outcomes. However, facilitating patients' self-awareness, reflection on, and sharing of their affective responses toward their therapist remains underexplored as a potential tool for enhancing this relationship and subsequent treatment outcomes. The primary objective of this study is to examine whether and how the patients' regular self-monitoring and self-reflection (fostered by the systematic compilation of a brief postsession battery) on their affective reactions toward the psychotherapist impact the quality of the therapeutic relationship and treatment outcomes in individual psychotherapy. Secondary objectives are to (1) explore whether and how the characteristics of the patient, the therapist, and the process moderate the effect of regular self-monitoring on the therapeutic relationship and outcomes; (2) examine the relationships between the affective response of the patient, the alliance, and the result of the therapy session outcome; and (3) explore how the affective responses of the patient unfold or change throughout the course of the therapy. We conducted a 1:1 randomized controlled trial of adults in individual psychotherapy versus individual psychotherapy plus self-monitoring. Participants will be enrolled through the web-based recruitment platforms "ResearchMatch" and "Research for Me," and data will be collected through web-based surveys. Participants in the control group will receive only their regular individual psychotherapy (treatment as usual) and will not complete postsession questionnaires. Participants in the intervention group will continue their regular individual psychotherapy sessions and complete the "in-Session Patient Affective Reactions Questionnaire" and the "Rift In-Session Questionnaire" following each therapy session in the 10 weeks of the trial. Additionally, after completion of the postsession battery, they will receive general written feedback encouraging them to discuss their feelings and reflections with their therapist. Participants in both groups will complete a comprehensive psychological assessment at baseline, midtrial (week 5), and end-of-trial (week 10). The primary outcome measure of the trial is the "Clinical Outcomes in Routine Evaluation-Outcome Measure," while the secondary outcomes are the "Real Relationship Inventory-Client-Short Form," the "Working Alliance Inventory-Short Revised," and the number of scheduled therapy sessions that the patient has missed or canceled. The trial was approved by the institutional review board of the University of North Carolina at Chapel Hill. Recruitment started in September 2023. A total of 475 individuals completed the baseline assessment. Data collection was completed in February 2024. The results are expected to be published in the autumn of 2024. This study could reveal key information on how regular self-monitoring and introspection can influence both the therapeutic relationship and treatment outcomes. Findings have the potential to shape interventions, enhance the efficacy of psychotherapeutic sessions, and possibly offer a cost-effective strategy for improving patients' well-being. ClinicalTrials.gov NCT06038747; https://classic.clinicaltrials.gov/ct2/show/NCT06038747. DERR1-10.2196/55369.

Statement of Retraction: Therapist Immediacy: The association with Working Alliance, Real Relationship, Session Quality and Time in Psychotherapy

Statement of Retraction: Therapist Immediacy: The association with Working Alliance, Real Relationship, Session Quality and Time in Psychotherapy

Supplemental Material for A Tripartite Model of the Psychotherapy Relationship: Interrelations Among Its Components and Their Unfolding Across Sessions

Supplemental Material for A Tripartite Model of the Psychotherapy Relationship: Interrelations Among Its Components and Their Unfolding Across Sessions

APA/APAGS Award for Distinguished Graduate Student in Professional Psychology: Sergio Domínguez Jr.

This award honors a graduate student who has demonstrated outstanding practice and application of psychology. "Sergio Domínguez Jr. is a PhD candidate in counseling psychology at the University of Wisconsin-Madison and a pre-doctoral intern in health service psychology at the University of Illinois Chicago Counseling Center. As a practitioner-scholar-advocate, their work focuses on facilitators and inhibitors to pleasure, particularly by using a racial-gender justice perspective as a vehicle toward achieving widespread freedom and liberation. Specifically, they are deeply invested in Black and Brown trans people's well-being, ethical and legal professional issues in psychology, and the transformative power of relationships in psychotherapy and in community-engaged psychological practice. Their connection to community and involvement in multilevel advocacy has enabled them to be a trusted collaborator for community-oriented individual, social, and systemic justice efforts. Sergio's dissertation involves a qualitative exploration of the ways trans people's gender euphoria defies systems of power that deprive all people from experiencing racialized gendered pleasure. After graduation, Sergio aspires to continue being a community-rooted psychological practitioner who intervenes individually, socially, and systemically to create pleasure-centric futures. While this award bears their name, this award was not earned by Sergio alone; instead, this award is shared with the many people who have done and will continue to do and support racial-gender justice advocacy." (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The curious reader’s guide to dissociation: understanding dissociative processes, a Commentary

Associative processes that provide salience through sorting of mental content rely upon dissociative processes to remove non-salient content from awareness, like not noticing the glasses on your nose. When association fails in trauma, as capacities to assimilate and accommodate experience are outstripped by that experience being outside the usual range of human experience, then more elaborate dissociative experience like depersonalization and derealization may become active to help us tolerate our perception even if it costs the price of isolated affect or additional amnesia for experience. With repetition of traumatic experience identity confusion and identity alteration may occur, effectively generating the less common dissociative identity disorder. This guide first explores the basis of dissociative experience as a prelude to the reader’s foray into the subject of this special issue of this journal. Additionally, the writer delves into aspects of the work of a world-class collection of authoritative articles to fully flesh them out or emphasize critically important perspectives. Finally, the centrality of the relationship in psychotherapy is emphasized as a requirement for effective treatment when persistent dissociative processes dominate the activities of a wounded human mind.

Retraction of Kivlighan et al. (2016).

Reports the retraction of "Working alliance, real relationship, session quality, and client improvement in psychodynamic psychotherapy: A longitudinal actor partner interdependence model" by Dennis M. Kivlighan Jr., Clara E. Hill, Charles J. Gelso and Ellen Baumann (Journal of Counseling Psychology, 2016[Mar], Vol 63[2], 149-161). The following article is being retracted (https://doi.org/10.1037/cou0000134). This retraction is at the request of coauthors Kivlighan, Hill, and Gelso after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. Baumann was not responsible for obtaining and verifying participant consent but agreed to the retraction of this article. (The following abstract of the original article appeared in record 2015-57048-001.) We used the Actor Partner Interdependence Model (APIM; Kashy & Kenny, 2000) to examine the dyadic associations of 74 clients and 23 therapists in their evaluations of working alliance, real relationship, session quality, and client improvement over time in ongoing psychodynamic or interpersonal psychotherapy. There were significant actor effects for both therapists and clients, with the participant's own ratings of working alliance and real relationship independently predicting their own evaluations of session quality. There were significant client partner effects, with clients' working alliance and real relationship independently predicting their therapists' evaluations of session quality. The client partner real relationship effect was stronger in later sessions than in earlier sessions. Therapists' real relationship ratings (partner effect) were a stronger predictor of clients' session quality ratings in later sessions than in earlier sessions. Therapists' working alliance ratings (partner effect) were a stronger predictor of clients' session quality ratings when clients made greater improvement than when clients made lesser improvement. For clients' session outcome ratings, there were complex three-way interactions, such that both Client real relationship and working alliance interacted with client improvement and time in treatment to predict clients' session quality. These findings strongly suggest both individual and partner effects when clients and therapists evaluate psychotherapy process and outcome. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Development of the Adult Self: An Existential, Relational, and Developmental Approach to Our Human Search for Meaning

The author offers a theory of the development of the adult self that can be used to understand existential life predicaments that may not originate in childhood. She proposes an existential and developmental approach to working with a client’s search for meaning in a relational psychotherapy and offers five developmental stages of the adult self, diagramed as concentric circles in an integrating Adult ego state. Drawing on the work of existential psychotherapists, developmental psychologists, and Levin-Landheer’s cycle of development, the author outlines possible tasks and conflicts of each life stage. Rather than a medicalized treatment plan, she offers an existential and cocreative perspective comprised of eight possible therapeutic phases that she calls encounters for change. The clinical examples she provides demonstrate how exploring and sharing our own painful truths about life’s journey can provide a spiritual, relational, and cocreative encounter for our clients and ourselves.

Discursive angles on the relationship in psychotherapy.

Research on the psychotherapy relationship has been dominated by quantitative-statistical paradigms that focus on relationship elements and their (evidence-based) effectiveness regarding the psychotherapy process. In this mini review, we complement this existing line of research with a discursive-interactional view that focuses on how the relationship is accomplished between therapists and clients. Our review highlights some of the main studies that use micro-analytic, interactional methods to explore relationship construction of the following elements: Affiliation, cooperation (Alignment), empathy and Disaffiliation-Repair. We not only provide a summary of important discursive work that provides a unique lens on how the relationship may be established and maintained, but also suggest that this kind of micro-analytic approach can offer more nuanced conceptualizations of the relationship by showing how different elements work together in a synergistic manner.

Understanding the role of emotion and expertise in psychotherapy: An application of dynamical systems mathematical modeling to an entire course of therapy.

The therapeutic relationship continues to be one of the most important factors in therapeutic outcomes. Given the place of emotion in the definition of the therapeutic relationship, as well as the demonstrated positive impact that emotional expression has on therapeutic process and outcome, it stands to reason that studying the emotional exchange between the therapist and client further would be warranted. This study used a validated observational coding system--the Specific Affect Coding System (SPAFF) and a theoretical mathematical model to analyze behaviors which make up the therapeutic relationship. Specifically, the researchers used to codify relationship-building behaviors between an expert therapist and his client over the course of six sessions. Dynamical systems mathematical modeling was also employed to create "phase space portraits" depicting the relational dynamics between the master therapist and his client over six sessions. Statistical analysis was used to compare SPAFF codes and model parameters between the expert therapist and his client. The expert therapist showed stability in affect codes over six sessions while the client's affect codes appeared to be more flexible over time, though model parameters remained stable across the six sessions. Finally, phase space portraits depicted the evolution of the affective dynamics between the master therapist and his client as the relationship matured. The clinician's ability to stay emotionally positive and relatively stable across the six sessions (relative to the client) was noteworthy. It formed the basis for a stable base from which she could explore alternative methods to relate to others that she had allowed to dictate her actions, which is in keeping with previous research on the role of therapist facilitation of the therapeutic relationship, emotional expression within the therapeutic relationship, and influence of these on client outcomes. These results provide a valuable foundation for future research on emotional expression as a key component of the therapeutic relationship in psychotherapy.

Development of a psychotherapy process prototype for the Real Relationship

Objective The Real Relationship (RR) describes the aspect of the psychotherapy relationship that is based on a genuine connection and a realistic view between patient and therapist. In the current study, we aimed to develop a Psychotherapy Process Q-set (PQS) prototype of the RR to facilitate post-hoc assessment of the RR in psychotherapy session recordings. We also aimed to measure the association between the RR-PQS and current PQS measures of theoretical treatment principles and the working alliance. Method We developed an RR-PQS prototype based on ratings of an ideal RR session by eight RR experts. We assessed the associations between the RR-PQS and existing cognitive behavioral and psychodynamic process prototypes, and seven PQS items known to predict the working alliance. Results RR experts agreed on the ideal RR session ratings to a high degree (ICC = 0.89). The RR-PQS was moderately related to both cognitive behavioral (r = 0.66, p < 0.01), and psychodynamic prototypes (r = 0.56, p < 0.01). PQS items predictive of the working alliance were characteristic of the RR-PQS. Conclusion The RR-PQS prototype appears to behave in theoretically predicted ways and may be a valid measure of the RR.

An initial validation of the Clients’ Experience of Therapy Scale (CETS): assessing the quality of psychotherapy process and outcome from clients’ perspectives

ABSTRACT In studies of psychotherapy, researchers typically rely on symptom-focused measures to assess treatment success. However, good psychotherapy can engage clients in many other transformations–such as, improved relationships, insight, and emotional engagement. In line with research indicating that clients value a distinct set of therapeutic gains, our goal was to develop a measure that assesses the quality of psychotherapy as experienced by clients. Initial items were based upon results from an omnibus meta-analysis of the qualitative literature on clients’ experiences of therapy, lending both construct and face validity. In this initial study, exploratory (Study 1) and confirmatory (Study 2) factor analyses were conducted. The Clients’ Experiences of Therapy Scale (CETS) contains five subscales including 15 questions. It demonstrated strong test-retest reliability and inter-item consistency across diverse demographic groups and psychotherapy orientations. Comparisons with symptom measures suggested that the scale assesses related but distinct constructs. The CETS shows potential to predict client dropout from therapy, correctly classifying 80.0% of cases posthoc. When used in routine outcome monitoring, because the items assess the quality of psychotherapy in relation to in-session process and micro-outcomes, they can provide feedback to therapists, on specific in-session dynamics to change, discuss with clients, or refine in practice.

Dyadic Interactions of Treatment-Resistant Schizophrenia Patients Having Followed Virtual Reality Therapy: A Content Analysis

(1) Background: Very little is known about the inner therapeutic processes of psychotherapy interventions for patients suffering from treatment-resistant schizophrenia. Avatar therapy (AT) is one such modalities in which the patient is undergoing immersive sessions in which they interact with an Avatar representing their main persistent auditory verbal hallucination. The aim of this study is to identify the most prevalent dyadic interactions between the patient and the Avatar in AT for patient's suffering from TRS. (2) Methods: A content analysis of 256 verbatims originating from 32 patients who completed AT between 2017 and 2022 at the Institut universitaire en santé mentale de Montréal was conducted to identify dyadic interactions between the patients and their Avatar. (3) Results: Five key dyads were identified to occur on average more than 10 times for each participant during the immersive sessions across their AT: (Avatar: Reinforcement, Patient: Self-affirmation), (Avatar: Provocation, Patient: Self-affirmation), (Avatar: Coping mechanisms, Patient: Prevention), (Patient: Self-affirmation, Avatar: Reinforcement), and (Patient: Self-appraisal, Avatar: Reinforcement). (4) Conclusion: These dyads offer a first qualitative insight to the interpersonal dynamics and patient-avatar relationships taking place during AT. Future studies on the implication of such dyadic interactions with the therapeutic outcome of AT should be conducted considering the importance of dyadic relationships in psychotherapy.