Therapeutic Alliance Research Articles

Understanding Pediatric Physical Therapists' Experiences With Middle Eastern Patients and Arabic Interpreters: A Qualitative Study.

The purpose of this study was to explore pediatric physical therapists' (PTs') experiences including successes, challenges, and barriers with cross-cultural communication with Arabic-speaking Middle Eastern children and their families who require interpreter services. Eight PTs consented to participate in qualitative dyadic interviews. Transcription and interviews were conducted virtually in Microsoft Teams. Quality criteria included member checking for validity and trustworthiness and bracketing to minimize investigator bias. Inductive thematic analysis was used to identify meaning units and major themes. The 6 themes that emerged were: fostering therapeutic relationships, practicing culturally sensitive care, communicating intentionally, experiencing successes, recognizing challenges, and tailoring a physical therapy plan of care. Representative quotations support each theme. Therapists perceive their experiences with Arabic-speaking children, families, and interpreters positively despite challenges related to cultural and language barriers. In sharing their experiences, therapists demonstrated self-reflection, openness to learning, and desire to build strong therapeutic alliances.

Revisiting longitudinal qualitative studies in social work: considerations for design and methodological insights.

This paper undertakes an analysis and discussion of the methodological challenges and insights derived from three longitudinal qualitative studies, all conducted in Chile during the COVID-19 pandemic and subject to comprehensive theoretical-methodological reflection processes centred on their respective designs. This analysis makes a significant contribution to interdisciplinary discussions within social research, with a particular emphasis on longitudinal trajectories. First, we present a comparative analysis of three studies in social work, utilising Saldaña's questions addressing changes and learning in longitudinal studies. The first study explores the labour trajectories of researchers, the second focuses on the educational trajectories of students, and the last examines therapeutic alliance trajectories between social workers and families within the child protection system. Following this, we delve into the methodological decisions made by the research group during the execution of these longitudinal studies. This encompasses an examination of participant involvement, temporal definitions of the adopted designs, and the most suitable methodological tools for analysing change processes over time. The outcomes of this comparative analysis reveal the distinctive characteristics of the three longitudinal studies, providing insights into how the time dimension is explored within them. We highlight key criteria essential for consideration in longitudinal qualitative research, particularly regarding participants and methodology. In conclusion, we advocate for an expanded reflection within the realm of longitudinal qualitative methodology, encompassing aspects such as design choices, approaches to data analysis, integration of technology in information processing, and strategies for maintaining participant engagement.

Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning

Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon. To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes. This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital. Duration of follow-up was 1 month. Data were analyzed from January 2022 to March 2023. The PediSICP includes clinician training preceding an ACP communication occasion supported by communication guides and a template for electronic medical record documentation. Outcomes of interest were parent, patient, and clinician experiences with and perceptions of the PediSICP. Feasibility was defined a priori as at least 70% clinician intervention completion rates. A total of 10 virtual trainings were conducted among 40 clinicians, including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist, and 30 trained clinicians (75%) conducted and documented 42 ACP conversations with 33 parents (median [IQR] age, 43 [35-51] years; 25 [76%] female) and 5 AYAs (median [IQR] age, 19 [17-19] years; 3 [60%] female) who completed the intervention. The median (IQR) conversation duration was 27 (10-45) minutes. Most clinicians (29 clinicians [97%]) agreed that they felt prepared for the conversation, and all clinicians recommended the PediSICP. Parents reported participation was worthwhile (27 parents [84%]), they felt listened to (31 parents [94%]), and would recommend the PediSICP (28 parents [85%]). Parents endorsed higher therapeutic alliance after the PediSICP intervention compared with before (The Human Connection scale mean [SD] score, 57.6 [6.4] vs 55.3 [7.8]; P = .03) and decreased anxiety immediately after the intervention (Generalized Anxiety Disorder-7-item mean [SD] score, 10.1 [7.3] vs 8.4 [6.9]; P = .003), which persisted at the 1-month follow-up (mean [SD] score, 7.7 [6.8]; P = .03). This pilot cohort study found that the PediSICP was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness. These findings suggest that the PediSICP may empower interprofessional clinicians and improve ACP with families of children and AYAs who are seriously ill.

Fluctuations in therapist responsiveness facing clients with borderline personality disorder: Starting therapy on the right foot

Objective The present paper focuses on therapist responsiveness during the initial therapy session with clients with borderline personality disorder (BPD), aiming to analyze therapist responsiveness at short intervals during the initial session and determine if it can predict therapeutic alliance from both therapist and client viewpoints. Method A sample of 47 clients participated in the study for 10 sessions of therapy. Therapeutic alliance from therapists’ and clients’ perspectives was rated after each session; external raters assessed therapist responsiveness during the initial session. Multiple linear regression models and linear mixed models with backward variable selection based on AIC were run to analyze whether specific therapist behaviors during session one predicted therapeutic alliance rated from therapists’ and clients’ perspectives. Results The results indicate that therapists normalizing and validating clients’ experiences during the first session are crucial for establishing therapeutic alliance for BPD clients; however, for therapists, the increase in variability of emotions verbalized by clients during the initial session negatively impacts therapeutic alliance. Conclusion The study contributes to further understand the impact of therapists’ behavior at the beginning of therapy with BPD clients. Therapist responsiveness is crucial for therapy outcome but is methodologically challenging; therefore, efforts in this direction should be pursued.

Development of a new observer-rated measure to assess the real relationship in psychotherapy sessions

Objectives Real relationship (RR) refers to a genuine human relationship between client and therapist, that has been found to be positively related to treatment outcome, and to predict unique variance in outcome over and above the working alliance. However, thus far, the measurement of RR has been limited to self-report. We aimed to develop an observer-rated version of the RR measure (RR-O) to assess RR in therapy sessions. Methods We adapted items from the self-report measures to an observer rated measure, which was reviewed by RR experts. The final 24-item RR-O was rated in 540 session transcripts from 27 psychoanalytic treatments that already had existing process and outcome scores. Results The RR-O showed good internal consistency and good interrater reliability. In hierarchical EFA, items clustered into a general RR factor, and client realism, client genuineness, therapist genuineness, and therapist realism group factors. In addition, the RR-O was positively related to another RR measure and to the therapeutic alliance. Conclusion The RR-O shows initial reliability and validity as an observer-rated measure of the RR to be used in post-hoc psychotherapy research. Future research should clarify the relation between RR-O and treatment outcome.

The use of patient-related outcomes (PRO) and experience (PRE) in assessing the periodontal and implant patient.

The purpose of this review was to summarize the evidence with regard to behavioral and psychosocial assessment of the periodontitis patient, the candidate for implant therapy, and the peri-implantitis patient. Periodontitis has an adverse effect on quality of life and its treatment can lead to significant improvements experienced by the patient. The latter is true for rehabilitation with dental implants, although patients harbor diverse expectations and perceptions of implant therapy, which can often interfere with satisfaction and/or influence long-term success. A thorough behavioral assessment of the candidate for implant therapy is essential, which should include, perceptions, expectations, as well as risk for behavioral disorders. Remedial action is essential to correct misperceptions and any identified risks. Finally, patients have limited awareness of limited ability to identify signs of peri-implantitis. The diagnosis of peri-implantitis can be a cause of significant distress, resentment, and loss of trust to the treatment and the caregivers. Despite documented value in clinical research, currently available instruments assessing patient-reported outcomes have little application in day-to-day clinical practice. Face-to-face patient to doctor open-ended communication remains the most effective way to comprehensively establish the long-term "therapeutic alliance" essential for the long journey for the periodontitis patient.

Creating a Therapeutic Alliance with Caregivers: An Introduction to Motivational Interviewing

Creating a Therapeutic Alliance with Caregivers: An Introduction to Motivational Interviewing

The relationship of early therapeutic alliance, baseline client symptom severity, and client race to duration in therapy and post client symptom severity

AbstractExtending the study of Shaw et al., this study aimed to determine whether early therapeutic alliance, baseline client symptom severity, and client race predicted treatment duration and post client symptom severity. Participants (N = 75) were clients at a community mental health clinic. Baseline client symptom severity, but not early therapeutic alliance, predicted post client symptom severity; client race predicted treatment duration. Collectively, early therapeutic alliance, baseline client symptom severity, and client race predicted post client symptom severity.

Ethical Dimensions of Digital Phenotyping Within the Context of Mental Healthcare

AbstractDigital phenotyping (DP) refers to the emerging field within digital (mental) health that involves the collection of data from individual’s digital devices (smartphones, wearable, Internet usage, etc.) to monitor and analyse their behaviours, activities and health-related patterns. That such ‘digital footprint’ data can be mined for behavioural insights is an intriguing idea, which has motivated an increasing amount of research activity, particularly in the field of digital mental health. Whilst of potentially revolutionary utility in (mental) healthcare, the idea of DP also raises a set of rich sociotechnical, ethical and philosophical considerations, and a cottage industry of sociotechnical and ethical critiques of DP has emerged, particularly within the humanities. Within this scene of early empirical investigation in the health/behavioural sciences on the one hand and general conceptual critiques from the humanities on the other, in this paper we instead explore a case for the potential utility of DP in circumstances of clinical mental health practice and examine its ethical dimensions in this context. After providing an explicatory framework for DP and making a case for it within this framework, we subsequently examine the ethical pros and cons of three topics pertaining to DP in clinical practice, namely (1) issues in psychometric assessment/testing, (2) the role and responsibilities of mental health practitioners with regard to DP technology, and (3) the value DP can afford clients in terms of self-awareness/empowerment and strengthening the therapeutic alliance with their clinician.

Chronic suicidal ideations: a risk or a protection.

Chronic suicidal ideations can be consistently present as part of the individual's sense of identity and self-regulation or as a reoccurring pattern to control intense feelings and communicate and relate experiences or intentions. While they can be the precursor to self-harm and suicide attempts, requiring a thorough risk assessment, they can also represent a way to control, avoid, or contain intolerable feelings and experiences. In addition, suicidal ideations can be either deeply internalized and hidden or indirectly or directly conveyed to others. This article focuses on understanding and approaching chronic suicidal ideations that specifically relate to self- and interpersonal characterological functioning, i.e., sense of identity, self-regulation, emotion regulation, and interpersonal intentions. Suicidal ideations must be identified and assessed both in terms of intention, i.e., motivation, plans, and means to harm oneself or end one's life, as well as in terms of function, i.e., related to selfregulatory strategies for counterbalancing or protecting against overwhelming, painful, and frightening external, interpersonal, or internal experiences. Therapeutic strategies and challenges will be discussed, including engaging patients in the therapeutic alliance and building consistency, trust, and reliability.

Application of the solution-focused brief strategies via telephone for family caregivers of persons with dementia: the Alzheimer’s Association National Helpline

Objectives Nearly 75% of persons living with dementia (PLWD) in the US live at home and are cared for by informal family members who have limited access to supportive and accessible services, indicating an increased need for these types of services (Alzheimer’s Association, 2023). The Alzheimer’s Association call centers offer free telephone care consultations, but it currently remains unclear which types of brief telephone support benefit caregivers. This study compares outcomes of participants who received traditional care consultation calls via the Alzheimer’s Association National Helpline with care consultation calls from Helpline staff trained in Solution-Focused Brief Strategies (SFBS), a client-centered evidence- and resource-based approach. Method Sequential callers were randomly assigned to the “traditional” or “SFBS” care consultation groups and were assessed at the time of call (baseline) and post-call (T1). The outcomes of interest were general self-efficacy (GSE), self-efficacy in managing emotions (PROMIS), caregiver mastery, therapeutic alliance, and goal setting. Results Of over 500 callers, callers receiving the SFBS scored higher on therapeutic alliance and goal-setting metrics, such as greater sense of collaboration on goals (effect size = 0.280, p = 0.0005, significant with Bonferroni correction), mutual agreement with care consultant on goals (effect size = 0.418, p < 0.0001, significant with Bonferroni correction), and believing the way the problem was resolved was correct (effect size = 0.286, p = 0.0007, significant with Bonferroni correction) than those receiving the traditional care consultation. Both groups reported improvements in the PROMIS measure, but there were no differences between groups. There were no significant differences in GSE or caregiver mastery scores between groups. Conclusion This study provides evidence for the effectiveness of the integration of SFBS in dementia care consultation calls as part of telephone-based supportive services for dementia caregivers.

‘Leaving my comfort zone’. A qualitative study of physiotherapists' experiences blending an eHealth psychosocial intervention with face-to-face physiotherapy

BackgroundMany physiotherapists do not feel adequately equipped to address psychosocial risk factors in people with complex pain states. Hence, a biopsychosocial blended intervention (Back2Action) was developed to assist physiotherapists to manage people with persistent spinal pain and coexisting psychosocial risk factors associated with the development or maintenance of persistent pain. ObjectiveThis study aimed to gain insight into the experiences of physiotherapists with this blended psychosocial intervention. Designand methods: This was an interpretative qualitative study with a reflexive thematic analysis of semi-structured interviews with physiotherapists (N = 15) who delivered Back2Action. The interview started with the grand-tour question: “What was your experience in using Back2Action?” Physiotherapist were encouraged to provide examples, and follow-up questions were posed to ensure a deeper understanding could be reached. ResultsFour themes were constructed: Physiotherapists became increasingly aware of (1) their own implicit expectations, biases and skills, and underlying treatment paradigms, and (2) the implicit expectations from their patients towards them. This led to (3) creating a deeper and stronger therapeutic alliance with the patient, but also (4) an understanding that implementation of a true biopsychosocial intervention – even if offered in a blended form – requires more practice, confidence and resources. ConclusionsBack2Action is considered a valuable treatment to deliver a biopsychosocial intervention in primary care. Considering the high level of knowledge, skills and competency of the participating physiotherapists, the perceived barriers may be more difficult to overcome for more junior physiotherapists.

“Close to the Problem” or “Close to Your Problem”? The Contribution of Bond to the Structure of Early and Advanced Therapeutic Alliance

The study analyzed the contribution of bond in the structure of the therapeutic alliance. Results were reported for two stages of the psychotherapeutic process: early and advanced. The study included 415 psychotherapist–patient dyads in the process of individual psychotherapy. Alliance estimation was based on Bordin’s model of alliance. The hypothesis was tested through structural equation modeling analysis. In both the early and advanced phases of psychotherapy, patient–therapist bond made a large contribution to the structure of the alliance, similar to that of the remaining two components: goals and tasks. The results indicate that bond is a crucial and permanent element in the structure of the relationship in the psychotherapeutic dyad, regardless of the stage of the process. In the advanced phase, the distance in weight between bond and the remaining two dimensions of alliance is minimal. The contribution of bond to the alliance structure as high as the contributions of goals and tasks signals not only the importance of understanding the patient’s problem but also the importance of mutual trust and respect.

Must The Show Go On? A Qualitative Study Exploring Barriers And Enablers To Manual Therapists' Care Of Dancers.

Dance Medicine is a growing discipline, and healthcare for dancers requires appreciating particularities of their artistic craft. Manual therapists (MTs) are often dancers' first choice when seeking care. Whilst dancers' experiences of injury and healthcare have been extensively researched, little is known of MTs' perspectives of caring for them. This study aimed to gain an understanding of MTs' perspectives of caring for dancers. Communication, treatment strategies and obstacles to a successful therapeutic alliance were examined to broaden knowledge and improve care. This was a qualitative study using Grounded Theory as a framework for data collection and analysis. A purposive sample of 8 participants was recruited-physiotherapists, chiropractors, and osteopaths with 2+ years' experience of treating dancers. Data collection was conducted via semi-structured interviews, which were transcribed verbatim, anonymized, member checked, and later analyzed. Data analysis constructed 3 categories which described the range of participants' experiences. Two categories were identified-(i) A Strangled Industry and (ii) Be-all End-all Patients-and found to culminate in a core category: (iii) Beyond Hands-on, which exemplified MTs' attempts to address clinical challenges. MTs experience several challenges when providing healthcare to dancers. These encompass psychosocial aspects relating to dancers' internal world and the dance industry environment. It suggests that caring for dancers demands comprehensive, collaborative, and psychologically informed approaches. Emphasis should also be given to developing and implementing dance-specific pain science for all stakeholders.

Asthma remission one, none and one-hundred thousand: the relevance of the patient’s view

Objective Achieving remission in severe asthma holds paramount importance in elevating patient quality of life and reducing both individual and societal burdens associated with this chronic condition. This study centers on identifying pivotal patient-relevant endpoints through standardized, reproducible methods, while also developing a patient-centric definition of remission, essential for effective disease management. Methods A discrete choice experiment (DCE) was conducted to assess patients’ perceptions on the four primary criteria for defining severe asthma remission, as outlined by the SANI survey. Additionally, it investigated the correlation between these perceptions and improvements in the doctor-patient therapeutic alliance during treatment decision-making. Results 249 patients (70% aged between 31–60, 59% women and 82% without other pathologies requiring corticosteroids) prioritize the use of oral corticosteroids (OCS, 48%) and the Asthma Control Test (ACT, 27%) in defining their condition, ranking these above lung function and exacerbations. This preference for OCS stems from its direct role in treatment, tangible tracking, immediate symptom relief, and being a concrete measure of disease severity compared to the less predictable and quantifiable exacerbations. Conclusions This study explores severe asthma remission from patients’ perspectives using clinician-evaluated parameters. The DCE revealed that most patients highly value OCS and the ACT, prefer moderate improvement, and avoid cortisone cycles. No definitive preference was found for lung function status. Integrating patient-reported information with professional insights is crucial for effective management and future research. Personalized treatment plans focusing on patient preferences, adherence, and alternative therapies aim to achieve remission and enhance quality of life.

Mental pathology in the field of personality and psychotic disorders, systematic review of its relationship with the commission of homicide and violent acts

AbstractMental pathology and violence have been studied by the scientific community, a topic that is sometimes perceived as controversial, partly due to the prevailing stigma around psychiatric disorders. In this project, all those factors concomitant with psychotic pathologies and ‘Cluster B’ antisocial disorders, which could interfere with the commission of violent actions, and their maximum expression, the homicide, are addressed from a comprehensive psychological perspective. To this end, a rigorous methodological selection of 15 high‐impact articles has been carried out, from which the results have been extracted and compared in this systematic review. The findings obtained revolve around the importance of adherence to treatment, the therapeutic alliance, the absence of toxic consumption, and concomitance with other mental pathologies, taking into account the idiosyncratic differences of the subjects, as well as between the pathologies and diagnoses described, always maintaining the comparison between said disorders, and with the population in absence of pathology.

Predictors of dropout, time spent on the program and client satisfaction in an internet-based, telephone-assisted CBT anxiety program among elementary school children in a population-based sample.

Increasing evidence has shown that childhood anxiety can be effectively treated by Internet-based cognitive behavioral therapy (ICBT). Being able to predict why participants decide to drop out of such programs enables scarce resources to be used appropriately. The aim of this study was to report dropout predictors for a population-based ICBT intervention aimed at children with anxiety, together with the time they and their parents spent on the program and client satisfaction rates. The study focused on 234 Finnish children aged 10-13 who received an ICBT intervention, with telephone support, for anxiety symptoms, as a part of a randomized control trial. Their parents also had access to Internet-based material and participated in the weekly telephone calls with the coach. Possible drop out factors were explored and these included various family demographics, child and parent psychopathology and therapeutic alliance. Just under a fourth (23.9%) of the children dropped out of the intervention. The risk was higher if the child did not fulfill the criteria for any anxiety diagnosis or reported a poorer therapeutic alliance. Family demographics and the COVID-19 pandemic did not increase the risk. The families spent an average of 127min on the webpage each week and an average of 32min on the phone calls. The overall satisfaction with the program was 87% for the children and 95% for the parents. Both the children and the parents found the telephone calls helpful. These findings are important in clinical practice when assessing a family's eligibility for ICBT.

Impact of Adverse Childhood Experiences in Young Adults and Adults: A Systematic Literature Review.

Investigations have shown the different impacts that ACEs have on an individual's adult life, on both physical and mental health, but they have not yet shown the issue of the influence of ACEs on adults and young adults. Objective/Participants and Setting: This systematic review, performed according to the PRISMA norms and guidelines, intended to understand the most frequent outcomes of adverse childhood experiences in the life of young adults and adults. Studies were identified through multiple literature search databases at EBSCOhost, Web of Science, and PubMed April 2023, and a total of 279 studies, published between 1999 and 2002, were excluded, 256 because of multiple factors: being duplicates, showing statistical analysis with correlations only, being systematic reviews or case studies, comprising individuals under the age of 18, and not meeting the intended theme; ultimately, we selected for the review a total of 23 studies. The impacts of the various articles are subdivided into three main themes: antisocial and criminal behaviour; sexual Behaviour and intimate partner violence; and attachment, quality of life, and therapeutic alliance.

The therapist role in parent-led cognitive behavioral therapy for children after trauma: treating trauma from a distance

ABSTRACT This article examines the therapist experience of their role in providing Stepped Care Cognitive-Behavioral-Therapy for Children after Trauma (SC-CBT-CT), a semi-homebased, parent-led trauma-treatment for children (7–12). Previous research has documented that parent-led, therapist-assisted psychological interventions are an acceptable and effective type of service delivery. Yet, the therapist perspective on their role when providing parent-led treatments has received limited research attention. Attention is therefore directed to the therapist experience of engaging parents, establishing relationships, and working with children’s trauma narratives from a distance—through the engagement of parents. The data material consists of semi-structured interviews with SC-CBT-CT therapists. To identify patterns of experience, thought, and viewpoints in the overall data, a stepwise thematic analysis approach was applied. Two core themes emerged: 1) Perceptions of therapeutic control and therapeutic presence when engaging parents to lead their own children through an exposure-based program; 2) Establishment and maintenance of therapeutic alliances with and between parents and children. Although parents are inherently well-positioned to engage with their own children about trauma, the article highlights that treatment adherence, progression, and perseverance is contingent upon systematic therapist guidance, monitoring, and availability for support and problem-solving.

‘Matters-of-concern’ associated with discontinuation of long-acting injectable buprenorphine: Findings from a longitudinal qualitative study

BackgroundDiscontinuation of medications such as methadone and buprenorphine amongst patients receiving opioid agonist treatment (OAT) is an international phenomenon. Recent developments in OAT medication include depot-injections of buprenorphine. Circumstances underlying discontinuation of these new formulations of medication are not fully understood from a qualitative perspective. MethodsData derive from a longitudinal qualitative study of patients’ experience of long-acting injectable buprenorphine (LAIB), involving semi-structured telephone-interviews held at six-points in time. The relevant dataset for this article consists of 44 interview transcripts, generated from 8 participants who were each affected by discontinuation of LAIB prescriptions (during the first 12-months of treatment). Analyses sought to identify circumstances associated with LAIB discontinuation and data were further situated within a framework of ‘evidence making intervention’ and associated ‘matters-of-concern’. Matters-of-concern relate to the ways in which an intervention is ‘made’ and constructed through engagement and practice, from the perspective of the recipient. FindingsIn this study, participants experienced either ‘discontinuation of LAIB prescriptions by treatment services’ or patient-led ‘opt-out’ from treatment. Matters-of-concern underlying the former were associated with late attendance for scheduled appointments, non-prescribed substance use or receiving a custodial sentence. Matters-of-concern relating to patient-initiated discontinuation were associated with personal circumstances that affected treatment motivation, side-effects (of buprenorphine), a preference to resume heroin use, or because individual treatment goals had been achieved. ConclusionThe assorted matters-of-concern that influence discontinuation of LAIB demonstrate that such OAT is complex and multi-faceted, is neither fixed nor stable, and does not generate universally shared outcome. Experiences of LAIB discontinuation are shaped by a wide range of social, temporal and treatment-related effects that include disconnected therapeutic alliance between patient and treatment providers. In order to maximise the benefits of LAIB it is necessary to develop meaningful therapeutic alliances (notwithstanding policy boundaries) to enable exploration of matters-of-concern during treatment.