Therapeutic Bond Research Articles

Where I Practice: On the Spaces of Family Medicine.

In this essay, the author explores 3 distinct "spaces" that have helped him metaphorically map the nature of his work as a family physician. These "spaces" represent cultural, personal, and relational environments in which he has practiced over the course of >30 years since beginning medical school. They concern, respectively, the dominant culture of medicine, one core philosophy of family medicine (the biopsychosocialexistential model), and the development of strong therapeutic bonds with patients. The author presents this textual and graphic exploration of "space" in hopes that others might reflect on their work, examine how they approach it, and bring richness and renewed meaning to their work as family physicians.

Therapeutic bond judgments: Congruence and incongruence.

The present study had 2 aims: (a) to implement West and Kenny's (2011) Truth-and-Bias model to simultaneously assess the temporal congruence and directional discrepancy between clients' and therapists' ratings of the bond facet of the therapeutic alliance, as they cofluctuate from session to session; and (b) to examine whether symptom severity and a personality disorder (PD) diagnosis moderate congruence and/or discrepancy. Participants included 213 clients treated by 49 therapists. At pretreatment, clients were assessed for a PD diagnosis and completed symptom measures. Symptom severity was also assessed at the beginning of each session, using client self-reports. Both clients and therapists rated the therapeutic bond at the end of each session. Therapists and clients exhibited substantial temporal congruence in their session-by-session bond ratings, but therapists' ratings tended to be lower than their clients' across sessions. Additionally, therapeutic dyads whose session-by-session ratings were more congruent also tended to have a larger directional discrepancy (clients' ratings being higher). Pretreatment symptom severity and PD diagnosis did not moderate either temporal congruence or discrepancy at the dyad level; however, during sessions when clients were more symptomatic, therapist and client ratings were both farther apart and tracked each other less closely. Our findings are consistent with a "better safe than sorry" pattern, which suggests that therapists are motivated to take a vigilant approach that may lead both to underestimation and to attunement to fluctuations in the therapeutic bond.

Preservice Counselors' Initial Perceptions of Client Grief Style

This analogue study examined the influence of client grief style (intuitive or instrumental) on initial preservice counselor perceptions of the client. Three hypotheses were tested: (a) that counselors would initially rate the global functioning of intuitive grievers as higher than that of instrumental grievers; (b) that counselors would rate their initial expectations about the therapeutic bond with intuitive grievers higher than instrumental grievers; and (c) that counselors would be more likely to encourage emotional catharsis with instrumental grievers, even though this technique may be contraindicated for this group. Results supported the second hypothesis but not the first and third; however, for the first and third hypotheses, significant differences were found in the opposite direction. Of particular clinical significance was the fact that 66% of participants reported being very likely to encourage emotional catharsis with instrumental grievers, suggesting a potential need for further training regarding interventions appropriate to this client group.

The effects of therapeutic bond within a brief intervention for alcohol moderation for problem drinkers.

The quality of the relationship between a therapist and his or her client can make a significant contribution to recovery from substance use disorders. Treatments often harness aspects of therapeutic relationships (e.g., therapeutic bond) to positively affect therapeutic outcomes. Within motivational interviewing (MI), for example, authors theorize that a relational component is 1 active component that affects change. The present study aims to examine the effects of relationships within a treatment setting on drinking. A secondary data analysis was performed on data collected from problem drinkers in a randomized controlled trial. Participants were assigned to MI or relational MI without directive elements (spirit-only MI). Participants answered questions about alcohol use and therapeutic bond before, during, and at the end of an 8-week treatment period. High levels of therapeutic bond and empathic resonance predicted decreased alcohol use at the end of treatment for participants in both conditions. This study highlights the importance of relational components in treatments for substance abuse. (PsycINFO Database Record

El chico que se echaba de menos.

For the past twenty years the discipline of art-therapy has been consolidating amongst the therapeutic community, eventually acquiring its own idiosyncrasy and procedure. Nevertheless, the different ways of art-therapy are still barely understood, and sometimes seen through stereotypes, by non-specialists. In the present text a practical view of art-therapy is treated by exhibiting the case of a youngster with drug-addiction issues and a corporal castration resulting from an unexpected accident. The case revolves around a double predicament, namely, the formation of the self body image and the construction of the narcissist subject. Through its development the key elements of an art-therapeutic process are revealed, such as the initial contact, the therapeutic bond, the mediated communication through artistic creations or the importance of the closing.

Vulnerable families as active agents of their own change process: a bidirectional perspective.

The literature on successful practice with vulnerable families reports social workers' efforts in forging therapeutic bonds with clients, their ability to both recognize clients' strengths and pain and support them as they work through adversity. Vulnerable families' own contribu- tions to their change process, however, have remained largely opaque. This article offers concrete conceptual tools to consider both social workers and clients from vulnerable families as active agents in the change process. Empirical evidence collected by practitioner-researchers through in-depth discussions with 10 vulnerable families illustrates clients' agentic capacities for autonomy, construction, and action as well as joint construction and maintenance of the helping relationships with social workers, thereby illustrating their active contribution to the process of change.

Modifications to the Technique of Analysis of BPD Adolescents

In this article I discuss certain modifications in technique that I applied working with borderline adolescents that enabled me to preserve the therapeutic bond and which, in my opinion, allowed me to obtain successful results. The differences with classical analysis are clear cut and concern, for example, the setting, the frequency of sessions, the nature of the transference, and modes of interpretation. It is important to keep our dialogue with the adolescent alive and avoid long silences that can be destructive. Part of the analyst’s work, in fact, consists in loaning his/her “images” (the product of his/her mind or imagination) to the concreteness of the patient. In the session these images seize something that is already present in the adolescent’s narrative as a creative hint to be developed that the analyst sees in the dialogue and deposits as a seed in his/her mind and which gives rise to a fruit produced by the analytical couple.

Communication Commentary: Bipolar Disorder: The Roller Coaster Ride: Optimizing the Therapeutic Alliance with Patients with Bipolar Disorder

Communication Commentary: Bipolar Disorder: The Roller Coaster Ride: Optimizing the Therapeutic Alliance with Patients with Bipolar Disorder

Supplemental Material for Therapeutic Bond Judgments: Congruence and Incongruence

Supplemental Material for Therapeutic Bond Judgments: Congruence and Incongruence

Working alliance in individual and group cognitive therapy for social anxiety disorder

The tripartite model of working alliance, including the therapeutic bond and agreement on tasks and goals, was examined in 54 patients who received individual or group cognitive behavior therapy (CBT) for social anxiety disorder (SAD) in a randomized trial. Alliance was significantly stronger in individual relative to group CBT but generally not related to outcome.

The therapeutic process in psychological treatments for eating disorders: a systematic review.

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled. Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified. Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated. As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

The working alliance in a randomized controlled trial comparing Internet-based self-help and face-to-face cognitive behavior therapy for chronic tinnitus

ObjectiveThis study (ID: NCT01205906) compared the impact of the working alliance between the therapist and the client on treatment outcome in a group and an Internet-based cognitive behavior therapy (GCBT vs. ICBT) for chronic tinnitus. MethodsThe Working Alliance Inventory — Short Revised (WAI-SR, scale range: 1–5) was administered to 26 GCBT and 38 ICBT participants after treatment weeks 2, 5, and 9, and the Tinnitus Handicap Inventory (THI) before and after the treatment. ResultsHigh alliance ratings were found in both ICBT (WAI-SR total scores at week 9: M=3.59, SD=0.72) and GCBT (WAI-SR total scores at week 9: M=4.20, SD=0.49), but significantly higher ratings occurred in GCBT on most WAI-SR scales (ps<.01). Significant time×group interactions for most WAI-SR scales indicated differences in alliance growth patterns between the treatments (ps<.001). Residual gain scores for the therapy outcome measure ‘tinnitus distress’ were significantly correlated with the agreement on treatment tasks between therapist and client in ICBT (r=.40, p=.014) and with the affective therapeutic bond in GCBT (r=.40, p=.043) at mid-treatment (week 5). ConclusionMore time was needed to build a strong alliance in ICBT although GCBT yielded generally higher alliance ratings. Moreover, different aspects of the therapeutic alliance might be important for treatment success in ICBT versus GCBT.

Neurofeedback Practitioner Factors Related to Client Adherence

Introduction. This study systematically identified, extracted, and organized neurofeedback (NFB) practitioner factors connected to client adherence. It is important to understand this connection because increased adherence leads to improved NFB outcomes. A previous NFB conceptual framework and previous NFB client adherence findings were used to guide the current study. Method. One hundred and ninety-eight NFB practitioners completed online surveys gathering demographic information and ratings of practice behaviors and characteristics. For data set analyses, this study utilized SPSS version 20 for descriptive statistics, frequencies, means, standard deviations, ranges, Pearson product-moment correlation analyses, and independent samples t -tests. Results. Findings indicated that the following significantly correlated with client adherence: (a) practitioner technical and interpersonal techniques; (b) practitioner commitment to improving technical and interpersonal skills; and (c) practitioner confidence displayed during sessions. Results also indicated commitment correlated separately with techniques and confidence. These results suggested that practitioners engaging in self-NFB sessions reported significantly higher adherence rates compared to practitioners not engaging in self-NFB sessions. Findings demonstrated that practitioners conducting ≧ 40 monthly NFB sessions reported significantly higher adherence rates compared to practitioners conducting < 40 monthly NFB sessions. Conclusion. This study concluded that practitioners with commitment to improving their technical and interpersonal expertise leads to increased confidence during NFB sessions, ultimately improving adherence and outcome rates. When averaging 40 or more NFB sessions with clients per month, practitioners provide themselves with continued opportunities to practice current and new technical and interpersonal skills. By conducting self-NFB, practitioners develop their own descriptions of physiological regulation and share their own results with clients, which in turn builds rapport and increases therapeutic bonds leading to higher adherence.

Mindfulness, mode deactivation, and family therapy: A winning combination for treating adolescents with complex trauma and behavioral problems.

MODE DEACTIVATION THERAPY (MDT) was developed in the 1990s after recognizing the lack of suitable treatment approaches for adolescents with behavioral problems and multiple co-existing conditions, which was often related to childhood trauma. The theoretical basis of MDT was framed on Beck's cognitive theory, Ellis' rational emotive behavior theory, and Piaget's cognitive development theory and concept of schemata. This research study is the most recent in a series that has been reported on since 2002 and were recently synthesized as a meta-analysis (Apsche, Bass, & DiMeo, 2011; Bass & Apsche, 2014; Swart & Apsche, in press). Considered separately and together, these studies consistently provide support of the effectiveness of Mode Deactivation Therapy with the specific target population of male adolescents with behavioral problems. On all accounts, effect sizes were high for target behavioral outcome effects, with statistically significant improvements that outperformed treatment-as-usual control groups by a large margin. This study aims to provide additional support of the efficacy of MDT, thereby reconfirming its value in the treatment for a population that is widely considered as difficult-to-treat. The philosophy of mode deactivation therapy By taking a step back again to the roots of cognitive theory, while blending in psychoanalytic considerations and elements--specifically acceptance and mindfulness--of other third wave approaches such as Dialectical Behavior Therapy and Acceptance and Commitment Therapy, MDT was developed to overcome inefficiencies that were typically encountered with standard Cognitive Behavioral Therapy (CBT), such as resistance to treatment, ill suitability for adolescents with serious comorbid problems, and short-lived improvements (Apsche & DiMeo, 2012). MDT hypothesized that adolescent externalized problem behavior is the function of internalizing disorders (Bass & Apsche, 2014); acknowledging that each emotional disorder that underlie dysfunctional behavior can be characterized by cognitive content that is specific to its outward expression (Hofmann, Sawyer, & Fang, 2010). The philosophy of modes and schemata are at the crux of the MDT conceptualization. Schemata represent all levels of our experience, at all levels of abstraction. Mode states are mind states that cluster schemas and coping styles into a temporary of being (Young, 2003, p. 37). In fact, already around 1600, Shakespeare proclaimed in Hamlet: There's nothing good or bad but thinking makes it so. The way that thoughts and feelings relate to our core beliefs--our inherent view of ourselves, others, and the world that has helped us cope since childhood--and how they bubble up as behavior, is the essence of understanding and treating behavioral problems. Core beliefs are strongly-held, rigid, and inflexible ideas that developed from childhood and tend to focus on situations and experiences that support and reinforce it. By examining these dysfunctional beliefs that are often outdated in current circumstances, and their relation to unhelpful thoughts and feelings, the MDT methodology directly targets the underlying causes in an accepting and nonjudgmental way. The new insight and awareness is harnessed to strengthen the therapeutic bond and the unique formulation of elements is posited to be the basic seed of the success that MDT has demonstrated with the adolescent population. The original conceptualization of MDT already embodied the philosophy of mindfulness, i.e. present-focused attention and importance of attaching to thoughts and feelings. Also, adolescents are invariably part of a family system, which is often where the origins of distress and dysfunction can be found. Therefore, the principles of mindfulness and family systems theory were also eventually--from 2006 onwards--incorporated into the MDT methodology. According to Bowenian family systems theory: When anxiety is low, we are able to think about our situations and our very existence. …

Anorexia nervosa, paternalism and clinical practice

Anorexia nervosa (AN) is an eating disorder whose therapeutic interventions usually produce unsatisfactory results. This disorder is characterized by high rates of relapse, tendency to chronicity, high morbidity and mortality1. Low motivation is a central issue that hinders AN treatment1. Interpersonal relationships seem to be crucial in AN and may play a role in this sense as well. We propose that specific patterns of interpersonal interactions can arise when professionals are dealing with AN subjects and that this peculiar rapport is not only a characteristic of the disorder in question, but could also be a part of what perpetuates and aggravates the problem. Those who interact with AN patients can refer feelings of helplessness, fear, anxiety and hopelessness2, pointing to a possible degree of aversivity in these relationships. This fact may be aggravated by the slow improvement typical of AN, which can be frustrating and, as a result of this, professionals can adopt a strong and directive attitude toward the patients trying to reach better outcomes in the treatment. In fact, a coercive attitude in AN can generate relatively quick results3, what can provide a transient attenuation of professional’s discomfort. This may have reinforcing effects over the controlling attitude, making it more likely to occur in future similar occasions. In other words, too much directivity appears to relief professional’s distress and, therefore, negatively reinforce coercive posture, but it may also have adverse consequences to the patient’s treatment4. Fallouts are noticed as a remarkably paternalistic approach – seen, for example, in procedures such as involuntary hospitalization not based on scientific guideless or arbitrary tube feeding – tends to increase the already high resistance in these patients5. An intimidating posture also can punish potentially unpleasant statements made by the patient, possibly suppressing genuine reports and predisposing to false descriptions of improvement. Coercion-generated improvements may be volatile and fragile and even unfavorable in the long term. For instance, forced hospitalizations decrease the voluntary search of treatment3, which is a major issue since the motivation to change is an important element for therapeutic success1. A healthy rapport seems to have an important role in reaching a favorable outcome in treatments since a mutual and reliable alliance in AN increases the chance of a continuous and more effective approach4. However, according to Darcy et al.6 the therapist-patient alliance is yet relatively under-researched especially when studied from the professional perspective and there is a deficiency of mental health professional’s continued training on the use of rational paternalistic techniques3. In short, some evidence suggests that a directive posture is more common in AN compared to other mental disorders and may have unfavorable effects over its treatment. It seems to be important to establish a positive therapeutic alliance to optimize motivation in this disorder. Prioritize cooperation in AN apparently can shifts the focus from control to an efficient therapeutic bond. Further research on the professional-patient relationship in AN cases is needed in other to elucidated this point and enhance the success of interventions.

Premature termination in couple therapy as a part of therapeutic process.

Aim of the studyThe aim of the study: The paper presents the qualitative study of premature termination in couple therapy. The aim of the research was to answer why couples drop-out from couple therapy at the early stage of treatment.Subject or material and methodsTo understand the complexity of this event the researchers decided to examine the phenomenon of early drop-out from three different perspectives, that is: from therapists and both spouses point of view.The therapists and couples that ended the therapy prematurely were interviewed. Among examined drop-out cases, there were selected three which fulfilled the criteria for early drop–out. Data were analyzed according to the method of cross-case analysis.ResultsAs a result common categories were singled out which were characteristic for those three cases of drop-out.DiscussionThe distinguished categories of ‘the split of the working alliance’ and ‘the split of the therapeutic bond’ show that the conflict which the couple brought to the therapy was reflected in their experience of the therapy and the therapist.ConclusionsPremature termination in couple therapy is a part of therapeutic process.

Inheriting Discontinued Bonds: Trauma-Descendant Relations With the Genocide Dead

Despite the scholarship on continuing bonds with the dead and the critique of pathologizing paradigms in trauma theory, little is known of the engagement between trauma descendants and relatives who perished prior to their birth. A sample of 55 Holocaust descendants was recruited in Israel to participate in semistructured ethnographic interviews. Descendants reported on the normalized presence of and engagement with the dead and the restoration of previously “discontinued” bonds. Findings were consistent with the scholarship on the therapeutic role of continuing bonds and with meta-analyses normalizing descendant psychosocial legacies. Jewish-Israeli paradigms of memory facilitated therapeutic bonds with the dead.

The journey from opposition to recovery from eating disorders: multidisciplinary model integrating narrative counseling and motivational interviewing in traditional approaches.

BackgroundIn the world of today’s of ever-briefer therapies and interventions, people often seem more interested in outcome than process. This paper focuses on the processes used by a multidisciplinary team in the journey from opposition to change to recovery from eating disorders. The approach outlined is most relevant to those with severe and enduring illness.MethodsThis paper describes a five-phase journey from eating-disorder disability and back to health as it occurs for patients in a community-based facility. This integrative model uses narrative and motivational interviewing counseling weaved into traditional approaches. It approaches illness from a transdiagnostic orientation, addressing the dynamics and needs demanded by the comorbidities and at the same time responding effectively in a way that reduces the influence of the eating disorder.The treatment described involves a five-phase journey: Preliminary phase (choosing a shelter of understanding); Phase 1: from partial recognition to full acknowledgment; Phase 2: from acknowledgment to clear cognitive stance against the eating disorder; Phase 3: towards clear stance against the “patient” status; Phase 4: towards re-authoring life and regaining self-agency; Phase 5: towards recovery and maintenance.ResultsIn a longitudinal study of patients with a severe and debilitating eating disorder treated with this approach. The drop-out rate was less than 10%. This was during the first two months of treatment for those diagnosed with bulimia nervosa, and this was higher than in those diagnosed with anorexia nervosa. At the end of treatment (15 months to 4 years later) 65% of those treated with anorexia nervosa and 81% of those treated with bulimia nervosa were either in a fully recovered state or in much improved. At the four-year follow-up, 68% of those diagnosed with anorexia nervosa and 83% of those diagnosed with bulimia nervosa were categorized as either fully recovered or much improved. All patients who completed the program were gainfully employed.ConclusionsThe collaborative work, which is the heart of the described model increases the patient’s and family’s ownership of treatment and outcome and strengthen the therapeutic bond, thus enhances recovery.

Terapia Cognitivo-Comportamental para Transtornos Alimentares: A Visão de Psicoterapeutas sobre o Tratamento

Os transtornos alimentares (TA) constituem uma área de crescente interesse dos profissionais da saúde. Todavia, ainda há poucos estudos brasileiros sobre o tratamento dessas patologias pela Terapia Cognitivo-Comportamental (TCC). O presente artigo se propõe a investigar como se dá o tratamento dos TA na visão de quatro terapeutas especializados nessa abordagem. O delineamento utilizado foi o de Estudos de Caso Múltiplos e as informações foram obtidas através de entrevistas abertas. Os resultados mostraram consenso sobre a importância do vínculo terapêutico, da interdisciplinaridade e do envolvimento familiar no tratamento. Entre as vantagens da TCC foram citadas a resposta rápida e a eficácia das técnicas. Quanto às limitações, foram mencionados aspectos como pouca motivação dos pacientes e questões econômicas. O principal critério de alta é um funcionamento global adequado. Finalmente, todos concordam em que novas pesquisas na área são importantes. Salienta-se especialmente a necessidade de novas investigações no contexto nacional.

Equine Facilitated Therapy with Children and Adolescents Who Have Been Sexually Abused: A Program Evaluation Study

Child sexual abuse (CSA) is a social problem that often inflicts long lasting psychological trauma and leads to psychopathology, behavioural problems and re-victimization. Treating young people who are presenting with the detrimental effects of CSA is often difficult because these effects off-set efforts at establishing a therapeutic bond. Animals have been found to facilitate the development of the therapeutic alliance between client and practitioner and therapies utilizing horses have the added bonus of empowering clients. This study aimed to evaluate an Equine Facilitated Program (EFT) run by Phoenix House, a sexual assault referral centre in Queensland, Australia. Participants were six boys and nine girls (aged 8-11 years) and 15 adolescent girls (aged 12-17 years). All participants provided several measures of data designed to establish levels of psychological distress at three points in time. That is, Time 1--intake into the service; Time 2--following approximately 6 weeks of in-clinic counselling and pre-EFT; and Time 3 post-EFT (9-10 week duration). Significant improvements in functioning were found between Time 2 and Time 3 assessment across all psychometric measures and for both age groups. No, or non-significant, improvements were found between Time 1 and Time 2 assessments. Overall the results show that EFT proved an effective therapeutic approach for the children and adolescents referred to the service. Of particular note was the finding that efficacy was similar across gender, age and Indigenous/non-Indigenous status. Implications of this and suggestions for further research are discussed. Language: en