The therapeutic alliance in psychodynamic psychotherapy and functional analytic psychotherapy

Psychodynamic Psychotherapy

Importance of the therapeutic alliance in Psychodynamic Psychotherapy

A vast number of therapists have jotted down the significance of the working alliance. One therapy sitting includes information which comprises of statements from both the patient and the therapist, as stated in the study conducted by Guilhardi (1997). This saying has been balanced off by Kerbauy (1999), who states that the appropriate variables in clinics are extensive groups that comprises of conflict to change, therapeutic relationship and relations among patient and therapist.

At present there is a wide ranging agreement between the therapists, relating to the importance of therapeutic relationship, but differences do lie as per the differing roles.

Some writers take therapeutic relationships as a technique to assist behavioral change. Not only this, the relationship is also regarded as a key to enhance the value of therapists. In addition to this, it leads to positive expectancy and solutions as well to overcome resistance (Raue & Goldfried, 1994).

If the therapist actively participates in the treatment then the results can be very fruitful, confirms Range (1995). If a good relationship develops between the patient and the therapist, then the patient feels quite comfortable in sharing his part of the conversation or information, which is of utmost necessity during the therapy (Lettner, 1995).

Shinohara (2000) also considers the therapeutic relationship as an element that determines the methodology of therapy, because it is this relationship that assists in carrying out the work and also enables the achievement of the targets.

There are some other authors as well who take this therapeutic relationship as the major means of change. According to these authors this relationship is basically an opportunity to solve the troubles after having regular conversations with the therapist; these discussions give more useful reactions than others (Kohlenberg & Tsai, 2001).

Robert J. Kohlenberg and Mavis Tsai are recognized as most reputable authors and they have developed Functional Analytic Psychotherapy (FAP). This therapy is based on the idea of strengthening clinical conditions and simplification to the outer environment. This can be done in the existence of a therapist via observation and intrusion on clinically relevant behavior (CRB). CRB's have three types of applicable behaviors, which are as follows: CRB1, this behavior takes place in the existence of the therapist; CRB2, talks about the improvement of the patients, while CRB3 refers to the patient's personal understanding of their behavior (Kohlenberg & Tsai, 2001).

Grouping is considered as a very significant factor in a patient-therapist relationship by Kohlenberg and Tsai (2001). Through this grouping it would become convenient for the patient to engage themselves in self-observation (Kohlenberg, & Tsai, 2001). It is concluded by these authors that the centre of the therapeutic process is the psychotherapeutic relationship.

In order to carry out the work, both psychoanalysis and psychodynamic therapy depend on the therapeutic alliance. This alliance is basically interlinked between the therapist and the patient. Through this alliance cycle the patient gets too experienced, and become capable of talking about and/or openly discussing aspects which he could not have thought of on his own. In-depth study of therapeutic alliance helps the analyst to specialize in assisting his patients more deeply and makes him explore his own intuition. The patient becomes more aware of his observations, senses and skills etc. The therapeutic alliance is also named as "envelope" by Dr. Glen Gabbard, Professor of psychiatry and psychotherapist at Baylor College of Medicine, as it represents a complete and whole relationship and also includes the psychodynamic treatment (Gabbard, 2009).

Importance of the therapeutic alliance in transference and counter-transference

Psychotherapy is considered as a major aspect of working alliance; its affects are obvious on the treatment and are helpful to realize advancement in the alliance as well as the damaging features. Numerous experimental facts have proved that working alliance is a significant analyzer of the end results observed by therapeutic treatment (Horvath & Greenberg, 1989, 1994; Martin, Garske, & Davis, 2000). Research has proved that patients' involvement during the treatment by working alliance is more under observation than those of the experts. In this study, various therapists' features are discussed that are involved in the advancement of working alliance. However, it is conceived that both patients and analysts participate in working alliance enhancement.

Counter-transference is analyzed as one of the negative features affecting the psychotherapy association. Freud (1910/1959) considered the phenomenon of counter-transference in is analysis. According to him, counter-transference of an expert destructively influences his capabilities to analyze patients, because he himself is preoccupied by his own requirements. Several studies of conceptualization of counter-transference have been put forward in the recent past. According to Gabbard (2001), in the study about counter-transference, a patient always reacts towards his analyst and would certainly try to change his therapist into a "transference medium." He also stated that counter-transference involves the participation of both the client and his analyst. Now it is obvious that the patient and the therapist both actively contribute to the analyst's knowledge as accomplishment, and therefore two types of counter-transference should be discussed here (suggested by Kiesler, 2001): one is subjective counter-transference in which the therapist analyzes his patient under the influence of his unsettled personal problems; the other type is Objective counter-transference, in this the analyst concludes results by studying patient's behaviors towards resolving his own problems. In objective type counter-transference therapist's behavior is detrimental towards therapeutic process if it remains hidden, while in the other type, analyst's response can be fruitful for the process.

Counter-transference is injurious to client in its objective as well as subjective type, if the personal response of the analyst is not realized properly at time of display. Therapist must emphasize his personal feelings and consider the outcomes that can be beneficial in knowing his clients more precisely, which in turn will also ensure that the therapy process is also improved. Thus, it is important to deal with the counter-transference feeling and behavior in different manners. These therapists' reactions can alternatively be discussed as counter-transference behaviors that influence the outcome in unfavorable means. In this context, counter-transference behavior was mainly under consideration and concluded that such behaviors, whatever source is behind them, are damaging to this therapy process (Gabbard, 2009).

Not much research has been done on counter-transference behavior that is why it is not properly applied and still under the refining process. Two aspects have mainly put into action as counter-transference behavior: one is no personal concerns are involved and secondly to prevent or avoid client material (e.g., Latts & Gelso, 1995; Watkins, 1985). A designed procedure is proposed by Friedman and Gelso (2000) which provides a complete guide of counter-transference behavior in a distinct way. Two types of Counter-transference behaviors are mentioned by the Inventory of Counter-transference Behavior (ICB), which include constructive i.e. positive and unconstructive i.e. negative counter-transference behaviors. The definition of positive counter-transference behavior is given as those behaviors that are favorable for clients but also prefer analyst's requirements without neglecting patient's concerns. The opposite stands true for the latter

The positive counter-transference behavior is possibly injurious (Gelso and Friedman, 2000). Like the positive and nice behaviors, over-supportive, friendliness, agreeing too much with client and engaging with self-interest of clients, leads to a detrimental situation where the client relationship might get damaged as in fulfilling the needs of the therapist the client might feel conflicted. Whereas, the negative counter-transference behavior is being over-critical, rejection of clients' ideas and thoughts, punitive and being irrational by pretending in front of the therapist. Thus, both the negative and positive behaviors have a negative impact on therapy (Gelso and Friedman, 2000).

There are some studies which define the process of negative impact of counter-transference behavior in a psychological session rather than other studies which only theoretically define this impact. Although, major theorists have explained counter-transference as harmful, others merely investigated its positive aspect. Actually it is rational in believing that the behavior which satisfies the needs of the therapist will help in achieving the targeted goals or help in developing an emotional relation with his client. Therefore, these counter-transference behaviors can affect working alliance and other components of therapeutic bond. Attachment Style is another variable of therapy which is inter-related to working alliance. Sheltered adults or secure adults can be easily distinguished in terms of intimate relationship value, the capability of maintaining these relations without tailoring their sovereignty and shows rationality to discuss relationships and its related issues (Horowitz and Bartholomew, 1991). Moreover, different studies define that these adults properly use their self-disclosure, empathic and reflective listening, and are helpful in problem solving (Pistole, 1989; Nachson and Mikulincer, 1991). In conclusion, it is very important to examine the bond in working alliance and the style of therapist's attachment.

There are different experimental studies which show a couple of therapist interpretations that secured how clinicians use their counter-transference feelings and thus reflect in bringing out their clients' needs and also provide their feedback instead of counter-transference behavior (Cue, Dozier and Barnett, 1994).Thus, the attachment style might be related to both working alliance and counter-transference. Furthermore Cue, Dozier and Barnett, (1994) also states that on one hand, the insecure adults will have lower competency effect level and unawareness about their underlying feelings and on other hand the organizations of adult attachments can affect the adults' internal managerial effect (Kobak and Dozier, 1992; Shaver and Hazan, 1987).

Importance of the therapeutic alliance in interpretation

The importance of interpretations linked to the strengthening of patient-therapist relationship also referred to as transference interpretations, was emphasized greatly by Freud (1905). However, this concept is a little controversial. Transference encompasses feelings, desires, thoughts and related behaviors which have their origin in early parental relations and descend up to a current interpersonal relationship. Such relations are frequently encountered in patient-therapist relationships and are specified by the term transference in clinical writings. Conclusively, transference defines elucidations and interpretations linked to patient-therapist relationship and the same convention is followed in this section as well. The term relational interpretation describes general relationships and we also use this term under the same domain. Relational interpretations are therefore the superset of transference interpretations.

The relation between interpretations and therapeutic alliance has been evaluated in a straightforward way by few investigations only. According to Piper et al. (1991), a relatively high part of transference interpretations were linked with poorer alliance. A regression analysis revealed the fact that quality of object relations failed to act as moderation of relations existing between outcome and transference interpretations despite the fact that it was the strongest one when considering patients with high quality of object relations. Any evidence presenting that primary causal direction was from alliance to interpretation or vice-versa was not obtained, apart from making an attempt by making the causal relation existing between these variables more flexible (Piper, Azim, Joyce, & McCallum, 1993). It was seen that some gender effects were consistent with the fact that transference interpretations and alliance were linked proportionately. Considering patients with high quality of object relations, it was observed that a major part of transference interpretation was associated with better alliance in males, and, for females it was linked with poorer alliance (Piper, Azim et al., 1993).

Crits-Christoph, Barber, and Kurcias (1993) assessed the linkage between the extent of accuracy of alliance and a therapist's interpretations. The evaluation was conducted on a sample size of 33 patients under treatment in psychoanalytic psychotherapy. For determining accuracy and outcome of the treatment the same methodology was adopted as described by Crits-Christoph et al. (1988). The results revealed that accuracy based on response and wish from other dimensions amicably predicted the changes in alliance from the initial to the final stage of the treatment (rp = .51,p = .004). On the contrary accuracy dependent on the response of self, did not predict the change in alliance significantly (rp =?.05).

The relationship of transference interpretations' proportion to that of therapeutic alliance was examined by Connolly, Crits-Christoph, Shappell, Barber, and Luborsky (1997). For this purpose, 33 patients were included in the sample who went through 16 sessions of supportive-expressive dynamic psychotherapy. No significant relationship was found in the transference interpretations' proportion when patients' therapeutic alliance was altered over different quality levels of interpersonal relationships. No concrete conclusion can be drawn as only few researches have studied the relationship between therapeutic alliance and interpretations.