NEGOTIATING THE THERAPEUTIC ALLIANCE

Negotiating the Therapeutic Alliance



Negotiating the Therapeutic Alliance

Introduction

A number of meta-analyses have demonstrated the overall efficacy of psychodynamic therapy or short-term dynamic psychotherapy across different types of disorders (1-2) and for specific psychiatric disorders (3-4). However, the mechanisms of action that account for this efficacy remain to be determined, and studies designed to clarify them represent the natural next step in research on short-term dynamic psychotherapy. In this type of research, investigators seek more specific answers to the perennial question of what works in psychotherapy. Rather than focusing on questions of main effects (e.g., "Does cognitive behavior therapy work better than a control condition for the treatment of major depression?"), researchers can identify potentially more clinically meaningful results by isolating the correlates of a particular set of interventions. By examining the potential impact of particular sets of interventions, researchers can help clinicians work more effectively and flexibly with their patients. This enables clinicians to choose from a variety of empirically supported intervention strategies as appropriate under the clinical circumstances rather than being forced to work within the limitations of a single manualized approach for a patient who has a specific disorder.

An affective treatment focus represents a relevant mechanism of action for short-term dynamic psychotherapy, as research indicates that contemporary psychodynamic therapies place greater emphasis on encouraging experience and expression of feelings compared with cognitive behavior therapies (6-8). Ablon and Jones, for example, asked expert psychodynamic and cognitive behavior therapists to use a Q-sort-derived questionnaire to describe an ideal psychotherapy of their respective orientations. Results indicated that the ideal psychodynamic therapy, in contrast to cognitive behavior therapy, contained a greater focus on patient affect. Jones and Pulos examined process ratings of psychodynamic and cognitive behavior therapy sessions and demonstrated that dynamic therapy contained greater affective emphasis. Blagys and Hilsenroth, in a review of the comparative psychotherapy process literature, identified seven techniques or processes that distinguish psychodynamic-interpersonal therapy from cognitive behavior therapy; among the various techniques or processes, psychodynamic-interpersonal therapy's affective emphasis had the most empirical support. This distinctive feature of contemporary psychodynamic therapy finds explicit theoretical elaboration in the work of a number of contemporary writers, including Fosha, McCullough and colleagues, and Wachtel. In this study, we sought to demonstrate more precisely the nature of psychodynamic therapy's efficacy by examining the relationship between therapist facilitation of patient emotional experience/expression and outcome. In addition, we examined the potential contribution of moderator variables, including the methodological quality of individual studies and the type of outcome construct used.

Literature Review

Ruptures or impasses or strains in the therapeutic alliance are inevitable. An alliance rupture or impasse is deterioration in the quality of the relationship between patient and therapist (Safran & Muran, 1996). The authors stated that one of the most important therapeutic skills consists of dealing therapeutically with repairing ruptures or therapeutic impasses in the therapeutic alliance. The therapist uses a wide range of different interventions for building and managing the therapeutic alliance and working through ruptures in the alliance as they ...