The alliance.

Two decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome. The magnitude of this relation appears to be independent of the type of therapy and whether the outcome is assessed from the perspective of the therapist, client, or observer. Although the strength of the connection between alliance and therapy outcome appears to be relatively uniform throughout therapy, the client's report of the early alliance may be the most clinically useful indicator. In successful treatments, the therapist's and client's assessments of the alliance tend to converge over time. Recent research suggests that the therapist's skills and personal factors both influence the likelihood of developing a good therapeutic alliance with the client. Though the relation between the therapist's level of training and the quality of the alliance is inconsistent, it is likely that the more trained therapists are able to form better alliances with severely impaired clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A fusion/separation model of psychotherapy.

Attempts to demonstrate the value of a style of psychotherapy that actively uses the effects of unconscious fusion between client and therapist. Clinical case illustrations are presented to show how the therapist's unconscious and conscious struggles evoked by the client's verbal and nonverbal behavior can be used for therapeutic leverage, especially with borderline clients. The author describes how he has used his pained, confused, and other seemingly maladaptive reactions to patients, by acknowledging them when stuck in therapy, to get things moving again. A fusion/separation model is described in which the therapist's ego boundaries are, and remain, highly permeable in a willed, conscious act of being/remaining vulnerable. Specifically, the therapist stays with the pain to let it emerge, while remaining distanced from it by looking at it, thus demonstrating that it is not lethal—that it can, in fact, be used constructively. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The spiritually responsible therapist: Religious material in the psychotherapeutic setting.

There exists a movement within the field of psychology to incorporate religious material into the overall conceptualization and treatment of the client. This article questions the appropriateness of such incorporation and emphasizes instead the distinction the therapist needs to make between religious and psychological material in the psychotherapeutic setting. The therapist must also be aware of how religious material can intensify the transference, resistance, and countertransference, thereby complicating the therapeutic process. Client issues that relate to the religious identity of the therapist or invoke a sense of exclusive similarity in the therapeutic dyad can further complicate the therapy. Such complications suggest that the avoidance of both overt and covert messages that communicate the therapist's personal values and beliefs may be beneficial for therapy. Case examples with 4 clients (aged 18–56 yrs) are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Resistance: A reconceptualization.

Discusses concepts of resistance in psychotherapy and argues that a therapist–client adversarial stance is common across many theoretical orientations, including Freudian and neoanalytic, nonanalytic (Gestalt, behavioral), and family therapies. The present authors advocate abandoning the concept of resistance because (1) research has shown that a cooperative client–therapist relationship is more beneficial to clients than an adversarial relationship; (2) research has shown that therapist understanding of the client–therapist relationship is poor; and (3) there is a move among analytic and nonanalytic approaches away from an adversarial client–therapist stance. It is suggested that the resistance concept be replaced with the therapist's recognition of possible client fears and misunderstanding of the therapy process. (73 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dimensions of the relationship between the Black client and the White therapist.

Discusses the psychological issues involved in having White therapists treat Black clients. The topics examined are the importance of the White therapist understanding his or her own feelings, countertransference, the detrimental effect of therapist guilt, and the impact of the therapist's need to be powerful. Also explored are the need for awareness of client–therapist interpersonal similarity and the need for an understanding of our social system for effective psychotherapy. Concrete suggestions are offered for helping therapists deal more effectively with Black clients. The White therapist–Black client relationship is proposed as a paradigm of how people with differing values learn to help each other. (34 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On reflection.

Theoretical explanations of the therapeutic process of reflection exhibit certain logical problems such as the existence of denied experiences. A theory is proposed that suggests that it is the therapist's task not to reveal to the client the presence of existing emotions or feelings, but to help in the creation of emotional attitudes. Emotions, like other experiences, are constructed out of stimuli that are selectively chosen. The therapist helps the client to select the appropriate stimuli and thus to experience the appropriate emotions and emotional attitudes. In this respect the therapist can be regarded as the transmitter of community judgments about the appropriate emotion in a given context. The teaching of these fundamental experiences is accomplished through the playing of language games by therapist and client. A prerequisite of effective learning by the client is the existence of a close bond between client and therapist, similar to the bond that exists between neonates and parents in imprinting situations. (36 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Understanding and overcoming parent resistance to play therapy.

Explores the nature and sources of parent resistance to play therapy, questions the concept of resistance as it is often understood, and suggests ways the play therapist can prevent or overcome it, addressing common mistakes therapists make that actually increase client resistance. It is stated that play therapist's own attitudes and the therapist–parent relationship can be used to overcome resistance that might interfere with therapeutic progress. Showing respect and empathy for parents can go far in creating a trusting collaborative therapeutic relationship that is needed for optimum outcomes. Similarly, helping parents see the connections between their problems and the course of therapy being recommended can make it easier for them to engage as partners in the process of change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The necessary and sufficient conditions of therapeutic personality change.

This reprinted article originally appeared in Journal of Consulting Psychology, 1957(Apr), Vol 21(2), 95-103. (The following abstract of the original article appeared in record 1959-00842-001.) "For constructive personality change to occur, it is necessary that these conditions exist and continue over a period of time: (1) Two persons are in psychological contact. (2) The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious. (3) The second person, whom we shall term the therapist, is congruent or integrated in the relationship. (4) The therapist experiences unconditional positive regard for the client. (5) The therapist experiences an empathic understanding of the client's internal frame of reference and endeavors to communicate this experience to the client. (6) The communication to the client of the therapist's empathic understanding and unconditional positive regard is to a minimal degree achieved." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Narrative empathy.

Therapeutic empathy is described as an active narrative process, in which the therapist attempts to construe and express the inner emotional logic of the client's problem patterns. The empathic narrative is contrasted to the external narrative, which describes the client from the outside and the client's behavior as making sense from the point of view of the theory rather than from that of the client's. The criterion of an empathic narrative is that it elicits from the client the response "That's me!" The external narrative, in distinction, fails to elicit this self-recognition. The persistent rejection of the therapist's formulations by the client and the ensuing state of therapeutic impasse is interpreted as being often due to the therapist's assumption that the client should accept an external narrative as if it were an empathic one. When such a situation develops, the therapist may overcome the impasse by acknowledging the externality of the previous therapeutic narrative and proposing a potentially empathic one in its stead. Three case examples of a 49-yr-old married woman, a teenage girl, and 28-yr-old single male are presented to demonstrate narrative empathy within the therapeutic context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist's style of participation and case outcome.

The purpose of this study was to develop and test a system for classifying some aspects of the therapist's behavior during the interview. The focus was on process rather than on content and involved both vocal and lexical aspects of the therapist's style of participation. 30 therapist responses were sampled from the 2nd and from the next-to-last interviews of each of 20 cases and were classified on each of 3 aspects. The behavior thus coded was vector analyzed by columns, thereby yielding factor loadings for interviews. Loadings on 2 of the resultant 3 factors were found to be related to case outcome as viewed by client and therapist. The findings for late interviews were more clear-cut than those for early interviews. Loadings on the same 2 factors were found to be related to the therapist's level of experience. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client behavior as a function of therapist style and client resources.

Examined the therapy career of 27 males and 21 females from pretherapy characteristics to outcome, focusing on the 3 issues: (a) degree to which each member of the dyad influenced the process level of the client at different stages, (b) interaction effects between therapist style and client personal resources, and (c) relationships between outcome and client process levels at different time points. The effect of client resources on client process level proved significant both early in therapy and at the midpoint. The therapist style effect was significant at the midpoint but not in early therapy. No significant Client * Therapist interactions were found. Client process in the 10th interview correlated significantly with outcome of therapy viewed from 3 perspectives: The client's, the therapist's, and that of a Rorschach diagnostician. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

When hearing clients work with a deaf therapist.

Not being able to hear can present significant challenges for the therapist and for the deaf therapist/hearing client dyad. It can also create opportunities. Although the literature indicates that most culturally Deaf therapists work with Deaf clients due to their mutual use of American Sign Language, I describe (a) the background of an audiologically deaf therapist who relies on speech reading rather than sign language, and (b) this therapist's clinical work with hearing clients. Some of the relational dynamics of these treatments are identified, and I conclude by noting how attention to communication can benefit the work of all psychotherapists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of therapist sex on the outcome of therapy.

Examines studies of the effects of therapist sex on the outcome of therapy. Most studies supported 1 of the following 3 viewpoints: Female therapists are more effective with both sexes of clients; matching therapist and client sex produces the greatest therapeutic benefit; therapist sex is a poor predictor of outcome in therapy. Strengths and weaknesses of these positions and some less commonly held views are discussed. Due to unimpressive statistical findings, conflicting evidence, and poor experimental control in prior research, it is cautiously concluded that a therapist's sex is a poor predictor of outcome in therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The necessary and sufficient conditions of therapeutic personality change.

(This reprinted article originally appeared in the Journal of Consulting Psychology, 1957, Vol 21, 95–203. The following abstract of the original article appeared in PA, Vol 33:842.) For constructive personality change to occur, it is necessary that these conditions exist and continue over a period of time: (1) Two persons are in psychological contact. (2) The first, whom shall be termed the client, is in a state of incongruence, being vulnerable or anxious. (3) The 2nd person, whom shall be termed the therapist, is congruent or integrated in the relationship. (4) The therapist experiences unconditional positive regard for the client. (5) The therapist experiences an empathic understanding of the client's internal frame of reference and endeavors to communicate this experience to the client. (6) The communication to the client of the therapist's empathic understanding and unconditional positive regard is to a minimal degree achieved. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy by precedent: Unexamined legacies from pre-1920 psychoanalysis.

Asserts that many psychotherapists employ a therapeutic stance characterized by an underplayed receptive style, hesitancy to answer questions or to give advice, wariness about being manipulated by the client, and preoccupation with the framework of therapy (e.g., fees, vacations, canceled appointments). While such a stance was appropriate to pre-1920 psychoanalytic theory (in which frustrating the client's strivings for regressive gratification was thought to be a prerequisite for insight), it is inappropriate to post-1920 theory (in which relief from guilt, humiliation, and fear is thought to be a prerequisite). The therapist's restrained style, originally thought to be facilitative can now be seen as having the potentially detrimental effect of reinforcing the inhibition and self-doubt that lie at the heart of the client's problems. The more significant form of client acting-out is not, as had been believed, asking questions, but rather failing to ask questions, and in general, the client's hesitancy to question where therapy is going and to challenge what the therapist is saying and doing. Therapists who are no longer concerned that advice-giving would feed into clients' regressive fantasies and make clients dependent on them can then focus on the real reason for not giving advice (i.e., that therapists have no advice to give). (29 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Getting the picture: The use of imagery to clarify therapeutic impasses.

Contends that imagery can be used to disclose the nature of the client–therapist relationship and to resolve therapeutic impasses. The most common forms of impasses in the relationship are the result of therapist's misperceptions, the pacing of therapy dealing with acting-out behavior, difficulties induced by transference and countertransference, and difficulties in making alliances with severely disturbed patients. To uncover latent images in the therapist–client interaction, therapists imagine a metaphoric meeting place with a client, what they become to each other there or what other forms they take, the activity both might be engaged in, what a dance between the 2 might look like, what might be done differently, and what translations can be made from the imaginal to the actual therapeutic relationship. Case illustrations with 4 female and 2 male clients are given. It is suggested that images clarify the symbolic and affective elements of the internal world. (45 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases.

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identity of two: The phenomenology of shame in borderline development and treatment.

Describes the identity of borderline individuals as being shame-based. Shame underlies anger as the major affective state, and shame creates an "identity of 2": bad self and good mother. Shame brings into focal awareness both the self and the other, with the imagery that the other rejects the self. The factors in the mother–child relationship that favor shame as the interactive matrix are discussed. Shame represents a complete mother–child system. It disallows firm boundaries between mother and child because the image of the self cannot be detached from the image of the other. There is no stable sense of self, defined by secure boundaries, and no ability to trust perceptions of self and the world. The therapist must provide the route out of shame by providing a new paradigm of nurturance that includes insistence on separation and forgiveness, as well as the identification of the system of shame. The therapist must be vigilant about his or her own shame and must be able to forgive the client's parents for the damage they have caused. The therapist's avoidance of shame, particularly as evidenced in the routine substitution of guilt as the problematic phenomenon, serves to protect him or her from powerful, painful feelings but acts as a disservice to the client who profoundly suffers shame. The goal for borderline clients is not to become shame-free, but to live lives undetermined by shame. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On receiving the patient's transference: the symbolizing and desymbolizing countertransference

This is an empirical study of the therapist's experience of the patient delineating the boundaries between empathy and constructive and destructive forms of countertransference. The unique step was taken of focusing a video camera on the therapist in order to trace the therapist's nonverbal behavior during listening. The same therapist was observed first in a "not-so-difficult" and then a "difficult" session; the sessions could then be distinguished along dimensions of rhythmicity or arrhythmicity of nonverbal behavior. These observations suggested three modes of experiencing the patient: empathy marked by rhythmicity, a symbolizing countertransference marked by a transitory arrhythmicity, and a desymbolizing countertransference marked by continuous arrhythmicity. The congruence of these formulations based on direct observation of therapist behavior and ones derived from retrospective reconstructions of analysts in sessions (Schwaber, Jacobs, and Laskey) was explored and was found to enhance the validity of the proposed formulations.     

Discriminating the "good" from the "bad" therapy hour: A study of dyadic interaction.

Investigated whether better interviews could be discriminated from worse interviews, using (1) relative client–therapist activity levels and (2) the degree of structure implicit in the therapist's messages. Eight 22–58 yr old clients and their therapists whose professional experience ranged from 1 to 4 yrs had congruent perceptions of 2 sessions, one good and one bad. Group and case-by-case comparisons were made of the natural language in these interviews. Results show metacomplementary patterns in both good and bad sessions, but client–therapist activity tended to be more asymmetrical in the worse interviews. In the bad sessions, these therapists either participated even more actively than their clients or were passive, while in their good sessions client–therapist participation levels were more balanced. In the good interviews, therapists consistently provided a moderate degree of structure (significantly more reassurance/encouragement, information, and interpretation), as opposed to lower structure (notably reflection/restatement) or higher structure (information seeking and guidance/advice) in their bad interviews. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)