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)     

Do treatment manuals undermine youth–therapist alliance in community clinical practice?

Objective: Some critics of treatment manuals have argued that their use may undermine the quality of the client–therapist alliance. This notion was tested in the context of youth psychotherapy delivered by therapists in community clinics. Method: Seventy-six clinically referred youths (57% female, age 8–15 years, 34% Caucasian) were randomly assigned to receive nonmanualized usual care or manual-guided treatment to address anxiety or depressive disorders. Treatment was provided in community clinics by clinic therapists randomly assigned to treatment condition. Youth–therapist alliance was measured with the Therapy Process Observational Coding System—Alliance (TPOCS–A) scale at 4 points throughout treatment and with the youth report Therapeutic Alliance Scale for Children (TASC) at the end of treatment. Results: Youths who received manual-guided treatment had significantly higher observer-rated alliance than usual care youths early in treatment; the 2 groups converged over time, and mean observer-rated alliance did not differ by condition. Similarly, the manual-guided and usual care groups did not differ on youth report of alliance. Conclusions: Our findings did not support the contention that using manuals to guide treatment harms the youth–therapist alliance. In fact, use of manuals was related to a stronger alliance in the early phase of treatment. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Linking mechanisms: Emotional contagion, empathy, and imagery.

Deconstructing the emotional relationship between patient and therapist is certainly a formidable task. Using research results from experimental social psychology, psychophysiology, and developmental psychology, this essay focuses on the automatic processes of mimicry, emotional synchrony, and physiological synchrony—all preludes to empathy. For the therapist to achieve an empathic posture, however, she must also imagine the perspective of the patient. Furthermore, to broaden and sharpen her empathic lens, she must tune in to the ubiquitous current of nonverbal communication that is part and parcel of the interactive treatment process. For these reasons, imagery proves to be a crucial element in the transition from simple attunement to empathy. A clinical vignette and a neuroscience perspective on image formation help illustrate the relationship between emotional contagion and imagery. It is suggested that there is a reciprocal relationship between the emotional ambience cocreated by the two participants and image formation. Sensorial images aid in the detection of gross emotional states as well as in the nuancing of their intensity. Affective ambience, on the other hand, seems to affect the selection of one particular image versus another. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Ira Hirsh (1922–2010).

Ira Hirsh was a person who had high standards, for himself as well as others. As an academic leader and scientist he could be forceful and demanding, but his goal was always the betterment of the field. He had an unflagging devotion to psychology as a hard science. Ira published The measurement of hearing (McGraw Hill, 1952), which quickly became the standard textbook in audiologists. In addition to this book, he published over 100 scholarly articles, many of which laid the groundwork for research that has revolutionized such fields as audiology, psychoacoustics, audiometry, and deaf education. For example, Ira was among the first scientists to push auditory research beyond the study of single tones, clicks, or noise bursts. Ira was preceded in death by his wife of 61 years, Shirley, who passed away in 2004. He is survived by his four children, Donald Hirsh of Chapel Hill, Elizabeth Hirsh of Salt Lake City, Eloise Hirsh of New York City, and Richard Hirsh of Chicago; one sister, Jane Davis of Rochester, New York; and seven grandchildren. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Care of others and self: A suicidal patient's impact on the psychologist.

Professional psychologists can be profoundly affected by their patients and must know how to take care of themselves physically and emotionally while delivering effective treatment. In this paper, I examine the effects of one patient on my personal and professional lives. Over the course of 2 years, the patient experienced numerous losses and became deeply depressed. Her symptoms included suicidal urges and self-harm (cutting). I describe the impact of the patient's life events on the therapy and on me as the therapist. I enumerate self-care strategies that preserved my ability to treat the patient without becoming distressed or impaired by the demands of the case. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The dependability of alliance assessments: The alliance–outcome correlation is larger than you might think.

Objective: To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance–outcome relationship. Method: We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. Results: At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3–9 explained 14.7% of outcome variance. Conclusion: Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance–outcome relationship. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Racial/ethnic disparities in therapist effectiveness: A conceptualization and initial study of cultural competence.

As a result of mental health disparities between White and racial/ethnic minority clients, researchers have argued that some therapists may be generally competent to provide effective services but lack cultural competence. This distinction assumes that client racial/ethnic background is a source of variability in therapist effectiveness. However, there have been no direct tests of the therapist as a source of health disparities. We provided an initial test of the distinction between general and cultural competence by examining client racial/ethnic background as a source of variability in therapist effectiveness. We analyzed cannabis use outcomes from a psychotherapy trial (N = 582) for adolescent cannabis abuse and dependence using Bayesian multilevel models for count outcomes. We first tested whether therapists differed in their effectiveness and then tested whether disparities in treatment outcomes varied across therapist caseloads. Results suggested that therapists differed in their effectiveness in general and that effectiveness varied according to client racial/ethnic background. Therapist effectiveness may depend partially on client racial/ethnic minority background, providing evidence that it is valid to distinguish between general and cultural competence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Positive regard.

This article reviews the research on the association between therapists' provision of positive regard and therapeutic outcome. Rogers' attempts to define the concept of positive regard are noted and two examples of positive regard are presented. A new meta-analysis, focusing on 18 studies, yielded an aggregate effect size of .27 (CI = .16, .38; p k = 18; N = 1067), indicating that positive regard has a moderate association with psychotherapy outcomes; like many other relational factors, it is a significant but not exhaustive part of the process-outcome equation. Therapists' provision of positive regard is strongly indicated in practice; at a minimum, it provides the basis for other mutative interventions. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Teaching trauma-focused exposure therapy for PTSD: Critical clinical lessons for novice exposure therapists.

Over the past 10 years, our experiences delivering exposure therapy and teaching clinicians to deliver exposure therapy for posttraumatic stress disorder (PTSD) have taught us some important lessons. We will focus on lessons learned as we have attended to clinicians' experiences as they begin to implement and apply the therapy. Specifically, we highlight common therapist expectations including the beliefs that the exposure therapy requires a new set of clinical skills, therapists themselves will experience a high level of distress hearing about traumatic events, and clients will become overly distressed. We then discuss common clinical challenges in the delivery of exposure therapy and illustrate them with case examples. The challenges addressed include finding the appropriate level of therapist involvement in session, handling client distress during treatment, targeting in-session covert avoidance, and helping the client shift from being trauma-focused to being more present and future oriented. Clinicians training exposure therapists and therapists new to the implementation of exposure therapy for PTSD should find this practical discussion of common expectations and initial clinical challenges reassuring and clinically useful. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Congruence in nondirective play and filial therapy: Response to Ryan and Courtney.

Differences in the training of nondirective play therapists between University of York (U.K.) approach and the Guerney and Landreth approaches (U.S.) has been raised by Ryan and Courtney (2009). York-trained therapists are encouraged to initiate expression of their own feelings at selective times to assure that therapists are congruent in their relationship with children in nondirective play-therapy. Congruence, an important component of the necessary and sufficient conditions for therapeutic personality change (Rogers, 1957), is based on the importance of therapist genuineness to maintain a trustful and safe therapeutic relationship. This article compliments Ryan and Courtney (2009) for introducing the importance of congruence in play therapy. The assumptions of nondirective play therapy in the Guerney approach was influenced significantly by their development of filial therapy and to the training of parents and therapists, This article asserts that congruence, in the Guerney approach, is incorporated by therapists expressing their own feelings only when this is initiated overtly or covertly by the child. Responding to a child in this way is dependent on the empathic attunement to a child's emotional motivation by a skillful parent or therapist. This raises questions about whether a nondirective stance is maintained in the York approach. (PsycINFO Database Record (c) 2011 APA, all rights reserved)