Therapeutic
Alliance
Case
Conceptualization
Therapeutic
Alliance
What is the Therapeutic Alliance?
Therapeutic
Alliance
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Therapeutic alliance (TA) is a strong predictor of outcome in
individual psychotherapy across diverse treatment orientations and modalities
(Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin, Garske &
Davis, 2000).
Therapeutic
Alliance
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Early alliance has been found to be a better predictor of
outcome than alliance averaged across sessions or measured in the middle or
late phase of treatment. (Martin, Garske, Davis, 2000)
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Implications for Therapy?
Therapeutic
Alliance
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Researchers have provided evidence that client ratings of the
alliance are stronger predictors of treatment outcome than are counselor
ratings (Connors, Carroll, DiClemente, Longabaugh, & Donovan, 1997; Horvath
& Symonds, 1991; Luborsky, 1994).
Factors
that Affect the TA
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Psychiatric symptoms do not predict alliance formation
(Mamodhoussen, Wright, Tremblay, & Poitras-Wright, in press).
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Implications?
Factors
that affect the TA
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Therapist Experience:
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In a review of 12 studies, a small positive relationship
between the therapists' experience and the quality of the therapeutic
relationship early in treatment was found
(Auerbach, Johnson, 1977).
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More recent study therapists' level of experience was not
found to be predictive of patients' alliance ratings (Dunkle, Friedlander,
1996)
Factors
that Affect the TA
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Evidence from the attachment literature suggests that the
quality of a client's early relational or family experiences may influence his
or her ability to form an alliance early in individual psychotherapy.
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Researchers have linked insecure attachment styles with poor
initial alliances in individual psychotherapy (Eames & Roth, 2000;
Mallinckrodt, Coble, & Gantt, 1995; Ogrodniczuk, Piper, Joyce, &
McCallum, 2000; Satterfield & Lyddon, 1995)
How to
Foster TA
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Warm
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Friendly
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Genuineness
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Open (posture)
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Eye contact
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Empathetic
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Active Listening!!!
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Frequently repeating back what client has said for
clarification
How to
Foster TA
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Demonstrate respect of patient
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What else do you think could help form a therapeutic
relationship?
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What makes you feel comfortable around people?
Multicultural
Issues and TA
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Cultural responsiveness/sensitivity results from shared
attitudes between therapist and client and is a better predictor of client
ratings of satisfaction, empathy, unconditional regard, and therapist
credibility than race.
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Ethnic and language match related to length of time in
treatment (Sue et al. 1991).
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Research on racial dynamics in the counseling dyad suggests
that the therapist must be aware of how both his/her own as well as the
client's racial identity affects the client
Ruptures
in TA
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Frequently in therapy your alliance with the client may
rupture
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If this happens – do not despair
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Generally, if had had a TA with a patient, it can be repaired
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An excellent opportunity for you to gather information about
the patient
Ruptures
in TA
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Assessment:
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Why did the TA rupture?
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Typically, if client has difficulty with TA, generally has
difficulty with other relationships in their life
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What behaviors/ events led to rupture
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Maintain dialogue with patient and discuss feelings. “It seems to me that something has changed in
our relationship ……”
Therapeutic
Alliance
Exercise
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Get into groups of two
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One person plays therapist – the other client
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Role play therapy scenario that has been provided
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We will discuss exercise and then switch roles
Case
Conceptualization
Definition
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Framework for a therapists’ understanding of the patient
(Beck, 1995)
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Therapists’ theoretical orientation will influence
conceptualization
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Key to good conceptualization:
l ASSESSMENT, ASSESSMENT, ASSESSMENT !!!!!!
Case
Conceptualization
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First few sessions are key to conceptualization development
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You should have a working conceptualization by the 2nd
or 3rd session
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Conceptualization is dynamic rather than static and can
change with new information or developments
Presenting
Problem
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“What brings you to therapy now?”
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“Can you tell me a little more about that?”
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“How does that affect your life?”
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“How long has this been going on?”
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“What sorts of other things have you tried?”
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“Is there anything going on in your life that has exacerbated
your condition?”
Presenting
Problem
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What is maintaining the current problem
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Dysfunctional beliefs “I always fail so why bother trying”
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Reinforcement – child gets attention from parents when they
start to throw a temper tantrum
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Coping style – avoidance – “if I don’t think about it – it
will go away”
History
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Information on Clients’ disorder
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Duration
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Frequency
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Other family member have the same
problem?
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Treatment History
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Have they seen a therapist before? For this problem? For another problem?
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What was that experience like? Why?
History
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What was their childhood like?
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Relationship with family
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Friends
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Siblings
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Abuse history
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Physical
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Verbal
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Sexual
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Who was perpetrator of abuse?
History
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Relationship history (where appropriate)
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Substance Abuse history
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Education
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Occupation
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Any Current medical conditions
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Current medications (psychiatric or otherwise)
Diagnosis
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Based upon the information you have gathered to date what is
the most likely diagnosis?
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What can rule out
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What further assessment should you do?
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Consultation with other treatment providers (informed
consent, HIPAA)
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Questionnaires assessments
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Medical assessment (to rule out medical
causes of disorder)?
Case
Conceptualization
Example -
Lindsay
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Can’t leave the house
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Overweight
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Worried that people will make fun of her
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Believes that people will reject her
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Lost job because she would call in sick too frequently
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Parents and brother made fun of her for being overweight as a
child
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Felt unloved by family
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Has few friends – only close friend just moved to Singapore
Case
Conceptualization
How does
CC guide Treatment
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Present Case conceptualization to patient for feedback
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Help rapport – collaborative
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Serves as a guide for treatment planning
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Help to determine therapy goals
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Provides framework if therapy goes “off track
Lindsay
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How would the Case Conceptualization of Lindsay guide
treatment?
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What areas would you target in treatment?
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Any other information you would like to know?