The Phases of Therapy
The therapeutic relationship between the patient and the nurse. Chapter exercise is not appropriate during the acute phase of a myocardial infarction. The . 4 • Termination is one of the most difficult but most important phases of the therapeutic nursepatient relationship. • Termination is a time to. There is much debate on the role of the therapeutic alliance.
Adequate internal consistency and inter-rater reliability Elvins and Green, ; Kolden, Therapeutic bond scales TBS Saunders et al. This instrument consists of 50 item belonging to the following dimensions: Altogether, these subscales provide a Global Bond scale.
Each item is rated on a point scale. All three scales and the Global Bond scale are related to patient ratings of session quality Martin et al. The report is filled in by the therapist and consists of six items rated on a five-point scale. Patients also respond to 12 items that rate the level of therapist collaboration. Alliance as measured by the PSR has been shown to be correlated with outcome in patients with severe and enduring mental illness such as schizophrenia Elvins and Green, ; Svensson and Hansson, The ARM was intended to describe components of the alliance in language designed to be acceptable within a wide range of theoretical orientations and was developed during the Second Sheffield Psychotherapy Project, a randomized comparison of cognitive—behavioural therapy and psychodynamic—interpersonal therapy for depression.
The ARM assesses five dimensions of the alliance: The ARM has five scales comprising 28 items rated on parallel forms by patients and therapists using a seven-point scale.
The internal consistency of the Client Initiative scale was low 0.
Phases of The Therapeutic Relationship
Some aspects of the alliance as measured by the ARM was correlated with psychotherapy outcome Stiles et al. Kim alliance scale KAS Kim et al. The scale comprises the three dimension of the alliance originally proposed by Bordin plus a fourth dimension: The KAS is a self report measure consisting of item 8 collaboration item, 11 communication item, 5 integration item, and 6 empowerment item each of one rated on a four-point scale.
The alphas for the four dimensions ranged from 0. Highly correlated with the ARM. The scale has not been used in outcome research. Open in a separate window Any attempt to measure something as complex as therapeutic alliance involves a series of conceptual and methodological shortcomings, which have probably hindered the development of research in this field. Single-case research is one method used to investigate this theoretical construct, but implies some methodological drawbacks regarding the simultaneous treatment of several factors, the need for an adequate number of repeated measurements, and the generalizability of results.
Meta-analysis is a possible research strategy that can be used to obtain the combined results of studies on the same topic. However, it is important to remember that meta-analysis is more valid when the effect being investigated is quite specific. According to Migoneanother hindrance is the so-called Rashomon effect named after the film by Akira Kurosawa: Di Nuovo et al.
Though designed by independent research teams, there is often good correlation between the scales used to rate the therapeutic alliance, which reveal that these instruments tend to assess the same underlying process Martin et al. None of their findings suggest that any one instrument was a stronger predictor of outcome than the others, in relation to the type of therapy being considered.
It is interesting to note that although almost all of these scales were originally designed to examine the perspective of only one member of the patient—therapist—observer triad, they were later extended or modified to rate perspectives that were not previously considered. The number of items included in the scales varies considerably between 6 and itemsas do the dimensions of the alliance investigated e. According to Martin et al.
Different approaches for the evaluation of alliance coexist in group psychotherapy. One of them is derived from individual psychotherapy. Although a comparison between different treatment modalities is a topic beyond the scope of this paper, it is worth noting that in the late s, some authors Marmar et al.
However, subsequently, Raue et al. This latter study compared 57 clients, diagnosed with major depression and receiving either psychodynamic—interpersonal or cognitive—behavioral therapy: They argue that these findings could reflect the effort in cognitive—behavioral therapy to give clients positive experiences and to emphasize positive coping strategies.
A more recent comparison was suggested by Spinhoven et al. Results obtained by evaluating alliance through WAI-Client and WAI-therapist after 3, 15, and 33 months, showed clear alliance differences between treatments, suggesting that the quality of the alliance was affected by the nature of the treatment.
Schema-focused therapy, with its emphasis on a nurturing and supportive attitude of therapist and the aim of developing mutual trust and positive regard, produced a better alliance according to the ratings of both therapists and patients. Ratings by therapists during early treatment, in particular, were predictive of dropout, whereas growth of the therapeutic alliance as experienced by patients during the first part of therapy, was seen to predict subsequent symptom reduction.
Phases of the Alliance during the Therapeutic Process and the Relationship with the Outcome There is much debate on the role of the therapeutic alliance during the psychotherapeutic process.
It may in fact be a simple effect of the temporal progression of the therapy rather than an important causal factor. On the basis of this hypothesis, we would expect a development in the alliance to be characterized by a linear growth pattern over the course of the therapy, and alliance ratings obtained in the early phases to be weaker predictors of outcome than those obtained toward the end of the therapy. However, according to the findings of numerous researchers, this is not the case.
Horvath and Marx describe the course of the alliance in successful therapies as a sequence of developments, breaches, and repairs. According to Horvath and Symondsthe extent of the relationship between alliance and outcome was not a direct function of time: The results of these studies have led researchers to consider the existence of two important phases in the alliance.
The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session.
Phases of The Therapeutic Relationship | Nursing Best Practice Guidelines
During the first phase, adequate levels of collaboration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of confidence in the procedures that constitute the framework of the therapy. The deterioration in the relationship must be repaired if the therapy is to be successful. This model implies that the alliance can be damaged at various times during the course of therapy and for different reasons.
The effect on therapy differs, depending on when the difficulty arises. In this case, the patient may prematurely terminate the therapy contract. According to Safran and Segalmany therapies are characterized by at least one or more ruptures in the alliance during the course of treatment. Randeau and Wampold analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies.
Although some studies are based on a very limited number of cases, the results appear consistent: While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used static measures of alliance. There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: Few studies have analyzed alliance at different stages in the treatment process.
According to the results proposed by Traceythe more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction high—low—high over the course of treatment.
When the outcome was worse, the curvilinear pattern was weaker. Kivlighan and Shaughnessy use the hierarchical linear modeling method an analysis technique for studying the process of change in studies where measurements are repeated to analyses the development of the alliance in a large number of cases.
According to their findings, some dyads presented the high—low—high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment.
In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development. Kivlighan and Shaughnessy distinguish three patterns of therapeutic alliance development: They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pattern, in that this appeared to be correlated with the best therapeutic outcomes.
In further studies of this development pattern, Stiles et al. Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative. No significant correlation was observed between any of the four patterns and the therapeutic outcome.
However, the authors observed a cycle of therapeutic alliance rupture—repair events in all cases: On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes. In particular, Stiles et al. The results of the study by De Roten et al. According to De Roten et al. De Roten et al. According to Castonguay et al.
This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon. Discussion and Conclusion According to their meta-analysis based on the results of 24 studies, Horvath and Symonds demonstrate the existence of a moderate but reliable association between good therapeutic alliance and positive therapeutic outcome.
More recent meta-analyses of studies examining the linkage between alliance and outcomes in both adult and youth psychotherapy Martin et al. Thus, it is not by chance that in their meta-analysis, Horvath and Luborsky conclude that two main aspects of the alliance were measured by several scales regardless of the theoretical frameworks and the therapeutic models: This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants.
In a helpful contribution, Hentschel points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: The use of neutral observers or the creation of counterintuitive studies is therefore recommended. From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well.
The development of a dynamic vision of the concept of therapeutic alliance is also apparent. The beginning phase is also where we will have to do more listening and less talking. Our duty is to accept what client is saying unconditional positive regard and start to understand their issues through their perspective.
We will have ongoing assessment during this part of the interviewing and also starting to formulate and develop treatment intervention. For all intents and purposes this is where we often begin preparation for the termination phase as well. We are helping our client explore deeper feelings and negative thoughts and help them build appropriate coping strategies. Many therapists also utilize tasks or homework during this phase to facilitate this process. This allows the client to work on some of the therapeutic interventions through exercises between therapy sessions.
What You Will Learn in A Mental Health Graduate Program | The Phases of Therapy
This also assist the therapist with assessing the clients understanding of what is being discussed in therapy usually reviewed in the beginning of next session and also helps build better insight for the client in addressing his or her issues.
Remember therapy has to be more introspective and active among client and therapist in this phase and not didactic.The Therapy Relationship – Key Ideas in Therapy (1/3)
With this understanding we are starting to prepare for the final stage of therapy, the termination phase. Termination Phase of the Therapeutic Process As with any healthy relationship saying goodbye can be a very hard thing to do.
During the termination phase we will help the client understand this process. We will help the client understand how this closure process is important as it relates to many important stages of life and transitions through the processes. The termination phase is you will be formulating an after care plan to help client with maintenance. This will include assisting clients to build support networks in order to identify alternative resources and areas for support in the event future issues should occur.
Termination also represents the closure of the professional relationship between client and therapist. For some patients longer term therapy may be necessary, and in some instances the therapist may need to make a referral to another source if appropriate.
The termination phase: Therapists' perspective on the therapeutic relationship and outcome.
As therapist we have to use our professional judgment to determine if ongoing therapy is necessary or if some of the issues have fallen outside of our area of expertise. Also, we must accept that although we want to help, therapy may not work for everyone, therefore it is helpful to be familiar with additional community resources that could be helpful for the patient.
So as you can see there are many steps throughout the process of therapy. All stages are essential to the successful completion through the therapeutic process. As therapist we must be skilled in facilitating smooth transitions from phase to phase as we complete therapy.