[acb-hsp] ... therapists characteristics impacting therapeutic alliance ...

Mon Nov 19 09:29:53 EST 2012

A review of therapist characteristics and techniques negatively impacting the

therapeutic alliance.

____________________________________________________________

Document 1 of 1

A review of therapist characteristics and techniques negatively impacting the therapeutic

alliance.

Author: Ackerman, Steven J. 1 ; Hilsenroth, Mark J. 1 Harvard Medical School, Massachusetts

Mental Health Ctr, Boston, MA, US

sackerm at mail.uark.edu

Publication info: Psychotherapy: Theory, Research, Practice, Training 38. 2 (2001):

171-185.

https://login.libproxy.edmc.edu/login?url=http://search.proquest.com/docview/614360743?accountid=34899

Abstract: This review is an examination of the therapist's personal attributes and

in-session activities that negatively influence the therapeutic alliance from a range

of psychotherapy perspectives. The literature used in this review was found by searching

PsychLit from 1988 to 1999. Therapist's personal attributes such as being rigid,

uncertain, critical, distant, tense, and distracted were found to contribute negatively

to the alliance. Moreover, therapist techniques such as over structuring the therapy,

inappropriate self-disclosure, unyielding use of transference interpretation, and

inappropriate use of silence were also found to contribute negatively to the alliance.

In addition, this review reveals how therapist's personal qualities and use of technique

have a similar influence on the identification or exacerbation of ruptures in the

Links: null

Full Text: Contents - Abstract

Introduction Therapist Personal Attributes that Contribute Negatively to the Alliance

Therapist Misapplication of Technique

Therapist Behaviors Producing Ruptures in the Alliance

Conclusions

Show less

Figures and Tables - Table 1

- Table 2

- Table 3

- Table 4

Show less Abstract The present review is a comprehensive examination of the therapist's

personal attributes and in-session activities that negatively influence the therapeutic

alliance from a broad range of psychotherapy perspectives. Therapist's personal attributes

such as being rigid, uncertain, critical, distant, tense, and distracted were found

to contribute negatively to the alliance. Moreover, therapist techniques such as

over structuring the therapy, inappropriate self-disclosure, unyielding use of transference

interpretation, and inappropriate use of silence were also found to contribute negatively

to the alliance. In addition, this review reveals how therapist's personal qualities

and use of technique have a similar influence on the identification or exacerbation

of ruptures in the alliance.

Introduction Originally, the therapeutic alliance was believed to be positive transference

from the patient toward the therapist ( Freud, 1913 ). Since that time, the therapeutic

alliance has developed into one of the most important variables in the understanding

of psychotherapy process and outcome ( Horvath & Symonds, 1991 ; Martin, Garske,

& Davis, 2000 ; Orlinsky, Grawe, & Parks, 1994 ). However, an area of research that

has been less addressed is the relationship between the alliance and the therapist's

personality variables as well as therapist use (or misuse) of therapeutic techniques

and interventions. Moreover, findings from the studies conducted have not been integrated

in a manner that helps clarify the relationship between the alliance and specific

personal attributes or technical interventions of the therapist.

Binder and Strupp (1997) reviewed the literature focused on "negative process" and

outcome in individual psychotherapy of adults. The authors traced the history of

negative process throughout the literature and concluded that negative process (i.e.,

alliance rupture) was unavoidable in the course of treatment regardless of the theoretical

approach. The authors pointed out that positive treatment outcomes rely on the therapist's

capacity to recognize and effectively control negative process in order to preserve

a positive therapeutic relationship. In many cases severe ruptures in the alliance

can impede the continued growth of the therapeutic relationship and, at times, lead

to premature treatment termination.

In the development of the Vanderbilt Therapeutic Alliance Scale (VTAS), a measure

designed to assess patient and therapist contributions to the alliance, Hartley and

Strupp (1983) identified specific therapist intrusive behaviors that negatively impact

the alliance. These intrusive behaviors include the therapist imposing his or her

own values, fostering dependency, making irrelevant comments, and utilizing inappropriate

interventions. The authors recommended that future research explore how these behaviors

impact the relationship between the patient and therapist, as well as assess the

process variables that influence fluctuations in the alliance.

Brossart, Willson, Patton, Kivlighan, and Multon (1998) explored alliance fluctuations

in short-term psychoanalytic therapy dyads in an attempt to develop a general model

of the alliance. The authors hypothesized that therapist's perception of the alliance

would impact the patient's perception of the alliance. This hypothesis was supported,

and they concluded that therapist's perceptions of the alliance in early sessions

contributed significantly to patient's perceptions of the alliance in subsequent

sessions. Specifically, they reported that "negative counselor perceptions of the

working alliance, if accepted or left unnoticed may adversely affect the ability

of the counselor and client to develop a healthy working alliance and ultimately

damage the therapeutic endeavor" (p. 203).

These studies identify the therapist's global (i.e., perception of the alliance)

and specific (i.e., making irrelevant comments) contributions that impede the development

of a positive alliance. These studies not only underscore the need for investigating

therapist activity that contributes negatively to the alliance, they recommend a

direction for this research to follow. Specifically, they suggest that future psychotherapy

research may benefit from a review of empirical findings from a variety of therapeutic

orientations (i.e., psychodynamic, existential, cognitive-behavioral, family therapy,

etc.) to identify the distinctive therapist variables that impede the development

and maintenance of a positive alliance, as well as contribute to the emergence of

alliance ruptures. The present review is a comprehensive examination of the therapist's

personal attributes and in-session activities that negatively influence the therapeutic

alliance from a broad range of psychotherapy perspectives. This broad focus on therapist

variables in relation to the alliance facilitates a closer examination of the psychotherapy

process and is a step toward the integration of past research. It is reasoned that

focusing on the therapist's negative contribution to the alliance will not only refine

and enhance our understanding of the construct, but it may also guide future research

toward the discovery of more efficacious and clinically superior therapeutic techniques.

More importantly, this review may help therapists with a range of experience in various

forms of psychotherapy obtain a greater understanding of the factors that may impede

the development of a strong connection with their patients on the therapeutic journey.

The first step in the present review was a literature search using PsycLit from 1988

to 1999 with the search terms: therapist activity, therapeutic alliance, and psychotherapy

process. We also reviewed Horvath and Greenberg's (1994) book, The Working Alliance:

Theory, Research, and Practice , chapters 8 and 11 in Bergin and Garfield's (1994)

Handbook of Psychotherapy and Behavior Change , and Psychoanalytic Abstracts through

1999. Next, to identify additional studies, we reviewed the references of the material

meeting our inclusion criteria. As a final step, we manually reviewed the previous

12 months of the journals that provided therapist activity and alliance material

in the previous steps (e.g., Journal of Consulting and Clinical Psychology, Journal

of Clinical Psychology, Journal of Counseling Psychology, Journal of Psychotherapy,

Practice, and Research, Psychotherapy , and Psychotherapy Research ).

Our inclusion criteria were as follows: (a) the investigation had to report a quantifiable

relationship between the alliance and some index of therapist variables; (b) the

focus of the study had to be identified as specifically examining therapist's personal

attributes or technical activity related to the deterioration or disruption of the

alliance. This review did not include studies examining the relationship between

alliance and outcome, unless the author(s) also examined and reported a quantifiable

relationship between therapist variables and alliance. These criteria revealed a

total of 14 studies investigating the relationship between therapist variables and

alliance. The present review will be organized according to therapist attributes

and techniques and will include recommendations for future research examining the

relationship between therapist activity and alliance.

Therapist Personal Attributes that Contribute Negatively to the Alliance The alliance

is one component of the larger therapeutic process and encompasses the interaction

between patient and therapist, including their expectations and attitudes about one

another. The interaction between the patient and therapist is impacted by the values,

beliefs, relational patterns, and expectations each participant brings into the treatment

room. While there is common agreement about patient characteristics impacting both

the alliance and process of psychotherapy, less is known about therapist characteristics.

As Strupp (1980) pointed out, "major decrements to the foundation of a good working

alliance are not only the patient's characterological distortions and maladaptive

defenses but-at least equally important-the therapist's personal reactions" (p. 953).

We believe the notion that therapists are well adjusted individuals with little negative

contribution to the therapeutic process has been overestimated. Therapists (even

those who are very well trained and experienced), like others, often find it difficult

to deal constructively with interpersonal conflicts in which they are actively involved

( Binder & Strupp, 1997 ). Therefore, it is important to identify the therapist's

personal characteristics that may lead to the emergence of negative process, disrupt

the therapeutic process or obstruct the development of a positive and strong alliance.

Marmar, Weiss, and Gaston (1989) explored the construct validity of the California

Therapeutic Alliance Rating System (CALTRAS) through the ratings of brief dynamic

psychotherapy sessions for pathological grief. The authors found that therapists

who were more rigid, self-focused, critical, and less involved in the psychotherapy

process were perceived as less understanding. In addition, these therapists evoked

more hostile resistance from their patients and had lower overall alliance ratings.

However, a potential limitation of this study was the use of an alliance score averaged

across sessions 2, 5, 8, and 11. Using an average alliance score makes it difficult

to determine if one phase of the treatment (e.g., beginning, middle, termination)

contributed more to the findings than another.

A number of additional studies reported similar patterns of undesirable attributes

of the therapists that resulted in the inability to form or maintain a positive alliance.

Eaton, Abeles, and Gutfreund (1993) reported that across all phases of insight-oriented

psychotherapy, therapists with poor alliance ratings were characterized as exploitive,

critical, moralistic, and defensive, as well as lacking warmth, respect, and confidence.

Examining unstructured psychotherapy from various orientations, Sexton, Hembre, and

Kvarme (1996) found a significant relationship between negative alliance ratings

and therapists who were rated as uncertain and tense. Likewise, using the Therapy

Session Report (TSR) from an early session of unstructured, open-ended treatment,

Saunders (1999) investigated the relationship between the patient's emotional state

and his or her perception of the therapist's emotional state. Saunders found that

a patient's ratings of the overall session quality were lower when the therapist

was perceived as distracted, tired, and bored. These findings are congruent with

other findings reporting that therapists who were perceived as belittling, blaming,

watching, managing, aloof, and distant had a difficult time engaging in the treatment

process and consequently, had lower alliance ratings ( Price & Jones, 1998 ).

The studies in this section of the review support the notion that the negative characteristics

of the therapist can impede the development of a positive alliance and diminish the

quality of an already established alliance (see Table 1 ). Therapists who exhibited

disregard for their patients, were less involved in the treatment process, and were

more self-focused were less likely to form a positive connection with their patients

( Marmar et al., 1989 ). There was common agreement among the studies that a poor

alliance was related to therapists who were not confident in their ability to help

their patients and were tense, tired, bored, defensive, blaming, or unable to provide

a supportive therapeutic environment ( Eaton et al., 1993 ; Price & Jones, 1998 ;

Saunders, 1999 ; Sexton et al., 1996 ). These findings suggest that how therapists

react to patients influences whether or not they are able to form a positive treatment

relationship. If the therapist reacts negatively toward the patient and appears disinterested

in the patient's concerns, it will likely be difficult to develop a positive treatment

relationship. Patients will be less likely to engage in the treatment process with

therapists who may remind them of other individuals in their lives with whom they

find it difficult to relate. Consequently, these negative interactions may weaken

the alliance and reduce the opportunity for patient change. Taken together, these

findings underscore the potentially adverse impact therapist's personal attributes

can have on the therapeutic relationship and process. Whether or not therapists can

be taught to be empathic and warm, it is of critical importance that they vigilantly

work toward conveying a respectful, flexible, accepting, and responsive attitude

toward their patients.

600?'600px':'auto');"> Enlarge this Image.

Summary of Therapist Personal Attributes that Contribute Negatively to the Alliance

Therapist Misapplication of Technique An important facet of psychotherapy research

has been the identification of techniques used by therapists to facilitate the development

of the alliance. If carried out appropriately, certain therapist's techniques can

impart a willingness from the patient to explore issues at a deep and potentially

meaningful level. However, if carried out incorrectly, these same techniques can

lead to negative treatment process and the experience of a weak alliance. This section

of the review examines the therapist's misapplication of techniques that impede the

continued development of the alliance and cause the deterioration of an existing

strong alliance. It is expected that failure to establish a treatment frame, unyielding

use of interpretation, and self-disclosure will interrupt the development or maintenance

of a positive alliance.

As described earlier, Marmar et al. (1989) investigated the therapeutic alliance

in brief dynamic grief therapy. In addition to the findings presented earlier, the

authors reported a significant positive relationship between the therapist's increased

focus on avoidance of important issues and the patient's hostile resistance. Moreover,

the therapist's unyielding attempts to link a patient's inappropriate reactions toward

the therapist (e.g., "shows hostility toward therapist" and "engages in a power struggle

with the therapist," p. 48) to earlier conflicted relationships with parental figures

(transference interpretations) were reported to be significantly and negatively related

to patient's commitment to the treatment process.

A study by Eaton et al. (1993) that was also described earlier, identified a significant

positive relationship between a weak alliance and the therapist's failure to structure

the session, failure to address resistance, inflexibility, inappropriate use of silence,

and use of superficial and destructive interventions. It is important to note the

contradiction between the finding in this study that the failure to address resistance

was related to a weak alliance and the finding presented by Marmar and colleagues

suggesting that addressing resistance was related to the patient's negative experience

of the alliance. These diverging results may be due to the amount of time and emphasis

placed on addressing resistance as well as the way in which the resistance was addressed.

It is also possible that these contradictory findings are the result of methodological

differences. Specifically, Eaton et al. (1993) rated sessions from outpatients seeking

psychotherapy for general problems, while Marmar and his colleagues rated sessions

from outpatients seeking psychotherapy to deal with issues related to loss of a spouse

or parent. On the one hand patients seeking therapy to deal with the death of a significant

person in their lives may experience a therapist who focuses on resistance as uncaring

and inattentive to their problems. On the other hand, patients seeking therapy for

general issues may experience a therapist who does not focus on resistance as uncaring

and inattentive to their problems. Taken together, these findings suggest that it

is important to consider the patient's presenting problem when attempting to find

a balance between disregarding patient resistance and placing too much emphasis on

challenging resistance.

Studying the alliance at different points in time-limited psychodynamic psychotherapy,

Coady and Marziali (1994) found that the therapist's increased use of belittling,

blaming, watching, and managing behaviors both early and late in therapy led to a

decrease in the alliance. In addition, they found a negative relationship between

therapist disclosure (i.e., sharing personal emotional conflicts) and expressing

behaviors (i.e., expressing negative sentiments regarding the patient in a way that

belittles or blames the patient), and ratings of the alliance early in therapy. Similar

results were reported by Price and Jones (1998) , who found that therapists who disclosed

their own emotional conflicts into the therapeutic setting had significantly lower

alliance ratings. Taken together, these results suggest that when the therapist focuses

too much on this type of self-disclosure (e.g., sharing personal conflicts) during

the treatment process, they may be breaching therapeutic boundaries with the end

result being a weaker alliance.

A series of studies by Piper and colleagues ( Piper, Azim, Joyce, & McCallum, 1991

; Piper, McCallum, Azim, & Joyce, 1993 ; Piper et al., 1999 ) focused on understanding

and examining the relationship between the use of transference interpretation and

the therapeutic alliance. The authors independently aggregated patient and therapist

ratings of the alliance taken after each session of short-term, time-limited psychodynamic

psychotherapy to form a patient impression score, a therapist immediate-impression

score, and a therapist reflective-impression score. Piper et al. (1991 , 1993) examined

the impact of the therapist's use of transference interpretations by comparing the

patient's and therapist's alliance scores with external judges' ratings on the Therapist

Intervention Rating System (TIRS; Piper et al., 1987 ). Transference interpretations

were defined as focusing on the conflicted dynamics in the current relationship between

the patient and therapist, and linking this dynamic to repeated problems that the

patient may have had with parental figures in the past. Both studies reported that

high concentrations of transference interpretations were inversely related to the

therapist's immediate and reflexive rating of the alliance. Piper and colleagues

suggested that the excessive, unyielding use of transference interpretations (one

out of every five interpretations) may have contributed to a weak alliance. The therapist's

perception of a weak alliance may be the result of patients withdrawing in response

to the overwhelming amount of attention paid to the transference relationship. The

therapist may have reacted to the presence of a weak alliance by increasing the amount

of transference interpretation in an attempt to move past a therapeutic impasse.

It could also be that the weak alliance may be a byproduct of the interaction between

the patient feeling overwhelmed and the therapist feeling pressured.

Similar results were reported by Piper et al. (1999) , who compared therapists with

low and high patient alliance ratings on external judge's ratings on the Vanderbilt

Psychotherapy Process Scale (VPPS; Suh, Strupp, & O'Malley, 1986 ). The authors reported

that the low-alliance-rated therapist group was rated higher on the use of transference

interpretations. The authors also described a pattern of interaction between the

patient and therapist in the last therapy session attended by patients who were treated

by the therapists in the low-alliance group. The interaction started with the patient

expressing a wish to leave therapy that may be related to frustration around not

having expectations met or increased discomfort around addressing painful issues.

The therapist responded by drawing attention to the potential transference issues

as well as by making links to other relationships. The patient responded with resistance

such as silence or verbal disagreement. The therapist continued to focus on transference

issues, and a power struggle developed between the patient and therapist. As the

session continued, the patient became increasingly resistant, and the therapist maintained

a focused line of inquiry into the transference. By the end of the session, the therapist

recommended continued treatment, and the patient reluctantly agreed to return for

future sessions. However, the patient did not come for any additional sessions. We

can conclude from this interaction that the therapist's unyielding use of transference

interpretations, inflexibility, and lack of responsiveness to explore the patient's

feelings or the "real" relationship (nontransference) in the room ( Greenson, 1967

) may have influenced the weakening of the alliance as well as the patient's decision

to discontinue treatment. It is important to state here that the therapist's continued

focus on the transference relationship is not necessarily the same as focusing on

the treatment relationship. Piper and colleagues defined the transference relationship

as specific to linking feelings, thoughts, and behaviors in the present moment (patient-therapist)

with specific persons from past experiences. However, a focus on the treatment relationship

would be specific to the interior of the therapy room and what is happening in the

therapeutic moment. To clarify, the authors reported that therapist's emphasis on

the transference interpretation, not the treatment relationship per se, was significantly

related to the experience of a weaker alliance. This is an important distinction

that will be discussed further in the next section of the review.

Ogrodniczuk, Piper, Joyce, and McCallum (1999) also assessed the impact of transference

interpretations in manualized short-term dynamic psychotherapy on the alliance. The

authors reported mixed findings regarding the frequency and concentration of transference

interpretations. Specifically, they reported a significant negative association between

the frequency of transference interpretations and patient-rated alliance in patients

with low quality of object relations, but not in patients with high quality of object

relations. Conversely, a significant positive association was reported between the

frequency of transference interpretation and therapist-rated alliance with high quality

of object-relations patients, but not in patients with low quality of object relations.

However, no significant findings were reported between the frequency or concentration

of transference interpretations and patient- or therapist-rated alliance when both

the high and low quality of object-relations patients were grouped together. Similar

to Piper et al. (1991 , 1993) , this study reported that the patient's quality of

object relations (high or low) was a moderating variable in the use of transference

interpretation. These findings highlight the importance of the therapist's need to

accurately assess the patient's quality of object relations in order to be able to

modulate the amount and intensity of transference interpretation that she or he provides

to patients. It is clear that with some patients, too much transference interpretation

detracts from the therapist's effectiveness and weakens the alliance.

A limitation of the previous three studies was the use of a composite rating of the

therapist's interventions, which did not allow the authors to control for the possibility

that the phase of treatment impacted the results. It is unclear if one phase of the

treatment (e.g., early or late) may have contributed more to the findings than another.

It may be that the use of transference interpretations early in treatment may be

less appropriate and aversive compared to the later phases of treatment. Another

potential limitation of these studies was the fact that the accuracy of the interpretations

was not assessed. Evidence exists to support the conclusion that accurate interpretations

are related to a positive alliance ( Crits-Christoph, Barber, & Kurcias, 1993 ) and

positive treatment outcomes ( Crits-Christoph, Cooper, & Luborsky, 1988 ). Therefore,

the negative relationship reported between alliance and the amount of transference

interpretations may also be associated with the inaccuracy of the interpretations

provided.

As expected, the studies reviewed in this section identified that the therapist's

misuse of certain therapeutic strategies adversely affects the alliance (see Table

2 ). These strategies include therapist inflexibility in treatment planning, inappropriate

use of silence ( Eaton et al., 1993 ), placing too much emphasis on patient resistance

( Marmar et al., 1989 ), self-disclosure of therapist's own emotional conflicts (

Coady & Marziali, 1994 ; Price & Jones, 1998 ), and unyielding use of transference

interpretation ( Ogrodniczuk et al., 1999 ; Piper et al., 1991 , 1993 , 1999 ). While

the misapplication of technique by therapists is generally related to technical strategies,

it is important not to underestimate the relational impact these misapplications

may have on the alliance. It is likely that patients who interact with a therapist

who makes these technical errors will feel less connected, less understood, and less

willing to commit to the therapeutic relationship. The development and support of

a strong alliance may serve as a springboard for patient change as well as provide

the therapist the opportunity to use a range of different therapeutic interventions.

However, the therapist's inappropriate use of therapeutic strategies can decrease

the likelihood of a positive therapeutic relationship and reduce the opportunity

for patient change.

600?'600px':'auto');"> Enlarge this Image.

Summary of Therapist Misapplication of Techniques that Contribute Negatively to the

Alliance

Therapist Behaviors Producing Ruptures in the Alliance This section of the review

discusses research focusing on ruptures or breaches in the therapeutic alliance.

Much of the research presented here supports the idea that ruptures are an expected

part of the treatment process and, subsequently, argues for the use of ruptures in

the alliance as fertile ground for patient change as well as opportunities for deepening

the therapeutic alliance (for a detailed description of this topic see: Safran &

Muran, 2000 ; Watson & Greenberg, 2000 ). However, it is important to recognize that

for a rupture in the alliance to be a growth experience and to be resolved, it must

first be recognized as occurring within the interior of the therapy relationship.

The primary goal of this section is to present findings related to therapists' behaviors

proposed to create ruptures in the alliance. Moreover, this section identifies potential

markers that may facilitate the recognition of rupture in the alliance. All of the

studies presented focus on specific therapist behaviors or responses that lead to

the development or continuation of ruptures in the alliance.

Using external judges' ratings on the Working Alliance Inventory, Castonguay, Goldfried,

Wiser, Raue, and Hayes (1996) examined the impact of therapist's use of cognitive

therapy strategies with a sample of depressed patients on the development of ruptures

in the alliance. The authors also used external judges' ratings on the Coding System

of Therapist Feedback (CSTF; Goldfried, Newman, & Hayes, 1989 ) to measure the therapist's

focus on the patient's interpersonal functioning. Castonguay and his colleagues examined

randomly selected therapy sessions from the first half of treatment (between sessions

four and seven) that focused on issues related to interpersonal functioning. The

sessions with low alliance ratings contained a number of signs that pointed to a

strain or breach of the alliance including "the expression of negative sentiment

regarding therapy, avoidance of therapeutic task, and unresponsiveness to the therapist's

interventions" (p. 501). The authors found that the strain was not resolved when

therapists continued to try to fit the patient's negative experience into the cognitive

model despite his or her expressed desire to explore the painful emotion connected

to the negative experience. In addition, strains in the alliance were not resolved

when therapists focused on how faulty cognitions influence the construction of negative

emotions and highlighted the importance of replacing these faulty cognitions. These

findings suggest a strain in the alliance may be exacerbated by the therapist's inflexible

adherence to cognitive treatment strategies and the inability to focus on the emotional

impact of interpersonal problems while encouraging patients to behave in ways that

can help them manage their interpersonal problems.

In a series of studies spanning the last decade, Safran and his colleagues ( Safran,

1993 ; Safran, Crocker, McMain, & Murray, 1990 ; Safran & Muran, 1996 , 2000 ) have

extensively examined ruptures in the alliance. Within this body of research, the

authors have operationally defined alliance ruptures as well as proposed a therapeutic

model to facilitate the recognition and repair of ruptures in the alliance. Ruptures

in the alliance are defined as either fluctuations in the quality of the therapeutic

relationship or an ongoing problem in establishing an alliance. In general, ruptures

are believed to occur when therapists either engage in or refrain from engaging in

patient's maladaptive interpersonal cycles that resemble the patient's relationships

outside of therapy. Alliance ruptures are an expected part of the treatment process

and may occur in a number of therapeutic interactions. Markers of tears in the alliance

were also identified in this research and separated into two general categories,

confrontation and avoidance of confrontation markers. Confrontation markers exist

when patients directly express their negative sentiments about the therapist or treatment

process. The avoidance of confrontation markers include times when patient's negative

sentiments are behaviorally acted out through withdrawal, distancing, or avoiding.

Once a rupture has been recognized it can be systematically examined, interpreted,

and hopefully resolved within the treatment process.

Another alliance rupture identification model was proposed by Watson and Greenberg

(2000) for experiential therapy. The authors described three types of ruptures that

can emerge when the alliance is developing early in treatment. First, patients may

experience a difficulty "turning inward to discover and represent their experience

in new ways" (p. 178). Second, patients "may question the purpose and value of engaging

in therapy, and view it as ineffective in helping them to achieve their goals" (p.

178). Third, patients may have "expectations that diverge from those of their therapist"

(p. 178) Watson and Greenberg also described alliance ruptures that arise later in

treatment. These included the patient's refusal to engage in treatment activities

or more relational issues related to the therapeutic bond.

An additional rupture identification model was presented in a study conducted by

Rhodes, Hill, Thompson, and Elliot (1994) , which examined the patient's memory of

resolved and unresolved therapeutic misunderstandings. The participants in this study

were therapists-in-training or practicing therapists who contributed data about experiences

from their personal treatment. The authors used narrative accounts of past therapeutic

misunderstanding, which were categorized as either resolved or unresolved. Resolution

was defined as the patient perceiving a satisfactory outcome and feeling able to

continue working with the therapist. A misunderstanding was considered unresolved

when the patient perceived an unsatisfactory outcome and felt the communication with

his or her therapist was diminished.

Rhodes and her colleagues reported that the precipitants of all the misunderstandings

reported could be classified as either the therapist doing something the patient

did not like or want (e.g., therapist was critical of patient decision, therapist

was not attentive to patient, or therapist gave unwanted advice), or the therapist

not doing something that the patient expected or wanted (e.g., therapist did not

remember important facts, and therapist missed importance of an issue). Regardless

of the outcome, in all of the misunderstandings reported, the patients experienced

negative feelings in response to their therapist's behavior. In the unresolved cases,

patients typically suppressed their negative feelings and placed the blame for the

therapist's behavior on themselves. Moreover, in the resolved cases the patients

reported that their therapist accommodated (e.g., apologized, accepted responsibility

for the problem, or simply changed their behavior). In the cases with unresolved

misunderstandings, the patients reported that their therapists were nonresponsive,

closed off, nonaccepting, or that they dogmatically maintained their original point

of view without taking the patient's point of view into consideration.

The work of Rhodes and her colleagues differs from the work of Safran and his colleagues

as well as from Watson and Greenberg (2000) in how the alliance rupture was recognized

and brought into awareness. In the Rhodes et al. model the patient was left to initiate

the expression of his or her negative feelings and identify the rupture in the alliance.

The therapist's role was to follow up on the patient's feelings and facilitate additional

expression. In the other models the therapist's recognition of the patient's negative

feelings was also highlighted. The therapist has the responsibility to draw attention

to the patient's negative reaction and acknowledge the existence of a breach in the

therapeutic alliance. A possible explanation for this difference is the fact that

the patients in the Rhodes et al. study were therapists-in-training or actual therapists

involved in their own personal psychotherapy. Because a therapist involved in personal

psychotherapy is potentially more informed about therapeutic strategy, she or he

may be more likely to express negative sentiments toward his or her therapist if

the therapeutic needs are not being met. An individual without psychotherapy training

may rely on the therapist to point out potential negative feelings related to therapist

behaviors.

The studies reviewed in this section support the notion that ruptures in the alliance

are an expected part of the therapeutic process. There is common agreement that a

rupture is likely to occur when a patient experiences negative feelings regarding

the therapist or the therapeutic process. Those therapist's contributions found to

be related to the development and exacerbation of alliance strains were similar to

those reported to contribute negatively to the alliance (see Table 3 ). These therapist

behaviors included rigid adherence to a treatment model ( Castonguay et al., 1996

), inflexibility ( Castonguay et al., 1996 ; Rhodes et al., 1994 ), being unresponsive,

being closed off, and conveying a sense of nonacceptance ( Rhodes et al., 1994 ).

In general, these findings suggest that ruptures (controntational or nonconfrontational)

can clearly be identified within the treatment process (see Table 4 ). In addition,

a common theme among these studies is that ruptures occur when the therapist is not

being attentive to the ongoing treatment relationship. Specifically, ruptures most

often transpire from the therapist not actively doing something the patient wants

or actively doing something that the patient does not want (see Table 4 ). The findings

of these studies suggest that while ruptures are a common treatment experience they

can have either a positive or negative impact on the treatment process. On the one

hand, the resolution of ruptures can lead to deeper exploration of relational patterns

and help patients develop the skills necessary to understand and resolve similar

patterns in other relationships. On the other hand, the nonresolution of ruptures

can lead to treatment failures and, more importantly, the continuation of maladaptive

relational patterns in the patient's life.

600?'600px':'auto');"> Enlarge this Image.

Summary of Therapist's Attributes and Techniques Found to Contribute Negatively to

the Alliance

600?'600px':'auto');"> Enlarge this Image.

Summary of Precipitants and Markers of Ruptures in the Alliance

Conclusions The studies included in this review suggest that the therapist's personal

attributes and use or misuse of therapeutic technique from a range of psychotherapy

orientations influence the maintenance and deterioration of the therapeutic alliance

as well as the establishment and progression of breaches in the alliance. The alliance

appears to capture the interactive process between the patient and therapist, which

may be an important variable in negotiating change in all forms of psychotherapy.

We found very little variation between the different theoretical orientations regarding

the therapist's negative impact on the alliance. While the majority of studies in

the present review utilized a form of psychodynamic treatment, evidence was also

presented to support the therapist characteristics and techniques as a variables

impacting the alliance in unstructured ( Hartley & Strupp, 1983 ; Saunders, 1999

; Sexton et al., 1996 ), cognitive-behavioral ( Castonguay et al., 1996 ; Eaton et

al., 1993 ), and client-centered therapy ( Eaton et al., 1993 ). However, we encourage

other treatment orientations to explore further the therapist's negative impact on

the alliance as intently as psychodynamic psychotherapy researchers.

A possible explanation for the consistency is that many of the identified therapist

techniques emphasize the therapeutic interactions that occur between the patient

and therapist within the context of the treatment session. Another possible explanation

comes from the work of Frank (1974) who proposed that if a variety of treatments

generate similar findings, there must be therapeutic elements that are common to

all treatment approaches. The core of these elements may be the relationship (therapeutic

alliance) between two people that provides the opportunity for relief from suffering.

This evidence supports the belief that the alliance is a pan-theoretical construct

impacting psychotherapy process on multiple levels. In addition, the present review

extends the findings of Krupnick et al. (1996) who reported no difference in the

strength and importance of the alliance between interpersonal psychotherapy, cognitive-behavioral

therapy, imipramine with clinical management, or a placebo with clinical management.

While some theoretical orientations may prove to be more efficacious with certain

patient populations, the findings from the present review suggest that all therapeutic

pursuits can benefit from a focus on the factors contributing to negative alliance.

Tables 1 and 2 summarize the therapist's personal attributes and the misapplication

of therapeutic technique that were found to be significantly related to the experience

of a weak alliance and the deterioration of an already existing alliance. The personal

attributes of the therapist that were found to negatively influence the alliance

include being rigid ( Marmar et al., 1989 ), aloof ( Eaton et al., 1993 ; Price &

Jones, 1998 ), tense ( Sexton et al., 1996 ), uncertain ( Sexton et al., 1996 ),

self-focused ( Marmar et al., 1989 ), and critical ( Eaton et al., 1993 ; Marmar

et al., 1989 ). The therapist's failure to develop a therapeutic frame ( Eaton et

al., 1993 ), inappropriate use of self-disclosure ( Coady & Marziali, 1994 ; Price

& Jones, 1998 ), and unyielding use of transference interpretations ( Piper et al.,

1991 , 1993 , 1999 ; Ogrodniczuk & Piper, 1999 ) were found to exemplify the category

of misapplication of therapeutic technique.

According to the studies reviewed, disruptions or ruptures in the alliance are generated

from a patient's negative reaction to the therapist or the treatment process (see

Table 4 ). This negative reaction may be generated in all treatment interactions

through the therapist participating in a patient's relational pattern or the therapist

choosing not to engage in a relational pattern. One study reported that it was important

for the patient to initiate the expression of his or her negative sentiments ( Rhodes

et al., 1994 ) while other studies emphasized the importance of the therapist drawing

attention to the patient's negative sentiments ( Safran & Muran, 1996 , 2000 ; Watson

& Greenberg, 2000 ). However, it appears that how or by whom the patient's negative

sentiments are brought into the room is less important than ensuring that the negative

sentiments are acknowledged and openly explored ( Crits-Christoph et al., 1993 ;

Foreman & Marmar, 1985 ; Horowitz, Rosenbaum, & Wilner, 1988 ; Rhodes et al., 1994

; Safran et al., 1990 ; Safran, 1993 ; Safran & Muran, 1996 , 2000 ; Watson & Greenberg,

2000 ). When a therapist is inattentive to a patient's experience, she or he is likely

to overlook a breach in the alliance or mistakenly assume that he or she has not

contributed to the breach. Errors such as these can be conceptualized as a lack of

empathy and may lead to the eventual breakdown of the alliance ( Horowitz et al.,

1988 ). The eventual breakdown of the alliance may also occur when a therapist dogmatically

relies on strategic interventions in an attempt to address breaches in the alliance

( Castonguay et al., 1996 ).

A pattern emerged between the therapist activities identified to cause deteriorations

in the alliance and the essential features related to the aggravation of breaches

in the alliance. In unresolved breaches in the alliance the therapist was portrayed

as nonresponsive, closed off, nonaccepting, and dogmatic in maintaining his or her

original point of view without taking the patient's perspective into account. These

therapist characteristics and technical errors are similar to the personal attributes

(e.g., rigid, aloof, distant, disrespectful, and self-focused) and misapplications

of technique (e.g., unyielding use of interpretation) found to contribute negatively

to the alliance.

Although the present review focused on the therapist's contributions to alliance,

it is critical that we not lose sight of the equally important role patients play

in the therapeutic relationship. Moreover, it is likely that the most promising strategy

for future research may be to examine the interpersonal exchanges between the patient

and therapist that impact the alliance. Investigating these in-session interactions

may deepen our understanding of the nature of the alliance and the specific variables

impacting it. Future researchers should work toward integrating quantitative and

qualitative analyses of the interactions between patients and therapists to present

a clinically meaningful picture of the data.

In summary, the present review has identified that a therapist's personal qualities

and use of technique can be significantly related to the deterioration of the alliance

during the general course of therapy. In addition, this review reveals how therapist's

personal qualities and use of technique have a similar influence on the identification

or exacerbation of ruptures in the alliance. A greater understanding of the therapist's

contributions to alliance, which include personal qualities and therapeutic technique,

may better equip clinicians to design and implement specific methods to identify

weak alliances with their patients. While the findings of this review do not provide

the clinician with a prescriptive manual to avoid the deterioration of the alliance,

they do provide a synthesized understanding of the variables negatively impacting

the relationship between the patient and therapist. Having a greater understanding

of this relationship may lead to better-trained therapists and possibly more therapeutic

successes. Future research may take this understanding even further and explore how

to integrate these findings into existing training principles. For instance, since

therapist attributes are relatively static it may be important to encourage therapists-in-training

to engage in their own personal psychotherapy to better understand potential countertransference

issues. In turn, supervision can then focus on developing interventions and techniques

to further the therapeutic process. In conclusion, we feel that the present review

provides researchers and clinicians alike with information that brings them closer

to answering the question, What impact does the therapist have on the alliance?

References

1 . Bergin, A. E., & Garfield, S. L. (1994). Handbook of psychotherapy and behavior

change. New York: John Wiley.

2 . Binder, J. L., & Strupp, H. H. (1997). Clinical Psychology Science and Practice.

3 . Brossart, D. F., Willson, V. L., Patton, M. J., Kivlighan, D. M., & Multon, K.

D. (1998). Psychotherapy.

4 . Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996).

Journal of Consulting and Clinical Psychology.

5 . Coady, N. F., & Marziali, E. (1994). Psychotherapy.

6 . Crits-Christoph, P., Barber, J. P., & Kurcias, J. S. (1993). Psychotherapy Research.

7 . Crits-Christoph, P., Cooper, A., & Luborsky, L. (1988). Journal of Consulting

and Clinical Psychology.

8 . Eaton, T. T., Abeles, N., & Gutfreund, M. J. (1993). Psychotherapy Research.

9 . Foreman, S. A., & Marmar, C. R. (1985). American Journal of Psychiatry.

10 . Frank, J. D. (1974). Journal of Nervous and Mental Disease.

11 . Freud, S., & Strachey, J. (1913). The standard edition of the complete psychological

works of Sigmund Freud. London: Hogarth Press.

12 . Goldfried, M. R., Newman, C. N., & Hayes, A. M. (1989). The coding system of

therapeutic focus.

13 . Greenson, R. (1967). The technique and practice of psychoanalysis. New York:

International Universities Press.

14 . Hartley, D. E., Strupp, H. H., & Masling, J. (1983). Empirical studies of psychoanalytic

theories. London: Analytic Press.

15 . Horowitz, M., Rosenbaum, R., & Wilner, N. (1988). Psychotherapy.

16 . Horvath, A. O., Greenberg, L. S., Horvath, A. O., & Greenberg, L. S. (1994).

The working alliance: Theory, research, and practice. New York: John Wiley.

17 . Horvath, A. O., & Symonds, B. D. (1991). Journal of Counseling Psychology.

18 . Krupnick, J. L., Sotcky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins,

J., & Pilkonis, P. A. (1996). Journal of Consulting and Clinical Psychology.

19 . Marmar, C. R., Weiss, D. S., & Gaston, L. (1989). Journal of Consulting and

Clinical Psychology.

20 . Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Journal of Consulting and

Clinical Psychology.

21 . Ogrodniczuk, J. S., & Piper, W. E. (1999). Journal of Psychotherapy Practice

and Research.

22 . Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., & McCallum, M. (1999). The Journal

of Nervous and Mental Disease.

23 . Orlinsky, D. E., Grawe, K., Parks, B. K., Bergin, A. E., & Garfield, S. L. (1994).

Handbook of psychotherapy and behavior change. New York: John Wiley.

24 . Piper, W. E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (1991). Archives

of General Psychiatry.

25 . Piper, W. E., Joyce, A. S., & McCallum, M. (1987). .

26 . Piper, W. E., Joyce, A. S., Rosie, J. S., Ogrodniczuk, J. S., McCallum, M.,

O'Kelly, J. G., & Steinberg, R. I. (1999). Psychotherapy.

27 . Piper, W. E., McCallum, M., Azim, H. F. A., & Joyce, A. S. (1993). American

Journal of Psychotherapy.

28 . Price, P. B., & Jones, E. E. (1998). Psychotherapy.

29 . Rhodes, R. H., Hill, C. E., Thompson, B. J., & Elliot, R. (1994). Journal of

Counseling Psychology.

30 . Safran, J. D. (1993). Psychotherapy.

31 . Safran, J. D., Crocker, P., McMain, S., & Murray, P. (1990). Psychotherapy.

32 . Safran, J. D., & Muran, J. C. (1996). Journal of Consulting and Clinical Psychology.

33 . Safran, J. D., & Muran, J. C. (2000). In Session: Psychotherapy in Practice.

34 . Saunders, S. M. (1999). Journal of Clinical Psychology.

35 . Sexton, H. C., Hembre, K., & Kvarme, G. (1996). Journal of Consulting and Clinical

Psychology.

36 . Strupp, H. H. (1980). Archives of General Psychiatry.

37 . Suh, C. S., Strupp, H. H., & O'Malley, S. S. (1986). Process Analysis Systems.

38 . Watson, J. C., & Greenberg, L. S. (2000). In Session: Psychotherapy in Practice.

Show less

Address for Correspondence: Steven J. Ackerman, 20 Forbes ST. #3, Jamaica Plain,

MA 02130

Email: sackerm at mail.uark.edu

© 2001 Division of Psychotherapy (29), American Psychological Association

Subject: Psychotherapy (major); Therapeutic Alliance (major); Therapist Characteristics

(major)

Classification: 3310: Psychotherapy&Psychotherapeutic Counseling

Population: Human

Identifier (keyword): therapists personal attributes, in-session activities, therapeutic

alliance, psychotherapy perspectives, negative impact

Methodology: Literature Review

Title: A review of therapist characteristics and techniques negatively impacting

the therapeutic alliance.

Author e-mail address: sackerm at mail.uark.edu

Contact individual: Ackerman, Steven J., 20; Forbes ST. #3, Jamaica Plain, 02130,

US,sackerm at mail.uark.edu

Publication title: Psychotherapy: Theory, Research, Practice, Training

Volume: 38

Issue: 2

Pages: 171-185

Publication date: 2001

Format covered: Print

Publisher: Educational Publishing Foundation

Country of publication: United States

ISSN: 0033-3204

eISSN: 1939-1536

Peer reviewed: Yes

Document type: Journal, Journal Article, Peer Reviewed Journal

Number of references: 38

DOI: <a href="http://dx.doi.org/10.1037/0033-3204.38.2.171">http://dx.doi.org/10.1037/0033-3204.38.2.171</a>

Release date: 14 Nov 2001 (PsycINFO); ; 10 Jul 2006 (PsycARTICLES);

Correction date: 17 Jan 2011 (PsycINFO)

Accession number: 2001-09102-006

ProQuest document ID: 614360743

Document URL: https://login.libproxy.edmc.edu/login?url=http://search.proquest.com/docview/614360743?accountid=34899

Copyright: ©Division of Psychotherapy (29), American Psychological Association 2001

Database: PsycARTICLES

____________________________________________________________

Contact us at: http://www.proquest.com/go/contactsupport

Terms and Conditions: http://search.proquest.com/info/termsAndConditions

Jessie Rayl
thedogmom63 at frontier.com
www.facebook.com/Eaglewings10
www.pathtogrowth.org
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://www.acb.org/pipermail/acb-hsp/attachments/20121119/f640e601/attachment-0001.html>