Dual Relationships, Multiple Relationships, & Boundaries
Share these quotes with friends, family, and coworkers, whether they're facing a mental health disorder or just going through a rough time. So, how does the Lao Tzu quote apply to client-centered therapy? . There is psychological contact (a relationship) between the client and the. You don't have to be a psychologist to come up with a great psychology quotes. This Top 15 list provides wise, informative, and educational tips about life.
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.
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.
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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.
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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.
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 work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in Research aimed at analyzing the components that make up the alliance continues to flourish and develop.
Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: Attention has recently turned toward the role of the therapeutic alliance in the various phases of therapy and the relationship between alliance and outcome.
We put ourselves in the best position to make sound decisions when we develop an approach to boundary crossings that is grounded in our general approach to ethics; stay abreast of the evolving legislation and case law, ethical standards, research, theory, and practice guidelines; take into account the relevant contexts for each client; engage in critical thinking that avoids the common cognitive errors to step away from our clinical responsibilities, avoid personal responsibility for our decisions, and rationalize our choices and behavior; and, when we make a mistake or suspect that our boundary decisions have led to trouble, use all available resources to figure out the best course of action to respond to the problem.
The results are interpreted taking into account cultural aspects which means a gift, as well as local constructions of what constitutes ethical behavior. Interpersonal and Biological Processes, While such excesses are often proffered as indicia of patient protection, the perversion of boundary theory may place professionals at risk for undeserved sanctions and may potentially harm patients themselves by frightening the professionals into rigidity in therapeutic interactions.
This extreme position is captured by a cartoon that shows a male patient putting forth his hand for a handshake with his female therapist: Boards themselves vary to a striking degree in their rigor, flexibility, and, regrettably, punitive attitudes toward the clinicians they license. The conduct of psychotherapy is an impossible task because there are no perfect therapists and no perfect therapies.
Knowing one's boundaries, however, makes the impossible task easier. A clinician leaves the office at the very end of the weekday and notes that a heavy snowfall with deep drifts has occurred during the day.
Driving home, he sees the last patient of the day struggling on foot, and offers the patient a potentially life-saving lift home or to local transport in his car.
Dual Relationships, Multiple Relationships, & Boundary Decisions
The clinician 1 behaves professionally during the ride, deferring clinical issues to the next meeting; 2 carefully records the situation and context when next in the office; and 3 explores or debriefs the patient on the experience at the next session, also recording that. The three general principles noted may constitute the critical distinguishing factors in subsequent challenges between a crossing and a violation.
All revolve around a basic question: What elements of our private world will we express to the outer world? Most often, disclosures involve negotiating an appropriate balance between the helpfulness of sharing a part of ourselves with another and the inappropriateness of even danger of overdoing it, of perhaps sharing too much too soon.
Psychotherapy, a place of nearly total confidentiality, provides a rich and unique settings in which to examine this quintessentially human conflict. In doing so, in studying the nature and consequences of disclosure, we can enrich our understanding of interpersonal relations in general and of something fundamental about the psychotherapeutic process.
Fantasy and Reality" in Professional Psychology: Research and Practice, August,p. A pilot comparison study of two disciplines" in American Journal of Family Therapy,vol.
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We again acknowledge the impossibility of setting firm boundaries appropriate for every consumer under every circumstance. We are concerned, however, that inappropriate crossings are often rationalized as benevolent or therapeutic. As Brown states, 'In the many cases in which I have testified as an expert witness regarding abuses in psychotherapy and the standards of care, it is a very common experience for me to hear the accused therapist pleading the cause of greater humanity, and even love, as the rationale for having had sex with, breast fed, slow-danced with, gone into business with, move in with, and so on with the complaining client'p.
You may have heard in workshops or read in books or journals that hugging a client, giving a gift to a client, or meeting a client outside of the office constitutes a multiple relationship and is prohibited by our ethics code or by the standard of care sustained by professional licensing boards. You may also have heard or read that telling a client something personal about yourself or unexpectedly encountering a client at a social event are examples of unprofessional multiple relationships.
The inaccuracies, or errors, in our thinking about nonsexual multiple relationships, mire us in confusion and controversy. The errors cripple our movement towards a comprehensive and practical model of ethical decision-making regarding multiple relationships with clients. This study also showed that male therapists are more likely to engage in nonsexual dual relationships with clients of the opposite sex than their female counterparts. A Practical Guide, 4th EditionWiley, Clarity in thinking through boundary issues for each client is essential.
Reflexively applying a rigid set of rules A central theme of this book is that we cannot shift responsibility to a set of rules Every client is unique in some ways, as is every therapist. Each situation is unique in some ways, and situations continue to change. Nothing can spare us the personal responsibility of making the best effort we can to assess the potential effects of boundary crossings Decisions about boundaries must be made with the greatest possible clarity about the potential benefits and harm, the client's needs and well-being, informed consent and informed refusal, and the therapist's knowledge and competence.
What about multiple social roles? Is it helpful, hurtful, or completely irrelevant for a therapist to provide therapy to a close friend, spouse, or step-child? Are there any potential benefits or risks to social outings with a client meeting for dinner, going to a movie, playing golf, or heading off for a weekend of sightseeingso long as there is no sexual or romantic involvement?
What about lending a client money to help pay the rent or buy food and medications? Under what circumstances should a therapist accept bartered services or products as payment for therapy sessions? The 15 years or so from the early s to the mids saw these and other questions about multiple relationships and boundaries discussed—and often argued—from virtually every point of view, every discipline, and every theoretical orientation. On Seeing Acquaintances as Patients.
Similarly, in the edition of their widely used textbook Ethics in Psychology: