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The therapeutic relationship in the literature encompasses a variety of terms – working alliance, therapeutic alliance, helping alliance (Bedi et al, 2005), such terms will be utilised depending on the identification in the literature.

Theory development

The theoretical foundations of the therapeutic relationship emerged in Freud’s writings (Horvath, 2006; Howgego et al, 2002; Kirsh & Tate, 2006); ”He felt that the positive, reality – based component of the relationship provided the basis for a therapeutic partnership against the common foe, the client’s neurosis.” (Horvath & Symonds, 1991:139). Transference and counter transference allowed problematic early experiences, impacting on current relationships to be analysed in a supportive counselling context (Howgego et al, 2002; Kirsh & Tate, 2006; Little, 2011). Further development in defining, quantifying and measuring the nature of the therapeutic relationship and its role/impact in psychotherapy has been the subject of four distinct theoretical positions (Horvath & Greenberg, 1989; Howgego et al, 2002).

Rogers (1951-1957) identified essential components of empathy, unconditional positive regard and congruence displayed by the client centred therapist (Horvath & Greenberg, 1989), this sees the client as “a passive partner in the interaction, with therapist offerings the major vehicle for change.” (Howgego et al, 2002: 171). Horvath (1989) observed that the client centred therapist position, “did not generalise across therapies as well as it was originally hoped.” (p.223). In reviewing ‘the alliance’, Horvath (2006) cited a history of evidence identifying “the client’s construal of the relationship that is most closely related to therapy effectiveness.”(p.259).

Greenson (1965), from a psychodynamic perspective, distinguished the real relationship’– contemporary contact with the therapist; the transference’ -fantasy influenced element of the relationship; and the working alliance – being the change focused collaborative efforts of client and therapist (Howgego et al, 2002:171). The general directional thrust of a psychodynamic perspective views the client role being to “work with the therapist’s interpretations.” (Raue et al, 1997), of the transference process.

Strong (1968) developed Social Influence Theory, making a direct link between the client’s view of the therapist as “trustworthy, expert and attractive” (Howgego et al, 2002:171), and “proportional to the likelihood of successful counselling outcome.” (Horvath & Greenberg, 1989:224). The client expectation of success is now linked entirely to therapist perceived capacity.

The work of Bordin (1976) represented a significant shift that defines the current construct of the therapeutic relationship. Bordin restructured the   relationship between client – therapist away from the ‘transference’ influenced impact of the subconscious, to a collaborative participation within the counselling relationship (Horvath & Greenberg, 1989). The equal partnership between the client and the therapist is the key to change (Howgego et al, 2002). Bordin defines therapeutic alliance as “the attachment and collaboration between the client and therapist. “ (Raue et al, 1997:27), his definition visited more recently as, “the quality of the personal bond between patient and therapist, and the degree of agreement between the two on the tasks and goals of therapy.” (Johansen et al, 2013:1169). The focus within this alliance is on the Tasks – the shared endorsement and commitment to behaviour and cognitions within the therapy, the Goals – outcome goals of therapy that receive an equal commitment, and Bonds – the attachment between therapist- client, including elements of trust, acceptance and confidence. (Horvath & Greenberg, 1989:224, Howgego et al, 2002:172).

Bordin, and Luborsky (1987) were significant in moving the focus to “theoretically neutral or pantheoretical grounds.”(Horvath, 2006:259), and in doing so broadened the relevance of the therapeutic relationship to “ all types of helping relationships” (Horvath, 2006:259). It is widely acknowledged that the quality of the therapeutic relationship is a predictive influence in client outcomes in psychotherapy (McGuire et al, 2007), this is also recognised in public mental health care. (McCabe & Priebe, 2004). The widespread multidisciplinary nature of those involved in delivery of service brings a range of approaches all sharing the working alliance in provision of service (McGuire et al, 2001; Johansen et al, 2013), and a number of measurement tools have been developed to assess the relationship (McCabe and Priebe, 2004).

Measurement of outcomes

The evidence in the literature appears to be without question in observing that a strong therapeutic relationship is a reliable predictor of good outcome of intervention across various diagnostic groups and modes of intervention (De Bolle et al, 2009; Bolsover, 2007; Fluckiger et al, 2012; Hovarth, 2006; Krupnik et al, 2006; Nath et al, 2012; Oades et al, 2005; Wright & Davis, 1994). Measuring the alliance, from a diagnostic, client, clinician and service perspective is the focus of various studies.

Horvath and Greenberg (1989) developed the Working Alliance Inventory (WAI) based on the work of Bordin (McCabe & Priebe, 2004); they reported early promise in the WAI’s capacity to capture counsellor and client outcome measures (Hovarth & Greenberg, 1989), and has found empirical support over many years (McCabe & Priebe, 2004; Gottlieb et al, 2011).

McCabe and Priebe (2004), in reviewing methods and findings of the therapeutic relationship in treating severe mental illness, identified fifteen different measures used in psychiatry incorporating the perspectives from client, counsellor and observers in a variety of combinations. (p. 118-119). All the measures bar four, were developed for psychotherapy, yet found to be reliable when applied in the public psychiatric sphere (McCabe & Priebe, 2004:121).

The ‘STAR brief scale’ was developed by McGuire et al (2007); it is designed to capture the perceptions of the therapeutic relationship of both multidisciplinary clinicians providing treatment, and clients with severe mental illness, in public psychiatry. This study identified the lack of such a tool, and proceeded to utilise the STAR brief scale among 17 community mental health teams in England and Sweden, it is reported as psychometrically sound and applicable to both research and use in routine care (McGuire et al, 2007:85).

Clinician/client perspectives and indicators for training

The building evidence of research and the development of various measures of the therapeutic relationship shed’s light on often different interpretations of the alliance from the position of both clinicians and clients. Bedi et al (2005) cite a lack of research from the consumer perspective, and that available evidence suggested “key differences between counsellor and client understandings of the alliance.” (p. 73). Horvath & Symonds (1991) did identify emerging evidence that “clients and observers’ reports of the alliance appear to be more predictive than are therapists’ judgements.” (p.147), and the continuing support for this view is quite strong (Bedi et al, 2012; Duff & Bedi, 2009; Johansson & Eklund, 2006); driving considerable effort to develop a better understanding of the incongruence, and the impact of this research on training and service development. Given that up to 60/% of psychotherapy outpatients, and up to 70% of clients of public psychiatry clients constitute early dropout from treatment (Johansson & Eklund, 2006:141), this appears a worthwhile direction.

Duff & Bedi (2010) present a particular focus on client perspective of counsellor behaviours that are predictors of the therapeutic alliance, fifteen behaviours were rated using the WAI, and those that most strongly supported a positive alliance were “seemingly small, strengths – fostering counsellor behaviours” (p.91), including basic communications – encouraging and positive statements, smiling, sound eye contact, reasonable attention to client (p. 101-2), and not self disclosure regarding similar experiences, client directing topics and verbal prompts (p. 101). This research noted the connection between early fostering of a sound therapeutic alliance being a strong predictor of outcomes, and the implications for counsellor training. Buck & Lysaker (2009) bring a focus to the training and supervision of graduate nurses in establishing therapeutic relationships “from which other work flows” (p.241). Johansson & Eklund (2006) identify the importance of an early sound alliance as a predictor of treatment outcomes, and the need for training and supervision of experienced staff who; “have the professional responsibility for offering a good therapeutic relationship and, by extension, an effective treatment regimen” (p.146).

Community mental health

Treatment via public mental health systems bring into focus time limits, contacts with multiple staff, coercive treatment and diagnosed symptoms of increased severity (McCabe & Priebe, 2004; Howgego et al, 2003; Spiers & Wood, 2010). The psychotherapist more identified in a private setting, becomes the case manager (Calsyn et al, 2006; Ziguras & Stuart, 2000), the lead clinician (McGuire et al, 2007), with far more of a team aspect to care and agendas driven by ‘models of care’ to address not only the mental health needs, but often the practical elements of housing, transport, social functioning and statutory requirements (Calsyn et al, 2006; McCabe & Priebe, 2004; Nath et al, 2012).

Bordin’s ‘pantheoretical’ model of the therapeutic relationship “offers the most utility for the case management field” (Howgego et al, 2003:172) and this opinion is clearly supported (Kirsh & Tate, 2011; Spiers & Wood, 2010), as is the evidence that a positive therapeutic relationship with a case manager is a strong predictor of positive treatment outcome (Calsyn et al, 2006; Gottlieb, et al, 2011; Spiers & Wood, 2010). The case managers “are the individuals charged with truly operationalizing the models.” (Kondrat & Early, 2010:392) of care which, as identified via current literature, is a ‘recovery focused model’ (Kondrat & Early, 2012; Nath et al, 2012; Oades et al, 2005). Collaborative recovery recognises the individual journey and “emphasises the development of new meaning and purpose as the person grows beyond the catastrophe of mental illness.” (Oades et al, 2005:280). Within this changing scenario, and noting the increased pressure to reduce amount of care provision, Spiers & Wood focused on “collaborative partnership, recovery and enhanced quality of life.” (201:38). They conducted a qualitative ethnography of mental health nurses who applied brief, solution focused practice with clients in sessions less than ten, and often single session crisis based contacts. The lack of available time enhanced the urgency to immediately harness mutual responsibility in collaboration toward goal setting and activation, with the experience of a strong alliance reported (Spiers & Wood, 2010).

Reference list

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