Academic journal article American Journal of Psychotherapy

Patient Participation in Psychodynamic Psychotherapy: Contributions of Alliance and Therapist Technique

Academic journal article American Journal of Psychotherapy

Patient Participation in Psychodynamic Psychotherapy: Contributions of Alliance and Therapist Technique

Article excerpt

The aim of this research is to investigate the relationship among patient participation, technique, and the working alliance during early sessions of psychodynamic psychotherapy. Participants in this study (N=88) were representative of those actually seeking outpatient treatment at a university-based community clinic. Results demonstrated that greater use of psychodynamic techniques is related to greater patient participation in early session process during psychodynamic psychotherapy (r=.23, p=.03). Moreover, greater use of two specific psychodynamic interventions was found to be significantly related to patient participation: "The therapist encourages the exploration of feelings regarded by the patient as uncomfortable" (r=.24, p=.03)," and "The therapist focuses attention on similarities among the patient's relationships repeated over time, settings or people" (r=.33, p=.001). The relationship between overall working alliance and patient participation was also found to be significant (r=.50, p<.0001). In addition, results demonstrated that higher levels of various facets of the working alliance are related to greater patient participation: Goals and Tasks (r=.43, p<.0001), Confident Collaboration (r=.39, p=.0002), Bond (r=.37, p=.0003) and Idealized Relationship (r=.34, p=.001). Finally, in order to highlight the relative contribution among alliance, technique, and participation, an examination of mediation was conducted. Results demonstrated that although both alliance and technique independently related to patient participation in a significant manner, alliance and technique were not significantly related to one another, indicating that the criteria for a meditational model were not met.

KEYWORDS: patient participation; alliance; technique; psychodynamic; mediation


The contemporary understanding of alliance is largely derived from the "here and now" interactions during therapy (Horvath, 2006) and Bordin's (1979) conceptualization of agreement on goals, tasks, and the bond between patient and therapist. A strong alliance can help the patient delve with greater ease into understanding and exploring more difficult dy- namics (Byrd, Patterson & Turchik, 2010). Extensive research demon- strates that this collaborative relationship is significantly related to out- come (Horvath, Del Re, Fluckiger, & Symonds, 2011). Horvath et al. (2011) stressed that key components in fostering a strong alliance include the therapist implementing a collaborative approach, possessing a non- defensive style, and demonstrating flexibility in his or her technique. Intervention and alliance building are not separate; often, they are related constructs, as effective treatment builds on the alliance (Horvath et al., 2011).

It is important to note that a patient concealing difficult emotional material is especially understandable if the therapeutic alliance is a poor one; thus, self-concealment can be viewed as self-protective in the presence of a poor therapeutic alliance (Pattee & Farber, 2008). Substantial research supports a related assertion by Hill, Gelso, and Mohr (2000) that honest involvement during a session is important for the development of a positive alliance. In addition, Kahn et al. (2008) demonstrated that patient disclosure is most profound when the therapist addresses the patient's emotional experience. Emotional content, or a high level of affect during sessions, was correlated with a high-impact session (Kahn et al., 2000).

The aim of this study was to investigate the relationship between patient participation and the working alliance during early treatment session process as well as to examine the association of such a relationship with therapist technique. Patient engagement during session is an impor- tant facet of effective treatment, since disclosure in therapy is beneficial to the therapeutic process (Farber et al., 2004). Therapist interventions affect alliance building, especially early in treatment, from the psychological assessment, to the initial interview, and the first session (Hilsenroth, Cromer & Ackerman, 2012). …

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