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

By Joseph, PhD Dena M.; Hilsenroth, PhD Mark J. et al. | American Journal of Psychotherapy, July 1, 2014 | Go to article overview

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


Joseph, PhD Dena M., Hilsenroth, PhD Mark J., Diener, PhD Marc J., American Journal of Psychotherapy


INTRODUCTION

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). Both therapeutic alliance and the techniques implemented in psychotherapy seem important to promote positive change. However, effective technique can go only so far in treatment without the presence of a strong alliance (Goldfried & Davila, 2005; Owen & Hilsenroth, 2011). They are likely linked constructs, as effective treat- ment in and of itself builds on alliance, and adequate alliance early in therapy is important for continued exploration and working through (Owen, Quirk, Hilsenroth, & Rodolfa, 2012).

The first hypothesis of this study is that in early sessions of psychody- namic psychotherapy, greater use of psychodynamic technique will be related to greater patient participation. Second, we hypothesized that higher levels of the overall working alliance will be associated with greater patient participation in early session process during psychodynamic psy- chotherapy. The third hypothesis is that specific psychodynamic-interper- sonal techniques will be related to greater patient participation in early session process during psychodynamic psychotherapy. Fourth, we hypoth- esized that higher levels of various facets of working alliance (e.g., sub- scales such as Bond) will be related to greater patient participation in early session process during psychodynamic psychotherapy. Finally, we decided that if results demonstrated that both alliance and technique were related to patient participation, then mediation analyses would be conducted to ascertain the unique contribution of alliance and technique with patient participation. We anticipated that the working alliance would mediate any relationship between technique and patient participation. …

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