Who is Psychotherapy for?

Notice that this question starts not with the “what” but with the “who”. How psychotherapy works is unlike in other medical fields, in which the doctor does the healing “work” while the patient lies restfully and tries to recuperate from his symptoms. In psychotherapy the therapists functions to support the patient in his/her efforts to alleviate his/her own symptoms.

The beauty of a successful outcome in psychotherapy is that it happens, it is permanent, and it leads the patient to a far better quality of life.

This means that the patient’s input is essential to the outcome. It is the skill of the therapist to lead the patient to this engagement. There are many techniques that can be employed, and hence many kind of therapies. However these methods are essentially means to guide the patient towards the motivation and awareness of him/herself. The ultimate work happens when there is contact between the client to him/herself and to the therapist. This contact takes effort on the part of the therapist to nurture, and when it happens, the patient feels a “shift” in his/herself. This shift is an indication the something internal has changed.

This may sound abstract, and it is. Psychotherapy is a craft and a skill learned. To be a psychotherapeutic client with successful outcome is also learnt. The beauty of a successful outcome in psychotherapy is that it happens, it is permanent, and it leads the patient to a far better quality of life.

That is the goal of therapy: to relieve psychological or somatic symptoms through dialogue and contact. A patient suffering debilitating panic attacks, for example, slowly learns the psychological process and childhood experiences behind these attacks. The therapist supports him/her into contacting his/her unconscious activity and past emotions and unmet needs. In receiving this contact, the therapist works with the client through these experiences. The client is then able to make meaning of these experiences and learns to find resources to deal with pending situations.

So, who is psychotherapy for? It is for anyone who needs clarity in his/her life. He/she does not need to be “sick” or “dysfunctional” to start therapy. In actuality, it is better (and also cost-effective) to enter therapy as a healthy, stressed out, panicky individual, than to wait till the stress becomes too overwhelming.

 

How do we classify mental diseases?

There are 2 main classifications standards that are used today in the western world to diagnose psychopathological symptoms.

In the field psychotherapy, the concept of diagnostics is controversial. The reason being that unlike some physical problems, psychological issues are individual. For example, there is no one single cause of borderline personality disorder (BPD), but an array of situations that occur in the patient’s life that leads up to the symptoms. Diagnosing the symptoms are also complex, since each patient has his/her own way of dealing with the psychological trauma that leads to the condition. However putting labels onto observable psychological and behavioral conditions are necessary for professional to communicate with administrative bodies like psychiatrists, insurance companies, the courts, etc.

The ICD-10 by the World Health Organization (WHO)

The ICD-1o is also known as the International Statistical Classification of Diseases. It is the most recognized diagnostic classification system in the medical profession, and is provided by the WHO.

In the ICD-10 classification of mental disorders (or psychopathology) is categorized in Chapter F. Click here to have a complete online list of the ICD-10 classification of mental disorders.

This chapter contains the following blocks:
  • F00-F09Organic, including symptomatic, mental disorders
  • F10-F19Mental and behavioural disorders due to psychoactive substance use
  • F20-F29Schizophrenia, schizotypal and delusional disorders
  • F30-F39Mood [affective] disorders
  • F40-F48Neurotic, stress-related and somatoform disorders
  • F50-F59Behavioural syndromes associated with physiological disturbances and physical factors
  • F60-F69Disorders of adult personality and behaviour
  • F70-F79Mental retardation
  • F80-F89Disorders of psychological development
  • F90-F98Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
  • F99-F99Unspecified mental disorder

ICD-11 is due to be out in 2018.

The DSM-5 by the American Psychiatric Association (APA)

DSM-5 is the short form for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

 The DSM-5 was published in May 2013. 

Research: The Psychotherapeutic Alliance in Research

Interdependent factors that make an alliance:

  • *the agreement between patient and therapist on the tasks and goals of treatment and
  • *the affective bond between patient and therapist.

Ruptures

Refer also to the 3RS manual on ruptures here.

Ruptures are understood as: misunderstanding events, impasses, alliance threats and markers of enactments.


A rupture is a deterioration in the alliance, manifested by

  1. a lack of collaboration between patient and therapist on tasks or goals, or
  2. by a strain in the emotional bond.

Although the word “rupture” connotes a major breakdown in the relationship, the term is also used to describe minor tensions of which one or both of the participants may be only vaguely aware. Ruptures can be obstacles to treatment and can contribute to patient dropout.

Resolution of Rupture as Opportunity for Therapeutic Change

Successful resolution of a rupture can serve as a corrective emotional experience (Alexander & French, 1946), providing a powerful opportunity for therapeutic change

Recognizing the negative impact that unresolved ruptures can have on
treatment outcome, and realizing that these ruptures can go unnoticed by the therapists research is done that is centered around the investigation of whether integrating rupture resolution techniques can improve the efficacy of a particular treatment.

The chapter in this reference gives a detailed account of the kind of research that has been done, that works on the alliance rupture and repair, with the goal of improving probability of training therapists to focus on the alliance.

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Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.
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Barber, J. P., Khalsa, S. R., Sharpless, B. A., Muran, J. C., & Barber, J. P. (2010). The validity of the alliance as a predictor of psychotherapy outcome. The therapeutic alliance: An evidence-based guide to practice, 29-43.

Empirical studies that have shown that alliance is correlated to good outcome:

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–70). New York: Oxford University Press.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.

Samstag, L. W., Batchelder, S. T., Muran, J. C., Safran, J. D., & Winston, A. (1998). Early identification of treatment failures in short-term psychotherapy: An assessment of therapeutic alliance and interpersonal behavior. Journal of Psychotherapy Practice and Research, 7, 126–143.

Samstag, L. W., Muran, J. C., Wachtel, P. L., Slade, A., Safran, J. D., & Winston, A. (2008). Evaluating negative process: A comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions. American Journal of Psychotherapy, 62, 165–194.

Tryon, G. S., & Kane, A. S. (1990). The helping alliance and premature termination. Counselling Psychology Quarterly, 3, 233–238.

Tryon, G. S., & Kane, A. S. (1993). Relationship of working alliance to mutual and unilateral termination. Journal of Counseling Psychology, 40, 33–36.

Tryon, G. S., & Kane, A. S. (1995). Client involvement, working alliance, and type of therapy termination. Psychotherapy Research, 5, 189–198.

Reference

Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2010). Alliance ruptures and resolution. The therapeutic alliance: An evidence-based guide to practice, 74-94.

Index of this book:

I. Critical Studies of the Therapeutic Alliance

  1. Alliance Theory and Measurement 7 Robert L. Hatcher

  2. The Validity of the Alliance as a Predictor 29 of Psychotherapy Outcome Jacques P. Barber, Shabad-Ratan Khalsa, and Brian A. Sharpless

  3. The Alliance over Time 44 William B. Stiles and Jacob Z. Goldsmith

  4. Qualitative Studies of Negative Experiences 63 in Psychotherapy Clara E. Hill

  5. Alliance Ruptures and Resolution 74 Catherine Eubanks-Carter, J. Christopher Muran, and Jeremy D. Safran xiv

Contents II. Practice and the Therapeutic Alliance

  1. A Psychodynamic Perspective 97 on the Therapeutic Alliance: Theory, Research, and Practice Stanley B. Messer and David L. Wolitzky 7. An Interpersonal Perspective on Therapy 123 Alliances and Techniques Lorna Smith Benjamin and Kenneth L. Critchfield 8. The Therapeutic Alliance 150 in Cognitive-Behavioral Therapy Louis G. Castonguay, Michael J. Constantino, Andrew A. McAleavey, and Marvin R. Goldfried 9. A Functional Analytic Psychotherapy (FAP) 172 Approach to the Therapeutic Alliance Mavis Tsai, Robert J. Kohlenberg, and Jonathan W. Kanter 10. The Therapeutic Alliance 191 in Humanistic Psychotherapy Jeanne C. Watson and Freda Kalogerakos 11. Therapeutic Alliances in Couple Therapy: 210 The Web of Relationships Adam O. Horvath, Dianne Symonds, and Luis Tapia 12. Therapeutic Alliances and Alliance Building 240 in Family Therapy Valentín Escudero, Laurie Heatherington, and Myrna L. Friedlander 13. The Therapeutic Alliance in Group Therapy 263 William E. Piper and John S. Ogrodniczuk III. Training Programs on the Therapeutic Alliance 14. Developing Skills in Managing 285 Negative Process Jeffrey L. Binder and William P. Henry Contents xv 15. Training in Alliance-Fostering Techniques 304 Paul Crits-Christoph, Katherine Crits-Christoph, and Mary Beth Connolly Gibbons 16. Developing Therapist Abilities to Negotiate 320 Alliance Ruptures J. Christopher Muran, Jeremy D. Safran, and Catherine Eubanks-Carter 17. Coda: Recommendations for Practice 341 and Training Brian A. Sharpless, J. Christopher Muran, and Jacques P. Barber