The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship

Abstract

This thesis addresses the complicated nature of the psychotherapeutic alliance, by attempting to deconstruct what is already in practice. In piecing out the different aspects of the relationship between psychotherapist and client, and referring back to relevant literature, one can understand better the dynamics that exist within the therapeutic encounter. In the process, one can also see how the different principles of different psychotherapy schools fit into what we understand today as the profession of psychotherapy. Considered a profession, psychotherapy is bound to ethics, within which is the question of competence and accountability. The importance of understanding what really happens in a client-therapist meeting that is unique to psychotherapy, and that which leads to therapeutic change, is emphasized in this paper, with case studies from classical texts and referred back to modern day change-process research.

Keywords: psychotherapeutic alliance, psychotherapeutic relationship, psychotherapeutic change, psychotherapeutic process, psychotherapeutic dialogue, I-Thou.

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Helbig_2017_Bachelor_Thesis-nh-s-p

How a therapist can tell the progress of the patient

Psychotherapeutic change is observable. Noticing the progress of the client is an important aspect of therapy.

An important aspect in the work of the therapist, is to track patient progress. In my practice, even if I do not mention to the patient, I look for signs at every session.

The healing process in psychotherapy is often a subtle one. Meeting the patient every week, it is possible for the therapist to overlook these changes. Therefore, I give special attention to looking out for the signs.

Importance of looking out for the patient’s progress and change during therapy sessions

It is important for the therapist to be alert to change. Patients are normally oblivious to the subtle changes in their own personality. Left on their own, individuals may start doubting their new sense of being (due to persistent introjects / resistances).

Noticing the client’s change and progress is helpful to him/her. The therapist, in bringing attention to the development of the patient, helps the patient to integrate fully with this new attitude or behavior, through:

  • acknowledgement of the perceived change,
  • appreciation of how the change is impacting the life of the client,
  • understanding of how the change is developing and meaning making,
  • assimilation of the experience, i.e. how it feels to exist with this change.

Some signs of change observable in the patient during the course of therapy.

There are many signs of change. Here is a brief description.

  • Change in how the patient makes eye contact, makes facial expressions.
  • Change in posture, dressing, hairstyle — not the usual change of styling, but when the client comes in, and his/her aura feels different.
  • Change in topics brought up in session — most individuals bring up a kind of focus topic (like work or kids…). I’d notice a change when the topic is suddenly no longer interesting to talk about, or when another becomes figural. Generally, when the topic becomes more about the experiences of the self, it is progress.
  • Change in the client’s emotional vocabulary.
  • Client’s own account of perceiving new feelings or losing anxiety . Especially after holidays, the client reports that certain old feelings of anxiety around the festive season is no longer felt.
  • Client making new decisions. This applies to clients who have difficulty doing so.
  • Client reducing medication (esp, meds that have been long time prescribed), or reports having alleviated physical symptoms.
  • Client reports that children / spouse, etc are “doing better” (usually relationshipwise).

Note that these changes may not mean that the goal of therapy is reached. Change indicates that the therapy is in progress, and the patient can look forward to more enrichment from the sessions.

Different Facets of Countertransference

Different feelings brought about by countertransference during a therapy session. Here is a rundown of how countertransference within a therapeutic relationship can manifest itself.

 

Transferences from therapist’s own childhood unfinished business is put onto the client. For example, the client reminds the therapist of his controlling mother.

Reactive feelings arising from therapist’s own narcissism.  Like defiance, being offended, wanting to take revenge, envy, lust, feeling insecure, feeling  inferior or superior, etc.

Complementary countertransference: when the therapist encounters the transference of the client, out of which incites the therapist to behave towards / feel towards the client the way the client’s  caregiver or significant other  would feel.

Identification with client’s significant other (parent, child, spouse, children, boss): in such a way that the therapist cannot empathize with the client.

Projective IdentificationFeelings of the patient’s childhood experiences which have been split/dissociated, and projected onto the therapist and simultaneously the therapist feels and acts in a way (e.g. sadistic, critical, judgmental… like his father) that leaves the therapist bewildered.

The consequences unrealized countertransference feelings is that the client is robbed of the empathy he/she needs from the therapeutic sessions, which ultimately renders the therapy unprogressive.

The challenging job of the psychotherapist is to be constantly aware of these feelings and the sources of these transference. Self awareness through self therapy, and workshops and supervision are the only and best way to work through these transferences.

 

 

Notes: A Study Using Psychotherapy and fMRI Neuroimaging

A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging.

Tables and images in article

Reference

Buchheim, A., Labek, K., Walter, S., & Viviani, R. (2013). A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging. Frontiers in human neuroscience, 7.

Former patients’ conceptions of successful psychotherapy

This article features a study by Binder et. al 2009,  Why did I change when I went to therapy? A qualitative analysis of former patients’ conceptions of successful psychotherapy. 

The findings of this study provides us with some answers to what patients or clients of psychotherapy regard as change in psychotherapy, and how they perceive their experience in therapy which is considered successful for them.

The client’s point of view is very important. Mental states cannot be fully measured, as opposed to physical states. There is no machine, or test kit to measure the mental state of health. A person’s mental wellness is witnessed through his/her ability to function in daily life, and also his/her own perception of how things are.

What is successful psychotherapy or counseling? If a client claims to feel better, we’d ask what they meant. It could mean they feel more relaxed, less stress, less anxiety.  They could say that they are able to sleep better, have less physical pain. Or they could feel more energetic– whichever is important to the client at the time.

Methodology of this Study

The qualitative research was conducted using semi-structured, qualitative, in-depth interviews with 10 former psychotherapy patients, recruited through an advertisement in a local newspaper. A descriptive and hermeneutically modified phenomenological approach– i.e. using expert interviewing and not just questionnaires in order to grasp full meaning of what is transpired in conversation –was used to analyze interview transcripts.

Findings

What was most important explicitly for the clients in the therapy?

1  Having a relationship to a wise, warm and competent professional.

  • the client’s feeling of safety within the therapeutic relationship was mention.
  • the therapist having the right doses of contact with the client, and
  • the therapist having flexibility in approach to working with the client.

2  Having a relationship with continuity, safety and hope when feeling inner discontinuity.

  • the continuity, consistency of the therapy.
  • therapist being with them through difficult emotional experiences.

3  Having beliefs about oneself and one’s relational world corrected.

  • the patient is able through therapy to reconnect with his/her meaning making, having a look at misconceptions or introjects of which the client was not aware of.
  • therapists guides the client through his change of the worldview.

4  Creating new meaning and see new connections in life patterns.

  • the idea of having been helped by having one’s beliefs and belief systems corrected,
  • help in making new choices, or change in habitual patterns
  • helps the client see how the his/her present experiences and behavior in reaction to the experiences are rooted in the past experiences, i.e getting clarity and insight.

Comments

Psychotherapy is quite unlike medicine. The clients’ or patients’ needs for treatment are very diverse and individual. Even though there is such a thing as diagnostics in psychiatry, we have to understand that these diagnostics are constructs for professionals to communicate the symptom of the client with each other. With psychological issues, the same symptom displayed may does not mean same source or cause of problem. It also does not mean that the clients with same symptoms will benefit from similar treatment.

Why this?

Put simply, it is because the mental state of the individual is the product of the individual’s relationships, culture, physical health, age, economic situation… etc. The psychotherapist sees the client as a whole person, whose experiences and meaning making are important in therapy.

The result of the findings reflect this.

Bibiliography

Binder, P. E., Holgersen, H., & Nielsen, G. H. (2009). Why did I change when I went to therapy? A qualitative analysis of former patients’ conceptions of successful psychotherapy. Counselling and Psychotherapy Research9(4), 250-256.