systemic therapy's theorising of the therapeutic relationship;. - the use of . engaged me with systemic 'being' and the possibility of 'living the theory'. It is. The proposal of a therapeutic alliance characterized by a variable pattern . context, some authors have found a solution: the systemic model of alliance toward a therapeutic goal and engagement around common themes. This paper is about the therapeutic relationship in systemic therapy and, more specifically, about engagement as a process. Beginning with.
Meta-analyses have demonstrated that empathy [ 20 ] and positive regard [ 21 ] are moderately associated with clinical outcomes in psychotherapy. For instance, physiotherapists often use touch during assessment and treatment, which is likely not the case in psychotherapy-oriented disciplines, such as psychology.
It is also relevant to note that delivery of physiotherapy services differs practically from other healthcare professions. For instance, physiotherapy treatment sessions can be longer in duration and occur on a more frequent basis during a particular treatment period e. In addition, physiotherapists may be more likely to form consistent relationships with their patients i. These factors could shape how physiotherapists approach interactions with patients and create an environment that provides the opportunity to develop the therapeutic relationship as a central component of the clinical interaction, as well as direct how the therapeutic relationship should be assessed.
The concept of engagement is an influential factor in outcomes and has been linked to the therapeutic relationship. In their content analysis of patient engagement, Higgins et al. But who is responsible for engaging the therapeutic relationship, physiotherapist or patient? For instance, Higgins et al. This implies a substantial degree of patient investment along side the provider. Given the importance placed on patient engagement in rehabilitation, understanding the therapeutic relationship in physiotherapy from patient and physiotherapist perspectives is needed.
Although this view is supported in research of physiotherapy services [ 23 ], historically, patient involvement in research of the therapeutic relationship has focused more on therapist perspectives. Therefore, patient contributions are essential for developing foundational knowledge of the therapeutic relationship in physiotherapy. Assuming meaningful engagement relies on a positive supportive relationship between patient and provider, we posed the question: Given the nature of the question and the limited understanding of the therapeutic relationship in physiotherapy, we undertook a qualitative investigation, using physiotherapist and patient perspectives, to identify and provide in-depth descriptions of the conditions of engagement necessary for a therapeutic relationship between physiotherapist and patient.
Methods Research team and reflexivity The research team consisted of 4 clinicians 2 physiotherapists, 1 occupational therapist, and 1 psychologistand a qualitative methodologist from human ecology.
Two of the 5 researchers had significant experience using qualitative methods in health research and a third, the lead author, was completing this project as a component of her doctoral thesis and led all aspects of the study. In doing so, the lead author was informed by previous and extensive training in qualitative methods as well as meta-theoretical perspectives from critical realism [ 2526 ] and psychotherapeutic contextual theory [ 27 ].
The lead author also applied experience gained as a contributor on other qualitative research studies. It is also relevant to note that the lead author had post-graduate training in psychotherapy, which informed prior clinical practice as a physiotherapist as well as her interest in therapeutic relationship as a research topic.
Design Interpretive description was the qualitative methodological orientation [ 2829 ] used to address the research question [ 28 ]. Grounded in naturalistic inquiry [ 30 ], interpretive description is a framework that guides researchers to maintain a path toward pragmatic versus theoretical findings when addressing clinical or applied problems.
Interpretive description does not prescribe the use of a specific theoretical framework, as do traditional methods e. When designing a study, Thorne suggests researchers consider various factors that could influence practice, including the disciplinary mandate e.
For this reason, an inductive approach was taken, eliminating the use of a theoretical framework or themes at the outset of the study, including psychotherapy theories or approaches. Setting The setting was private practice physiotherapy clinics in Edmonton, Canada.
Reasons for situating the study in these clinics included: Sampling strategy and recruitment Physiotherapist sampling strategy and recruitment Purposive sampling was used to recruit 11 physiotherapists 6 female. Two authors including the lead author who are physiotherapists used their knowledge of the private practice community to identify physiotherapists who could provide in-depth accounts of their therapeutic relationship experiences.
Administrative staff in the Department of Physical Therapy, University of Alberta sent an email invitation to therapists, directing them to contact the first author with questions or if interested in participating. Upon contact, the lead author reviewed the study information sheet with all potential participants. Three therapists did not respond to the email and 1 declined to participate after speaking with the lead author. Purposive sampling enabled sampling across factors such as treatment specializations e.
Patient sampling strategy and recruitment Purposive and convenience sampling were used to recruit 7 patient participants 4 male.
Administrative staff in 3 clinics purposively identified patients they believed would be able to provide candid accounts of the relationships with their therapists. Staff provided patients with study information sheets and directed them to contact the lead author with questions or if interested in participating. Upon contact, the study information sheet was reviewed with all potential participants. One patient was deemed ineligible for the study after speaking with the lead author.
Data generation and analysis Data generation and analysis were inductive and iterative. Although physiotherapists and patients had separate interview guides, they were similar in that both began with broad questions to provoke responses on the clinical interaction in general e.
However, questions in the interview guides differed since physiotherapists form therapeutic relationships with many patients whereas patients will not have this breadth of experience. We have described the rationale for both patient and physiotherapist interview guides elsewhere [ 34 ]. Various rigour strategies, described below, were used to critique the data generation process in order to continually inform interview quality. Two mock interviews were completed, which informed refinement of the interview guides prior to initiating participant interviews.
Concurrent data generation and analysis allowed for interview guide revisions to reflect the evolving analysis. The lead author completed all interviews and data analysis. Data were generated until a point of saturation [ 36 ] was achieved representing a meaningful reflection of clinical reality. Data analysis occurred in 2 concurrent phases: To support an inductive process that would generate findings congruent with the physiotherapy context, psychotherapy theory e.
Content analysis began with initial coding [ 38 ] or the assignment of a specific word or phrase to summarize a key attribute of a portion of text [ 39 ]. As patterns of codes were recognized [ 4041 ], they were grouped into categories and sub-categories [ 42 ].
Negative cases [ 43 ] within participant accounts contributed to clarifying aspects of the conditions of engagement. The lead author completed all interviews and analysis in partial fulfillment of her doctoral thesis. It is worth noting that the lead author had not met the patient participants prior to the study. However, given the lead author had previously worked in private practice physiotherapy, she knew some of the physiotherapist participants on a professional basis, to varying degrees, prior to the study commencing.
Various rigour strategies that involved researcher, participants, and external reviews were used throughout the study to address transparency and trustworthiness of the research process and findings. Personal researcher strategies involved journaling to: Two patient participants engaged in member reflections [ 45 ] about the ongoing analysis and 2 researchers and healthcare providers were involved in peer debrief [ 4447 ].
An external audit [ 44 ] was completed at project completion, confirming that the research process was thorough and the quality and nature of the findings were congruent with the process. Results Four foundational conditions fostering engagement between physiotherapist PT and patient within a therapeutic relationship were identified and labeled: Physiotherapists make conscious choices about the amount of time they spend in direct proximity with patients in a potentially chaotic setting laden with competing responsibilities.
While scheduling longer sessions e. Patients also noticed when therapists were not present and the negative impact this had on their experiences, such as when they perceived therapists were rushing.
The Therapeutic Relationship in Systemic Therapy - Google Livres
The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session. During the first phase, adequate levels of collaboration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of confidence in the procedures that constitute the framework of the therapy. The deterioration in the relationship must be repaired if the therapy is to be successful.
This model implies that the alliance can be damaged at various times during the course of therapy and for different reasons. The effect on therapy differs, depending on when the difficulty arises. In this case, the patient may prematurely terminate the therapy contract.
According to Safran and Segalmany therapies are characterized by at least one or more ruptures in the alliance during the course of treatment. Randeau and Wampold analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies.
Although some studies are based on a very limited number of cases, the results appear consistent: While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used static measures of alliance. There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: Few studies have analyzed alliance at different stages in the treatment process.
According to the results proposed by Traceythe more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction high—low—high over the course of treatment. When the outcome was worse, the curvilinear pattern was weaker. Kivlighan and Shaughnessy use the hierarchical linear modeling method an analysis technique for studying the process of change in studies where measurements are repeated to analyses the development of the alliance in a large number of cases.
According to their findings, some dyads presented the high—low—high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment.
In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development. Kivlighan and Shaughnessy distinguish three patterns of therapeutic alliance development: They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pattern, in that this appeared to be correlated with the best therapeutic outcomes.
In further studies of this development pattern, Stiles et al. Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative. No significant correlation was observed between any of the four patterns and the therapeutic outcome.
However, the authors observed a cycle of therapeutic alliance rupture—repair events in all cases: On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes. In particular, Stiles et al. The results of the study by De Roten et al. According to De Roten et al. De Roten et al. According to Castonguay et al. This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon.
Discussion and Conclusion According to their meta-analysis based on the results of 24 studies, Horvath and Symonds demonstrate the existence of a moderate but reliable association between good therapeutic alliance and positive therapeutic outcome. More recent meta-analyses of studies examining the linkage between alliance and outcomes in both adult and youth psychotherapy Martin et al.
Thus, it is not by chance that in their meta-analysis, Horvath and Luborsky conclude that two main aspects of the alliance were measured by several scales regardless of the theoretical frameworks and the therapeutic models: This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants. In a helpful contribution, Hentschel points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: The use of neutral observers or the creation of counterintuitive studies is therefore recommended.
From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. The development of a dynamic vision of the concept of therapeutic alliance is also apparent. The work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in Research aimed at analyzing the components that make up the alliance continues to flourish and develop.
Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: Attention has recently turned toward the role of the therapeutic alliance in the various phases of therapy and the relationship between alliance and outcome.
So far, few studies have regarded long-term psychotherapy involving many counseling sessions. This topic, along with a more detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects.
Equally important, in our opinion, will be the findings of studies regarding drop-out and therapeutic alliance ruptures, which must necessarily consider the differences between that perceived by the patient and that perceived by the therapist. Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgments The authors thank Mauro Adenzato for his valuable comments and suggestions to an earlier version of this article. A Research Handbook, eds Greenberg L. Guilford Press;— Bibring E.
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