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Exploring the similarities and differences

3414 words (14 pages) Essay in Psychology

5/12/16 Psychology Reference this

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Studies has revealed that different types of therapy have similar success rates, nevertheless of the theoretical underpinnings (Smith & Glass, 1977). For instance, short-term psychodynamic psychotherapy and cognitive behaviour therapy are equally effective in treating depression (see Leichsenring, 2001 for a review). This has led to the suggestion that the therapeutic working alliance relationship, which is common to all one-to one therapy, maybe an important aspect in influencing outcome (Howe, 1999). This highlights the need for clinical theory, practice and research to address the issue of the therapeutic working alliance relationship and how its role in facilitating favourable outcomes can best be used.

To provide an in-depth analysis of this issue, this essay will focus on two orientations that are based on different theoretical underpinnings, Cognitive Behaviour Therapy and psychoanalytic. How these two perspectives conceptualise and use the therapeutic working alliance relationship will first be discussed. Relevant studies within this area will then be presented. Following this, an analysis of how the two viewpoints differ, and what similarities they share will be discussed. Finally, conclusions will be made regarding the role of the therapeutic working alliance relationship across cognitive behaviour therapy and psychodynamic orientations, including consideration of implications for clinical practice and research, as well as possible directions for the future.

The aim of this to discuss and explore the similarities and the differences in the way in which the working alliance is conceptualised and applied to clinical practice -term Psychodynamic Counselling and Cognitive Behaviour Therapy also known as CBT.

The therapeutic Working Alliance plays an important role in Psychodynamic Counselling and Cognitive Behaviour Therapy (CBT) because; it helps the counsellor and client to agree and work to build up a ‘relationship’ together to achieve a successful counselling.

The concept of the therapeutic working alliance or ‘alliance ‘has many definitions that depend on which theoretical orientation is subscribed to. Firstly it is important to define what exactly the therapeutic Working Alliance is and how the concept came about. This will further enable us to understand its implication on the practice of short-term Psychodynamic and Cognitive Behavioural Therapy (CBT)

Many authors believe that the Therapeutic Working Alliance is vital to the practice of Psychodynamic and Cognitive Behavioural Therapy in counselling. Both Patton and Meara p. 97 view ‘the central role of the Therapeutic Working Alliance as a phenomenon in psychoanalytic, they argue that it is a component of the relationship between counsellor and client to help to fulfil client mental state. Equally, both Westbrook and Kirk (2007) view the Therapeutic Working Alliance “relationship as a key essence of therapy. Similarly, Summers and Barber also view ‘the Therapeutic Working Alliance as the “holy grail of psychotherapy success’. And (Howard 2010) also said that the “Therapeutic Working Alliance is that part of the element of the therapeutic relationship in which counsellors and client reach an agreement to work side by side to help clients attain the changes their needs to make.

According to the Psychoanalytic Electronic Publishing on the 2 November 2010 “Research on the Psychotherapy in general and Psychodynamic therapy in particular has consistently found that the quality of the Alliance predicts the outcome of the treatment. Little empirical evidence exists for the notion that the therapeutic alliance set the stage for techniques to be most effective, although adequately studies of this interaction between technique and alliance are scarce. Research suggests that that the therapeutic alliance is influence in part pre-exist characteristic and part by quality of therapist intervention. Limitation on the empirical literature on the alliance are presented and some suggestions for future research are given” [1] 

The Therapeutic Working Alliance is emotional relationship between the counsellor and the client together with interpretation and insight are seen as the main vehicles of change within psychodynamic therapy. (Bateman & Holmes, 1995). Freud originally considered Therapeutic Working Alliance in his primitive theoretical papers on transference. In his work or research of Hysteria, he initially talks of the consequence of making a so-called collaboration of the patient. The characteristic of the transference in relationship was his main concern and the significant of transference analysis. (Muran and Safran p.3) Transference is thus a distortion of reality, or the actual relationship, in that a psychic displacement of the past is projected onto a present relationship (Bateman & Holmes, 1995). transference can be manifest in early or later stage in therapeutic working alliance. This imply when the client transfer her or his feelings negatively or positively to the counsellor. It can be seen as the way parts of the objects and object-relationships, which make up the client’s internal world, become enacted in relationship with the counsellor. Negative transference is challenging and can put the counsellor in awkward situation, whereby the client behaves in an appropriate manner or have a sexual feeling for the counsellor. Whereas, positive transference imply when the client sees the counsellor as a tyrant or saviour, this can productively examine so the client become aware of his or her hidden feelings. However, according to Murran and Safran Freud also articulated of the “unobjectionable positive transference that should not be investigated as, it gives the patient with the drive necessary to collaborate effectively with the counsellor and he recognise a affability and a caring part to a some as “the vehicle of success in Psychoanalysis.”

The concept of the Therapeutic Working Alliance in Psychoanalytic

The Therapeutic Working the Alliance in short-term Psychodynamic has the same theoretical concept as well as in the therapeutic working alliance in Psychodynamic, the only difference is short-term is time limited. Rank was one of the important people who played a part in, in fixing of a particular time for ending, to stir up the client wish and attention on, dependency and distinction problems.(Muran and Safron) also the development of the therapeutic working alliance in short-term Psychodynamic was carry out by Murran and Safron in the early 1990s. According Murran and Barber” the therapeutic working alliance is centred counselling treatment informed to, by findings from task analytic work and brief rational therapy also known as (BRT)and tested its effectiveness”.(Murran and Safron,2002) In the therapeutic working alliance in short-term Psychodynamic, the counsellor equally, emphasis on helping the client to identify conflicts and issues and help the client to move on.

The concept of the therapeutic working alliance in short-term Psychodynamic lays down a significant bridge “relationship” and method aspects in counselling. The emotional relationship between the counsellor and the client together with interpretation and insight are seen as the main vehicles of change within psychodynamic therapy. (Bateman & Holmes, 1995). There three main components, bond, task and goals which was ascertain by Bordin (1979) in order to have an effectiveness in the therapeutic working alliance. Bordin view the therapeutic working as a reciprocal establishment of the counsellor and the client that into account sharing goals, agreement with acknowledgment of the task, each individual to achieve in the relationship and an attachment bond.(summers and Barber 2010) Moreover, according to Patton and Meara” Greenson’s concept of the therapeutic working alliance incorporates and ‘observing’ self, or the objective, reasonable side of the person that is willing to collaborate with the counsellor. The most directly relevant of these three components are necessary and sufficient in the Therapeutic Working Alliance. These components truly describe the counsellor qualities and attitudes which, present, will enable the counsellor and the client to have a successful counselling. Moreover, the bond in the Therapeutic Working Alliance denotes the attachment between the counsellor and the client; hold the values, qualities and attitudes to be non-judgemental and attentive towards the client. The counsellor is show, empathy, caring, unconditional positive regard, emotionally engaged to make the client feel that he or she is important and safe in the counsellor’s hands, in another word, the bond forms the trust and confidence between the counsellor and client will enable the counselling sessions to be affective. According to Muran and Safran ‘the virtuosity of the bond contemplates the degree to which the counsellor and the client are the position to discuss terms, about the tasks and goals of counselling, and the means to discuss terms about the tasks and goals in counselling in turn mediates the quality of the bond.’ Secondly a tasks, is also important and it does have a valuable place in the Therapeutic Working Alliance. A task in the Therapeutic Working calls the counsellor and the client to also work together as well as having an individual role. The counsellor’s role is to listen attentively and put aside whatever preconceptions he or she and try to be open and to understand the client. Also requires the counsellor to train the client for his or her tasks which will help the client to reflect and understand this will therefore, give the client a great comfort and responds better or open up more. In addition to this, Howard said ‘listening is the focal point aptitude in building a Therapeutic Working Alliance.’ This lead to the last component goals, with the understanding and the help of the counsellor will enlighten and empower the client to understand as well as reflect and find out a sense of purpose, or to see exactly where changes in her life needs to work on, and move on in the counselling to achieve his or her goals. Summers and Barber said that ‘successful outcome of the tasks and goals will makes easier the bond because the client feels devoted when the counselling is progression.’ Another factor to be considered in the Therapeutic Working is transference and counter transference. This is when the client manifests an early experience with an important figure as child to the counsellor which in return the counsellor experiences his or her thoughts and feelings that are relation to the client transference. This transference can then be used to explore the past and gain greater understanding of the client’s difficulties, through interpretation of the transference (Bateman et al., 2000). The counsellor should keep the boundaries and objective of the counselling clear to create a successful Therapeutic Working Alliance. In contrast to this, more contemporary perspectives believe transference and the Therapeutic Working Alliance as mutually evolving(Bateman et al.., 2000). Moreover, Slavin and Kreigman,1992 as cited in Bateman and Holmes,1995) say that transference epitomise the use of learned experience in new situations so that a review of earlier experience can take place consequently, transference is an ‘earlier revelation rather than a distortion of the existing experience. In addition to this, Alex Coren said that a ‘mutual examination is set about where both the counsellor and the client observe the developing narrative “as if” it was a cooperative story engaged up by two different people. Countertransference implies the thoughts and feelings experienced by the counsellor which are relevant to the client’s internal world and which may be used by the counsellor to understand the meaning of his client’s communications to help rather than hinder treatment (Bateman & Holmes, 1995, p 109-110).

Various studies in the Therapeutic Working Alliance in Cognitive Behaviour Therapy have varied in their results thus; this has compelled a thorough understanding of the practice/ its construct. According to Seligman “cognitive-behavioural therapy (CBT) has become one of the most often practiced treatments for depression in the course of the past two decades, and it has been found to be an effective treatment of depression in most efficacy studies.” [2] Its objective is to alleviate depression by directly changing the client’s irrational and negative beliefs. An effective therapist-client relationship is crucial for treatment as the quality of the relationship will ultimately determine the therapeutic outcome. Having said that, in CBT, although the therapeutic relationship is seen as necessary it is however not enough because Roth and Fonagy believe that in treatment trials there is “typically a beneficial effect from CBT over and above that of being in therapeutic relationship”. [3] This implies that the therapeutic relationship is not that much of a determining factor in the outcome of treatment.

Additionally, some evidence shows that the nature of the client’s participation might be the strongest determinant of outcome. For instance a client is more susceptible to do well if he or she is involved in the therapeutic task such as, offering suggestions about treatment, interact and trust fully the counsellor. So a client who consistently does the task set out to them has more chance of reaching their goals than the one who does not. The Therapeutic Working Alliance relationship administers the opportunity to exceedingly evoke new skills which can be established to real life situations; and therefore, it can be portrayed as a beneficial subject for working on problems. For instance, evaluation is used to a great extent in the session where the counsellor will teach the client how to think with positive thoughts, before the client employs the same technique in real life situations.

The conceptualisation of the Therapeutic Working Alliance in Cognitive Behaviour Therapy

The Therapeutic Working Alliance in Cognitive Behaviour Therapy concept originated from the Psychoanalytic works. The method in which Cognitive Behaviour Therapy has viewed the Therapeutic Working Alliance’s the role in producing change has shifted over the years. By traditions, the Therapeutic Working Alliance was perceived as a derivative of the therapeutic process and not enough attention was paid into it. (Gilbert and Leahy). Beck et al. (1979) say that a good relationship was ‘sufficient but not necessary’ for change in clients. This cognitive change came about by applying specific techniques within the context of a ‘therapeutic collaboration. Beck et al.(1979) argue that the role of the counsellor is to able to show a characteristic of empathy, caring and genuiness towards the client when applying cognitive techniques. Basics trust and understanding are seen essential in providing a collaborative empiricism, as this is characterised, has important implication for clinical practice in that the relationship is mutual with both the counsellor and the client to work together in an exploratory way. RUPTURE to The concept of the Therapeutic Working Alliance is identified by Bordin (1979) which is composed of three components, which is the bond, the task and the goal. Bordin believed the three component are necessary for an effective therapeutic working Alliance however, the Therapeutic working Alliance at its most basic might not be successful with a client who drops out due to the fact he or she finds the counsellor unwarm. This relationship needs to be established in a period of the beginning of three or four session however, the quality of the relationship might not remain permanent. The progress of the treatment differs as the counselling session carry on, a conduct to failure may be necessary in the relationship in order for the counselling to be successful. Hence, a concern should be emphasis all the way through the course of the treatment on the quality of the Therapeutic working relationship. (Westbrook and Kennerly,2007)

Within the CBT model in therapeutic Working Alliance does take place however, it is not recognised or dealt with in the Psychodynamic ways. It is rather regarded as a relationship in its own right, with the potential for equipping the client with new evidence about the varieties of possibilities for relationships. Moreover, another factor that can happened in the Therapeutic working Alliance is rupture, this implies when the client’s obstacle have frequently become so ingrained, that he or she is incapable to cope with without help. However, although he or she recognises their inabilities to cope, changing such behaviour would prone to be difficult, throughout the process the client may experience great emotional behaviour due to their struggles with dealing with their problem. It is vital for the counsellor to able to be quick to spot and intervene with the signs of rupture as early as possible in the Therapeutic Working Alliance, for instance the client might behave in uncooperative manner by expressing a doubt about the method, lacking to trust, not doing homework tasks. Therefore, it is the counsellor’s role to be able to identify the area where the rupture laid or what exactly part of the component the relationship is struggling with. Westbrook and Kennerly suggest that ‘ if the rapture in the relationship appears to be associated with the bond between the counsellor and the client, its need to dealt first with within the present therapeutic relationship in the need of assuming that the issue is to do with the client’s unsociable character. In other hand, should the formulation shows that the client may perhaps struggling to trust anyone, at that point it may be needed to contemplate the rupture as a characteristic pattern, which an emotional correctives will be provide in the Therapeutic Working Alliance.

The development of schema therapy within the Cognitive Behaviour therapy area views the Therapeutic Working Alliance as a vital part of change. A schema is defined as a ‘broad organising principle for making sense of individual’s life experience. (Young, et al.,2003) schema therapy tries to aid the client to identify he or her schema, and comprehend its roots in childhood and relate them to the issues he is undergoing. The Therapeutic Working Alliance is central to and used in these techniques. Firstly, to have compassion and confront schemas as they are activated in the therapy, a development named empathic confrontation. Secondly, to provide the client a remedial emotional experience, the counsellor acts in a consistent way towards the client that offers an ‘antidote’ to the client’s initial deficient parenting involvement Young et al., 2003)

Further cognitive theory was developed by Safran by utilising interpersonal theory concept of the schema. Safran argues that the interpersonal schema defined as generic representations of self-other relationship, are developed in infant through interactions with care giver and guide the maintenance of interpersonal relatedness all through life. (Safron, 1990a). These interpersonal schemas drive cognitive-interpersonal cycles, in which maladaptive expectations and dysfunctional behaviours become activated and subsequently reinforced. Interpersonal behaviours produce an interpersonal ‘pull’ in others that allows for schema-consistent responses which in turn reinforce the behaviours.(Corrie,2004) Safran (1990b) highlights becoming a ‘participant observer, so to avoid becoming entangled with the client’s dysfunctional cognitive-interpersonal cycle, and using the counsellor’s countertransference reactions to identify problematic behaviour and communications that can be explore further. (Safran and Segal, 1990)

Most modern cognitive orientated counsellors would argue, to varying degrees, the Therapeutic working Alliance is important in effecting change with clients. Nevertheless, an innovative kind of computer based treatment has emerged that challenges this view. Computer-based cognitive Behaviour Therapy (CCBT) packages have been developed to treat problems such as anxiety, panic, phobias and depression. A review of sixteen research studies concluded altogether some evidence exists that CCBT may be effective as therapist-led cognitive behaviour therapy, but the evidence was not conclusive (kaltenthaler, et al., 2004).apart from schema therapy, Cognitive Behaviour Therapy has typically regarded the Therapeutic working Alliance as importance, but has not used it as a mechanism for change. Development in theory are now taking the interpersonal aspects of the relationship into account, which has produce a resurgence of interest in the relationship as a possible means for facilitating change.

Therapeutic working alliance in Cognitive Behaviour Therapy (CBT) is formed between the counsellor and the client to gain a shared view of problem in relation to the client’s thoughts, feelings and behaviour, usually in relation to the here and now. This usually leads to the agreement of personalised and time limited goals and strategies which the counsellor will continually monitor and evaluate with the client. The outcome of therapy is to focus on specific psychological and practical skills, through reflection and exploration of the meaning attributed to events and situations, and re-evaluation of those meanings. The treatments are intrinsically empowering, aimed at enabling the client to tackle their own problems by employing their resources. Acquiring and using such skills is seen as the main target, the active component being promotion of change, particular using ‘homework’ to put what has been learned in practice between session. The client will optimistically attribute the progress in their problems to their own efforts, with their alliance with the counsellor.(Grazebook and Garland,2005)

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