Term Paper: Therapeutic Alliance, Attachment Theory and Retention

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Therapeutic Alliance, Attachment Theory and Retention in Therapy

Numerous studies have established that, "...therapeutic alliance is an essential component of successful therapy. All forms of individual psychotherapy have demonstrated a connection between outcome and therapeutic alliance "(Delaney, 2006). It is important to note that the significance of the therapeutic alliance goes beyond the parameters any one theory and is considered a "pantheoretical" factor of treatment. (Delaney, 2006) While the general concept and praxis of therapeutic alliance is associated with outcome, it is also aligned with the issue of retention.

This study will attempt to provide an overview of the relationship between therapeutic alliance and retention with reference to the underlying influence of attachment theory. The subject of therapeutic alliance has been in recent years the subject of numerous papers and studies and it is often seen as an essential element of the therapeutic process.

A central aim of this study is, through the analysis of the interrelationship between alliance, retention and attachment theory, to provide the groundwork to determine whether one can detect if the client experiencing the therapeutic alliance in a positive way. Related to this is the need to ascertain the effectiveness of therapy and alliance from both the client or patient's point-of-view and from the perspective of the therapist.

Another issue at stake in this study is to ascertain the most appropriate stage for determining the effective measurement of the status of the alliance. These in turn leads to important practical issues, such as the type of action that she be taken if the therapeutic alliance is not beneficial and whether the patient should be referred to another therapist or work through the alliance difficulties.

Brief background to the understanding of therapeutic alliance brief overview of the history and significance of therapeutic alliance is necessary as a prolegomena to the understanding of the links or the variables that intersect between therapeutic alliance and retention.

In a contemporary sense, therapeutic alliance is an essential part of psychotherapy can be traced to Bordin's (1979) conceptualization of the alliance. This is a clearly measurable and definable concept. Bordin's definition of therapeutic alliance consists of three interconnected components. These are:

The body of trust between therapist and client or patient.

The agreement on the goals of the theory.

Tasks or the agreement on the specific activates that facilitate the development of therapy towards various intervention goals. (FAW et al. 2005)

Furthermore, the therapeutic alliance is considered as "...the most important determinant in treatment continuance and success... As well as the most frequently identified factor contributing to the outcome of therapy" (Delaney R.O. 2006).

The imperative nature of therapeutic alliance and the collaborative aspect of therapy in psychoanalytic theory can be related back to the work of Freud. This refers to the impact in Freud's theory of the concept of transference, where, "....the client displacing repressed wishes, fantasies, and aspects of past relationships from childhood onto the therapist" (Delaney R.O. 2006). The question of retention and the reason for a patient choosing to endure and remain in the process of therapy was raised by Freud. (Freud, 1912) the answer that Freud gave to this his question reflects on the issues at stake in this paper.

He concluded that the client was able to view the therapeutic relationship as positive aspects of previous relationships and that the client could bond with, or have an alliance with, the therapist to work together to fight against the client's negative past experiences. Freud then viewed this as an aspect of the client's positive ego that was capable of forming a real, true bond with the therapist's rational ego. (Delaney R.O. 2006).

The above quotation points to a number of issues that will be explored in this paper. The first is that retention is directly connected to the perceptions of the therapeutic alliance. The patient or client's perception of the bond that is formed - particularly within the first few sessions - is a determining factor in the period of retention. Secondly, the process of therapeutic alliance works both ways in terms of perception and is concerned as well with the way that the therapist perceives the worth or value of the therapeutic alliance.

In 1934, Sterba defined alliance as the relationship between the reasonable aspects of both the therapist and the client. (Sterba, 1934) Therefore, in order to enable positive outcomes and retention, the client's ego "...needed to be strengthened in its interactions with the therapist" (Delaney, 2006). This process was facilitated by an intense form of understanding and cooperation between therapist and client. The concept of alliance was therefore seen as an indispensable process, whereby the client would accept or acquiesce to the therapist's view and insight into the particular problem, which in turn would increase the likelihood of positive outcomes to the therapy.

The view of therapeutic alliance was taken further by therapists such as Zetzel, Rogers and Greenson in the 1950s and 1960s. These therapists advanced beyond the theory of transference towards an understanding of the therapeutic alliance as a conscious process, which leads to the development of a situation of trust and cooperation between the client and the therapist.

For example, Zetzel (1956) redefined the therapeutic alliance as describing "...the authentic object relationship which promoted the client's ability to withstand analysis" (Delaney, 2006). This view stresses the way that the therapeutic alliance also alters or potentially changes the perceptions and emotional and cognitive stance of the client or patent. Zetzel believed that,."..it was the ability to foster and maintain this alliance with even the most disturbed clients that would allow for a successful analysis of the transference and the success of the treatment "(Delaney, 2006).

This view was developed by other theorists such as Rogers (1957), in which the therapeutic relationship between the patient and the therapist was placed at the centre of the therapy. In this regard, a central aim for the therapist was to establish a firm, stable and consistent relationship or alliance with the patient or client. For this to occur there were certain preconditions that need to exist. These included, among others, that there had to be psychological context between the therapist and client; the therapist should invest in the relationship; there should also be unequivocal acceptance of one another; empathy and, importantly, that the client should be aware of and understand the aims and interaction with the therapist.

These theories were to lead to numerous clinical trials in the 1950 and 60s, which tended to establish the view that empathic client - therapist alliances resulted in better results and outcomes. (Horvath, 2001). A study by Horvath, (2001) reveals a cardinal issue. This was that the behavior and actions of the therapist were not as important as the way that the client or patient perceived these actions or behaviors. (Horvath, 2001)

In other words, the way that the client reacted to the intention and the degree of empathy from the therapist was deemed the most significant aspect in the therapeutic process in terms of positive outcomes and retention measurement. This is supported by theorists like Greenson who noted that that positive collaboration between client and therapist was one of the essential components for therapeutic success. (Greenson, 1967)

The concept of therapeutic alliance was further developed in the late 1970s by Luborsky (1976). He redefined the contemporary understanding of therapeutic alliance. In this definition, the way that the therapist made the client feel safe and accepted was emphasized. Secondly, the client is encouraged to cooperate and even collaborate with the therapist in the process of therapy. (Luborsky, 1976) This type of alliance would then lead to a form of shared commitment from both client and therapist, which would have the best chance of positive therapeutic outcomes.

Bordin was to take this redefinition of therapeutic alliance further and establish certain criteria that were measurable and clear. In Bordin's view, the alliance between the client and the therapist was a conscious and collaborative relationship, which was not concerned with transference. (Bordin, 1979)

In essence, this view stresses that in the first instance there should be an agreement between the client and the therapist as to the aims and intentions of the therapy; as well as an agreement on certain specific tasks and their aims and purposes within the ambit of the therapy. (Bordin 1979) Finally, the tasks, aims and the actions in the therapeutic alliance should be consistent with the milieu and the lifestyle of the client or patient.

Agreement on goals occurs when the clients and the therapist agree about the targets of change while in therapy. The clients must also perceive that the therapist is truly invested in helping them to achieve their goals, aided by a mutual fondness, attachment and trust (Delaney R.O. 2006).

All these theoretical aspects tended to elevate the importance of the therapeutic alliance in psychotherapy. The therapeutic alliance was seen in many instances as being in itself therapeutic. (Rogers 1957). In the 1900s, therapeutic alliance was seen by many as being a prerequisite for… [END OF PREVIEW]

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