A tripartite model of the psychotherapy relationship: Interrelations among its components and their unfolding across sessions.

The tripartite model of the therapy relationship, which includes the working alliance, real relationship, and transference-countertransference configuration, has been a useful way to conceptualize the complexity of the connection between a therapist and a client. However, little research has focused on the interrelationships between these three components over time. This study sought to replicate the findings of Bhatia and Gelso (2018) by examining the between-person relationships among each of the three elements averaged across all sessions. Additionally, we extended earlier work by examining the within-person relationship between the working alliance, the real relationship, and transference-countertransference with themselves as well as with each of the other elements across sessions. Using 5,931 sessions across 142 clients and 36 therapists, we examined time-ordered associations among the cocreated working alliance, cocreated real relationship, and the therapist-rated transference-countertransference configuration using latent variable dynamic structural equation modeling. Results replicated the findings of Bhatia and Gelso (2018), demonstrating that in one session, the working alliance and the real relationship were positively related, and both the working alliance and the real relationship were negatively related to the transference-countertransference configuration. Regarding the interrelations over time, the findings revealed that the working alliance in the previous session had a significant and positive relationship with real relationship in the current session, and the real relationship in the previous session was related to reduced transference-countertransference in the current session. These findings provide support for complex interrelations among the components over time. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Working alliance after transferring from one therapist to another in a training clinic: Influence of therapist attachment style.

This study investigated how client working alliance changed after transferring from one therapist to another: (a) When pre- and post-transfer therapists' attachment anxiety/avoidance were congruently higher or lower and (b) when the pretransfer therapists' attachment anxiety/avoidance were more or less discrepant from the posttransfer therapists. A Tau-U analysis and a multilevel polynomial regression and response surface analysis were used to analyze longitudinal data about 23 transferred clients in open-ended psychodynamic psychotherapy with doctoral-level therapist trainees (n = 29). When first and second therapists' attachment anxiety/avoidance levels were congruent, the higher the two therapists' attachment anxiety and avoidance levels were, the greater was the decrement in clients' ratings of working alliance after transfers. When first and second therapists' attachment anxiety/avoidance levels were discrepant from each other, the more the first and second therapists' attachment were different from each other in terms of anxiety, the greater decrement in clients' ratings of working alliance there was after transfers. Meanwhile, the more the two therapists' attachment avoidance levels were different from each other, the less decrement in clients' ratings of working alliance there was after transfers. Therefore, the attachment orientations of the pre- and post-transfer therapists combined to influence client working alliance after transfers. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A strong alliance is not enough: Item-level variation in an alliance measure moderates the alliance strength and client outcome relationship.

[Retraction notice: A retraction for this article was reported in Vol 70(4) of Journal of Counseling Psychology (see record 2023-89440-002). The following article (https://doi .org/10.1037/cou0000629) is being retracted. This retraction is at the request of coauthors Kivlighan and Hill after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. An was not responsible for obtaining and verifying participant consent but agreed to the retraction of this article.] This study investigated within-client effects of session-to-session working alliance (WA) strength (mean of client's and therapists' ratings of Working Alliance Inventory [WAI] items for a session; WAI-M) and intra-individual variance of working alliance (WAI-IIV; variation in how the same individual responds to different items in the WAI for a session) of therapist and client on overall client functioning. Specifically, we explored how the strength and intra-individual variance for therapist and client working alliance at a previous session (Time t-1) would relate to overall client functioning at a current session (Time t). We also explored whether the effect of WA-M on overall client functioning would be different at different levels of WAI-IIV. The dynamic structural equation modeling (Asparouhov et al., 2018) was used to analyze longitudinal data from 4,489 sessions at a university clinic where 17 doctoral student therapists provided low-cost, open-ended, individual psychodynamic psychotherapy to 135 adult community clients. We found that client-rated WAI-M and WAI-IIV had positive within-client main effects on next-session client functioning when controlling for autoregressive effects. Findings on WAI-M by WAI-IIV interaction effects revealed that the relationship between WAI-M at a previous session and client functioning at a current session was significant only when WAI-IIV was low (i.e., high intra-individual consistency across WAI items). Therapists' WAI-M, WAI-IIV, and interaction of WAI-M and WAI-IIV did not predict the next session client functioning significantly. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Therapist challenges and client responses in psychodynamic psychotherapy: An empirically supported case study.

In this case study of an adult female client working with a doctoral student female therapist in 85 sessions of individual psychodynamic psychotherapy, we analyzed the antecedents, challenges, and consequences for 53 challenges in the intake and first five sessions, the middle three sessions, and the final three sessions. Within the context of a strong therapeutic relationship and when the client was balanced in being defended as well as open/reflective, the therapist's challenges that were of high quality (deep, clear, empathic, and moderately forceful) were associated with the client becoming more open/reflective. In contrast, when the client was defended (but not open/reflective), the therapist's challenges were of lower quality and were associated with the client becoming more defended and closed off. Thus, both the antecedent client state and the quality of the therapist challenges were associated with the consequences of challenges in terms of the client's response. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The process and outcome of spiritually integrated psychotherapies: A cross-cultural study in Asia, Africa, Europe, and Latin America.

We investigated the process and outcome of spiritually integrated psychotherapies (SIPs) with 34 Catholic therapists and 359 clients in Asia, Africa, Europe, and Latin America using a practice-based evidence design. The three most frequently used spiritual interventions across all therapists were: "encouraging personal prayer," "affirming trusting God," and "encouraging listening to the heart," but "discussing hope" was also one of the top three in Asia and Africa, "self-control" in Asia, "spiritual confrontation" and "self-disclosure" in Latin America, and "listening to spiritual issues" in Europe. In addition, using growth curve analyses, we found a significant decrease in both spiritual and nonspiritual distress over the course of SIPs; the levels of spiritual and nonspiritual concerns were highly correlated (but distinct) at any given time point. Also, the nonspiritual outcomes at one session significantly predicted the subsequent session's spiritual outcomes, but not the other way around. Finally, a moderate number of spiritual interventions were associated with a faster decline in nonspiritual distress than was a low number, although we found mixed results regarding whether a high number of spiritual interventions was associated with a faster decline of clients' nonspiritual distress than a moderate number. Results suggest that therapists should attend to spiritual concerns in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Changes in client attachment in relation to client distress: A response surface analysis.

Using multilevel polynomial regression and response surface analysis, we studied the association between Time 1 (T) and Time 2 (T + 1) attachment anxiety and attachment avoidance, and T + 1 psychological distress in 253 nine-session time periods for 65 adult community clients working with 13 doctoral student therapists in open-ended psychodynamic psychotherapy. Results indicated that when client attachment anxiety was consistent and higher from the beginning (T) to the end (T + 1) of a nine-session time period, clients tended to report higher distress at the end of the period; when attachment anxiety was consistent and lower across a time period, clients tended to report lower distress. When attachment anxiety decreased across a time period, clients reported lower distress at the end of the period; when attachment anxiety increased across a time period, clients reported higher distress. Neither within-client consistency nor change in attachment avoidance in a time period was significantly related to client distress at the end of the period. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).