Effects of including a dog on treatment motivation and the therapeutic alliance in child and adolescent psychotherapy: study protocol for a randomized controlled trial.

BACKGROUND: Motivation and a therapeutic alliance are crucial for successful therapy. It is assumed that dogs can increase motivation and help support therapeutic relationships. This is one of the reasons for including dogs in psychotherapy. While the positive effects of psychotherapy with dogs have been documented over the past years, little is known about the underlying mechanisms of animal-assisted psychotherapy. This study therefore aims to investigate whether and how the presence of a dog affects motivation and the therapeutic alliance in child and adolescent psychotherapy. METHODS: The study is a randomized controlled trial assessing motivation and the therapeutic alliance during the first five sessions of psychotherapy attended by children and adolescents with different psychiatric disorders. We will recruit 150 children and adolescents and randomly assign them to one of three conditions: (a) a dog is present but not integrated in the therapeutic narrative, (b) a dog is actively integrated in the therapeutic narrative, and (c) no dog is present. The children's and adolescents' evaluations of the therapeutic alliance and of their motivation will be assessed as the primary outcomes using standardized questionnaires before and after the first five therapy sessions as well as at follow-up. Further outcomes include the therapists' evaluations of the therapeutic alliance and their motivation, treatment adherence of the children and adolescents, and treatment satisfaction of the children and adolescents, their parents, and of the therapists. Interventions are conducted by experienced therapists who regularly work with their dogs. Outcomes will be analyzed using general linear models, with the treatment group as a fixed factor and the baseline values as covariates. DISCUSSION: This study provides information on the possible motivation and alliance-enhancing effects of integrating a dog into child and adolescent psychotherapy. This is relevant for practice, as these two components are strong predictors of therapy outcome. Moreover, the study will contribute to a better understanding of how a dog should be incorporated into psychotherapeutic settings. This can lead to a more purposeful inclusion of dogs in psychotherapy for children and adolescents. TRIAL REGISTRATION: The trial was registered on ClinicalTrials.gov, NCT05384808, on 20 May 2022.

Dynamic relations between mentalization techniques and therapeutic alliance in psychodynamic child therapy: An evidence-based case study.

Therapeutic alliance and mentalization are common factors inherent to all effective treatments. Mentalization-based interventions have the potential to create a safe relationship, which makes further mentalizing interventions possible. However, to date, no study has examined the bidirectional relationship between these variables in child psychotherapy. In an evidence-based case study design, psychodynamic therapy processes of two Turkish children (age: 9 and 10 years) who presented with social withdrawal problems were compared. All their sessions (34 sessions from Case No. 1 and 31 from Case No. 2) were coded using the Therapy Process Observational Coding System-Alliance Scale and Mentalization-Based Treatment for Children Adherence Scale. Outcome scales pertaining to symptoms, attachment, and mentalization were administered at baseline and at termination. Time-series Granger Causality tests revealed that in the case with clinically significant outcome, mentalization techniques predicted therapeutic alliance in the subsequent sessions, which predicted the use of further mentalization interventions. However, this relationship was not supported in the case with no significant improvement. Selected sessions were clinically analyzed with verbatim session vignettes. Our findings indicate that mentalization techniques in child therapy are closely related to the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exploring the processes of connection and disconnection in imagery work in a patient with depression and dependent personality disorder.

Imagery work is a useful therapeutic tool in the treatment of depression. It is central in different therapeutic approaches, such as cognitive behavioral therapy and compassion-focused therapy. The clinical case of Cynthia is presented. Cynthia started therapy for severe depression associated with social anxiety and dependent personality disorder. At different key moments in the therapy, the proposed change strategies led to ruptures in the therapeutic alliance. For example, difficulties in accepting depression, fears of being judged by the therapist, guided imagery of compassion and work on the termination of therapy were both triggers of ruptures and spaces for working on the issues linked to the therapeutic relationship. The interactions between different factors of the therapeutic relationship from the perspectives of both the patient and therapist and the implementation of imagery practices in session are presented.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode".

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Patient-Oncologist Therapeutic Alliance Among Young Adults with Cancer: Relationships with Meaning and Peace of Mind.

Cancer diagnosis and subsequent treatment can impact how young adults make sense of their worlds and disrupt peace of mind. The patient-oncologist therapeutic alliance, built upon mutual care, respect, and trust, may foster a deeper understanding of one's illness and promote peace of mind. The study examined relationships between a comprehensive cancer-specific measure of therapeutic alliance and meaning and peace of mind among young adults with cancer (N = 56). Results indicated that a stronger therapeutic alliance was positively associated with meaning and peace of mind. Findings highlight the importance of the patient-oncologist therapeutic alliance in facilitating positive psychological outcomes among young adults with cancer.

Effectiveness of mindfulness-based interventions on psychotherapy processes: A systematic review.

In the field of psychotherapy, scientific research has highlighted the importance of empathy and therapeutic alliance in regard to the effectiveness and better results of psychological treatments. In recent years, mindfulness-based interventions (MBIs) have shown to be effective at increasing empathy and therapeutic alliance and how this could affect the patients' symptomatology. In this study, we conducted a systematic review of the effectiveness of MBIs applied to psychotherapists to improve their empathy, the therapeutic alliance and the patients' symptomatology. Sixteen studies evaluating the impact of an MBI on some of these variables were identified, of which six included measures evaluated by the patients whose psychotherapists received the MBI. The risk of bias of the included studies was analysed following the methodological standards. We found very different designs and methodologies in the studies included in this review, with few of them including a control group. The results show a limited increase in empathy, measured by the psychotherapist, after an MBI. However, the results in therapeutic alliance are not conclusive, as well as the improvements in the perception of patients about their symptomatology. It is concluded that MBIs can have a beneficial effect on the psychotherapeutic practice, through the development of psychotherapists' empathy. Future research would require new studies with a higher methodological quality, and in which the effects of MBIs on empathy, therapeutic alliance and patients' symptomatology and the relationships between them are analyzed.

[Scientific medicine and care relationship: From the therapeutic alliance to the therapeutic effect of the alliance]. / Médecine scientifique et relation de soin : de l'alliance thérapeutique à l'effet thérapeutique de l'alliance.

The new paradigm of precision medicine in oncology questions today the respective place of evidence-based medicine and doctor-patient relationship. Based on the results of a randomized study comparing the efficacy of a homeopathic molecule in the prevention of nausea and vomiting induced by chemotherapy in non-metastatic breast cancer, this article extends and develops the discussion of maintaining an unresolved tension between medical art and medical science, between care and cure. This tension sets a base for the authors of the therapeutic alliance in medicine, defined as a dialectic constantly adjourned between the alliance of the doctor with the patient and his therapy, and the therapeutic effect of this alliance. Because if a policy or a public opinion were to promote an exclusively rational medicine deprived of the field of relation to care, or on the contrary a medicine based only on clinical sense and intuition, then respectively the ethics of care and the progress of therapy would be threatened. It is advisable to be aware of erring from the truth, amplified today by social networks, as much due to a tide of scientific positivism, as an excess of the "good caring soul". Taking into account the therapeutic alliance makes it possible to no longer oppose scientific medicine and care relationship.

Effects of therapeutic alliance on clinical outcomes in patients with symptomatic knee osteoarthritis undergoing an exercise program: A randomized clinical trial protocol.

BACKGROUND: Previous evidence has shown that seniors physical therapists applying electrotherapy and an enhanced therapeutic alliance in their sessions can positively influence the levels of analgesia of patients with chronic low back pain. It is currently unknown if these effects can be achieved in people with symptomatic knee osteoarthritis when receiving treatment focused on therapeutic exercise. AIM: To determine the effects of different therapeutic alliance levels during the application of a therapeutic exercise program on pain intensity and pressure pain threshold in patients with symptomatic knee osteoarthritis. METHOD: This will be a randomized, parallel, two-arm, clinical trial. An intervention of three sessions of therapeutic exercise will be applied for one week. Patients aged 45 to 65 years old with a clinical and radiographic diagnosis of knee osteoarthritis will participate. Also, patients with a pain intensity of at least three months duration and 3 to 8 points in a numerical rating scale will be included. Patients will be randomly assigned to a therapeutic exercise experimental group with an enhanced therapeutic alliance (e.g., active listening, personalized conversation, empathy) or limited therapeutic alliance (e.g., one-way verbalization, brief interaction). Physical therapists will be trained in delivering these two levels of the therapeutic alliance. The pressure pain thresholds at the symptomatic knee and the pain intensity will be measured before and after the intervention. DISCUSSION: The results of this research will determine the impact of the therapeutic alliance as a nonspecific relevant factor during the application of a therapeutic exercise program in the treatment of patients with symptomatic knee osteoarthritis. CLINICAL TRIALS REGISTRATION NUMBER: NCT04390932.

ANTECEDENTES: Evidencia previa ha demostrado que los fisioterapeutas expertos que aplican electroterapia junto con una alianza terapéutica mejorada pueden influir positivamente en los niveles de analgesia de los pacientes con dolor lumbar crónico. Actualmente se desconoce si estos efectos se pueden lograr en personas con artrosis de rodilla sintomática cuando reciben un tratamiento basado en ejercicio terapéutico. OBJETIVO: Determinar los efectos de diferentes niveles de alianza terapéutica durante la aplicación de un programa de ejercicio terapéutico sobre la intensidad del dolor y el umbral del dolor a la presión en pacientes con artrosis de rodilla sintomática. MÉTODO: Este será un ensayo clínico aleatorizado, paralelo, de dos brazos. Se aplicará una intervención de tres sesiones de ejercicio terapéutico durante una semana. Participarán personas de 45 a 65 años con diagnóstico clínico y radiográfico de artrosis de rodilla sintomática, con intensidad del dolor entre 4-7 puntos en la escala numérica del dolor con al menos 3 meses de duración. Los participantes serán asignados al azar a un grupo experimental de ejercicio terapéutico con una alianza terapéutica mejorada (por ejemplo, escucha activa, conversación personalizada, empatía) o alianza terapéutica limitada (por ejemplo, verbalización unidireccional, breve interacción). Se capacitará a los fisioterapeutas para brindar estos dos niveles de alianza terapéutica. Los umbrales del dolor a la presión en la rodilla sintomática y la intensidad del dolor se medirán antes y después de la intervención. DISCUSIÓN: Los resultados de esta investigación determinarán el impacto de la alianza terapéutica como factor inespecífico durante la aplicación de un programa de ejercicio terapéutico en el tratamiento de pacientes con artrosis de rodilla sintomática. NÚMERO DE REGISTRO DE ENSAYOS CLÍNICOS: NCT04390932.

Building the alliance and using experiential techniques in the early phases of psychotherapy for avoidant personality disorder.

Individuals experiencing avoidant personality disorder (AvPD) tend to make sense of social interactions via maladaptive self-and other attributions. They also experience difficulties in recognizing emotions. A further feature of AvPD psychopathology is the tendency to resort to maladaptive coping strategies, such as behavioral avoidance and perfectionism. Despite its impact, psychological treatments for AvPD remains poorly investigated. Herein, we describe the first five sessions of Metacognitive Interpersonal Therapy with a 28-year-old woman, whose treatment goal was to reduce social avoidance. We describe how this goal was achieved through a combination of working through the therapeutic relationship, alongside experiential techniques such as guided imagery, rescripting, and bodily work. Through this treatment configuration, the patient was able to increase self-awareness of her own emotions, enabling her to realize that she was guided by rigid schemas; specifically seeing herself as inadequate and others as judgmental. Finally, implications for the treatment of AvPD are discussed.

Acceptance and commitment therapy and the therapeutic relationship: Rupture and repair.

The therapeutic relationship is an essential part of effective therapy. Therapists facing a rupture in this alliance are challenged to mend the discord in a forward moving and effective treatment service. In acceptance and commitment therapy (ACT) the alliance is characterized by client and therapist working together, using the core processes of ACT, creating a vital and moment-by-moment collaborative experience. As a transdiagnostic, behavioral intervention, acceptance, and mindfulness processes and commitment and behavioral change processes are used to create meaningful and engaged lives. ACT's core methods promote psychological flexibility in response to problems in living, psychopathology, and enhancement of general well-being. However, flexibility in session can be lost to therapeutic ruptures. In ACT, processes such as defusion, perspective-taking, choice, and values play a role in restoring a cooperative, engaged alliance repair. We will explore the therapeutic relationship within the ACT model and present its perspective on rupture and repair in psychotherapy.

Development of therapeutic alliance in mentalization-based treatment-Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder.

Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidence-based treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

Therapeutic Alliance Formation for Adolescents and Young Adults with Autism: Relation to Treatment Outcomes and Client Characteristics.

Therapeutic alliance may influence treatment outcomes for individuals with autism spectrum disorder (ASD). The present study examined the trajectory of alliance, observationally-measured at four timepoints during a 16-week mindfulness-based treatment targeting emotion regulation problems in adolescents and young adults with ASD (n = 37, mean age = 15.28, 78.40% male). Variability in alliance as a function of client characteristics and the degree to which alliance predicted emotion regulation outcomes were assessed using parent-report forms. Results demonstrate that alliance fluctuates throughout treatment. Moreover, stronger alliance predicts decreased dysphoria at posttreatment. Results also suggest that increased ASD symptom severity and depression predict weaker alliance early and throughout treatment. Findings highlight a need for clinicians to consider the importance of developing strong alliance for clients with ASD.

The Mindfulness-Based Phase-Oriented Trauma Therapy (MB-POTT): Hypnosis-informed mindfulness approach to trauma.

Hypnosis has long been successfully used in the treatment of trauma and related disorders. In this paper, I describe a hypnosis-informed approach to PTSD using mindfulness. The Mindfulness-Based Phase-Oriented Traumatic Therapy (MB-POTT) follows the phase-oriented tradition that was originally proposed by Pierre Janet, later expanded by Daniel Brown and Erika Fromm using clinical hypnosis. MB-POTT comprises four distinct, yet recursive, stages: (1) therapeutic alliance building and symptom stabilization, (2) formation of a narrative about the trauma, (3) re-creation of meaning of life after trauma, and (4) future symptom management. In explaining these categories, I delineate the nature of mindfulness, both similarities and dissimilarities to hypnosis, with an emphasis on techniques that resemble hypnotic approaches (e.g., ego state therapy, ego-strengthening). Finally, I provide a case study in which MB-POTT was implemented with a client who suffered from PTSD after a near-fatal industrial accident.

Defending the art of physical therapy: Expanding inquiry and crafting culture in support of therapeutic alliance.

The successful practice of physical therapy requires a professional culture that places value on the interpersonal relationships that foster healing, and the face time required to build those relationships. Pressures on current practice are not facilitating this approach. The drive for increased productivity, cost effectiveness and ultimately, profit, are changing the landscape in which we practice. This phenomenon is fueled by an overemphasis on quantitative research in evidence-based medicine and an underappreciation of clinical expertise and patient values. This imbalance undermines the holistic, patient-centered approach that has been the basis for physical therapy since its inception. Authors suggest that in order to preserve defining characteristics of the profession, there is an urgent need to redirect our research agenda and PT education with a focus on the study of contextual and psychosocial factors that influence treatment outcomes. Recent research findings indicate that the effect of therapeutic alliance may be as important to outcomes as the chosen intervention. The authors suggest that excellence in Doctor of Physical Therapy (DPT) education must incorporate education addressing the vital importance of therapeutic alliance and also include training in the skills for developing such unique intentional relationships.

[Maintaining a Strong Therapeutic Alliance: Initial Experiences with the Alliance-Focused Training (AFT) in Germany]. / Umgang mit Spannungen und Krisen in der therapeutischen Beziehung: Erste Erfahrungen mit einem handlungsorientierten Ausbildungs- und Supervisionskonzept.

AIMS: Alliance Focused Training (AFT) 1 aims at enhancing therapists' competences in resolving ruptures in the therapeutic alliance using video recordings and role-plays. This pilot study funded by the Heigl Foundation aimed at presenting initial results and clinical experiences with AFT in Germany, and to prepare a subsequent RCT. METHODS: 7 trainee therapists participated. Therapies of 15 patients with depressive disorder were analyzed. RESULTS AND CONCLUSION: Trainees experienced AFT as very helpful for their professional development and for dealing with alliance ruptures. The therapeutic competence significantly improved both in self and in observer ratings. The results indicate that AFT is a promising approach to improve psychotherapy training, emphasizing the relevance of the planned proof of concept RCT.

Gazing Back, Playing Forward: Contemporary Psychoanalytic Musings on the Relational Essence of Hypnotherapeutic Action.

To build bridges between hypnosis and contemporary psychoanalysis, this article addresses how hypnosis, when used in psychotherapy, facilitates curative action through its relational essence. The author's extensive experience with hypnosis, psychotherapy, and psychoanalysis orient the narrative toward the unconscious patient-therapist interaction, with particular attention paid to the ethics of the inherent hypnotic seduction. Whether used primarily in relief-oriented ways or geared toward more transformative therapeutic aims, powerful unconscious factors are in play for both patient and therapist and are explicated to illustrate the interactive and frequently unformulated, intersubjective factors that facilitate effective, psychotherapeutic hypnosis. Consequently, therapists attuned to such intersubjective dynamics can make use of their own internal mental activities to understand a patient's current state of mind and level of developmental functioning, and thereby subsequently formulate mutative interventions. For instance, because hypnotizability reflects the ability to play in imaginative space, the regression promoted in hypnotherapy may activate both an illusion of omnipotence and its optimal disillusionment through the relational context. This requires going beyond more traditional, procedural ways of bifurcating hypnotic interventions as being either direct or indirect and instead further distinguish hypnotic interventions in accordance with their maternal and paternal relational dimensions. Arguably, then, the skillful hypnotherapist needs to maintain a coupling interplay between the maternal, maximally receptive and the paternal, more active modes of functioning within hypnotic play space.

In the Intersubjective Space: Hypnosis Through a Neuropsychological Lens.

This article explores five interwoven principles about relationship that impact on attentional focus as it relates to the practice of clinical hypnosis. It first reviews how relationship is an irreducible feature of life that greatly predates the arrival of human beings. Second, it describes brain structures that, from an evolutionary perspective, appeared relatively recently, and the neuropsychological abilities those structures confer on human relationships. Third, it links those social brain structures to trance, an inborn response to novelty that is an important feature of our adaptive learning capacity. It further suggests that narrative is a multilevel concept that is deeply embodied and constitutes the sorbate from which hypnotic interactions can draw their rich impact. Finally, the article posits that hypnosis represents a skill set through which attuned clinicians engage in co-creative dances with clients, where the choreography of their interaction attends and responds to spontaneously arising and/or deliberately seeded opportunities for adaptive change. Reconstructed descriptions of interactions with clients are provided to illustrate the application of the principles presented.

The Generative Presence of Relatedness.

In this guest editorial, the authors introduce a special issue of the American Journal of Clinical Hypnosis that focuses on relational factors of hypnosis in psychotherapy. The authors have invited a number of esteemed colleagues to comment on aspects of the therapeutic relationship, and how it informs and influences the processes, techniques, and outcomes of hypnosis and therapy. In addition to summarizing each of these articles, this article analyzes the major relational themes that present across the articles.

Longing and Fear: The Ambivalence About Having a Relationship in Psychotherapy.

It is unquestioned that reaching the hypnotic state is helped along by relational factors and that, conversely, relational experiences can be deepened through hypnosis. It is also true that deepening the experience of being in a relationship with another person is neither comfortable nor indicated for every patient or therapist. Most humans feel ambivalent about closeness. People vary in their desire for and their skill in sustaining mature intimacy. When we move along the continuum from rudimentary notions about relational factors in psychotherapy, such as rapport, to complex concepts, such as enactments, we move along a corresponding continuum of increasing need for specialized training, supervised experience, and personal therapy. The field of psychotherapy has been plagued from its inception by not knowing what to do with the tensions that emerge when two people listen to and look at each other. Avoiding relational factors may be a very human response to a very daunting matter.

Dancing in the In-Between: Hypnosis, Transitional Space, and Therapeutic Action.

This article develops the idea that hypnosis is an interactive phenomenon occurring in a relational matrix. A tripartite model for explicating this relational matrix is presented, which includes a discussion of transference, contemporary relationship factors, and the interaction of these to produce a sense of therapeutic alliance. These relationship factors are central to the therapeutic action of hypnosis as a vehicle to potentiate change and growth. The unique and specific contribution of each of these factors to the process of hypnotherapy and to therapeutic action is examined. Phenomenologically, this relational interaction is conceptualized as occurring in transitional space, shaped by processes of regression and attunement. From this perspective, the hypnotherapist is viewed as a kind of transitional object whose empathic presence contains and facilitates those interactive phenomena which evoke and balance the transferential and contemporary aspects of the relationship and which allow for uniquely evocative developmentally focused interventions in trance work. Several examples are presented from an ongoing case that demonstrate how these relational variables shape the hypnotherapeutic process and how they can be used for uncovering and self-examination, for structural maturation, for affect regulation, and for emerging ego mastery. The therapeutic action demonstrated relies on hypnotic interventions rooted in the various components of the relational matrix made possible by the clinician's awareness of and attunement to these and by hisor her informed and sensitive management of them and of his or her own intersubjectivity. Specific strategies are presented via these examples to effectively utilize this experience in the service of treatment goals.