The helping alliance and premature termination

The "educational alliance" as a framework for reconceptualizing feedback in medical education

Feedback has long been considered a vital component of training in the health professions. Nonetheless, it remains difficult to enact the feedback process effectively. In part, this may be because, historically, feedback has been framed in the medical education literature as a unidirectional content-delivery process with a focus on ensuring the learner's acceptance of the content. Thus, proposed solutions have been organized around mechanistic, educator-driven, and behavior-based best practices. Recently, some authors have begun to highlight the role of context and relationship in the feedback process, but no theoretical frameworks have yet been suggested for understanding or exploring this relational construction of feedback in medical education. The psychotherapeutic concept of the "therapeutic alliance" may be valuable in this regard.In this article, the authors propose that by reorganizing constructions of feedback around an "educational alliance" framework, medical educators may be able to develop a more meaningful understanding of the context-and, in particular, the relationship-in which feedback functions. Use of this framework may also help to reorient discussions of the feedback process from effective delivery and acceptance to negotiation in the environment of a supportive educational relationship.To explore and elaborate these issues and ideas, the authors review the medical education literature to excavate historical and evolving constructions of feedback in the field, review the origins of the therapeutic alliance and its demonstrated utility for psychotherapy practice, and consider implications regarding learners' perceptions of the supervisory relationship as a significant influence on feedback acceptance in medical education settings.

Psychotherapy engagers versus non-engagers: differences in alliance, therapist verbal response modes, and client attachment

For each of four therapists, we studied two clients who did not return after intake (non-engagers) and two clients who continued for at least eight sessions of psychodynamic psychotherapy (engagers), for a total of 16 cases yielding 3877 therapist verbal response units. Engagers and non-engagers did not differ in terms of working alliance measured after the intake session. In terms of therapist verbal response modes for non-engagers compared to engagers, therapists used more approval-reassurance in the beginning third of intake sessions, and more reflections of feeling but less information about the helping process in the last third of intake sessions. Non-engagers had higher pre-intake attachment anxiety than engagers. Implications for practice and research are discussed.

Processing the therapeutic relationship

The authors propose that if therapists and clients process their therapeutic relationship (i.e., directly address in the here and now feelings about each other and about the inevitable problems that emerge in the therapy relationship), feelings will be expressed and accepted, problems will be resolved, the relationship will be enhanced, and clients will transfer their learning to other relationships outside of therapy. The authors review theories supporting the idea of processing the therapeutic relationship, discuss the relevant empirical literature in this area, and provide their conceptualization of the construct of processing the therapeutic relationship based on the theory and empirical findings. Finally, they discuss methodological concerns and suggest implications for clinical practice, training, and further research.

Working Alliance, Treatment Satisfaction, and Patterns of Posttreatment Use Among Adolescent Substance Users

This longitudinal study examined the relationships among the working alliance, treatment satisfaction, and posttreatment use among adolescents in treatment for substance abuse. Adolescents (N = 600) from the Cannabis Youth Treatment study (M. L. Dennis et al., 2002) completed measures of working alliance and treatment satisfaction as well as substance use and substance-related problems at intake and 3, 6, 9, 12, and 30 months' postintake. When controlling for initial substance use and substance-related problems, working alliance, but not treatment satisfaction, predicted use at 3 and 6 months' postintake. Neither working alliance nor treatment satisfaction were predictive of longitudinal patterns of posttreatment use. Implications for the assessment of working alliance and treatment satisfaction are discussed.

Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.

The future of optimism

Recent theoretical discussions of optimism as an inherent aspect of human nature converge with empirical investigations of optimism as an individual difference to show that optimism can be a highly beneficial psychological characteristic linked to good mood, perseverance, achievement, and physical health. Questions remain about optimism as a research topic and more generally as a societal value. Is the meaning of optimism richer than its current conceptualization in cognitive terms? Are optimism and pessimism mutually exclusive? What is the relationship between optimism and reality, and what are the costs of optimistic beliefs that prove to be wrong? How can optimism be cultivated? How does optimism play itself out across different cultures? Optimism promises to be one of the important topics of interest to positive social science, as long as it is approached in an even-handed way.