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Abstract
Objective: Notwithstanding consistent findings of significant relationships between the alliance and outcome, questions remain to be answered about the relatively small magnitude of those correlations, the mechanisms underlying the association, and how to conceptualize the alliance construct. We conducted a preliminary study of an approach to the alliance based on interpersonal defense theory, which is an interpersonal reconceptualization of defense processes, to investigate the promise of this alternative approach as a way to address the outstanding issues. Method: We employed qualitative, theory-building case study methodology, closely examining alliance processes at four time points in the treatment of a case in terms of a case formulation based on interpersonal defense theory. Results: The results suggested that our approach made it possible to recognize key processes in the alliance and that it helps explain how the alliance influences outcome. Our analyses also provided a rich set of concrete illustrations of the alliance phenomena identified by the theory. Conclusions: The findings suggest that an approach to the alliance based on interpersonal defense theory holds promise. However, although the qualitative method we employed has advantages, it also has limitations. We offer suggestions about how future qualitative and quantitative investigations could build on this study.
Resumo
Objetivo: Não obstante as constatações consistentes de relações significativas entre a aliança e o resultado, continuam carecendo de respostas questões sobre a magnitude relativamente pequena dessas correlações, sobre os mecanismos subjacentes à associação e sobre como conceituar o constructo aliança. Realizamos um estudo preliminar de uma abordagem da aliança baseada na teoria da defesa interpessoal, que é uma reconceitualização interpessoal dos processos de defesa, para investigar a promessa desta abordagem alternativa como forma de abordar as questões pendentes. Método: Empregamos metodologia de estudo de caso qualitativa, teórico-construtiva, examinando atentamente os processos de aliança em quatro pontos de tempo no tratamento de um caso em termos de uma formulação de caso baseada na teoria da defesa interpessoal. Resultados: Os resultados sugeriram que nossa abordagem permitiu reconhecer processos chave na aliança e que ajuda a explicar como a aliança influencia o resultado. Nossas análises também forneceram um rico conjunto de ilustrações concretas dos fenômenos da aliança identificados pela teoria. Conclusão: Os resultados sugerem que uma abordagem da aliança baseada na teoria da defesa interpessoal é promissora. No entanto, embora o método qualitativo que empregamos tenha vantagens, também tem limitações. Oferecemos sugestões sobre como futuras investigações qualitativas e quantitativas poderiam basear-se neste estudo.
Zusammenfassung
Ziel: Ungeachtet der konsistenten Befunde zu signifikanten Beziehungen zwischen der Allianz und dem Behandlungsergebnis, bleiben offene Fragen bezüglich der relativ kleinen Ausprägung dieser Korrelationen, der zugrundeliegenden Mechanismen der Assoziation und der Konzeptualisierung des Konstruktes der Allianz. Wir führten eine erste Studie zu einem Allianzansatz durch, der auf der interpersonalen Abwehrtheorie basiert, wobei es sich um eine interpersonale Rekonzeptualisierung von Abwehrprozessen handelt, um das Potential dieses alternativen Ansatzes, diese offenen Fragen zu beantworten, zu untersuchen. Methode: Wir setzten qualitative, theoriebildende Fallstudienmethoden ein und führten eine detaillierte Untersuchung der Allianzprozesse zu vier Zeitpunkten während der Behandlung eines Falles unter Berücksichtigung der auf der interpersonalen Abwehrtheorie basierten Fallkonzeption durch. Ergebnisse: Die Ergebnisse legen nahe, dass unser Ansatz die Erkennung von zentralen Prozessen in der Allianz ermöglichte und einen Beitrag zur Erklärung leistet, wie die Allianz das Behandlungsergebnis beeinflusst. Außerdem lieferten unsere Analysen eine bereichernde Reihe konkreter Darstellungen des Allianzphänomens, welche von der Theorie identifiziert wurden. Schlussfolgerungen: Die Befunde deuten darauf hin, dass ein Allianzansatz, welcher auf der interpersonalen Abwehrtheorie basiert, vielversprechend ist. Obwohl die qualitative Methode, die wir einsetzen, Vorteile hat, bringt sie auch Einschränkungen mit sich. Wir machen Vorschläge, wie zukünftige qualitative und quantitative Untersuchungen auf dieser Studie aufbauen könnten.
摘要
目的：縱使研究一致發現同盟與治療成效的顯著關係，但仍無法解答這些相關數值相對來說強度仍小、這些關聯性底層的機制、以及如何概念化同盟的構念。我們以人際防衛理論為基礎進行了一項有關同盟取向的初步研究，該理論係將防衛歷程予以人際再概念化，探究以此理論作為替代取向來說明這個重要議題的可能性。方法：我們採用質性、理論建構式的個案研究方法論，運用人際防衛理論仔細檢視一個個案在治療四個時間點的個案概念化。結果：結果顯示本取向可以用來辨識同盟的主要歷程，且有助於解釋同盟如何影響成效。我們的分析對於防衛理論中蘊含的同盟現象亦提供極為豐富且具體的描述。結論：研究發現顯示運用人際防衛理論概念化同盟取向是值得期待的。然而，雖然我們採用的質性方法有其優點，但也有其限制。我們對於如何以本研究作基礎進行未來質化和量化的研究提供建議。
Obiettivo: Nonostante le solide prove di una relazione significativa tra alleanza ed esito, rimangono ancora senza risposta le domande circa la forza relativamente piccola di queste correlazioni, i meccanismi che sottendono l'associazione e come concettualizzare il costrutto dell'alleanza. Abbiamo condotto uno studio preliminare su un approccio all'alleanza basato sulla teoria delle difese interpersonali, che è una ri-concettualizzazione interpersonale dei meccanismi di difesa, per valutare il potenziale di questo approccio alternativo come un modo per affrontare le questioni in sospeso. Metodo: Abbiamo utilizzato metodologie di studio dei casi di tipo qualitativo e teorico, esaminando attentamente i processi di alleanza in quattro momenti temporali nel trattamento di un caso nei termini di una formulazione del caso basata sulla teoria delle difese interpersonali. Risultati: I risultati suggeriscono che il nostro approccio ha permesso di riconoscere i processi chiave nell'alleanza e che aiuta a spiegare come l'alleanza influenza l'esito. Le nostre analisi hanno inoltre fornito un ricco insieme di illustrazioni concrete dei fenomeni di alleanza identificati dalla teoria. Conclusioni: I risultati suggeriscono che un approccio all'alleanza basato sulla teoria delle difese interpersonali è promettente. Tuttavia, anche se il metodo qualitativo impiegato ha dei vantaggi, ha anche delle limitazioni. Presentiamo dei suggerimenti su come costruire ricerche future qualitative e quantitative su questo studio.
Acknowledgement
The authors thank Barry Cohen, William Jock, and Sumru Tufekcioglu for their assistance with data analysis.
Notes
1 Views of countertransference have focused either on therapist responses that result from the pull exerted by features of a patient's behavior or on therapist reactions that stem from the therapist's own conflicts. Our conceptualization is most similar to the former idea, but the second notion also is important because it helps explain why therapists do not always behave in ways that conform to the tenets about the feed-forward effects of patients’ defensive behavior.
2 The method we employed for examining the patient's noncoordinating interpersonal behavior pattern shares some similarities with conversation analysis. In particular, both involve careful analysis of sequential features of interaction. However, whereas practitioners of conversation analysis attempt to identify “devices” that play a role in conversational practices across members of a given discourse community, our method focuses on identifying individual differences in patterns of coordination. Readers interested in comparing the two approaches can refer to Westerman (Citation2011a).
3 When SASB is used for systematic coding, behaviors like this are given what are called “complex codes,” a term that refers to the fact that two different SASB characterizations apply to the behavior. With regard to Sharon's defensive, noncoordinating pattern, using our broad SASB-based notions, we could say that it reflected two different kinds of behaviors, acting independently and taking a stand and also going along/complying with the other, which can be described as a passive-aggressive pattern.
4 Some clarification of terms is useful here. We would not describe this formulation in itself as a countertransference reaction on the therapist's part because we use that concept to refer to how a therapist acts toward a patient (e.g., validating independence, guiding, attacking, and so forth). Taken by itself, we consider it to be an inaccurate formulation. However, the manner in which the therapist offered his interpretation about Sharon's confusion in turns 12, 14, 16, 18, 20, 24, 30, and 36 makes it a countertransference response because he behaved in a guiding way towards the patient, which is a positive response distinct from her wish.