This article was downloaded by: [Luis Botella]On: 28 October 2013, At: 14:35Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

European Journal ofPsychotherapy & CounsellingPublication details, including instructions for authorsand subscription information:http://www.tandfonline.com/loi/rejp20

The co-constructed therapyalliance and the technical andtactical quality of the therapistinterventions in psychotherapyLuísa Soares a , Lluís Botella b & Sergi Corbella ba University of Madeira , Funchal, Madeira Island,Portugalb Facultat de Psicologia, Ciències de l'Educació ide l'Esport Blanquerna , Universitat Ramon Llull ,Barcelona, SpainPublished online: 03 Aug 2010.

To cite this article: Luísa Soares , Lluís Botella & Sergi Corbella (2010) The co-constructed therapy alliance and the technical and tactical quality of the therapistinterventions in psychotherapy, European Journal of Psychotherapy & Counselling, 12:2,173-187, DOI: 10.1080/13642537.2010.482735

To link to this article: http://dx.doi.org/10.1080/13642537.2010.482735

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the “Content”) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, orsuitability for any purpose of the Content. Any opinions and views expressedin this publication are the opinions and views of the authors, and are not theviews of or endorsed by Taylor & Francis. The accuracy of the Content shouldnot be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions,claims, proceedings, demands, costs, expenses, damages, and other liabilities

whatsoever or howsoever caused arising directly or indirectly in connectionwith, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expresslyforbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

European Journal of Psychotherapy and CounsellingVol. 12, No. 2, June 2010, 173–187

The co-constructed therapy alliance and the technical and tactical

quality of the therapist interventions in psychotherapy

Luısa Soaresa*, Lluıs Botellab and Sergi Corbellab

aUniversity of Madeira, Funchal, Madeira Island, Portugal; bFacultat de Psicologia,Ciencies de l’Educacio i de l’Esport Blanquerna, Universitat Ramon Llull, Barcelona,Spain

(Received 31 March 2010; final version received 28 June 2010)

This study sought to describe a brief review of studies conducted on thetherapeutic alliance, taking into consideration therapeutic process andoutcomes. We seek to reflect about the need to encourage the communitieswho engage in and conduct research on clinical practice not only toimplement surveys of empirically validated measures of therapeuticoutcomes, but also make them a regular practice among all clinicalmental health psychotherapists. We therefore suggest the followingparadigm – the Practice Based on Evidence of Results (PBER) – as away to improve the quality of technical and tactical interventions ofpsychotherapists

Keywords: alliance; process; therapeutic outcome; clinical practice

1. Research focused on therapeutic process and outcome – the therapeutic

alliance

Two guiding concepts of research are emphasised in this article: therapeuticprocess and therapeutic outcome. According to Machado, (1994) the field ofresearch in psychotherapy has usually been divided into research focused onprocess and research focusing on results. The research that has focused on thetherapeutic process has concentrated on finding out which key factors can beseen as leading to certain results. Within this, the therapeutic alliance wasconsidered as a significant dimension in the therapeutic process. This is aconcept that is seen as central to building a psychotherapeutic relationship(Corbella & Botella, 2003) and as part of the therapeutic process (Arnkoff,1995; Goldfried & Davidson, 1994; Newman, 1998; Safran, 1998). Accordingto Rogers (1951, 1957) being empathetic, consistent and unconditionallyacceptance of the client are three core characteristics that the therapist shoulddevelop in order to establish an effective therapeutic relationship. This concept

*Corresponding author. Email: lsoares@uma.pt

ISSN 1364–2537 print/ISSN 1469–5901 online

� 2010 Taylor & Francis

DOI: 10.1080/13642537.2010.482735

http://www.informaworld.com

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

of alliance between the client and therapist was quite evident in the scientific

field throughout the twentieth century (e.g., Bordin, 1975; Bowlby, 1988;

Freud, 1912/1996; Greenson, 1965; Horvath, 1981; Horvath & Greenberg,

1989; Luborsky, 1976; Machado & Horvath, 1999; Rogers, 1957; Sterba, 1934;

Strong, 1968; Zetzel, 1956). However, Machado and Horvath (1999) point to

a concept of the therapeutic alliance that is trans-theoretical and relates to

an active collaboration between the therapist and client, emphasizing the

importance of compatibility between both participants. In that sense, Corbella

and Botella (2003) argue that therapy is a process in which the client learns,

or modifies certain behaviours or habits, but the technical quality of the

interventions made by the therapist is essential.

Definition of therapeutic alliance

Bordin (1976) identified three dimensions of the therapeutic alliance that are

still commonly accepted by the scientific community. They are a) agreement on

tasks; b) relationship/positive bond; and c) agreement on goals. Bordin’s

conceptualisation provided a benchmark for the explanation of the therapeutic

alliance and its components and served as basis for the construction of various

alliance assessment instruments. Luborsky (1976) on the other hand, has

developed a concept of alliance closer to the psychodynamic perspective,

arguing that it is a dynamic entity, which develops throughout the changes that

occur during the various stages of the psychotherapeutic process (Horvath &

Luborsky, 1993; Corbella & Botella, 2003). Corbella and Botella (2003) present

the theory of Luborsky (1976) describing two types of therapeutic alliance,

according to the phase of therapy in which the client is. Type 1 alliance occurs

mostly at the beginning of therapy and is characterized by the feelings client

experience when helped and supported by the therapist. Type 2 alliance is

described as occurring at later stages in the therapeutic process and it is

characterized as the client’s sense of working together towards the reduction of

unhappiness and psychological suffering. Although the theories of Bordin and

Luborsky appear to be complementary, they present differences. For example,

the alliance of type 1 (Luborsky, 1976), can be understood as the feeling of

comfort that clients experienced when feel welcomed and can relate to the sense

of acceptance or positive relationship advocated by Bordin. The agreement on

tasks and goals by the therapist and the client can be seen as comparable to

Luborsky’s Type 2 alliance. It is interesting to analyze the alliance not only on

a structural level, but also on the level of content of the therapeutic work

identified, both by the therapist and by the client; for instance, to observe if an

agreement on goals and tasks made by the therapist and the client is also

compatible in terms of therapeutic content. One example of this is that both

therapist and client might mark on a questionnaire ‘my therapist and I are

in agreement about goals’. In this example, it would be relevant to distinguish

whether they were able to formulate the same goal in terms of content, such as

to ‘reduce/control the anxiety’ (considered the content of the goals).

174 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

The idea here therefore was to make an ‘observational journey’ throughoutthe therapeutic process in terms of both structural and therapeutic content.Regarding the study of this structural dimension, the research has pointed outseveral useful indicators, such as the recommendation of several empiricallyvalidated instruments for evaluating the therapeutic alliance, as we shall seebelow. However, as far as therapeutic content is concerned and its compat-ibility between therapist and client, little has been done to this point, and it istherefore important to define lines of possible future research in this direction.

Corbella and Botella (2003) state that some authors have advocated theimportance of the negotiation of tasks and goals between therapist and client.They consider these as focal points for the establishment of a therapeuticalliance and for the therapeutic change (Pizer, 1992; Safran & Muran, 2000).This new design is distinct from the perhaps more conventional idea thatassumes the principle of the alliance as the therapist’s responsibility; meaningthat it is the therapist who ensures that the client identifies with him and adoptshis ideas about what goals and tasks should be worked towards in therapy(Corbella & Botella, 2003). In fact, these same authors distinguish two lines oftherapeutic relations: ‘a real relationship’ and a ‘working alliance’. The ‘realrelationship’ is the bond between client and therapist, while ‘working alliance’refers to their ability to work together to achieve the established goals. Theauthors offer a more constructive vision about the therapeutic alliance; forexample, ‘a joint construction between client and therapist, the expectations,opinions, that both can develop in working together, the relationship and thevision of each one are relevant elements to the establishment of therapeuticalliance,’ (Corbella & Botella, 2003, p. 208).

Kokotovic and Tracey (1990), in turn define ‘working alliance’ (p. 16, alsocalled the working relationship or therapy alliance), as the feeling that bothparticipants have of themselves which enables them to work productivelytowards a common goal. This ability to attach in a working alliance issometimes related to the quality of interpersonal experiences (past andpresent), of the client as well as with the level of psychological adjustmentand with the kind of problems they encounter in psychotherapy. Moras andStrupp (1982) found that a history of healthy interpersonal relationshipscorrelated with the capacity of the client to form an effective therapy alliance.On the other hand, clients who have high levels of stress (with correspondinglower levels of psychological adjustment) are more vulnerable and willconsequently have greater difficulty in forming a solid working alliance(Kokotovic & Tracey, 1990). Perhaps unsurprisingly however, it is these clientswho have the greatest need of a therapeutic alliance and an urgent need to builda therapeutic work.

Some research samples studied in experimental, non-naturalistic researchexploring psychotherapeutic effectiveness are arguably often not the mosttypical examples of the reality observed in clinical practice. It is argued thatclients who comprise research samples often tend to be less disturbed, havefewer co-morbility conditions and have less complex problems than the onesthat commonly are observed in clinical practice (Beutler & Howard, 1998).Indeed, these clients, with higher levels of disturbance, the most frequent

European Journal of Psychotherapy and Counselling 175

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

conditions of co-morbility and more complex problems, which cover manydifferent areas of life, have been shown to have much more difficulty incommitting to a process of research on a regular and systematic basis whichis sufficient to produce valid and consistent data. It is arguable that morevulnerable and disturbed clients may struggle, for example, to understand thequestionnaires and that their attendance at therapy may be infrequent or moreinconsistent than other, less disturbed clients, leading to these researchparticipants becoming ‘missing’ subjects in clinical samples. As a consequence,the data collected does not include that of these clients.

Regarding the moment of psychotherapy in which the alliance therapyshould be measured, research has shown that measures of the alliance therapyobtained at the beginning of the therapeutic process, around the fourth sessionare the best prognosis of therapeutic results (Horvath, 1981). Kokotovic andTracey (1990) note that, forming an effective working alliance takes time andtherefore, to measure it before the third session does not appear to be valid.However, Morgan, Luborsky, Crits-Christoph, Curtis and Solomon (1982)argue more towards the position taken in this review, that many cli-ents and therapists can establish an effective working alliance as early as thefirst session, especially in brief therapies and that which is otherwise limitedin time.

Corbella and Botella (2003) present us a review of research stating thatthere are currently more than 20 measures for evaluating the therapeuticalliance, but highlight the most used as being: California PsychotherapyAlliance Scales (CALPAS/CALTRAS; Gaston & Ring, 1992; Marmar, Weiss,& Gaston, 1989), the Penn Helping Alliance Scales (Penn/HAQ/HAcs/Har;Alexander & Luborsky, 1986); Helping the Alliance II Questionnaire (HAQ-II;Luborsky et al., 1996), the Therapeutic Alliance Scale (TAS; Marzialli, 1984),the Vanderbilt Therapeutic Alliance Scale (VPPS/VTAS; Hartley & Strupp,1983), the Working Alliance Inventory (WAI; Horvath, 1981, 1982) andIntegrative Psychotherapeutic Alliance (IPAS, EAPI; Pinsof & Catherall,1986). Most of these scales were adapted to be answered either by the client, orby the therapist, as well as an outside observer, showing good psychometricproperties (Horvath & Symonds, 1991).

Several studies present results that identify a significant correlation betweentherapeutic alliance and psychotherapeutic outcomes (e.g. Barber, Connolly,Crits-Christoph, Gladis, & Siqueland, 2000; Horvath & Symonds, 1991; Klee,Abeles, & Muller, 1990; Luborsky, 1994; Luborsky, Crits-Christoph,Alexander, Morgolis, & Cohen, 1983; Luborsky, McLellan, Woody, O’Brien,& Auerbach 1985; Marmar, Horowitz, Weiss, & Marziali 1986; Safran, &Wallner, 1991; Weerasekera, Linder, Greenberg, & Watson, 2001). The qualityof the therapeutic alliance is shown to be a good predictor of the resultsachieved by a variety of psychotherapeutic approaches (Horvath & Symond1991; Luborsky 1994, 2000) and can be a central dimension to assess the actualoutcome of psychotherapy.

Corbella and Botella (2003), in referring to the studies of Hatcher (1999),Stiles, Agnew-Davis, Hardy, Barkham and Shapiro (1998) posit that, of allthe aspects of the therapeutic alliance, cooperation and confidence seem to

176 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

be those with the greatest correlation to psychotherapeutic outcomes.Moreover, in contrast to the position that the therapeutic alliance takes timeto form and cannot be effectively measured prior to the fourth session, it isargued that the first sessions are particularly important for establishing agood relationship with the client (Mohl, Martinez, Ticknor, Huang, & Cordell,1991; Plotnicov, 1990) and the most obvious result of a poor therapeu-tic alliance is, according to Bordin (1979), a premature termination by theclient.

The concepts developed by Anderson, Ogles and Weis (1999) also used anddefended by Corbella and Botella (2003) are essentially that the therapeuticrelationship is of such importance that therapeutic inspiration and creativityare essential to both facilitate the establishment of an alliance in the earlysessions and to keep it throughout the therapeutic process. Ceberio (2003)states that in therapy, not all tactics are technical, but all techniques aretactical. These tactics are the product of the spontaneity and creativity of thetherapist in terms of the therapist’s knowing when and how to apply standardtherapeutic techniques. Ceberio (2003) argues that all the techniques and tacticsapplied by the therapist can be divided into three types:

. The verbal interventions are those developed in the context of thesession. They are characterised by the level of persuasion, by theability to be steering in the field of semantic milestones.

. The body interventions are those that are implemented by bodilytechniques such as psychodrama, body expression and body exercisesas well as gestaltic games. This would include everything that involvesanalogical language or anything that involves the language throughgestures, actions and the use of the body in the context of the session.

. The interventions of action take place, largely outside thecontext of the session and are the traditional prescriptions ofbehaviour.

According to the same author, the therapeutic relationship can beconceived as choreography, where we can implement these three types ofinterventions. The priority in this dance of interventions, and one that requiresmore training, is to incorporate the ability to sense the most appropriatemoment and introduce the best type of intervention together by evaluatingwhich one best suits that particular client.

Clinical experience shows that some therapeutic styles may be moreappropriate than others for certain clinical conditions. Instead of adapting toa certain therapeutic standard, the therapists could perhaps seek to discover inwhat situations their own style may be more appropriate (Fernandez-Alvarezet al., 2003). Most research studies done with English-speaking subjects(Beutler, Clarkin, & Bongar, 2000; Beutler et al., 2003; Beutler, Moleiro &Talib, 2002; Caine, Wijensinghe, & Winter, 1981) and with Spanish-speakingsubjects (Corbella, Garcia, Botella, & Keena, 2001) suggest that the relativecompatibility between the personal characteristics of the therapist, thecharacteristics of the client, and aspects of treatment, are significant in theeffectiveness of therapeutic interventions.

European Journal of Psychotherapy and Counselling 177

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

2. PBER – Practice Based on Evidence of Results, focused on the

psychotherapeutic outcome

The evaluation of therapeutic results appears to be an uncommon practicewithin the context of current Portuguese psychotherapy research, unlike the

international situation, where the link between research results and clinical

practice seems to be more established (although far from what some would see

as desirable). In this international context, research has generally shown that

mental health psychotherapists seem more familiar with the routine evaluation

procedures of their therapeutic results (Machado, 1994). The studies focusedon these results emphasized (in what sense?), on therapeutic techniques

and theoretical approaches, although do not seem to take as much consider-

ation of the analysis of other potentially important variables, such as those

of the therapist and of the client (Machado, 1994).An effective psychotherapy, regardless of the adopted methodology, is

arguably a psychotherapy that achieves significant levels of change in thoseareas established as therapeutic goals (Moreira, Goncalves, & Beutler, 2005).

Lambert (1992) identified four factors that contribute to a successful treatment:

(i) techniques; (ii) expectations; (iii) changes that occur outside the therapeutic

context; and (iv) the therapeutic relationship. More recent studies have focused

on a more specific aspect of this relationship: the characteristics of the personsinvolved in the relationship, specifically the clients, therapists and the

interaction or alliance between them (Fernandez-Alvarez, Garcia, Lo Bianco,

& Corbella, 2003). On the other hand, the ways in which several theoretical

models and therapies are organized to achieve their therapeutic goals differ

according to the conceptions held as to the client’s psychopathology, the

mechanisms of change and the necessary techniques to achieve this change(Moreira, Goncalves & Beutler, 2005).

Barkham et al. (2001) refer a review of studies of Froyd, Lambert and

Froyd (1996) where they found that out of 1430 assessment measures of results,

830 of them were only used once. They also state that in order to resolve the

inconsistent use of different measures of evaluating the therapeutic outcomes,

it would be necessary to adopt a core battery (Strupp, Horowitz, & Lambert,1997; Waskow, 1975). A core battery would be a standardized and sufficiently

broad instrument to be applied by the largest possible number of experts in

mental health. The authors also argue that for a therapeutic result measure-

ment to be accepted either by researchers or by therapists, it must have a clear

theoretical framework and must also be sufficiently flexible to be used in the

measurement of various disorders, as well as individuals with different degreesof disruption (average, moderate and severe).

Consequently, we raise the obvious question, which is whether different

therapists, motivated by different theories and working on different scenarios

can apply only one measure of the outcome of their work? Evans et al. (2000)

present the proposal of the CORE-OM, (Clinical Outcome in Routine

Evaluation – Outcome Measure) as a standard measure for assessing thetherapeutic outcome, or the change in therapy, in different contexts and in

different clinical populations. They suggest the necessary requirements for the

178 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

development of a measure of the therapeutic result:

Requirements for the development of a therapeutic outcome measurement

(Evans et al., 2000)Content:

. Short and readable.

. Meta-theoretical (must measure the change in therapy, regardless of

the theoretical reference underlying it).. Able to detect the clinical change.. With validity and consistency.. Sensitive to the needs of the clients.

Procedure:

. Simple.

. Easy to run.

. Easy to compute results.

. Supported by non-clinical and clinical standards.

. Easy to interpret.

Utility:

. Helps in the evaluation process.

. Improves the management of the clinical case.

. Provides inter-instruments information and inter-sessions.

. Encourage the beginning, the planning and the development of an

intervention.

Lambert et al. (2001), Lambert et al. (2002) and also Whipple et al. (2003)

refer to several studies that involve the collection of weekly information about

the evolution of clients in therapy and share this information with the therapist

(with graphics and data concerning the evolution of the client). The results

show that the feedback given to the therapist about a failed intervention

reduces the premature termination of therapy. The therapy was able to take

a more positive direction when such feedback was given to the therapist.Mellor-Clark et al. (2001) suggest that it is important to assess the outcome

and effectiveness of psychotherapy with validated and published measures.

In the literature review by Mellor-Clark and Barkham (2000), the authors

found that 30% of clinical therapists used measures created by them and that

only 15% used measures validated and published in the scientific community.Recently, several authors have been working on a scientific paradigm in the

field of psychotherapy, PBE – Practice Based Evidence (e.g. Evans, Connell,

Barkham, Marshall, & Mellor-Clark, 2003). This paradigm does not corre-

spond to the Portuguese situation which seems to be more the opposite, namely

that the practice of psychotherapy is still undertaken without evaluating the

results. There is still no regulatory system for psychologists and the research

that is done in the area of assessing the psychotherapeutic process is still not

sufficiently extensive. One fact that may explain this is that evaluating

the effectiveness of psychotherapy may previously have generated some

European Journal of Psychotherapy and Counselling 179

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

controversy, like some resistance from the therapist, to be evaluated by the

client or someone else, and in having that resistance, less research has been

done by them to diminish this lack of psychotherapeutic evaluation, and it has

become very difficult to homogenize the procedures given the wide variety of

theoretical approaches existing in the psychotherapeutic community, not only

at the national level but also globally.In the international context, in 1993, the Society for Psychotherapy

Research (Barkham et al., 1998) found that the more frequently used measures

for evaluating the therapeutic outcome were: Symptom Check List-SCL-90-R

(Derogatis, 1983, 1994) Hamilton Rating Scale for Depression (HRSD,

Hamilton, 1959), Beck Anxiety Inventory (BAI, Beck, Epstein, Brown, &

Speer, 1988), State-Trait Anxiety Inventory (STAI, Spielberger, Gorsuch,

Lushene, Vagg, & Jacobbs, 1983), Beck Depression Inventory (BDI, Beck,

Steer, & Garbin, 1988), Social Adjustment Scale (SAS-M, Cooper, Osborn,

Gath, & Feggetter, 1982), Inventory of Interpersonal Problems (IIP, Horowitz,

Rosenberg, Baer, Ureno, & Villasenor, 1988) and Rosenberg Self-esteem

Measure (RSM, O’Malley, & Bachman, 1979; Rosenberg, 1965).More recently in 1998, Barkham, et al. identified a number of studies where

different measures for evaluating the results were presented. In these studies

Froyd, Lambert, & Froyd, (1996) recognized the following instruments as

those applied significantly more: (a) Beck Depression Inventory (BDI, Beck,

Steer & Garbin, 1988), State-Trait Anxiety Inventory (STAI, Spielberger,

Gorsuch, Lushene, Vagg & Jacobbs, 1983), Hamilton Rating Scale for

Depression (HRSD, Hamilton, 1967), Symptom Checklist-90-R; (SCL-90-R,

Derogatis, 1983, 1994), John Wallace Marital Adjustment Scale (LWMAS,

Locke & Wallace, 1959) and Minnesota Multiphasic Personality Inventory

(MMPI, Hathaway & McKinley, 1943).Piotrowski & Lubin (1990), showed that the MMPI and the BDI were the

most used in assessing the depression, the STAI was the most used in the

assessment of anxiety and the MMPI and the SCL-90-R were the most

common resources for the evaluation of health. Barkham et al. (1998), also

mention the importance of using measures of assessment that have undergone

a standardized and psychometric analysis. For example, in the case of the

CORE-OM, (Barkham et al., 1998; CORE System Group, 1998) the measures

that form its preparation basis, (more usual with clinical populations) were the

BDI (Beck et al., 1988), the HADS (Hospital Anxiety and Depression Scale,

Snaith, 2003), the IIP (Horowitz et al., 1988), the SCL-90-R, (Derogatis, 1983,

1994) and the BSI (Brief Symptom Inventory; Derogatis & Melisaratos, 1983).In the Portuguese context, the SCL-90-R (Derogatis, 1983, 1994), which

assesses psychological symptoms, has already been adapted to the Portuguese

population by Baptista (1993) and the CORE-OM, which assesses the general

well-being of the subject (why? In what ways?) is currently under the process

of translation into Portuguese by a team of researchers of the Autonomous

University of Lisbon (Sales et al., 2008). Some research made in Portugal, with

Portuguese clients has demonstrated that towards a clinical sample, without

severe clinical pathology and on the use of both these assessment instruments,

180 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

it’s suggested the use of the CORE-OM, which revealed therapeutic outcome

indicators, similar to the SCL-90-R (Soares, 2007).

3. Conclusions

Currently in Portugal, there is an International Congress of Psychological

Assessment, Forms and Contexts, organized by the University of Minho,

Institute of Education and Psychology, which seeks to present an update of the

instruments of psychological assessment, empirically worked at a national level

as well as internationally. This meeting seems to be praised, but it has been

insufficient in the field of psychotherapy and it’s necessary to know more

deeply the points of view of the client and therapist and about the therapeutic

process. The understanding of these particular dyads and its compatibility

seems to be little explored in the Portuguese context.The European Federation of Psychologists Associations (EFPA) conducted

an interesting study (Muniz, Bartram, Evers, Boben, Matesic, et al., 2001) in

which it applied a questionnaire to several European psychologists and they

observed that the greatest number of psychologists who answered the

questionnaire were Spanish (3455), 2407 of them were British, 2079

Germans, 321 Slovenes, 218 Croats and 210 were Belgian psychologists. No

Portuguese psychologist participated in this research. Portugal is still a very

peripheral region of Europe. The Spanish reality seems to be more disposed to

participate in clinical evaluation trials. Notably, the results of this study show

that the Europeans psychologists in general, have a positive attitude towards

the assessment procedures, with regard to psychological testing, but at the same

time express their concerns towards the need of institutions to adopt a more

active attitude in promoting good practices for psychological evaluating. This

psychological evaluation tends to be seen, even by some psychologists, as

separating the dimensions of human beings, which are assessed when they work

inappropriately. For example, the psychological tests mainly used by psychol-

ogists and mentioned in the above study, were intelligence tests, personality

questionnaires and assessment scales of depression.We might add to this idea of assessment, especially regarding the field of

psychotherapy, that it could be helpful to not only know the dysfunctional

dimensions of the clients, but also the styles of each of the figures involved in a

psychotherapy process. Corbella and Botella (2004), Corbella (2005), points

out that even in choosing a therapist for a particular type of client, we must

take into consideration the levels of resistance of the client and the style of the

therapist. He suggests, for instance, that those clients more resistant should be

working with therapists with a less directive style. Corbella also suggests that

training psychologists for psychotherapy must extend the personal style of the

therapist, should promote self-reflection and a flexible style in psychotherapy.We can in fact recognize a co-constructive approach, regarding psycho-

therapy and given the two points of view, the style of the therapist and the

client. The therapy alliance, the therapeutic process and the therapeutic

European Journal of Psychotherapy and Counselling 181

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

outcome may be more effective, active and secure if we take into account these

two points of view.Let’s now take into consideration the following two dimensions: techniques

and tactics of the ‘therapeutic dance’. Consider the techniques themselves as

the specific behaviours, the skills that are assimilated by the therapist,

for example, empathy, verbal reformulation, non-verbal behaviour and

interpretations made by the therapist. The tactics, also likely to be learned

with the acquisition of more clinical experience by therapists; these will be

considered to be those moves needed to achieve a certain goal, for instance, the

selection and coordination by the therapist of certain questions in crucial

moments of psychotherapy. These tactical strategies could enhance the client

to move onwards, in one or another direction.Psychotherapy is the product of a therapy team, composed by a therapist

and his client. The characteristics of one and another – when connected and

engaging in a job together – can be better improved if the therapist knows how

the client is, both before and after the therapy; if he knows the therapeutic

relationship and understands both styles that are involved in the therapeutic

work (Soares, 2007). Some results emerging from Soares’ (2007) study make

us consider a change of paradigm, for example helping therapists who are in

training to know their style, to realize their capabilities and greater success

rates with certain styles of clients, can improve their performance with a

greater proportion of clients. One way to do this would be to put into action

the PBER.

References

Alexander, E.B., & Luborsky, L. (1986). The Penn Helping Alliance Scales.

In L.S. Greenberg & W.M. Pinsof (Eds.), The psychotherapeutic process: A research

handbook (pp. 325–366). New York: Gulford.Anderson, T., Ogles, B.M., & Weis, A. (1999). Creative use of interpersonal skills in

building a therapeutic alliance. Journal of Constructivist Psychology, 12(4), 313–330.Arnkoff, D.B. (1995). Two examples of strains in the therapeutic in an integrative

cognitive therapy. In Session-Psychotherapy in Practice, 1(1), 33–46.Baptista, A. (1993). A genese da perturbacao de panico. Tese de Doutoramento Nao

Publicada. Instituto de Ciencias Biomedicas Abel Salazar-Universidade do Porto.Barber, J.P., Connolly, M.B., Crits-Christoph, P., Gladis, L., & Siqueland, I. (2000).

Alliance predicts patients’ outcome beyond in-treatment change in symptoms.

Journal of Consulting and Clinical Psychology, 68(6), 1027–1032.Barkham, M., Evans, C., Margison, F., McGrath, G., Mellor-Clark, J., Milne, D., et al.

(1998). The rationale for developing and implementing core outcome batteries

for routine use in service settings and psychotherapy outcome research. Journal of

Mental Health, 7, 35–47.

Barkham, M., Margison, F., Leach, C., Lucock, M., Mellor-Clark, J., Evans, C., et al.

(2001). Service profiling and outcomes benchmarking using the CORE-OM:

Toward practice-based evidence in the psychological therapies. Journal of

Consulting and Clinical Psychology, 69, 184–196.

182 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

Beck, A.T., Epstein, N., Brown, G., & Speer, R.A. (1988). An inventory for measuring

clinical anxiety: Psychometric properties. Journal of Consulting and Clinical

Psychology, 56, 893–897.Beck, A.T., Steer, R.A., & Garbin, M.G. (1988). Psychometric properties of the Beck

Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review,

8(1), 77–100.Beutler, L.E., & Howard, K.I. (1998). Clinical utility research: An introduction.

Journal of Clinical Psychology, 54(3), 297–301.

Beutler, L.E., Clarkin, J.F., & Bongar, B. (2000). Guidelines for the Systematic

Treatment of the Depressed Patient. New York: Oxford University Press.Beutler, L., Moleiro, C., Malik, M., Harwood, T.M., Romanelli, R.,

Gallagher-Thompson, D., et al. (2003). A comparison of the Dodo, EST, and

ATI predictors among co-morbid stimulant dependent, depressed patients. Clinical

Psychology & Psychotherapy, 10, 69–85.

Beutler, L., Moleiro, C., & Talib, H. (2002). Resistance. In J. Norcross (Ed.),

Psychotherapy relationships that work: Therapists contributions and responsiveness to

patient needs (pp. 129–144). New York: Oxford University Press.Bordin, E.S. (1975, Setember). The working alliance: Basis for a general theory of

psychotherapy. Comunicacao apresentada no Encontro Anual da American

Psychological Association Washington, DC.Bordin, E.S. (1976). The generalization of the psychoanalytic concepts of the working

alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260.

Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working

alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260.Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London:

Routlege.Caine, T.M., Wijensinghe, O.B.A., & Winter, D.A. (1981). Personal styles in neurosis:

Implications for small group psychotherapy and behaviour therapy. London:

Routledge and Kegan Paul.Ceberio, M.R. (2003). Que es la psicoterapia? Interpsiquis. Retrieved October 10, 2003,

from www.psiquiatria.com.Cooper, P., Osborn, M., Gath, D., & Feggetter, G. (1982). Evaluation of modified

self-report measure of social adjustment. British Journal of Psychiatry, 141, 68–75.

Corbella, S. (2005). Estilo Personal del Terapeuta y Seleccion de Tratamientos.

Documento Nao Publicado: Universidad Ramon Llull.Corbella, S. & Botella, L. (2003). La alianza terapeutica: historia, investigacion y

evaluacion. Anales de Psicologıa, 19, 205–221.Corbella, S., & Botella, L. (2004). Investigacion en Psicoterapia: Proceso, Resultado y

Factores Comunes. Madrid: Vision Net.

Corbella, S., Garcia, F., Botella, L., & Keena, C. (2001, June). Compatibility between

therapist’s personnal style and patient’s personality. The Barcelona-Buenos Aires

Project. Comunicacao apresentada no Annual Meeting of Society for

Psychotherapy Research, Montevideo, Uruguay.CORE System Group,. (1998). CORE System (Information Management) Handbook.

Leeds: CORE System Group.

Derogatis, L.R. (1983). SCL-90-R: Administration, Scoring & Procedures: Manual.

Towson, MD: Clinical Psychometric Research.Derogatis L.R. (1994). SCL-90-R: Administration, Scoring and Procedures Manual.

National Computer Systems, Inc. Minneapolis.Derogatis, L.R., & Melisaratos, N. (1983). The Brief Symptom Inventory: an

introductory report. Psychological Medicine, 13, 595–605.

European Journal of Psychotherapy and Counselling 183

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

Evans, C., Mellor-Clark, J., Margison, F., Barkham,M., Audin, K., et al. (2000). CORE:

Clinical outcomes in routine evaluation. Journal of Mental Health, 9(3), 247–255.Evans, C., Connell, J., Barkham, M., Marshall, C., & Mellor-Clark, J. (2003).

Practice-Based evidence: Benchmarking NHS Primary Care Counselling Services at

National and Local Levels. Clinical Psychology and Psychotherapy, 10, 374–388.Fernandez-Alvarez, H., Garcia, F.S., Lo Bianco, J., & Corbella, S. (2003).

Questionnaire on the Personal Style of the Therapist PST-Q. Clinical Psychology

and Psychotherapy, 10, 116–125.Freud, S. (1912/1996). Uma nota sobre o inconsciente em psicanalise. ESB das obras

completas de Sigmund Freud. Rio de Janeiro: Imago.Froyd, J.E., Lambert, M.J., & Froyd, J.D. (1996). A review of practices of

psychotherapy outcome measurement. Journal of Mental Health, 5, 11–15.Gaston, L., & Ring, L.M. (1992). Preliminary results on the inventory of therapeutic

strategies. Journal of Psychotherapy Practice and Research, 1(2), 135–146.Goldfried, M.R., & Davison, G.C. (1994). Clinical behaviour therapy (exp ed).

New York: John Wiley and Sons.

Greenson, R.R. (1965). The working alliance and the transference neuroses.

Psychoanalysis Quarterly, 34, 155–181.Hamilton, M. (1959). The assessment of anxiety by rating. British Journal of Medical

Psychology, 32, 50–55.

Hamilton, M. (1967). Development of a rating scale for primary depressive illness.

British Journal of Social and Clinical Psychology, 6, 278–296.Hartley, D.E., & Strupp, H.H. (1983). The therapeutic alliance. Its relationship to

outcome in brief psychotherapy. In J. Masling (Ed.), Empirical studies in analytic

theories (pp. 1–37). Hillsdale, NJ: Erlbaum.

Hatcher, R. (1999). Therapist’s views of treatment Alliance and collaboration in

Therapy. Psychotherapy Research, 4, 405–423.Hathaway, S.R., & McKinley, J.C. (1943). The Minnesota Multiphasic Personality

Inventory. Minneapolis, MN: University of Minnesota Press.Horowitz, L.M., Rosenberg, S.E., Baer, B.A., Ureno, G., & Villasenor, V.S. (1988).

Inventory of Interpersonal Problems: Psychometric properties and clinical

applications. Journal of Consulting and Clinical Psychology, 56, 885–892.Horvath, A.O. (1981). An exploratory study of the Working alliance: Its measurement

and relationship to outcome. Canada: Dissertacao de Doutoramento nao publicada,

Universidade de British Columbia.Horvath, A.O. (1982). Working Alliance Inventory (Revised Ed.). Instructional

Psychology Research Group, 82. Simon Frasier University, Burnaby, British

Columbia, Canada.Horvath, A.O., & Greenberg, L.S. (1989). Development and validation of the Working

Alliance Inventory. Journal of Counselling Psychology, 86, 223–233.Horvath, A.O., & Luborsky, L. (1993). The role of therapeutic alliance in

psychotherapy. Journal of Counselling and Clinical Psychology, 51(4), 561–573.

Horvath, A.O., & Symonds, B.D. (1991). Relation between alliance and outcome

in psychotherapy: A meta-analysis. Journal of Counselling Psychology, 38, 139–149.Klee, M.R., Abeles, N., & Muller, R.T. (1990). Therapeutic alliance: Early indicators,

course and outcome. Psychotherapy, 27(2), 166–174.

Kokotovic, A.M., & Tracey, T.J. (1990). Working Alliance in the early phase of

counselling. Journal of Counselling Psychology, 27, 320–327.Lambert, M. (1992). Implications for outcome research for psychotherapy integration.

In J.C. Norcross & M.R. Goldstein (Eds.), Handbook of psychotherapy integration

(pp. 94–129). New York: Basic Books.

184 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

Lambert, M.J., Whipple, J.L., Smart, D.W., Vermeersch, D.A., Nielsen, S.L., &

Hawkins, E.J. (2001). The effects of providing therapists with feedback on patient

progress during psychotherapy: are outcomes enhanced? Psychotherapy Research,

11, 49–68.

Lambert, M.J., Whipple, J.L., Vermeersch, D.A., Smart, D.W., Hawkins, E.J., Nielsen,

S.L., et al. (2002). Enhancing psychotherapy outcomes via providing feedback

on client progress: a replication. Clinical Psychology and Psychotherapy, 9, 91–103.

Locke, H.J., & Wallace, K.M. (1959). Short marital adjustment and prediction tests:

Their reliability and validity. Marriage and Family Living, 21, 251–255.Luborsky, L. (1976). Helping alliances in psychotherapy. In J.L. Cleghhorn (Ed.),

Successful psychotherapy (pp. 92–116). New York: Brunner/Mazel.Luborsky, L. (1994). Therapeutic alliances as predictors of psychotherapy outcomes:

Factors explaining the predictive success. In A.O. Horvath & L.S. Greenberg (Eds.),

The working alliance: Theory, research and practice (pp. 38–50). New York: Wiley.Luborsky, L. (2000). A pattern-setting therapeutic alliance study revised. Psychotherapy

Research, 1, 17–29.Luborsky, L., Barber, J.P., Siqueland, L., Johnson, S., Najavits, L.M., Frank, A., et al.

(1996). The Revised Helping Alliance Questionnaire (HAQ-II). Journal of

Psychotherapy Practice and Research, 5, 260–271.Luborsky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983).

Two helping alliance methods for predicting outcomes of psychotherapy:

A counting signs vs. a global rating method. Journal of Nervous and Mental

Disease, 171(8), 480–491.Luborsky, L., McLellan, A.T., Woody, G.E., O’Brien, C.P., & Auerbach, A. (1985).

Therapist success and its determinants. Archives of General Psychiatry, 42, 602–611.

Machado, P.P. (1994). Retos actuales a la investigacion en psicoterapia. Psicologia

Conductual, 2(1), 113–120.Machado, P.P., & Horvath, A.O. (1999). Inventario da Alianca Terapeutica:

Versao portuguesa do Working Alliance Inventory. In M.R. Simoes,

L.S. Almeida, & M. Goncalves (Eds.), Provas Psicologicas em Portugal (Vol. 2,

pp. 87–94). Braga: SHO.

Marmar, C.R., Horowitz, M.J., Weiss, D.S., & Marziali, E. (1986). The development of

the Therapeutic Alliance Rating System. In L.S. Greenberg & W.M. Pinsof (Eds.),

The Psychotherapeutic Process: A Research Handbook (pp. 367–390). New York:

Guilford Press.

Marmar, C.R., Weiss, D.S., & Gaston, L. (1989). Toward validation of the California

therapeutic alliance rating system. Psychological Assessment, 1, 46–52.Marziali, E. (1984). Three viewpoints on the therapeutic alliance: Similarities,

differences, and associations with psychotherapy outcome. Journal of Nervous and

Mental Disease, 172(7), 417–423.Mellor-Clark, J., & Barkham, M. (2000). Quality evaluation: methods, measures &

meaning. In C. Feltham & I. Horton (Eds.), The Handbook of Counselling and

Psychotherapy. London: Sage Publications.Mellor-Clark, J., Connell, J., Barkham, M., & Cummins, P. (2001). Clinical outcomes in

primary health care: a CORE system data profile. The European Journal of

Psychotherapy, Counselling & Health, 4(1), 65–86.Mohl, P.C., Martinez, D., Ticknor, C., Huang, M., & Cordell, J. (1991).

Early dropouts from psychotherapy. Journal of Nervous and Mental Disease,

179(8), 151–173.Moras, K., & Strupp, H.H. (1982). Pretherapy interpersonal relations, patient’s alliance,

and outcome in brief therapy. Archives of General Psychiatry, 39, 405–409.

European Journal of Psychotherapy and Counselling 185

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

Moreira, P., Goncalves, O., & Beutler, L.E. (2005). Metodos de Seleccao de Tratamento.

Porto: Porto Editora.Morgan, R., Luborsky, L., Crits-Christoph, P., Curtis, H., & Solomon, J. (1982).

Predicting the outcome of psychotherapy by the Penn Helping Alliance Rating

Method. Archives of General Psychiatry, 39, 397–402.Muniz, J., Bartram, D., Evers, A., Boben, A., Matesic, K., et al. (2001).

Testing practices in European Countries. European Journal of Psychological

Assessment, 17(3), 201–211.Newman, C.F. (1998). The therapeutic relationship and alliance in short term

cognitive therapy. In J.D. Safran & J.C. Muran (Eds.), The therapeutic alliance in

brief psychotherapy (pp. 95–122). Washington: American Psychiatric Association.

O’Malley, P.M., & Bachman, J.G. (1979). Self-esteem and education: sex and cohort

comparisons among high school seniors. Journal of Personality and Social

Psychology, 37, 1153–1159.Pinsof, W.M., & Catherall, D.R. (1986). The integrative psychotherapy alliance:

Family, couple and individual therapy scales. Journal of Marital and Family

Therapy, 12(2), 137–151.Piotrowski, C., & Lubin, B. (1990). Assessment practices of health psychologists:

Survey of APA division 38 clinicians. Professional Psychology: Research and

Practice, 21, 99–106.

Pizer, S.A. (1992). The negotiation of paradox in the analytic process.

Psychoanalytic Dialogues, 2(2), 215–240.Plotnicov, K.H. (1990). Early termination from counselling: The client’s perspective.

Dissertacao de Doutoramento Nao Publicada: University of Pittsburgh, PA.Rogers, C.R. (1951). Client-centered therapy. Cambridge, MA: Riverside Press.

Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality

change. Journal of Consulting Psychology, 21, 95–103.Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton

University Press.Safran, J.D. (1998). Widening the scope of cognitive therapy. New Jersey: Jason Aronson

Inc.

Safran, J.D., & Muran, J.C. (2000). Negotiating the therapeutic alliance: A relational

treatment guide. New York: The Guilford Press.Safran, J.D., & Wallner, L.K. (1991). The relative predictive validity of two therapeutic

alliance measures in cognitive therapy. Psychological Assessment, 3(2), 188–195.Sales, C., Moleiro, C., Goncalves, S., Silva, I., Duarte, J., & Evans, C. (2008, June).

Translating of the CORE-OM into Portuguese and initial data on its use in Portugal.

Comunicacao a ser apresentada no SPR, 39th International Meeting, Barcelona,

Spain, Society for Psychotherapya Research.Snaith, P.R. (2003). The hospital anxiety and depression scale. Health and Quality of

Life Outcomes, 1:29. Retrieved October 19, 2005, from http://www.hqlo.com/

content/1/1/29

Soares, L. (2007). Parar, pensar e avaliar a psicoterapia - contribuicoes da investigacao de

dıades de terapeutas e clientes portugueses. Tese de Doutoramento apresentada na

Faculdade de Psicologia e de Ciencias da Educacao e do Desporto da Universidade

Ramon Llull, Barcelona. ISBN: B53734–2007.Spielberger, C.D., Gorsuch, R.L., Lushene, R., Vagg, P.R., & Jacobbs, G.A. (1983).

Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting

Psychologists Press.Stiles, W.B., Agnew-Davis, R., Hardy, G.E., Barkham, M., & Shapiro, D.A. (1998).

Relations of the alliance with psychotherapy outcome: Findings in the second

186 L. Soares et al.

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3

Sheffield Psychotherapy Project. Journal of Consulting and Clinical Psychology,66(5), 791–802.

Sterba, R. (1934). The fate of the ego in analytic therapy. International Journal ofPsychoanalysis, 15, 117–126.

Strong, S.R. (1968). Counselling: A interpersonal influence process. Journal ofCounselling Psychology, 15, 215–224.

Strupp, H.H., Horowitz, L.M., & Lambert, M.J. (Eds.), (1997). Measuring patient

changes in mood, anxiety and personality disorders: Toward a core battery.Washington, DC: American Psychological Association.

Waskow, I.E. (1975). Selection of a core battery. In I.E. Waskow &M.B. Parloff (Eds.),

Psychotherapy Change Measures (pp. 245–269). Rockville, MD: National Instituteof Mental Health.

Weerasekera, P., Linder, B., Greenberg, L., & Watson, J. (2001). The working alliance

in client-centered and process–experiential therapy of depression. PsychotherapyResearch, 11(2), 221–233.

Whipple, J.L., Lambert, M.J., Vermeersch, D.A., Smart, D.W., Nielsen, S.L., &Hawkins, E.J. (2003). Improving the effects of psychotherapy: the use of early

identification of treatment failure and problem solving strategies in routine practice.Journal of Counselling Psychology, 50, 59–68.

Zetzel, E. (1956). Current concepts of transference. International Journal of

Psychoanalysis, 37, 369–375.

European Journal of Psychotherapy and Counselling 187

Dow

nloa

ded

by [

Lui

s B

otel

la]

at 1

4:35

28

Oct

ober

201

3