THE THERAPEUTIC ALLIANCE IN GROUP VERSUS INDIVIDUAL SYSTEMIC-DIALECTICAL PSYCHOTHERAPY: A COMPARATIVE STUDY

Marilena Mandrakou1, Rossetos Gournellis2 and Valeria Pomini3

1MsC, Social worker- Social Anthropologist, Systemic Psychotherapist

2Professor of Psychiatry and Psychogeriatric, 2ndDepartment of Psychiatry, National and Kapodistrian University of Athens, University General Hospital “Atticon”

3PhD, Clinical Psychologist–Psychotherapist, 1st Department of Psychiatry, National and Kapodistrian University of Athens

This article is based on the diplomatic thesis entitled:“The therapeutic alliance in group therapy and in individual psychotherapy of systemic dialectical approach. Reciprocal connection relationships aimed at therapeutic change. Evaluation and comparison of 8 therapeutic frameworks”, which was conducted as part of the Master Program “Promotion of Mental Health / Prevention of Psychiatric Disorders”, Medical School, National and Kapodistrian University of Athens, June 2020.

Abstract

The therapeutic alliance between therapist and client during psychotherapy is the most significant factor that determines the outcome of therapy. In the framework of systemic psychotherapy, the analysis of the features and peculiarities of the therapeutic alliance remains still insufficient. The paper aims to contribute to the knowledge about the therapeutic alliance, firstly, by examining its development in group and individual systemic-dialectical psychotherapy, secondly, by addressing and answering questions regarding the factors that influence this type of alliance, and, finally, by determining possible differences arising in group and individual psychotherapy.

Key-Words: Therapeutic relationship, working alliance, group psychotherapy, individual psychotherapy, systemic-dialectical approach

Introduction

The therapeutic relationship constitutes the framework of collaboration between the therapist and the client (Papakostas et al. 2015) in the realization of the therapeutic process and it is also regarded as the core of psychotherapy, independently of the therapeutic approach used by the therapist (Pomini, 2021). In particular, the therapeutic alliance is a type of collaboration that develops in the therapeutic system, to resolve the problem of the client (Pomini, 2021) and is one of a few variables that are generally accepted by all psychotherapeutic approaches (Pomini & Tomaras, 2015). According to Edward Bordin, the therapeutic alliance is the catalytic substance of every therapeutic relationship that consists of three basic ingredients: a) the agreement on the therapeutic goals b) the consent of the tasks (therapeutic activities) required by the therapy and c) the emotional bond between the therapist and the client (Bordin, 1979). When the client has developed a good alliance with the therapist, they deal with the techniques and interventions of the therapist in a more positive way and vice versa, when the interventions of the therapist are concise and effective, the trust of the client is reinforced, and the alliance becomes stronger. Hence, the therapeutic alliance is not only a requirement for the therapeutic work but can also constitute the main factor of change (Bordin, 1979).

In individual psychotherapy, the therapeutic alliance has been studied sufficiently. The therapeutic alliance has been correlated to the therapeutic outcome and therapeutic process in various types of psychotherapy, as well as, with the ability of the client to develop a therapeutic collaboration (Sprenkle & Blow, 2004). However, the therapeutic alliance has not yet been studied sufficiently in the context of systemic psychotherapy (Escudero, 2016).

Already, there is an increasing interest in the evaluation of the therapeutic alliance arising in systemic psychotherapy of individuals, couples, and families, through the formation or adaptation of particular tools. These tools highlight aspects such as, the commitment to the therapeutic process, the emotional bond with the therapist, the sense of security, as well as, the sense of a common purpose, among the members of a group, or, between the therapist and the client (Pomini & Tomaras, 2015).

The findings of the applications of these tools demonstrate that all these four components, influence the behavior of the individuals involved in the therapeutic process in a positive way and are further linked to a positive outcome of psychotherapy (Escudero et al., 2008). Nonetheless, the study of the particularities of the therapeutic alliance in systemic phycology for families and couples could benefit from the complimentary use of qualitative and quantitative methods that analyze its components and their relations to the therapeutic outcome (Pomini & Tomaras, 2015).

The systemic view of psychotherapy as an interaction of systems, combined with the consideration that every individual is not a compact and indivisible component of a system, but rather a cell that consists of its own interacting systems and subsystems (Pinsof & Lebow, 2005), puts both group and individual therapy at the same framework. According to the current systemic view, the only necessary distinction between individual and group psychotherapy is the setting of boundaries between the direct and indirect subsystem of the client. In this way, individual and group therapy could be viewed not as distinct types of therapy, but rather as different frameworks of intervention and strategies that deal with different problems in different systems.

In systemic couple and family therapy, the extended therapeutic alliance has become a basic factor for the positive development of therapy, while, at the same time, it appears to be a more complex and multidimensional parameter in comparison to the therapeutic alliance in individual psychotherapy. The personal alliance between the client and the therapist influences and gets influenced by the quality of collaborations among the other members of the group (Friedlander et al., 2018). During group therapy, the focus shifts from intrapersonal to interpersonal interactions involving the therapists, every member of the group, as well as the group as a whole entity (Gournas, 2015). The multilevel therapeutic relationship that develops acts as a more complex background that sustains both pronounced and non-palpable stirring and emotional relationships. Τhe members of the group, having at their disposal a variety of individuals to discuss with and a variety of therapeutic behaviors to observe, they have more opportunities to develop a personal therapeutic relationship, a fact that enhances their commitment to the therapeutic plan. Hence, in the framework/context of group physiotherapy, the therapeutic relationship consists of a network of multiple relationships that develop between individuals, pairs, and subsystems. Relationships that are different, but in the framework of group psychotherapy, they compose a veil of interpersonal relationships that goes beyond the collection of its elements and formulates a more complex and global therapeutic relationship within the boundaries of the therapeutic system. As a result, the therapeutic alliance becomes reinforced as a whole, while the strength, tension and intimacy of the alliance between the therapist and the client becomes more relaxed, which also favors the therapeutic process.

Research goals and questions

The purpose of this paper is to investigate the establishment of the therapeutic alliance between the psychotherapist and the client and the possible interactions of specific factors (such as the trust, the development of a sense of security, the commitment of the client to the therapeutic process, etc.), as well as the possible differentiation between the group and individual systemic psychotherapy. To this end, three axes were defined, and the following research goals were set/formulated:

First Axis: Existence and development of the therapeutic alliance in systemic psychotherapy. For this axis, the nature of the therapeutic alliance was explored by studying its three fundamental components, namely, the bond, goals, and tasks.

Second Axis: Effects of sub-factors in the formation, maintenance, and development of the therapeutic relationship. For this axis, the effect of factors such as, the development of the client’s trust on the skills of the therapist, the client’s commitment to the therapeutic process, the development of a sense of security and sharing common goals and the level of agreement on the goals of the therapeutic process, was explored.

Third Axis: Differences of the therapeutic alliance in group and individual systemic psychotherapy. For this axis, the possible differences in the basic components of the therapeutic alliance of these two different types of psychotherapy were explored.

Method

The research process for this paper was performed during the period of May to September, 2019. A questionnaire that best fit the needs of the research was formulated and distributed, firstly, among the members of one therapeutic group, as a test trial. In this way, it was possible to identify some minimal necessary corrections, mainly in the section of explanations and clarifications to the participants and make the necessary adjustments.

Eleven (11) psychotherapists, members of the Hellenic Association for Systemic Therapy of Family, Individuals and Groups (HELASYTH), were then chosen randomly. This choice was realized in three stages. At the first stage, there was a drawing of thirty (30) physiotherapists, based on their identity number in the list of (HELASYTH). At the second stage, this list was refined by considering only those therapists that coordinate a therapeutic group and have a sufficient number (two and above) of clients in individual psychotherapy and finally, at the third stage, by considering their availability.

The questionnaires were given to the psychotherapists along with appropriate instructions on how they should be completed by the clients, for both group and individual sessions. All necessary measures were taken to ensure the anonymity of the individuals who participated in the research.

With this procedure, eighty-six (86) questionnaires were completed by clients who have participated in a therapeutic group, eighty-six (86) questionnaires by the therapists for each member of their group, thirty-two (32) questionnaires by clients of individual therapy and thirty-two (32) questionnaires by the therapists for each of their client.

The questionnaire of the Therapeutic Alliance (WAI, Horvath & Greenberg, 1986) was selected as it was considered the most appropriate questionnaire for the purpose of the research. The questionnaire consists of thirty-six (36) statements aiming at evaluating the way in which the therapist and client evaluate each other for specific therapeutic procedures that take place during the session (Mitskidou, 2008).

The purpose of the questionnaire was the evaluation of the overall therapeutic relationship between the therapist and the client, as well as its three factors-dimensions, the Goal, which refers to the level of agreement between the therapist and the client about the goals of the treatment, the Task, which refers to the level of agreement between the therapist and the patient about the method through which the goal(s) will be achieved, and the Bond, which refers to the development of a bond between the two participants in the therapeutic process. This questionnaire is the most frequently used tool in the international literature for the evaluation of the therapeutic alliance, as it can be used for any type of treatment, which makes it the most suitable one for most research studies (Mitskidou, 2008). The rating is based on a 7-point Likert scale, which indicates the frequency of occurrence of the situation described in each statement within the session that has just ended. The scale is available in three forms: one for the therapist, one for the client and one for an independent judge. In the present study, the scale for the client and the scale for the therapist were used¹.

This questionnaire is the only one that has been translated in Greek² and has been used in the Greek population from 2004 (Apostolopoulou & Giovazolias, 2021). Reliability analysis conducted for the three subscales showed that the questionnaire has a satisfactory level of reliability and internal consistency (the factor Cronbach’s alpha is quite satisfactory since it is 0.93 and 0.87 for the scales of the client and for the therapist, respectively) (Mystikidou, 2008).

Results

For the needs of the research, the beliefs of the clients and the therapists about the therapeutic alliance were examined jointly and separately, as were the questionnaires from group and individual therapies. In this way, it was possible to compare the views of the therapists with the views of the clients and identify any differences. The variables used corresponded to specific questionnaire statements and in each case, the scales were calculated as the mean value of the responses to the questionnaire statements (after first considering the negative statements).

A total of one hundred and eighteen (118) questionnaires were collected from clients (of which eighty-six (86) participated in treatment groups and thirty-two (32) followed an individual psychotherapy program) and one hundred and eighteen (118) questionnaires from the respective therapists. The investigation of the internal consistency and reliability of the data was carried out by calculating, in each case, Cronbach's alpha with the values for each variable being about 0,85, which indicates that the data have a very high internal consistency and reliability, with respect to the measured variables.

First Axis (Existence and development of the therapeutic alliance in systemic psychotherapy): The degree of development of the therapeutic bond, agreement of goals and strategies was measured through a One Sample t-test. The Test Value for all three cases was considered equal to 5,5 which corresponds to 75% of the scale (1-7) and in relation to the statements in the questionnaire corresponds to answers greater than "often". The test was performed on the whole sample, but also separately in the following categories: client, therapist, group therapy, individual therapy, group client, individual client, group therapist, individual therapist³.

For each of the three variables (Bond, Goal, Task) the test results are presented in Tables 1, 2 and 3 respectively. The results show that there is a clear indication of the development of a bond between the therapist and the client, of the agreement on the goals of the treatment and of the agreement on the strategies (methods) through which the goals will be achieved, at the level of statistical significance α = 0,05 in the total of clients and therapists.

The only case where there seems to be no positive response is in the subcategory of therapists in individual psychotherapy, in terms of agreement on goals. In this case, the test was repeated with Test Value = 5,3 (corresponds to 71,7% of the scale) and it was found that for this value Sig. = 0,025 (t = 2,350, Mean diff. = 0,302) and hence, in this case there is also a clear indication of agreement on the goals.

Table 1

Onesamplet-test for the variable «Bond»

Table2

Onesamplet-test for the variable «Goal»

Table 3

Onesamplet-test for the variable «Task»

Second Axis (Effects of sub-factors in the formation, maintenance, and development of the therapeutic alliance): The linear correlation of the variable "Bond" with the variables "Trust", "Security", "Commitment" and "Goal" through the Pearson criterion and the homonymous coefficient, were examined. The results in each case and for each pair of variables are shown in Tables 4, 5, 6 and 7.

Table 4

Checking the correlation “Bond” – “Trust”

Table 5

Checking the correlation of the variables “Bond” – “Security”

Table 6

Checking the correlation for the variables “Bond” – “Commitment”

Table 7

*Checking the correlation for the variables “Bond” – “Goal” *

The tables show the statistically significant dependence of the Bond on all four variables. More specifically, the Bond is highly correlated to the Trust, with the coefficient r being equal to 0.8, as in the case of the correlation of the Bond with the Goal. The correlation of the Bond and the Security is obvious as extremely strong, since the value of r ranges, per case, from 0.8 to 0.94! Finally, there is a relatively high correlation between the Bond and the Commitment, with values of the parameter r around 0.68.

Third Axis (Differences of the therapeutic alliance in group and individual systemic psychotherapy)**: **To check for any difference, a t-test of independent samples was conducted, while assuming the equality of the mean values of the two cases, compared to the alternative hypothesis that the mean values differ, and it was found that there is no significant difference between group and individual psychotherapy, in terms of Bond, Goals and Task, except from the case where the clients are examined separately, for which a difference was found in the variables of Goal and Task, in favor of individual psychotherapy. Tables 8, 9, and 10 show the mean values and standard deviations for individual and group therapy, when therapists and clients are treated together or separately.

Table 8

Mean values and standard deviations for individual-group therapy (Overall)

Table 9

Mean values and standard deviations for individual-group therapy (Therapists)

Table 10

Mean values and standard deviations of individual-group therapy (Clients)

Discussion

According to the results of the research it was found that there is a clear indication of development of a therapeutic bond between the therapist and the client, and to a particularly very high degree (the mean value of the questionnaires was near the 90% of scale), while the other two factors of the therapeutic alliance, the Goal and the Tasks were also found to have high values (80% and 81%, respectively). Hence, it was confirmed that the therapeutic alliance is also developed to a high degree in the systemic psychotherapy. This conclusion is independent of whether the sample was mixed (therapists and clients of group or individual psychotherapy) or whether it was limited to a certain population.

The second conclusion derived from the research was that the development of the therapeutic alliance is highly related to the four (4) factors that were examined, which are the trust in the therapists’ capabilities, the security that the client feels, the client’s commitment to the therapeutic process and the mutual understating and agreement for the goals.

Finally, no significant differentiation was found between group and individual psychotherapy. Although the mean values of the variables of the individual therapy were larger than the ones of the group therapy, implying that the therapeutic alliance within individual therapy may be stronger, however, statistically this difference was not sufficient to differentiate those two cases. Nevertheless, some small differences in favor of the individual therapy appeared. From the clients’ side it appears that in terms of goals and the way these are achieved, individual psychotherapy is superior to group psychotherapy. This is natural since in the context of group therapy, the relationship between the therapist and the client extends over the group and is less focused on person-to-person communication. Also, the complex and polyphonic structure of the group, although offering the variety of interactions that the client needs, it creates veils of ambiguity with regard to the goals and tasks that will fulfill them, as each member of the group comes in contact with the issues, goals and tasks of all group members. Individual psychotherapy is focused on the specific client, and this helps the client gain a greater sense of understanding of the therapeutic process.

Finally, it is also worth mentioning the response of the therapists and clients during the research. Their participation was decisive and, although the volume of questionnaires was large, they responded very warmly and willingly, which manifests the quality of the therapeutic relationship that has been formed from both sides.

Limitations

One of the positive aspects of thisstudy was the satisfactory number of participants (118 + 118 = 236 therapists and clients) and the well-weighted questionnaire with satisfactory reliability and internal consistency.

Limitations consist in the fact that the sample was not completely random (since the selection was made formalist of therapists) and that some of the therapists who were selected and met the criteria, refused to participate (38,9 %).

The fact that most of the clients were women (77,4%) may be considered as a limitation, but, on the other hand, the percentageis similar to that of the therapists (81,8%), making the two groups more homogeneous.

Another element that needs to be emphasized is the different structure of the groups in terms of the time their members have been participating in it.In the context of systemic group psychotherapy, groups are usually of open type, meaning that individuals join or complete their therapy at different times (Gournas, 2015). The different developmental phase of each member makes the formation and maintenance of the therapeutic relationship even more complex and is undoubtedly an additional challenge for the therapist and the therapeutic process (Papastilianou, 2021).

Conclusion and directions for further research

Based on the results of this work, previous findings seem to be confirmed. However, knowledge on the characteristics and particularities of the therapeutic alliance in systemic psychotherapy remains still incomplete. Further investigation is needed on these issues, which could offer more knowledge to ensure the quality of the therapeutic process and improve its effectiveness. In particular, it would be interesting to repeat this study in various forms of groups (i.e., mixed, different ages, multicultural, etc.) but to also extend it to other therapeutic approaches. It would also be useful to examine the role that the gender, of both the therapist and the client, plays in the therapeutic alliance, as well as their age.

Through the study of previous research, the special role of the therapist in the therapeutic alliance has been raised. Hence, it would be interesting to investigate the ways through which systemic psychotherapists contribute to the alliance and to the sense of common goal, based on variables from their personality, years of experience, etc.

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