Therapeutic alliance is the most important treatment variable in psychotherapy. A concise summary is: 1. The therapeutic alliance between the patient and therapist is the strongest predictor of positive therapy outcomes, more so than the specific treatment approach. 2. Both the patient and therapist characteristics influence outcomes, such as the patient's motivation and personality traits, as well as the therapist's competence and ability to develop trust. 3. Effective communication through empathy, active listening, and avoiding judgment helps strengthen the alliance and engagement of the patient in treatment.

1. Road to Psychotherapy

2. Definition
• Psychotherapy is the treatment of psychological disorders or
maladjustments by a psychological technique, as a
psychoanalysis, group therapy, or cognitive and behavior
therapy, etc.

3. Myths about Psychotherapy
• There is one best therapy
• Therapy simply does not work
• Therapy is just talking or nagging
• Therapists can “read minds”
• People who go to therapists are crazy or just weak
• Only the rich can afford therapy
• Psychotherapy is to change people

4. Reception of Patient
• Impression at the door
• Receptionist (knows the name),
• Euphemism (Mr., Mrs., madam, Abu, Um, etc)
• Confidentiality
• Privacy

5. What does this mean?
- Can I help
- Trust me
- You are in good hands
- Help me

6. Physical Environment
Physical Environment (setting)
•Work environment
•Free from distractibility
•intermittent noise is more distracting than continuous noise.
•Meaningful sounds, such as conversation in next office, are
more distracting than non-meaningful sounds such as street
noise
•Some patients are more noise sensitive than others, and
therefore more adversely affected by noise (p. 70)
•Physical consistency
•Human consistency

7. Motivational Environment
Intrinsic vs. Extrinsic motivation:
• Environment of intrinsic vs. extrinsic motivation is sometimes useful:
• Intrinsic reinforcement (e.g., feeling of pride, respect, accomplishment
and satisfaction) is sometimes more important for motivation than
extrinsic reinforcement (e.g., reward) which tends to reduce motivation
• When extrinsic rewards used, the person believes that his or her behavior
is motivated by external factors
• Consequently, when the rewards are taken away, the person is no longer
motivated to engage in the behavior
• It is known that when volunteer work is motivated by given rewards,
enthusiasm decreases.

8. Symptoms of disorganized physical setting:
• Environmental reinstatement effect – short-term or long-term
• helps with memory..
• Contextual environment … keep the patient in the same room if possible
• state-dependent anxiety treatment, especially with GAD people
• Fatigue is associated with performance decrements (homework assignments),
especially complex tasks that provide little feedback
• Hippocampus
Activation In
context
Dependent state
Prefrontal cortex

9. Accommodation
Accommodation:
• therapist adjustment when interacting with family structure.
• Mirroring the style and affect of the members
• Posture mirroring
Salvador Minuchin (1921)
• He smokes a cigarette if client starts smoking a cigarette
Research on Quality of life(QOL)
• Our QOL research, family caregiver rating matching well patient’s subjective
rating of him or herself . Diabetes, Cancer, psychiatric

10. Empathy: Effective Communication Techniques
Sympathy vs. empathy
Listen Actively
• Be attentive:
• Carl Rogers: Understanding, listening caring, unconditional regards
•Be impartial: don't form an opinion, just listen.
•Reflect back: restating what has been said helps to know that you
understand the patient – don’t talk more than it is needed
•Summarize: helps to recognize what was important during session
• Avoid being preacher – clergyman or sheikh
•Understand resistant vs. reluctant
•Transferences
• Unrequited love (non reciprocal).. Not transference, and represented in
anxiety and depression.. You many feel it and then address it indirectly
•Compassionate vs. passionate love
•Puppy love

11. Empathy: Effective Communication Techniques
Nonverbal Message
•Posture: let your body show that you are interested by sitting up and leaning
toward patient.
•Equal positioning: if the patient is standing, you stand. If the patient is
sitting, you sit as well
•Facial expression: Feelings are reflected in facial expressions.
•Gestures: your body language reveals a lot about how you interpret a
message,
•Avoid sending signals that make patient believe that you are angry, in a
hurry, bored, etc.
•Nonverbal consistency throughout sessions

12. Effective Communication (cont..)
Express Thoughts and Feelings
•Be open and honest:
•Trusting
•Warmth
•Speak clearly: don't mumble, jargon or talk too quietly or quickly.
• Avoid professional terminology
•Professionalism vs. humbleness or simplicity
• Avoid being layperson vs. professional (e.g., homosexuality)
•Avoid bias : YAVIS (young attractive verbal intelligent and successful)
Communicate Without Being Adversarial ‫مخاصم‬ ,‫منازع‬ ,‫معاد‬
•Non-judgmental: talk about your concern without blaming the client.
•Don’t evaluate thoughts, feelings, and actions. Such as good, bad.. I have been drinking all night
(oh, that’s bad)
•For example, you might be upset that your client is not carrying out homework assignment.
•Rather than talking about the patient not doing his/her job, discuss your idea of how
noneffective session would be without doing assignment
•Use "I" messages: Rather than say, "You didn't do your homework ," say, "I didn't understand
what happened to that assignment
•“ I feel disappointed” instead of “you disappoint me”

13. Empathy is not a uniquely human trait. Animals demonstrate empathy, which suggests a
deep-rooted propensity for feeling the emotions of others.
An example of consolation among chimpanzees: A juvenile puts an arm around a screaming
adult male, who has just been defeated in a fight with his rival. Consolation probably reflects
empathy, as the objective of the consoler seems to be to alleviate the distress of the other

14. Mirror Neurons and Empathy
‫العاكسة‬ ‫العصبية‬ ‫الخلايا‬
Sympathy vs. empathy
• Mirror neurons exist in humans and macaque monkeys,
• Activate when an action is observed, and also when it is performed.
• mirror neurons in humans fire when sounds are heard.
• If you hear someone eating an apple, some of the same neurons fire as when
you eat the apple yourself.
• "How empathetic seems to be related to how strongly our mirror neuron
system is activated,"
• Classical conditioning
• Authors: Valeria Gazzola, at the school of behavioral and cognitive neurosciences neuroimaging centre at the
University of Groningen, the Netherlands

15. Mirror Neuron (motor mimicry)
• Neuron "mirrors" the behavior of the other, as though the observer were
itself acting.
• Found in the premotor cortex, the supplementary motor area, the primary
somatosensory cortex and the inferior parietal cortex.
• Important for imitation and language acquisition.for understanding the
actions of other people, and for learning new skills by imitation.
• Involves in language, and autism.
• Thinner in Autistic than normal

16. Postcentral Gyrus
• It is the location of primary somatosensory cortex, the main sensory
receptive area for the sense of touch
• Central sulcus in the front postcentral gyrus
• Parietal lobe (in yellow)

17. Verbal Communication
Verbal Communication (Mehrabian 1971)
7% Verbal
• What we say,
• Words, phrases and content
38% Vocal
• How we say it,
• Tone, intonation, pitch and pace
• Sarcasm comes into this category
Bluck/Bennett

18. Nonverbal Communication
55%
• Body movement
• Body language
• Gestures
• Facial expressions
• Eye contact
Bluck/Bennett

19. Nonverbal Communication (cont.…)

20. LABELS GIVEN TO MENTALLY ILL
• Lunatics
• Crazy
• Insane
• Idiots
• Feeble-minded
• Brain-sickness
• Beast
• Animals
• Witches
• Sorcerers
• Werewolves‫مستذئب‬
• Madness
• Possessed
• Disturbed
• Maniac
• Unbalanced

21. Pejorative Terms and Preferred Terminology
Avoid using these terms: Use Instead
Able bodied person Non-disabled person
implies that the person with the
disability is not ‘able’.
;
Afflicted; Afflicted by; Person with/
Crippled by; Person who experiences
Condition Impairment
Deaf-dumb, deaf-mute Speech impaired person
A person does not hear and
speak/voice. A person who is mute
may be able to hear.
Defect, defective disability is appropriate.
She suffers from a birth "she has a congenital disability."
defect." (offensive)
Deformed Disability is appropriate.

23. Treatment Variable
Therapeutic alliance
• Most important treatment variable
• Patient’s ability to establish interpersonal and trust relationship
• Patient starts thinking of session outside therapy room *
Duration
• Around 26 session, showing fairly linear positive relation
• If curve becomes flattened, you should refer patient
Type of treatment
• No type of treatment or approach is viewed as superior to the other

24. Client Variables
Are better predictors of therapy outcome than are therapist variables or
treatment variables (Luborsky et al., 1980)
Intelligence
• Highly intelligent patients seem to benefit from psychotherapy
• Intelligence is the ability to function adaptively in the environment
• patients with low intelligence are more likely to have trouble
incorporating and deploying new learning
• Strengths and weaknesses

25. Personality Characteristics:
•Passive aggressive:
- angry, sarcastic, critical patient
•Borderline:
- promiscuity, attachment
•Paranoid:
- avoid asking sensitive information at the beginning of session
- Don’t like to reveal confidential information in the first session
- After 5- 6 sessions, it is appropriate to probe more..
-Or after establishment of therapeutic alliance
•Histrionic:
- promiscuous, seeking attention
-can impress you and then you assume that their problem is minor
-Present himself or herself in a favorable light..
•Depressed:
-Take their complaints seriously

26. Patient Variables (cont..)
• Antisocial: manipulative, lack remorse,
• Obsessive Compulsive:
- intellectual and can test your competence
• Narcissistic:
- will drop out if you don’t acknowledge his or her self love, entitlement, or importance
during the first few sessions
• Dependent and Avoidant:
- depend on you absolutely to make decision and solve their problems
• Differentiate between whether male patient is love-shy or avoidant PD
Three personality factors that are related to positive outcome:
1. Ego strength
- Ability to benefit from a psychotherapy and withstand stress
2. suggestibility
- Tendency to accept and act on the suggestions of others.
- A patient’s intense emotions to be more receptive to ideas.
- Suggestibility decreases as age increases.
- levels of self-esteem, assertiveness, and other qualities can make some people
more suggestible

27. 3. Anxiety tolerance
- Handle anxiety-provoking situations without having them adversely
affect ability to function
Openness/Nondefensiveness:
• Cooperative patients achieve the best results
• Defensive, non-cooperative and hostile patient tend to have unsuccessful
experience
Motivation:
• Motivation to change at the beginning of therapy is found not to be as
important as the development of motivation during therapy.
• Patient learns more about motivation from therapy
Understanding of Goals;
• Both therapist and client being clear on goals of treatment is the
moderate predictor of treatment success

28. Socioeconomic Status (SES):
• people from lower SES were considered poor candidates for therapy
• This is more related to therapist low expectations than a function of the
patient him or herself
• Lower class clients are usually referred to less-experienced therapists and
to terminate prematurely
Expectations:
• Patients with high
expectations about therapy
Tend to not do as well as
patients with moderate
expectations
• Expectancy of 15%

29. Therapist variable
Age:
• Therapist – patient age similarity is associated very weakly with treatment
outcome
Ethnicity:
• Therapist ethnicity factor does not affect outcome
• Therapist-patient similarity is sometimes associated with early
termination and drop-out
• My experience with a Mexican man who interviewed me for citizenship…
OR American Indians who just involve in drugs
• Similarity of values, life styles, and experiences have a greater positive
impact
Emotional Well-Being:
• therapist emotional stability and well-being has a clear modest
relationship to therapy success
Expectation
• Therapist-patient shared expectancy about what therapy will be like,
increases positive outcome

30. Self-Disclosure
• Revealing of information will not produce increased treatment
effectiveness
• Excessive self-disclosure early in therapy relationship may result in a
negative first impression.
• Should be moderate, appropriate to situation, and similar or reciprocal
• Could be harmful if negative
Orientation
• Therapist orientation accounts for very little variance
• Gender
• No significant relationship between therapist-client gender similarity and
outcome
Competence
• The most important of therapist variables

31. Responses to Avoid
Avoid
- Judgmental and
evaluative statements
(feeling, thought, action)
- Philosophical
Probing statements
Hostile responses
False reassurance
statements
(don’t worry..be ok)

32. Effective Probing Statements
POOR BETTER
Why did you yell at him?
Why did you say that?
Why can’t you sleep
Do you drink?
1. Tell me more about what happened
2. How did you happen to yell at home?
3. What led up to the situation?
1. Can you tell me what you mean?
2. I’m not sure I understand
3. How did you happen to say that?
1. Tell me more about your sleeping problem
2. Can you identify what prevents you from
sleeping?
3. How is it that you are unable to sleep?
1. How often you drink?
2. Tell me more about your drinking habit
3. How many times your drink per day, week,
etc?

33. Example of False Reassurance Response:
• A Saudi student in an applied school is dismissed from college, loses his
job, and starts fighting with parents.
• You lie to him when you say “Don’t worry, no problem, it’s Okay.
• Will think of you as not wanting to assist.
• What happen to this student requires specific action from his part to
prevent even more disastrous developments
• Person who gives false reassurance usually knows this, and so does the
person who receives it
Arab communication:
• When two Arabs meet

34. self-fulfilling prophesy:
• A false definition of the situation that evokes a new behavior that
makes the original conception become true,
• For example, labelling behavior as delinquent may cause more
delinquent behaviour

35. Copyright 2004 - Prentice Hall 15-35
How We View Our Patient
Attribution:
• involves deciding why certain events occurred and why certain people
behaved as they did.
• Internal vs. external attribution
• With internal attributions, behavior is seen as being caused by factors residing
within a person (internalization)
• With external attributions, the causes of behavior are viewed as residing
outside an individual.
• The attribution error occurs when internal factors are emphasized to the
exclusion of external or situational factors.
• Did You Offer Sympathy for Her?

36. Copyright 2004 - Prentice Hall 15-36
How We View Our Patients
Attitudes:
• Attitudes are evaluative judgments (negative, positive, or neutral) that are formed
about people, places, and things.
• Affect, cognition, and behavior are the three components of an attitude.
• Discrimination consists of behaviors directed at members of a particular group
that affect them adversely.
• Racism
• Modern discrimination (behavior)
• Bias
Prejudice (feeling; (medial prefrontal cortex)
 MPF cortex is activated when looking to ordinary persons
 MPF is silent when looking to social outcasts; drug addicts
medial prefrontal

37. Evaluating a bad Therapist: Danger Signals
Therapist Who
• makes sexual advances
• Repeated verbal threats or is physically aggressive
• Excessively hostile, controlling, blaming, or belittling
• Talks repeatedly about his/her own problems
• Encourages prolonged dependence on patient
• Demands absolute trust or tells client not to discuss therapy with
anyone else
• Discussing therapy issues with other is a step toward full awareness and
readiness to do activities
• Confidentiality and privacy

38. Too Far

39. Too close

40. Hands crossed

41. Legs crossed: arrogance

42. Too high

43. Too High
Turkish ambassador
Was humiliated by
Israeli officials due to
anti Israeli TV show

44. Unavailable: Invisible

45. Equal Height (correct)

46. Therapeutic Relationship and Alliance
The conclusion for therapists:
No matter what therapeuticNo matter what therapeutic
technique or model is used,technique or model is used,
it is not likely to be effectiveit is not likely to be effective
if there is not a strong client-if there is not a strong client-
therapist relationshiptherapist relationship..

47. Therapeutic Alliance:
Outcome by Type of Factor

48. Successful Therapy
• Psychotherapy outcome depends not only on
method of therapy.
• Qualities of client and therapist, and their alliance,
also determine success.

49. Acknowledgement:
• Many thanks to Ms. Abeer Al Abdulaziz who
has generously contributed to this lecture by
taking the snapshots
• Many thanks to Dr. Mohamed Al-Qahtani
(senior psychiatric resident) for his role-play of
a patient

50. Professor Kurt Haas (1988)
State University of New York – New Paltz
Don’t Do Harm

51. Thank you!