Now Moments in Professional Care - The Importance of Positive Affect in Patient-Therapist Matching

Keywords

Positive Affect; Unwavering Interest; Matching; Psychoanalysis; Humanistic Approaches.

Introduction

Towards the end of the 1980s Orlinsky & Howard elaborated the general model of psychotherapy based on empirical process studies. The probability to achieve therapeutic success is higher if the following four factors are coordinated: matching of treatment model and disorder, patient and treatment model, the therapist and patient and the therapist and disorder [1]. Even if the model represents a good basis, it has to be extended by other important factors, like the matching of gender or educational level. These in turn depend on the therapist’s believe system of human being. Both gender and level of education are vulnerable to stereotypical thinking. Women are often seen as irritable, emotional and having more social interest. On the other hand, the patient also has a specific objective in the therapy and preference toward the therapist [2]. His idea often correlated with a certain conception of an upcoming therapy, according to the nosological theories (behavioral theory, system theory, phenomenology etc.).

Psychoanalysis has also a long tradition with the subject of matching in a therapeutic process. The psychoanalytic method achieves a permanent change in the patient's symptoms, the positive result requires among use of therapeutic interventions that enough time is spent in a positive and caring therapeutic relationship” [3]. Knowlegde about the development of symptoms alone had no contribution to the positive changes, it depends on the experience with the analyst [4]. The experience in the ‘here and now’ in a relationship between patient and therapist [5], the countertransference in the current therapeutic process, involving the focus on early interpretation of the dominant affect in the activated transference relationship in the here and now have to be focused.

Furthermore patient’s experience with the psychoanalyst includes affect regulation and affect-perception by the psychoanalyst. Especially the dominance of positive over negative affects contributes to a successful treatment [6]. Significantly, the regulation of infant’s emotions shows parallels to the psychoanalytic relationship. The mother facilitates the mirroring both negative and positive emotions by her unwavering interest in her infant. So the infant could recognize his own emotions due the tag of mother’s mirrored facial expression. The patient experiences a mirroring of his emotions and a therapist who recognizes externalized internal conflicts and is able to contain and work them through with the patient – an effort, that requires an attitude dominated by basic interest for the patient.

The positive affect in patient-therapist matching – a basic ingredient for all treatment methods?

The treatment techniques dealing with externalizing mechanisms are visualized in a case study based on systemic therapy about a client with somatization disorder. Mr. L felt completely powerless and let down by the doctors and his family. Consequently, he also didn’t see himself as part of a solution. Here the systemic therapy works with the motivation of the patient. Three potential motivation-states can be distinguished into "visitor", "complainant", and "customer". As an involved "visitor" the client sees himself without conflicts. He isn’t motivated to change his behaviour. The "complainant" acknowledges his problems, but doesn’t see himself as a part of a solution. Other than the "customer": He is motivated to change his behaviour, because he sees himself as part of the problem and also of a solution. Systemic therapist’s target is to use interventions which invite "visitors" and "complainants" to become "customers" [7]. Thus, the therapist-patient relationship isn’t oriented towards a deficit-oriented patient model, where the patient is explicitly dependent on the therapist. Now the customer encounters the therapist as a contractor.

The establishment of a good therapeutic relationship is a basis in which a safe space is created by the therapist’s availability and interest, and the patient’s motivation for self-efficacy.

In turn, the self-efficacy processes correlate to systemic therapy resource orientation. The consequence was a positive change in self-relation: The "I am helpless" was replaced by “I’m able to achieve my aims”. Moreover, these changes had strong positive effects on physical symptoms.

In Mr. M the focus is increasingly on establishing psychotherapy as the above-mentioned safe and trusting place. Mr. M suffers from an acute stress reaction with physical symptoms. His stress tolerance, self-efficacy, as well as his resource activation increased significantly through skills training, mindfulness exercises, imagination and understanding the own externalization mechanisms.

An inner safe room can be created, inter alia, by the imagination. It should be a place where the client feels very secure. Also at first, this place should ensure safety outside the therapy. The relationship to the therapist is the constant safe room where the patient improves his self-experience and experiences positive changes, this can be internalized for a long lasting period – basically as an interested good object.

Taking another treatment method, Mr. N was treated in individual psychology child and adolescent analysis. The matching on the relationship level was very crucial due to the severe course of disease and many traumatic experiences. A strong relationship was complicated by the diversity of symptoms. Mr. N's desperate acting and the reduction of his unbearable inside tensions caused by aggressive fantasies and self-injurious behavior prevented a transference relationship for months. Subsequently, the therapist was unable to act and felt powerless. In the therapeutic relationship it’s especially important to interpret these dynamics as early as possible. Also, an early processing of negative emotions will be possible by ‘holding’ and ‘containing’ the externalizing and projective mechanisms. Psychoanalytic techniques [6, 8] can only develop, when the therapist’s attitude is accompanied by openness and positive affect/interest.

Discussion

Literature on the matching in psychotherapy is restricted on four essential aspects. Orlinsky's and Howard's model is often the only presented model of matching. This means that the better the relationship experiences and the treatment focus fit each other, the more positive is the treatment outcome. What the therapeutic focus exactly is, hasn’t been elaborated yet. It’s especially the unwavering interest in the patient, as well as focusing on the affect that lead to a successful therapy [8]. These factors are available in the three mentioned treatment methods, each with positive results. Already at the beginning, maintaining and showing positive affects towards the patient is hard work for the therapist in the third case vignette. Therefore it’s important that the patient-therapist matching has a great importance in the therapeutic training. At this point no difference should be made in therapy methods, because it’s the job of each therapist and clinician to offer a successful treatment to the patient and to have general interest in the patient through his acquired skills.