CombatCounselor Q&A: Episode 1 (April 1, 2014) on Spreecast

Is a Smaller Amygdala The Cause Or An Effect of PTSD?

In an recent PsychCentral.com article by Janice Wood, researchers at Duke University and the Durham VA Medical Center discovered that combat veterans with post traumatic stress disorder (PTSD) are more likel to have a significantly smaller amygdala than those without PTSD. The amygdala is a small structure in the brain which regulates emotions, in this case fear and anxiety, with anxiety literally being  "the fear of fear".

Wood states that "their study provides evidence that smaller amygdala volume is associated with PTSD, regardless of the severity of trauma. But, they add, it’s not clear whether the physiological difference was caused by a traumatic event, or whether PTSD develops more readily in people who naturally have smaller amygdalas."

“Researchers found 20 years ago that there were changes in volume of the hippocampus associated with PTSD, but the amygdala is more relevant to the disorder,” said Rajendra A. Morey, M.D., M.S., assistant professor at Duke and lead author of the study.

Morey noted that studies in animals have established the amygdala’s role in regulating fear, anxiety and stress responses, but its effect on human behavior is less well known. “It’s associated with how fear is processed, especially abnormal fear processing,” he said. “So it makes sense to look at the structure of the amygdala.”

The researchers recruited 200 combat veterans who served in Iraq and Afghanistan after Sept. 11, 2001; half had PTSD and the other half had been exposed to trauma, but did not developed PTSD. Amygdala and hippocampus volumes were computed from MRI scans of all 200.

The researchers found significant evidence that PTSD was associated with smaller volume in both the left and right amygdala, and confirmed previous studies linking the disorder to a smaller left hippocampus. The researchers emphasize that the differences in brain volumes were not due to the extent of depression, substance abuse, trauma load or PTSD severity, factors they took into account in their statistical model.

PTSD strikes nearly 14 percent of combat veterans serving in Iraq and Afghanistan, according to the Department of Veterans Affairs. PTSD also is estimated to affect 6.8 percent of adults in the general population who have suffered abuse, crimes and other traumas.

“The next step is to try to figure out whether a smaller amygdala is the consequence of a trauma, or a vulnerability that makes people get PTSD,” Morey said.

He said the study showed that amygdala volume does not appear to be affected by the severity, frequency or duration of trauma, indicating that these factors do not cause the amygdala to shrink. It appears more likely, according to the researchers, that people with measurably smaller amygdala to begin with are susceptible to PTSD, but more studies are needed to make that determination.

Morey said he and colleagues are exploring that question, and are intrigued by evidence from their study that suggests people may have a propensity for developing PTSD based on inherently smaller amygdala volume.

“This is one piece in a bigger puzzle to understanding why some people develop PTSD and others do not,” Morey said. “We are getting closer to that answer.”

Funding for the study, which was published in the journal Archives of General Psychiatry, came from the U.S. Department of Veterans Affairs and the National Institutes of Health.

The CombatCounselor Channel on Spreecast

LETTER TO THE EDITOR: Air Force Times

According to an article in your March 24, 2014 issue, George W, Bush and Army General Chiarelli, well respected  psychologists and scientists?, believe and profess that removing the word "disorder" from post-traumatic stress disorder (PTSD) is going to single-handedly end the military and veteran mental health and PTSD stigmas. Sorry boys, don't be ignorant ... ain't gonna happen!

President Bush's endorsement of this half-baked idea is as sound as my abilities in brain surgery and General Chiarelli's influence and support would be better utilized by focusing on the real causes of the stigmas, lack of confidentiality in military mental health, the macho bravado and ignorance endemic in the military, and the inaccurate portrayal of veterans and military members in the media.

PTS Without "Disorder" WILL NOT END THESE STIGMAS gentlemen. Use your clout to attack their real causes before more American heroes decide suicide is a better alternative than seeking treatment, risking security clearance and career, or being called a wimp. 

As a licensed professional counselor with 23+ years of experience treating military and veterans with anxiety (including PTSD) and depression, a retired military officer, and disabled veteran, I have written and advocated extensively on this topic. Specifically, my article THE STIGMAS KILLING AMERICAN HEROES.  http://www.combatcounselor.com/2012/12/article-stigmas-killing-american-heroes.html and two White House Petitions asking President Obama to address the stigmas, which garnered a whopping 70 signatures each out of the tens of thousands who heard my pleas, outlined clear, tangible courses of action. I have also written to Air Force Times on numerous occasions regarding this exact topic, but was ignored. But who can blame you when you have such authoritative experts in psychology and military/veteran mental health as President Bush and General Chiarelli?

C.T. Sorrentino, LtCol, USAF (Ret)

aka CombatCounselor

Lawrence, KS

#BringBoweHome ... Seeking the Release of Sgt Bowe Bergdahl (USA)

SGT BOWE BERGDAHL - CAPTURED JUNE 30, 2009

Army Sergeant Bowe Bergdahl was captured on June 30th, 2009 while on patrol near the town of Yahya Khel in the Paktika Province in Southeast Afghanistan and near the border with Pakistan.

Bowe recently received national media attention after this video was exposed:

http://www.cnn.com/2014/01/15/world/asia/us-prisoner-video/

For more background on his capture and efforts for his release, read more here:

http://en.wikipedia.org/wiki/Bowe_Bergdahl

This young man has been in captivity for nearly 5 years, but have you heard much, if anything, about him? Probably not. Why is our government and the media covering this up and what are they doing to ensure his safe release or recovery?

You and your family members are home, safe, and secure, but Sgt Bowe Bergdahl's family has been worrying about their son, brother, and grandson for nearly five years ... PLEASE SIGN THIS WHITE HOUSE PETITION, endorsed by Bowe's father Bob on Twitter:

@bobbergdahl

Let's help #BringBoweHome soon and safely!

Key Words: sgt, Bowe, Bergdahl, bob, US, Army, Afghanistan, patrol, capture, captured, captivity, Taliban, Pakistan, Navy, SEALS, CombatCounselor, combat, counselor

Copyright 2013 - CombatCounselor and 3rd Wave Media Group, LLC - All Rights Resreved

Is The Voice's Will Champlin Just Shy or Is There More To It?

Is Will Champlin, the very talented contestant and finalist on this season’s NBC’s The Voice, just very shy or does he possibly struggle with what has been referred to until recently as Asperger’s Syndrome? Could NBC, The Voice, or Will himself be waiting until the season is over to make an announcement, not wanting to influence fan voting either positively or negatively?

As a licensed professional counselor with over 30 years experience as a clinician and experience working with and treating those with autism, I would personally not be surprised. If Will did have Asperger’s Disorder (now referred to as Autism Spectrum Disorder in the new DSM-V) or another form of autism, all I could say is BRAVO! Not because I would ever wish something as debilitating as autism on anyone, but because he could make an excellent ambassador and role model for those individuals and families struggling with autism and other mental health concerns and obviously overcame great odds to achieve the success he has on The Voice. That could potentially have a massive impact on the elimination of the many negative stigmas surrounding not just autism, but all mental disorders, something I have personally been fighting very hard to achieve.

I am not going to detail the differences between DSM-IV-TR and DSM-V diagnoses here as that would take many pages and is not really relevant to this discussion. Let it suffice to say that whether we call it “Asperger’s Disorder” or “Autism Spectrum Disorder” is not important because they are both merely diagnoses, labels we as clinicians are often mandated to provide and do not define who a person is.

Will Champlin appears to be an extremely quiet person and smiles are few and far between, both symptoms of what we used to call Asperger’s and other Autism Spectrum Disorders. In-fact, Carson Daly commented for the first time just last week that it was nice to see Will finally smiling. Will also appears rather uncomfortable on stage with difficulty making eye contact. Another thing that has stood out is Will’s unwillingness, inability, or lack of comfortableness touching others. Most, if not all Voice contestants hug or otherwise touch Carson Daly after a performance or when greeting others, including their coaches and other contestants, but Will does not. 

I have seen Carson deliberately not touch Will in those situations and last week, while the very talented (and probable winner of this season’s show) Tessanne Chin and James Wolpert (who was eliminated last week), Adam Levine’s two other finalists, were holding each other tightly while waiting for the announcement of whom would be moving on to the #VoiceFinale, Will Champlin stood alone and emotionless. These are all symptoms of the Autism Spectrum Disorders, a very few symptoms of a very complex set of criteria we use to make diagnoses.

I do not know Will Champlin and do not have enough information to make a diagnosis, nor should I. Maybe he is just a very shy person or maybe he struggles with autism. All I am saying is that based on the behaviors I witnessed during this season of The Voice, he could be one of the millions of people who struggle with the developmental disorder we refer to as “autism”. 

Autism comes in many forms and varies wildly in severity, as do all of what we in the profession call “mental disorders”. Whether Will Champlin has a diagnosable disorder or not cannot and will not be determined here nor would it define him. However, an influential person with Asperger’s, Autism Spectrum Disorder, or whatever label we as humans feel the need to put on people with symptoms of social discomfort, could bring positive awareness to the struggles the millions of people with mental health issues suffer through each and every day.

I have written extensively about the stigmas surrounding mental disorders such as PTSD, anxiety, and depression, both in general and specifically in the military. My goal here is to help eliminate those stigmas and the many misconceptions the public has regarding mental disorders and mental health treatment. 

The winner of this season’s The Voice has not been announced as I write this and believe Tessanne Chin will likely win. But I am pulling for Will Champlin mostly because I would like Will to succeed on the Voice and in life. 

Good luck Will!

Key Words: NBC, television, The Voice, voice, Will Champlin, Carson Daly, show TV, singing, song, talent, Asperger's, autism, spectrum, disorder, CombatCounselor, combat, counselor, psychology, therapy

Copyright 2013 - CombatCounselor and 3rd Wave Media Group, LLC - All Rights Reserved

Online Therapy: Boon or Bust?

In a modern world with technology making it easier and easier to communicate across the street or around the planet, we as psychotherapists face uncharted ground and ethically borderline situations when communicating with clients. I see people who call themselves "therapists" on Twitter and other social networking sites offering therapy via email and Skype (to name just two potential platforms) ... AND THAT CONCERNS ME!

Based on my experience, education, and knowledge of clinical ethical standards for our profession, email is "dodgy" to say the least, offering little protection for confidential communications. Skype therapy has been challenged by licensing boards and professional ethical standards (National Board of Certified Counselors, American Counseling Association, American Mental Health Counselors Association) based on state of licensure, with restrictions on whom licensed clinicians can see, particularly concerning domicile of both parties.

In Missouri and Colorado, two states in which I am licensed, licensed professional counselors (LPC) like myself ARE NOT ALLOWED to see clients outside of our state, even if it happens to be over the internet. The reasons for this are numerous, but, most importantly, the well being of our clients should be utmost in our minds. We cannot travel across state lines to see clients and, therefore, cannot travel virtually cross state lines via the internet either.

There are situations where it may be advantageous to see clients remotely, especially when a client is housebound or in geographically remote areas where face-to-face visits would be cost or time prohibitive. Otherwise, it is ALMOST ALWAYS IN THE CLIENTS BEST INTEREST to meet in person. 

Research on language has indicated that a majority of human communication is "non-verbal" with estimates ranging from 70 to 90 percent. Body language is one non-verbal mode of commuication where context is critical in understanding what is being communicated. Electronic commuications do not allow us to experience body language when discussing sensitive and often complex personal experience as is necessary when performing psychotherapy. Intonation is another non-verbal cue we use to determine what exactly is being communicated, a phenomena that is severely restricted, particularly in written communication.

Confidentiality is of utmost concern when working with clients and electronic commuications are not secure, allowing for potential exposure of extremely sensitive experiences, thoughts, and emotions. Would you want the NSA listening in on your therapy season?  I know I do not!

The individuals performing "Skype Therapy" are many times unlicensed, a fact that can easily be manipulated on websites, blogs, and social networking sites. Few understand that WE MUST BE LICSENED in the state in which we practice in order to offer psychotherapy to the public. Licensure involves AT LEAST a masters degree in psychology or counsleng, and in some cases a doctorate (PhD or PsyD) degree from an accredited institution of higher learning. On top of the degree, practicums, supervision, and post-graduate experience totaling in the thousands of hours (3,000 and up in most states) are required in addition to passing a national exam in order to become licensed. People have been "hanging shingles" for many years without proper training, education, and licensure, so why would things be any different today? 

I have preached about unlicensed and other unqualified individuals (can you say "life coach?) elsewhere in this blog, so I will not elaborate here. It will suffice to say that being "certified" is not enough. I, for example, am a National Certfied Counselor (NBCC - since 1991), but I am AND MUST BE licensed in the state in which I practice in order to LEGALLY PERFORM PSYCHOTHERAY. 

As I have also mentioned in other articles, YOU MUST CHECK AN INDIVIDUALS LICENSE BEFORE INITIATNG THERAPY WITH THE STATE REGULATORY AGENCY COVERING PSYCHOTHERAPISTS IN YOUR AREA. Then, and only then, should you consider undergoing treatment, whether it is face-to-face or over the internet. I would recommend face-to-face treatment in all but the most austere or complex situations.

Social Dystrophy™: Are Technology or Values to Blame?

Would "Social Dystrophy" be an appropriate term for the lack of social skills endemic in today's population? I came up with the term “social dystrophy” while exercising at the YMCA last week, having experienced more then the usual number of rude and obnoxious people that day. I cannot take credit for coining it because somebody already created a website, http://nyrixxblog.socialdystrophy.com, having apparently had similar experiences with humans.

According to Dictionary.com, “dystrophy” can be defined as “faulty or inadequate development” faulty or inadequate nutrition or development”. Dystrophy would then imply that there were some social skills in the first place, which may not necessarily be the case and may eliminate the term as an appropriate label for what we are experiencing. I may be generalizing, and I know there are many pitfalls in that and there are many socially adept people out there, young and old, but the problem seems to be getting worse and worse with the advent of new communication technologies (being invented almost daily). Let me elaborate and provide some poignant examples as well as potential solutions.

I was at the market the other day looking for my rewards card before placing my items on the conveyor (there was no line when I arrived and few customers in sight). Before I had a chance to hand my card to the cashier, some middle aged guy rushes up and starts putting his shopping items on the conveyor. As they whizzed past me on their way to the cashier, I looked back and politely asked "would it be OK if I continued to put my items on the conveyor and finish checkout?" while the cashier looked on in dismay. The man, who was accompanied by his teenage son, glared at me defiantly and stated "I didn't turn the conveyor on!" Really? Is that an answer or any kind of excuse for being rude and in such a hurry that you cannot wait until I complete a simple task? Dumbfounded by his ridiculous answer, I politely asked if he would remove his things so I could continue with my shopping, but his reply cannot can be repeated here, cursing and insisting that I was being rude simply because I wanted to continue my shopping without having to move his out of the way. Let me just say that the situation deteriorated from there with the man using profanity and insulting my character…what an excellent role model for his teenage son!

Then there are the people at the gym who turn the fans around the cardiovascular equipment on without bothering to ask the people who have been there for some time, and do not like the fan blowing on us, if we would mind if they “turned the fan on”. How difficult would it be to say, “excuse me, can I turn this on? Too difficult, obviously, for a social misfit who does not care about anybody but him or herself or does not have the social skills or training to communicate with other humans.

Still at the gym, there are the people, usually young, who barge past us in the locker room on their way to a locker they just cannot live without. Many times there are areas of the locker room totally empty and available, but they NEED THAT locker, cannot wait a few minutes until we are done, or do not have the skills or inclination to say "excuse me". Is that really so difficult?

Then there is the guy in his BMW that lays on his horn when I have the nerve to continue in the lane that I was traveling in after leaving a stop light. If he had not been too busy talking on his cellphone, he would have been cognizant of which lane was his and where he should have been driving. Instead, he thinks I am the moron when in fact he should have been ticketed for an illegal lane change, aggressive driving, and disturbing the peace.

I could go on and on and experience numerous instances like those above DAILY! Really? Daily? Yes, DAILY! Well, why is this happening daily and why does it seem to be getting worse as time goes on? In this reporter’s opinion, technology and a lack of clear core values are at the root of the problem.

Technology has grown so quickly and become so engrained in our culture, our lives, that we “think” we cannot live without it. How many times have you seen a car swerving all over the road, only to catch up to the driver and find them chatting or texting on their cellphone? If you live in any metropolitan area, or anywhere else for that matter, you see it all the time. Everywhere you go people young and old are talking on the phone or texting their friends about some inane subject, completely oblivious to what is happening around them or considering what affect their behavior may have on others. They simply do not care! It has gotten to such an extreme that people are texting the person standing next to them or in the same room! C’mon folks, is it really that demanding or difficult to look someone in the eye, open your mouth, and emit the words it takes so long to “thumb” on your smartphone (a misnomer).

The ability of humans to communicate is slowly deteriorating because of technology. Whether it is cellphones or computers, the internet or email, laptops or iPads – you name it – technology has made us (yes, I am not immune) not only more productive, but lazy! Before cellphones, computers, and the internet became commonplace, which was not all that long ago, people waited until they returned home to call a friend or even write a letter which may have taken several days to arrive once posted, and everybody seemed to be a lot happier, a lot less stressed than we are today. If technology and human behavior continue at this pace, the ability to communicate verbally, face to face, making eye contact and the whole shebang, is going to become a thing of the past. It is quickly becoming clear, particularly in the younger generations who have grown up with these technologies, that human communication is deteriorating rapidly and we should all be very concerned about that dilemma.

Finally, I believe it is a loss of focus on or undefined core values that can account for much of the self-centered behavior we see daily. The world in general and our country specifically, politically, corporately and personally, has lost touch with what is important to us – our values. I see it day in and day out in my practice, when I ask a client to tell me what they value, they look at me like I have a penis growing out of my forehead. “My values? What do you mean exactly?” When I explain what values are, they routinely come up with “my family” or “my job”, still not quite grasping the concept.

Values, according to Encarta Dictionary, are “the accepted principles or standards of a person or group”. They define what we are about and, if clear and well defined, help us act in a moral, ethical, or legal way when presented with novel or familiar situations. That sounds pretty important! But few people can tell me what their values are and that is pretty scary. It is no wonder that people are running around thinking of little but themselves when they have no moral, ethical, or legal map to help get where they are going. That is why the world and our nation are in crisis, financial and otherwise, at this moment and it is also why people do not care about anybody but themselves.

Put down the phone, clarify your values (what is important to you), look people in the eye when you speak to them, treat people with dignity and respect, and act on your values...even if you are having a bad day, or are anxious or depressed...be selfless, not selfish and the world will be a better place to live.

More on values in a future post…

Key Words: social, dystrophy, values, value, core, inept, incompetent, CombatCounselor, combat, counselor, psychology, therapy, CBT, ignorant, ignorance, SocialDystrophy, technology, phone, text

CombatCounselor Describes War-Induced Stress On Kansas City TV Station KMBC

An experienced combat veteran, retired Air Force lieutenant colonel, and expert in working with military and veterans with post-traumatic stress disorder (PTSD), Chris Sorrentino, a licensed professional counselor, Executive Director of Kansas City Cognitive-Behavioral Therapy, and President of Help4VetsPTSD, a non-profit dedicated to military and veterans with PTSD, discusses combat stress with ABC News affiliate:

Counselor Describes War-Induced Stress - Kansas City News Story - KMBC Kansas City

Sorrentino went on to describe his sorrow for the families of the 16 Afghanis allegedly killed by a US solider and for the soldier's family.  "My heart and prayers go out to the families of the victims, the soldier, and the Afghani people for their unimaginable losses" Sorrentino told Maria Antonia via Skype this afternoon.  LtCol Sorrentino happened to be out of the area at the time, working with re-deploying soldiers at an undisclosed location.

"The military is a microcosm of American society", Sorrentino added, stating: "and the extremely unfortunate events that occurred in Panjwai district, a rural suburb of Kandahar and a traditional Taliban stronghold, are not at all indicative of the behavior of our brave, dedicated, selfless military personnel and should be considered an isolated event". Our deployed military are heroes and this incident should not reflect negatively on them in any way.  It is understandable and warranted for the Afghan people to be horrified and upset about the attack, just as many American are, and justice will be served as the soldier's fate is determined in a court of law.

The facts have yet to be determined, but Sorrentino concluded "the negative stigma attached to mental health treatment in the military has existed for decades and will not, unfortunately, end anytime soon".  "If the attacks were related to combat-related stress or other psychological issues, an environment more conducive to military members seeking treatment, rather than fearing reprisal or loss of a security clearance, could have potentially mitigated this threat ".  LtCol Sorrentino asked President Obama to "end the negative stigma associated with military mental health care" in a question and answer session after January's State of the Union Address.  Unfortunately, Obama ignored Colonel Sorrentino's pleas and failed to respond to his question.

Title: CombatCounselor Describes War-Induced Stress On Kansas City TV Station KMBC

Key Words:  KMBC, TV, Kansas City, MO, MIsouri, combatcounselor, combat, counselor, war, induced, stress, PTSD. PTS, trauma, disorder, television, 

The Therapeutic Alliance

This article focuses on therapeutic (working) alliance in counseling, a critical component related to successful outcome in counseling.  I examine a small number of studies, providing background related to the general effects of counseling and the Working Alliance Inventory (WAI) and discussing the impact of the alliance in counseling.  I conclude with a discussion of the implications of the information presented, specifically focusing on the contextual model and the importance of general effects in counseling, the importance of developing a collaborative relationship with clients early on, understanding how clients early formative and current relationships affect their ability to form a working alliance, achieving a balance between process related techniques and alliance strengthening skills, and, finally, evaluating client attachment style and how it may affect the working alliance.  

                        Keywords: Alliance, therapeutic, counseling, client, attachment, contextual.

           The therapeutic alliance, or “working” alliance as Bordin (1979) defined it, is widely accepted as a crucial component of successful outcome in counseling and has been studied extensively.  I examine a relatively small number of studies here and with a somewhat limited focus due to time and other constraints related to this assignment.  I will start by providing some background related to the general effects of counseling as well as a widely used instrument in measuring the alliance, the Working Alliance Inventory (WAI).  I will then discuss the impact of the alliance in counseling, focusing on a few key studies, finishing with a discussion of the implications of the information presented.

General Effects and the Therapeutic Alliance

            In Wampold’s book, The Great Psychotherapy Debate, he identified therapist effects as a “critical factor in the success of therapy” (2001, p. 202).  More specifically, in their article on therapist and patient variability in the therapeutic alliance, Baldwin, Imel, and Wampold (2007) pointed out that it is the therapist’s contribution to the alliance that is foremost in determining a successful outcome for the client.  Wampold (2001) supported the contextual model (versus the medical model), contending that is the general effects (common factors – therapeutic alliance, therapist competence, a belief, by the therapist and client, in the effectiveness of the therapy, etc.) of psychotherapy that are key to a successful outcome, not the specific effects (techniques) of any particular therapeutic approach.   That being said, it is widely contended that it is the therapeutic alliance that will account for a great deal of the variability, both positive and negative, in the client’s outcome.

The Working Alliance Inventory (WAI)

            The Working Alliance Inventory (WAI), developed by Horvath and Greenberg in 1968, is a widely used instrument for measuring the therapeutic alliance and was the instrument of choice in the majority of the studies discussed here. The WAI is a 36-item self report survey consisting of three subscales that mirror Bordin’s three components of the working alliance, goals, tasks, and bonds, and uses a 7-point Likert-type scale.  Parallel forms are available for both clients and counselors (Satterfield and Lyddon, 1995).

The Therapeutic (Working) Alliance

            One of the most important tasks that we as counselors have is to form a positive, healthy, nurturing working alliance with our clients.  As we discussed briefly above, Bordin (1979) defined the working alliance as a collaborative process in which client and counselor  (a) mutually endorse goals or counseling outcomes; (b) join in tasks related to the attainment of successful outcomes; and (c) establish positive personal attachments, or bonds, which are characterized by trust, acceptance, and confidence.  A good working alliance is based on two important factors.  The first factor is the relationship that the counselor develops and fosters from the very beginning of counseling.  Kokotovic and Tracey (1990) found that clients who were viewed by their counselors as having poor social relationships in general had greater difficulty in forming working relationships (alliances) with their counselors.  A second factor is the relationship the client has or had with his or her parents, because that relationship will give us insight into how the client relates to their social network and, ultimately, most likely predict how they will relate to their counselor.  In support of that assertion, Mallinckrodt (1991) also reported evidence of a correlation between clients’ recollections of the quality of their childhood bonds with their parents and the strength of the working alliance.

            In Kivlighan’s (1990) study, the relationship between counselor technical activity (use of intentions – set limits, educate, assess, explore, change, restructure, and support) and working alliance (as rated by the client) was analyzed during the course of four counseling sessions.  Two groups of undergraduate students were asked to participate in a study in which sessions were analyzed to see if the use of intentions by the counselor affected the quality of the therapeutic alliance.  The study found that during the four sessions, three of the intentions mentioned above, assess, explore, and support, were negatively correlated with the working alliance as measured by the WAI.  The authors were somewhat surprised by the negative correlation of the support intention (offering support or encouragement) with the alliance, but concluded that this may have occurred because it put the client in a more passive role.  They also proposed the following questions: 1) “Can counselors be trained to decrease their use of the assessment, explore, and support intentions?” and 2) “Would this training affect client-rated alliance?” We are not sure that such training would be either indicated or useful based on a study with such obvious limitations, considering the importance of assessment, exploration, and support in counseling.  At best, the study points to the need to balance such strategies, with the counselor paying particular attention to the use of intentions that may put the client in a more passive role versus those that will enhance the working alliance.

            According to Satterfield (1995), a client whose attachment style is characterized by a lack of trust in the availability and dependability of others (low level of “depend”) may be more likely to evaluate the counseling relationship in negative terms, particularly during the early phase of counseling. The authors recruited ninety-six first-time clients seeking counseling through the university to participate in a study in which they completed the Adult Attachment Scale (AAS) prior to counseling and the WAI (client version) after the third session.  Sixty participants completed the study and the authors concluded that client attachment, particularly the “depend” measure, is in-fact negatively correlated with the working alliance and may lead to unfavorable counseling outcomes. They also recommended further research on the impact of counselor knowledge of client attachment dimensions and the affect they may have on the working alliance.

Conclusions

            What should counselors focus on if we are to accept the hypothesis of the contextual model and the importance of general effects in counseling as proposed by Wampold?  Based on the research, one of the most important things we can do is learn how to better foster a therapeutic, empathic, nurturing alliance with our clients.  As Bordin (1979) recommended, we should focus on developing a collaborative relationship with our clients early on, setting mutually agreeable goals, working together toward successful outcomes, and establishing positive bonds.  Kokotovic and Tracey (1990) and Mallinckrodt (1991), taught us that we should understand how our clients early formative relationships and their ability to form and maintain current relationships affect their ability to form a strong working alliance.  Kivlighan  (1990) emphasized the importance of focusing on a balance between process related techniques (intentions) and alliance strengthening skills, such as those endorsed by Carl Rogers (genuineness, empathy, and warmth).  Finally, Satterfield (1995) points us to the need to assess our client’s attachment style, looking particularly for those clients who may be characterized by a lack of trust in the availability and dependability of others, and how their attachment style may contribute to the alliance.   In conclusion, because alliance effects are so intertwined with outcome, whether positive or negative, we owe it to our clients to “do no harm” and do everything in our power to foster a positive working alliance.

References

Baldwin, S.A., Imel, Z.E., & Wampold, B.E. (2007).  Untangling the alliance-outcome correlation: Exploring the importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75 (6), 842-852.

Bordin, E. S. (1979).  The generalization of psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.

Kivlighan, D. M. (1990). Relation between counselors' use of intentions and clients' perception of working alliance. Journal of Counseling Psychology, 37(1), 27-32.

Kokotovic, A. M. and T. J. Tracey (1990). Working alliance in the early phase of counselor. Journal of Counseling Psychology, 37, 16-21.

Mallinckrodt, B. (1991). Clients' representations of childhood emotional bonds with parents, social support, and formation of the work alliance. Journal of Counseling Psychology, 38, 401-409.

Satterfield, W. A. and W. J. Lyddon (1995). "Client attachment and perceptions of the working alliance with counselor trainees. Journal of Counseling Psychology, 42 (2), 187-189.

Wampold, B. (2001).  The Great Psychotherapy Debate. Mahwah, NJ: Lawrence Erbaum Associates.

© CombatCounselor 2011 – All Rights Reserved

"To be" in Italian is "essere" from the Latin root "esse" and is defined as "Being". Are you "Doing" or "Being"? Before you go to bed each night, reflect on your day and note the things you did that brought you closer to your values, then plan tomorrow in a value-based way.

For more information and DAILY INSPIRATIONS, follow me at hhtp://www.Twitter.CombatCounselor, you'll be glad you did!

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