Clinical social work is tailored to provide healthcare support to people with psychological, psychosocial or bio-psychosocial disorders. A case of psychosocial symptoms of ill children may include sorrow over the illness, fearing to die and fear of being alienated. Also, the effort invested in unraveling the physical status and results of illness. At higher levels of the professional work has resulted to expertise referred to as the advanced clinical social workers. The scope of work coupled with code of ethics demands high levels of confidentiality and privacy as the right of the clients have to be protected and respected. Prior understanding of the skills and role in the social work fraternity is fundamental; mainstream physicians may not immediately appreciate their psychosocial importance for patients at the hospital. This can further extend to the family members of the patient. This means their services may stay withdrawn even in cases where they are much needed unknowingly. The scope of professional practice for advanced social workers entails: providing interventions based on founded diagnosis. Due to diversity of knowledge base there is a call for specialization in a certain field. Cases handled may be intrapersonal or of family dynamics; abnormal growth and behavioral disorders; trauma, illness as well as cultural impacts. This requires high level of adept in case assessment and management, treatment planning, analysis and evaluation of results, diagnosis precision and in depth knowledge and skill in social work. Summers and Barber (2003) and Betan et al., (2005) have from there different perspectives shown that therapeutic relationship between patients and therapists would prevail primarily because of training and years of professional practice. Whether or not a patient struggles with variations of culture, class, ethnicity, race, age, sexual orientation, spirituality or gender would depend on capacity and adept of the therapist.
The concept of empathy entails a social element that allows one to attach or generate closeness with another person’s circumstances in terms of physical, social or psychological experiences. This creates a nexus between the two. According to Summers and Barber (2003), the concept of empathy is a primary ingredient in therapeutic treatment. Parties involve a professional clinical cum social worker while the other is seeking treatment services. The professional party seeks to provide attention to provide professional solutions to enhance wellbeing of the other (Summers & Barber, 2003). The connection explores thoughts, feelings, attitude or situation. The clinical social workers should act in a expressing how they perceive, experience, understand and recognize the mental concerns of the other. Professionally, this should be expressed in a manner to relay emotional attachment as if have undergone similar experience before. In this case the feelings are communicated in a constructive and realistic way (Summers & Barber, 2003). The ultimate of the concept is to show the party that the professional is fully aware of the state they are in a compassionate way. Clinical social worker in expressing will become sensitive to the pressing concerns of the clients and apply their solutions in a way showing understanding to their state. In expressing their state the client may outburst and vent on a person working to help them, hence adequate preparedness is required in order to avoid mishandling them. To listen, provide and vicariously recognize the felt needs are prioritized in clinical social work. Closely linked to the concept of empathy is sympathy. Though, sympathy relates to a feeling of sorrow on what the client feels. It mainly experience among relatives than at professional when contrasted with empathy. Nevertheless, the client vent out thus the recipient should properly conduct that show restrain and understanding.
Therapist-patient alliance exists when a collaborative bond in which communication between the parties enhances this. Ultimate achievement is a positive working relationship conducive for both. The level at which both parties communicate at each can provide a gauge for the health of the alliance. The communication is nurtured by a prevailing positive feeling towards each other. A common purpose is identified by parties so as to focus the relationship. Both should also identify and recognize the objective role that should be played by each. Finally, a bond cements the relationship. The bond should preferably be empathetic. Depending on circumstances, the concept of alliance should requisite to treatment. On the side of a clinical social worker, the concept of alliance can be achieved overtime through exposure in practice or through professional clinical training. In some this is inherent. Through clinical training, the necessary skills are identified and acquired. This is achieved by gaining confidence and skill through exposure to higher challenges and induction on specific professional requirements. In advancing the concept of alliance, therapist should have prior consent that clients may have initial negative feelings against therapy. Therapists should take the initiative to ameliorate them by applying interpersonal skills. Interpersonal relationship will prevail as the patient pre-treatment expectations communicated in a manner that improvement foreseeable. As the alliance warms up the level vent out and hostility begins to fall down. Clinical training that exposes the therapists to further skills on nonverbal communication of the client comparatively has greater advantage in achieving empathy and alliance as this impacts on identified behavioral traits. More disturbed patients are better handled with enhanced behavioural techniques; this needs continuous improvement for both training and practicing therapists to better their skills (Summers & Barber, 2003). Data has been used in alliance building between the therapist and patient. Patient data may be applied to train therapists to identify possible difficulties and correlating through pairing both patient and therapist data. According to Summers and Barbers, (2003) achieving adept in the concept of therapeutic alliance is progressive throughout training and professional practice. There is increased skill among professionals in implementing therapeutic alliance, perfected talking skills and management of circumstances with years of practice. Building skill in alliance during patient and therapist relationship is greatly influenced degree of exposure to these kind scenarios. However age may be limiting though fine tuning skills afterwards through accumulated practice hours and handling of more complex conceptual cases. Clinicians become more focused with duration of professional practice. Depending on the interpersonal capacities to grasp some aspects of the concept of alliance are efficiently acquired compared to others. According to Summers and Barbers, (2003) formulating goals and scheming tasks may be acquired efficiently than bond development. A comparison of bond scores showed that those with greater experience were relatively higher (Summers & Barber, 2003).
According to Summers and Barber (2003), there are three measures that can be applied in the concept of therapeutic alliance. The first is the Helping Alliance scale that consists of a 19-item scale. This involves a questionnaire posed to a patient responding on the amount of benefit have had from an administered therapy. In the recent times the questionnaire has been revised. The revision has focused in ensuring that the measuring of alliance is improved towards independent responses on gains made (Summers & Barber, 2003). The second type of measure is the working Alliance Inventory is based on sub-elements: congruency on tasks to be implemented, harmony in setting goals as well as how well the patient and the therapist relate with each other (Summers & Barber, 2003). This type of measures is developed based on two versions: the self report as well as the observer rater (Summers & Barber, 2003). The observer rater version has been identified as reliable in interrelating. The working Alliance inventory consists of 36 items (Summers & Barber, 2003). The final is the California Psychotherapy Alliance Scales (CLAPAS) (Summers and Barber, 2003). The CALPAS questionnaire is multidimensional. The questionnaire consists of 24 items (Summers & Barber, 2003). It is a self report approach. The reliability of self report from patients is higher than that of therapists. There are four level at which CALPAS measures therapeutic alliance between the patient and the therapist: the status of the patient in building a subjective relationship during the therapy, bases on which the bonding functions affectively; the way in which therapist construe and apply the concept of empathy with the patient and the consent on how goals have been set as well as treatment has been scheduled (Summers & Barber, 2003). Ratings per item are at 6 point likert scale (Summers & Barber, 2003). In most cases high intercorrelations while using CALPAS measures have been obtained (Summers & Barber, 2003).
The state of resistance occurs when a therapeutic attendant administers hypnotic sessions with no significant progress expressed by patient. The concept of resistance is articulated in the Freud’s Theory of resistance. This concept is manifested by patients’ obstinacy with regard to conversing, recalling or thinking about a past experience that may worry them much or create fear. In such a case a deliberate effort in the behavioral is observed in tending to avoid the disturbing ideas (Betan et al., 2005). Depending on circumstance resistance can prevent the context of information from reaching awareness, while in others may withhold material and deliberately avoid with awareness. According to Betan, et al., (2005) therapists’ role should be partly to create a working relationship that is responsive to fears and expectations. In practice, psychoanalysis therapy is primarily regarded as the re-education in order to resist intrapersonal resistances. This is reflected in a responsive manner by the patient in their feelings and behaviors towards the therapists. The therapy is administered in a manner responsive to patient’s attitude, thoughts, feelings and behavior. The patient experiences a self-fulfilling. The concept of resistance can be modeled in two ways, were in the first instance of patient condition fails to improve because of benefits that are attached to their status, for example, the socio-economic or physical status of the patient. In the second model case considers the main causal symptoms manifested partially as tradeoff for other psychological concerns. In either of the models as much as there are many contributing factors some underlying factors still influence and remain an understood or unearthed. These are associated with some motives. Rooting for an intellectual insight in overcoming resistance could be through revisiting the disturbing situations, staging similar circumstances as experienced before or working through to provide direct that therapy to the patient. This involves subsequent psychoanalysis procedures. During the therapy, the patient is gradually transformed procedurally through treatment. In working through their status the patient is aided to really understand their prevailing conditions as part of main therapy. It is recommended the therapist remains impartial throughout the process (Betan et al., 2005). This provides the opportunity for comprehending the full dimensions of the concept of resistance. Transference may persist with resistance. According to Summers and Barber (2003), research on the concept of alliance has shown that patients have responded with high scores. This means that in cases of low scores, such cases should be attended to.
Repairing alliances concept involves undertaking actions that restore an environment between patient and therapist that allows for a collaborative and a functional relationship. Well founded therapeutic relationship is sustainable when there is ability often repair alliances (Summers and Barber, 2003). In repairing the alliance the therapist follows a sequence of procedures. The therapists present a window for the patient to express any thoughts, attitude, feelings and emotions of reaction towards therapy or therapist. Then the therapist empathizes with the patient’s condition while expressing understanding, showing dignity and subjectively affirming the patient’s concerns as experienced. Lastly is the redressing the negative concerns of the patient. There is need to acknowledge the personal contribution that led to the strain as restoration protocol of a working relationship is underway. An additive procedure can be implemented so that it provides a window for evaluating whether a treatment package is impacting positively in the repair interventions. The procedure applies a cause and effect dimension. This is evidence based as a measure of the impact made. Alliances should not only foster cordiality but also indicate in the earliest opportunity any outcome that lead up to a strain. Hence, in averting the strain the therapist should apply robust flexible technique. Therapist could deploy active social elements such as keen listener during oral communication, exhibiting empathy as well as posing questions gently in mending and maintaining a streamlined relationship. This is feasible considering an alliance can be a predictor of the ultimate success and how interventions have been applied and their consequent results. As therapy tends to full repair, therapist should maintain their awareness on those negative feelings that could lead to a past experience. In any event, the therapist should respond openly and non-defensively manner.
Initial interpretation of the countertrasference concept had the notion that therapy is susceptible on the unconscious feelings of the therapists’ psychoanalysis (Betan et al., 2005). According to Betan et al., (2005) Freud was the first to conceptualize countertransference. This is in recognition of the possible reaction that could be exhibited by the patient towards the therapist. Overtime the scope extended comprehensively into emotional and behavioral aspects. Thus, this needed a facilitation mechanism rather than abandoning this therapeutic branch (Betan et al., 2005). In this design, an active and interactive association was fronted to allow for insight into the patient’s emotions and behavior associated to their experience. In this case, the therapists are drawn into the patients to empathize with their feelings (Betan et al., 2005). In this case the concept of countertransference is a composite of psychoanalysis and practice thereof. By definition the concept of contertransference takes into account the recognizing and understanding of the feelings and emotions of the patient; their affective responses towards the therapists and their behavioral conduct Transference involves finding fulfillment and satisfaction with emotional feelings of another person (Betan et al., 2005). Transference manifested in a prototype character (Betan et al., 2005). Research into management of countertransference has related certain situations. For instance, people undergoing depressing are vulnerable to experiencing more often reactions, to a proportion more or less matching their self-criticism. Also people that are sensitive to being rejected tend to experience higher frequency of rejection in their relationships (Betan et al., 2005). This is because internal feelings manifest as they strive to make this work in their relationships. Rejection is associated with a possessive and alienation behavior. Functional interpretation of concept of countertransference response considers deviation caused by reactions by patients confirming unresolved conflict through behavior and emotions. Some of the behaviors that could be manifested include unusual quietness, disregarding a subject, switching elusively matter under discussion and expressing dissatisfaction. Betan et al., (2005) study on patients’ personality and the contratransference phenomena variables on age, gender, race, class, literacy level and span of therapy were focused on. There was no significant difference along the variables with patients. The study engaged data from clinicians, psychologists and psychiatrists. The data in the three sample exhibited similar trends. Betan et al., (2005) considers traumatic experiences with survivors of childhood sexual molestation as sensitive. There is the eminent challenge posed by the clinician as they seem to be too inquisitive or detailed accounts of the experience from a patient. Alternatively, the clinician should enquire from the patient a sum up of the events that relate actually being molested. The degree to which to trace boundary between either is subjective as the element of intimacy on divulging very personal details may instill fear related to the traumatic event. Consequently, the clinician is bound on whether to apply the divulged information or maintain the information as a secret. Holding back the details by the therapists could translate to unwillingness by them not to talk about the substance of the trauma experience of the patient. There is an inherent conflict lessons in distinguishing what are the sensitive issues during the clinical exercise as well as what has functional objective for use during therapy.
Betan et al., (2005) employed three measures for the concept of countertransference. The first one is the clinical data form. This measure an array of aspects related to population dynamics, illness diagnosis as well as etiology (Betan et al., 2003). The first step involves the therapist presents personal details to the patient on general professional background, theoretical understanding, location and mode of professional practice and gender. Similarly the data regarding the patient is relayed to the therapist. This contains age, gender, ethnicity, education level and so on. The clinician then provide the patient’s ratings on adaptive functioning, developmental and family background of the patient. The second measure type is the Axis II diagnosis (Betan et al., 2003). This is used to measure axis II disorders. The clinician is tasked to opt, either a criterion of DSM-IV axis II diagnoses is present or absent (Betan et al., 2003). The criteria are randomly ranked. The third measure is the Countertransference Questionnaire (Betan et al., 2005). This has a questionnaire with 79 items. According to Betan et al., (2005) the therapist provides ethically recommended, psychometrically sound tools for measuring Countertransference tendencies. The items rate mental and behavioral tendencies of the therapists onto to the patient (Betan et al., 2005). Limitations with these three measures include: self-report measures used in the assessing concept of countertransference. This is disadvantaged in the fact that the observer is not independent of the process of assessing. The independent observer may divulge further details on particular patterns of the therapist (Betan et al., 2005). The assumption is that the therapist was reliable and provided all relevant data towards the study. According to Betan et al., (2005), the training background of the therapist forms a primary part of the causes of self biases. There are therapists trained as MD while others have PhD training (Betan et al., 2005). Both are deemed to produce data that are different from each other. The second limitation is the therapist feedback rates. This is linked willingness of the therapist to spare more time to participate in the study. This means limited spared to reflect on the responses provided (Betan et al., 2005).
In advanced clinical social work, the use of concepts in gauging the level of adept in the skill applied may be presented by some challenges (Betan et al., 2005). These include: establishing the criteria for setting limits especially the lowest one; the range of variation that can be allowed and the impacts on residents and patients during the data collection (Betan et al., 2005).
References
Betan, E., Heim, A. K., Conklin, C. Z. & Western, D. (2005). Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation. American Psychiatric Association, 162, 890-898.
Summers, R. F. & Barber, J. P. (2003). Therapeutic Alliance as a Measurable Psychotherapy Skill. Academic Psychiatry, 27, 160-165. Web.