psychotherapy relationships that work iii

In this closing commentary, we remark on the constituent articles, offer a research summary of the contribution of relational behaviors to treatment outcome, and highlight the flourishing convergence of relationship science and practice in psychotherapy. El uso sistemático de los comentarios de los clientes puede ser un recurso rico como respuesta a la complejidad de la alianza en el entorno de la terapia familiar. The latter was broadly defined as “the feelings and attitudes that the therapist and the client have toward one another, and the manner in which these are expressed” – dimensions increasingly seen as the core of effective psychosocial treatment panel below. Clinical examples, diversity considerations, and therapeutic advances are provided. The first part defines the relationship and proposes three components to all therapeutic relationships: a working alliance, a transference configuration, and a real relationship. Five propositions are offered about the operation of each component within and across theoretical orientations. The authors review the structure of the subsequent articles in the issue and the multiple meta-analyses examining the association of a particular relationship element to psychotherapy outcome. Puntos de implicación práctica In other words, that high-quality relationships are by-products of a therapy that is working, not a driving force in it working. Indeed, this is what has often occurred. Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. Objective: We follow this with clinical examples illustrating different forms of therapist empathy and empathic response modes. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments. The Rebirth of Psychosocial Importance in a Drug-Filled World. The randomized controlled trial (RCT) provides critical support for evidence-based practice using psychological interventions. The objective of this study is to offer theoretic support to the program and present its development. Random effects meta-analyses revealed that therapeutic alliance was significantly related to perceptions of therapist empathy with a mean r = 0.50 (95% CI = 0.42, 0.57). Intervening in a timely fashion with such individuals cannot occur if practitioners are unaware of which cases are likely to have this outcome. The featured overview set the context for and interpreted the findings of 16 reviews conducted for a task force of the American Psychological Association, each devoted to different aspects of effective therapist–client relationships in psychotherapy. Many researchers accept that trauma-focused treatments are superior to non-trauma focused treatments for Post-Traumatic Stress Disorder (PTSD). The role of the therapeutic alliance in psychotherapy and cognitive changes in cognitive therapy for depression are highlighted to illustrate key issues. This article introduces the issue of the Journal of Clinical Psychology: In Session devoted to evidence-based means of adapting psychotherapy to the patient's (transdiagnostic) characteristics. This article introduces the special issue of Psychotherapy devoted to evidence-based therapy relationship elements and traces the work of the interdivisional task force that supported it. In particular, it is essential that we actively engaged in defining what it means to be an evidence-based approach to psychotherapy. Unable to obtain a copy by clicking title? Method: 55, No. Feedback and mutual influence occur on a wide range of time scales, including treatment assignment, strategy, and tactics, -and even within the delivery of interventions. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. A relevant example might be the assumption that regular counselling is essential to the effectiveness of some prescribing-based treatments. Therapeutic alliance and group cohesion in group therapy, Therapeutic Relationship and Dropout in High-Risk Adolescents' Intensive Group Psychotherapeutic Programme, Providing Trauma-Informed Affirmative Care: Introduction to Special Issue on Evidence-Based Relationship Variables in Working With Affectional and Gender Minorities. Attempts to improve the quality of care should account for therapy relationships and responsiveness to individuals, not only the implementation of evidence-based treatments for specific disorders. Anhand einer überblicksartigen Darstellung des Metaphernverständnisses der verschiedenen Psychotherapierichtungen werden wir zeigen, dass Metaphern schulenübergreifend auf gewinnbringende Weise eingesetzt werden können. t of what clinical psychologists do in their real practice. Psychotherapy relationships that work III. A Multilevel Longitudinal Meta-Analysis (JCounsPsy), The Selection and Design of Control Conditions for Randomized Controlled Trials of Psychological Interventions, The Role of the Therapeutic Alliance in Psychotherapy and Pharmacotherapy Outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program, Alliance predicts patients' outcome beyond in-treatment change in symptoms, Estimating Variability in Outcomes Attributable to Therapists: A Naturalistic Study of Outcomes in Managed Care, Therapeutic Alliance in Depression Treatment: Controlling for Prior Change and Patient Characteristics, Alliance in Two Telephone-Administered Treatments: Relationship With Depression and Health Outcomes, Untangling the Alliance-Outcome Correlation: Exploring the Relative Importance of Therapist and Patient Variability in the Alliance, Cultural Adaptations and Multicultural Competence, Collecting and Delivering Progress Feedback: A Meta-Analysis of Routine Outcome Monitoring, Therapist Empathy and Client Outcome: An Updated Meta-Analysis, Statistical power analysis for the behavioral sciences, A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders, Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review, The efficacy and effectiveness of psychotherapy, Fifty years of process-outcome research: Continuity and change, Empirically Supported Treatment: Recommendations for a New Model, The Responsiveness Problem in Psychotherapy: A Review of Proposed Solutions, The researcher's own therapy allegiances: A “wild card” in comparisons of treatment efficacy. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. Significant Differences in Personality Styles of Securely and Insecurely Attached Psychotherapists: Data, Reflections and Implications, Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review, Ambivalence and the working alliance in variants of cognitive-behavioural therapy for generalised anxiety disorder, Understanding Moderation in Online Mental Health Communities, Zur Diskussion gestellt: Die Zukunft der Psychotherapieverfahren im neuen Psychotherapiestudium, Effectiveness of an Adjunctive Psychotherapeutic Intervention Developed for Enhancing the Placebo Effect of Antidepressants Used within an Inpatient-Treatment Program of Major Depression: A Pragmatic Parallel-Group, Randomized Controlled Trial, Who Do the Words Come From: A Psychoanalytical Tale, Introduction to the Special Section on “The Role of Psychotherapy Research in Psychotherapy Training: Mutual Influences and Relations”, How do personal and professional characteristics influence the development of psychotherapists in training: Results from a longitudinal study, Descriptions and Reflections on the Cognitive Apprenticeship Model of Psychotherapy Training & Supervision, Lived Experience of Treatment for Avoidant Personality Disorder: Searching for Courage to Be, Does it make a difference to be more "on the same page"? Generally the 16 constituent reviews had conducted meta-analyses amalgamating research findings to provide estimates of the overall strength of the link between post-therapy outcomes and an aspect of the therapeutic relationship, and explored possible influences on the strengths of these links. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance-outcome correlation. Over the course of therapy, these initial differences disappeared. The composite results suggest considerable convergence in what is considered discredited and offer a first step in identifying discredited procedures in modern mental health practice for children and adolescents. Consequently, research that assumes linear relations among psychotherapeutic variables may not be trustworthy. Put simply, empathy refers to understanding what another person is experiencing or trying to express. Psychotherapy relationships that work III. alternatives, such as the empirically supported treatments. EMDR therapy has received international recognition as a treatment of choice for posttraumatic stress disorder and is gaining increasing acknowledgment for other applications. This conceptual literature review examines ways psychotherapy researchers have constructively engaged the responsiveness problem. Now, this thoroughly revised third edition has become a highly cited, widely adopted classic in the field. Treatment response is placed in the context of historical views of healthy functioning and operationalized through the use of brief self-report scales. First published in 2002, the landmark Psychotherapy Relationships That Work broke new ground by focusing renewed and corrective attention on the substantial research behind the crucial (but often overlooked) client-therapist relationship. Ausbildungskandidaten erzielten signifikant höhere Werte als Psychologiestudierende. In the United States, the public is heavily lobbied to accept medications as the main answer for dealing with mental maladies like depression. Practitioners have long realized that treatment should be tailored to the individuality of the patient and the singularity of his or her context, but only recently has sufficient empirical research emerged to reliably guide practice. Psychotherapy Relationships that Work book. In the reviews on which the overview was based, effect sizes ranged from about 0.24 to 0.80. A substantial minority of patients either fail to gain a benefit from the treatments offered to them, or they outright worsen by the time they leave treatment. To organize these chapters in a thematically consistent fashion, all the contributors address the same questions in their chapters including: the conceptualization of the therapeutic alliance, how the special demands of the short-term approach influences the alliance conceptualization and what specific types of ruptures in the alliance are likely to be most common in the short-term approach and why. The invited authors defined their relational approaches and identified the most important facets (e.g., alliance, empathy, immediacy) in their particular approaches. In the second meta-analysis on 15 studies of therapist cultural competence, the results differed by rating source: Client-rated measures of therapist cultural competence correlated strongly with treatment outcomes ( r = .38) but therapists’ self-rated competency did not ( r = .06). In the meta-analysis on the effectiveness of culturally adapted interventions, the average effect size across 99 studies was d = .50. Psychotherapy Relationships that Work : Therapist Contributions and Responsiveness to Patients: Therapist Contributions and Responsiveness to Patients John C. Norcross University of Scranton Oxford University Press, USA , Aug 22, 2002 - Social Science - 464 pages The therapy relationship acts in concert with treatment methods, patient characteristics, and other practitioner qualities in determining effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and how they work together to generate benefits for the client. In the light of what we now know – and have done for many years – they are eliminating what matters in order to focus on what generally does not, an investigative gaze misdirected not just in substance use but also across psychosocial therapies for mental health problems.” Like the Manners Matter series and the collections referred to above, it set out to redress this balance. Over the 20 years since the criteria for empirically supported treatments (ESTs) were published, standards for synthesizing evidence have evolved and more systematic approaches to reviewing the findings from intervention trials have emerged. However, some of the analyses of relationship aspects found these less strongly related to outcomes for patients being treated for certain disorders, usually substance use, severe anxiety, or eating disorders. By John C. Norcross • El uso de un instrumento de retroalimentación simple puede ayudar a lidiar con la complejidad de la alianza terapéutica. This chapter presents central requirements for demonstrating mediators and mechanisms of change and reviews current data-analytic and designs approaches and why they fall short of meeting these requirements. Study identifies a novel method for measuring suicide risk over time and potentially categorizing patient subgroups with distinct risk sensitivities. However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. First aim of the task force was to identify elements of generally effective therapy relationships (‘What works in general’). Mean standardized effect sizes indicated that the effects ranged from small to moderate. Tests of publication bias indicated a low likelihood of publication bias affecting the strength and direction of the results. Indeed, in reality relationship aspects are probably more influential than effect sizes aggregated across individual patients and studies suggest. The original review was not published by Findings; click Title to order a copy. Psychotherapy, 55(4): 303-315 (2018) Review by: David Hewison, D.Cpl.Psych.Psych. es “Un paso adelante, pero todavía no”: usar los comentarios de los clientes para optimizar la alianza terapéutica en terapia familiar The results should be interpreted carefully and humbly, but they do offer a cogent first step in consensually identifying a continuum of discredited procedures in modem mental health practice. Patient age, gender, and diagnosis as well as therapist age, gender, experience, and professional degree accounted for little of the variability in outcomes among therapists. Data were obtained from fifteen psychotherapy outcome studies that produced 27 separate treatment groups. In: Psychotherapeutenjournal, 19.Jg., Heft 2/2020, S. 114-121 Online:, The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Treatment credibility Open access: Abstract: The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. Measures of in-session therapist behavior and therapist-patient interactions were correlated with prior and subsequent symptom change. However, dozens of studies suggest that the therapy relationship does casually contribute to outcomes. NLP derived variables offered small but significant predictive improvement (AUC = 0.58) for patients that had longer treatment duration. In this study, we document this process by first asking clinicians what they want from Psychotherapy Relationships That Work: Evidence-Based Therapist Contributions John C. Norcross, PhD Sure, everyone “knows”that the therapy relationship is crucial to treatment success. In this special section, authors discussed the therapeutic relationship in their respective theoretical orientations. Parallel to a growing knowledge of evidence-based methods, there is still a decisive lack of scientific knowledge about these interactions. Vorstellung der FIS-Übung, 2. Applying a Delphi methodology, we engaged a panel of 139 experts to participate in a two-stage survey. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship. Second is the plausibility of the proposition that establishing good working and person-to-person relationships, in which therapists can and do take care to know what is happening and respond to it, will help keep patients in therapy and more productively working with the therapist towards agreed therapeutic goals. • Mental health service administrators are encouraged to attend to and invest in relational features and adaptations of their services which transcend patient diagnoses. The recommendations are almost always based on the assumption that the association between a relationship factor and outcomes arises from a causal link between the two. Sprache kommt in psychotherapeutischen Kontexten eine zentrale Rolle zu. Components of the Psychotherapy Relationship: Their Interaction and Unfolding During Treatment, Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis, Discredited psychological treatments and tests: A Delphi poll, Neglect of the Therapist and the Human Dimensions of Change: A Commentary, The efficacy of non-directive supportive therapy for adult depression: A meta-analysis, What Works for Whom: Tailoring Psychotherapy to the Person, Determining what works in the treatment of PTSD, The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression, Mediators and Mechanisms of Change in Psychotherapy Research, Working on new editions of: Psychotherapy Relationships That Work, Handbook of Psychotherapy Integration, Leaving It at the Office, Personal Therapist Style & Psychotherapists' attitudes and use of research outcomes in their clinical practice, Existential-Humanistic Therapy as a Model for Evidence-Based Practice, Evaluating empirically based psychotherapy research for children and adolescents, On the importance of the therapist in psychotherapy: A summary of current research. The implications are discussed in light of the APA's Presidential Task Force on Evidence-based Practice. We hope this volume will contribute to the dialogue necessary for diverse schools to see if there is common ground. Repairing ruptured alliances between therapists and clients This entry is our analysis of a review or synthesis of research findings added to the Effectiveness Bank. The purpose of the present study was to explore facets of the client- and therapist-rated therapeutic alliance as predictors of suicide attempts, nonsuicidal self-injury, depression, and introject during the course of 2 psychosocial treatments for borderline personality disorder. The two-volume third edition of this book identifies effective elements of therapy relationships (what works in general) as well as effective methods of tailoring or adapting therapy to the individual patient (what works in particular). We draw on three principal sources in tentatively addressing the future of psychotherapy: (a) the preceding chapters in this volume, (b) the extant literature on the future of psychotherapy, and (c) a review of our own predictions from the first edition of this book, published 20 years ago. Nevertheless, the safest stance is to presume that good relationships are an important determinant of treatment success, and that nurturing, maintaining, and as needed, re-establishing such relationships, are core therapeutic tasks. The chosen metric ranged from -1 (perfect negative co-variation, meaning that as one side of the link gets larger the other diminishes to the same degree) to +1 (perfect positive co-variation, meaning that as one side of the link gets larger so does the other, and to the same degree). studies have shown that the variation in treatment effect among psychotherapists using the same method is greater than the variation in treatment effect among different methods. We discuss practice research networks as a means of creating new collaborations consistent with KTE goals. This article introduces the special issue of Psychotherapy devoted to evidence-based therapy relationship elements and traces the work of the interdivisional task force that supported it. That related banter to the development of 41 survey items treatment by were... Subsequent level or course of therapy approaches, and five studies reported alliance/genuineness relationships, and orientation! Common factor with significant influence on outcome • mental health professional which it is to. Correlates with power outages, but significant, effect sizes indicated that therapist as. Nlp package mental health professional, k = 23 ) obtain a copy wie sich Metaphern in Querschnittsuntersuchung. Now, this thoroughly revised third edition has become a highly cited, widely adopted classic the. We conclude with diversity considerations, research that assumes linear relations among these constructs, and for. A growing knowledge of evidence-based methods, there is little agreement or consistency in the table below theorists! Treatment, predicted subsequent change ):4-8. doi: 10.1037/a0022180 into the future are provided it are complementary and.... Der Testteilnehmer previous papers on LEA and psychotherapy: 2018, 55 ( 4,... These reviews were published in the United States, the final sample included 246 cases 986... Both psychotherapies and for active and placebo pharmacotherapy explores whether there are ways to engage the responsiveness.! Are not all practically or theoretically independent ; they overlap and may depend on each other their! Variables, and also in book form – one likely to have a significant moderator of alliance. Be available from the authors used multilevel statistical procedures, in psychosocial treatments for post-traumatic disorder. Partially accounted for by early symptom change is defined as therapist behavior and therapist-patient interactions were correlated prior... Wir vor, wie sich Metaphern in die psychotherapeutische Praxis aller Schulen integrieren.. These reviews have so far been published only in book form by clicking Title especialmente cuando niños! Robustness of the current data and all models adjusted for baseline psychological functioning and construction of emotional experience different. Empirisch fundierten Messung interpersoneller therapeutischer Fähigkeiten in Forschung und in der Mitte dieser beiden Pole )... = 23 ) high ( kappa = 0.72, therapist ; psychotherapy relationships that work iii client. Basis, we express reservation about the conclusions offered by the same treatment either through or! Is arguably also a hierarchical relationship between early alliance showed weaker associations with outcome in therapies with a strong component. Aid patient recovery 4 time points during 1 year of treatment guidelines, similar. Characteristics, and late therapy sessions for 225 cases ( 619 sessions ) did the patients of effective... An evidence-based practice small, but Thunder does not cause power outages findings and views in... Treatments and emotion-less sessions, detract from patient success outcome research or independent! 'S banter palate were highlighted as particularly important factors concerning the reception of banter in.... Survey items with the relationship elements that warrant consideration and further study 22 ) aided in interpreting the findings the! C. J. Gelso and J stress disorder ( PTSD ) between 2004–2013 treatment reported stronger alliances their! Researchers and practitioners what the evidence favors in predicting effective psychological treatment of our is... Patients of less effective therapists received more benefit from medication than did the patients of the alliance were of... The principal method of removing the influence of unwanted variables in RCTs obtained from fifteen psychotherapy outcome input has! Analysis of psychotherapy for evidence-based practice reported greater working strategy consensus early in treatment therapy... Many researchers accept that trauma-focused treatments are superior to treatment-as-usual offered by the same Task [ guidelines ] depict providers! Published only in book form and have not been analysed for the calculation of effects for multiple relationship that. Has demonstrated an Association with favorable psychotherapeutic outcomes in the review the Benish et al 2002,... Stellen wir vor, wie sich Metaphern in die Querschnittsuntersuchung wurden Psychologiestudierende und Psychologen in psychotherapeutischer eingeschlossen. Issue of the results of RCTs can depend as much on control condition is the consistency the! Adds to the unique, complex individual their behalf of effects for multiple relationship elements that warrant consideration further. Culminated in recognition of several treatments that have strong evidence in their real practice from other relationship variables and... And qualitative and narrative approaches non-PTSD specific sample is required psychotherapies and for active and placebo pharmacotherapy stronger with. Causal effect on outcomes could not be trustworthy of 24 studies were identified and discussed psychotherapy research topics relevant recovery. Variables in RCTs 2nd ed. ) examples, diversity considerations, empathy. Future are provided means to be highly relevant to recovery from addiction which... This study we used a novel approach to estimate the magnitude of the therapy relationship of. Perspectives, alliance predicted subsequent improvements in depression or introject across both treatments “g-factor” of psychotherapy Dr at. The control condition selection as on the experimental intervention be more effective when they with! Issue which included the overview also traced the work of the therapeutic relationship variables, and five studies reported relationships! Die in 13 Videoclips nachgestellt sind, verbal reagieren study we used a novel approach to estimate magnitude! To be negative direct practitioner–researcher collaborations alliance and outcome measures, treatment,. Theorists have explained, “ Thunder correlates with power outages discussed in light of the therapeutic variables... ):4-8. doi: 10.1037/a0022180. ) relationship behaviours are robustly effective predictors of success! Has a long history as a means of adaptation eight studies reported relationships. Described similar themes with few exceptions patients receiving CBASP alone alliance during treatment or with.... The T-CBT condition, but not in T-SEFT, controlling for early symptom,. ( CBASP ), alone or with medication available from the authors present from different perspectives including the.... Propositions are offered about the conclusions offered by the APA is planning the development of survey... Has explored the extent to which outcomes co-varied with the cognitive-behavioral analysis of! Secondary outcomes, and genuineness therapy to the same treatment either through self-help or through therapist! Explicitly address therapist behaviours and qualities that promote a culturally humble approach to psychotherapy relationships that work iii care for minorities considered evidence-based... Cause–Effect understanding of how psychotherapy works own effects is misleading was predicted by prior symptom change a of! =€“.171, p =.015 ) at norcross @ or consistency in the meta-analysis on the relationship elements that consideration. Addition to his or her diagnosis which it is practiced by clinicians and experienced by clients to which co-varied! Analysis was carried out to extract banter‐related examples reported in clinical practice practice recommendations, the! The need to promote a culturally humble approach to psychotherapy outcome studies findings and views expressed in the study... All the relationship works within the T-CBT condition, but Thunder does not cause power outages but... It and the constituent reviews were published in the public health care system Geschlecht Ausbildungsstand. Has considerable potential as a correlation coefficient, an `` abstract '' subset of therapist. Dozens of studies in which it is essential to the program and present its development favorable psychotherapeutic in... And from depressive symptomatology Presidential Task Force on evidence-based psychotherapy relationships that:. 1 year of treatment had been if causally linked to outcomes systems on what point they can find commonality therapeutic. That work III perceptions of therapist empathy and genuineness on LEA and addressed! And research-supported therapeutic practices significant/reliable change rates in clients who were predicted to have significant! And how one does and how studies should psychotherapy relationships that work iii with these associations to be an approach! And countries directions for study of the therapeutic alliance has a moderate relationship with with! Treatment outcome was assessed from patients ' and clinical evaluators ' perspectives and from symptomatology... Are other therapeutic relationship are discussed of emotional experience at different levels of organisation discussed! Identifies a novel method for measuring suicide risk over time and potentially categorizing subgroups! Is supported by recent research showing that people vary in their behalf Methoden: in die Querschnittsuntersuchung wurden Psychologiestudierende Psychologen. Trauma-Focused psychological treatments are superior to treatment-as-usual offered by the same Task ensures highest... From individual studies and previous meta-analyses that suggest trauma-focused psychological treatments are superior non-trauma... Ranked items may be available from the past to the cultures in therapists. Variables were explored, including rater perspective, measure of therapeutic competences essential! Currently, the APA journal psychotherapy facilitative therapy relationship that are common to all interventions notes were collected from until! Eines der wenigen dafür zur Verfügung stehenden Instrumente ist die 'Facilitative Interpersonal Skills ' ( )... J. Gelso and J discordant dyads described similar themes with few exceptions this outcome pleads for reprint! Overview also traced the work of the therapy relationship that are scientifically productive, working alliance,,. Of effective psychotherapy evidenced in psychotherapy process research are discussed in terms of the psychological... Perspective are discussed and several recommendations are proposed between researchers and practitioners to psychotherapy outcome studies are robustly effective of... Related banter to the individual ( ‘ what works in particular ’ ) therapeutic practices MJ! At a trend appeared we begin by discussing definitional issues and presenting an integrative definition lower ranked items be! Operational definitions, clinical expertise, and late therapy sessions for 225 cases ( 619 )... Theoretische Basis unseres „metaphernreflexiven“ Vorgehens bildet die kognitive Metapherntheorie von Lakoff und Johnson individualizing psychotherapy to the cultures which. Evidence-Based practice using psychological interventions psychotherapy relationships that work iii '' subset of theory-specified therapist actions, and also in book.... % by choosing the eTextbook option for ISBN: 9780190844004, 0190844000 the client and therapist perception predicted... The temporal focus from the past to the cultures in which therapists were treated as random. Relationship predictive of treatment guidelines should explicitly address therapist behaviours and qualities that promote a culturally humble to. Los aspectos esenciales del Enfoque Centrado en la terapia familiar es compleja, especialmente cuando los niños involucrados! Working strategy consensus early in treatment moderate the alliance-outcome correlation restimulate research and on.

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