No Masters Fall from the Sky:

Therapeutic Alliance and Attachment in Speech Therapy Settings

Claudia Ruivo Carreira*1, Maria do Rosário Dias *2  

*1 Egas Moniz – Multidisciplinary Research Center in Health Psychology Campus Universitário, Quinta da Granja, 2829-511 Monte de Caparica, Portugal

*2 Egas Moniz – Multidisciplinary Research Center in Health Psychology Campus Universitário, Quinta da Granja, 2829-511 Monte de Caparica, Portugal

Abstract – Attachment Style is considered an influent variable in establishing and maintaining a therapeutic relation. However, the scientific literature pertaining to Therapeutic Alliance in Speech Therapy has been virtually absent. The current study aims at exploring the Therapist’s input to the dance that takes place in that specific intersubjective therapeutic encounter, as part of a larger study: a comparative and correlational exploratory study conducted, which sample comprised 31 therapeutic dyads (Speech-Language Pathologists and their adult Patients) and in which three instruments were used – socio-demographic questionnaire; the Adult Attachment Scale (EVA); and the client and therapist versions of the Working Alliance Inventory (WAI). Results show that the Therapist’s Attachment Style has a significant impact on the relational component of the established Alliance. Therefore, the relational quality imprinted in therapy is weighted as a key-element in the Patient’s adherence to therapy and in therapy’s outcome itself. To be cognizant of the correlations between Attachment Styles and Therapeutic Alliance will help in gauging strengths and weaknesses when planning clinical interventions – an invaluable contribution towards improving both the quality of the healthcare provided and the speech therapists’ training, for it will add to their awareness of the relational dimension as motor for change.

Keywords: Attachment, Therapeutic Relationship, Therapeutic Alliance, Speech Therapy

 “It´s not enough to know the kind of disorder a person has; One must know the kind of person who has the disorder”

(Van Riper, s/data)

We might add: and must know ourselves and what we bring to therapy settings.

Introduction 

The therapeutic relation, common ground to all therapeutic approaches, lies in the creation of a genuine space – the therapeutic space – founded on the application of a particular protocol, which parameters circumscribe a space and a time able to welcome and to facilitate processes of change (Amaral Dias, 1983; Coimbra de Matos, 2006, 2007, 2011; Fourie, 2009, 2011), and where the therapist is capable of holding and of meeting the needs of those who come to them (Rogers, 1957; Winnicott, 2000), which makes it an elite therapeutic instrument in healthcare provision (Wallin, 2007).

In the field of speech therapy, there is nowadays a clinical awareness associated with those behavioural and emotional aspects that involve the patient (Fourie, 2009; Geller, 2011; Geller & Foley, 2009; Phillips & Mendel, 2008; Van Riper, 1973), and are implicit in two fundamental and defining vectors: (i) the pathology itself, and (ii) how that pathology affects the patient’s life or interaction (Fourie, 2009; Simmons-Mackie & Damico, 2011). That said, and despite being crucially significant in the rehabilitation process, the intersubjective aspects of the therapeutic relation, those qualities inherent to the role of “being a therapist” and to the development of adequate therapeutic relations, have been widely neglected.

In fact, upon looking into the scientific literature produced in the last 100 years, one finds but a few and rather scattered references to the study of the basic context where the clinical work is developed; one finds some considerations on the impact of speech-language pathologists (SLP) attitudes and feelings on specific pathologies such as disfluency (Van Riper, 1973), and the identification, made by patients, of some SLP personality and behavioral traits that affect the therapeutic relation (Crane & Cooper, 1983; Fourie, 2009; Van Riper & Erickson, 1996). In this line, Oratio e Hobb (1977) point out the importance of SLP technical skills – the use of reinforcement strategies, the implementation of transference processes of skills acquired in therapy setting and the flexible posture in response to patients needs. On the other hand, the conclusions of Stech, Curtis, Troesche e Binnie (1973) concerning SLP perspectives state that “appropriate” responses, positive motivation and compliance in patients are valued as having a positive impact in the therapeutic relationship, and negative emotions and poor interpersonal skills as having negative impact.

Recently, there is a concern regarding the way SLP conduct the therapeutic project, and to the process of embedding a mental perspective within this expertise domain (Geller & Foley, 2009). In this line, Fourie (2009, 2011) studied how adult patients with acquired communication and swallowing disorders described various qualities and actions in their clinicians that they believe are therapeutic. These included Therapeutic Actions (empowerment, being soothing, being practical) and Therapeutic Qualities (being understanding, erudite, inspiring).

Notwithstanding the fact that the door is open to study the outline and contents of the therapeutic setting, shaped as an asymmetric encounter of two distinct personal realities, thereby inevitably creating an (in)formal and (in)definite working alliance, we note a scarcity (a virtual non-existence) of empirical studies aimed at assessing individual perceptions and relations between patients’ and therapists’ individual relational patterns – attachment styles (AS) – in the context of the working alliance (WA) quality in speech therapy settings.

Thus, we hope that our study may constitute a pioneering contribution to both training and practice of speech therapy professionals, based on the awareness of the relational dimension as motor of change and optimisation of therapeutic outcomes, beyond the technical expertise highlighted in that field of knowledge.

Now, because a relationship can be described as interpersonal and intersubjective, made of (des) adjustments, (des) encounters, (un) expected moments (Coimbra de Matos, 2011), and because patterns played out in our first attachments are reflected subsequently, not only in the ways we relate to others, but also in our habits of feeling and thinking, two crucial aspects emerge: (i) the personal attachment style (AS) , which can be secure, preoccupied or avoidant; and (ii) the therapeutic (or working) alliance (WA).

1.1. (Working) Therapeutic Alliance

The Therapeutic Alliance is a paramount aspect in the construction of the therapeutic relation (Bordin, 1979; Bowlby, 1988; Horvath & Greenberg, 1989; Luborsky, 1976; Rogers, 1957). It has been repeatedly found as a predictor of treatment adherence and has been positively associated with therapeutic change across different health care professions and clinical questions (Castonguay, Constantino & Holtforth, 2006; Hall, Ferreira, Mahler, Latimer & Ferreira, 2010; Horvath & Bedi, 2002; Horvath, Del Re, Fluckiger & Symonds, 2011; Horvath & Greenberg, 1989; Horvath & Symonds, 1991; Martin, Garske & Davis, 2000; Sharf, Primavera & Diener, 2010).

On a conceptual level, Bordin (1979) argues that every therapy involves three key elements which define the overall quality of the WA: (i) agreement concerning the goals; (ii) agreement concerning the therapeutic tasks; and (iii) the bond between therapist and patient. Thus, the Alliance is interpersonal, developed and expressed as bi-directional and interactive, defined as the emotional bond experienced by the patient and the therapist, as well as the agreement of both regarding the therapeutic goals and therapeutic tasks that are needed in order to reach those goals.

Researchers have identified influence variables that affect the WA quality, namely: i) pre-treatment patient variables such as clinic improvement before the evaluation of the Alliance(Crits-Christoph, Gibbons & Hearon, 2006), attachment style/quality of past and current relations (Beretta, Roten, Stigler, Drapeau, Fisher & Despland, 2005; Coutinho & Ribeiro, 2009; Goldman & Anderson, 2007; Satterfield & Lyddon, 1995, 1998), psychopathologic diagnosis (Coutinho & Ribeiro, 2009), self-concept and social adjustment (Mallinckrodt, Coble & Gantt, 1995) or gender (Hietanen & Punamaki, 2006); ii) therapist variables, such as attachment styles (Black, Hardy, Turpin & Parry, 2005; Dozier, Cue & Barnett, 1994) and micro behaviors adopted in session (Duff & Bedi, 2010); iii) relational match between patient and therapist (Petrowski, Nowacki, Pokorny & Buchheim, 2011; Shaver & Mikulincer, 2009), set in the agreement (or not) of attachment styles of the therapeutic couple.

1.2. Attachment Styles

The scientific literature regarding Attachment Styles is supported in the psychotherapy field, and it focus, mainly, the patient AS as an impact variable in the quality and development of the WA (Bachelor, Meunier, Laverdiére & Gamache, 2010; Byrd, Patterson & Turchik, 2010; Goldman & Anderson, 2007; Hersoug, Hoglend, Monsen, Havik 2002; Hietanen & Punamek, 2010; Ligiéro & Gelso, 2002). Accordingly, it is pointed out that patients with secure AS tend to form stronger Alliances (Kivlighan, Patton & Foote, 1998; Mallinckrodt, Goble & Gantt, 1995; Satterfield & Lyddon, 1998), while  patients with insecure AS tend to present variability in the way they establish the Alliance with the therapist (Diener & Monroe 2011;  Eames & Roth, 2000; Smith, Msefti & Golding, 2010). Specifically, secure patients tend to manifest comfort and security in the relation, in which the responses are perceived as of support and sensible to one´s needs, managing to negotiate goals with the therapist and resolve situations of rupture in the therapeutic process. On the other hand, preoccupied patients are capable of retrieving benefits of the therapist as source of comfort, but have difficulties in using the therapist as secure base to explore difficulties. Frequently they manifest a positive initial perception of the Alliance, a perception that tends to decrease in middle therapy (Faria, Fonseca, Lima, Soares & Klein, 2009). Regarding avoidant attachment, it has been associated with retraction from getting help in times of stress and need, including search for support within the therapeutic relation (Shaffer, Vogel & Wei, 2006), and decrease of session frequency and treatment adherence (Morris, Berry, Wearden, Jackson, Dornan & Davis, 2009).

Notwithstanding, therapist´s responses in session tend to reflect their own attachment patterns: AS relates to the perception of the Alliance by the therapist (Black, Hardy, Turpin & Parry, 2005), with the therapist´s ability to empathize with the patient, and it influences the Alliance ratings made by the patients across time (Kramer, Roten, Beretta, Michel & Despland, 2008; Sauer, Lopez & Gormley, 2003; Sibrava, 2010). Although not consensual, it is expectable that therapist with secure AS deal well with ruptures in the relation, while therapists with preoccupied attachment style, given their fear of rejection, have increased difficulties (Shaver & Mikulincer, 2009).

Nonetheless, there is a certain empirical neglect regarding the way that therapist´s personal characteristics interact with the ones the patient brings to the therapy setting and with the strength of the Alliance (Duff & Bedi, 2010).

We will endeavour to explore the therapist’s input to the dance that takes place in the intersubjective therapeutic encounter – an integral part of a more comprehensive study set out to empirically assess the relation between the strength/quality of the Working Alliance as perceived by the dyads and adult Attachment Styles, in Speech Therapy settings. Specifically, sought to achieve two specific objectives: (i) to describe the relation between WA dimensions (agreement as to the tasks; agreement as to goals; therapeutic bond) and AS in the therapist´s group; (ii) to verify if the AS explains variability in the WA dimensions perceived by the therapist´s group.

 

2. Method

2.1. Participants

The sample involves 31 therapeutic dyads: Speech-language pathologists and patients. Sample selection was such as to guarantee that participants were licensed speech-language pathologists, with current work experience with adult patients, and no less than three full years of clinical experience.

Speech-language pathologists: A total of 19 SLP (17 female; 2 male), aged between 26 and 55 years (A=39; SD=9), 63% of whom working in public hospitals and 37% in private practices, participated in the study. Those therapists’ working experience varied between 3 and 33 years (A=16; SD= 9): eight participants having 10 years working experience; five participants, between 10 and 20 years; and six participants with over 20 years of clinical experience. Most participants (84.2%) lived in the Greater Lisbon area. 

2.2. Instruments

Every participant responded to three instruments: i) sociodemographic questionnaire; ii) the Portuguese version of Adult Attachment Scale (Canavarro, Dias, Lima, 2006;  Collins & Read, 1990); iii) the Portuguese version of Working Alliance Inventory (WAI, Horvath 1981, 1982, cited in Machado & Horvath, 1999; Horvath & Greenberg, 1989).

2.3. Procedures 

Speech-language pathologists were contacted through the Speech Therapists Portuguese Association and through formal procedures directed to public and private healthcare facilities.  Participants in the study were those who exhibited the requirements set for sample eligibility and who were willing to voluntarily take part in the study under condition of anonymity and data confidentiality. Sample selection was conducted through a non-probabilistic technique – intentional and available.

Quantitative treatment of the data was made using the Statistical Package for Social Sciences (SPSS), version 19.0 for Windows.

3. Results

3.1. Therapeutic Alliance and Attachment

Internal analysis performed on the data supplied by participating therapists shows the existence of significant relations: the therapist’s preoccupied AS holds a significant, negative and strong relation with the bond dimension of the WA; and the therapist’s avoidant AS holds a significant, positive and strong relation with the bond dimension of the WA. The Working Alliance dimension tends to vary as a function of insecure Attachment Styles: therapists with preoccupied AS tend to consider the relation they establish with their patients as being more fragile, whereas therapists with avoidant attachment AS perceive the relations they establish with their patients as being strong.

In attempting to break down the observed correlations, a multiple regression analysis was performed; factors selected were the three AS (secure, avoidant and preoccupied) and the therapist’s years of working experience. Assumptions concerning normal distribution, independence, linearity, homoscedasticity and multicollinearity were duly tested. The assumption of independence was validated by Durbin-Watson statistics (d=1.280) and multicollinearity by VIF (1.113).

Multiple regression analysis identified the variable “therapist’s preoccupied AS” (beta=-0,652; p value < 0,05) as predictor for the bond dimension of the WA perceived by the therapist (adjusted coefficient of determination ar2= 0,338), where 34% of variation in the perception of the bond dimension of the WA were found to be due to preoccupied AS. The model fits (p valor =0,01 < α = 0,05).

Because therapist’s occupational variables – years of working experience – is pointed out as having an impact in the relational dynamic (Coutinho & Ribeiro, 2009), we decided to test their explanatory value. Results show that, in isolation, that variable is statistically significant (r2=0,254; p value =0,004 < α =0,005; beta = 0,643); however, when integrated in a more comprehensive model, one that also contemplates Attachment Styles, it ceases to be so. Therefore, although working experience is reported to be a differentiating factor (Coutinho & Ribeiro, 2009), given that it makes no sense to us to consider it in isolation due to the artificiality is encompasses, we see that, within the dynamic created by the set of factors that integrate an explanatory model, the value of the therapist’s experience becomes diluted (Hersung, Hoglend, Monsen & Havik, 2001). The absence of a linear relation leads us thus to infer that there should, indeed, be other therapist-related variables, of a more internal and stable nature, not easily altered by training and experience, which appear have an impact in the relation they establish with their patients.

4. Discussion of results

The therapeutic relation was addressed in our exploratory study as a particular form of adult attachment. Despite significantly different from the “original attachment” relation, it seems to involve working properties activated in interpersonal situations, such as that which develops in the intersubjective context of the encounter that takes place in a speech therapy setting. We have thus assessed intrapersonal perceptions within the group of therapists, in an effort to examine the relations that emerge in that setting and inputs inherent to therapists.

4.1. Therapeutic Alliance and attachment

Within the set of variables likely to relate to and explain the variability of perceptions on WA, we elected to look into AS. Data associated with psychotherapeutic settings indicate that there is a relation between Attachment style and Alliance assessment, and that the former has an influence on the latter throughout the course of the therapeutic project (Goldman & Anderson, 2007). In light of this, we set ourselves to try and understand whether the same hold true for speech therapy settings.

The examined body of literature states that, in general, a secure AS facilitates establishing and keeping the Alliance, and that insecure AS lead to an Alliance of a lesser quality (Diener & Monroe, 2011; Eames & Roth, 2000; Smith, Msefti & Golding, 2010), a finding that seems to be consistent with Attachment Theory (Bowlby, 1969).

That said, our results indicate that therapists with insecure AS can develop strong Alliances. This would mean that the fact that one’s internal representations of interpersonal relations are such as to conceive such relations as being more complex or difficult does not prevent one from developing positive relations in the context of therapy.

In fact, we see that therapists establish a strong alliance both when exhibiting secure and insecure AS, thus contradicting the hypothesis that secure therapists would be better suited to adapt themselves to their patients. One would thus say that the AS is not ‘automatically mapped’ onto the relation. That premise is illustrated in, and supported by, inconsistent results, inherent to the effects of insecure AS on the perception of the Alliance (Diener & Monroe, 2011; Smith, Msefti & Golding, 2010). Notwithstanding he ‘marked imprint’ of AS in the context of the therapeutic relation, SLP  may not necessarily or inevitably manifest their attachment styles when working with their patients. That being the case, then actions, behaviours and relational patterns exhibited in the course of a session are likely to provide information more pertinent to the practice itself than the information one can gather via descriptions of therapists’ relationship traits.

In our study, we found that the therapist’s AS was linked to his/her perception of the Alliance – a finding that agrees with the data obtained by Black, Hardy, Tupin and Parry (2005). Specifically, results show that the therapist’s AS bears on the assessment of the affective dimension of the WA. It is, after all, natural enough that the therapist’s personal traits, namely his/her attachment style, are more closely associated with the relational dimension of the WA, given the interpersonal relation implicit in the Alliance (Orlinsky & Howard, 1986).

For purposes of dissecting this relation, the counterpoint between the concepts of “bonding” and “attachment” emerges as important. Klaus and Kennel (1976) were the first to be sensitive to the nuance between these two conceptual dimensions: (i) bonding refers the process by which a mother establishes a connection with her baby, and to the link that is forged between mother and infant – it relates, thus, to the development of the attachment and to the development of the infant’s personality; (ii) attachment refers to the link that is established between the infant and the infant’s caregiver (the direction is opposite to the one described in bonding), a link that results from the caregiver’s responsiveness model concerning the infant’s needs. Klaus and Kennel say that any factor that influences the mother/caregiver’s ability to consider her/himself as competent to care for and protect the child holds the potential to show in the care provided and, therefore, in the structuring and sedimentation of the attachment of the child/individual in need of that care. Parallel to it, we can consider here the therapist’s bonding: the connection the therapist has with their patient, which takes form in the therapist’s perceptions and in how s/he manages their role as caregiver.

An example: let us consider a speech-language pathologist with a preoccupied AS. Such therapist’s personal difficulties in managing care provision in terms of reciprocity, dependency, trust, confidence and responsibility may have a significant impact on the outcome, where the patient is concerned, for such therapist may come to shape his/her sessions focusing on how the patient reacts and manifests positively.

It is therefore important for the therapist to have a personal and professional well-defined identity, accompanied by a set of technical-relational competences:  ability to monitor how the messages (content, shape, tone) are being experienced by the patient (Watchel, 1998), ability to monitor the nonverbal choreography and the ability to affectively enter into the patient´s relational matrix (Mitchell, 1988). Also, as a therapist, our capacity to be mindful may be critical to our efforts to help the patient– a mindfulness awareness (Fonagy, 1999) might be the key. A mindful stance allows us to be more present, open and capable of responding – like the good enough mother – to the requirements of the moments as they emerge in the interaction with the patient. Also, it fosters the experience of being aware of the body as well an attitude of acceptance. Based on the here and now, we are less vulnerable to our tendencies to be preoccupied or avoidant. Developing and amplifying this competences are in need so as to the therapist place her/himself in the position of a ‘new relational object’ and become interested in the healthy component of the patient’s self, and thus promote the negotiated changes (Coimbra de Matos, 2007, 2011) and therapeutic adherence.

How the therapist connects with his/her patient is important, for it allows him/her to provide a timely, effective and efficient response to the patient’s needs, attending to situations of incongruence and rendering a flexible intervention.

The speech therapy setting differs from the psychotherapeutic one. In speech therapy, clinical practice continues to abide by tradition: it lies on the cognitive and pedagogic dimension, it addresses well-defined issues, and it is essentially centered in pedagogically outlined tasks to reach the set, typically short-term, goals of the therapeutic process.

Knowing that speech-language pathologists project their personal traits onto their professional activity, it emerges as important to reflect on and to reconfigure the therapeutic setting, in an attempt to “re-balance the technical and caring dimensions, and restore the relational dimension of the clinical practice” (Dias, 1997).

Relational communication and the “use of self” (to understand and make use of feelings, thoughts, values and behaviour in the clinical work developed with the patient and patient’s family) (Geller, 2011) therefore should consubstantiate practices anchored in the contemporary –relational and affective – model (Geller & Foley, 2009; Morais, 2011).

The question arises concerning speech therapy future professionals as relational identification models (Phillips & Mendel, 2008). As to this issue, Morais (2011), as well as Dias, Costa, Manuel, Neves, Geada & Justo(2001), underline the influence carried by health professionals’ individual factors into the exercise of their profession. These authors refer here not only to personality traits, but also to non-verbal messages that are continually being processed in the therapist-patient dual interaction. It is thus pertinent that, throughout their basic academic training, health professionals should be given the opportunity to develop autonomous and proactive behaviour-reading exercises, so as to prepare them for the ‘relational stage’ plays they will later enact in the course of their professional activity. They should be trained in dissecting the potential consequences of the value of the communication codes of what they convey, testing their own awareness and feeling towards the patient, so as to increment their professional effectiveness.

5. Conclusion

Despite not having addressed many aspects that support the WA, one contribution put forward by our empirical study is the notion that the person of the SLP emerges as a privileged therapeutic instrument in the appointment setting. Within that symbolic domain, acknowledging that the SLP experiences a range of feelings, the gains and losses, the successes and frustrations, that occur in the course of the therapeutic process, with a variable underlying emotional charge, but which possibility of acceptance, reflection and management does not seem to be recognised.

Speech therapy praxis draws, traditionally, from a relational model of technical orientation; a model that is typically represented as a therapeutic act of pedagogic nature, and one that favours an information model in the relation, and one that tends to endorse the notion of the therapist as a central character, centred on behavioural prescription to the patient, aimed at bringing about the latter’s autonomy and empowerment. Intersubjectivity in the building up of the Alliance requires, however, attentive therapists, therapists who are able to expertly recognise attitudes and behaviours (their own and their patients’) that are beyond the scope of the technical and scientific element of the intervention. As such, therapeutic responsiveness falls under the purview of the therapist, who has to customize and implement interventions in response to the patient’s needs; a responsiveness that is to translate as a micro-process, aimed at the therapeutic goals specific to each dyad and to their respective and particular relational conditions.

Attachment Styles allow us to frame a profile that does not define the speech therapy clinical intervention itself, but that does offer a conceptual framework tailoring the manner of building the Alliance considering AS with the potential to change how clinicians think of, and respond to, patients, and how they understand the dynamics of the therapeutic relation in a manner which reduces the chances of dropout or non adherence to the tasks. The working alliance should therefore be contextualized in the speech-language pathologist’s technique and “relational mastery”, in the patient’s participation and in the dyads’ relational traits.

In their basic training, it is pertinent that they are given access to a communicational model that considers personal contributions’ and life experiences’ impact in the therapeutic relation, so that SLP may reflect on how to best conduct their therapies, rather than solely on the pedagogic tasks and goals that make up the therapy.

The education structure itself should be responsible for providing psycho-pedagogic support, creating a learning atmosphere conducive to the development of intra- and inter-personal communication. Such an objective should find expression in the syllabus, and translate as an increment of role-play exercises and promotion of debate activities suited to the discussion of problems associated with students’ feelings and reactions concerning their caring activity.

The art of the therapist is a result of intrinsic talent and training – there is not black or white (either you have a talent or you don´t); for if there were, we would be cutting off and limiting endless potential, exploration and growth. Embedding a mental health perspective into speech therapy settings will led to SLP becoming in fact more relationally orientated and psychotherapeutically informed for understanding what the patient represents and triggers in them influences aspects of the clinical work.

As to the limitations of our study, it should be noted that our data is of exploratory nature, and based on self-report instruments, where assessment is drawn from subjects’ mental representations, rather than from actual behaviour, assessed in loco (i.e., in appointment settings). Now, this may introduce an effect of ‘social desirability’ which, in turn, may have had an influence on the working alliance classification reported by the dyads.

A road can be said to have been paved for future research on the specificities of ‘working alliance throughout the therapeutic processes’; further research may consider using wider samples, composed by differentiated target-populations, as it may fid interesting to focus on examining therapeutic intervention processes with children and adolescents, in that in both these patient-groups adherence to treatments is non-voluntary, thus requiring the participation of other elements, foreign to the basic therapist-patient dyad, which are the patients’ primary caregivers, here in a role of secondary patients.

Acknowledgments: The authors give their thanks all the speech-language pathologists and their patients that participated in this study; to the institutions that opened their doors; to Prof.Ana Paula Martins, Olinda Roldão and Paula Correia.

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Maria do Rosario Dias has a PhD in clinical psychology from the School of Psychology and Educational Sciences, at the University of Lisbon (Portugal), and received her Master’s Degree in Educational Sciences from the same University. She is Associate Professor of Psychology at the Cooperativa de Ensino Superior – Egas Moniz. Her research interests have been primarily focused on health education and health psychology, particularly in the field of Psycho-oncology, with an emphasis on doctor-patient communication in hospital contexts, the disclosure of information to breast cancer patients, the psychosocial profiles of breast cancer patients, and the impact of breast cancer on partners and children. Ms. Rosario Dias has published two books addressing these concerns, “The Lost Emerald: Information given to breast cancer patients” (1997; 2ªEdition 2005), and more recently, the book “Are Mass Media Health strategists?”  Her second book looks at the role of mass media in breast cancer prevention. Also, she is co-editor of Clinic Dentistry: Bio-psycho-social contributes (2000) and co-publisher, jointly with Estrella Durá, PhD (Spain), of “Oncologic Psychology–The Land of Oncolological Psychology” (2002), which is a collection of  papers from Spanish and Portuguese researchers in the field of oncology. In 1995, the Portuguese Psychologists Association honored her with their Distinguished  Professional Award. For the last two years she has been named as a Member of the Portuguese Jury of the European Health Education Award, a body organized by the European Commission. She is a member of the Portuguese Committee of Europa Donna, member of the European Society of Health Psychology, and a founding member of the Portuguese Society of Health Psychology.  She is currently a Member of the Portuguese Society’s Executive Committee, and has recently been appointed as Chairman of the Psycho-oncology Group. Certified by the International Union against Cancer (U.I.C.C.) as a Trainer of Volunteers, she leads international Reach to Recovery Train-the-Trainers workshops. As a trained child psychotherapist, she is a founding member of the Portuguese Association of Psychoanalytic Psychotherapy of Children and Youngsters and has published a number of books of literature for children. Ms. Rosario Dias has taken part in more than sixty national or international scientific events and has published more than thirty papers in scientific magazines, in addition to some of her research work in the field of health psychology. She founded Egas Moniz-Multidisciplinary Research Center in Health Psychology in 2003. The work developed in the center has been acknowledged this year, receiving, for the second time, an award on childhood obesity prevention.

Claudia Ruivo Carreira is a Psychologist licensed by the Faculty of Psychology and Education Sciences of University of Lisbon (2007), a Speech and Language Therapist licensed by the Egas Moniz Health Superior School (2012). She is a psychotherapist trainee and an assisting researcher at Egas Moniz – Multidisciplinary Research Center in Health Psychology (CIMPS-EM) where she has participated in several research projects with the presentation and publication of papers at national and international conferences and in professional journals. Within the field of clinical psychology, she worked in the child psychiatry department of Dona Estefânea Hospital from 2007 to 2010, performing psychological evaluation, individual psychotherapy and parental education. She has worked in private practice since 2009 at “Clinic and Psychology in Campo Pequeno” and at schools in the Seixal area. As a health professional she works mostly with children with relationship problems and with communication disorders. She is a member of the Portuguese Psychologists Association (OPP) and a member of the Speech Therapists Portuguese Association (APTF). She has presented and published papers focusing on clinical practice at national and international events and journals, respectively.. She also holds Advanced Formation in Intervention programs in Health at School, Family and Community, and she currently participates in various research projects in the field of health psychology that focus on eating habits, healthcare communication and therapeutic relation.

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