Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement

Abstract

Objective: Although the working alliance as been found to be a robust predictor of psychotherapy outcome, critics have questioned the causal status of this effect. Specifically, the effect of the alliance may be confounded with the effect of prior symptom improvement. The objective of the present study was to test this possibility. Method: A large dataset from primary care psychotherapy was used to study relationships between alliance and outcome using piecewise multilevel path analysis. Results: Initial symptom level and symptom change up to session three predicted the alliance at session three. Working alliance significantly predicted symptom change rate from session three to termination, even while controlling for several possible confounds. Conclusions: The alliance predicts outcome over and above the effect of prior symptom improvement, supporting a reciprocal influence model of the relationship between alliance and symptom change.     

Interpersonal differentiation within depression diagnosis: Relating interpersonal subgroups to symptom load and the quality of the early therapeutic alliance

Abstract

We examined interpersonal problems in psychotherapy outpatients with a principal diagnosis of a depressive disorder in routine care (n=361). These patients were compared to a normative non-clinical sample and to outpatients with other principal diagnoses (n=959). Furthermore, these patients were statistically assigned to interpersonally defined subgroups that were compared regarding symptoms and the quality of the early alliance. The sample of depressive patients reported higher levels of interpersonal problems than the normative sample and the sample of outpatients without a principal diagnosis of depression. Latent Class Analysis identified eight distinct interpersonal subgroups, which differed regarding self-reported symptom load and the quality of the early alliance. However, therapists' alliance ratings did not differentiate between the groups. This interpersonal differentiation within the group of patients with a principal diagnosis of depression may add to a personalized psychotherapy based on interpersonal profiles.     

Therapists’ therapies: The relation between training therapy and patient change in long-term psychotherapy and psychoanalysis

Abstract

Patients’ development across stages in long-term psychodynamic psychotherapy or psychoanalysis was studied in relation to various parameters of their therapists’ training, or personal, therapies. The change variable was symptom distress, the General Symptom Index, according to the Symptom Checklist-90. A series of latent class regression analyses revealed that one class of therapists (16% of the sample) whose patients had the least change in treatment, and in fact had nonsignificant deterioration, was significantly overrepresented by psychotherapists with long psychoanalyses for their training therapies. Alternative interpretations of the findings are discussed.

Zusammenfassung

Die Therapien der Therapeuten: Die Beziehung zwischen Therapeutentraining und der Veränderungen der Patienten bei Langzeitpsychotherapie und Psychoanalyse

Entwicklung der Patienten in verschiedenen Stadien von Langzeittherapie oder Psychoanalyse wurde in Beziehung gesetzt zu verschiedenen Parametern der Ausbildung ihrer Therapeuten bzw. deren persönlicher Therapien. Die Veränderungsvariable war der Symptomstress entsprechend dem allgemeinen Symptomindex nach der Symptomcheckliste-90. Eine Reihe von Regression Analysen mit latenten Klassen zeigte eine Klasse von Therapeuten auf (16% der Stichprobe), deren Patienten die geringsten Veränderungen aber auch keine Verschlechterung aufwiesen. In dieser Klasse waren Psychotherapeuten mit langen Lehranalysen überrepräsentiert. Es werden auch alternative Interpretationen dieser Ergebnisse diskutiert.

Résumé

Les thérapies des thérapeutes?: la relation entre la thérapie didactique et le changement chez le patient dans la psychothérapie et psychanalyse de longue durée

Le développement des patients à travers les phases de psychothérapies psychodynamiques ou de psychanalyses de longue durée était étudié en relation à divers paramètres de la thérapie personnelle ou didactique de leurs thérapeutes. La variable de changement était la détresse symptomatique, le General Symptom Index selon la Symptom Checklist-90. Une série d'analyses par la régression par classe latente a révélé qu'une classe de thérapeutes (16% de l’échantillon) dont les patients avaient changé le moins voire se détérioraient de façon non significative était surreprésentée de façon significative par des psychothérapeutes ayant eu de longues psychanalyses comme thérapies didactiques. Des interprétations alternatives des résultats sont discutées.

Resumen

Terapia de terapeutas. La relación entre el tratamiento didáctico y el cambio del paciente en psicoterapia y psicoanálisis a largo plazo

Se estudió el desarrollo de los pacientes a través de etapas en psicoterapia psicodinámica o psicoanálisis a largo plazo, en relación con diversos parámetros del entrenamiento de sus terapeutas o terapias personales. La variable de cambio fue un síntoma de distrés, del ïndice General de Síntomas, de acuerdo con el Symptom Checklist-90. Una serie de análisis de regresión de clase latente reveló que una clase de terapeutas (16% de la muestra), cuyos pacientes habían experimentado el cambio menor en el tratamiento y que, de hecho, no tuvieron deterioro significativo, estuvo significativamente sobrerrepresentada por psicoterapias con psicoanálisis largos en sus terapias didácticas. Se debate sobre interpretaciones alternativas de los hallazgos.

Resumo

As terapias dos terapêutas: A relação entre terapia de treino e a mudança do paciente em psicoterapia de longo prazo e psicanálise

Foi estudada a relação entre o desenvolvimento dos pacientes ao longo dos estádios da psicoterapia psicodinâmica de longo prazo ou psicanálise e os vários parâmetros da terapia, de treino ou pessoal, dos seus terapeutas. A variável de mudança foi a sintomatologia psicopatológica, o Índice de Perturbação Geral da Lista de Sintomas de Derrogatis (SCL-90). Uma série de análises de regressão ( La Lent Class Regression) revelou que um grupo de terapeutas (16% da amostra), cujos pacientes tiveram as menores mudanças no tratamento e sem deterioração significativa, estava significativamente sobre-representados por psicoterapeutas com longa experiência de psicanálise para as suas terapias de treino. Serão discutidas interpretações alternativas para os resultados.

     

The role of therapist adherence,therapist competence,and alliance in predicting outcome of individual drug counseling: Results from the National Institute Drug Abuse Collaborative Cocaine Treatment Study

Abstract

This study tested hypotheses related to linear and curvilinear relations among adherence, competence, and outcome and interactions of these effects with the quality of the therapeutic alliance among patients (N=95) who received individual drug counseling as part of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Results support a hypothesized curvilinear relation between adherence and outcome as well as an interaction between this curvilinear effect and alliance early in treatment. For patients with a strong therapeutic alliance, counselor adherence to the treatment model was essentially irrelevant to treatment outcome. When the alliance was weaker, by contrast, a moderate (vs. high or low) level of counselor adherence was associated with the best outcome. The current results suggest that studies of the relation between therapist's adherence to models of treatment and outcome may need to take into account the complex moderating effect of therapeutic alliance.

Diese Studie testete Hypothesen bezüglich linearer und kurvilinearer Beziehungen zwischen vorgabegetreuem Vorgehen, Kompetenz und Erfolg, sowie der Interaktion zwischen diesen Variablen und der Qualität der therapeutischen Allianz bei Patienten (n?=?95), die individuelle Drogenberatung im Rahmen der gemeinsamen Drogenabhängigkeits-Behandlungs-Studie des Nationalen Instituts zur Kokain-Abhängigkeit erhielten. Die Ergebnisse unterstützten die vorhergesagte kurvilineare Beziehung zwischen vorgabegetreuem Vorgehen und dem Ergebnis, sowie einer Interaktion dieses kurvilinearen Effekts und der Allianz zu einem frühen Zeitpunkt der Behandlung. Für Patienten mit einer starken therapeutischen Allianz war das vorgabengetreue Vorgehen des Beraters zum Behandlungsmodell für das Behandlungsergebnis ohne Einfluss. Dagegen zeigte ein moderat vorgabengetreues Vorgehen des Beraters (im Vergleich zu einem hohen oder niedrigen Festhalten an den Vorgaben) den besten Erfolg, wenn die Allianz schwächer war. Die vorliegenden Ergebnisse legen nahe, dass Studien zur Beziehung zwischen einem Vorgehen des Therapeuten konform zu den Behandlungsrichtlinien und dem Ergebnis den komplexen Moderatoreffekt der therapeutischen Allianz berücksichtigen müssen.

Cette étude a testé des hypothèses au sujet de relations linéaires et curvilinéaires entre adhérence, compétence et résultat, et des interactions de ces effets avec la qualité de l'alliance thérapeutique chez des patients (N?=?95) qui avaient reçu du counseling individuel pour abus de drogues dans le cadre de l'Etude en Collaboration de l'Institut National pour l'Abus de Drogues sur le Traitement de la Cocaïne. Les résultats apportent du soutien à l'hypothèse d'une relation curvilinéaire entre adhérence et résultat ainsi que d'une interaction entre cet effet curvilinéaire et l'alliance en phase précoce du traitement. Pour les patients avec une alliance thérapeutique forte, l'adhérence du conseiller au modèle de traitement ne jouait pas de rôle essentiel pour le résultat du traitement. En cas d'alliance plus faible, par contre, un niveau modéré (versus haut ou bas) d'adhérence du conseiller était associé avec le meilleur résultat. Ces résultats suggèrent que des études de la relation entre l'adhérence du thérapeute à un modèle de traitement et le résultat devraient tenir compte l'effet de modération complexe de l'alliance thérapeutique.

Este estudio testeó hipótesis vinculadas con las relaciones lineales y curvilíneas entre adherencia, competencia y resultado así también como interacciones de estos efectos con la calidad de la alianza terapéutica entre pacientes (n?=?95) que recibieron Cunseling individual por drogas como parte del Estudio Colaborativo del tratamiento por cocaína del Instituto Nacional para el Abuso de Drogas. Los resultados apoyaron la hipótesis de la relación curvilineal entre adherencia y resultado, así también como la interacción entre este efecto curvilineal y la alianza temprana. Para los pacientes con una fuerte alianza terapéutica, la adherencia del consejero al modelo de tratamiento fue totalmente irrelevante al resultado. En los casos en los que la alianza fue más débil, en cambio, un nivel de adherencia del consejero (ni alta ni baja) estuvo asociada con el resultado mejor. Estos resultados sugieren que los estudios de la relación entre la adherencia del terapeuta a los modelos de tratamiento y resultado han de tener en cuenta el efecto moderador de la alianza terapéutica.

Let me know pls if this is all. Best, Beatriz

Il ruolo dell'adesione e della competenza del terapeuta ed il ruolo dell'alleanza nella previsione dell'esito del counseling individuale per le droghe: i risultati dall'Istituto Nazionale sull'abuso di droghe in equipe con lo Studio di trattamento della cocaina. Questo studio ha valutato le ipotesi collegate alle relazioni lineari e curvilinee tra adesione, competenza ed esito e le interazioni tra questi effetti con la qualità dell'alleanza terapeutica in pazienti (N: 95) che hanno ricevuto un counseling individuale sulle droghe come parte dello Studio di trattamento della cocaina in collaborazione con l'Istituto Nazionale di abuso di droghe.

I risultati supportano un'ipotizzata relazione curvilinea tra adesione ed esito, così come un'interazione tra questo effetto curvilineo e l'alleanza all'inizio del trattamento.

Per i pazienti con una forte alleanza terapeutica, l'adesione del counselor al modello di trattamento è stata essenzialmente irrilevante rispetto all'esito del trattamento. Quando l'alleanza era pi[ugrave] debole, al contrario, un moderato (verso l'alto o il basso) livello di adesione del counselor è stato associato con un miglior esito.

I risultati attuali suggeriscono che gli studi sulla relazione tra l'adesione del terapeuta ai modelli di trattamento e l'esito potrebbero aver bisogno di considerare il complesso effetto moderatore dell'alleanza terapeutica.

Este estudo estudou as hipóteses de relação linear e curvilínea entre adesão, competência e resultado e as interacç[otilde]es destes efeitos com a qualidade da aliança terapêutica em pacientes (N=95) que receberam aconselhamento individual para toxicodependência como parte do Estudo Colaborativo do Tratamento da Dependência da Cocaína do Instituto Nacional para o Abuso de Drogas. Os resultados apoiaram a relação curvilínea entre adesão e resultado, bem como uma interacção entre este efeito curvilíneo e aliança inicial. Para pacientes com uma forte aliança terapêutica, a adesão do terapeuta ao modelo terapêutico era, essencialmente, irrelevante para os resultados do tratamento. Quando a aliança era mais fraca, em contrate, um nível moderado (vs. baixo ou elevado) de adesão do terapeuta estava associado a melhores resultados. Estes resultados sugerem que estudos da relação entre adesão do terapeuta a modelos de tratamento e resultados terapêuticos podem necessitar de ter em consideração o efeito moderador complexo da aliança terapêutica.

     

Development and validation of a revised short version of the working alliance inventory

Abstract

Although countertransference phenomena have been given much attention within psychotherapy theory, single-case studies and clinical anecdotes, empirical research is still conspicuous by its absence. To assess the therapists’ emotional reactions, which are understood to be part of the countertransference (CT), we used the Feeling Word Checklist 58 (Røssberg, Hoffart, &; Friis, 2003); a self-report questionnaire, comprising 58 feeling words. The aims of the present study were to examine the underlying factor structure and psychometric properties of these factors, and to validate the factors by exploring the relationships between countertransference feelings and the following variables: therapeutic alliance, patient personality pathology, suitability for psychodynamic therapy, interpersonal problems, level of general functioning, and symptoms. Six therapists, who treated 75 patients, with weekly, psychodynamic therapy, over 1 year, completed the checklist after each session. To establish the number of subscales in the checklist, a principal component analysis with promax rotation was conducted. The analysis revealed four clinically meaningful factors named Confident, Inadequate, Parental and Disengaged. The psychometric properties of all subscales proved to be acceptable. Alliance as reported by both patient and therapist showed differential correlations with the subscales. The patients’ relational functioning showed stronger correlations with the CT feelings than the patients’ symptoms and level of functioning. The four subscales found in the Feeling Word Checklist-58 seem to capture clinically meaningful aspects of the therapeutic dyad, and countertransference feelings are systematically related to different relational variables.     

Le concept d’injustice épistémique en psychiatrie : quels apports,de la clinique à la classification des troubles mentaux ?

ObjectivesThe concept of epistemic injustice was developed in 2007 by Miranda Fricker. It designates a specific category of prejudices, where the subject's capacity to produce knowledge is denied or undermined. Several authors have applied this concept to the field of health and argue that people with a medical condition are more vulnerable to epistemic injustices than healthy people. In psychiatry, some authors believe that patients are even more vulnerable to such injustices in clinical practice than patients of other specialties. Some others identify certain forms of epistemic injustice in the classifications of mental disorders, and postulate that it could lead to epistemic losses in classifications, diagnoses and care. In France, this concept is relatively unexplored in psychiatry. The aim of this paper is to identify and summarize the potential contributions of the concept in psychiatry, from the clinical practices to the definition of mental disorders.Materials and methodsFirst, we will define the main types of epistemic injustice described by Fricker. We will then see how these injustices can occur in the field of health. Finally, we will study why patients with a mental disorder are particularly affected by these injustices, the potential impact on psychiatric nosography and the ways to address these epistemic injustices.ResultsThere are two types of epistemic injustice. In testimonial injustices, a person's speech is unwittingly considered to be of little or no credibility by his interlocutor, because of negative prejudices against him or his community. Hermeneutic injustice occurs when a person fails to convey their experience, due to a lack of hermeneutical resources to interpret and communicate it. In healthcare, the credibility of the patient's testimony can be diminished by several factors and general prejudices. Additionally, there is a lack of interpretive resources to understand and share many aspects of the experience of illness. In addition to this, the epistemic privilege accorded to healthcare professionals, particularly physicians, leads to accentuating the epistemic imbalance. The type of doctor-patient relationship, and its evolution, also impact the respective epistemic positions. In psychiatry, patients are seen as more vulnerable to epistemic injustices. Crichton thus identifies three common factors to all mental disorders, including a general prejudice of irrationality and unreliability. In addition, each pathology has specific factors exposing patients to a weakening of their epistemic capacity. To correct these injustices, several tools have been proposed, such as including the study of epistemic injustice in physician's training or using a phenomenological toolbox. Anke Bueter also suggested the existence of a specific form of testimonial injustice in psychiatric classifications, known as “pre-emptive”, which excludes the possibility for ill people and their relatives to testify. However, taking these testimonies into account could act as a corrective mean in the construction of nosography. This nosography is indeed based, in psychiatry, on value judgments, due to the lack of objective data. Several authors, including Bueter, therefore call for a better integration of users in the revisions of classifications, to improve their validity. This could have implications for the clinic, research and its funding, and other issues such as stigmatization. However, how exactly the users’ point of view could be integrated still needs to be defined. Several proposals have been found in the literature.ConclusionWe consider that the concept of epistemic injustice is a useful tool towards a better articulation between experiential and medical knowledges. In clinical practice, if the clinician is trained in this concept, he will be able to identify situations at risk of epistemic injustice, attempt to neutralize this imbalance and thus carry out a more exhaustive clinical examination and more appropriate care for the patient. Regarding nosography, strengthening the epistemic position of users and integrating their knowledge could improve the validity of classifications. The question of the validity of psychiatric nosography is a problem that the scientific community has faced for a long time, and it therefore seems interesting to continue this reflection through the concept of Fricker. In both cases, it is necessary to continue developing tools to better define, analyze and integrate this experiential knowledge.     

医联体药师团队参与COPD患者长期用药安全评估管理工作模式的实践研究

摘 要 目的：探讨医改新形势下医联体药师团队参与慢性阻塞性肺疾病(COPD)患者长期用药安全评估新型管理模式,为药师参与慢病管理提供参考。方法: 选取在我院及医联体所辖5家社区卫生服务中心就诊且符合入选标准的126例COPD患者,由我院临床药师带动指导社区药师共同参与,与医生协作,对患者进行为期1年的安全用药干预管理,包括：用药安全综合评估与分级管理、追踪随访与用药指导,全程化处方审核、建立共享数据库等。结果:该工作模式干预1年后,患者安全用药认知能力及用药依从性较干预前均显著提高（P＜0.01）,患者COPD疾病控制情况（CAT评分）明显改善（P＜0.05或P＜0.01）,药师有效辨识并干预不合理处方能力显著提升（P＜0.01）。结论: 医联体药师团队参与COPD患者长期用药安全评估管理工作模式对于保障COPD 患者安全用药,提高药物治疗效果,提高药师团队专业服务水平具有显著作用。