Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement

Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence–outcome association. The current study aims to examine whether therapists' interpersonal behaviours and patients' active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness‐based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater's explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory‐II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients' active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists' interpersonal skills, and patients' active engagement did not predict posttreatment depressive symptom reduction. Patients' active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient's in‐session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.     

Is therapist alliance or whole group cohesion more influential in group psychotherapy outcomes?

This study examined the differential ability of early in treatment measures of therapeutic alliance (Working Alliance Inventory), group cohesion (California Psychotherapy Alliance Scale for Group) and group climate (Group Climate Questionnaire) to predict outcome in a 16‐session dynamic group psychotherapy for adults with major depression. Six successful therapy groups with 30 patients receiving psychodynamic group therapy were studied. Patient perceptions of the therapist alliance was not related to outcome, however, perceptions of levels of conflict and group members' ability to work actively and purposefully in treatment did predict outcome. Future research should further investigate how patients' perceptions of the whole group influence their clinical improvement. Copyright © 2008 John Wiley & Sons, Ltd.     

The mindfulness‐based cognitive therapy adherence scale: inter‐rater reliability,adherence to protocol and treatment distinctiveness

The development of the Mindfulness‐Based Cognitive Therapy Adherence Scale (MBCT‐AS) is described. This 17‐item scale measures therapist adherence to the treatment protocol for Mindfulness‐Based Cognitive Therapy (MBCT), a treatment for the prevention of recurrence in Major Depressive Disorder. The MBCT‐AS assesses therapist behaviours specific to (MBCT) as well as therapy practices that MBCT shares with Cognitive Behaviour Therapy (CBT). To determine the utility of this scale, we compared delivery of group MBCT against group CBT, with independent ratings of taped sessions provided to measure adherence to MBCT and CBT for therapists in both groups. The results showed that: (a) raters can reliably use the MBCT‐AS; (b) MBCT therapists demonstrated adherence to the treatment protocol, as measured by the MBCT‐AS; and (c) MBCT is distinguishable from CBT on both the MBCT‐AS and a scale measuring adherence to CBT (CBT‐AS). These findings indicate that the MBCT‐AS may be a useful tool for ensuring the proper delivery of MBCT in future research, and may be helpful in determining the elements of MBCT that are unique to that treatment. Copyright © 2002 John Wiley & Sons, Ltd.     

Mindfulness‐based cognitive therapy for residual depressive symptoms

Objectives. Mindfulness‐based cognitive therapy (MBCT) is a new group‐based intervention for prevention of relapse in recurrent depression which has not been scientifically evaluated regarding its clinical effectiveness for ameliorating residual depressive symptoms following a depressive episode. The aim of this study was to assess the efficacy of MBCT in reducing residual depressive symptoms in psychiatric outpatients with recurrent depression, and to particularly explore the effects of mindfulness techniques on rumination. Design. The design of this study was a mixed model complex design. Design 1 consisted of a consecutive series of patients. They were assigned to either MBCT or TAU. The independent variables were time and group allocation, and dependent variables were Beck Depression Inventory (BDI) and Rumination Scale. In Design 2, the TAU group proceeded to complete an MBCT group, and the BDI and Rumination Scale results of the two groups were collapsed. Method. Nineteen patients with residual depressive symptoms following a depressive episode, and who were attending outpatient clinic, were assigned to either MBCT or treatment as usual (TAU), with the TAU group then proceeding to complete an MBCT group. Depressive and ruminative symptoms were assessed before, during, and after treatment, and at one‐month follow‐up. Results. A significant reduction in depressive symptoms was found at the end of MBCT, with a further reduction at one‐month follow‐up. A trend towards a reduction in rumination scores was also observed. Conclusions. Group MBCT has a marked effect on residual depressive symptoms, which may be mediated through the mindfulness‐based cognitive approach towards excessive negative ruminations in patients with residual depressive symptoms following a depressive episode.     

Long‐term outcome and post‐treatment effects of psychoanalytic psychotherapy with young adults

Objectives. The short‐ and long‐term effects of open‐ended, long‐term psychoanalytic psychotherapy for young adults were investigated. Possible changes during the year and a half follow‐up, as well as predictors of change, were explored. Design. Patients aged 18–25 years who accepted the offered psychoanalytic individual or group psychotherapy were included. Patients filled out questionnaires and were interviewed at intake, termination, and follow‐up. Alliance data were collected after the second session of psychotherapy proper. Methods. The primary outcome measures were the Symptom Checklist‐90 and the Inventory of Interpersonal Problems. The Helping Alliance Questionnaire‐II was used to measure alliance. Mixed model ANOVAs were used to analyse changeover time and prediction of change in relation to gender, treatment format, treatment duration, and in individual psychotherapy, therapist‐ and patient‐rated alliance. Results. All outcome measures changed significantly from intake to follow‐up. None changed significantly during the follow‐up period, but there was a tendency towards recurring symptoms and an improvement in one of the object relational measures during the follow‐up. The latter was the only outcome measure that did not change significantly during treatment. Lower therapist‐rated alliance was predictive of greater change in psychiatric symptoms for patients with high levels of symptoms at intake. Conclusions. The long‐term effectiveness of psychoanalytic psychotherapy for young adults was supported. Low therapist‐rated alliance implies that the therapists have identified problematic interactions, which might have mobilized their effort to solve the problems. Further research on cases reporting no gain or even deterioration is needed.     

Collaboration in Mindfulness‐Based Cognitive Therapy

In this article, we describe the nature of therapeutic collaboration between psychotherapist and group participants in mindfulness‐based cognitive therapy (MBCT), which occurs in a group format and incorporates cognitive therapy and mindfulness practices with the aim of preventing depression relapse. Collaboration is a central part of two components of MBCT: inquiry and leading mindfulness practices. During the process of inquiry, the therapist‐initiated questions about the participant's moment‐to‐moment experience of the practice occurs in a context of curious, open, and warm attitudes. In addition, collaboration is maintained through co‐participation in mindfulness practices. We provide a case illustration of collaboration in these contexts and conclude with recommendations for clinical practice.     

Therapeutic alliance: predicting continuance and success in group treatment for spouse abuse

This study examined the role of the therapeutic alliance between client and therapist on group treatment outcome in 70 husband-to-wife violent couples. Strength of husbands' alliance assessed at Session 1 was positively associated with treatment outcome, as measured by decreased husband-to-wife mild and severe psychological and physical aggression. Strength of wives' alliance was unrelated to treatment outcome. Finally, although alliance was related to treatment outcome, it was unrelated to treatment completion.     

Therapist and patient perceptions of alliance and progress in psychological therapy for women diagnosed with gynecological cancers

Objective: The goal was to understand both therapist and patient perspectives on alliance and session progress for women in treatment for gynecological cancer. We used a longitudinal version of the one-with-many design to partition variation in alliance and progress ratings into therapist, patient/dyad, and time-specific components. We also evaluated therapist and patient characteristics that predict alliance and session progress. Method: Two hundred and three women and their therapists completed measures of alliance and session progress across a 6-session course of treatment. Participants also completed preintervention measures of self-esteem, depression, cancer-specific distress, emotional expressivity, and use of protective buffering. Results: Patients reported higher alliance and greater progress than did therapists. When therapists reported particularly strong alliance with particular patients, those patients concurred. More experienced therapists reported higher alliances and more progress but their patients did not agree. Patients who began treatment in more difficult psychosocial circumstances tended to have less positive session outcomes on average but evidenced more improvement across therapy sessions. Conclusions: Patients rated their alliance and progress more positively than did their therapists, although there was substantial relative agreement between therapists and patients. Alliance and progress improved over time, particularly among patients who evidenced higher levels of distress and poorer physical functioning. More experienced therapists were more confident in their abilities but their patients did not share this perception. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

The relationship between interpersonal problems and the helping alliance

Using data from a large longitudinal naturalistic study on course and outcome of psychotherapy, the present paper investigates the amount of interpersonal problems in an outpatient sample (N = 714) and the extent to which a patient's interpersonal problems determine the quality of the helping alliance. The results show that at the beginning of psychotherapy, subjects reported significant interpersonal distress on 2.43 of the eight IIP scales. Interpersonal problems were most prevalent in the octants "introverted," "submissive," "exploitable," and "overly nurturant." Furthermore, interpersonal problems were related to the helping alliance in different ways: "Too hostile" patients reported relatively poor initial helping alliance whereas "too friendly" patients rated more favorably the relationship to the therapist. However, interpersonal problems at intake did not predict the therapeutic alliance one-and-a-half years later. The results indicate that a poor initial helping alliance might be reversed during the course of treatment. Implications for future research and psychotherapeutic practice are discussed.     

Self‐reported attachment styles and therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy

The aims of this study were to explore the relationship between therapists' self‐reported attachment styles and therapeutic orientation with the self‐reported general therapeutic alliance and therapist‐reported problems in psychological therapy. A sample of 491 psychotherapists from differing therapeutic orientations responded to a postal questionnaire. The questionnaire contained standardized measures of therapeutic alliance quality, attachment behaviours, a checklist of problems in therapy, and a brief personality inventory. Therapist‐reported attachment styles generally explained a significant additional proportion of the variance in alliance and problems in therapy, over and above variance explained by general personality variables. Self‐reported secure attachment style was significantly positively correlated with therapist‐reported general good alliance. Self‐reported anxious attachment styles were significantly negatively correlated with good alliance, and significantly positively correlated with the number of therapist‐reported problems in therapy. Therapeutic orientation independently predicted a small but significant amount of the variance in reported general alliance quality in addition to that explained by attachment behaviours.     

Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: a study of process and outcome

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.     

What do these sounds tell us about the therapeutic alliance: Acoustic markers as predictors of alliance

Predicting the trajectories of alliance formation that the patient is likely to establish with the therapist during treatment, even before their first meeting, can help prevent the potentially harmful consequences of deterioration in alliance, such as poor outcome and premature dropout. The present study aimed to examine the ability of four pretreatment acoustic markers to predict the alliance that is likely to be formed in the course of treatment: F0 span, speech rate, pause proportion and jitter. Data from 560 observations of 38 patients were collected as part of an ongoing randomized clinical trial of short-term psychotherapy for major depressive disorder. The acoustic markers were measured using high-quality recordings at baseline, before the patient and therapist ever met or had any type of communication. A multilevel model was used to examine the ability of the four acoustic markers to predict the slopes of alliance formation in the course of treatment, all markers being introduced in the same model. The clinical utility of the acoustic markers was explored in two case studies. The model explained 22% of the variance in alliance formation. Higher levels of both jitter and pause proportion at baseline predicted less strengthening of the alliance in the course of treatment. The findings, which should be replicated in larger samples, suggest that much of the therapeutic alliance can be predicted based on the acoustic characteristics of the patient's voice in the first 3 min of their intake, before they even meet their therapist.     

Therapeutic alliance in telephone-administered cognitive-behavioral therapy for hematopoietic stem cell transplant survivors

Objective: A strong therapeutic alliance has been found to predict psychotherapeutic treatment success across a variety of therapeutic modalities and patient populations. However, only a few studies have examined therapeutic alliance as a predictor of psychotherapy outcome among cancer survivors, and none have examined this relation in telephone-administered cognitive-behavioral therapy (T-CBT). This study evaluated the extent to which therapeutic alliance affected psychotherapy outcomes in survivors of hematopoietic stem cell transplantation (HSCT), a treatment for some cancers. Method: Forty-six patients enrolled in a randomized clinical trial of T-CBT for posttraumatic stress disorder (PTSD) completed a baseline assessment (including self-report measures of PTSD symptoms, depression, and general distress), 10 individual T-CBT sessions, and follow-up assessments at 6, 9, and 12 months post-baseline. Therapeutic alliance was assessed after the 3rd T-CBT session with the Working Alliance Inventory, which yields overall and subscale (task, bond, and goal) scores. Results: Analyses revealed that higher total therapeutic alliance scores prospectively predicted decreased depressive symptomatology; higher task scores predicted decreased overall distress, depressive symptomatology, symptoms of re-experiencing, and avoidance; and higher bond scores predicted decreased depressive symptomatology and symptoms of re-experiencing. Conclusions: These results suggest that assessments of therapeutic alliance should be incorporated into routine clinical care, and therapeutic alliance should be specifically cultivated in interventions to maximize psychotherapeutic benefits involving vulnerable populations such as cancer survivors. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

A grounded theory analysis of the therapeutic relationship with clients sexually abused as children and non‐abused clients

The objective of this study was to investigate whether clients with a history of child sexual abuse (CSA) and non‐abused clients differ in their views of the therapeutic relationship. Two groups of 17 clients receiving psychological therapy, those who reported a history of CSA and a matched group who had not reported abuse, were asked in a semi‐structured interview about what was important to the therapeutic alliance. The accounts of the two groups were analysed using grounded theory, and then compared. The qualitative analysis demonstrated that both groups identified many similar important issues. These included factors relating to the therapist, to therapy itself, and to the client's perception of the relationship. Women in the CSA group emphasized the interpersonal qualities of the therapist and how they felt about their relationship, while the other clients talked more about therapeutic techniques and progress in therapy. Important issues mentioned exclusively by the CSA group included the therapist's commitment, being believed, and the therapist not showing negative reactions. Copyright © 2001 John Wiley & Sons, Ltd.     

Untangling the alliance-outcome correlation: exploring the relative importance of therapist and patient variability in the alliance

Although the therapeutic alliance is a consistent predictor of psychotherapy outcomes, research has not distinguished between the roles of patient and therapist variability in the alliance. Multilevel models were used to explore the relative importance of patient and therapist variability in the alliance as they relate to outcome among 331 patients seen by 80 therapists (therapist average caseload was 4.1). Patients rated both the alliance and outcome and all models adjusted for baseline psychological functioning. The results indicated that therapist variability in the alliance predicted outcome, whereas patient variability in the alliance was unrelated to outcome. Reasons why therapist variability as opposed to patient variability predicted outcome are discussed. Clinical implications include therapists monitoring their contribution to the alliance, clinics providing feedback to therapists about their alliances, and therapists receiving training to develop and maintain strong alliances.     

The role of evidence-based therapy relationships on treatment outcome for adults with trauma: A systematic review

Objective: The purpose of this paper was to systematically review and synthesize the empirical literature on the effects of evidence-based therapy relationship (EBR) variables in the psychological treatment for adults who experienced trauma-related distress. Method: Studies were identified using comprehensive searches of PsycINFO, Medline, Published International Literature on Traumatic Stress, and Cumulative Index to Nursing and Allied Health Literature databases. Included in the review were articles published between 1980 and 2015, in English that reported on the impact of EBRs on treatment outcome in clinical samples of adult trauma survivors. Results: Nineteen unique studies met inclusion criteria. The bulk of the studies were on therapeutic alliance and the vast majority found that alliance was predictive of or associated with a reduction in various symptomotology. Methodological concerns included the use of small sample sizes, little information on EBRs beyond alliance as well as variability in its measurement, and non-randomized assignment to treatment conditions or the lack of a comparison group. Conclusions: More research is needed on the roles of client feedback, managing countertransference, and other therapist characteristics on treatment outcome with trauma survivors. Understanding the role of EBRs in the treatment of trauma survivors may assist researchers, clinicians, and psychotherapy educators to improve therapist training as well as client engagement and retention in treatment.     

Attachment and therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

We examine associations between client attachment style and therapeutic alliance in a 3‐arm randomized controlled trial of brief motivational interviewing and cognitive–behavioural therapy compared with longer term motivational interviewing and cognitive–behavioural therapy or standard care alone. Client self‐report measures of attachment style were completed at baseline, and both clients and therapists in the treatment arms of the trial completed alliance measures 1 month into therapy. We found that insecure–anxious attachment was positively associated with therapist‐rated alliance, whereas clients with insecure–avoidant attachment were more likely to report poorer bond with therapist. There was no evidence that client attachment significantly predicted clinical or substance misuse outcomes either directly or indirectly via alliance. Nor evidence that the length of therapy offered interacted with attachment to predict alliance.     

A meta‐analysis of the effects of internet‐ and computer‐based cognitive‐behavioral treatments for anxiety

Internet‐and computer‐based cognitive‐behavioral treatments have been introduced as novel approaches to deliver standard, quality treatment that may reduce barriers to care. The purpose of this review is to quantitatively summarize the literature examining the treatment effects of Internet‐ or computer‐based treatment (ICT) on anxiety. Nineteen randomized controlled ICT trials were identified and subjected to fixed and random effects meta‐analytic techniques. Weighted mean effect sizes (Cohen's d) showed that ICT was superior to waitlist and placebo assignment across outcome measures (ds=.49–1.14). The effects of ICT also were equal to therapist‐delivered treatment across anxiety disorders. However, conclusions were limited by small sample sizes, the rare use of placebo controls, and other methodological problems. In addition, the number of available studies limited the opportunity to conduct analyses by diagnostic group; there was preliminary support for the use of ICT for panic disorder and phobia. Large, well‐designed, placebo‐controlled trials are needed to confirm and extend the results of this meta‐analysis. © 2008 Wiley Periodicals, Inc. J Clin Psychol 65: 1–21, 2009.     

Therapeutic alliance and outcome in routine psychiatric out‐patient treatment: Patient factors and outcome

Objective. This study investigated the importance of the therapeutic alliance in a routine psychiatric out‐patient unit regarding treatment outcome and the influence of patient factors. Design. The study had a naturalistic and longitudinal design where the treatments the patient received were determined by the normal routines at the unit and were performed by a variety of staff representative of a psychiatric out‐patient unit. Method. Newly admitted patients were diagnosed according to the International Classification of Diseases – 10th Revision and completed questionnaires regarding the therapeutic alliance, symptoms, and interpersonal problems at the beginning and termination of their treatment (N=76). The time limit for the termination assessments was set at 18 months. Results. The therapeutic alliance at the beginning of treatment did not correlate with outcome, however, at the end of the treatment the alliance significantly explained about 15% of the variance of the outcome (global severity index). An improvement of the alliance during the treatment significantly correlated with most of the outcome variables. The relation of the alliance to outcome was equal among the different diagnosis groups and treatment forms. Conclusion. The results showed that the therapeutic alliance is an important variable for treatment outcome in routine psychiatric treatment, and improving the therapeutic alliance may be one of the most important factors for increasing the total effectiveness of a treatment unit.     

Effects of expressive writing on depressive symptoms—A meta‐analysis

This meta‐analysis addresses the question of whether expressive writing shows an effect on reducing depressive symptoms. It focuses on samples of physically healthy adults with varying degrees of stress but without posttraumatic stress disorder. A total of 39 randomized controlled trials with 64 intervention‐control group comparisons were obtained through keyword search in databases and backward search. Expressive writing did not yield significant long‐term effects on depressive symptoms. However, effects were larger when the number of sessions was higher and when the writing topic was more specific. The results of this meta‐analysis did not support the effectiveness of brief, self‐directed expressive writing as an intervention that decreases depressive symptoms in physically healthy adults with varying degrees of psychological stress. Future research should examine whether longer, more directed writing interventions with additional therapeutic support would lead to different results.