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.     

Using the primary process emotional–behavioural system to better meet patient needs in psychotherapy

In order to increase therapeutic impact by enhancing awareness of clients' nonverbal communications, this article operationalizes the therapeutic alliance as a needs‐satisfaction process. The client's competence as a needs seeker and the therapist assisting with the client's expression and satiation of basic social needs are proposed as being key mechanisms of change. Functional model of primary emotions derived from Panksepp's seven primary emotional systems (care seeking, caretaking, lust, fear and anxiety, anger, play, seeking, plus dominance and disgust) is integrated with Functional Analytic Psychotherapy's emphasis on in‐session contingent natural reinforcement of clients' target behaviours. By identifying in‐the‐moment cues of underlying emotional–behavioural functions drawn from a categorization of clients' nonverbal communication can bridge the gap between client private events and therapist observables, in order to maximize therapist attunement and responsiveness to clients, and to increase the effectiveness of clinical interventions.     

A quantitative and qualitative exploration of client‐therapist interaction and engagement in treatment in an alcohol service

Studies have suggested that differences in the effectiveness of therapists may be related to the therapist's ability to maintain a facilitative stance in the face of client resistance or hostility. The current study, examined a sample of audiotaped sessions from Hyams, Cartwright, and Spratley's (1996) study of engagement in an alcohol treatment service in an attempt to see whether the therapists' effectiveness at engaging clients in treatment was related to client‐therapist interaction in assessment interviews. It was hypothesized that there would be (1) more overall negative interpersonal behaviour (2) more negative interpersonal behaviour by the therapist and (3) more negative interpersonal complementarity in interviews where the client failed to engage. Structural Analysis of Social Behaviour was used to assess the interpersonal behaviour of clients and therapists in three case comparisons, each of which focused on an engage and a non‐engage case provided by one of three participating therapists. An additional series of follow‐up qualitative case studies was carried out on the interviews where the client failed to engage. The results were mixed, with the qualitative analyses providing more support for the hypotheses than the quantitative analysis. It was concluded that problematic interpersonal processes might be harder to gauge in assessment sessions than later on in therapy and methodological recommendations were made for enhancing the likelihood of detecting problematic processes in future studies.     

Therapeutic alliance in psychological therapy for people with schizophrenia and related psychoses: A systematic review

Therapeutic alliance is a key predictor of therapy outcomes. Alliance may be particularly pertinent for people with schizophrenia as this group often have a history of interpersonal trauma and relationship difficulties including difficult relationships with mental health staff. This review aimed to determine (a) the quality of therapeutic alliance between people with schizophrenia and their therapists; (b) whether alliance predicts therapeutic outcomes; and (c) variables associated with alliance. Databases were searched from inception up to April 2015. The search yielded 4,586 articles, resulting in 26 eligible studies, involving 18 independent samples. Weighted average client and therapist Working Alliance Inventory‐Short Form total scores were 64.51 and 61.26, respectively. There was evidence that alliance predicts overall psychotic symptomatic outcomes and preliminary evidence for alliance predicting rehospitalization, medication use, and self‐esteem outcomes. There was evidence for specific client‐related factors being linked to different perspectives of alliance. For example, poorer insight and previous sexual abuse were associated with worse client‐rated alliance, whereas baseline negative symptoms were associated with worse therapist‐rated alliance. Therapist and therapy‐related factors, including therapists' genuineness, trustworthiness, and empathy were associated with better client‐rated alliance, whereas suitability for therapy, homework compliance, and attendance were associated with better therapist‐rated alliance. Key clinical implications include the need to consider alliance from both client and therapist perspectives during therapy and training and supervision to enhance therapist qualities that foster good alliance. Future research requires longitudinal studies with larger samples that include pan‐theoretical, well‐validated alliance measures to determine causal predictor variables.     

Longitudinal changes in therapeutic alliance with people with psychosis: Relationship between client and therapist assessments

Although the clinical significance of therapeutic alliance with people with psychosis is well established, the agreement between client and therapist assessments of therapeutic alliance and the longitudinal changes of both assessments have been rarely addressed. The current study examined client and therapist assessments of therapeutic alliance longitudinally and sought to determine whether insight and severity of symptoms moderated the degree to which therapist and client assessments were in agreement with one another. Forty-five participants diagnosed with a schizophrenia spectrum disorder and their therapists were administered a therapeutic alliance questionnaire (Working Alliance Inventory-Short Form) monthly for 6 months. Baseline symptoms were assessed using the PANSS. Results did not produce evidence that insight into illness moderated the relationship between agreement on the therapeutic alliance. However, symptoms of emotional discomfort at baseline predicted differences in agreement between clients and therapists on the relationship aspect of therapeutic alliance over the course of therapy. These results suggest that the ability to express symptoms of emotional discomfort may affect whether clients and therapists form similar appraisals of the strength of the therapeutic alliance.     

Early psychotherapy processes: An examination of client and trainee clinician perspective convergence

Convergence in the therapist–client dyad has been hypothesized to play an important role in the development of the therapeutic relationship and in successful therapy outcomes. Further, understanding the client's views and opinions of treatment has been identified as a critical skill for therapists in training to learn in order to reach professional competency in conducting psychotherapy. This study assessed convergence for 151 trainee therapist–client dyads on the identification of goals and tasks of treatment and on ratings of the therapeutic relationship, effectiveness of therapy and the client's current coping ability with life stressors. Results indicated that trainee therapists' and clients' ratings were significantly correlated; however, trainee therapists were more negative in their ratings of the relationship and progress of treatment and matched their clients' goals for treatment only 31.1% of the time. Training and practice implications are discussed. Copyright © 2009 John Wiley & Sons, Ltd.     

Enhancing psychotherapy outcomes via providing feedback on client progress: a replication

Several systems have been developed to monitor and feedback information about a client's responses to psychotherapy as a method of enhancing client outcome. The current study divided 1020 clients into four groups (two experimental and two control) to determine if feedback regarding client progress, when provided to a therapist, affected client outcome and number of sessions attended. Results showed that feedback increased the duration of treatment and improved outcome for clients identified as potential treatment failures thereby replicating an earlier study using nearly identical methodology. Nearly twice as many clients in the feedback group achieved clinically significant or reliable change and fewer were classified as deteriorated by the time treatment ended. For those clients who were predicted to have a positive response to treatment, feedback to therapists resulted in an equal number of treatment sessions and equivalent outcomes compared to the no feedback controls. The results are discussed in terms of quality management in routine clinical practice and the need to base treatment decisions on clients' response to treatment rather than arbitrary session limits. Suggestions for additional research aimed at enhancing the effects of feedback on client outcome are made. Copyright © 2002 John Wiley & Sons, Ltd.     

Integrating spirituality into alcohol treatment

Spirituality is presumed by millions of Americans to be directly relevant to problems of alcohol abuse. We summarize findings regarding the role of religion and spirituality in the prevention and treatment of substance abuse and present a case illustration. We also consider mechanisms responsible for these effects. We offer advice about why, by whom, and how religion and spirituality should be discussed with clients with substance use disorders. In a recent clinical trial, therapists trained in a client‐centered approach to facilitate exploration of spirituality fostered clients' use of spiritual practices. We suggest that the therapist's ability to skillfully engage clients in a discussion of spirituality is largely determined by how the therapist balances the dual roles of authoritative expert and evocative facilitator. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:185–198, 2009.     

Do we know when our clients get worse? an investigation of therapists' ability to detect negative client change

Routine clinical judgment is often relied upon to detect client deterioration. How reliable are therapists' judgments of deterioration? Two related studies were conducted to investigate therapist detection of client deterioration and therapist treatment decisions in situations of deterioration. The first study examined therapists' ability to detect client deterioration through the review of therapy progress notes. Therapist treatment decisions in cases of client deterioration were also explored. Therapists had considerable difficulty recognizing client deterioration, challenging the assumption that routine clinical judgment is sufficient when attempting to detect client deterioration. A second study was a survey of therapists asking how they detect client deterioration and what treatment decisions they make in response. Symptom worsening was the most commonly stated cue of deterioration. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: ? Clinicians may have a difficult time detecting when their client's symptoms are worsening. ? Outcome assessment strategies do exist to help clinicians detect client deterioration.     

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.     

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.     

Waiting for supershrink: an empirical analysis of therapist effects

Improving the effects of psychotherapy has been accomplished through a variety of methods. One infrequently used method involves profiling patient outcomes within therapist in order to find the empirically supported psychotherapist. This study examined data collected on 1841 clients seen by 91 therapists over a 2.5‐year period in a University Counseling Center. Clients were given the Outcome Questionnaire‐45 (OQ‐45) on a weekly basis. After analysing data to see if general therapist traits (i.e. theoretical orientation, type of training) accounted for differences in clients' rate of improvement, data were then analysed again using Hierarchical Linear Modeling (HLM), to compare individual therapists to see if there were significant differences in the overall outcome and speed of client improvement. There was a significant amount of variation among therapists' clients' rates of improvement. The therapists whose clients showed the fastest rate of improvement had an average rate of change 10 times greater than the mean for the sample. The therapists whose clients showed the slowest rate of improvement actually showed an average increase in symptoms among their clients. Use of this information for improving quality of patient outcomes is discussed. Copyright © 2003 John Wiley & Sons, Ltd.     

Therapeutic relationship and improvement as perceived by clients and therapists

Therapeutic relationship as perceived by clients (N = 54) and therapists (N = 8) at a community mental health clinic was rated on Lorr's (1965) five main factors: Understanding, Accepting, Critical, Independence-Encouraging, and Authoritarian (Directive). These perceptions were correlated with client and therapist ratings of improvement. In addition, discrepancies between client and therapist ratings of the relationship were correlated with outcome measures. Findings indicated that client perceptions of therapists as Understanding and Accepting were correlated most highly with self-reported improvement. Therapists self-perception of Independence-Encouraging was correlated most highly with client-rated improvement, while therapists' self-perception of Accepting and Understanding was correlated most highly with therapist-rated improvement. Differences between client and therapist ratings of the Understanding and Accepting qualities of the therapeutic relationship showed the highest negative correlations with both client and therapist improvement ratings. Implications for therapeutic and research strategies are discussed.     

Therapist effects: facilitative interpersonal skills as a predictor of therapist success

This study examined sources of therapist effects in a sample of 25 therapists who saw 1,141 clients at a university counseling center. Clients completed the Outcome Questionnaire‐45 (OQ‐45) at each session. Therapists' facilitative interpersonal skills (FIS) were assessed with a performance task that measures therapists' interpersonal skills by rating therapist responses to video simulations of challenging client–therapist interactions. Therapists completed the Social Skills Inventory (SSI) and therapist demographic data (e.g., age, theoretical orientation) were available. To test for the presence of therapist effects and to examine the source(s) of these effects, data were analyzed with multilevel modeling. Of demographic predictor variables, only age accounted for therapist effects. The analysis with age, FIS, and SSI as predictors indicated that only FIS accounted for variance in outcomes suggesting that a portion of the variance in outcome between therapists is due to their ability to handle interpersonally challenging encounters with clients. © 2009 Wiley Periodicals, Inc. J Clin Psychol 65:1–14, 2009.     

Therapist effects in yearlong psychodynamic therapy: An exploratory study

A large body of research indicates that therapists can have a strong impact on treatment outcome, but little is known about the relationship between therapist effects and treatment phase. Our objective was to examine the interactive effect of therapist effectiveness and treatment phase on the outcome of 1 year of dynamic therapy. Therapists' effectiveness scores were defined as the extent of change for each therapist on the OQ‐45 scores across their clients at five time points. The sample included 24 therapists who conducted psychodynamic therapy with 65 clients in a naturalistic setting. A three‐level hierarchical linear model was applied. In accordance with the hypotheses, a significant main effect was found for effectiveness (estimate = 1.69, p < .05), for the two‐way interactions between effectiveness and time (estimate = 1.36, p < .01), and for effectiveness and initial severity of symptoms (estimate = ?0.02, p < .05). Simple slope analysis was conducted showing that among the less effective therapists, no significant change in outcome was found as time progressed; among the more effective therapists, outcome improved as time progressed. In addition, therapists were more influential in the treatments of clients with low initial severity. Our findings lend some support to the notion that therapist effects become increasingly influential as therapy progresses. The findings highlight the need for further research into changes in the magnitude of therapists' effect in various phases of therapy. Furthermore, the severity level of the initial symptoms of the client should be taken into account.     

SUPPORTING RECOVERY IN THE COMMUNITY: SIX‐MONTH OUTCOMES OF CLIENTS PARTICIPATING IN THE PHOENIX HOUSE BRONX COMMUNITY RECOVERY CENTER (BCRC)

Community recovery centers (CRCs) have the potential to be an important component in the substance abuse continuum of care, yet we lack data on their effectiveness. This study examines the 6‐month outcomes of 260 clients participating in the Phoenix House Bronx Community recovery Center (BCRC). At follow‐up, clients were significantly less likely to report substance use (odds ratio [OR] = 0.4, p = 0.002) and showed improvements on a variety of other psychosocial domains as well. Fewer clients were also using formal inpatient (OR = 0.3, p < 0.001) and outpatient substance abuse treatment services at follow‐up (OR = 0.5, p = 0.011). These data provide preliminary evidence for the effectiveness of recovery centers to sustain abstinence, enhance recovery capital, and curtail the use of formal, more expensive substance abuse treatment. Additional studies documenting the type and amount of services received in recovery centers, randomized trials of referrals to recovery centers and referral as usual, and studies of cost‐effectiveness are needed.     

Effects of graduate clinicians' personal therapy on therapeutic alliance

This study investigates the effects of clinician personal therapy on therapeutic alliance early in treatment. Therapists who had received personal therapy assessed 30 outpatients, and therapists who had not undergone personal therapy assessed 30 outpatients. These groups of patients were matched on key demographic, diagnostic and psychiatric severity data. Results demonstrated no significant group differences on patient‐rated alliance. Significant differences were observed for the therapist‐rated alliance variables of therapist confidence, goal and task agreement, as well as overall alliance, with higher scores from those therapists who had received personal therapy. In addition, significant differences were found in the number of therapy sessions attended, with the treatments of those therapists who had received personal therapy being twice as long. The impact of personal therapy in relation to structured training and a therapeutic model of assessment on graduate clinicians' ability to form positive collaborative relationships with their patients is discussed. Copyright © 2009 John Wiley & Sons, Ltd.     

Beyond ethnic match: Effects of client–therapist cognitive match in problem perception,coping orientation,and therapy goals on treatment outcomes

This study examined the outcome effects of cognitive match between Asian and White outpatient clients and their therapists. Many clinicians believe that one hindrance to the treatment of ethnic minority clients is that therapists and clients may not share common assumptions and attitudes about therapy and about the problems that are presented in treatment. The study investigated client–therapist similarity in their perceptions of the presenting problem, coping orientation, and expectations about treatment goals. This study constituted a more rigorous test of the cognitive match hypotheses in that it was prospective in nature, used separate and independent sources for the cognitive predictors, employed multiple outcome measures, and focused on specific attitudes and perceptions that are quite salient and relevant to treatment. Cognitive match on treatment goals was predictive of session impact. Moreover, cognitive matches in avoidant coping orientation and in perceived distress associated with interpersonal problems were predictive of certain treatment outcomes. The findings may help explain why clients matched on ethnicity with their therapists tend to stay longer in treatment and do better in psychotherapy. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 569–585, 2005.