The Therapeutic Alliance and CBASP-Specific Skill Acquisition in the Treatment of Chronic Depression

This study examined the influences of proposed specific and common psychotherapeutic factors in a sample of chronically depressed adult outpatients. Participants (N = 324) were drawn from a multi-site clinical trial that compared the efficacies of the cognitive behavioral analysis system of psychotherapy (CBASP), nefazodone, and their combination. This report is limited to patients receiving CBASP alone or combination treatment. A series of regression analyses were performed to test whether: (1) the ability to utilize the skills taught in CBASP mediated the relationship between the early therapeutic alliance and endpoint depression, and (2) the therapeutic alliance moderated the relationship between skill utilization and endpoint depression. Neither model was supported. Instead, each of these factors contributed independently and additively to alleviation of depressive symptoms.     

Is Cognitive Therapy Suitable for Treating Individuals with Personality Dysfunction?

In this study, the impact of personality dysfunction on suitability for cognitive therapy was examined empirically. Thirty-six (36) mental health outpatients were evaluated with regard to the extent of personality dysfunction and suitability for short-term cognitive therapy. All participants were interviewed by a psychiatrist using the Personality Disorders Examination (PDE) to assess personality dysfunction, and by a psychologist using the Suitability for Short-Term Cognitive Therapy Scale (SSCT) to assess cognitive therapy suitability. Participants also completed the Millon Clinical Multiaxial Inventory–Revised (MCMI-II) to provide a multimethod assessment of personality dysfunction. Analysis of the correlations between suitability for cognitive therapy and personality dysfunction for both the independent-interviewer rated method (the PDE) and the self-report method (MCMI-II) indicated that greater dysfunction was significantly associated with poorer suitability for cognitive therapy. Results were most clear for the general therapy subscale of the SSCT relative to the cognitive therapy specific subscale. A tentative item analysis of the SSCT scale indicated that alliance potential (both in-session and out-of-session ratings), security operations, chronicity, personal responsibility for change, and compatibility with the cognitive therapy rationale were most strongly affected (negatively) by personality dysfunction. These data suggest that, although personality dysfunction has an impact on suitability, cognitive therapy may not be any more contraindicated than any other form of psychotherapy. Theoretical developments within cognitive therapy to address personality dysfunction specifically also support the use of cognitive therapy with this population. Suggestions for specific process and procedural modifications to cognitive therapy when working with personality dysfunction that address the factors that contribute to poor suitability are outlined.     

Fostering Cognitive Change in Cognitive Therapy of Depression: An Investigation of Therapeutic Strategies

There is little evidence regarding which therapist strategies promote cognitive change in cognitive therapy (CT) of depression. Drawing from a sample of CT patients, we selected two consecutive sessions for which patients reported markedly different amounts of cognitive change (CC; i.e., a low and high cognitive change session). We then investigated whether four observer-rated psychotherapy process variables differentiated high and low CC sessions. Our analyses focused on 62 patients with large session-to-session differences in self-reported CC. Results from single predictor models showed the therapeutic alliance and therapists’ use of cognitive methods predicted high versus low CC session type. In a model including multiple predictors, only cognitive methods remained significant. These findings are consistent with the view that cognitive methods promote CC in CT.

     

Role behavior expectancies and alliance change in short-term individual psychotherapy

Patients and therapists participating in a clinical trial of short-term, time-limited individual (STI) psychotherapy were asked to rate expectancies regarding their own and their counterpart's role behaviors during sessions. Significant relationships differed according to the index of alliance used (patient, therapist) and as a function of scores on a global patient personality measure known as Quality of Object Relations (QOR). Among high-QOR (or mature) cases, the patient's expectancy of being able to contribute to the treatment process was inversely associated with change in the patient-rated alliance. For those with low QOR (more primitive object relations), congruence of expectancies regarding a supportive therapist role was directly associated with change in the therapist-rated alliance. Results are discussed in terms of evaluating and preparing patients for psychotherapy and the appropriate therapeutic strategies for patients of different QOR.     

The factor structure of the working alliance inventory in cognitive-behavioral therapy

Studies of the therapeutic alliance in cognitive-behavioral therapy (CBT) have varied in their results, necessitating a deeper understanding of this construct. Through an exploratory factor analysis of the alliance in CBT, as measured by the Working Alliance Inventory (shortened, observer-rated version), the authors found a two-factor structure of alliance that challenges the commonly accepted one general factor of alliance. The results suggest that the relationship between therapist and client (Relationship) may be largely independent of the client's agreement with and confidence in the therapist and CBT (Agreement/ Confidence), necessitating independent measures of these two factors, not one measure of a general alliance factor.     

Time-limited psychotherapy with adolescents

Short-term dynamic therapies, characterized by abbreviated lengths (10-40 sessions) and, in many cases, preset termination dates, have become more widespread in the past three decades. Short-term therapies are based on rapid psychodynamic diagnosis, a therapeutic focus, a rapidly formed therapeutic alliance, awareness of termination and separation processes, and the directive stance of the therapist. The emotional storm of adolescence, stemming from both developmental and psychopathological sources, leaves many adolescents in need of psychotherapy. Many adolescents in need of therapy resist long-term attachment and involvement in an ambiguous relationship, which they experience as a threat to their emerging sense of independence and separateness. Short-term dynamic therapy can be the treatment of choice for many adolescents because it minimizes these threats and is more responsive to their developmental needs. The article presents treatment and follow-up of a 17-year-old youth, using James Mann's time-limited psychotherapy method.     

Sudden Gains During Patient-Directed Expressive Writing Treatment Predicts Depression Reduction in Women with History of Childhood Sexual Abuse: Results from a Randomized Clinical Trial

Sudden gains are large reductions in symptoms measured in a single between-session interval and are positively associated with long-term treatment outcomes. To date, sudden gains have mostly been observed in therapist-directed psychotherapies. There are currently mixed findings surrounding the mechanisms underlying sudden gains, with some support for a cognitive mechanism and some support for therapist characteristics such as the therapeutic alliance. In this study of 77 female survivors of childhood sexual abuse, sudden gains in trauma symptoms were found in a randomized clinical trial of a patient-directed expressive writing intervention. Women in the active treatment condition (who wrote about their beliefs related to sexuality or trauma) exhibiting sudden gains in trauma symptoms showed larger improvements in depression than those in the control condition (who merely wrote about their daily needs). The extension of sudden gains from psychotherapy to a client-directed treatment refines our understanding of the mechanisms underlying these gains, and supports the hypothesis that cognitive change is a likely mechanism underlying sudden gains.     

Quality of working alliance in psychotherapy: therapist variables and patient/therapist similarity as predictors.

Therapist characteristics were explored as possible predictors of working alliance, rated early and later in therapy both by therapists (n=59) and patients (n=270) in an ongoing multisite project on process and outcome of psychotherapy. Patients and therapists had divergent perspectives on the working alliance. Therapists' experience, training, skill, and progress as therapists did not have any significant impact on alliance as rated by patients. Training and skill were positively related to alliance as rated by therapists. Interpersonal relationships on the cold-warm dimension had a moderate impact for both patients' and therapists' alliance ratings. Some implications for therapist training are discussed.     

Effective microprocesses in early sessions of dynamic psychotherapy

This naturalistic study examined effective microprocesses in early sessions of dynamic psychotherapy. A multiple-regression data analytic strategy focused on the proportion of variance accounted for by process variables in session outcome as judged by the patient. This measure of session outcome in early sessions of dynamic therapy was associated with overall treatment outcome. Specific microprocesses differentially emerged as contributors to session progress as therapy proceeded, accounting for 55% of the variance in session 3 and 58% in session 7. Findings are discussed in terms of specific as well as fundamental change processes in early sessions of dynamic psychotherapy. The usefulness of the generic model of psychotherapy for guiding exploratory change process research is also highlighted.     

Early Identification of Treatment Failures in Short-Term Psychotherapy: An Assessment of Therapeutic Alliance and Interpersonal Behavior

Early sessions of patients categorized as dropouts (n = 25), good outcome (n = 28), and poor outcome (n = 20) completers of a 40-session protocol of short-term psychotherapy were compared to determine predictive validity of in-session measures of therapeutic alliance and interpersonal behavior (Working Alliance Inventory, Session Evaluation Questionnaire, and Interpersonal Adjective Scale). A number of significant differences were found among the three groups: both patients and therapists in the dropout group rated the relationship as more problematic than those in the good outcome group, and patients in the dropout group also rated the relationship as more problematic than those in the poor outcome group, while therapists'' ratings did not distinguish dropouts from poor outcome. Differences between good and poor outcome groups were nonsignificant. These findings have clinical significance, particularly in early identification of patients at risk for treatment failure.Research on the therapeutic alliance has consistently confirmed the centrality of the alliance construct and its predictive value in the overall outcome of therapy, as well as in the ongoing process of therapy. Bordin,¹ in one of his last works, emphasized that the repair and working-through of strains or ruptures in the alliance is crucial to the process of change. While this is certainly not news to our colleagues in analytic circles, who have been writing about and working clinically with transference, defense, and alliance phenomena for many years, Bordin''s transtheoretical language has enabled psychotherapy researchers to begin testing these multifaceted concepts empirically.     

A Randomized Prospective Study Comparing Supportive and Dynamic Therapies: Outcome and Alliance

The authors report preliminary results of Brief Supportive Psychotherapy (BSP) in the Beth Israel Brief Psychotherapy Program for a sample with primarily Cluster C Axis II disorders. This study compares 24 patients treated with BSP with 25 patients treated with Short-Term Dynamic Psychotherapy (STDP). STDP was chosen because its confrontational methods contrast dramatically to BSP, which emphasizes building self-esteem, reducing anxiety, and enhancing coping mechanisms. Videotaped therapies were based on manualized 40-session protocols. Similar degrees of improvement were seen in BSP and STDP at termination and at 6-month follow-up. A study of therapeutic alliance in BSP showed stable and high levels of alliance in good-outcome cases and more variability in poor-outcome cases. These preliminary findings are consistent with other studies and suggest supportive psychotherapy may be effective for many patients, leading to significant and lasting change. (The Journal of Psychotherapy Practice and Research 1998; 7:261–271)In recent years, more attention has been paid to supportive therapy, with the publication of reviews,^1–5 texts and manuals,^6–9 and some psychotherapy outcome studies.^10–13 However, clinicians rarely view supportive therapy as a first-line treatment. In clinical practice, supportive therapy is generally reserved for patients believed to be unsuitable for expressive therapy (or other approaches)—individuals with severe personality disorders or chronic Axis I disorders, or those lacking motivation or insight. In psychotherapy research, supportive therapy is often included as a control in studies of “active” treatments, whether behavioral or psychodynamic, rather than as a modality to be studied on its own merits. In some studies,^10,12,14 psychotherapy researchers have determined that an “active” treatment is no better than the “control” of supportive therapy. Although such findings may indicate the efficacy of “nonspecific factors” in psychotherapy, they also raise the possibility that supportive therapy may be more efficacious than has been traditionally believed.We are reporting here on preliminary results of supportive therapy as studied at Beth Israel Medical Center''s Brief Psychotherapy Research Program.^15,16 This project has compared several forms of psychotherapy in a prospective, randomized fashion, using videotapes and a variety of therapist-, patient-, and observer-rated measures of process and outcome. Initially the Brief Psychotherapy Project compared Short-Term Dynamic Psychotherapy (STDP), an intense, highly confrontive treatment developed by Davanloo,^17,18 with Brief Adaptive Psychotherapy (BAP), a traditional “insight-oriented” psychotherapy¹⁹ designed to be similar to that practiced by dynamically oriented therapists in the community. Other cells now include Cognitive-Behavioral Therapy (CBT)²⁰ and Brief Relational Therapy (BRT).²¹ Brief Supportive Psychotherapy (BSP) was added to the Brief Psychotherapy Research Project in 1988 to broaden the range of treatment approaches under study. Like STDP and the other treatments, BSP was a time-limited, manual-based psychotherapy. We have published a manual⁷ and several papers and book chapters^15,16,22 providing a definition of supportive therapy and a rationale for considering it to be an active form of psychotherapy, potentially as effective a means for structural psychological change as the more traditionally “exploratory” or “expressive” therapies.Our model-based (and literature-based) belief in the effectiveness of supportive therapy has until now been supported only by the anecdotal experience with the Brief Psychotherapy Research Project, where many BSP cases had positive outcomes. We hypothesize that BSP may be effective not only with the low-functioning patients to whom it has long been prescribed, but also with higher-functioning patients who have traditionally been treated in expressive psychotherapy. In assessing treatment outcome, this study reverses the traditional question of psychotherapy research. Rather than investigating whether another therapy is as good as or better than supportive psychotherapy, our hypothesis is that BSP has equal or greater efficacy compared with a “control” of STDP, as measured by a variety of outcome measures. In previous work,²³ STDP has been demonstrated to be superior to a wait-list control condition.In addition, we are interested in beginning to characterize and describe the quality of therapeutic alliance in BSP. Despite its importance, there has been little systematic work in this area. In one study, Salvio et al.²⁴ compared alliance in cognitive, gestalt, and supportive/ self-directed therapy by using the Working Alliance Inventory (WAI) and the Barrett-Lennard Relationship Inventory (which measures therapist qualities of empathy, positive regard, and congruence), measuring alliance four times during treatment. Salvio et al. found little variation from the beginning to the end of therapy, and no significant difference in quality of the alliance among the three therapies.In studying BSP, we expect that the alliance will be positive and stable throughout therapy in good-outcome cases, whereas in problematic or poor-outcome cases, we expect that alliance will be less positive and will fluctuate widely. We hypothesize that the alliance in BSP will differ from alliance in dynamic psychotherapy, especially STDP, which is a confrontational, anxiety-provoking treatment. The friendly, anxiety-reducing approach of the BSP therapist, we believe, should allow the patient to feel more comfortable early in treatment and to feel more “understood” in early sessions. If the BSP treatment is going well, we would expect the level of alliance to remain stable and high. In contrast, in STDP, patients may experience the frequent interpretations and the anxiety-inducing techniques of that treatment as threatening and foreign, and thus there may be significant fluctuations in the therapeutic alliance even in good-outcome cases.     

Therapist Competence and Outcome of Cognitive Therapy for Depression

The Cognitive Therapy Scale (CTS) has been widely used in cognitive therapy training Centers to assess therapist competence but competence has not previously been clearly shown to be associated with cognitive therapy outcome, possibly because an insufficient range of competence has been sampled. Competence was compared with alliance as process variables that might relate to change in therapy. A randomly selected therapy session from each of 30 courses of cognitive therapy for depression was rated using the CTS. Both therapeutic alliance and therapist competence were related to outcome. In regression analyses, the alliance remained significantly related to outcome when controlling for competence, but not vice versa. These relationships with outcome were primarily attributable to therapists rather than to clients. Associations with outcome appeared stronger for clients who completed therapy than for those who did not. These findings suggest that measurable factors both common to diverse treatments methods and specific to particular methods should be included in efforts to account for therapy outcome.     

Alliance thérapeutique et abandon des traitements de l’obésité

Dropout rate from obesity treatment is highly problematic. In psychotherapy, a number of Meta analyses have demonstrated a significant relationship between treatment drop out and therapeutic alliance. Very few studies, however, have paid attention to this relationship in obesity treatment. This review aims to investigate how personal and interpersonal variables impact alliance and drop out.     

Evaluation of a short-term group psychotherapy used as part of the rehabilitation process in nursing home patients

Abstract

Purpose: The aim of this study was to assess the impact of a 4-week group psychotherapy on the efficacy of physiotherapy in patients rehabilitated in a nursing home (NH). Materials and methods: The study was performed on 28 women, aged 77.1 (±5.6) years. Thirty-six percent were rehabilitated due to orthopaedic injuries, 36% had undergone a stroke, 28% suffered from chronic diseases of old age. Subjects were divided into two groups: experimental (n?=?13) and control (n?=?15). In the experimental group, a short-term, goal-focused group psychotherapy was used. To assess cognitive impairment, mood and functional status the Mini Mental State Examination (MMSE), the Geriatric Depression Scale (GDS-15) and the Barthel Index (BI) were used. Results: In the experimental group a four times greater improvement in mood was observed and two times greater physiotherapy efficacy (PE) in the first month of stay in an NH as compared to the control group. The effects of psychotherapy were independent of the type of disease, the patients’ age, number of comorbidities and cognitive status (ranging from 15 to 30 points on the MMSE). Conclusions: Short-term group psychotherapy can be an effective method of supporting the process of rehabilitating older, disabled people rehabilitated in an NH.

• Implications for Rehabilitation

• Psychotherapy can improve the efficacy of treatment and rehabilitation in different somatic illnesses despite the advanced age of respondents, high disability rate, and the presence of cognitive impairments.

• Even short-term (4 weeks) group psychotherapy can provide effective support for the rehabilitation in the elderly.

     

Efficacy of short-term dynamic psychotherapy : past, present, and future

The author outlines the history of brief dynamic psychotherapy, describes some of its characteristics, and addresses methodological requirements for assessing the efficacy of psychotherapy. Review of two major meta-analyses suggests that manual-based brief dynamic psychotherapy by trained therapists is likely to be as effective as other forms of psychotherapy and more effective than no treatment. More studies are needed that 1) compare brief dynamic psychotherapy with other forms of treatment for specific psychiatric disorders; 2) use theory-specific measures of outcome in addition to measures of symptoms; and 3) compare brief dynamic psychotherapy with long-term psychotherapy.     

Relatedness, group work, and outcome in long-term inpatient psychotherapy groups

Process and outcome measures were compared in two long-term groups. The measure "Relatedness" reflected an individual's attachment to and comfort with the group, and "Group Work" indicated perception of the group as having a positive working climate. High Relatedness scores predicted better outcome at 18-month follow-up. Group Work scores were not related to outcome. Relatedness and Group Work scores were not correlated. Results replicate in a group psychotherapy population the importance, reported in individual therapy literature, of an early and sustained positive therapeutic alliance (Relatedness). However, a measure that is closely related to the concept of "working alliance" (Group Work) did not predict outcome.     

Day treatment programme for patients with eating disorders: randomized controlled trial

AIM: This paper reports a randomized controlled trial to compare the effects of day treatment programmes for patients with eating disorders with those of traditional outpatient treatment. BACKGROUND: Eating disorders are common, especially in adolescents, and their worldwide prevalence is increasing. Treatment interventions for patients with eating disorders have traditionally been offered on an outpatient or inpatient basis, but the recent introduction of day hospital programmes offers the possibility of greater cost-effectiveness and relapse-prevention for this population. METHODS: Volunteers from an outpatient clinic for eating disorders were randomly assigned either to a treatment group (n = 21), participating in a modified day treatment programme based on the Toronto Day Hospital Program, or to a control group (n = 22) receiving a traditional outpatient programme of interpersonal psychotherapy, cognitive behaviour therapy and pharmacotherapy. Data were collected from January to December 2002 using the Eating Disorder Examination, Eating Disorder Inventory-2, Beck Depression Inventory, and Rosenberg Self-Esteem Scale. RESULTS: Participants in the day treatment programme showed significantly greater improvements on most psychological symptoms of the Eating Disorder Inventory-2, frequency of binging and purging, body mass index, depression and self-esteem scores than the control group. They also showed significant improvement in perfectionism, but the group difference was not significant. CONCLUSION: Nurses in day treatment programmes can play various and important roles establishing a therapeutic alliance between patient and carer in the initial period of treatment. In addition, the cognitive and behavioural work that is vital to a patient's recovery, that is, dealing with food issues, weight issues and self-esteem, is most effectively provided by a nurse therapist who maintains an empathic involvement with the patient.     

心理干预辅助药物治疗帕金森病抑郁与认知障碍

目的:探讨心理干预对帕金森病(PD)抑郁及认知功能障碍的影响.方法:PD患者70例按入院顺序(单双号)分为心理干预组(在常规药物治疗基础上给予心理干预)和常规治疗组(仅给予常规药物治疗),各35例,于入组、治疗1周及2个月时,采用汉密尔顿抑郁量表(HAMD)、抑郁自评量表(SDS)、简易智能精神状态检查量表(MMSE)...     

Contribution of patient defense mechanisms and therapist interventions to the development of early therapeutic alliance in a brief psychodynamic investigation

This preliminary study examined how patients' defense mechanisms and psychotherapists' techniques influence early alliance formation. The authors assessed the relationships among defense mechanisms, therapist interventions, and the development of alliance in a sample of 12 patients undergoing Brief Psychodynamic Investigation (4 sessions). Alliance development occurred rapidly and was clearly established by the third session. Neither defensive functioning nor supportive or exploratory interventions alone differentiated early alliance development. However, the degree of adjustment of therapists' interventions to patients' level of defensive functioning discriminated a low alliance from both improving and high alliances. The adjustment of therapeutic interventions to patients' level of defensive functioning is a promising predictor of alliance development and should be examined further, alongside other predictors of outcome.