Depth of emotional experience and outcome

Abstract The relationship between theme-related depth of experiencing (EXP) and outcome was explored in experiential therapy with depressed clients. The study sought to investigate whether depth of EXP predicts outcome, whether change in depth of EXP over therapy predicts outcome, and how these factors compare with the therapeutic alliance as predictors of outcome. The sample consisted of 35 clients, each of whom received 16 to 20 weeks of therapy. Themes that had emerged across therapy were identified. Depth of EXP was measured in relation to themes in one early session and in three sessions sampled from blocks across the last half of therapy. Analyses revealed that EXP on core themes in the last half of therapy was a significant predictor of reduced symptom distress and increased self-esteem. EXP did not correlate significantly with changes on the Inventory of Interpersonal Problems. EXP on core themes also accounted for outcome variance over and above that accounted for by early EXP and alliance.     

The mediating role of the therapeutic alliance in understanding early discontinuance

Abstract

Objective: The objective of this study was to test whether the therapeutic alliance mediated the relationship between previously identified predictors of premature termination and dropout during the first three sessions of treatment. Method: In this naturalistic study, 994 cases receiving individual, couple and family, or high-conflict coparenting therapy provided demographic information and completed assessments prior to treatment. Following the first session, clients completed a measure of the therapeutic alliance. Two hundred and five (20.6%) discontinued therapy prior to the fourth session. Logistic and ordinary least squares regression was used across m?=?20 imputed datasets to examine the effect of pressure to attend therapy, age, gender, education, distress, therapy format, and therapist experience on whether clients continued in therapy and whether the alliance mediated this relationship. Results: After controlling for age, therapist experience, education, and pressure to attend therapy; general distress and participating in high-conflict coparenting were associated with higher rates of early termination. The effect of both distress and therapy format on dropout, however, was mediated by the therapeutic alliance. Conclusions: By focusing on improving the therapeutic alliance with high-conflict coparenting cases as well as clients with higher levels of distress, therapists may be able to increase client retention.     

The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process

Objective: The experiencing scale (EXP) is an often used measure of client's depth of processing and meaning-making in-session. While research suggests that “client experiencing” predicts psychotherapy outcomes, this relationship has never been summarized in a meta-analysis. We examine this specific client factor as an in-session process predictor of good treatment outcomes. Method: A meta-analysis quantified the relationship between client experiencing and therapy outcomes using a total of 10 studies and 406 clients. Results: Analysis indicated that client experiencing is a small to medium predictor of standardized symptom improvements at final treatment outcomes with an effect of r?=??.19 (95% CI ?.10 to ?.29), which we consider a “best estimate” for robustly quantifying the association between EXP and self-reported clinical outcomes. However, effects were higher (i.e., r?=??.25) when observational measures of outcome were also included: Subgroup analyses indicated that EXP effects were moderated by the modality of outcome measurement (i.e., symptom reports vs. observational measures). On the other hand, statistical index, treatment phase, or treatment approach did not have significant impacts, which addresses some perennial questions in the EXP literature. Conclusions: Client experiencing is a small to medium predictor of treatment outcomes and a probable common factor.     

Therapists’ recognition of alliance ruptures as a moderator of change in alliance and symptoms

Therapists’ awareness of ruptures in the alliance may determine whether such ruptures will prove beneficial or obstructive to the therapy process. Objective: This study investigated the associations between therapists’ recognition of these ruptures, and changes in clients’ alliance ratings and symptom reports, using time-series data in a naturalistic treatment setting. Method: Eighty-four clients treated by 56 therapists completed alliance measures after each session, and the clients also completed symptom measures at the beginning of each session. Results: Therapists’ recognition of alliance rupture in non-rupture sessions was positively associated with clients’ alliance ratings in the next session and this effect was significantly higher when rupture did occur. There was also a significant interaction effect for functioning ratings: Therapists’ recognition of alliance ruptures abolished the negative effect of ruptures on clients’ symptom ratings in the following session. Conclusion: These results highlight the importance of therapists’ recognition of deterioration in the alliance for a repair process to take place that may eventually lead to an improved relationship and outcome.     

An in-session exploration of ruptures in working alliance and their associations with clients’ core conflictual relationship themes,alliance-related discourse,and clients’ postsession evaluations

Abstract

This exploratory study examined (a) the relationship among the occurrence of ruptures in the working alliance, the emergence of client's core conflictual relationship themes (CCRT), and focus of discourse within therapeutic sessions and (b) the relationship between ruptures in the working alliance and client's postsession evaluations of session's smoothness and depth. The authors included 151 sessions from five therapies conducted in a student counseling center. Sessions were content analyzed by independent raters, and a self-report questionnaire was given to clients after each session. Ruptures were positively related to the emergence of clients’ CCRT during the session, but only when the therapist was addressed as the “other.” Sessions with ruptures were characterized by heightened discussion of working alliance components and were evaluated as less smooth than sessions without ruptures. Findings are discussed, and the importance of ruptures in working alliance for therapeutic change is emphasized.     

Predictors of outcome and completion status in cognitive therapy for depression

Abstract

The aim of this study was to investigate the relationship among therapy outcome, premature termination, and client interpersonal style and therapeutic alliance. Of the 94 clients who began cognitive therapy for the treatment of depression, 24 did not complete their agreed-on number of therapy sessions, had poorer outcomes and alliance scores, and were more likely to have an ambivalent interpersonal style. However, mediation of this relationship between interpersonal style and completion status by alliance was not significant. Therapy outcomes for all clients were better for clients with a secure interpersonal style than for those with an insecure interpersonal style, particularly avoidant. The association between interpersonal style and outcome was mediated by the therapeutic alliance.     

The Psychotherapy Outcome Problem: The Development of the Outcome Stability Index

Objective: Psychotherapy research commonly utilizes clients’ last session score as an indicator of treatment outcome. We examined whether this last session score is consistent with what would be predicted based on clients’ general trajectory in psychological functioning across sessions. We focused on the unstandardized residual variance at the last session, as this represents the degree to which the session score is divergent (or not) from what is predicted from the previous sessions (i.e., Outcome Stability Index; OSI). Method: The sample included 27,958 clients who attended on average 9.41 sessions. Each session, clients completed the Behavioral Health Measure-20 as a measure of psychological functioning. We converted the unstandardized residual variance for clients’ last session score into a Cohen’s d coefficient to aid in interpretation. Results: The mean OSI was 0.07 (SD?=?0.58), suggesting excellent stability in their last session therapy outcome scores. However, approximately 33% of clients demonstrated poor or extremely problematic stability in their last session therapy outcome scores. Clients who demonstrated poor stability were classified as demonstrating reliable deterioration. Conclusions: Researchers may want to consider reporting OSI to assist readers’ understanding of the stability of therapy outcomes.

Clinical or methodological significance of this article: Therapy outcome scores can vary from session to session, which can influence how we understand therapy outcomes that rely on last session scores. Studies examining therapy outcomes could report the Outcome Stability Index to better contextualize the results.     

Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa

Objective: This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa. Method: Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale. Results: Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT. Conclusions: As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.     

Patient–therapist convergence in alliance ratings as a predictor of outcome in psychotherapy for generalized anxiety disorder

Objective: Although patients and therapists aligning over time on their perceptions of alliance quality is regarded as clinically important, few studies have examined the influence of such dyadic convergence on psychotherapy outcomes. This study tested whether early treatment convergence in patient–therapist alliance ratings was associated with subsequent worry and distress reduction in psychotherapy for generalized anxiety disorder (GAD), and whether treatment type and the dyad members’ initial alliance perceptions moderated these associations. Method: Data derived from a randomized trial for which patients with severe GAD received either 15 sessions of standard cognitive-behavioral therapy (CBT; n?=?43) or CBT integrated with motivational interviewing (n?=?42). Patients and therapists rated the alliance after each session. Patients rated worry after each session, and their distress multiple times. Results: As predicted, dyadic multilevel modeling revealed that early alliance convergence was associated with greater subsequent worry (p?=?.03) and distress (p?=?.01) reduction, and the combination of low initial patient-rated alliance and low convergence was associated with the worst outcome for the distress variable (p?=?.04). Conclusions: Results suggest that alliance convergence may be an important clinical process that bears on outcome, rendering it an important marker for therapist responsiveness.     

Beyond the tip of the iceberg: Exploring the potential of the meaning extraction method and aftercare e-mail themes

Abstract

The objectives were to examine the relationships among clients' affect regulation capacities, in-session emotional processing, outcome, and the working alliance in 66 clients who received either cognitive–behavioral therapy or process-experiential emotion-focused therapy for depression. Clients’ initial level of affect regulation predicted their level of emotional processing during early and working phases of therapy. Clients’ peak emotional processing in the working phase of therapy mediated the relationship between their initial level of affect regulation and their level of affect regulation at the end of therapy; and clients' level of affect regulation at the end of therapy mediated the relationship between their peak level of emotional processing in the working phase of therapy and outcome. Clients’ affect regulation at the end of therapy predicted outcome independently of the working alliance. The findings suggest that clients' level of affect regulation early in therapy has a significant impact on the quality of their in-session processing and outcome in short-term therapy. Limitations of the study and future directions for research are discussed.     

The therapeutic alliance in internet interventions: A narrative review and suggestions for future research

Objectives: Research on Internet interventions has grown rapidly over the recent years and evidence is growing that Internet-based treatments often result in similar outcomes as conventional face-to-face psychotherapy. Yet there are still unanswered concerns such as whether a therapeutic alliance can be established over the Internet and whether the alliance is important in this new treatment format. Methods: A narrative review of studies formally assessing the therapeutic alliance in Internet interventions was conducted. It is the first review summarizing findings on the therapeutic alliance that (i) distinguishes between different forms of Internet interventions and (ii) does not restrict itself to specific Internet-based treatment formats such as guided self-help treatments, e-mail or videoconferencing therapies. Results: Independent of communication modalities, diagnostic groups and amount of contact between clients and therapists, client-rated alliance scores were high, roughly equivalent to alliance ratings found in studies on face-to-face therapy. Mixed results were found regarding the therapist-rated alliance and alliance-outcome associations. Conclusions: The review points to the limitations of the available evidence and identifies unanswered questions. It is concluded that one of the major tasks for future research is to identify unique characteristics of the therapeutic alliance in the different treatment formats.     

The relation between outcome expectation,therapeutic alliance,and outcome among depressed patients in group cognitive-behavioral therapy

Objective: Although patients’ expectation for improvement correlates with their treatment outcome, there remains limited information regarding the mechanisms through which outcome expectation influences outcome. Although several studies have revealed alliance as a mediator of the expectancy-outcome relation, most have focused on individual psychotherapy only. More research is needed examining mediators, including alliance quality, of the outcome expectation-outcome relation in group therapy. Method: This study focused on such associative chains among 91 depressed outpatients who completed 10 weeks of group cognitive-behavioral therapy. We conducted simple and multiple mediation analyses, accounting for the nested data structure. Results: As predicted, we found: (i) The relations between baseline outcome expectation and both posttreatment anxiety and depression were mediated by alliance quality; (ii) the early therapy outcome expectation-posttreatment anxiety relation was mediated by mid-treatment alliance; (iii) the relation between early alliance and posttreatment interpersonal problems was mediated by during-therapy outcome expectation; and (iv) the relation between baseline outcome expectation and posttreatment interpersonal problems was mediated by two variables acting in turn, early alliance and during-therapy outcome expectation. All other tested models were not significant. Conclusions: Results suggest that bidirectional relations between outcome expectation and alliance, with both directions influencing outcome. Clinical and empirical implications are discussed.     

Patient characteristics and the therapist as predictors of depressed patients’ outcome expectation over time: A multilevel analysis

Objective: Although there is an established link between patients’ early positive outcome expectation for and their actual improvement from therapy, there is little research on patients’ change in outcome expectation across therapy and both patient and therapist correlates of early outcome expectation level and change. The present study examined: (i) the overall trajectory of change in patients’ outcome expectation through cognitive-behavioral therapy (CBT) for depression; (ii) patient characteristics as predictors of both initial outcome expectation and change in outcome expectation; and (iii) between-therapist effects in outcome expectation change. Method: Depressed patients (N?=?143) received a brief course of CBT. Outcome expectation was measured at screening, pretreatment, session 7, and session 14. Results: Outcome expectation linearly increased from screening to session 14. When controlling for other patient characteristics at intake, having previous depressive episodes was negatively associated with initial outcome expectation and higher well-being was positively associated with initial outcome expectation. When controlling for early alliance and early symptom change, outcome expectation change was predicted by previous depressive episodes. Finally, therapist effects emerged in outcome expectation over time. Conclusions: Various depressed patients’ characteristics predict initial outcome expectation level and change, with significant between-therapists’ differences related to outcome expectation change.     

Stages of change and the working alliance in psychotherapy

Abstract

This study investigated whether the working alliance mediates between the stages of change and symptom improvement. It also investigated whether progression to a higher stage of change was associated with an enhancement in working alliance and outcome scores. Fifty-six adult clients receiving counseling at a community mental health clinic completed measures after the first, fifth, and termination sessions. Using the Baron and Kenny (1986) and bootstrapping procedures, the working alliance was found to be a mediating variable. A multivariate analysis of variance indicated that clients who progressed from a lower stage to a higher stage reported stronger working alliances and more symptom improvement than those who did not progress. These results offer further support for the importance of a strong working alliance in psychotherapy.     

Client and therapist agreement about the client's problems—Associations with treatment alliance and outcome

Objective: A shared understanding of the patient's symptoms and problems is seen by most theories as a crucial aspect of the collaboration in therapy, presumably influencing alliance and outcome. The empirical ground for this argument is not solid, however. Several studies have found weak associations between a common view of the patient's problems and outcome. The purpose of the present study was to analyze whether agreement in the understanding of the patient's depression and anxiety problems was important for alliance and outcome. Method: The study used data from a practice-based study using the CORE system with 846 patients who received psychological treatment in primary care. Results: The analyses indicated that although patients who were assessed by their therapists as having depression and anxiety problems scored higher on these subscales than other patients, about half of the patients reported such problems when the therapists did not, and vice versa. Agreement was not associated with better alliance or outcome. Conclusions: Productive collaboration in psychotherapy may be based on other factors than agreement about symptoms.     

Mind the gap: In-session silences are associated with client attachment insecurity,therapeutic alliance,and treatment outcome

Objective: The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa. Method: 69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N?=?175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed. Results: Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment. Conclusion: The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.     

Contribution of defensive functioning to the quality of working alliance and psychotherapy outcome

We analyzed whether defense mechanisms changed and/or predicted outcome during brief dynamic psychotherapy (N = 43, max 40 sessions, Norwegian Multisite Study on Process and Outcome of Psychotherapy). Defenses were rated with the Defense Mechanism Rating Scales (DMRS, clinician-rated) and Defense Style Questionnaire (DSQ self-rated). Overall defensive functioning (ODF) as rated by DMRS changed significantly. We found that the initial ODF's neither predicted the quality of working alliance nor influenced the outcome. Symptoms improved most rapidly early in therapy, while defenses changed during the last half of therapy, consistent with the phase model of change.     

Alliance ruptures and resolution during cognitive behaviour therapy with patients with borderline personality disorder

Abstract

Objective: To explore the process of rupture resolution in cognitive behaviour therapy (CBT) with two good outcome clients with borderline personality disorder (BPD). Method: This study employed task-analytic methods to investigate whether the existing CBT rupture resolution model for depression could be validated. Quantitative analyses identified rupture-repair sequences and 41 rupture resolution attempts were systematically analysed. Results: The final model shared similarities with the existing model although additional components, including an “external observer” were identified. Focus on affective experience was also hypothesized to be important. Conclusions: The final theoretical rupture resolution model may be a useful tool when working with BPD clients in CBT. It is however recognized that further research on data from larger samples is needed. Clinical implications for managing alliance ruptures with BPD clients are discussed.     

Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome

Objectives: Therapist effects, independent of the treatment provided, have emerged as a contributor to psychotherapy outcomes. However, past research largely has not identified which therapist factors might be contributing to these effects, though research on psychotherapy implicates relational characteristics. The present Randomized Clinical Trial tested the efficacy of therapists who were selected by their facilitative interpersonal skills (FIS) and training status. Method: Sixty-five clients were selected from 2713 undergraduates using a screening and clinical interview procedure. Twenty-three therapists met with 2 clients for 7 sessions and 20 participants served in a no-treatment control group. Results: Outcome and alliance differences for Training Status were negligible. High FIS therapists had greater pre–post client outcome, and higher rates of change across sessions, than low FIS therapists. All clients treated by therapists improved more than the silent control, but effects were greater with high FIS than low FIS therapists. From the first session, high FIS therapists also had higher alliances than low FIS therapists as well as significant improvements on client-rated alliance. Conclusions: Results were consistent with the hypothesis that therapists’ common relational skills are independent contributors to therapeutic alliance and outcome.     

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.