Therapist predictors of early patient-rated working alliance: A multilevel approach

Abstract

The present study investigated whether and how various therapists' (N=68) self-reported characteristics relating to their therapeutic work predicted patients' (N = 335) early ratings of the working alliance in a naturalistic psychotherapy study. Results from multilevel modeling demonstrated that certain self-reports accounted well for the therapist effect in the early alliance. The effect of therapists' experiences of difficulties in practice was particularly strong: a negative influence of difficulties termed negative personal reaction (NPR) and a surprising positive influence of another factor, professional self-doubt (PSD), were found. The latter was interpreted as reflecting an attitude of therapist humbleness and sensitivity, which seems to facilitate alliance development. A negative impact of self-reported skills in using one's own and the patients' emotional reactions in the therapeutic relationship (advanced relational skills) was found when controlling for a warm interpersonal style. The negative effect of advanced relational skills depended on the level of NPR difficulties. The findings suggest that therapists should be cautious in using this kind of relational skill unless they experience relating to patients in a warm manner and report low levels of NPR in their practice.     

Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol

Objective: In the past decade, variation in outcomes between therapists (i.e., therapist effects) have become increasingly recognized as an important factor in psychotherapy. Less is known, however, about what accounts for differences between therapists. The present study investigates the possibility that therapists' basic therapy-related interpersonal skills may impact outcomes. Method: To examine this, psychotherapy postgraduate trainees completed both an observer- and an expert-rated behavioral assessment: the Therapy-Related Interpersonal Behaviors (TRIB). TRIB scores were used to predict trainees' outcomes over the course of the subsequent five years. Results: Results indicate that trainees' with more positively rated interpersonal behaviors assessed in the observer-rated group format but not in a single expert-rated format showed superior outcomes over the five-year period. This effect remained controlling for therapist characteristics (therapist gender, theoretical orientation [cognitive behavioral or psychodynamic], amount of supervision, patient's order within therapist's caseload), and patient characteristics (patient age, gender, number of comorbid diagnoses, global severity, and personality disorder diagnosis). Conclusions: These findings underscore the importance of therapists' interpersonal skills as a predictor of outcome and source of therapist effects. The potential utility of assessing therapists' and therapists-in-training interpersonal skills are discussed.     

Unpacking the therapist effect: Impact of treatment length differs for high- and low-performing therapists

Objective: Differences between therapists in their average outcomes (i.e., therapist effects) have become a topic of increasing interest in psychotherapy research in the past decade. Relatively little work, however, has moved beyond identifying the presence of significant between-therapist variability in patient outcomes. The current study sought to examine the ways in which therapist effects emerge over the course of time in psychotherapy. Method: We used a large psychotherapy data set (n?=?5828 patients seen by n?=?158 therapists for 50,048 sessions of psychotherapy) and examined whether outcomes diverge for high-performing (HP) and low-performing (LP) therapists as treatment duration increases. Results: Therapists accounted for a small but significant proportion of variance in patient outcomes that was not explained by differences between therapists' caseload characteristics. The discrepancy in outcomes between HP and LP therapists increased as treatment duration increased (interaction coefficient?=?0.071, p?p?=?.040). Conclusions: Indeed, patterns of change previously described ignoring between-therapist differences (e.g., dose-effect, good-enough level model) may vary systematically when disaggregated by therapist effect.     

Effects of sex and gender in ten types of psychotherapy

Objective: This paper addresses the results of two samples of a large naturalistic (effectiveness study) outpatient process-outcome study in Switzerland (Practice-Oriented Outpatient Psychotherapy Study). Ten different types of psychotherapy were investigated by looking at the role of the sex or gender of therapists and patients with regard to treatment outcome by including several nonspecific therapeutic factors. Method: Ten different types of psychotherapy, 237 patients, and 68 therapists were included in the study. A subsample of 116 cases was analyzed with regard to therapists' technical interventions. Results: Sex and gender issues of both therapists and patients did not play a crucial role in any type of psychotherapy investigated. Gender issues appeared to play an indirect role. Female therapists intervene more empathically, whereas male therapists tend to use more confrontational techniques. Conclusions: Since the results show that therapists differ substantially with regard to their intervention techniques due to their sex, they should become more conscious of their interventions by considering patients' severity of psychological problems and patients' level of psychological functioning so as to not over or underchallenge them.     

Therapists' in-session experiences with depressive clients: A grounded theory

Objective: This study explores the experiential process of psychotherapists during a session with a currently depressive client. Method: Individual and focus group interviews were conducted with 30 therapists and the grounded theory method was used as a methodological framework. Results: The therapists' experience was conceptualized as Experiential oscillation between getting closer to a client's depressive experience and moving away from it. Its development over the course of a session is depicted by a six-phase Depression Co-experiencing Trajectory model. Conclusions: The resultant theory interconnects different therapists' emotional responses to a depressive client within a coherent process model, which allows us to track the changes in therapists' experiences, to name the relations between them, and to connect them with the therapy's in-session microprocesses.     

Improving the yield of psychotherapy research

Objective: Although the effectiveness of psychotherapy is well documented, little progress has been made in elucidating mechanisms of change. Major impediments to progress are the homogeneity assumptions evident in many psychotherapy studies. Case-specific research strategies avoid treating patients, therapists, and treatments as homogeneous variables and such studies are more successful at elucidating the link between psychotherapy processes and treatment outcome. Method: A case-specific, process-outcome study comprised of 39 patients treated by experienced therapists is presented. We did not focus on a supposedly homogeneous diagnostic group of patients (e.g., depressed patients) or particular manualized brands of therapy. Instead, we identified each patient's particular problems and conflicts (plan formulation) and then determined the degree to which therapists effectively addressed the patient's problems—that is, the degree to which therapists' interventions were compatible with (i.e., responsive to) the patient's plan. Results: Correlations between ratings of therapist responsiveness (plan compatibility of interventions) and a variety of outcome assessments were significant and substantial (accounting on average for 25% of outcome variance). Conclusion: The findings presented here suggest that the extent to which therapists are responsive to their patients' plans is a strong predictor of treatment outcome and of patients feeling positively about their therapy experience.     

The influence of baseline symptoms and insight on the therapeutic alliance early in the treatment of schizophrenia

BackgroundThe consistent association between therapeutic alliance and outcome underlines the importance of identifying factors which predict the development of a positive alliance. However, only few studies have examined the association between pretreatment characteristics and alliance formation in patients with schizophrenia.ObjectiveThe study examined whether symptoms and insight would predict the therapeutic alliance in psychotherapy of schizophrenia. Further, the associations and differences between patient and therapist alliance ratings were studied.MethodsEighty patients with schizophrenia spectrum disorders received manual-based psychotherapy. Assessment of symptoms and insight was conducted at baseline, and questionnaire-based alliance ratings were obtained three weeks into treatment. Patient and therapist alliance ratings were examined separately.ResultsPatient and therapist alliance ratings were not significantly correlated (r = 0.17). Patient ratings of the alliance were significantly higher than the ratings of their therapists (d = 0.73). More insight in psychosis significantly predicted higher patient ratings of the alliance. Less positive and negative symptoms were significant predictors of higher therapist alliance ratings.ConclusionThe findings indicate that symptoms and insight have an influence on the therapeutic alliance in the treatment of schizophrenia spectrum disorders. Patients' and therapists' perceptions of the alliance do not seem to demonstrate much convergence.     

Alliance Prediction of Outcome Beyond in-Treatment Symptomatic Change as Psychotherapy Processes

For older depressed adults treated in behavioral, cognitive, or brief dynamic therapy, we examined alliance-outcome associations over and above initial symptomatology and in-treatment symptomatic change, as therapy progressed. Patients and therapists completed the California Psychotherapy Alliance Scales, CALPAS, after the 5th, 10th, and 15th sessions. For each moment, an hierarchical multiple regression analysis was conducted with BDI scores at termination as criterion, and the following sequence of predictors: (a) initial BDI scores; (b) in-treatment BDI change scores up to where the alliance was measured; and (c) both patients' and therapists' CALPAS scores. For the whole sample, no substantial association was found between alliance and outcome (5% to 18%). Within treatment conditions, the alliance uniquely contributed to outcome with increasing variance accounted for as therapy progressed, and especially in behavior and cognitive therapy; from 19%–32% at the 5th session, to 36%–57% at the 15th. Given the small sample sizes, these findings are tentative and await replication in larger samples.     

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.     

Clients' and therapists' perceptions of intrasessional connection: An analogue study of change over time,predictor variables,and level of consensus

Abstract

Clients' and therapists' within-session experiences of relational connection were investigated using an analogue design. Eighty “therapist–client” dyads rated, on a minute-by-minute basis, their levels of connection to the other over a 20 minute counselling session. Therapists' and clients' feelings of connection increased over time with a negatively accelerating curve. Clients experienced a greater increase in feelings of connection with therapists that they perceived as less anxious; while older therapists, and therapists who believed they were perceived as more agreeable, experienced a deeper connection. Clients' and therapists' perception of connection were significantly associated, with a median within-dyad correlation of .76.     

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.     

Therapists' and clients' experiences of alliance ruptures: A qualitative study

Abstract

Aim: We explored therapists' and clients' experiences of alliance rupture events for the first 15 sessions of each of eight cases; therapists were each paired with one client who had a personality disorder. Method: All sessions were videotaped and rated with the Rupture Resolution Rating System. Approximately 1 week after a rupture, clients and therapists were individually interviewed about the causes of the rupture, how the rupture evolved, the impact of the rupture on the therapeutic process, and experiences during the event. The interviews were analyzed by five judges using consensual qualitative research (CQR; Hill, 2011). Results: Typically, rupture events involved a repetition of a previous rupture event, the rupture emerged when the client was not prepared to respond to the therapist's intervention, both therapists and clients felt confused and ambivalent, and confrontation events activated intense and negative feelings. We discuss the implications for practice, training, and research.     

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.     

Convergence in patient–therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment

Objective: This study tested whether discrepancy between patients’ and therapists’ ratings of the therapeutic alliance, as well as convergence in their alliance ratings over time, predicted outcome in chronic depression treatment. Method: Data derived from a controlled trial of partial or non-responders to open-label pharmacotherapy subsequently randomized to 12 weeks of algorithm-driven pharmacotherapy alone or pharmacotherapy plus psychotherapy. The current study focused on the psychotherapy conditions (N?=?357). Dyadic multilevel modeling was used to assess alliance discrepancy and alliance convergence over time as predictors of two depression measures: one pharmacotherapist-rated (Quick Inventory of Depressive Symptoms-Clinician; QIDS-C), the other blind interviewer-rated (Hamilton Rating Scale for Depression; HAMD). Results: Patients’ and therapists’ alliance ratings became more similar, or convergent, over the course of psychotherapy. Higher alliance convergence was associated with greater reductions in QIDS-C depression across psychotherapy. Alliance convergence was not significantly associated with declines in HAMD depression; however, greater alliance convergence was related to lower HAMD scores at 3-month follow-up. Conclusions: The results partially support the hypothesis that increasing patient–therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.     

The effect of perceived burdensomeness and thwarted belongingness on therapists' assessment of patients' suicide risk

Objective: The interpersonal theory of suicide posits that perceived burdensomeness and thwarted belongingness are two causal interactive suicidal risk factors. The aim of this study was to examine whether therapists are affected by these factors upon assessing patients' suicide risk. Method: Using an experimental design, 388 mental health professionals were presented with a text vignette describing a hypothetical patient with either high or low perceived burdensomeness and with either high or low thwarted belongingness. Results: The findings revealed that both factors affected therapists' risk assessment of psychache, suicidal ideation, suicide attempt and resilience. Conclusions: The study results highlight the interpersonal theory as an important theory for understanding the factors upon which therapists and mental health professionals rely when assessing suicide risk.     

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.     

The relationships between adult attachment,theoretical orientation,and therapist-reported alliance quality among licensed psychologists

Objective: Attachment anxiety has been depicted as an undesirable therapist characteristic based on findings that preoccupied therapists, relative to those with other attachment styles, report more ruptures in the therapeutic alliance. What has not been considered, however, is the extent to which attachment dynamics are related to theoretical orientations and how attachment styles and theoretical orientations combine to predict therapists' perceptions of the quality of their alliances. Method: The present surveyed 290 licensed psychologists nationally. Results: Results revealed that even within a sample of primarily secure psychologists, higher 15 levels of attachment anxiety correlated positively with the endorsement of psychodynamic orientations, and negatively with the endorsement of cognitive-behavioral orientations and self-reported alliance quality. Endorsement of cognitive-behavioral orientations, in turn, correlated positively with therapist-reported alliance quality. Conclusion: The results are discussed in terms of the extent to which attachment dimensions should be considered in therapists' understandings of their therapeutic alliances.     

Patient-Therapist Perspective of the Working Alliance in Psychotherapy

This study aimed to examine perceptions of the working alliance in a sample of Spanish patients and therapists. The alliance was measured after the third and tenth psychotherapy sessions using patient and therapist versions of the Spanish adaptation of the Working Alliance Inventory (WAI). After both sessions, correlations between the patients’ and therapists’ ratings, both of total alliance and of the various dimensions of the alliance, were moderate at best. Moreover, after the third psychotherapy session, patients’ scores for the total alliance and the Goal and Task subscales were significantly higher than the scores from their therapists in these dimensions. Following the tenth session, patient ratings exceeded those of their therapists only on the Task subscale. Finally, in contrast to the ratings of patients, therapists’ alliance ratings increased significantly between the third and tenth sessions of psychotherapy. Certain recommendations are presented to improve the study of patient and therapist perceptions of the working alliance and to increase the convergence between them with regard to this central treatment variable.     

The Spiritualities of Therapists' Lives

Summary

We situate how the personal spiritual quests of our own lives have influenced our work as family therapists, particularly influencing our chosen theories of change. We provide a definition of and approach to spirituality that centers its ethical, moral, and deeply relational nature, and propose that therapists' own spirituality can be a beneficial resource in the relationships they build and foster with those who consult them. Careful attention is given to how God calls us into relationships with others. Narrative therapy and spirituality are both defined as inherently relationalist practices and ways of being. Drawing on narrative therapy ideas, we describe a four step process we have used to explore therapists' spirituality in supervisory contexts specifically focusing on the relational nature of their work, and illustrate this process by giving supervision dialogues from some of our experiences.