Therapeutic alliance, cohesion and outcome in a long-term analytic group. A preliminary study

We studied the ongoing relationship of patients and their therapist in a long-term, analytic group. The therapeutic alliance was rated weekly and group cohesion was rated every month, by patients and therapist. The patients' symptoms (SCL-90-R) and interpersonal problems (IIP-C) were rated every third month during therapy (self-reports). There was a steady increase in the alliance ratings by patients and therapist during the first 2 years of therapy. This differs from findings in short-term therapies, where the alliance quickly reaches a high level and then remains stable throughout therapy. Therapist ratings of early alliance correlated significantly with positive symptomatic outcome, but did not predict interpersonal change. Patients' alliance ratings did not predict change. Early cohesion ratings did not predict change. The concordance between the patients' and the therapist's alliance ratings was highest between 16 and 30 sessions, and was essentially maintained throughout therapy. An early concordance of patient and therapist alliance ratings predicted a better symptomatic outcome. The measures of therapeutic alliance and cohesion used in this study seem to address different elements in the group process.     

Interaction between alliance and technique in predicting patient outcome during psychodynamic psychotherapy

The current study examined whether alliance interacted with psychodynamic interventions to predict patients' psychotherapy outcomes. A prospective study of psychodynamic psychotherapy with 68 outpatients who were treated by 23 therapists was used. The patients rated the alliance with their therapist early in treatment. Therapist use of psychodynamic techniques was reliably rated by independent clinicians for the same sessions. The therapy outcomes were measured at the end of treatment based on the patients' global symptomatology as well as estimate of improvement across a broad range of functioning. In all models, we controlled for the patients' pretherapy psychiatric severity. Analyses were conducted using multilevel modeling to account for therapist effects. Results revealed that patient rated alliance was significantly related to improvement on a measure of broad band functioning. In addition, alliance and psychodynamic interventions interacted to predict this scale of multidimensional therapy outcome. Further, results showed that several individual psychodynamic techniques interacted with alliance that were meaningfully related to this measure of broad band outcome including (1) linking current feelings or perceptions to the past; (2) focusing attention on similarities among patient's relationships repeated over time, settings, or people; and (3) identifying recurrent patterns in patient's actions, feelings, and experiences. In this sample of outpatient psychodynamic treatments, the dynamic techniques were most effective when provided in the context of strong alliances.     

Therapists’ and clients’ perception of each other and working alliance in the behavioral treatment of panic disorder and agoraphobia

Abstract

Fifty-nine patients who fulfilled criteria for a primary diagnosis of panic disorder with moderate to severe agoraphobia were treated with 16 sessions of behavioral therapy. The study investigated the relationship between therapists’ and clients’ perception of each other, working alliance, and outcome. There was initially a low correspondence between therapist and client perceptions but a growing consensus during treatment. This was most pronounced regarding high ratings of therapist qualities and the perception of the client as attractive. Clients’ perceptions showed virtually zero correlation with outcome regardless of time. Therapist perception of client as showing active participation and goal direction yielded positive correlations with outcome at posttreatment and follow-up from Session 4 and throughout treatment. No significant relation between working alliance and outcome was found apart from the fact that those who improved during follow-up rated the alliance significantly higher than those who did not improve.     

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.     

The mindfulness-based relapse prevention adherence and competence scale: Development,interrater reliability,and validity

Abstract

The present study describes the development of the Mindfulness-Based Relapse Prevention Adherence and Competence Scale (MBRP-AC), a measure of treatment integrity for mindfulness-based relapse prevention (MBRP). MBRP is a newly developed treatment integrating core aspects of relapse prevention with mindfulness practices. The MBRP-AC was developed in the context of a randomized controlled trial (RCT) of MBRP efficacy and consists of two sections: Adherence (adherence to individual components of MBRP and discussion of key concepts) and Competence (ratings of therapist style/approach and performance). Audio recordings from 44 randomly selected group treatment sessions (50%) were rated by independent raters for therapist adherence and competence in the RCT. Findings evinced high interrater reliability for all treatment adherence and competence ratings, and adequate internal consistency for Therapist Style/Approach and Therapist Performance summary scales. Ratings on the MBRP-AC suggested that therapists in the recent RCT adhered to protocol, discussed key concepts in each session, and demonstrated the intended style and competence in treatment delivery. Finally, overall ratings on the Adherence section were positively related to changes in mindfulness over the course of the treatment.     

Effects of therapist general self-disclosure and countertransference disclosure on ratings of the therapist and session

Therapist decisions about self-disclosure depend theoretically upon both content and context, such as the quality of the therapeutic relationship. In this analogue study, 224 undergraduates viewed 1 of 3 videos for which the working alliance was described as positive or negative and in which a therapist made general self-disclosures, countertransference disclosures, or no disclosures. Interaction effects indicated that participants rated sessions as deeper and the therapist as more expert when the therapist made general disclosures compared to no disclosures, but only when the alliance was positive. When the alliance was negative, participants perceived sessions as shallower and the therapist as less expert when the therapist made either general or countertransference disclosures compared to no disclosures. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

The negative effect of alexithymia on the outcome of group therapy for complicated grief: what role might the therapist play?

Alexithymia is a patient characteristic that reflects deficits in the cognitive processing and regulation of emotions. It is generally considered to have an adverse effect on the outcome of psychotherapy. Little is known about the processes through which alexithymia exerts this effect. One proposed mechanism suggests that patients with alexithymia trigger negative therapist reactions that contribute to poor outcome for such patients. This study examined whether therapist reactions to a patient mediate the relationship between alexithymia and outcome in group psychotherapy for complicated grief. Alexithymia was assessed with the Toronto Alexithymia Scale-20. Therapist reactions to a patient, reflecting the therapist's perceptions of a patient's positive qualities, personal compatibility, and significance as a group member, were assessed with a cohesion questionnaire. Outcome in several areas of functioning was measured. We found that alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less favorable outcome and that this relationship was mediated by therapist reactions to a patient. The mediation provided by therapist reactions to a patient accounted for approximately one third to one half of the direct effect of alexithymia on psychotherapy outcome. This suggests that therapist reactions to a patient represent a major mechanism through which alexithymia exerts its effect.     

How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Negative,not positive symptoms predict the early therapeutic alliance in cognitive behavioral therapy for psychosis

Abstract

Objective: The strength of therapeutic alliance is consistently associated with therapy outcome. The aim of this study was to identify relevant predictors for early therapeutic alliance in cognitive behavioral therapy for psychosis. Method: Fifty-six patients with schizophrenia spectrum disorders were included in the analysis. Possible predictors (positive and negative symptoms, depression, insight, social functioning, theory of mind, and medication adherence) were assessed at baseline. Alliance was assessed after each therapy session. Results: Lower negative symptoms significantly predicted higher patient and therapist rated alliance. Conclusions: The findings indicate that negative symptoms might be a barrier to the development of therapeutic alliance. Assumed underlying processes and practical implications are discussed.     

Alliance and outcome in late-life depression

Older adults who met criteria for major depressive disorder were randomly assigned to behavioral, cognitive, or brief dynamic therapy. Symptoms were equally reduced across the three treatment conditions. Early in treatment, alliance ratings were obtained from both therapists and patients and were related to outcome. We calculated one therapist alliance composite score and five patient alliance factor scores. In general, no agreement was found between therapists' and patients' judgments of alliance. Levels of alliance were found to be not significantly different across the three treatment conditions. For the sample as a whole, only the patient factor of Patient Commitment was found to be associated with depressive symptoms after treatment, with the strongest findings in the cognitive therapy condition. The Patient Commitment factor uniquely contributed to outcome over and above the contribution of initial symptomatology and symptomatic change at midpoint in therapy. Expected trends of association with outcome were observed for the therapist alliance composite score in brief dynamic therapy and for the patient factor of Patient Working Capacity in both cognitive and brief dynamic therapy. Findings are discussed in terms of their theoretical and clinical implications.     

Racism and Social Action

Objective: The therapeutic alliance is possibly a crucial factor in treatment for borderline personality disorder (BPD). Among predictors of therapeutic alliance, aspects that have not yet been considered are metacognition or the patient’s capacity to be aware of mental states. We therefore explored whether metacognition predicted alliance and if metacognition and therapeutic alliance together predicted outcome in brief treatment for BPD.

Method: In a secondary analysis of a randomized controlled trial, we included N = 36 patients with BPD in the current study. The original trial assessed the effects of a 10 session psychiatric standard treatment with or without the added the Plan Analysis and the Motive Oriented Therapeutic Relationship. We assessed the therapeutic alliance session by session (Working Alliance Inventory), metacognition at session 1 (using the Metacognitive Assessment Scale-Revised) and outcome (using residual gains on the Outcome Questionnaire-45.2 between sessions 1 and 10).

Results: A more differentiated capacity to understand the mind of the others at treatment onset predicted an increase of therapist-rated alliance over time. Therapist rated alliance was the only significant outcome predictor (B = ?0.85, R Squared = .12).

Conclusions: More differentiated metacognition predicted therapeutic alliance which in turn affected outcome, thus making metacognition a relevant therapy target early in therapy for BPD. Future studies should expand this investigation to patients with better functioning, treated with different modalities and with longer treatments.     

Self-Compassion as a Mediator in the Effect of Dispositional Mindfulness on Anxiety and Aggressiveness in College Students with Left-Behind Experience

Few studies have comprehensively explored the mechanism of the association between dispositional mindfulness and the process of internalization and externalization. Given that dispositional mindfulness can enhance the level of self-acceptance, the present study investigated the role of self-compassion in the effect of dispositional mindfulness on anxiety and aggressiveness among college students with left-behind experience (LBE). A total of 385 Chinese college students with LBE reported their level of dispositional mindfulness, anxiety symptoms, aggressiveness, and self-compassion. Dispositional mindfulness was negatively associated with anxiety and aggressiveness after controlling for gender, age, and whether they are the only child in family. Additionally, self-compassion partially mediated the link between dispositional mindfulness and anxiety, but it didn’t mediate the link between dispositional mindfulness and aggressiveness. The findings highlight the importance of dispositional mindfulness and selfcompassion on reducing internalizing and externalizing problems of college students with left-behind experience and also provide coping strategies for the intervention of this special group.     

Is there an optimal adjustment of interpretation to the patients' level of defensive functioning?

In this process-outcome study, we explored whether the therapists' Adjustment Ratio of interpretation would be predictive of the development of working alliance in brief dynamic psychotherapy (N = 39, max 40 sessions). Therapist interventions were rated in an early session (7th) and in the mid-phase of therapy (16th session). We found that, what was assumed to be an optimal Adjustment Ratio in relation to patients' defensive functioning, was associated with lower quality of working alliance, whereas what was assumed to be a poor Adjustment Ratio was associated with a more favorable alliance. The general finding was that when relatively more supportive interventions were given to patients with higher ODF, the working alliance was improved. Implications of the findings are discussed.     

Relapses in recurrent depression 1 year after psychoeducational treatment: the role of therapist adherence and competence, and the therapeutic alliance

Psychoeducation has proved to be an effective treatment method for the prevention of relapse in recurrent depression. However, little is known about the processes which could account for the effects of psychoeducational treatment. In this study, patients with recurrent depression (currently remitted) received, over a period of 8 months, 16 sessions of psychoeducational treatment, in order to prevent relapse. Therapist adherence and competence, and the therapeutic alliance, were investigated as predictors of reducing the recurrence risk in depression. Videotapes of 43 participants in a psychoeducational treatment for depression were analyzed, in order to evaluate therapist adherence and competence. Additionally, the therapeutic alliance was assessed by means of a questionnaire. One year after treatment, no associations were found between therapist adherence or competence and the risk of relapse. The patients' view of the therapeutic alliance was moderately associated with the time to relapse. However, the correlation disappeared when controlled for the number of previous depressive episodes. The latter was the most important predictor of time to relapse, explaining 15% of variance.     

Psychotherapy for social phobia: How do alliance and cognitive process interact to produce outcome?

Abstract

The purpose of this study was to ascertain whether and how alliance and specific cognitive process may interact to influence outcome. Eighty social phobic patients were randomized to 10-week residential cognitive or interpersonal therapy, conducted mostly in groups. They completed process and outcome measures weekly. The ratings were analyzed with mixed models. It was found that initial patient-rated alliance predicted the course of social anxiety throughout therapy and that this effect was indirect through the cognitive process. However, this indirect effect did not interact with treatment. There was a trend toward an indirect effect of weekly variations in alliance rated by the individual therapist through weekly variations in subsequent cognitive process on weekly variations in subsequent social anxiety. Thus, the results support a facilitative rather than an active ingredient perspective on the role of alliance.     

Therapeutic alliance,empathy, and genuineness in individual adult psychotherapy: A meta-analytic review

Objective: Alliance, empathy, and genuineness are each integral parts of the therapeutic relationship. No previous meta-analysis has explored the extent to which therapist empathy and genuineness contribute to the therapeutic alliance. Method: In this meta-analysis, a multifaceted search strategy yielded 53 studies. Forty studies reported alliance/empathy relationships, eight studies reported alliance/genuineness relationships, and five studies reported both. Results: Random effects meta-analyses revealed that therapeutic alliance was significantly related to perceptions of therapist empathy with a mean r?=?0.50 (95% CI?=?0.42, 0.57). Therapeutic alliance was also significantly related to perceptions of therapist genuineness with a mean r?=?0.59 (95% CI?=?0.45, 0.71). Tests of publication bias indicated a low likelihood of publication bias affecting the strength and direction of the results. Potential moderating variables were explored, including rater perspective, measure of therapeutic relationship variables, and client race/ethnicity. Conclusions: Therapeutic alliance has a moderate relationship with perceptions of therapist empathy and genuineness. Of note, there may be reason to believe that when rated by the same person, these constructs have significant overlap and lack discreteness. Future directions for study of the therapeutic relationship are discussed. Implications for practice are provided.     

Exploration of session process: relationship to depth and alliance

This study investigates the relationship between the Depth of elaboration, the therapeutic alliance, and dimensions of the psychotherapy process--the therapist interventions, the patient contributions, and patient/therapist patterns of interaction. Sixty psychotherapy sessions that were audio-taped and transcribed were rated by external judges by using a battery of instruments that included the Psychotherapy Process Q-Set (Jones, 1985, 2000), the Working Alliance Inventory-Observer (Horvath, 1981, 1982; Horvath & Greenberg, 1989), and the Depth Scale of Session Evaluation Questionnaire (Stiles & Snow, 1984a). The results show a significant positive correlation between Depth and therapeutic alliance, as well as between Depth, therapeutic alliance, and some variables of the therapeutic process. The findings indicate the importance of therapist interventions that focus on the patient's affects, relational patterns, and the "here and now" of the relationship in the increase of the Depth of elaboration and therapeutic alliance. The clinical implications of this study will be discussed.     

INFLUENCES OF PATIENTS’ AND THERAPISTS’ INTERPERSONAL PROBLEMS AND THERAPEUTIC ALLIANCE ON OUTCOME IN PSYCHOTHERAPY

Abstract

The aim of this study was to investigate the importance of therapists’ and patients’ interpersonal problems as well as the impact of the therapeutic alliance on symptomatic outcome in psychotherapy. Of interest were direct effects of interpersonal problems, represented through the dimensions of affiliation and control, as well as possible interaction effects between patient and therapist variables on outcome. Further hypotheses referred to therapist differences in the predictive impact of the therapeutic alliance for outcome. Outcome ratings of 1,513 psychotherapy inpatients treated by 31 psychodynamically oriented individual psychotherapists were studied. Therapists’ and patients’ interpersonal dispositions were assessed with the Inventory of Interpersonal Problems, and patients answered standardized outcome measures before and after therapy and retrospectively evaluated the therapeutic alliance at discharge. The results indicate that dominant patients profited better from their therapy and that therapists’ interpersonal disposition did not have a direct influence on outcome. The influence of the therapeutic alliance on outcome varied among the therapists. The general positive effect of therapeutic alliance on outcome was stronger for less affiliative therapists. Limitations of the study and implications of the results are discussed.     

The Art Therapy Working Alliance Inventory: the development of a measure

Two studies present the development and validation of the Art Therapy Working Alliance Inventory measure, based on Bordin’s [1979. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252–260] conceptualisation of the therapeutic working alliance. The measure captures unique aspects of the art therapy working alliance that take into account the client’s relation to the art medium in the presence of the art therapist. The measure’s reliability and validity were examined. In Study 1, 40 art therapy students, who participated in art therapeutic simulations as clients during their training programme, rated the measure in its development phase; in Study 2, 104 art therapy students completed the final questionnaire and the Working Alliance Inventory in regard to therapeutic simulations. Exploratory factor analysis revealed three main factors: perceiving the art medium as an effective therapeutic tool (Art Task); the affective and explorative experience during art-making (Art Experience); and, acceptance of the art therapist’s interventions in the art medium (Art Therapist Acceptance). Associations were found between Art Task and Art Therapist Acceptance with each of the working alliance components, as well as between Art Experience with the Bond component. Implications for practice and research are discussed.

Plain-language summary

• In verbal psychotherapy, a strong therapeutic alliance between client and therapist is necessary to achieve therapeutic goals. In art therapy, this alliance includes a third object: the art medium, comprised of art materials, artmaking and artworks.

• In this study, we developed and tested a new questionnaire for art therapy service users which measures the client-art medium alliance formed in art therapy. The new questionnaire is based on the Working Alliance Inventory, a well-known measure used in psychotherapy (Horvath & Greenberg, 1989) and is called the Art Therapy-Working Alliance Inventory.

• In order to measure the alliance between the client and the art medium, the Art Therapy-Working Alliance Inventory asks about three main areas: the client’s perception of the art medium as a therapeutic tool (Art-Task), the client’s affective experience of his/her artwork (Art Experience), and the client’s acceptance/rejection of the art-therapist’s interventions in the art medium (Art Therapist Acceptance).

• We asked 104 art therapy students to assume the role of clients in simulated art therapy sessions and then fill out the questionnaire at the end. We found a strong association between the two alliance scores; in other words, the stronger the alliance between the client and the art therapist, the stronger the alliance between the client and the art medium.

• Thus, we concluded that the Art Therapy-Working Alliance Inventory can serve as a useful tool in the research of art therapy practice.

     

Psychotherapy for social phobia: how do alliance and cognitive process interact to produce outcome?

The purpose of this study was to ascertain whether and how alliance and specific cognitive process may interact to influence outcome. Eighty social phobic patients were randomized to 10-week residential cognitive or interpersonal therapy, conducted mostly in groups. They completed process and outcome measures weekly. The ratings were analyzed with mixed models. It was found that initial patient-rated alliance predicted the course of social anxiety throughout therapy and that this effect was indirect through the cognitive process. However, this indirect effect did not interact with treatment. There was a trend toward an indirect effect of weekly variations in alliance rated by the individual therapist through weekly variations in subsequent cognitive process on weekly variations in subsequent social anxiety. Thus, the results support a facilitative rather than an active ingredient perspective on the role of alliance.