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.     

Therapists’ and clients’ ratings of real relationship,attachment, therapist self-disclosure,and treatment progress

Objective: While there has been much research on the role of the working alliance in psychotherapy, researchers only recently began investigating the role of the real relationship in treatment. Methods: In the current study on therapist and client dyads, we used actor–partner interdependence modeling (APIM) to examine associations between therapists’ and clients’ ratings of the real relationship, therapist self-disclosure, attachment, and treatment progress. APIM analyses allowed for an examination into how therapists’ and clients’ views of a particular phenomenon might affect their own ratings (actor), as well as the others’ (partner) ratings of that same phenomenon. Results: Significant negative associations between therapist self-reported attachment anxiety and avoidance and therapist-rated real relationship and treatment progress. Significant positive associations were found between client-rated real relationship and client-rated treatment progress. These results and others are discussed in the context of the literature along with implications for future research in this area.     

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.     

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.     

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.     

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.     

A qualitative and quantitative study of psychotherapists’ congruence in Singapore

Abstract

This study explores the phenomenological world of 11 Satir-based Singaporean Chinese therapists with regard to their experience of congruence. A mixed qualitative-cum-quantitative research method was used in this study. A phenomenological methodology was used to explore (a) the phenomenological world of therapists with regard to their lived experience of congruence in their personal or inner lives, (b) how this congruence is used in psychotherapy, and (c) how therapists can enhance their level of congruence. Quantitative findings include (a) significant nonparametric correlations among the intrapersonal, interpersonal, and transpersonal levels of congruence with overall congruence; (b) significant nonparametric correlation between intrapersonal congruence and interpersonal congruence; (c) significant nonparametric correlations between overall congruence and interpersonal congruence with self-esteem and life satisfaction; and (d) significant nonparametric correlations between intrapersonal congruence and self-esteem. These results may have research and clinical implications for the practice of psychotherapy.     

Addressing religion and spirituality in psychotherapy: clients’ perspectives1

This paper addresses those patients who neither complete treatment nor drop out from clinical trials but who deviate from the protocol treatment by seeking or receiving additional treatment. Psychotherapy researchers may be missing important information by withdrawing these patients from analyses or combining them with dropouts from treatment. In a multisite psychotherapy outcome study for patients with cocaine dependence, patients who deviated from protocol could be distinguished from completers and dropouts on pretreatment patient characteristics. Patients who deviated from protocol were more likely to be African American, to have higher psychiatric severity, and to have had more previous drug treatment attempts. Data indicate that there is a value in obtaining follow-up assessment after the protocol deviation and including these patients in data analysis to avoid bias in findings. Differential outcome for protocol deviation patients compared to dropouts and completers is discussed. In diesem Beitrag werden Patienten beschrieben, die in klinischen Studien weder die behandlung beenden noch abbrechen, die aber deren Einschlusskriterien nicht erfüllen, weil sie zusätzliche Behandlung erhalten oder suchen. Psychotherapieforschern gehen wichtige Informationen verloren, wenn sie diese Patienten nicht in ihre Analysen mit einbeziehen bzw. wenn sie sie als dropouts behandeln. In einer multizentrischen Untersuchung zum Psychotherapieergebnis bei kokainabhängigen Patienten konnten jene Patienten, die die Kriterien nicht erfüllten, deutlich von den anderen Gruppen im Hinblick auf Mermale vor Behandlungsbeginn differenziert werden. So waren bspw. unter den Patienten, die die Kriterien nicht erfüllten, häufiger Afro-Amerikaner; sie waren psychiatrisch auffälliger und waren im Vorfed häufiger medikamentös behandelt worden. Die Daten zeigen, dass es u. U. sinnvoll ist, diese Patienten katamnestisch mit zu untersuchen und sie ggf. in die Datenanalyse mit einzubeziehen, um Fehler zu vermeiden. Differentielle Therapieergebnisse für die Gruppe von Patienten, die die Kriterien nicht erfüllten, werden im Vergleich zu den dropouts und den Patienten, die die Therapie regulär beendeten, diskutiert. Cet article vise les patients qui ne terminent pas le traitement sans l'abndonner, mais qui dévient du protocole du traitement en cherchant ou en recevant une thérapie additionnelle. Les chercheurs en psychothérapie risquent de rater des informations importantes en retirant ces patients de l'analyse ou en les mêlant aux abandons du traitement. Dans une étude multicentrée au sujet des résultats de psychothérapies pour des patients dépendants à la cocaine, les patients déviant du protocole ont pu être différenciés des patients terminants et des abandons sur la base de caractéristiques relevés avant le traitement. Les patients déviant du protocole avaient plus de chances d'être Afro-Américains, d'être atteints plus gravement sur le plan psychiatrique, et d'avoir traversé déjà plusieurs cures précédentes. Les données indiquent qu'il est valable d'obtenir une évaluation suivie après la déviation du protocole et d'inclure ces patients dans l'analyse des données pour éviter un biais dans les résultats. Les résultats différentiels des des patients déviants du protocole par rapport à ceux qui terminent et aux abandons sont discutées. Este trabjo se refiere a pacientes que no completaron el tratamiento ni abandonaron los intentos clínicos pero que se desviaron del protocolo del tratamiento por buscar o recibir tratamiento adicional. os investigdores en psicoterapia pueden perder importante informatión si retiran a estos pacientes del anélisis o los mezclan con los que abandonaron el tratamienot. En un estudio multicéntrico sobre resultados de la psicoterapia en pacientes con dependencia cocaínca, se pudo diferenciar los que se desviaron del protocolo de los que completaron el tratamiento y de los que lo abandondaron, por medio del use de uso de características obtenidas ante del al tratamiento. Los que se desviaron del protocolo pertenecían en mayor grado al grupo afro-americano; padecín mayor severidad psiquiétrica y habían intentado previamente més tratamientos por drogas. Los datos indican que, para evitar sesgos en los resultados, sn útiles tanto los seguimientos posteriores a la desviación del protocolo como la inclusión de estos pacientes en los anélisis de datos. Se comparan los resultados de los pacientes que se desviaron del protocolo con los que lo abandonaron y los que lo completaron.     

Structural changes in counselor trainee intention use and clients’ session evaluation

Abstract

Profile analysis and Pathfinder Network Analysis (Schvaneveldt, 1990) were used to examine changes in procedural knowledge and procedural structural knowledge, respectively, of 32 counselor trainees and to examine convergence in their procedural knowledge and procedural structural knowledge with the procedural knowledge structure of 42 experienced counselors. Procedural knowledge was derived from the pattern and level of intention use (Hill & O'Grady, 1985) in a pre- and posttraining counseling session. Procedural structural knowledge was derived from the co-occurrence of the intentions used in these two counseling sessions. Only counselor trainees’ structure of intention use changed from pre- to posttraining, becoming more similar to the structure of intention use of the experienced counselors. At both pre- and posttraining, when trainees’ structure of intention use was more similar to that of experienced counselors, their clients rated counseling sessions as smoother (pre- and posttraining) and deeper (posttraining only). The use of knowledge structures as a criterion for assessing the effectiveness of counseling skills training is discussed.     

The role of cultural beliefs and expectations in the treatment process: clients’ reflections following individual psychotherapy

Qualitative data acquired within the recent Czech part of the independent, multi-site collaborative research project Corrective Experiences are the core basis of this paper. Eight post-treatment interviews with clients of individual therapies were analysed with a special focus on the role of cultural beliefs and cultural expectations in the clients’ change of interpersonal attitudes. The methodology of this research is based on in-depth interviews providing data on significant shifts or changes in attitudes toward relationships after the end of therapy. All clients completed their therapeutic treatments prior to the interviews. We monitored the experiences of our participants in the following significant domains: first, how they perceive the aspect of the self and others, including relationships that had been modified, and second, what they perceive as corrective experiences within as well as outside of therapy and in interactions with others. These data were then analysed within the Czech cultural context with the intention of understanding the dynamics of clients’ relationships and the role of cultural knowledge in the psychotherapeutic treatment.     

Caregiving spouses’ attachment orientations and the physical and psychological health of individuals with Alzheimer's disease

Objective: Attachment theory is a useful framework for understanding how caregiving dyads regulate emotions and maintain feelings of security in reaction to a loved one's chronic illness. In this study we examined the extent to which the attachment orientations (anxiety and avoidance) of persons with Alzheimer's disease (AD) and their spousal caregivers were associated with each partner's report of the physical and psychological health symptoms of the person with AD.

Method: Fifty-eight individuals with AD and their spousal caregivers each completed a 12-item self-report measure of trait attachment orientation and rated the physical and psychological health symptoms of the person with AD over the past two weeks. Data from the persons with AD were used after determining that they were able to provide reliable responses.

Results: As predicted, individuals with AD who were high in anxious attachment self-reported more physical and psychological symptoms, particularly when their caregivers were high in anxious attachment. Also, caregivers perceived more physical symptoms in individuals with AD who were high in avoidant attachment.

Conclusion: This study highlights the importance of considering the attachment security of both caregivers and persons with AD when considering how each partner views the psychological and physical health symptoms of the person with AD. Our results have implications for providing care-recipients and caregivers with improved, tailored care.     

How high level of anxiety in Panic Disorder can interfere in working memory? A computer simulation and electrophysiological investigation

Panic disorder (PD) is characterized by repeated and unexpected attacks of intense anxiety, which are not restricted to a determined situation or circumstance. The coherence function has been used to investigate the communication among brain structures through the quantitative EEG (qEEG). The objective of this study is to analyze if there is a difference in frontoparietal gamma coherence (GC) between panic disorder patients (PDP) and healthy controls (HC) during the Visual oddball paradigm; and verify if high levels of anxiety (produced by a computer simulation) affect PDP's working memory. Nine PDP (9 female with average age of 48.8, SD: 11.16) and ten HC (1 male and 9 female with average age of 38.2, SD: 13.69) were enrolled in this study. The subjects performed the visual oddball paradigm simultaneously to the EEG record before and after the presentation of computer simulation (CS). A two-way ANOVA was applied to analyze the factors Group and the Moment for each pair of electrodes separately, and another one to analyze the reaction time variable. We verified a F3-P3 GC increased after the CS movie, demonstrating the left hemisphere participation during the anxiety processing. The greater GC in HC observed in the frontal and parietal areas (P3-Pz, F4-F8 and Fp2-F4) points to the participation of these areas with the expected behavior. The greater GC in PDP for F7-F3 and F4-P4 pairs of electrodes assumes that it produces a prejudicial “noise” during information processing, and can be associated to interference on the communication between frontal and parietal areas. This “noise” during information processing is related to PD symptoms, which should be better known in order to develop effective treatment strategies.     

Influence of anxiety and alexithymia on brain activations associated with the perception of others’ pain in autism

The circumstances under which empathy is altered in ASD remain unclear, as previous studies did not systematically find differences in brain activation between ASD and controls in empathy-eliciting paradigms, and did not always monitor whether differences were primarily due to ASD “per se”, or to conditions overlapping with ASD, such as alexithymia and anxiety. Here, we collected fMRI data from 47 participants (22 ASD) viewing pictures depicting hands and feet of unknown others in painful, disgusting, or neutral situations. We computed brain activity for painful and disgusting stimuli (vs. neutral) in whole brain and in regions of interest among the brain areas typically activated during the perception of nociceptive stimuli. Group differences in brain activation disappeared when either alexithymia or anxiety – both elevated in the ASD group – were controlled for. Regression analyses indicated that the influence of symptoms was mainly shared between autistic symptomatology, alexithymia and anxiety or driven by unique contributions from alexithymia or anxiety. Our results suggest that affective empathy may be affected in ASD, but that this association is complex. The respective contribution of alexithymia and anxiety to decreased affective empathy of people with ASD may be due to the association of those psychiatric conditions with reduced motor resonance/Theory of Mind.     

Mom’s diet matters: Maternal prebiotic intake in mice reduces anxiety and alters brain gene expression and the fecal microbiome in offspring

Compelling evidence links enteric microbes to brain function and behavior. Galacto-oligosaccharide prebiotics have been shown to modulate the composition of gut flora and induce metabolic, neurochemical, and behavioral changes in adult rodents. Despite the brain being most susceptible to environmental factors, such as nutrients and toxins, during the earliest stages of development, it is unknown whether maternal prebiotic supplementation during gestation and lactation influences the offspring gut microbiome, brain, or behavior. The aim of this study was to test whether maternal galacto-oligosaccharide intake during pregnancy and lactation alters the brain and behavior in naïve and endotoxin-challenged offspring.CD1 female mice received either normal drinking water or water supplemented with Bimuno® galacto-oligosaccharides (B-GOS) during gestation and suckling. Offspring behavior was tested at weaning age or adulthood, and a cross-foster design was employed in a separate cohort to differentiate between effects of prenatal and postnatal maternal B-GOS intake. Lipopolysaccharide was also administered to pups at postnatal day 9 to determine whether maternal B-GOS influences the neurobiological and behavioral effects of a neonatal pro-inflammatory challenge in adulthood. Fecal microbiome composition and metabolites were analyzed to explore potential relationships between the maternal microbiome, the offspring gut microbiome, and the offspring brain and behavior.Maternal B-GOS supplementation increased exploratory behavior and reduced expression of hippocampal glutamate receptor genes in young, weaning-age offspring. In addition, postnatal, but not prenatal, B-GOS supplementation increased fecal butyrate and propionate levels. Finally, in adult offspring, perinatal B-GOS intake increased cortical glutamate receptor subunits in females, increased social preference, and reduced anxiety. We provide novel and comprehensive evidence for the influence of maternal prebiotic intake on offspring behavior, brain gene expression, and gut microbiome composition in mice.     

Factors influencing the person–carer relationship in people with anxiety and dementia

Objective: The relationship between people with dementia and their carers is complex and has a significant impact on the dementia experience. The aim of this current study was to determine (1) which factors are associated with the quality of the patient–carer relationship and (2) whether these differ between the two perspectives.

Method: Participants (people with dementia and their carers) were taken from a randomised controlled trial of cognitive behaviour therapy for anxiety in dementia. The quality of the relationship from both perspectives, anxiety and depression in both parties; and the quality of life, neuropsychiatric symptoms and cognitive functioning in people with dementia was examined at three time points (baseline, 15 weeks and 6 months).

Results: There were 127 observations from 50 dyads (100 individuals) across the three time points. Factors significantly related to quality of relationship from the person with dementia's perspective were their own aggression, agitation, irritability, depression, anxiety and quality of life. Factors significantly associated with quality of relationship from the carer's perspective were their own anxiety and depression, and the depression, irritability, behavioural disturbances and quality of life of the person with dementia. People with dementia generally rated the quality of relationship higher, irrespective of level of dementia, depression or anxiety.

Conclusion: This study is novel in that it provides a valuable insight into the impact of mental health on relationship quality for both members of the dyad. The findings emphasise the importance of providing interventions which target mood for both parties, and behavioural problems for people with dementia.