Alliance and termination status in couple therapy: A comparison of methods for assessing discrepancies

Abstract

Much of the empirical data available about therapeutic alliance and its relationship to termination status come from individual psychotherapies. We know less about therapeutic alliance in couple therapy. A unique characteristic of alliance in couple or family therapy is the possibility of discrepancies in alliance between system members. In this study we sought to demonstrate three statistical techniques: standard deviations, the intraclass correlation to assess discrepancies in alliance over time during the initial stage of couple therapy, and the use of these various measures to predict termination status using a sample of 72 couples from a university-based training clinic. Differences in partners' alliances operationalized either as categorical or continuous variables but when analyzed separately at each time point were not predictive of termination status. When multilevel modeling was used, a difference in the way the discrepancies changed over a period of time was related to termination status.     

Alliance in couple and family therapy

Couple and family therapy (CFT) is challenging because multiple interacting working alliances develop simultaneously and are heavily influenced by preexisting family dynamics. An original meta-analysis of 24 published CFT alliance-retention/outcome studies (k = 17 family and 7 couple studies; N = 1,416 clients) showed a weighted aggregate r = .26, z = 8.13 (p < .005); 95% CI = .33, .20. This small-to-medium effect size is almost identical to that reported for individual adult psychotherapy (Horvath, Del Re, Flückiger, & Symonds, this issue, pp. 9-16). Analysis of the 17 family studies (n = 1,081 clients) showed a similar average weighted effect size (r = .24; z = 6.55, p < .005; 95% CI = .30, .16), whereas the analysis of the 7 couple therapy studies (n = 335 clients) indicated r = .37; z = 6.16, p < .005; 95% CI = .48, .25. Tests of the null hypothesis of homogeneity suggested unexplained variability in the alliance-outcome association in both treatment formats. In this article we also summarize the most widely used alliance measures used in CFT research, provide an extended clinical example, and describe patient contributions to the developing alliance. Although few moderator or mediator studies have been conducted, the literature points to three important alliance-related phenomena in CFT: the frequency of "split" or "unbalanced" alliances, the importance of ensuring safety, and the need to foster a strong within-family sense of purpose about the purpose, goals, and value of conjoint treatment. We conclude with a series of therapeutic practices predicated on the research evidence.     

A comparison of methods of assessing adaptive behaviour in pre-school children with developmental disabilities

Measures of adaptive behaviour provide valuable information about the social competence of children with developmental disabilities and as such are important for decisions regarding diagnosis and school placement. This study compared the Scales of Independent Behaviour and the revised Vineland Adaptive Behaviour Scales - Survey Form in the assessment of 128 pre-school children with developmental disabilities. A factor analysis of the Vineland domain scores and Scales of Independent Behaviour cluster scores revealed one similar, significant factor, representing personal independence for both tests. The summary scores of both tests were found to correlate moderately with IQ and with the extent of integration children achieved in their subsequent school placement. Recommendations are made regarding use of the two instruments for assessing children with developmental disabilities.     

Relationship problems and mental illness: Indications for couple therapy

Relationship problems are common when a psychiatric diagnosis is present. Criticism and blame may be a typical theme. Couple oriented approaches are clearly indicated in the treatment of mental illness. In addition to improving relationships and the quality of life in the mentally ill and their spouses, interventions can make a significant impact on the outcome of the illness.     

A competency-based approach to couple and family therapy supervision

The competency-based movement continues to guide professional psychology. This has been highlighted through the establishment of essential foundational and functional competencies. The current paper focuses on the intervention competency domain and delineates its relevance within the field of couple and family therapy (CFT). We begin by providing an overview of 8 essential components of CFT: developing a systemic formulation, forging a systemic therapeutic alliance, understanding family-of-origin issues, reframing, managing negative interactions, building cohesion/intimacy/communication, restructuring/parenting, and understanding and applying evidence-based CFT models. We then provide a brief illustration of foundational and functional competencies essential to CFT. We conclude by addressing the CFT competency within an integrative approach to supervision and provide a case illustration that depicts this process. The relevance of establishing unique, evidence-based, theory-specific competency components is highlighted. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Measuring therapy adherence in Parkinson's disease: a comparison of methods

The objective of this study was to assess different methods of measuring therapy adherence in Parkinson's disease (PD). In a single centre observational study, 112 patients with idiopathic PD were randomised to a crossover trial of active monitoring (n = 69, simple tablet count and electronic monitoring), or to no monitoring (n = 43, control group). All patients completed a self report and visual analogue scale (VAS) indicating therapy intake. In the active monitoring group, 56 (81% of cases) used > or = 80% of their medication, and 13 (19% of cases) used <80%, based on electronic monitoring. Median adherence for self report was 100% (interquartile range (IQR) 100 to 100) and for VAS was 100% (IQR 95 to 100), in both active and control groups. Patients taking > or = 80% of prescribed medication had a median total adherence of 98% (IQR 93 to 101) by electronic monitoring, which was similar to that from other METHODS: self report 100%, IQR 100 to 100; VAS 100%, IQR 95 to 100; simple tablet count 98%, IQR 89 to 100. Median total adherence in patients taking <80% of medication was significantly lower by electronic monitoring (69%, IQR 44 to 74) than by other methods: self report 100%, IQR 100 to 100; VAS 100%, IQR 95 to 100; and simple tablet count 90%, IQR 78 to 100 (all p<0.0001). Sensitivities of self report (10%), VAS (17%), and simple tablet count (50%) were all low for detecting suboptimal medicine intake. Self report, VAS, and simple tablet counts are insensitive as predictors of suboptimal medicine usage in PD. How patients take their medicines influences interpretation of the therapy response and consequent management decisions, with implications for clinical trial analysis and clinical practice.     

Strategies for assessing Asperger''s syndrome: A critical review of data based methods

Asperger's syndrome has gained tremendous recognition and popularity in the last 20 years. However, controversy around the nature of the disorder, whether it is distinct from high functioning autism, and whether it can be reliably and validly diagnosed has continued throughout this period unabated. Fortunately, there has been a strong tradition of developing systematic data based methods of differential diagnosis in the autism spectrum disorders. The bulk of the effort has been in autism, but there has been moderate, yet consistent efforts to develop data based methods to diagnose Asperger's syndrome as well. The present paper provides an up to date critical review of the existing literature on the topic. Strengths, weaknesses of the research, and avenues for future efforts are discussed.     

A comparison of three scales for assessing social functioning in primary care

OBJECTIVE: Assessment of functional status is increasingly important in clinical trials and outcome research. Although several scales for assessing functioning are widely used, they vary in coverage, and direct comparisons among them are rare. Comparative information is useful in guiding selection of appropriate scales for research applications. METHOD: Results from three scales that measure functioning-the Medical Outcomes Study 36-item Short-Form Health Survey, the Social Adjustment Scale Self-Report, and the Social Adaptation Self-Evaluation Scale-were compared in a consecutively selected sample of 211 patients coming to primary care. Patients also received psychiatric assessments. RESULTS: All three scales were acceptable to patients, showed few significant correlations with demographic variables, and were able to differentiate psychiatrically ill and well patients. Correlations among scales, even among scale items that assessed similar domains of functioning, were modest. CONCLUSIONS: Although all three scales are presumed to assess functional status, their item content and coverage differ. Selection of a scale requires a review of the scale items and consideration of research priorities and the characteristics of the study group. If functional status is a critical outcome measure, use of more than one scale may be necessary.     

Evaluation of the Hamburg model of couple therapy in the treatment of low sexual desire and vaginismus. A prospective group comparison

The Hamburg model of sex therapy was evaluated in a number of studies until the beginning of the 1980s. For the “classic” sexual dysfunctions (e.g. orgasmic dysfunction, vaginismus, erectile dysfunction, and premature ejaculation), response rates of 75%–80% were reported. Later, the indication was extended to hypoactive sexual desire disorder (HSDD). However, less is known about the efficacy of the Hamburg model in the treatment of HSDD. In the present analyses, 22 pair treatments were evaluated, with the female subject suffering from either HSDD (12 pairs) or vaginismus (10 pairs). Treatments were carried out as intensive therapies (three weeks with daily sessions) between 1995 and 2011 at the Hamburg Institute for Sex Research and Forensic Psychiatry. In the statistical analyses, assessments from both therapists and patients were used and collected immediately before and after completion of treatment, as well as three months and approximately 1.5 years after the end of treatment. For vaginismus, similar results to those of previous studies were found. In contrast, catamnestic data indicated that women with HSDD showed poorer results in terms of sexual desire, satisfaction, and coitus frequency. Thus, women with HSDD may not benefit from the Hamburg model in the long run.     

Primary-school-based art therapy: A mixed methods comparison study on children’s classroom learning

ABSTRACT

Background: In the UK an estimated one in ten primary school pupils have diagnosable mental health problems which may impact their education.

Aims/context: This study examined a primary-school-based art therapy service for children experiencing social, emotional and mental health difficulties to assess the intervention’s acceptability and possible changes in classroom learning.

Methods: A mixed methods before-and-after study was conducted with 25 children in art therapy and a comparison group of 25 children per subject for reading, writing and maths attainment. A focus group with 10 teachers and interviews with 37 children were used to examine perceptions of art therapy and classroom learning.

Results: Academic attainment was similar between the art therapy and comparison children. Both groups’ learning rate resembled that of national minimum expectations. Children and teachers perceived art therapy to be helpful for engagement with classroom learning, relationships with teachers and peers, and learning time.

Conclusions: Further research is needed to develop this primary-school-based art therapy programme, assess transferability, and examine wider educational outcomes.

Implications for practice: Primary-school-based art therapy may be particularly helpful when it is perceived as: a safe place, sessions being social and fun, facilitates coping strategies, expressing, thinking and talking, as well as making artwork.

Plain-language summary

In the UK an estimated one in ten primary school pupils suffer from mental health problems, and this can affect their educational attainment. Thus, it is important that therapies help children to gain positive outcomes both in mental health and educationally.

We looked at one art therapy service, which specifically focuses on helping children to understand their own and others’ minds (metallization), within one primary school in London. Thirty-seven children referred to art therapy with social, emotional and mental health difficulties were included. Ten class teachers participated. The aims were to see if the children, and their teachers, found the approach acceptable and if there were any indications of changes in classroom learning.

There were no differences in reading, writing and maths scores between children attending art therapy and comparison children receiving usual education support. However, all the children learned at the same rate as the national minimum expectation. Art therapy may have prevented the increasing educational attainment gap that social, emotional and mental health difficulties can bring.

We held a focus group with the class teachers and interviewed the children and both reported experiencing art therapy as helpful for engagement with classroom learning, relationships with teachers and peers, and learning time. Specific aspects of art therapy which they considered helpful were: art therapy being a safe place; learning coping strategies; expressing, thinking and talking in art therapy; making artwork; and sessions being social and fun. The teachers also appreciated: advocating and sharing information; psychoeducation and collaborative work; reflecting on actions; encouraging independence; framing school as a positive place with trusted adults; working with transitions and endings.

We recommend further research, including more art therapists, schools, teachers, parents and children, to further develop and assess this approach to art therapy in primary schools.     

Thirty-minute relaxation: A comparison of some methods

Eighty subjects were recruited to participate in a variety of 30-min taped relaxation training procedures. They were randomly assigned to muscle relaxation, mental relaxation, a combination of the foregoing, or self-relaxation, half of the subjects in each condition receiving music paired with the relaxation. Relaxation effects were assessed by measuring pre- to post-treatment change on self-report inventories and EMG indices. All relaxation conditions resulted in significant change in the relaxed direction on EMG measurement and a state anxiety inventory. Music was not found to have an enhancing effect upon relaxation.     

A comparison of methods for measuring event-related potentials

Visual event-related potentials (ERPs) were recorded from 21 hyperactive children under 2 attention conditions and 4 doses of stimulant drug (methylphenidate). This data base was used to evaluate several methods of EP component measurement. These methods were (1) conventional visual peak and trough selection; (2) automatic feature extraction based on peaks; (3) automatic features extraction based on segments; (4) gross amplitude measures; (5) principal components analysis on normalized data and latency-adjusted data. No one method emerged as the best overall. Rather it is the case that different methods are best suited to different purposes, and criteria for choosing methods are outlined.     

Integrative cognitive therapy for depression: A randomized pilot comparison

This pilot study examined the efficacy of an integrative form of cognitive therapy (ICT) for depression that incorporates specific strategies for addressing alliance ruptures. Although a previous study on depression found that ICT was superior to a wait-list condition (L. G. Castonguay et al., 2004), the current study provides the 1st direct comparison between ICT and traditional cognitive therapy (CT). Twenty-two depressed adults were randomly assigned to ICT or CT (11 patients per condition), which were delivered by clinicians in training. Outcome was assessed with a specific depression measure and a global symptomatology measure. The groups were also compared on patient-perceived alliance quality and therapist empathy. Effect size estimates revealed that ICT patients evidenced greater posttreatment improvement on both outcome measures (with small to medium effects) and more clinically significant change than did CT patients. ICT patients also had higher alliance and empathy scores across treatment (with medium to large effects). The findings, albeit very preliminary, support the potential viability of ICT and the potential causal influence of the rupture-repair interventions on treatment process and outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Outcomes in couple therapy: Reduced psychiatric symptoms and improved sense of coherence

In Sweden, only a few empirical studies of couple therapy have been performed. This is the hitherto most comprehensive assessment of clinical treatment. Effectiveness of treatment is reported and compared with non-clinical ratings. Initially the couples displayed marital distress, many psychiatric symptoms, dyadic interactions characterized by high criticism and a low sense of coherence. In Sweden, couple therapy is primarily aimed to reduce marital distress and does not focus on individual disorders. It should be seen as innovative that overall psychic symptoms (Global Symptom Index, GSI) as well as depressive symptoms were reduced (more than one standard deviation) for both women and men to the extent of 50–55%. Normal values were attained by 73–78%. Of those who initially identified a low sense of coherence, 22% of the women and 37% of the men improved (more than one standard deviation). Normal values were attained by 68–70%. The treatment was relatively short, which meant that, with relatively limited treatment, it was also possible to attain relatively significant improvements in all dimensions of psychiatric symptoms.     

Outcomes in couple therapy: reduced psychiatric symptoms and improved sense of coherence

In Sweden, only a few empirical studies of couple therapy have been performed. This is the hitherto most comprehensive assessment of clinical treatment. Effectiveness of treatment is reported and compared with non-clinical ratings. Initially the couples displayed marital distress, many psychiatric symptoms, dyadic interactions characterized by high criticism and a low sense of coherence. In Sweden, couple therapy is primarily aimed to reduce marital distress and does not focus on individual disorders. It should be seen as innovative that overall psychic symptoms (Global Symptom Index, GSI) as well as depressive symptoms were reduced (more than one standard deviation) for both women and men to the extent of 50-55%. Normal values were attained by 73-78%. Of those who initially identified a low sense of coherence, 22% of the women and 37% of the men improved (more than one standard deviation). Normal values were attained by 68-70%. The treatment was relatively short, which meant that, with relatively limited treatment, it was also possible to attain relatively significant improvements in all dimensions of psychiatric symptoms.     

Aphasic speech with and without SentenceShaper: Two methods for assessing informativeness

BACKGROUND: SentenceShaper((R)) (SSR) is a computer program that is for speech what a word-processing program is for written text; it allows the user to record words and phrases, play them back, and manipulate them on-screen to build sentences and narratives. A recent study demonstrated that when listeners rated the informativeness of functional narratives produced by chronic aphasic speakers with and without the program they gave higher informativeness ratings to the language produced with the aid of the program (Bartlett, Fink, Schwartz, & Linebarger, 2007). Bartlett et al. (2007) also compared unaided (spontaneous) narratives produced before and after the aided version of the narrative was obtained. In a subset of comparisons, the sample created after was judged to be more informative; they called this "topic-specific carryover". AIMS: (1) To determine whether differences in informativeness that Bartlett et al.'s listeners perceived are also revealed by Correct Information Unit (CIU) analysis (Nicholas & Brookshire, 1993)-a well studied, objective method for measuring informativeness-and (2) to demonstrate the usefulness of CIU analysis for samples of this type. METHODS #ENTITYSTARTX00026; PROCEDURES: A modified version of the CIU analysis was applied to the speech samples obtained by Bartlett et al. (2007). They had asked five individuals with chronic aphasia to create functional narratives on two topics, under three conditions: Unaided ("U"), Aided ("SSR"), & Post-SSR Unaided ("Post-U"). Here, these samples were analysed for differences in % CIUs across conditions. Linear associations between listener judgements and CIU measures were evaluated with bivariate correlations and multiple regression analysis. OUTCOMES #ENTITYSTARTX00026; RESULTS: (1) The aided effect was confirmed: samples produced with SentenceShaper had higher % CIUs, in most cases exceeding 90%. (2) There was little CONCLUSIONS: That the percentage of CIUs was higher in SSR-aided samples than in unaided samples confirms the central finding in Bartlett et al. (2007), based on subjective judgements, and thus extends the evidence that aided effects from SentenceShaper are demonstrable across a range of measures, stimuli and participants (cf. Linebarger, Schwartz, Romania, Kohn, & Stephens, 2000). The data also attest to the effectiveness of the CIU analysis for quantifying differences in the informativeness of aphasic speech with and without SentenceShaper; and they support prior studies that have shown that CIU measures correlate with the informativeness ratings of unfamiliar listeners.