Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations.     

The therapeutic alliance in couples and family therapy

The therapeutic alliance is central to couples and family therapy. Although the formal concept of therapeutic alliance has not been used widely within the family therapy field, virtually every prominent clinical theorist has addressed the importance of establishing and maintaining a positive therapeutic relationship with the family. The alliance in couples and family treatment differs from the alliance in individual psychotherapy in that the couples and family therapist must establish and maintain multiple alliances. They also must adopt a conceptual framework that accounts for the interactions within triangles or three-person systems, recognize the influence of the system operating on him or her, and appreciate how different models of family therapy define the position of the therapist in relation to the couple or family. An integrative review of the therapeutic alliance in couples and family therapy is followed by a discussion of problems in the therapeutic relationship. Two general clinical strategies for managing difficulties in the alliance then are illustrated through case vignettes.     

Banter in psychotherapy: Relationship to treatment type,therapeutic alliance,and therapy outcome

Introduction

The use of humor in psychotherapy is widely considered to improve therapy outcomes and typically depends on context, patient sensitivity, and the therapist's humor style. Different types of humor may impact treatment type, therapeutic alliance, and therapy outcome; however, evidence from psychotherapy sessions on the role of banter has been sparse to date. Therefore, the study aims to examine banter in a secondary analysis of psychotherapy sessions.

Method

The sample consisted of 68 depressed outpatients treated with one of three treatment types: psychoanalytic therapy (PA), psychodynamic therapy (PD), and cognitive-behavioral therapy (CBT). Banter and therapeutic alliance were rated for therapy sessions taken from the middle phase of treatment, outcome was assessed at the end of treatment.

Results

The main findings were (1) clinical examples of banter in psychotherapy were found in 62 from 68 sessions, (2) significantly more bantering in the main bantering category of facilitation for CBT sessions as compared to other treatment types, (3) facilitative banter as a significant predictor for the positive introject, (4) a significant correlation between bantering and bond between therapist and client. Furthermore, based on these results, psychometric properties of the Klagenfurt Bantering Instrument (KBI) are reported.

Conclusion

From a bantering perspective, this study emphasizes the need to consider session context, client response, and sarcastic markers when categorizing negative banter using the KBI.     

Youth versus parent working alliance in usual clinical care: distinctive associations with retention, satisfaction, and treatment outcome.

We investigated associations between both youth-therapist and parent-therapist alliances and retention, satisfaction, and symptom improvement among 65 youth and their parents receiving usual community-based outpatient mental health services. Parent (but not youth) alliance was significantly related to more frequent family participation, less frequent cancellations and no-shows, and greater therapist concurrence with termination decision. In contrast, youth (but not parent) alliance was significantly related to both youth and parent reports of symptom improvement. Youth and parent alliance were each significantly related to their satisfaction with services. Findings suggest that youth and parent alliance may play important but distinctive roles in the processes and outcomes of usual clinical care.     

Social support and treatment outcome in behavioral family therapy for child conduct problems.

This study assessed the role of social support in the outcome of child management training (CMT) for single parents of conduct problem children and assessed the impact of adjunctive ally support training (AST) on treatment outcome. Single parents (N = 22) with a child diagnosed as oppositional or conduct-disordered received CMT or CMT plus AST. Each group received the same 6-week parent training program and the AST group received an extra social support intervention. Measures of parent behavior, child deviance, social support (SS), and parental depression were obtained at pre- and posttreatment and at 6-month follow-up. Both groups improved, and changes maintained at follow-up. AST produced no extra gains. Responders from either group were more likely than nonresponders to report high levels of SS from friends. Results emphasize the importance of SS and the difficulty of incorporating changes in SS into treatment programs.     

Therapeutic alliance and outcome in routine psychiatric out‐patient treatment: Patient factors and outcome

Objective. This study investigated the importance of the therapeutic alliance in a routine psychiatric out‐patient unit regarding treatment outcome and the influence of patient factors. Design. The study had a naturalistic and longitudinal design where the treatments the patient received were determined by the normal routines at the unit and were performed by a variety of staff representative of a psychiatric out‐patient unit. Method. Newly admitted patients were diagnosed according to the International Classification of Diseases – 10th Revision and completed questionnaires regarding the therapeutic alliance, symptoms, and interpersonal problems at the beginning and termination of their treatment (N=76). The time limit for the termination assessments was set at 18 months. Results. The therapeutic alliance at the beginning of treatment did not correlate with outcome, however, at the end of the treatment the alliance significantly explained about 15% of the variance of the outcome (global severity index). An improvement of the alliance during the treatment significantly correlated with most of the outcome variables. The relation of the alliance to outcome was equal among the different diagnosis groups and treatment forms. Conclusion. The results showed that the therapeutic alliance is an important variable for treatment outcome in routine psychiatric treatment, and improving the therapeutic alliance may be one of the most important factors for increasing the total effectiveness of a treatment unit.     

Patient expectations and therapeutic alliance as predictors of outcome in group cognitive-behavioral therapy for insomnia

Despite growing evidence for the efficacy of cognitive-behavioral therapy for insomnia (CBT-I), few data exist on the relation between process and outcome for this treatment. Drawing on interpersonal theory and the broader psychotherapy literature, this study examined the contribution of patient expectations and the therapeutic alliance to outcomes in group CBT-I. For patients with low early treatment expectations for improvement, those perceiving the therapist as higher in affiliation had greater reduction in sleep problems. Perceiving the therapist as critically confrontive was generally associated with less treatment satisfaction, and particularly so for those individuals who came to treatment with high expectations for improvement. Critical confrontation also differentiated dropouts from continuers, with dropouts experiencing their therapist as more critically confrontive.     

Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression

Prior analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program demonstrated that perfectionism was negatively related to outcome, whereas both the patient's perception of the quality of the therapeutic relationship and the patient contribution to the therapeutic alliance were positively related to outcome across treatment conditions (S. J. Blatt, D. C. Zuroff, D. M. Quinlan, & P. A. Pilkonis, 1996; J. L. Krupnick et al., 1996). New analyses examining the relations among perfectionism, perceived relationship quality, and the therapeutic alliance demonstrated that (a) the patient contribution to the alliance and the perceived quality of the therapeutic relationship were independent predictors of outcome, (b) perfectionistic patients showed smaller increases in the Patient Alliance factor over the course of treatment, and (c) the negative relation between perfectionism and outcome was explained (mediated) by perfectionistic patients' failure to develop stronger therapeutic alliances.     

Therapist effects on outcome and alliance in inpatient psychotherapy

As an addition to the ongoing discussion concerning the magnitude of therapist effects on outcome in psychotherapy, we investigated therapist variability in a large inpatient psychotherapy sample. We included global symptomatic outcome (Global Severity Index of the Symptom Checklist-90 Revised [SCL-90-R]; German version, Franke, 1995) and alliance (Helping Alliance Questionnaire; German version, Bassler, Potratz & Krauthauser, 1995) ratings of 2554 inpatients who were treated by 50 psychotherapists. Multilevel regression analyses (HLM; Raudenbush, Bryk, Cheong, & Congdon, 2004) were used for analyses. Overall, therapists accounted for a much greater variability on alliance (33%) than on outcome (3%). Therapists were differentially effective with regard to their patients' symptom severity at the beginning of treatment, and therapists differed in the degree that a positive alliance was associated with therapeutic outcome. The relatively small therapist effect on outcome is attributed to compensatory mechanisms in the specific context of inpatient therapy.     

Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder

This study examined the related contributions of the therapeutic alliance and negative mood regulation to the outcome of a 2-phase treatment for childhood abuse-related posttraumatic stress disorder (PTSD). Phase 1 focused on stabilization and preparatory skills building, whereas Phase 2 was comprised primarily of imaginal exposure to traumatic memories. Hierarchical regression analyses indicated the strength of the therapeutic alliance established early in treatment reliably predicted improvement in PTSD symptoms at posttreatment. Furthermore, this relationship was mediated by participants' improved capacity to regulate negative mood states in the context of Phase 2 exposure therapy. In the treatment of childhood abuse-related PTSD, the therapeutic alliance and the mediating influence of emotion regulation capacity appear to have significant roles in successful outcome.     

Drug therapy: alliance and compliance

The non-chemical aspects of prescribing psychotropic drugs are discussed as they embody and illuminate various aspects of the physician-patient relationship. Inclusion of prescribing phenomena within the framework of the therapeutic exploration, and maintenance of an alliance that permits “participant prescribing,” enhance the value of prescribing in the overall therapy program.     

The relationship between patient suitability,therapeutic alliance,homework compliance and outcome in cognitive therapy for psychosis

Objective. This paper examines the relationships between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive–behaviour therapy (CBT) for psychosis. Method. 29 patient and therapist dyads completed patient and therapist versions of the California Psychotherapeutic Alliance Scale (CALPAS) at session 3 and 21 at session 9. The level of patient homework compliance was rated by therapist and patient, using visual analogue scales, at therapy sessions 3 (29 dyads) and 9 (20 dyads). The Positive and Negative Symptoms of Schizophrenia (PANSS) scale was used to measure psychotic symptoms pre‐ and post‐treatment. Patient suitability for the treatment was measured at session 3, using the Suitability for Short‐Term Cognitive Therapy Scale. Results. Only two of the specific hypotheses were supported. There was no significant agreement between patients and therapists on the quality of the therapeutic alliance at session 3, but by session 9 two (patient commitment and working strategy consensus) of the four sub‐scales were significantly associated, although there was little evidence that the quality improved over time. Lower patient suitability and insight at session three predicted a lower therapeutic alliance. Therapeutic alliance predicted level of homework compliance. The only significant predictor of outcome was the PANSS positive symptoms sub‐scale pre‐treatment score. Conclusions. These results suggest that patients who experience psychotic symptoms can be successfully engaged early in therapy as can those with affective disorders but that therapeutic alliance may not have a direct effect on outcome. Copyright © 2006 John Wiley & Sons, Ltd.     

Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: a study of process and outcome

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.     

Treatment alliance and its association with family functioning, adherence, and medical outcome in adolescents with severe, chronic asthma.

OBJECTIVE: To examine the concept of treatment alliance in the care of adolescents with asthma. METHODS: Measures of treatment alliance were obtained from 60 adolescents with severe, chronic asthma admitted to a tertiary care facility, their parents, and their asthma specialists at the referral center. Associations were examined between the alliance measures and multimeasure, multiagent data concerning family functioning and asthma treatment adherence and outcome. RESULTS: Physicians' reports of treatment alliance were associated with concurrent family functioning and asthma medication adherence, as well as with asthma treatment adherence and outcome in the year after the stay at the asthma center. CONCLUSIONS: As emphasized in the recently revised Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (NHLBI, 1997), the ability of children with asthma, their parents, and their physician to create a positive partnership, or treatment alliance, appears to have an important role in optimal asthma management.     

Pretreatment social relations, therapeutic alliance, and improvements in parenting practices in parent management training

The authors examined the parent-therapist alliance in parent management training for children (N = 218; 53 girls and 165 boys, ages 2-14) referred clinically for oppositional, aggressive, and antisocial behavior. The interrelations of pretreatment parent social relationships, the parent-therapist alliance over the course of treatment, and improvements in parenting practices at the end of treatment were evaluated by different raters. As expected, the better the quality of the parent-therapist alliance, the greater the improvements in parenting practices by the end of treatment. Social relations of the parents prior to treatment were associated with the parent-therapist alliance during treatment and parental improvements at the end of treatment. The relation between the therapeutic alliance and improvement in parenting practices was partially explained by pretreatment parent social relations.     

Group cohesion and working alliance: prediction of treatment outcome in cardiac patients receiving cognitive behavioral group psychotherapy

BACKGROUND: Various definitions of both group cohesion and working alliance are used in theories on group psychotherapy, making the study of their relative contribution to the treatment outcome difficult. In this study, two different, nonoverlapping questionnaires were used to explore the relationship between group cohesion, working alliance and treatment outcome in a time-limited, structured cognitive behavioral group psychotherapy aiming at the reduction of coronary risk factors. METHODS: After having undergone percutaneous transluminal coronary angioplasty, 42 patients were treated with the aim to reduce exhaustion, anxiety, hostility and depression. The newly developed Group Cohesion Questionnaire (GCQ) and the Helping Alliance Questionnaire (HAQ-II, measuring the bond between individual patients and the group psychotherapist) were administered after the fifth and tenth treatment session. Exhaustion, quality of life, anxiety, blood pressure and heart rate were measured before and after treatment. To test the relationship between the GCQ, the HAQ-II and outcome variables, Pearson Product-Moment correlations and hierarchical regression was applied. RESULTS: Principal Component Analysis of the GCQ yielded two dimensions, the bond with the group as a whole and the bond with other group members. Hierarchical regression showed that both the bond with other group members and working alliance contributed significantly and independently to the prediction of posttreatment systolic and diastolic blood pressure as well as posttreatment quality of life (confidence). CONCLUSIONS: Conceptually and empirically, group cohesion and the working alliance may be considered to represent different relationships in a psychotherapy group, contributing in different ways to the treatment outcome in cardiac patients receiving cognitive behavioral group psychotherapy.     

The therapeutic alliance and family psychoeducation in the treatment of schizophrenia: an exploratory prospective change process study

Although family psychoeducation has been shown to be highly efficacious in the treatment of schizophrenia, the mechanisms underlying the treatment's success are poorly understood. The therapeutic alliance in behavioral family management (BFM) was examined to determine whether the alliance plays a role in the efficacy of this treatment. One early BFM session (mean session = 6.5) involving 28 schizophrenia patients and their relatives who participated in the National Institute of Mental Health's Treatment Strategies in Schizophrenia study was coded using the System for Observing Family Therapy Alliances. Results indicated that when relatives developed a positive therapeutic alliance, patients were less likely to show prodromal signs of relapse and be rehospitalized over a 2-year follow-up period. When patients developed a positive alliance, relatives became less rejecting and were less likely to feel burdened over a 2-year period. The data suggest that the development of a positive therapeutic alliance within family psychoeducation may play an important role in preventing the escalation of psychotic symptoms and improving family relationships. (PsycINFO Database Record (c) 2008 APA, all rights reserved).     

The therapist-parent alliance in family-based therapy for adolescents

This article describes procedures for developing a therapeutic alliance with a parent within the context of family therapy for adolescents. After an overview of the general clinical model, specific themes and interventions are described that provide a map to facilitate this process. Following Bordin's (1979) model, alliance is conceptualized in three parts: bonds, goals, and tasks. The bond phase consists of the therapist showing empathy and understanding toward the parent and the parent developing empathy toward their own life struggles. The goal phase consists of defining parent-child relationship building as a primary focus of treatment. The task phase consists of preparing parents to better communicate with their adolescent. These phases can occur sequentially within a single session with a parent alone. The alliance building session sets the foundation for parent-adolescent conflict resolution leading to reattachment in future sessions.