Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only.     

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.     

Personality disorder and early therapeutic alliance in two time-limited therapies

Abstract

This study examined the relationship of pre-treatment personality disorder diagnosis to the quality of early therapeutic alliance in 145 patients randomly assigned to either cognitive behavioral therapy or brief relational therapy. The pre-treatment diagnosis was established by DSM-IV (SCID) and Wisconsin Personality Inventory. Quality of the alliance was assessed by patient and therapist reports using the 12-item Working Alliance Inventory, Session Evaluation Questionnaire, and direct questions of ruptures. Results indicated that pre-treatment personality disorder as determined by SCID predicted no variables of early psychotherapy process. Factor scores yielded from a PCA of the WISPI indicated that high impulsivity, dysregulation, and lability were associated with lower patient and therapist ratings of session depth of exploration and higher patient ratings of rupture intensity.     

Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

BackgroundThis paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis.MethodsAll clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5 months, 9 months and 18 months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy.ResultsAt baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point.ConclusionsFindings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.     

Client attachment orientations,working alliances,and responses to therapy: A psychology training clinic study

Abstract

The authors examined the associations between client attachment orientations, working alliance, and progress in therapy. Ninety-five clients at two university-based training clinics completed measures of adult attachment, attachment to therapist, and working alliance immediately preceding the third counseling session with therapists-in-training. A standardized measure of progress in therapy was administered at intake, third counseling session, and termination. Hierarchical linear modeling findings indicated that stronger working alliances and secure attachment to therapist were significantly associated with greater reductions in client distress over time. Higher levels of adult attachment anxiety were significantly associated with greater distress ratings at the outset of treatment. Directions for future research and suggestions for developing therapeutic relationships in the context of specific client attachment orientations are discussed.     

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

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

Youth working alliance: a core clinical construct in need of empirical maturity

The therapeutic alliance has long been recognized as an important component of successful psychotherapy for adults; research has established robust links to outcome. Until recently, however, research on the alliance between youth and their therapists has been sparse. The present review synthesizes the existing findings regarding the youth alliance and utilizes the adult alliance literature and the child and adolescent developmental literatures to suggest future avenues of research. Weak alliance was found to predict premature termination, and strong alliance predicted symptom reduction, with some support for differential effects of the youth-therapist and parent-therapist alliances. In addition, the youth alliance is moderated by several patient and therapist characteristics, including the particular problems of patients and the interpersonal skills of therapists. The field has yet to coalesce around a single definition of the youth alliance, however, making it difficult to assess research results. Adult models of the alliance continue to be used heuristically despite some evidence that the alliance operates differently for youth. Tightening the operational definition of the youth alliance and addressing methodological issues will be essential in future efforts to understand how the alliance develops and what role it may play in the treatment process for youth.     

Patient characteristics and the therapist as predictors of depressed patients’ outcome expectation over time: A multilevel analysis

Objective: Although there is an established link between patients’ early positive outcome expectation for and their actual improvement from therapy, there is little research on patients’ change in outcome expectation across therapy and both patient and therapist correlates of early outcome expectation level and change. The present study examined: (i) the overall trajectory of change in patients’ outcome expectation through cognitive-behavioral therapy (CBT) for depression; (ii) patient characteristics as predictors of both initial outcome expectation and change in outcome expectation; and (iii) between-therapist effects in outcome expectation change. Method: Depressed patients (N?=?143) received a brief course of CBT. Outcome expectation was measured at screening, pretreatment, session 7, and session 14. Results: Outcome expectation linearly increased from screening to session 14. When controlling for other patient characteristics at intake, having previous depressive episodes was negatively associated with initial outcome expectation and higher well-being was positively associated with initial outcome expectation. When controlling for early alliance and early symptom change, outcome expectation change was predicted by previous depressive episodes. Finally, therapist effects emerged in outcome expectation over time. Conclusions: Various depressed patients’ characteristics predict initial outcome expectation level and change, with significant between-therapists’ differences related to outcome expectation change.     

Interpersonal predictors of early therapeutic alliance in a transdiagnostic cognitive-behavioral treatment for adolescents with anxiety and depression

The importance of therapeutic alliance in predicting treatment success is well established, but less is known about client characteristics that predict alliance. This study examined alliance predictors in adolescents with anxiety and/or depressive disorders (n=31) who received a transdiagnostic cognitive-behavioral treatment, the Unified Protocol for the Treatment of Emotional Disorders in Youth (Ehrenreich, Buzzella, Trosper, Bennett, & Barlow, 2008) in the context of a larger randomized controlled trial. Alliance was assessed at session three by therapists, clients, and independent observers. Results indicated that alliance ratings across the three informant perspectives were significantly associated with one another, but that pretreatment interpersonal variables (e.g., social support, attachment security, and social functioning in current family and peer relationships) were differentially associated with varying informant perspectives. Adolescent and observer ratings of alliance were both predicted by adolescent self-reports on measures reflecting how they perceive their interpersonal relationships. In addition, adolescent-reported symptom severity at pretreatment predicted observer ratings of alliance such that adolescents who indicated greater anxiety and depressive symptoms were rated as having stronger early alliances by independent observers. Therapists perceived having weaker early alliances with adolescents evidencing clinically significant depression at intake as compared with adolescents diagnosed with anxiety disorders alone. Future research is needed to examine whether identification of relevant interpersonal factors at intake can help improve initial therapeutic engagement and resulting outcomes for the psychosocial treatment of adolescents with anxiety and depressive disorders.     

Relationships among patient hostility,anger expression,depression, and the working alliance in a work hardening program

Hostility, anger expression, and depression may adversely affect the response of chronic pain patients to pain or functional restoration programs by hampering the development of good working alliances between patients and physical or occupational therapists. Measures of hostility, anger expression, and depression and the Working Alliance Inventory (WAI) were completed by 71 patients with chronic pain (stemming from work-related injuries) prior to starting a “work hardening” program. The physical or occupational therapist acting as any given patient's “program manager” completed the WAI, as well. Hostility and anger expression were correlated negatively only with patient ratings of the working alliance. Therapist ratings were predicted by the interaction of patient anger expression and depression, such that therapists reported their poorest alliances with patients who were both depressed and expressed anger. Results imply that hostility and the propensity to express anger may diminish a pain patient's capacity to foster a collaborative relationship with physical or occupational therapists, while therapists may readily become alienated from depressed and irritable patients. Center for Medical Psychology Healthsouth The authors wish to thank the physical and occupational therapists and staff of the Healthsouth Industrial Rehabilitation Centers at Avondale Avenue in Chicago. IL, and in Oak Lawn. IL, for facilitating the conduct of this study.     

Patient Attachment Orientation and the Early Working Alliance-A Study of Patient and Therapist Reports of Alliance Quality and Ruptures

This study investigated the relationship between attachment orientation in adult patients and the early therapeutic alliance. Attachment was measured by self-report following the first session of therapy. The alliance was studied using patient and therapist ratings of its quality and reports of ruptures following early sessions. The sample comprised 30 clinical psychology outpatients treated by 11 experienced therapists. Correlation and multiple regression statistics provided partial support for the hypothesized relationships between attachment orientation and reports of alliance quality and ruptures. In line with predictions, fearful attachment was associated with lower alliance ratings (significantly with patient ratings at sessions 3 and 5 and therapist ratings at session 2) and secure attachment was associated with higher alliance ratings (significantly with therapist ratings at session 5). Preoccupied attachment and dismissing attachment were associated with improvement in alliance ratings over time, although there was some question about the reliability of these findings. Additionally, the frequency of rupture reporting varied with attachment orientation. Preoccupied attachment was associated with more frequent reports of ruptures and dismissing attachment was associated with fewer reports of ruptures. Implications for clinical understanding and future research are discussed.     

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.     

Client attachment to therapist: Relation to client personality and symptomatology, and their contributions to the therapeutic alliance

This study examined the relation of client attachment to the therapist to diverse facets of the therapeutic alliance, client personality, and psychopathological symptoms, as well as the relative importance of therapeutic attachments, personality, and symptomatology in predicting the alliance. Eighty clients in ongoing therapy completed measures of client attachment to therapist (CATS), personality (6FPQ), psychopathological symptoms (BSI), and therapeutic alliance (WAI-Short, CALPAS, HAQ). Secure and Avoidant-Fearful attachment to the therapist correlated positively and negatively, respectively, with total and subscale alliance scores. Preoccupied-Merger therapeutic attachment was unrelated to the alliance. Exploratory analyses suggested however that the relationship between Preoccupied-Merger attachment and the alliance was moderated by the extent to which clients were distressed. Clients' therapeutic attachments were unrelated to basic personality dimensions. Preoccupied-Merger attachment to the therapist correlated significantly with several symptom dimensions. Clients' therapeutic attachments emerged as superior and more consistent predictors, relative to client personality and symptomatology, of the therapeutic alliance.     

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.     

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.     

Respective Contributions of Therapist and Client Adult Attachment Orientations to the Development of the Early Working Alliance: A Preliminary Growth Modeling Study

The authors investigated the temporal relationship between client and therapist attachment orientations and early working alliance. Attachment was measured by self-report after the 1st session of therapy. The working alliance ratings were completed after the 1st, 4th, and 7th therapy sessions. Hierarchical linear modeling results indicated that anxiously attached therapists had a significant positive effect on the client working alliances after the 1st session but significant negative effects over time. No other therapist or client attachment variables or related interactions had a significant effect on client working alliance ratings. Results also indicated that time was a significant positive predictor of client working alliance ratings.     

Connection between patient and therapist and therapist's competence in schema-focused therapy of personality problems

Abstract

The aim of this study was to examine whether the connection between patient and therapist, therapist competence, and the interaction between connection and competence, measured in the early process of schema-focused therapy of personality problems, influenced treatment outcome. Connection is a rater-observed measure of the intimacy and mutual engagement between patient and therapist that appears to represent an easily observable aspect of the therapeutic alliance. The sample consisted of 35 patients with panic disorder and/or agoraphobia and DSM–IV Cluster C personality traits who participated in an 11-week inpatient program. Patients and an expert observer rated the schema-focused individual therapy sessions. Better observer-rated connection in the first session predicted greater across-session reduction in the strength of belief in the particular schemas addressed in the individual therapies. Connection was unrelated to across-session symptomatic improvement and to overall change. Competence predicted a reduction in maladaptive schemas during the schema-focused treatment and in the number of Cluster C personality traits from pretreatment to the follow-up period but was unrelated to across-session change. There was no interaction between connection and competence, indicating that they influenced treatment independently of each other.     

Therapist self-disclosure and the therapeutic alliance in the treatment of eating problems

Evidence is mixed regarding the potential utility of therapist self-disclosure. The current study modelled relationships between perceived helpfulness of therapist self-disclosures, therapeutic alliance, patient non-disclosure, and shame in participants (n = 120; 95% women) with a history of eating problems. Serial multiple mediator analyses provided support for a putative model connecting the perceived helpfulness of therapist self-disclosures with current eating disorder symptom severity through therapeutic alliance, patient self-disclosure, and shame. The analyses presented provide support for the contention that therapist self-disclosure, if perceived as helpful, might strengthen the therapeutic alliance. A strong therapeutic alliance, in turn, has the potential to promote patient disclosure and reduce shame and eating problems.     

The Impact of the Therapist's Personal Family Life on the Ability to Establish Viable Therapeutic Alliances in Family and Marital Therapy

The therapeutic alliance formed by a family therapist is a complex phenomenon in which the therapist must ally with the system as well as with the individual members of the system. Further, many individual members may be in conflict with one another and highly sensitive to the Therapist's alliance with the other members of the system. Traditional definitions of the alliance in individual therapy are not adequate to describe these multiple levels on which the alliance is manifested. The therapeutic alliance established by family therapists is conceptualized as occurring between two interpersonal systems, the patient system and the therapist system. The therapist system includes indirect elements from the therapist's professional and personal life. The therapist's personal life includes both immediate and remote elements in the form of the therapist's current family life as well as family of origin experiences. These elements impact on the therapist's alliances in a variety of ways, such as coloring the therapist's ideas about fairness, normalcy and the appropriateness of roles in family life. This paper examines the possible influence of several dimensions of the therapist's personal family life: family roles, the family emotional atmosphere, the extent of triangulation, the degree of differentiation, unresolved interpersonal conflicts, and styles of coping with family developmental stages.