Predictive value of object relations for therapeutic alliance and outcome in psychotherapy for depression: an exploratory study

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.     

Pretreatment expectations, interpersonal functioning, and symptoms in the prediction of the therapeutic alliance across supportive-expressive psychotherapy and cognitive therapy

Therapeutic alliance has been a robust predictor of therapy outcome, yet little is known about which patient variables predict the development of an alliance between patient and therapist in time-limited manualized therapies. The authors evaluated pretreatment predictors of therapeutic alliance, controlling for symptom change before its assessment, using a large sample of patients treated with either supportive-expressive (SE) dynamic psychotherapy or cognitive therapy. They found that SE patients with greater pretreatment expectations of improvement formed better alliances with their therapist at Session 2, and expectations significantly predicted alliance at Session 10 for both treatment groups. Further, patients in the SE condition demonstrated a significant relation between positive expectations and growth in alliance. Women achieved better alliances at Session 10. Finally, hostile-dominant interpersonal problems significantly predicted poor alliance. Pretreatment symptom level was not significantly predictive of alliance.     

Contribution of defensive functioning to the quality of working alliance and psychotherapy outcome

We analyzed whether defense mechanisms changed and/or predicted outcome during brief dynamic psychotherapy (N = 43, max 40 sessions, Norwegian Multisite Study on Process and Outcome of Psychotherapy). Defenses were rated with the Defense Mechanism Rating Scales (DMRS, clinician-rated) and Defense Style Questionnaire (DSQ self-rated). Overall defensive functioning (ODF) as rated by DMRS changed significantly. We found that the initial ODF's neither predicted the quality of working alliance nor influenced the outcome. Symptoms improved most rapidly early in therapy, while defenses changed during the last half of therapy, consistent with the phase model of change.     

Self-report measures as predictors of psychotherapy outcome

A retrospective clinical study using existing patient records investigated the predictive value of a number of variables. Eighty-three new admissions to a large outpatient clinic completed a battery of eight self-report questionnaires that have been shown to be reliable and have a measure of discriminant validity. The battery consisted of items tapping anxiety, depression, obsessive-compulsive symptoms, phobias, borderline personality disorder, and histrionic, obsessive-compulsive, and paranoid personality styles. Outcome of therapy, which was predominantly dynamically-oriented, was assessed by residual difference scores computed from pre- and posttherapy Global Assessment Scale (GAS) ratings. Only patients attending five or more sessions (N = 37) were considered in the analyses. Patients high on the Anxiety Scale pretherapy showed relatively greater improvement in functioning than those with low initial scores. Patients scoring high on the Histrionic, Paranoid, and Obsessive-Compulsive Personality Scales showed the least relative improvement.     

Psychodynamic variables as predictors of psychotherapy outcome

Predicting the outcome of psychotherapy is a central concern in psychiatry. Twenty-one medical students seeking psychotherapy were evaluated on a number of psychodynamic and process variables using self-report scales and scales completed by the therapist before, during, and after psychotherapy. There were significant differences between patients and a comparison group on eight variables before therapy. Ten psychodynamic variables (six representing ego defense mechanisms) and four process variables were found to be highly correlated with outcome measures; the process variables were the best predictors of outcome. The data support the use of psychodynamic and process variables as predictors of outcome in psychoanalytically oriented psychotherapy.     

Transference interpretations, therapeutic alliance, and outcome in short-term individual psychotherapy

Relationships between the proportion of transference interpretations provided by therapists and both therapeutic alliance and therapy outcome were investigated for a sample of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical trial investigation. Inverse relationships were found between the proportion of transference interpretations and both therapeutic alliance and favorable therapy outcome for patients with a history of high quality of object relations. An examination of individual sessions revealed evidence that was consistent with two different, but not mutually exclusive, causal explanations. The first concerned the negative effects of high proportions of transference interpretations; the second concerned the reaction of the therapist to the presence of a weak therapeutic alliance. While the evidence from our study was correlational, it was sufficiently strong to warrant alerting clinicians to the possibility of negative treatment effects when high levels of transference interpretations are used with certain types of patients receiving short-term individual psychotherapy.     

Working alliance as a mediator of client attachment dimensions and psychotherapy outcome

Studies that employ multidimensional attachment measures to explore the impact of attachment style on psychotherapy process and outcome are virtually absent in the literature. Further, the role of the working (therapeutic) alliance as a mediator of the influence of attachment on treatment outcome has not been formally investigated. In order to address these gaps in the research, archival data from 66 psychotherapy clients treated at a university graduate program training clinic were used to examine the influence of three adult attachment dimensions (Comfort with Closeness, Comfort Depending on Others, and Rejection Anxiety) on the therapeutic alliance and outcome, as well as to assess whether the alliance mediates the relationship between attachment and therapy outcome. Both Comfort with Closeness and Comfort Depending on Others were significantly related to alliance and outcome, whereas Rejection Anxiety was not significantly related to either variable. Alliance was a significant partial mediator of the effect of Comfort with Closeness on outcome. The results suggest that multidimensional measures of attachment capture important influences on alliance and psychotherapy and that Comfort with Closeness promotes successful outcome by virtue of its influence on alliance.     

Cohesion, alliance and outcome in group psychotherapy

Cohesiveness has been viewed as the group psychotherapy equivalent of the therapeutic alliance in individual treatment. Although researchers have attempted to study the concept of cohesion in group treatment, understanding of this so-called "curative" group factor remains quite primitive. In this study of 12 time-limited psychotherapy groups, with a total of 90 nonpsychotic outpatients, we explore the relationships between cohesion, alliance and treatment outcome. Our cohesion measure is a new instrument, the Harvard Community Health Plan Group Cohesiveness Scale, developed for use with group therapy videotapes. To measure alliance we have modified the Penn Helping Alliance Scale (Group Alliance Scale) to be scored from videotapes of group sessions. Both of these instruments use trained observers to make ratings for the group-as-a-whole. The outcome battery for patients in these groups included a widely varied set of measures, enabling us to view change from a number of perspectives. Our findings indicate that cohesion and alliance as measured here are related concepts. We also find that both cohesion and alliance appear to have strong relationships with improved self-esteem and reduced symptomatology for patients in these groups. In addition, it appears that outcome is most related to cohesion in the first 30 minutes of a group session. Implications of these and other findings are discussed.     

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.     

Levels and patterns of the therapeutic alliance in brief psychotherapy

We examined the relevance of the level and pattern of the therapeutic alliance in 44 cases of three different, manualized 30-session treatments using patient ratings of the Working Alliance Inventory after each session. It was hypothesized that both high-alliance level and either a linear increase in alliance rating or a series of brief rupture-and-repair episodes would be found in successful treatments. We also hypothesized that a more global high-low-high pattern predicted in the literature would not be present. Consistent with the literature, higher alliance levels were found to be related to improved outcome. As predicted, we did not find a global, high-low-high pattern. Local rupture-and-repair patterns were found in 50% of the cases; linear trends were found in 66% of the cases. There was no relationship between outcome and either pattern. We found no differences among the treatments.     

Metacognition as a predictor of therapeutic alliance over 26 weeks of psychotherapy in schizophrenia

Research to identify client factors that impact treatment outcome has found that deficits in metacognitive abilities and weaker therapeutic alliance are both associated with poorer treatment outcomes for schizophrenia. However, it is unknown if metacognition and therapeutic alliance are related in any way, in particular, if metacognitive abilities predict therapeutic alliance. This study explored whether differing capacities for mastery, a domain of metacognition that involves the ability to use knowledge about mental states to respond to psychological challenges, predicted client perceptions of therapeutic alliance assessed by the Working Alliance Inventory - Short Form (WAI-S). Participants were 63 adults with schizophrenia or schizoaffective disorder enrolled in a 6-month program of cognitive behavioral or supportive therapy, placed into a high, intermediate or minimal mastery group as measured by the Metacognitive Assessment Scale (MAS). Repeated measures ANOVA found group effects for the total WAI-S score, with the high and intermediate mastery groups having better alliance scores than the minimal mastery group. The group effects approached significance when neurocognition was controlled for. Results suggest that greater capacity for mastery predict stronger therapeutic alliance, but do not predict its development over time.     

Suitability for brief dynamic psychotherapy: psychodynamic variables as predictors of outcome

The success rate in predicting symptom change 2 years after brief dynamic psychotherapy increased 20% by adding quality of interpersonal relations from a psychodynamic evaluation interview to DSM-III diagnoses, Axis V and Axis II. The success rate in predicting dynamic change 4 years after therapy increased nearly 40% by adding the same variable. Selection criteria such as circumscribed focus, motivation and involvement in the evaluation interview were shown to be redundant as predictors.     

Evaluating negative process: a comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions

The aim of this study was to investigate the interrelationships of three measures of the therapeutic relationship and their validity in predicting treatment outcome, including the early identification of two treatment-failure conditions. Forty-eight patient-therapist dyads, in 30-session therapies for personality-disordered patients, were classified as premature dropout (DO), poor outcome (PO), or good outcome (GO) cases. Poor and Good Outcomes were determined by a reliable change score. Dropout cases were terminated during the first third of treatment, and patients cited dissatisfaction with the therapy or therapist. Assessment of working alliance, interpersonal behavior and a new measure of narrative coherency in the first third of treatment revealed that DO dyads had significantly poorer alliances and less coherent narratives in early sessions, while PO dyads, who ultimately completed the 30-session treatment protocol, unexpectedly demonstrated the highest degree of hostile complementarity. Clinical implications of the results are discussed.     

Dropout and therapeutic alliance: a meta-analysis of adult individual psychotherapy

This meta-analytic review of 11 studies examined the relationship between psychotherapy dropout and therapeutic alliance in adult individual psychotherapy. Results of the meta-analysis demonstrate a moderately strong relationship between psychotherapy dropout and therapeutic alliance (d = .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. The meta-analysis included a total of 1,301 participants, with an average of 118 participants per study, a standard deviation of 115 participants, and a range from 20 to 451 participants per study. Exploratory analyses were conducted to determine the influence of variables moderating the relationship between alliance and dropout. Client educational history, treatment length, and treatment setting were found to moderate the relationship between alliance and dropout. Studies with a larger percentage of clients who completed high school or higher demonstrated weaker relationships between alliance and dropout. Studies with lengthier treatments demonstrated stronger relationships between alliance and dropout. Inpatient settings demonstrated significantly larger effects than both counseling centers and research clinics. No significant differences were found between client-rated, therapist-rated, and observer/staff-rated alliance. Recommendations for clinicians and researchers are discussed.     

Therapists' attachment, patients' interpersonal problems and alliance development over time in inpatient psychotherapy

The focus of this study is the investigation of the relation between patients' interpersonal problems, therapists' attachment representations, and the development of the therapeutic alliance over time. The authors investigated weekly alliance ratings of 281 psychotherapy inpatients, treated by 12 psychotherapists. Alliance quality was measured with the Inpatient Experience Scale. Multilevel regression models showed that patients' interpersonal problems were associated with the level of alliance quality. Therapists' attachment security was not related to alliance development, but higher attachment preoccupation of therapists was associated with lower levels of alliance quality. In addition, an interaction effect between therapists' degree of attachment preoccupation and patients' interpersonal problems explained variations of the alliance development curve over time. Limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Early memories, object relations, and current relationship functioning

This study examined the relationship between dependency themes in 140 inpatients' early childhood memories (EM) and social interactions involving dependent behavior. Hierarchical regression analyses revealed that the type of dependent EM predicted overt behavior above and beyond demographic and diagnostic categories. Patients expressing clinging dependent themes in their narratives had greater involvement in social activities in the therapeutic community program and with nurses, whereas patients expressing counterdependent themes engaged in more hostile interactions with nursing staff members, were more self-destructive, and had more emergency department admissions over the course of inpatient treatment. Results are considered in light of the clinical utility of EMs.     

Patient predictors of process and outcome in short-term individual psychotherapy

Twenty-one psychiatric outpatients were treated with short-term, psychoanalytically oriented, individual psychotherapy. Outcome ratings were provided by the patient, the therapist, and an independent assessor. Process ratings were provided by the patient and the therapist at the end of therapy. From a series of multiple regression analyses two pretherapy predictor scores (defensive style of the patient, object choice of the patient) emerged as good predictors of several of the process and outcome ratings. The two predictor scores were statistically independent of one another and were not significantly related to initial severity of disturbance. Attention to these two concepts in future research and in clinical assessment of patients for short-term individual psychotherapy is recommended.     

Personality traits,interpersonal problems and therapeutic alliance in early schizophrenia spectrum disorders

Background

The quality of the therapeutic alliance is associated with engagement in- and thus important to the outcome of- treatment in schizophrenia. In non-psychotic disorders, general personality traits and individual patterns of interpersonal problems have been linked to the formation and quality of the therapeutic alliance. The role of these factors in relation to therapeutic alliance has not previously been explored in schizophrenia spectrum disorders.

Aim

To investigate associations between personality traits, interpersonal problems and the quality of the therapeutic alliance in early schizophrenia spectrum disorders.

Methods

Demographic and clinical characteristics including Positive and Negative Syndrome Scale (PANSS) scores were assessed in 42 patients. Personality traits and interpersonal problems were assessed with the NEO Five factor Inventory (NEO-FFI) and the circumplex model of the Inventory of Interpersonal Problems (IIP-64C). Therapeutic alliance was measured with the Working Alliance Inventory – short form (WAI-S).

Results

Patient WAI-S scores were predicted by IIP-64C Submissive/Hostile interpersonal problems, age and PANSS excitative symptoms. Therapist WAI-S scores were predicted by NEO-FFI Agreeableness and the PANSS insight item.

Conclusion

Core traits of personality and dimensions of interpersonal problems are associated with both patients' and therapists' perceptions of the quality of the working alliance.