Suitability for psychoanalytic psychotherapy: validation of the Dynamic Assessment Interview (DAI)

OBJECTIVE: To examine the predictive validity of a particular interview and rating scale of patient suitability for psychoanalytic psychotherapy: The Dynamic Assessment Interview (DAI) scale. METHOD: Seventy-four psychiatric out-patients were interviewed with the DAI and the associations between DAI-scores and measures of outcome and of therapeutic alliance were investigated. RESULTS: Small to moderate correlations were found between the DAI suitability score and outcome (0.06-0.46) and between DAI suitability score and early rated alliance (0.14-0.45). The predictive value of the DAI-score was limited although on a par with the alliance measures used in the study. No other pretherapy predictor variable investigated was found significantly to predict outcome. CONCLUSION: The predictive power of the DAI measure was limited, a result, which is in agreement with results from former studies on suitability.     

INFLUENCES OF PATIENTS’ AND THERAPISTS’ INTERPERSONAL PROBLEMS AND THERAPEUTIC ALLIANCE ON OUTCOME IN PSYCHOTHERAPY

Abstract

The aim of this study was to investigate the importance of therapists’ and patients’ interpersonal problems as well as the impact of the therapeutic alliance on symptomatic outcome in psychotherapy. Of interest were direct effects of interpersonal problems, represented through the dimensions of affiliation and control, as well as possible interaction effects between patient and therapist variables on outcome. Further hypotheses referred to therapist differences in the predictive impact of the therapeutic alliance for outcome. Outcome ratings of 1,513 psychotherapy inpatients treated by 31 psychodynamically oriented individual psychotherapists were studied. Therapists’ and patients’ interpersonal dispositions were assessed with the Inventory of Interpersonal Problems, and patients answered standardized outcome measures before and after therapy and retrospectively evaluated the therapeutic alliance at discharge. The results indicate that dominant patients profited better from their therapy and that therapists’ interpersonal disposition did not have a direct influence on outcome. The influence of the therapeutic alliance on outcome varied among the therapists. The general positive effect of therapeutic alliance on outcome was stronger for less affiliative therapists. Limitations of the study and implications of the results are discussed.     

Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome

The purpose of the study was to compare an interview measure of quality of object relations to questionnaire and interview measures of recent interpersonal functioning with respect to the prediction of therapeutic alliance and psychotherapy outcome. The sample consisted of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical-trial investigation. Ratings of therapeutic alliance were provided independently by the patient and the therapist after each session. Outcome measures, which were provided by three sources (patient, therapist, and independent assessor), covered the areas of interpersonal functioning, psychiatric symptomatology, self-esteem, and life satisfaction. Quality of object relations, which characterizes the patient's lifelong pattern of relationships, was the best predictor. It was significantly related to patient-rated and therapist-rated therapeutic alliance and to patient improvement of both general symptomatology and specific target problems. The study also replicated previous studies that have reported significant relationships between therapeutic alliance and therapy outcome. The advantages of pretherapy predictors of therapy outcome, such as quality of object relations, are discussed.     

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.     

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.     

Therapist and client perceptions of therapeutic presence: The development of a measure

Abstract

The authors developed two versions of a therapeutic presence measure, based on an earlier model of presence (Geller & Greenberg, 2002)—Therapeutic Presence Inventory–therapist (TPI-T) and client (TPI-C) versions—to measure in-session therapeutic presence. They explored their reliability and validity in two studies. In the first, items generated from the previously established model were subjected to analyses and expert ratings. In the second study, therapists and clients rated therapists' presence postsession. Therapists also completed the Relationship Inventory, and clients assessed two additional factors: session outcome, using the Client Task Specific Measure–Revised, and therapeutic alliance, using the Working Alliance Inventory. Findings revealed that both versions of the TPI had good reliability and construct validity. However, TPI-T had low predictive validity and the TPI-C showed good predictive validity. In particular, clients reported positive therapeutic alliance and change following sessions when they felt their therapist was present with them.     

Different perspectives of the therapeutic alliance and therapist technique in 2 forms of dynamically oriented psychotherapy.

OBJECTIVE: This study addresses several issues concerning patients' and therapists' perceptions of key therapy process variables. This includes examining whether patients and therapists differ in their perceptions of the therapeutic alliance and therapist technique, what the relation is between perceptions of the alliance and technique, and whether these perceptions are predictive of treatment outcome. METHOD: Patient and therapist perceptions of the therapy process were provided in a comparative trial of 2 forms of short-term individual dynamic psychotherapy. Patients (n = 144) were randomly assigned to each condition. Treatment outcome was assessed using a large, comprehensive battery of reliable measures. RESULTS: The findings revealed several differences in the patients' and therapists' ratings of the alliance and technique in the 2 forms of therapy. Patient ratings of the alliance and technique were predictive of treatment outcome. CONCLUSION: The findings contribute to understanding the extent to which therapy participants share views of therapy processes and highlight the importance of the therapist's attending to the patient's perception of therapy.     

Neurocognitive correlates of therapeutic alliance in schizophrenia

Although therapeutic alliance in schizophrenia has been linked with treatment adherence and outcome, less is known about its clinical correlates. This study explored neurocognition as a possible predictor of perceived therapeutic alliance among people with schizophrenia in cognitive behavior therapy. Twenty-four participants with schizophrenia spectrum disorders and their therapists were administered the Working Alliance Inventory, Short Form after 3 months of therapy. Totals for clients and therapists were correlated with measures of verbal memory, premorbid intelligence, visual spatial reasoning, executive function, and attention, all obtained before beginning therapy. Poorer performance on verbal memory was significantly related to client report of stronger alliance, whereas better performance on visual spatial reasoning was significantly related to therapist report of stronger alliance. Client and therapist ratings of therapeutic alliance were significantly and positively related. Clients' abilities may differentially affect therapist and client perception of therapeutic alliance in schizophrenia.     

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.     

Therapeutic alliance and family-based treatment for adolescents with anorexia nervosa

This pilot study examines the role of therapeutic alliance in relation to weight gain and change in psychological measures during family-based treatment for adolescent anorexia nervosa (AN). Our sample consisted of 14 adolescents with AN and their families. Therapeutic alliance was measured using the System for Observing Family Therapy Alliances Scale. Those adolescents who attained at least 85% of their ideal body weight at the end of treatment had parents who showed a stronger therapeutic alliance with the therapist during the second session of treatment, while adolescents who were remitted on psychological measures showed a higher therapeutic alliance between themselves and the therapist early in treatment. It appears that therapeutic alliance plays an important role in outcome in family-based treatment for AN. Further study is needed in this area to explore the role of the therapist in creating and maintaining a strong therapeutic alliance.     

Video-tape role induction for psychotherapy: moving forward

Role induction (RI) has been shown to decrease premature termination and to enhance the therapeutic alliance and symptom relief. We examine the effects of a video-tape RI on premature termination rates, outcome, and the process variable of therapeutic alliance. Sixty-eight clients and their therapists (N = 26) participated in the study. Each client completed baseline measures of symptom status before beginning the therapy. Clients were then randomly assigned to either a video-tape RI condition or a no videotape treatment-as-usual condition. After the first session of therapy, clients and therapists separately completed outcome and alliance measures. Providing a video-tape RI to clients as they entered therapy did not lead to better results in attendance, outcome, or process variables. Considering possibilities that lie beyond the design of this study, so as to understand these results, is encouraged in an effort to advance the field's thinking about RI and how it can best be harnessed for continued positive effects moving forward.     

Predictors of outcome and completion status in cognitive therapy for depression

Abstract

The aim of this study was to investigate the relationship among therapy outcome, premature termination, and client interpersonal style and therapeutic alliance. Of the 94 clients who began cognitive therapy for the treatment of depression, 24 did not complete their agreed-on number of therapy sessions, had poorer outcomes and alliance scores, and were more likely to have an ambivalent interpersonal style. However, mediation of this relationship between interpersonal style and completion status by alliance was not significant. Therapy outcomes for all clients were better for clients with a secure interpersonal style than for those with an insecure interpersonal style, particularly avoidant. The association between interpersonal style and outcome was mediated by the therapeutic alliance.     

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.     

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.     

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.     

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.     

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.     

Crisis intervention response and long-term outcome: a pilot study.

We investigated whether process variables (therapeutic alliance and insight) measured at the termination of crisis intervention predict long-term treatment compliance and 2-year outcome. Thirty-seven consecutive depressed psychiatric patients assigned to outpatient crisis intervention (CCI) were assessed with both questionnaires and standardized instruments at intake, 1 week, and CCI termination (mean, 6 weeks). Thirty-one subjects (84%) were also evaluated at 1-year and 2-year follow-up. We found that working alliance and development of insight predicted positive global change and symptom improvement at 1 and 2 years' follow-up. Furthermore, the observed correlation between process measures and 2-year outcome was found to be independent of age, sex, symptoms severity at intake, improvement of symptoms at CCI termination, premorbid adjustment, DSM-III-R axis I/axis II diagnosis, and therapeutic alliance at intake.     

The therapeutic alliance: the key to effective patient outcome? A descriptive review of the evidence in community mental health case management

OBJECTIVE: The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. METHOD: MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. RESULTS: A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and 'goodness-of-fit' between patients and case managers was sparse with no published Australian studies. CONCLUSIONS: The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.     

Testing the Working Alliance Inventory (WAI) in a French primary care setting

BACKGROUND: Working alliance has shown a predictive value of the outcome in different therapeutic settings but was not yet studied in a non-medical setting. METHODS: The predictive value and the factor structure of the Working Alliance Inventory (WAI) [36-item client version; as reported by Horvath and Greenberg (J Couns Psychol 36:223-233, 1989)] were studied in a French primary care setting on a sample of 130 adults accessing social services. RESULTS: The WAI total score completed after the first meeting was positively predictive of quality of the working alliance 4 months later. An exploratory factor analysis produced two orthogonal factors which explained 45.12% of the total variance: a first factor (23 items) labelled 'positive expectations about the usefulness of help' and a second factor (13 items) labelled 'absence of suspicion about the effects of help'. CONCLUSIONS: The WAI is shown to be applicable to primary care social work settings to measure the working alliance phenomenon and predict disruption of practitioner-client relationship.