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.     

Negative symptoms and poor insight as predictors of the similarity between client and therapist ratings of therapeutic alliance in cognitive behavior therapy for patients with schizophrenia

Recent studies have found that clients with schizophrenia rate therapeutic alliance more highly than therapists. Unclear is whether there are clinical characteristics which predict the degree of difference in client and therapist ratings. To explore this, we correlated client and therapist ratings of therapeutic alliance with baseline assessments of positive negative, and disorganized symptoms and awareness of need for treatment. Participants were 40 adults with schizophrenia enrolled in a 6-month program of cognitive behavior therapy. Results indicated that clients produced higher ratings of therapeutic alliance than therapists and that therapist and client general ratings were more disparate when clients had fewer negative symptoms and better insight. Higher overall client ratings of therapeutic alliance were linked to lower levels of positive, negative, and disorganized symptoms and better awareness of need for treatment. Higher overall therapist ratings were linked only to lower levels of disorganized symptoms among clients.     

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.     

Client-therapist agreement on target problems, working alliance, and counseling outcome

It is widely asserted that clients and therapists should agree on which client problems are to be the focus of treatment. According to working alliance theory, client-therapist agreement on therapy objectives contributes to treatment success. However, few empirical studies exist of the relevance of target problem agreement to therapy outcome. We examined the relationships among actual client-therapist agreement on target problems, working alliance (perceived agreement), and therapy outcome. Client-counselor dyads completed target complaint lists and symptom ratings at 3 points during therapy. Improvement and working alliance ratings were also completed after the 4th session and at a final ratings point. Fourth-session target complaint agreement and working alliance contributed to the prediction of therapy outcome. However, actual target complaint agreement was unrelated to working alliance (perceived agreement) ratings. Implications for working alliance theory are discussed.     

A Multisite,Randomized Controlled Clinical Trial of Computerized Cognitive Remediation Therapy for Schizophrenia

The effectiveness of cognitive remediation therapy (CRT) for the neuropsychological deficits seen in schizophrenia is supported by meta-analysis. However, a recent methodologically rigorous trial had negative findings. In this study, 130 chronic schizophrenic patients were randomly assigned to computerized CRT, an active computerized control condition (CC) or treatment as usual (TAU). Primary outcome measures were 2 ecologically valid batteries of executive function and memory, rated under blind conditions; other executive and memory tests and a measure of overall cognitive function were also employed. Carer ratings of executive and memory failures in daily life were obtained before and after treatment. Computerized CRT was found to produce improvement on the training tasks, but this did not transfer to gains on the primary outcome measures and most other neuropsychological tests in comparison to either CC or TAU conditions. Nor did the intervention result in benefits on carer ratings of daily life cognitive failures. According to this study, computerized CRT is not effective in schizophrenia. The use of both active and passive CCs suggests that nature of the control group is not an important factor influencing results.Key words: schizophrenia, cognition, neuropsychology, cognitive remediation     

How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

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.     

Which executive skills should we target to affect social functioning and symptom change? A study of a cognitive remediation therapy program

This study examined the link between executive function and functional outcome in schizophrenia to identify useful psychological intervention targets and explore how executive function changes affect social functioning and symptoms. Participants from two randomized controlled trials (n = 63) with poor social functioning, positive and negative symptoms, and cognitive impairment completed seven measures of executive function. Three cognitive factors were extracted: verbal working memory, response inhibition speed, and stimulus-driven responding. Participants received individual cognitive remediation therapy (CRT) (n = 18), a control therapy (occupational therapy activities) (n = 14), or treatment as usual (n = 19). Only the CRT group improved on verbal working memory. No group improved on the other factors. Although verbal working memory was significantly associated with social functioning and symptom severity 3 months after baseline, change in this factor did not predict change in either functional outcome. There was a significant interaction between group and the stimulus-driven responding factor, and for the CRT group only, a change to a more externally focused responding style was associated with reduced social problems and symptoms. Regardless of treatment type, increased response inhibition speed was associated with reduced negative symptoms. Stimulus-driven responding and response inhibition speed may therefore make useful targets for intervention.     

Predictors of the Working Alliance in Assertive Community Treatment

Past research has found that a positive working alliance between clients and their case managers is modestly correlated with client outcomes. The current study tried to identify the predictors of the working alliance in a sample of 115 clients who were receiving services from Assertive Community Treatment (ACT) teams. All of the clients suffered from severe mental illness, had a substance use disorder and were homeless at baseline. Both the client’s rating and the case manager’s rating of the working alliance were assessed at 3 months and 15 months post baseline. Client characteristics, particularly motivation to change, explained more of the variance of the client’s rating of the alliance than treatment variables or client change on the outcome variables. On the other hand, treatment variables (e.g., the amount of transportation services provided) and client change on the outcome variables explained more of the variance of the case manager’s rating of the alliance.Dr. Robert J. Calsyn and Mr. Lemming are affiliated with the University of Missouri-St. Louis. Dr. Gary A. Morse is affiliated with the Community Alternatives. Dr. W.D. Klinkenberg is affiliated with the Missouri Institute of Mental health.     

Do baseline client characteristics predict the therapeutic alliance in the treatment of schizophrenia?

This study examined clinical predictors of client and therapist alliance ratings early in therapy, the relationship between client and therapist alliance ratings, and the psychometric properties of the Working Alliance Inventory in individuals with schizophrenia receiving manual-based treatment. Assessment of clinical symptoms and social functioning were conducted at baseline, and alliance ratings were obtained at 5 weeks. The Working Alliance Inventory had high internal consistency, but there were low correlations between client and therapist ratings. Results also indicated that social functioning and the activation and autistic preoccupation factors on the Positive and Negative Syndrome Scale were significant predictors of therapists' alliance ratings. There were no significant relationships between clinical predictors and clients' therapeutic alliance ratings. The findings indicate that client interpersonal factors are significant predictors of the therapist-rated alliance in the treatment of schizophrenia. Low correlations between clients' and therapists' ratings of the alliance should be examined in future research.     

Therapist differences in cognitive-behavioral psychotherapy for generalized anxiety disorder: a pilot study

Little is known about factors differentiating more and less effective therapists or the mechanisms through which therapists influence outcome. In the present study, the performance of a small sample of 4 therapists was compared in the context of delivering cognitive-behavioral psychotherapy (CBT) to 32 clients with generalized anxiety disorder. More effective therapists were characterized by higher observer-rated CBT competence, higher client outcome expectations and client treatment credibility assessments, and higher early treatment client ratings of therapeutic alliance quality. Higher early CBT competence was associated with higher client midtreatment outcome expectations, which in turn were associated with better posttreatment outcomes. Although these findings are preliminary given the small sample of therapists and clients, they suggest that the common factor of outcome expectations might be a mechanism through which the specific factor of psychotherapist competence exerts its influence on treatment outcome. The implications of these findings and directions for future research are discussed.     

The magnitude of client and therapist working alliance ratings

Researchers studying the working alliance frequently comment that clients and therapists tend to rate the alliance highly. The authors conducted this study to determine the accuracy of these comments by examining of the magnitude of adult client and therapist working alliance ratings in 63 refereed articles published between 1990 and 2007. The authors wondered if clients and therapists generally tend to use just the higher points of rating scales for measures of working alliance. The 63 articles used 9 different measures of the working alliance and provided working alliance ratings by 6,441 clients and 6,359 therapists. Results indicate that clients tend to use only the top 20% of rating points and therapists tend to use only the top 30% of rating points on alliance measures. Implications of the findings include the possibility that clients and therapists do not differentiate among lower rating points on the scales, tend to rate the alliance according to a social desirability or dissonance-reducing response set, or provide ratings that accurately reflect the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

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.     

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.     

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.     

Cognitive predictors of social functioning improvements following cognitive remediation for schizophrenia

A greater understanding of the links between cognitive and social functioning changes is needed to refine cognitive treatments for schizophrenia. To date, studies have been cross-sectional, and few have investigated the impact of cognitive change. This single-blind randomized controlled trial explored the links between changes in executive/memory functions and social behavior, as well as the moderating effect of cognitive remediation therapy (CRT). A total of 85 participants with schizophrenia received 40 sessions of CRT (an individual psychological therapy aiming to improve attention, memory, and problem solving) or treatment-as-usual. At baseline, social functioning was significantly associated with "verbal working memory," "response inhibition," "verbal long-term memory," and "visuo-spatial long-term memory," but not "schema generation," factors. However, only improvement in "schema generation" predicted improved social functioning. This was true whether or not participants had received CRT. These results suggest that cross-sectional associations between cognitive functions and social functioning may not offer the best means for identifying good targets for intervention. Improvement in the ability to generate new schemas has a beneficial impact on social functioning.     

Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome

Objectives: Therapist effects, independent of the treatment provided, have emerged as a contributor to psychotherapy outcomes. However, past research largely has not identified which therapist factors might be contributing to these effects, though research on psychotherapy implicates relational characteristics. The present Randomized Clinical Trial tested the efficacy of therapists who were selected by their facilitative interpersonal skills (FIS) and training status. Method: Sixty-five clients were selected from 2713 undergraduates using a screening and clinical interview procedure. Twenty-three therapists met with 2 clients for 7 sessions and 20 participants served in a no-treatment control group. Results: Outcome and alliance differences for Training Status were negligible. High FIS therapists had greater pre–post client outcome, and higher rates of change across sessions, than low FIS therapists. All clients treated by therapists improved more than the silent control, but effects were greater with high FIS than low FIS therapists. From the first session, high FIS therapists also had higher alliances than low FIS therapists as well as significant improvements on client-rated alliance. Conclusions: Results were consistent with the hypothesis that therapists’ common relational skills are independent contributors to therapeutic alliance and outcome.     

Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial

BACKGROUND: Schizophrenia with an onset in adolescence is known to be associated with a poorer outcome and cognitive difficulties. These impairments have an impact on quality of life and represent treatment targets. Cognitive remediation therapy (CRT) attempts to improve cognitive deficits by teaching information processing strategies through guided mental exercises. The objective of this study is to evaluate the efficacy of CRT in alleviating cognitive deficits compared to treatment as usual and explore the mediating and moderating effects of cognitive improvement. METHOD: Single-blind randomized controlled trial with two groups, one receiving CRT (N21) and the other standard care (N19) assessed at baseline, 3 months (post therapy) and follow-up (3 months post therapy). Participants were recruited from specialist inpatient and community mental health services and were young patients with recent onset schizophrenia (average age of 18) and evidence of cognitive and social behavioural difficulties. The intervention was individual cognitive remediation therapy delivered over a period of 3 months with at least three sessions per week. The main outcome measures were cognition (memory, cognitive flexibility and planning) and secondary outcomes (symptoms, social contacts and self-esteem). RESULTS: Compared to standard care, CRT produced significant additional improvements in cognitive flexibility as measured by the Wisconsin Card Sort Test (WCST). Therapy moderated the effects of improved planning ability on symptoms such that improvements only had a beneficial effect when they were achieved in the context of CRT. Improvements in cognition in all domains had a direct effect on social functioning and improvements in WCST had a direct effect on overall symptom improvement. CONCLUSIONS: Cognitive remediation therapy can contribute to the improvement in WCST even in adolescents. The changes in cognitive outcomes also contributed to improvements in functioning either directly or solely in the context of CRT. Evidence of the mediator and moderator effects of cognitive changes should lead to more effective therapy development.     

Correlates of the real relationship in psychotherapy: A study of dyads

Abstract

This study examined several theoretical propositions regarding the role of the real relationship using a sample of 59 psychotherapy dyads. As hypothesized, positive associations were evident between therapist ratings of the real relationship and their ratings of the working alliance and client progress; negative associations were found between therapist ratings of the real relationship and attachment avoidance. For clients, significant and hypothesized associations were found between ratings of the real relationship and secure attachment to therapists as well as their perceptions of therapist empathy. Regression analyses showed that client ratings of the real relationship were significantly associated with their ratings of progress in treatment above and beyond their ratings of the working alliance, therapist empathy, and attachment.     

Attachment as a predictor of therapeutic outcome: a case study of a young patient with psychosis

Therapeutic alliance is one of the predictors of a successful therapy. In the current case study of the 26 year old male student diagnosed with paranoid schizophrenia we discuss the possible consequences of a short break in the therapeutic process on the treatment outcome. The client was appointed to an assistant psychologist for study support sessions and to work on his social skills and anxieties. The therapy continued regularly for a month and a half with some visible results in motivation, engagement and mood. After a break in the sessions due to the psychologist's absence, the client did not attend the sessions regularly. He became more withdrawn, his compliance with medical treatment was diminished and he did not meet his study goals.