Relations of the alliance with psychotherapy outcome: findings in the Second Sheffield Psychotherapy Project

Are psychodynamic and psychoanalytic therapies effective? A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence-based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identified by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty-two RCTs were identified of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identified: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post-traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance-related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi-experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.

Convergence in patient-therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment

OBJECTIVE

This study tested whether discrepancy between patients' and therapists' ratings of the therapeutic alliance, as well as convergence in their alliance ratings over time, predicted outcome in chronic depression treatment.

METHOD

Data derived from a controlled trial of partial or non-responders to open-label pharmacotherapy subsequently randomized to 12 weeks of algorithm-driven pharmacotherapy alone or pharmacotherapy plus psychotherapy. The current study focused on the psychotherapy conditions (N = 357). Dyadic multilevel modeling was used to assess alliance discrepancy and alliance convergence over time as predictors of two depression measures: one pharmacotherapist-rated (Quick Inventory of Depressive Symptoms-Clinician; QIDS-C), the other blind interviewer-rated (Hamilton Rating Scale for Depression; HAMD).

RESULTS

Patients' and therapists' alliance ratings became more similar, or convergent, over the course of psychotherapy. Higher alliance convergence was associated with greater reductions in QIDS-C depression across psychotherapy. Alliance convergence was not significantly associated with declines in HAMD depression; however, greater alliance convergence was related to lower HAMD scores at 3-month follow-up.

CONCLUSIONS

The results partially support the hypothesis that increasing patient-therapist consensus on alliance quality during psychotherapy may improve treatment and longer term outcomes.

Transference and countertransference: A review

Originally a psychodynamic concept, the therapeutic relationship (also therapeutic alliance, helping alliance or simply alliance) has become a pan-theoretical model for the professional relationship between a therapist and his or her client (Kivlighan, 1995). With the development of this concept in the latter half of the 20th century, psychotherapeutic theory and practice saw a paradigm shift away from strict adherence to technique with little room for responsive, individual behavior from the therapist and toward the "authentic" human relationship at the core of therapy. This meant that more consideration was given to the idea of mutual influence from patient and therapist to the success of therapy (Safran & Muran, 2006). This article aims to provide a comprehensive overview of the complex and shifting research on the therapeutic relationship to promote a greater understanding of the concept.

Early Therapeutic Alliance, Treatment Retention, and 12-Month Outcomes in a Healthy Lifestyles Intervention for People with Psychotic Disorders

Engaging and retaining individuals with psychotic disorders in psychosocial treatments is difficult. Early therapeutic alliance, treatment retention, and 12-month outcomes were examined in a subsample of smokers with a psychotic disorder (N = 178) participating in a healthy lifestyles study comparing a telephone versus face-to-face delivered intervention. Therapeutic alliance was assessed using the Agnew Relationship Measure; primary outcomes were treatment retention and changes in symptoms and health behaviors. Contrary to expectations, early alliance did not predict treatment retention. However, elements of both client- and therapist-rated alliance predicted some clinical outcomes (e.g., higher confidence in the therapeutic alliance at session 1 predicted improvements in 12-month depression). Some modest interactions between early alliance and intervention condition were also identified (e.g., clients initially with lower self-perceived initiative, or higher therapist-perceived bonding benefited preferentially from the telephone-delivered intervention), highlighting the need to further examine the interplay between therapeutic alliance and treatment modality.

The working alliance: Where have we been, where are we going?

OBJECTIVE

This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptualization.

METHOD

Major research efforts on the topic are reviewed. The review includes both theoretical and empirical literature on the working alliance and related constructs, such as alliance ruptures and repair, and therapeutic negotiation. Existing measures of the working alliance are also reviewed.

RESULTS

The working alliance is critiqued on both theoretical and empirical grounds, including the strengths and limitations of current approaches and assessments. Recent theoretical developments are reviewed, among them work on alliance rupture and repair and the reconceptualization of the alliance as a process of therapeutic negotiation. Emerging applications of advanced statistical techniques to measure the working alliance are also considered.

CONCLUSION

The review concludes by supporting recent efforts that have attempted to increase the sophistication of measurement tools and statistical approaches, and encouraging future research in these areas.

Traumatized refugees, their therapists, and their interpreters: three perspectives on psychological treatment

OBJECTIVES

To study how traumatized refugees, their therapists, and their interpreters perceive both curative and hindering factors in psychological therapy, thereby highlighting the mediators of change in a transcultural clinical setting.

DESIGN

Four experienced clinical psychologists affiliated to two centres for the rehabilitation of traumatized refugees, were asked to select their two 'most successful' and two 'least successful' cases by going back to all the cases that they had concluded within the last 2 years, a pool of approximately 200 patients. The selected 16 patients, their therapists, and their interpreters were invited to semi-structured, in-depth, individual interviews with the aim of acquiring more knowledge on what had been helpful and what not helpful in the psychological treatment.

METHOD

The senior author who conducted the interviews was not aware of whether the patient belonged to the 'successful' or 'unsuccessful group' prior to the interview. All interviews were audio taped. A qualitative phenomenological approach was used in the analysis of the data. The data were analysed (1) triad by triad for the 16 triads consisting of a patient, his/her therapist, and his/her interpreter, and (2) separately for each of the three groups of respondents. The analysis involved going through each protocol sentence by sentence and developing key-concepts for the therapeutic interventions and for the interpersonal relations. When the generation of key-concepts was finalized, the material was analysed for a second time, in order to place the relevant data under the key-concepts/categories. The categories and illustrative verbatim quotations from the interviews are presented in separate tables for the three groups.

RESULTS

The relationship between the therapist, patient, and interpreter, and the development of trust and a good working alliance was seen by all as the most important curative factor. Psychoeducative methods, cognitive interventions, as well as the provision of practical help and advice were also regarded as curative and facilitating factors. Hindering factors fell into the following five categories: factors related to the patient, to the therapist, to the interpreter, to the therapeutic method itself, and to factors external to the therapy. Therapists and interpreters considered severe psychopathology and substance abuse in addition to PTSD; chronic pain and physical illness; lack of motivation for treatment; and overwhelming social and/or economic problems as obstructive factors for the establishment of a working alliance and more generally for a successful outcome. As to the patients who did not benefit from the treatment, the unsuitability of a psychological treatment for their symptoms, and social and economic problems were seen as the main hindering factors.

CONCLUSION

The therapeutic or working alliance is a common element of all types of psychological treatments, and is generally considered as a 'non-specific' factor. There are grounds to modify this view in working with traumatized and tortured patients from different cultural backgrounds. In cases where patients have experienced humiliation and evil, and now live in exile, the establishment of a relation of trust in fellow human beings is the first aim of the treatment. The article argues that the professional's compassion constitutes a primary factor in the therapeutic process in such cases. The risks of overinvolvement in the treatment of heavily traumatized patients are well described in the literature, and have also appeared in this study. In psychotherapy research, strong personal commitment is seldom mentioned by therapists for fear of its being considered unprofessional or unethical. However, a strong commitment can be of value, not only for the patients, but also for the therapists and interpreters themselves. The results of this study suggest that deep compassion on the part of the professionals is widespread in the treatment of traumatized patients, and that it is considered as a healing factor by most patients, interpreters, and therapists.

The dependability of alliance assessments: the alliance-outcome correlation is larger than you might think

OBJECTIVE

To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship.

METHOD

We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used.

RESULTS

At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3-9 explained 14.7% of outcome variance.

CONCLUSION

Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance-outcome relationship.

Two short forms of the Agnew Relationship Measure: the ARM-5 and ARM-12

This article reports the development and psychometric properties of two short forms of the 28-item Agnew Relationship Measure, the ARM-12 and ARM-5. For the ARM-12, results of previous research were used together with conceptual considerations to select three items to represent each of four ARM subscales: Bond, Partnership, Confidence, and Openness. For the ARM-5, item-analytic principles were used to select five items to represent overall alliance. In all three ARMs, client and therapist versions were constructed to contain parallel items. We drew data to assess reliability and validity from three UK trials of brief therapy for depression. Results indicated that the two short ARMs have acceptable psychometric properties and that they converged with each other and with the full ARM.

Clients' and therapists' views of the therapeutic alliance: similarities, differences and relationship to therapy outcome

To better understand how clients' and therapists' views of the therapeutic alliance differ and overlap, this study investigated, first, the components of the alliance that are relevant to the therapy participants; second, their relationship to post-therapy outcome; and third, the relationships between participants' alliance constructs. To identify participants' views, exploratory factor analyses were performed on clients' (n = 176) and therapists' (n = 133 observations) ratings of the Working Alliance Inventory (short form), the Helping Alliance Questionnaire and the California Psychotherapy Alliance Scales and conducted both on each measure separately and on the three measures combined. The results of the separate analyses indicated in general poor correspondence between the participant-derived components and each measure's a priori constructs. Results of the joint analyses suggested that clients view the alliance in terms of six basic components (Collaborative Work Relationship, Productive Work, Active Commitment, Bond, Non-disagreement on Goals/Tasks and Confident Progress), five of which were found to predict client-rated and/or therapist-rated post-therapy outcome. Results for therapists suggested four basic components (Collaborative Work Relationship, Therapist Confidence & Dedication, Client Commitment & Confidence, Client Working Ability), of which three predicted post-therapy outcome. Findings of significant, but modest to low moderate, correlations between several client and therapist joint factors suggested that despite similarities, the therapy partners' views of the alliance differ in important ways. Compared with therapists, clients appear to place greater emphasis on helpfulness, joint participation in the work of therapy and negative signs of the alliance. Implications of these findings are discussed.

KEY PRACTITIONER MESSAGE

Therapists should not assume that their views of the therapeutic relationship and therapeutic work are shared by their clients and are encouraged to seek the client's feedback. Therapists may benefit from conveying that the client's perspective on problems and relevant work is valued and that they are working with the client as a team. Therapists may need to explicitly address how the therapeutic work is helpful and conducive to desired changes.

Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research

This paper proposes a historical excursus of studies that have investigated the therapeutic alliance and the relationship between this dimension and outcome in psychotherapy. A summary of how the concept of alliance has evolved over time and the more popular alliance measures used in literature to assess the level of alliance are presented. The proposal of a therapeutic alliance characterized by a variable pattern over the course of treatment is also examined. The emerging picture suggests that the quality of the client-therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. In our opinion, with regard to the relationship between the therapeutic alliance and outcome of psychotherapy, future research should pay special attention to the comparison between patients' and therapists' assessments of the therapeutic alliance. This topic, along with a detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects.

The Psychometric Properties of the WAI in a Career Counseling Setting: Comparison With a Personal Counseling Sample

This study investigated the psychometric properties of the Working Alliance Inventory-Client version (WAI-C) and Working Alliance Inventory-Short and revised (WAI-SR) in a career counseling setting. Moreover, it compared the impact of career versus personal counseling settings based on results obtained using the WAI-SR. Subjects were 188 French-speaking career counseling clients and 95 French-speaking personal counseling clients, mainly students. For the career counseling sample, total reliability was .87 for the WAI-C and .76 for the WAI-SR. The shape of the distribution was normal but the variance was significantly lower for the career counseling sample. Exploratory factor analyses (EFAs) and confirmatory factor analyses (CFAs) confirmed the presence of an overall working alliance factor but indicated a clearer hierarchical structure for the WAI-SR than for the WAI-C. The psychometric properties seemed only slightly affected by the counseling setting, suggesting that this inventory is also relevant for career counseling, especially the WAI-SR, which has a more robust factorial structure.

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

OBJECTIVE

This study investigated the importance of the therapeutic alliance in a routine psychiatric out-patient unit regarding treatment outcome and the influence of patient factors.

DESIGN

The study had a naturalistic and longitudinal design where the treatments the patient received were determined by the normal routines at the unit and were performed by a variety of staff representative of a psychiatric out-patient unit.

METHOD

Newly admitted patients were diagnosed according to the International Classification of Diseases-10th Revision and completed questionnaires regarding the therapeutic alliance, symptoms, and interpersonal problems at the beginning and termination of their treatment (N=76). The time limit for the termination assessments was set at 18 months.

RESULTS

The therapeutic alliance at the beginning of treatment did not correlate with outcome, however, at the end of the treatment the alliance significantly explained about 15% of the variance of the outcome (global severity index). An improvement of the alliance during the treatment significantly correlated with most of the outcome variables. The relation of the alliance to outcome was equal among the different diagnosis groups and treatment forms.

CONCLUSION

The results showed that the therapeutic alliance is an important variable for treatment outcome in routine psychiatric treatment, and improving the therapeutic alliance may be one of the most important factors for increasing the total effectiveness of a treatment unit.

An evaluation of the impact of a large group psycho-education programme (Stress Control) on patient outcome: does empathy make a difference?

Large psycho-education groups are being increasingly used in mental-health promotion and the treatment of common mental-health problems. In individual therapy there is a well-established link between therapist empathy, therapeutic relationship and patient outcome but the role of empathy within large psycho-educational groups is unknown. This service evaluation investigated the impact of a 6-week large psycho-education group on patient outcome and the role of perceived therapist empathy on outcome. Within a before–after experimental design, 66 participants completed baseline and endpoint measures; Clinical Outcome Routine Evaluation (CORE), Patient Enablement Instrument (PEI), and the modified Consultation and Relational Empathy (CARE) measure. The results showed that the intervention had a positive impact on patient outcome; the CORE score reduced significantly over the 6 weeks by 0.63 (95% CI 0.82–1.14) (t= 9.18, d.f. = 55,p= <0.001) and attendees felt highly enabled. Attendees perceived the course leader as highly empathetic. However, the relationship between perceived empathy and attendee outcome was less clear; no significant relationship was found with the main outcome measure (the change in CORE score). Factors that influenced the main outcome included age, symptom severity at baseline, having a long-term illness or disability, and whether attendees tried the techniques at home (homework). These findings suggest that large group psycho-education is an effective treatment for mild to moderate mental-health problems, at least in the short term. The role of therapist empathy remains ambiguous but may be important for some patient outcomes.

Effectiveness of Career Counseling and the Impact of the Working Alliance

This study analyzes the role of the working alliance on the life satisfaction and career decision difficulties of clients participating in career counseling in Switzerland. The study also compares these career counseling clients to a group of students who did not seek counseling, to explore the overall effectiveness of a face-to-face career counseling intervention, using a pre—post design. Results indicated that the working alliance was positively associated with clients’ satisfaction with the intervention and with the final level of their life satisfaction. Working alliance was also negatively associated with the final levels of career decision difficulties. Moreover, clients’ career decision difficulties significantly decreased and their life satisfaction increased throughout the intervention. These findings suggest that working alliance represents an important variable to better understand career interventions’ underlying mechanisms. Moreover, face-to-face career counseling is effective considering career-specific as well as broader, life-related indicators.

Helping alliance and outcome in psychotherapy: what predicts what in routine outpatient treatment?

This naturalistic longitudinal study analyzed the reciprocal dependency of the helping alliance and symptom outcome over the course of mid- and long-term outpatient psychotherapy as practiced in routine care in Germany. Patient-rated helping alliance and symptom distress were assessed repeatedly over a 2-year period in a sample of 259 outpatients in psychodynamic, cognitive-behavioral, and psychoanalytic psychotherapy. Hierarchical linear models showed that initial symptom distress negatively predicted subsequent quality of the helping alliance but not vice versa. Only initial symptom distress affected symptom status at the last treatment session. These results raise doubts about the helping alliance being a strong predictor of outcome and indicate that other patient and therapist variables might be more important for treatment success.

Social bonds and posttraumatic stress disorder

Retrospective and prospective studies consistently show that individuals exposed to human-generated traumatic events carry a higher risk of developing Posttraumatic Stress Disorder (PTSD) than those exposed to other kinds of events. These studies also consistently identify perceptions of social support both before and after a traumatic event as an important factor in the determining vulnerability to the development of PTSD. We review the literature on interpersonal traumas, social support and risk for PTSD and integrate findings with recent advances in developmental psychopathology, attachment theory and social neuroscience. We propose and gather evidence for what we term the social ecology of PTSD, a conceptual framework for understanding how both PTSD risk and recovery are highly dependent on social phenomena. We explore clinical implications of this conceptual framework.

Psychodynamic psychotherapy: a systematic review of techniques, indications and empirical evidence

PURPOSE

Psychodynamic psychotherapy is one of the most frequently applied methods of psychotherapy in clinical practice. However, it is the subject of controversial discussion, especially with regard to empirical evidence. In this article we aim to give an up-to-date description of the treatment and to review the available empirical evidence. Evidence is reviewed for both efficacy and mechanisms of change of short- and moderate-term psychodynamic psychotherapy. Furthermore, results of effectiveness studies of long-term psychoanalytic therapy are reviewed.

METHODS

With regard to efficacy, a protocol for a Cochrane review for (short-term) psychodynamic psychotherapy is available specifying inclusion criteria for efficacy studies.

RESULTS

Twenty-three randomized controlled trials of manual-guided psychodynamic psychotherapy applied in specific psychiatric disorders provided evidence that psychodynamic psychotherapy is superior to control conditions (treatment-as-usual or wait list) and, on the whole, as effective as already established treatments (e.g. cognitive-behavioural therapy) in specific psychiatric disorders. With regard to process research, central assumptions of psychodynamic psychotherapy were confirmed by empirical studies.

CONCLUSIONS

Further research should include both efficacy studies (on specific forms of psychodynamic psychotherapy in specific mental disorders) and effectiveness studies complementing the results from experimental research settings. Future process research should address the complex interactions among interventions, patient's level of functioning, helping alliance and outcome.

Young people's experiences of individual psychoanalytic psychotherapy

Greater emphasis is currently being placed on user involvement in shaping the delivery of mental health services and the need for increasing the evidence base for psychotherapeutic interventions such as individual psychoanalytic psychotherapy (IPP). This qualitative study reports on the range of experiences of six young people aged between 16 and 21 years in undertaking IPP. Interpretative phenomenological analysis was used to develop an in-depth understanding of their experiences. The themes identified the young people's initial expectations and concerns about starting psychotherapy, experiences of learning the ropes of therapy and the process and meaning of ending therapy. The affective relationship with the therapist was of particular importance to the young people concerned. Positive experiences of IPP included being listened to and being accepted, and talking and thinking in depth. The power differentials with respect to being a patient were also evident. The paper concludes by suggesting that paying greater attention to young people's views of psychotherapy may improve their initial engagement and help to develop services in more appropriate ways. Qualitative methodologies provide a useful adjunct to conducting process and outcome research in this context.

Does the quality of the working alliance predict treatment outcome in online psychotherapy for traumatized patients?

Background

The provision of online counseling and online therapy is steadily increasing. The results of a number of controlled trials investigating the efficacy of online approaches indicate that some of these new treatment alternatives might indeed be effective. Yet, little is known about how the therapeutic relationship (or working alliance) evolves over the Internet and whether it influences treatment outcome as it does in traditional face-to-face therapy. The working alliance has been defined as the extent to which a patient and a therapist work collaboratively and purposefully and connect emotionally.

Objective

The aim of the study was to investigate the quality and predictive relevance of the therapeutic alliance for patients receiving a short-term, Internet-based, cognitive-behavioral therapy program for posttraumatic stress reactions.

Methods

After rigorous screening for exclusion criteria of high dissociative tendencies, risk of psychosis, and suicidal tendencies, 48 patients, who had experienced a traumatic event in the past, were included in the online treatment study. The short form of the Working Alliance Inventory (WAI-S) was administered at the fourth treatment session. The relevance of the therapeutic relationship for treatment outcome was assessed in terms of residual gain from pretreatment assessment to the end of treatment. The revised Impact of Event Scale (IES-R) and the depression and anxiety subscales of the Brief Symptom Inventory (BSI) were used to assess treatment outcome.

Results

A total of 48 participants were included in the analysis. Overall, high alliance scores were found. In contrast to previous studies of conventional face-to-face therapy, there was only a low to modest association (.13 to .33) between the quality of the therapeutic relationship and treatment outcome.

Conclusion

High alliance scores indicate that it was possible to establish a stable and positive therapeutic relationship online. However, the therapeutic relationship was found to be a less relevant predictor of the therapy outcome than in face-to-face approaches. We discuss whether this finding can be attributed to methodological reasons such as the restricted range of alliance ratings obtained or the time of administration of the WAI-S, or whether the therapeutic relationship might be less relevant to the treatment outcome of online therapy approaches.

Self-reported attachment styles and therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy

The aims of this study were to explore the relationship between therapists' self-reported attachment styles and therapeutic orientation with the self-reported general therapeutic alliance and therapist-reported problems in psychological therapy.A sample of 491 psychotherapists from differing therapeutic orientations responded to a postal questionnaire. The questionnaire contained standardized measures of therapeutic alliance quality, attachment behaviours, a checklist of problems in therapy, and a brief personality inventory.Therapist-reported attachment styles generally explained a significant additional proportion of the variance in alliance and problems in therapy, over and above variance explained by general personality variables. Self-reported secure attachment style was significantly positively correlated with therapist-reported general good alliance. Self-reported anxious attachment styles were significantly negatively correlated with good alliance, and significantly positively correlated with the number of therapist-reported problems in therapy. Therapeutic orientation independently predicted a small but significant amount of the variance in reported general alliance quality in addition to that explained by attachment behaviours.

Therapeutic Alliance, Negative Mood Regulation, and Treatment Outcome in Child Abuse-Related Posttraumatic Stress Disorder

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

A review of therapist characteristics and techniques positively impacting the therapeutic alliance

The present review is a comprehensive examination of the therapist's personal attributes and in-session activities that positively influence the therapeutic alliance from a broad range of psychotherapy perspectives. Therapist's personal attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to contribute positively to the alliance. Therapist techniques such as exploration, reflection, noting past therapy success, accurate interpretation, facilitating the expression of affect, and attending to the patient's experience were also found to contribute positively to the alliance. This review reveals how these therapist personal qualities and techniques have a positive influence on the identification or repair of ruptures in the alliance.

Convergent validity of the Agnew Relationship Measure and the Working Alliance Inventory

The convergent validity of the Agnew Relationship Measure (ARM) and the Working Alliance Inventory (WAI) was assessed in samples drawn from 2 comparative clinical trials of time-limited psychotherapies for depression. In 1 sample, clients (n = 18) and therapists (n = 4) completed self-report versions of both measures after every session (n = 198). In the other sample, clients (n = 39) and therapists (n = 6) completed the ARM, and observers subsequently rated selected audiotaped sessions (n = 78) using the WAI. In both samples, the ARM's core alliance scales (Bond, Partnership, and Confidence) were correlated with the WAI's scales (Bond, Tasks, and Goals) strongly when assessed within client and therapist perspectives and, with some qualifications, moderately when assessed between client, therapist, and observer perspectives, supporting the assumption that the ARM and the WAI measure some of the same core constructs.