Therapeutic Alliance in Depression Treatment: Controlling for Prior Change and Patient Characteristics

The relationship between expressive suppression, therapeutic bond, and treatment outcomes of a positive affect intervention for adults with anxiety and/or depression

Expressive suppression (ES; reducing emotional expression) is linked with reduced social connectedness in individuals with anxiety or depression. One implication is that people who use ES may have difficulty establishing a bond with their therapist which may impede clinical improvement. We examined this hypothesis in 33 adults with clinically elevated anxiety or depression receiving treatment focused on enhancing positive thoughts, emotions, and behaviors. At baseline, participants rated ES for positive and negative emotions during a standardized conversation task designed to generate connectedness. They also rated measures of early (session 3) perceived therapeutic bond and treatment outcomes (i.e. positive affect and social connectedness). ES of positive (r = -.39, p = .018), but not negative (r = .06, p = .747), emotions was negatively associated with therapeutic bond. Therapeutic bond mediated the relationship between greater ES of positive emotions during affiliation and lower post-treatment positive affect, 95% bias-corrected bootstrap confidence interval [-0.021, -0.000], adjusted for pre-treatment positive affect, as well as lower post-treatment social connectedness [-0.397, -0.015]; however, the indirect effect was not significant when accounting for pre-treatment social connectedness (p > .05). ES of positive emotions may be an important factor in the development of therapeutic bond and therefore treatment outcomes for individuals with anxiety or depression.

The effect of Oxytocin administration on patient-therapist alliance congruence: Results from a randomized controlled trial

OBJECTIVES

The effects of oxytocin (OT) administration on psychotherapeutic processes have thus far been elusive. This study explored the effect of OT administration on patient-therapist congruence of the working alliance.

METHOD

Inpatients with mental disorders (N = 87) participating in a randomized controlled trial received OT (n = 44) or placebo (n = 43) intranasally twice a day, for four weeks. Patients and therapists rated the alliance after each session.

RESULTS

Oxytocin significantly moderated the level of agreement (b = -0.56, SE = 0.25, t = -2.30, p = 0.02), such that patients receiving OT demonstrated lower discrepancy (b = -0.73, p < 0.001) than did those receiving placebo (b = -1.30, p < 0.001). On the other hand, the mutual covariance of patient-therapist ratings across sessions was positive and significant for patients receiving placebo (b = 0.26, p = 0.01) but not for patients in the OT group (b = -0.06, p = .56).

CONCLUSION

Oxytocin can reduce discrepancies of patient-therapist perceptions of the alliance, although additional studies are needed to explore OT's effect on alliance development over time. As alliance congruence is associated with therapy outcomes, such intervention may lead to enhancement of therapeutic gains.

Therapists who foster social identification build stronger therapeutic working alliance and have better client outcomes

BACKGROUND

For decades we have known that therapeutic working alliance is a key contributor to client engagement and positive outcomes in therapy. However, we have made little progress in narrowing down its determinants, which is critical in supporting trainees to optimize such alliance. We make a case for the value of incorporating social psychological frameworks into models of alliance and explore the role of social identity processes in the development of therapeutic alliance.

METHOD

Across two studies, over 500 psychotherapy clients completed validated measures of alliance, social identification with their therapist, positive therapy outcomes, and a range of client and therapist characteristics.

FINDINGS

Social identification strongly predicted alliance in both samples, whereas client and therapist characteristics showed few such associations. Alliance mediated the relationship between social identification and positive therapy outcomes. In addition, we found evidence that (a) personal control is a key psychological resource in therapy that arises from social identification, and (b) therapists who engage in identity leadership (i.e., who represent and build a social identity that they share with clients) are more likely to foster social identification and its downstream benefits.

INTERPRETATION

These data show that social identity processes are key to the emergence of working alliance. We conclude with a discussion of how recent social identity and identity leadership interventions might be adapted to train therapists in relevant identity-building skills.

Providing Self-Led Mental Health Support Through an Artificial Intelligence-Powered Chat Bot (Leora) to Meet the Demand of Mental Health Care

Digital mental health services are becoming increasingly valuable for addressing the global public health burden of mental ill-health. There is significant demand for scalable and effective web-based mental health services. Artificial intelligence (AI) has the potential to improve mental health through the deployment of chatbots. These chatbots can provide round-the-clock support and triage individuals who are reluctant to access traditional health care due to stigma. The aim of this viewpoint paper is to consider the feasibility of AI-powered platforms to support mental well-being. The Leora model is considered a model with the potential to provide mental health support. Leora is a conversational agent that uses AI to engage in conversations with users about their mental health and provide support for minimal-to-mild symptoms of anxiety and depression. The tool is designed to be accessible, personalized, and discreet, offering strategies for promoting well-being and acting as a web-based self-care coach. Across all AI-powered mental health services, there are several challenges in the ethical development and deployment of AI in mental health treatment, including trust and transparency, bias and health inequity, and the potential for negative consequences. To ensure the effective and ethical use of AI in mental health care, researchers must carefully consider these challenges and engage with key stakeholders to provide high-quality mental health support. Validation of the Leora platform through rigorous user testing will be the next step in ensuring the model is effective.

The impact of working alliance in managing youth anxiety and depression: a scoping review

A working alliance (WA) is a multidimensional construct signifying a collaborative relationship between a client and a therapist. Systematic reviews of therapies to treat depression and anxiety, almost exclusively in adults, show WA is essential across psychotherapies. However, there are critical gaps in our understanding of the importance of WA in low-intensity therapies for young people with depression and anxiety. Here, we describe an initiative to explore the effect of WA on anxiety and depression outcomes in youth aged 14-24 years through a scoping review and stakeholders' consultations (N = 32). We analysed 27 studies; most were done in high-income countries and evaluated one-on-one in-person therapies (18/27). The review shows that optimal WA is associated with improvements in: relationships, self-esteem, positive coping strategies, optimism, treatment adherence, and emotional regulation. Young people with lived experience expressed that: a favourable therapy environment, regular meetings, collaborative goal setting and confidentiality were vital in forming and maintaining a functional WA. For a clinician, setting boundaries, maintaining confidentiality, excellent communication skills, being non-judgmental, and empathy were considered essential for facilitating a functional WA. Overall, a functional WA was recognised as an active ingredient in psychotherapies targeting anxiety and depression in young people aged 14-24. Although more research is needed to understand WA's influence in managing anxiety and depression in young people, we recommend routine evaluation of WA. Furthermore, there is an urgent need to identify strategies that promote WA in psychotherapies to optimise the treatment of anxiety and depression in young people.

Understanding Components of Therapeutic Alliance and Well-Being from Use of a Global Digital Mental Health Benefit During the COVID-19 Pandemic: Longitudinal Observational Study

Digital mental health services leverage technology to increase access to care, yet less is known about the quality of therapeutic relationships in a virtual setting. This study examined components of therapeutic alliance (a mechanism underlying successful treatment) and its association with beneficial treatment outcomes in a real-world, virtual setting. The objective is to examine (1) participant ratings of components of therapeutic alliance with providers in a virtual setting, (2) changes in subjective well-being and depressive symptoms among participants who began care with elevated depressive symptoms, and (3) the association between components of alliance and changes in participants’ well-being. Adults (N = 3,087, M age = 36 ± 9 years, 54% female) across the world with access to digital mental health benefits who engaged in videoconference sessions with a licensed therapist (18%, 555/3,087), certified coach (65%, 2,003/3,087), or both (17%, 529/3,087) between Sept. 29, 2020 and Oct. 12, 21. Participants completed 2 adapted items from the Working Alliance Inventory (goals and bonds subscales) after each session, and ratings were averaged across visits (Cronbach’s ɑ = .72). Participants’ World Health Organization-Five (WHO-5) Well-Being Index scores at the start and end of the study period were used to measure changes in subjective well-being. Descriptive and inferential statistics were conducted to examine average alliance ratings across demographics and utilization types and the association between alliance and well-being. The median adapted therapeutic alliance score was 4.8 (range: 1–5) and did not differ by age, country, or baseline well-being (Ps > .07). Females reported higher components of alliance than males (4.88 vs. 4.67, P = .01). Participants utilizing telecoaching reported higher components of alliance than those utilizing teletherapy or both telecoaching and teletherapy (4.83 v. 4.75, P = .004), though effect sizes were negligible. Among those with elevated baseline depressive symptoms (n = 835), participants reported an average WHO-5 increase of 15.42 points (95% CI 14.19–16.65, P < .001, Cohen d = 1.06) with 58% (485/835) reporting clinical recovery and 57% (481/835) reporting clinical improvement in depressive symptoms. Higher components of therapeutic alliance scores predicted greater well-being at follow-up (b = 2.04, 95% CI 0.09–3.99, P = .04) after controlling for age, sex, baseline WHO-5, and number of days in care (R² = .06, P < .001). Exploratory analyses indicated this association did not differ by utilization type, baseline well-being, or session utilization (Ps > .34). People with access to one-on-one videoconferencing care via a digital mental health benefit formed a strong bond and sense of alignment on goals with both coaches and therapists. Higher components of alliance scores were associated with improvements in subjective well-being among participants who began care with elevated depressive symptoms, providing evidence that a positive bond and goal alignment with a provider are two of many factors influencing virtual care outcomes. Continued focus on the quality of therapeutic relationships will ensure digital mental health services are patient-tailored as these platforms expand equitable access to evidence-based care.

Negative Effects of a Multimodal Inpatient CBASP Program: Rate of Occurrence and Their Impact on Treatment Outcome in Chronic and Treatment-Resistant Depression

Background: A growing number of studies indicate that the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is effective in treating chronic depression. However, there is no systematic research into possible negative effects. Therefore, the objectives of the study were to investigate the rate of occurrence of negative effects of an inpatient CBASP program and their impact on treatment response. Methods: Patients with chronic depression and treatment resistance who completed the 12-week multimodal inpatient CBASP treatment program in an open trial (N = 52) retrospectively completed the Inventory for the Assessment of Negative Effects of Psychotherapy (INEP) during follow-up data collection. Severity of depressive symptoms was assessed self- and observer-rated at admission, discharge, and 6 months follow-up. Rates of occurrence of negative effects were calculated and binary logistic regression analyses were conducted to determine the relationship to treatment outcome. Results: The results indicate that 92.3% of patients reported having experienced at least one negative effect and 45.2% indicated dependence on their therapist. Stigmatization and financial concerns as well as intrapersonal changes were reported by about one-third. Only dependence on the therapist negatively impacted treatment outcome in both outcome measures. Conclusions: While almost all patients reported at least one negative effect of a multimodal inpatient CBASP treatment program, most of the reported negative effects appear to be benign. However, dependence on the therapist seems to have a negative impact on treatment outcome. If these results can be replicated in future large-scale, randomized controlled prospective studies, CBASP therapists should be aware of possible dependence and consciously address it during treatment.

Long-Term Effects of Home-Based Family Therapy for Non-responding Adolescents With Psychiatric Disorders. A 3-Year Follow-Up

Objective

Home-based treatment of families with low socio-economic status and multiple psychosocial problems (multi-problem families, MPFs) is gaining importance in clinical social epidemiology and health services research. The sustainability of the treatment is of special importance in order to breach transgenerational effects.

Methods

We examined outcome, effect size, and clinical significance of home-based treatment for 84 multi-problem families in a naturalistic setting. 48 of the families were available for a follow-up after 3 years. The baseline characteristics of these family systems included low collaboration, an increased family adversity index, minors with high rates of child psychiatric disorders, a high prevalence of comorbidity, low relational family functioning, and adolescents who refused any form of treatment or had unilaterally terminated different forms of treatment before. The home-based family therapy consisted of one or two face-to-face counseling sessions per week over an average of 28.8 months (SD = 19.2). The symptoms and competence of the adolescents, the caregivers, and the family structure were assessed with 13 variables.

Results

All variables showed significant improvement rates (pre- vs. post- treatment) with medium to high effect sizes (mean of Cohen's d = 1.04, range = 0.34 - 2.18). All variables showed a sustained or even further improvement at follow-up.

Conclusion

This study provides evidence of statistically (p), practically (d), and clinically (RCI) significant changes in symptom and competence-related variables among adolescents and caregivers in MPFs with sustainable long-term effects in the 3-year follow-up period.

Clinical Demonstration of the Potential of Parental Feedback in Reducing Deterioration During Group Psychotherapy With Children

In recent years, great efforts have been exerted to minimize the rates of deterioration in clinical practice, especially in child psychotherapy. The present study explored the potential effect of routine outcome monitoring (ROM) with parents as a preventive intervention to reduce deterioration in children. Twenty-five children receiving treatment for emotional problems were randomized to parent-based, ROM-assisted group psychotherapy or to treatment as usual (TAU). A mixed-methods approach was utilized, with the number of deteriorating cases compared at the group level and two case illustrations assessed at the individual level. At the group level, there were fewer cases of deterioration in child's anxiety, parental stress, and quality of parent's alliance in the ROM-assisted group, compared with TAU. Case studies illustrated how ROM can be used as a tool to communicate with parents to prevent deterioration. Routine outcome monitoring in child psychotherapy may thus benefit therapy process and outcome. Limitations and directions for future research are discussed.

The Role of Entrapment in Crisis-Focused Psychotherapy Delivered in Psychiatric Emergency Settings: A Comparative Study

Although many mental health centers offer crisis intervention services as part of their psychiatric emergency facilities, studies assessing outcome, and process of crisis intervention psychotherapy are scarce. One potential psychological construct that might be unique to crisis intervention psychotherapy is entrapment, a psychological construct which reflects an individual's subjective perception of being in uncontrollable, unremitting, and inescapable circumstances. In this study we aimed to investigate whether changes in entrapment affect the process and outcome of crisis intervention psychotherapy, as compared to its effect in short-term psychotherapy delivered in outpatient units. Sixty-nine patients were recruited for the study. Patients were assessed for level of entrapment, symptoms, well-being, and the working alliance at three time points. The moderating effect of the type of therapy on the associations between changes in entrapment and changes in symptoms, well-being, and the working alliance were assessed using the Hayes process script. The dynamics of change following crisis intervention psychotherapy, as well as the effect of changes in entrapment on symptomatic relief, were illustrated using a clinical vignette of a patient treated in the crisis unit. Results of the moderation analyses indicated that entrapment had a more substantial effect on symptom distress in crisis intervention psychotherapy as compared to its effect in the short-term psychotherapy. Further, the difference in the effect of entrapment across the study groups was manifested primarily in internal entrapment, whereas no moderating effect was found for external entrapment. Clinical vignettes demonstrated the dynamics through which crisis intervention psychotherapy produces changes in entrapment by offering potential outlets from internal thoughts and interpretations of life circumstances. These results suggest that entrapment is a potential underlying process unique to crisis intervention psychotherapy. Limitations, directions for future research, and clinical implications are discussed.

Cognitive Behavioral Therapy for Body Image and Self-Care (CBT-BISC) among Sexual Minority Men Living with HIV: Skills-Based Treatment Mediators

Individuals develop coping skills in response to body image distress; however, the degree to which body image improvements are mediated by skill acquisition is unknown. The current study assessed skills-based mediators of CBT-BISC (n = 22) versus enhanced treatment-as-usual (n = 22) for sexual minority men with HIV and body image disturbance. Skills-based mediators included avoidance, appearance fixing, and acceptance and cognitive reappraisal. Results revealed that CBT-BISC significantly reduced body image disturbance and improved coping skills. Latent difference score mediation indicated that changes in acceptance and cognitive reappraisal significantly predicted body image disturbance changes (b = -.96, p = .001). These strategies may, therefore, have a unique role in reducing body image disturbance in sexual minority men with HIV. Clinicians may wish to prioritize these strategies in CBT-BISC. Future treatment research, with methodologically rigorous mediation designs, is needed to assess mechanisms of change and consequently improve efficacy.

The effect of process and outcome feedback in highly distressed outpatients: A randomized controlled trial

Objectives: Although process and outcome feedback is considered to be facilitative of psychotherapeutic processes, recent studies have suggested that such feedback may not produce the same effect when applied to highly distressed patients. This study examined the effect of process and outcome feedback in highly distressed patients treated in a public mental health center in Israel.Method: Patients (n = 197) were randomly allocated to receive feedback, or to treatment as usual. Therapists in the feedback condition received weekly reports, whereas therapists in the control group received no feedback. After attrition from study and treatment, a total of 123 cases were analyzed.Results: Feedback had no significant effect on either symptom reduction or on well-being. However, patients in the feedback group showed higher gains in alliance as compared to the treatment as usual group.Conclusion: Process and outcome feedback might have a potential beneficial effect of improving alliance for patients with severe symptomatology, with whom the establishment of an alliance can be challenging. The current findings also stress the need to continue to study the effect of feedback on therapy outcomes in diverse clinical settings. Limitations and directions for future research are discussed.

Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation

Objective: To introduce readers to instrumental variable analyses for causal inferences using as an example a test of the hypothesis that the quality of the therapeutic alliance has a causal role in relation to the outcome of psychotherapy. Method: We used data from a recent non-inferiority trial of cognitive and dynamic therapies for major depressive disorder in a community mental health setting. The data (N = 161) were analyzed using standard approaches as well as a multilevel 2-stage instrumental variables approach that allows for causal interpretations by removing the influence of unmeasured confounds. Results: Instrumental variables were created at the patient and therapist level using baseline patient and therapist variables. These baseline variables predicted the alliance but were otherwise unrelated to treatment outcome other than through their effects on the alliance. Standard multilevel mixed effects analyses revealed statistically significant associations of the alliance with outcome at the therapist level of analysis. The therapist level effect remained statistically significant when using the instrumental variables approach. Conclusion: Our results support the hypothesis that, at least at the therapist level, the alliance plays a causal role in producing better outcomes. Instrumental variable analyses can be a useful tool to supplement standard analyses.

Treatment Fidelity in Mind-Body Interventions

PURPOSE

To contribute to the treatment fidelity literature by providing real-world examples and suggestion for future research and potential clinical application, this article reports on implementation, assessment, and evaluation of treatment fidelity in mind-body self-care approaches in at-risk women.

METHOD

Aligning with best practices, treatment fidelity was integrated into three randomized clinical trials. The first examined the effects of a tai chi intervention designed to decrease cardiometabolic risk factors in women; the second examined the effects of a tailored guided imagery intervention on pregnancy outcomes in African American women; and the third explored effects of a mindful physical activity intervention (yoga) on psychological outcomes in women with moderate to severe depressive symptoms.

FINDINGS

Each of the studies successfully designed, implemented, and evaluated strategies to address recommended treatment fidelity components. These strategies provided qualitative and quantitative data that informed intervention refinement, directions for future research, and application in clinical practice.

CONCLUSIONS

The treatment fidelity framework used here is based on best practices and was a feasible and reliable approach for ensuring and reporting on treatment fidelity, which is contributing to future research to foster translation of potentially effective mind-body self-care approaches into practice.

Implementing routine outcome monitoring in public mental health services in Israel: Shared and unique challenges

OBJECTIVES

This study aimed to assess the feasibility, benefits, and challenges of routine outcome monitoring (ROM) in a public mental health centre in Israel. This is the first initiation of ROM implementation in a setting of a large psychiatric hospital, affiliated with the largest health maintenance organization in Israel, Clalit Health Services.

METHODS

Four ambulatory units were invited to participate in the implementation of ROM. Prior to initiation of recruitment, staff meetings were held and broad descriptions of current knowledge regarding benefits and challenges were discussed. Upon initiation of recruitment, patients completed outcome and process questionnaires during each session, and reports of patients' progress were sent to therapists soon after sessions ended.

RESULTS

One hundred sixty-three patients were invited to participate in measurement and feedback of therapy outcomes. Overall, 101 patients and 32 therapists agreed and actively participated in the implementation phase of ROM, producing 535 evaluated measurements and reports. Clinical, methodological, legal, administrative, and ethical aspects of the implementation were encountered and documented throughout the implementation process.

CONCLUSIONS

Medical confidentiality issues, as well as the multidisciplinary nature of hospital staff work, serve as central and unique challenges for incorporating ROM in a public psychiatric hospital. Other challenges that were previously reported in other implementation studies were also encountered and included therapist overload and objections, attrition, and the need for organizational support. Recommendations for future pioneering efforts for ROM implementation in large psychiatric facilities are discussed.

Treatment expectancy, working alliance, and outcome of Trauma-Focused Cognitive Behavioral Therapy with children and adolescents

BACKGROUND

It has been shown that positive treatment expectancy (TE) and good working alliance increase psychotherapeutic success in adult patients, either directly or mediated by other common treatment factors like collaboration. However, the effects of TE in psychotherapy with children, adolescents and their caregivers are mostly unknown. Due to characteristics of the disorder such as avoidant behavior, common factors may be especially important in evidence-based treatment of posttraumatic stress symptoms (PTSS), e.g. for the initiation of exposure based techniques.

METHODS

TE, collaboration, working alliance and PTSS were assessed in 65 children and adolescents (age M = 12.5; SD = 2.9) and their caregivers. Patients' and caregivers' TE were assessed before initiation of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Patients' and caregivers' working alliance, as well as patients' collaboration were assessed at mid-treatment, patients' PTSS at pre- and post-treatment. Path analysis tested both direct and indirect effects (by collaboration and working alliance) of pre-treatment TE on post-treatment PTSS, and on PTSS difference scores.

RESULTS

Patients' or caregivers' TE did not directly predict PTSS after TF-CBT. Post-treatment PTSS was not predicted by patients' or caregivers' TE via patients' collaboration or patients' or caregivers' working alliance. Caregivers' working alliance with therapists significantly contributed to the reduction of PTSS in children and adolescents (post-treatment PTSS: β = - 0.553; p < 0.001; PTSS difference score: β = 0.335; p = 0.031).

CONCLUSIONS

TE seems less important than caregivers' working alliance in TF-CBT for decreasing PTSS. Future studies should assess TE and working alliance repeatedly during treatment and from different perspectives to understand their effects on outcome. The inclusion of a supportive caregiver and the formation of a good relationship between therapists and caregivers can be regarded as essential for treatment success in children and adolescents with PTSS.

Five Interpersonal Factors Are Predictive of the Response to Treatment of Major Depression With Antidepressants in Primary Care

Introduction: Factors relating to the interpersonal relationship between the patient and their physician and social environment are important components, which contribute to their response to treatment for major depressive disorder. This study aimed to assess the influence of optimism, perfectionism, therapeutic alliance, empathy, social support, and adherence to medication regimen in the response to antidepressant treatments in the context of normal primary care clinical practice. Method: We conducted a prospective study in which 24 primary care physicians administered sertraline or escitalopram to 89 patients diagnosed with major depressive disorder. The response to treatment and remission of the episode was assessed at 4 and 12 weeks by Cox regression. The effect of adherence to the medication regimen was assessed by multiple regression statistical techniques. Results: Adherence to medication (HR = 0.262, 95% CI = 0.125-0.553, p < 0.001) and patient perfectionism (HR = 0.259, 95% CI = 0.017-0.624, p < 0.01) negatively predicted the initial response to treatment, whereas patient optimism (HR = 1.221, 95% CI = 1.080-1.380, p < 0.05) positively predicted it. Patient optimism (HR = 1.247, 95% CI = 1.1-1.4, p < 0.05), empathy perceived by the patient (HR = 1.01, 95% CI = 1001-1002, p < 0.05), and therapeutic alliance (HR = 1.02, 95% CI = 1001-1.04, p < 0.05) positively predicted episode remission, while patient perfectionism (HR = 0.219, 95% CI = 0.093-0.515, p < 0.001) and low adherence to the treatment regimen (HR = 0.293, 95% CI = 0.145-0.595, p < 0.001) negatively predicted it. Finally, social support (p < 0.01) and therapeutic alliance (p < 0.05) predicted adherence to the medication regimen. Conclusions: In addition to taking the antidepressant drug, other factors including the personal interactions between the patient with their primary care physician and with their social environment significantly influenced the patients' initial response and the final rate of episode remission.

Pharmacotherapy for social anxiety disorder: Interpersonal predictors of outcome and the mediating role of the working alliance

Social anxiety disorder (SAD) is highly prevalent and associated with high levels of impairment and distress. Therapies for SAD leave many patients symptomatic at the end of treatment, and little is known about predictors or mechanisms of treatment outcome. Given the interpersonal dysfunction fundamental to SAD, this study investigated whether prominent interpersonal features of SAD (submissive behavior, childhood maltreatment, suppression of anger, and depression) predicted attrition and response to pharmacotherapy and whether the working alliance mediated these relationships. This is the first study to examine the role of the working alliance in pharmacotherapy for SAD. One hundred thirty-eight treatment-seeking individuals with a primary diagnosis of SAD received 12 weeks of open treatment with paroxetine. Higher levels of depression predicted greater severity of SAD at the end of treatment, and higher levels of submissive behavior and childhood emotional maltreatment predicted a greater probability of attrition from treatment. The psychiatrist-assessed working alliance mediated response to pharmacotherapy for individuals who reported a history of emotional maltreatment. These results identify variables that predict pharmacotherapy outcome and emphasize the importance of the working alliance as a mechanism of treatment response for those with a history of emotional maltreatment. Implications for person-specific treatment selection are discussed.

Validity of the Flemish working alliance inventory in a Dutch physiotherapy setting in patients with shoulder pain

BACKGROUND

Working alliance is the interaction between the patient and therapist. It is a crucial part of the physiotherapeutic process. One instrument to measure working alliance is available in Dutch/Flemish language and validated in psychotherapy setting.

OBJECTIVE

This study aims to validate the Working Alliance Inventory Short-Form in a Dutch physiotherapy setting.

DESIGN

A prospective cohort study in primary-care physiotherapy.

METHOD

To validate the Dutch/Flemish version of the working alliance inventory short-form (WAV-12) a RASCH analysis was used.

RESULTS

Sixty-six physiotherapists enrolled in total 389 patients with an average age of 50 years and a mean duration of shoulder pain of 33 weeks. A total of 274 patients filled in one or more items of the WAV-12. The WAV-12 showes good discriminative abilities and all items contributed to a one-dimensional construct. Due to the selective nature of the missing items, we believed rewording was necessary to make it more suitable to the physiotherapy setting. We performed a Delphi study and revised the WAV-12 into the PAS (Physio Alliance Scale). The validity of the revised version is unknown and is therefore not sufficiently strong to be implemented as a measurement tool.

LIMITATIONS

The response rate for three items especially was low and we found ceiling effects in ten items.

CONCLUSION

Although the measurement instrument shows good internal consistency and reliability, we made adjustments to the WAV-12 for Dutch physiotherapy setting.

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.

Working Alliance, Interpersonal Problems, and Depressive Symptoms in Tele-Interpersonal Psychotherapy for HIV-infected Rural Persons: Evidence for Indirect Effects

OBJECTIVE

Interpersonal psychotherapy (IPT) has demonstrated efficacy for the treatment of depression, yet little is known about its therapeutic mechanisms. As a specific treatment, IPT has been shown to directly reduce depressive symptoms, although it is unclear whether these reductions occur via interpersonal changes. Within IPT, the potential role of the working alliance, a common factor, as a predictor of depression and interpersonal changes is also unclear.

METHOD

Participants were 147 depressed persons living with HIV in rural communities of 28 U.S. states enrolled in a randomized clinical trial. Seventy-five patients received up to 9 sessions of telephone-administered IPT (tele-IPT) plus standard care and 72 patients received standard care only. Two models were tested; one included treatment condition (tele-IPT vs. control) and another included the working alliance as independent variables.

RESULTS

The first model found an indirect effect whereby tele-IPT reduced depression via decreased social avoidance. There was a direct effect between tele-IPT and reduced depression. In the second model, the working alliance influenced depressive symptom relief via reductions in social avoidance. Both goal and task working alliance subscales were indirectly associated with reductions in depressive symptoms, also through reductions in social avoidance. There were no direct effects involving the working alliance. Tele-IPT's influence on depressive symptom reduction was primarily through a direct effect, whereas the influence of working alliance depression was almost entirely via an indirect effect through interpersonal problems.

CONCLUSION

Study findings have implications for IPT when intervening with depressed rural people living with HIV/AIDS over the telephone.

Helping Alliance and Unmet Needs in Routine Care of People With Severe Mental Illness Across Europe: A Prospective Longitudinal Multicenter Study

The helping alliance (HA) refers to the collaborative bond between patient and therapist, including shared goals and tasks. People with severe mental illness have a complex mixture of clinical and social needs. Using mixed-effects regression, this study examined in 588 people with severe mental illness whether an increase in the HA is associated with fewer unmet needs over time, and whether change in the HA precedes change in unmet needs. It was found that a reduction in unmet needs was slower in patients with higher HA (B = 0.04, p < 0.0001) only for patient-rated measures. Improvement in both patient-rated and staff-rated HA over time was associated with fewer subsequent patient-rated (B = -0.10, p < 0.0001) and staff-rated (B = -0.08, p = 0.0175) unmet needs. With positive changes in the HA preceding fewer unmet needs, findings provide further evidence for a causal relationship between alliance and outcome in the treatment of people with severe mental illness.

Enlight: A Comprehensive Quality and Therapeutic Potential Evaluation Tool for Mobile and Web-Based eHealth Interventions

BACKGROUND

Studies of criteria-based assessment tools have demonstrated the feasibility of objectively evaluating eHealth interventions independent of empirical testing. However, current tools have not included some quality constructs associated with intervention outcome, such as persuasive design, behavior change, or therapeutic alliance. In addition, the generalizability of such tools has not been explicitly examined.

OBJECTIVE

The aim is to introduce the development and further analysis of the Enlight suite of measures, developed to incorporate the aforementioned concepts and address generalizability aspects.

METHODS

As a first step, a comprehensive systematic review was performed to identify relevant quality rating criteria in line with the PRISMA statement. These criteria were then categorized to create Enlight. The second step involved testing Enlight on 42 mobile apps and 42 Web-based programs (delivery mediums) targeting modifiable behaviors related to medical illness or mental health (clinical aims).

RESULTS

A total of 476 criteria from 99 identified sources were used to build Enlight. The rating measures were divided into two sections: quality assessments and checklists. Quality assessments included usability, visual design, user engagement, content, therapeutic persuasiveness, therapeutic alliance, and general subjective evaluation. The checklists included credibility, privacy explanation, basic security, and evidence-based program ranking. The quality constructs exhibited excellent interrater reliability (intraclass correlations=.77-.98, median .91) and internal consistency (Cronbach alphas=.83-.90, median .88), with similar results when separated into delivery mediums or clinical aims. Conditional probability analysis revealed that 100% of the programs that received a score of fair or above (≥3.0) in therapeutic persuasiveness or therapeutic alliance received the same range of scores in user engagement and content-a pattern that did not appear in the opposite direction. Preliminary concurrent validity analysis pointed to positive correlations of combined quality scores with selected variables. The combined score that did not include therapeutic persuasiveness and therapeutic alliance descriptively underperformed the other combined scores.

CONCLUSIONS

This paper provides empirical evidence supporting the importance of persuasive design and therapeutic alliance within the context of a program's evaluation. Reliability metrics and preliminary concurrent validity analysis indicate the potential of Enlight in examining eHealth programs regardless of delivery mediums and clinical aims.

'She believed in me'. What patients with depression value in their relationship with practitioners. A secondary analysis of multiple qualitative data sets

BACKGROUND

Clinical guidance promotes the practitioner-patient relationship as integral to good quality person-centred care for patients with depression. However, patients can struggle to engage with practitioners and practitioners have indicated that they want more guidance on how to establish effective relationships with their patients.

OBJECTIVE

To identify what practitioner attributes patients with depression particularly value or find problematic.

METHOD

A secondary analysis of data collected during four qualitative studies, all of which entailed interviewing patients diagnosed with depression about their treatment experiences. Patients in the four studies had received different treatments. These included antidepressants, cognitive behaviour therapy, facilitated physical activity and listening visits. We thematically analysed 32 patient accounts.

RESULTS

We identified two complimentary sets of important practitioner attributes: the first based on the practitioner's bearing; the second based on the practitioner's enabling role. We found that patients value practitioners who consider their individual manner, share relevant personal information, show interest and acceptance, communicate clearly and listen carefully, collaborate on manageable goals and sanction greater patient self-care and self-compassion. It was also evident that patients receiving different treatments value the same practitioner attributes and that when these key practitioner qualities were not evident, patients were liable not to re-attend or comply with treatment.

CONCLUSION

The practitioner attributes that patients with depression most value have a positive impact on their engagement with treatment. Patients emphasise the importance of a practitioner's demeanour and encouragement, rather than the amount of time or specific treatment a practitioner is able to provide.

Common Factors in Pediatric Psychiatry: A Review of Essential and Adjunctive Mechanisms of Treatment Outcome

OBJECTIVE

The purpose of this article is to review the literature on hypothesized behavioral correlates of pharmacotherapy treatment response. A particular focus is placed on what have been referred to as "common factors" across mental health treatments, including medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes. These understudied factors may provide unique explanations for mechanisms of symptom change, patient risk as a result of protocol deviation, and attenuated treatment outcomes.

METHOD

A literature search was conducted to evaluate the relationship between treatment processes in pediatric psychiatry and medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes.

RESULTS

Substantial variability and room for improvement was identified for each common factor. Behavioral protocols have already been developed to address many aspects of common factors in pediatric psychiatric treatment, but are not yet a part of many practice parameters.

CONCLUSION

Interventions to improve common factors can be used immediately in tandem with psychopharmacological interventions to provide increased symptom relief and reduce patient risk. Furthermore, incorporating instruction in common factors interventions can positively affect training of future providers and enhance understanding of the mechanisms of effect of medications. An increased focus on common factors, with a particular emphasis on quantifying the magnitude and mechanisms of their effects on psychopharmacological interventions stand to benefit child patients, their families, treatment providers, training facilities, and pharmaceutical manufacturers.

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.

Psychiatrists' Attitudes Toward Non-Pharmacologic Factors Within the Context of Antidepressant Pharmacotherapy

OBJECTIVE

Recent meta-analyses of antidepressant clinical trials have suggested that up to 82 % of response can be attributed to non-medication-related factors. The present study examines psychiatrists' attitudes regarding non-pharmacologic factors within the context of antidepressant pharmacotherapy.

METHODS

A web-based, 20-question cross-sectional survey was distributed to 101 staff psychiatrists and 48 post-graduate trainees in psychiatry at an academic hospital in Boston, MA. Demographics, practice characteristics, beliefs about non-pharmacologic factors affecting prescribing practices, perceived response and remission rates, and opinions about the need for further investigations in the psychopharmacology process were assessed.

RESULTS

Overall completion rate was 53 %. The final sample included 79 responses. The medians for clinician-perceived response rates (54 %) and remission rates (33 %) were in agreement with published rates. The reported median of the what portion of clinical outcomes is believed to be due to placebo effects (26 %) was numerically lower than suggested by literature. The contribution of the active ingredients of medications was perceived to be significantly higher than the contribution of patient characteristics and clinician characteristics. A longer time since graduation from medical school was significantly associated with higher belief in the effect of the active ingredients of antidepressant medications and with less perceived importance of placebo effects.

CONCLUSION

These findings suggest a discrepancy between empirical evidence and psychiatrists' beliefs on the impact of placebo effects on clinical outcomes. Educating antidepressant prescribers about the evidence based on psychosocial mediators of placebo effects' contribution to outcome may represent a promising strategy for improving clinical outcomes.

Therapeutic alliance mediates the association between personality and treatment outcome in patients with major depressive disorder

BACKGROUND

Patient personality traits have been shown to influence treatment outcome in those with major depressive disorder (MDD). The trait agreeableness, which reflects an interpersonal orientation, may affect treatment outcome via its role in the formation of therapeutic alliance. No published studies have tested this hypothesis in patients with MDD.

METHOD

Participants were 209 outpatients with MDD who were treated in a randomized control trial. Mediation analyses were conducted to examine the role of therapeutic alliance in the association between pretreatment personality and the reduction of depression symptom severity during treatment. Separate models were estimated for patient- versus therapist-rated therapeutic alliance.

RESULTS

We found a significant indirect effect of agreeableness on the reduction of depression severity via patient-rated therapeutic alliance. Results were replicated across two well-validated measures of depression symptom severity. Results also partially supported indirect effects for extraversion and openness. Therapist ratings of alliance did not mediate the association between personality and treatment outcomes.

LIMITATIONS

Patients were recruited as part of a randomized control trial, which may limit the generalizability of results to practice-based clinical settings. Due to constraints on statistical power, intervention-specific mediation results were not examined.

CONCLUSIONS

These results highlight the importance of personality and the role it plays in treatment process as well as outcome.

Cognitive-Behavioural Analysis System of Psychotherapy (CBASP), a drug, or their combination: differential therapeutics for persistent depressive disorder: a study protocol of an individual participant data network meta-analysis

INTRODUCTION

Despite important advances in psychological and pharmacological treatments of persistent depressive disorders in the past decades, their responses remain typically slow and poor, and differential responses among different modalities of treatments or their combinations are not well understood. Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) is the only psychotherapy that has been specifically designed for chronic depression and has been examined in an increasing number of trials against medications, alone or in combination. When several treatment alternatives are available for a certain condition, network meta-analysis (NMA) provides a powerful tool to examine their relative efficacy by combining all direct and indirect comparisons. Individual participant data (IPD) meta-analysis enables exploration of impacts of individual characteristics that lead to a differentiated approach matching treatments to specific subgroups of patients.

METHODS AND ANALYSIS

We will search for all randomised controlled trials that compared CBASP, pharmacotherapy or their combination, in the treatment of patients with persistent depressive disorder, in Cochrane CENTRAL, PUBMED, SCOPUS and PsycINFO, supplemented by personal contacts. Individual participant data will be sought from the principal investigators of all the identified trials. Our primary outcomes are depression severity as measured on a continuous observer-rated scale for depression, and dropouts for any reason as a proxy measure of overall treatment acceptability. We will conduct a one-step IPD-NMA to compare CBASP, medications and their combinations, and also carry out a meta-regression to identify their prognostic factors and effect moderators. The model will be fitted in OpenBUGS, using vague priors for all location parameters. For the heterogeneity we will use a half-normal prior on the SD.

ETHICS AND DISSEMINATION

This study requires no ethical approval. We will publish the findings in a peer-reviewed journal. The study results will contribute to more finely differentiated therapeutics for patients suffering from this chronically disabling disorder.

TRIAL REGISTRATION NUMBER

CRD42016035886.

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

BACKGROUND

This paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis.

METHODS

All clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5months, 9months and 18months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy.

RESULTS

At baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point.

CONCLUSIONS

Findings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.

Psychotherapy Outcome Research: Issues and Questions

Emphasis on identifying evidence-based therapies (EBTs) has increased markedly. Lists of EBTs are the rationale for recommendations for how psychotherapy provider training programs should be evaluated, professional competence assessed, and licensure and reimbursement policies structured. There are however methodological concerns that limit the external validity of EBTs. Among the most salient is the circularity inherent in randomized control trials (RCTs) of psychotherapy that constrains the manner in which the psychological problems are defined, psychotherapy can be practiced, and change evaluated. RCT studies favor therapies that focus of specific symptoms and can be described in a manual, administered reliably across patients, completed in relatively few sessions, and involve short-term evaluations of outcome. The epistemological assumptions of a natural science approach to psychotherapy research limit how studies are conducted and assessed in ways that that advantage symptom-focused approaches and disadvantage those approaches that seek to bring broad recovery-based changes. Research methods that are not limited to RCTs and include methodology to minimize the effects of "therapist allegiance" are necessary for valid evaluations of therapeutic approaches that seek to facilitate changes that are broader than symptom reduction. Recent proposals to adopt policies that dictate training, credentialing, and reimbursement based on lists of EBTs unduly limit how psychotherapy can be conceptualized and practiced, and are not in the best interests of the profession or of individuals seeking psychotherapy services.

Dynamic relationships of therapist alliance and group cohesion in transdiagnostic group CBT for anxiety disorders

OBJECTIVE

Little is known about the temporal variability of the alliance-symptom change and cohesion-symptom change relationships over the course of group therapy. These questions were examined in a sample of 373 clients receiving a transdiagnostic cognitive behavior therapy (tCBT), which culled the principle research-supported mechanisms of change for anxiety disorders.

METHOD

The authors examined relationships between the client versions of the Working Alliance Inventory and Group Cohesion Scale in predicting subsequent symptom change, as assessed by the state scale of the State-Trait Anxiety Inventory.

RESULTS

Alliance and cohesion were significant predictors of next session anxiety scores. The alliance was consistently associated with anxiety symptoms (rs = -.152 to -.198, ps < .05), but cohesion only showed significant relationships with anxiety symptoms at Sessions 8 and 10 (Session 8, r = -.233, p = .020, and 10, r = -.236, p = .027). Alliance-anxiety relations remained constant, whereas cohesion-anxiety relations substantially increased from earlier to later sessions.

DISCUSSION

Differences that were obtained in the relation of alliance and cohesion with anxiety symptoms suggests that these processes have different roles within group tCBT. If replicated, the present findings would suggest that the dynamic relationships between alliance and cohesion and symptoms within group CBT for anxiety disorders have been an important omission in process-outcome studies.

The development and implementation of a theory-informed, integrated mother-child intervention in rural Uganda

RATIONALE

A randomised cluster effectiveness trial of a parenting intervention in rural Uganda found benefits to child development among children 12-36 months, relevant parenting practices related to stimulation, hygiene and diet, and prevented the worsening of mothers' depressive symptoms. An examination of underlying implementation processes allows researchers and program developers to determine whether the program was implemented as intended and highlight barriers and facilitators that may influence replication and scale-up.

OBJECTIVES

The objectives of this study were to describe and critically examine (a) perceived barriers and facilitators related to implementation processes of intervention content, training and supervision and delivery from the perspectives of delivery agents and supervisors; (b) perceived barriers and facilitators related to enactment of practices from the perspective of intervention mothers participating in the parenting program; and c) whether the program was implemented as intended.

METHODS

Semi-structured interviews were conducted at midline with peer delivery agents (n = 12) and intervention mothers (n = 31) and at endline with supervisors (n = 4). Content analysis was used to analyze qualitative data in terms of barriers and facilitators of intervention content, training and supervision, delivery and enactment. Additionally, mothers' recall and enactment of practices were coded and analyzed statistically. Monitoring of group sessions and home visits were examined to reveal whether the program was implemented as intended.

RESULTS

Among the program's five key messages, 'love and respect' targeting maternal psychological well-being was the most practiced by mothers, easiest to implement by delivery agents, and mothers reported the most internal facilitators for this message. A detailed manual and structured monitoring forms were perceived to facilitate training, intervention delivery, and supervision. Interactive and active strategies based on social-cognitive learning theory were reported as facilitators to intervention delivery. Only program attendance, but not barriers, facilitators or message recall, was significantly positively related to message enactment. Monitoring of group sessions and home visits showed that the program was largely implemented as intended.

CONCLUSIONS

This implementation assessment revealed a number of important barriers and facilitators from the perspectives of delivery agents, supervisors and program participants. The methods and results are useful to examining and informing the content, delivery, and scaling up of the current program as well as future mother-child interventions in LMIC settings.

Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder

Trauma-focused cognitive behaviour therapy is effective in treating posttraumatic stress disorder but non-response rates range between 25% and 50%. Results of previous research on patient characteristics predicting outcome are inconsistent and mainly focused on demographic and diagnostic variables. This study examined whether behavioural predictors of poor treatment response can be observed in early sessions. It was predicted that greater patient perseveration, lower expression of thoughts and feelings and weaker therapeutic alliance would be associated with poorer outcomes. We also explored the relationships of patient behaviours with therapeutic alliance and the efficiency and competence of treatment delivery. Audio or video recordings of the initial treatment sessions of 58 patients who had shown either good (n = 34) or poor response (n = 24) to cognitive therapy for PTSD (CT-PTSD, Ehlers & Clark, 2000) were blindly coded for patient perseveration, expression of thoughts and feelings, therapeutic alliance, efficiency and competency of treatment delivery and therapist competence. Poor responders showed more perseveration and less expression of thoughts and feelings in the initial session. Patient perseveration and low expression of thoughts and feelings were associated with poorer therapeutic alliance and compromised treatment delivery. Patients with these behavioural characteristics may benefit from additional treatment strategies. Limitations of the study and implications for clinical practice are discussed.

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The study examined whether patient behaviour in initial treatment sessions predicts outcome.

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Poor treatment responders showed more perseveration and lower expression of thoughts and feelings than good responders.

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These patient characteristics were associated with poorer therapeutic alliance.

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These characteristics were also associated with lower ratings of the efficacy and competency of treatment delivery.

The Multisystemic and Multilevel Investigation of the Expanded Therapeutic Alliance-Psychological Functioning Relationship in Individual Therapy

The expanded therapeutic alliance, consisting of multiple interpersonal alliance relationships, is a common factor inherent to the practice of all systemic therapies. The following study has three specific aims: (a) Bring an expanded, multisystemic emphasis to the study of the therapeutic alliance in individual therapy; (b) Understand better the session-by-session relationship between alliance and psychological functioning, including distinguishing within-person from between-person variability by using multilevel modeling techniques; and (c) Explore the role of early attachment relationships and family-of-origin experiences in moderating the alliance-psychological functioning relationship. Instead of taking only one or two alliance measurements throughout treatment like in the majority of previous research, we measured both alliance and psychological functioning continuously at each session for 296 subjects.

The relationship between patient object relations and the therapeutic alliance in a naturalistic psychotherapy sample

OBJECTIVES

This study examined the relationship between patients' object relations and interpersonal process in psychotherapy. Namely, we tested the hypothesis that the quality of patients' object relations is positively associated with both patient- and therapist-rated alliance quality.

DESIGN

Psychotherapy was administered naturalistically, with quantitative data collection before and during treatment.

METHODS

Participants included 73 adult outpatients and 23 therapists at two mental health clinics. Using the Bell Object Relations and Reality Testing Inventory, we measured four dimensions of patients' object relations at baseline-alienation, insecure attachment, egocentricity, and social incompetence. Using the Working Alliance Inventory, we measured alliance from patient and therapist perspectives. Control variables included time, patient demographics, symptom severity, and clinic. We employed hierarchical linear modelling to analyse data with a nested structure, with 138 sessions at Level 1, 73 patients at Level 2, and 23 therapists at Level 3.

RESULTS

Patient alienation and insecure attachment were associated with lower patient-rated alliance, while egocentricity was associated with higher patient-rated alliance. Patients' object relations were not significantly associated with therapist-rated alliance. On average, patients perceived the alliance more positively than their therapists, with a weak positive correlation between the alliance perspectives.

CONCLUSIONS

The results suggest that object relation dimensions may be important patient characteristics for forecasting therapeutic relationship quality. They also call for more attention to differences between alliance rating perspectives.

PRACTITIONER POINTS

Treatment may benefit from more attention to the quality of patients' object relations. If patients present with high levels of alienation and insecure attachment, therapists may need to pay especially close attention to the therapeutic alliance, and prudently address any ruptures in its quality. When monitoring the alliance quality, it is important to consider that patients and therapists may have different perspectives. Therapists relying solely on their own perceptions are at risk of missing alliance difficulties, and patients' object relations may be uniquely predictive of their own sense of the alliance. Therefore, it may be helpful to ask patients in session and through standardized measures for feedback on how they perceive the goals and tasks of treatment and the emotional bond with their therapist. Again, any alliance tensions could then be addressed directly as a means to maintaining engagement in the service of better outcome.

Therapist-client relationships in a psychological therapy trial for psychosis and substance misuse

BACKGROUND

This study aimed to explore factors associated with outcomes in a randomised controlled trial of integrated motivational interviewing and cognitive behavioural therapy for psychosis and substance misuse.

METHOD

Clients and therapists completed self-report measures of alliance and clients completed a self-report measure of adult attachment. Trial therapists were also asked to identify challenges in therapy, client strengths and reasons for client making and not making changes in relation to substance misuse.

RESULTS

Neither therapist-rated nor client-rated alliance was significantly related to objective outcomes. Client insecure attachment avoidance was associated with poorer symptoms and functioning at 12 and 24 months; although not changes in substance misuse. Therapists' perceptions of therapeutic processes (e.g., challenges to therapy, client strengths, client reasons for change and alliance) were consistent with previous literature. Therapists' perceptions of client improvement were associated with reductions in substance use at the end of treatment and their ratings of therapeutic alliance.

CONCLUSION

Insecure adult attachment styles may be a potentially important predictor of symptom outcomes for people with psychosis and substance misuse. Trial therapists may also provide an important source of information about therapeutic processes and factors associated with outcome.

Does alliance predict symptoms throughout treatment, or is it the other way around?

OBJECTIVE

Scholars increasingly recognize that therapeutic alliance and symptomatic change are associated with one another. A common assumption is that alliance predicts symptomatic change. However, the issue is far from settled. One challenge in determining the causality is the establishment of temporal precedence showing that alliance, as opposed to previous symptomatic change, drives subsequent symptomatic reduction.

METHOD

To make further advances in untangling this chicken-and-egg question, we employed autoregressive cross-lagged modeling over 4 time points in a sample of 149 depressive patients receiving supportive-expressive psychotherapy or clinical management combined with pharmacotherapy or clinical management combined with placebo.

RESULTS

Using this methodology, we found that both alliance and symptoms across treatment made significant and unique contributions in predicting subsequent symptomatic levels throughout treatment. Additionally, alliance, but not symptoms, predicted subsequent alliance levels. No differences were found between treatments.

CONCLUSIONS

Our findings imply that alliance temporally precedes symptomatic levels throughout treatment.