The first session matters: Therapist responsiveness and the therapeutic alliance in the treatment of borderline personality disorder

OBJECTIVES

The focus of the present research is to investigate the impact of therapist responsiveness at the very first session of therapy on the evaluation of therapeutic alliance from the therapist's perspective and from patient's perspective in the context of guideline-based treatment for borderline personality disorder.

DESIGN

The study has a correlational and longitudinal design applied to a 10-session therapy in a naturalistic setting.

METHODS

A total of four trained raters evaluated therapist responsiveness during the first session of therapy. After each therapy session, therapists and patients filled out the short form of the Working Alliance Inventory measuring working alliance; the sample included 13 therapists and 47 patients. Correlational analysis as well as hierarchical linear modelling exploring the relationship between first session therapist responsiveness and working alliance were performed.

RESULTS

The global evaluation of responsiveness revealed a significant relationship with the temporal evolution of the alliance rated from the therapists' perspective.

DISCUSSION

There is the necessity to further explore therapist appropriate responsiveness which could potentially explain several psychotherapy research results. Moreover, it could help in finding alternatives in order to facilitate patients' early engagement in therapy as well as facilitating the building process of therapeutic alliance. Finally, an effort should be made in order to study more individualized operationalization of responsiveness.

The therapeutic relationship and change processes in child psychotherapy: a qualitative, longitudinal study of the views of children, parents and therapists

Through the perspectives of children, parents and therapists, this study explored the therapeutic relationship as a change facilitator in different moments of psychotherapy. The children, parents, and therapists (N=15) who formed part of five therapeutic treatments were studied using a qualitative, longitudinal design. Thirty semi-structured interviews were done; half at the beginning and half after four months of psychotherapy. Children’s drawings were incorporated, and data were analysed through grounded theory methods and qualitative analysis guidelines for drawings. Participants identified several aspects of the therapeutic relationship as change facilitators. From the first encounters, the therapists’ close and adaptable attitude promoted an improved motivation for psychotherapy and enhanced engagement among children and parents. Later in the process, a positive, child-centred and affective therapeutic relationship fostered the child’s trust with the therapist as well as a positive relational experience, promoting associated changes in children and the development of socio-affective tools. Parents and therapists saw their own relationship as a change facilitator, as well as a broader understanding in parents of their children and an improved relationship with them. Parent’s and child’s changes helped each other. Specific and common aspects between participants’ perspectives provided a richer understanding of the studied phenomena. This study supports the view that a positive therapeutic relationship facilitates early changes in the motivation of children and parents, and provides them with a healing, relational experience as it develops. A positive parent-therapist relationship is also key for changes to further progress.

The Role of Personality Functioning on Early Drop out in Outpatient Substance Misuse Treatment

Treatment initiation is a major factor contributing to positive outcomes, but the supporting literature remains limited. It is difficult to draw conclusions regarding predictors of dropout, and there is a need to target clients' major early attrition vulnerabilities. Despite empirically validated models for assessing personality, little is known about its role in the treatment process. Studies that have been conducted in this area have focused mainly on stable personality traits and provide conflicting evidence. Aims: The aim of this study is to examine to what extent service users' personality functioning are potential determinants of early drop out. Methodology: A cross-sectional multi-site design examined the therapy process in a naturalistic setting in 5 outpatient preparation treatment centers with 210 service users. The current study adopts a contemporary dimensional-based framework, similar to the Alternative Model of Personality Disorder of the DSM-V and examines the role of characteristic adaptations (SIPP-118) on early drop out (CEST-Intake). Findings: From the broad spectrum of personality traits, only Depression remained significant predictor of drop out. Higher dysfunctional levels in Social Concordance [OR] = 1.85, Wald =19.87, p =.002, 95% CI [1.1, 1.9] as well as the facets Aggression Regulation, Respect and Purposefulness were also predictors of early drop out, while Treatment Readiness and Desire for Help accounted for a significant amount of variance. Conclusions: These findings extend our knowledge of the predictive role of characteristic adaptations in treatment and suggest it may be important to assess these individual differences early on and to design personalized-informed interventions.

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.

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.

Braving the Elements: Ambivalence as Opportunities for Change in Individual Psychotherapy With Men Using Intimate Partner Violence

This study examines client utterances that can be understood as ambivalent in violence-focused therapy. The purpose is to enrich our scientific understanding of client contributions to therapy when they appear ambivalent to the therapeutic project and develop clinically relevant perspectives that enable us to help this and other client groups. Using constructivist grounded theory analysis of five completed therapies, we describe three categories of client ambivalence present throughout all five therapies: I am bad, but I am not that bad; I have tried and tried in vain; and I know it is wrong, but I have to, I have no choice. The categories are described and understood from a clinical perspective. They are developed on the basis of an interpretation of what seems to be at stake for the client in the here-and-now of therapy. Clinical implications are discussed.

Exploring outcomes and initial self-report of client motivation in a college counseling center

OBJECTIVE

To explore the association between college counseling center clients' initial self-report of motivation and counseling outcome.

PARTICIPANTS

The sample was composed of 331 student clients who utilized a college counseling center from August 2007 to August 2009. The college is a public, mid-size, urban university in the Southeast.

METHODS

Motivation was measured at intake by a self-report of change readiness item. A quantitative study that employed a 5-group, pretest-posttest design included 331 student participants. Counseling outcome was measured using the Outcome Questionnaire 45.2.

RESULTS

As assigned by the clients' self-report of change readiness, counseling outcome for 5 motivation groups differed significantly (p = .004; α < .05). Compulsory participation in counseling was treated as a possible confound and was not a significant factor in counseling outcome (p = .268; α < .05).

CONCLUSIONS

Participants' initial self-report of motivation was significantly associated with counseling outcome.

Heart rate variability and the anxious client: cardiac autonomic and behavioral associations with therapeutic alliance

This exploratory study was designed to investigate the link between a client's heart rate variability (HRV) and the forming of a therapeutic alliance (TA) during psychotherapy. Change in HRV is associated with many psychological and physiological situations, including cardiac mortality. Cardiac effects were evaluated during therapy in 30 symptomatically anxious clients using HRV during six weekly 1-hour therapy sessions (S1-S6). Therapeutic index (TI), a measure of TA, was evaluated using skin conductance resonance between client and therapist. The Working Alliance Inventory provides a subjective measure of TA. State and trait anxiety and mood states were also assessed. Most HRV parameters were highest during S4. The sympathovagal balance was highest in S1 but stabilized after S2. In S4, TI was linked to high HRV parameters. Overall higher anxiety levels seem to be associated to lower HRV parameters. Conversely, in S4, high HRV parameters were linked to higher mood scores. This study found that a subjective measure of TA contradicted the physiological outcome. Results suggest that physiological data collected during therapy are a more accurate barometer of TA forming. These research findings suggest a need for further research identifying physiological markers in clients with a variety of mental health disorders over long-term therapy.

Patient-clinician ethnic concordance and communication in mental health intake visits

OBJECTIVE

This study examines how communication patterns vary across racial and ethnic patient-clinician dyads in mental health intake sessions and its relation to continuance in treatment, defined as attending the next scheduled appointment.

METHODS

Observational study of communication patterns among ethnically/racially concordant and discordant patient-clinician dyads. Primary analysis included 93 patients with 38 clinicians in race/ethnic concordant and discordant dyads. Communication was coded using the Roter Interaction Analysis System (RIAS) and the Working Alliance Inventory Observer (WAI-O) bond scale; continuance in care was derived from chart reviews.

RESULTS

Latino concordant dyad patients were more verbally dominant (p<.05), engaged in more patient-centered communication (p<.05) and scored higher on the (WAI-O) bond scale (all p<.05) than other groups. Latino patients had higher continuance rates than other patients in models that adjusted for non-communication variables. When communication, global affect, and therapeutic process variables were adjusted for, differences were reversed and white dyad patients had higher continuance in care rates than other dyad patients.

CONCLUSION

Communication patterns seem to explain the role of ethnic concordance for continuance in care.

PRACTICE IMPLICATIONS

Improve intercultural communication in cross cultural encounters appears significant for retaining minorities in care.

Treatment Process Predictors of Program Completion or Dropout among Minority Adolescents Enrolled in a Brief Motivational Substance Abuse Intervention

This study documented significant differences in alliance in a predominantly Latino sample of adolescents who either completed or dropped out of a Guided Self-Change treatment program. Therapeutic alliance, working alliance and patient involvement were assessed via ratings of audio-recorded segments of participants' counseling sessions. Descriptive discriminant function analysis identified working alliance goals, patient participation and therapist warmth and friendliness variables as significantly predictive of completion status. These results were confirmed via follow-up logistic regression analyses. The use of brief clinical tools to monitor and manage alliance among adolescents receiving treatment who are at risk for drop-out is discussed.

Where did all the pathological gamblers go? Gambling symptomatology and stage of change predict attrition in longitudinal research

Attrition can introduce a systematic bias that can negatively affect validity (Cook and Campbell, Quasi-experimentation: design and analysis issues for field settings. Rand McNally, Chicago, 1979). Current longitudinal research in gambling, however, has generally overlooked the reasons for attrition. The current research examined the relationship between pathological gambling symptomatology, stage of change and attrition. Three hundred and seventy-nine participants were contacted 12 months after initially participating in a study on gambling for a follow-up session. Logistic regression revealed those in the contemplation and preparation stages of change reported higher levels of pathological gambling symptomatology and were more likely to drop out of the study compared to those in the precontemplation stage. As predicted, gambling symptomatology mediated the relationship between stages of change and attrition. The implication for longitudinal research on gambling as well as extant findings that have used this methodological approach is discussed.