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Levi E, Peysachov G, Admon R, Zilcha-Mano S. Cortisol interdependence during psychotherapy in major depressive disorder. Psychoneuroendocrinology 2024; 163:106983. [PMID: 38367530 DOI: 10.1016/j.psyneuen.2024.106983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/16/2024] [Accepted: 01/30/2024] [Indexed: 02/19/2024]
Abstract
The current study explored cortisol interdependence between patients and therapists during psychotherapy, the possible moderating effect of patient alliance ratings on this interdependence, and the associations between cortisol interdependence and treatment outcome. While cortisol interdependence was explored in other interpersonal contexts, its presence in psychotherapy has remained unexplored. We hypothesized that (a) patients' and therapists' cortisol levels at pre-session will predict their own and their partner's subsequent cortisol levels at post-session, (b) patient ratings of their relationship with their therapists will moderate these partner effects, and (c) cortisol interdependence will be associated with better treatment outcome. Fifty dyads undergoing 16 weeks of psychodynamic treatment for major depressive disorder participated in this study. Patient-therapist salivary cortisol samples were collected at eight time points, alongside a post-session patient-rated alliance questionnaire and a symptom severity interview. For analyses we employed the actor-partner interdependence model. Results revealed that (a) patients' and therapists' cortisol levels before sessions predicted their own post-session cortisol changes. However, significant cortisol interdependence was observed in patients' pre-session cortisol levels predicting therapists' post-session cortisol levels. Furthermore, (b) poorer alliance ratings associated with more pronounced cortisol interdependence, and (c) in dyads where patient pre-session cortisol predicted therapist's post-session cortisol, a better treatment outcome was found. This study found novel evidence of cortisol interdependence in psychotherapy and is partially in line with other studies inspecting cortisol interdependence in adjacent research fields. These findings emphasize the intricate psychophysiological interactions within therapeutic relationships and their associations with treatment outcome.
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Affiliation(s)
- Eyal Levi
- Department of Psychology, University of Haifa, Israel
| | | | - Roee Admon
- Department of Psychology, University of Haifa, Israel; The Integrated Brain and Behavior Research Center (IBBRC), University of Haifa, Israel
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Li X, Wu M, Li F. Examining therapist estimation of client working alliance and client symptom outcome using truth and bias model and response surface analysis. Psychother Res 2024; 34:503-517. [PMID: 37014789 DOI: 10.1080/10503307.2023.2193671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/15/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE The aims of this study were to investigate the congruence and discrepancy between Chinese therapist trainees' estimated client working alliance (WA) and their clients' actual WA rating, and how the congruence and discrepancy predicted client symptom outcome. METHODS Participants were 211 beginning therapist trainees and 1216 clients. Data from their 6888 sessions were analyzed using Truth and Bias Model and Response Surface Model. RESULTS AND CONCLUSIONS (i) Chinese trainees' estimation of client WA was on average significantly lower than actual client WA. (ii) At the between-person level, whether the trainee generally over- or underestimated client WA was not related to the client's initial symptom level or symptom improvement rate. (iii) At the within-person between-session level, a session where a trainee accurately perceived high client WA, compared to a session where the trainee accurately perceived low client WA, was followed by greater client symptom relief before the next session. In the case of estimation bias, a session where the trainee underestimated client WA was followed by greater client symptom reduction in the next session, rather than the other way around when the trainee overestimated client WA. Implications on therapist training were discussed.
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Affiliation(s)
- Xu Li
- Department of Educational Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Manxuan Wu
- Department of Educational Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Feihan Li
- Faculty of Psychology, Beijing Normal University, Beijing, People's Republic of China
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Schaffler Y, Jesser A, Humer E, Haider K, Pieh C, Probst T, Schigl B. Process and outcome of outpatient psychotherapies under clinically representative conditions in Austria: protocol and feasibility of an ongoing study. Front Psychiatry 2024; 15:1264039. [PMID: 38510799 PMCID: PMC10951102 DOI: 10.3389/fpsyt.2024.1264039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/16/2024] [Indexed: 03/22/2024] Open
Abstract
Background While most studies assessing psychotherapy efficacy are randomized-controlled trials conducted in research institutions or short clinical treatments, the understanding of psychotherapy effectiveness under regular, clinically representative conditions, particularly in outpatient practice, remains limited. Representative data examining the effectiveness of psychotherapy under real-world conditions in Austria is lacking. Aims and Methods This paper introduces a naturalistic observational combined process- and outcome study, implementing a dual-perspective approach through standardised pre- and post-treatment questionnaires and evaluating changes in the therapeutic alliance after each session. Further, semi-structured qualitative interviews aim to illuminate the personal experiences of patients and therapists. The primary objective of the presented study is to discern whether symptoms markedly decrease following therapy. A significant secondary goal is to trace the therapeutic alliance's evolution from both patient and therapist viewpoints, emphasising the alliance-outcome association and gender dynamics within the pairs. This paper discusses the project's feasibility after three years and shares key insights. Discussion Recruitment for this study has posed substantial challenges due to psychotherapists' concerns regarding data protection, extensive documentation, and philosophical reservations about the study design. Consequently, we recruited fewer participants than initially planned. Despite these hurdles, qualitative data collection has shown notable success. Given psychotherapists' busy schedules and reluctance to participate, more potent external incentives or a legal obligation may be necessary to encourage participation in future studies.
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Affiliation(s)
- Yvonne Schaffler
- Department for Psychosomatic Medicine and Psychotherapy, University for Continuing Education Krems, Krems, Austria
| | - Andrea Jesser
- Faculty of Psychotherapy Science, Sigmund Freud University Vienna, Vienna, Austria
| | - Elke Humer
- Department for Psychosomatic Medicine and Psychotherapy, University for Continuing Education Krems, Krems, Austria
- Faculty of Psychotherapy Science, Sigmund Freud University Vienna, Vienna, Austria
| | - Katja Haider
- Department for Psychosomatic Medicine and Psychotherapy, University for Continuing Education Krems, Krems, Austria
| | - Christoph Pieh
- Department for Psychosomatic Medicine and Psychotherapy, University for Continuing Education Krems, Krems, Austria
| | - Thomas Probst
- Division of Psychotherapy, Department of Psychology, Paris Lodron University Salzburg, Salzburg, Austria
| | - Brigitte Schigl
- Department Psychology and Psychodynamics, Karl Landsteiner University of Health Sciences, Krems, Austria
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Prusiński T. Personality disorder type only sometimes matters: An exploration of patient's personality disorder as a source of variance in early therapeutic alliance. Clin Psychol Psychother 2023. [PMID: 38149525 DOI: 10.1002/cpp.2943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE The study aimed to analyse personality disorders among patients in the early phase of psychotherapy as a source of variance in the quality of the emerging alliance. METHODS The sample consisted of 131 individual psychotherapy patients with borderline (BPD), narcissistic (NPD), dependent (DPD) and obsessive-compulsive (OCPD) personality disorders and 131 psychotherapists. Different sources of alliance estimation were included. Therapeutic alliance was operationalized on several dimensions. The hypothesis was tested using an independent samples one-way analysis of variance. RESULTS The study revealed a significant effect of personality disorder type on early therapeutic alliance quality. BPD patients rated their early alliance the lowest compared to NPD, DPD and OCPD patients. This trend was dominant and replicated regardless of who rated the alliance and which dimension of alliance was estimated. CONCLUSIONS NPD, DPD and OCPD patients have better initial therapeutic alliances than BPD patients, and their alliances do not differ significantly. BPD patients build weaker alliances, and what poses a challenge for them is not only developing a strong and close bond but also conceptualizing goals and reaching agreement on tasks.
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Affiliation(s)
- Tomasz Prusiński
- Institute of Psychology, The Maria Grzegorzewska University, Warsaw, Poland
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Lavi-Rotenberg A, Kivity Y, Igra L, Atzil-Slonim D, Hasson-Ohayon I. A dyadic session-by-session assessment of therapeutic alliance and short-term outcome among clients with schizophrenia in comparison with clients with emotional disorders. Psychol Psychother 2023; 96:1029-1043. [PMID: 37665174 DOI: 10.1111/papt.12494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 08/27/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Although the clinical significance of the therapeutic alliance (TA) is well documented, the literature regarding the establishment of TA and the relation between client-therapist agreement on it to short-term outcome among various diagnostic groups-and specifically among clients diagnosed with serious mental illness (SMI)-is sparse. The aim of the present study was to examine the effect of client diagnosis on the abovementioned TA characteristics. METHOD Dyadic analyses of session-by-session (SBS) data were used to compare clients diagnosed with schizophrenia and clients diagnosed with emotional disorders (based on a clinical interview) in their TA characteristics. RESULTS TA as initially rated by clients was stronger in the emotional disorders group than in the schizophrenia group. Higher TA ratings, regardless of whether these were provided by the therapist or the client, predicted better subsequent functioning in the emotional disorders group, whereas in the schizophrenia group, this association was observed only among good-outcome cases. CONCLUSIONS Establishing TA, having client-therapist agreement on it, and having clients derive therapeutic benefit from it might be more challenging with clients with schizophrenia than with clients with emotional disorders. Special attention should be given to specific challenges and needs regarding clients' diagnosis in order to enhance favourable therapy outcomes.
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Affiliation(s)
| | - Yogev Kivity
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Libby Igra
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
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Cersosimo BH, Hilsenroth MJ, Bornstein RF, Gold JR, Blais MA. Convergence in patient and therapist alliance ratings early in treatment with Personality Assessment Inventory clinical scales and subscales. Clin Psychol Psychother 2023; 30:1512-1519. [PMID: 37544895 DOI: 10.1002/cpp.2891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/22/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
We examined discrepancies in 81 patient-therapist dyads' alliance ratings early in treatment (3rd or 4th session) in relation to Personality Assessment Inventory clinical scales, subscales and global psychopathology. Results indicated that PAI global psychopathology (mean clinical elevation) and the scales of Aggression [AGG], Somatization [SOM], and Anxiety-Related Disorders [ARD] were significantly, negatively associated with an absolute difference of patient and therapist alliance ratings at Session 3. Higher initial scores on these clinical scales at treatment onset are associated with less difference (i.e., more convergence) in patient/ therapist ratings of alliance at Session 3. Correlations between PAI clinical subscales and absolute differences of patient and therapist alliance ratings at Session 3 also demonstrated statistically significant inverse relationships for several PAI subscales of Aggression- Attitude [AGG-A], Aggression-Physical [AGG-P], Somatic- Health Concerns [SOM-H], Anxiety-Related Disorders-Traumatic Stress [ARD-T], Anxiety-Related Disorders- Obsessive Compulsive [ARD-O], Borderline Features-Affective Instability [BOR-A], Borderline- Self-Harm [BOR-S], Anxiety-Physiological [ANX-P], Depression-Physiological [DEP-P] and Antisocial-Stimulus Seeking [ANT-S]. Again, higher scores on these subscales at treatment onset are associated with less difference (i.e., more convergence) in patient/therapist ratings. We also examined group differences between patients rating alliance higher (Group 1) and therapists rating alliance higher (Group 2) and found that Group 1 had significantly lower scores on Mania-Activity Level [MAN-A]. Clinical implications of results are discussed.
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Affiliation(s)
- Bianca H Cersosimo
- Derner School of Psychology, Adelphi University, Garden City, New York, United States
| | - Mark J Hilsenroth
- Derner School of Psychology, Adelphi University, Garden City, New York, United States
| | - Robert F Bornstein
- Derner School of Psychology, Adelphi University, Garden City, New York, United States
| | - Jerold R Gold
- Derner School of Psychology, Adelphi University, Garden City, New York, United States
| | - Mark A Blais
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Grossman-Giron A, Fisher H, Atzil-Slonim D, Maoz H, Nitzan U, Tzur Bitan D. The effect of Oxytocin administration on patient-therapist alliance congruence: Results from a randomized controlled trial. Psychother Res 2023:1-11. [PMID: 37856680 DOI: 10.1080/10503307.2023.2269300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
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.
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Affiliation(s)
- Ariella Grossman-Giron
- Department of Behavioral Sciences, Ariel University, Ariel, Israel
- Shalvata Mental Health Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Fisher
- Department of Psychology, Haifa University, Haifa, Israel
| | | | - Hagai Maoz
- Shalvata Mental Health Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Nitzan
- Shalvata Mental Health Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dana Tzur Bitan
- Shalvata Mental Health Center, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Community Mental Health, University of Haifa, Haifa, Israel
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Mosavi NS, Ribeiro E, Sampaio A, Santos MF. Data mining techniques in psychotherapy: applications for studying therapeutic alliance. Sci Rep 2023; 13:16409. [PMID: 37775524 PMCID: PMC10541430 DOI: 10.1038/s41598-023-43366-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/22/2023] [Indexed: 10/01/2023] Open
Abstract
Therapeutic Alliance (TA) has been consistently reported as a robust predictor of therapy outcomes and is one of the most investigated therapy relational factors. Research on therapists' and clients' contributions to the alliance development and the alliance-outcome relationship had shown mixed results. The relation of the therapist's and client's biological markers with the alliance is an important and under-investigated topic. Taking advantage of data mining techniques, this exploratory study aimed to investigate the role of different therapist and client factors, including heart rate (HR) and electrodermal activity (EDA), in relation to TA. Twenty-two dyads with 6 therapists and 22 clients participated in the study. The Working Alliance Inventory (WAI) was used to evaluate the client's and therapist's perception of the alliance at the end of each session and through the therapy processes. The Cross-Industry Standard Process for Data Mining (CRISP-DM) was used to explore patterns that may contribute to TA. Machine Learning (ML) models have been employed to provide insights into the predictors and correlates of TA. Our results showed that Linear Regression (LR) was the best technique for predicting the therapist's TA, with client "Diagnostic" and therapy "Termination" being identified as significant predictors of the therapist's TA. In addition, for clients' TA, the Random Forest (RF) was shown to have the best performance. The therapist's TA and therapy "Outcome" were observed as the most influential predictors for the client's TA. In addition, while the Heart Rate (therapist) was negatively associated with the therapist's TA, EDA in the client was a physiological indicator related to the client's TA. Overall, these findings can assist in identifying key factors that therapists should focus on to enhance the quality of therapeutic alliance. Results are discussed in terms of their consistency with empirical literature, innovative and interdisciplinary research on the therapeutic alliance field, and, in particular, the use of the Data Mining approach in a psychotherapy context.
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Affiliation(s)
| | - Eugénia Ribeiro
- Psychotherapy and Psychopathology Research Lab, Centre for Research in Psychology (CIPsi), School of Psychology, University of Minho, Braga, Portugal
| | - Adriana Sampaio
- Psychological Neuroscience Lab, Center for Research in Psychology (CIPsi), School of Psychology, University of Minho, Braga, Portugal
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Modlin NL, Miller TM, Rucker JJ, Kirlic N, Lennard-Jones M, Schlosser D, Aaronson ST. Optimizing outcomes in psilocybin therapy: Considerations in participant evaluation and preparation. J Affect Disord 2023; 326:18-25. [PMID: 36707036 DOI: 10.1016/j.jad.2023.01.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 01/11/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023]
Abstract
Recent studies have demonstrated the promise of psilocybin therapies in creating positive changes for those with poor mental health across multiple diagnostic categories, including major depressive disorder (MDD), end-of-life anxiety, and obsessive-compulsive disorder (OCD). While there may be a large population that is eligible to participate in psilocybin therapy based on psychiatric diagnosis and medical clearance, little attention has been given to intrapersonal and interpersonal factors that might influence patient's readiness (i.e., eligibility and capacity) for psychedelic interventions. This paper proposes that readiness assessment includes both intrapersonal and interpersonal factors in order to improve safety, patient care, and treatment outcomes. While at the present time a reliable and valid instrument has not been developed, we propose that three specific areas of focus - patient presentation, therapeutic alliance, and patient safety - may be used to establish a patient's readiness for psilocybin therapy, thus increasing therapy optimization and personalization.
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Affiliation(s)
- Nadav Liam Modlin
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Tammy M Miller
- Institute for Advanced Therapeutics and Diagnostics, Sheppard Pratt, Towson, MD, United States of America
| | - James J Rucker
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, Beckenham, United Kingdom
| | | | | | - Danielle Schlosser
- Compass Pathfinder Ltd, London, United Kingdom; Weill Institute for Neurosciences, University of California, San Francisco, United States of America
| | - Scott T Aaronson
- Institute for Advanced Therapeutics and Diagnostics, Sheppard Pratt, Towson, MD, United States of America; University of Maryland School of Medicine, Department of Psychiatry, 701 West Pratt Street, Baltimore, MD 21201, United States of America.
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Wheaton MG, Mcingvale E, Van Meter AR, Björgvinsson T. Quality of the therapeutic working alliance as a factor in intensive residential treatment of obsessive-compulsive disorder. Psychother Res 2023; 33:442-454. [PMID: 36314194 DOI: 10.1080/10503307.2022.2138618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Intensive residential treatment (IRT) for obsessive-compulsive disorder (OCD) includes frequent meetings with a cognitive-behavioral therapist. We examined whether this therapeutic working alliance relates to IRT outcomes. METHOD Data came from a naturalistic sample of patients with OCD (n = 124) who received IRT at a specialty OCD clinic. Patients completed measures of OCD severity and well-being at admission and discharge. Both the patient and treating psychologist completed the Working Alliance Inventory-Short Form (WAI-SF). Alliance ratings were tested as predictors in models predicting outcomes (discharge scores adjusting for baseline and treatment duration) as well as logistic regression predicting treatment response (≥35% symptom reduction in OCD symptoms). RESULTS Patient and clinician ratings of the quality of the alliance were weakly yet significantly correlated. Patient ratings of the alliance predicted outcomes, while therapist ratings did not. Moreover, greater discrepancy between patient and client ratings predicted worse outcomes. Patient ratings of the task dimension of the alliance uniquely related to responder status. CONCLUSIONS Patient perceptions of the working alliance, particularly as pertaining to agreement on therapeutic tasks, related to success with IRT for OCD. Further study is needed test interventions to improve task alliance as a strategy to enhance treatment.
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Rivera AP, Maisto SA, Connors GJ, Schlauch RC. Therapists' first impression of treatment motivation moderates the relationship between the client-rated therapeutic alliance and drinking outcomes during treatment. Alcohol Clin Exp Res 2023; 47:806-821. [PMID: 36863860 DOI: 10.1111/acer.15040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 01/09/2023] [Accepted: 02/08/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION First impressions can influence interpersonal relationships for extended periods, with negative first impressions leading to more negative judgments and behaviors between individuals months after their initial meeting. Although common factors such as therapeutic alliance (TA) are well studied, less is known of the potential influence of a therapist's first impression of their client's motivation on TA and drinking outcomes. Based on data from a prospective study of the perceptions of the TA among clients receiving cognitive-behavioral treatment (CBT), this study examined how therapists' first impressions may moderate the relationship between client-rated TA and drinking outcomes during treatment. METHODS One hundred fifty-four adults participated in a 12-week course of CBT and completed measures of TA and drinking behaviors following each treatment session. Additionally, therapists completed a measure of their first impression of their client's motivation for treatment following the first session. RESULTS Time-lagged multilevel modeling revealed a significant within-person TA by therapists' first impression interaction that predicted percent days abstinent (PDA). Specifically, among participants rated as lower on first impressions of treatment motivation, higher within-person TA predicted greater PDA in the interval prior to the next treatment session. Within-person working alliance was not associated with PDA among individuals rated higher on first impressions of treatment motivation who demonstrated higher PDA throughout treatment. Furthermore, significant between-person TA by first impressions interactions were found for both PDA and drinks per drinking day (DDD), such that among individuals with lower treatment motivation, TA positively predicted PDA and negatively predicted DDD. CONCLUSION Although therapists' first impressions of a client's treatment motivation are positively associated with treatment outcomes, clients' perception of the TA may mitigate the impact of poor first impressions. These findings highlight the need for additional nuanced examinations of the relationship between TA and treatment outcomes, emphasizing the contextual factors that influence this relationship.
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Affiliation(s)
- Alexander P Rivera
- Department of Psychology, University of South Florida, Tampa, Florida, USA
| | - Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Gerard J Connors
- Research Institute on Addictions, University at Buffalo, Buffalo, New York, USA
| | - Robert C Schlauch
- Department of Psychology, University of South Florida, Tampa, Florida, USA
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Saraiya TC, Jarnecke AM, Bauer AG, Brown DG, Killeen T, Back SE. Patient- and therapist-rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment. Clin Psychol Psychother 2023; 30:410-421. [PMID: 36509681 PMCID: PMC10079590 DOI: 10.1002/cpp.2810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 11/14/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Concurrent Treatment of Posttraumatic Stress Disorder (PTSD) and Substance Use Disorders Using Prolonged Exposure (i.e., COPE) is an efficacious, integrated, psychotherapy that attends to PTSD and substance use disorders simultaneously. No study has examined how therapeutic alliance functions during the provision of COPE and how this compares to non-integrated treatments, such as relapse prevention (RP) for substance use disorders. Understanding the role of alliance in COPE versus RP could inform treatment refinement and ways to enhance treatment outcomes. METHODS Participants (N = 55 veterans) were randomized to 12, individual, weekly sessions of COPE or RP in a randomized clinical trial. Piecewise linear mixed effect models examined how mid-treatment (1) patient-rated alliance, (2) therapist-rated alliance, and (3) the convergence between patient- and therapist-rated alliance as measured by a difference score predicted reductions in PTSD symptoms and substance use across treatment and follow-up periods. RESULTS Both patient- and therapist-rated alliance predicted reductions in PTSD symptoms in COPE. Higher patient-rated alliance predicted lower percent days using substances in RP. Difference score models showed higher patient-rated alliance relative to therapist-rated alliance scores predicted symptom reductions in COPE whereas higher therapist-rated alliance scores relative to patient-rated alliance scores predicted symptom reductions in RP. DISCUSSION Preliminary findings show a unique relationship between the rater of the alliance and treatment modalities. Patient-rated alliance may be important in trauma-focused, integrated treatments whereas therapist-rated alliance may be more important in skills-focused, substance use interventions.
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Affiliation(s)
- Tanya C. Saraiya
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, New Jersey, USA
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Amber M. Jarnecke
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexandria G. Bauer
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, New Jersey, USA
| | - Delisa G. Brown
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Therese Killeen
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sudie E. Back
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
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Rognstad K, Wentzel-Larsen T, Neumer SP, Kjøbli J. A Systematic Review and Meta-Analysis of Measurement Feedback Systems in Treatment for Common Mental Health Disorders. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:269-282. [PMID: 36434313 PMCID: PMC9931854 DOI: 10.1007/s10488-022-01236-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
To investigate the effects of measurement feedback systems (MFSs) in therapy on mental health outcomes through a literature review and meta-analysis. Using a three-level modeling approach, we conducted a meta-analysis of all effect sizes from randomized controlled studies of MFSs used in the treatment of common mental health disorders. Eighty-two effect sizes were extracted from the thirty-one included studies. Analyses were performed to consider the post-treatment effects of the MFS-assisted treatment compared to treatment as usual. A separate analysis was done for the subgroup "not-on-track" patients as it is theorized that MFSs will be clinically useful because they make therapists aware of patients who fail to progress. MFSs had a significant effect on mental health outcomes (d = 0.14, 95% CI [0.082-0.206], p < .001). Further analysis found a larger effect in patients identified as less respondent to therapy, the "not-on-track" group (d = 0.29, 95% CI [0.114, 0.464], p = .003). Moderation analyses indicated that the type of outcome measurement and type of feedback system used, and whether it was used for a child and youth or adult population, influenced effect sizes. MFSs seem to have a small positive effect on treatment outcomes. The effects seem to be larger for "not-on-track" patients, the group of patients that would usually not benefit much from treatment.
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Affiliation(s)
- Kristian Rognstad
- Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway. .,Department of Psychology, University of Oslo, Oslo, Norway.
| | - Tore Wentzel-Larsen
- Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway ,Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway
| | - Simon-Peter Neumer
- Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway ,Regional Centre for Child and Youth Mental Health and Child Welfare, UIT The Arctic University of Norway, Tromsø, Norway
| | - John Kjøbli
- Regional Center for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway ,Department of Education, University of Oslo, Oslo, Norway
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14
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Tanzilli A, Boldrini T, Carone N, Gualco I, Lingiardi V, Williams R. Patient personality dimensions, relational patterns and therapeutic alliance in clinical practice: An empirical investigation. Clin Psychol Psychother 2023; 30:97-111. [PMID: 35981709 DOI: 10.1002/cpp.2779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/03/2022] [Accepted: 08/15/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Transference (meant in this context, as the patient relational patterns expressed towards the clinician) and therapeutic alliance play a crucial role in the treatment of personality pathology. To date, no empirical study examined the association between these two dimensions of the clinical relationship and patients' personality maladaptive traits in psychotherapy. METHODS A national sample of therapists (N = 100) of different theoretical orientations assessed dysfunctional personality features of a patient in their care using a comprehensive and empirically grounded dimensional diagnostic approach from the Shedler-Westen Assessment Procedure-200 (SWAP-200). Moreover, they filled in the Psychotherapy Relationship Questionnaire (PRQ) to identify interpersonal patterns expressed early in treatment by the patients and the Working Alliance Inventory (WAI-T) to evaluate quality of therapeutic alliance. RESULTS Overall, the most severe and maladaptive dimensions of patients' personality were associated with more negative clinician-patient dynamics and poorer levels of therapeutic alliance in statistically significant and clinically relevant ways. Notably, the hostile transference was predicted by both SWAP Hostility and Psychopathy, whereas the SWAP Narcissism was the strongest predictor of the special/entitled transference. The latter was also predicted by SWAP Emotional Dysregulation; conversely, the SWAP Dysphoria was the most robust predictor of anxious/preoccupied pattern. The SWAP Schizoid Orientation and Psychopathy predicted avoidant/dismissing attachment pattern; moreover, they were strongly and negatively related to the SWAP Psychological Health that was the best predictor of positive transference and alliance. CONCLUSIONS Findings support that therapists' careful understanding of patients' interpersonal ways during early treatment stages may meaningfully inform diagnostic and therapeutic processes.
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Affiliation(s)
- Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Tommaso Boldrini
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - Nicola Carone
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Ivan Gualco
- Center for Individual and Couple Therapy, Genoa, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Riccardo Williams
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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15
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Earleywine M, Low F, Altman BR, De Leo J. How Important Is a Guide Who Has Taken Psilocybin in Psilocybin-Assisted Therapy for Depression? J Psychoactive Drugs 2023; 55:51-61. [PMID: 35318904 DOI: 10.1080/02791072.2022.2047842] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Promising outcomes of Psilocybin-Assisted Therapy (PAT) for depression have generated concerted efforts to replicate, extend, and refine protocols to maximize efficacy. Psychotherapy research reveals that clients benefit most when important components of treatment align with their personal preferences. One open question related to PAT concerns the importance of the psilocybin experience of the guides (trained professionals present during acute effects). We sought to assess the importance of a guide who had used psilocybin to potential clients with depressive symptoms. Over 800 MTurk respondents with depressive symptoms rated the import of a guide who had used psilocybin relative to alternative characteristics in guides and cognitive behavioral (CBT) therapists. Importance ratings for guides who had used psilocybin significantly exceeded the "somewhat important" level (50 on a 0-100 scale), other guide-related qualities, and comparable ratings for a cognitive behavioral therapist who shared demographics, had experience with depression and received cognitive therapy personally. People of color (those who are not Caucasian) and those who had previous therapy gave significantly higher importance ratings for guides who had used psilocybin. Participants who chose to list other qualities important for guides listed very similar ones for CBT therapists, often emphasizing proper training and an empathic demeanor. Guides who have used psilocybin, who inform clients of the fact, might have advantages for facilitating PAT's antidepressant effects, as least in a subset of clients.
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Affiliation(s)
- Mitch Earleywine
- Department of Psychology, University at Albany, State University of New York, Albany, NY, USA
| | - Fiona Low
- Department of Psychology, University at Albany, State University of New York, Albany, NY, USA
| | - Brianna R Altman
- Department of Psychology, University at Albany, State University of New York, Albany, NY, USA
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16
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Wu Q, McWey LM, Ledermann T. Which therapist perceptions best predict client outcomes? A naturalistic examination. JOURNAL OF MARITAL AND FAMILY THERAPY 2023; 49:151-168. [PMID: 36150140 DOI: 10.1111/jmft.12611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 08/26/2022] [Accepted: 08/28/2022] [Indexed: 06/16/2023]
Abstract
Examining associations between therapists' perceptions of therapy sessions and client-reported outcomes in naturalistic settings (real-life therapy settings) can provide valuable guidance for the assessment, treatment, and monitoring of clients. This study included data of 1334 sessions from 127 clients (86 individual and 41 couple cases) and 15 therapists, collected at a therapy training center. Clients reported their personal functioning and individual symptoms before each session. Therapists rated clients' participation, receptivity, session progress, goal progress, and therapeutic alliance at the end of each therapy session. Multilevel Structural Equation Modeling analyses revealed that therapist-rated client participation and goal progress predicted better personal functioning, beyond clients' previous personal functioning scores. In contrast, none of therapist-rated session variables predicted clients' individual symptoms, beyond previous symptom scores. Power analyses suggested sufficient statistical power to detect small effect sizes. Findings of the current study have clinical implications for treatment planning and progress monitoring.
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Affiliation(s)
- Qiong Wu
- Department of Human Development and Family Science, College of Health and Human Sciences, Florida State University, Tallahassee, Florida, USA
| | - Lenore M McWey
- Department of Human Development and Family Science, College of Health and Human Sciences, Florida State University, Tallahassee, Florida, USA
| | - Thomas Ledermann
- Department of Human Development and Family Science, College of Health and Human Sciences, Florida State University, Tallahassee, Florida, USA
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17
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Whelen ML, Ezawa ID, Strunk DR. Congruence in patient and therapist-rated alliance predicts subsequent depressive symptoms in cognitive behavioral therapy for depression. Psychother Res 2022:1-10. [DOI: 10.1080/10503307.2022.2156304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Megan L. Whelen
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Iony D. Ezawa
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
| | - Daniel R. Strunk
- Department of Psychology, The Ohio State University, Columbus, OH, USA
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18
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Strappini F, Socci V, Saliani AM, Grossi G, D’Ari G, Damato T, Pompili N, Alessandri G, Mancini F. The therapeutic alliance in cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Front Psychiatry 2022; 13:951925. [PMID: 36147968 PMCID: PMC9488733 DOI: 10.3389/fpsyt.2022.951925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background The therapeutic alliance has been recognized as one of the most researched key elements of treatment across different therapeutic approaches and diagnostic domains. Despite its importance, our current understanding of its clinical relevance in patients with obsessive-compulsive disorder (OCD) is still debated. This study aimed to examine empirical evidence on the effect of alliance on treatment outcomes in Cognitive Behavioral Therapy (CBT) in patients with OCD in a systematic review and meta-analysis. Methods Original peer-reviewed articles until March 2022 were included if they were (1) written in English; (2) included a clinical group with a current primary OCD diagnosis; (3) involved individual CBT; (4) used a validated therapeutic alliance scale that was related to the outcome measurement; (5) reported an effect size. Results Thirteen studies were included, six of which contained sufficient statistical information to be included in the meta-analysis. A total of 897 patients took part in all reviewed studies. We found a modest effect of alliance on post-treatment outcome [Tau 2 = -0.1562 (C.I. 95%: -0.2542 to -0.0582)]. Discussion The results show the existence of considerable variability and methodological inconsistencies across studies. We discuss the role of methodological factors that could account for this divergence, the research limitations, and the implications for current research. Systematic review registration [https://osf.io/dxez5/?view_only=bc2deaa7f0794c8dbef440255b2d4b3b].
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Affiliation(s)
| | - Valentina Socci
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Coppito, Italy
| | | | - Giuseppe Grossi
- Association School of Cognitive Psychotherapy (APC-SPC), Rome, Italy
| | - Giulia D’Ari
- Association School of Cognitive Psychotherapy (APC-SPC), Rome, Italy
| | - Titti Damato
- Association School of Cognitive Psychotherapy (APC-SPC), Rome, Italy
| | - Nicole Pompili
- Association School of Cognitive Psychotherapy (APC-SPC), Rome, Italy
| | - Guido Alessandri
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Francesco Mancini
- Association School of Cognitive Psychotherapy (APC-SPC), Rome, Italy
- Department of Human Sciences, Guglielmo Marconi University, Rome, Italy
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19
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Heinze PE, Weck F, Hahn D, Kühne F. Differences in psychotherapy preferences between psychotherapy trainees and laypeople. Psychother Res 2022; 33:374-386. [PMID: 35847994 DOI: 10.1080/10503307.2022.2098076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Despite increasing research on psychotherapy preferences, the preferences of psychotherapy trainees are largely unknown. Moreover, differences in preferences between trainees and their patients could (a) hinder symptom improvement and therapy success for patients and (b) represent significant obstacles in the early career and development of future therapists. We compared the preferences of n = 466 psychotherapy trainees to those of n = 969 laypersons using the Cooper-Norcross Inventory of Preferences. Moreover, we compared preferences between trainees in cognitive-behavioural therapy (CBT) and psychodynamic trainees. We found significant differences between both samples in 13 of 18 items, and three of four subscales. Psychotherapy trainees preferred less therapist directiveness (d = 0.58), more emotional intensity (d = 0.74), as well as more focused challenge (d = 0.35) than laypeople. CBT trainees preferred more therapist directiveness (d = 2.00), less emotional intensity (d = 0.51), more present orientation (d = 0.76) and more focused challenge (d = 0.33) than trainees in psychodynamic/psychoanalytic therapy. Overall, the results underline the importance of implementing preference assessment and discussion during psychotherapy training. Moreover, therapists of different orientations seem to cover a large range of preferences for patients, in order to choose the right fit.
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Affiliation(s)
- Peter Eric Heinze
- University of Potsdam, Clinical Psychology and Psychotherapy, Potsdam, Germany
| | - Florian Weck
- University of Potsdam, Clinical Psychology and Psychotherapy, Potsdam, Germany
| | - Daniela Hahn
- Johannes Gutenberg-University Mainz, Clinical Psychology, Psychotherapy and Experimental Psychopathology, Mainz, Germany
| | - Franziska Kühne
- University of Potsdam, Clinical Psychology and Psychotherapy, Potsdam, Germany
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20
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Sagui-Henson SJ, Welcome Chamberlain CE, Smith BJ, Li EJ, Castro Sweet C, Altman M. 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. JOURNAL OF TECHNOLOGY IN BEHAVIORAL SCIENCE 2022; 7:439-450. [PMID: 35855977 PMCID: PMC9278317 DOI: 10.1007/s41347-022-00263-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/15/2022] [Accepted: 06/07/2022] [Indexed: 01/23/2023]
Abstract
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.
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21
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Stoeten C, de Haan HA, Postel MG, Brusse-Keizer M, Ter Huurne ED. Therapeutic Alliance in Web-Based Treatment for Eating Disorders: Secondary Analysis of a Randomized Controlled Trial. JMIR Form Res 2022; 6:e33813. [PMID: 35771608 PMCID: PMC9284349 DOI: 10.2196/33813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background In face-to-face therapy for eating disorders, therapeutic alliance (TA) is an important predictor of symptom reduction and treatment completion. To date, however, little is known about TA during web-based cognitive behavioral therapy (web-CBT) and its association with symptom reduction, treatment completion, and the perspectives of patients versus therapists. Objective This study aimed to investigate TA ratings measured at interim and after treatment, separately for patients and therapists; the degree of agreement between therapists and patients (treatment completers and noncompleters) for TA ratings; and associations between patient and therapist TA ratings and both eating disorder pathology and treatment completion. Methods A secondary analysis was performed on randomized controlled trial data of a web-CBT intervention for eating disorders. Participants were 170 females with bulimia nervosa (n=33), binge eating disorder (n=68), or eating disorder not otherwise specified (n=69); the mean age was 39.6 (SD 11.5) years. TA was operationalized using the Helping Alliance Questionnaire (HAQ). Paired t tests were conducted to assess the change in TA from interim to after treatment. Intraclass correlations were calculated to determine cross-informant agreement with regard to HAQ scores between patients and therapists. A total of 2 stepwise regressive procedures (at interim and after treatment) were used to examine which HAQ scores predicted eating disorder pathology and therapy completion. Results For treatment completers (128/170, 75.3%), the HAQ-total scores and HAQ-Helpfulness scores for both patients and therapists improved significantly from interim to post treatment. For noncompleters (42/170, 24.7%), all HAQ scores decreased significantly. For all HAQ scales, the agreement between patients and therapists was poor. However, the agreement was slightly better after treatment than at interim. Higher patient scores on the helpfulness subscale of the HAQ at interim and after treatment were associated with less eating disorder psychopathology. A positive association was found between the HAQ-total patient scores at interim and treatment completion. Finally, posttreatment HAQ-total patient scores and posttreatment HAQ-Helpfulness scores of therapists were positively associated with treatment completion. Conclusions Our study showed that TA in web-CBT is predictive of eating disorder pathology and treatment completion. Of particular importance is patients’ confidence in their abilities as measured with the HAQ-Helpfulness subscale when predicting posttreatment eating disorder pathology and treatment completion.
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Affiliation(s)
- Claudia Stoeten
- Tactus Addiction Care, Deventer, Netherlands
- Mediant, Hengelo, Netherlands
| | - Hein Arnoud de Haan
- Tactus Addiction Care, Deventer, Netherlands
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, Netherlands
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22
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Coman EN, Steinbach S, Cao G. Spatial perspectives in family health research. Fam Pract 2022; 39:556-562. [PMID: 34910138 DOI: 10.1093/fampra/cmab165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Emil N Coman
- University of Connecticut School of Medicine, Health Disparities Institute, Hartford, CT, United States
| | - Sandro Steinbach
- University of Connecticut, Department of Agricultural and Resource Economics, Storrs, CT, United States
| | - Guofeng Cao
- University of Colorado Boulder, Department of Geography, Boulder, CO, United States
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23
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DeGrush E, LaFrance WC. Psychotherapeutic Tools to Enhance the Neurologist-Patient Interaction. Semin Neurol 2022; 42:107-113. [PMID: 35272353 DOI: 10.1055/s-0042-1742288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Despite providing care for patients with "disturbances of the same organ," the brain, the therapeutic approaches used by neurologists and psychiatrists are, to some extent, distinct. With recognition of the closely coupled relationship between physical health and mental health, there is increased awareness of the need to provide an integrated, neuropsychiatric approach to the care of patients in neurology. In this review article, we provide a broad overview of how neurologists can use psychotherapeutic principles to enhance patient-physician interactions in the neurological setting (e.g., developing a therapeutic alliance; frame/boundary setting; active, empathic listening; acknowledging affect). These practices relate to a broad range of conditions, including, but not necessarily limited to epilepsy, traumatic brain injury, and functional neurological (conversion) disorder. The authors provide practical approaches that a neurologist can learn to leverage psychotherapeutic tools to enhance clinical encounters.
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Affiliation(s)
- Elizabeth DeGrush
- Departments of Psychiatry and Neurology, UMASS Memorial Medical School, Worcester, Massachusetts
| | - W Curt LaFrance
- Department of Psychiatry, Rhode Island Hospital, Brown University, Providence, Rhode Island.,Department of Neurology, Rhode Island Hospital, Brown University, Providence, Rhode Island
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24
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de Jong S, Hasson-Ohayon I, Lavi-Rotenberg A, Carter SA, Castelein S, Lysaker PH. Longitudinal assessments of therapeutic alliance predict work performance in vocational rehabilitation for persons with schizophrenia. Psychol Psychother 2021; 94:915-928. [PMID: 33904233 DOI: 10.1111/papt.12346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 03/18/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To promote functional recovery in persons diagnosed with a psychotic disorder, vocational interventions have emerged over the last few decades which range from sheltered employment to supported employment in the community. DESIGN Using data from a 6-month vocational rehabilitation programme, we examined whether assessments of the therapeutic alliance were related to the quality of work performed in this work placement. Our first hypothesis was that stronger alliances would be related to better work performance. Second, we expected that client assessments of the TA would better predict outcomes than therapist assessments. Third, we expected that the discrepancy between assessment scores from the client and therapist (client rating minus therapist rating) would be a better predictor for outcome than individual assessments by the therapists or clients. RESULTS Clients systematically rated the alliance higher than therapists. Modelling the data longitudinally, we found both therapist and client ratings predictive of outcome, though client assessments over time were inversely related to work performance. CONCLUSIONS Discrepancy in scores was also shown to be predictive of work performance during the program. Clinicians are advised to routinely assess the therapeutic alliance from both client and therapist perspectives and calculate the discrepancy between them as they may indicate ruptures are occurring and thus hamper the intervention. PRACTITIONER POINTS Clinicians are advised to regularly assess the therapeutic alliance from both their own and the client's perspective. Growing discrepancy in scores may impede intervention effectiveness. Therapeutic alliance may help buffer against work stresses experienced by participants in a vocational programme. Be aware that therapists tend to rate the alliance lower than their clients.
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Affiliation(s)
- Steven de Jong
- Lentis Research, Lentis Psychiatric Institute, Groningen, the Netherlands
| | | | | | - Sarah A Carter
- University College Roosevelt, Utrecht University, Middelburg, The Netherlands
| | - Stynke Castelein
- Lentis Research, Lentis Psychiatric Institute, Groningen, the Netherlands.,Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral Sciences, University of Groningen, Groningen, the Netherlands
| | - Paul H Lysaker
- Department of Psychiatry, Roudebush VA Medical Center and the Indiana University School of Medicine, Indiana, USA
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25
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Gergov V, Marttunen M, Lindberg N, Lipsanen J, Lahti J. Therapeutic Alliance: A Comparison Study between Adolescent Patients and Their Therapists. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111238. [PMID: 34769766 PMCID: PMC8583560 DOI: 10.3390/ijerph182111238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
The aim of this study was to examine the congruence of adolescent- and therapist-rated therapeutic alliance, and to explore which rating or combination of ratings would predict treatment outcome or premature termination. We also studied whether the alliance changes over the course of treatment and if the change is related to the outcome or dropout. This study comprised 58 adolescents clinically referred for psychotherapeutic interventions. The alliance (Working Alliance Inventory, patient/therapist ratings) and treatment outcomes (Beck Depression Inventory, Clinical Outcomes in Routine Evaluation—Outcome Measure) were measured at baseline and at 3-, 6-, and 12-month follow-ups. The alliance did not change significantly over the course of therapy, but adolescent and therapist ratings did not correlate. Low values in the early assessment of adolescent-rated alliance and discrepancy between the ratings were significant predictors of undesirable treatment outcome. Weak adolescent- or therapist-rated alliance later in treatment and change for the worse in adolescent-rated alliance was associated with treatment dropout. As adolescent-rated alliance predicts treatment outcome better than therapist-rated alliance, therapists should frequently use assessments of therapeutic relationship within the therapy and pay attention if the adolescent feels the alliance is weakening or his/her evaluation is contrary to the therapist’s.
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Affiliation(s)
- Vera Gergov
- Adolescent Psychiatry, Helsinki University Hospital, University of Helsinki, 00260 Helsinki, Finland;
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, 00290 Helsinki, Finland; (J.L.); (J.L.)
- Correspondence: ; Tel.: +358-(0)40-9622443
| | - Mauri Marttunen
- Adolescent Psychiatry, Helsinki University Hospital, University of Helsinki, 00260 Helsinki, Finland;
- Mental Health Unit, National Institute for Health and Welfare, 00300 Helsinki, Finland
| | - Nina Lindberg
- Forensic Psychiatry, Helsinki University Hospital, University of Helsinki, 00260 Helsinki, Finland;
| | - Jari Lipsanen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, 00290 Helsinki, Finland; (J.L.); (J.L.)
| | - Jari Lahti
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, 00290 Helsinki, Finland; (J.L.); (J.L.)
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26
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Gelkopf M, Mazor Y, Roe D. A systematic review of patient-reported outcome measurement (PROM) and provider assessment in mental health: goals, implementation, setting, measurement characteristics and barriers. Int J Qual Health Care 2021; 34:ii13–ii27. [PMID: 32159763 DOI: 10.1093/intqhc/mzz133] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 11/08/2019] [Accepted: 12/03/2019] [Indexed: 01/27/2023] Open
Abstract
PURPOSE To review and integrate the literature on mental-health-related patient-reported outcome measures (PROMs) and routine outcome measures (ROMs), namely in the domains of goals, characteristics, implementation, settings, measurements and barriers. PROM/ROM aims mainly to ascertain treatment impact in routine clinical practice through systematic service users' health assessment using standardized self-report, caretaker and/or provider assessment. DATA SOURCES Psych INFO and PubMed including Medline, Biomed Central, EMBASE Psychiatry and Elsevier Science's Direct. STUDY SELECTION Systemized review of literature (2000-2018) on implementation and sustainability of PROMs/ROMs in adult mental health settings (MHS). DATA EXTRACTION AND SYNTHESIS Systemized review of literature (2000-2018) on numerous aspects of PROM/ROM implementation and sustainability in adult MHS worldwide. RESULTS Based on 103 articles, PROMs/ROMs were implemented mostly in outpatient settings for people with assorted mental health disorders receiving a diversity of services. Frequency of assessments and completion rates varied: one-third of projects had provider assessments; about half had both provider and self-assessments. Barriers to implementation: perceptions that PROM/ROM is intrusive to clinical practice, lack of infrastructure, fear that results may be used for cost containment and service eligibility instead of service quality improvement, difficulties with measures, ethical and confidentiality regulations and web security data management regulations. CONCLUSION Improving data input systems, sufficient training, regular feedback, measures to increase administrative and logistic support to improve implementation, acceptability, feasibility and sustainability, follow-up assessments and client attrition rate reduction efforts are only some measures needed to enhance PROM/ROM efficiency and efficacy.
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Affiliation(s)
- Marc Gelkopf
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.,Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel
| | - Yael Mazor
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.,Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel
| | - David Roe
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.,Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.,Department of Clinical Medicine, Psychiatry, Aalborg University, Denmark
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27
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Prior K. Comorbid mental and substance use disorders: A common and complex treatment consideration. Bull Menninger Clin 2021; 85:89-99. [PMID: 34032462 DOI: 10.1521/bumc.2021.85.2.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Katrina Prior
- Postdoctoral research fellow at the Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
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28
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Bollmann S, Köhler S, Guhn A, Schamong I, Sterzer P, Brakemeier EL. Differentielle Beziehungsgestaltung in der Verhaltenstherapie: Auf dem Weg zu einer evidenzbasierten individualisierten Beziehungsgestaltung. VERHALTENSTHERAPIE 2021. [DOI: 10.1159/000511640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Im Zuge der Anfänge der Verhaltenstherapie (VT) und der “kognitiven Wende” wurde der aktiven Beziehungsgestaltung und damit verbundenen Faktoren zunächst nur zweitrangig Beachtung geschenkt, obwohl die Bedeutung der Beziehung zwischen Therapeut und Patient auch in der VT bereits relativ früh erkannt wurde. Seitdem hat sich die VT substanziell weiterentwickelt. Insbesondere die aktive Gestaltung der therapeutischen Beziehung in Abhängigkeit verschiedener Variablen ist mittlerweile fester Bestandteil einer jeden VT. In dieser Übersichtsarbeit werden Konzepte der Beziehungsgestaltung dargestellt, welche der VT zugerechnet und im Rahmen der Ausbildung im deutschsprachigen Raum gelehrt werden. Fokussiert wird auf folgende drei Ansatzpunkte: Die Ausrichtung der Beziehung an (1) Therapiephasen, (2) Bedürfnissen, Motiven und Erwartungen sowie (3) frühen traumatisierenden Beziehungserfahrungen. Die aktuelle Studienlage legt nahe, dass pauschalisierte Handlungsempfehlungen zur aktiven Gestaltung der therapeutischen Beziehung zu kurz greifen. Ausgehend von der individuellen Problematik des einzelnen Patienten wird die Realisierung der therapeutischen Beziehung im Sinne einer differentiellen Beziehungsgestaltung beschrieben und diskutiert.
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29
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Nakash O, Cruz-Gonzalez M, Lincoln AK, Banerjee S, Alegría M. Similarities in client-clinician perceptions of subjective social status and its association to similarities in the quality of working alliance and client anxiety symptoms. Psychother Res 2021; 31:1079-1091. [PMID: 33752581 DOI: 10.1080/10503307.2021.1900618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Subjective social status (SSS) has largely been ignored within psychotherapy literature. We investigated the association between similarities in client-clinician perceptions of SSS, similarities in their report of the quality of working alliance, and resultant anxiety symptoms. Participants represented a primarily low-income, culturally diverse sample of 312 clients receiving care from 68 clinicians at 13 outpatient mental health clinics in the Northeastern United States between September 2013 and August 2016. As part of a larger randomized controlled trial, clients and clinicians completed the MacArthur Scale of subjective social status and the Working Alliance Inventory (WAI), and clients completed the Generalized Anxiety Disorder 7-item Scale (GAD-7). At the within-clinician level, client-clinician dyads with less similar perceptions of the client's SSS were characterized by less similar perceptions of their alliance, which in turn resulted in worsening anxiety symptoms. Clinicians' correct perception of their clients' social status might be important for sharing a similar view of the client-clinician level of alliance, which can, in turn, contribute to lowering the client's anxiety symptoms.
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Affiliation(s)
- Ora Nakash
- School for Social Work, Smith College, Northampton, MA, USA.,Baruch Ivcher School of Psychology Interdisciplinary Center (IDC), Herzliya, Israel
| | - Mario Cruz-Gonzalez
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alisa K Lincoln
- College of Social Sciences and Humanities and Bouvé College of Health Sciences; Institute for Health Equity and Social Justice Research, Northeastern University, Boston, MA, USA
| | - Souvik Banerjee
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Margarita Alegría
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Departments of Medicine and Psychiatry, Harvard Medical School, Boston, MA, USA
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30
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Gal G, Shadmi E, Hoter-Ishay G, Gelkopf M, Roe D. Comparing outcome measures of persons with severe mental illness in vocational rehabilitation programs: a dual perspective of consumers and providers. Int J Qual Health Care 2021; 34:ii105–ii111. [PMID: 32232319 DOI: 10.1093/intqhc/mzaa030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/18/2020] [Accepted: 03/05/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Vocational rehabilitation for people with severe mental illness (SMI) has many benefits. Among the existing models, supported employment has consistently shown to have better impact on vocational outcomes while the findings on non-vocational outcomes are inconsistent. One source of variation with regard to non-vocational outcomes could be related to differences between consumers' self-reports and the providers' point of view. DESIGN A cross-sectional study of people with SMI consuming three different vocational services and their service providers. SETTING Data were collected as part of the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement project. PARTICIPANTS The current data is based on 3666 pairs of people with SMI consuming vocational services and their service providers. INTERVENTIONS Vocational services included supported employment, sheltered workshops and vocational support centers. MAIN OUTCOME MEASURES The consumers-filled self-report questionnaires, which consisted of the following patient-reported outcome measurements (PROMs): quality of life, functioning and illness management. Primary professional providers were given instruments that mirrored the ones designed for self-report. RESULTS According to providers' ratings, supported employment was associated with higher functioning (F = 78.6, P < 0.001) and illness management (F = 33.0, P < 0.001) compared to other vocational services. PROMs revealed that supported employment was associated with higher functioning only (F = 31.5, P < 0.001). Consumers rated themselves higher compared to providers on all measures. CONCLUSIONS This study provides a deeper insight into non-vocational outcomes of people with SMI participating in vocational services and suggests differences in perspectives between consumers and providers with regard to outcome measures.
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Affiliation(s)
- Gilad Gal
- School of Behavioral Sciences, Tel Aviv-Yaffo Academic College, Rabenu Yerucham st, Yaffo, 6818211, Israel
| | - Efrat Shadmi
- The Cheryl Spencer Nursing Department of Nursing, Faculty of Social Welfare and Health Sciences, Haifa University, Abba Khoushy Ave 199, Haifa, 3498838, Israel
| | - Gili Hoter-Ishay
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, Haifa University, Israel
| | - Marc Gelkopf
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, Haifa University, Israel
| | - David Roe
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, Haifa University, Israel.,Department of Clinical Medicine, Psychiatry, Aalborg University, Nybrogade 12, 9000 Aalborg, Denmark
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31
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Hasson‐Ohayon I, Jong S, Igra L, Carter SA, Faith LA, Lysaker P. Longitudinal changes in therapeutic alliance with people with psychosis: Relationship between client and therapist assessments. Clin Psychol Psychother 2021; 28:1243-1253. [DOI: 10.1002/cpp.2572] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/16/2022]
Affiliation(s)
| | | | - Libby Igra
- Department of Psychology Bar‐Ilan University Ramat‐Gan Israel
| | - Sarah A. Carter
- Utrecht University: University College Roosevelt Middelburg The Netherlands
| | - Laura A. Faith
- Department of Psychology University of Missouri‐Kansas City Kansas City Missouri USA
| | - Paul Lysaker
- Department of Psychiatry Roudebush VA Medical Center and the Indiana University School of Medicine Indianapolis Indiana USA
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32
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Nissen-Lie HA, Solbakken OA, Falkenström F, Wampold BE, Holmqvist R, Ekeblad A, Monsen JT. Does it make a difference to be more "on the same page"? Investigating the role of alliance convergence for outcomes in two different samples. Psychother Res 2020; 31:573-588. [PMID: 32957850 DOI: 10.1080/10503307.2020.1823030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Objective: To better understand the complexity of dyadic processes, such as the mechanisms of the working alliance, researchers recommend taking advantage of innovations in data analytic procedures when studying the interactions between therapists and patients that are associated with favorable therapeutic outcomes. Inspired by a recent line of alliance research using dyadic multilevel modeling, the present study investigated the hypothesis that convergence in the patient-therapist working alliance (i.e., increased similarity in ratings of the alliance across treatment) would be associated with better outcomes. Method: Data were retrieved from two samples: 1. A randomized controlled trial for treatment resistant depression (N = 96 dyads), and 2. An archival dataset of naturalistic psychotherapies from public health care (N = 139 dyads). Multilevel growth curve analysis was employed to investigate the degree of change in session-to-session agreement of global WAI ratings between therapists and patients (i.e., alliance convergence) as a predictor of symptom reduction in the BDI-II and the SCL-90R. Results: Contrary to our expectations, alliance convergence did not predict outcome in either sample, but was negatively associated with symptom severity in Study 2. Implications for understanding the complexity of dyadic processes and alliance work in psychotherapy are discussed.
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Affiliation(s)
| | | | - Fredrik Falkenström
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Bruce E Wampold
- University of Wisconsin-Madison, Madison, WI, USA.,Research Institute, Modum Bad Psychiatric Center, Vikersund, Norway
| | - Rolf Holmqvist
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Annika Ekeblad
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden.,Sundsvall Hospital, Sundsvall, Sweden
| | - Jon T Monsen
- Department of Psychology, University of Oslo, Oslo, Norway
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33
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Penix EA, Swift JK, Russell KA, Trusty WT. Client and therapist agreement in moment-to-moment helpfulness ratings in psychotherapy: A microprocess approach. J Clin Psychol 2020; 77:36-48. [PMID: 32678473 DOI: 10.1002/jclp.23030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 11/07/2022]
Abstract
METHOD Clients (n = 16; Mage = 32.88 years; 81% female) and their therapists (n = 10; 80% female) from a training clinic provided moment-to-moment ratings while reviewing a video recording of a recent session. West and Kenny's Truth-and-Bias (T&B) model was used to examine agreement in ratings. Multilevel modeling was used to evaluate the agreement-alliance association while controlling for sessions completed. RESULTS Consistent with the T&B model, client-therapist ratings were temporally congruent and were not discrepant overall. Greater congruence and smaller discrepancies were linked with stronger alliances. CONCLUSIONS The within-session and between-dyad variability in helpfulness ratings highlight the utility of moment-to-moment rating methods. Findings suggest that therapists should attune to client perceptions on a within-session level and attunement may be a target for enhancing the alliance.
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Affiliation(s)
- Elizabeth A Penix
- Department of Psychology, Idaho State University, Pocatello, Idaho, USA
| | - Joshua K Swift
- Department of Psychology, Idaho State University, Pocatello, Idaho, USA
| | - Kelley A Russell
- Department of Psychology, University of Alaska Anchorage, Anchorage, Alaska, USA
| | - Wilson T Trusty
- Department of Psychology, Idaho State University, Pocatello, Idaho, USA
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34
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Drivenes K, Haaland VØ, Hauge YL, Vederhus JK, Irgens AC, Solli KK, Regevik H, Falk RS, Tanum L. Discrepancy in Ratings of Shared Decision Making Between Patients and Health Professionals: A Cross Sectional Study in Mental Health Care. Front Psychol 2020; 11:443. [PMID: 32265780 PMCID: PMC7108784 DOI: 10.3389/fpsyg.2020.00443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 02/25/2020] [Indexed: 01/20/2023] Open
Abstract
Background A defined goal in mental health care is to increase the opportunities for patients to more actively participate in their treatment. This goal includes integrating aspects of user empowerment and shared decision-making (SDM) into treatment courses. To achieve this goal, more knowledge is needed about how patients and therapists perceive this integration. Objective To explore patient experiences of SDM, to describe differences between patient and therapist experiences, and to identify patient factors that might reduce SDM experiences for patients compared to the experiences of their therapists. Methods This cross-sectional study included 992 patients that had appointments with 267 therapists at Sørlandet Hospital, Division of Mental Health during a 1-week period. Both patients and therapists completed the CollaboRATE questionnaire, which was used to rate SDM experiences. Patients reported demographic and treatment-related information. Therapists provided clinical information. Results The analysis included 953 patient-therapist responder pairs that completed the CollaboRATE questionnaire. The mean SDM score was 80.7 (SD 20.8) among patients, and 86.6 (SD 12.1) among therapists. Females and patients that did not use medication for mental health disorders reported higher SDM scores than males and patients that used psychiatric medications (83.3 vs. 77.7; p < 0.001 and 82.6 vs. 79.8; p = 0.03, respectively). Patients with diagnoses involving psychotic symptoms reported lower SDM scores than all the other patients (66.8 vs. 82.3; p < 0.001). The probability that a patient would report lower SDM scores than their therapist was highest among patients that received involuntary treatment (OR 3.2, p = 0.02), patients with treatment durations longer than 2.2 years (OR 1.9, p = 0.001), and patients that required day care or in-patient care (OR 3.2, p = 0.01 and OR 3.2, p < 0.001, respectively). Conclusion We showed that both therapists and patients reported good SDM experiences in decisional situations, which indicated that SDM was implemented well. However, the SDM scores reported by in-patients and patients with prolonged or involuntary treatments were significantly lower than scores reported by their therapists. Our findings suggested that it remains a struggle in mental health care to establish a common understanding between patients and therapists in decisional processes regarding treatments for some patient groups.
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Affiliation(s)
- Karin Drivenes
- Sørlandet Hospital, Kristiansand, Norway.,Hospital Pharmacies Enterprise, South Eastern Norway, Oslo, Norway
| | - Vegard Ø Haaland
- Sørlandet Hospital, Kristiansand, Norway.,Clinical Neuroscience Research Group, Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
| | - Yina L Hauge
- Hospital Pharmacies Enterprise, South Eastern Norway, Oslo, Norway
| | | | | | - Kristin Klemmetsby Solli
- Oslo Centre for Biostatistics and Epidemiology, Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of R&D in Mental Health, Akershus University Hospital, L renskog, Norway.,OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Hilde Regevik
- Sørlandet Hospital, Kristiansand, Norway.,Hospital Pharmacies Enterprise, South Eastern Norway, Oslo, Norway
| | - Ragnhild S Falk
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Lars Tanum
- Oslo Centre for Biostatistics and Epidemiology, Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Vestfold Hospital Trust, Tønsberg, Norway
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35
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Penix EA, Swift JK, Trusty WT. Integrating clients' moment‐to‐moment ratings into psychotherapy research: A novel approach. COUNSELLING & PSYCHOTHERAPY RESEARCH 2020. [DOI: 10.1002/capr.12296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Joshua K. Swift
- Department of Psychology Idaho State University Pocatello Idaho
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36
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Kooistra L, Ruwaard J, Wiersma J, van Oppen P, Riper H. Working Alliance in Blended Versus Face-to-Face Cognitive Behavioral Treatment for Patients with Depression in Specialized Mental Health Care. J Clin Med 2020; 9:jcm9020347. [PMID: 32012722 PMCID: PMC7073833 DOI: 10.3390/jcm9020347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 12/24/2022] Open
Abstract
This study investigates working alliance in blended cognitive behavioral therapy (bCBT) for depressed adults in specialized mental health care. Patients were randomly allocated to bCBT (n = 47) or face-to-face CBT (n = 45). After 10 weeks of treatment, both patients and therapists in the two groups rated the therapeutic alliance on the Working Alliance Inventory Short-Form Revised (WAI-SR; Task, Bond, Goal, and composite scores). No between-group differences were found in relation to either patient or therapist alliance ratings, which were high in both groups. In the full sample, a moderate positive association was found between patient and therapist ratings on Task (ρ = 0.41, 95% CI 0.20; 0.59), but no significant associations emerged on other components or composite scores. At 30 weeks, within-and between-group associations between alliance and changes in depression severity (QIDS, Quick Inventory of Depressive Symptomatology) were analyzed with linear mixed models. The analyses revealed an association between depression over time, patient-rated alliance, and group (p < 0.001). In face-to-face CBT, but not in bCBT, lower depression scores were associated with higher alliance ratings. The online component in bCBT may have led patients to evaluate the working alliance differently from patients receiving face-to-face CBT only.
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Affiliation(s)
- Lisa Kooistra
- Department of Clinical, Neuro-and Developmental Psychology and the Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Correspondence:
| | - Jeroen Ruwaard
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Department of Psychiatry and the Amsterdam Public Health Research Institute, GGZ inGeest/Amsterdam UMC, Vrije Universiteit, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jenneke Wiersma
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
| | - Patricia van Oppen
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Department of Psychiatry and the Amsterdam Public Health Research Institute, GGZ inGeest/Amsterdam UMC, Vrije Universiteit, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Heleen Riper
- Department of Clinical, Neuro-and Developmental Psychology and the Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Research and Innovation, GGZ inGeest Specialized Mental Health Care, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands; (J.W.); (P.v.O.)
- Department of Psychiatry and the Amsterdam Public Health Research Institute, GGZ inGeest/Amsterdam UMC, Vrije Universiteit, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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37
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The Impact of Patients' and Therapists' Views of the Therapeutic Alliance on Treatment Outcome in Psychotherapy. J Nerv Ment Dis 2020; 208:56-64. [PMID: 31688492 DOI: 10.1097/nmd.0000000000001111] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article reports about the role of psychotherapists in creating a good enough therapeutic alliance as the basic task for other therapeutic factors come into play. Data from a naturalistic study involving 237 patients treated by 68 psychotherapists using 10 different psychotherapy approaches were analyzed in a process-outcome research design. The results show that therapists had to adapt their alliance perspectives to patients' level of alliance ratings as treatments progressed. Treatment concepts did not play a role in outcome. The view of a similar quality of the therapeutic alliance seems to be an indispensable precondition for favorable treatment outcomes. Successful treatments were conducted more often by therapists who showed significant convergence of alliance ratings over time, whereas discrepant alliance ratings correlated significantly with unsuccessful treatments.
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38
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Solomonov N, Barber JP. Conducting psychotherapy in the Trump era: Therapists' perspectives on political self-disclosure, the therapeutic alliance, and politics in the therapy room. J Clin Psychol 2019; 75:1508-1518. [PMID: 31132301 DOI: 10.1002/jclp.22801] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/02/2019] [Accepted: 05/04/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine therapists' perspectives on political self-disclosure, perceived shared values with patients, and the therapeutic alliance. METHOD Therapists from all US states completed a structured survey (N = 268; 62% Democrats; 7% Republicans; 23% independents; 8% others). RESULTS Most therapists (87%) reported they discussed politics in-session; 63% reported political self-disclosure (21% explicit; 42% implicit). Therapists who perceived political similarity with most patients were more likely to report political discussions and self-disclosure. Therapists who reported shared political views with a higher percentage of patients, and those who explicitly disclosed, also reported stronger alliances. Clinton supporters reported significant observed preelection-postelection increases in political discussions, increases in patients' expression of negative emotions, and decreases in positive emotions. Trump supporters reported the opposite phenomenon. CONCLUSIONS Politics play an important role in therapeutic processes as in-session political discussions are common and perceived political similarity may affect decisions to self-disclose and alliance quality.
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Affiliation(s)
- Nili Solomonov
- Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Jacques P Barber
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, New York
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Crits-Christoph P, Gallop R, Gaines A, Rieger A, Connolly Gibbons MB. Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation. Psychother Res 2018; 30:53-67. [PMID: 30451094 DOI: 10.1080/10503307.2018.1544724] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, PA, USA
| | - Averi Gaines
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Agnes Rieger
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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40
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Doran JM, Gómez-Penedo JM, Safran JD, Roussos A. A therapist version of the Alliance Negotiation Scale. Clin Psychol Psychother 2018; 25:745-753. [PMID: 29722105 DOI: 10.1002/cpp.2197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 11/06/2022]
Abstract
The aim of the current study was to design and evaluate a therapist version of the Alliance Negotiation Scale (ANS). The ANS was created in order to operationalize the construct of dyadic negotiation in psychotherapy and to augment existing conceptualizations of the working alliance. The ANS has existed only as a client self-report form since its inception and has demonstrated promise as a psychotherapy process measure. This research intended to develop a complementary therapist self-report version of the measure. The scale creation process is discussed in detail, and the results of a preliminary psychometric investigation are reported. The ANS-Therapist version (ANS-T) was developed using a sample of therapists (n = 114) through a principal components analysis procedure. The ANS-T contains 9 unidimensional items and was moderately correlated with therapist-reported working alliance (r = .468). The results of the study support the composition of the ANS-T and provide initial support for the reliability and validity of the measure.
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Affiliation(s)
- Jennifer M Doran
- VA Connecticut Healthcare System, CT, USA.,Department of Psychiatry, Yale School of Medicine, CT, USA
| | | | | | - Andrés Roussos
- CONICET, Universidad de Buenos Aires, Buenos Aires, Argentina
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41
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Piccoli GB, Sofronie AC, Coindre JP. The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions. BMC Med Ethics 2017; 18:61. [PMID: 29121886 PMCID: PMC5680775 DOI: 10.1186/s12910-017-0219-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Case presentation Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”. Conclusions An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. .,Nephrology, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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Coyne AE, Constantino MJ, Laws HB, Westra HA, Antony MM. Patient–therapist convergence in alliance ratings as a predictor of outcome in psychotherapy for generalized anxiety disorder. Psychother Res 2017; 28:969-984. [DOI: 10.1080/10503307.2017.1303209] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Alice E. Coyne
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Michael J. Constantino
- Department of Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Holly B. Laws
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Henny A. Westra
- Department of Psychology, York University, Toronto, ON, Canada
| | - Martin M. Antony
- Department of Psychology, Ryerson University, Toronto, ON, Canada
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