Therapeutic alliance in psychological treatment for depression and alcohol use comorbidity: The client's perspective

Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance

OBJECTIVE

Developing good interpersonal relationships is one of the main impediments for people with an antisocial personality disorder (ASPD). However, in treatment of psychiatric disorders, establishing a strong therapeutic alliance (TA) is important for effective treatment. Nevertheless, there is little knowledge on how to establish this TA with this challenging patient group. This study investigates which factors are important in TA development.

METHOD

For this study, a qualitative research methodology is applied. In-depth interviews with therapists experienced in treating ASPD were conducted and analysed through thematic analysis.

RESULTS

The analysis revealed six themes important in alliance formation: the patient's needs, regulating interpersonal dynamics, connective attitude, connective skills, treatment process and treatment goals. Each theme is defined including aspects of the recommended therapeutic attitude and required skills for therapists working with patients with ASPD.

CONCLUSIONS

This study determined that, for therapists working with patients with ASPD, several key factors are essential in establishing a strong TA. These factors include the ability to be firm, authentic, non-judgmental and genuinely involved. An attentive presence is crucial, in which the therapist takes initiative in establishing contact and makes the patient feel that he is truly seen as an autonomous and equal person. In doing so, the therapist needs to provide clarity and structure while remaining perceptive to boundary violations. The therapist must be able to set limits using a clear yet kind tone of voice. Furthermore, it was notable that an intensive appeal is made to the therapist's reflective capacity in these treatments.

Patient- and therapist-rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment

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.