Open door review

Helping alliance

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The role of alliance in the relationship between therapist competence and outcome in Brief Psychodynamic Psychotherapy

Despland, J.-N., de Roten, Y., Drapeau, M., Currat, T., Beretta, V., & Kramer, U. (2009). The role of alliance in the relationship between therapist competence and outcome in brief psychodynamic psychotherapy. Journal of Nervous and Mental Disease, 197(5), 362-367. doi: 10.1097/NMD.0b013e3181a20849

Summary

Therapist competence is a key variable for psychotherapy research. Empirically, the relationship between competence and therapeutic outcome has shown contradictory results and needs to be clarified, especially with regard to possible variables influencing this relationship. A total of 78 outpatients were treated by 15 therapists in a very brief 4-session format, based on psychoanalytic theory. Data were analyzed by means of a nested design using hierarchical linear modeling. No direct link between therapist competence and outcome has been found, however, results corroborated the importance of alliance patterns as moderator in the relationship between therapist competence and outcome. Only in dyads with alliance change over the course of treatment was it clear that competence is positively related to outcome. These findings are discussed with regard to the importance for outcome of therapist competence and alliance construction processes.

The results support to a large extent our 3 hypotheses. The results also indicate that no direct relationship exists between level of competence and outcome in BPI. This means that even after training in BPI and years of experience, a high level of therapist competence does not guarantee a positive outcome (Barber et al., 2006; Sandell, 1985). This also means that other variables, or variable combinations, account better for outcome variation. Results indicate that competent therapists tend to establish a growing alliance over the course of BPI, compared with less competent therapists. The highly significant coefficients indicate the important contribution of the therapist’s level of competence in alliance construction processes. The latter are conceived as coconstruction processes, based on patient-dependent, therapist-dependent and dyad-specific variables. One could say that within the context of relational progression (growing alliance), the more competent the therapist, the better the outcome, whereas, paradoxically, within the context of relational stagnation (stable alliance), the more competent the therapist, the less positive the outcome (small symptom reduction, no change, or deterioration). For the latter, the exact opposite holds true; competence does have a direct effect on outcome, but no interaction effect has been found. Thus, the more competent the therapist is on the subscale of general psychotherapeutic attitude, the better the outcome. This result might reflect that the therapist’s basic interactional and therapeutic skill of empathic, nonjudgmental consideration towards the patient is a necessary, but as such, an insufficient therapeutic ingredient in psychodynamic psychotherapy. It seems that alliance has an influence on the relationship between competence and outcome. We find, on the one hand, for the subsample with relational progression over the 4 sessions of BPI, therapist competence is of importance in the sense that low competence yields low outcome. As the level of training is related to competence, in the cases of relational change, more training in BPI, for example, in the form of more frequent case supervisions should help to produce a positive outcome. It also indicates that competence is certainly a necessary condition for treatment outcome, but as such insufficient; alliance evolution, as an emergent characteristic of a successful therapeutic process, needs to be taken into account. On the other hand, in cases stagnating in alliance over the 4 sessions of BPI, therapist competence is also important but in the opposite sense: low to moderate competence yields the best outcome and the more competent the therapist, the less positive the outcome. It could be said that, in the latter cases, the therapist does “more of the same” by delivering competent interventions, which finally have only a limited impact on symptom change. Two reasons might be at stake: (1) in these patients, the impact of the intervention is confined to an internal psychodynamic level, with no direct impact on our outcome measure (2) The patient–due to his dysfunctional relationship patterns- establishes a rigid level of alliance and is thus highly resistant to the therapeutic relationship and the therapist’s interpretations, even more so if they are competently delivered. These results complete Barber et al’s (2006) study on the moderator effect of adherence. For competence, as we defined it, a linear moderator model might be most accurate, compared with adherence, where a curvilinear yields similar effects of alliance. Using these approaches, we conclude that the highest competencescore is the optimal within the differential context of growing alliance, whereas for adherence, the median adherence is in any case the optimal (Barber et al., 2006).

Because context-embeddedness of the technique (e.g., “skillfulness” and “providing a therapeutic milieu”) is the main difference between Barber et al’s (2006) definition of adherence and ours of competence, we hypothesize that more outcome variance is explained with the wide concept of competence, compared with adherence, when taking into account the context of the applied psychodynamic technique. If this assumption holds true, it might also account for the absence of effect of the competence measure by Barber et al. (2006) who defined competence less broadly than it was done in our study (see Introduction section).

On the other hand, it might be argued that our definition of competence is so broad that risks of confounds with other context variables, such as the therapeutic alliance, are not excluded. Empirically, such a critic does not stand further examination, as the differential effect of stable alliance demonstrates: even if the therapist’s competence varies in these dyads, alliance remains the same, indicating at least some independence between these variables. Several limitations of this study should be underlined. This is a naturalistic study; although the distribution of the patients between the therapists was controlled for, the patients were not randomly assigned to the therapists. Consequently, there was no controlled distribution of patients to therapists according to their number of years of training and experience. Such a control would have enabled us to partial out the influence of therapists’ training and level of experience. In this study, it confounds with competence due to high correlations.

Contact

Jean-Nicolas Despland, Prof., Yves de Roten, PhD, Martin Drapeau, Prof., Thierry Currat, MD, Veronique Beretta, MPs, and Ueli Kramer, PhD

Email: Yves.DeRoten@chuv.ch

Accuracy of therapist perceptions of patients' alliance: Exploring the divergence

Hartmann, A., Joos, A., Orlinsky, D.E., Zeeck, A. (2014). Accuracy of therapist perceptions of patients’ alliance: Exploring the divergence. Psychotherapy Research, 25(4), 408–419. http://dx.doi.org/10.1080/10503307.2014.927601

Summary

The therapeutic alliance is a well-established predictor of psychotherapy outcome, yet much research has shown that therapists’ and patients’ views of the alliance can diverge substantially. Therapists systematically underestimate their patients’ perceived level of alliance, and the correlation between therapist and patient estimates of patient alliance is only moderate. The present study explored the divergence between therapists’ and patients’ perspectives on patients’ alliance experience, and its relations to therapists’ concurrent work involvement and session process experiences.

Sample

The study sample includes 98 treatment cases, conducted by 26 psychodynamic psychotherapists of varying experience levels. Half of the sample consisted of individual outpatient treatments (private practice) and the other half were individual treatments in a day clinic setting (university hospital). Most of the 98 patients suffered from a major depressive disorder.

Results

Therapist-patient divergence was significantly related to therapists’ case-wise work involvement, but not to therapist’s views of session process. The best predictor of therapist-patient divergence was therapists experiencing a “distressed practice” work involvement pattern.

Although therapists’ work involvement experiences are not commonly investigated, they can be a relevant predictor of therapy processes.

Evaluation

Although the sample comprised 98 therapies, the nesting of therapies in 26 therapists limited the statistical power of the investigation and its results. Yet the findings already appear to have interesting and potentially clinically relevant if tentative implications.

Contact

Armin Hartmann

Department of Psychosomatic Medicine and Psychotherapy, University Clinic of Freiburg, Hauptstr.8, Freiburg 79104, Germany.

Email: armin.hartmann@uniklinik-freiburg.de

Website: http://www.uniklinik-freiburg.de/psychosomatik/patientenversorgung/ansprechpartner/ansprechpartner-direktion.html

Alliance in individual psychotherapy

Horvath, A. O.; Del Re, A. C.; Flückiger, C.; & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy 48(1): 9-16.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work (pp. 33-70). New York: Oxford University Press.

Summary

The concept of the alliance is currently one of the most intensely researched subjects in the psychotherapy research literature. This new research synthesis examines the relation between alliance and the outcomes of individual Psychotherapy, including over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as “alliance,” “therapeutic alliance,” “helping alliance,” or “working alliance” were the inclusion criteria. Several potential moderators also were explored.

In terms of the research synthesis presented in this report, it is important to emphasize that the authors know about the lack of a precise consensual definition of the alliance construct. As a consequence, the alliance and its relation to outcome and other therapy variables has been gleaned from studies which, in practice, define the alliance by the diverse instruments used to measure it. Within the 201 studies in this collection of data, over 30 different alliance measures were used—not counting different versions of the same instruments. Similar to previous reports, the four “core measures”: California Psycho-therapy Alliance Scale, (CALPAS), Helping Alliance Questionnaires (HAq), Vanderbilt Psycho-therapy Process Scale (VPPS), and Working Alliance Inventory (WAI) accounted for approximately 2/3 of the data. In research on the shared factor structure of the WAI, CALPAS and HAq, the concept of “confident collaborative relationship” was identified as the central common theme. Each of these four instruments has been in use for over 20 years and has demonstrated an acceptable level of internal consistency. Fifty-four of the research reports in this data set used less well validated instruments or assessment procedures; the relation of most of these measures to the core instruments, or to each other, are not well documented, and sometimes nonexistent. As noted, the diversity in the “de facto” definition of the alliance that has emerged via the use of a variety of assessment measures has become an important source of variability across studies.

For identifying studies published between 1973 and 2000, the authors relied on data from previous analyses (Horvath & Symonds, 1991 & Horvath & Bedi, 2002) but the effect sizes (ES) where recalculated (using more up-to-date methods) for all but 10 of the oldest unpublished studies which were no longer available. To locate data from the years 2000 to 2009, first electronic databases were searched (PsycINFO/EBSCO) using the same keywords as the Horvath and Bedi (2002) analysis. Next the bibliography of studies included in the analysis was cross-referenced. The criteria for inclusion in this report were: (1) the study author referred to the therapy process variable as “alliance” (including variants of the term); (2) the research was based on clinical as opposed to analogue data; (3) five or more adult patients participated in the study, and; (4) the data reported were such that we could extract or estimate a value indicating the relation between alliance and outcome. In contrast to previous meta-analyses, the literature search was extended to material available in Italian, German, or French, as well as English. The number of studies in the current study is roughly double the size of the data available for the previous (Horvath & Bedi, 2002) meta-analysis.

The analyses of this research synthesis were done using the assumptions of a random model and numerical estimates were calculated using restricted maximum likelihood (random effects) model. The aggregate effect size (ES), for the 190 independent alliance/outcome relations was r _ .275. The 95% confidence interval of this averaged ES ranged from .249 to .301. The magnitude of the relationship we found in the current meta-analysis is a little larger but similar to the values reported in previous research (Horvath & Symonds, 1991 r _ .26, k _ 26; Horvath & Bedi, 2002, r _ .21, k _ 100). The median effect size of ESs of the current data set was .28 suggesting that the group of effect sizes we collected was not strongly skewed. The overall effect size of .275 is statistically significant at p _ .0001 level indicating a moderate but highly reliable relation between alliance and psychotherapy outcome. In Addition, the impact of six categorical variables were investigated that have the potential of moderating the relation between alliance and outcome: alliance measure (CALPAS, VPPS, HAq, WAI, and Other); alliance rater (client, therapist, observer); time of alliance assessment (Early, Mid, Late, Averaged); outcome measure (BDI, SCL, Dropout); type of treatment (CBT, IPT, Psychodynamic, Substance Abuse); and publication source (journal, books/chapters, unpublished/thesis). There are several noteworthy features that apply to all of these results: All of the aggregate alliance-outcome correlations in each category are statistically significant beyond p _ .001. This result strongly supports the claim the impact of the alliance on therapy outcome is ubiquitous irrespective of how the alliance is measured, from whose perspective it is evaluated, when it is assessed, the way the outcome is evaluated, and the type of therapy involved.

The quality of the alliance matters. The next most common feature is the finding that, with very few exceptions, within each of these subsets of data, the ES are very diverse in magnitude. It was noted earlier that heterogeneity of the ESs in a large-scale meta-analysis is not unusual. However, these results indicate that the high degree of variability remains practically unchanged within each level of these potential moderators.

Evaluation

The positive relation between the quality of the alliance and diverse outcomes for many different types of psychological therapies is confirmed in this meta-analysis. While the overall ES of r _ .275 accounts for a relatively modest proportion of the total variance in treatment outcome, the magnitude of this correlation, along with therapist effects, is one of the strongest and most robust predictors of treatment success empirical research has been able to. By including all research in which the authors refer to the process variable as alliance, the study might have collected and summarized a number of different kinds of things. A practical response to this conceptual problem is to conclude that this meta-analysis reports the results of alliance-outcome relation as it is researched at this time. In general, Studies on the alliance construct are an important contribution to psychotherapy research by creating diverse implications for therapeutic practice.

Contact

Prof. Adam O. Horvath

Simon Fraser University, Faculty of Education

8888 University Drive, Burnaby, BC, Canada V5A 1S6

Email: horvath@sfu.ca

Website: www.sfu.ca

The working alliance and the stability of therapeutic outcomes in the treatment of depressed patients: A process-outcome study

Huber, D., Henrich, G., Clarkin, J. & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry, 76(2), 132-149.

Huber, D., Zimmermann, J., Henrich, G. & Klug, G. (2012). Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients—A three-year follow-up study. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58(3), 299-316.

Summary

In a process-outcome design comparing different forms of psychotherapy (psychoanalytic psychotherapy, psychodynamic psychotherapy, and cognitive-behavioral therapy) the study investigated whether the working alliance has differential impact on outcomes and their stability.

The working alliance is viewed as a mediator variable serving to explain the treatment process and its influence on different outcomes. We assume the working alliance to be one of three components constituting the therapeutic relationship that is, beyond the working alliance, the real relationship between patient and therapist and the transference.

Meta-analyses suggest working alliance as a robust predictor of different outcomes, however, the predictive power is relatively low, explaining only 7% of the outcome variance. Nevertheless, the working alliance can be regarded as a substantial predictor, taking into account that other curative factors explain rarely more than 15% of outcome variance.

The patient sample is derived from the prospective and partly randomized MPS sample consisting of 100 patients (intent-to-treat sample) who met the DSM-IV criteria for major depressive disorder (psychoanalytic psychotherapy=35, psychodynamic psychotherapy=31, cognitive-behavioral therapy=34); the completer sample comprises 85 patients. Therapy sessions of each patient have been audiotaped but 13 cases had to be excluded due to low audio quality (psychoanalytic psychotherapy=26, psychodynamic psychotherapy=24, cognitive-behavioral therapy=22).

Patients were assessed at pretreatment, at post-treatment and at follow-up each year after treatment termination up to three years. Self-rating questionnaires important for the study described here are the Beck-Depression Inventory (BDI) and the Inventory of Interpersonal Problems (IIP-short version).

As Stiles and Goldsmith (2010) recommended, we decided to measure the process in a multimodal way including patients, therapists and external rater assessments. For measuring the working alliance we choose the Working Alliance Inventory (WAI-observer rating short form). The WAI is a trans-theoretical instrument suitable for different treatment approaches, based on three dimensions: (1) agreement on tasks, (2) agreement on goals, (3) development of bond.

Measurement points for WAI are 6 and 12 months after beginning of treatment; ratings are performed by trained raters.

As a second process measure we use the Helping Alliance Questionnaire (patient and therapist version [HAQ-P and HAQ-T]). The inventory consists of 11 items assessing two aspects of the therapeutic working alliance: (1) perceived helpfulness by the therapist and (2) collaboration and bond with the therapist.

Measurement points for HAQ-P and HAQ-T are 6 and 12 months after beginning of treatment. In an explorative approach the following main research questions are addressed:

Does working alliance (WAI and HAQ) predict therapy outcomes (BDI and IIP) and their stability through follow-up?

Are there differences in the predictive power of working alliance as a function of the modality of measurement (patient, therapist, external rater)?

Do differences exist concerning the predictive power of working alliance as a function of treatment (psychoanalytic psychotherapy, psychodynamic psychotherapy, cognitive-behavioral therapy)?

Statistical analyses are performed by multiple regression analyses.

Evaluation

The study intends to contribute to the relevance of the working alliance as part of the therapeutic relationship. Within this frame, the treatment dependent impact of the working alliance will enhance a better understanding of different mechanisms of change.

Contact

Prof. D. Huber, M.D., Ph.D.

International Psychoanalytic University (IPU), Stromstrasse 3b, 10555 Berlin, Germany.

E-mail: dorothea.huber@ipu-berlin.de

Therapeutic alliance and psychotherapy process

Colli A., & Lingiardi V. (2009). The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy. Psychotherapy Research, 19, 718-734.

Lingiardi V., Colli A., Gentile D., & Tanzilli A. (2011). Exploration of session process: Relationship to depth and alliance. Psychotherapy, 48, 391-400.

Lingiardi V. (2013). Trying to be useful: Three different interventions for one therapeutic stance. Psychotherapy, 50, 413-418.

Summary

The goal of our studies was to investigate the relationship between psychotherapy process, therapeutic alliance, and therapist activity using an assessment method based on therapy sessions’ transcripts. The research design implied that independent raters evaluated psychotherapy sessions of various theoretical approaches (mostly psychodynamic and cognitive– behavioral) with different process measures.

In a first study, we presented the validation and the application of a new rating system for the assessment of alliance ruptures and repairs in psychotherapy: the Collaborative Interactions Scale (CIS; Colli, Lingiardi, 2009). The CIS (composed of two main scales: one for the evaluation of patient rupture and collaborative processes, CIS-P, and one for the evaluation of therapist positive and negative contributions to the therapeutic relationship, CIS-T) furnishes a great deal of information about: 1) the patient capacity to self-disclose intimate and salient information in session, to experience emotions in a modulated fashion, to work actively with the therapist’s comments, or to deepen the exploration of salient themes; and 2) two main aspects of therapist activities: the quality of the intervention (timing, attunement, tactfulness, comprehensibility) and their form (e.g., clarification, confrontation, interpretation).

The CIS is a reliable rating system, useful in both empirical research and clinical assessments. In the second study, we explored the relationship between the depth of elaboration, the therapeutic alliance, and some dimensions of psychotherapy process (including the therapist’s interventions, the patient’s contributions, and patient/therapist’s patterns of interaction) evaluated with the Psychotherapy Process Q-Set (PQS; Jones, 1985, 2000). In line with the findings of Blagys and Hilsenroth (2000), our research showed the importance of therapist interventions that focus on the patient’s affects (particularly those regarded as unacceptable emotions and feelings), recurring and enduring interpersonal patterns, and the “here and now” of the relationship in the increase of the depth of elaboration and patient/therapist alliance (see also Lingiardi, 2013).

Evaluation

The aims of these studies were to study in a clinically articulated and empirically grounded way the psychotherapy process in order to clarify what happens during the session, which kind of therapist interventions are more effective in relation to specific process factors (such as the depth of elaboration, or ruptures and resolutions processes), and which kind of patient/therapist dynamics are related to a good therapeutic relationship. The main limitations is that for the moment we studied only the observer perspective of evaluation; even if our findings are in line with previous studies that use both patient and therapist perspectives, in the future it will be necessary to investigate all the three perspectives simultaneously.

Contact

Prof. Vittorio Lingiardi, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi, 78 - 00185 Rome, Italy.

Email: vittorio.lingiardi@uniroma1.it

Dr. Antonello Colli, Department of Human Science, Carlo Bo University of Urbino, Via Bramante, 17 - 61029 Urbino, Italy.

E-mail: antonello.colli@uniurb.it

Dr. Annalisa Tanzilli, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi, 78 - 00185 Rome, Italy.

Email: annalisa.tanzilli@uniroma1.it

Dr. Daniela Gentile, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi, 78 - 00185 Rome, Italy.

Email: daniela.gentile@uniroma1.it

Psychological intervention and change in depression process studies

Krause, M., Altimir, C., & Horvath, A. O. (2011). Deconstructing the therapeutic alliance: Reflections on the underlying dimensions of the concept, Clínica y Salud, 22(3), 267-283.

Krause, M., Altimir, C., Pérez, C., & de la Parra, G. (2015). Generic change indicators in therapeutic processes with different outcomes. Psychotherapy Research, 25(5), 533-545. .

Background

Cumulative findings in psychotherapy research support the centrality of the therapeutic relationship, and especially of the alliance, for psychotherapy and change. This underscores the importance of examining the intrinsic relational character of the psychotherapeutic change process, through the study of the specific micro-processes involved in the dynamic construction and maintenance of the therapeutic relationship that ultimately bear influence over therapeutic change. It is of particular interest to further explore the ways in which patient and therapist mutually regulate and negotiate their affective exchange in the process of establishing and shaping the alliance.

Subprojects

1. Analysis of the underlying dimensions of the concept of alliance

2. Generic Change Indicators in therapeutic processes with different outcomes

3. A single case study of patient and therapist’s verbal and nonverbal relational offers during rupture and resolution strategy episodes.

4. A single case study of patient and therapist’s synchronic facial-affective regulation during ruptures and resolution strategies and its association with process outcome, alliance, and therapy evolution.

Research questions

1. What is the relationship between the processes that build up the elements of the therapeutic relationship that belong to different synchronic levels of analysis (micro, meso and macro) and how do they evolve along the psychotherapeutic process?

2. What are the implicit and explicit elements, expressed through facial and verbal behavior, respectively, of the affective regulation process between patient and therapist in episodes of rupture of the alliance and of resolution strategies, in a psychoanalytic psychotherapy?

Design and method

Subproject 1: Systematic qualitative study of former patients and therapists’ reports of their experience in therapy; and qualitative analysis of the item contents of the most often used instruments of alliance. Subproject 2: transversal comparison of over 39 therapeutic processes regarding ongoing change, and final outcome. Subprojects 3 and 4: A single case study, systematically analyzed with qualitative and quantitative procedures, regarding nonverbal facial behavior and regulatory processes within the negotiation of the alliance. A nested analysis approach was implemented for the association between variables belonging to different levels of analysis.

Sample

Subproject 2: 39 therapeutic processes. Subprojects 3 and 4: 1 individual therapy 

Treatment

Subproject 2: Individual psychodynamic and gestalt, family social-constructionist, couples humanistic and group CBT. Subprojects 3 and 4: Individual short-term Psychodynamic focal therapy.

Measures

Outcome Questionnaire (OQ-45.2), Working Alliance Inventory (WAI), Rupture Resolution Rating System (3RS), Facial Action Coding System (FACS), Generic Change Indicators (GCI).

Results

During the momentary deterioration of the alliance –expressed in rupture episodes–, patient facially expresses negative affect and attempts to regulate her emotional arousal, and the degree of affective contact and involvement with the therapist, while therapist attempts to down-regulate his own emotional expressions. Simultaneously, at the verbal level, therapist attempts relational offers such as proposing, questioning and being conciliator, while patient offers a receptive stance. Meanwhile, during therapist’s reparatory attempts, patient nonverbally re-establishes contact and emotional involvement with the therapist, while therapist verbally offers the patient a friendly and validating attitude, at the same time that facially expresses patient’s dissociated negative affects based on an active assessment of the patient’s internal affective state. Finally, participants’ synchronic smiles were observed in rupture and resolution strategies episodes, indicating a positive affective attunement and attempts to preserve the bond in the presence of relational conflict.

All studies indicate that clinical significant change is related to high-stage transformations of representations in the patient, particularly those referred to the construction and consolidation of new meanings, and a synergic relationship between initial-stage representational changes and higher-ordered ones was observed in these therapies.

Evaluation

Future studies require an accumulation of more in-session episodes and therapies, for the confirmation of the micro-facial affective patterns observed in the present study, and their evolution and change along the therapy process. Future studies should also attempt measuring the therapeutic alliance at the episode level, so that more clear associations can be made between the oscillations of the alliance and that of the facial-affective regulatory patterns, the ruptures and resolution strategies, and the process outcome indicators.

Contact

Carolina Altimir, Psicóloga, PhD

Investigadora Adjunta

Instituto Milenio para la Investigación en Depresión y Personalidad- MIDAP

Universidad de Las Américas

Centro de Investigación en Psicoterapia (CIPsi)

E-mail: caltimir.colao@gmail.com

Email: caltimir.colao@gmail.com

Psychological intervention and change in depression. Adolescent psychotherapy: Therapeutic alliance, subjective change and relational patterns

Background

The empirical study of psychotherapy with children and adolescents has fallen behind the studies with adults, being of recent development. These studies occur in artificial contexts, include only some types of psychotherapies (mostly CBT) at the expense of research in natural contexts. Studies that consider the children’s and adolescents’ own perspectives about the therapeutic process are scarce. Alliance is a central generic change factor.

The quality of the alliance relates consistently to outcome. The alliance observed during the first sessions, has a stronger relation with treatment outcomes than the alliance measured in the middle of treatment or the mean value of the alliance. In psychotherapy with adolescents there are contradictory evidence regarding which of the first sessions relates more to final outcome and which perspective relates stronger to outcome.

On the other hand, different psychoanalytic theories conceptualize adolescence as a vital moment in which it´s possible to define specific psychological conditions whit process qualities. These features are triggered with puberty and mobilize different relational tasks. In this context, it´s important to study the influence of relational characteristics of adolescents in the therapeutic process at different levels.

Research questions

This research has two sub-studies:

- In therapeutic processes with adolescents:  How is the relation of the therapeutic alliance with change (process and outcome) and adherence, considering the perspective of the adolescents and their therapists and the differences of psychodynamic therapies compared to other therapies.

-Which are the characteristics of relational patterns of adolescents?  What is the link between Prevalent Relational Patterns in adolescence, the change process and Therapeutic Alliance?

Subprojects

- Therapeutic alliance, communicative actions, and generic change indicators in the initial phase of psychotherapy with adolescents, and their connection with outcomes and adherence to treatment.

-Relational patterns in adolescents with depressive symptoms.

Design and method

The studies are multiple case study design. The studies use mixed designs that combined qualitative techniques and quantitative analysis. Process studies have a non-experimental design, with data obtained from natural intervention contexts.

Sample

-20 adolescents (15 female, 5 male); 13-17 years old. Disorders / complaints: Depression (8), Anxiety (3), Behavioral problems (3), Adaptation disorders (3) Developmental crisis (2), Others (1). Therapy approaches: psychodynamic, systemic, social-construccionist and CBT.

-10 individual Psychotherapies with adolescents with depressive symptoms (Approximately 8 sessions) videotaped. Were analyzed psychotherapies with psychodynamic, integrative and cognitive focus.

Measures

Horvath’s Working Alliance Inventory - WAI (Chilean Version: Santibáñez, 2001) (first three sessions).

Outcome Questionnaire OQ 45.2 (Chilean Version: De la Parra  & Von Bergen, 2001)

Generic Change Indicators (GChI, Krause, et al., 2007)

Relevant episodes: Change Episodes (Krause et al., 2006; Krause et al., 2007) and Rupture Episodes (Safran & Muran, 1996, 2000, 2006).

CCRT-LU (Luborsky, 1977;  Albani, C., et al. 2002; CCRT-LU-S: López del Hoyo, et al., 2004)

Results

Initially, therapeutic alliance (3rd session) correlates with final results (results OQ), both for adolescents (total score) and therapists (sub scale goals). There are no differences by theoretical orientation. Only the alliance perceived by therapists (not by adolescents) – of session 1 and 2 – relates to intermediate results (6th session). The alliance of session 2 (subscale goals) perceived by psychodynamic therapists, correlates with intermediate results.

Alliance, evaluated from the perspective of the adolescents in session 2, specifically on the task subscale, predicted the probability of finalizing the process. This was not observed when the alliance was measured from the perspective of the therapists. Alliance, perceived by the therapist in session 1 and 2, correlates with the Ongoing Change (GCI obtained in that session). Ongoing Change (higher GCI in the first three sessions) predicted adherence to therapy.

In the second sub-study, we have found a link between harmony in relationship narratives and the level of depressive symptoms and the Predominant Relational Patterns appear in relevant episodes of psychotherapy. 

Evaluation

Therapists and adolescents perspectives on the alliance are related to the development of the process and the final outcome, but the therapists perspective relates specifically to ongoing change and intermediate outcome, while the adolescents perspective relates to adherence. The fact that ongoing change predicts adherence means that early changes (first three sessions) help adolescents to stay in therapy.

Contact         

Olga Fernández

Email: ofernandezg@uc.cl

H. Daniel Espinosa Duque / Doctor en Psicoterapia

Docente Investigador / Facultad de Psicología 

Universidad CES / Calle 10A # 22-04 / Medellín, Colombia


hespinosa@ces.edu.cowww.ces.edu.co

Email: hdespinosa@uc.cl

Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438-450.

Brief Summary

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability.

Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study. In the past two decades, psychotherapy researchers and practitioners have postulated that the therapeutic alliance—defined broadly as the collaborative and affective bond between therapist and patient—is an essential element of the therapeutic process. The primary reason the alliance has grown in significance is the consistent finding that the quality of the alliance is related to subsequent therapeutic outcome. Another reason interest in the alliance has increased in the past 20 years is the inability of researchers to find a consistent difference in the effectiveness of psychotherapy across orientations. Consequently, many contemporary theories of psychotherapeutic change now emphasize the importance of the alliance, so much so that some theorists have referred to the alliance as the "quintessential integrative variable" (Wolfe & Goldfried, 1988, p. 449) of therapy. Although there are differences among the many alliance conceptualizations, most theoretical definitions of the alliance have three themes in common: (a) the collaborative nature of the relationship, (b) the affective bond between patient and therapist, and (c) the patient's and therapist's ability to agree on treatment goals and tasks (Bordin, 1979).

Using various techniques, this review indicates that alliance is moderately related to outcome (7 = .22). The average allianceoutcome correlation is within the range of many other effect sizes that are associated with psychotherapy outcome. In addition, the relation of alliance and outcome appears to be consistent, regardless of many of the variables that have been posited to influence this relationship. Indeed, the test of homogeneity suggests that the correlation represents a homogeneous population. In sum, the present metaanalysis indicates that the overall alliance-outcome correlation represents a single population of effects that cannot be reduced by a moderator variable into a more explanatory model of the relation of the alliance and outcome. This meta-analysis supports the belief that the relation of the therapeutic alliance with outcome is consistent within the psychotherapy literature. What is evident from this review is that the strength of the alliance is predictive of outcome, whatever the mechanism underlying the relation. From the empirical review of the reliabilities of the various alliance scales, it seems clear that all the alliance measures have adequate reliability. Although the overall reliability index for the various scales was somewhat lower than that found in the previous meta-analysis (.79 vs. .86), the present index still reaches an acceptable standard of consistency. Moreover, when the overall alliance index was separated by individual alliance scales, every alliance measure had an overall reliability index above .70. Surprisingly, even the scales that are not well established as measures of the alliance had adequate reliabilities. Given these results, all the alliance scales seem to have acceptable reliability. This meta-analysis did not implicate a specific alliance scale as being more reliable than the others, but it also failed to eliminate a scale from further consideration as a research tool because of its psychometric properties. These results suggest that researchers cannot base their choice of an alliance scale on its reliability indices; the scales all tend to receive strong support. The alliance ratings of patients, therapists, and observers all tended to have adequate reliability. Although the ratings of therapists seemed to be slightly less consistent than those of patients and observers, therapists' ratings of the alliance were still within the acceptable range. Across therapy sessions, patients tended to rate the alliance more consistently than did therapists or observers. On the basis of the present meta-analysis, it seems that patients tend to view the alliance as stable, whereas therapists and observers tend to indicate more change over time in their alliance ratings.

The implications of this finding are clear: Because patients tend to view the alliance consistently throughout treatment, they are more likely to view the alliance as positive at termination if their initial assessment was positive. Thus, therapists must be effective at establishing positive alliances with their patients early in the therapy process. However, because of the small sample size of this comparison, the greater consistency of patient ratings across alliance sessions should be considered a tentative finding.

Most of the alliance scales have been shown to be related to outcome. The Penn scales, the Vanderbilt scales, the WAI, and the CALPAS were moderately correlated with outcome, but the TARS failed to receive support. In addition, the Penn scales, the Vanderbilt scales, the WAI, and the CALPAS have received far more empirical scrutiny than any of the other alliance scales. Of these measures, the WAI is likely to be appropriate for most research projects. The scale was designed to measure alliance factors in all types of therapy and to measure the theoretical constructs underlying the alliance. The scale provides both an overall alliance score and also an assessment of Bordin's (1979) three aspects of the alliance: the bond, the agreement on goals, and the agreement on tasks. The WAI also provides an assessment of Horvath and Luborsky's (1993) two core aspects of the alliance measured by most scales: (a) therapist-patient affective attachments  and (b) collaboration or willingness to invest in the therapy process. In addition, patient-, therapist-, and independent observerrated versions of the scale are available, as are shortened versions of these scales. The overall correlation of alliance and outcome did not seem to be influenced by publication status. Although the unpublished studies included in the meta-analysis had a slightly lower average correlation than did the published studies, the difference was not significant. Similarly, it is highly unlikely that enough unlocated studies with null results exist in file drawers to reduce the overall allianceoutcome correlation to a level of nonsignificance. Indeed, it would take 331 studies averaging null results to reduce the correlation of the alliance and outcome to .05.

Contact

Daniel J. Martin, John P. Garske, and M. Katherine Davis

Ohio University

Repairing alliance ruptures

Safran, J. D., & Muran, J. C. (2006). Has the concept of the alliance outlived its usefulness? Psychotherapy, 43, 286-291.

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48 (1). 80-87.

Safran, J. D., & Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work. New York, NY: Oxford University.

Brief Summary 

One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance is a robust predictor of outcome across a range of different treatments and that, conversely, weakened alliances are correlated with unilateral termination by the patient. In the last two decades, there has emerged what we have characterized as a “second generation” of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur (Safran, Muran, Samstag, & Stevens, 2002). A rupture in the therapeutic alliance can be defined as a tension or breakdown in the collaborative relationship between patient and therapist (Safran & Muran, 2006). In this article, we provide a review of this research and metaanalyses of two different types of relevant studies.

The first set of analyses examined the association between the presence of rupture-repair episodes and treatment outcome in three studies including a total of 148 patients. The aggregated correlation was .24, z = 3.06, 95% CI [.09, .39], p = .002, a medium size effect that indicates that the presence of rupture-repair episodes was positively related to good outcome. The second set of analyses examined the impact of rupture resolution training or supervision on patient outcome in eight published studies including a total of 376 patients. Both prepost and group-contrast effect sizes were calculated. The mean weighted prepost r for the rupture resolution training studies was .65, z = 5.56, 95% CI [.46, .78.], p = .001. Given the particularly large effect sizes produced by two studies, the results were recalculated excluding these studies (leaving six studies with 252 patients), yielding an effect size of .52, z = 6.94, 95% CI [.40, .63], p = .001. These results provide evidence that rupture resolution training/supervision led to significant patient improvement; however, with a prepost design, we cannot determine whether this improvement was greater than what patients would experience with treatment from therapists who were not trained in rupture resolution. A meta-analysis of the between-groups effect sizes for the seven studies with control conditions (a total of 343 patients) yielded a mean weighted effect size of .15, z = 2.66, 95% CI [.04, .26], p = .01. When one outlier study was removed, leaving six studies with 321 patients, the mean weighted effect size was reduced to .11, z = 2.24, 95% CI [.01, .21], p =.03. These results indicate that rupture resolution training/supervision leads to small but statistically significant patient improvements relative to treatment by therapists who did not such training.

Evaluation

We have reviewed the growing body of evidence indicating that repairing ruptures in the therapeutic alliance is related to positive outcome. On the basis of this review, research supported implications for therapeutic practices are described.

Contact

Dr. J. Christopher Muran
Derner Institute for Adv Psy Studies
Associate Dean
Adelphi University
158 Cambridge Ave Garden City
New York 11530  United States
(516) 877-4803 (Phone); (516) 877-4805 (Fax)

Investigating the impact of alliance-focused training on interpersonal process and therapists´capacity for experiential reflection

Safran, J. D., & Muran, J. C. (2007). Therapist Relational Interview: Administration manual. Unpublished manuscript.

Safran, J. D., Muran, J. C., Demaria, A., Boutwell, C., Eubanks-Carter, C. & Winston, A. (2014). Investigating the impact of alliance-focused training on interpersonal process and therapists´ capacity for experiential reflection. Psychotherapy Research, 24(3), 269-285.

Brief Summary

In this article we present preliminary findings from a research program designed to investigate the value of alliance-focused training (AFT), a supervision approach designed to enhance therapists´ability to work constructively with negative therapeutic process. In the context of a multiple baseline design, all therapists began treating their patients using cognitive therapy and then joined AFT supervision groups at either session 8 or 16 of a 30 session protocol.

Study 1 investigated the impact of AFT on patient and therapist interpersonal process as assessed through the Structural Analysis of Social Behavior (SASB; Benjamin, 1974). Study 2 investigated the impact of AFT on therapists´tendency to reflect on their relationships with their patients in an experientially grounded fashion, as assessed via the Experiencing Scale (EXP). Since one of the goals of AFT is to train therapists to use their own emerging feelings as important clues regarding what may be taking place in the therapeutic relationship, we hypothesized that they would show increased levels of EXP after undergoing AFT. This dimension of therapists´reflective style was assessed with the use of a semi-structured interview designed to probe for therapists´tendency to reflect on their own internal experience when responding to questions about their relationships with the patients they were treating in the study. This interview, known as the Therapist Relationship Interview (TRI; Safran & Muran, 2007) was then coded with the Experiencing Scale (EXP).

The results of both studies 1 and 2 were for the most part consistent with hypotheses. In Study 1, several significant shifts in both therapist and patient interpersonal process emerged after CBT was augmented with AFT. All significant differences in therapist inter-personal process (except for Disclosing & Expressing) emerged on the“other” or“transitive” surface of the SASB (Surface 2). All significant differences in patient interpersonal process emerged on the“self-focused” or “intransitive” surface of the SASB (Surface 1). Consistent with our hypotheses, the majority of significant differences between training modalities in both therapist and patient interpersonal processes emerged regardless of time of implementation of AFT (session 8 or session 16).

In Study 2, results were consistent with the hypothesis that after receiving AFT, therapists would demonstrate a greater tendency during TRI interviews to reflect on their relationships with their patients in a personally involved, experientially grounded fashion than they did after receiving CBT training.

Evaluation

Taken together, the findings of studies 1 and 2 provide intriguing preliminary evidence regarding the potential of alliance-focused training to have a positive impact on both in-session interpersonal process, and on therapists´ capacity to reflect on the therapeutic relationship in a fashion that incorporates their own felt experience. Further research will be essential to evaluate whether differences in SASB and EXP ratings are related to ultimate outcome. Since all patients received some combination of CBT and AFT, we did not expect to find between-group differences in treatment outcome. It will, however, be critical to examine whether differences in treatment process are meaningfully related to one another and predictive of treatment outcome. At the present time, we continue to enter more patients and therapists into the larger, ongoing research project, and will be in the position to examine these questions in the future.

Contact

Dr. J. Christopher Muran
Derner Institute for Adv Psy Studies
Associate Dean
Adelphi University
158 Cambridge Ave Garden City
New York 11530  United States
(516) 877-4803 (Phone); (516) 877-4805 (Fax)