Alliance In Psychotherapy Research Articles

Association between nonverbal synchrony, alliance, and outcome in psychotherapy: Systematic review and meta-analysis

Objective: Research on nonverbal synchrony (NVS) as a core element in the therapeutic relationship has substantially increased and suggests that NVS influences therapeutic alliance and outcomes. Method: Studies on NVS regarding body movements, vocal pitch, peripheral physiological measures, and hormonal states were included. A random-effects multilevel meta-analysis was performed on 23 publications from 13 trials. Results: There was no significant overall association between NVS and alliance/outcome (r = .03, p = .644). Across modalities, there was a marginally significant association between higher NVS and smaller interpersonal problems (r = .10, p = .084) and a nonsignificant effect for the association between NVS and alliance (r = .06, p = .316), symptomatic outcome (r = -.06, p = .320), and other outcomes (r = .07, p = .255). There was significant heterogeneity between studies (I 2 = 56.47). Moderator analyses revealed that vocal pitch synchrony was negatively associated with alliance/outcome (r = -.20, p = .011), while NVS of peripheral physiological parameters was positively correlated with alliance/outcome (r = .32, p = .006). Conclusion: Findings suggest that specific modalities of NVS show specific associations with outcomes. More research is needed to investigate whether NVS across modalities reflects a unified underlying construct.

The relationship between interpersonal problems and therapeutic alliance in psychotherapy: A three-level mixed-effects meta-analysis.

Psychotherapy is an interpersonal process of collaboration toward specified treatment goals. The therapeutic alliance is well established as an important factor of psychotherapeutic change. However, the experience of distress in social interactions, commonly referred to as interpersonal problems, might be interfering with the collaborative process during psychotherapy. This study systematically reviews the literature and obtains an estimate of the relationship between pretreatment interpersonal problems and the quality of the therapeutic alliance. Overall, 27 studies with 48 correlation coefficients were included in the final analysis. Due to the nested structure of the data, a three-level meta-analytic approach with a restricted maximum likelihood estimator was applied. Alliance assessment phase, alliance rater, alliance measure instrument, and treatment type were tested as potential moderators. Heterogeneity and publication bias test were performed. The meta-analysis showed a small, but significant negative relationship between interpersonal problems at the beginning of psychotherapy and subsequent therapeutic alliance (r = -.12, SE = .02, 95% CI [-.16, -.08], p < .001, d = -.27). Only alliance assessment phase accounted for significant variability. There were no indications for a substantial publication bias. Interpersonal problems of patients before psychotherapy are a robust predictor for lower therapeutic alliance quality, albeit a small effect size. Consequently, patients who experience interpersonal problems may face greater challenges in developing a strong alliance with their therapists, especially in early stages of the treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Validation of the intersession alliance measure: Individual, couple, and family versions.

Monitoring the therapeutic alliance throughout treatment can improve client outcomes and lead to improved care. The individual, couple, and family versions of the intersession alliance measure (IAM) were developed to facilitate routine monitoring of the expanded therapeutic alliance. Psychometric properties of the three versions of the IAM were examined using a clinical sample. Participants were drawn from clinics in the United States participating in the Marriage and Family Therapy Practice Research Network. Using this sample, results indicate that items on each version of the IAM load on one factor, are invariant across sex, and that each version has good internal consistency, test-retest reliability, and concurrent validity. The IAM-C and IAM-F also have good predictive validity, while the IAM-I has more limited evidence for its predictive validity. These results suggest that the IAMs are valid and reliable measures that can facilitate the routine monitoring of the expanded therapeutic alliance in psychotherapy.

Statement of Retraction: Therapist Immediacy: The association with Working Alliance, Real Relationship, Session Quality and Time in Psychotherapy

Statement of Retraction: Therapist Immediacy: The association with Working Alliance, Real Relationship, Session Quality and Time in Psychotherapy

Effects of including a dog on treatment motivation and the therapeutic alliance in child and adolescent psychotherapy: study protocol for a randomized controlled trial

BackgroundMotivation and a therapeutic alliance are crucial for successful therapy. It is assumed that dogs can increase motivation and help support therapeutic relationships. This is one of the reasons for including dogs in psychotherapy. While the positive effects of psychotherapy with dogs have been documented over the past years, little is known about the underlying mechanisms of animal-assisted psychotherapy. This study therefore aims to investigate whether and how the presence of a dog affects motivation and the therapeutic alliance in child and adolescent psychotherapy.MethodsThe study is a randomized controlled trial assessing motivation and the therapeutic alliance during the first five sessions of psychotherapy attended by children and adolescents with different psychiatric disorders. We will recruit 150 children and adolescents and randomly assign them to one of three conditions: (a) a dog is present but not integrated in the therapeutic narrative, (b) a dog is actively integrated in the therapeutic narrative, and (c) no dog is present. The children’s and adolescents’ evaluations of the therapeutic alliance and of their motivation will be assessed as the primary outcomes using standardized questionnaires before and after the first five therapy sessions as well as at follow-up. Further outcomes include the therapists’ evaluations of the therapeutic alliance and their motivation, treatment adherence of the children and adolescents, and treatment satisfaction of the children and adolescents, their parents, and of the therapists. Interventions are conducted by experienced therapists who regularly work with their dogs. Outcomes will be analyzed using general linear models, with the treatment group as a fixed factor and the baseline values as covariates.DiscussionThis study provides information on the possible motivation and alliance-enhancing effects of integrating a dog into child and adolescent psychotherapy. This is relevant for practice, as these two components are strong predictors of therapy outcome. Moreover, the study will contribute to a better understanding of how a dog should be incorporated into psychotherapeutic settings. This can lead to a more purposeful inclusion of dogs in psychotherapy for children and adolescents.Trial registrationThe trial was registered on ClinicalTrials.gov, NCT05384808, on 20 May 2022.

The role of interpersonal coordination dynamics in alliance rupture and repair processes in psychotherapy-A systematic review.

The purpose of this systematic review is to expand our knowledge of the underlying mechanisms of the alliance in psychotherapy. This is done by examining the association between alliance rupture and repair processes and interpersonal coordination dynamics. A systematic review based on PRISMA guidelines was conducted, aimed at papers investigating the association between alliance rupture and repair episodes and different behavioral modalities (i.e., physiology, movement) in the psychotherapeutic interaction. Seventeen studies were included for full text-analysis. The results indicate that rupture and repair episodes were associated with interpersonal coordination dynamics. Different modalities (movement, heart rate, and vocalization) were found to serve as markers for alliance rupture and repair events. Facial expressions, physiological arousal, vocalization, and behavior were found to play important roles in the therapeutic interaction in relation to mutual emotion regulation, empathic response, safety, trust, and meaning-making. Limitations of this review are discussed, including the great methodological variation and selection bias observed in the reviewed studies. Recommendations for future research in this area are presented. Overall, interpersonal coordination dynamics was found to have the potential to help identify and manage alliance ruptures and foster repairs in the therapeutic interaction, which has high potential for future clinical work and training.

Preliminary evidence for the importance of therapeutic alliance in MDMA-assisted psychotherapy for posttraumatic stress disorder

ABSTRACT Background: MDMA-assisted psychotherapy (MDMA-AP) is a combined psychotherapeutic and pharmacologic intervention that shows promise in the treatment of posttraumatic stress disorder (PTSD). Although therapeutic alliance has been established as a key predictor across psychotherapies and is emphasised within MDMA-AP treatment manuals, research has not yet examined the relationship between therapeutic alliance and MDMA-AP treatment outcomes. Objective: Examine whether therapeutic alliance predicts changes in PTSD symptoms following MDMA-AP. Method: Twenty-three individuals with chronic PTSD participated in a MDMA-AP clinical trial that included a randomised (MDMA vs. placebo) and open-label phase. The present analyses focused on participants who were administered MDMA over the course of the randomised and open-label phases (n = 22). Therapeutic alliance was assessed using the Working Alliance Inventory at sessions baseline (pre-session 3) and sessions 4 and 9. PTSD symptoms were assessed using the Clinician Administered PTSD Scale and the Impact of Events Scale-Revised. Results: Controlling for baseline clinician-assessed PTSD severity, therapeutic alliance at sessions 4 and 9 (but not baseline) significantly predicted post-MDMA-AP clinician-assessed PTSD severity. Controlling for baseline self-reported PTSD severity, therapeutic alliance at baseline (although this did not survive correction for multiple comparisons) and sessions 4 and 9 predicted post-MDMA-AP self-reported PTSD severity. Conclusions: The present results provide the first preliminary evidence for the relationship between the therapeutic alliance and treatment outcomes within MDMA-AP for PTSD. These findings highlight the important role of psychotherapy, and common psychotherapeutic factors, within MDMA-AP. Replication in studies with larger and more diverse clinical samples remain necessary. Trial registration: ClinicalTrials.gov identifier: NCT00090064.

How are online and face-to-face psychotherapy perceived by clients? A metaphor analysis

Studies about online psychotherapy have gained momentum as the coronavirus pandemic has had an impact on conducting them face to face. The effectiveness and therapeutic alliance in online psychotherapy have been examined and sometimes compared with face-to-face psychotherapy. In these studies, it was seen that mainly quantitative methods were used. Exploratory qualitative research is needed to refine the literature on online psychotherapy. For this purpose, in this study, data obtained from clients who received face-to-face or online psychotherapy were analyzed using the metaphor analysis method, which is one of the descriptive phenomenological approaches. According to the data obtained from 116 people, nine different categories of metaphors related to online and face-to-face psychotherapy were obtained. The most frequent metaphors about online psychotherapy belonged to categories of convenience, artificiality, similarity to face-to-face psychotherapy, and ineffectiveness. The frequent metaphors about face-to-face psychotherapy belonged to categories of contact, effectiveness, reality, and difficulty. When the participants were divided into two groups according to their age, the opinions about online psychotherapy differed in the two age groups. Similarly, the opinions of people who received psychotherapy with different methods differed for the online psychotherapy. Clinical implications and limitations were discussed.

Retraction of Kivlighan et al. (2016).

Reports the retraction of "Working alliance, real relationship, session quality, and client improvement in psychodynamic psychotherapy: A longitudinal actor partner interdependence model" by Dennis M. Kivlighan Jr., Clara E. Hill, Charles J. Gelso and Ellen Baumann (Journal of Counseling Psychology, 2016[Mar], Vol 63[2], 149-161). The following article is being retracted (https://doi.org/10.1037/cou0000134). This retraction is at the request of coauthors Kivlighan, Hill, and Gelso after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. Baumann was not responsible for obtaining and verifying participant consent but agreed to the retraction of this article. (The following abstract of the original article appeared in record 2015-57048-001.) We used the Actor Partner Interdependence Model (APIM; Kashy & Kenny, 2000) to examine the dyadic associations of 74 clients and 23 therapists in their evaluations of working alliance, real relationship, session quality, and client improvement over time in ongoing psychodynamic or interpersonal psychotherapy. There were significant actor effects for both therapists and clients, with the participant's own ratings of working alliance and real relationship independently predicting their own evaluations of session quality. There were significant client partner effects, with clients' working alliance and real relationship independently predicting their therapists' evaluations of session quality. The client partner real relationship effect was stronger in later sessions than in earlier sessions. Therapists' real relationship ratings (partner effect) were a stronger predictor of clients' session quality ratings in later sessions than in earlier sessions. Therapists' working alliance ratings (partner effect) were a stronger predictor of clients' session quality ratings when clients made greater improvement than when clients made lesser improvement. For clients' session outcome ratings, there were complex three-way interactions, such that both Client real relationship and working alliance interacted with client improvement and time in treatment to predict clients' session quality. These findings strongly suggest both individual and partner effects when clients and therapists evaluate psychotherapy process and outcome. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using therapeutic metacommunication and systematic monitoring of the working alliance in adolescent psychotherapy: a clinical case study

ABSTRACT The quality of the working alliance as assessed by the patient is the most robust predictor of the therapeutic outcome. However, the working alliance is much less studied in youth psychotherapy than among adults, even though it might be a more complex phenomenon. This clinical case study presents examples of how a problematic working alliance is addressed through therapeutic metacommunication and how strengthening the therapeutic alliance contributes to the outcome in the psychotherapy of an adolescent girl. The results of this study encourage further studies of working alliances in adolescent psychotherapy apart from child and adult psychotherapy.

The Therapeutic Alliance in Psychedelic-Assisted Psychotherapy: A Novel Target for Research and Interventions

The Therapeutic Alliance in Psychedelic-Assisted Psychotherapy: A Novel Target for Research and Interventions

Therapeutic Alliance: Associations with Childhood Trauma and Parental Bonding

Literature has shown the importance of therapeutic alliance in the psychotherapeutic process and seeks to understand factors that can interfere in its establishment, such as childhood trauma and parental bonding. As such, this study aims to evaluate therapeutic alliance in psychodynamic psychotherapy from the perspective of adult patients and the correlation between parental bonding and childhood trauma. A cross‐sectional and correlational study was carried out with 180 adult patients who started psychodynamic psychotherapy between May 2015 and May 2016 in a mental health clinic whereby Working Alliance Inventory, Parental Bonding Instrument and Childhood Trauma Questionnaire tools were used. The results show that there are correlations between the father's care and total alliance, as well as the dimensions of goal and bond, but those with mother did not reach statistical significance. The dimensions of emotional abuse and emotional neglect show an inverse correlation with the therapeutic alliance. These results point to the importance of experience of early relationships in establishing therapeutic alliance, relevance of the father figure in this process, and the need for clinicians to be aware of these attachment factors and patient childhood traumas to establish a strong therapeutic relationship.

Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic

Objective The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment. Methods We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome. Results Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress. Conclusions Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy – in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.

A balancing act: how interpreters affect the therapeutic alliance in psychotherapy with trauma-affected refugees-a qualitative study with therapists.

The therapeutic alliance (TA) has the highest predictive value concerning the success of psychotherapy. The presented study aimed to explore how the presence of an interpreter affects the TA when working with trauma-affected refugees. Semi-structured interviews were conducted with seven psychologists working in an outpatient clinic specialized in mental health care for migrant and refugee patients with trauma-related mental health problems in Denmark. Interviews were transcribed verbatim and analyzed using a structuring content analysis approach. TA has been described as a dynamic therapist-interpreter-patient alliance triangle consisting of three distinct but highly intertwined and mutually influential dyadic alliances. Specific factors affecting the quality of the TA were identified, e.g., interpreter being emotionally attuned yet not overly involved; interpreter being barely visible yet present as a human being. Characteristics of trauma-affected refugee patients affecting the TA formation were also identified, e.g., a high level of personal distrust, different understandings of mental disorders and psychotherapy, stigmatization, perceptions of authorities. The presence of interpreters was perceived ambivalently and the formation of a good TA seems to be a balancing act. Based on the findings, recommendations for forming and maintaining a good TA in interpreter-mediated psychotherapy are provided.

A natural language processing approach reveals first-person pronoun usage and non-fluency as markers of therapeutic alliance in psychotherapy

It remains elusive what language markers derived from psychotherapy sessions are indicative of therapeutic alliance, limiting our capacity to assess and provide feedback on the trusting quality of the patient-clinician relationship. To address this critical knowledge gap, we leveraged feature extraction methods from natural language processing (NLP), a subfield of artificial intelligence, to quantify pronoun and non-fluency language markers that are relevant for communicative and emotional aspects of therapeutic relationships. From twenty-eight transcripts of non-manualized psychotherapy sessions recorded in outpatient clinics, we identified therapists' first-person pronoun usage frequency and patients' speech transition marking relaxed interaction style as potential metrics of alliance. Behavioral data from patients who played an economic game that measures social exchange (i.e. trust game) suggested that therapists' first-person pronoun usage may influence alliance ratings through their diminished trusting behavior toward therapists. Together, this work supports that communicative language features in patient-therapist dialogues could be markers of alliance.

Association of patients’ pre-therapy strengths and alliance in outpatient psychotherapy: A multilevel growth curve analysis

Objective Meta-analytic evidence showed robust associations between the alliance in psychotherapeutic dyads and treatment outcomes. Recent studies have indicated that facets of positive mental health are additionally relevant predictors of both the alliance and success of psychotherapy. However, the impact of patients’ pre-therapy strengths on the alliance at the beginning and during treatment has been scarcely examined. Method 428 patients (62.4% female, M age = 40.79), treated by 41 therapists, underwent cognitive behavioral therapy in a German outpatient training and research center. Alliance from patients’ perspectives was assessed at the beginning and during treatment. Data were analyzed with multilevel growth curve modeling. Results Alliance increased during psychotherapy, with a quadratic trajectory best representing this trend on average, p < .001. Pre-therapy strengths were positively related to alliance intercept, b = 0.0537, p < .001. No interaction was found between the included time variables and pre-therapy strengths in the prediction of the alliance slope. Conclusion Positive mental health facets should be considered in psychotherapy research and practice. Future studies may focus on the parallel development of patients’ strengths with other process factors in treatment.

Changes in meaning in life, working alliance, and outcome in psychodynamic psychotherapy: What leads to what?

We examined how meaning in life was associated with working alliance (WA) and outcomes, all from the client perspective. Random intercept lagged cross-panel analyses were used to analyze data from intake and after every eight sessions for the first 24 sessions of open-ended individual psychodynamic psychotherapy from 94 clients nested within 12 therapists. We found that, for all four time periods, working alliance in one 8-week time period predicted both Meaning in Life Measure-Experience (MILM-E) and Meaning in Life Measure-Reflectivity (MILM-R) in the subsequent time period, and MILM-R in one 8-week time period predicted client outcome in the subsequent time period. These findings suggest that having a strong working alliance is associated with clients developing more meaning in life, and reflectivity about meaning in life is associated with clients improving in psychotherapy. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Interpersonal guilt and the working alliance in psychotherapy: The moderating role of childhood experience.

Interpersonal guilt often encompasses pathogenic beliefs that imply omnipotent responsibility for others and concerns about abandoning, humiliating or threatening others. This study sought to examine how interpersonal guilt may influence patients' and therapists' ratings of early working alliance and the potential moderating effect of perceived adverse parenting in childhood. Ninety-five patients and their 19 therapists in an outpatient psychotherapy clinic rated their early working alliance after the first and the fifth session in treatment. We conducted separate moderation analyses for patient and therapist-reported working alliance and controlled for psychological distress at baseline. Results suggest that perceived adverse parenting in childhood significantly moderated the effect of interpersonal guilt on the working alliance in such a way that for patients reporting very low levels of perceived adverse experiences, the interpersonal guilt beliefs had a positive effect on working alliance, whereas for those with very high levels of perceived adverse experiences, interpersonal guilt had a negative effect on working alliance. This same pattern of moderation was found for patient- and therapist-reported working alliance at session 1 and therapist-reported working alliance at session 5. Thus, although the effect of interpersonal guilt on the working alliance depends somewhat on the perspective of the working alliance rating (patient or therapist), it mainly depends on developmental experiences of the patient.

The therapeutic alliance in psychotherapy for adolescent depression: Differences between treatment types and change over time.

Although the alliance is usually considered a generic factor common to all therapies, there are theoretical reasons to suspect that it may develop differently in different types of therapies. Yet, in youth psychotherapy, little is known about this issue to date. This study investigated whether the mean strength of the alliance, as well as its trajectory over time, differed between three equally effective psychological treatments for adolescent depression. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioral therapy (CBT) and short-term psychoanalytic psychotherapy (STPP) versus a brief psychosocial intervention (BPI) in the treatment of adolescent depression. Adolescents’ (N = 338) and therapists’ (n = 159) ratings of the alliance were collected using the Working Alliance Inventory short form at 6, 12, and 36 weeks after randomization. Data were analyzed using multilevel linear models. Results showed that adolescents’ and therapists’ mean alliance ratings differed between treatment types, being highest in CBT and lowest in the STPP at all time points. Mean therapists’ alliance ratings increased slightly over time in all arms, while mean adolescents’ ratings were stable over time in CBT and BPI but slightly increased in the STPP group. These findings suggest that the mean strength of the alliance differs between treatment type, and future research is required to pinpoint what factors contribute to these differences and their relationship with treatment outcomes.

A Meta-Analysis on Differences and Associations between Alliance Ratings in Child and Adolescent Psychotherapy

ABSTRACT Objective The alliance in child and adolescent psychotherapy is widely recognized as an important factor in therapy. Studies on the alliance have increasingly focused on assessment of the alliance as a dyadic construct, measuring both client and therapist alliance ratings. However, cross-informant reports of the alliance in child psychotherapy have not yet been subjected to meta-analysis. Therefore, the present meta-analysis aims to increase knowledge on the degree of convergence and divergence between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy. Methods A series of three-level meta-analyses of 78 studies was conducted to investigate differences and associations between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy. Results Findings indicated that children and parents in general rated the alliance more positively than their therapists (d = 0.35, d = 0.72, respectively), and that child-therapist and parent-therapist alliance ratings were moderately correlated (r = .32, r = .23, respectively). Associations between child and therapist ratings and observer ratings were moderate to large (r = .43, r = .53, respectively). Conclusions It can be concluded that children and parents generally report more positively on the alliance compared to their therapists, which is consistent with research on the alliance in adult populations. The small to moderate associations between alliance ratings indicate that individuals to some extent have a shared perspective on their alliance, and that the various perspectives on alliance should be acknowledged when dealing with children and parents in therapy. Implications for future research are discussed.