Early Alliance Research Articles

Therapeutic alliance and suicidal ideation in brief cognitive behavioral therapy for outpatients

ObjectiveThe therapeutic alliance is central to psychotherapy. However, research on the relationship between alliance and suicidality is scarce. We examined whether pretreatment suicidality is associated with an impaired alliance formation in brief cognitive behavioral therapy (CBT) and whether the therapeutic alliance is associated with change in suicidal ideation (difference between pretreatment and posttreatment assessment).MethodsN = 643 outpatients (64% female; age: M[SD] = 37.09[13.15], range: 18–73 years), received 12 sessions of manual-based short-term CBT for primary diagnosis treatment. Using self-report questionnaires, suicidal ideation and behavior were assessed before and after therapy, patient-rated therapeutic alliance was assessed after the fourth session and posttreatment. We performed correlation analyses and two hierarchical linear regressions, unadjusted and adjusted for possible confounding variables (age, gender, lifetime suicide attempts and depression).ResultsPretreatment suicidal ideation was not predictive of the quality of the early alliance. In addition, the therapeutic alliance was not predictive of change in suicidal ideation.ConclusionsIn the outpatient setting, no association was found between therapeutic alliance and suicidality. Future studies should investigate therapeutic alliance as a predictor of prospective suicidal behavior in different clinical settings.

Client characteristics and early working alliance development: A person-centered research approach

Objective Certain client characteristics are associated with early working alliance difficulties in psychotherapy. However, there is limited quantitative evidence on whether combinations of these characteristics (e.g., intersectional identities, prior treatment experiences) are related to alliance development. The present study leveraged a person-centered research approach to examine profiles of early alliance development and differences in the latent class structure of client characteristics among alliance development profiles. Method Individual psychotherapy clients (N = 2,579) rated the working alliance for their first four sessions and self-reported demographics, treatment history, and psychological distress. Therapists provided their assessment of clients’ primary presenting concerns at baseline. Results Latent profile analysis revealed three profiles of working alliance development: high and stable, moderate and increasing, and low and stable. Follow-up person-centered analyses (multigroup confirmatory latent class analysis) indicated that clients in the alliance profiles differed in their combinations of clinical and demographic characteristics. For example, women of color with high baseline distress and a history of prior psychotherapy were over-represented in the low and stable alliance profile. Conclusion These results are consistent with recommendations to holistically consider how clients’ characteristics and experiences shape psychotherapy processes. Results also highlight the utility of person-centered quantitative methods in psychotherapy research.

Heterosexual couples' initial role and outcome expectations as predictors of the therapeutic alliance and relationship satisfaction prior to the fourth session.

We sampled routinely collected measures of role and outcome expectations, the expanded therapeutic alliance, and relationship satisfaction completed by 253 heterosexual couples seen by 35 therapists in the Marriage and Family Research Practice Network (Johnson et al., 2017) and investigated these variables as interdependent dyadic processes using the latent congruence model (Cheung, 2009) and the mediated actor-partner interdependence model (Ledermann et al., 2011). Taken together, we found a direct association between a couple's mean role and outcome expectation scores at Session 1 and individual partners' alliance perceptions at Session 3. Further, men rated the alliance more favorably when their outcome expectations were higher and the partners' outcome expectations were less discrepant. In terms of role expectations, both men and women began therapy expecting to be more actively engaged in the process than their partner. Whereas women rated the alliance more favorably when they had high role expectations for their partner as well as themselves, men rated the alliance more favorably when they had high expectations for their female partner's engagement in the therapy. Notably, alliance at Session 3 did not mediate the association between initial expectations and Session 4 relationship satisfaction due to a strong association (r = 0.85) between relationship satisfaction rated prior to Sessions 1 and 4. In other words, although the best predictor of relationship status before the fourth session was how the relationship was perceived before couple therapy began, men's and women's initial role and outcome expectations were important contributors to the early alliance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Therapist verification of patient self-concepts as a responsive precondition for early alliance development and subsequent introject change

Objective Social psychological research has indicated that people strive for self-consistent feedback and interactions, even if negative, to preserve the epistemic security of knowing themselves. Without such self-verification, any interpersonal exchange may become frustrated, anxiety-riddled, and at risk for deterioration. Thus, it may be important for therapists to meet patients’ self-verification needs as a responsive precondition for early alliance establishment and development. We tested this hypothesis with patients receiving cognitive behavioral therapy for generalized anxiety disorder—a condition that may render one’s self-verification needs especially strong. We also tested the hypothesis that better early alliance quality would relate to subsequent adaptive changes in and posttreatment level of patients’ self-concepts. Method Eighty-four patients rated their self-concepts at baseline and across treatment and follow-up, their postsession recollection of their therapist’s interpersonal behavior toward them during session 2, and their experience of alliance quality rated after sessions 3–6. Results As predicted, the more therapists verified at session 2 a patient’s baseline self-concepts (which trended toward disaffiliative and overcontrolling, on average), the more positively that patient perceived their next-session alliance. Moreover, better session 3 alliance related to more adaptive affiliative and autonomy-granting self-concepts at posttreatment. Conclusion Results are discussed within a therapist responsiveness framework.

Personality disorder type only sometimes matters: An exploration of patient's personality disorder as a source of variance in early therapeutic alliance.

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. 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. 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. 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.

To what extent are early alliance perceptions a function of romantic partners' initial expectations for couple therapy?

AbstractIn this study, we investigated the association between clients' initial outcome expectations and their subsequent perceptions of the expanded therapeutic alliance. Romantic partners (N = 252) who received at least four sessions of systemic couple therapy from thirty‐one therapists from the Marriage and Family Therapy Practice Research Network (Johnson et al., 2017; www.mft‐prn.net) completed an outcome expectation measure before session 1 and a therapeutic alliance measure before session 4. Results showed a strong association between expectations and alliance (r = 0.51). While fourteen per cent of the variability in session 4 alliance scores was uniquely attributable to therapists, 31.6 per cent of the variability in the expectations/alliance association was uniquely attributable to couples, with only 6.1 per cent uniquely attributable to individual clients. Taken together, these results suggest that, while some therapists are better at developing strong alliances, couple and client factors associated with expectations for therapy set the stage for how the expanded alliance develops.

Therapeutic Alliance, Attendance, and Outcomes in Youths Receiving CBT or Client-Centered Therapy for Anxiety

ABSTRACT Objective Positive associations between therapeutic alliance and outcome (e.g. youth symptom severity) have been documented in the youth anxiety literature; however, little is known about the conditions under which early alliance contributes to positive outcomes in youth. The present study examined the relations between therapeutic alliance, session attendance, and outcomes in youths (N = 135; 55.6% female) who participated in a randomized clinical trial testing the efficacy of cognitive-behavioral therapy or client-centered therapy for anxiety. Method We evaluated a conceptual model wherein: (1) early alliance indirectly contributes to positive outcomes by improving session attendance; (2) alliance-outcome associations differ by intervention type, with stronger associations in cognitive-behavioral therapy compared to client-centered therapy; and (3) alliance-outcome associations vary across outcome measurement timepoints, with the effect of early alliance on outcomes decaying over time. Results Contrary to hypotheses, provider ratings of early alliance predicted greater youth-rated anxiety symptom severity post-treatment (i.e. worse treatment outcomes). Session attendance predicted positive youth-rated outcomes, though there was no indirect effect of early alliance on outcomes through session attendance. Conclusions Results show that increasing session attendance is important for enhancing outcomes and do not support early alliance as a predictor of outcomes.

Social Network and Resources Integration Within Logistics Industry in China --- With Case Study of Cainiao Network

The business network in logistics industry is essential for integrating resources and establish firms own advantage of compettitiveness in the market, as well as providing more comprehensive services that facilitate firms to gain its revenue. Construction of intermediary platforms has therefore been an effective mean. Cainiao, a subdivided branch of Chinese giant enterprise Alibaba, has seized this opportunity. Though the debate about how social networks function to boost the high-quality development of firms has been very hot over the last three decades, few studies have mentioned and worked to understand to the linkage between social network analysis (SNA) and logistics chain management. Hence, the purpose of this research is to identify the construction of a business network by the giant Chinese logistics companies and its enhancing function of collaboration among firms and embeddedness for the success of Cainiao, which constructs the whole network. This paper will be carried out in concept explaination of essential terms in SNA and the practice of them into operation of Cainiao Network, as well as some diagrams made by Ucinet software will be applied. Results of the study show that through the early alliance of giant express enterprises, Cainiao has gained a wide network map that permits it to utilize abundant resources for the firms prosperity, and boosts the conjunction between the other companies and customers.

Innovation beyond firm boundaries: Strategic alliances and corporate innovation

In this paper, we empirically analyze how strategic alliances affect the innovation output of the firms forming the alliance. We find a positive effect of R&D-related strategic alliances on corporate innovation, as measured by the quantity and quality of patents filed. This effect is stronger for firms led by CEOs with higher general managerial skills, firms with greater experience from earlier alliances, and firms operating in R&D-intensive industries. Furthermore, the innovation-fostering effect of strategic alliances is more pronounced if alliance partnering firms share a common institutional blockholder or have a higher degree of technological proximity. We also document, for the first time in the literature, a unique contractual mechanism through which firms share the benefits of innovation with their alliance partners, namely, “co-patenting.”

The alliance-outcome association in borderline and obsessive-compulsive personality disorder.

Personality disorders are considered a possible factor affecting the relationship between therapeutic alliance and therapy outcome. The present study investigated the alliance-outcome effect in patient groups with borderline personality disorder (BPD) and obsessive-compulsive personality disorder (OCPD). Data derived from a sample of n = 66 patients, treated in a day care hospital setting with a dialectical-behavioral and schema therapeutic treatment concept. Patients rated their symptom severity at admission, early alliance after 4-6 therapy sessions and symptom severity as well as alliance at discharge. Results showed no significant differences between BPD and OCPD patients regarding symptom severity and alliance. Multiple regression analyses indicated that the alliance was a significant predictor of symptom reduction, however only in the OCPD group. Our results showed an exceptionally strong alliance-outcome relationship in OCPD patients, suggesting that focusing on building a strong alliance and measuring it early in therapy may be especially beneficial for this patient group. For patients with BPD, a more regular screening of the therapeutic alliance might be helpful.

The Therapy Process Observational Coding System: Group cohesion scale in youth anxiety treatment: Psychometric properties.

There are no well-established measures of group cohesion, defined as the collaborative bond between group members, in group cognitive behavioral therapy (GCBT) with youth. We therefore examined the Therapy Process Observational Coding System for Child Psychotherapy-Group Cohesion Scale (TPOCS-GC), which has previously only been used with adult samples, in a youth sample. Observers coded 32 sessions from 16 groups with 83 youth aged 8 to 15 years (90.7% European White). Youth had anxiety disorders and received manualized GCBT in community clinics. We examined psychometric properties of the TPOCS-GC and its' construct validity in terms ofrelations with pretreatment variables, alliance and fidelity during treatment, and post-treatment variables. Group cohesion was measured twice during treatment (early and late). The TPOCS-GC was internally consistent (α = 0.72) and was reliably coded (M ICC = 0.61). Higher clinical severity at pretreatment predicted lower early group cohesion. Higher youth age, higher clinical severity at pretreatment, and higher youth-rated early alliance predicted lower late group cohesion. Higher therapist-rated early alliance predicted higher early group cohesion. Higher therapist-rated late alliance predicted higher late group cohesion. Higher late group cohesion predicted lower clinical severity and higher client treatment satisfaction at post-treatment. Early group cohesion did not predict any post-treatment variables. A four-item version of the TPOCS-GC can be reliably used in youth GCBT. The TPOCS-GC is distinct from, but associated with, multiple clinical variables.

The Relationship Between Patients' Personality Traits, the Alliance, and Change in Interpersonal Distress in Intensive Group Treatment for Personality Dysfunction.

This study examined patients' personality traits as operationalized by the five-factor model in relation to early alliance and reduction of interpersonal distress through an intensive group treatment program for personality dysfunction. A sample of 79 consecutively admitted psychiatric outpatients with personality dysfunction who attended an 18-week intensive group treatment program completed the NEO Five-Factor Inventory at pretreatment, the Inventory of Interpersonal Problems at pre- and posttreatment, and the Edmonton Therapeutic Alliance Scale, a measure of the therapeutic alliance with the program therapist, at Session 5. Results indicated that patients who were relatively extraverted tended to rate the alliance with their program therapist higher and subsequently reported more improvement of interpersonal distress. The presence of a personality disorder did not moderate this mediation. Patients' extraversion likely promotes a bonding with the therapist and facilitates the interpersonal group work necessary for improvement. Assessing patients' level of extraversion before starting intensive group treatment might indicate which intervention strategies could be useful with that patient within the program frame.

Child-therapist and parent-therapist alliances and outcome in the treatment of children with oppositional defiant/conduct disorder

Objective This study examined the quality of therapeutic alliance from different rater perspectives (child, parent, therapist) in cognitive behavioural therapy for children with oppositional defiant disorder (ODD) and conduct disorder (CD), and its association with symptom severity. Further, a panel model with an autoregressive cross-lagged panel design was used to explore whether therapist-rated and parent-rated therapeutic alliance influences change in symptom severity, or vice versa. Methods Sixty boys aged 6–12 years with a principal diagnosis of ODD/CD, and their parents, received individually delivered social competence training for childhood aggressive behaviour problems. Child, therapist, and parent ratings of therapeutic alliance and symptom severity were measured twice. Results Our results indicate good to very good therapeutic alliance that was relatively stable over time. The cross-sectional analyses of the alliance-symptom association revealed moderate correlations. However, effects of early alliance on later treatment outcome or of early symptom severity on later alliance were marginal. The only significant association was found between early parent-rated therapist-parent alliance and later parent-rated symptom severity. Conclusion Our study shows a moderate correlation between simultaneously assessed therapeutic alliance and symptoms. The findings of the panel model indicate that an early good therapeutic alliance is a component of later therapeutic success (parent perspective).

Bringing experimental therapeutics clinical trials network (ETCTN) to underrepresented population.

6542 Background: Access to health care including clinical trials (CT) leading to paradigm-changing cancer treatments are critical for high quality cancer care and equity in society. In this report, we highlight methods in accruing to ETCTN wherein underrepresented rural, low-income, and racial minorities comprise >50% of enrollment. Methods: University of Kansas Cancer Center (KUCC) is one of eight National Cancer Institute (NCI) designated cancer centers awarded CATCH-UP.2020 (CATCH-UP), a congressionally mandated P30 supplement to enhance access for minority/underserved populations to ETCTN precision medicine CT. KUCC catchment area is 23% rural by Rural Urban Continuum Codes (RUCC); almost 90 % of counties are designated primary care HPSA’s (Health Professional Shortage Areas). KUCC Early Phase and Masonic Cancer Alliance (rural outreach network) partnered to operationalize CATCH-UP. We engaged disease-focused champion investigators in disease working groups and MCA physicians who selected scientifically sound CT that fit catchment area needs. Patient and Investigator Voices Organizing Together, a patient research advocacy group provided practical feedback. MCA navigator coordinated recruitment. Telehealth was used for rural patients that would have a significant distance to travel just to be screened. Results: CATCH-UP was initiated in September 2020. Twenty-eight CT were activated, many in community sites. Average activation time was 81 days. Delays were mainly from CT amendments. KUCC enrolled the first patient in the CATCH-UP program. In 6 months, we met accrual requirements (24/year, 50% minorities). During first year, we enrolled 47 (>50% minorities), an increase of 680% from our average accrual of 6/year (>50% minorities) in ETCTN through Early Drug Development Opportunity Program (2016-2020). To date, we have enrolled 61, 54% from rural, HPSA, race and other minorities. Although the proportion of minorities did not change but remained high, this funding allowed us to substantially increase the number of patients from a catchment area with high proportion of geographically and socioeconomically underserved minorities given access to early phase CT through ETCTN. Conclusions: Amid COVID-19 pandemic, the NCI CATCH-UP program and methods we used allowed access to novel therapies for rural, medically underserved, and other minority groups. Funded by NIH: 3P30CA168524-09S2.

Predictors of therapeutic alliance, treatment feedback, and clinical outcomes among African American women in treatment for co-occurring PTSD and SUD

IntroductionBlack women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women. MethodsThis study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women's Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire. ResultsStepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = 0.411, p = .021 and β = 0.383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group. ConclusionsEducation and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

The Role of Personality in Early Alliance Formation in the Context of Clinical Supervision of Psychotherapists in Training

The literature suggests that working alliance is an important predictor of clinical supervision outcomes. However, little is known about the individual factors that influence the development and maintenance of the working alliance. This study aims to explore the role of supervisor and trainee personality traits in the development of early working alliances, as well as supervisor and trainee concordance rates in the context of clinical supervision. This study used the NEO-PI-3 measure to assess personality traits and the Working Alliance Inventory-Supervisor and Trainee Versions (WAI) measures to assess working alliance ratings. Results suggest that supervisors rate the strength of their alliances as significantly stronger than trainees (p < .05). While no trainee personality traits were found to predict their perception of the early alliance, the openness domain was found to be significantly associated to supervisor’s self-reported ratings of alliance. Implications of these findings are discussed.

Exploring alliance–outcome associations in a combined mental health and academic counselling setting for at‐risk students: The differential role of alliance components, personality, gender and pre‐treatment severity

AbstractThis study investigated the differential role of therapeutic alliance components in predicting mental health and academic performance outcomes of a combined academic and personal counselling initiative. The study also explored the role of pre‐treatment severity and gender in alliance formation, as well as the moderating role of personality on alliance‐outcome associations in at‐risk students at a Canadian University. Pre‐ and post‐measures of mental health (SF‐36 Mental Health Composite Summary) and academic performance (GPA) were obtained for 78 at‐risk students enrolled in the counselling initiative. Criteria for risk included academic struggles, struggles with mental health, or both. Personality and demographic variables were obtained prior to the start of counselling and strength of therapeutic alliance was measured between sessions 3 and 6. Results showed that while all of the alliance components significantly predicted increases in student GPA, the task subscale predicted increases in mental health. Personality type preference was not found to moderate these associations. Furthermore, gender and pre‐symptom severity were not related to early alliance formation. The findings support the importance of the therapeutic alliance across counselling contexts and suggest that relationship oriented counselling initiatives may support both academic performance as well as psychological well‐being in at‐risk students. Implications are discussed.

The Role of Personality in Early Alliance Formation in the Context of Clinical Supervision of Psychotherapists in Training

The literature suggests that working alliance is an important predictor of clinical supervision outcomes. However, little is known about the individual factors that influence the development and maintenance of the working alliance. This study aims to explore the role of supervisor and trainee personality traits in the development of early working alliances, as well as supervisor and trainee concordance rates in the context of clinical supervision. This study used the NEO-PI-3 measure to assess personality traits and the Working Alliance Inventory-Supervisor and Trainee Versions (WAI) measures to assess working alliance ratings. Results suggest that supervisors rate the strength of their alliances as significantly stronger than trainees (p &lt; .05). While no trainee personality traits were found to predict their perception of the early alliance, the openness domain was found to be significantly associated to supervisor’s self-reported ratings of alliance. Implications of these findings are discussed.

Trust Dynamics during Early Alliance Operation: The Role of Partner Engagement

Coopetitive endeavors offer valuable strategic options for firms. Yet, many of them are failure-prone as partners must balance collective and private interest. While interpartner trust is considere...

Does the working alliance mediate the therapist competence-outcome relationship in cognitive behavior therapy for depression?

Objective: This study examined whether the working alliance mediated the effect of therapist competence on subsequent depression symptomology during Cognitive Behavioral Therapy (CBT). We also tested the potential moderation effect of alliance on subsequent depressive symptomology, based on participants’ cognitive aptitude. Method: A total of 86 sessions were coded as the prediction interval across 50 patient-therapist dyads (age M = 39.22, SD = 8.78; 76% female). While accounting for prior depression, competence, and alliance levels, predictors were assessed early treatment (session 1; n = 45 sessions), mid-treatment (session 12; n = 41 sessions), and depressive symptomology was assessed at the subsequent session to the predictor assessments to investigate within-session variability of process variables. Results: Mediation analysis revealed that the effect of early treatment therapist competence on symptom change was mediated by alliance (indirect effect: β = −.17, 95% percentile bootstrap CI [−.32, −.01]). The positive association involving early treatment alliance and next session outcome was conditional upon low cognitive aptitude levels. Conclusions: Our result offers preliminary support for alliance as a mediator of the effect of competence, and that alliance-outcome relations vary as a function of client aptitude. These novel findings require replication and extension.