Initial Alliance Research Articles

Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating

Objective: This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy. Method: Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores. Results: Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores. Conclusion: Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Individual's pretreatment psychological symptoms and progress in couples therapy: A person-centered analysis.

This study examined how individual pretreatment symptoms (depression and anxiety) predicted longitudinal, relational processes in couples therapy (the therapeutic alliance and couple satisfaction). This study included 99heterosexual couples receiving systemic couples therapy. Partners reported their individual pretreatment symptoms of depression and anxiety before intake. Each member reported their therapeutic alliance with the therapist at the end of sessions 2-8, as well as their couple satisfaction before intake and at the end of sessions 4 and 8. A Latent Profile Analysis revealed four profiles characterizing couples on their pretreatment psychological symptoms, namely both higher (where both members of the couple had higher depressive and anxiety symptoms), female higher, male higher, and both lower profiles. Furthermore, longitudinal, dyadic multilevel models revealed that men in male higher, female higher, and both higher profiles had higher initial alliance levels, compared to men in the both lower profile. In contrast, only female partners in the both higher profile had a higher initial therapeutic alliance than those in the both lower profile. Men in the both higher profile had faster reductions in their alliance, whereas other profiles did not predict changes in male or female alliance. Additionally, the male higher and both higher profiles predicted a lower initial level of couple satisfaction in males but not females. The profiles did not predict changes in couple satisfaction, which may be a result of lowered power due to missing data. Findings were discussed in the context of systemic family theory, with clinical implications for distressed couples.

The Effect of Therapeutic Alliance on Dropout in Cognitive Processing Therapy for Posttraumatic Stress Disorder.

A substantial number of individuals who undergo cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) drop out before receiving a full course of treatment. Therapeutic alliance, defined as the working relationship between the therapist and client, is a dynamic process within therapy that may change over time. Research suggests that therapeutic alliance is associated with dropout in various treatments. However, no studies have yet examined the association between therapeutic alliance and dropout in CPT, and few studies have examined therapeutic alliance longitudinally over the course of treatment. Examining alliance in CPT through different methods may increase clinicians' understanding of how to tailor interventions to prevent treatment dropout. The present study examined the association between therapeutic alliance and treatment dropout among 169 participants in a randomized implementation effectiveness trial. In total, 33.1% of clients dropped out over the course of CPT, and nearly half of these individuals dropped out during the first six sessions. Continuous-time survival analysis results indicated that mean ratings of alliance significantly predicted treatment dropout, Wald χ2 (1, N = 167) = 4.08, Exp(β) = .64, p = .043, whereas initial alliance, late alliance, and change in alliance over treatment did not. These findings suggest that overall therapeutic alliance is an important predictor of dropout from CPT.

Ayesha Memorial Hospital (B)

The case is divided into two parts, and an epilogue is provided to the students at the end of the discussion. Case A discusses the protagonist’s arrival at a hospital that is affected by a hidden power struggle between opposing parties. In an attempt to exercise his influence and improve the hospital’s operations, the protagonist introduces reforms and changes to the hospital’s processes. However, as a result of his increasing influence and knack for not respecting the status quo, he realizes that there are people in the management who feel threatened by his influence and plan to damage his status in the hospital. At the conclusion of Case A, he has been handed a letter that informs him of a disciplinary committee case against him on serious allegations of misuse of authority, torture and even sexual harassment. He is concerned that he has been set up by his opponents, who have resources and credibility that might make it difficult for him to escape from this situation unscathed. Thus, in the given situation the protagonist weighs his possible options. Case B concerns how the protagonist responds to his disciplinary committee case. Policy changes previously initiated by the protagonist and his alliance with the vice-president serve as important tools. They neutralize the resources that are used by the protagonist’s opponents in an investigation against him. In the end, the protagonist, Murtaza; therefore, successfully comes out of this situation unscathed. The epilogue discusses how the protagonist’s initial alliance with the vice-president, in light of changing circumstances, begins to wither away as the mutual opposition they both once shared also begins to weaken.

Ayesha Memorial Hospital (A)

The case is divided into two parts and an epilogue is provided to the students at the end of the discussion. Case A discusses the protagonist Murtaza’s arrival in a hospital that is affected by a hidden power struggle between opposing parties. In an attempt to exercise his influence and improve the hospital’s operations, the protagonist introduces reforms and changes to the hospital’s processes. However, as a result of his increasing influence and knack for not respecting the status quo, he realizes that there are people in the management who feel threatened by his influence and plan to damage his status in the hospital. At the conclusion of Case A, he has been handed a letter that informs him of a disciplinary committee case against him on serious allegations of misuse of authority, torture and even sexual harassment. He is concerned that he has been set-up by his opponents, who have resources and credibility that might make it difficult for him to escape from this situation unscathed. Thus, in the given situation the protagonist weighs his possible options. Case B concerns how the protagonist responds to his disciplinary committee case. Policy changes previously initiated by the protagonist and his alliance with the vice-president serve as important tools. They neutralize the resources that are used by the protagonist’s opponents in an investigation against him. In the end, the protagonist, therefore, successfully comes out of this situation unscathed. The epilogue discusses how the protagonist’s initial alliance with the vice-president, in light of changing circumstances, begins to wither away, as a mutual opposition that they both once shared also begins to weaken.

Network imprinting, learning and subsequent alliance tie formation

Does the form of a firm’s initial alliance – dyadic or multipartner – imprint the firm, and so shape the course of its subsequent alliance path? Does this subsequent path strengthen or weaken this imprinting? To examine these questions, we study patterns of alliance formation among firms comprising the German biotechnology industry over its complete history from 1996 to 2015. We find that while firms’ initial alliances indeed shape their subsequent alliance paths, as firms accumulate alliance experience along these paths, these experiences overwhelm the effect of imprinting from the initial alliance. Notably, the direction of imprinting and subsequent alliance effects for the focal firm depends on whether the firm’s initial alliance is dyadic (initial suppression reversed by subsequent experience) or multipartner (initial amplification reversed by subsequent experience). Thus, among the firms we study, alliance trajectories are shaped initially by their own initial alliances, but adapt to experience over time. Thus, we emphasize the significance of alliance imprinting and experience for understanding the unique dynamics of dyadic and multipartner alliances.

Meet the Parents: An Empirical Study of Spin-off Network Development

Entrepreneurship scholars have actively studied issues pertaining to new venture network development. In this study, we revisit the empirical relationship between new venture’s initial alliance at ...

Alliance across group treatment for veterans with posttraumatic stress disorder: The role of interpersonal trauma and treatment type.

Examine initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans. One hundred and seventy-eight male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or non-interpersonal) impacted initial levels of alliance or change in alliance over time. Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a non-interpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p > .05), but did not have significantly different initial alliance ratings. The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance.

Patient–therapist convergence in alliance ratings as a predictor of outcome in psychotherapy for generalized anxiety disorder

Objective: Although patients and therapists aligning over time on their perceptions of alliance quality is regarded as clinically important, few studies have examined the influence of such dyadic convergence on psychotherapy outcomes. This study tested whether early treatment convergence in patient–therapist alliance ratings was associated with subsequent worry and distress reduction in psychotherapy for generalized anxiety disorder (GAD), and whether treatment type and the dyad members’ initial alliance perceptions moderated these associations. Method: Data derived from a randomized trial for which patients with severe GAD received either 15 sessions of standard cognitive-behavioral therapy (CBT; n = 43) or CBT integrated with motivational interviewing (n = 42). Patients and therapists rated the alliance after each session. Patients rated worry after each session, and their distress multiple times. Results: As predicted, dyadic multilevel modeling revealed that early alliance convergence was associated with greater subsequent worry (p = .03) and distress (p = .01) reduction, and the combination of low initial patient-rated alliance and low convergence was associated with the worst outcome for the distress variable (p = .04). Conclusions: Results suggest that alliance convergence may be an important clinical process that bears on outcome, rendering it an important marker for therapist responsiveness.

Identity and initial structure in inter-firm alliances: a social identity perspective

Purpose– The purpose of this paper is to examine how firms use the identities of their alliance partners in choosing initial governance structures in strategic alliances. It proposes that social identity from the perspective of an established firm participating in an inter-firm alliance can be constructed on the basis of ownership categories and market categories of the firm’s alliance partners.Design/methodology/approach– The study focusses on a sample of 478 alliances involving 36 focal firms in the US semiconductor industry over a nine-year period (1995-2003). The sample is analyzed using logistic regression methods.Findings– The author finds evidence suggesting that joint venture (JV) structures are more likely when an alliance has more partners that identify as privately held firms or subsidiaries of other firms. The results also suggest that JV structures are more likely when an alliance involves strong product market identity with partners and less likely when an alliance involves strong geographic identity with partners.Originality/value– These findings provide some novel insights into potential heuristics that alliance managers use in making initial alliance structure decisions. In particular, this paper contributes to a growing stream of research that considers the optimal alliance structures for different partner configurations by showing the potential influence of partners’ identities in simplifying these important decisions.

The alliance in psychiatric rehabilitation: Client characteristics associated with the initial alliance in a supported employment program.

The therapeutic alliance is associated with outcomes for individuals in psychiatric rehabilitation programs. However, there are no known studies examining factors associated with the alliance in these programs. To determine whether client characteristics associated with the alliance across multiple populations and program types were associated with the alliance for individuals enrolling in a supported employment program. Previously collected data were available for 70 individuals served by the single employment specialist in the program. Potential independent variables and the strength of their relationship to the alliance were identified, then further explored using a forward stepwise logistic regression model. Seventy-three percent of the sample had the highest possible alliance rating. Being older and having a smaller social network size were significantly correlated with a high alliance, but neither remained a predictor of the alliance, controlling for the effects of the other. Client age and social network size were associated with the initial alliance, though not in a model containing both variables. Low power may have hindered the ability to show additional relationships, and the uniqueness of the program structure limits the generalizability to other programs. Future research should investigate the variables examined further.

Phases in Individual Psychotherapy for Paranoid Disorders

For a very long time paranoia was considered to be a contraindication for individual psychotherapy, and the dynamic operations that lie at the basis of the paranoid process were in fact thought to be unreachable. This paper is an attempt to systematize years of experience involving the psychotherapy of the paranoid. We will outline the specific problems that occur while working with these patients. The process of psychotherapy stems from an understanding of the development of the paranoid process, its mechanisms and phenomenological expression. We will show all the crucial moments of individual psychotherapy which determine the phases of the therapeutic process. The first phase incorporates the following: establishing a therapeutic agreement, the creation of an initial therapeutic alliance and its transformation into a genuine therapeutic alliance. The second phase incorporates the following: uncovering the defensive nature of the paranoid construction, which requires a series of intermediate steps such as: undermining the projected system and paranoid defenses, defining and explaining the introjective configuration, an explanation of the origin of the introjective configurations and so on. During the final phase of the separation, we can consider the termination phase of the treatment or can decide to leave the therapeutic process open.

Do Alliances Lead to Competition? An Empirical Analysis of the US Biopharmaceutical Industry

This study extends the learning race perspective to examine whether familiarity between firms developed through R&D alliances will motivate them to engage in technological competitions. Specifically, we argue that the payoffs of an alliance, in terms of common and private benefits that accrue to individual firms, are updated over the course of alliances between two firms. Firms are likely to reduce competition in their initial alliance contacts for the prospect of larger common benefits over private benefits. However, the likelihood of competition is heightened at later stages of their repeated interactions due to increased payoffs in private benefits. We further contend that this U-shaped relationship between the number of R&D alliances and technological competition is moderated by partner firm’s reputation of trustworthiness and technological similarity with the focal firm. Analyses of US biopharmaceutical firms during 1985 and 2004 support our hypotheses. Our study contributes to an enriched understand...

Training in time-limited dynamic psychotherapy: A systematic comparison of pre- and post-training cases treated by one therapist

Objective: This qualitative study systematically compared cases treated by the same therapist in order to understand the group comparison findings of a larger study on training of experienced therapists (the “Vanderbilt II” psychotherapy project). Method: The therapist, Dr C., was selected based on the therapist's overall treatment successes. His two patients were selected based on their outcomes and the relative training cohort from which they were drawn: a case with successful outcome from the pre-training cohort and a case of negligible improvement from the post-training cohort. Results: Dr C. demonstrated a variety of interpersonal skills throughout his pre-training case, though there was also poor interpersonal process throughout. However, in the second case he had considerable difficulty in adapting his typical therapeutic approach to the requirements of the time-limited dynamic psychotherapy (TLDP) manual, even while appearing to work hard to find ways to use the manual. Conclusions: Dr C.'s spontaneity, and his unique set of interpersonal skills may enhanced his initial rapport and alliance building with clients and yet may not have interfaced well with TLDP. His unique interpersonal skills also may have contributed to problems of interpersonal process. Future research may benefit from examining the interaction of between therapist interpersonal skills and the implementation of the treatment manual.

EPA-0816 - Individual psychotherapy for paranoid disorders

For a very long time paranoia was considered to be a contraindication for individual psychotherapy, and the dynamic operations that lie at the basis of the paranoid process were in fact thought to be unreachable. This paper is an attempt to systematize years of experience involving the psychotherapy of the paranoid. We will outline the specific problems that occur while working with these patients. The process of psychotherapy stems from an understanding of the development of the paranoid process, its mechanisms and phenomenological expression. We will show all the crucial moments of individual psychotherapy which determine the phases of the therapeutic process. The first phase incorporates the following: establishing a therapeutic agreement, the creation of an initial therapeutic alliance and its transformation into a genuine therapeutic alliance. The second phase incorporates the following: uncovering the defensive nature of the paranoid construction, which requires a series of intermediate steps such as: undermining the projected system and paranoid defenses, defining and explaining the introjective configuration, an explanation of the origin of the introjective configurations and so on. During the final phase of the separation, we can consider the termination phase of the treatment or can decide to leave the therapeutic process open.

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.

Trajectory and Predictors of Alliance in Cognitive Behavioral Therapy for Youth Anxiety

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7–17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel “alliance rupture” model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

How experienced therapists introduce the technical aspects in the initial alliance formation: Powerful decision makers supporting clients' agency

The initial work on the technical aspects of the working alliance was explored in a naturalistic study of the practices of nine experienced teacher therapists. Using the qualitative method of Grounded theory, eight therapist action descriptions were identified, forming two categories: (1) Supporting the client's agency: (a) exploring the clients' solution strategies, (c) underlining the clients' choice/authority, (d) sharing the basis for the decision, (e) demonstrating collaboration linguistically by hedging; (2) Expressing agency: (a) immediate implementation of method, (b) educating, (c) challenging, (d) constituting oneself as an expert. Implications for the view of therapist power, negotiation, consensus and collaboration are discussed.

Psychotherapy for social phobia: How do alliance and cognitive process interact to produce outcome?

The purpose of this study was to ascertain whether and how alliance and specific cognitive process may interact to influence outcome. Eighty social phobic patients were randomized to 10-week residential cognitive or interpersonal therapy, conducted mostly in groups. They completed process and outcome measures weekly. The ratings were analyzed with mixed models. It was found that initial patient-rated alliance predicted the course of social anxiety throughout therapy and that this effect was indirect through the cognitive process. However, this indirect effect did not interact with treatment. There was a trend toward an indirect effect of weekly variations in alliance rated by the individual therapist through weekly variations in subsequent cognitive process on weekly variations in subsequent social anxiety. Thus, the results support a facilitative rather than an active ingredient perspective on the role of alliance.

Bankruptcy spillover effects on strategic alliance partners

This paper examines whether a party to a strategic alliance or joint venture suffers from spillover effects when the other partner files for bankruptcy. We find that the non-bankrupt strategic alliance partners, on average, experience a negative stock price reaction around their partner firm's bankruptcy filing announcement. This negative effect is strongest for longer partnerships and those with higher returns at the announcement of the initial alliance formation. Furthermore, horizontal alliance firms in declining industries have lower returns, indicating that industry conditions can exacerbate expected problems for the non-bankrupt firm. Non-bankrupt partners also experience drops in profit margins and investment levels in the subsequent two years with the worst performance concentrated among the longer-term agreements. There is very little impact on the returns or performance for joint venture partners, which suggests that these agreements are more insulating for the partner firm.