Treatment Alliance Research Articles

Understanding the concept of the therapeutic alliance in group treatment for alcohol and drug problems

ABSTRACTThis article investigates how treatment factors are described by different client groups and by treatment staff. The material consists of interviews with clients (n = 81) and treatment staff (n = 18). The analysis focuses on two central themes – the importance of the treatment group and of the treatment staff, along with how these descriptions relate to the concept of the therapeutic alliance. The descriptions differ in parts between the client groups and between clients and staff. Clients as well as staff highlight structural and qualitative aspects of cohesion, but general patterns of how these are expressed in the groups are hard to grasp. However, some exceptions appear; while the clients often relate recognition to own experience of substance abuse, the staff often refer to external aspects of recognition, such as gender and/or experience of parenting. The results indicate that the social preconditions of the group members can influence group cohesion. In the treatment, focus is initially on cohesion and later on making change possible. This might create a dilemma; the homogeneity that initially creates cohesion can also act as a restraint on change. This is described in the results in relation to gender homogeneous client groups in treatment.

Formulation and Treatment of Chronic Suicidality in Patients with Developmental Trauma

Although the psychodynamic literature has examined some of the links between developmental trauma and suicidal thinking and behavior, much of this scholarship focuses on the management of chronic suicidality in the treatment of patients with borderline personality disorder. In this paper, we examine the relationship between complex trauma and the broad spectrum of chronic self-destructive thoughts and behaviors commonly seen in clinical practice. We incorporate perspectives from psychodynamic theory with an emphasis on attachment theory in our understanding of the underlying mechanisms involved. We describe how we use this developmental understanding to address chronic suicidality in ongoing clinical treatment beyond management and safety planning, by providing psychoeducational, cognitive, behavioral and affect-focused strategies that serve to enhance the treatment alliance.

Therapeutic alliance and treatment outcome in the outpatient treatment of urban adolescents: The role of callous-unemotional traits.

Callous-unemotional (CU) traits designate a unique subset of youth with externalizing psychopathology who have a severe pattern of aggressive behavior and tend to have worse outcomes in treatment. However, little research has addressed how CU traits relate to different components of psychotherapy, such as the therapeutic alliance. The current study examined the role of CU traits in predicting therapeutic alliance in 59 adolescents (M age = 15.3, 51% female, 64% Hispanic American, 15% African American) who were part of a larger randomized naturalistic trial of outpatient behavioral psychotherapy. Multilevel regression analysis further investigated the role of therapeutic alliance in predicting treatment outcome (as measured by self-reported delinquency) and the moderating role of CU traits. Results suggested that regardless of the severity of their externalizing problems, youth with higher levels of CU traits reported more positive ratings of therapeutic alliance. In addition, a positive therapeutic alliance predicted reductions in delinquent behavior, and this association was even stronger for youth higher in CU traits. Our results suggest that CU traits are related to improvement in the formation of the therapeutic alliance among youth with externalizing psychopathology, perhaps because these youth lack many of the social and emotional deficits that other youth with conduct problems possess. Adolescents high in CU traits should not be viewed as untreatable. Indeed, the therapeutic alliance may be an important mechanism for affecting meaningful change in these adolescents' lives. (PsycINFO Database Record

Sexual orientation differences in treatment expectation, alliance, and outcome among patients at risk for suicide in a public psychiatric hospital

BackgroundSexual minority (SM) individuals (gay, lesbian, bisexual, or otherwise nonheterosexual) are at increased risk for mental disorders and suicide and adequate mental healthcare may be life-saving. However, SM patients experience barriers in mental healthcare that have been attributed to the lack of SM-specific competencies and heterosexist attitudes and behaviors on the part of mental health professionals. Such barriers could have a negative impact on common treatment factors such as treatment expectancy or therapeutic alliance, culminating in poorer treatment outcomes for SM versus heterosexual patients. Actual empirical data from general psychiatric settings is lacking, however. Thus, comparing the treatment outcome of heterosexual and SM patients at risk for suicide was the primary aim of this study. The secondary aim was to compare treatment expectation and working alliance as two common factors.MethodsWe report on 633 patients from a suicide prevention inpatient department within a public psychiatric hospital. Most patients were at risk for suicide due to a recent suicide attempt or warning signs for suicide, usually in the context of a severe psychiatric disorder. At least one indicator of SM status was reported by 21% of patients. We assessed the treatment outcome by calculating the quantitative change in suicide ideation, hopelessness, and depression. We also ran related treatment responder analyses. Treatment expectation and working alliance were the assessed common factors.ResultsContrary to the primary hypothesis, SM and heterosexual patients were comparable in their improvement in suicide ideation, hopelessness, or depression, both quantitatively and in treatment responder analysis. Contrary to the secondary hypothesis, there were no significant sexual orientation differences in treatment expectation and working alliance. When adjusting for sociodemographics, diagnosis, and length of stay, some sexual orientation differences became significant, indicating that SM patients have better outcomes.ConclusionsThese unexpected but positive findings may be due to common factors of therapy compensating for SM-specific competencies. It may also be due to actual presence of SM competencies – though unmeasured – in the department. Replication in other treatment settings and assessment of SM-specific competencies are needed, especially in the field of suicide prevention, before these findings can be generalized.

Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: An investigation of mediation.

Patients' outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., 2011a; Barlow, Sauer-Zavala, et al., in press) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP versus SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance (B = .037, SE = .05, 95% CI [.005, .096]). Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.

Maladaptive Coping Styles in Adolescents with Internet Gaming Disorder Symptoms

Problematic Internet gaming represents a potential public health concern due to its negative consequences for players and their families. It has been argued that disordered gaming may manifest more readily in vulnerable individuals who lack alternative means of coping. This study investigated Internet gaming disorder (IGD) in relation to coping, including emotion- and problem-focused coping styles. The sample was 823 adolescents (402 males) recruited from secondary schools. Participants completed surveys including the DSM-5 IGD checklist and the Brief COPE. Symptoms of IGD were significantly positively related to denial and behavioural disengagement but were not related to 10 other coping styles. Hours spent gaming and denial coping were the strongest predictors of IGD symptoms. These findings suggest that IGD may co-occur with a tendency toward denial coping, highlighting the significant challenge for practitioners in obtaining reliable assessment by self-report and developing an effective therapeutic alliance in interventions for adolescents.

Learning Psychodynamic Psychotherapy in Southeast Asia.

The subjective nature of psychodynamic psychotherapy (PP) makes training and supervision more abstract compared to other forms of psychotherapy. The issues encountered in the learning and supervision process of PP of Malaysian psychiatry trainees are discussed in this article. Issues of preparation before starting PP, case selection, assessment of patients, dynamic formulations, supervision, anxieties in the therapy, countertransference, termination of therapy, the treatment alliance, transfer of care, the therapeutic setting, and bioethical considerations are explored. Everyone's experience of learning PP is unique and there is no algorithmic approach to its practice. With creative thinking, effort, and "good enough" supervision, a trainee can improve PP skills, even in underserved areas of the world.

Overcoming professionals’ challenging experiences to promote a trustful therapeutic alliance in addiction treatment: A qualitative study

Background and aimsA good therapeutic alliance plays a major role in the healing process. Professionals working in addiction treatment report high levels of psychological distress related to work and this may challenge the establishment of a trustful therapeutic alliance, and lead to a loss of care quality provided to service users. The purpose of this study was to investigate the experience of specialized professionals, its effects on trust and the therapeutic alliance, and the means to restore them. DesignWe conducted a qualitative study using a semi-structured questionnaire and a narrative tool. Discourse was extracted from focus groups and individual interviews and analyzed following the Interpretative Phenomenological Analysis method. ParticipantsTwenty-six professionals from three addiction treatment centers in the Paris area were interviewed. FindingsThe difficulties weighing on the care alliance were described by the participants in terms of their nature, their effects and means to overcome them. Emotional drain leads to a climate of relational distrust and the temptation to desert or over-control patients. Teambuilding, specific training and self-care are viewed as means to restore a therapeutic alliance based on an appropriate type of trust. ConclusionsDistrust deriving from professionals’ challenging experiences may lead to worrying consequences. Promoting democratic organization of care structures, specific training, and also responsible self-care on the part of professionals could help to restore a type of trust that helps to establish a therapeutic alliance suited to service user individualities. This could ultimately be beneficial for user care, professional wellbeing and team functioning.

Parent-Professional Alliance and Outcomes of Child, Parent, and Family Treatment: A Systematic Review

This review systematically explored research examining the relation between parent-professional alliance and outcomes of psychosocial treatments provided to children, and their parents and families. Study findings and methodological characteristics were reviewed to investigate the evidence linking the alliance between parents and professionals to outcomes of child, parent, and family treatment as well as to identify factors that may influence the alliance-outcome association. A systematic review of the literature was conducted that included a search of three electronic databases using specified search terms, followed by a hand search to identify relevant studies. A total of 46 studies (37 published articles and 9 unpublished dissertations) met inclusion criteria. Overall, the findings indicated that higher levels of parent-professional alliance were significantly associated with improved clinical outcomes and stronger treatment engagement. However, some studies found that the parent-professional alliance was not significantly related to clinical outcomes or treatment engagement, and a few studies showed that higher levels of alliance were related to less positive clinical outcomes and lower levels of treatment engagement. Several theoretical (problem type, child age, parent sex) and methodological (source and timing of alliance measurement, alliance-outcome informants, outcome domain, timing of outcome measurement) factors were identified that could influence the alliance-outcome association. Together, our findings emphasize the importance of alliance awareness when working with parents as well as a need for future studies to investigate factors influencing the quality of the parent-professional alliance and alliance-outcome association in child, parent, and family treatment.

The Role of Gender as a Moderator of the Alliance‐Outcome Link in Acute Inpatient Treatment of Severely Disturbed Youth

Research is needed to further examine the role of treatment alliance or engagement among child and adolescent patients in inpatient psychiatric settings. In this study, 72 newly admitted patients on an inpatient adolescent psychiatric unit completed measures of symptom severity and treatment alliance. Female patients showed greater symptom severity at both admission and discharge. Residualized gain score analysis showed that male gender predicted greater symptom reduction. Treatment alliance also predicted greater symptom reduction, but only among women. These results suggest that alliance or engagement with acute inpatient psychiatric services may play a more important role among women than men in predicting symptomatic change in severely disturbed adolescents. Copyright © 2016 John Wiley & Sons, Ltd.

Mind the gap: In-session silences are associated with client attachment insecurity, therapeutic alliance, and treatment outcome

Objective: The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa. Method: 69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N = 175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed. Results: Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment. Conclusion: The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.

Comparison of simple canalith repositioning treatment and medication therapeutic alliance in the management of canalithiasis associated with benign paroxysmal positional vertigo of the horizontal semicircular canal

Objective:To compare the therapeutic efficacy and the recurrence rate between the simple repositioning method and the reposition manoeuvre plus medication in the treatment of horizontal semicircular canal otolith benign paroxysmal positional vertigo (HSC-BPPV). Method:Sixty-two patients diagnosed with otolith HSC-BPPV by roll maneuver test were randomly divided into canalith repositioning group (32 patients) and reposition plus drug treatment group (30 patients). Patients in the canalith repositioning group were treated only with Barbecue reposition maneuver; patients in the reposition plus drug treatment group were treated firstly with Barbecue reposition maneuver and then were given Alprostadil, Cinepazide and Betahistine drug treatment. Both groups were evaluated after 7 days and 28 days treatment, and the recurrence rate was analyzed after 3 months. Result:After 7 days of the treatment , the recovery rate of the two groups was 62.5% and 73.3%, respectively. There's no significant difference between the two groups. However, the total effective power of the reposition plus drug treatment group was 96.7%, which was significantly higher than that of the canalith repositioning group (75.0%) (χ²=5.858, P<0.05). There were 8 patients in the canalith repositioning group showed changes of BBPV types after treatment, while only 1 patient in the reposition plus drug treatment group showed lesion changes. The difference was statistically significant (χ²=4.061, P<0.05). After 28 days of the treatment, the recovery rate and the total effective power of the two groups was 100%, respectively. There is no statistical difference in the total effective rate between the two groups. After 3 months follow-up, 2 patients in the canalith repositioning group (6.25%) and in the reposition plus drug treatment group (6.67%) showed BBPV recurrence, and no significant difference in the recurrence rate was found between the two groups (P>0.05). Conclusion:The repositioning maneuver is the preferred method for treating HSC BPPV. Canalith reposition maneuver plus medication has no obvious effect on the recovery rate and the recurrence rate, it only increases the effective rate and reduces the changes of the BBPV types.

The Impeding Role of Self-Critical Perfectionism on Therapeutic Alliance During Treatment and Eating Disorder Symptoms at Follow-up in Patients with an Eating Disorder.

This study examines the impeding role of self-critical perfectionism at onset of treatment on therapeutic alliance during treatment and eating disorder symptoms at follow-up in patients with an eating disorder. Participants were 53 female patients with a mean age of 21.1 years treated for an eating disorder in a specialized inpatient treatment unit. Self-critical perfectionism was assessed at admission, therapeutic alliance was assessed during treatment (after three months of treatment), and eating disorder symptoms were assessed at admission, after three months and one year later. Self-critical perfectionism negatively related to treatment alliance with the therapist. Although self-critical perfectionism was not directly predictive of subsequent changes in eating disorder symptoms, it was indirectly related to less reduction in body dissatisfaction through the therapeutic alliance. These results point to the importance of self-critical perfectionism in the therapeutic alliance and in changes in body image problems. Treatment implications are discussed.

Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa.

BackgroundTherapeutic alliance (TA) has been found to be a significant predictor of outcome for patients with severe and enduring anorexia nervosa (SE-AN), accounting for more variance than treatment type. To better understand how to promote TA for this population, the aim of the current study was to investigate predictors of TA in adults with SE-AN.MethodsParticipants were 63 adult females with SE-AN presenting to an outpatient, multi-site randomized controlled trial conducted at two clinical sites. Participants’ perception of the quality of their therapeutic relationship, demographic information, and eating disorder symptomatology were assessed via interview and questionnaire measures.ResultsBaseline ratings of how successful participants believed treatment would be for them was the only variable to significantly predict early (p = .01), mid (p = .009), and late treatment alliance (p = .03). No other variables investigated predicted the quality of patient rated TA at any point in treatment (ps > .57).ConclusionsResults suggest instilling hope in treatment outcome may enhance TA, and in turn, outcomes for patients with SE-AN in outpatient therapy.

Longitudinal associations of visit satisfaction and treatment alliance with outcomes in pediatric obesity clinic visits

ABSTRACTRelationships between health care providers and families may be critical to effective weight management for youth with obesity. In this study, 50 youth with obesity (ages 5–16) and their caregivers completed questionnaires at three successive obesity clinic visits. Results suggest that visit satisfaction and treatment alliance contribute positively to parent/youth self-efficacy and self-reported treatment adherence. However, more weight loss was associated with less favorable treatment alliance and visit satisfaction. Findings suggest that an optimal approach to weight management may require a balance between maintaining a positive rapport and challenging families to make and sustain meaningful lifestyle changes.

Planning early childhood audiologic intervention programs on a regional scale: introduction to an Italian study.

SUMMARYNon-uniform, late, or inappropriate care of childhood with permanent hearing impairment (PHI) predisposes many children to develop communicative- behaviour problems and impaired psychosocial adjustment that can persist in adolescence and adulthood.In March 2014, the CCM (Centro Controllo Malattie or Disease Control Centre) of the Italian Ministry of Health funded a project entitled " Preventing Communication Disorders: a Regional Program for Early Identification, Intervention and Care of Hearing Impaired Children". The project involved 5 tertiary centres with UNHS programs formally approved by the Region. The main purpose of the project is to define and launch an integrated regionally-based public health model for identification, diagnosis and intervention of childhood PHI. The first phase of the project investigated the state of art and produced recommendations for positive changes in identification, diagnosis, therapy and care of childhood PHI in Italy, taking into account diagnostic and treatment innovations, family empowerment, treatment alliance and an interdisciplinary approach. Recommendations drawn from this initial phase will represent the basis for a regional system for early intervention that is validated, integrated and shared between the five regions.

Pathological Narcissism and Narcissistic Personality Disorder: Recent Research and Clinical Implications

This review is focused on integrating recent research on emotion regulation and empathic functioning with specific relevance for agency, control, and decision-making in narcissistic personality disorder (NPD, conceptualized as self direction in DSM 5 Section III). The neuroscientific studies of emotion regulation and empathic capability can provide some significant information regarding the neurological/neuropsychological underpinnings to narcissistic personality functioning. Deficiencies in emotion processing, compromised empathic functioning, and motivation can influence narcissistic self-regulation and agential direction and competence in social interactions and interpersonal intimate relationships. The aim is to expand our understanding of pathological narcissism and NPD and suggest relevant implications for building a collaborative treatment alliance.

The Importance of the Therapeutic Alliance When Working with Sexual Offenders

While there is general agreement in the literature regarding the importance of the therapeutic alliance in psychological interventions with people, the forensic context raises some unique challenges. This paper will discuss the significance of the therapeutic alliance in interventions with offenders, especially sexual offenders and the impact on treatment efficacy and change. Therapist characteristics will also be reviewed as well as some of the obstacles and challenges present in a correctional setting, which can impact on the therapeutic alliance. Lastly, the role of transference and countertransference is also considered.

The working alliance in treatment of military adolescents.

Although the working alliance-outcome association is well-established for adults, the working alliance has accounted for 1% of the variance in adolescent therapy outcomes. How the working alliance unfolds in therapy and is modeled in therapy studies may substantially affect how much variance is attributed to the working alliance. The sample included 2,990 military youth who were treated by 98 therapists and attended at least 8 therapy sessions. The average age was 14.91 years (SD = 1.79). Each session, clients completed the Outcome Rating Scale as a measure of psychological well-being/distress and the Session Rating Scale as a measure of working alliance. We utilized 3 models to examine the working alliance-outcome association in therapy: (a) mono-method model (i.e., 1 rating of working alliance correlated with outcomes), (b) aggregate-assessment model (i.e., multiple sessions aggregated and correlated with outcomes), and (c) change-based model (i.e., changes in working alliance scores correlated with outcomes). Findings supported the change-based model. The amount of variance explained in youth outcomes via growth in working alliance scores in the change-based model was approximately 9.8%, which suggests that a key mechanism of client-perceived change for adolescents in therapy may be the continual development of the working alliance over the course of treatment. The monitoring of and continual promotion of the working alliance among military youth in the early phases of therapy may help therapists improve treatment outcomes.

Canadian psychologists’ test feedback training and practice: A national survey.

Psychologists play unique role among mental health professionals, one that is characterised by the development, administration, and interpretation of psychological tests (Meyer et al., 2001). Testing is an integral and multidimensional aspect of psychological practice that provides wealth of valuable information to clinicians and clients. Psychologists are also ethically obligated to share assessment results with clients whenever possible, an exchange referred to as test feedback (TFB). The Canadian Code of Ethics for Psychologists (Canadian Psychological Association [CPA], 2000) states that psychologists are to suitable information about the results of assessments, evaluations, or research findings to the persons involved, if appropriate and if asked. This information would be communicated in understandable language. The code also states that psychologists are to Protect the skills, knowledge, and interpretations of psychology from being misused, used incompetently, or made useless by others (Section III.15; Section IV.11, CPA, 2000).TFB is key element in collaborative, humanistically oriented approaches to assessment, such as therapeutic assessment (TA). TA is an empirically based assessment model developed by SteRyan phen Finn and is described as a semi-structured form of collaborative assessment that uses psychological testing as the centerpiece of brief therapy (Finn & Tonsager, 2002, p. 10). Critical aspects of TA include: (a) helping clients to generate personally relevant questions they would like addressed through the assessment, (b) collecting relevant background information pertaining to the clients' questions, (c) exploring past testing-related hurts, (d) involving clients as active agents throughout the assessment process, including collaboratively discussing test results in order to address their initial questions (Finn, 1996, 2007).Research results suggest the TA model offers many positive effects for children, adolescents, adults, and couples presenting with variety of problems. These include decreased client symptomatology, improved treatment alliance, heightened compliance with treatment recommendations, enhanced self-esteem and increased levels of hope, with global composite effect sizes hovering around .40 (Ackerman, Hilsenroth, Baity, & Blagys, 2000; Hanson, Claiborn, & Kerr, 1997; Hilsenroth, Peters, & Ackerman, 2004; Meyer et al., 2001; Ougrin, Zundel, Ng, Habel, & Latif, 2013; Poston & Hanson, 2010). There is also strong evidence that clients experience considerable benefits from receiving TFB in general (Allen, Montgomery, Tubman, Frazier, & Escovar, 2003; Newman & Greenway, 1997; Poston & Hanson, 2010). In light of the many benefits TFB offers to consumers of psychological testing, it is important to study Canadian psychologists' assessment and TFB practices. It is also important to study how they learned to do so. Finally, it is important to uncover the reasons why some Canadian psychologists might not be regularly offering TFB to clients.In an American study examining psychologists' TFB training and practice, Curry and Hanson (2010) found that 91.7% of respondents reported providing TFB to clients at least sometimes, 35% reported doing so all of the time, and 2.8% reported never providing TFB. Recently graduated clinical psychologists reported providing TFB to clients more consistently than clinical psychologists who earned their degrees earlier, although no such trend was found among school and counselling psychologists. Almost one third of respondents indicated predoctoral training was minimally helpful in learning to provide TFB. However, this rating of the helpfulness of predoctoral training did not coincide with TFB utilization in practice. Ratings of postdoctoral training helpfulness were positively correlated with providing TFB. The primary method of learning indicated by respondents consistently providing TFB was through trial-and-error and the most common reason for not providing TFB was conducting assessments in forensic settings. …