Patient-rated Alliance Research Articles

An Examination of the Treatment Utility of the MMPI-2-RF: Prediction of Post-Treatment Depressive Symptoms and Increased Understanding of the Therapeutic Alliance in an Inpatient Mood Disorder Treatment

The study examined the ability of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) substantive scales to predict depressive symptoms in a psychiatric inpatient setting. The indirect effect of patient-rated alliance with their treatment team on these relationships was also investigated. Participants included 678 (52.5% female, 97.1% White) inpatients diagnosed with a mood disorder. MMPI-2-RF scales, Patient Health Questionnaire (PHQ-9) at intake and discharge, and Working Alliance Inventory-Short at discharge were used to test study hypotheses regarding MMPI-2-RF predictive utility and the influence of alliance. Jacobson and Truax’s (1991) reliable change index (RCI) was calculated to identify those who did (74% of the sample) and did not (24%) make reliable and clinically significant depressive symptom change, and the predictive utility of MMPI-2-RF scores in distinguishing these groups was examined. MMPI-2-RF scales assessing internalizing and somatic dysfunction accounted for an additional 2% to 8% of the variance in depressive symptoms reported at discharge, above and beyond depressive symptoms reported at intake. Somatic scales were also able to differentiate groups based on clinically significant change on the PHQ-9 (small-sized effect). The relationship between MMPI-2-RF scales and depressive symptoms at discharge was indirect through alliance in 64% of models. Clinical implications are discussed.

Patient social functioning in acute mental health inpatient wards: the role of emotional regulation, attachment styles and nurse–patient relationships

Background/aims Improvement in social functioning is an important aspect of recovery from severe mental health problems. Nurses on acute mental health wards play an important role in facilitating this recovery. Therefore, it is important to explore potential predictors of social functioning and the quality of nurse–patient relationships. The aim of this study was to explore associations between patient social functioning, nurse–patient therapeutic alliances, emotional regulation, attachment style and nurse distress in acute mental health settings. Methods: A questionnaire-based, cross-sectional approach with correlational and regression analyses was used for this study. A total of 50 nurse–patient dyads in acute mental health inpatient wards across four NHS trusts in the north-west of England took part. Patients and nurses completed questionnaires regarding demographic information, emotional regulation, attachment style and alliance. Nurses also rated patient social functioning and their own distress. Results The patient anxious attachment style was associated with difficulties in regulating emotions. Patient emotional regulation, patient insecure attachment and the patient-rated alliance predicted nurse-rated patient social functioning. Nurse emotion regulation, nurse insecure attachment style and nurse-rated alliance did not significantly predict nurse-rated patient social functioning and correlations were non-significant. Nurse distress was associated with nurse emotion regulation, nurse anxious attachment and nurse-rated alliance. These factors significantly predicted nurse distress. Conclusions: Patient social functioning is predicted by emotion regulation, attachment and alliance. Similarly, nurse distress is predicted by nurse emotion regulation, attachment style and alliance. Interventions targeting emotion regulation or attachment-informed wards would be beneficial.

The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder

Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings.Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD).Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome.Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings.Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.

Processes of change in trauma-focused CBT

Background: Numerous studies have shown that trauma-focused psychological treatments for PTSD are effective (Lewis, Roberts, Andrew, Starling, & Bisson, 2020). Few studies to date have investigated the processes of change during treatment. There is initial evidence that these treatments change problematic beliefs about the trauma and its consequences, and that belief change drives symptom change (Brown, Belli, Asnaani, & Foa, 2018). Further studies of other candidate processes are needed. Objective: To investigate the temporal relationships between changes in theory-derived (Ehlers & Clark, 2000) treatment specific processes (appraisals, trauma memory characteristics, and unhelpful cognitive and behavioural responses) and non-specific processes (working alliance) and symptom change during a course of cognitive therapy for PTSD (e.g. Wild et al., 2020). Study 1 Methods: Session by session changes in self-reports of cognitive factors and PTSD symptoms obtained from patients treated in routine clinical care were analysed with bivariate latent change score models (LCSM). Results: Were preceded by changes in for most measures, changes in cognitive factors preceded changes in PTSD symptoms, but not vice versa. Study 2 Methods: Patient and therapist ratings of working alliance were taken repeatedly. Autoregressive, cross-lagged models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Results: Higher patient and therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance. A better working alliance at the start of treatment predicted treatment outcome. For most measures, changes in cognitive factors preceded changes in PTSD symptoms, but not vice versa. Conclusions: Study 1 extended previous findings that that cognitive and behavioural processes suggested by theoretical models of PTSD play a key role in driving symptom improvement during trauma-focused CBT. Changes in cognitive factors preceded symptom change. This result suggests that monitoring these processes during therapy may help therapist in maximising treatment outcomes in individual patients, and may also point to further ways of optimising treatments in general. Study 2 suggested that working alliance may be an important factor in setting the necessary conditions for effective treatment, but did not find evidence of a temporal precedence of changes in working alliance driving symptom change.

Indirect effect of patient outcome expectation on improvement through alliance quality: A meta-analysis

Objective: A meta-analysis revealed a positive correlation between patients’ optimistic baseline, or early treatment, outcome expectation (OE) and posttreatment improvement (Constantino, Vîslă, et al., [2018]. A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473–485. https://doi.org/10.1037/pst0000169). However, little is known about mechanisms through which OE operates. Increasingly, several individual studies have pointed to higher therapeutic alliance quality as a promising mediator (candidate mechanism) of the positive OE-improvement link. In this study, we conducted the first meta-analysis of this indirect effect, hypothesizing that alliance would partially mediate the OE-outcome link. Method: We included published articles involving a clinical sample; therapist-led treatment of at least 3 sessions; pre- or early treatment patient OE measures; during-treatment patient-rated alliance measures; posttreatment outcome measures; and statistical tests of mediation. This meta-analysis included 10 independent samples and over 1,000 patients. Results: As expected, better alliance quality partially mediated the association between more optimistic OE and improvement; that is, although both were significant, a multivariate analysis revealed that the direct effect was significantly lower than the total effect (standardized difference = −.12, p < .001, 95% CI [−.20, −.05]). Publication bias was low, as was heterogeneity except for the alliance-outcome path. Conclusions: Better alliance may be one process that helps transmit the therapeutic influence of early patient OE.

The alliance mediates outcome in cognitive–behavioral therapy for social anxiety disorder, but not in attention bias modification

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16–20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

The role of the working alliance in psychological treatment of substance use disorder outpatients

Objective: The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship. Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM). Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation. Conclusions: Patients’ attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.

Predictors and moderators of treatment dropout in cognitive-behavioral and psychodynamic therapies for panic disorder

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive–behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients. Trial registration: ClinicalTrials.gov identifier: NCT00353470.

Working Alliance in Blended Versus Face-to-Face Cognitive Behavioral Treatment for Patients with Depression in Specialized Mental Health Care.

This study investigates working alliance in blended cognitive behavioral therapy (bCBT) for depressed adults in specialized mental health care. Patients were randomly allocated to bCBT (n = 47) or face-to-face CBT (n = 45). After 10 weeks of treatment, both patients and therapists in the two groups rated the therapeutic alliance on the Working Alliance Inventory Short-Form Revised (WAI-SR; Task, Bond, Goal, and composite scores). No between-group differences were found in relation to either patient or therapist alliance ratings, which were high in both groups. In the full sample, a moderate positive association was found between patient and therapist ratings on Task (ρ = 0.41, 95% CI 0.20; 0.59), but no significant associations emerged on other components or composite scores. At 30 weeks, within-and between-group associations between alliance and changes in depression severity (QIDS, Quick Inventory of Depressive Symptomatology) were analyzed with linear mixed models. The analyses revealed an association between depression over time, patient-rated alliance, and group (p < 0.001). In face-to-face CBT, but not in bCBT, lower depression scores were associated with higher alliance ratings. The online component in bCBT may have led patients to evaluate the working alliance differently from patients receiving face-to-face CBT only.

Associations between alliance, physiotherapists’ confidence in managing the patient and patient-reported distress in chronic low back pain practice

Purpose Physiotherapists often feel insecure when managing patients with chronic low back pain associated with psychological factors. This uncertainty could hinder physiotherapists in fostering strong patient-therapist alliances in chronic low back pain practice. The purpose of this study was to explore associations between patient-rated alliance, physiotherapists’ self-reported confidence in managing the patient and patient-reported psychological distress. Methods Patients with chronic low back pain (N = 21) self-reported their psychological status at baseline. After the intake session, physiotherapists self-reported their confidence (enthusiasm and competence) in managing the patient with chronic low back pain. Patient-rated alliance was measured after the third physiotherapy session. A linear mixed model estimated associations between alliance (dependent variable), physiotherapists’ confidence and patient-reported distress. Results The linear mixed model estimated a positive interaction effect (therapist confidence × patient distress) on patient-rated alliance (estimated effect, β = 0.15; 95% Confidence Interval = 0.03–0.27). Conclusions Higher self-reported confidence in managing the patient with chronic low back pain by physiotherapists was associated with higher patient-reported alliance after the third physiotherapy sessions. The positive effect between therapist confidence and patient-rated alliance appeared to be dependent on patient-reported psychological distress at baseline.

The Therapeutic Alliance Over 10 Sessions of Therapy for Borderline Personality Disorder: Agreement and Congruence Analysis and Relation to Outcome.

The authors examined whether alliance dynamics are affected by tailoring the therapeutic relationship to the individual patient in brief psychotherapy of borderline personality disorder. Sixty patients were randomized to 10-session Good Psychiatric Management (GPM-BV) or GPM combined with Motive-Oriented Therapeutic Relationship techniques (MOTR+GPM-BV). Patient- and therapist-rated alliance was assessed weekly. Self-reported symptomatic distress was assessed pre-, mid-, and posttreatment. In MOTR+GPM-BV, stronger therapist-rated alliance predicted lower symptomatic distress in the same timepoint, but not in a lag, whereas symptomatic distress predicted therapist-rated alliance in a lag. Therapist-rated alliance was lower than patient-rated alliance in GPM-BV but not in MOTR+GPM-BV. In MOTR+GPM-BV, higher agreement on strong alliance tended to predict lower symptomatic distress. Patient- and therapist-rated alliances were temporally congruent, but congruence did not predict outcome. Addressing the relationship needs of patients may partly exert its salutary effect by increasing agreement between patients' and therapists' experience of the alliance.

Therapeutic Alliance Between Dietitians and Patients With Head and Neck Cancer: The Effect of Training in a Health Behavior Change Intervention.

BackgroundThe relationship between a clinician and their client—the “therapeutic alliance” is a robust predictor of outcome in healthcare settings; yet, few interventions to improve alliance have been tested. Motivational interviewing is a client-centered approach that embodies many principles and strategies consistent with a strong therapeutic alliance.PurposeTo examine whether alliance is enhanced by training dietitians to deliver a motivational interviewing informed health behavior change intervention (“Eating as Treatment”; EAT) as part of routine consultations with patients with head and neck cancer. The predictive ability of motivational interviewing techniques was also assessed.MethodsA secondary analysis of the EAT stepped-wedge cluster-randomized controlled trial was conducted. Patients with head and neck cancer undergoing radiotherapy (n = 307) were treated by radiotherapy dietitians (n = 29) during the control (Treatment as Usual) or intervention (EAT) phase. Alliance was rated during the first and final weeks of radiotherapy, and again 4 and 12 weeks post-radiotherapy. Dietetic sessions were audiotaped. Week one sessions were objectively rated for dietitians’ use of motivational interviewing techniques.ResultsGeneralized linear-mixed effects regressions found no effect of EAT on dietitian-rated alliance (p = .237). After excluding outliers, patient-rated alliance was 0.29 points lower after EAT training (p = .016). Post hoc analyses revealed lower patient ratings on perceived support and dietitian confidence. Hierarchical multiple regressions found that no specific motivational interviewing techniques predicted patient-rated alliance. Dietitian acknowledgment of patient challenges was related to dietitian-rated alliance (β =.15, p =.035).ConclusionsPatient and dietitian ratings of alliance were high after EAT training, but not significantly improved. Further research is needed to better understand the differential impact of intervention training and delivery on patient and clinician ratings of therapeutic alliance.Clinical Trial informationTrial registration number ACTRN12613000320752

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

ABSTRACTBlended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.

My care manager, my computer therapy and me: The relationship triangle in computerized cognitive behavioural therapy

Previous research has reported mixed findings regarding the relationship between therapeutic alliance, engagement and outcomes in e-mental health. This study aims to overcome some of the methodological limitations of previous research and extend our understanding of alliance-outcome relationships in e-mental health by exploring the nature of the relationship triangle between the patient, their care manager and their computerized cognitive behavioural therapy (CCBT) program, accessed with or without an Internet Support Group (ISG).Positive patient-rated alliance with both their care manager and the CCBT program itself was found and these were significantly associated with measures of engagement and clinical outcome. The magnitude of this association was moderate, and within the range of that reported for traditional face-to-face psychotherapies in recent meta-analyses. Limitations of the study, including the reliance on completer data and a cross-sectional design, and directions for future research are presented. Our findings suggest that both the training and supervision of support staff and the optimization of CCBT interventions themselves to enhance alliance and experience may lead to improved engagement and outcomes.Trial Registration: Clinicaltrials.gov Identifier: NCT01482806https://www.clinicaltrials.gov/ct2/show/NCT01482806?term=rollman&rank=4

Relationships among alexithymia, therapeutic alliance, and psychotherapy outcome in major depressive disorder

Previous studies have found that alexithymia predicts process and outcome of psychodynamic psychotherapy across a range of psychiatric disorders. There is preliminary evidence that alexithymia may exert its effects on outcome through the therapist. Other studies have found that alexithymia does not influence outcome of cognitive-behavioral therapy (CBT). The aim of the current study was to investigate the capacity of alexithymia to predict therapist- and patient-rated therapeutic alliance and response to CBT and interpersonal psychotherapy (IPT) for major depressive disorder. A total of 75 adults with major depressive disorder were randomized to receive weekly sessions of manualized individual CBT or IPT for a period of 16 weeks. Pre-treatment alexithymia exhibited a positive direct effect on depression change, and a negative indirect effect on depression change via patient-rated alliance at week 13. There was no mediating role of therapist-rated alliance. Although these findings are preliminary, they suggest that pre-treatment alexithymia has meaningful links to psychotherapy process and outcome, and that nuanced analyses incorporating intervening variables are necessary to elucidate the nature of these links.

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.

Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study

BackgroundClinical decision-making is the vehicle of health care provision, and level of involvement predicts implementation and satisfaction. The aim of this study was to investigate the impact of decision-making experience on recovery.MethodsData derived from an observational cohort study “Clinical decision making and outcome in routine care for people with severe mental illness” (CEDAR). Adults (aged 18–60) meeting standardised criteria for severe mental illness were recruited from caseloads of outpatient and community mental health services in six European countries. After consenting, they were assessed using standardised measures of decision-making, clinical outcome and stage of recovery at baseline and 1 year later. Latent class analysis was used to identify course of recovery, and proportional odds models to investigate predictors of recovery stage and change.ResultsParticipants (n = 581) clustered into three stages of recovery at baseline: Moratorium (N = 115; 19.8%), Awareness/Preparation (N = 145; 25.0%) and Rebuilding/Growth (N = 321; 55.2%). Higher stage was cross-sectionally associated with being male, married, living alone or with parents, and having better patient-rated therapeutic alliance and fewer symptoms. The model accounted for 40% of the variance in stage of recovery. An increased chance of worse outcome (change over 1 year to lower stage of recovery) was found for patients with active involvement compared with either shared (OR = 1.84, 95% CI 1.15–2.94) or passive (OR = 1.71, 95% CI = 1.00–2.95) involvement. Overall, both process (therapeutic relationship) and outcome (symptomatology) are cross-sectionally associated with stage of recovery.ConclusionsPatient-rated decision-making involvement and change in stage of recovery are associated. Joint consideration of decision practise within the recovery process between patient and clinician is supposed to be a useful strategy to improve clinical practice (ISRCTN registry: ISRCTN75841675. Retrospectively registered 15 September 2010).

Change in patients' interpersonal impacts as a mediator of the alliance-outcome association in treatment for chronic depression.

Theories posit that chronically depressed individuals have hostile and submissive interpersonal styles that undermine their interpersonal effectiveness and contribute to the cause and maintenance of their depression. Recent findings support this theory and demonstrate that chronically depressed patients' interpersonal impacts on their therapist become more adaptive (i.e., less hostile and submissive, and more friendly and assertive) during a targeted chronic depression treatment: cognitive-behavioral analysis system of psychotherapy (CBASP). In this study, the authors examined whether such changes in interpersonal impacts (as rated by clinicians' experiences of interacting with their patients) mediated the association between early patient-rated alliance quality and final session depression. Data derived from a large trial for chronic depression that compared the efficacy of CBASP, nefazodone, and their combination. The current subsample (N = 220) included patients in the CBASP and combined conditions who completed at least 1 depression assessment and the alliance measure, and whose therapists completed at least 1 interpersonal impacts assessment. Mediation models were fit using a bootstrapping procedure for assessing indirect effects. As hypothesized, results supported a mediating effect; higher early alliance predicted decreases in patient hostile-submissiveness during therapy, which in turn related to lower final session depression (indirect effect B = -.02, 95% confidence interval: -.07, -.001). This indirect effect accounted for 13% of the total effect of alliance on depression. There was no moderating effect of treatment condition on the indirect effect. Results further support CBASP change theory and suggest a candidate mechanism of the alliance's effect on outcome. (PsycINFO Database Record

Patients' pre-treatment interpersonal problems as predictors of therapeutic alliance in long-term psychodynamic psychotherapy

Information on how the patient's interpersonal problems predict alliance development during long-term therapy is lacking. The aim of this study was to explore how the patient's pre-treatment interpersonal problems predict the development of alliance in long-term psychotherapy. Altogether 128 adult outpatients experiencing mood or anxiety disorder were assigned to long-term psychodynamic psychotherapy in the Helsinki Psychotherapy Study. The Inventory of Interpersonal Problems (IIP) total score and the eight octant scores, assessed at baseline, were used as predictors. The trajectories of change in patient- and therapist-rated Working Alliance Inventory (WAI) were used as outcome measures at 7, 12, and 36 months of follow-up after baseline. Study of the changes by time showed that the patient-rated alliance was significantly improved by the 36-month follow-up, i.e. the most usual end-point of therapy, in persons with higher pre-treatment level of the IIP total score. Low total IIP score and low to moderate level of hostile type problems showed no slope of improvement of patient-rated alliance during follow-up. The therapist-rated alliance showed a similar course as the patient-rated alliance with the exception of a faster improvement for higher IIP scores. In conclusion, a higher level of patients' interpersonal problems predicted favorable alliance development.

Alliance ruptures and repairs in psychotherapy in primary care

Objective: The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome. Method: The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model. Results: The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern. Conclusions: The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.