Therapeutic Working Alliance Research Articles

Recruitment issues in a multicenter randomized controlled trial about the effect of the Cultural Formulation Interview on therapeutic working alliance

This short communication concerns recruitment issues in a multicenter randomized controlled trial. An overview of anticipated and unexpected recruitment issues at various organizational levels is discussed as encountered in this trial. These experiences are shared to assist researchers in avoiding similar experiences, prevent wasting valuable research resources, and justify the time and energy committed by enrolled participants.

Relational processes of cultural humility in counseling: A structural equation modeling study

AbstractThe relational nature of cultural humility (CH) has been evident since the beginning of its conceptual and empirical explorations in multicultural counseling. However, few studies have intentionally used a theory‐driven framework to examine the relational processes of CH. In the current study, we used a structural equation modeling approach to examine the relationships between CH, empathy, therapeutic working alliance, and real relationship through a common factors framework. Using a sample of 610 adult counseling clients, we found that CH accounted for approximately 60% of the variance in the working alliance and 58% of the variance in the real relationship. Moreover, we found that empathy partially mediated the dispositional and situational effects of CH on both relational outcomes. We discussed strategies to cultivate CH in counseling relationships. We also recommended future researchers identify other theoretically related mediators and moderators.

DO CHILDHOOD MEMORIES INFLUENCE THE THERAPEUTIC RELATIONSHIP? AN EMPIRICAL BAYESIAN SEM APPROACH.

This study aims to explore the interplay of these concepts in a sample patients diagnosed with schizophrenia and related psychotic disorders. Hence, the potentially mediating role of countertransference in the relationship between recalled parenting styles, childhood trauma and therapeutic working alliance was examined. A total sample of 30 patients (Age: 38.60; SD = 16.37; 50% female) treated for psychotic disorders in an inpatient setting were assessed. Pathways between the variables Recalled Parental Styles, Childhood Trauma, Countertransference and Working Alliance were estimated via frequentist and empirical Bayesian Structural Equation Modeling (EBSEM). Both maximum likelihood and EBSEM derived results suggested direct effects of remembered parental style on childhood trauma, as well as of childhood trauma on negative countertransference. Positive and negative countertransference were associated with working alliance. Furthermore, the findings suggested indirect effects of remembered parental style on negative countertransference via childhood trauma, as well as remembered parental style with working alliance mediated via childhood trauma and negative countertransference. Childhood trauma showed a significant indirect effect on working alliance via negative countertransference. The results provide preliminary support for the idea that traumatic memories from the past influence the therapeutic relationship in the present. In correspondence to this, the clinical significance of concepts like reverie and containment are discussed.

The effect of the cultural formulation interview on therapeutic working alliance: a study protocol.

The Cultural Formulation Interview (CFI) is designed to improve understanding of patients' mental health care needs. The lack of empirical evidence on the impact and effectiveness of CFI use in clarifying people's perspectives, experiences, context, and identity, and in preventing cultural misunderstandings between migrant patients and clinicians, inspired this study. The objective is to examine the effect of the CFI on the strength of therapeutic working alliances, and the potential mediating or moderating role of perceived empathy. A multicenter randomized controlled trial will be conducted, involving migrant patients, their confidants, and clinicians. The CFI will be administered in the intervention group, but not in the control group. Validated questionnaires will be used to assess therapeutic working alliances and perceived empathy. T-tests and linear regression analyses will be conducted to investigate between-group differences and possible mediating or moderating effects. This study will indicate whether or not the CFI strengthens the therapeutic working alliance between patients and clinicians, as moderated and/or mediated by perceived empathy. Research on the effect and impact of using the CFI in mental health care for migrant patients is important to clarify whether its use strengthens the therapeutic working alliance with clinicians. This can lead to a reduction in cultural misunderstandings and improve mental health care for migrant patients. The results may also be important for the implementation of the CFI as a standard of care. This research protocol was tailored to the needs of patients in collaboration with experts by experience. It was approved by the Ethical Review Board of the Tilburg Law School and registered in the Clinical Trials Register under number NCT05788315. Positive results may stimulate further implementation of the CFI in clinical practice, and contribute to improving the impact of the CFI on the therapeutic working alliances.

How Outcome Measures Could Support Transactional Analysts in Clinical Practice to Improve Treatment Trajectories, Manage Risk, Minimise Client Drop-Out Rates and Support Clinical Supervision.

This article presents a review of the literature on the use of Outcome Measures (OMs) in counselling and psychotherapy. Recent Transactional Analysis (TA) research and literature has focussed on the theory and practice of using Outcome Measures (OM) with clients who present with depression, anxiety, and other mood disorders which support the evidence base for the effectiveness of TA. The use of OMs amongst counsellors, psychotherapists remains low, with time constraints during sessions, and the perception of an increase in the burden of their workload and paperwork. Counsellors and psychotherapists report that clients dislike completing the OMs, they are uncertain over which OMs to use and when, and they have had insufficient training on how to use and interpret OM data. Some counsellors and psychotherapists fear that OMs will interrupt or damage the therapeutic relationship and working alliance. Recent studies estimate that only between 7% and 37% of counsellors and psychotherapists utilise OMs as part of their clinical practice. Research studies have found that many counsellors and psychotherapists overestimate their clinical effectiveness by up to 65% and clients who plateau, deteriorate, and subsequently drop out of treatment are missed. The current research with counsellors and psychotherapists who use OMs confound these perceptions, and corroborate that OMs are; convenient, improve the treatment process and trajectory, engage clients in being able to express themselves and see their progress, support ethical practice, clarifies the clients' strengths and vulnerabilities, supports interpersonal functioning, identifying areas of difficulty or stress, screen for and manage risk. This article will explore these issues and give more depth and detail into the ‘pros and cons’ of OM use in private practice and suggest some practical ways to implement OM theory into clinical practice.

The association between counselor ratings of working alliance and in‐session empathy among sex offender counselors

AbstractFactors such as the therapeutic relationship and working alliance have been shown to be important predictors for client outcomes in broad counseling settings with diverse client populations. The present study used linear multiple regression analysis to explore how relational factors such as in‐session empathy and mindfulness impact working alliance when providing sex offender counseling. Results from sex offender counselor participants (N = 109) showed that the perspective taking aspect of empathy was most impactful on working alliance and that in‐session mindfulness was less impactful on working alliance.

Associations between therapeutic working alliance, meaningful experiences, and affective distress

AbstractWe used structural equation modeling to test client meaningful experiences in counseling and the therapeutic working alliance (TWA) as predictors of affective distress, controlling for clients’ age, gender, race and ethnicity, and length of counseling relationship. In a sample of 306 adult clients engaging in counseling, we a found statistically significant relationship between client meaningful experiences in counseling and the TWA (r = 0.80, p < 0.001). There was a significant and negative direct effect from client meaningful experiences in counseling to affective distress (β = −0.45, p < 0.001). However, we did not find a significant direct effect of the TWA on affective distress (β = −0.00, p = 0.97). Implications for counselors, supervisors, and counselor educators are discussed.

Retraction of Gerstenblith et al. (2022).

Reports the retraction of "The triadic effect: Associations among the supervisory working alliance, therapeutic working alliance, and therapy session evaluation" by Judith A. Gerstenblith, Kathryn V. Kline, Clara E. Hill and Dennis M. Kivlighan Jr. (Journal of Counseling Psychology, 2022[Mar], Vol 69[2], 199-210). The following article is being retracted (https://doi.org/10.1037/cou0000567). This retraction is at the request of coauthors Kivlighan and Hill after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. Gerstenblith and Kline were not responsible for obtaining and verifying participant consent but agreed to the retraction of this article. (The following abstract of the original article appeared in record 2021-88607-001.) Several theorists (Bandura, 1969; Hackney & Goodyear, 1984; Searles, 1955) suggest parallels between the relationship in supervision and the relationship in therapy. We examined supervisor and therapist trainee ratings of supervisory working alliance (SWA) in 1 week predicting client-rated therapeutic working alliance (TWA) and client-rated therapy session evaluation (TSE) in the following week as well as TWA and TSE ratings in 1 week predicting SWA ratings in the following week. Our data included 663 weeks of therapy nested within 28 trainees nested within 15 supervisors, disaggregated into differences between supervisors, differences within supervisors, and differences within trainees. At the between-supervisor level, when supervisors' trainees rated the SWA higher on average compared with other supervisors' trainees' average SWA ratings, their clients' average TWA rating was higher. In contrast, when supervisors rated the SWA higher on average compared with other supervisors' average SWA ratings, their trainees' clients' average TSE rating was higher but the average TWA rating was lower. At the within-supervisor level, when trainees rated a higher SWA on average compared with other trainees' average SWA ratings with the same supervisor, their clients' average TSE rating was higher. The theoretical prediction of parallel relationships in supervision and therapy was supported, but only for between-supervisor and within-supervisor differences in SWA. We found no evidence that week-to-week changes in SWA or client-rated TWA or TSE reflected parallel relationships. We provide suggestions for further research, including exploring the mechanisms through which supervision relates to the therapy process and outcome. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examining between- and within-person effects of the self-stigma of seeking psychological help on the therapeutic working alliance: The moderating role of psychological distress.

The self-stigma (i.e., shame) associated with psychotherapy is a prominent barrier to seeking psychological help, but less is known about its effects after treatment begins. Evidence suggests that self-stigma may interfere with the formation of the therapeutic alliance, but no studies have examined this throughout the course of psychotherapy. Self-stigma's erosion of the alliance may be most pronounced when clients experience heightened psychological distress, but this also has not been examined. Therefore, the present study addresses these omissions among 37 clients who completed at least three therapy sessions for research credit. Participants completed measures of self-stigma and past-week symptoms of distress before each session and ratings of the working alliance after. Predictor variables were disaggregated into between-person (time-invariant or average levels) and within-person (time-variant or session-by-session changes) components to enable investigation of for whom (and under what conditions) self-stigma was associated with the therapeutic alliance. Results indicated that higher levels of self-stigma (between and within persons) predicted a worse alliance. When examined as an interaction effect alongside distress in a multilevel moderation model, higher between-person ratings of self-stigma predicted a weaker therapist-client alliance across levels (M ± 1 SD) of within-person distress. Notably, its effects became more pronounced as symptoms of distress increased, indicating a period in which clients are simultaneously most likely to need help yet least likely to feel allied with their therapist. Findings highlight the importance for therapists to simultaneously monitor and consider both average and session-by-session fluctuations in self-stigma and distress to develop and maintain the working alliance. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Therapists who foster social identification build stronger therapeutic working alliance and have better client outcomes

BackgroundFor decades we have known that therapeutic working alliance is a key contributor to client engagement and positive outcomes in therapy. However, we have made little progress in narrowing down its determinants, which is critical in supporting trainees to optimize such alliance. We make a case for the value of incorporating social psychological frameworks into models of alliance and explore the role of social identity processes in the development of therapeutic alliance. MethodAcross two studies, over 500 psychotherapy clients completed validated measures of alliance, social identification with their therapist, positive therapy outcomes, and a range of client and therapist characteristics. FindingsSocial identification strongly predicted alliance in both samples, whereas client and therapist characteristics showed few such associations. Alliance mediated the relationship between social identification and positive therapy outcomes. In addition, we found evidence that (a) personal control is a key psychological resource in therapy that arises from social identification, and (b) therapists who engage in identity leadership (i.e., who represent and build a social identity that they share with clients) are more likely to foster social identification and its downstream benefits. InterpretationThese data show that social identity processes are key to the emergence of working alliance. We conclude with a discussion of how recent social identity and identity leadership interventions might be adapted to train therapists in relevant identity-building skills.

Impact of personality dysfunction on interdisciplinary treatment team working alliance in an inpatient psychiatric population.

Cluster B personality disorders (PDs) share specific traits that can result in interpersonal conflict. As therapeutic working alliance has a strong relationship with improved outcomes, there is interest in understanding the relationship between PDs, working alliance, and clinical outcomes. This is especially compelling in inpatient populations, where symptoms are severe, and patients are working with a treatment team. The aims of this study were to (a) assess whether higher team working alliance is associated with lower depressive symptoms, (b) assess whether patients with Cluster B PD traits have worse working alliance with their team than patients without those Cluster B PD traits, and (c) assess whether higher team working alliance is associated with lower depressive symptoms when Cluster B PD traits are present. Team working alliance was measured at baseline and at discharge for 3,406 inpatients at a psychiatric hospital. Improved team working alliance was associated with lower depression scores at discharge. Patients with borderline personality disorder traits had worse team working alliance, whereas patients with narcissistic personality disorder and antisocial personality disorder traits had similar working alliance scores as other patients. Borderline personality disorder and antisocial personality disorder traits moderated the association between team working alliance and depressive symptoms differently. Findings suggest that team working alliance works similarly to therapist working alliance. Of clinical importance is the finding that team working alliance and its relationship with depression symptoms differ based on Cluster B PD traits, and the importance of strong working alliance regardless of interpersonal challenges due to personality pathology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A double-edged hormone: The moderating role of personality and attachment on oxytocin's treatment facilitation effect

BackgroundStudies exploring the potential augmenting effect of oxytocin for patients with mental disorders have thus far reported mixed effects. However, oxytocin’s effect may differ across patients with different interpersonal characteristics. This study aimed to examine the moderating role of attachment and personality traits on the effect of oxytocin administration on the therapeutic working alliance and symptomatic change, among hospitalized patients with severe mental illness. MethodsPatients (N = 87) were randomly assigned to receive oxytocin or placebo, as an add-on to psychotherapy for a period of four weeks, in two inpatient units. Therapeutic alliance and symptomatic change were measured weekly, and personality and attachment were assessed at pre- and post-intervention. ResultsOxytocin administration was significantly associated with improvement of depression (B=2.12, SE=0.82, t = 2.56, p = .012), and suicidal ideation (B=0.03, SE=0.01, t = 2.44, p = .016) for patients low in openness and extraversion, respectively. Nonetheless, oxytocin administration was also significantly associated with a deterioration in the working alliance for patients high in extraversion (B=−0.11, SE=0.04, t = −2.73, p = .007), low in neuroticism (B=0.08, SE=0.03, t = 2.01, p = .047) and low in agreeableness (B=0.11, SE=0.04, t = 2.76, p = .007). ConclusionsOxytocin may act as a double-edged sword when it comes to its effect on treatment process and outcome. Future studies should focus on routes to characterize patients who might benefit the most from such augmentation. Clinical trial registrationPre-registration in clinicaltrials.com: NCT03566069; Israel Ministry of Health: MOH_2017–12–05_002003.

Factors promoting alliance quality: Differentiation of therapeutic alliance according to the formal aspects of the psychotherapeutic process and demographic variables

Background and ObjectivesThe study's main aim was to determine which formal aspects of psychotherapy (therapist's work experience, number of sessions held, frequency of meetings, length of sessions) contributed to the quality of the therapeutic (working) alliance. The alliance was also analyzed for demographic variables. MethodsThe sample consisted of 428 participants, and the working alliance was evaluated in 262 psychotherapist–patient dyads. To assess its quality, the author used the full version of the Working Alliance Inventory (WAI). ResultsThe analyzes led to several conclusions. Their results indicate that the quality of working alliance increases if psychotherapy is conducted by an experienced specialist, if the frequency of sessions is high, and if the sessions are longer. They do not, however, pinpoint the demographic markers of therapeutic alliance quality. ConclusionThe formal aspects of the psychotherapeutic process influence the quality of the working alliance. Alliance develops to an equal degree in people of different ages and with diverse levels of education, regardless of the presence or absence of close interpersonal relationships in their lives.

Quality of the therapeutic working alliance as a factor in intensive residential treatment of obsessive-compulsive disorder

Objective: Intensive residential treatment (IRT) for obsessive-compulsive disorder (OCD) includes frequent meetings with a cognitive–behavioral therapist. We examined whether this therapeutic working alliance relates to IRT outcomes. Method: Data came from a naturalistic sample of patients with OCD (n = 124) who received IRT at a specialty OCD clinic. Patients completed measures of OCD severity and well-being at admission and discharge. Both the patient and treating psychologist completed the Working Alliance Inventory-Short Form (WAI-SF). Alliance ratings were tested as predictors in models predicting outcomes (discharge scores adjusting for baseline and treatment duration) as well as logistic regression predicting treatment response (≥35% symptom reduction in OCD symptoms). Results: Patient and clinician ratings of the quality of the alliance were weakly yet significantly correlated. Patient ratings of the alliance predicted outcomes, while therapist ratings did not. Moreover, greater discrepancy between patient and client ratings predicted worse outcomes. Patient ratings of the task dimension of the alliance uniquely related to responder status. Conclusions: Patient perceptions of the working alliance, particularly as pertaining to agreement on therapeutic tasks, related to success with IRT for OCD. Further study is needed test interventions to improve task alliance as a strategy to enhance treatment.

Associations between therapeutic working alliance and social cognition in neuro-rehabilitation

The aim of this study was to investigate the impact of brain injury survivors´ social cognition abilities on their working alliance with their therapist. Participants in this study were individuals who were enrolled in a vocational rehabilitation programme for acquired brain injury. Seventy-two individuals with complicated mild to severe acquired brain injury (49%TBI, 38% stroke, 14% other injury; mean age 44.9 years; 75% male) entered in the study between 1.5 and 31 years after their injury (Md=5 years). The therapeutic alliance was rated retrospectively at the time of study by the participants´ primary therapists on the Working Alliance Inventory (WAI). Social cognition measures (Reading the Mind in the Eyes Test, Recognition of Faux Pas Test, The Awareness of Social Inference Test, TASIT; Social Situations Task, Bangor Gambling Task) were administered as well as a standard neuropsychological test battery and the Hospital Anxiety and Depression Scale. Multilevel analyses revealed that both the TASIT and the Social Situations Task, but neither the standard neuropsychological tests nor the HADS were significantly related to WAI ratings. These findings indicate the impact that difficulties with emotions recognition and social rule violations can have on the formation of a therapeutic alliance.

Ethics in Psychotherapy: Informed Consent, Digital Professionalism, and Sexual Misconduct.

Ethics in Psychotherapy: Informed Consent, Digital Professionalism, and Sexual Misconduct.

Cultural auditing to enhance reflective counseling practices with Indigenous families

AbstractContemporary researchers in counseling consider cultural sensitivity and respectfulness as vital to developing a therapeutic working alliance. The author explores using a cultural audit to reflexively support cultural reflection, sensitivity, and respectfulness. A case example is used to present the cultural audit process in the client cultural context of a First Nations elder and grandfather. Implications are discussed, including cultural repertoire expansion of counselors and counseling practitioners via culture‐infused therapeutic working alliances.

The triadic effect: Associations among the supervisory working alliance, therapeutic working alliance, and therapy session evaluation.

Several theorists (Bandura, 1969; Hackney & Goodyear, 1984; Searles, 1955) suggest parallels between the relationship in supervision and the relationship in therapy. We examined supervisor and therapist trainee ratings of supervisory working alliance (SWA) in 1 week predicting client-rated therapeutic working alliance (TWA) and client-rated therapy session evaluation (TSE) in the following week as well as TWA and TSE ratings in 1 week predicting SWA ratings in the following week. Our data included 663 weeks of therapy nested within 28 trainees nested within 15 supervisors, disaggregated into differences between supervisors, differences within supervisors, and differences within trainees. At the between-supervisor level, when supervisors' trainees rated the SWA higher on average compared with other supervisors' trainees' average SWA ratings, their clients' average TWA rating was higher. In contrast, when supervisors rated the SWA higher on average compared with other supervisors' average SWA ratings, their trainees' clients' average TSE rating was higher but the average TWA rating was lower. At the within-supervisor level, when trainees rated a higher SWA on average compared with other trainees' average SWA ratings with the same supervisor, their clients' average TSE rating was higher. The theoretical prediction of parallel relationships in supervision and therapy was supported, but only for between-supervisor and within-supervisor differences in SWA. We found no evidence that week-to-week changes in SWA or client-rated TWA or TSE reflected parallel relationships. We provide suggestions for further research, including exploring the mechanisms through which supervision relates to the therapy process and outcome. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The relation between the working alliance on mental illness and criminal thinking among justice-involved people with co-occurring mental illness and substance use disorders.

The therapeutic working alliance is an important factor in producing treatment change and positive therapeutic outcomes for people with mental illness, yet little is known about the working alliance's role in treatment change in people with mental illness that is justice involved. In addition to treating the mental illness symptoms of justice-involved people with mental illness, addressing factors known to predict criminal behavior (including criminal thinking) could optimize posttreatment outcomes and reduce future justice involvement. This study examines the role of the working alliance in treatment change in a clinical treatment sample of 265 adult male and female justice-involved people with mental illness and substance use disorders completing probation sentences in a residential treatment facility. Repeated measures moderation analyses were used to test participants' reported working alliance as a moderator of change from pre- to posttreatment scores of self-reported mental illness symptoms and criminal thinking. The working alliance significantly moderated reductions in depression, anxiety, anger, and manic symptoms (R 2 ranging from .03 to .09), and general, reactive, and current criminal thinking (R 2 ranging from .04 to .11). These findings expand the literature on the relation between working alliance and changes in mental illness symptoms by testing this association in the understudied population of justice-involved people with mental illness; these results also suggest the working alliance is associated with changes in criminal thinking. Treatment providers working with justice-involved people with mental illness should assess and emphasize the development of a working alliance to maximize treatment change. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Facilitating goals, tasks, and bonds via identity leadership: Understanding the therapeutic working alliance as the outcome of social identity processes.

Facilitating goals, tasks, and bonds via identity leadership: Understanding the therapeutic working alliance as the outcome of social identity processes.