Alliance In Therapy Research Articles

Feedback in group psychotherapy for eating disorders: A randomized clinical trial.

To investigate the effect of client feedback in group psychotherapy on attendance and treatment outcome for patients with eating disorders. We conducted a randomized clinical trial with central randomization stratified for diagnosis and treatment type according to a computer-generated allocation sequence concealed to the investigators. One-hundred and 59 adult participants, diagnosed with bulimia nervosa, binge eating disorder, or eating disorder not otherwise specified according to DSM-IV, were included. Eighty participants were allocated to the experimental group, and 79 participants to the control group. Both groups received 20-25 weekly group psychotherapy sessions. In the experimental group, participants gave and received feedback about therapy progress and alliance, measured before and after each session using the Outcome Rating Scale and the Group Session Rating Scale. The primary outcome was rate of attendance to treatment sessions; the secondary outcome was severity of eating disorder symptoms measured with the Eating Disorder Examination interview. Exploratory outcomes were psychological distress measured with the Symptom Checklist-90-R and the Outcome Rating Scale, social functioning measured with the Sheehan Disability Scale, and episodes of self-harm and suicide measured with a modified version of the Self-Harm Inventory. Feedback compared with control did not affect the rate of attendance (0.59 vs. 0.58; p = .96), the severity of symptoms (2.03 vs. 2.02; p = .46), or any of the exploratory outcomes (p values from 0.06 to 0.67). Feedback neither increased attendance nor improved outcomes for outpatients in group psychotherapy for eating disorders. The results are discussed from different perspectives. (PsycINFO Database Record

Predictors of premature termination from psychotherapy for anorexia nervosa: Low treatment credibility, early therapy alliance, and self-transcendence

Predictors of premature termination from psychotherapy for anorexia nervosa: Low treatment credibility, early therapy alliance, and self-transcendence

Building Alliances with (In)Voluntary Clients: A Study Focused on Therapists' Observable Behaviors.

This study aimed to compare therapists' observable behaviors to promote alliances with involuntary and voluntary clients during brief family therapy. The therapists' contributions to fostering alliances were rated in sessions 1 and 4 using videotapes of 29 families who were observed in brief therapy. Using the System for Observing Family Therapy Alliances, trained raters searched for specific therapist behaviors that contributed to or detracted from the four alliance dimensions: engagement in the therapeutic process, an emotional connection with the therapist, safety within the therapeutic system, and a shared sense of purpose within the family. The results showed that when working with involuntary clients, therapists presented more behaviors to foster the clients' engagement and to promote a shared sense of purpose within the family. However, in the fourth session, the therapists in both groups contributed to the alliance in similar ways. The results are discussed in terms of (a) the therapists' alliance-building behaviors, (b) the specificities of each client group, and (c) the implications for clinical practice, training, and research.

Epidemiological features of invasive mold infections among solid organ transplant recipients: PATH Alliance® registry analysis.

Epidemiological characteristics of 333 proven and probable invasive mould infections (IMIs) among solid organ transplant recipients (SOTRs) identified between 2004 and 2008 from the Prospective Antifungal Therapy Alliance (PATH) registry are presented. Liver transplant recipients (LTRs) had the lowest median time to IMIs (109 days; interquartile range [IQR] 24-611 days), the highest rate of disseminated disease (n/N = 18/33; 55%), and highest mortality (n/N = 21/33; 64%). Lung transplant recipients had highest median time to IMIs (486 days; IQR 117-1358 days) and lowest mortality (n/N = 31/184; 17%). Complete or partial response at week 12 in patients with invasive aspergillosis (IA) was 67% (n/N = 189/281), and 41% (n/N = 9/22) in mucormycosis patients. In the composite outcome of death or no response to therapy, LTRs had the worst outcome. Higher suspicion of mold infection and institution of appropriate antifungal prophylactic strategies are warranted, especially in high risk LTRs.

Attachment, distancing, and the working alliance in drama therapy

Abstract This study investigates the interaction of attachment styles and drama therapy (DT) techniques at various levels of therapeutic distance during brief therapy. Five mothers with children diagnosed with psychiatric disorders participated in a DT support group. Mother attachment styles and their responses to DT techniques were assessed using the Relationships Scales Questionnaire (RSQ). Participants had insecure attachment styles and appeared to prefer an overdistanced approach. Therefore, attuning to client attachment styles may help drama therapists titrate distance and support the therapeutic process.

Agreement between clients with schizophrenia and mental health workers on clients' social quality of life: The role of social cognition and symptoms.

Studies have showed that therapists and mental health workers of persons with schizophrenia tend to estimate their patients' social quality of life (SQoL) as poorer than the clients' own estimation. This study explores the hypothesis that this discrepancy is related to clients' social cognition and symptomatology. Cross-sectional assessment of both clients and their mental health workers. Ninety persons with schizophrenia and 12 persons who were formal care providers participated in the study. All responded to a parallel version (client and clinician) of social quality-of-life scales. Clients' emotion identification, theory of mind and symptoms were also assessed. Low social cognitive abilities of persons with schizophrenia, as well as negative symptomatology and having children, may be related to the negative bias of mental health workers, with regard to their client's SQoL. While more severe levels of negative symptoms and more deficits of social cognition were related to reduced levels of agreement, paradoxically, a relatively normative family life that includes parenting was also related to lower levels of agreement. Attention should be given to low agreement between clients with schizophrenia and clinicians with regard to the client's quality of life, as it is central to alliance and outcome. Clinicians tend to estimate clients' social quality of life as poorer than the clients' own estimation when those clients have low social cognition, high negative symptomatology and children. There is a need to identify additional factors that contribute to agreement and alliance in therapy. Longitudinal assessment during therapy can trace the process of construction of agreement.

Therapeutic Alliance and Adherence in Family Therapy

Abstract: The purpose of this study was to test out the alliance and treatment adherence as explanatory factors that contribute to the effectiveness of family therapy. Seven family therapists and four clients participated voluntarily. A system for observing family therapy alliances (SOFTA-o) and self-reports (SOFTA-s) were used to measure therapeutic alliance. Therapeutic adherence was measured using a Family Therapy Adherence Scale and Goal Attainment Scale to measure outcome. Third and fifth therapy sessions were recorded and scales were applied at the end of these sessions. Findings indicated a low relationship between clients’ perception of the therapeutic alliance and therapeutic adherence, a strong relationship between therapeutic alliance, adherence and outcome was found. Clinical, training and research implications are discussed.Keywords: Therapeutic alliance, adherence, outcome, family therapy.

Alliance and adherence in a systemic therapy.

The client-therapist working alliance is a key contributor to effective adult psychotherapy. However, little is known about its role in family and systemic therapy. Moreover, few studies have assessed alliance longitudinally or have investigated how it interrelates with other process variables, such as therapist adherence (i.e. the extent to which the therapist adheres to the treatment protocol or manual). We hypothesised that alliance and adherence interrelate over the course of the therapy. This study investigated the bidirectional associations between alliance and therapist adherence using cross-lagged panel analyses for a sample of 1970 adolescents and their families participating in Multisystemic Therapy (MST). A number of client characteristics were included as moderators, namely demographic characteristics, type and severity of adolescent problem behaviour, and whether or not the MST treatment was court ordered. Alliance and adherence were scored by the primary caregiver through telephone interviews at monthly intervals during treatment. Alliance in 1month predicted therapist adherence in a subsequent month. Adherence only predicted subsequent alliance during the middle part of the treatment process. The results were not moderated by any of the client factors. The results suggest that alliance and therapist adherence may reinforce one another during therapy. Although alliance may facilitate the development of therapist adherence, adherence may subsequently deepen and consolidate the client-therapist alliance. These results are independent of client characteristics.

Non-music components to develop working alliance in psychiatric music therapy: a phenomenological investigation

Non-music components to develop working alliance in psychiatric music therapy: a phenomenological investigation

Therapeutic Alliance in Internet-Delivered Cognitive Behaviour Therapy for Depression or Generalized Anxiety.

This research demonstrated that therapeutic alliance ratings were very strong at both mid- and post-treatment among patients who received Internet-delivered cognitive behaviour therapy (ICBT) for depression or anxiety in clinical practice. Among patients receiving ICBT for depression, lower ratings of therapeutic alliance were associated with patients reporting concurrent treatment by a psychiatrist and with the receipt of fewer phone calls and emails from the therapist. Among patients receiving ICBT for generalized anxiety, ratings of alliance were higher when patients were treated by registered providers as compared to graduate students. Therapeutic alliance ratings did not predict outcome in ICBT for depression or anxiety. Practitioners have reason to be confident that a therapeutic relationship can be formed in ICBT when delivered in clinical practice.

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.

Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

BackgroundThis paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis. MethodsAll clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5months, 9months and 18months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy. ResultsAt baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point. ConclusionsFindings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.

Corrective relational experiences in psychodynamic-interpersonal psychotherapy: Antecedents, types, and consequences.

In posttherapy interviews with 31 clients who had recently terminated from individual open-ended psychodynamic-interpersonal psychotherapy, 18 reported having had at least 1 corrective relational experience (CRE) during psychotherapy, whereas 13 did not report any CREs. CREs typically occurred in the context of therapeutic relationships that were primarily positive but also had minor difficulties. Therapists typically facilitated CREs by identifying or questioning client behavior patterns and conveying trustworthiness. Corrective shifts for clients typically involved a new understanding of the therapy experience and variantly involved gaining a new understanding of behavior patterns. Consequences generally included improvements in the therapy relationship and intrapersonal well-being. Qualitatively, the 13 non-CRE clients more frequently reported wishing the therapist's theoretical orientation was a better match than did the 18 CRE clients. Quantitatively, the CRE clients rated themselves as having more interpersonal problems at intake on the Inventory of Interpersonal Problems-32 (Barkham, Hardy, & Startup, 1996), had marginally significant improvements in interpersonal functioning over time, rated their therapy alliances higher on the Working Alliance Inventory-Short Revised (Hatcher & Gillaspy, 2006) midtherapy, and rated their therapy alliances higher over time compared with the non-CRE clients. Implications for practice and research are discussed.

A conversation analytic study of building and repairing the alliance in family therapy

In this paper, we draw from the methods of conversation analysis to illustrate how different alliances that form the ‘web of relationships’ of family therapy are ruptured and subsequently repaired. By focusing on the interactional practices of a master therapist, Dr Salvador Minuchin, we examine how he effectively manages a disaffiliative episode that occurred at the very beginning of a therapy session. In particular, we show how Minuchin's practices function to re‐establish consensus and a positive alliance and to endorse the mother's parental authority (in a context where she claims to be helpless and lack agency). Minuchin thus uses a range of alliance building strategies to join with the family by sharing their distress and, at the same time, moves the conversation forward in a therapeutically‐driven direction to facilitate a restructuring of familial roles and relations.Practitioner points Find ways to disagree with clients’ position without generating stress or rupture in the alliance Verbal and nonverbal discursive moves to join with clients can create an inclusive context for the therapy Discursive strategies can endorse client authority and counter a self‐deprecating client stance

Working Together to Promote Diabetes Control: A Practical Guide for Diabetes Health Care Providers in Establishing a Working Alliance to Achieve Self-Management Support.

The quality of the “patient-carer” relationship is the foundation of self-management support and has been shown to influence treatment outcome in relation to psychological and somatic illness, including diabetes. It has long been accepted within applied psychology that the quality of the client-therapist relationship—termed the working alliance—is of central importance to treatment outcome and may account for a significant degree of the overall treatment effect. Diabetes healthcare providers have recently expressed a need for further training in communication techniques and in the psychological aspects of diabetes. Could we take a page from the psychological treatment manual on working alliance in therapy to guide the diabetes healthcare provider in their role of supporting the person with diabetes achieve and maintain better metabolic control? This paper examines the role of the working alliance in diabetes care and offers a practical guide to the diabetes healthcare provider in establishing a working alliance with the person with diabetes in managing diabetes.

How therapist self-disclosure relates to alliance and outcomes: A naturalistic study

This study examined therapists’ self-disclosure within early sessions of a naturalistic database of 52 therapy dyads collected at a university counseling center. Therapist orientations and client issues varied. We identified both types and functions of therapist self-disclosure in order to explore how self-disclosures related to therapy alliance and outcomes. Findings indicated that the number of disclosures was not significantly correlated with outcome or alliance scores. Central findings regarding the function of self-disclosures included that disclosures that acted to humanize the therapist were associated with fewer clinical symptoms post-session than disclosures expressing appreciation or encouragement. Also, disclosures that conveyed similarity between the therapist and client were associated with fewer post-session clinical symptoms and interpersonal problems when compared to disclosures that conveyed neither similarity nor dissimilarity. As well, neutral therapist self-disclosures were associated with better client functioning than disclosures that relayed negative or positive information about the therapist. Suggestions are provided for clinical practice and future research.

The relationships between therapeutic alliance and internalizing and externalizing symptoms in Trauma-Focused Cognitive Behavioral Therapy

Therapeutic alliance has been considered an important factor in child psychotherapy and is consistently associated with positive outcomes. Nevertheless, research on alliance in the context of child trauma therapy is very scarce. This study examined the relationships between child therapeutic alliance and psychopathology in an empirically supported child trauma therapy model designed to address issues related to trauma with children and their caregivers. Specifically, we examined the extent to which the child's psychopathology would predict the establishment of a positive alliance early in treatment, as well as the association between alliance and outcome. Participants were 95 children between the ages of 7 and 12 and their caregivers, who went through a community-based Trauma-Focused Cognitive Behavioral Therapy program in Canada. Caregivers filled out the CBCL prior to assessment and following treatment. Children and therapists completed an alliance measure (TASC) at three time points throughout treatment. Symptomatology and child gender emerged as important factors predicting alliance at the beginning of treatment. Girls and internalizing children developed stronger alliances early in treatment. In addition, a strong early alliance emerged as a significant predictor of improvement in internalizing symptoms at the end of treatment. Our findings indicate that symptomatology and gender influence the development of a strong alliance in trauma therapy. We suggest that clinicians should adjust therapeutic style to better engage boys and highly externalizing children in the early stages of therapy.

Therapeutic Alliance With Depressed Adolescents: Predictor or Outcome? Disentangling Temporal Confounds to Understand Early Improvement

Psychotherapy research reveals consistent associations between therapeutic alliance and treatment outcomes in the youth literature; however, past research frequently suffered measurement issues that obscured temporal relationships between alliance and symptomatology by measuring variables later in therapy, thereby precluding examination of important early changes. The current study aimed to explore the directions of effect between alliance and outcome early in therapy with adolescents by examining associations between first- and fourth-session therapeutic alliance and symptomatology. Thirty-four adolescents (∼63% female, 38% ethnic/racial minority) participated in a school-based cognitive-behavioral therapy for adolescents with depression. Participants completed the Beck Depression Inventory at baseline and Session 4, and therapeutic alliance was coded from audiotapes of Sessions 1 and 4 by objective coders using the Alliance Observation Coding System. Autoregressive path analyses determined that first-session therapeutic alliance was a strong significant predictor of Session 4 depression symptoms, but pretreatment depression scores were not significantly predictive of subsequent therapeutic alliance. Adding reciprocal effects between alliance and depression scores did not adversely affect model fit, suggesting that reciprocal effects may exist. Early therapeutic alliance with adolescents is critical to fostering early gains in depressive symptomatology. Knowing alliance's subsequent effect on youth outcomes, clinicians should increase effort to foster a strong relationship in early sessions and additional research should be conducted on the reciprocal effects of therapeutic alliance and treatment outcome in adolescence.

Using the Assessment for Signal Clients as a feedback tool for reducing treatment failure

Objective: The Clinical Support Tools (CSTs) were developed to help therapists organize and target potential problems that might account for negative outcomes in psychotherapy. The core of CST feedback is the Assessment for Signal Clients. The purpose of this study was to describe and identify patterns of problems that typically characterize off-track cases. Method: The responses and scores from 107 off-track clients from a hospital-based outpatient clinic were analyzed. Results: A cluster analysis of the 107 off-track clients revealed three client types: those whose problems were characterized by alliance and motivational difficulties; those characterized by social support and life event difficulties; and those whose problems had an indistinguishable pattern. Log-linear modeling showed that if patients had less therapeutic alliance problems they were also less likely to have motivational problems. Findings were also consistent with the cluster analysis, which showed that a relatively higher percentage of not-on-track participants received signal alerts for the social support items and scale. Conclusions: Individuals whose progress goes off-track while in psychotherapy appear to have their greatest difficulty with social support, followed closely by motivation for therapy and therapeutic alliance.

Client-therapist alliance discrepancies and outcome in cognitive-behavioral therapy for youth anxiety.

Studies exploring the association between alliance and outcome in youth cognitive-behavioral therapy (CBT) have yielded inconsistent results based upon whose perspective is measured. The current study explored the degree to which youth with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, anxiety disorders and their therapists agree in their ratings of the alliance at multiple assessment points and evaluated whether inter-rater discrepancies predicted treatment outcome. Youth (N = 62; Mage = 12.43, SD = .76) received empirically supported CBT. Paired samples t tests assessed for significant disagreement between youth- and therapist-rated alliance at sessions 4, 8, and 12. Regression analyses were conducted to evaluate whether discrepancies between raters at each time point predicted posttreatment anxiety symptom scores. Overall, alliance was positive for both child (aged 7-12 years) and adolescent (aged 13-16 years) clients. Discrepancies between youth and therapist ratings of alliance were statistically significant at session 4 for children and session 8 for adolescents, with youth rating the relationship more favorably than therapists. However, rating discrepancies did not predict youth- or parent-reported treatment outcome. Considerable variability may exist between youth and therapist perspectives on the therapeutic alliance, indicating potential attunement problems, particularly during earlier phases of treatment. However, these discrepancies did not negatively affect treatment response. Implications for alliance research and clinical practice are discussed.