Treatment Alliance Research Articles

Therapeutic alliance and outcome in routine psychiatric out-patient treatment: Patient factors and outcome

This study investigated the importance of the therapeutic alliance in a routine psychiatric out-patient unit regarding treatment outcome and the influence of patient factors. The study had a naturalistic and longitudinal design where the treatments the patient received were determined by the normal routines at the unit and were performed by a variety of staff representative of a psychiatric out-patient unit. Newly admitted patients were diagnosed according to the International Classification of Diseases-10th Revision and completed questionnaires regarding the therapeutic alliance, symptoms, and interpersonal problems at the beginning and termination of their treatment (N=76). The time limit for the termination assessments was set at 18 months. The therapeutic alliance at the beginning of treatment did not correlate with outcome, however, at the end of the treatment the alliance significantly explained about 15% of the variance of the outcome (global severity index). An improvement of the alliance during the treatment significantly correlated with most of the outcome variables. The relation of the alliance to outcome was equal among the different diagnosis groups and treatment forms. The results showed that the therapeutic alliance is an important variable for treatment outcome in routine psychiatric treatment, and improving the therapeutic alliance may be one of the most important factors for increasing the total effectiveness of a treatment unit.

The International LAM Registry: A Component of an Innovative Web-Based Clinician, Researcher, and Patient-Driven Rare Disease Research Platform

A relative inability to capture a sufficiently large patient population in any one geographic location has traditionally limited research into rare diseases. Clinicians interested in the rare disease lymphangioleiomyomatosis (LAM) have worked with the LAM Treatment Alliance, the MIT Media Lab, and Clozure Associates to cooperate in the design of a state-of-the-art data coordination platform that can be used for clinical trials and other research focused on the global LAM patient population. This platform is a component of a set of web-based resources, including a patient self-report data portal, aimed at accelerating research in rare diseases in a rigorous fashion. Collaboration between clinicians, researchers, advocacy groups, and patients can create essential community resource infrastructure to accelerate rare disease research. The International LAM Registry is an example of such an effort. 82.

A National Heart, Lung, and Blood Institute History and Perspective on Lymphangioleiomyomatosis

The rapidly evolving progress in lymphangioleiomyomatosis (LAM) research is an ongoing story of exemplary patient advocacy, collaboration between private organizations and government, outstanding scientists, and good timing. LAM is a rare, slowly progressive disease characterized by the proliferation of smooth muscle-like cells and cystic lesions that gradually destroy the lungs. LAM also produces lesions in the lymphatic tissues and is often accompanied by renal angiomyolipomas. It may occur sporadically or it may be associated with tuberous sclerosis complex (TSC). LAM affects mostly young and middle-aged women and rarely affects men. In the mid 1990s, when the National Heart, Lung, and Blood Institute (NHLBI) first began supporting research on LAM, it was a disease of unknown origin with no effective treatment other than lung transplantation. Patients had no support network and were often being managed with high doses of progesterone or oophorectomy to abrogate the effect of estrogen. Since that time, establishment of LAM patient advocacy and support groups, increased support for research in LAM by the NHLBI, launching and completion of a LAM patient registry, and development of a LAM tissue bank have combined to result in substantial research accomplishments and progress in both basic and clinical LAM research. The role played by NHLBI in LAM research illustrates some of the unique features of the NIH in the American biomedical research enterprise. NHLBI's intramural program supported the first studies on this rare orphan disease, and established essential infrastructure to facilitate research. Patient registries and tissue repositories were created and made available to the scientific community. Patient advocates ensured that these resources were used and shared. Funding opportunities enabled investigators to link tissues and clinical data, rapidly advancing the cellular and molecular biologic understanding of the disease. Support of these activities is now more broadly supported, and the scientific opportunities explored by an increasing number of investigators. NHLBI looks forward to development of more effective therapies, bringing industry and other partners into this exciting field of science and medicine (Fig. 1). FIG. 1. Essential partners in biomedical research. Patient Advocacy LAM patients and patient interest groups have been and continue to be the vital core of the LAM research enterprise. They have participated directly in the research effort, giving, their time, blood, and tissues. LAM patients and advocates have also formed strong support networks, raised funds, organized patient and scientific meetings, lobbied, educated, served as advisors, and provided financial support for investigators, especially those at early stages of their careers. This effort was sparked by the parent of a LAM patient, and a tireless advocate who worked vigorously in the mid 1990s to garner support for developing a LAM patient registry and tissue bank. A “Labor of Love” campaign was launched that engaged patients, women's organizations, churches, schools, educators, and doctors in efforts to boost recognition and support for a registry. The timing was good for this type of patient involvement, as the scientific community was ripe for such a partnership following a decade of AIDS advocacy. The research establishment had come to appreciate patients working closely with investigators, having an active voice in the management of their disease, and lobbying vigorously for research and treatment. The LAM Treatment Alliance was created in 2005 and is accelerating LAM research by many means, including fund raising, creating a seminar series for investigators, sponsoring scientific meetings, awarding grants, and raising public awareness. (LAM Treatment Alliance website http://lamtreatmentalliance.org/index.html). The Alliance has been instrumental in aiding in the continued collection of tissue and distribution of materials.

P03-02 - Therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive-compulsive disorder

ObjectivesThe purpose of the current study was to investigate the influence of therapeutic alliance (TA) as a treatment process variable on outcome in cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD). Although CBT for pediatric OCD disorder is considered a first-line treatment, not all youth have positive treatment responses, suggesting the need for investigating factors that enhance or reduce treatment effects.MethodsTwenty-five youth aged 7-17 years (M = 13.16, SD = 2.69) with a principal diagnosis of OCD and parents participated in the study. Using a multiple-informant, multiple-time point design, the current study examined the role of TA in family-based CBT for pediatric OCD.ResultsFindings indicated(1)stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome,(2)larger, more positive early alliance shifts (rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome.ConclusionsTA was a predictor of subsequent change in OCD symptoms in youth treated with CBT. These findings correspond with alliance-outcome research among youth treated with evidence based therapies for behavior disorders.

Understanding factors associated with early therapeutic alliance in PTSD treatment: Adherence, childhood sexual abuse history, and social support.

Therapeutic alliance has been associated with better treatment engagement, better adherence, and less dropout across various treatments and disorders. In treatment of posttraumatic stress disorder (PTSD), it may be particularly important to establish a strong early alliance to facilitate treatment adherence. However, factors such as childhood sexual abuse (CSA) history and poor social support may impede the development of early alliance in those receiving PTSD treatment. We sought to examine treatment adherence, CSA history, and social support as factors associated with early alliance in individuals with chronic PTSD who were receiving either prolonged exposure therapy (PE) or sertraline. At pretreatment, participants (76.6% female; 64.9% Caucasian; mean age = 37.1 years, SD = 11.3) completed measures of trauma history, general support (Inventory of Socially Supportive Behaviors), and trauma-related social support (Social Reactions Questionnaire). Over the course of 10 weeks of PE or sertraline, they completed early therapeutic alliance (Working Alliance Inventory) and treatment adherence measures. Early alliance was associated with PE adherence (r = .32, p < .05) and overall treatment completion (r = .19, p < .05). Only trauma-related social support predicted the strength of early alliance beyond the effects of treatment condition (β = .23, p < .05); CSA history was not predictive of a lower early alliance. Given the associations with adherence, clinicians may find it useful to routinely assess alliance early in treatment. Positive trauma support, not CSA history, may be particularly important in the development of a strong early therapeutic alliance.

Traitement d’un premier épisode maniaque

When the first episode of mania is not directly related to a somatic or toxic disease it indicates bipolar disorder. These former possibilities must always be excluded from a laboratory and morphological assessment. They are clinically difficult to identify mostly because the clinical presentation is usually atypical. Whilst they may occur at any age they mostly involve young people, and drug use is common. Psychotic presentations are particularly common as are some symptoms such as irritability. Treatment of the acute phase is no different from that of other manic episodes although the challenges are very different as whilst there is often a risk of functional deterioration after an initial episode this risk increases considerably with repeated episodes. It is therefore essential to establish a quality treatment alliance as soon as possible which will facilitate the introduction, acceptance and adherence to preventative treatment and adherence to the different lifestyle recommendations. Clinical studies are needed in order to provide more information about the most suitable preventative treatment in this population.

Patients' beliefs about the causes of systemic lupus erythematosus

Beliefs about the causes of SLE have rarely been investigated. The purpose of this study was to explore these beliefs. Face-to-face interviews were carried out with a total of 33 women with SLE, fulfilling the ACR criteria, with a median age of 40 (range 15-65) years. Data were analysed using interpretative phenomenological analysis. Women attributed SLE to many causes, some of them being not congruent with biomedical models. The most frequent beliefs about the causes of SLE related to autoimmunity, psychological and familial causes, heredity, magico-religious causes (especially in first- and second-generation migrants) and infectious causes. Autoimmunity was often seen as a self-destructive process. Being diagnosed with SLE prompted 'Why me?' and 'Why now?' questioning among these women, who attempted to reconstruct coherence in their life histories. For clinicians, analysis of the beliefs about the causes clarifies what is at stake for the patient. The objective is to allow patients to produce narrative to describe their chronic illness experience in order to facilitate a long-term treatment alliance. Further studies are required to understand relationships between beliefs about causes, psychological distress and SLE morbidity.

Working Alliance Inventory‐Short Revised (WAI‐SR): psychometric properties in outpatients and inpatients

The Working Alliance Inventory-Short Revised (WAI-SR) is a recently refined measure of the therapeutic alliance that assesses three key aspects of the therapeutic alliance: (a) agreement on the tasks of therapy, (b) agreement on the goals of therapy and (c) development of an affective bond. The WAI-SR demonstrated good psychometric properties in an initial validation in psychotherapy outpatients in the USA. The generalizability of these findings is limited because in some countries a substantial portion of individual psychotherapy is delivered in inpatient settings. This study investigated and compared the psychometric properties of the WAI-SR in German outpatients (N = 88) and inpatients (N = 243). In both samples reliability (alpha > 0.80) and convergent validity with the Helping Alliance Questionnaire were good (r > 0.64). Confirmatory factor analysis showed acceptable to good model fit for the proposed Bond-Task-Goal model in both samples. Multi-group analysis demonstrated that the same constructs were measured across settings. Alliance ratings of outpatients and inpatients differed regarding the overlap of alliance components and the magnitude of the alliance ratings: The differentiation of the alliance components was poorer in inpatients and they reported lower alliances. Unique aspects of the alliance in inpatient treatment are discussed and a need for further research on the alliance in inpatient settings is pointed out. Overall, the WAI-SR can be recommended for alliance assessment in both settings.

Disproportionate Use of Psychiatric Emergency Services by African Americans

Disproportionate Use of Psychiatric Emergency Services by African Americans

The Supporting Alliance in Child and Adolescent Treatment: Enhancing Collaboration Among Therapists, Parents, and Teachers

Research indicates that the therapeutic alliance between therapist and pediatric patient is most effective in the context of a productive supporting alliance--an alliance encompassing the network of relationships among therapists, parents and teachers. In this essay, we develop a model of the supporting alliance, arguing that the child's primary relationships with various parties (therapists, teachers, and parents) imply a set of secondary relationships among those parties (parent-therapist, therapist-teacher, parent-teacher). We review the literature on these secondary relationships, focusing on their nature and discussing the benefits of and obstacles to establishing productive collaborations in each case. We also describe three sorts of pathology that can afflict the supporting alliance as a whole, and discuss the importance of patient autonomy and therapist-patient confidentiality relative to the supporting alliance. Finally, we identify directions for future research and highlight implications for practice.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

“I am not Complaining”—Ambivalence Construct in Schizoid Personality Disorder

Patients with schizoid personality disorders (SPD) often challenge clinicians because of their seemingly detached and restricted affective behaviour, which may be interpreted as lack of motivation for treatment and lifestyle changes. However, Bleuler indicated the intrapsychic dynamics of ambivalence in schizoid disorder, and it has been discussed in later literature on psychopathology. Schizoid ambivalence refers to contrasting feelings in patients of a seemingly emotionally detached appearance that may curtain an inner, heightened sensitivity and longing for closeness. This article introduces different diagnostic and theoretical descriptions of the ambivalence construct in the schizoid personality disorder. The discussion is elaborated by means of a case example, presenting both the patient's and professionals' points of view on the treatment process. We use the concepts of treatment alliance and countertransference as explanatory models in the discussion of how the schizoid ambivalence may affect the treatment relationship.

Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting.

Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers. A research paradigm called patient-focused research--a method of enhancing outcome via continuous progress feedback--holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy. The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy. Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback. Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived.

Sexual Side Effects of Antidepressant Medications: An Informed Consent Accountability Gap

Sexual side effects of antidepressant medications are far more common than initially reported, and their scope, quality, and duration remain poorly captured in the literature. Antidepressant treatment emergent sexual dysfunctions may decrease clients’ quality of life, complicate psychotherapy, and damage the treatment alliance. Potential damage to the treatment alliance is greatest when clients have not been adequately informed of risks related to sexual side effects. It had previously been assumed that sexual side effects always resolve shortly after medications are discontinued. Emerging evidence, however, suggests that in some individuals, sexual dysfunction side effects may persist indefinitely. The authors argue that all psychologists should be well-informed about sexual side effects risks of antidepressant medications, should routinely conduct a pre-medication baseline assessment of sexual functioning, and take an active role in the informed consent process.

The Physician as Patient: A Clinical Handbook for Mental Health Professionalsby Michael F. Myers, M.D., and Glen O. Gabbard, M.D. Arlington, Va, American Psychiatric Publishing, 2008, 252 pp., $46.00.

The Physician as Patient: A Clinical Handbook for Mental Health Professionalsby Michael F. Myers, M.D., and Glen O. Gabbard, M.D. Arlington, Va, American Psychiatric Publishing, 2008, 252 pp., $46.00.

Stem Cells and Cell Therapies in Lung Biology and Lung Diseases

The University of Vermont College of Medicine and the Vermont Lung Center, with support of the National Heart, Lung, and Blood Institute (NHLBI), the Alpha-1 Foundation, the American Thoracic Society, the Emory Center for Respiratory Health,the Lymphangioleiomyomatosis (LAM) Treatment Alliance,and the Pulmonary Fibrosis Foundation, convened a workshop,‘‘Stem Cells and Cell Therapies in Lung Biology and Lung Diseases,’’ held July 26-29, 2009 at the University of Vermont,to review the current understanding of the role of stem and progenitor cells in lung repair after injury and to review the current status of cell therapy approaches for lung diseases. These are rapidly expanding areas of study that provide further insight into and challenge traditional views of the mechanisms of lung repair after injury and pathogenesis of several lung diseases. The goals of the conference were to summarize the current state of the field, discuss and debate current controversies, and identify future research directions and opportunities for both basic and translational research in cell-based therapies for lung diseases.

Health Beliefs About Depression Among African American Women

A qualitative descriptive research study was conducted to explore the health beliefs of African American women and depression to improve insight regarding treatment decisions. Focus group interviews were performed with purposeful sampling of 14 self-identified African American women. Responses and comments were sorted into five major content areas that represent the core constructs of the Health Belief Model. Practitioners must seek to understand clients' understanding and explanations of depression to gain insight about ways to build an effective treatment alliance with clients and other practitioners.

Metaphors of a Shifting Sense of Self in Men Recovering from Substance Abuse and Suicidal Behavior

The purpose of this descriptive study was to explore and interpret men's experience of sense of self within the context of recovery from substance abuse and suicidal behavior. A secondary analysis of data from a previous study of four young Norwegian men revealed how a shifting sense of self was constructed through the use of metaphors. The analysis identified three themes related to the participants' sense of self: The Meaning of Being Isolated, The Meaning of Being Close to the Point of No Return, and The Meaning of Still Being on the Edge. By acknowledging metaphorical expressions as a source of important knowledge, this study reflects on how mental health professionals can use metaphors in the recovery process. As part of the' treatment alliance and therapeutic communication, we suggest that metaphors may aid the assessment of suicidal ideation, promote a sense of a more active self, and signal acceptance and recognition of subjectivity.

Quality and Use of Trauma Histories Obtained From Psychiatric Outpatients: A Ten-Year Follow-Up

In 1996 Eilenberg and colleagues reviewed 180 charts and reported that trauma histories were poorly documented at a general psychiatric clinic. This study is a ten-year replication of that work. A total of 107 randomly selected charts from the same clinic were reviewed for assessment of trauma history. The quality of the assessments was rated. Fifty-six percent of charts contained a thorough description of trauma severity, compared with 15% in the initial study. Documentation of posttraumatic symptoms improved significantly in all categories but remained low. Documentation of diagnostic formulations and treatment plans for patients with a trauma history was thorough in a small proportion of charts (14%), as was found in the initial study (9%). Although some improvements were found in recording trauma histories, eliciting such a history did not lead to thorough documentation of posttraumatic symptoms or to inclusion of the history in the diagnostic formulation or treatment plan.