Working Alliance Inventory-Short Revised Research Articles

Enhancing Psychotherapy Outcomes by Encouraging Patients to Regularly Self-Monitor, Reflect on, and Share Their Affective Responses Toward Their Therapist: Protocol for a Randomized Controlled Trial.

The quality of the therapeutic relationship is pivotal in determining psychotherapy outcomes. However, facilitating patients' self-awareness, reflection on, and sharing of their affective responses toward their therapist remains underexplored as a potential tool for enhancing this relationship and subsequent treatment outcomes. The primary objective of this study is to examine whether and how the patients' regular self-monitoring and self-reflection (fostered by the systematic compilation of a brief postsession battery) on their affective reactions toward the psychotherapist impact the quality of the therapeutic relationship and treatment outcomes in individual psychotherapy. Secondary objectives are to (1) explore whether and how the characteristics of the patient, the therapist, and the process moderate the effect of regular self-monitoring on the therapeutic relationship and outcomes; (2) examine the relationships between the affective response of the patient, the alliance, and the result of the therapy session outcome; and (3) explore how the affective responses of the patient unfold or change throughout the course of the therapy. We conducted a 1:1 randomized controlled trial of adults in individual psychotherapy versus individual psychotherapy plus self-monitoring. Participants will be enrolled through the web-based recruitment platforms "ResearchMatch" and "Research for Me," and data will be collected through web-based surveys. Participants in the control group will receive only their regular individual psychotherapy (treatment as usual) and will not complete postsession questionnaires. Participants in the intervention group will continue their regular individual psychotherapy sessions and complete the "in-Session Patient Affective Reactions Questionnaire" and the "Rift In-Session Questionnaire" following each therapy session in the 10 weeks of the trial. Additionally, after completion of the postsession battery, they will receive general written feedback encouraging them to discuss their feelings and reflections with their therapist. Participants in both groups will complete a comprehensive psychological assessment at baseline, midtrial (week 5), and end-of-trial (week 10). The primary outcome measure of the trial is the "Clinical Outcomes in Routine Evaluation-Outcome Measure," while the secondary outcomes are the "Real Relationship Inventory-Client-Short Form," the "Working Alliance Inventory-Short Revised," and the number of scheduled therapy sessions that the patient has missed or canceled. The trial was approved by the institutional review board of the University of North Carolina at Chapel Hill. Recruitment started in September 2023. A total of 475 individuals completed the baseline assessment. Data collection was completed in February 2024. The results are expected to be published in the autumn of 2024. This study could reveal key information on how regular self-monitoring and introspection can influence both the therapeutic relationship and treatment outcomes. Findings have the potential to shape interventions, enhance the efficacy of psychotherapeutic sessions, and possibly offer a cost-effective strategy for improving patients' well-being. ClinicalTrials.gov NCT06038747; https://classic.clinicaltrials.gov/ct2/show/NCT06038747. DERR1-10.2196/55369.

Therapeutic Alliance and Group Cohesion Across Telehealth Delivery of Mentalizing-focused Parenting Groups

ABSTRACT This study assessed changes in therapeutic alliance and group cohesion among parents/primary caregivers enrolled in Connecting and Reflecting Experience (CARE), a short-term, group-based, mentalizing-focused parenting program designed to support a diverse community facing socioeconomic and health disparities. Caregivers (N = 44) experiencing parenting stress or parent-child relational challenges were recruited from their children’s outpatient psychiatry clinic to participate in one of nine 12-session telehealth CARE groups. Caregivers completed the Working Alliance Inventory-Short Revised and the Therapeutic Factors Inventory Cohesiveness subscale after CARE Sessions 1 and 12. Ratings of group cohesion and therapeutic bond with facilitators increased significantly across treatment. Findings indicate that caregivers from underserved families with high levels of parenting stress experienced an increase in group cohesion and therapeutic alliance throughout a telehealth adaptation of CARE.

Translation of the working alliance inventory short revised into Italian using a Delphi procedure and a forward-backward translation.

Enhancing treatment adherence, especially for chronic diseases, can be achieved through therapeutic alliance, potentially elevating the quality of care. An instrument to evaluate the therapeutic alliance could be beneficial in routine clinical settings, educational environments, and extensive research efforts at national and European levels. In this study, we translated therapist and patient versions of the Working Alliance Inventory Short Revised (WAI-SR) into Italian. An email-based Delphi method was employed for the English-to-Italian translation, incorporating a forward-backward process. The initial translation team comprised two Italian family physicians proficient in English, a linguist, and a psychiatrist. The forward translation was then reviewed by 18 Italian family physicians through a Delphi process and was subjected to a backward translation by two Italian English teachers. A cultural correspondence was subsequently identified to adjust translations within a national and international framework. All 18 experts fully engaged in the Delphi process, and consensus was achieved by the second Delphi round. A cultural check checked for discrepancies regarding linguistic consistency with other translations and found no difference. This Italian translation of the WAI-SR is expected to support Italian family physicians aiming to enhance their clinical practice and therapeutic outcomes. It could also be a valuable tool for Italian medical students to foster therapeutic relationships and improve their communication skills.

Patient Expectations and Therapeutic Alliance Affect Pain Reduction Following Lidocaine Infusion in an Interdisciplinary Chronic Pain Clinic

Pain experience is affected by both ascending nociceptive signals and descending modulation. Expectations can affect pain experience and augment treatment-induced analgesia through descending inhibitory modulation of pain. This open-label, prospective cohort study examined the association between participant expectation ratings and pain reduction in adult participants with chronic pain receiving an intravenous lidocaine infusion. We aimed to explore whether: 1) participants’ expectations of treatment efficacy were associated with pain reduction over 8 weeks after infusion; and 2) participants’ therapeutic alliance was associated with expectations and/or pain reduction. We recruited 70 participants with chronic pain scheduled for lidocaine infusion. Study measures included pain intensity (pre-treatment, post-treatment, and daily for 8 weeks), treatment expectations (EXPECT), and therapeutic alliance (Trust in Physician and Working Alliance Inventory-Short Revised). Baseline treatment expectations were significantly correlated with pain reduction (r = .42, P < .01). Therapeutic alliance was significantly correlated with expectations (r = .27, P < .05) and pain reduction (r = .38, P < .01). This study quantifies the contribution of: 1) treatment expectations; and 2) therapeutic alliance to the magnitude of lidocaine-induced pain reduction. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes. PerspectiveThis study evaluates the relationship between pain reduction and ratings of: 1) treatment expectations; and 2) therapeutic alliance following an intravenous lidocaine infusion. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes.

The development of a Brief Working Alliance Inventory for clients and therapists using multilevel factor analysis and item response theory in the United States and China.

This study aimed to investigate the multilevel factor structure of the therapist and client versions of the 12-item Working Alliance Inventory-Short Revised (WAI; Hatcher & Gillaspy, 2006) in the United States and China, and to create a three-item brief version (WAI-B3) using multilevel factor analysis (M-FA) and multilevel item response theory (M-IRT). We gathered eight data sets from two samples each in United States and China with a total of 21,623 sessions from 376 therapists and 2,455 clients. M-FA results with the first four data sets (two American and two Chinese) suggested that the 12-item WAI across therapist and client versions, and in both United States and China showed a dominant general WA factor with three specific subgroup factors corresponding to the Goal, Task, and Bond items. We then constructed a three-item WAI-B3 by selecting items 11, 10, and 9 through M-IRT, as the best representative of Goal, Task, and Bond subscales, respectively, for both the therapist and client versions in United States and China. With the other four data sets (two American, two Chinese) to test the WAI-B3, we found adequate multilevel reliability, structural validity, and convergent validity with the original 12-item WAI scores. Multilevel measurement invariance tests provided tentative and mixed support for the equivalence of WAI-B3 between the American and Chinese data sets and between therapist and client versions. We recommend that the WAI-B3 be used in routine clinical practice to track therapy process, and that the WAI-B3 be tested with other client and therapist populations and cultures. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient-physician alliance and patient’s sense of self-efficacy are negatively associated with resistance to treatment among patients with type 2 diabetes

AimsResistance to treatment is prevalent among patients diagnosed with chronic conditions, including type 2 diabetes (T2DM). The current study aimed to examine the relationship between patient characteristics, patient-physician relationship, and resistance to treatment in T2DM. MethodsA sample of 120 T2DM patients were recruited by means of non-randomized sampling and through a public post on Facebook. Participants were asked to fill-in several questionnaires online: Rotter’s Locus of Control questionnaire (short version); the General Self-efficacy (GSE) questionnaire; the Working Alliance Inventory - Short Revised (WAI-SR) - evaluating patient-physician relationship; and, finally, the Resistance to Treatment Questionnaire (RTQ) - which meant to capture the intensity of resistance to treatment and served as the dependent variable in this study. ResultsInterestingly, better patient-physician relationship and higher sense of self-efficacy among patients were found to negatively associate with patient’s resistance to treatment (r = −.53, p < .001, and, r = −.26, p < .01, respectively). Patient-physician relationship explained 22% of the variance of resistance to treatment, and self-efficacy explained 6% of the variance. ConclusionsStronger patient-doctor relationship and higher sense of self-efficacy are shown to robustly associate with lower resistance to treatment among patients with T2DM. Current findings may instructor educate physicians as to the importance of the alliance with these chronic patients.

The within-client alliance-outcome relationship: A response surface analysis.

The authors examined how stability/change in working alliance predicted subsequent symptoms, and how stability/change in symptoms predicted subsequent alliance in a sample of 188 adult clients with 44 doctoral student therapists over the course of 893 eight-session time periods of individual psychodynamic psychotherapy. Clients completed the Working Alliance Inventory-Short Revised (WAI-SR; Hatcher & Gillaspy, 2006) after every session and the Outcome Questionnaire-45 (OQ; Lambert et al., 1996) before intake and every eighth session. The authors used multilevel polynomial regression and response surface analyses to examine within-client effects. The authors found that change in the alliance across an eight-session period did not have an immediate temporal effect on symptoms, but when alliance was stable and stronger compared to other periods, subsequent symptoms were lower. Similarly, change in symptoms across an eight-session period did not have an immediate temporal effect on alliance, but when symptoms were stable and lower compared to other periods, subsequent alliance was stronger. These results suggest that sustained improvements in the alliance contribute to subsequent symptom improvements, and vice versa. The authors conclude that it is important to work to improve and maintain improvements in the working alliance and symptoms. Limitations and future directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"The 'roller coaster ride': A longitudinal investigation of the dynamic relationship between Chinese counseling trainees' self-efficacy and their clients' outcome and the mediating effects of working alliance and session evaluation": Correction to Li et al. (2021).

Reports an error in "The "roller coaster ride": A longitudinal investigation of the dynamic relationship between Chinese counseling trainees' self-efficacy and their clients' outcome and the mediating effects of working alliance and session evaluation" by Xu Li, Feihan Li, Chaihua Lin, Shitao Chen and Yuge Han (Journal of Counseling Psychology, Advanced Online Publication, Nov 29, 2021, np). In the article, the scale for the Working Alliance Inventory-Short Revised (WAI-SR) was incorrectly described in the Measures section as a "5-point scale that ranges from 1 to 5." The WAI-SR used the original 7-point scale ranging from 1 to 7. All versions of this article have been corrected. (The following abstract of the original article appeared in record 2022-06516-001.) Based on the social-cognitive theory, this study investigated the dynamic association between counseling trainees' self-efficacy and their clients' outcome (i.e., symptom distress), and the mediating effects of therapist- and client-rated working alliance and session quality. Data set included 1,352 sessions conducted by 87 master's level therapist trainees with their 317 clients in China. Before every session, therapists completed a measure of self-efficacy and clients reported their symptom distress; and after every session, both therapists and clients rated their working alliance and session quality. Results showed that, (a) over the course of therapy, the initial level of therapist self-efficacy did not predict how quickly client symptom declined; (b) the initial level of client distress did not predict how quickly therapist self-efficacy increased; and (c) client distress decline was not related to therapist self-efficacy increase over the course of therapy. However, at the session-to-session level, higher therapist self-efficacy before one session significantly predicted lower client distress before the next session, and higher client distress before one session significantly predicted lower therapist self-efficacy before the subsequent session. Therapist and client perceptions of working alliance were both significant mediators, while their session quality ratings were not. Findings supported the dynamic and reciprocal relationship between therapist self-efficacy and client distress at the immediate session-to-session level rather than the overall trajectory level, and revealed its specific mediating mechanism through the relationship building between therapist and client. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The "dyadic dance": Exploring therapist-client dynamics and client symptom change using actor-partner interdependence modeling and multilevel mixture modeling.

[Correction Notice: An Erratum for this article was reported in Vol 69(4) of Journal of Counseling Psychology (see record 2022-76740-001). In the article, the scale for the Working Alliance Inventory-Short Revised (WAI-SR) was incorrectly described in the Measures section as a "5-point scale ranging from 1 to 5." The WAI-SR used the original 7-point scale ranging from 1 to 7. All versions of this article have been corrected.] Using longitudinal actor-partner interdependence modeling and multilevel mixture modeling, the aims of this study were to investigate the therapist-client dyadic dynamic patterns (i.e., therapist and client consistency and their mutual influences in perceptions of working alliance) and how these dynamic patterns related to client symptom change with varied treatment lengths. Data set included 1,520 sessions conducted by 85 master's level therapist trainees with their 283 clients in China. Before every session, clients reported their symptom; after every session, both therapists and clients rated their working alliance. (a) Therapist consistency was positively associated with greater client symptom improvement, especially in relatively longer therapy course. (b) Client consistency and therapist-client mutual influence dynamics did not individually relate to client symptom improvement. (c) Two subgroups of therapist-client dyads with distinct dyadic dynamic patterns were identified: one subgroup (Dyadic Independence) showing significant self-consistency and nonsignificant mutual influence and the other subgroup (Mutual Influence) showing significant self-consistency as well as mutual influence. (d) The mutual influence subgroup was associated with greater client improvement than the dyadic independence subgroup, especially in shorter therapy. A dyadic dynamic pattern characterized by the presence of therapist and client self-consistency as well as mutual influence may be conducive to positive therapeutic outcome in terms of client symptom improvement. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The "roller coaster ride": A longitudinal investigation of the dynamic relationship between Chinese counseling trainees' self-efficacy and their clients' outcome and the mediating effects of working alliance and session evaluation.

[Correction Notice: An Erratum for this article was reported in Vol 69(4) of Journal of Counseling Psychology (see record 2022-76740-002). In the article, the scale for the Working Alliance Inventory-Short Revised (WAI-SR) was incorrectly described in the Measures section as a "5-point scale that ranges from 1 to 5." The WAI-SR used the original 7-point scale ranging from 1 to 7. All versions of this article have been corrected.] Based on the social-cognitive theory, this study investigated the dynamic association between counseling trainees' self-efficacy and their clients' outcome (i.e., symptom distress), and the mediating effects of therapist- and client-rated working alliance and session quality. Data set included 1,352 sessions conducted by 87 master's level therapist trainees with their 317 clients in China. Before every session, therapists completed a measure of self-efficacy and clients reported their symptom distress; and after every session, both therapists and clients rated their working alliance and session quality. Results showed that, (a) over the course of therapy, the initial level of therapist self-efficacy did not predict how quickly client symptom declined; (b) the initial level of client distress did not predict how quickly therapist self-efficacy increased; and (c) client distress decline was not related to therapist self-efficacy increase over the course of therapy. However, at the session-to-session level, higher therapist self-efficacy before one session significantly predicted lower client distress before the next session, and higher client distress before one session significantly predicted lower therapist self-efficacy before the subsequent session. Therapist and client perceptions of working alliance were both significant mediators, while their session quality ratings were not. Findings supported the dynamic and reciprocal relationship between therapist self-efficacy and client distress at the immediate session-to-session level rather than the overall trajectory level, and revealed its specific mediating mechanism through the relationship building between therapist and client. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"The 'dyadic dance': Exploring therapist-client dynamics and client symptom change using actor-partner interdependence modeling and multilevel mixture modeling": Correction to Li (2021).

Reports an error in "The "dyadic dance": Exploring therapist-client dynamics and client symptom change using actor-partner interdependence modeling and multilevel mixture modeling" by Xu Li (Journal of Counseling Psychology, Advanced Online Publication, Dec 02, 2021, np). In the article, the scale for the Working Alliance Inventory-Short Revised (WAI-SR) was incorrectly described in the Measures section as a "5-point scale ranging from 1 to 5." The WAI-SR used the original 7-point scale ranging from 1 to 7. All versions of this article have been corrected. (The following abstract of the original article appeared in record 2022-06134-001.) Using longitudinal actor-partner interdependence modeling and multilevel mixture modeling, the aims of this study were to investigate the therapist-client dyadic dynamic patterns (i.e., therapist and client consistency and their mutual influences in perceptions of working alliance) and how these dynamic patterns related to client symptom change with varied treatment lengths. Data set included 1,520 sessions conducted by 85 master's level therapist trainees with their 283 clients in China. Before every session, clients reported their symptom; after every session, both therapists and clients rated their working alliance. (a) Therapist consistency was positively associated with greater client symptom improvement, especially in relatively longer therapy course. (b) Client consistency and therapist-client mutual influence dynamics did not individually relate to client symptom improvement. (c) Two subgroups of therapist-client dyads with distinct dyadic dynamic patterns were identified: one subgroup (Dyadic Independence) showing significant self-consistency and nonsignificant mutual influence and the other subgroup (Mutual Influence) showing significant self-consistency as well as mutual influence. (d) The mutual influence subgroup was associated with greater client improvement than the dyadic independence subgroup, especially in shorter therapy. A dyadic dynamic pattern characterized by the presence of therapist and client self-consistency as well as mutual influence may be conducive to positive therapeutic outcome in terms of client symptom improvement. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Using AI chatbots to provide self-help depression interventions for university students: A randomized trial of effectiveness

BackgroundDepression impacts the lives of a large number of university students. Mobile-based therapy chatbots are increasingly being used to help young adults who suffer from depression. However, previous trials have short follow-up periods. Evidence of effectiveness in pragmatic conditions are still in lack. ObjectiveThis study aimed to compare chatbot therapy to bibliotherapy, which is a widely accepted and proven-useful self-help psychological intervention. The main objective of this study is to add to the evidence of effectiveness for chatbot therapy as a convenient, affordable, interactive self-help intervention for depression. MethodsAn unblinded randomized controlled trial with 83 university students was conducted. The participants were randomly assigned to either a chatbot test group (n = 41) to receive a newly developed chatbot-delivered intervention, or a bibliotherapy control group (n = 42) to receive a minimal level of bibliotherapy. A set of questionnaires was implemented as measurements of clinical variables at baseline and every 4 weeks for a period of 16 weeks, which included the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder scale (GAD-7), the Positive and Negative Affect Scale (PANAS). The Client Satisfaction Questionnaire-8 (CSQ-8) and the Working Alliance Inventory-Short Revised (WAI-SR) were used to measure satisfaction and therapeutic alliance after the intervention. Participants' self-reported adherence and feedback on the therapy chatbot were also collected. ResultsParticipants were all university students (undergraduate students (n = 31), postgraduate students (n = 52)). They were between 19 and 28 years old (mean = 23.08, standard deviation (SD) = 1.76) and 55.42% (46/83) female. 24.07% (20/83) participants were lost to follow-up. No significant group difference was found at baseline. In the intention-to-treat analysis, individuals in the chatbot test group showed a significant reduction in the PHQ-9 scores (F = 22.89; P < 0.01) and the GAD-7 scores (F = 5.37; P = 0.02). Follow-up analysis of completers suggested that the reduction of anxiety was significant only in the first 4 weeks. The WAI-SR scores in the chatbot group were higher compared to the bibliotherapy group (t = 7.29; P < 0.01). User feedback showed that process factors were more influential than the content factors. ConclusionsThe chatbot-delivered self-help depression intervention was proven to be superior to the minimal level of bibliotherapy in terms of reduction on depression, anxiety, and therapeutic alliance achieved with participants.

Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study.

BackgroundThere are far more patients in mental distress than there is time available for mental health professionals to support them. Although digital tools may help mitigate this issue, critics have suggested that technological solutions that lack human empathy will prevent a bond or therapeutic alliance from being formed, thereby narrowing these solutions’ efficacy.ObjectiveWe aimed to investigate whether users of a cognitive behavioral therapy (CBT)–based conversational agent would report therapeutic bond levels that are similar to those in literature about other CBT modalities, including face-to-face therapy, group CBT, and other digital interventions that do not use a conversational agent.MethodsA cross-sectional, retrospective study design was used to analyze aggregate, deidentified data from adult users who self-referred to a CBT-based, fully automated conversational agent (Woebot) between November 2019 and August 2020. Working alliance was measured with the Working Alliance Inventory-Short Revised (WAI-SR), and depression symptom status was assessed by using the 2-item Patient Health Questionnaire (PHQ-2). All measures were administered by the conversational agent in the mobile app. WAI-SR scores were compared to those in scientific literature abstracted from recent reviews.ResultsData from 36,070 Woebot users were included in the analysis. Participants ranged in age from 18 to 78 years, and 57.48% (20,734/36,070) of participants reported that they were female. The mean PHQ-2 score was 3.03 (SD 1.79), and 54.67% (19,719/36,070) of users scored over the cutoff score of 3 for depression screening. Within 5 days of initial app use, the mean WAI-SR score was 3.36 (SD 0.8) and the mean bond subscale score was 3.8 (SD 1.0), which was comparable to those in recent studies from the literature on traditional, outpatient, individual CBT and group CBT (mean bond subscale scores of 4 and 3.8, respectively). PHQ-2 scores at baseline weakly correlated with bond scores (r=−0.04; P<.001); however, users with depression and those without depression had high bond scores of 3.45.ConclusionsAlthough bonds are often presumed to be the exclusive domain of human therapeutic relationships, our findings challenge the notion that digital therapeutics are incapable of establishing a therapeutic bond with users. Future research might investigate the role of bonds as mediators of clinical outcomes, since boosting the engagement and efficacy of digital therapeutics could have major public health benefits.

Micro-Psychology in Public Health Promotion

Introduction: NT is an evidence-based complementary therapy, which applies nutrition and lifestyle science to underlying pathophysiology, resulting in personalized health improvement advice. Efficacy depends on establishing a quality relationship between therapist and client. The aim of the pilot study was to measure the effectiveness of NT at the UoW teaching clinic using the Working Alliance Inventory-Short Revised (WAI-SR) and a symptom-specific outcome measure, Measure Yourself Medical Outcome Profile 2 (MYMOP2).

Evaluating the Effectiveness of Nutritional Therapy in the McClelland Teaching Clinic at the University of Worcester

Introduction: NT is an evidence-based complementary therapy, which applies nutrition and lifestyle science to underlying pathophysiology, resulting in personalized health improvement advice. Efficacy depends on establishing a quality relationship between therapist and client. The aim of the pilot study was to measure the effectiveness of NT at the UoW teaching clinic using the Working Alliance Inventory-Short Revised (WAI-SR) and a symptom-specific outcome measure, Measure Yourself Medical Outcome Profile 2 (MYMOP2).

The Relationship of the Therapeutic Alliance to Patient Characteristics and Functional Outcome During an Episode of Physical Therapy Care for Patients With Low Back Pain: An Observational Study

Research supports the relevance of the therapeutic alliance (TA) between patients and physical therapists on outcomes, but the impact of TA during routine physical therapist practice has not been quantified. The primary objective of this study was to examine the relationship between TA assessed during a physical therapy episode of care for patients with low back pain and functional outcome at the conclusion of care. The secondary objective was to examine psychometric properties of the Working Alliance Inventory-Short Revised (WAI-SR) form, a patient-reported TA measure. This study was a retrospective analysis of prospectively collected data from 676 patients (mean [SD] age=55.6 [16.1] y; 55.9% female) receiving physical therapy for low back pain in 45 outpatient clinics from 1 health system in the United States. Participating clinics routinely collect patient-reported data at initial, interim, and final visits. The lumbar computer-adapted test (LCAT) was used to evaluate functional outcome. The TA was assessed from the patient's perspective at interim assessments using the WAI-SR, bivariate correlations were examined, and regression models were examined if interim WAI-SR scores explained outcome variance beyond a previously validated multivariate prediction model. Internal consistency and ceiling effects for the WAI-SR were examined. Interim WAI-SR scores were not correlated with patient characteristics or initial LCAT, but they were correlated with final LCAT and LCAT change from initial to final assessment. WAI-SR total score (adjusted R2=0.36), and Task (adjusted R2=0.38) and Goal subscales (adjusted R2=0.35) explained additional variance in outcome beyond the base model (adjusted R2=0.33). Internal consistency was higher for WAI-SR total score (α=.88) than for subscales (α=.76-.82). Substantial ceiling effects were observed for all WAI-SR scores (27.2%-63.6%). Findings support the importance of TA in physical therapist practice. Measurement challenges were identified, most notably ceiling effects. This study supports the impact of the patient-physical therapist alliance on functional outcome. Results extend similar findings from controlled studies into a typical physical therapist practice setting. Better understanding of the role of contextual factors including the therapeutic alliance might be key to improving the magnitude of treatment effect for discrete physical therapist interventions and enhancing clinical outcomes of physical therapy episodes of care.

Future orientation in successful therapies: Expanding the concept of goal in the working alliance.

To better understand how therapists facilitate client goal attainment in therapy, we analyzed therapists' future-oriented actions in good outcome cases in which clients recorded high ratings on goal items in the Working Alliance Inventory-Short Revised. We selected clients who were within the clinical range (OQ-45.2) at pretreatment, demonstrated reliable change at the end of treatment, and recorded high WAI client goals scores early in treatment. Qualitative analyses of transcripts of the initial three sessions and client posttreatment interviews were integrated into a combined analysis to identify themes across the two separate sets of findings. Therapist future-oriented activity included: (1) Picking up explicit and implicit intentions; (2) using linguistic devices, such as meta-communication, action language, and hedging; (3) using evocative interventions; and (4) nudging the client into practicing change. Core finding: Therapists aligned with clients' directionality in a forward-driven, gradually evolving process. Conceptual and clinical implications are discussed.

An intervention for parents with severe personality difficulties whose children have mental health problems: a feasibility RCT.

The children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs. To develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial. A pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation. Two NHS mental health trusts and concomitant children's social care services. Parents who met the following criteria: (1) the primary caregiver of the index child, (2) aged 18-65 years, (3) have severe personality difficulties, (4) proficient in English and (5) capable of providing informed consent. Index children who met the following criteria: (1) aged 3-11 years, (2) living with index parent and (3) have significant emotional/behavioural difficulties. Exclusion criteria were (1) having coexisting psychosis, (2) participating in another parenting intervention, (3) receiving inpatient care, (4) having insufficient language/cognitive abilities, (5) having child developmental disorder, (6) care proceedings and (7) index child not residing with index parent. The Helping Families Programme-Modified - a 16-session intervention using structured, goal-orientated strategies and collaborative therapeutic methods to improve parenting, and child and parent functioning. Usual care - standard care augmented by a single psychoeducational session. Trial feasibility - rates of recruitment, eligibility, allocation, retention, data completion and experience. Intervention acceptability - rates of acceptance, completion, alliance (Working Alliance Inventory-Short Revised) and experience. Outcomes - child (assessed via Concerns About My Child, Eyberg Child Behaviour Inventory, Child Behaviour Checklist-Internalising Scale), parenting (assessed via the Arnold-O'Leary Parenting Scale, Kansas Parental Satisfaction Scale), parent (assessed via the Symptom Checklist-27), and health economics (assessed via the Client Service Receipt Inventory, EuroQol-5 Dimensions). The findings broadly supported trial feasibility using non-diagnostic screening criteria. Parents were mainly referred from one site (75.0%). Site and participant factors delayed recruitment. An estimate of eligible parents was not obtained. Of the 86 parents referred, 60 (69.7%) completed screening and 48 of these (80.0%) were recruited. Participants experienced significant disadvantage and multiple morbidity. The Helping Families Programme-Modified uptake (87.5%) was higher than usual-care uptake (62.5%). Trial retention (66.7%, 95% confidence interval 51.6% to 79.6%) exceeded the a priori rate. Process findings highlighted the impact of random allocation and the negative effects on retention. The Helping Families Programme-Modified was acceptable, with duration of delivery longer than planned, whereas the usual-care condition was less acceptable. At initial follow-up, effects on child and parenting outcomes were detected across both arms, with a potential outcome advantage for the Helping Families Programme-Modified (effect size range 0.0-1.3). For parental quality-adjusted life-years, the Helping Families Programme-Modified dominated usual care, and child quality-adjusted life-years resulted in higher costs and more quality-adjusted life-years. At second follow-up, the Helping Families Programme-Modified was associated with higher costs and more quality-adjusted life-years than usual care. For child quality-adjusted life-years, when controlled for baseline EuroQol-5 Dimensions, three-level version, usual care dominated the Helping Families Programme-Modified. No serious adverse events were reported. The Helping Families Programme-Modified is an acceptable specialised parenting intervention. Trial methods using non-diagnostic criteria were largely supported. For future work, a definitive efficacy trial should consider site selection, recruitment methods, intervention efficiency and revised comparator condition. Current Controlled Trials ISRCTN14573230. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 14. See the NIHR Journals Library website for further project information.

Randomised feasibility trial of the helping families programme-modified: an intensive parenting intervention for parents affected by severe personality difficulties

BackgroundSpecialist parenting intervention could improve coexistent parenting and child mental health difficulties of parents affected by severe personality difficulties.ObjectiveConduct a feasibility trial of Helping Families Programme-Modified (HFP-M), a specialist parenting...

Group cognitive behavioural therapy of physical and psychological menopausal symptoms of Chinese women, delivered via Internet and mobile phone versus face to face: A protocol for a randomized non-inferiority trial

BackgroundMenopause syndrome generally includes psychological problems. Group treatment delivered via the Internet and mobile phone (imGT) may improve women’s physiological and psychological conditions. ObjectiveTo investigate the efficacy of group cognitive behavioural therapy of menopause-related mood swings and quality of life, delivered face to face or via the Internet and mobile phone. MethodsThis protocol is for a randomized controlled clinical trial with a sample of 140 menopausal women divided into 2 groups: imGT and face-to-face group treatment (ffGT). The primary outcome will be the improvement in the menopausal symptoms of the two groups, as assessed by the Greene Climacteric Scale. The secondary outcomes will be: quality of life, assessed by the Short Form 36 Health Survey Questionnaire; insomnia, assessed by the Pittsburgh Sleep Quality Inventory; anxiety, assessed by the Hamilton Anxiety Rating Scale; and therapeutic alliance, assessed by the Working Alliance Inventory-Short Revised and Client Sat­is­fac­tion Qes­tion­naire-8. imGT will be performed once a week for 1.5 h for 10 weeks with a daily ‘Punched-in’ on the WeChat app; ffGT will be performed once a week for 1.5 h for 10 weeks. All outcomes will be assessed at baseline, at a post-intervention evaluation (week 10), and at a follow-up evaluation (week 22). DiscussionThis study will be the first clinical trial to examine the effects of imGT on menopausal women in China. If imGT is found to be non-inferior to ffGT, it will facilitate access to menopausal health services.