Therapist effects and the outcome-alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia

The therapeutic alliance between study participants and intervention facilitators is associated with acute effects and clinical outcomes in a psilocybin-assisted therapy trial for major depressive disorder

We examined if the therapeutic alliance between study participants and intervention facilitators in a psilocybin-assisted therapy (PAT) trial changed over time and whether there were relationships between alliance, acute psilocybin experiences, and depression outcomes. In a randomized, waiting list-controlled clinical trial for major depressive disorder in adults (N = 24), participants were randomized to an immediate (N = 13) or delayed (N = 11) condition with two oral doses of psilocybin (20mg/70kg and 30mg/70kg). Ratings of therapeutic alliance significantly increased from the final preparation session to one-week post-intervention (p = .03, d = .43). A stronger total alliance at the final preparation session predicted depression scores at 4 weeks (r = -.65, p = .002), 6 months (r = -.47, p = .036), and 12 months (r = -.54, p = .014) post-intervention. A stronger total alliance in the final preparation session was correlated with higher peak ratings of mystical experiences (r = .49, p = .027) and psychological insight (r = .52, p = .040), and peak ratings of mystical experience and psychological insight were correlated with depression scores at 4 weeks (r = -.45, p = .030 for mystical; r = -.75, p < .001 for insight). Stronger total alliance one week after the final psilocybin session predicted depression scores at 4 weeks (r = -.85, p < .001), 3 months (r = -.52, p = .010), 6 months (r = -.77, p < .001), and 12 months (r = -.61, p = .001) post-intervention. These findings highlight the importance of the therapeutic relationship in PAT. Future research should explore therapist and participant characteristics which maximize the therapeutic alliance and evaluate its relationship to treatment outcomes. Trial registration: Registration: Clinicaltrials.gov NCT03181529. https://classic.clinicaltrials.gov/ct2/show/NCT03181529.

Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder

Objective: The therapeutic alliance is related to treatment outcome but less is known about the agreement on alliance between patients and therapists and its relationship to outcomes. We examined the association of patient-therapist congruence of alliance perceptions, early and late in cognitive behavioral therapy for panic disorder in relation to symptom reduction and dropout. Method: Patients (n = 181) and their therapists provided alliance ratings early and late during 11-session treatment. Independent evaluators rated patients' symptomatic levels post-treatment. Polynomial regression and response surface analysis were used to examine congruence as a predictor of outcome. Results: Early in therapy, stronger combined patient-therapist alliances, regardless of agreement, predicted lower symptom severity at the end of therapy and a lower likelihood of dropout. Late in treatment, the outcome was worse when therapist ratings of the alliance were higher than those of the patient. Conclusions: Therapist-patient agreement on the strength of the alliance is important for symptom improvement and dropout. The study highlights the importance of understanding the dyadic nature of the alliance and its impact on therapeutic change.

Which, who and when? Therapeutic processes in group cognitive behaviour therapy for anxiety disorders

The evidence for the effect of therapeutic alliance in group cognitive behaviour therapy (CBT) for anxiety disorders is unclear. Identifying whether the alliance-outcome relationship depends on (1) which components are assessed, (2) who is measuring the alliance and (3) when the alliance is measured will help to clarify the role of the client-therapist relationship in therapy. The present study explored the effects of alliance component (agreement vs. bond), rater perspective (client vs. therapist) and timing (early vs. late therapy) on the alliance-outcome relationship. Individuals with an anxiety disorder enrolled into transdiagnostic group CBT were studied, with n = 78 at early therapy and n = 57 at late therapy. Results showed that greater client-rated agreement significantly predicted improved post-treatment outcomes throughout the course of therapy, while stronger client-rated bond in late therapy predicted reduced treatment gains. In contrast, therapist perceptions of agreement and bond were not associated with post-treatment outcomes at any point in therapy. Client-reported group cohesion also was not associated with additional variance in outcome after accounting for client-rated alliance. Overall, the findings highlight the importance of prioritizing the client's perception of the client-therapist relationship in CBT for anxiety disorders, as well as distinguishing the effects of component, rater and timing in future process-outcome studies.

Testing Clinical Intuitions About Barriers to Improvement in Cognitive-Behavioral Therapy for Panic Disorder

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians' beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians' intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = -0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = -.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

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

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

Patient alliance with the program predicts treatment outcomes whereas alliance with the therapist predicts adherence in internet-based therapy for panic disorder

This study examines relationships among different aspects of therapeutic alliance with treatment outcome, adherence and attrition in internet delivered cognitive behavioral therapy (ICBT) for panic disorder.

We examined alliance-outcome relationships in ICBT (N = 74) using a newly developed self-report alliance measure that disentangles alliance with program content (Internet Patient's Experience of Attunement and Responsiveness with the program; I-PEARp) and with the therapist (I-PEARt). We compared ICBT outcomes of patient rated and therapist-rated alliance with conventional alliance scales (WAI-6 and WAI-T).

Consistent with our hypothesis, I-PEARp and I-PEARt distinguished between different aspects of the alliance and predicted outcomes better than standard alliance scales. Furthermore, higher ratings of I-PEARp were associated with subsequent lower symptoms and lower symptoms were associated with higher subsequent alliance. In contrast, I-PEARt predicted adherence, but not symptoms. Although therapists' ratings of alliance (thI-PEAR) improved significantly during treatment, they did not predict subsequent symptoms, adherence, or dropout.

Results indicate that the patient experience of the alliance in ICBT includes two aspects, each of which uniquely contributes to outcomes; patient connection to the program is related to symptom outcomes whereas the dyadic relationship with the therapist serves as the glue to allow the treatment to hold.

Elements of the therapeutic relationship in CBT for anxiety disorders: A systematic review

To optimise the effects of cognitive behaviour therapy (CBT) for anxiety disorders, research has increasingly focussed on understanding mechanisms of change. Specifically, the therapeutic relationship has been identified as a potential "active ingredient" of therapy. The evidence for the effects of eleven elements of the therapeutic relationship (alliance, collaboration, goal consensus, group cohesion, empathy, positive regard, feedback, emotional expression, outcome expectations, treatment credibility, alliance rupture-repair) on treatment outcomes in CBT for anxiety disorders was systematically reviewed. Fifty unique studies were included, and findings were qualitatively reviewed and summarised. Results revealed consistent and sizeable evidence for the cohesion-outcome and expectation-outcome relationships. There was emerging evidence for the effects of collaboration, empathy, and alliance rupture-repair on outcomes. However, the evidence for goal consensus and credibility on outcomes was limited. Notably, review of the alliance literature revealed substantial inconsistencies across studies. No studies were identified for positive regard, feedback, and emotional expression. Overall, further research is needed to clarify the role of the therapeutic relationship in CBT for anxiety disorders. These findings will contribute to the conceptual integration of therapeutic relationship constructs in cognitive behavioural models, and help to improve treatments and outcomes for individuals.

Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation

BACKGROUND

Mental health clinicians frequently experience intense negative emotional responses to suicidal patients, which have been related to treatment outcome. This study examines the therapeutic alliance as a mediator of the relationship between clinicians' negative emotional responses at the initial encounter and patients' suicidal ideation (SI) concurrently and 1 month later.

METHODS

We assessed 378 adult psychiatric outpatients (62.7% female; mean age = 39.1 ± 14.6 years) and their 61 treating clinicians. Following the initial encounter, self-report questionnaires assessed clinicians' emotional responses to their patients, patients' and clinicians' perception of the therapeutic alliance, and patients' SI. The SI was reassessed 1 month after the initial visit. Multilevel mediation analyses were performed.

RESULTS

Patients' (but not clinicians') perception of the therapeutic alliance mediated the relationship between clinicians' negative emotional responses to patients and patients' SI 1 month following the initial visit (indirect effect estimate = 0.015; p < .001).

CONCLUSIONS

The association between clinicians' negative emotional response and patients' prospective SI appears to be transmitted, at least partly, through the patients' perception of the poorer early quality of the therapeutic alliance. Thus, clinicians' awareness and management of their emotional states appear essential both for the identification of suicidal risk and to enhance therapeutic alliance and treatment outcomes.

Service- and practitioner-level variation in non-consensual dropout from child mental health services

Non-attendance of mental health service appointments is an international problem. In the UK, for example, the estimated cost of non-attendance in child mental health services is over £45 million (US dollar 60.94 million) per annum. The objective of this study was to examine whether there were service- and practitioner-level variation in non-consensual dropout in child mental health services. This was an analysis of routinely collected data. Service-level variation (as services covered different geographic areas) and practitioner-level variation were examined in N = 3622 children (mean age 12.70 years; SD 3.62, 57% female, 50% white or white British) seen by 896 practitioners across 39 services. Overall, 35% of the variation in non-consensual dropout was explained at the service level and 15% at the practitioner level. Children were almost four times more likely to drop out depending on which service they attended (median odds ratio = 3.92) and were two-and-a-half times more likely to drop out depending on which practitioner they saw (median odds ratio = 2.53). These levels of variation were not explained by levels of deprivation in areas covered by services or by children's demographic and case characteristics. The findings of the present research may suggest that, beyond service-level variation, there is also practitioner-level variation in non-consensual dropout in child mental health services.

Prognosis Prediction Using Therapeutic Agreement of Video Conference-Delivered Cognitive Behavioral Therapy: Retrospective Secondary Analysis of a Single-Arm Pilot Trial

BACKGROUND

The therapist-patient therapeutic alliance is known to be an important factor in cognitive behavioral therapy (CBT). However, findings by previous studies for obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD) have not been consistent regarding whether this alliance provides symptomatic improvements.

OBJECTIVE

This study investigated predictors of symptom improvement in patients receiving CBT via video conferencing.

METHODS

A total of 29 patients who participated in a previous clinical trial were recruited for the current study. Therapeutic alliance and clinical background in patients with OCD, PD, and SAD were measured at first session or the eighth session, which were calculated by multiple regression analyses to estimate the impact on therapeutic response percentage change.

RESULTS

The multiple regression analyses showed that, among the independent variables, only patients' agreement in the therapeutic alliance remained viable, as other variables were a best fit for the excluded model (P=.002). The results show that patients' agreement on therapeutic goals and tasks explains the prognosis, as the normalization factor beta was 0.54 (SE 32.73; 95% CI 1.23-5.17; P=.002) and the adjusted R2 was .266.

CONCLUSIONS

Patients' agreement on therapeutic goals and tasks predicts improvement after CBT via video conferencing.

TRIAL REGISTRATION

UMIN Clinical Trial Repository UMIN000026609; https://tinyurl.com/ye6dcbwt.

Psychometric evaluation of the Working Alliance Inventory-Therapist version: Current and new short forms

Background: The Working Alliance Inventory (WAI) and its short forms are widely used, although the properties of the therapists' versions have been little studied. Method: We examined the psychometric properties of two short forms (WAI-S-T, WAI-SR-T), and explored the creation of a psychometrically stronger short form using contemporary measure development techniques. Well-fitting items from the full 36-item WAI were identified in a development sample (131 therapists, 688 patients) using multi-level Bayesian Structural Equation Modeling, accounting for therapist rated effects. Multi-level Item Response Theory (IRT) methods aided creation of a revised short form (WAI-S-T-IRT). Factor structures of the three forms were assessed using multi-level ML estimation with robust standard errors. Results: Collinearity problems for the Goal and Task dimensions led to testing a two-factor model (Goal-Task, Bond). All three measures showed satisfactory fit; the WAI-S-T-IRT fit slightly better but differences were minor. Testing the structures in an independent sample (N = 1117) yielded essentially the same results. No version showed strong measurement invariance. Discussion: Continued use of current therapist forms is supported; differentiation of theoretical dimensions is difficult with current measures, and may not be possible with self-report forms.

Correlation structure in hierarchical linear modelling: An illustration with the therapeutic alliance

Previous studies have found an association between therapeutic alliance and treatment outcome, but only recently have researchers begun to analyse time-lagged relationships between session-to-session measures of alliance and outcomes with hierarchical linear modelling (HLM). HLM assumes simple correlation structures between any two measurements from the same client. In this paper, we suggest that this assumption might be problematic. Session-to-session measurements of outcomes (Outcome Questionnaire-10.2) and alliance (Working Alliance Inventory) in a sample (N = 63) were used to perform HLM analyses to test time-lagged (lag +1) relations between outcomes and alliance in both directions. A first set of analyses replicated the models consistently used in the literature, whereas a second set of models considered a correlation structure as a function of time. A correlation independent of time distance resulted in a bidirectional influence between alliance and outcomes (the model commonly used in the literature), but when considering a correlation structure as a function of time, only the outcomes were predictive of alliance. Considering a more complex correlation structure as a function of time seems to be an important analytical strategy for addressing the issue of variability in within-client measurements over time. This study highlights how the misspecification of a statistical model, namely, not considering a time-dependent correlation structure of the response variable, may lead to misleading findings in HLM studies. This is particularly relevant in process-outcome research, such as studies analysing the impact of therapeutic alliance on clinical outcomes.

Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation

Objective: To introduce readers to instrumental variable analyses for causal inferences using as an example a test of the hypothesis that the quality of the therapeutic alliance has a causal role in relation to the outcome of psychotherapy. Method: We used data from a recent non-inferiority trial of cognitive and dynamic therapies for major depressive disorder in a community mental health setting. The data (N = 161) were analyzed using standard approaches as well as a multilevel 2-stage instrumental variables approach that allows for causal interpretations by removing the influence of unmeasured confounds. Results: Instrumental variables were created at the patient and therapist level using baseline patient and therapist variables. These baseline variables predicted the alliance but were otherwise unrelated to treatment outcome other than through their effects on the alliance. Standard multilevel mixed effects analyses revealed statistically significant associations of the alliance with outcome at the therapist level of analysis. The therapist level effect remained statistically significant when using the instrumental variables approach. Conclusion: Our results support the hypothesis that, at least at the therapist level, the alliance plays a causal role in producing better outcomes. Instrumental variable analyses can be a useful tool to supplement standard analyses.

A relational perspective on the association between working alliance and treatment outcome

Objective: Evidence is inconclusive on whether variability in alliance ratings within or between therapists is a better predictor of treatment outcome. The objective of the present study was to explore between and within patient and therapist variability in alliance ratings, reciprocity among them, and their significance for treatment outcome. Method: A large primary care psychotherapy sample was used. Patient and therapist ratings of the working alliance at session three and patient ratings of psychological distress pre-post were used for analyses. A one-with-many analytical design was used in order to address problems associated with nonindependence. Results: Within-therapist variation in alliance ratings accounted for larger shares of the total variance than between-therapist variation in both therapist and patient ratings. Associations between averaged patient and therapist ratings of the alliance for the individual therapists and their average treatment outcome were weak but the associations between specific alliance ratings and treatment outcome within therapies were strong. Conclusions: The results indicated a substantial dyadic reciprocity in alliance ratings. Within-therapist variation in alliance was a better predictor of treatment outcome than between-therapist variation in alliance ratings.

A systematic review of therapist effects: A critical narrative update and refinement to review

OBJECTIVE

To review the therapist effects literature since Baldwin and Imel's (2013) review.

METHOD

Systematic literature review of three databases (PsycINFO, PubMed and Web of Science) replicating Baldwin and Imel (2013) search terms. Weighted averages of therapist effects (TEs) were calculated, and a critical narrative review of included studies conducted.

RESULTS

Twenty studies met inclusion criteria (3 RCTs; 17 practice-based) with 19 studies using multilevel modeling. TEs were found in 19 studies. The TE range for all studies was 0.2% to 29% (weighted average = 5%). For RCTs, 1%-29% (weighted average = 8.2%). For practice-based studies, 0.2-21% (weighted average = 5%). The university counseling subsample yielded a lower TE (2.4%) than in other groupings (i.e., primary care, mixed clinical settings, and specialist/focused settings). Therapist sample sizes remained lower than recommended, and few studies appeared to be designed specifically as TE studies, with too few examples of maximising the research potential of large routine patient datasets.

CONCLUSIONS

Therapist effects are a robust phenomenon although considerable heterogeneity exists across studies. Patient severity appeared related to TE size. TEs from RCTs were highly variable. Using an overall therapist effects statistic may lack precision, and TEs might be better reported separately for specific clinical settings.

The Role of Practitioner Resilience and Mindfulness in Effective Practice: A Practice-Based Feasibility Study

A growing body of literature attests to the existence of therapist effects with little explanation of this phenomenon. This study therefore investigated the role of resilience and mindfulness as factors related to practitioner wellbeing and associated effective practice. Data comprised practitioners (n = 37) and their patient outcome data (n = 4980) conducted within a stepped care model of service delivery. Analyses employed benchmarking and multilevel modeling to identify more and less effective practitioners via yoking of therapist factors and nested patient outcomes. A therapist effect of 6.7 % was identified based on patient depression (PHQ-9) outcome scores. More effective practitioners compared to less effective practitioners displayed significantly higher levels of mindfulness as well as resilience and mindfulness combined. Implications for policy, research and practice are discussed.

What matters more? Common or specific factors in cognitive behavioral therapy for OCD: Therapeutic alliance and expectations as predictors of treatment outcome

CBT for obsessive-compulsive disorder (OCD) is a strong challenge to the contention that common factors explain most of the variance in outcomes in all therapies and all disorders, given that the treatment is focused and placebo response is low. In this study, the relative contributions of expectancy and therapeutic alliance as predictors of outcome in the treatment of OCD are examined and compared to the contribution of specific treatment effects. One hundred and eight patients with OCD were randomly assigned to two forms of CBT: exposure and response prevention (EX/RP) or stress management training (SMT). Measures of OCD symptoms, quality of life, therapist and patient expectancy and alliance were collected at several timepoints. Treatment type was a substantially stronger predictor of symptom reduction compared to alliance and expectancy. However, neither specific nor common factors predicted improvement in quality of life very well. Only in EX/RP, symptom change was associated with subsequent changes in alliance. Finally, therapist effects were estimated using Bayesian methods and were negligible. In the context of CBT for OCD, the data support the specific factor model, and suggest that the relative contribution of common vs. specific factors likely varies by disorder and by treatment type.

The Development of the Working Alliance and Its Ability to Predict Outcome in Emotion-Focused Therapy for Social Anxiety Disorder

The study focuses on the alliance of 12 patients receiving emotion-focused therapy for social anxiety. Anxiety symptoms and patient perception of the working alliance were examined weekly. The first eight sessions of each patient were coded for within- and between-sessions alliance levels (1008 segments were coded). At the sample level, the alliance shows linear development over time but high variability between individuals. More than half the patients showed alliance development consistent with the rupture-resolution pattern. Without accounting for the temporal relationship between alliance and symptoms, alliance significantly predicted symptoms across treatment. When we accounted for the temporal relationship between alliance and symptoms, we found that symptoms can predict alliance but alliance cannot predict symptoms. We obtained the same findings using patient-rated and coded alliance.

Prediction and moderation of improvement in cognitive-behavioral and psychodynamic psychotherapy for panic disorder

OBJECTIVE

To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients.

METHOD

Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS).

RESULTS

Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI_95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI_95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (≥27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment.

CONCLUSIONS

Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

Treatment engagement in the early phase of cognitive-behavior therapy for panic disorder: A grounded theory analysis of patient experience

Exposure-based cognitive-behavior therapy (EBCBT) is the treatment of choice for panic disorder (PD). However, little is known about early treatment processes that facilitate retention in treatment and positive outcomes of PD treatment. We studied the development of early treatment process with semi-structured individual in-depth interviews with 12 patients with PD, conducted post session 3. Grounded theory was used to analyze the transcripts. The development of early treatment process was captured by four thematic categories: approaching the problem, easing in and opening up, building trust and bonding, and making sense of panic. The developmental scheme culminated to the core category: Jointly Engaging in PD Therapy versus Awaiting Relief, capturing early engagement or disengagement from PD therapy respectively. The emergent core category was cross-validated against distal treatment outcome. Emergent processes can be replicated and incorporated in early treatment procedures of EBCBT for PD. Clinical practice recommendations are discussed.

The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients' interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists' adherence (r=0.54) and therapeutic alliance (r=0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients' interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r=0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.

Therapist Effects on and Predictors of Non-Consensual Dropout in Psychotherapy

BACKGROUND

Whereas therapist effects on outcome have been a research topic for several years, the influence of therapists on premature treatment termination (dropout) has hardly been investigated. Since dropout is common during psychological treatment, and its occurrence has important implications for both the individual patient and the healthcare system, it is important to identify the factors associated with it.

METHOD

Participants included 707 patients in outpatient psychotherapy treated by 66 therapists. Multilevel logistic regression models for dichotomous data were used to estimate the impact of therapists on patient dropout. Additionally, sociodemographic variables, symptoms, personality style and treatment expectations were investigated as potential predictors.

RESULTS

It was found that 5.7% of variance in dropout could be attributed to therapists. The therapist's effect remained significant after controlling for patient's initial impairment. Furthermore, initial impairment was a predictor of premature termination. Other significant predictors of dropout on a patient level were male sex, lower education status, more histrionic and less compulsive personality style and negative treatment expectations.

CONCLUSIONS

The findings indicate that differences between therapists influence the likelihood of dropout in outpatient psychotherapy. Further research should focus on variables, which have the potential to explain these inter-individual differences between therapists (e.g., therapist's experience or self-efficacy). Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGES

There are substantial differences between therapists concerning their average dropout rates. At the patient level, higher initial impairment, male sex, lower education, less compulsive personality style, more histrionic personality style and low treatment expectations seem to be risk factors of non-consensual treatment termination. Psychometric feedback during the course of treatment should be used to identify patients who are at risk for dropout.

The relationship between alliance and outcome: Analysis of a two-person perspective on alliance and session outcome

OBJECTIVE

Better alliance is known to predict better psychotherapy outcomes, but the interdependent and interactive effects of both therapist- and patient-reported alliance levels have yet to be systematically investigated.

METHOD

Using actor-partner interdependence model analysis the authors estimated actor, partner, and 2 types of interactive effects of alliance on session outcome in a sample of 241 patient-therapist dyads across 30 sessions of cognitive-behavioral and alliance-focused therapy.

RESULTS

Findings suggest that the most robust predictors of session outcome are within-treatment changes in patient reports of the alliance, which predict both patient and therapist report on outcome. Within-treatment changes in therapist reports of the alliance, as well as differences between patients and between therapists in their average ratings of alliance levels across treatment, predict outcome as reported by the specific individual. Although alliance was found to be a significant predictor of outcome in both treatments, for therapist-reported alliance and outcome it had a stronger effect in alliance-focused therapy than in cognitive-behavioral therapy. Additionally, dyads with the highest pooled level of alliance from both partners fared best on session outcome.

CONCLUSIONS

The results are consistent with a 2-person perspective on psychotherapy, demonstrating the importance of considering the interdependent and interactive nature of both patient and therapist alliance levels on session outcome. (PsycINFO Database Record

Therapist-reported alliance: Is it really a predictor of outcome?

Most of the literature on the alliance-outcome association is based exclusively on differences between patient reports on alliance. Much less is known about the unique contribution of the therapist's report to this association across treatment, that is, the association between therapist-reported alliance and outcome over the course of treatment, after controlling for the patient's contribution. The present study is the first to examine the unique contribution of the therapist-reported alliance to outcome, accounting for reverse causation (symptomatic levels predicting alliance), at several time points in the course of treatment. Of 156 patients randomized to dynamic supportive-expressive psychotherapy, antidepressant medication with clinical management, and placebo with clinical management, 149 were included in the present study. Alliance was assessed from the perspective of both the patient and the therapist. Outcome measures included the patients' self-reported and diagnostician-rated depressive symptoms. Overall, the findings demonstrate that the therapists' contribution to the alliance-outcome association was explained mainly by prior symptomatic levels. However, when a time lag of several sessions was introduced between alliance and symptoms, a positive association emerged between alliance at 1 time point and symptomatic distress assessed several sessions later in the treatment, controlling for previous symptomatic level. The findings were similar whether or not we controlled for the patient's perspective on the alliance. Taken together, the findings attest to the importance of improving therapists' ability to detect deterioration in the alliance.

Patient characteristics and variability in adherence and competence in cognitive-behavioral therapy for panic disorder

Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change.

OBJECTIVE

(a) statistically demonstrate between- and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change.

METHOD

Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment.

RESULTS

Significant between- and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity.

CONCLUSIONS

Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.