Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy

Background

The therapeutic alliance (TA) is a robust and pantheoretical predictor of treatment outcome in Face-to-Face- (F2F-) and Online-psychotherapy (Online-PT). Many authors have proposed several conceptualizations of TA, which are oftentimes operationalized. The resulting diversity of conceptualizations and measures is presented in this review.

Methods

We performed a three-parted literature search for self-report-instruments of TA in individual, voluntary F2F-PT with adults (1. utilization of past reviews, 2. systematic literature search yielding 5,205 articles, 3. reference lists). Analogously, we conducted a systematic literature search for instruments of TA in the Online-setting (yielding 200 articles). Additionally, we analyzed the content of the instruments qualitatively.

Results

A current overview of 48 instruments for measuring TA (46 for F2F-PT, 2 for Online-PT) including their conceptual backgrounds, characteristics and main content aspects is presented. Most instruments (n = 24) operationalize one or more theoretical conceptualizations of TA. Other instruments are adaptation/syntheses of existing measures (n = 14), based on literature searches (n = 3) or on an empirical survey (n = 3) and two instruments provide no conceptual background information. The content of the instruments mainly focused on the following aspects: 1. Self-disclosure and authenticity; 2. Agreement; 3. Active participation, motivation and compliance; 4. Trust and secure attachment; and 5. Considering needs/abilities/wishes of the patient. Additionally, a narrative review of various approaches to conceptualize TA is presented and linked to respective corresponding instruments.

Discussion

The broad variety of conceptualizations and measures of TA makes coherent research on TA difficult. There are conceptual challenges such as the role of attachment style in TA that remain to be clarified. The current conceptualizations and measures do not incorporate the practical experience and expertise of psychotherapists and patients sufficiently. A metatheoretical conceptualization and measure of TA based on an empirical survey of psychotherapists and patients could address these issues.

Growth curves of common factors in psychotherapy: Multilevel growth modelling and outcome analysis

OBJECTIVE

A large body of literature discusses change mechanisms underlying psychotherapy with an emphasis on common factors. The present study examined how different comprehensive common factors change over the course of therapy and whether this change was associated with clinical outcome at discharge.

METHOD

Three hundred forty-eight adults (mean age = 32.1, SD = 10.6; 64% female) attended a standardized 14-week day-clinic psychotherapy program. They provided longitudinal data on common factors based on weekly assessments. Additionally, pre- and post-assessment questionnaires on clinical outcome were completed. Using multilevel modelling, we predicted common factors by time (week in therapy). Multiple linear regression models tested the association between changes in common factors and clinical outcome.

RESULTS

The common factor 'Therapeutic Alliance' was best fitted by linear growth models, whereas models for the common factors 'Coping', 'Cognitive Integration' and 'Affective Processing' indicated logarithmic changes over time. 'Coping', that is change in patients' ability to cope with their individual problems, was most closely linked with outcome.

CONCLUSIONS

The present study provides evidence for the changeability of common factors over the course of therapy as well as their specific contributions to psychotherapeutic progress.

Bouldering psychotherapy is effective in enhancing perceived self-efficacy in people with depression: results from a multicenter randomized controlled trial

BACKGROUND

Recent studies have suggested that therapeutic climbing/bouldering may have positive effects on perceived self-efficacy. Nevertheless, there is still an urgent need for high-quality studies, as many existing studies have suffered from methodological problems. Therefore, the current work was aimed at investigating the effect of a manualized bouldering psychotherapy (BPT) on perceived self-efficacy in people with depression, compared with a home-based physical exercise program (EP) and state-of-the-art cognitive behavioral group therapy (CBT).

METHODS

In a prospective, multicenter, randomized controlled trial, 233 people with depression were randomly assigned to one group (BPT, EP, or CBT). Perceived self-efficacy was assessed at baseline (t0) and directly after the 10-week intervention period (t1) with the GSE. In addition, depression was assessed with the PHQ-9 and the MADRS. We computed t tests, analyses of variance (ANOVAs), confounder-adjusted hierarchical regression analyses, mediation analyses, and several sensitivity analyses.

RESULTS

BPT participants showed a significantly larger increase in perceived self-efficacy on the GSE compared with the EP (an increase of 3.04 vs. 1.26 points, p = .016, Cohen's d = 0.39). In the confounder-adjusted hierarchical multiple regression analysis, group allocation (BPT vs. EP) was found to be the only significant predictor of the postintervention GSE score (β = .16, p = .014) besides the baseline GSE score (β = .69, p < .001). No differences were found between BPT and CBT participants regarding the effect on perceived self-efficacy. Only in the CBT group, the relationship between depression at baseline and postintervention was partially mediated (23%) by perceived self-efficacy.

CONCLUSIONS

Participation in the manualized BPT in a group setting leads to a clinically relevant enhancement of perceived self-efficacy in people with depression. This effect is superior to that of physical exercise alone. The results provide also initial indications that BPT is comparable to CBT in enhancing perceived self-efficacy, suggesting a strong case for a broader use of BPT as a supplement to existing health services. Future studies should focus on the modes of action of BPT and its effect on perceived self-efficacy in people with other mental or physical disorders. Trial registration ISRCTN12457760, registered partly retrospectively, 26 July 2017.

Common Factors in Biofeedback Administered by Psychotherapists

Common factors are nonspecific therapeutic elements common across different varieties of psychotherapy. In a recent study, 68 expert psychotherapy researchers with a variety of allegiances collectively rated biofeedback as being negatively associated with many common factors (Tschacher et al. in Clin Psychol Psychother 21(1):82-96, 2014), including the therapeutic alliance. However, it seems implausible that biofeedback could benefit so many people while being incompatible with the therapeutic alliance and other common factors. The present study investigated the experiences of biofeedback clients who participated in a brief heart rate variability biofeedback protocol in order to explore the potential roles of common factors in biofeedback. The results of this study offer preliminary evidence that many common factors-including therapeutic alliance, self-efficacy expectation, mastery experiences, provision of explanatory scheme, mindfulness, and even cognitive restructuring-may play a role in biofeedback outcomes. Future research on this topic should include mediation and moderation models investigating the role of specific common factors on outcome and process studies to help determine what clinician behaviors are most helpful. Deeper investigation of common factors in biofeedback may benefit future biofeedback research and practice and address the concerns of colleagues outside of the biofeedback community who believe that biofeedback is at odds with common factors.

Klassen allgemeiner Wirkfaktoren der Psychotherapie und ihr Zusammenhang mit Therapietechniken

Zusammenfassung. Theoretischer Hintergrund: Bis heute wird die Frage, welche Faktoren für die Wirkung von Psychotherapie verantwortlich sind, kontrovers diskutiert. Im Zentrum dieser Diskussion stehen zwei vermeintlich gegensätzliche Wirkmodelle – das Modell spezifisch wirksamer Therapietechniken und das allgemeine Wirkfaktorenmodell. Allgemeine Wirkfaktoren und Therapietechniken sind konzeptuell jedoch auf unterschiedlichen Ebenen des Psychotherapieprozesses angesiedelt. An Stelle der Entweder-oder-Debatte sollte deshalb die Analyse ihres Zusammenwirkens in den Vordergrund rücken. Fragestellung: Mit Hilfe von Expertenratings wurde untersucht, ob sich verschiedene allgemeine Wirkfaktoren durch typische Zusammenhänge mit bestimmten Therapietechniken zu übergeordneten Klassen zusammenfassen lassen. Methode: 68 deutschsprachige Psychotherapieexperten schätzten in einer internetbasierten Umfrage ein, mit welchen spezifischen Therapietechniken verschiedene allgemeine Wirkfaktoren zusammenhängen. Mittels Faktorenanalyse wurde dann geprüft, welche Klassen von allgemeinen Wirkfaktoren sich durch bestimmte Muster von Technikzusammenhängen abbilden. Durch eine hierarchische Regressionsanalyse wurden zudem die Stärke und Richtung der Zusammenhänge zwischen einzelnen Wirkfaktorenklassen und den verschiedenen Techniken untersucht. Ergebnisse: Die Faktorenanalyse zeigt, dass den Zusammenhängen zwischen allgemeinen Wirkfaktoren und Techniken eine vierdimensionale Struktur unterliegt. Die vier Klassen von allgemeinen Wirkfaktoren hängen jeweils mit einer bestimmten Gruppe von Therapietechniken zusammen. Schlussfolgerungen: Die Vielzahl allgemeiner Wirkfaktoren lässt sich mittels ihrer Operationalisierung durch Therapietechniken zusammenfassen.

[How timely are the methods taught in psychotherapy training and practice?]

ISSUES

Even though many psychotherapists consider themselves to be eclectic or integrative, training and reimbursement in the modern healthcare system are clearly oriented toward the model of distinct psychotherapy approaches. Prompted by the proposition to favor general, disorder-oriented psychotherapy, we investigate how timely distinctive methods are that are taught in training and practice.

METHODS

We reviewed the pertinent literature regarding general and specific factors, the effectiveness of integrative and eclectic treatments, orientation toward specific disorders, manualization and psychotherapeutic training.

RESULTS

There is a lack of systematic studies on the efficacy of combining therapy methods from different approaches. The first empirical findings reveal that a superiority of combined versus single treatmentmethods has yet to be demonstrated. The development of transnosological manuals shows the limits of disorder-specific treatment.General factors such as therapeutic alliance or education about the model of disease and treatment rationale require specific definitions.

CONCLUSION

Taking reference to a specific treatment approach provides important consistency of theory, training therapy and supervision, though this does not preclude an openness toward other therapy concepts. Current manualized examples show that methods and techniques can indeed be integrated from other approaches. Integrating different methods can also be seen as a developmental task for practitioners and researchers which may be mastered increasingly better with more experience.

Measuring Verbal Psychotherapeutic Techniques-A Systematic Review of Intervention Characteristics and Measures

Language is one of the most important “tools” of psychotherapists. The working mechanisms of verbal therapeutic techniques, however, are still marginally understood. In part, this is due to the lack of a generally acknowledged typology as well as a gold standard for the assessment of verbal techniques, which limits the possibility of conducting studies focusing this topic. The present study reviews measures used in clinical research which assess directly observable dimensions of verbal interventions in a reliable manner. All measures were evaluated with respect to their theoretical foundation, research goals, assessment modes, and various psychometric properties. A systematic search in databases (PubMed, PsycInfo, PsycArticles, PSYNDEX, Web of Science, Embase) followed by an additional “snowballing” search covering the years 1940–2013 yielded n = 179 publications eligible for review. Within these publications, 34 measures were identified showing great heterogeneity regarding the aspects under study. Only two measures reached the highest psychometric standards and can be recommended for clinical use without any reservation. Central problems include deficiencies in the systematization of techniques as well as their partly ambiguous and inconsistent definitions. To promote this field of research, it will be important to achieve a consensus concerning the terminology, conceptions and measures of verbal interventions.

Unique and shared techniques in cognitive-behavioural and short-term psychodynamic psychotherapy: a content analysis of randomised trials on depression

Randomised controlled trials (RCTs) of psychotherapeutic interventions assume that specific techniques are used in treatments, which are responsible for changes in the client's symptoms. This assumption also holds true for meta-analyses, where evidence for specific interventions and techniques is compiled. However, it has also been argued that different treatments share important techniques and that an upcoming consensus about useful treatment strategies is leading to a greater integration of treatments. This makes assumptions about the effectiveness of specific interventions ingredients questionable if the shared (common) techniques are more often used in interventions than are the unique techniques. This study investigated the unique or shared techniques in RCTs of cognitive-behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP). Psychotherapeutic techniques were coded from 42 masked treatment descriptions of RCTs in the field of depression (1979-2010). CBT techniques were often used in studies identified as either CBT or STPP. However, STPP techniques were only used in STPP-identified studies. Empirical clustering of treatment descriptions did not confirm the original distinction of CBT versus STPP, but instead showed substantial heterogeneity within both approaches. Extraction of psychotherapeutic techniques from the treatment descriptions is feasible and could be used as a content-based approach to classify treatments in systematic reviews and meta-analyses.

[The future of psychotherapy in psychosomatic medicine]

OBJECTIVE

To review the current perspectives and trends of psychotherapy as a key area of psychosomatic medicine with regard to both societal and scientific challenges as well as patient health care services. Also, to draw conclusions regarding the future training and practice of psychosomatic medicine and psychotherapy.

RESULTS

Psychotherapy is confronted with many new challenges because of the high prevalence of mental and psychosomatic disorders, because of their increasing recognition as major health problems and because of the rapid technological and demographic changes going on in modern society. Despite its growth, psychotherapeutic care is still limited in many, especially rural, regions and for patients with complex psychosomatic and somatopsychic disorders.

CONCLUSIONS

New models of training as well as integrated and multimodal care are needed in order to provide both, rapid, low-threshold and specialized, disorder-specific care.

Towards a taxonomy of common factors in psychotherapy-results of an expert survey

BACKGROUND

How change comes about is hotly debated in psychotherapy research. One camp considers 'non-specific' or 'common factors', shared by different therapy approaches, as essential, whereas researchers of the other camp consider specific techniques as the essential ingredients of change. This controversy, however, suffers from unclear terminology and logical inconsistencies. The Taxonomy Project therefore aims at contributing to the definition and conceptualization of common factors of psychotherapy by analyzing their differential associations to standard techniques.

METHODS

A review identified 22 common factors discussed in psychotherapy research literature. We conducted a survey, in which 68 psychotherapy experts assessed how common factors are implemented by specific techniques. Using hierarchical linear models, we predicted each common factor by techniques and by experts' age, gender and allegiance to a therapy orientation.

RESULTS

Common factors differed largely in their relevance for technique implementation. Patient engagement, Affective experiencing and Therapeutic alliance were judged most relevant. Common factors also differed with respect to how well they could be explained by the set of techniques. We present detailed profiles of all common factors by the (positively or negatively) associated techniques. There were indications of a biased taxonomy not covering the embodiment of psychotherapy (expressed by body-centred techniques such as progressive muscle relaxation, biofeedback training and hypnosis). Likewise, common factors did not adequately represent effective psychodynamic and systemic techniques.

CONCLUSION

This taxonomic endeavour is a step towards a clarification of important core constructs of psychotherapy.

KEY PRACTITIONER MESSAGE

This article relates standard techniques of psychotherapy (well known to practising therapists) to the change factors/change mechanisms discussed in psychotherapy theory. It gives a short review of the current debate on the mechanisms by which psychotherapy works. We provide detailed profiles of change mechanisms and how they may be generated by practice techniques.