Research on psychotherapy integration: Recommendations and conclusions from an NIMH workshop

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.

Renegotiating tasks or goals as rupture repair: A task analysis in a cognitive-behavioral therapy for personality disorder

OBJECTIVE

The purpose of this study was to provide some definition of rupture repair in a cognitive-behavioral therapy (CBT) for personality disorders, specifically how treatment tasks or goals are renegotiated.

METHOD

Following a task analysis, a rational model was developed with the support of an expert panel. An empirical analysis was conducted on six CBT cases sampled from a clinical trial that included personality disordered patients and treatment adherent therapists. Two sessions from each case indicating rupture repair were selected, based on patient and therapist ratings of the Working Alliance Inventory-12 item version (WAI-12) and rupture presence. A qualitative analysis of the sessions was conducted with the support of the observer-based Rupture Resolution Rating System (3RS-2022).

RESULTS

The empirical analysis provided some support for many of the stages defined in the rational model, but less support for the hypothesized sequences of stages. A rational-empirical synthesis yielded a revised model that suggested therapists combine various strategies in rupture repair in a variety of ways, not necessarily in consistent sequences.

CONCLUSIONS

The renegotiation of tasks and goals in this CBT sample was variable. The importance of responsiveness and the need to validate the rational-empirical model were highlighted.

One more time with less jargon: An introduction to "Rupture Repair in Practice"

In this introduction to this issue on Rupture-Repair in Practice, we present our understanding of alliance ruptures using common language to appeal to all theoretical orientations. Specifically, we define withdrawal movements away from another or oneself (efforts towards isolation or appeasement) and confrontation movements against another (efforts towards aggression or control). In addition to these interpersonal markers, we suggest that therapist emotional experiences can be considered as intrapersonal markers indicating rupture. We emphasize understanding ruptures as relational phenomena. Then we present various pathways toward rupture-repair, highlighting renegotiation of therapy tasks or goals and exploration of patient and therapist contributions and needs. We explain how these paths can be understood as critical change processes that can transform obstacles in treatment into opportunities. We finish with some mention of our alliance-focused training for self-development. This issue represents an important step towards demonstrating the transtheoretical and practical potential of rupture-repair.

Positive Association Between Therapeutic Alliance and Quality of Life in Psychodynamic Psychotherapy, Cognitive Behavior Therapy, and Interpersonal Therapy: The Patient's Perspective

BACKGROUND

The therapeutic alliance (TA) is considered a common psychotherapeutic factor associated with positive results in psychotherapies. There are no studies relating the TA with quality of life (Qol).

OBJECTIVES

Our objective was to evaluate whether there is an association between the TA and Qol across three different psychotherapies.

METHODS

A cross-sectional study, which included outpatients undergoing individual psychotherapeutic treatment was conducted. When analyzing the total sample, the correlation of the TA with Qol domains did not present statistical significance. When considering only the sample of patients who were undergoing treatment in psychodynamic psychotherapy (PP), there was a statistically significant association between the TA and the psychological domain of Qol (p < 0.05). When using a regression model for adjusting for confounding factors, the association between psychological domain with the TA on the PP patients sample lost significance (p = 0.221).

DISCUSSION

These findings suggest that the TA seems to be more strongly related to better QoL in PP.

Therapists' and Clients' Perceptions of Bonding as Predictors of Outcome in Multisystemic Therapy®

This longitudinal study examined whether strength of and balance in self-reported caregiver, youth, and therapist emotional bonds in mid- and late treatment predicted outcomes in Multisystemic Therapy of adolescent behavior problems in a sample of 164 caregiver-youth dyads. Strength of and balance in bonds related to outcome in different ways, depending on the source of the report and time. Results showed a limited association between family members' emotional connection with the therapist and treatment outcome, whereas therapists' perceptions of bond with the caregiver showed highly significant associations across time. Caregiver-therapist agreement on emotional connection at both time points predicted therapist evaluation of treatment success and successful termination, but this was largely explained by therapists' level of alliance. Balance in bonds with the therapist between caregiver and youth had no significant associations with any outcome. The study major limitations such as examining only one component of alliance and possible implications are discussed.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths

BACKGROUND

Suicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention.

METHODS

Thematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment.

RESULTS

Two main themes were identified. The first, 'A therapy that works', revealed inpatients' views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, 'Concerns about in-patient suicide-focused therapy', depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients' whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians.

CONCLUSIONS

We conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting.

TRIAL REGISTRATION NUMBER

ISRCTN 17890126 , Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance

Objective

The alliance been recognized as an essential common factor and robust predictor of outcome. The present study sought to further our knowledge of the alliance and to promote the integration of research and practice by assessing consensus among peer-nominated expert therapists of varying theoretical orientations on the effectiveness of clinical strategies to repair alliance ruptures.

Method

This study drew on the behavioral-analytic model (Goldfried & D'Zurilla, 1969) and the methodology of the Expert Consensus Guideline Series (Frances, Docherty, & Kahn 1997). In Phase I, 69 therapists submitted clinical situations describing alliance ruptures. In Phase II, 177 therapists generated responses to the situations, and clinical strategies underlying the responses were identified. In Phase III, 134 peer-nominated experts (a mean of 22.3 therapists per situation) rated the effectiveness of these clinical strategies.

Results

The experts reached consensus on the use of strategies that validated the client's experience and explored the rupture during the rupture session. Change-oriented interventions (e.g., changing interpersonal interactions; highlighting patterns of behavior, thought, or emotions) were generally rated as less effective to use during the rupture, but effective for use in future sessions.

Conclusions

The findings are consistent with the growing literature on the value of using certain alliance-focused interventions during a rupture. The findings point to the importance of therapists' awareness of the state of the alliance so that they can identify when ruptures are occurring.

Neural Substrate of Group Mental Health: Insights from Multi-Brain Reference Frame in Functional Neuroimaging

Contemporary mental health practice primarily centers around the neurobiological and psychological processes at the individual level. However, a more careful consideration of interpersonal and other group-level attributes (e.g., interpersonal relationship, mutual trust/hostility, interdependence, and cooperation) and a better grasp of their pathology can add a crucial dimension to our understanding of mental health problems. A few recent studies have delved into the interpersonal behavioral processes in the context of different psychiatric abnormalities. Neuroimaging can supplement these approaches by providing insight into the neurobiology of interpersonal functioning. Keeping this view in mind, we discuss a recently developed approach in functional neuroimaging that calls for a shift from a focus on neural information contained within brain space to a multi-brain framework exploring degree of similarity/dissimilarity of neural signals between multiple interacting brains. We hypothesize novel applications of quantitative neuroimaging markers like inter-subject correlation that might be able to evaluate the role of interpersonal attributes affecting an individual or a group. Empirical evidences of the usage of these markers in understanding the neurobiology of social interactions are provided to argue for their application in future mental health research.

Therapeutic relationship in the treatment of geriatric depression with executive dysfunction

BACKGROUND

The effects of therapeutic relationship (TR) in elder mental health are understudied. A greater understanding of TR in geriatric psychotherapy is particularly needed for treating late-life depression with executive dysfunction, which predicts poor response to antidepressant medication and presents unique clinical challenges.

METHODS

Participants were older patients (N = 220) with major depression and executive dysfunction who received 12 weeks of problem-solving therapy or supportive therapy in a randomized control trial. Multilevel growth curve modeling and latent change scores were used to analyze TR dimensions of Understanding and Accepting at the patient level (individual patient ratings, N = 194) and therapist level (ratings of each therapist averaged across participants, N = 10).

RESULTS

TR predicted reduction of depression in both treatment groups, while treatment×TR interactions were not significant. Patients treated by therapists with higher average Understanding (patient and therapist level) and Accepting (therapist level) ratings had greater decreases in depression. The patient level×therapist level interaction for Understanding approached statistical significance (p=.065), suggesting a synergistic effect on treatment outcome. Together, Understanding and Accepting predicted 21% of variance in depression level changes.

LIMITATIONS

TR was not assessed throughout the course of treatment (only after the first therapy session and at post-treatment) and did not include ratings from an objective evaluator.

CONCLUSIONS

Assessment of patient's experience of the TR and of therapist ability to foster Understanding and Accepting can play a significant role in the delivery of geriatric psychosocial interventions.

Therapeutic Alliance With a Fully Automated Mobile Phone and Web-Based Intervention: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Studies of Internet-delivered psychotherapies suggest that clients report development of a therapeutic alliance in the Internet environment. Because a majority of the interventions studied to date have been therapist-assisted to some degree, it remains unclear whether a therapeutic alliance can develop within the context of an Internet-delivered self-guided intervention with no therapist support, and whether this has consequences for program outcomes.

OBJECTIVE

This study reports findings of a secondary analysis of data from 90 participants with mild-to-moderate depression, anxiety, and/or stress who used a fully automated mobile phone and Web-based cognitive behavior therapy (CBT) intervention called "myCompass" in a recent randomized controlled trial (RCT).

METHODS

Symptoms, functioning, and positive well-being were assessed at baseline and post-intervention using the Depression, Anxiety and Stress Scale (DASS), the Work and Social Adjustment Scale (WSAS), and the Mental Health Continuum-Short Form (MHC-SF). Therapeutic alliance was measured at post-intervention using the Agnew Relationship Measure (ARM), and this was supplemented with qualitative data obtained from 16 participant interviews. Extent of participant engagement with the program was also assessed.

RESULTS

Mean ratings on the ARM subscales were above the neutral midpoints, and the interviewees provided rich detail of a meaningful and collaborative therapeutic relationship with the myCompass program. Whereas scores on the ARM subscales did not correlate with treatment outcomes, participants' ratings of the quality of their emotional connection with the program correlated significantly and positively with program logins, frequency of self-monitoring, and number of treatment modules completed (r values between .32-.38, P≤.002). The alliance (ARM) subscales measuring perceived empowerment (r=.26, P=.02) and perceived freedom to self-disclose (r=.25, P=.04) also correlated significantly in a positive direction with self-monitoring frequency.

CONCLUSIONS

Quantitative and qualitative findings from this analysis showed that a positive therapeutic alliance can develop in the Internet environment in the absence of therapist support, and that components of the alliance may have implications for program usage. Further investigation of alliance features in the Internet environment and the consequences of these for treatment outcomes and user engagement is warranted.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number (ACTRN): 12610000625077; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=335772&isReview=true (Archived by WebCite at http://www.webcitation.org/6efAc5xj4).

Intrinsic Connectivity Networks in post-traumatic stress disorder during sub- and supraliminal processing of threat-related stimuli

OBJECTIVE

To investigate the functional connectivity of large-scale intrinsic connectivity networks (ICNs) in post-traumatic stress disorder (PTSD) during subliminal and supraliminal presentation of threat-related stimuli.

METHOD

Group independent component analysis was utilized to study functional connectivity within the ICNs most correlated with the Default-mode Network (DMN), Salience Network (SN), and Central Executive Network (CEN) in PTSD participants (n = 26) as compared to healthy controls (n = 20) during sub- and supraliminal processing of threat-related stimuli.

RESULTS

Comparing patients with PTSD with healthy participants, prefrontal and anterior cingulate cortex involved in top-down regulation showed increased integration during subliminal threat processing within the CEN and SN and during supraliminal threat processing within the DMN. The right amygdala showed increased connectivity with the DMN during subliminal processing in PTSD as compared to controls. Brain regions associated with self-awareness and consciousness exhibited decreased connectivity during subliminal threat processing in PTSD as compared to controls: the claustrum within the SN and the precuneus within the DMN.

CONCLUSION

Key nodes of the ICNs showed altered functional connectivity in PTSD as compared to controls, and differential results characterized sub- and supraliminal processing of threat-related stimuli. These findings enhance our understanding of ICNs underlying PTSD at different levels of conscious threat perception.

Effect of client-therapist gender match on the therapeutic relationship: an exploratory analysis

Matching clients and counselors on the basis of heuristics, such as gender, is common in clinical practice. Considerable research has examined the effect of gender matching on the therapeutic alliance with equivocal results. Researchers have offered various hypotheses to explain these findings without consensus. This study sought to examine gender matching in a naturalistic setting and proposed that gender matching varies in importance depending upon the stage of the therapeutic relationship. It was hypothesized that gender matching affects the therapeutic alliance initially and then becomes less important as other factors come into play. Results did not support the hypothesis but showed a general "female effect." Across all stages of therapy, female clients matched with female therapists reported therapeutic alliance ratings higher than dyads with a male therapist. Dyads with a female therapist and male client also reported alliance higher than male gender matched dyads. Implications of these results, limitations, and future directions are discussed.

The working alliance: Where have we been, where are we going?

OBJECTIVE

This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptualization.

METHOD

Major research efforts on the topic are reviewed. The review includes both theoretical and empirical literature on the working alliance and related constructs, such as alliance ruptures and repair, and therapeutic negotiation. Existing measures of the working alliance are also reviewed.

RESULTS

The working alliance is critiqued on both theoretical and empirical grounds, including the strengths and limitations of current approaches and assessments. Recent theoretical developments are reviewed, among them work on alliance rupture and repair and the reconceptualization of the alliance as a process of therapeutic negotiation. Emerging applications of advanced statistical techniques to measure the working alliance are also considered.

CONCLUSION

The review concludes by supporting recent efforts that have attempted to increase the sophistication of measurement tools and statistical approaches, and encouraging future research in these areas.

Patient-oncologist alliance as protection against suicidal ideation in young adults with advanced cancer

BACKGROUND

Young adults with cancer are at an increased risk of suicidal ideation. To the authors' knowledge, the impact of the patient-oncologist alliance on suicidal ideation has not been examined to date. The current study examined the relationship between the patient-oncologist therapeutic alliance and suicidal ideation in young adults with advanced cancer.

METHODS

A total of 93 young adult patients (aged 20 years-40 years) with incurable, recurrent, or metastatic cancer were evaluated by trained interviewers. Suicidal ideation was assessed with the Yale Evaluation of Suicidality scale, dichotomized into a positive and negative score. Predictors included diagnoses of major depressive disorder and posttraumatic stress disorder, physical quality of life, social support, and use of mental health and supportive care services. The Human Connection Scale, dichotomized into a strong (upper third) and weak (lower two-thirds) therapeutic alliance, assessed the strength of the patients' perceived oncologist alliance.

RESULTS

Approximately 22.6% of patients screened positive for suicidal ideation. Patients with a strong therapeutic alliance were found to be at reduced risk of suicidal ideation after controlling for confounding influences of cancer diagnosis, Karnofsky performance status, number of physical symptoms, physical quality of life, major depressive disorder, posttraumatic stress disorder, and social support. A strong therapeutic alliance was also associated with a reduced risk of suicidal ideation after controlling for mental health discussions with health care providers and use of mental health interventions.

CONCLUSIONS

The patient-oncologist alliance was found to be a robust predictor of suicidal ideation and provided better protection against suicidal ideation than mental health interventions, including psychotropic medications. Oncologists may significantly influence patients' mental health and may benefit from training and guidance in building strong alliances with their young adult patients.

Patient-oncologist alliance, psychosocial well-being, and treatment adherence among young adults with advanced cancer

PURPOSE

Patients who develop a strong alliance with their health care providers have been shown to have higher levels of psychosocial well-being and rates of treatment adherence. Young adults with cancer have lower levels of psychosocial well-being and treatment adherence relative to patients with cancer in other age groups. This study sought to evaluate the relationships between the patient-oncologist alliance, psychosocial well-being, and treatment adherence in young adults with advanced cancer.

PATIENTS AND METHODS

Ninety-five young adults (age 20 to 40 years) with advanced cancer were administered measures of alliance, psychosocial well-being, willingness to adhere to treatment, and treatment adherence. Relationships between alliance and psychosocial well-being were examined bivariately. Multiple linear regression models examined the relationship between alliance and adherence, controlling for confounding influences (eg, psychosocial well-being).

RESULTS

Alliance was significantly (P ≤ .01) and positively associated with greater perceived social support and less severe illness-related grief. After controlling for significant confounding influences (ie, metastases, appraised support, and grief), alliance remained significantly (P ≤ .01) associated with greater willingness to adhere to treatment and greater adherence to oral medication.

CONCLUSION

By developing a strong alliance, oncologists may enhance psychosocial well-being and increase treatment adherence in young adult patients with advanced cancer.

Functional Analysis of the Verbal Interaction Between Psychologist and Client During the Therapeutic Process

The goal of this study is to analyze the verbal interaction that takes place between client and therapist over the course of a clinical intervention so as to analyze the potential learning processes that may be responsible for changes in the client’s behavior. A total of 92 sessions were analyzed, corresponding to 19 clinical cases treated by 9 therapists specializing in behavioral therapy. The variables considered were therapist and client verbal behaviors, and these were categorized according to their possible functions and/or morphologies. The Observer XT software was used as a tool for the observational analysis. The results led to the conclusion that the therapist responds differentially to client verbalizations, modifying the verbal contingencies as his or her client content approaches or becomes more distant from therapeutic objectives. These results suggest the possible existence of verbal “shaping” processes through which the therapist guides the client’s verbal behavior toward more adaptive forms. In addition, this study proposes an alternative to the traditional controversy regarding the relevance of the therapeutic relationship versus the treatment techniques used to explain clinical change. This article suggests that such differentiation is unnecessary because the therapeutic relationship and the treatment techniques should act in the same manner, this is, in providing the context for the occurrence of what is truly therapeutic, namely, the learning processes.

Look to the relationship: a review of African American women substance users' poor treatment retention and working alliance development

Emergent findings specific to African American women confirm that their substance user treatment retention rates are significantly lower than other groups, which is problematic given that substance user treatment is effective largely to the extent that clients are retained in treatment. This article reviews existing literature concerning disparities in treatment retention, highlights a significant barrier to treatment retention for this population, and presents support for an empirical focus on culturally responsive working alliance development as a promising step toward improving retention rates for African American women substance users.

The therapeutic relationship and adherence to antipsychotic medication in schizophrenia

Objective

Previous research has shown that a better therapeutic relationship (TR) predicts more positive attitudes towards antipsychotic medication, but did not address whether it is also linked with actual adherence. This study investigated whether the TR is associated with adherence to antipsychotics in patients with schizophrenia.

Methods

134 clinicians and 507 of their patients with schizophrenia or a related psychotic disorder participated in a European multi-centre study. A logistic regression model examined how the TR as rated by patients and by clinicians is associated with medication adherence, adjusting for clinician clustering and symptom severity.

Results

Patient and clinician ratings of the TR were weakly inter-correlated (r_s = 0.13, p = 0.004), but each was independently linked with better adherence. After adjusting for patient rated TR and symptom severity, each unit increase in clinician rated TR was associated with an increase of the odds ratio of good compliance by 65.9% (95% CI: 34.6% to 104.5%). After adjusting for clinician rated TR and symptom severity, for each unit increase in patient rated TR the odds ratio of good compliance was increased by 20.8% (95% CI: 4.4% to 39.8%).

Conclusions

A better TR is associated with better adherence to medication among patients with schizophrenia. Patients' and clinicians' perspectives of the TR are both important, but may reflect distinct aspects.

Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research

This paper proposes a historical excursus of studies that have investigated the therapeutic alliance and the relationship between this dimension and outcome in psychotherapy. A summary of how the concept of alliance has evolved over time and the more popular alliance measures used in literature to assess the level of alliance are presented. The proposal of a therapeutic alliance characterized by a variable pattern over the course of treatment is also examined. The emerging picture suggests that the quality of the client-therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. In our opinion, with regard to the relationship between the therapeutic alliance and outcome of psychotherapy, future research should pay special attention to the comparison between patients' and therapists' assessments of the therapeutic alliance. This topic, along with a detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects.

Psychotherapy, psychopathology, research and practice: pathways of connections and integration

This paper describes three pathways of connections between different communities of knowledge seekers: integration of psychotherapeutic approaches, integration of psychotherapy and psychopathology, and integration of science and practice. Some of the issues discussed involve the delineation and investigation of common factors (e.g., principles of change), improvement of major forms of psychotherapy, clinical implications of psychopathology research, as well as current and future directions related to practice-research networks. The aim of this paper is to suggest that building bridges across theoretical orientations, scientific fields, professional experiences, and epistemological views may be a fruitful strategy to improve our understanding and the impact of psychotherapy.

Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies

A wave of new developments has occurred in the behavioral and cognitive therapies that focuses on processes such as acceptance, mindfulness, attention, or values. In this review, we describe some of these developments and the data regarding them, focusing on information about components, moderators, mediators, and processes of change. These "third wave" methods all emphasize the context and function of psychological events more so than their validity, frequency, or form, and for these reasons we use the term "contextual cognitive behavioral therapy" to describe their characteristics. Both putative processes, and component and process evidence, indicate that they are focused on establishing a more open, aware, and active approach to living, and that their positive effects occur because of changes in these processes.

Social networks and social control of probationers with co-occurring mental and substance abuse problems

Probationers with co-occurring mental and substance abuse problems (PCPs) are both subject to considerable social control, and at high risk of probation failure. In this study, we screened 601 probationers for symptoms, interviewed 82 identified PCPs about their relationships, and then followed these PCPs for eight months to record treatment nonadherence and other probation violations. First, PCPs' social networks were small, heavily comprised of professionals and opposing forces who engaged in risky behavior, and saturated with pressure to adhere to treatment. Second, the size and composition of PCPs' social networks were more relevant to rule compliance than social support and undermining. Third, the quality of PCPs' relationships was key: satisfying relationships with clinicians and, to a lesser extent, officers and the core network related to low perceived coercion, high treatment adherence, and low risk of future violations. In particular, having a likable clinician who engaged in participatory decision-making reduced the risk of violations. Implications for contextually sensitive risk reduction efforts are discussed.

Strategic eclecticism in hypnotherapy: effectiveness research considerations

Hypnosis is attempting to come to grips with the EST (Empirically Supported Therapy) revolution in mental health practice. However, there are ways to account for outcome outside of simple empirical validation of treatment models. In this light, strategic eclecticism as a broader research-based consideration is used to illustrate empirical principles within Eriksonian hypnotherapeutic approaches.

Youth working alliance: a core clinical construct in need of empirical maturity

The therapeutic alliance has long been recognized as an important component of successful psychotherapy for adults; research has established robust links to outcome. Until recently, however, research on the alliance between youth and their therapists has been sparse. The present review synthesizes the existing findings regarding the youth alliance and utilizes the adult alliance literature and the child and adolescent developmental literatures to suggest future avenues of research. Weak alliance was found to predict premature termination, and strong alliance predicted symptom reduction, with some support for differential effects of the youth-therapist and parent-therapist alliances. In addition, the youth alliance is moderated by several patient and therapist characteristics, including the particular problems of patients and the interpersonal skills of therapists. The field has yet to coalesce around a single definition of the youth alliance, however, making it difficult to assess research results. Adult models of the alliance continue to be used heuristically despite some evidence that the alliance operates differently for youth. Tightening the operational definition of the youth alliance and addressing methodological issues will be essential in future efforts to understand how the alliance develops and what role it may play in the treatment process for youth.

Are patient expectations still relevant for psychotherapy process and outcome?

Patient expectations have been regarded as a variable affecting the course of psychotherapy for more than 50 years. Yet, even though expectations are often considered a factor common to most psychotherapy systems, their importance may be undervalued. This paper places the expectancy issue in a historical context, discusses the varied definitions of expectancy, and reviews the extant expectancy research literature. Discussion of results affirms the continuing relevance of patient expectations, suggests that they may be even more vital to the psychotherapy process than is often acknowledged, highlights research strengths and weaknesses, and calls attention to areas on which clinicians and researchers might focus to improve treatment effectiveness.

Integrative dimensions of psychotherapy training

This paper investigates the influence of integrative factors on psychotherapy education. The broad relevance of integrative psychotherapy to residency training and continuing mental health education is discussed. Following a review of the existing literature on the education of integrative psychotherapists, the article systematically examines the integrative and pedagogic issues to be considered in planning psychotherapy training informed by integrative principles. The integrative issues are organized into 5 categories: attitudinal set, knowledge base, clinical techniques and skills, developmental tasks and challenges, and systemic institutional factors. The educational issues can be divided into 4 categories: content, format and process, sequence, and faculty development. Brief descriptions of actual educational interventions illustrate the implementation of such ideas. Specific recommendations are made regarding the development of integrative educational initiatives and future study of unresolved questions.

The early impact of therapeutic alliance in brief psychodynamic psychotherapy

INTRODUCTION

Therapeutic alliance is a key component of the psychotherapeutic process. This study estimated the impact of the therapeutic alliance as measured by CALPAS-P in an individual brief psychodynamic psychotherapy program.

METHODS

To study the impact of the therapeutic alliance patients in psychotherapy answered to the CALPAS-P at the first and third session and to the Self-report Questionnaire (SRQ-20), to the Beck Depression Inventory (BDI) and to the Hamilton Anxiety Scale at the beginning and at the end of psychotherapy.

RESULTS

The study of the impact of the therapeutic alliance in brief psychodynamic psychotherapy showed that higher TUI scores in the first session were significantly associated to the improvement on the BDI. Patients with best scores in the working alliance, measured at the third PWC session had also significant symptomatic changes.

DISCUSSION

The study of the impact of the therapeutic alliance in brief psychotherapy indicated that patients who perceived that their therapists had the best capability to understand and to be involved in their issues had best results in reducing depressive symptoms and patients with higher capability to form the working alliance reached the best psychotherapy outcomes.