The dependability of alliance assessments: the alliance-outcome correlation is larger than you might think

The family alliance as a facilitator of therapeutic change in systemic relational psychotherapy for borderline personality disorder: A case study

Managing the Therapeutic Alliance is often complex when it comes to the treatment of borderline personality disorder (BPD), but the alliance is crucial for the success of the therapy. Combined individual and family interventions have been shown to be very useful in treating of these cases. This study has two objectives. First, to describe how the family therapeutic alliance facilitates therapeutic change through family psychotherapy for families with a member diagnosed with BPD. Second, to analyze how the therapeutic change achieved through combined individual and family systemic relational psychotherapy affects the individual functioning of the patient with BPD. This single case study used the System of Observation of Family Therapy Alliances (SOFTA-o) to analyze the therapeutic alliance, along with two semi-structured clinical interviews, one at the beginning and one at the end of therapy. Results show a dynamic and positive evolution of the therapeutic alliance throughout the therapeutic process and how this alliance facilitated therapeutic change, both reducing the symptomatology of the patient with BPD and improving family communication and functioning. Results contribute to highlighting the importance of including family therapy as an intervention unit in protocols for patients with BPD.

Applying the practice-based competencies to evaluate and characterize the contracting process within genetic counseling sessions

Contracting is a skill used by genetic counselors (GCs) to establish a shared vision for the session. Ensuring that patients and GCs are aligned on expectations for the encounter allows GCs to meet patient needs and support patient autonomy. Although contracting is described in the practice-based competencies (PBCs), the process has not been systematically observed in practice. We sought to further elucidate the skills used for contracting within genetic counseling sessions through directed content analysis of transcripts from 148 simulated prenatal and cancer genetic counseling sessions. An a priori codebook and rating scale were developed based on four contracting sample skills described in the PBCs: (a) describing the genetic counseling process, (b) eliciting client concerns, (c) applying client concerns to a session agenda, (d) modifying the agenda in response to emerging concerns. The rating scale described the quality of each skill on a 4-point scale of "absent," "minimal," "adequate," and "excellent." The codebook and rating scale were pilot tested with 40% of transcripts (n = 60). Three authors independently coded and rated the final 60% of transcripts (n = 88), resolving discrepancies via a consensus process. We found that the four PBC skills were present in most sessions (88%-98%), and on average, GCs received "adequate" scores on all four skills. We also identified three additional components of contracting not described in the PBCs: assessing whether client concerns were met, inviting to interrupt, and providing opportunity for partner concerns. This study represents the first attempt to evaluate GC performance of a PBC during a genetic counseling session. Our findings demonstrate that the PBC sample contracting skills reflect practice and suggest that they can be used in assessment of the genetic counseling contracting process. This type of analysis could be adapted in the future to provide support for other standards of practice in the genetic counseling field.

Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial

BACKGROUND

Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression.

OBJECTIVE

This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments.

METHODS

We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables.

RESULTS

Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005).

CONCLUSIONS

To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-016-1511-1.

Dissemination of a dissonance-based body image promotion program for mothers and daughters in church settings: A controlled pilot study of Reclaiming Beauty

This proof of concept, controlled pilot study expands on existing dissonance-based body image promotion programs by testing a modified version of the Body Project for 136 mothers and daughters aged 11-18 years old in church settings called Reclaiming Beauty. Mothers (n = 30) and their daughters (n = 35) who participated in Reclaiming Beauty were compared to mothers (n = 32) and daughters (n = 39) in a waitlist, assessment-only, control group on body image, eating psychopathology, and risk factor measures (thin-ideal internalization, physical appearance comparison) at pre-, post-, and 6-month-follow-up assessments. Intent-to-treat, multilevel modeling indicated that mothers and daughters in the Reclaiming Beauty group experienced significant improvement in body appreciation, body shape concerns, eating psychopathology, thin-ideal internalization, and physical appearance comparison over a six-month period compared to control participants. Changes in thin-ideal internalization and appearance comparison did not predict body image and eating psychopathology at follow-up. Baseline levels of body satisfaction did not moderate the effect of the program, except for its effect on body shape concerns. Findings provide preliminary support for delivering a dissonance-based body image promotion intervention to mothers and their daughters and the feasibility of leveraging the mother-daughter relationship as well as delivering interventions in church settings.

Where it all begins: Predicting initial therapeutic skills before clinical training in cognitive behavior therapy

To train novice students adequately, it is crucial to understand where they start and how they develop their skills. This study examined the impact of novice students' characteristics on their initial clinical micro-skills when treating simulated patients with cognitive behavior therapy. The sample consisted of 44 graduate psychology students treating seven simulated patients. Clinical micro-skills were measured both using video-based ratings in reaction to short video clips of simulated patients (via the Facilitative Interpersonal Skills (FIS) performance task) and by using video-based ratings within a session with a simulated patient (using the Inventory of Therapeutic Interventions and Skills; ITIS). Two separate LASSO regressions were performed using machine learning to select potential predictors for both skills assessments. Subsequently, a bootstrapping algorithm with 10,000 iterations was used to examine the variability of regression coefficients. Using LASSO regression, we identified two predictors for clinical micro-skills in standardized scenarios: extraversion (b = 0.10) and resilience (b = 0.09), both were not significantly associated with clinical micro-skills. Together, they explained 15% of the skill variation. Bootstrapping confirmed the stability of these predictors. For clinical micro-skills in sessions, only competitiveness was excluded by LASSO regression, and all predictors showed significant instability. The results provide initial evidence that trainees' resilience and extraversion should be promoted in the clinical training of cognitive behavior therapy. More studies on clinical micro-skills and training with larger sample sizes are needed to fully understand clinical development.

Temporal sequencing of change in trauma-related beliefs and therapeutic alliance during prolonged exposure and sertraline for chronic PTSD

OBJECTIVE

Changes in trauma-related beliefs and therapeutic alliance have been found to temporally precede symptom reduction; however, it is likely these processes do not act in isolation but rather in interactive ways.

METHODS

The present study examined the temporal relationships between negative posttraumatic cognitions (PTCI) and therapeutic alliance (WAI) in 142 patients who were part of a randomized trial comparing prolonged exposure (PE) to sertraline for chronic PTSD.

RESULTS

Using time-lagged mixed regression models, improvements in the therapeutic alliance predicted subsequent improvements in trauma-related beliefs (d = 0.59), an effect accounted for by between-patient variability (d = 0.64) compared to within-patient variability (d = .04) giving weaker support to the causal role of alliance on outcome. Belief change did not predict improvements in alliance and neither model was moderated by treatment type.

CONCLUSION

Findings suggest alliance may not be an independent driver of cognition change and point to the need for additional study of the impact of patient characteristics on treatment processes.

The therapeutic alliance in couple therapy: Patterns by treatment and sex in a randomized controlled trial of emotionally focused therapy and treatment as usual

The formation and development of the therapeutic alliance in couple therapy is a complex process and a key contributor to positive treatment outcomes. This study explored differences in trajectories of therapeutic alliance by sex and treatment condition among 24 couples randomized to receive Emotionally Focused Therapy or treatment as usual. The results identified a curvilinear growth pattern for alliance across both treatment groups. Female partners reported higher alliance than male partners after the first session across treatment groups, and female partners receiving Emotionally Focused Therapy reported higher initial alliance than female partners receiving treatment as usual. The rates of change for alliance did not differ by sex or treatment condition. The implications of the change pattern and differences in alliance formation by sex and treatment are discussed.

Adherence patterns to oral hypoglycemic agents among primary care patients with type 2 diabetes

AIMS

To examine patterns of adherence to oral hypoglycemic agents among primary care patients with type 2 diabetes mellitus and to assess whether these patterns were associated with baseline intervention allocation, sociodemographic characteristics, and clinical indicators.

METHODS

Adherence patterns were examined by Medication Event Monitoring System (MEMS) caps at baseline and 12 weeks. Participants (n = 72) were randomly allocated to a Patient Prioritized Planning (PPP) intervention or a control group. The PPP intervention employed a card-sort task to identify health-related priorities that included social determinants of health to address medication nonadherence. Next, a problem-solving process was used to address unmet needs involving referral to resources. Multinomial logistic regression examined patterns of adherence in relation to baseline intervention allocation, sociodemographic characteristics, and clinical indicators.

RESULTS

Three patterns of adherence were found: adherent, increasing adherence, and nonadherent. Participants assigned to the PPP intervention were significantly more likely to have a pattern of improving adherence (Adjusted Odds Ratio (AOR)= 11.28, 95% confidence interval (CI)= 1.78, 71.60) and adherence (AOR=4.68, 95% CI=1.15, 19.02) than participants assigned to the control group.

CONCLUSION

Primary care PPP interventions incorporating social determinants may be effective in fostering and improving patient adherence.

Patient- and therapist-rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment

OBJECTIVE

Concurrent Treatment of Posttraumatic Stress Disorder (PTSD) and Substance Use Disorders Using Prolonged Exposure (i.e., COPE) is an efficacious, integrated, psychotherapy that attends to PTSD and substance use disorders simultaneously. No study has examined how therapeutic alliance functions during the provision of COPE and how this compares to non-integrated treatments, such as relapse prevention (RP) for substance use disorders. Understanding the role of alliance in COPE versus RP could inform treatment refinement and ways to enhance treatment outcomes.

METHODS

Participants (N = 55 veterans) were randomized to 12, individual, weekly sessions of COPE or RP in a randomized clinical trial. Piecewise linear mixed effect models examined how mid-treatment (1) patient-rated alliance, (2) therapist-rated alliance, and (3) the convergence between patient- and therapist-rated alliance as measured by a difference score predicted reductions in PTSD symptoms and substance use across treatment and follow-up periods.

RESULTS

Both patient- and therapist-rated alliance predicted reductions in PTSD symptoms in COPE. Higher patient-rated alliance predicted lower percent days using substances in RP. Difference score models showed higher patient-rated alliance relative to therapist-rated alliance scores predicted symptom reductions in COPE whereas higher therapist-rated alliance scores relative to patient-rated alliance scores predicted symptom reductions in RP.

DISCUSSION

Preliminary findings show a unique relationship between the rater of the alliance and treatment modalities. Patient-rated alliance may be important in trauma-focused, integrated treatments whereas therapist-rated alliance may be more important in skills-focused, substance use interventions.

A Three-level Meta-analysis on the Alliance-Outcome Association in Child and Adolescent Psychotherapy

Previous meta-analyses have found small to moderate associations between child-therapist alliance and treatment outcomes. However, these meta-analyses have not taken into account changes in alliance (i.e., alliance shifts), alliance agreement (i.e., congruence or discrepancies between child-therapist ratings), and the role of alliance as a moderator in relation to treatment outcomes (i.e., an interaction effect of alliance and treatment condition on treatment outcomes). A series of multilevel meta-analyses of 99 studies was conducted to investigate several types of alliance-outcome associations in child and adolescent psychotherapy. Associations between child-therapist alliance and child outcomes (r = 0.17), changes in child-therapist alliance and child outcomes (r = 0.19), child-therapist alliance as a moderator of outcomes (r = 0.09), and parent-therapist alliance and child outcomes (r = 0.13) were small. Associations between child-therapist alliance agreement and outcomes (r = 0.21) and between parent-therapist alliance and parent outcomes (r = 0.24) were small to moderate. This meta-analysis provides the most updated and comprehensive overview of the alliance-outcome association in child and adolescent psychotherapy, showing that the alliance continues to show impact on treatment outcomes. Alliance research in youth psychotherapy has increasingly focused on several complex aspects of the alliance-outcome association, such as the role of changes in alliance, alliance discrepancies, client and therapist variability, and the reciprocal association between alliance and prior symptom change in relation to treatment outcomes. Implications for future research and clinical practice are discussed.

Early trajectories of symptom change and working alliance as predictors of treatment outcome

OBJECTIVE

We aim to examine how different trajectories of symptom change and working alliance in early psychotherapy predict treatment outcomes.

METHOD

We performed a growth mixture model (GMM) to examine trajectories of symptom change and working alliance in the first five therapy sessions in a sample of 272 outpatients and tested the association of early symptom trajectories and alliance patterns with treatment outcome.

RESULTS

We identified two symptom trajectories: high symptom/steady change (63.2%) and early improving (36.8%), and four alliance development patterns: undeveloped alliance (40.1%), strengthening moderate alliance (31.6%), optimal alliance (17.3%), and improved alliance (11%) in early psychotherapy. The symptom trajectories and alliance patterns both independently and interactively predicted treatment outcomes. The optimal alliance was generally associated with the best outcome. The effect of improved alliance on treatment outcome was moderated by symptom trajectories: for high symptom/steady change subgroup, the improved alliance was related to better treatment outcome, whereas for early improving subgroup, the improved alliance was associated with poorer outcome.

CONCLUSIONS

Patients fell into different trajectories regarding symptom reduction and alliance development in early psychotherapy that affected final treatment outcome. Combining early symptom trajectories and alliance trajectories simultaneously can facilitate routine outcome monitoring and contribute to the prediction of treatment outcome.

Baseline overly accommodating interpersonal problems in relation to parsed alliance-outcome associations in cognitive behavioral therapy for generalized anxiety disorder

Given its interpersonal underpinnings, relational factors may be salient in psychotherapy for generalized anxiety disorder (GAD). Supporting this point, research has indicated a positive total alliance-improvement correlation in cognitive behavioral therapy (CBT) for GAD. However, less research has disaggregated this correlation into within- and between-patient components, or examined theory-informed ways in which patient characteristics influence to these components. Thus, we first investigated parsed alliance-outcome associations in CBT for GAD. Second, consistent with theory that alliance may represent a direct interpersonal change correlate, we tested whether within-patient alliance improvements were especially therapeutic for patients with higher levels of an interpersonal problem prototypical of GAD-over accommodation. Also, consistent with theory that between-patient differences in overall alliance may be influenced by patients' preexisting relational characteristics, we tested whether more overly accommodating patients reported poorer average alliances that, in turn, related to worse outcomes.

Sixty-nine patients received variants of CBT. Patients rated over accommodation at baseline, and alliance and outcome across treatment.

As hypothesized, within-patient alliance improvements correlated with subsequent anxiety reduction, and this association was stronger for more overly accommodating patients. All between-patient associations were nonsignificant.

Results help clarify the nuanced role of alliance in CBT for GAD.

Patient Experiences With Telemental Health During the COVID-19 Pandemic

Telemental health (TMH) was an effective and relatively well-accepted way of delivering mental health care prior to the COVID-19 pandemic and has become widely adopted through the pandemic. Although recent findings show telehealth remains relatively well accepted across health care broadly, little is known about how patient experiences of TMH may have changed through the pandemic as many sectors were virtualized. These findings describe patient experiences with TMH at an outpatient mental health clinic approximately 1 year after the clinic rapidly transitioned to full TMH due to COVID-19. Respondents are 137 adult patients. Most patients reported TMH to be extremely or very effective (85.0%) and better than anticipated (76.8%). Most patients (74.6%) were interested in continuing at least some visits by TMH after the pandemic. A small subset of patients who rated their relationship with their provider as better in-person than by TMH also reported a preference for most or all visits in-person. Results provide preliminary support that TMH remains a well-accepted option for many patients. Mental health clinics may best serve patients by offering a hybrid model of care that includes both TMH and in-person services.

Prospective associations between working alliance, basic psychological need satisfaction, and coaching outcome indicators: a two-wave survey study among 181 Dutch coaching clients

BACKGROUND

The coach-coachee working alliance and coachee motivation seem important factors for achieving positive coaching results. Self-determination theory, specifically basic psychological need theory, has been proposed as a relevant framework for understanding these relationships. The current longitudinal survey study therefore investigates prospective associations between coachees' appraisal of the working alliance, basic psychological need satisfaction, and the coaching outcome indicators goal attainment, wellbeing, absence of psychopathology, and personal growth initiative.

METHODS

The sample (N = 181) consisted of Dutch coachees that were recruited across a range of coaching settings and contexts. Online self-report questionnaires were administered twice (T0 and T1), with an intervening time of 3 weeks, assessing working alliance, basic psychological need satisfaction, goal attainment, wellbeing, absence of psychopathology, and personal growth initiative. Parallel analysis with Monte Carlo simulations and confirmatory factor analyses were performed to assess the dimensionality of working alliance and basic psychological need satisfaction scores. Multiple regression analyses (stepwise) were used to examine prospective (T0 to T1) associations between working alliance and basic psychological need satisfaction, and their association with outcome indicators.

RESULTS

The coachees' perception of the working alliance was positively and reciprocally, although modestly, associated with basic psychological need satisfaction. In addition, both working alliance and basic psychological need satisfaction were prospectively associated with goal attainment, but not with other outcome indicators.

CONCLUSIONS

Results provide tentative support for a role of basic psychological need satisfaction in facilitating the establishment of a good working alliance. Additionally, the perception of a good quality, need supportive relationship with the coach appears to be associated with better goal achievement, but not with other outcome indicators. Associations were generally modest, and more research is needed to better measure and comprehend the unique contributions of specific relational and motivational factors to outcomes in coaching and assess the robustness of the current study findings.

The Association Between Political Climate and Trainees' Supervision Experiences and Needs

This study examined whether political climate influenced trainees' clinical work, supervisory experiences, and supervisory alliance. Data were collected from 366 trainees in a nationwide survey. Most trainees believed the political atmosphere affected clients to some degree. Over half reported political dialogue with supervisors, more often when political affiliation was similar. Supervisory alliances were most positive when trainees were aware of their supervisors' political beliefs, regardless of agreement. Trainees wanted supervisors to provide greater awareness of multicultural issues and political climate in their clinical work. We recommend that supervisors invite trainees to discuss political effects on their clinical work.

What Works for Whom: Patients' Psychological Resources and Vulnerabilities as Common and Specific Predictors of Working Alliance in Different Psychotherapies

Background

Across different types of psychotherapy, one of the most robust predictors of better therapeutic outcomes is a good working alliance between patient and therapist. Yet there is little comparative research on whether particular patients more likely achieve a better alliance in certain treatments which represent particular therapeutic approaches or durations.

Methods

326 patients suffering from depressive and/or anxiety disorder were randomized into two short-term (solution-focused or psychodynamic) and one long-term (psychodynamic) therapy models. Treatments lasted ~7 and 36 months, respectively. Before randomization, patients were assessed with the interview-based Suitability for Psychotherapy Scale and filled Childhood Family Atmosphere and Life Orientation Test questionnaires. Patients filled Working Alliance Inventory after 3rd therapy session and at end of treatment; the long-term therapy patients, additionally, at 7 months' time point. Linear regression models were used.

Results

Greater psychological resources (e.g., capacity for self-reflection, affect regulation, flexible interaction) had little effect on alliance during the course of the short-term therapies. However, they did predict better working alliances at end of long-term as opposed to short-term therapy. Childhood adversities impacted alliances already at 7 months.

Conclusions

Although patients with certain qualities achieve better alliances in long-term as opposed to short-term therapies, apparently the theoretical orientation of therapy makes little difference. For patients with childhood adversities, differences between long-term (psychodynamic) treatment vs. various brief therapy models may be particularly salient.

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.

Within-patient perceptions of alliance and attunement: Associations with progress in psychotherapy

The most frequently examined aspect of the therapeutic relationship is the working alliance, which reflects the conscious collaborative bond, and agreement on task and goal. In addition to the established importance of the working alliance, the therapists' attunement and responsiveness might reflect another important aspect of the therapeutic relationship that can be considered in relation to session-by-session progress over treatments. Emerging research suggests that the quality of the working alliance not only differs between patients but also within patients over time. However, little is known about the quality of the therapeutic relationship between and within patients in relation to progress in psychotherapy. We examined fluctuations of the working alliance measure (WAI) and the newly developed measure of the Patients' Experiences of Attunement and Responsiveness (PEAR) during treatment in a naturalistic sample of patients in an outpatient psychotherapy clinic. Multilevel modelling was used to examine the respective contribution of these measures to subsequent improvement in psychological functioning longitudinally. Results suggest that the within-patient effect, instead of between-patient effect, was significant for WAI (and did not reach significance for PEAR), indicating that the fluctuation of WAI was predictive of psychological functioning in the subsequent month. Based on these findings, therapists and their patients might benefit from regular tracking of the patient-reported working alliance. The findings underscore the importance of the alliance, specifically at the within-patient level. It also highlights the challenge for research to tap into other aspects of the therapeutic relationship that can help explain progress in therapy. Given the breadth and accessibility of the working alliance construct, more work is needed for researchers to examine the construct of attunement and responsiveness.

The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review

It is well established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6472 studies, of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalizability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.

Therapeutic Alliance in Cognitive Behavioural Therapy in Child and Adolescent Mental Health-Current Trends and Future Challenges

This extended literature review proposes to present the trends in the therapeutic alliance, outcomes, and measures in the last decade within the premises of individual cognitive behaviour therapy (CBT) and its innovations, used as an interventional measure in the context of child and adolescent mental health setting. A brief background of the rationale for conducting this literature search is presented at the start. This is followed by the methodology and design which incorporates the inclusion and exclusion criteria and the basis for the same. The critical appraisal of the primary studies is presented in the literature review section with a brief description of the summary features of the studies in the study tables followed by the results and discussion of the study findings. To summarise, the literature review of primary studies conducted in the last decade demonstrates the need for further research to be conducted both in the field of CBT in children and therapeutic alliance, competence, and therapy outcomes, integrating perspectives in child development, carer alliance, and the social construct theory in children, to allow for further innovations in CBT in the context of increasing challenges in the current times of exponentially developing technology and its utility without compromising the quality of therapy. In conclusion, recommendations are made as a guideline for future studies and research in this field.

When less is more: The perception of psychotherapy techniques as a function of patient personality disorder

OBJECTIVE

Psychopathology research suggests that individuals with higher levels of personality disorder (PD) traits, especially those with a comorbid major depressive disorder (MDD), tend to be highly aroused in interpersonal contexts, manifested by an intensified perception of interpersonal interactions. Little is known about the way this tendency manifests in the process of psychotherapy. The current study explored the patient's perception of techniques in psychotherapy among patients with higher vs. lower levels of PD, as well as the patient-therapist agreement on techniques used.

DESIGN

The study used an integration of qualitative and quantitative methodology on data from a randomized controlled trial (RCT) for the treatment of depression.

METHOD

Sixty-nine patients with MDD participated in the study and were evaluated for PD symptoms prior to treatment. A set of multilevel analyses were conducted to assess the association between PD and perception of techniques, as well as a zoom-in exploration within a case study.

RESULTS

Patients with higher levels of PD reported more techniques implemented by the therapist than patients with lower levels. In addition, the agreement between patient and therapist on techniques was lower, such that patients with PDs reported more techniques than their therapist. The case study supported these findings and illustrates the potential for patients with PDs to perceive a greater use of techniques as a sign of therapist investment.

CONCLUSION

Consistent with psychopathology research, the findings suggest that patients with PDs tend to experience techniques as more intense than the therapist, in comparison with patients without PD.

PRACTITIONER POINTS

There are indications that patients with higher levels of personality disorder traits will tend to experience the techniques in psychotherapy in a more intense manner than patients with lower level personality disorder traits. It is likely that patients with higher levels of personality disorder traits will experience their therapists as more active than therapists think they are. Therapists of patients with higher levels of personality disorders should be sensitive of each of their patients' experiences. As the case study demonstrated at least in some cases patients with higher levels of personality disorder may experience the techniques in an intense manner as a sign of therapist investment, however, other patients may experience this differently. Therefore, it is crucial for the therapist to be aware of how the patient experienced the encounter - investment or intrusiveness.

Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis

BACKGROUND

Therapeutic alliance is a key element of successful therapy. Despite being particularly relevant in people with posttraumatic stress disorder (PTSD), due to fear, mistrust and avoidance, there has not yet been a comprehensive systematic review of therapeutic alliance in this population. This review explored (a) variables which may predict alliance and (b) whether alliance predicts PTSD outcomes.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the review identified 34 eligible studies. Studies were subjected to a quality assessment. Predictors of alliance were considered in a narrative synthesis. Twelve studies were entered into a meta-analysis of the association between therapeutic alliance and PTSD outcomes.

RESULTS

There was some evidence for individual variables including attachment, coping styles and psychophysiological variables predicting the alliance. Therapy variables did not predict alliance. The therapeutic alliance was found to significantly predict PTSD outcomes, with an aggregated effect size of r = -.34, across both in-person and remote therapies.

LIMITATIONS

Included studies were restricted to peer-reviewed, English language studies. Quality of included studies was mostly rated weak to moderate, primarily reflecting issues with selection bias in this area of research.

CONCLUSIONS

This is the first review to demonstrate that therapeutic alliance is a consistent predictor of PTSD outcomes, in both in-person and remote therapies, and the effect appears at least as strong as in other populations. This is of relevance to clinicians working with traumatized populations. The review identified a need for further research to determine variables predicting alliance in therapy for PTSD.

Does the working alliance mediate the therapist competence-outcome relationship in cognitive behavior therapy for depression?

Objective: This study examined whether the working alliance mediated the effect of therapist competence on subsequent depression symptomology during Cognitive Behavioral Therapy (CBT). We also tested the potential moderation effect of alliance on subsequent depressive symptomology, based on participants' cognitive aptitude.Method: A total of 86 sessions were coded as the prediction interval across 50 patient-therapist dyads (age M = 39.22, SD = 8.78; 76% female). While accounting for prior depression, competence, and alliance levels, predictors were assessed early treatment (session 1; n = 45 sessions), mid-treatment (session 12; n = 41 sessions), and depressive symptomology was assessed at the subsequent session to the predictor assessments to investigate within-session variability of process variables.Results: Mediation analysis revealed that the effect of early treatment therapist competence on symptom change was mediated by alliance (indirect effect: β = -.17, 95% percentile bootstrap CI [-.32, -.01]). The positive association involving early treatment alliance and next session outcome was conditional upon low cognitive aptitude levels.Conclusions: Our result offers preliminary support for alliance as a mediator of the effect of competence, and that alliance-outcome relations vary as a function of client aptitude. These novel findings require replication and extension.

Similarities in client-clinician perceptions of subjective social status and its association to similarities in the quality of working alliance and client anxiety symptoms

Subjective social status (SSS) has largely been ignored within psychotherapy literature. We investigated the association between similarities in client-clinician perceptions of SSS, similarities in their report of the quality of working alliance, and resultant anxiety symptoms.

Participants represented a primarily low-income, culturally diverse sample of 312 clients receiving care from 68 clinicians at 13 outpatient mental health clinics in the Northeastern United States between September 2013 and August 2016. As part of a larger randomized controlled trial, clients and clinicians completed the MacArthur Scale of subjective social status and the Working Alliance Inventory (WAI), and clients completed the Generalized Anxiety Disorder 7-item Scale (GAD-7).

At the within-clinician level, client-clinician dyads with less similar perceptions of the client's SSS were characterized by less similar perceptions of their alliance, which in turn resulted in worsening anxiety symptoms.

Clinicians' correct perception of their clients' social status might be important for sharing a similar view of the client-clinician level of alliance, which can, in turn, contribute to lowering the client's anxiety symptoms.

An explanatory sequential investigation of the working alliance as a change process in videoconferencing psychotherapy

OBJECTIVES AND DESIGN

Debate exists as to patient experience, and the importance, of the working alliance (WA) in videoconferencing psychotherapy (VCP). This study used a two-phase explanatory sequential design to investigate the WA as a change process in VCP.

METHODS

Phase I: sessional VCP outcome and WA data were analysed using multilevel modelling (n = 46). Phase II: participants (n = 12) from Phase I were recruited to semi-structured interviews, analysed using thematic framework analysis.

RESULTS AND CONCLUSIONS

Results demonstrate: (1) a significant correlation between WA and outcome (F(1, 15.19) = 25.01, p < 0.001), (2) previous session WA significantly predicted outcome in the next session (F(1, 355.61) = 4.47, p < 0.05), and (3) previous session outcome significantly predicted next session WA (F(1, 55.3) = 15.19, p < 0.001), with three core themes explaining patient experience (engaging with the medium, connection with the therapist, and working via the medium). Results are discussed and future research recommended.

Effects of alliance ruptures and repairs on outcomes

This study explored whether treatment outcomes in a trial on the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) vs. Supportive Psychotherapy (SP) for patients with early-onset chronic depression differ between alliance patterns.

Session-to-session ratings of the therapeutic alliance (Helping Alliance Questionnaire (HAQ)) from 254 outpatients with chronic depression (CBASP: 134; SP: 120) who took part in a multicenter randomized controlled trial of CBASP vs. SP were used to categorize patients into three alliance pattern categories for the patients' and therapists' rating separately. Based on the reliable change in the HAQ from one session to the next categories were: no rupture, unrepaired rupture, rupture-repair. Depression severity (24-item Hamilton Rating Scale for Depression) at post-treatment, at 12- and 24- months follow-up was the outcome.

The alliance pattern categories for therapists and patients did not differ between CBASP and SP. Only the alliance patterns calculated for patients were associated with outcome: in the unrepaired rupture category, patients had higher HRSD-ratings across time points (p = 0.047).

CBASP was not associated with more or fewer ruptures or repairs as compared to SP in the treatment of chronic depression. The study highlights the need to resolve ruptures to avoid poor outcomes.Trial registration: ClinicalTrials.gov identifier: NCT00970437.

The Temporal Associations of Therapeutic Alliance and Manual Adherence With Depressive Symptom Change in Cognitive Behavioral Therapy for Adult Outpatient Major Depression

Background: The therapeutic alliance is considered an important causal agent of psychotherapy efficacy. However, studies in cognitive behavioral therapy (CBT) for depression have suggested that alliance might be more of a consequence rather than a cause of depressive symptom change, while adherence to CBT specific techniques was found to be associated with subsequent depression change. We aimed to add to this body of literature by assessing the temporal associations of both therapeutic alliance and manual adherence with depressive symptom change in a relatively large sample of depressed adult outpatients over the full course of CBT. Methods: Adults with a major depressive episode (n = 98) participating in a randomized clinical trial were offered 22 weeks of CBT and rated the Penn Helping Alliance Questionnaire (HAq-I) at weeks 5 and 22. Therapists rated their adherence to the CBT manual after each session and observers assessed the Hamilton Depression Rating Scale scores at weeks 0, 5, 10, and 22. Linear mixed model analyses were used to assess the associations of alliance and adherence with prior and subsequent depression change. Results: HAq-I Relationship and manual adherence ratings were not significantly associated with prior nor with subsequent depression change (p > 0.14). Prior depression change was associated with the HAq-I subscale Perceived helpfulness at the end of treatment (r = 0.30, CI = 0.03-0.56, p = 0.03). Conclusion: We were not able to replicate prior depression change in CBT for depression to be associated with improved quality of the therapeutic alliance when using a more "pure" measure of the therapeutic relationship. Limitations of this study include the subjective alliance and adherence assessments. Our findings indicate the need to appropriately distinguish between the perceived helpfulness and the relationship factors when examining therapeutic alliance.

Associations between patient experience and clinical outcomes in general mental health clinics: Findings from the veterans outcomes assessment survey

For mental health, evidence linking the patients' experiences of care with treatment outcomes is limited. We report findings from the Veterans Outcome Assessment (VOA) survey of Veterans beginning treatment in Veterans Health Administration (VHA) mental health programs with follow-up after approximately 3 months. In addition to assessments of symptoms and functioning, it includes key components of the Experience of Care and Health Outcomes (ECHO) survey including patient reports of communication with clinicians and of the overall quality of mental health care. For Veterans treated in VHA general mental health clinics, significant associations between ratings of communication and quality at baseline, and both retention in treatment and patient-reported outcomes assessed at follow-up demonstrate that better patient experience predicts more favorable outcomes. Further research is necessary to determine whether including them in measurement-based care could improve outcomes by facilitating the early identification of problems in providing care.

The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder

Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.

The alliance mediates outcome in cognitive-behavioral therapy for social anxiety disorder, but not in attention bias modification

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16-20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

Within and between associations of nonverbal synchrony in relation to Grawe's general mechanisms of change

The examination of nonverbal synchrony has become a promising line of psychotherapy research. Although several studies have found between-dyad associations between nonverbal synchrony and multidimensional outcomes, the findings remain heterogeneous, and within-dyad effects remain to be investigated. The present study examines within and between effects of nonverbal synchrony on mastery, resource activation, problem actuation, and motivational clarification (Grawe's general mechanisms of change). Four-hundred and twenty-three videotaped sessions of 175 patients were analysed using motion energy analysis (MEA), providing values to quantify nonverbal synchrony in the patient-therapist dyad. Grawe's general mechanisms of change in psychotherapy were rated using the Inventory of Therapeutic Interventions and Skills (ITIS). On average, patient-therapist nonverbal synchrony was greater than chance. Hierarchical linear modelling revealed that nonverbal synchrony was significantly associated with higher mastery and less resource activation on the within-dyad level. Nonverbal synchrony was not associated with problem actuation or motivational clarification, and in general, no associations were found on the between-dyad level. The results demonstrate the importance of disentangling within and between effects of nonverbal synchrony and provide initial evidence that nonverbal synchrony is tied to the specific therapeutic strategies observed in psychotherapy sessions.

The role of the working alliance in psychological treatment of substance use disorder outpatients

Objective: The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship.Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM).Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation.Conclusions: Patients' attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.

The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial

BACKGROUND

Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes.

OBJECTIVE

The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties.

METHODS

A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment.

RESULTS

We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ₀₂=-1.74, standard error [SE]=0.40, 95% CI -2.52 to -0.96, t₂₀₆=-4.37, P<.001) and patient well-being (γ₀₂=3.10, SE=1.14, 95% CI 0.87-5.33, t₁₉₈=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68).

CONCLUSIONS

The results of this study point out the importance of attuning internet interventions to patients' expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient's individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

Effects of the therapist's statements on the patient's outcome and the therapeutic alliance: A systematic review

This systematic review summarizes articles that examined the effects of the psychotherapist's statements on the outcome of the patient and the therapeutic alliance. The databases PsychINFO, PSYNDEX, PubMed, and PsychARTICLES were searched, and English peer-reviewed articles were included. Participants should be adult patients with Diagnostic and Statistical Manual of Mental Disorders diagnosis who were receiving evidence-based psychotherapy in an individual setting. Studies with a standardized, observer-based measurement of the therapist's verbal utterances on the basis of verbatim transcripts of therapy sessions were included. Furthermore, there should be a standardized measurement of the symptom outcome or a measurement of the therapeutic alliance. The 10 included articles showed that supportive and exploratory statements and addressing aspects in the therapeutic relationship were perceived as positive regarding symptom outcome. Negative effects were particularly evident with controlling and challenging statements of the therapist. Regarding the therapeutic alliance, both positive and negative as well as nonsignificant results were obtained. The results of this review suggest that the question of which statements by therapists correlate positively or negatively with the outcome of therapy and the therapeutic alliance cannot be answered unequivocally and must be applied to more individual and specific situations.

Therapist Alliance-Building Behaviors, Alliance, and Outcomes in Cognitive Behavioral Treatment for Youth Anxiety Disorders

OBJECTIVE

The alliance influences outcomes in CBT for youth anxiety disorders. Thus, knowledge about how therapists can enhance the alliance is needed.

METHOD

Seventy-three youth with anxiety diagnoses (M age = 11.5 years, SD = 2.2; range 8 to 15 years; 47.9% boys; 90.4% white-European) participated in 10-session cognitive behavioral therapy in community clinics. Therapist alliance-building behaviors in session 2 was reliably coded with the observer-rated Adolescent Alliance-Building Behavior Scale (Revised) (AABS(R)). Alliance was measured as youth- and therapist-rated alliance, and youth-therapist alliance discrepancy in session 3. Outcomes were diagnostic recovery and anxiety symptom reduction at post-treatment and one-year follow-up, and treatment dropout. We examined the direct effects of alliance-building on alliance, alliance on outcomes, and alliance-building on outcomes in multilevel mediation models, and between- versus within-therapist variance across these effects.

RESULTS

The alliance-building behaviors collaborate, present treatment model, and explore motivation positively predicted alliance, whereas actively structuring the session (i.e., dominating) negatively predicted alliance. The alliance-building behaviors attend to experience, collaborate, explore motivation, praise, and support positively predicted outcomes. The alliance-building behaviors present treatment model, express positive expectations, explore cognitions, and support negatively predicted outcomes. The effect of collaborate on symptom reduction was mediated by youth-therapist alliance discrepancy. There was almost zero between-therapist variance in alliance-building, and considerable within-therapist variance.

CONCLUSION

Therapist alliance-building behaviors were directly (positively and negatively) associated with alliance and/or outcomes, with only one effect mediated by alliance. Alliance-building behaviors varied far more within therapists (i.e., across clients) than between therapists.

The Structure of Competence: Evaluating the Factor Structure of the Cognitive Therapy Rating Scale

The Cognitive Therapy Rating Scale (CTRS) is an observer-rated measure of cognitive behavioral therapy (CBT) treatment fidelity. Although widely used, the factor structure and psychometric properties of the CTRS are not well established. Evaluating the factorial validity of the CTRS may increase its utility for training and fidelity monitoring in clinical practice and research. The current study used multilevel exploratory factor analysis to examine the factor structure of the CTRS in a large sample of therapists (n = 413) and observations (n = 1,264) from community-based CBT training. Examination of model fit and factor loadings suggested that three within-therapist factors and one between-therapist factor provided adequate fit and the most parsimonious and interpretable factor structure. The three within-therapist factors included items related to (a) session structure, (b) CBT-specific skills and techniques, and (c) therapeutic relationship skills, although three items showed some evidence of cross-loading. All items showed moderate to high loadings on the single between-therapist factor. Results support continued use of the CTRS and suggest factors that may be a relevant focus for therapists, trainers, and researchers.

Patient Extratherapeutic Interpersonal Problems and Response to Psychotherapy for Depression

OBJECTIVES

This paper aimed to synthesize empirical findings of patient extratherapeutic interpersonal variables associated with individual psychotherapy treatment outcomes in adult outpatients with depression.

METHODS

A systematic search strategy was used to identify relevant studies. Thematic analysis was used to identify recurring themes in the findings.

RESULTS

Forty studies met search criteria. Three themes of patient extratherapeutic interpersonal variables were identified: capacity to engage with others, capacity to navigate relationships, and capacity to achieve intimacy, progressing from basic to advanced levels of interpersonal interaction. Interpersonal variables such as interpersonal distress and style, attachment orientation, and quality of object relations were particularly useful in predicting treatment outcomes, whereas access to social support and marital status provided mixed results, likely because they do not account for relationship quality.

CONCLUSIONS

Recognizing variables associated with treatment response can help clinicians identify patients at risk for nonresponse and guide efforts for adapting existing therapies and developing new ones.

The Relationship of MMPI-2-RF Scales to Treatment Engagement and Alliance

Clients' personality characteristics can be important correlates of treatment engagement and alliance. The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) is one of the most comprehensive and widely used personality measures in clinical settings and includes measures of symptom validity. A few prior studies using the MMPI-2 and MMPI-2-RF suggest that externalizing characteristics and the validity scales might be associated with treatment engagement, but no studies to date have examined MMPI correlates of treatment alliance. This study examined the relationship of MMPI-2-RF scales to treatment engagement and alliance in 134 individuals seeking outpatient treatment at a psychology department training clinic. It was predicted that validity scales and externalizing scales would be related to treatment engagement (premature termination, no-show rate) and to alliance. Contrary to expectations, MMPI-2-RF validity scales were not related to premature termination but high scores on F-r were related to higher no-show rates and high scores on Symptom Validity (FBS-r) were related to lower alliance. As predicted, higher scores on scales assessing externalizing psychopathology were related to premature termination and higher no-show rate. Exploratory analyses also suggested higher scores on somatic and interpersonal scales were related to lower alliance. Accuracy statistics using clinical cutoffs on MMPI scales are provided.

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.

Does Disclosure About the Common Factors Affect Laypersons' Opinions About How Cognitive Behavioral Psychotherapy Works?

Background: Written and online information about cognitive-behavioral therapy (CBT) prioritizes the role of specific techniques (e.g., cognitive restructuring) and typically omits discussion of “common factors” (e.g., the working alliance, or therapist empathy). However, according to extensive psychotherapy process research the common factors may be important mediators of client improvement.

Objectives: This study aimed to assess lay opinions about the role of specific and common factors in CBT for depression. We also aimed to determine how different client disclosure processes might affect lay opinions about the relative importance of specific and common factors in CBT.

Methods: We conducted a web-based experiment involving a sample of US participants who had never undergone psychotherapy. All participants were presented with similar vignettes describing an individual suffering from depression whose doctor recommends CBT. Participants were randomized to read one of six vignettes created in a 2 × 3 factorial design that crossed client gender with type of informed consent (Standard CBT Disclosure vs. Common Factors and CBT Disclosure vs. No Disclosure).

Results: Disclosure type had a significant effect on participants' ratings of Common and Specific factors in psychotherapy. As compared to the CBT disclosure, participants allocated to the Common Factors disclosure rated Empathy and Positive Regard as significantly more important to treatment outcome, and rated the Specific factors of CBT as significantly less important to outcome. There were no significant differences between No Disclosure and Standard CBT Disclosure, and these participants rated Specific factors of CBT and the Working Alliance as more important components in treatment, and Empathy and Positive Regard as less important.

Conclusions: The content of information disclosures influences lay opinions about the importance of specific and common factors in CBT. Further research should investigate ethically acceptable disclosures to CBT and other forms of psychotherapy, including whether disclosure practices affect treatment outcome.

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.

Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta-analysis

Videoconferencing psychotherapy (VCP)-the remote delivery of psychotherapy via secure video link-is an innovative way of delivering psychotherapy, which has the potential to overcome many of the regularly cited barriers to accessing psychological treatment. However, some debate exists as to whether an adequate working alliance can be formed between therapist and client, when therapy is delivered through such a medium. The presented article is a systematic literature review and two meta-analyses aimed at answering the questions: Is working alliance actually poorer in VCP? And is outcome equivalence possible between VCP and face-to-face delivery? Twelve studies were identified which met inclusion/exclusion criteria, all of which demonstrated good working alliance and outcome for VCP. Meta-analyses showed that working alliance in VCP was inferior to face-to-face delivery (standardized mean difference [SMD] = -0.30; 95% confidence interval [CI] [-0.67, 0.07], p = 0.11; with the lower bound of the CI extending beyond the noninferiority margin [-0.50]), but that target symptom reduction was noninferior (SMD = -0.03; 95% CI [-0.45, 0.40], p = 0.90; CI within the noninferiority margin [0.50]). These results are discussed and directions for future research recommended.

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.