Research on the alliance: Knowledge in search of a theory

Listening quality leads to greater working alliance and well-being: Testing a social identity model of working alliance

OBJECTIVES

Characterization of psychotherapy as the "talking cure" de-emphasizes the importance of an active listener on the curative effect of talking. We test whether the working alliance and its benefits emerge from expression of voice, per se, or whether active listening is needed. We examine the role of listening in a social identity model of working alliance.

METHODS

University student participants in a laboratory experiment spoke about stress management to another person (a confederate student) who either did or did not engage in active listening. Participants reported their perceptions of alliance, key social-psychological variables, and well-being.

RESULTS

Active listening led to significantly higher ratings of alliance, procedural justice, social identification, and identity leadership, compared to no active listening. Active listening also led to greater positive affect and satisfaction. Ultimately, an explanatory path model was supported in which active listening predicted working alliance through social identification, identity leadership, and procedural justice.

CONCLUSIONS

Listening quality enhances alliance and well-being in a manner consistent with a social identity model of working alliance, and is a strategy for facilitating alliance in therapy.

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

Background

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

Methods

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

Results

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

Discussion

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

Points of departure: A qualitative study exploring relational facilitators and barriers in the first treatment session

Objective To explore how patients and therapists in an outpatient specialized substance use disorder treatment setting experienced the first treatment session, and to identify relational facilitators and barriers seen from both patient and therapist perspectives.Method: The study is based on a qualitative approach and semi-structured interviews of patients (n = 12) and therapists (n = 12). Interviews were conducted soon after the first treatment session and analyzed in accordance with reflexive thematic analysis.Results: We identified subthemes for patients and therapists, respectively. In addition, we found that patients and therapists described certain comparable experiences and actions which we integrated as core themes: (a) feeling uncertain about what to expect; (b) forming first impressions; (c) balancing multiple concurrent concerns; (d) seeking feedback from the other; and (e) sensing a way forward. The subthemes specify patients' and therapists' unique meanings and approaches to each core theme. Finally, we summarized unique and shared relational facilitators and barriers.Conclusion: Patients and therapists use the first session to form an impression of the other, but they are also concerned with the impression they themselves give. They, therefore, monitor the other's in-session reactions and responses which constitute facilitators or barriers for their own further relational actions.

Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating

OBJECTIVE

This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy.

METHOD

Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores.

RESULTS

Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores.

CONCLUSION

Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Therapist's effect on children's therapeutic alliance: A naturalistic study

OBJECTIVES

The therapeutic alliance (TA) has been shown to be a predictor of psychotherapy treatment success. In the case of psychotherapy with children, there is a dearth of information on TA's role. The aims of the paper are: (1) To estimate the therapist effects on children TA; (2) to investigate if therapists' TA predicts children's TA; (3) to analyze if children's age and sex predict children's TA; (4) to evaluate if the therapist's characteristics predict children's TA.

METHODS

The sample consisted of 77 children undergoing psychotherapy in Argentina, and the therapists (N = 29) providing services to those children. The assessment tools utilized for the study included the Therapy Alliance Scale for Children and the Personal Style of the Therapist Questionnaire (PST-Q).

RESULTS

Findings indicated that 2% of the children's TA was explained by the therapists (ICC = 0.02), while 17% of the therapists' TA was explained by the therapists (ICC = 0.17). Therapists' TA predicted children's TA. Children's age and sex did not have an effect on their own TA. Moreover, therapists with more experience achieved higher scores of children's TA. Finally, the Operative dimension of the PST had a negative effect on children's TA (i.e., therapists who prefer more spontaneous interventions over structured ones may experience higher levels of therapeutic alliance with child patients).

CONCLUSION

We found a positive effect of the therapist's TA on children's TA, especially in the preference for using more spontaneous intervention techniques. We discuss the implications of the findings on the training of psychotherapists who provide services to children.

The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder

OBJECTIVE

Few studies have investigated the role of generic relational factors, such as group cohesion and working alliance, in group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD). The aim of this study was to examine the temporal associations among working alliance, group cohesion, and an index of a CBT-specific factor, homework engagement, as correlates of fear of negative evaluation and symptoms of social anxiety in group CBT for SAD.

METHOD

There were 105 participants with a diagnosis of social anxiety disorder who were randomly assigned to 12 sessions of group imagery-enhanced or standard CBT. Participants completed measures at various time points during the 12-session interventions, and the relationship among variables was examined through random-intercept cross-lagged panel models.

RESULTS

Group cohesion was significantly associated with social anxiety symptoms at the end of treatment, however there was no significant relationship with working alliance. Greater homework engagement predicted lower social interaction anxiety, but only during mid-treatment.

CONCLUSION

The results highlight the importance of supporting group cohesion and maximising homework engagement during core components of social anxiety treatment such as behavioural experiments.

Better outcomes through patient - Provider therapeutic connections? An exploratory study of proposed mediating variables

BACKGROUND

Patient-provider therapeutic connections (TCs) have been theorized to enhance patient outcomes as well as care provider job satisfaction and to reduce burnout. High-quality TCs may result in better matching of health care to patient needs, and thus, better care quality and patient outcomes. For care providers, work environments that enable high-quality TCs may make the work more motivating and facilitate resilience.

METHOD

We surveyed patients (n = 346) and care providers (n = 341) about their experiences of TCs, and how TCs related to outcomes. We tested parallel mediation models to examine relations.

RESULTS

TCs predicted better patient health status, mental health status, and satisfaction, and predicted greater care provider job satisfaction and lower burnout. TCs were theorized to operate through two sets of mechanisms (health self-efficacy and activation for patients; meaningfulness of work and psychological safety for providers). Results revealed significant indirect associations between TCs and outcomes for both groups.

CONCLUSIONS

TCs are associated with patient and provider outcomes; however, these relations appear to be explained by several mediating variables. It appears that TCs are associated with better outcomes for patients through health self-efficacy and activation, and TCs are associated with better outcomes for care providers through meaningfulness of work and psychological safety.

A natural language processing approach reveals first-person pronoun usage and non-fluency as markers of therapeutic alliance in psychotherapy

It remains elusive what language markers derived from psychotherapy sessions are indicative of therapeutic alliance, limiting our capacity to assess and provide feedback on the trusting quality of the patient-clinician relationship. To address this critical knowledge gap, we leveraged feature extraction methods from natural language processing (NLP), a subfield of artificial intelligence, to quantify pronoun and non-fluency language markers that are relevant for communicative and emotional aspects of therapeutic relationships. From twenty-eight transcripts of non-manualized psychotherapy sessions recorded in outpatient clinics, we identified therapists' first-person pronoun usage frequency and patients' speech transition marking relaxed interaction style as potential metrics of alliance. Behavioral data from patients who played an economic game that measures social exchange (i.e. trust game) suggested that therapists' first-person pronoun usage may influence alliance ratings through their diminished trusting behavior toward therapists. Together, this work supports that communicative language features in patient-therapist dialogues could be markers of alliance.

Common factors, Responsiveness and Outcome in Psychotherapy (CROP): study protocol for a naturalistic prospective cohort study of psychotherapy in Denmark

INTRODUCTION

The aim of the Common factors, Responsiveness and Outcome in Psychotherapy (CROP) study is to identify client and psychologist characteristics and therapeutic processes associated with the outcome of psychotherapy delivered by psychologists employed in the Danish primary sector or fully self-employed. The study addresses two main questions. First, how are specific characteristics of clients and psychologists related to the outcome of therapy and do these characteristics moderate the outcome of different psychotherapeutic approaches? Second, to what extent do therapists adapt their approach to client characteristics and preferences and how does such responsiveness impact the process and outcome of therapy?

METHODS AND ANALYSIS

The study is a naturalistic prospective cohort study carried out in collaboration with psychologists in private practice in Denmark. Self-reported data are collected from the participating psychologists and their participating clients before, during (weekly and postsession) and after psychotherapy (at end of treatment and 3 months follow-up). The estimated target sample size is 573 clients. The data are analysed using multilevel modelling and structural equation modelling approaches to capture predictors and moderators of the effect and rate of change in psychotherapy as well as session-to-session changes during the therapy process.

ETHICS AND DISSEMINATION

The study has been approved by the IRB at the Department of Psychology, University of Copenhagen (IRB number: IP-IRB/01082018) and the Danish Data Protection Agency. All study data are fully anonymised and all clients have given informed consent to participation in the study. The study findings will be presented in articles in international, peer-reviewed journals as well as to psychotherapy practitioners and other professionals across Denmark.

TRIAL REGISTRATION NUMBER

NCT05630560.

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background

Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and Methods

A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results

Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions

The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

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.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

When does doctor's recommendation become patient's resolution? The regulatory potential of procedural justice in the context of compliance with medical advice and the treatment process

The main aim of the study was to find empirical evidence to answer the following question: If an important personal interest-namely, health and the prospect of a long life-is not enough to motivate a person to follow recommendations from doctors and medical experts, what factor plays a significant role? The author tested the regulatory potential of procedural justice in this context. The sample consisted of 210 participants, patients of independent primary healthcare facilities and specialist hospital outpatient clinics. The empirical data were analyzed by means of structural equation modeling (SEM). Seven SEM models were tested in the analyses. The adopted analytical strategy brought valuable results. The study supported the main hypothesized relationship, showing that procedural justice was a factor increasing the acceptance of and compliance with medical advice and doctor's perceived competence. The results of analyses indicate that the fair treatment of patients in healthcare institutions can be regarded as a significant factor regulating patients' health behavior. The procedural effect is significant for increasing patients' positive evaluation of doctors' competence. Also, the evaluation of a doctor as competent increases patient compliance.

Measuring working alliance and technical alliance from the perspective of healthcare professionals working with people with mild intellectual disabilities: adaptation, factor structure and reliability

BACKGROUND

The establishment of a valuable and meaningful working alliance between people with mild intellectual disabilities (IDs) and healthcare professionals is critically important for improving both the quality of life and impact of therapy for people with mild IDs. Measuring the working alliance as a treatment or support component is therefore of utmost relevance. In light of the increased use of eHealth tools, it is also essential to measure the alliance using these tools, which is referred to as technical alliance. There was a lack of validation of these two measurements for healthcare professionals working with people with mild IDs, which this study sought to address.

METHOD

Both the validated Working Alliance Inventory - Short Form - MID (WAI-SF-MID) and Technical Alliance Inventory - Short Form - MID (TAI-SF-MID) for general patient populations were adapted for healthcare professionals working with people with mild IDs. A two-step approach was conducted to systematically adapt both measurements with an expert group of healthcare professionals. Confirmatory factor analysis was conducted to test a three-factor structure for both the WAI-SF-MID (N = 199) and the TAI-SF-MID (N = 139), and internal consistency was determined for both scales.

RESULTS

An acceptable-to-good model fit was found for both the WAI-SF-MID and the TAI-SF-MID; confirmatory factor analysis confirmed a three-factor model for both measurements. Cronbach's alpha and McDonald's omega were excellent for both total scales (≥0.90) and acceptable to good for sub-scales of both versions.

CONCLUSION

Both the WAI-SF-MID and the TAI-SF-MID are promising measurements for determining healthcare professionals' perspective on the (digital) working alliance with people with mild IDs.

A Meta-Analysis on Differences and Associations between Alliance Ratings in Child and Adolescent Psychotherapy

OBJECTIVE

The alliance in child and adolescent psychotherapy is widely recognized as an important factor in therapy. Studies on the alliance have increasingly focused on assessment of the alliance as a dyadic construct, measuring both client and therapist alliance ratings. However, cross-informant reports of the alliance in child psychotherapy have not yet been subjected to meta-analysis. Therefore, the present meta-analysis aims to increase knowledge on the degree of convergence and divergence between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy.

METHODS

A series of three-level meta-analyses of 78 studies was conducted to investigate differences and associations between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy.

RESULTS

Findings indicated that children and parents in general rated the alliance more positively than their therapists (d = 0.35, d = 0.72, respectively), and that child-therapist and parent-therapist alliance ratings were moderately correlated (r = .32, r = .23, respectively). Associations between child and therapist ratings and observer ratings were moderate to large (r = .43, r = .53, respectively).

CONCLUSIONS

It can be concluded that children and parents generally report more positively on the alliance compared to their therapists, which is consistent with research on the alliance in adult populations. The small to moderate associations between alliance ratings indicate that individuals to some extent have a shared perspective on their alliance, and that the various perspectives on alliance should be acknowledged when dealing with children and parents in therapy. Implications for future research are discussed.

Longitudinal measurement invariance of the Working Alliance Inventory - Short form across coaching sessions

BACKGROUND

Throughout the psychotherapeutic and coaching literature, the client-therapist or coach-coachee working alliance has been highlighted as key force driving positive outcome. The Working Alliance Inventory Short form (WAI-S) for coaching charts the quality of working alliance throughout coaching sessions and is broadly applied in coaching research. Due to a shortfall in research on psychometric properties of the WAI-S, the purpose of this study was to examine (a) if the theorized three-factor structure of the 12-item WAI-S forms a solid representation of the dimensions of working alliance in coaching, and (b) longitudinal measurement invariance (LMI) of the WAI-S.

METHOD

Data were collected in a two-wave study design comprising a main study sample of N = 690 Dutch coachees that completed the questionnaire at the first measurement, of which N = 490 also completed the questionnaire at the second measurement. Post hoc sensitivity analysis was performed based on the original sample, lacking additional information on covariates, and included both completers and dropouts, comprising N = 1986 respondents at T1, and N = 1020 respondents at T2.

RESULTS

Confirmatory factor analyses evidenced best fit of the three-factor model in comparison to one-, and two-factor models at both time points. Despite the fact that multigroup confirmatory factor analysis detected non-invariant intercepts, our findings overall supported measurement invariance across coaching sessions.

CONCLUSIONS

As decisions in both clinical and scientific practices generally rely on outcome assessment of interpersonal change in scores on the same measure over time, we believe our findings to be of contributing value to the consolidation of interpretation and accuracy of scorings on the WAI-S in coaching.

The first session is the one that counts: An exploratory study of therapeutic alliance

Background

The controversy about whether psychotherapy outcome is the consequence of the techniques themselves, common factors or both is still current. The importance of common factors has been demonstrated, although it is also known that they alone are insufficient. At the present time, the contextual model grants heavy weight to the therapeutic alliance in the first sessions and seems to predict positive final results. Furthermore, monitoring sessions has demonstrated that this alliance improves.

Objectives

To analyze the relationship between the therapeutic alliance and patient's perceived improvement during the first five sessions of therapy, and find out whether the therapeutic alliance is maintained or unstable within that timeframe.

Methods

Thirty-four patients at a university psychological care service who had had at least five therapy sessions participated. Of these, 70.46% were women (Mage = 24.24, SD = 6.73). The patients filled out the Outcome Rating Scale and Session Rating Scale the week before each session. Data were analyzed by the Dual STATIS method.

Results

The compromise matrix explained 77.36% of the variability. The position of the vectors and the distribution of the position of the patients on the graph show that as their perception increased, therapeutic alliance remained stable. Moreover, the position of the vectors shows that the therapeutic alliance was forged in the first session and remained stable during the following sessions.

Conclusion

This exploratory study demonstrated the importance of the first session in establishing the therapeutic alliance, and for it to remain stable, regardless of whether the rest of the therapeutic process has variations or changes. Novel use of the STATIS method for analyzing measurements in the first five sessions, showed that beginning the therapeutic intervention with a strong alliance, produced the favorable, lasting effects necessary for development of the intervention.

The Working Alliance as a Mediator Between Fidelity to Strengths Model Case Management and Client Outcomes

OBJECTIVE

The purpose of this study was to examine how the client–case manager working alliance in strengths model case management (SMCM) mediates the relationship between fidelity to the SMCM intervention and clients’ quality of life, hope, and community functioning.

METHODS

In total, 311 people with severe mental illness, served at seven community mental health agencies in Canada, participated in the study. They were new to SMCM and participated in five structured interviews every 4.5 months for 18 months to measure the quality of the client–case manager working alliance and clients’ quality of life, hope, and community functioning. The team-level SMCM fidelity scale was administered six times over 3 years. Ordinary least-squares path analysis was used to test simple mediation models.

RESULTS

Higher fidelity to SMCM was associated with better client outcomes indirectly through the working alliance. Higher SMCM fidelity predicted a stronger working alliance, which in turn predicted greater improvements in client quality of life (at 9 months and 18 months), hope (at 18 months), and community functioning (at 9 months).

CONCLUSIONS

The results support the view that SMCM is an effective intervention. When the intervention was implemented as planned, it fostered stronger working alliances between clients and case managers and contributed to greater improvements in the quality of life, hope, and functioning of people with severe mental illness. The findings of this study highlight the value of ongoing monitoring of implementation fidelity to achieve high-fidelity interventions that may lead to positive client outcomes.

Enhancing working alliance through positive emotional experience: A cross-lag analysis

Although psychotherapy research has traditionally focused on decrease in distress, emotion research suggests the important role of positive emotional experience in healing and growing. Objective: The present study investigates the relationship between positive emotional experiences and working alliance. Method: We chose to investigate this relationship in accelerated experiential dynamic psychotherapy (AEDP), taking advantage of the modality's focus on both negative and positive emotional experiences. Fifty-eight clients receiving 16-sessions individual AEDP reported on their post-session levels of working alliance and positive emotions (enlivenment affect, positive relational affect, and peacefulness). The alliance-emotion relationship for each emotional categories was tested with separate disaggregated cross-lagged panel models. Results: Across the three categories, higher positive emotions at the end of the previous session were associated with higher working alliance at the end of the next session. On the other hand, working alliance did not contribute to any of the positive emotions in the next time point. Furthermore, the three emotion categories showed different patterns of development. Conclusion: The findings suggest that fostering positive emotions may be a promising venue to enhance working alliance. Furthermore, differentiating specific positive emotions is likely important both for research and practice.

The Working Alliance Inventory's Measurement Properties: A Systematic Review

Measurement properties of the Working Alliance Inventory (WAI) and its various translations and adaptations for specific target groups have been investigated for over 30 years. No systematic review analyzing studies on measurement properties of the WAI has been conducted to date. COnsensus-based Standards for the selection of health Measurements INstruments (COSMIN) were developed for conducting high-quality systematic reviews on measurement properties in a transparent and standardized way. Aim of this study was to systematically review studies on measurement properties of the WAI, and its adapted versions, within psychotherapy, and other healthcare contexts using COSMIN criteria. PsycINFO, Medline, and EMBASE were searched (1989–2021). In all phases of the review procedure, study selection, data extraction, risk of bias assessment, rating of the quality of measurement properties, and rating of the quality of evidence for measurement properties, disagreement between reviewers was resolved by discussion. Results on validity, internal structure, reliability, construct validity, and responsiveness were analyzed. In total 66 studies were included. In most studies, evidence for measurement properties was according to COSMIN criteria, insufficient, lacking, or conflicting. Content validity was rated insufficient because neither patients nor healthcare professionals were involved in the development and validation process. Hence evidence for content validity of the WAI is unknown. Conflicting evidence was found for structural validity. Evidence for internal consistency could not be established. Limited evidence was found for inter-rater reliability and convergent validity. Conflicting evidence was also found for test-retest reliability and divergent validity. COSMIN criteria exposed persistent problems in validation studies of the WAI. These findings may indicate that measurement properties of the WAI are not up to current standards, or that COSMIN criteria may be less appropriate for assessing measurement properties of the WAI, or it could indicate both. The results of this systematic review suggest that WAI outcomes should be interpreted with caution and further research is needed regarding the content validity and hypotheses development. For the future, the theoretical framework underlying the measurement of the working alliance needs to be studied in psychotherapy and other health contexts, and tested in methodologically sound studies.

A Qualitative Study of the Working Alliance in the Strengths Model of Case Management with People with Severe Mental Illness

The purpose of this study was to examine clients' perceptions of the client-case manager working alliance in the context of receiving the Strengths Model of Case Management. Twenty people with severe mental illness, with a SMCM case manager, participated in semi-structured, qualitative interviews. Using first and second cycle coding, data were analyzed thematically. People in the study attributed personal life changes to their relationship with their case manager. They valued their case managers' flexibility and highlighted their work on a wide range of goals of their choosing. Case managers approached the SMCM intervention responsive to their clients' preferences and choices. The working alliance serves as a key element of the SMCM intervention. Clients describe the working alliance as helping to improve their lives. This study supports the implementation of SMCM with people with severe mental illness due to its focus on fostering a strong working alliance.

The Effects of Health Care Chatbot Personas With Different Social Roles on the Client-Chatbot Bond and Usage Intentions: Development of a Design Codebook and Web-Based Study

Background

The working alliance refers to an important relationship quality between health professionals and clients that robustly links to treatment success. Recent research shows that clients can develop an affective bond with chatbots. However, few research studies have investigated whether this perceived relationship is affected by the social roles of differing closeness a chatbot can impersonate and by allowing users to choose the social role of a chatbot.

Objective

This study aimed at understanding how the social role of a chatbot can be expressed using a set of interpersonal closeness cues and examining how these social roles affect clients’ experiences and the development of an affective bond with the chatbot, depending on clients’ characteristics (ie, age and gender) and whether they can freely choose a chatbot’s social role.

Methods

Informed by the social role theory and the social response theory, we developed a design codebook for chatbots with different social roles along an interpersonal closeness continuum. Based on this codebook, we manipulated a fictitious health care chatbot to impersonate one of four distinct social roles common in health care settings—institution, expert, peer, and dialogical self—and examined effects on perceived affective bond and usage intentions in a web-based lab study. The study included a total of 251 participants, whose mean age was 41.15 (SD 13.87) years; 57.0% (143/251) of the participants were female. Participants were either randomly assigned to one of the chatbot conditions (no choice: n=202, 80.5%) or could freely choose to interact with one of these chatbot personas (free choice: n=49, 19.5%). Separate multivariate analyses of variance were performed to analyze differences (1) between the chatbot personas within the no-choice group and (2) between the no-choice and the free-choice groups.

Results

While the main effect of the chatbot persona on affective bond and usage intentions was insignificant (P=.87), we found differences based on participants’ demographic profiles: main effects for gender (P=.04, η_p²=0.115) and age (P<.001, η_p²=0.192) and a significant interaction effect of persona and age (P=.01, η_p²=0.102). Participants younger than 40 years reported higher scores for affective bond and usage intentions for the interpersonally more distant expert and institution chatbots; participants 40 years or older reported higher outcomes for the closer peer and dialogical-self chatbots. The option to freely choose a persona significantly benefited perceptions of the peer chatbot further (eg, free-choice group affective bond: mean 5.28, SD 0.89; no-choice group affective bond: mean 4.54, SD 1.10; P=.003, η_p²=0.117).

Conclusions

Manipulating a chatbot’s social role is a possible avenue for health care chatbot designers to tailor clients’ chatbot experiences using user-specific demographic factors and to improve clients’ perceptions and behavioral intentions toward the chatbot. Our results also emphasize the benefits of letting clients freely choose between chatbots.

Patient-provider therapeutic connections to improve health care: Conceptual development and systematic review of patient measures

BACKGROUND

The Triple Aim (improved population health, improved patient experiences, and lower costs) has influenced U.S. health care since it was introduced in 2008. With it, value-based purchasing has brought unprecedented focus on patient experience measurement. Despite having devoted extensive resources toward improving patient experiences, inconsistent improvements suggest there are some dimensions not yet being widely measured or addressed. Furthermore, a renewed focus on health disparities calls for stronger patient-provider connections in order to reduce health care inequities.

PURPOSE

The aim of this study was to articulate the concept of therapeutic connections (TCs) in health care and examine existing survey measures, from the patient perspective, to learn whether they capture the TC construct.

METHOD

We interviewed subject matter experts (n = 24) and patients (n = 22) about measuring TCs and then conducted a systematic review of quantitative measures from three databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria.

RESULTS

Of 31 unique measures, none captured all of the theorized TC dimensions. Most were measures of collaboration and shared decision-making or caring.

DISCUSSION

Focusing on the nature of patient-provider connections is vital because they are the backbone of most delivery models seeking to achieve the Triple Aim. Further development of the TC concept and measures is warranted to facilitate organizational and financing policies that meaningfully support widespread improvement.

PRACTICE IMPLICATIONS

A focus on barriers and facilitators of TCs is needed. Without advancing our understanding of the role TCs play in care, policymakers and practitioners will be limited in their ability to make impactful changes.

The Strength of Alliance in Individual Psychotherapy and Patient's Wellbeing: The Relationships of the Therapeutic Alliance to Psychological Wellbeing, Satisfaction With Life, and Flourishing in Adult Patients Attending Individual Psychotherapy

OBJECTIVES

The central aim of the research was to verify and determine the strength of the relationships of therapeutic alliance to wellbeing, life satisfaction, and flourishing in patients attending individual psychotherapy. The relationships were assessed based on different sources of information about the quality of the working alliance: patient's evaluation and patient's and psychotherapist's joint evaluations.

DESIGN

The author applied Bordin's pantheoretical model of alliance and two different conceptions of wellbeing, operationalized as hedonistic and eudaimonic.

METHODS

The 411 participants included 252 patients and 159 psychotherapists. To test the hypotheses, 16 joint and separate models of structural relations were built and analyzed empirically using SEM. Correlations were analyzed between alliance factors and those of wellbeing, satisfaction, and flourishing.

RESULTS

The actual impact of working alliance quality on psychological wellbeing proved to be stronger compared to the relations between alliance and satisfaction or flourishing. The results of analyses revealed low, though usually positive and significant, correlations between the dimensions of alliance and those of wellbeing, life satisfaction, and flourishing.

CONCLUSIONS

The empirical data and the strategy of analyses brought the expected results, confirming that patient's and psychotherapist's perception of a strong therapeutic alliance is crucial for the optimization of patient's functioning and wellbeing. It turns out that the therapeutic alliance is, above all, a factor of wellbeing understood more deeply than merely as current pleasure. The study also showed that no factor isolated from other components of alliance increased the quality of patient's mental functioning more than others.

It takes two to tango: The therapeutic alliance in community brain injury rehabilitation

Objective:

A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.

Method:

This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.

Results:

A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.

Conclusion:

These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

Therapist in-session feelings predict change in depressive symptoms in interpersonal and brief relational psychotherapy

Objective: Brief Relational Therapy (BRT) includes the idea that the therapists use their in-session feelings in meta-communications about the therapy relationship to facilitate resolution of alliance ruptures. The current study aimed to explore the effect of therapist feelings on patient depressive symptoms in BRT compared to Interpersonal Psychotherapy (IPT).Methods: The effects of therapist feelings were studied in 40 patients randomized to 16 sessions of IPT or BRT, using the Feeling Word Checklist-24, the Patient Health Questionnaire-9 and the Working Alliance Inventory. Data was analyzed using dynamic structural equation modeling.Results: Negative therapist feelings predicted increase and positive feelings decrease in next-session PHQ-9 via the alliance and the patients' engaged feelings, in both treatments. The direct effect of negative therapist feelings on PHQ-9 differed significantly between BRT and IPT, with more negative feelings predicting a decrease in PHQ-9 in BRT but not in IPT.Conclusion: Negative therapist feelings may cause increase/less decrease and positive feelings more decrease in depressive symptoms via disruptions in the alliance. In BRT, if the alliance is unaffected by negative therapist feelings, the patient's depressive symptoms may improve. Findings need replication in a larger sample.

The Impact of Clients’ and Therapists’ Characteristics on Therapeutic Alliance and Outcome

This article investigates distances between therapists and their clients in their experience of the therapeutic alliance across the duration of the psychotherapeutic treatments in a naturalistic study. We looked at the working alliances from different vantage points—rupture, repair of ruptures, distances in the alliance impressions of both clients and therapists—and their correlation with treatment outcome. The only predictive variable of alliance ruptures was the inability of therapists to bond sufficiently with their clients regarding a sustainable working atmosphere, which could be identified through a continuous distant alliance rating by the therapists. Alliance ruptures in turn significantly predicted premature termination of treatments, whereas alliance ruptures per se did not necessarily predict treatment outcome. The paper discusses the possible role of the quality of therapists’ attachment styles as a potentially crucial variable in an effective working alliance in psychotherapy.

Trajectories of change in the therapeutic alliance during Cognitive Analytic Therapy for depression

BACKGROUND

Managing the alliance is considered to be a core competency and central therapeutic change process during cognitive analytic therapy (CAT). This study examined latent trajectories of change in the alliance and their relationship to depression treatment outcomes.

DESIGN

Secondary analysis of a randomized controlled trial.

METHODS

A sample of N = 79 depressed participants completed standardized alliance (WAI-SF) and depression symptom measures (PHQ-9) every session during an 8-session CAT intervention. Growth mixture modelling was applied to model alliance trajectories and to classify cases into different latent classes. Associations between alliance class and post-treatment PHQ-9 scores were examined using hierarchical linear regression, controlling for confounders.

RESULTS

There were two classes of alliance trajectories. The majority class (91%) displayed stable alliance trajectories, whilst a minority class (9%) had initially poor alliance ratings that significantly improved during treatment. Baseline severity and early change in depression symptoms significantly predicted treatment outcomes, but early alliance and longitudinal alliance change did not.

CONCLUSIONS

Alliance trajectories did not significantly predict depression treatment outcomes after controlling for initial symptom severity and early change. An important limitation concerns the small sample size, so future replication in larger samples is necessary.

THERapy-Related InterACTion (THER-I-ACT) in Rehabilitation-Instrument Development and Inter-Rater Reliability

Objective: To develop an instrument for the observation of therapeutic communication interactions during rehabilitation sessions and test its inter-rater reliability. Methods: The new instrument THER-I-ACT (THERapy-related Inter-ACTion) has been designed to assess both the frequency and timing of therapeutic interactions in the thematic fields information provision, feedback, other motivational interaction, and bonding. For this inter-rater reliability study, a sample of stroke survivors received arm rehabilitation as either arm ability training, arm basis training, or mirror therapy, or neglect training as individually indicated. Therapy sessions were video-recorded (one for each participant) and therapeutic interactions rated by two independent raters using THER-I-ACT. Results: With regard to the instrument's comprehensiveness to document therapeutic interactions with pre-defined categories the data from 29 sessions suggested almost complete coverage. Inter-rater reliability was very high both for individual categories of therapeutic interaction (frequency and time used for interaction) (intraclass correlation coefficient, ICC 0.91-1.00) and summary scores for the thematic fields of interaction (again for frequency and time used for interaction) (ICC 0.98-1.00). The inter-rater reliability for rating engagement and being focussed for both the therapist and patient was substantial (ICC 0.71 and 0.86). Conclusions: The observational study documented that by use of the newly designed THER-I-ACT various types of therapy-related communication interactions performed by therapists can be assessed with a very high inter-rater reliability. In addition, the thematic fields and categories of therapeutic interaction as defined by the instrument comprehensively covered the type of interaction that occurred in the therapeutic sessions observed.

The working alliance in blended versus face-to-face cognitive therapy for depression: A secondary analysis of a randomized controlled trial

INTRODUCTION

We explored the working alliance as measured by both clients and therapists. The working alliance has been known to predict the outcome of psychotherapy and is often considered an important common factor. This study raised the question of how to conceptualize the working alliance in the blended format.

METHODS

This was an exploratory study derived from a randomized controlled trial comparing bCBT and face-to-face cognitive behavioural therapy (ftf CBT) on depression. The change in depressive symptoms was measured with the Patient Health Questionnaire (PHQ-9) and the working alliance was measured using the Working Alliance Inventory.

ANALYSES

Correlation coefficients were calculated for the working alliance as reported by clients and therapists, working alliance was then examined at item and dimension level (task, bond, goal). Linear regression models were applied to investigate the predictive value of the working alliance on treatment outcome. Interaction between the level of working alliance and treatment condition was also considered.

RESULTS

Client and therapist working alliance ratings correlated at r = 0.44 and clients rated the working alliance higher than therapists (x̄ _clients  = 48.6, x̄ _therapists  = 44.6). ftf CBT and bCBT had comparable joint working alliance ratings (x̄ _ftf  = 46.4, x̄ _bCBT  = 46.8). Items had little deviation apart from item 4 with high positive values. The level of working alliance from the total sample did not significantly predict outcome based on the client's perspective. Contrarily, seen from the therapist's perspective, it did (b = 0.00, p = .044). Using the mean from these predictors as a composite variable, was also significant (b = 0.00, p = .039, R² _adj  = 0.07). There was no significant interaction with treatment condition.

DISCUSSION

Clients and therapists may lay emphasis on different aspects of the working alliance. The finding that therapist-rated working alliance was better than client working alliance at predicting outcome went against common findings; this pattern may be specific to bCBT.

CONCLUSION

Clients rated the working alliance slightly higher than therapists on average. Clients and therapists as well as treatment conditions had different profiles on dimension deviations. Therapist ratings of the working alliance appeared to better predict treatment outcome than client ratings. Joint working alliance predicted outcome using client and therapist composite means. The working alliance was equally strong in ftf CBT and bCBT. The absence of interaction with treatment condition indicated that the working alliance was equally predictive of outcome in ftf CBT as in bCBT.

Differentielle Beziehungsgestaltung in der Verhaltenstherapie: Auf dem Weg zu einer evidenzbasierten individualisierten Beziehungsgestaltung

Im Zuge der Anfänge der Verhaltenstherapie (VT) und der “kognitiven Wende” wurde der aktiven Beziehungsgestaltung und damit verbundenen Faktoren zunächst nur zweitrangig Beachtung geschenkt, obwohl die Bedeutung der Beziehung zwischen Therapeut und Patient auch in der VT bereits relativ früh erkannt wurde. Seitdem hat sich die VT substanziell weiterentwickelt. Insbesondere die aktive Gestaltung der therapeutischen Beziehung in Abhängigkeit verschiedener Variablen ist mittlerweile fester Bestandteil einer jeden VT. In dieser Übersichtsarbeit werden Konzepte der Beziehungsgestaltung dargestellt, welche der VT zugerechnet und im Rahmen der Ausbildung im deutschsprachigen Raum gelehrt werden. Fokussiert wird auf folgende drei Ansatzpunkte: Die Ausrichtung der Beziehung an (1) Therapiephasen, (2) Bedürfnissen, Motiven und Erwartungen sowie (3) frühen traumatisierenden Bezie­hungserfahrungen. Die aktuelle Studienlage legt nahe, dass pauschalisierte Handlungsempfehlungen zur aktiven Gestaltung der therapeutischen Beziehung zu kurz greifen. Ausgehend von der individuellen Problematik des einzelnen Patienten wird die Realisierung der therapeutischen Beziehung im Sinne einer differentiellen Beziehungsgestaltung beschrieben und diskutiert.

Can you see what I see? A comparison of client and observer perspectives of the alliance and group cohesion in CBT

Both therapeutic alliance and group cohesion have been identified as "demonstrably effective" relationship elements in therapy. However, the overwhelming majority of process-outcome research has relied on clients as raters of the therapeutic relationship. A lack of convergence between client, therapist, and observer perspectives has raised questions regarding how best to measure relationships in therapy. Interest in observational measures has grown, as they may offer more objective and reliable measurements of process. This study compared the predictive validity of client and observer ratings of the alliance (Agreement and Bond) and group cohesion in the context of group cognitive behaviour therapy (CBT) for anxiety disorders. Results showed that client and observer ratings of process were not significantly correlated, and regarding the alliance, only client-rated Agreement predicted client-rated treatment gains. In contrast, both client and observer-ratings of group cohesion were found to uniquely contribute to treatment outcomes. If replicated, the findings from the present study suggest that (1) while client ratings of alliance consistently predict client-rated outcomes, the predictive validity of observer measures has yet to be established, and (2) both clients and observers provide meaningful and distinct information about group cohesion in therapy.

The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa

BACKGROUND

Adolescents with anorexia nervosa have set-shifting inefficiencies that can be exacerbated by starvation and that may interfere with outcomes of treatment interventions. Cognitive Remediation Therapy (CRT), an adjunctive treatment focused on improving set-shifting, can target inefficiencies and may augment treatment effectiveness. The best way to add CRT to the standard of care (Family Based Treatment, FBT) for adolescents with anorexia remains understudied.

METHODS/DESIGN

This is a randomized controlled trial designed to determine if CRT is effective in increasing flexibility in adolescents with anorexia and/or their parents. Participants are adolescents 12-18 years old with anorexia and their parents. 54 family groups will be randomized into one of three groups: FBT only, FBT plus Parent-focused CRT, or FBT plus Adolescent-focused CRT. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study.

DISCUSSION

This is the first study of its kind to apply CRT to parents. All forms of CRT in the context of anorexia have targeted the individual with anorexia's thinking style. We propose that it may be impactful to target the parent of the adolescent with anorexia as parents carry the burden of treatment and re-nourishment of their child during FBT and may have similar thinking styles.

CONCLUSION

This study takes an experimental therapeutics approach to further our understanding of the mechanisms of treatment for adolescents with anorexia. It focuses on increasing cognitive flexibility in patients or their parents and determining the appropriate dose of CRT needed to achieve positive change.

TRIAL REGISTRATION

ClinicalTrails.gov Identifier NCT03928028.

The Role of Intolerance of Uncertainty and Working Alliance in the Outcome of Cognitive Behavioral Therapy for Generalized Anxiety Disorder Delivered by Videoconference: Mediation Analysis

BACKGROUND

Previous meta-analyses have shown a significant relationship between working alliance and treatment outcome in general. Some studies have examined the relationship between working alliance and treatment outcome during telepsychotherapy, but to the best of our knowledge, no study has examined the mediating role of individual components of the working alliance.

OBJECTIVE

As part of a clinical trial of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) delivered by videoconference (VC), the aim of this study is to examine the mediating role of intolerance of uncertainty on the relationship between the components of the working alliance and treatment outcome.

METHODS

A sample of 46 adults with primary GAD received 15 sessions of CBT for GAD delivered over VC. Participants completed the measure of working alliance immediately after the fifth therapy session. The degree of change in intolerance of uncertainty (a key psychological process) was assessed from pre- to posttreatment. Treatment outcome was assessed via changes in GAD symptoms from pretreatment to the 6-month follow-up.

RESULTS

The results revealed that the therapeutic bond did not predict treatment outcome (r=-0.23; P=.12). However, agreement on therapeutic goals and tasks did predict treatment outcome (r=-0.42; P=.004 and r=-0.37; P=.01, respectively). In addition, the relationship between consensus on therapeutic tasks and treatment outcome was completely mediated by changes in intolerance of uncertainty (unstandardized β=-0.03; r2=0.12), whereas consensus relative to treatment goals had a direct impact on treatment outcome.

CONCLUSIONS

These results provide a better understanding of the differential role of the components of the working alliance in telepsychotherapy as a facilitative factor for changes in key cognitive processes, leading to therapeutic change.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 12662027; http://www.isrctn.com/ISRCTN12662027.

Court-Mandated Patients' Perspectives on the Psychotherapist's Dual Loyalty Conflict - Between Ally and Enemy

BACKGROUND

Mental health professionals working in correctional contexts engage a double role to care and control. This dual loyalty conflict has repeatedly been criticized to impede the development of a high-quality alliance. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma.

METHODS

This qualitative interview study investigates patients' perceptions of their therapists' dual role conflict in court-mandated treatment settings. We interviewed 41 older incarcerated persons using a semi-structured interview guide, the interviews were subsequently analyzed following thematic analysis.

RESULTS

We first present the patients' perceptions of their treating psychotherapist's dual loyalty conflict, which was linked to their overall treatment experience. In a second step, we outline the study participants' reasons for this judgment, which were most commonly linked to feelings of trust or betrayal. More specifically, they named certain therapist characteristics and activities that enabled them to develop a trustful therapeutic alliance, which we grouped into four topics: (1) respecting the patient's pace and perceived coercion; (2) patient health needs to be first priority; (3) clarity in roles and responsibilities; and (4) the art of communication - between transparency and unchecked information sharing.

DISCUSSION

Developing a high quality alliance in mandatory offender treatment is central due to its relationship with recovery and desistance. Our findings show that some therapists' characteristics and activities attenuate the negative impact of their double role on the development and maintenance of the alliance. To increase the effectiveness of court-mandated treatments, we need to support clinicians in dealing with their dual role to allow the formation of a high quality therapeutic alliance. Our qualitative interview study contributed to this much-needed empirical research on therapist' characteristics promoting a trustful relationship in correctional settings.

Therapieprozesse in der Kinder- und Jugendlichenpsychotherapie

Zusammenfassung. Theoretischer Hintergrund: Die Psychotherapieforschung zu therapeutischen Wirkfaktoren bei Kindern steckt in den Kinderschuhen. Mit dem Stundenbogen für Kinder und Jugendliche Patientenversion (SBKJ-P) wurde ein entsprechendes Messinstrument entwickelt. Die erfassten Wirkfaktoren sind Problemaktualisierung, Ressourcenaktivierung, Problembewältigung, motivationale Klärung als auch Rolle der Eltern und therapeutische Allianz. Fragestellung: Untersucht werden die Faktorstruktur, interne Konsistenz und konvergente Validität. Methode: Die Stichprobe umfasst 123 Kinder und Jugendliche (62 Mädchen) im Alter zwischen 7 und 18 Jahren ( MW = 13.1, SD = 3.03). Ergebnisse: Die Ergebnisse zeigen, dass der SBKJ-P ein verständliches, reliables und valides Instrument für die Prozess- und Verlaufsmessung von allgemeinen therapeutischen Wirkfaktoren darstellt. Diskussion und Schlussfolgerung: Der SBKJ-P erlaubt eine zuverlässige Einschätzung der Qualitätssicherung im psychotherapeutischen Prozess.

Alliance Ruptures and Resolutions in Personality Disorders

PURPOSE OF REVIEW

This review provides an overview of the state of research on alliance ruptures and resolutions in the treatment of personality disorders (PDs). We discuss frequently used instruments to measure alliance ruptures and resolutions. We discuss the effectiveness of rupture resolution processes and highlight possible avenues for research to explore. Innovative assessments with the potential to reveal the link of ruptures and resolutions and mechanisms of psychotherapeutic change are discussed.

RECENT FINDINGS

The assessment of alliance rupture and resolutions is heterogeneous. Instruments vary largely with respect to a direct or indirect assessment, the time resolution of assessment (integral therapy, phase, session, event), session sampling strategy and perspectives (patient, therapist, observer). The heterogeneity in the instruments and study designs impedes comparability and interpretation of the findings. Results support the hypothesis that ruptures are more frequent in PD. Results also point towards beneficial effects of rupture resolution patterns, early alliance quality, and resolution complexity. Few studies control findings for pretreatment factors. Evidence points to the direction that rupture resolution processes can be considered a general principle of change in the treatment of PD. The concept of alliance ruptures and resolutions provides a useful tool for the management of the therapeutic alliance and its moments of deteriorations throughout the treatment course. Dimensional pretreatment personality functioning is considered a key variable in future studies to highlight what works for whom.

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

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

Getting to "Yes": Overcoming Client Reluctance to Engage in Chair Work

Goals

Securing clients’ active and enthusiastic collaboration to participate in activities therapists would like to implement in therapy (e.g., free association, in vivo exposure, or the engagement in chair work) is a core mission in therapy. However, from the clients’ perspective, these tasks frequently represent novel challenges that can trigger anxiety and reluctance. Thus, a key element in therapy is the negotiation between therapist and client to move beyond such reluctance to potentially effective therapy activities and, at the same time, maintain positive relational affiliation between therapist and client. In this research we examined (1) a collection of therapist proposal/client response sequences that were geared toward recruiting participation in chair work and (2) sequences containing hesitation or instances where decisions to engage in chair work were deferred and related relational disaffiliation. Our goal was to identify the conversational resources (both verbal and non-verbal) that worked to reject a proposed activity (or convey impending rejection) and examine the interactional practices directed at resolving client reluctance.

Method

We used the conceptual and methodological resources of Conversation Analysis to examine a corpus of proposal/response sequences that targeted chair work entry in Emotion-focused Therapy.

Results

The resulting data set included some smooth and successful engagements and others more challenging, involving clients delaying or resisting engagement with chair work. Clients were found to defer or refuse engagement through a range of resources such as withholding a response (silence), questioning the authenticity of the task, or directly refusing. We identified specific therapist practices that facilitated engagement in “refusal-implicative” contexts such as proffering “or” alternatives, offering extended rationales for the activity (accounting), and elaborating on the proposals. We observed that the therapists’ deontic stance (mitigated and reduced claims to authority) and moderated epistemic positioning (deference to the client’s primacy of knowledge and information) played an important role in facilitating engagement.

Conclusion

Our research highlights the kinds of interactional sequences in which clients and therapists are able to achieve alignment in mutually working toward chair work entry. Based on these observations, we offer some practical advice to therapists in formulating proposals to engage clients during in-therapy work.

Meaning profiles and the perception of the working alliance at the start of outpatient person-centered, experiential, and existential psychotherapies

OBJECTIVE(S)

Quantitative research on meaning in life in the context of psychotherapy is relatively limited. The current study aims to investigate the profiles of the meaning of clients and their perception of the working alliance and initial symptomatology at the start of therapy.

DESIGN

In a sample of 145 clients (62.1% female; mean age, 34.77) who started person-centered psychotherapy, the relationship between meaning, search for meaning, symptomatology, and the working alliance was analyzed. The assessment took place after the second session.

RESULTS

Cluster analysis revealed four profiles: Low Presence High Search, High Presence Low Search, High Presence High Search, and Low Presence Low Search. These meaning profiles are distinguished in terms of symptomatology but not in terms of the working alliance perception. However, the experience of meaning is significantly associated with the working alliance.

CONCLUSIONS

Results show the relevance of meaning-related questions for certain groups of clients at the start of therapy.