Working alliance in treating staff and patients with Schizophrenia Spectrum Disorder living in Residential Facilities

OBJECTIVES

Working Alliance (WA) is important in the care of patients with Schizophrenia Spectrum Disorders (SSD). This study aims to determine which sociodemographic and clinical factors are associated with WA, as assessed by patients and staff members in Residential Facilities (RFs), and may predict WA dyads' discrepancies.

METHODS

Three hundred and three SSD patients and 165 healthcare workers were recruited from 98 RFs and characterized for sociodemographic features. WA was rated by the Working Alliance Inventory (WAI) for patients (WAI-P) and staff members (WAI-T). SSD patients were assessed for the severity of psychopathology and psychosocial functioning.

RESULTS

Pearson's correlation revealed a positive correlation (ρ = .314; p < .001) between WAI-P and WAI-T ratings. Linear regression showed that patients with higher education reported lower WAI-P ratings (β = -.50, p = .044), while not being engaged in work or study was associated with lower WAI-T scores (β = -4.17, p = .015). A shorter lifetime hospitalization was associated with higher WAI-P ratings (β = 5.90, p = .008), while higher psychopathology severity negatively predicted WAI-T (β = -.10, p = .002) and WAI-P ratings (β = -.19, p < .001). Better functioning level positively foresaw WAI-T (β = .14, p < .001) and WAI-P ratings (β = .12, p < .001). Regarding discrepancies, staff members' age was associated with higher dyads discrepancy in Total scale and Agreement subscale scores, which were also associated with more severe negative symptoms, while patients' age was negatively correlated to Relationship subscale discrepancy.

CONCLUSIONS

This study provides insight into the factors that influence WA in SSD patients and health workers in RFs. The findings address interventions to improve WA and ultimately patient outcomes.

The Risk, Need, and Responsivity Relevance of Working Alliance in a Sexual Offense Treatment Program: Its Intersection With Psychopathy, Diversity, and Treatment Change

The current study examined the self-reported working alliance of men attending a high intensity sexual offense treatment program and its associations with psychopathy, sexual violence risk, treatment change, and recidivism, in a Canadian sample of 317 incarcerated men followed up an average of approximately 10 years post release. Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) self-reported total, Task, Bond, and Goal scores were positively correlated with treatment related changes in risk, and inversely associated with Psychopathy Checklist-Revised (PCL-R; Hare, 1991; Wang & Hare, 2003) scores. The Affective facet of the PCL-R, representing the callous-unemotional features of the syndrome, uniquely predicted lower Bond and Goal scores controlling for the other facets. Cox regression survival analyses demonstrated that sexual violence risk predicted increased sexual recidivism while change predicted decreased sexual recidivism controlling for PCL-R total score; however, WAI scores (particularly the Goal component) were also unexpectedly associated with increased sexual recidivism. For violent recidivism, psychopathy, risk, and change incremented the prediction of general violence, while the WAI was not significantly associated with this outcome. A set of parallel analyses, stratified by Indigenous ethnocultural heritage, demonstrated some continuity, but also potential areas of difference, in substantive findings. Risk, need, responsivity implications of the working alliance for the treatment of high psychopathy correctional clientele, and how this may intersect with Indigenous heritage, are discussed.

Therapeutic relationships in speech-language pathology: A scoping review of empirical studies

PURPOSE

This scoping review provides an overview of empirical studies investigating therapeutic relationships between speech-language pathologists (SLPs), clients, and caregivers across all ages and clinical areas, and identifies areas of future research.

METHOD

The Joanna Briggs Institute's (JBI) scoping review method was employed. Systematic searches were conducted across seven databases and four grey literature databases. Research published in English and German until 3 August 2020 was included. Data were extracted for the primary aim, terminology and theoretical foundations, research design, and focus. Central findings concerning the input-, process-, outcome-, and output-level of speech-language pathology were categorised.

RESULT

Of 5479 articles, 44 articles were included in the analysis. Psychotherapy was the leading discipline for the theoretical foundation and measurement of relationship quality. Most findings focused on therapeutic attitudes, qualities, and relational actions to build the basis of a positive therapeutic relationship. A small number of studies indicated connections between clinical outcomes and the quality of the relationships.

CONCLUSION

Future research needs to address precision of terminology, expansion of qualitative and quantitative research methods, development and psychometric examination of measuring instruments specific to SLPs and the development and evaluation of concepts to support professional relationship building in speech-language pathology training and everyday work.

Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study

BACKGROUND

Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored.

OBJECTIVE

This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention.

METHODS

Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention.

RESULTS

Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would.

CONCLUSIONS

Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

The relationship between expressive suppression, therapeutic bond, and treatment outcomes of a positive affect intervention for adults with anxiety and/or depression

Expressive suppression (ES; reducing emotional expression) is linked with reduced social connectedness in individuals with anxiety or depression. One implication is that people who use ES may have difficulty establishing a bond with their therapist which may impede clinical improvement. We examined this hypothesis in 33 adults with clinically elevated anxiety or depression receiving treatment focused on enhancing positive thoughts, emotions, and behaviors. At baseline, participants rated ES for positive and negative emotions during a standardized conversation task designed to generate connectedness. They also rated measures of early (session 3) perceived therapeutic bond and treatment outcomes (i.e. positive affect and social connectedness). ES of positive (r = -.39, p = .018), but not negative (r = .06, p = .747), emotions was negatively associated with therapeutic bond. Therapeutic bond mediated the relationship between greater ES of positive emotions during affiliation and lower post-treatment positive affect, 95% bias-corrected bootstrap confidence interval [-0.021, -0.000], adjusted for pre-treatment positive affect, as well as lower post-treatment social connectedness [-0.397, -0.015]; however, the indirect effect was not significant when accounting for pre-treatment social connectedness (p > .05). ES of positive emotions may be an important factor in the development of therapeutic bond and therefore treatment outcomes for individuals with anxiety or depression.

Use Intention and User Expectations of Human-Supported and Self-Help eHealth Interventions: Internet-Based Randomized Controlled Trial

BACKGROUND

Self-help eHealth interventions provide automated support to change health behaviors without any further human assistance. The main advantage of self-help eHealth interventions is that they have the potential to lower the workload of health care professionals. However, one disadvantage is that they generally have a lower uptake. Possibly, the absence of a relationship with a health care professional (referred to as the working alliance) could lead to negative expectations that hinder the uptake of self-help interventions. The Unified Theory of Acceptance and Use of Technology (UTAUT) identifies which expectations predict use intention. As there has been no previous research exploring how expectations affect the adoption of both self-help and human-supported eHealth interventions, this study is the first to investigate the impact of expectations on the uptake of both kinds of eHealth interventions.

OBJECTIVE

This study investigated the intention to use a self-help eHealth intervention compared to a human-supported eHealth intervention and the expectations that moderate this relationship.

METHODS

A total of 146 participants were randomly assigned to 1 of 2 conditions (human-supported or self-help eHealth interventions). Participants evaluated screenshots of a human-supported or self-help app-based stress intervention. We measured intention to use the intervention-expected working alliance and the UTAUT constructs: performance expectancy, effort expectancy, and social influence.

RESULTS

Use intention did not differ significantly between the 2 conditions (t142=-1.133; P=.26). Performance expectancy (F1,140=69.269; P<.001), effort expectancy (F1,140=3.961; P=.049), social influence (F1,140=90.025; P<.001), and expected working alliance (F1,140=26.435; P<.001) were positively related to use intention regardless of condition. The interaction analysis showed that performance expectancy (F1,140=4.363; P=.04) and effort expectancy (F1,140=4.102; P=.045) more strongly influenced use intention in the self-help condition compared to the human-supported condition.

CONCLUSIONS

As we found no difference in use intention, our results suggest that we could expect an equal uptake of self-help eHealth interventions and human-supported ones. However, attention should be paid to people who have doubts about the intervention's helpfulness or ease of use. For those people, providing additional human support would be beneficial to ensure uptake. Screening user expectations could help health care professionals optimize self-help eHealth intervention uptake in practice.

TRIAL REGISTRATION

OSF Registries osf.io/n47cz; https://osf.io/n47cz.

Measuring the therapeutic bond in genetic counseling: Testing measurement error in the bond subscale of the Working Alliance Inventory

The therapeutic relationship is a key component of successful genetic counseling. In psychotherapy, a strong therapeutic relationship can improve patient health outcomes and a poor relationship can worsen psychological functioning. Investigation of the therapeutic relationship in genetic counseling has shown evidence for a similar pattern. Reliable measurement of the therapeutic relationship is necessary for consistency across studies in the genetic counseling context. One measure that has been adapted for use in genetic counseling is the Working Alliance Inventory (WAI). However, there have been no studies of the factor structure or item-level method bias analyses for the genetic counseling-adapted version of the WAI. The goal of this study was to test the factor structure of the WAI observer version (WAI-O) bond subscale and assess method bias in a genetic counseling context. We hypothesized that differences in factor structures would exist for items that were positively (n = 9) versus negatively (n = 3) worded (reverse coded). Secondary data analysis was performed on two data sets that utilized the WAI-O in genetic counseling contexts. Data set 1 used simulated genetic counseling sessions that were judged by analog clients recruited through crowdsourcing platforms (N = 861). Data set 2 was conducted with genetic counseling clients, and sessions were evaluated by a research team (N = 120). Principal axis factor analysis with oblique oblimin rotation supported a two-factor solution for the WAI-O bond subscale across data sets. Items factored based on wording, with the positively worded items loading together and the negatively worded items loading on the second factor. Confirmatory factor analyses supported the removal of all negatively worded items from the instrument across data sets. Results suggest that the negatively worded items on the WAI-O may be capturing a construct inconsistent with the positively worded items and support rewording and/or excluding them from use for a more reliable measure of the therapeutic bond.

Predictors of homework engagement in group CBT for social anxiety: client beliefs about homework, its consequences, group cohesion, and working alliance

OBJECTIVE

Group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) is effective, but little data exist on generic relational components of the therapeutic process, such as group cohesion and therapy alliance, and central CBT-specific components such as homework engagement, beliefs, and perceived consequences. The aim of this study was to investigate the relationships between homework, group cohesion, and working alliance during group CBT for social anxiety disorder.

METHOD

Participants (N = 105) with SAD engaged in 12 sessions of group CBT. Measures of homework, working alliance, and group cohesion were completed at multiple points throughout treatment. Random-intercept cross-lagged panel models were used to evaluate the prospective relationships between measures.

RESULTS

Prospective relationships between the homework outcomes did not vary throughout the treatment period, with the only significant relationships seen between the random intercepts ("trait" levels). Homework beliefs were a significant negative predictor of future group cohesion, but only in mid- to late-treatment. Homework consequences and working alliance were significantly and positively predictive of each other throughout therapy.

CONCLUSION

Early homework engagement is associated with higher engagement throughout therapy. Working alliance and homework engagement are important to bolster early in group CBT.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12616000579493..

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.

Do program practices matter for mentors?: How implementation of empirically supported program practices is associated with youth mentoring relationship quality

This study investigates how the implementation of program-level practices by formal youth mentoring programs is associated with the quality of youth mentoring relationships as contexts for youth development and also examines whether this connection is mediated by the mentor-staff working alliance. Using data from mentors (n = 542) participating in multiple programs (n = 55), multilevel path models examined hypothesized direct and mediated effects. Parallel analyses were conducted with assessments of program practices from staff (n = 219). Greater exposure to program practices was associated with higher ratings of mentoring relationship satisfaction, commitment, and security and lower mentor-youth relationship negativity. The mentor-staff working alliance either partially or fully mediated these associations. Staff-reported practices predicted mentoring relationship satisfaction and commitment without mediation by the working alliance. This study suggests program practices contribute to stronger youth mentoring relationships. The findings also highlight the mentor-staff working alliance in supporting the development of positive mentoring relationships.

Agenda-setting in first sessions of business coaching-a focus on coaches' practices to manage the agenda and establish the working alliance

Introduction

Agenda-setting is a central communicative task for professionals and a joint activity of all participants particularly at the onset of helping interactions such as coaching. Agreeing on goal(s) and assigning tasks alongside establishing a trustful bond prepare the ground for the success of the interaction. The professional agent initiates and sets the agenda as part of their professional role and responsibility, i.e., based on their professional epistemic and deontic authority. Concurrently, by orienting to clients' epistemic authority and by yielding power, control, and agency to clients to co-manage the ensuing interaction, agenda-setting is the first opportunity for client-centeredness, which is a central characteristic and success factor for the working alliance in coaching.

Procedure and Methods

We take first steps in filling a research gap by providing a first analysis of the interactional unfolding of agenda-setting in coaching and by showcasing that and how agenda-setting as a joint activity of coach and client contributes to their working alliance. More precisely, we investigate agenda-management practices in five first sessions of business coaching to (1) document and analyze how the joint activity 'agenda-setting' is implemented via various (coach-initiated) social actions, (2) detail their contribution to establishing the working alliance, and (3) to interpret the emerging practices of agenda-management against the concept of 'client-centeredness'. For the analysis, we draw on conceptual and methodological resources from interactional linguistics alongside linguistic pragmatics and conversation analysis.

Results

We found 117 instances of 'agenda-setting' in our data which can be assigned to the seven social actions "Delivering Agenda Information", "Requesting Agenda Information", "Requesting Agenda Agreement", "Requesting Agenda Action", "Suggesting Agenda Action", "Offering Agenda Action" and "Proposing Agenda Action".

Discussion

The social actions display that agenda-setting serves to establish a common ground regarding goals, tasks and the relational bond of coach and client, and (after this has been achieved) to negotiate future coaching actions. Thus, the joint activity of 'doing' agenda-setting can be shown to be 'doing' working alliance at the same time.

Living with stroke during the first year after onset: an instrumental case study exploring the processes that influence adjustment

PURPOSE

The purpose of the study was to explore the experiences of an individual navigating life in the first year after stroke, with attention to the influence of health professionals on adjustment.

METHOD

In-depth interviews were completed at regular intervals with an individual in rural Australia. This longitudinal approach supported the exploration of views over time. Interview transcripts were coded and analysed using strategies consistent with constructivist grounded theory methods. Findings are presented as an instrumental case study.

RESULTS

The experience of stroke was one of adjustment to a new reality and of an altered and evolving concept of self: captured within the themes of fragmentation, loss, and reconstruction. Self-efficacy emerged as a driver in the adjustment process. Interactions with health professionals influenced adjustment and impacted on conceptualisations of self and self-efficacy.

CONCLUSIONS

Adjustment to stroke necessitated a reconceptualization of self. Relationships and interactions with others emerged as potential facilitators. For health professionals working with people after stroke, knowledge of the adjustment process and attention to practices that affirm personhood and enhance self-efficacy have the potential to facilitate long term outcomes. Processes linked to adjustment are represented visually to guide conceptual understandings and facilitative actions.

IMPLICATIONS FOR REHABILITATIONAll interactions with health professionals, including casual or ad hoc interactions, have the potential to influence adjustment after stroke.Health professionals who interact in ways that recognise personhood may have an especially positive influence on processes linked to adjustment.Giving time to listen to personal narratives and reflections may assist with sense-making and support the process of reconceptualising self after stroke.Through bidirectional sharing of experience and ideas, health professionals can facilitate the experience of self-efficacy.

Outcome expectations and working alliance may be more important for patients from rural areas during the transition to college life: An exploratory within-patient analysis

OBJECTIVE

Research has given limited attention to the distinction between patients from rural and urban areas, especially concerning the frequent overlap between rural living and low socio-economic status (SES). To shed more light on this, we explored the differential treatment processes between patients from rural and urban areas.

METHOD

Seven hundred and fourteen patients recruited from a university counseling center in China filled out the questionnaires for Outcome Expectation (OE), Session Alliance Inventory (SAI) and Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) each session. Data was analyzed using the disaggregated cross-lagged panel model and the asymmetric fixed-effect model.

RESULTS

The findings indicated a reciprocal within-patient relation between OE and SAI for the whole sample. SAI mediated the effect of OE on next-session CORE-OM for patients from rural areas, with a significantly greater indirect effect than for patients from the urban areas. Asymmetric effects were found for OE among patients from urban areas, for whom drops in OE predicted worse next-session CORE-OM more strongly than improvements in OE predicted improved CORE-OM.

CONCLUSION

This study provided preliminary evidence for differential OE-alliance-outcome predictions between patients with different SES and affirmed a reciprocal OE-alliance relation in a Chinese sample during the transition period of college.

Mastery of teletherapy is related to better therapeutic relationship and presence in teletherapy: the development of the teletherapy intervention scale

Introduction

Providing teletherapy requires a unique therapeutic approach and mastery of the teletherapy context. We aimed to develop a self-report scale for therapeutic interventions pertinent to teletherapy, and to examine its relationship with teletherapy process variables, and therapists' attitudes towards teletherapy technology.

Method

A total of 839 therapists participated in a survey study that included standardized measures of therapeutic process (real relationship, working alliance, therapeutic presence), attitudes towards and intention to use teletherapy in the future, and a list of 13 teletherapy intervention items that we hypothesized to be specific to the teletherapy format.

Results

Twelve of the 13 teletherapy intervention items loaded on one factor, with good reliability. The 12-item Teletherapy Intervention Scale was positively related to working alliance, the real relationship, therapeutic presence in teletherapy sessions, as well as to positive attitudes towards teletherapy and intention to use teletherapy in the future.

Discussion

Aspects specific to the practice of teletherapy may be successfully captured by a self-report scale, and adequately navigating the challenges and opportunities of teletherapy might enhance the therapeutic process. Further studies are needed to provide additional validation of the scale, and in how to best use this Teletherapy Intervention Scale in research and clinical training.

Ambivalent toward life, ambivalent toward psychotherapy? An investigation of the helping alliance, motivation for treatment, and control expectancies in patients with suicidal ideation in inpatient psychotherapy

BACKGROUND

Research has found that patients with suicidal ideation (SI) are at high risk for unfavorable outcomes. The present work aimed to expand the knowledge about their characteristics and treatment success.

METHODS

Data were drawn from a routine assessment of N = 460 inpatients. We used patients' self-report data as well as therapists' reports covering baseline characteristics, depression and anxiety symptoms (at the start and end of therapy), psychosocial stress factors, helping alliance, treatment motivation, and treatment-related control expectancies. In addition to group comparisons, we conducted tests of associations with treatment outcome.

RESULTS

SI was reported by 232 patients (50.4% of the sample). It co-occurred with higher symptom burden, more psychosocial stress factors, and negation of help. Patients reporting SI were more likely to be dissatisfied with the treatment outcome (although their therapists were not). SI was related to higher levels of anxiety symptoms after treatment. In regression models of depression and anxiety symptoms, interactions of SI with the external control expectancy powerful others were observed, suggesting that in patients with frequent SI, this control expectancy hindered recovery.

DISCUSSION/CONCLUSION

Patients reporting SI are a vulnerable group. Therapists could support them by addressing (potentially conflicting) motivations and control expectancies.

The power (and limits) of the therapeutic relationship: Working alliance, psychiatric distress, and the role of trait emotional intelligence

OBJECTIVE

The working alliance between therapists and patients is an important factor in the psychotherapy processes. Trait emotional intelligence has also been found to be malleable in treatment and to play a significant role in patient outcomes. The present study investigated how the relationship between measured working alliance and patient symptoms may differ depending on changes in patient trait emotional intelligence capacities.

METHODS

One hundred twenty-nine adults at a community mental health clinic completed self-report measures at the beginning of treatment, as well as 8 months into treatment. Hierarchical linear regressions were computed to assess the interaction of working alliance and trait emotional intelligence scores on patient symptom scores. Simple slope tests were used to probe significant interactions.

RESULTS

Trait emotional intelligence served as a significant moderator on the relationship between working alliance and patient symptoms. Specifically, the relationship between working alliance and patient symptoms was only significant for participants who reported an improvement in trait emotional intelligence over the course of treatment.

CONCLUSION

Results demonstrate that the impact of working alliance on patient symptom outcomes depended on patient improvement in trait emotional intelligence capacities. Such findings emphasize the importance of investigating the nuanced individual factors that impact the ways in which working alliance relates to treatment outcomes.

Therapists' perception of the working alliance, real relationship and therapeutic presence in in-person therapy versus tele-therapy

Although teletherapy is increasingly common, very little is known about its impact on therapeutic relationships. We aimed to examine differences between therapists' experiences of teletherapy and in-person therapy post-pandemic with regard to three variables pertinent to the therapeutic relationship: working alliance, real relationship, and therapeutic presence.

METHODS

In a sample of 826 practicing therapists, we examined these relationship variables, as well as potential moderators of these perceived differences including professional and patient characteristics and covid-related variables.

RESULTS

Therapists reported feeling significantly less present in teletherapy and their perceptions of the real relationship were somewhat impacted, but there were no average effects on their perceived quality of the working alliance. Perceived differences in the real relationship did not persist with clinical experience controlled. The relative reduction in therapeutic presence in teletherapy was driven by the ratings of process-oriented therapists and therapists conducting mostly individual therapy. Evidence for moderation by covid-related issues was also found, with larger perceived differences in the working alliance reported by therapists who used teletherapy because it was mandated and/or not by choice.

CONCLUSION

Our findings might have important implications for generating awareness around the therapists' lowered sense of presence in teletherapy compared to in-person teletherapy.

Quality of the therapeutic working alliance as a factor in intensive residential treatment of obsessive-compulsive disorder

OBJECTIVE

Intensive residential treatment (IRT) for obsessive-compulsive disorder (OCD) includes frequent meetings with a cognitive-behavioral therapist. We examined whether this therapeutic working alliance relates to IRT outcomes.

METHOD

Data came from a naturalistic sample of patients with OCD (n = 124) who received IRT at a specialty OCD clinic. Patients completed measures of OCD severity and well-being at admission and discharge. Both the patient and treating psychologist completed the Working Alliance Inventory-Short Form (WAI-SF). Alliance ratings were tested as predictors in models predicting outcomes (discharge scores adjusting for baseline and treatment duration) as well as logistic regression predicting treatment response (≥35% symptom reduction in OCD symptoms).

RESULTS

Patient and clinician ratings of the quality of the alliance were weakly yet significantly correlated. Patient ratings of the alliance predicted outcomes, while therapist ratings did not. Moreover, greater discrepancy between patient and client ratings predicted worse outcomes. Patient ratings of the task dimension of the alliance uniquely related to responder status.

CONCLUSIONS

Patient perceptions of the working alliance, particularly as pertaining to agreement on therapeutic tasks, related to success with IRT for OCD. Further study is needed test interventions to improve task alliance as a strategy to enhance treatment.

Psychometric properties of the Fletcher Recovery Housing Alliance Measure (FRHAM-12)

Background: Recovery Housing (RH), an important resource for substance use disorder (SUD) recovery, centers on shared lived experience. Program evaluation considers the contribution of environmental factors to outcomes, yet most research on outcomes has focused on patient factors and fidelity to protocols. Investigations of process measures reflecting the dynamic interplay between patient factors and the treatment program are limited. Alliance, one's perceived connection with others, is a process measure associated with mental health outcomes and includes domains "tasks," "goals," and "bonds." We posit that alliance serves as a proxy construct to measure the impact of shared experience in RH.Objectives: Develop and assess the psychometric properties of the Fletcher Recovery Housing Alliance Measure (FRHAM-12) for RH.Methods: A cross-sectional survey with the 12-item FRHAM-12 was administered to 271 individuals (60% men, 39% women, 1% other) within six RH centers in Kentucky. Item-total correlations, internal consistency reliability, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA) were conducted.Results: The FRHAM-12 was found to have a strong internal consistency (0.924 alpha coefficient) and the EFA yielded a single component (56.38% of cumulative scale variance). CFA indicated acceptable levels of absolute and relative fit of a unidimensional scale with values of 0.67 and 0.976 for the standardized root mean square residual and relative fit index.Conclusion: This study aimed to construct and validate an initial measure for RH alliance resulted in the brief, FRHAM-12; a tool with strong internal and factor validity. Future research should examine the measure's predictive and concurrent validity.

Clinician experiences of homework in couples and family therapy: A survey of perceived impact on the working alliance

The process of engaging clients in homework assignments has been studied extensively in research settings, but rarely have the challenges in the implementation of the science been considered in couples and family therapy. A survey was conducted of 226 clinicians regarding (1) their experience of homework adherence (quantity and quality) with couple and family clients, and (2) their experience of the impact of homework non-completion (IHN) on the working alliance. Clinicians working with families reported less overall homework quantity and quality. However, across both couples and family clients, more negative IHN was reported among clinicians experiencing less homework quantity, both in terms of IHN bond (couple ρ = 0.71, p < 0.001; family ρ = 0.78, p < 0.001) and IHN agreement (couples ρ = 0.25, p < 0.001; ρ = 0.19, p = 0.006), and among clinicians with fewer years of clinical experience (r = 0.19, n = 136, p < 0.05). The present findings suggest that, in the context of couples and family therapy, there is a risk of perceived negative IHN on the working alliance. There would be merit to future investigations examining the processes of facilitating homework engagement within the context of a strong working alliance.

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.

Patient and mentor language style matching as a predictor of working alliance, engagement with treatment as usual, and eating disorders symptoms over the course of an online guided self-help intervention for anorexia nervosa

OBJECTIVE

The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors.

METHOD

87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention.

RESULTS

Both early (1^st session) and late (6^th session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads.

CONCLUSIONS

These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome.

The moderating and mediating role of telepresence and cognitive change in cognitive behaviour therapy delivered via videoconference

In this study, we combined the results of two controlled trials and examined the relationships between working alliance, telepresence, cognitive change and treatment outcome. Sixty-five participants with a primary diagnosis of generalized anxiety disorder (GAD) or panic disorder with agoraphobia (PDA) received cognitive behaviour therapy delivered via videoconference. Participants completed measures of working alliance and telepresence after three psychotherapy sessions. They also completed measures of treatment outcome and dysfunctional beliefs (cognitive change) specific to PDA and GAD at pretreatment and posttreatment. Results revealed that telepresence at the fifth session moderated the relationship between the working alliance at the first and fifth sessions. As telepresence increased, its impact on the working alliance diminished. Cognitive change mediated the relationship between the working alliance at the fifth session and treatment outcome.

The Effect of Dog Presence on the Therapeutic Alliance: A Systematic Review

The development of a therapeutic alliance represents one of the most important processes that occurs in psychological therapy and is one of the strongest predictors of treatment outcome. To ensure the effective delivery of psychological interventions, it is important to explore factors which may improve the therapeutic alliance. There are well-documented effects of human-animal interactions in social settings, and researchers have also considered the effect of dog presence on the therapeutic alliance. A systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. Database searches included CINAHL, Cochrane, Embase, MEDLINE, PsycINFO, and Scopus. The inclusion criteria were studies that assessed the effect of dog presence on the therapeutic alliance and provided a quantitative outcome measure. Six studies met the inclusion criteria and were included in the systematic review. Three of the included studies observed no significant effect of dog presence on the therapeutic alliance; three studies did observe a positive effect, with effect sizes ranging from d = 0.10 to d = 0.58. All six studies took place in either research or clinical settings. Studies differed in terms of help-seeking versus non-help-seeking populations, where help-seeking populations were genuinely pursuing a psychological intervention. Heterogeneity was observed regarding study procedure and outcome measures used. Current data is limited, and initial evidence suggests that the effect of dog presence on the therapeutic alliance remains unclear, illustrated by inconsistent outcomes across the included studies. Further research is warranted before introducing dogs into therapeutic settings for this purpose.

Coaching during a crisis: Organizational coaches' praxis adaptation during the initial stages of the Covid-19 pandemic

The chaotic initial stages of the Covid-19 pandemic severely challenged organizations. Economies shut down and millions of people were confined to their homes. Human resource practitioners turned to organizational coaching, a trusted human resource development intervention for help, however, to remain relevant during the crisis coaches had to adapt their praxis. The working alliance describes the mutual bond, goal, and task alignment between coach and client and is an indication of coaching efficacy. This study investigates to what extent organizational coaches' praxis adaptation at the start of the pandemic maintained a working alliance that still served the human resource development (HRD) paradigms of learning, performance, and meaningful work. Interviews with 26 organizational coaches from USA, UK, Australia, and South Africa recorded during the first general lockdown (April 2020) were inductively analyzed using thematic analysis and deductively interpreted through the working alliance theory and desired HRD outcome paradigms. Findings reveal seven organizational coaching praxis adaptations judged to support all three working alliance components, with "task" and "goal" more prominent than "bond," suggesting a pragmatist preference reminiscent of crisis management. Praxis adaptation also seems to promote all three HRD paradigms of learning, performance, and meaningful work on individual and/or organizational levels. This study strengthens the already well-established link between HRD and coaching by positing that coaching is a dynamic, pragmatic, self-adaptive intervention that supports HRD during a crisis. Understanding coaches' praxis adaptation during the volatile initial stages of a crisis is important for HRD theory and practice given HRDs increasing reliance on 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.

How does hostile resistance interfere with the benefits of cognitive-behavioral therapy for panic disorder? The role of therapist adherence and working alliance

Objective Although clients' hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive-behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r  = -.36, p  =  .04) and subsequent declines (r  = -.58, p  <  .0001) in the working alliance. Nevertheless, hierarchical linear modeling revealed that neither a declining alliance nor therapist adherence (whether treated as linear or curvilinear) was independently predictive of symptom change, nor did these factors mediate hostile resistance's association with worse symptomatic improvement. Exploratory logistic regressions similarly indicated that neither adherence nor alliance moderated whether hostilely resistant clients dropped out. Conclusion: This is the first study to establish a bidirectional association between hostile resistance and a declining working alliance. Findings also add to a mixed literature on the adherence-outcome relationship.

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.

Factors That Foster Therapeutic Alliance in Pediatric Sports and Orthopedics: A Systematic Review

Therapeutic alliance has been defined as building rapport between provider and patient in order to enhance patient motivation to improve outcomes. The purpose of this systematic review was to identify factors that patients look for that help build a strong therapeutic alliance in their pediatric sports or orthopedics healthcare provider, to identify if these factors differ across healthcare professions, and to identify any differences in therapeutic alliance between patients and their provider regarding in-person and telehealth visits. Scientific databases were searched from inception until August 2022. The search strategy resulted in 2195 articles with 11 studies included in the final analysis. The main attributes adolescents look for in their pediatric sports healthcare provider were shared decision making and understanding patients' sports and goals. These factors were found to differ among parents, sex, race, and socioeconomic status. The top factors improving therapeutic alliance in telehealth were having an already established relationship with the provider, visits lasting longer than 30 min, and having an English-speaking provider for English-speaking patients. The available literature highlights factors that contribute to the development of a stronger therapeutic alliance in the pediatric sports and orthopedics population. As these factors differ among adolescents, parents, sex, race, and socioeconomic status, this review provides insight in what patients and families look for in their provider when seeking care.

The therapeutic alliance in cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis

Background

The therapeutic alliance has been recognized as one of the most researched key elements of treatment across different therapeutic approaches and diagnostic domains. Despite its importance, our current understanding of its clinical relevance in patients with obsessive-compulsive disorder (OCD) is still debated. This study aimed to examine empirical evidence on the effect of alliance on treatment outcomes in Cognitive Behavioral Therapy (CBT) in patients with OCD in a systematic review and meta-analysis.

Methods

Original peer-reviewed articles until March 2022 were included if they were (1) written in English; (2) included a clinical group with a current primary OCD diagnosis; (3) involved individual CBT; (4) used a validated therapeutic alliance scale that was related to the outcome measurement; (5) reported an effect size.

Results

Thirteen studies were included, six of which contained sufficient statistical information to be included in the meta-analysis. A total of 897 patients took part in all reviewed studies. We found a modest effect of alliance on post-treatment outcome [Tau 2 = -0.1562 (C.I. 95%: -0.2542 to -0.0582)].

Discussion

The results show the existence of considerable variability and methodological inconsistencies across studies. We discuss the role of methodological factors that could account for this divergence, the research limitations, and the implications for current research.

Systematic review registration

[https://osf.io/dxez5/?view_only=bc2deaa7f0794c8dbef440255b2d4b3b].

Alliance With an Unguided Smartphone App: Validation of the Digital Working Alliance Inventory

The working alliance may be relevant in unguided smartphone-based interventions, but no validated measure exists. We evaluated the psychometric properties of the six-item Digital Working Alliance Inventory (DWAI) using a cross-sectional survey of meditation app users (n = 290) and the intervention arm of a randomized trial testing a smartphone-based meditation app (n = 314). Exploratory factor analysis suggested a single-factor solution which was replicated using longitudinal confirmatory factor analysis. The DWAI showed adequate internal consistency and test-retest reliability. Discriminant validity was supported by a lack of association with social desirability, psychological distress, and preference for a waitlist condition. Convergent validity was supported by positive associations with perceived app effectiveness and preference for an app condition. Supporting predictive validity, DWAI scores positively predicted self-reported and objective app utilization. When assessed at Weeks 3 or 4 of the intervention, but not earlier, DWAI scores predicted pre-post reductions in psychological distress.

Building strong therapeutic relationships quickly: The effect of the perceived working alliance on veterans' intensive PTSD treatment outcomes

Intensive treatment programs (ITPs) are successful at reducing posttraumatic stress disorder (PTSD) and depression symptoms in veterans. However, the role of the working alliance in the context of ITPs is largely unexplored. The purpose of this study was to examine veteran-rated working alliance with their individual cognitive processing therapy (CPT) provider as a predictor of changes in PTSD and depression symptoms as well as negative posttrauma cognitions in two unique ITP formats. Data were collected from 128 veterans who completed a 2-week ITP, involving 2 × individual CPT/day, as well as 73 veterans who completed a 3-week ITP, involving 1 × group CPT/day and 1 × individual CPT/day. Both ITPs included adjunctive wellness, skills, and psychoeducation services in addition to CPT. Linear mixed-effects models were used to determine whether changes in working alliance predicted changes in PTSD and depression symptoms. Stronger veteran-reported working alliance with their individual CPT therapist, most notably agreement on tasks, predicted significant reductions in both the 2-week and 3-week programs in PTSD (ps = .012 and .002, respectively) and depression symptoms (ps = .009 and .007, respectively) and negative posttrauma cognitions (ps = .009 and .016, respectively). These results highlight the importance of veterans' perceived working alliance with their individual treatment therapists in ITPs. Results suggest that a strong working alliance that is meaningful for treatment outcomes can be developed quickly despite the brevity of this intensive treatment format. Future research should examine ways to facilitate the development of a strong working alliance prior to or as early as possible in ITPs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Changing to remote psychological therapy during COVID-19: Psychological therapists' experience of the working alliance, therapeutic boundaries and work involvement

RESEARCH AIMS

This study aimed to investigate psychological therapists' perceived ability to form a working alliance and maintain therapeutic boundaries, and their work involvement patterns whilst working remotely via telephone or videoconferencing. Furthermore, the study aimed to explore therapists' experience of therapeutic boundaries when working remotely and how they managed these.

METHOD

A mixed-method sequential explanatory design was adopted. Descriptive and inferential statistics were used to analyse quantitative data, with thematic analysis used to analyse qualitative data.

RESULTS

In total, 161 psychological therapists completed an online survey, and 12 participants were selected using maximum variation sampling to engage in a semi-structured interview. Although results between therapists varied, some perceived abilities regarding the working alliance and therapeutic boundaries differed when working remotely compared to face-to-face therapy. Therapists' work involvement patterns also differed compared to existing data for face-to-face therapy, indicated by increased rates of stressful involvement. Considering therapists' experience of therapeutic boundaries, four overarching themes were identified: 'different boundaries in remote therapy', 'work home boundary', 'changes in the therapeutic safe space' and 'impact of boundaries when working remotely'.

CONCLUSIONS

Aspects of the working alliance and therapeutic boundaries are experienced differently by therapists working remotely, which relates to how they experience their work. The findings have clinical implications for increasing therapists' awareness of potential changes in their perceived abilities regarding the working alliance and therapeutic boundaries when working remotely, therefore, enabling them to address these changes where required. Future research possibilities are considered.

Conceptual Invariance, Trajectories, and Outcome Associations of Working Alliance in Unguided and Guided Internet-Based Psychological Interventions: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

The role of working alliance remains unclear for many forms of internet-based interventions (IBIs), a set of effective psychotherapy alternatives that do not require synchronous interactions between patients and therapists.

OBJECTIVE

This study examined the conceptual invariance, trajectories, and outcome associations of working alliance across an unguided IBI and guided IBIs that incorporated clinician support through asynchronous text messaging or video messaging.

METHODS

Adults with high education attainment (n=145) with subclinical levels of anxiety, stress, or depressive symptoms were randomized to 1 of 3 treatment conditions for 7 weeks. All participants received treatments from MyCompass, an unguided IBI using cognitive behavior therapy. Participants in condition 2 and 3 received supplemental, asynchronous clinician support through text and video, respectively. Working alliance with the IBIs was measured weekly using select items from the 12-item version of the Agnew Relationship Measure. Symptom and functional outcomes were assessed at baseline, at the end of treatment, and 1-month follow-up.

RESULTS

Working alliance with the IBIs was conceptually invariant across the 3 conditions. Working alliance followed a quadratic pattern of change over time for all conditions and declined significantly only in the text-support condition. After controlling for baseline symptoms, higher baseline levels of working alliance predicted less depression and less functional impairment at follow-up, whereas faster increases in working alliance predicted less worry at the end of treatment and at follow-up, all of which only occurred in the video-support condition.

CONCLUSIONS

Working alliance with the IBIs was generally established in the initial sessions. Although working alliance is conceptually invariant across IBIs with or without clinician support, the associations between working alliance and treatment outcomes among IBIs may differ depending on clinician involvement and the modalities of support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05122429; https://clinicaltrials.gov/ct2/show/NCT05122429.

"What shall we focus on?" - A thematic analysis of what characterizes cognitive-behavior therapy sessions with high or low quality of working alliance

OBJECTIVE

Several studies have shown that the quality of the working alliance predicts symptomatic improvement session-by-session, including in cognitive-behavioral therapy (CBT). We wanted to explore what characterizes CBT sessions with high and low alliances further using qualitative analysis.

METHOD

Ten CBT-sessions were selected from eight patients' therapies in a larger research project on psychotherapy for patients with major depression. Five sessions were chosen from high- and five from low-alliance sessions, based on therapist- and patient-reported Working Alliance Inventory scores. Transcripts of these sessions were analyzed using thematic analysis.

RESULTS

The analysis yielded four themes, each structured into two sub-themes: Therapist style, Person in focus, Content focus, and Therapeutic direction. In contrast to low-alliance sessions, high-alliance sessions were characterized by a more exploring as opposed to expert therapist style; a focus on the patient's thoughts, feelings, and behavior, rather than a diffuse focus or a focus on other people's actions/external events; and a sense of moving forward rather than stagnation.

CONCLUSION

Our qualitative analysis showed theoretically and clinically meaningful processes in CBT sessions of high- vs low working alliance. This method is a useful complement to quantitative within-patient analyses, to expand on the meaning of quantitative findings.

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.

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 Moderating Role of Working Alliance in the Association Between Depression and Suicide Ideation in Messaging Therapy

Introduction: Suicide is one of the leading causes of death worldwide, and it can be prevented by psychotherapy. The objective of this study was to examine the risk factors predicting suicide ideation during messaging psychotherapy, and the moderating role of working alliance (WA) in the association between baseline depression and later suicide ideation. Materials and Methods: A large outpatient sample (n = 4,388) engaged in daily messaging with licensed clinicians from a telemedicine provider. Using a longitudinal design, depression and anxiety symptoms were assessed at baseline, using the Patient Health Questionnaire (PHQ-8) for depression and the Generalized Anxiety Disorder (GAD-7) for anxiety. The WA was measured with the short version of the Working Alliance Inventory after 3 weeks of therapy, and suicide ideation was assessed at baseline and after 6 weeks of therapy, by item 9 of the Patient Health Questionnaire (PHQ-9). Demographic measures were also assessed. Results: Results indicate that depression (β = 0.09, p < 0.001), baseline suicide ideation (β = 0.50, p < 0.001), and WA (β = -0.08, p < 0.001), especially the task subscale (β = -0.14, p < 0.001), significantly predicted suicide ideation after 6 weeks. WA (β = -0.07, p < 0.001), especially the task (β = -0.14, p < 0.001) and bond subscales (β = 0.06, p = 0.002), moderated the association between depression at baseline and suicide ideation after 6 weeks, so that experiencing higher quality of WA decreased the association between depression and suicide ideation. Discussion and Conclusions: Suicide ideation may be reduced by experiencing the therapeutic relationship as beneficial, even among at-risk populations, which suffer from depressive symptoms. It is the first study to show this moderation effect in any platform of therapy.

Working together: An investigation of the impact of working alliance and cohesion on group psychotherapy attendance

OBJECTIVES

Group psychotherapy holds considerable potential for cost-effective treatment delivery. However, issues with client attendance can compromise the efficacy of such treatments. To date, client specific factors are amongst the most researched predictors of attendance in psychotherapy, with much less of a focus given to process factors, particularly in the group therapy context. This study aimed to determine which process factors influenced attendance in the context of a group therapy programme for adults with anxiety. It was hypothesized that (1) the working alliance and group cohesion would be moderately correlated, (2) both the working alliance and group cohesion would explain unique variance in session attendance, and (3) the working alliance would act as a moderator for attendance, when group cohesion was low.

DESIGN

The study utilized a within participants design.

METHODS

Participants were 91 adults (aged 18-74 years) who took part in a 9-week, transdiagnostic cognitive behavioural group therapy programme for the treatment of anxiety disorders.

RESULTS

Working alliance and group cohesion were significantly, but only moderately correlated (rs ranging .41 to .55). Together, working alliance and group cohesion significantly predicted total session attendance (17.70% variance explained). Working alliance did not moderate the relationship between group cohesion and session attendance.

CONCLUSIONS

The importance of individual and group processes in influencing group therapy engagement is highlighted, including the role of fostering bonds within the group and between clients and therapists.

PRACTITIONER POINTS

A complex array of process factors has been argued to influence treatment outcomes in group therapy The quality of the relationship between group therapy clients, as well as the relationship between a client and the therapist, predict session attendance. The quality of the relationship between the client and the therapist may be the most important predictor of session attendance. Therapists should foster positive relationships between each client and the therapist in group therapy, as well as assisting each client to foster positive relationships with other group members.

Professional identity, perceived job performance and sense of personal accomplishment among social workers in Israel: The overriding significance of the working alliance

This study examined the associations between social workers' professional identity and the quality of their work, as reflected by their perceived job performance and sense of personal accomplishment. Based on literature attesting to the contribution of the working alliance between social workers and their service-users to the attainment of interventions' goals, a model in which the working alliance mediated the associations between social workers' professional identity and the quality of their work was also tested. The study's sample consisted of 570 social workers in Israel, from a wide range of professional and organisational backgrounds. The study was cross-sectional, and data were gathered using an online questionnaire. Its results demonstrate direct effects of social workers' professional identity on the quality of their work. At the same time, social workers' working alliance with service-users acted as a mediator in the association between certain aspects of workers' professional identity and the quality of their work. These findings reassert and broaden understandings regarding the crucial role of relationships with service-users in the discussion of social work professional identity and its outcomes. The specific associations found also offer sustenance to the idea that autonomous social workers, who are committed to their profession, manage to generate stronger working alliances with their service-users; which in turn makes them better at what they do.

An exploration of clinical variables that enhance therapeutic alliance in patients seeking care for musculoskeletal pain: A mixed methods approach

INTRODUCTION/OBJECTIVES

Therapeutic alliance (TA) is an integral part of building a patient and clinician relationship. TA begins at the initial encounter; however, the specific TA behavioural practices that are most impactful and linked to pain reduction and improved function remain unclear. The primary objective of this study was to explore physical therapist behaviours and interactions during the initial physical therapy evaluation and how they related to the patient's perception of TA. A secondary objective was to explore the relationship between TA, pain intensity, and function.

METHODS

A mixed methods study was conducted. Pain intensity, TA and self-reported function were assessed at three time points. Spearman's Rho (ρ) was used to quantify if there was an association between increased TA and function and reduced pain intensity, while a checklist of TA themes and behavioural practices was used for the qualitative analysis.

RESULTS

There was a statistically significant negative correlation between patient-perceived TA and pain intensity immediately after the initial evaluation (ρ = -0.39 [p = 0.048]). Behavioural practices associated with higher TA included information gathering, pausing to listen, using humour and transitions, and use of clarifying questions. Behavioural practices associated with patient-perceived lower TA interactions were lack of touch, the absence of pain neuroscience education, and not restating what the patient said during the interview.

CONCLUSION

This study highlights a relationship between TA and reduction of pain intensity after the initial evaluation and identifies key behavioural practices that could positively and negatively impact TA during the clinical encounter.

Therapist Attachment and the Working Alliance: The Moderating Effect of Emotional Regulation

Objective: To explore whether the therapist's emotional regulation strategies moderate the relationship between therapist attachment and the working alliance from the therapist's perspective. Method: A non-experimental, descriptive correlational design was used. Sixty-three psychotherapists (6 men, 57 women) participated in this study, ranging in age from 27 to 69 years, with a mean age of 39.3 years. The therapists completed the Attachment evaluation questionnaire for adults, the Spanish Adaptation of the Working Alliance Inventory, and the Difficulties in Emotion Regulation Scale. Associations between attachment and emotional regulation traits and working alliance were examined using multilevel modeling, controlling for therapist demographics, and clinical experience. Results: Moderation analyses revealed significant interaction effects between therapist attachment and emotional regulation strategies. Conclusion: Attachment styles would not significantly affect the therapist's ability to establish an adequate therapeutic alliance bond. The results show that the attachment style of the therapists interacted with their emotional regulation abilities.

Contemporary Supportive Therapy: A Review of History, Theory, and Evidence

Supportive psychotherapy interventions were developed as a part of psychodynamic psychotherapy work, and supportive psychotherapy was historically considered to be the default form of therapy only for lower-functioning patients. These roots unfortunately have resulted in supportive psychotherapy being viewed as an inferior form of treatment. In reality, supportive psychotherapy is a practical and flexible form of psychotherapy that helps patients with a wide range of psychiatric illnesses, including mood disorders, anxiety disorders, posttraumatic stress disorder, schizophrenia, personality disorders, eating disorders, body dysmorphic disorder, and substance use disorders. In addition, supportive psychotherapy can be well-suited to higher-functioning patients, as well as to patients who are chronically lower-functioning. There is also evidence to support the use of supportive psychotherapy in patients with certain medical illnesses, including coronary artery disease, some gastrointestinal illnesses, HIV infection, and certain types of cancer. The goals of supportive psychotherapy include helping patients to understand emotional experiences, improving affective regulation and reality-testing, making use of their most effective coping strategies, and engaging in collaborative problem solving to reduce stressors and increase effective engagement with support systems.

Depth of experiencing and therapeutic alliance: What predicts outcome for whom in emotion-focused therapy for trauma?

OBJECTIVE

The purpose of this study was to determine the extent to which therapeutic processes - working alliance and depth of experiencing - contributed to outcome.

METHOD

Individual differences in these processes were examined at the early and working phases to determine their impact on symptom reduction. An archival data set of N = 42 individuals who underwent emotion-focused therapy for trauma for childhood maltreatment was used to examine the differential quality of client processes throughout treatment.

RESULTS

For those who had difficulty forming an alliance early in therapy, alliance scores during the working phase were the best predictor of outcome (β = -.42). This was complemented by a process change of improvement in alliance from the early to working phases (d = 1.0). In contrast, for those who had difficulty engaging in deepened experiencing early in therapy, depth of experiencing in the working phase was the best predictor of outcome (β = -.36). This was complemented by an improvement in depth of experiencing from the early to working phases (d = .69).

CONCLUSIONS

The findings of this study suggest that focusing on the process that clients have trouble with early in therapy contributes to the best treatment outcome.

PRACTITIONER POINTS

Sometimes early treatment sessions reveal an abundance of one kind of processing but limitations to another, which poses a puzzle for treatment planning. Our findings suggest that within the first four sessions, therapists could develop tailored treatments based on the relative presence or absence of critical therapeutic changes processes. When it becomes evident that therapy is progressing with a weaker alliance between client and therapist, therapists should redouble their efforts in alliance-building. However, when therapy is developing in a fashion that lacks deep emotional experiencing on the part of the client, treatment efforts should aim to facilitate a richer exploration of moment-by-moment experience. As such, our findings suggest relying on the existing processing strengths within a dyad (e.g., emphasis on an already strong relationships, or augmenting an existing aptitude for deeper experiencing) while shortcomings exist in another kind of process is not optimal responding. Therapists should focus their work on the process that clients have trouble with early in therapy to facilitate the best treatment outcome.

Responsible Relations: A Systematic Scoping Review of the Therapeutic Alliance in Text-Based Digital Psychotherapy

Introduction: Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy. Text-based digital psychotherapy has become increasingly common, yet much remains unclear about the alliance and its importance for delivering mental health care via a digital format. To employ text-based digital therapies responsibly, more insight is needed into the type and strength of the therapeutic alliance online. Methods: A systematic scoping review was performed searching four databases: Scopus, PsycINFO, Web of Science, and Wiley Online Library. A total of 23 studies were selected and data was extracted and tabulated to explore the characteristics of studies on text-based psychotherapy, measurements of the therapeutic alliance and associations of the alliance with treatment outcome. Results: The therapeutic alliance in text-based digital interventions was studied with a variety of client groups, though mostly for clients diagnosed with anxiety and/or depression issues. Treatment modalities were predominantly internet-based cognitive behavioral therapy (ICBT) and tailored platforms for distinct client groups (e.g., PTSD). Almost all treatments used asynchronous text-based communication, such as e-mails and integrated messaging functions, which were mainly used to give feedback on tasks. For measurements, a version of the Working Alliance Inventory (WAI) was used in most studies. Measurements with the WAI or WAI- short form indicated a good therapeutic alliance with a weighted mean score of 5.66 (on a scale of 1 to 7) and a weighted standard deviation of 0.84. Relations between the therapeutic alliance and treatment outcomes were mostly positive, with many studies reporting significant associations (n = 8 out of 10) or significant effects of the therapeutic alliance on treatment outcomes (n = 5 out of 6). Discussion: Our scoping review suggests that a good therapeutic alliance can be established in digital psychotherapy through text-based communication, and shows support for a positive relationship between the alliance and treatment outcomes. These findings illustrate that text-based online psychotherapy can be a responsible treatment option as far as the establishment of the therapeutic alliance is concerned. However, current measures of the therapeutic alliance might miss important aspects of the alliance in digital treatment, such as the presence of empathy or compassion.

Satisfaction with antipsychotics as a medication: the role of therapeutic alliance and patient-perceived participation in decision making in patients with schizophrenia spectrum disorder

OBJECTIVES

The aim of this study was to identify independent predictors of satisfaction with antipsychotics in patients with schizophrenia spectrum disorders treated in a mental health catchment area.

METHODS

Observational analytical study of patients (n = 150) recruited through a convenience sampling method from five mental health units. Satisfaction with the antipsychotic as a medication was evaluated using the Treatment Satisfaction Questionnaire for Medication (TSQM). Therapeutic alliance was assessed by the Working Alliance Inventory Short Form (WAI-S). Patient-perceived participation in decision-making was assessed using COMRADE (Combined Outcome Measure for Risk communication And treatment Decision making Effectiveness). A multiple linear regression analysis was performed to identify variables independently associated with the TSQM 'Global Satisfaction' total score.

RESULTS

Two variables - age and higher level of self-perceived participation in treatment decision-making - were directly, significantly, and independently associated (β coefficient values: 0.209 and 0.432, respectively) with a higher TSQM Global satisfaction score. In addition, the severity of psychotic symptoms was inversely associated with satisfaction (β coefficient value: -0.205) (R² = 0.355; R² adj. = 0.291; F(13) = 5.554; p < 0.01).

CONCLUSIONS

These findings suggest that involving the patient in treatment decision-making and optimising the treatment to reduce symptoms, especially in younger patients, could increase satisfaction with antipsychotic treatment.Key PointsPatient involvement in shared decision-making is relevant for treatment satisfaction.Current evidence suggests that improving the doctor-patient relationship optimises antipsychotics outcomes.Self-perceived participation in decision-making predicts satisfaction with antipsychotic medication.Types of antipsychotics do not determine consistent differences in satisfaction.

Observing the Working Alliance in Videoconferencing Psychotherapy for Alcohol Addiction: Reliability and Validity of the Working Alliance Inventory Short Revised Observer

The coronavirus disease-2019 (COVID-19) pandemic has affected the mental health and alcohol consumption of individuals. Videoconferencing psychotherapy has become a fundamental mode of treatment for people with alcohol use disorders. However, there are still doubts about its effectiveness and the therapeutic relationship. The working alliance is considered a foundation of effective practice in cognitive behavioral therapy (CBT). Observer measurements of the working alliance have demonstrated reliability and meaningful associations with the reduction of symptoms. However, translations of instruments to evaluate the working alliance and examine its construct have not previously been conducted for online psychotherapy for alcohol addiction. This study aimed for the cross-cultural adaptation of the Working Alliance Inventory-Short Form-Observer (WAI-SR-O) for Brazil and the evaluation of its reliability and evidence of its validity in videoconferencing psychotherapy for alcoholism. The WAI-SR-O was applied by pairs of observers for the evaluation of the working alliance in 19 recorded sessions of videoconferencing psychotherapy of 10 clients with a diagnosis of alcohol addiction. The sessions were also evaluated by the therapist (WAI-T) and client (WAI-C). The WAI-SR-O shows a moderate inter-rater intraclass correlation coefficient (ICC = 0.67) for the general scale, higher ICC for the goals and bond subscales, and a moderate value for the task subscale. The internal consistency was good (a = 0.86). The results show low but significant correlations among the goals and bond subscales of the WAI-SR-O and the general, goals, and bond scales of the WAI-T. No correlations were found with the WAI-C. As the literature points out, the client, therapist, and observer versions of the WAI evaluated the alliance differently, requiring further study. The WAI-SR-O proved to be a reliable and valid measurement for the evaluation of the working alliance in videoconferencing psychotherapy for alcohol addiction, becoming an important tool for the study of the working alliance in telepsychotherapy.

The relationship between working alliance with peer mentors and eating psychopathology in a digital 6-week guided self-help intervention for anorexia nervosa

OBJECTIVE

The quality of working alliance (WA) is associated with treatment outcomes across several types of psychiatric disorders and psychological interventions. This study examined the role of WA with peer mentors (people with lived experience of illness) and student mentors (graduated psychology students) in a 6-week, digital, guided self-help (GSH) intervention for anorexia nervosa.

METHOD

Ninety-nine patients rated weekly, for 6 weeks: (a) eating psychopathology using the short version of the Eating Disorder Examination Questionnaire (EDE-QS) and (b) WA with a student mentor (n = 14) or a peer mentor (n = 10). WA was assessed by asking patients the extent to which they felt comfortable working with their mentor and the extent to which they agreed with them on the goals for support. WA with mentors and the association with eating psychopathology change were measured on a session-by-session basis. The analysis involved a random intercepts cross-lagged panel model.

RESULTS

WA with peer mentors was slightly higher than WA with students (ES = 0.3). Peer mentors' WA in the previous session was significantly associated with eating psychopathology ratings in the next session. No significant relationship was found between the previous session's EDE-QS scores and peer mentor alliance in the following session. In the student mentor group, there were no session-by-session associations between WA and eating psychopathology. However, greater WA with the student mentor across sessions was associated with less eating psychopathology.

DISCUSSION

These findings suggest that clinical outcomes are in part associated with the characteristics of the mentor delivering guidance in an online GSH for eating disorders.

Relationships Between the Therapeutic Alliance and Reactions to Artistic Experience With Art Materials in an Art Therapy Simulation

In art therapy, art-making plays an important role in the therapeutic relationship. To better understand the triangular relationship between the art therapist, the client and the artwork, this study investigated the association between the therapeutic alliance and reactions to artistic experiences with art materials in an art therapy simulation. The simulation consisted of a series of 6-8 sessions in which art therapy students were divided into teams composed of a permanent observer (art therapist) and creator (client). The client's role was to self-explore through art- making, and the art therapist's role was to accompany the client. Thirty-four students, all women, who played the art therapist role, and 37 students (one male) who played the client participated in the study. Of these participants, there were 24 pairs where both participants filled out all the questionnaires. A short version of the Working Alliance Inventory (WAI) was completed by the clients and the art therapists on the second session (T1) and on the penultimate session (T2). The clients also completed the Art-Based Intervention Questionnaire (ABI) at T2. Significant positive correlations were found between indices of the WAI for the art therapist and the client and the clients' reactions to the artistic experience with art materials on the ABI. The evaluation of the emotional bond between the art therapist and the client at the start of the simulation significantly predicted the client's reactions to the artistic experience with art materials at the end of the simulation and explained 45.4% of the variance for this variable. These findings highlight factors related to the development and influence of the therapeutic alliance, as well as the role of the artistic experience in art therapy and lay the groundwork for further research.