Therapeutic Alliance in Depression Treatment: Controlling for Prior Change and Patient Characteristics.

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-Behavioral Analysis System of Psychotherapy as a Maintenance Treatment for Chronic Depression.

Although the efficacy of maintenance pharmacotherapy for the prevention of recurrence in major depressive disorder (MDD) is well documented, few studies have tested the efficacy of psychotherapy as a maintenance treatment. The authors examined the efficacy of the cognitive-behavioral analysis system of psychotherapy (CBASP) as a maintenance treatment for chronic forms of MDD. Eighty-two patients who had responded to acute and continuation phase CBASP were randomized to monthly CBASP or assessment only for 1 year. Significantly fewer patients in the CBASP than assessment only condition experienced a recurrence. The 2 conditions also differed significantly on change in depressive symptoms over time. These findings support the use of CBASP as a maintenance treatment for chronic forms of MDD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interpersonal styles of chronically depressed outpatients: Profiles and therapeutic change.

Theoretical accounts posit that chronically depressed individuals are perceived as hostile and/or submissive, which compromises their ability to satisfy their interpersonal needs. The current study assessed the interpersonal tenets of McCullough's (2000) chronic depression theory and examined change in interpersonal functioning following McCullough's treatment for chronic depression (viz., Cognitive-Behavioral Analysis System of Psychotherapy; CBASP). Data derive from a randomized 12-week clinical trial that compared the efficacy of CBASP, nefazodone, and their combination for chronic depression. To assess patients' interpersonal impacts, CBASP therapists completed the Impact Message Inventory (IMI) following an early and a late session. IMI data were compared to normative and clinical comparison samples to assess depression-related interpersonal profiles and clinically significant change in interpersonal functioning. As predicted, chronically depressed patients were initially perceived as more submissive and hostile than the comparison groups. Patients' interpersonal impacts on their therapists changed in adaptive, theoretically predicted ways by the end of CBASP treatment, either with or without medication. Individual-level clinical significance data were less robust. The findings generally substantiate McCullough's interpersonal theory and provide preliminary evidence of change in interpersonal impacts following treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social problem solving and depressive symptoms over time: A randomized clinical trial of cognitive-behavioral analysis system of psychotherapy, brief supportive psychotherapy, and pharmacotherapy.

Objective: Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009). Method: Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks. Results: CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions. Conclusions: It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Review of Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP).

Reviews the book, Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP) by James P. McCullough Jr. (see record 2006-11486-000). The premise of this book is that therapeutic neutrality does not apply to the psychotherapy of chronically depressed individuals, and that disciplined personal involvement is an efficacious and perhaps necessary component of their treatment. Cognitive behavioral analysis system of psychotherapy (CBASP) is a learning model, in which the therapist focuses on teaching patients to recognize the consequences of their behavior. McCullough addresses practical and theoretical objections to this therapeutic approach, which include fears of overinvolvement, and inappropriate behavior, and clinical risks of flooding patients with excessively personal information and content. Ultimately, most readers will finish reading this volume with many open questions, some specific to McCullough's approach, others related to the challenging condition of chronic depression itself. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder.

This study investigated the quality and development of the therapeutic alliance as a mediator of change in schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder. Seventy-eight patients were randomly allocated to 3 years of biweekly SFT or TFP. Scores of both therapists and patients for the therapeutic alliance were higher in SFT than in TFP. Negative ratings of therapists and patients at early treatment were predictive of dropout, whereas increasingly positive ratings of patients in the 1st half of treatment predicted subsequent clinical improvement. Dissimilarity between therapist and patients in pathological personality characteristics had a direct effect on growth of the therapeutic alliance but showed no relationship with clinical improvement. The authors conclude that the therapeutic alliance and specific techniques interact with and influence one another and may serve to facilitate change processes underlying clinical improvement in patients with borderline personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Alliance and Treatment Adherence in Two Interventions for Bulimia Nervosa: A Study of Process and Outcome.

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist × Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nonverbal synchrony in psychotherapy: Coordinated body movement reflects relationship quality and outcome.

Objective: The authors quantified nonverbal synchrony—the coordination of patient's and therapist's movement—in a random sample of same-sex psychotherapy dyads. The authors contrasted nonverbal synchrony in these dyads with a control condition and assessed its association with session-level and overall psychotherapy outcome. Method: Using an automated objective video analysis algorithm (Motion Energy Analysis; MEA), the authors calculated nonverbal synchrony in (n = 104) videotaped psychotherapy sessions from 70 Caucasian patients (37 women, 33 men, mean age = 36.5 years, SD = 10.2) treated at an outpatient psychotherapy clinic. The sample was randomly drawn from an archive (N = 301) of routinely videotaped psychotherapies. Patients and their therapists assessed session impact with self-report postsession questionnaires. A battery of pre- and postsymptomatology questionnaires measured therapy effectiveness. Results: The authors found that nonverbal synchrony is higher in genuine interactions contrasted with pseudointeractions (a control condition generated by a specifically designed shuffling procedure). Furthermore, nonverbal synchrony is associated with session-level process as well as therapy outcome: It is increased in sessions rated by patients as manifesting high relationship quality and in patients experiencing high self-efficacy. Higher nonverbal synchrony characterized psychotherapies with higher symptom reduction. Conclusions: The results suggest that nonverbal synchrony embodies the patients' self-reported quality of the relationship and further variables of therapy process. This hitherto overlooked facet of therapeutic relationships might prove useful as an indicator of therapy progress and outcome. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment style.

This article provides a brief review of attachment theory and recent research studies on its implications for individual psychotherapy. Attachment theory offers a conceptual framework that helps illuminate how past experiences with caregivers might influence current transactions between therapist and patient. Both patients and therapists may form internal working models that are based, in part, on early experiences of interpersonal responsiveness. Such working models are reflected in secure, anxious-ambivalent, and anxious-avoidant attachment styles, which describe whether patients (and therapists) tend to be comfortable and confident in relationships, fearful of abandonment, or defensively separate. Recent studies showed that attachment styles in the context of therapy can be measured reliably and related to therapeutic process (e.g., the alliance) and outcome (e.g., treatment response). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance as mediator of expectancy effects in short-term individual therapy.

The authors investigated the hypothesis that the therapeutic alliance mediates the relationship between pretherapy expectancy of improvement and psychotherapy outcome. Data were drawn from a comparative trial of 2 forms of short-term, time-limited individual psychotherapy (W. E. Piper, A. S. Joyce. M. McCallum, & H. F. Azim, 1998). Measures of expectancy and outcome were based on an individualized assessment of target objectives; outcome was considered from 3 perspectives (patient, independent assessor, therapist). Using the R. M. Baron and D. A. Kenny (1986) procedure, the authors, found evidence in support of the hypothesized mediation effect. The effect was evident when the alliance was rated from the perspective of either patient or therapist, and it accounted for one third of the direct impact of expectancy on outcome. Clinical implications and limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment preferences affect the therapeutic alliance: Implications for randomized controlled trials.

The influence of treatment preferences on the development of the therapeutic alliance was investigated. Seventy-five patients were followed while participating in a randomized controlled trial comparing supportive-expressive psychotherapy with sertraline or pill placebo in the treatment of major depressive disorder. Therapeutic alliance was assessed before treatment and at the 3rd, 5th, and 9th weeks of treatment. Among patients initially preferring psychotherapy, those receiving psychotherapy experienced increases in their alliance over time, whereas those receiving active medication or placebo experienced decreases. Among patients preferring pharmacotherapy, there were no differences in alliance development whether they received psychotherapy, active medication, or placebo. These relations were observed even when controlling for symptom severity. Thus, the congruence of patients' treatment preference and the treatment that they ultimately received influenced the development of the therapeutic alliance. Because alliance is a robust predictor of outcome, treatment preferences may need to be carefully considered in randomized controlled trial settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cohesion in group psychotherapy.

Insight into the therapeutic relationship in group psychotherapy requires an understanding of the treatment context. Cohesion is defined as the therapeutic relationship in group psychotherapy emerging from the aggregate of member leader, member-member, and member-group relationships. Using this definition, evidence for the relationship between cohesion, patient outcome, an treatment processes is reviewed. Six empirically supported principles that undergird the development and maintenance of cohesion are presented touching on pregroup preparation, ear group structure, leader interaction, feedback, leader modeling, and member emotional expression. The limitations the present research are discussed; leading to opportunities for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance: Theme and variations.

The therapeutic alliance is often misconceived, misunderstood, or ignored in conceptualizing the therapeutic process and the therapeutic relation in analysis and other forms of therapy. Conversely, I will argue that the alliance is indispensable in all forms of therapy. After briefly outlining the nature of the alliance, I discuss some of the empirical findings regarding its utility in various therapeutic contexts. I then consider its role and function in various therapeutic settings other than adult analysis and psychotherapy, including child analysis, treating various forms of psychopathology, and related contexts like supervision, forensic psychiatry, and hospital and medical treatment. The alliance plays a definite but analogous role in all of these, with differences according to context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of therapists' training on group therapeutic outcome.

The outcome of group therapy for psychotic patients was used as the dependent variable in assessing the comparative efficacy of trained and untrained therapists. The latter were undergraduate students with no training or experience in psychotherapy. For this reason, their role in psychotherapy was viewed as analogous to that of a placebo in studies assessing drug effects. Changes in psychological test performance of 295 patients before and after 5 mo. of group therapy served as the criterion of therapeutic behavior change. By comparison to an untreated control group the lay therapists achieved slightly better results than psychiatrists and psychiatric social workers doing group therapy with similar patients. Caution is urged in extending the implications of these results beyond group therapy with schizophrenic patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Research summary on the therapeutic relationship and psychotherapy outcome.

Factors that influence client outcome can be divided into four areas: extratherapeutic factors, expectancy effects, specific therapy techniques, and common factors. Common factors such as empathy, warmth, and the therapeutic relationship have been shown to correlate more highly with client outcome than specialized treatment interventions. The common factors most frequently studied have been the person-centered facilitative conditions (empathy, warmth, congruence) and the therapeutic alliance. Decades of research indicate that the provision of therapy is an interpersonal process in which a main curative component is the nature of the therapeutic relationship. Clinicians must remember that this is the foundation of our efforts to help others. The improvement of psychotherapy may best be accomplished by learning to improve one's ability to relate to clients and tailoring that relationship to individual clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis.

Changes in maladaptive cognitions may constitute therapeutic processes of multidisciplinary pain programs. A cross-lagged panel design was used to determine whether (a) early-treatment cognitive change predicted late-treatment outcome index change, but not vice versa; and (b) these effects remained significant with depression change controlled. Ninety chronic pain patients, in a 4-week multidisciplinary program, completed measures of catastrophizing, pain helplessness, depression, pain, interference, and activity level at pre-, mid-, and posttreatment. With depression changes controlled, early-treatment catastrophizing and pain helplessness changes predicted late-treatment outcome index changes, but not vice versa; early-treatment depression changes predicted late-treatment activity changes, but not vice versa. Findings advance understanding of pain treatment process and suggest that negative cognition changes may indeed affect improvements in treatment outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Guess who's coming to therapy? Getting comfortable with conversations about race and ethnicity in psychotherapy.

Despite the fact that clinical psychology training programs now typically offer course work in multicultural issues, many professional psychologists may continue to feel unsure about how and when to incorporate multicultural awareness into their everyday clinical work. Having open discussions with clients regarding issues of race and ethnicity is one way to actively include a multicultural element into psychotherapy, as well as to strengthen the therapeutic alliance and promote better treatment outcome. The authors make several recommendations designed to provoke thought and stimulate conversation about race and ethnicity in the context of psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)