Interpersonal complementarity and the therapeutic alliance: A study of relationship in psychotherapy.

Examined the relationship between the therapeutic alliance and interpersonal complementarity during the early stage of psychotherapy. 36 pairs of patients (aged 18–57 yrs) and therapists from 14 outpatient settings recorded their perceptions of their therapeutic alliance, using a working alliance inventory, and rated each other's therapy behaviors on the Checklist of Interpersonal Transactions. There were positive associations between patient–therapist interpersonal complementarity and both patients' and therapists' perceptions of the alliance. The more extreme/abnormal the patient's interpersonal behavior, the more both patient and therapist perceived a less positive working alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Manualization and competence monitoring of short-term anxiety-provoking psychotherapy.

Developed and assessed the validity and reliability of a rating form to assess therapist performance in short-term anxiety-provoking psychotherapy (STAPP). The STAPP Therapist Competence Rating Form (STCRF) is intended for use by nonparticipant observers of taped therapy sessions. Two raters independently observed and rated 31 therapy sessions, using the STCRF. The STCRF showed acceptable coefficients of internal consistency, interrater reliability on mean STCRF scores, and convergent and discriminant validities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relation between specific and general dimensions of the psychotherapy process in interpersonal psychotherapy of depression.

This article examines the relation between general dimensions of the psychotherapy process, rated with the Vanderbilt Psychotherapy Process Scale (VPPS), and a type of manual-guided psychotherapy, Short-Term Interpersonal Psychotherapy of Depression (IPT). With the use of data from a training program in IPT, two types of analyses were performed. First, VPPS factors were correlated with IPT therapist competence ratings. This analysis showed that all VPPS-rated dimensions of patient and therapist behaviors were significantly correlated with IPT competence ratings. Especially strong correlations occurred between IPT competence ratings and the VPPS therapist factors of (a) Exploration and (b) Warmth and Friendliness. Second, to evaluate whether the general process features that influenced IPT competence ratings were also related to the therapy's effectiveness, correlations between VPPS process dimensions and patient outcome were performed. This analysis indicated that VPPS-rated therapist behaviors were significantly predictive of patient outcome, whereas patient behaviors were generally not significantly related to outcome. Taken together, the findings indicate the importance of general aspects of the psychotherapy process in therapist evaluation and efficacy of manual-guided psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist competence and patient outcome in interpersonal psychotherapy of depression.

This article examines whether the therapist's level of competence in conducting interpersonal psychotherapy of depression (IPT) is associated with patient improvement. Data from 35 depressed outpatients treated for up to 16 sessions as part of the IPT training program for the National Institute of Mental Health Treatment of Depression Collaborative Research Program were used. Multiple regression analyses were performed to predict outcome from 4th-session ratings of therapist skill while controlling for important pretreatment patient characteristics including level of depression, social adjustment, and expectations of treatment outcome. The results showed that measures of therapist performance contributed significantly to the prediction of patient-rated change and change in the apathy associated with depression but not to measures of social adjustment at 16 weeks. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two aspects of the therapeutic alliance: Differential relations with depressive symptom change.

Objective: The therapeutic alliance has been linked to symptom change in numerous investigations. Although the alliance is commonly conceptualized as a multidimensional construct, few studies have examined its components separately. The current study explored which components of the alliance are most highly associated with depressive symptom change in cognitive therapy (CT). Method: Data were drawn from 2 published randomized, controlled clinical trials of CT for major depressive disorder (n = 105, mean age = 40 years, female = 62%, White = 82%). We examined the relations of 2 factor-analytically derived components of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) with symptom change on the Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996) that occurred either prior to or subsequent to the examined sessions. WAI ratings were obtained at an early and a late session for each therapist–patient dyad. Results: Variation in symptom change subsequent to the early session was significantly related to the WAI factor that assesses therapist–patient agreement on the goals and tasks of therapy but not to a factor assessing the affective bond between therapist and patient. In contrast, both factors, when assessed in a late session, were significantly predicted by prior symptom change. Conclusions: These findings may reflect the importance, in CT, of therapist–patient agreement on the goals and tasks of therapy. In contrast, the bond between therapist and patient may be more of a consequence than a cause of symptom change in CT. The implications of these results and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The effect of therapist self-disclosure on patients' perceptions of empathy, competence and trust in an analogue psychotherapeutic interaction.

Psychodynamically oriented clinicians uniformly contraindicate the use of therapist self-disclosure, whereas practitioners disposed toward a humanistic-existential perspective often regard this practice as an essential condition of treatment. In the present study, 57 psychotherapy patients (aged 18–55 yrs) read 1 of 3 patient–therapist dialogs in which the degree of therapist self-disclosure was high, low, or nil. Ss completed the Relationship Inventory and Sorenson Relationship Questionnaire to measure perceived therapist empathy, competence, and trust. Findings confirm the prediction that greater therapist self-disclosure would be related to poorer evaluations of the therapist. Results question the use of self-disclosure as a psychotherapeutic technique and suggest that self-disclosure may adversely affect the perceptions on which the therapeutic alliance is based. (46 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client–therapist value similarity and psychotherapy outcome: A microscopic analysis.

Examined the association between patient–therapist pretreatment value similarity and subsequent improvement in 45 nonpsychotic psychiatric outpatients (aged 19–54 yrs) who were randomly assigned to 22 therapists. Pre-assignment assessment of similarity in 36 value dimensions on the Rokeach Value Survey was investigated to determine how the dimensions influenced symptomatic and global changes in the therapy process. Treatment outcome was assessed both by patient and therapist reports, and the SCL-90 was used to evaluate pre- to posttreatment symptom change on 9 symptom dimensions. In addition, therapists were asked to complete a subjective rating of improvement at the end of treatment. The results indicate that a complex pattern of similarity and differences in specific values promoted maximal improvement. Moreover, specific improvement measures were influenced differently by various patient–therapist value patterns. Generally, therapist ratings of outcome were enhanced by pretreatment dissimilarities in value placed on social ascendance and achievement and similar value emphasis being placed on humanistic and philosophical concerns. Patient ratings of outcome were also enhanced if patient and therapist shared philosophical and humanistic concerns, but were further facilitated if values relating to social attachment and independence were ranked differently for patient and therapist. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist adherence/competence and treatment outcome: A meta-analytic review.

Objective: The authors conducted a meta-analytic review of adherence–outcome and competence–outcome findings, and examined plausible moderators of these relations. Method: A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria. Results: R-type effect size estimates were derived from 32 adherence–outcome and 17 competence–outcome findings. Neither the mean weighted adherence–outcome (r = .02) nor competence–outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence–outcome and competence–outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence–outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance. Conclusions: One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence–outcome and competence–outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rights of clients, responsibilities of therapists.

Discusses ways in which ethical principles can be put into practice in the client–therapist relationship. Historically, ethical codes for therapists were drawn up to protect the professions from regulation by external agencies. Implicit in the ethical codes, however, is a model for the client–therapist relationship that fosters the goals of mental health. It is suggested that just as ethical codes have been given specific content in standards for providers of psychological services in human service facilities, ethical codes can be given specific content in the client–therapist relationship. It is recommended that therapists take responsibility for incorporating ethical standards into their practices so that clients' rights will be an integral part of therapy. Four illustrative situations are presented: providing clients with information to make informed decisions about therapy, using contracts in therapy, responding to clients' challenges to therapists' competence, and handling clients' complaints. (63 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression.

This study attempted to replicate an earlier study (R. J. DeRubeis & M. Feeley, 1990) of the prediction of symptom change from process variables in cognitive therapy for depressed outpatients. Measures of in-session therapist behavior and therapist–patient interactions were correlated with prior and subsequent symptom change. One of the positive findings was confirmed, but the other received only marginal support. A "concrete" subset of theory-specified therapist actions, measured early in treatment, predicted subsequent change in depression. The therapeutic alliance was predicted by prior symptom change in 1 of the 2 later assessments, but only at a trend level. Several negative findings were similar to those obtained in the earlier study. Specifically, the alliance, an "abstract" subset of theory-specified therapist actions, and facilitative conditions did not predict subsequent change. Implications for causal inferences in psychotherapy process research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role of manual-guided training in the conduct and efficacy of interpersonal psychotherapy for depression.

This article reviews findings from manual-guided training programs in short-term interpersonal psychotherapy (IPT) for depression, an exploratory treatment that focuses on symptom reduction and improvement of social functioning. The literature revealed (a) that experienced, dynamically trained therapists were able to achieve a high level of competence in IPT after comparatively brief training and were able to maintain adherence to the manual over a lengthy study; (b) that general dimensions of the psychotherapy process, including therapist warmth and patient difficulty, were highly correlated with ratings of therapist competence in the performance of IPT; and (c) that therapists judged as performing IPT more competently tended to be more effective. Although definitive evidence on the effectiveness of manual-guided training is lacking, the use of manuals and systematic therapist training appear to be useful for the conduct of psychotherapy efficacy research. Findings showing that manual adherence is related to therapist efficacy suggest a role for these procedures in clinical training and competency determination. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of patient and therapist-reported experiences of the initial session to outcome: An initial investigation.

Explored the impact of the initial psychotherapeutic session on outcome in 32 therapist–patient dyads. Ss were 18+ yrs old. Therapy consisted of a maximum of 8 sessions. The therapeutic interaction was assessed with selected portions of the Therapy Session Report, completed immediately after the first session by the participants. It was found that the patient's perception of the therapist's functioning during the first meeting related significantly to patient and therapist reports of symptom change subsequent to 4 sessions and length of treatment. In addition, there was a significant, linear decline in symptoms (reported by patient and therapist) after 8 therapy sessions. (3 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A sociological perspective on the therapeutic alliance: Ethnomethodology and conversation analysis.

Traditional perspectives consider the therapeutic alliance as tied to specific goals of positive patient change. Psychometric studies suggest that the therapeutic alliance is better conceptualized as linked to aspects of the patient–therapist dyad independent from therapeutic goals. A framework to capture the relational identity of the alliance, proposed by E. Bordin (see record 94-105022-001), centers on patient–therapist collaboration. Ethnomethodology, a sociological research paradigm, suggests that "collaboration" in psychotherapy consists of methods that establish an impression of common sense between patient and therapist. These methods involve verbal and para-verbal cues, often subtle and implicit, that compose a subtext to the more explicit dialogue about therapeutic goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between patient-therapist compatibility and treatment effectiveness.

Studied patient attraction to therapist, therapist attraction to patient, and patient change as a function of interpersonally oriented therapist-patient compatibility. Fundamental Interpersonal Relations Orientation scale scores were used to assign a high- and a low-compatibility psychiatric patient to each of 24 therapists. High-compatibility matched patients were found to have a significantly more favorable view of their therapists after both 3 and 11 wk. of interaction. However, therapists did not prefer relating to their high-compatibility over their low-compatibility match patients. There was no difference in the amount of behavioral change found in the high-compatibility, low-compatibility, and untreated-control groups. It is concluded that by use of such matching procedures a higher level of interpersonal attraction can be promoted between patients and their therapists, but the significance of therapist-patient attraction for treatment effectiveness remains to be demonstrated. (39 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dependability of alliance assessments: The alliance–outcome correlation is larger than you might think.

Objective: To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance–outcome relationship. Method: We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. Results: At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3–9 explained 14.7% of outcome variance. Conclusion: Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance–outcome relationship. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Communication processes in structural family therapy: Case study of an anorexic family.

In examining the process of change in structural family therapy, interpersonal control patterns were observed within and across 15 sessions of inpatient treatment of a chronic anorexic family. Results showed that the primary therapist maintained a consistently active, dominant, and central position in the therapeutic system. As predicted, complementarity (Therapist one-up/Family Member one-down) was the predominant relational control pattern; with the anorexic daughter, complementarity was observed more frequently in the early and late phases of treatment than in the middle, restructuring phase. Although several hypotheses could not be adequately tested because of an unexpected low frequency of within-family interaction, there was some evidence that the therapist challenged family behaviors indicative of enmeshment and intergenerational coalitions and that changes in the family's rigid communication style may have occurred over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client-therapist complementarity and therapeutic outcome.

Studied 120 tape recorded psychotherapy sessions representing early, middle, and late interviews with 20 undergraduate self-referrals. Clients were divided into successful (n = 10) and unsuccessful (n = 10) outcome groups on the basis of clinicians' ratings of pre- and post-MMPI data. Raters scored the response units of clients and therapists and labeled as complementary the following elicitation-response sequences: dominance followed by submissive behavior, submissive behavior followed by dominance, friendliness followed by friendliness, and hostility followed by hostility. Comparisons between outcome groups showed no differences in therapist complementarity during the early stage (as predicted), a significantly lower level of therapist complementarity for the successful group during the middle stage (as predicted), and no differences during the last stage (contrary to prediction). Furthermore, during the early stage of therapy more disturbed clients elicited greater therapist complementarity (as predicted). (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change.

Objective: The efficacy of cognitive therapy (CT) for depression has been well established. Measures of the adequacy of therapists' delivery of treatment are critical to facilitating therapist training and treatment dissemination. While some studies have shown an association between CT competence and outcome, researchers have yet to address whether competence ratings predict subsequent outcomes. Method: In a sample of 60 moderately to severely depressed outpatients from a clinical trial, we examined competence ratings (using the Cognitive Therapy Scale) as a predictor of subsequent symptom change. Results: Competence ratings predicted session-to-session symptom change early in treatment. In analyses focused on prediction of symptom change following 4 early sessions through the end of 16 weeks of treatment, competence was shown to be a significant predictor of evaluator-rated end-of-treatment depressive symptom severity and was predictive of self-reported symptom severity at the level of a nonsignificant trend. To investigate whether competence is more important to clients with specific complicating features, we examined 4 patient characteristics as potential moderators of the competence-outcome relation. Competence was more highly related to subsequent outcome for patients with higher anxiety, an earlier age of onset, and (at a trend level) patients with a chronic form of depression (chronic depression or dysthymia) than for those patients without these characteristics. Competence ratings were not more predictive of subsequent outcomes among patients who met (vs. those who did not meet) criteria for a personality disorder (i.e., among personality disorders represented in the clinical trial). Conclusions: These findings provide support for the potential utility of CT competence ratings in applied settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)