Combined use of root conditioning, fibrin-fibronectin system and a collagen membrane to treat a localized gingival recession: a 10-case report

The relationship between the therapeutic alliance and treatment participation and drinking outcomes during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were significant predictors of treatment participation and drinking behavior during the treatment and 12-month posttreatment periods, after a variety of other sources of variance were controlled. Ratings of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes. Therapists ratings of the alliance in the aftercare sample predicted only percentage of days abstinent during treatment and follow-up. The results document the independent contribution of the therapeutic alliance to treatment participation and outcomes among alcoholic outpatients.     

Using transtheoretical model profiles to differentiate levels of alcohol abstinence success.

Using data from 673 outpatient and 510 aftercare clients in Project MATCH, this study identified drinking-outcome-related differences in profiles across transtheoretical model (TTM) variables. Abstinent, moderate, and heavier drinking outcome groups were formed as a function of their 1-year posttreatment drinking behavior. Using profile analysis, group differences in the shapes of the mean profiles on TTM-related measures of stage and self-efficacy were found (a) for both the outpatient and aftercare populations and (b) at both the baseline and end-of-treatment time points. The use of cognitive and behavioral change processes during treatment was measured and the scores for each were included in the creation of the end of treatment profiles. The relation between number of TTM goals attained and probabilities of successful drinking outcome supports the usefulness of profile differences in predicting long-term drinking outcomes and can enable therapists to help clients set interim goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What explains the relationship between the therapist structure × patient reactance interaction and drinking outcome? An examination of potential mediators.

Recent research found that among patients in aftercare treatment for alcoholism the level of therapist structure interacted with the level of patients' interpersonal reactance to predict alcohol use outcomes. The present study examined two sets of potential mediators of this interaction effect among a sample from two aftercare sites of Project MATCH (n = 127). The mediator constructs were types of pro-recovery change talk and resistance to therapeutic work. Dependent variables were percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD) across the year after treatment. Multiple-mediator models using bootstrapped estimates of indirect effects were used to test for mediation. Results indicated that the 'taking steps' aspect of change talk partially mediated the Structure × Reactance interaction effect on both PDA and PHDD post treatment. Resistance was not found to mediate the interaction effect though resistance did predict worse drinking outcomes. Depending on patients' openness to being influenced by others, therapist structure early in treatment may promote or inhibit pro-recovery steps taken by aftercare patients between treatment sessions. Those steps in turn play an important role in predicting future alcohol use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in adolescent substance abuse treatment: A one-with-many analysis.

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Client attachment and perceptions of the working alliance with counselor trainees.

The relationships among 3 dimensions of client attachment (depend, anxiety, and close) and client ratings of the working alliance were examined in a sample of first-time clients (N?=?60) seeking services through a university-based counseling clinic. Working alliance ratings were collected from all participants immediately after their 3rd counseling session with a counselor-in-training. A significant association was found between the depend dimension of attachment and client working alliance ratings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist differences in cognitive–behavioral psychotherapy for generalized anxiety disorder: A pilot study.

Little is known about factors differentiating more and less effective therapists or the mechanisms through which therapists influence outcome. In the present study, the performance of a small sample of 4 therapists was compared in the context of delivering cognitive–behavioral psychotherapy (CBT) to 32 clients with generalized anxiety disorder. More effective therapists were characterized by higher observer-rated CBT competence, higher client outcome expectations and client treatment credibility assessments, and higher early treatment client ratings of therapeutic alliance quality. Higher early CBT competence was associated with higher client midtreatment outcome expectations, which in turn were associated with better posttreatment outcomes. Although these findings are preliminary given the small sample of therapists and clients, they suggest that the common factor of outcome expectations might be a mechanism through which the specific factor of psychotherapist competence exerts its influence on treatment outcome. The implications of these findings and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Process and treatment adherence factors in group cognitive-behavioral therapy for partner violent men.

This study used multilevel modeling to examine process and treatment adherence factors as predictors of collateral partner reports of abuse following participation in a cognitive-behavioral group treatment program for partner violent men (N = 107). Therapist working alliance ratings predicted lower levels of physical and psychological abuse at the 6-month follow-up and were the strongest predictors of outcome. Homework compliance partially mediated associations between early alliance ratings and psychological abuse at follow-up. Greater group cohesion during treatment, assessed by client report, also predicted lower physical and psychological abuse at follow-up. The findings support the promotion of a collaborative therapeutic environment to induce change among partner violent men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The magnitude of client and therapist working alliance ratings.

Researchers studying the working alliance frequently comment that clients and therapists tend to rate the alliance highly. The authors conducted this study to determine the accuracy of these comments by examining of the magnitude of adult client and therapist working alliance ratings in 63 refereed articles published between 1990 and 2007. The authors wondered if clients and therapists generally tend to use just the higher points of rating scales for measures of working alliance. The 63 articles used 9 different measures of the working alliance and provided working alliance ratings by 6,441 clients and 6,359 therapists. Results indicate that clients tend to use only the top 20% of rating points and therapists tend to use only the top 30% of rating points on alliance measures. Implications of the findings include the possibility that clients and therapists do not differentiate among lower rating points on the scales, tend to rate the alliance according to a social desirability or dissonance-reducing response set, or provide ratings that accurately reflect the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Studying psychotherapy using the one-with-many design: The therapeutic alliance as an exemplar.

Most psychotherapy research uses a one-with-many design, in which each therapist (the one) treats multiple clients (the many), which raises the challenge of nonindependent data. We present a statistical model for analyzing data from studies that use a one-with-many design. This model addresses the problems associated with nonindependence and can address theoretically relevant questions. To illustrate this model, we analyzed data in which 65 therapists and their 227 clients rated their therapeutic alliance. The primary finding was that both therapist and client alliance ratings were largely relational (i.e., specific to the unique therapist–client combination). There was little consensus among clients treated by the same therapist about the quality of the therapeutic alliance, although some therapists reported forming stronger alliances than other therapists. There was substantial dyadic reciprocity, indicating that if a therapist reported an especially good alliance with a particular client (better than with his or her other clients), then that client was also likely to report an especially good alliance (better than those reported by the therapist’s other clients). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Session impact, working alliance, and treatment outcome in brief counseling.

Examined associations among working alliance, session evaluations over the course of brief counseling, and counseling outcome. At a training clinic, 61 clients and student counselors from 41 dyads completed ratings of session depth, smoothness, positivity, and arousal after their 1st 12 sessions. Alliance ratings were completed after the 4th session and at termination. Clients and counselors also provided 5 measures of counseling outcome. Results indicated that session evaluations were significantly related to later alliance ratings, and positive alliance ratings predicted subsequent session evaluations. Both linear and curvilinear session effects were suggested. Associations for client ratings were generally stronger than for counselor ratings. Both alliance and session evaluations were significant unique predictors of client-related outcome, but only alliance predicted counselor-rated outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Racial microaggressions against African American clients in cross-racial counseling relationships.

This study examined the relationships among African American clients' perceptions of their White counselors with respect to (a) perceived racial microaggressions in cross-racial counseling relationships, (b) the counseling working alliance, (c) their counselors' general and multicultural counseling competence, and (d) their counseling satisfaction. Findings revealed that greater perceived racial microaggressions by African American clients were predictive of a weaker therapeutic alliance with White therapists, which, in turn, predicted lower ratings of general and multicultural counseling competence. Greater perceived racial microaggressions also were predictive of lower counseling satisfaction ratings. In addition, African American clients' perceptions of racial microaggressions had a significant indirect effect on these clients' ratings of White counselors' general and multicultural counseling competence through the therapeutic working alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance in motivational enhancement therapy and counseling as usual for substance use problems.

Data from a community-based multicenter study of motivational enhancement therapy (MET) and counseling as usual (CAU) for outpatient substance users were used to examine questions about the role of the alliance in MET and CAU. Most (94%) of the sample met diagnostic criteria for abuse or dependence (primarily alcohol and/or cocaine). Sixteen therapists for CAU and 14 for MET participated. No reliable differences in patient ratings (n = 319) on the Helping Alliance Questionnaire–II (HAq-II) were evident for MET compared to CAU, but significant differences between therapists were found within each condition in mean patient-rated HAq-II scores. Overall, average levels of alliance were high. The between-therapists component of the alliance, but not the within-therapist component, was significantly associated with self-reported days of primary substance use during the follow-up period from Week 4 to Week 16 (Cohen’s d = 0 .39; n = 257). Therapists with either low or very high alliances had relatively poorer average outcomes (quadratic effect, d = 0.44). For therapists in both MET and CAU, increased use of MET fundamental techniques and MET advanced techniques during treatment sessions was associated with higher levels of alliance. Implications of the findings for conceptualization of the alliance and for training of therapists are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clients’ secret keeping and the working alliance in adult outpatient therapy.

This research investigated the relations among clients’ keeping relevant secrets in therapy, the working alliance, and symptom change. Clients (N = 83) in outpatient therapy and their therapists (N = 22) at a mental health hospital completed confidential surveys after a session of ongoing therapy. The clients who reported keeping a relevant secret (27.7%) scored significantly lower on the Working Alliance Inventory (WAI) than did clients who said that they were not, even when the analyses controlled for clients’ social desirability scores and for therapist effects. Therapists of these clients also reported a weaker working alliance, even though the therapists typically did not know that the clients were keeping a relevant secret. However, keeping a relevant secret was not related to symptom change. The findings support the long-standing belief that secret keeping in therapy either hurts the therapeutic relationship or happens when the relationship is relatively weak. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The treatment effectiveness of outpatient substance misuse treatment organizations between court-mandated and voluntary clients

Do outpatient substance misuse treatment organizations have different outcomes for court-mandated and voluntary clients depending on the mix of those clients? Do client characteristics, organizational factors, and treatment practices predict organizational treatment outcome rates? A nationally representative sample of 330 nonmethadone outpatient substance misuse treatment organizations was surveyed in 1990. Sixty-four of the organizations had 75% or more court-mandated clients; 122 of the organizations had 25% or less court-mandated clients. Organizations with 75% or greater court-mandated clients had a greater rate of clients failing to comply with their treatment plan than organizations with 25% or less court-mandated clients, but there were no differences in clients meeting the goals of their treatment. Client characteristics, organizational factors, and treatment practices are evaluated through multivariate regression to determine their impact on organizational rates of treatment success and failure among clients.     

Early therapeutic alliance and treatment outcome in individual and family therapy for adolescent behavior problems.

The impact of early therapeutic alliance was examined in 100 clients receiving either individual cognitive- behavioral therapy (CBT) or family therapy for adolescent substance abuse. Observational ratings of adolescent alliance in CBT and adolescent and parent alliance in family therapy were used to predict treatment retention (in CBT only) and outcome (drug use, externalizing, and internalizing symptoms in both conditions) at post and 6-month follow-up. There were no alliance effects in CBT. In family therapy, stronger parent alliance predicted declines in drug use and externalizing. Adolescents with weak early alliances that subsequently improved by midtreatment showed significantly greater reductions in externalizing than adolescents whose alliances declined. Results underscore the need for ongoing developmental calibration of intervention theory and practice for adolescent clinical populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Program diversity and treatment retention rates in the Drug Abuse Treatment Outcome Study (DATOS).

Stays of 3 months or longer in drug abuse treatment generally predict better follow-up outcomes. In a national sample of community-based programs that participated in the Drug Abuse Treatment Outcome Study, median lengths of stay were 3 months for clients in long-term residential and outpatient drug-free treatments and 1 year for clients in outpatient methadone treatment. However, individual programs within each of these modalities differed widely in how long they kept their clients in treatment as well as their service delivery. Programs treating individuals with heavier cocaine and alcohol use and more psychological dysfunction usually had shorter retention rates. Nonetheless, even after statistically controlling for these client differences, some programs were more effective than others in engaging and retaining clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internal validity of Project MATCH treatments: discriminability and integrity

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.     

Predictive validity of therapeutic alliance in group marital therapy.

The relation between marital distress, therapeutic alliance formation, and treatment outcome was investigated in a group marital skills training program in which 63 couples met for 9 weekly 3-hr sessions. Treatment outcome was assessed before and after completion of treatment through a series of self-report measures. The quality of the therapeutic alliance as viewed by the couples and the therapists was monitored at the 3rd session. Results indicate that levels of marital distress neither impaired nor facilitated alliance formation. In addition, it was demonstrated that patients' and therapists' ratings of the strength of the therapeutic alliance constitute a determinant of successful treatment. It appears, however, that the strength of the alliance is a more powerful predictor of therapeutic success among men than among women. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictive factors for outcome of treatment for alcohol problems

Two samples of problem drinkers were followed up 2 and 4 years after they completed treatment. The first consisted of 72 men and 16 women admitted to a program for alcoholics (the inpatient sample), and the second, of 57 men and 35 women who participated in a program of outpatient treatment (the outpatient sample). At start of treatment, the outpatient sample, was generally characterized by a higher degree of social integration and more moderate alcohol problems than those found in the inpatient sample. These differences were sustained during the part of the follow-up period for which comparative data existed. In both samples it was possible to identify subgroups whose alcohol consumption throughout the observation period did not exceed average consumption in a comparative group of the Norwegian population. The most important predictive factors for alcohol consumption in the inpatient sample were degree of social integration, consumption before start of treatment, and sex. In the outpatient sample the most important factors were level of consumption and relative contribution of heavy drinking to the drinking pattern before start of treatment and the client's own goals as regards to alcohol. In both samples there was a close connection between alcohol consumed, total situation, and individual degree of satisfaction. For both groups, less frequent drinking and reduction of heavy drinking were most important for feeling satisfied with the drinking outcome. The therapeutic implications of the qualitative changes in drinking patterns are discussed.     

Assessing relationship quality in mandated community treatment: Blending care with control.

Traditional measures of the therapeutic alliance do not capture the dual roles inherent in relationships with involuntary clients. Providers not only care for, but also have control over, involuntary clients. In 2 studies of probationers mandated to psychiatric treatment (n=90; n=322), the authors developed and validated the revised Dual-Role Relationships Inventory (DRI-R). The authors found that (a) relationship quality in mandated treatment involves caring and fairness, trust, and an authoritative (not authoritarian) style, (b) the DRI-R assesses these domains of relationship quality, is internally consistent, and relates in a theoretically coherent pattern with ratings of within-session behavior and with measures of the therapeutic alliance, relationship satisfaction, symptoms, and treatment motivation, and (c) the quality of dual-role relationships predicts future compliance with the rules, as assessed by probation violations and revocation. The DRI-R covaries with multiple domains more strongly than a leading measure of the therapeutic alliance, suggesting that it better captures the nature and effect of relationship quality in mandated treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)