Impact of motivational interviewing on participation and outcome in residential alcoholism treatment.

Tested motivational interviewing (a strategy to increase motivation for change) as a preparation for residential alcoholism treatment. 28 consecutive alcoholism admissions to a psychiatric hospital were assigned alternately to receive or not to receive a 2-session motivational assessment and interview shortly after intake, in addition to standard evaluation and treatment procedures. Patients who received the motivational interview participated more fully in treatment (as evidenced by therapist ratings) and showed significantly lower alcohol consumption at a 3-mo follow-up interview. The beneficial effects of motivational interviewing on outcome were mediated by increased participation in treatment. The extent to which the received treatment outcome conformed to patients' pretreatment expectations was predictive of outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression.

Prior analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program demonstrated that perfectionism was negatively related to outcome, whereas both the patient's perception of the quality of the therapeutic relationship and the patient contribution to the therapeutic alliance were positively related to outcome across treatment conditions (S. J. Blatt et al, see record 1996-02770-018; J. L. Krupnick et al, see record 1996-05271-014). New analyses examining the relations among perfectionism, perceived relationship quality, and the therapeutic alliance demonstrated that (a) the patient contribution to the alliance and the perceived quality of the therapeutic relationship were independent predictors of outcome, (b) perfectionistic patients showed smaller increases in the Patient Alliance factor over the course of treatment, and (c) the negative relation between perfectionism and outcome was explained (mediated) by perfectionistic patients' failure to develop stronger therapeutic alliances. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

Contribution of the therapeutic alliance to outcome in active versus control psychotherapies.

Few studies have examined the role of the therapeutic alliance scores in active versus control psychotherapies. Using data from a randomized clinical trial of psychotherapy and pharmacotherapy for cocaine dependence, it was found that therapeutic alliance scores were rated as significantly more positive in cognitive-behavioral treatment than clinical management, a psychotherapy control condition. However, level of the therapeutic alliance was associated with outcome for the control but not the active psychotherapy. These data suggest that control conditions, which are intended to control for common factors of psychotherapies such as the therapeutic alliance, may exert their effect on outcomes primarily through the level of those common factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preparing clients for alcoholism treatment: Effects on treatment participation and outcomes.

In this study, 126 clients (87 men, 39 women) entering outpatient alcoholism treatment were assigned randomly to 1 of 3 preparatory conditions: a role induction (RI) session, a motivational interview (MI) session, or a no-preparatory session control group (CG). Clients assigned to the MI preparatory condition attended more treatment sessions and had fewer heavy drinking days during and 12 months after treatment relative to CG clients. Clients assigned to MI, relative to CG clients, also had more abstinent days during treatment and during the first 3 months posttreatment, although this difference was not maintained through the remainder of the 12-month follow-up period. Clients assigned to the RI condition showed no significant advantage over those in the CG condition. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in behavior therapy.

It may be argued that behavior therapy has proceeded with minimal regard for the therapeutic alliance (TA) as a key mechanism of change. However, ignoring the role of TA in behavior therapy may not only be problematic on a practical level, but also may be inconsistent with basic principles that underlie behavior therapy. In beginning to address these issues, the authors consider the role of TA in behavior therapy with a focus on relevant basic principles. Keeping a focus on these basic principles, the authors then outline three contemporary behavior therapies that already incorporate a focus on the therapeutic relationship and conclude with a clinical case illustration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of perfectionism, depression, and therapeutic alliance during treatment for depression: Latent difference score analysis.

The authors examined the longitudinal relationship of patient-rated perfectionism, clinician-rated depression, and observer-rated therapeutic alliance using the latent difference score (LDS) analytic framework. Outpatients involved in the Treatment for Depression Collaborative Research Program completed measures of perfectionism and depression at 5 occasions throughout treatment, with therapeutic alliance measured early in therapy. First, LDS analyses of perfectionism and depression established longitudinal change models. Further LDS analyses revealed significant longitudinal interrelationships, in which perfectionism predicted the subsequent rate of depression change, consistent with a personality vulnerability model of depression. In the final LDS model, the strength of the therapeutic alliance significantly predicted longitudinal perfectionism change, and perfectionism significantly predicted the rate of depression change throughout therapy. These results clarify the patterns of growth and change for these indicators throughout depression treatment, demonstrating an alternative method for evaluating longitudinal dynamics in therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Severity of psychosocial stress and outcome of alcoholism treatment.

Examined the relation between stressful life events and drinking outcome among 129 male alcoholics (aged 22–70 yrs) who had completed an alcohol treatment program. Life events were assessed for the year prior to treatment and for the 3 mo after treatment and were rated on a modified version of the Psychiatric Epidemiology Research Interview and the Contextual Rating System (G. W. Brown and T. O. Harris, 1982). Approximately 40% of the pretreatment stressors were found to be directly or indirectly related to alcohol use. When stressors related to drinking were excluded from consideration, men who returned to drinking after treatment were found to experience more severe or highly threatening stress before their relapse than men who remained abstinent during the follow-up period. These data suggest that although less severe stress may not increase risk for relapse, acute severe stressors and highly threatening chronic difficulties may be associated with elevated relapse risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Examining the relationship between the therapeutic bond and the phases of treatment outcome.

Examined the association between the therapeutic bond—an element of the therapeutic alliance—and treatment effectiveness. 114 psychotherapy clients completed self-report questionnaires at intake and throughout open-ended, psychodynamically oriented psychotherapy. Three bond scales, role investment (RI), empathic resonance (ER), and mutual affirmation (MA), were contrasted to session quality and the three phases of outcome (remoralization, remediation, and rehabilitation). Results indicated that different aspects of the bond predicted session quality and treatment outcome. Clients who felt motivated and invested in therapy (relatively high RI) and who reported that the therapeutic environment was friendly and affirmative (relatively high MA) were likely to rate the session as being helpful and productive. Clients who had a relatively high sense of understanding and of being understood (ER) experienced greater remoralization and remediation (but not rehabilitation). The results are placed within the context of recent research into the therapeutic alliance. (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)     

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)     

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)     

The relationship between adult attachment style and therapeutic alliance in individual psychotherapy: A meta-analytic review.

The present study examined the relationship between adult attachment style and therapeutic alliance in individual psychotherapy. Search procedures yielded 17 independent samples (total N = 886, average n = 52, standard deviation = 24) for inclusion in the meta-analysis. Results indicated that greater attachment security was associated with stronger therapeutic alliances, whereas greater attachment insecurity was associated with weaker therapeutic alliances, with an overall weighted effect size of r = .17, p .10) with the exception of the source of alliance ratings; results indicated that patient-rated alliance demonstrated a significantly larger relationship with attachment compared with therapist-rated alliance (Qbetween = 3.95, df = 1, p = .047). Implications for clinical practice and future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The real relationship in psychotherapy: Relationships to adult attachments, working alliance, transference, and therapy outcome.

The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive–behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive–behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The treatment outcome pursuit: A mandate for the clinician and researcher working alliance.

Suggests that the illusiveness of a working alliance between clinicians and researchers has been an issue of concern for psychology. Clinicians criticize researchers for producing findings that are not useful or relevant to clinical practice. Researchers criticize clinicians for not making use of research, for being arbitrary in treatment choices, and for being uninformed. The reason that a working alliance is now possible and in fact necessary for clinicians and researchers is discussed. The changing market forces and environmental, legislative, and societal changes have mandated collaboration between the 2 groups. Methods through which to develop alliances are described, and new paradigms are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review.

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the therapeutic alliance in psychotherapy.

Traces the development of the concept of the therapeutic working alliance from its psychodynamic origins to current pantheoretical formulations. Research on the alliance is reviewed under 4 headings: the relation between a positive alliance and success in therapy, the path of the alliance over time, the examination of variables that predispose individuals to develop a strong alliance, and the exploration of the in-therapy factors that influence the development of a positive alliance. Important areas for further research are also noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The resolution of ruptures in the therapeutic alliance.

This article outlines some of the main features of a research program on ruptures in the therapeutic alliance and reports some of the major findings to date. A rupture in the therapeutic alliance is a deterioration in the quality of the relationship between patient and therapist; it is an interpersonal marker that indicates a critical opportunity for exploring and understanding the processes that maintain a maladaptive interpersonal schema. Following the task-analytic research paradigm, a preliminary model of the resolution process was developed and then tested and revised with 2 different data sets. A series of lag 1 sequential analyses were used to confirm the hypothesized sequences of events within resolution sessions and to demonstrate a difference between resolution and nonresolution sessions. This article describes the evolution of a model of rupture resolution and then discusses its implications for treatment development and evaluation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)