Repairing alliance ruptures.

Increasingly, research on the therapeutic alliance has shifted its focus to clarifying the factors contributing to alliance development, including the processes involved in resolving alliance ruptures. This article provides a brief review of the empirical literature on ruptures in the alliance and their resolution or repair. In sum, the research is promising, indicating the relevance of ruptures and resolution to psychotherapy outcome. However, much of the research thus far consists of small samples or qualitative studies. In many respects, such research should be considered in the early stages of development. Provisional practice implications are presented, suggesting that therapists be more attentive to ruptures, explore patient negative feelings about therapy, and respond to those feelings in an open and nondefensive fashion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of structured clinician training on patient and therapist perspectives of alliance early in psychotherapy.

This study investigates the effects of structured clinician training in a Therapeutic Model of Assessment (TMA) and Short-Term Psychodynamic Psychotherapy (STPP) on therapeutic alliance variables measured early in treatment. Thirty-four outpatients received psychotherapy from clinicians who had undergone structured training in a TMA and STPP. A 2nd group of 34 outpatients were assessed using a standard model of assessment and received general, nonstructured training in psychodynamic-eclectic treatment. Groups were matched on key demographic and clinical variables. Results demonstrated significant differences between the 2 groups on both patient- and therapist-rated alliance variables, with higher scores from those in the structured clinical training group. The impact that structured training and supervision may have on graduate clinicians' ability to form positive collaborative relationships with their patients is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does the alliance cause good outcome? Recommendations for future research on the alliance.

Research has consistently documented that the quality of the therapeutic alliance is related to the outcome of diverse psychotherapies. Insufficient attention, however, has been directed at identifying the nature and magnitude of the causal relationship between the alliance and outcome. In this commentary, we discuss the major threats to causal interpretation of alliance-outcome correlations and provide suggestions for future research that would help clarify the extent to which the alliance causes positive outcomes. Assuming the alliance is a causal factor in relation to outcome, we provide recommendations for research on the alliance that would attempt to improve patient care by enhancing the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A review of therapist characteristics and techniques negatively impacting the therapeutic alliance.

This review is an examination of the therapist's personal attributes and in-session activities that negatively influence the therapeutic alliance from a range of psychotherapy perspectives. The literature used in this review was found by searching PsychLit from 1988 to 1999. Therapist's personal attributes such as being rigid, uncertain, critical, distant, tense, and distracted were found to contribute negatively to the alliance. Moreover, therapist techniques such as over structuring the therapy, inappropriate self-disclosure, unyielding use of transference interpretation, and inappropriate use of silence were also found to contribute negatively to the alliance. In addition, this review reveals how therapist's personal qualities and use of technique have a similar influence on the identification or exacerbation of ruptures in the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Working alliance as a mediator of client attachment dimensions and psychotherapy outcome.

Studies that employ multidimensional attachment measures to explore the impact of attachment style on psychotherapy process and outcome are virtually absent in the literature. Further, the role of the working (therapeutic) alliance as a mediator of the influence of attachment on treatment outcome has not been formally investigated. In order to address these gaps in the research, archival data from 66 psychotherapy clients treated at a university graduate program training clinic were used to examine the influence of three adult attachment dimensions (Comfort with Closeness, Comfort Depending on Others, and Rejection Anxiety) on the therapeutic alliance and outcome, as well as to assess whether the alliance mediates the relationship between attachment and therapy outcome. Both Comfort with Closeness and Comfort Depending on Others were significantly related to alliance and outcome, whereas Rejection Anxiety was not significantly related to either variable. Alliance was a significant partial mediator of the effect of Comfort with Closeness on outcome. The results suggest that multidimensional measures of attachment capture important influences on alliance and psychotherapy and that Comfort with Closeness promotes successful outcome by virtue of its influence on alliance. (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)     

Working alliance: Current status and future directions: Editor's introduction.

A special section of this issue of the Journal examines theoretically where we are in the area of working alliance and what is needed to advance understanding in this area. Six articles have been prepared by some of the very best minds in the field of psychotherapy in the area of working alliance. I am sure you will find these pieces to be thoughtful and far reaching and, just as important, they should provide energy and direction for research and thought on working alliance in the years ahead. The six papers are followed by a summary and integration by Dr. Samstag, in which she points out common themes and points of divergence among the six papers. From these, she develops some of her own thoughts about where we should be heading. As implied, our hope in creating this special section was that it would stimulate better theory, research, and clinical practice related to the working 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)     

Patient's and therapist's views of early alliance building in dynamic psychotherapy: Patterns and relation to outcome.

Patients and therapists have somewhat divergent perspectives of alliance. Usually in psychotherapy research, the focus is on the patient's view of alliance, predicting parts of outcome. This study questions this hypothesis by applying the shape-of-change procedure to patient's and therapist's view of alliance-building processes in dynamic psychotherapy. The results of this naturalistic study indicate that none of the 3 patient patterns is related to outcome at the end of psychotherapy, but a specific therapist's pattern--out of 2--is linked to positive symptom change. These results are discussed in the context of present research on therapeutic alliance, especially in terms of level and process, its measurement, and potential in predicting outcome in dynamic psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy.

This meta-analytic review of 11 studies examined the relationship between psychotherapy dropout and therapeutic alliance in adult individual psychotherapy. Results of the meta-analysis demonstrate a moderately strong relationship between psychotherapy dropout and therapeutic alliance (d = .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. The meta-analysis included a total of 1,301 participants, with an average of 118 participants per study, a standard deviation of 115 participants, and a range from 20 to 451 participants per study. Exploratory analyses were conducted to determine the influence of variables moderating the relationship between alliance and dropout. Client educational history, treatment length, and treatment setting were found to moderate the relationship between alliance and dropout. Studies with a larger percentage of clients who completed high school or higher demonstrated weaker relationships between alliance and dropout. Studies with lengthier treatments demonstrated stronger relationships between alliance and dropout. Inpatient settings demonstrated significantly larger effects than both counseling centers and research clinics. No significant differences were found between client-rated, therapist-rated, and observer/staff-rated alliance. Recommendations for clinicians and researchers are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care.

To estimate the variability in outcomes attributable to therapists in clinical practice, the authors analyzed the outcomes of 6,146 patients seen by approximately 581 therapists in the context of managed care. For this analysis, the authors used multilevel statistical procedures, in which therapists were treated as a random factor. When the initial level of severity was taken into account, about 5% of the variation in outcomes was due to therapists. Patient age, gender, and diagnosis as well as therapist age, gender, experience, and professional degree accounted for little of the variability in outcomes among therapists. Whether or not patients were receiving psychotropic medication concurrently with psychotherapy did affect therapist variability. However, the patients of the more effective therapists received more benefit from medication than did the patients of less effective therapists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy length of stay and outcome: A meta-analysis of the effect of therapist sex.

This meta-analysis combined results from 64 published and unpublished studies that sought to determine the effect of therapist sex on the outcome of psychotherapy. The articles were obtained using PsychLit and PsychInfo and spanned the years 1930–2000. Results show that therapist sex was found to be a poor predictor of outcome for both male and female clients. Level of therapist training, theoretical orientation of treatment, quality of study, age of clients, and number of treatment sessions did not moderate the minimal effect of therapist sex on the outcome of psychotherapy. The authors conclude that the sex of the therapist has little overall effect on the outcome of psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The alliance in child and adolescent psychotherapy.

The therapeutic alliance has a long history in the child and adolescent psychotherapy literature. This article examines prominent views on the alliance with youth and considers a number of issues that distinguish youth alliance from its adult counterpart. A meta-analysis of alliance–outcome associations in individual youth therapy is presented. In order to provide a direct comparison with the adult literature, the review included only prospective studies of individual youth therapy that used an explicit measure of alliance. Results from 16 studies revealed consistency with the adult literature with a weighted mean correlation of .22 (k = 16, n = 1306, p     

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)     

Patient collaboration as a criterion for the therapeutic alliance.

In this article we show that a focus on patient collaboration, as a marker for the therapeutic alliance, is advantageous not only for theory and research but also for clinical practice. This point of view in no way minimizes the importance of the therapist's activity or the clinical significance of the interaction between patient and therapist. Rather, it focuses attention on how the therapist's personality, skill, and technique interact with the problems the patient brings to psychotherapy. (PsycINFO Database Record (c) 2011 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)     

The alliance in context: Accomplishments, challenges, and future directions.

Research on the alliance is reviewed in a historic context. Different conceptualizations of the nature and role of the alliance are examined within the framework of theories about the role and function of the relationship in treatment. The evolution of these concepts is cast in the broader context of the current debate concerning an appropriate conceptual framework for empirically supported therapy. Using these perspectives, several persistent challenges are highlighted: the need to develop a clearer definition of the alliance; the challenge of reaching a broad consensus about the alliance's relation to other elements in the therapeutic relationship; and the task of more clearly specifying the role and function of the alliance in different phases of treatment. The paper concludes with an examination of how such a historically informed perspective might offer useful indicators for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Has the concept of the therapeutic alliance outlived its usefulness?

In this article, we provide a brief summary of our current thinking about the constructs of the therapeutic alliance and ruptures in the therapeutic alliance. We speculate about some of the factors that have led to sustained interest in these constructs by psychotherapy researchers and discuss some of the conceptual problems associated with them. We also consider the question of whether the therapeutic alliance continues to be a meaningful construct, and we delineate more and less promising avenues of research for the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the relation of mean reaction time and intraindividual reaction time variability.

Researchers often statistically control for means when examining individual or age-associated differences in variances, assuming that the relation between the 2 is linear and invariant within and across individuals and age groups. We tested this assumption in the domain of working memory by applying variance-heterogeneity multilevel models to reaction times in the n-back task. Data are from the COGITO study, which comprises 101 younger and 103 older adults assessed in over 100 daily sessions. We found that relations between means and variances vary reliably across age groups and individuals, thereby contradicting the invariant linearity assumption. We argue that statistical control approaches need to be replaced by theoretical models that simultaneously estimate central tendency and dispersion of latencies and accuracies and illustrate this claim by applying the diffusion model to the same data. Finally, we note that differences in reliability between estimates for means and variances need to be considered when comparing their unique contributions to developmental outcomes. (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)