"The association between global and specific measures of the therapeutic relationship": Erratum.

Reports an error in "The association between global and specific measures of the therapeutic relationship" by Nick F. Coady and Elsa Marziali (Psychotherapy: Theory, Research, Practice, Training, 1994[Spr], Vol 31[1], 17-27). This article contained, as Figure 1, an SASB model. The authorship and copyrights for the model were not acknowledged. The following acknowledgement should have been included: "From Benjamin (1983), Intrex User's Manual. Intrex Interpersonal Institute, P.O. Box 581037, Salt Lake City, UT 84158. Reprinted by permission." An apology is offered to the author, Dr. Lorna Smith Benjamin. The particular version used in the article was developed in collaboration with Clinton W. McLemore. (The following abstract of the original article appeared in record 1994-46203-001.) Examined the association between global and specific measures of the therapeutic relationship in Sessions 3, 5, and 15 of 9 cases of time-limited psychodynamic psychotherapy. L. S. Benjamin's (see PA, Vol 53:2991; see also, 1984) structural analysis of social behavior (SASB) model provided the specific measure of relationship. There were more consistent associations between ratings of client contributions to the alliance and SASB ratings of client behaviors than there were for the same therapist variables. Additionally, analyses show that external (i.e., nonself) judgments of client and therapist contributions to the alliance, rather than therapist or client self-ratings of contributions to the alliance, were most frequently associated with the SASB behavior codes. Finally, different therapist and client behaviors seemed to be associated with quality of the therapeutic relationship at different points in the therapeutic process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases.

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internalization of interpersonal process in time-limited dynamic psychotherapy.

[Correction Notice: An erratum for this article was reported in Vol 31(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2009-17141-002). This article contained, as Figure 1, an SASB model. The authorship and copyrights for the model were not acknowledged. The following acknowledgement should have been included: "Adapted from Benjamin (1984). Principles of Prediction using Structural Analysis of Social Behavior (SASB). In R. A. Zucker, J. Aronoff, and A. J. Rabin (Eds.), Personality and the Prediction of Behavior (pp. 121- 174). New York: Academic." An apology is offered to the author, Dr. Lorna Smith Benjamin. The particular version used in the article was developed in collaboration with Clinton W. McLemore.] Investigated the internalization of positive aspects of therapist–patient (TP) interactions among 70 patients and their 16 therapists who participated in a 5-yr study (H. H. Strupp et al, unpublished) of time-limited dynamic psychotherapy. Patients sought help for anxiety, depression, or other problems with a clear interpersonal component and qualified for an Axis I or Axis II diagnosis on the Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III). Instruments included the Structural Analysis of Social Behavior and outcome measures of depression, anxiety, and psychological functioning. Patients' intrapsychic functioning became more similar to interpersonal activity in the TP relationship over the course of psychotherapy. Intrapsychic movement toward interpersonal activity in the TP relationship was associated with positive outcome on measures of depression, anxiety, and on independent clinician ratings of patient psychological functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist Alliance-Building Behavior Within a Cognitive-Behavioral Treatment for Anxiety in Youth.

Explored the specific behavior of therapists contributing to a child client's perception of a therapeutic alliance with youth (n = 56) who received a manualized cognitive-behavioral treatment for anxiety disorders. The first 3 sessions were coded for 11 therapist behaviors hypothesized to predict ratings of alliance. Child, therapist, and observer alliance ratings were gathered after the 3rd and 7th therapy sessions. "Collaboration" positively predicted early child ratings of alliance, and "finding common ground" and "pushing the child to talk" negatively predicted early child ratings of alliance. Although no coded therapist behaviors predicted early therapist ratings of alliance, "collaboration" and "not being overly formal" positively predicted therapist alliance ratings by Session 7. Child, observer, and therapist ratings of alliance were significantly correlated. Results are discussed with regard to the identified behavior of the therapist as a step toward the identification of empirically supported strategies for building a stronger child-therapist alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient and therapist introject, interpersonal process, and differential psychotherapy outcome.

The Structural Analysis of Social Behavior (SASB [L. S. Benjamin; see PA, Vol 53:2991]) system was used to study the interpersonal process between patient and therapist in the 3rd session of 14 therapeutic dyads. Dyads were grouped into good and poor outcomes cases (n?=?7) on the basis of the amount of change in the patients' introject as measured by the INTREX Introject Questionnaire. Strong support was found for the following hypotheses based on interpersonal theory, linking therapists' introject state, interpersonal process in therapy, and outcome: (1) Poor outcome cases (no introject change) were typified by interpersonal behaviors by the therapist that confirmed a negative patient introject; (2) the number of therapists' statements that were subtly hostile and controlling was highly correlated with the number of self-blaming statements by the patients; (3) therapists with disaffiliative introjects tended to engage in a much higher level of problematic interpersonal processes that have been associated with poor outcome. Implications for future research and therapist training are discussed. (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)     

Therapist multicultural competency: A study of therapy dyads.

[Correction Notice: An erratum for this article was reported in Vol 44(1) of Psychotherapy: Theory, Research, Practice, Training (see record 2007-04278-014). The fifth author's name should be spelled as follows: Alexa Mislowack.] This study examined the role of therapist multicultural competence (TMC). Fifty-one therapy dyads completed measures of therapist multicultural competency, working alliance, and their satisfaction with therapy. Clients also completed measures of therapist attractiveness, expertness, trustworthiness, and empathy. Results showed strong associations between clients' ratings of TMC and ratings of the working alliance, therapist empathy, and satisfaction. Clients' combined rating of therapist expertness, attractiveness, and trustworthiness were not associated with their TMC ratings but were significantly associated with therapists' self-appraised TMC ratings. Therapists' ratings of their TMC were associated with their ratings of the working alliance and satisfaction with their work. Results are discussed in the context of the relevant literature, as are implications for training and research. (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)     

The therapeutic alliance and its relationship to alcoholism treatment participation and outcome.

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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders.

Reviews the book, Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders by Lorna Smith Benjamin (see record 2003-02042-000). Lorna Smith Benjamin offers a refreshing and unique treatment approach with this book, for a group of patients who are defined less by a specific diagnosis than by their failure to respond to one or more treatment trials. A master clinician, Benjamin has spent most of her career researching and treating the interpersonal processes of patients with personality disorders and other interpersonal problems. Benjamin is especially impressive when describing the causality of the proposed model and the treatment. Reviews of empirical research are interwoven throughout the middle chapters and are linked smartly to critical treatment issues (e.g., attachment theory, insight, empathy, the therapeutic alliance). Benjamin's own research tool, the Structural Analysis of Social Behavior (SASB), is referred to throughout, but mostly discussed in a single chapter. Those knowledgeable in SASB will immediately recognize it in most of the treatment concepts. Yet those who are not familiar with SASB will have no problem mastering this book, even if they entirely skip the SASB chapter and references. It's hard to imagine many clinicians not advancing their own thinking and practices about working with their most difficult patients by reading this book. Benjamin has advanced the understanding of working with difficult patients to a new level. Regardless of whether this book proves to be superior in clinical trials, Benjamin's unique contribution to thinking about therapy is already a classic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Internalization of interpersonal process in time-limited dynamic psychotherapy": Erratum.

Reports an error in "Internalization of interpersonal process in time-limited dynamic psychotherapy" by R. Steven Harrist, Stephen M. Quintana, Hans H. Strupp and William P. Henry (Psychotherapy: Theory, Research, Practice, Training, 1994[Spr], Vol 31[1], 49-57). This article contained, as Figure 1, an SASB model. The authorship and copyrights for the model were not acknowledged. The following acknowledgement should have been included: "Adapted from Benjamin (1984). Principles of Prediction using Structural Analysis of Social Behavior (SASB). In R. A. Zucker, J. Aronoff, and A. J. Rabin (Eds.), Personality and the Prediction of Behavior (pp. 121- 174). New York: Academic." An apology is offered to the author, Dr. Lorna Smith Benjamin. The particular version used in the article was developed in collaboration with Clinton W. McLemore. (The following abstract of the original article appeared in record 1994-46214-001.) Investigated the internalization of positive aspects of therapist–patient (TP) interactions among 70 patients and their 16 therapists who participated in a 5-yr study (H. H. Strupp et al, unpublished) of time-limited dynamic psychotherapy. Patients sought help for anxiety, depression, or other problems with a clear interpersonal component and qualified for an Axis I or Axis II diagnosis on the DSM-III. Instruments included the Structural Analysis of Social Behavior and outcome measures of depression, anxiety, and psychological functioning. Patients' intrapsychic functioning became more similar to interpersonal activity in the TP relationship over the course of psychotherapy. Intrapsychic movement toward interpersonal activity in the TP relationship was associated with positive outcome on measures of depression, anxiety, and on independent clinician ratings of patient psychological functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder.

[Correction Notice: An erratum for this article was reported in Vol 43(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2006-12148-017). The correct legend for Figure 1 on page 500 should read as follows: Figure 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press, copyright Guilford Press, and from: Benjamin (1987), Use of the SASB dimensional model to develop treatment plans for personality disorders, I: Narcissism. Journal of Personality Disorders, 1, 43-70, copyright Guilford Press.] The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient-therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The prediction of child psychotherapy outcome: Factors specific to treatment.

Examined the prediction of child psychotherapy outcome from client, parent, and process factors specific to the therapeutic relationship. 31 children (mean age 11 yrs) were assessed by some independent and therapist ratings, as were parental behaviors, at admission and at discharge from a community mental health center. The primary diagnoses were adjustment disorder (89%) and functional enuresis (11%). Process was evaluated by therapist ratings on the Psychotherapy Process Inventory by P. E. Baer et al (see record 1981-11629-001). Results support the importance of treatment dosage and client participation to global change in impairment and are consistent with findings of B. Gomes-Schwartz (see record 1979-26509-001). Change (decrease) in the severity of Ss' primary problem through treatment was predicted by less frequent parental psychological punishment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client attachment to therapist: Relation to client personality and symptomatology, and their contributions to the therapeutic alliance.

This study examined the relation of client attachment to the therapist to diverse facets of the therapeutic alliance, client personality, and psychopathological symptoms, as well as the relative importance of therapeutic attachments, personality, and symptomatology in predicting the alliance. Eighty clients in ongoing therapy completed measures of client attachment to therapist (CATS), personality (6FPQ), psychopathological symptoms (BSI), and therapeutic alliance (WAI–Short, CALPAS, HAQ). Secure and Avoidant–Fearful attachment to the therapist correlated positively and negatively, respectively, with total and subscale alliance scores. Preoccupied-Merger therapeutic attachment was unrelated to the alliance. Exploratory analyses suggested however that the relationship between Preoccupied–Merger attachment and the alliance was moderated by the extent to which clients were distressed. Clients' therapeutic attachments were unrelated to basic personality dimensions. Preoccupied–Merger attachment to the therapist correlated significantly with several symptom dimensions. Clients' therapeutic attachments emerged as superior and more consistent predictors, relative to client personality and symptomatology, of the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between behavioral marital therapy outcome and process variables.

This study was conducted to identify therapist and client behaviors with a positive response to social learning-based behavioral marital therapy. A sample of 32 couples receiving treatment was examined. Immediately after each therapy session, the therapist, husband, and wife independently completed process ratings forms that measured therapist and client behaviors during the session. Composite scales, derived from these ratings, were entered into multiple regression equations to examine their relationship with posttherapy marital satisfaction. After controlling for pretherapy marital satisfaction and the other predictor variables, therapists', husbands', and wives' ratings of positive client behavior (i.e., collaboration, active participation, and homework compliance) were positively associated with therapy outcome. Implications for marital therapy and suggestions for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior.

16 therapists participated in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy. Changes in therapist behavior were measured with the Vanderbilt Therapeutic Strategies Scale (an adherence measure), the Vanderbilt Psychotherapy Process Scale (VPPS), and interpersonal process codings using the Structural Analysis of Social Behavior (SASB). The training program successfully changed therapists' technical interventions in line with the manualized protocol. After training, there was increased emphasis on the expression of in-session affect, exploration of the therapeutic relationship, an improved participant–observer stance, and greater use of open-ended questions. There was also an indication of unexpected deterioration in certain interpersonal and interactional aspects of therapy as measured by the VPPS and SASB ratings. These results question the assumption that greater control of the therapy variable is straightforwardly achieved with manuals and adherence scales. Changing or dictating specific therapist behaviors to achieve technical adherence may alter other therapeutic variables in unexpected and even counterproductive ways. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship formation and relational control as correlates of psychotherapy quality and outcome.

This study examined the nature of therapist–client interactions within and across seven psychotherapy cases (a) to test whether therapeutic outcome is a function of a transition from relational incongruence to relational congruence (S. Strong, 1982), and (b) to investigate the relation of relational congruence and control to qualitative aspects of the therapy relationship and to therapy outcome. Measures of therapist and client response patterning served as indices of relational congruence and of relational control. Relationship quality was assessed in terms of therapist and client ratings of their working alliance and of therapy session depth and smoothness. Outcome was operationalized in terms of symptom reduction. Results showed limited support for a relationship between relational congruence and therapy outcome and suggested that relational control is not a significant factor in client or therapist evaluations of relationship quality or therapy outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Accurate empathy: Confusion of a construct.

Presents empirical and logical evidence to refute the C. Truax (see PA, Vol. 48: Issue 5) rejoinder to an earlier critique by the authors. It is argued that the construct accurate empathy is markedly confused. The accurate empathy scale is shown to lack discriminant validity, and its relationship to therapeutic outcome is considered. The meaning of ratings of empathy in the absence of client responses is questioned. Finally, the use of repeated measurement of the same therapist is shown to be faulty on both statistical and design grounds and to yield spuriously inflated reliability coefficients. (17 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)