Testing a model of change in the experiential treatment of depression.

In this study, we measured emotional processing and the alliance across 3 phases of therapy (beginning, working, and termination) for 74 clients who each received brief experiential psychotherapy for depression. Using path analysis, we proposed and tested a model of relationships between these 2 processes across phases of therapy and how these processes relate to predict improvement in the domains of depressive and general symptoms, self-esteem, and interpersonal problems after experiential treatment. Both therapy processes significantly increased across phases of therapy. Controlling for both client processes at the beginning of therapy, working phase emotional processing was found to directly and best predict reductions in depressive and general symptoms, and it could directly predict gains in self-esteem. Within working and termination phases of therapy, the alliance significantly contributed to emotional processing and indirectly contributed to outcome. Surprisingly, beginning therapy alliance (measured after Session 1) also directly predicted all outcomes. Furthermore, only clients’ beginning therapy process predicted reductions in interpersonal problems. Therefore, although the proposed theory of change was supported, clients’ beginning therapy processes may constrain clients’ success in experiential treatment and in particular their outcomes in some problem domains related to depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The annihilating power of absoluteness: Superego analysis in the severe neuroses, especially in character perversion.

Many find the concept of a superego not relevant anymore. Yet, there is much evidence for the cardinal relevance of what is meant with this theoretical construct. This is particularly true for the treatment of severely disturbed patients--especially those with severe forms of character perversion and addictions. The archaic superego serves in its absoluteness as primitive affect regulation. The more we assume a stance of authority, the more we tend to get enmeshed in very important regressive transference-countertransference enactments of these superego figures, functions, and affects. The working alliance breaks apart because the regression can merely be experienced, not reflected upon. This is particularly true for cases of character perversion, especially those of a severe sadomasochistic nature. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Analysis of the development of the working alliance using hierarchical linear modeling.

The relation between the working alliance and therapeutic outcome was examined in 21 therapist–client dyads. This relation was analyzed in terms of the level of alliance at the 3rd counseling session, midpoint of treatment, and last session with linear and curvilinear models of the temporal development of the working alliance. Analyses were conducted with hierarchical linear modeling. Results revealed a significant association between the linear growth function on therapist ratings of the working alliance and therapeutic outcome. The use of hierarchical linear modeling in counseling psychology research and the need for conceptualizing the working alliance as a temporally variant as opposed to a static process are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empathy and the working alliance: The mistranslation of Freud's Einfühlung.

Suggests that the working alliance has emerged as an important theoretical construct in both psychotherapeutic practice and research. A great deal of attention has been paid to the therapist's contributions to the working alliance, with empathy posited as a necessary condition for a strong attachment between patient and therapist. Although Freud has been recognized for laying the theoretical groundwork for what is called the working alliance, he has generally not been credited with making an association between empathy and the therapeutic relationship. It is demonstrated that in 1913, Freud did posit empathy (Einfühlung) as a necessary condition for the therapeutic relationship, and that this has been overlooked by English-speaking readers due to a translation error. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Breaches in the therapeutic alliance: An arena for negotiating authentic relatedness.

Argues that the clarification of the processes involved in working through breaches or ruptures in the therapeutic alliance, is a vitally important task for psychotherapy theorists and researchers. It is suggested that these inevitable problems in the therapeutic alliance provide important opportunities for clarifying factors that may create barriers to authentic relatedness in clients' everyday lives. Working through these problems can provide clients with valuable experience in the important tasks of reconciling the needs for relatedness and agency and of coming to accept both self and other. The current paradigm shift in psychotherapy theory and practice toward more relational and constructivist perspectives, however, has established a particularly ripe climate for enhancing the understanding of the client–therapist relationship through a differentiated exploration of these concerns. (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)     

Conceptualizing the therapeutic alliance from a psychoanalytic perspective.

Defines the therapeutic alliance as the patient's active collaboration in the work of psychotherapy or psychoanalysis. The failure to differentiate alliance from transference has in part led to the skepticism regarding the concept of alliance. The patient's active use of the treatment process as a resource for self-understanding and constructive change constitutes his/her collaboration. The nature of collaboration varies with the type of treatment. The alliance depends significantly upon the patient's ability to maintain an observing ego; the activation of transferences significantly affects this process. The alliance is influenced by a core of object relations capacities that are essential to forming a trusting relationship. Defining alliance as patient collaboration makes a sharp distinction between technique and alliance. It is suggested that a scale devised to assess the degree of collaboration, based on this conceptualization, by the present 3rd author and colleagues (1983) provides an instrument for future research. (25 ref) (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)     

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)     

Alliance in individual psychotherapy.

This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as “alliance,” “therapeutic alliance,” “helping alliance,” or “working alliance” were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was r = .275 (k = 190); the 95% confidence interval for this value was .25–.30. The statistical probability associated with the aggregated relation between alliance and outcome is p     

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.     

The therapeutic alliance and family psychoeducation in the treatment of schizophrenia: An exploratory prospective change process study.

Although family psychoeducation has been shown to be highly efficacious in the treatment of schizophrenia, the mechanisms underlying the treatment's success are poorly understood. The therapeutic alliance in behavioral family management (BFM) was examined to determine whether the alliance plays a role in the efficacy of this treatment. One early BFM session (mean session = 6.5) involving 28 schizophrenia patients and their relatives who participated in the National Institute of Mental Health's Treatment Strategies in Schizophrenia study was coded using the System for Observing Family Therapy Alliances. Results indicated that when relatives developed a positive therapeutic alliance, patients were less likely to show prodromal signs of relapse and be rehospitalized over a 2-year follow-up period. When patients developed a positive alliance, relatives became less rejecting and were less likely to feel burdened over a 2-year period. The data suggest that the development of a positive therapeutic alliance within family psychoeducation may play an important role in preventing the escalation of psychotic symptoms and improving family relationships. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of patient pretreatment characteristics to the therapeutic alliance in diverse psychotherapies.

The prediction of the therapeutic alliance from patient pretreatment characteristics was investigated with a sample of elderly depressed outpatients treated in behavioral, cognitive, and brief dynamic psychotherapy (N?=?60). For the sample as a whole, a higher degree of patient defensiveness was related to a lower patient contribution to the alliance as reflected in patient commitment and working capacity. Also, the availability of environmental support was positively associated with greater patient commitment across treatment conditions. The association of patient pretreatment characteristics with alliance was similar across behavioral and cognitive therapy and less similar across brief dynamic and behavioral or cognitive therapy. The nature of the therapeutic alliance in diverse treatment modalities is discussed, and implications for selection criteria and technical strategies for engaging the difficult patient are explored. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of leaders' working alliance in premarital education.

Premarital (and general relationship) education programs, as a prevention method, have been shown to have a positive effect on marital quality and can prevent divorce. However, it is unclear whether these positive effects are consistent across leaders who conduct premarital education programs. Examining the variability in relationship outcomes attributed to the leaders of premarital education programs, and the role of general therapeutic factors such as working alliance in explaining relationship outcomes, may help increase the effectiveness of these programs. Accordingly, this study examined 31 leaders who trained 118 couples (236 attendees) in a randomized clinical trial of the Prevention and Relationship Enhancement Program (PREP), a research-based and empirically supported premarital education program being compared with a treatment as usual track. The results demonstrated that couples' relationship outcomes from pre- to post-training varied on the basis of the leader who provided the premarital education training. Both training in PREP and aggregated leader working alliance quality (as rated by attendees) explained variability between leaders in change in attendees' observed negative and positive communication. Leaders' aggregated working alliance quality also explained change in relationship satisfaction. In addition, attendees' ratings of their leaders' working alliance predicted change in their relationship satisfaction and confidence, and attendees had higher positive communication when they reported better working alliance with their leader. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

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)     

The Association Between Patient Characteristics and the Therapeutic Alliance in Cognitive-Behavioral and Interpersonal Therapy for Bulimia Nervosa.

The therapeutic alliance is an established predictor of psychotherapy outcome. However, alliance research in the treatment of eating disorders has been scant, with even less attention paid to correlates of alliance development. The goal of this study was to examine the relation between specific patient characteristics and the development of the alliance in 2 different treatments for bulimia nervosa (BN). Data derive from a large, randomized clinical trial comparing cognitive- behavioral therapy (CBT) and interpersonal therapy (IPT) for BN. Across both treatments, patient expectation of improvement was positively associated with early- and middle-treatment alliance quality. In CBT, baseline symptom severity was negatively related to middle alliance. In IPT, more baseline interpersonal problems were associated with poorer alliance quality at midtreatment. (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 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)     

Process and Outcome in Cardiac Rehabilitation: An Examination of Cross-Lagged Effects.

Cardiac rehabilitation patients improve cardiorespiratory fitness and quality of life, yet therapeutic processes that produce these changes remain unknown. A cross-lagged panel design was used to determine whether early-treatment enhancement of self-efficacy regarding abilities to change diet and exercise habits and the quality of the patient-staff working alliance predicted late-treatment changes in a wide range of outcomes, but not vice versa. Eighty cardiac patients participating in a 12-week program completed measures at early, mid- and late treatment. Early-treatment changes in exercise self-efficacy predicted late-treatment changes in activity level, depression, and working alliance, but not vice versa. Diet self-efficacy changes correlated with concurrent changes in fat intake and body weight. Early-treatment changes in cardiorespiratory fitness and activity level predicted late-treatment changes in working alliance, but not vice versa. Findings suggest that increased exercise self-efficacy represents an important therapeutic mechanism by which rehabilitation gains are realized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)