Do Gender and Racial Differences Between Patient and Therapist Affect Therapeutic Alliance and Treatment Retention in Adolescents?

Parents, referral sources, and even therapists wonder whether the gender and racial match between therapists and patients contributes to poorer alliances and treatment dropout. Six hundred adolescent substance abusers and their therapists from a large randomized clinical trial were grouped according to matches and mismatches on both gender and race, and alliance ratings were collected from both patients and therapists. Results revealed that gender-matched dyads reported higher alliances and were more likely to complete treatment. Racial matching predicted greater retention but not patient-rated alliance. However, therapists in mismatched dyads rated significantly lower alliances. Results suggest that, although multicultural training remains critical, training emphasis should also be placed on understanding how gender and racial differences affect therapeutic processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders.

Participants were 30 adult outpatients diagnosed with avoidant personality disorder or obsessive-compulsive personality disorder who enrolled in an open trial of cognitive therapy for personality disorders. Treatment consisted of up to 52 weekly sessions. Symptom evaluations were conducted at intake, at Sessions 17 and 34, and at the last session. Alliance variables were patients' first alliance rating and "rupture-repair" episodes, which are disruptions in the therapeutic relationship that can provide corrective experiences and facilitate change. Stronger early alliances and rupture-repair episodes predicted more improvement in symptoms of personality disorder and depression. This work points to potentially important areas to target in treatment development for these personality disorders. (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)     

Therapists’ attachment, patients’ interpersonal problems and alliance development over time in inpatient psychotherapy.

The focus of this study is the investigation of the relation between patients’ interpersonal problems, therapists’ attachment representations, and the development of the therapeutic alliance over time. The authors investigated weekly alliance ratings of 281 psychotherapy inpatients, treated by 12 psychotherapists. Alliance quality was measured with the Inpatient Experience Scale. Multilevel regression models showed that patients’ interpersonal problems were associated with the level of alliance quality. Therapists’ attachment security was not related to alliance development, but higher attachment preoccupation of therapists was associated with lower levels of alliance quality. In addition, an interaction effect between therapists’ degree of attachment preoccupation and patients’ interpersonal problems explained variations of the alliance development curve over time. Limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment expectancies, patient alliance and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Prior analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research program indicated that patients' expectancies of treatment effectiveness (S. M. Sotsky et al., 1991) and the quality of the therapeutic alliance (J. L. Krupnick et al., 1996) predicted clinical improvement. These data were reanalyzed to examine the hypothesis that the link between treatment expectancies and outcome would be mediated by patients' contribution to the alliance. Among 151 patients who completed treatment, this hypothesis was suported, suggesting that patients who expect treatment to be effective tend to engage more constructively in session, which help bring about symptom reduction. Therapists' expectancies for patient improvement also predicted outcome, although this association was not mediated by the alliance. None of the expectancy scales interacted with alliance ratings in the prediction of clinical improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alliance predicts patients' outcome beyond in-treatment change in symptoms.

The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive–compulsive personality disorder who received supportive–expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' expectancies, the alliance in pharmacotherapy, and treatment outcomes in bipolar disorder.

Bipolar disorder is characterized by a chronic and fluctuating course of illness. Although nonadherence to pharmacotherapy is a frequent problem in the disorder, few studies have systematically explored psychosocial factors related to treatment discontinuation. Previous research with depressed patients receiving psychotherapy has suggested that expectancies for improvement are related to treatment outcomes and that the therapeutic alliance may partially mediate this relationship. The current study found evidence for a similar relationship between patients' initial expectancies for improvement, patient and doctor-rated alliance, and long-term outcomes in bipolar patients treated with pharmacotherapy for up to 28 months following an acute episode. The results highlight the need for the assessment of expectancies and alliance in bipolar treatment and suggest possible targets for psychosocial interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems. (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 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)     

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)     

Personality traits as seen by patients, therapists and other group members: The Big Five in personality disorder groups.

Interactional group psychotherapy is based on the assumption that patients bring their problematic personality problems into the group, and that feedback and the ability to test new behaviors leads to change. A corollary of this assumption is that there should be consensual validation among therapists and other group members (OGMs) regarding a patient's personality. The present study tested this corollary. 35 group patients with personality disorders were rated by themselves, their therapists, and OGMs on a measure of the Big Five personality factors. Substantial agreement was found between the therapists and OGMs regarding a target patient's personality, with lesser agreement with the target patient's self ratings. Furthermore, the degree of agreement between self and others was positively related to the number of personality disorder symptoms prior to beginning the group. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence.

This study assessed the effects of training on the performance of 65 therapists in delivering manual-guided therapies to 202 cocaine-dependent patients. Changes in ratings of therapists' adherence and competence was assessed in 3 treatment modalities: supportive-expressive dynamic therapy (SE), cognitive therapy (CT), and individual drug counseling. Effects of manual-guided training on the therapeutic alliance were also assessed. Training effects were examined through a hierarchical linear modeling approach that examined changes both within cases and across training cases. A large effect across cases was detected for training in CT. Supportive-expressive therapists and individual drug counselors demonstrated statistically significant learning trends over sessions but not over training cases. Training in SE and CT did not have a negative impact on the therapeutic alliance, although alliance scores for trainees in drug counseling initially decreased but then rebounded to initial levels. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality, Interpersonal, and Motivational Predictors of the Working Alliance in Group Cognitive-Behavioral Therapy for Partner Violent Men.

Recent studies have demonstrated that the working alliance predicts treatment outcome for partner violent men. This study examined the influence of personality and interpersonal characteristics, motivational readiness to change, and demographic factors on working alliance formation among a sample of men (N = 107) participating in a cognitive-behavioral group treatment program for partner violence. Motivational readiness to change was the strongest predictor of the working alliance. Psychopathic personality characteristics also emerged as a strong (negative) predictor of the working alliance. Lower levels of borderline personality characteristics and interpersonal problems, self-referred status, married status, and higher age and income predicted higher working alliance ratings. The results support recent clinical efforts to address motivational readiness in programs for partner violent men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A step toward disentangling the alliance/improvement cycle in family therapy.

The authors focused on 2 unique aspects of the alliance in conjoint therapy: feeling safe in the therapeutic context with other family members and the family's shared sense of purpose about treatment (i.e., productive within-family collaboration). Low-income, multiproblem families were seen in a community clinic by therapists with varying theoretical orientations and a wide range of experience. Alliance-related behavior was assessed using the System for Observing Family Therapy Alliances (M. L. Friedlander, V. Escudero, & L. Heatherington, 2006). The significant mediated model showed that parent safety contributed to productive family collaboration in the 1st session, which, in turn, predicted global improvement rated after Session 3. Given the heterogeneous sample of clients, therapists, and therapy approaches, findings support the ecological validity of the alliance in family therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation model.

Demonstrated that therapeutic empathy has a moderate-to-large causal effect on recovery from depression in a group of 185 patients (aged 18–75 yrs) treated with cognitive-behavioral therapy (CBT). The authors simultaneously estimated the reciprocal effects of depression severity on therapeutic empathy and found that this effect was quite small. In addition, homework compliance had a separate effect on clinical recovery, over and above the effect of therapeutic empathy. The patients of novice therapists improved significantly less than did the patients of more experienced therapists, when controlling for therapeutic empathy and homework compliance. Ss who terminated therapy prematurely were less likely to complete the self-help assignments between sessions, rated their therapists as significantly less empathic, and improved significantly less. Ss with borderline personality disorder improved significantly less, but they rated their therapists as just as empathic and caring as other patients. The significance of these findings for psychotherapy research, treatment, and clinical training is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrative Cognitive Therapy for Depression: A Preliminary Investigation.

This study is a preliminary investigation of an integrative treatment aimed at improving the efficacy of cognitive therapy (CT) for depression. The development of the treatment protocol was based on process findings, which suggested that strategies used in CT to resolve alliance ruptures may actually exacerbate problems in the therapeutic relationship. The protocol integrates, within the traditional CT treatment manual, procedures to repair alliance ruptures that are derived from or consistent with humanistic and interpersonal therapies. Although conducted by inexperienced therapists, the integrative treatment led to greater improvement than a waiting-list condition. The results also compare favorably to previous findings for CT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perceived effectiveness of psychotherapy: A function of suggestion?

Investigated the relationship between theoretical orientation and the perceived effectiveness of psychotherapy. 20 analytically oriented therapists and 20 behavior therapists listened to 2 taped excerpts of sessions labeled "early" and "late" sessions of either behavior therapy or psychotherapy and then rated the effectiveness of treatment. The interviews were constructed to be ambiguous and portray no personality change. Instructions to each group varied the suggestion of whether a behavior therapist or analytic therapist conducted treatment. Results indicated that suggestion of professional identification was ineffective in biasing therapeutic effectiveness ratings. Analytic therapists as a group judged therapeutic outcome more positively across both suggestions than did behavior therapists, which is interpreted as a greater predisposition to see change where none existed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)