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)     

Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems.

This study examined the impact of treatment adherence and therapist competence on treatment outcome in a controlled trial of individual cognitive-behavioral therapy (CBT) and multidimensional family therapy (MDFT) for adolescent substance use and related behavior problems. Participants included 136 adolescents (62 CBT, 74 MDFT) assessed at intake, discharge, and 6-month follow-up. Observational ratings of adherence and competence were collected on early and later phases of treatment (192 CBT sessions, 245 MDFT sessions) by using a contextual measure of treatment fidelity. Adherence and competence effects were tested after controlling for therapeutic alliance. In CBT only, stronger adherence predicted greater declines in drug use (linear effect). In CBT and MDFT, (a) stronger adherence predicted greater reductions in externalizing behaviors (linear effect) and (b) intermediate levels of adherence predicted the largest declines in internalizing behaviors, with high and low adherence predicting smaller improvements (curvilinear effect). Therapist competence did not predict outcome and did not moderate adherence-outcome relations; however, competence findings are tentative due to relatively low interrater reliability for the competence ratings. Clinical and research implications for attending to both linear and curvilinear adherence effects in manualized treatments for behavior disorders are discussed. (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)     

Examining the alliance using the Psychotherapy Process Q-Set.

The alliance between therapist and patient was investigated using the Psychotherapy Process Q-Set (PQS), an instrument that quantitatively describes therapy sessions in a manner that captures the complexity of the therapy process. More specifically, the PQS was used to examine the treatment processes being assessed by observer ratings on the California Psychotherapy Alliance Scales (CALPAS). Using data from 30 brief psychodynamic psychotherapy treatments (patients aged 20–81 yrs), three PQS factors were found to be associated with alliance: Patient–Therapist Interaction, Patient Capacity/Commitment, and Therapist Countertransference. In multiple regression analyses with scales constructed from these three factors, Patient–Therapist Interaction was found to predict alliance ratings, while the other two aspects of the treatment process did not account for any significant additional variance in the alliance ratings. Results suggest that Patient–Therapist Interaction plays a defining role in the alliance construct, as assessed by the observer version of the CALPAS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"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)     

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

[Correction Notice: An erratum for this article was reported in Vol 31(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2009-17141-001). 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.] 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)     

Relation between cooperation and empathy in young children.

The results of time-sampled, naturalistic coding and teacher and observer ratings of cooperative behavior in 32 preschoolers were correlated with N. D. Feshbach and K. Roe's (1968) measure of empathy. Whereas the coded measure of cooperation was unrelated to empathy, all 3 ratings of cooperation were positively and significantly related to empathy. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

List of therapist intentions illustrated in a case study and with therapists of varying theoretical orientations.

The Intentions List (IL), a 19-item list of therapist intentions, was developed and examined in 2 studies. In Study 1, the use of intentions was investigated in 20 sessions of time-limited therapy with a young neurotic female; 3 trained judges analyzed each session. Across-treatment decreases occurred in the following intentions: setting limits, getting information, supporting, clarifying, hoping, and catharting; increases occurred in insight, change, and reinforcing change. Within sessions, there were decreases in getting information, clarifying, and catharting. In Study 2, the IL was used by 42 experienced therapists in their sessions of ongoing treatment with a neurotic individual or family. MANOVA showed that 7 intentions predicted differential ratings of theoretical orientations. Univariate correlations indicated that feelings and insight were related to psychoanalytic ratings; change, reinforcing change, and setting limits were related to behavioral ratings; and "therapist needs" was related to humanistic ratings. All Ss followed a similar pattern of decreases in clarifying and getting information and increases in catharting, insight, and change. The quality of sessions was related to more focus and feelings and to less getting information and supporting. It is concluded that the IL is an empirically based, pantheoretical measure of therapists' cognitive behavior. (44 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dimensions of psychotherapy: A factor-analytic study of ratings of psychotherapy sessions.

Rated tape recordings of 60 early sessions of psychoanalytically oriented therapy on 110 process variables. The ratings of 3 Os were clustered and factor analyzed. 4 factors were rotated and interpreted as (a) patient health vs. distress, (b) optimal empathic relationship, (c) active directive mode, and (d) interpretive mode with receptive patient. For 27 of the 30 patients, outcome ratings were obtained from the therapist (patient improvement and success + patient satisfaction). Patient improvement was not predicted by any process ratings. Success + patient satisfaction, on which women scored higher than men, was predicted by patient health vs. distress. Patients rated in early sessions as healthy and low in distress had better prognoses. Optimal empathic relationship qualities related positively to success in therapies low in directive mode, but for relatively directive therapies, this relationship was negative. (31 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client-therapist complementarity and therapeutic outcome.

Studied 120 tape recorded psychotherapy sessions representing early, middle, and late interviews with 20 undergraduate self-referrals. Clients were divided into successful (n = 10) and unsuccessful (n = 10) outcome groups on the basis of clinicians' ratings of pre- and post-MMPI data. Raters scored the response units of clients and therapists and labeled as complementary the following elicitation-response sequences: dominance followed by submissive behavior, submissive behavior followed by dominance, friendliness followed by friendliness, and hostility followed by hostility. Comparisons between outcome groups showed no differences in therapist complementarity during the early stage (as predicted), a significantly lower level of therapist complementarity for the successful group during the middle stage (as predicted), and no differences during the last stage (contrary to prediction). Furthermore, during the early stage of therapy more disturbed clients elicited greater therapist complementarity (as predicted). (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward the validation of the California Therapeutic Alliance Rating System.

The California Therapeutic Alliance Rating System, CALTARS, was used by judges to rate four therapy sessions for each of 52 subjects treated in brief dynamic psychotherapy for pathological grief. A principal-components analysis provided support for the theoretically proposed domains of alliance. The interrater reliability at the treatment level was satisfactory for the five component-based scales. As hypothesized, scores reflecting positive contribution to the alliance were positively related to educational attainment, motivation for psychotherapy, pretreatment interpersonal functioning, patient experiencing in therapy, symptom improvement, and gains in interpersonal functioning but negatively associated with stressful life events and greater therapist emphasis on addressing patient resistances. As further hypothesized, scores reflecting negative contribution to the alliance were positively associated with greater therapist emphasis on addressing resistances. Alliance ratings were largely independent of pretreatment symptomatology. These findings build toward the construct validity of the CALTARS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

The relationship between therapeutic alliance and treatment outcome was examined for depressed outpatients who received interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Clinical raters scored videotapes of early, middle, and late therapy sessions for 225 cases (619 sessions). Outcome was assessed from patients' and clinical evaluators' perspectives and from depressive symptomatology. Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance were significantly related to treatment outcome; ratings of therapist contribution to the alliance and outcome were not significantly linked. These results indicate that the therapeutic alliance is a common factor with significant influence on outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dependability of alliance assessments: The alliance–outcome correlation is larger than you might think.

Objective: To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance–outcome relationship. Method: We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. Results: At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3–9 explained 14.7% of outcome variance. Conclusion: Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance–outcome relationship. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The relationship of parental warm responsiveness and negativity to emerging behavior problems following traumatic brain injury in young children.

Parenting behaviors play a critical role in the child's behavioral development, particularly for children with neurological deficits. This study examined the relationship of parental warm responsiveness and negativity to changes in behavior following traumatic brain injury (TBI) in young children relative to an age-matched cohort of children with orthopedic injuries (OI). It was hypothesized that responsive parenting would buffer the adverse effects of TBI on child behavior, whereas parental negativity would exacerbate these effects. Children, ages 3–7 years, hospitalized for TBI (n = 80) or OI (n = 113), were seen acutely and again 6 months later. Parent–child dyads were videotaped during free play. Parents completed behavior ratings (Child Behavior Checklist; T. M. Achenbach & L. A. Rescorla, 2001) at both visits, with baseline ratings reflecting preinjury behavior. Hypotheses were tested using multiple regression, with preinjury behavior ratings, race, income, child IQ, family functioning, and acute parental distress serving as covariates. Parental responsiveness and negativity had stronger associations with emerging externalizing behaviors and attention-deficit/hyperactivity disorder symptoms among children with severe TBI. Findings suggest that parenting quality may facilitate or impede behavioral recovery following early TBI. Interventions that increase positive parenting may partially ameliorate emerging behavior problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Alliance and Treatment Adherence in Two Interventions for Bulimia Nervosa: A Study of Process and Outcome.

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist × Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Verbal interaction analysis of empathic and nonempathic responses of therapists.

Analyzed 100 5-min samples from 35 tape-recorded psychotherapy sessions and rated them on empathic understanding. Silence behaviors appear to be indicative of high levels of therapist empathy. Of the 5 therapist verbal behaviors that together formed the best discriminators between groups of empathy ratings, only 1 talk behavior appeared. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression.

This study attempted to replicate an earlier study (R. J. DeRubeis & M. Feeley, 1990) of the prediction of symptom change from process variables in cognitive therapy for depressed outpatients. Measures of in-session therapist behavior and therapist–patient interactions were correlated with prior and subsequent symptom change. One of the positive findings was confirmed, but the other received only marginal support. A "concrete" subset of theory-specified therapist actions, measured early in treatment, predicted subsequent change in depression. The therapeutic alliance was predicted by prior symptom change in 1 of the 2 later assessments, but only at a trend level. Several negative findings were similar to those obtained in the earlier study. Specifically, the alliance, an "abstract" subset of theory-specified therapist actions, and facilitative conditions did not predict subsequent change. Implications for causal inferences in psychotherapy process research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two aspects of the therapeutic alliance: Differential relations with depressive symptom change.

Objective: The therapeutic alliance has been linked to symptom change in numerous investigations. Although the alliance is commonly conceptualized as a multidimensional construct, few studies have examined its components separately. The current study explored which components of the alliance are most highly associated with depressive symptom change in cognitive therapy (CT). Method: Data were drawn from 2 published randomized, controlled clinical trials of CT for major depressive disorder (n = 105, mean age = 40 years, female = 62%, White = 82%). We examined the relations of 2 factor-analytically derived components of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) with symptom change on the Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996) that occurred either prior to or subsequent to the examined sessions. WAI ratings were obtained at an early and a late session for each therapist–patient dyad. Results: Variation in symptom change subsequent to the early session was significantly related to the WAI factor that assesses therapist–patient agreement on the goals and tasks of therapy but not to a factor assessing the affective bond between therapist and patient. In contrast, both factors, when assessed in a late session, were significantly predicted by prior symptom change. Conclusions: These findings may reflect the importance, in CT, of therapist–patient agreement on the goals and tasks of therapy. In contrast, the bond between therapist and patient may be more of a consequence than a cause of symptom change in CT. The implications of these results and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy.

This study examined whether (a) therapist behaviors thought to enhance family treatment predicted caregiver in-session responses, and (b) caregiver race, racial match between caregiver and therapist, and family financial hardship moderated the relationships between therapist and caregiver behavior. Observers coded caregiver and therapist behavior during one session of multisystemic therapy for substance abusing adolescents. Therapist teaching, focusing on strengths, making reinforcing statements, problem solving, and dealing with practical family needs predicted caregiver engagement and/or positive response, regardless of race, racial match, or financial hardship. Caregiver race, financial hardship, and therapist–caregiver racial match occasionally moderated the relationship between other therapist and caregiver behaviors. Findings suggest both commonalities and differences in how therapist behavior may function to engage caregivers in family treatment, depending on diversity-related factors. (PsycINFO Database Record (c) 2010 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)