Negative factors in brief psychotherapy: An empirical assessment.

18 male undergraduates with symptoms of depression, anxiety, and unsatisfying interpersonal relationships were seen in brief therapy by professional psychodynamic and experiential therapists. Judges rated audiotapes of early therapy sessions using the Vanderbilt Negative Indicators Scale (VNIS), which consists of 5 subscales representing factors believed to deter therapeutic progress. The hypothesis that negative factors in therapy, as assessed by the VNIS, would be inversely related to outcome was confirmed. The Errors in Technique subscale was the most consistent predictor of outcome. Subscales tapping deficiencies in Patient Qualities and the Patient–Therapist Interaction as well as Global Session Ratings were also related to outcome, although ratings of Therapist Personal Qualities were not. VNIS ratings were more strongly related to the outcome of psychodynamic therapy than experiential therapy and were more often associated with the therapist's and independent clinician's assessments of outcome than the patient's assessment of outcome. (23 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of six measures of working alliance.

Compared 6 measures of working alliance: the California Psychotherapy Alliance Scales (CALPAS), the Penn Helping Alliance Scales (PHAS), the Vanderbilt Therapeutic Alliance Scale (VTAS), Working Alliance Inventory—Observer Form (WAI—O), Working Alliance Inventory—Client Form, and Working Alliance Inventory—Therapist Form. All measures had high internal consistency. Observers were able to reach high levels of interrater reliability on all the observer-rated measures (CALPAS, PHAS, VTAS, WAI—O). Evidence of construct validity was found for the CALPAS, VTAS, and WAI—O, given that they were all highly correlated with each other. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' and therapists' shared and unique views of the therapeutic alliance: An investigation using confirmatory factor analysis in a nested design.

Analyzed large general factor found in measures of the therapeutic alliance by use of confirmatory factor analysis (CFA) in a nested design. Ratings by 38 therapists and their 144 patients on the California Psychotherapy Alliance Scales (CALPAS), the Revised Penn Helping Alliance Questionnaire (HAQ-R), and the Working Alliance Inventory (WAI) were adjusted for therapist effects. A set of models for S and therapist ratings was tested with CFA, and a 3-factor model was confirmed, x–2(4)?=? 7.19, p> .13; GFI?=?.98; RMSR?=?.02; CFI?=?1.0. A shared-view factor (best represented by HAQ-R) accounted for 44% of patients' and 27% of therapists' variance. Unique factors accounted for 56% of therapists' and 43% of Ss' variance. S views split between HAQ and WAI factors; The WAI factor was most expressive of therapist views. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Process and treatment adherence factors in group cognitive-behavioral therapy for partner violent men.

This study used multilevel modeling to examine process and treatment adherence factors as predictors of collateral partner reports of abuse following participation in a cognitive-behavioral group treatment program for partner violent men (N = 107). Therapist working alliance ratings predicted lower levels of physical and psychological abuse at the 6-month follow-up and were the strongest predictors of outcome. Homework compliance partially mediated associations between early alliance ratings and psychological abuse at follow-up. Greater group cohesion during treatment, assessed by client report, also predicted lower physical and psychological abuse at follow-up. The findings support the promotion of a collaborative therapeutic environment to induce change among partner violent men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Therapist Multicultural Competency: A Study of Therapy Dyads": Correction.

Reports an error in "Therapist Multicultural Competency: A Study of Therapy Dyads" by Jairo N. Fuertes, Thomas I. Stracuzzi, Jennifer Bennett, Jennifer Scheinholtz, A. Mislowack, Mindy Hersh and David Cheng (Psychotherapy: Theory, Research, Practice, Training, 2006[Win], Vol 43[4], 480-490). The fifth author's name should be spelled as follows: Alexa Mislowack. (The following abstract of the original article appeared in record 2006-23019-010.) 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)     

Therapeutic alliance and clinical outcome in the NIMH Treatment of Depression Collaborative Research Program: Preliminary findings.

Investigated the effect of the therapeutic alliance on clinical outcome in the 7 most improved and 7 least improved cases in the 4 treatments investigated in a study (I. Elkin et al; see PA, Vols 72:20648 and 77:10249) of treatment of depression. The treatments were interpersonal therapy (IPT), cognitive-behavior therapy, imipramine plus clinical management, and placebo plus clinical management. Clinical observer ratings of alliance, using Vanderbilt Therapeutic Alliance Total Scale scores, were compared across and within treatment groups and were related to clinical status at termination. Despite selective, significant relationships between alliance and outcome across treatments, the alliance–outcome relationship was significant only for IPT within treatments. (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)     

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)     

Using psychodynamic, cognitive behavioral, and control mastery prototypes to predict change: A new look at an old paradigm for long-term single-case research.

This article illustrates a method of testing models of change in individual long-term psychotherapy cases. A depressed client was treated with 208 sessions of control mastery therapy (CMT), an unmanualized approach that integrates elements of psychodynamic therapy (PDT) and cognitive behavioral therapy (CBT). Panels of experts developed prototypes of ideal PDT, CBT, and CMT process using the Psychotherapy Process Q-set (PQS; J. S. Ablon & E. E. Jones, 1999; E. E. Jones, L. A. Parke, & S. Pulos, 1992; E. E. Jones & S. M. Pulos, 1993). Independent observers rated every 4th session (N = 53) with the PQS. Using correlations between ideal and actual PQS ratings followed by paired t tests, the authors compared adherence to the CMT prototype with adherence to plausible alternative models advocated by the PDT and CBT experts. Bivariate time series analyses determined whether prototype adherence predicted an estimated index of symptom change. Results showed that the therapist's behavior was most consistent with the CMT prototype and that this aspect of the CMT prototype along with particular aspects of the other prototypes influenced estimated symptom change. The results, which replicate and extend earlier findings, support the validity of this approach to studying long-term therapies but also highlight its limitations. (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)     

Therapist session intentions in cognitive–behavioral and psychodynamic–interpersonal psychotherapy.

Theories of psychotherapy are implemented by therapists' intentional actions within sessions. This study examined the structure and construct validity of the Therapist Session Intentions (TSI) form. Ten therapists rated their therapeutic intentions following each of 2,305 therapy sessions of cognitive–behavioral or psychodynamic–interpersonal therapy in the Second Sheffield Psychotherapy Project. Seven conceptually coherent clusters of intentions, or therapeutic foci, were identified: treatment context, session structure, affect, obstacles, encouraging change, behavior, and cognition-insight. Contrasting patterns of therapeutic focus across treatments and changes in focus across sessions within treatments appeared conceptually coherent. Correlations across a subsample of sessions confirmed correspondences of the TSI foci with dimensions found previously in observers' ratings. (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)     

In-session exposure tasks and therapeutic alliance across the treatment of childhood anxiety disorders.

The study examined the shape of therapeutic alliance using latent growth curve modeling and data from multiple informants (therapist, child, mother, father). Children (n = 86) with anxiety disorders were randomized to family-based cognitive–behavioral treatment (FCBT; N = 47) with exposure tasks or to family education, support, and attention (FESA; N = 39). Children in FCBT engaged in exposure tasks in Sessions 9–16, whereas FESA participants did not. Alliance growth curves of FCBT and FESA youths were compared to examine the impact of exposure tasks on the shape of the alliance (between-subjects). Within FCBT, the shape of alliance prior to exposure tasks was compared with the shape of alliance following exposure tasks (within-subjects). Therapist, child, mother, and father alliance ratings indicated significant growth in the alliance across treatment sessions. Initial alliance growth was steep and subsequently slowed over time, regardless of the use of exposure tasks. Data did not indicate a rupture in the therapeutic alliance following the introduction of in-session exposures. Results are discussed in relation to the processes, mediators, and ingredients of efficacious interventions as well as in terms of the dissemination of empirically supported treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Change in coordination across phases of psychotherapy and outcome: Two mechanisms for the role played by patients' contribution to the alliance.

Investigated the mechanisms underlying associations between patients' contribution to the alliance and outcome by examining relations between change in the alliance over the course of treatment and improvement in Short-Term Dynamic Psychotherapy (STDP) and Brief Adaptive Psychotherapy (BAP). Findings for STDP were consistent with 1 model about the role played by the alliance, according to which change in the alliance over the course of therapy is the vehicle for overall improvement. Results for BAP were consistent with the other main position proposed in the literature, which argues that a positive alliance provides the foundation for successful treatment. Discussion includes suggesting that it might prove useful in future research to group therapy approaches in terms of these 2 models and that this idea may explain 2 apparently contradictory sets of findings from previous studies on relations between change in the alliance and outcome. (PsycINFO Database Record (c) 2010 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)     

Contribution of therapist experience and personal characteristics to the working alliance.

The authors hypothesized that level of experience and selected personal characteristics of therapists would predict clients' perceptions of the working alliance early in treatment. 73 22–64-yr-old therapists in university settings completed measures that assessed level of self-directed hostility, perceived social supports, and degree of comfort with attachment, and their clients completed a measure that estimated the working alliance between the 3rd and 5th sessions of therapy. As predicted, level of self-directed hostility, perceived social support, and degree of comfort with closeness in interpersonal relationships were significantly predictive of the bond component of the working alliance. Contrary to predictions, experience level was not uniquely predictive of clients' alliance ratings on the goal and task components of the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)