Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance.

Although the therapeutic alliance is a consistent predictor of psychotherapy outcomes, research has not distinguished between the roles of patient and therapist variability in the alliance. Multilevel models were used to explore the relative importance of patient and therapist variability in the alliance as they relate to outcome among 331 patients seen by 80 therapists (therapist average caseload was 4.1). Patients rated both the alliance and outcome and all models adjusted for baseline psychological functioning. The results indicated that therapist variability in the alliance predicted outcome, whereas patient variability in the alliance was unrelated to outcome. Reasons why therapist variability as opposed to patient variability predicted outcome are discussed. Clinical implications include therapists monitoring their contribution to the alliance, clinics providing feedback to therapists about their alliances, and therapists receiving training to develop and maintain strong alliances. (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)     

Alliance as a Mediator of Expectancy Effects in Short-Term Group Psychotherapy.

This study investigated whether the therapeutic alliance mediates between patient expectancy of improvement and the outcome of time-limited, short-term group psychotherapy. Data were drawn from a comparative trial of 2 forms (interpretive and supportive) of time-limited group therapy for complicated grief (W. E. Piper, M. McCallum, A. S. Joyce, J. S. Rosie, & J. S. Ogrodniczuk, 2001). Patients' outcome expectancy was based on individualized target objectives for treatment, and alliance was assessed from patient and therapist perspectives. The data were analyzed through the use of hierarchical linear modeling. Patient-rated alliance played a mediating role in the relationship between outcome expectancy and group benefit, suggesting that the expectancy-outcome association is expressed through the development of a collaborative relationship between the individual members and the group therapist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the alliance and techniques in predicting outcome of supportive-expressive dynamic therapy for cocaine dependence.

We examine the complex relations among therapeutic alliance, adherence to Supportive-Expressive Therapy (SET), therapist competence, and their interactions in predicting change in drug use. Experts rated early therapy sessions of cocaine dependent patients (n = 108) randomized to SET as part of the Collaborative Cocaine Treatment Study. Moderate adherence to SET and competent delivery of SET were separately associated with poorer outcome. Further, strong alliance combined with low levels of SET adherence was associated with a better outcome than moderate or high levels. Moreover, the usage of nonprescribed techniques (i.e., Individual Drug Counseling [IDC]) by SET therapists predicted better outcome in a subsample (n = 36), and SET patients receiving high levels of IDC adherence had less predicted drug use compared with those with high levels of SET techniques. Overall results may suggest that decreasing cocaine use through straightforward drug counseling techniques instead of trying to help patients understand the reasons for their use is a better initial road to recovery. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance and outcome: Impact of treatment length and pretreatment symptomatology.

Studied data collected in 1978–1982 in a research project at a university psychological clinic that provides low-cost services to families in the community. Data consisted of pre- and posttherapy written measures and audiotapes from selected sessions with 40 patients (aged 20–57 yrs). Findings indicate that (1) strength of therapeutic alliance was established within the 1st 3 sessions of therapy with little change over the course of therapy, (2) short length therapy cases had lower levels of therapist positive alliance, (3) therapeutic alliance was predictive of outcome, and (4) therapeutic alliance was adversely affected by pretreatment symptomatology. (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)     

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 alliance.

Two decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome. The magnitude of this relation appears to be independent of the type of therapy and whether the outcome is assessed from the perspective of the therapist, client, or observer. Although the strength of the connection between alliance and therapy outcome appears to be relatively uniform throughout therapy, the client's report of the early alliance may be the most clinically useful indicator. In successful treatments, the therapist's and client's assessments of the alliance tend to converge over time. Recent research suggests that the therapist's skills and personal factors both influence the likelihood of developing a good therapeutic alliance with the client. Though the relation between the therapist's level of training and the quality of the alliance is inconsistent, it is likely that the more trained therapists are able to form better alliances with severely impaired clients. (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)     

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)     

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)     

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)     

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)     

The alliance as mediator of expectancy effects in short-term individual therapy.

The authors investigated the hypothesis that the therapeutic alliance mediates the relationship between pretherapy expectancy of improvement and psychotherapy outcome. Data were drawn from a comparative trial of 2 forms of short-term, time-limited individual psychotherapy (W. E. Piper, A. S. Joyce. M. McCallum, & H. F. Azim, 1998). Measures of expectancy and outcome were based on an individualized assessment of target objectives; outcome was considered from 3 perspectives (patient, independent assessor, therapist). Using the R. M. Baron and D. A. Kenny (1986) procedure, the authors, found evidence in support of the hypothesized mediation effect. The effect was evident when the alliance was rated from the perspective of either patient or therapist, and it accounted for one third of the direct impact of expectancy on outcome. Clinical implications and limitations of the study are discussed. (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)     

Attachment to the therapist.

This study examines the ways in which therapists function as attachment figures for patients. Patients in long-term psychoanalytic therapy answered questionnaires about their feelings about their therapists and their closest personal relationships. Components of attachment prominent in the therapeutic relationships were looking up to the therapist and feeling the therapist was responsive to emotional needs. Stronger attachment to therapists was associated with greater frequency and duration of therapy, a stronger working alliance, and greater security of the patients' attachment style, as well as with the gender of the patient and therapist. Using attachment theory to understand psychoanalytic relationships emphasizes the unique importance of a therapist to a patient and can offer new perspectives on both therapeutic and attachment processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrative cognitive therapy for depression: A randomized pilot comparison.

This pilot study examined the efficacy of an integrative form of cognitive therapy (ICT) for depression that incorporates specific strategies for addressing alliance ruptures. Although a previous study on depression found that ICT was superior to a wait-list condition (L. G. Castonguay et al., 2004), the current study provides the 1st direct comparison between ICT and traditional cognitive therapy (CT). Twenty-two depressed adults were randomly assigned to ICT or CT (11 patients per condition), which were delivered by clinicians in training. Outcome was assessed with a specific depression measure and a global symptomatology measure. The groups were also compared on patient-perceived alliance quality and therapist empathy. Effect size estimates revealed that ICT patients evidenced greater posttreatment improvement on both outcome measures (with small to medium effects) and more clinically significant change than did CT patients. ICT patients also had higher alliance and empathy scores across treatment (with medium to large effects). The findings, albeit very preliminary, support the potential viability of ICT and the potential causal influence of the rupture-repair interventions on treatment process and outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Teaching and learning short-term dynamic psychotherapy: Parallel processes.

Examines the parallels between teaching and short-term therapy by characterizing the latter in terms of 4 categories—structure, attributes, actions, and experiences—and discusses the experience of teaching short-term dynamic psychotherapy in a didactic seminar. Student-therapists spontaneously introduce a time limit, experience anxiety, and resist change. The teacher-therapist forms a good learning alliance and interprets resistances and anxiety in a way that parallels the therapist's approach to the patient. A case study of consultation with a therapist treating a 23-yr-old male illustrates how the therapist can assimilate and act on the consultant's attitudes. The therapist used his experience with the consultant in order to understand the patient's experience with himself. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-concept and self-esteem as moderators of client transference.

Operationalized transference as (a) the similarity of clients' perceptions of their therapist and their perceptions of their parents and (b) therapists' ratings on a transference scale, Therapy Session Check Sheet (TSCS; H. Graff and L. Luborsky, 1977), and examined the moderating role of self-esteem and ego development on client transference. Ss were 62 clients (aged 19–63 yrs) who were already involved in therapy, and 29 therapists (aged 25–61 yrs). The Barrett-Lennard Relationship Inventory (G. T. Barrett Lennard, 1962, 1973) measured the facilitative conditions (regard, empathy, and unconditionality) and therapist–parent similarity and the TSCS measured the therapists' perceptions of transference. Additional measures were the Ego Identity Scale (A. L. Tan, et al, 1977) and the Rosenberg Self-Esteem Scale (M. Rosenberg, 1979). Results support the idea that self-esteem and ego development impact a client's view of the therapist and parental figures and are associated with therapists' views of transference. Persons with low ego identity and low self-esteem tended to see their therapists and parental figures more dissimilarly; and the more transference that a therapist perceived, the greater the tendency for the client to have low ego identity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)