Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa

This study examined the relationship between therapeutic alliance and primary symptom change (weight gain) during CBT for anorexia nervosa. The aims were threefold: (1) to establish the strength of the therapeutic alliance across the treatment, (2) to determine whether early therapeutic alliance is associated with the completion of CBT for this client group, and (3) to determine the direction of the relationship between therapeutic alliance and weight gain. Adult outpatients (N = 65) with a diagnosis of anorexia nervosa (or atypical anorexia nervosa) completed a measure of alliance at session six and at the end of treatment. Weight was recorded at the start of treatment, session six and at the end of treatment. The strength of the alliance was consistently high in the sample. However, early therapeutic alliance was not associated with either the likelihood of completing treatment or subsequent weight gain. In contrast, both early and later weight gain were associated with the strength of subsequent alliance. These findings indicate that it might be advisable to focus on techniques to drive weight gain rather than rely on the therapeutic alliance to bring about therapeutic change.     

Relational dynamics between psychotherapy clients and clinic administrative staff: A pilot study

Extensive empirical research has established therapeutic alliance as one of the most stable predictors of psychotherapy outcomes. Nearly all the contemporary empirical literature on therapeutic alliance focuses on the therapist-client dyad without attending to the relational experiences many clients in outpatient clinics have with administrative staff. Literatures from the fields of social work, psychiatric nursing and milieu therapy suggest there are more systemic relational and environmental dynamics that impact treatment beyond the therapist-client dyad, although these issues have been considered primarily in inpatient settings. A relational ecology framework has been developed drawing upon relational psychoanalysis, attachment theory and symbolic anthropology to help conceptualise the broader relational dynamics beyond the therapist-client dyad that may impact a more systemic therapeutic alliance in certain outpatient contexts. In an initial cross-sectional pilot study with a sample of clients (N = 107) receiving psychotherapy at a community mental health clinic in the Northeastern United States, the present study found client ratings of both (a) the therapeutic alliance with their therapists and (b) their alliance with administrative staff each significantly positively predicted client ratings of treatment. Thus, ratings of administrative alliance predicted client ratings of treatment over and above the effects of the therapist-client therapeutic alliance. These findings provide preliminary support for further investigation of the relational ecology of outpatient psychotherapy and suggest that client experiences of relational and environmental dynamics with administrative staff may be important contributors to psychotherapy outcomes. Limitations of the present study and implications for future research and practice are discussed.     

Mortality salience increases language style matching and well-being

The present research examined whether people imitate the language style of others (i.e., the use of function words) as a form of liking when mortality concerns are salient. In Study 1, participants answered questions about death or public speaking and then engaged in an instant messaging conversation with a confederate. In Study 2, participant pairs verbally discussed a news article about increasing homicide rates or the rise in academic pressure. Next, everyone completed measures of self-esteem, life satisfaction, and relationship need satisfaction. The results revealed that, in comparison to the control conditions, participants exhibited greater language style matching (LSM) following reminders of death (Studies 1 & 2). Further, mediational analyses showed that higher LSM after mortality salience was associated with better psychological and social well-being (Study 2). Although the threat of death has been shown to make people more hostile and disparaging toward dissimilar others, the present work suggests that individuals, even strangers, may feel closer through language coordination following thoughts of mortality.     

Resistance and outcome expectations in cognitive‐behavioural therapy for generalised anxiety disorder

Greater client resistance has been consistently found to be negatively associated with outcome in psychotherapy. However, the pathways through which resistance impacts such outcomes are underexplored. Given that client outcome expectation (OE) has been identified as an important common factor in psychotherapy, the goals of the present study were to examine: (a) the impact of resistance on subsequent client and therapist OE (COE & TOE, respectively); and (b) whether COE and/or TOE mediate the relationship between resistance and outcome. These relationships were tested among 44 clients with severe generalised anxiety disorder treated with cognitive‐behavioural therapy in the context of a randomised controlled trial (Westra, Constantino, & Antony, 2016). Resistance was measured at a mid‐treatment session, and COE and TOE were assessed at baseline and immediately after the resistance session. Treatment outcome was measured via client‐rated worry severity at post‐treatment. As predicted, higher resistance was associated with lower subsequent COE and TOE; B = ?.73, p < .001 and B = ?.46, p < .001, respectively. In turn, lower post‐resistance COE predicted higher post‐treatment worry (B = ?.5, p < .001), indicating mediation. In contrast, TOE did not mediate the relationship between resistance and outcome (B = ?.02, p = .876). These results suggest that resistance can be demoralising to both clients and therapists. However, only lower client morale may be detrimental to therapy outcome. This study contributes to understanding outcome pathways through two common therapy processes.     

The development of therapeutic alliance during psychological assessment: patient and therapist perspectives across treatment

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn & Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher & Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.     

Therapeutic progress and symptom elevation in treating dismissive attachment: A case study

A dismissive or avoidant attachment style can present clinical challenges in psychotherapy as the attachment style may interfere with the development of a constructive therapeutic alliance and impact the level of disclosure, expressions of distress, and risks for premature drop-out. This paper reports a naturalistic case study and offers an in-depth examination of a treatment with a client with dismissive attachment, including a detailed examination of relational interventions and countertransference struggles. Furthermore, this paper considers the notable differences between quantitative scores on a well-validated, practice-based clinical symptom inventory and the qualitative outcomes for this client to offer clinical and research implications in treatment with dismissive attachment.     

工作同盟和领悟对咨询效果的影响

为了解短程咨询中工作同盟和领悟对咨询效果的影响,以12个个案94次会谈为对象,考察工作同盟、领悟分别与会谈效果、治疗效果的关系,并考察二者共同作用于效果的方式。结果表明,咨访双方评定的工作同盟都可以正向预测会谈效果,但不能预测治疗效果;领悟与会谈有效性正相关,领悟正向预测治疗效果;咨询师评定的同盟的三个维度以领悟为中介影响其对会谈效果的评价。     

Client process in short term dynamic psychotherapy1

In this study, a single case design was used to examine significant client events in a process of short-term dynamic psychotherapy. The Category System of Client Good Moments (Mahrer, 1988) was used as a measure of therapeutic process. Client speaking turns were rated for three sessions (early, middle, and late) of the complete sixteen session treatment conducted according to davanloo's (1978) model of short-term dynamic psychotherapy (STDP), and categories of good moments identified. The results showed that the salient client change-events were related to the client's (a) provision of significant information, (b) exploration of feelings, and (c) insight and understanding across the three sessions. Additionally, the results also showed a statistically significant increase in client-reported behavior change and sense of well-being for the late session. The results suggest that in-session report of behavior change is an important component of therapeutic process. The implications of these results for an atheoretical, data-driven understanding of therapeutic change processes are presented.     

Emotion in an alliance rupture and resolution sequence: A theory‐building case study

Aims: Alliance rupture and resolution processes are occasions for the client to have his or her core interpersonal patterns activated in the here and now of the therapy and to negotiate them with the therapist. So far, no studies have been conducted on emotional processing, from a sequential perspective using distinct emotion categories, in alliance rupture and resolution therapy sessions. This is the objective of this theory‐building case study. Method: This client underwent a 34‐session long, psychodynamic psychotherapy within the context of an open trial. An alliance rupture‐resolution sequence of two subsequent sessions, along with a third control session, was selected from this case and these sessions were rated using the Classification of Affective‐Meaning States (CAMS), an observer‐rated method to classify distinct emotions, according to current emotion‐focused models. Results: The results indicate that the rupture session was associated, above all, with core maladaptive fear, evoked in the actual here and now of the therapeutic relationship, whereas the resolution session was associated with the expression and experience of adaptive hurt as regards biographical issues of the client. Discussion: These results are discussed with regard to the alliance rupture and resolution model and the exploration of integrating client's emotional processing in the model.     

Therapists’ perspective on the therapeutic relationship: Examining a tripartite model

The components of a tripartite model of the therapeutic relationship, namely the working alliance, the transference configuration (transference and countertransference), and real relationship, were examined in terms of how they relate to one another and to the outcome of a psychotherapy session, from the therapists’ perspective. Although previous studies have examined these components separately, no study to date has examined the components together in their relation to session outcome. Licensed psychotherapists (n = 249) were recruited from two Divisions of the American Psychological Association. Therapists completed measures for the last session they had with a client. Results revealed that from the therapist’s perspective the real relationship and working alliance related positively to session outcome, and countertransference behavior related negatively to session outcome. The components related to each other mostly as predicted by the tripartite model, and a principal-axis factor analysis revealed the presence of four distinct factors resembling the components theorized to comprise the tripartite model. The components together accounted for 27% of the variance in session outcome and only the real relationship and the working alliance predicted session outcome when all the components were looked at simultaneously in a regression model.     

Therapeutic immediacy across long-term psychodynamic psychotherapy: an evidence-based case study

C. E. Hill (2004) recently developed the concept of therapist immediacy to capture discussion by the therapist about the therapeutic relationship that occurs in the here-and-now of a therapy session. This concept has been expanded to include discussion about the therapeutic relationship by both the client and therapist, captured by the term therapeutic immediacy (K. Kuutmann & M. Hilsenroth, 2011). Although prior research has examined the use of therapeutic immediacy across short-term treatment, the present study is the first to examine the use of immediacy across a long-term (4 years) psychotherapy. Also, this is the first study to assess the interrater reliability of therapeutic immediacy, which was found to achieve good to excellent levels across raters. The most frequently used categories of client and therapist immediacy are presented. Finally, the authors provide an in-depth qualitative examination of 5 therapeutic immediacy segments across the treatment judged by the raters to have high levels of depth/intensity (4.5 or higher out of 5) to examine the role of therapeutic immediacy in exploring meaningful treatment issues. Clinical utility, potential limitations, and future research on therapeutic immediacy are discussed.     

An Indicator of Suicidal Ideation on the Rorschach Test

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn &; Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher &; Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.     

Exploring actor-partner interdependence in family therapy: whose view (parent or adolescent) best predicts treatment progress?

Predictions of family therapy outcome consistently vary depending on which client rates the alliance. We used the actor-partner interdependence model (Kenny, Kashy, & Cook, 2006) to test the interdependence of parents' and adolescents' ratings of alliance, session depth/value, and improvement-so-far after Sessions 3, 6, and 9. Initial analyses found trivial between-therapists variance; therefore, a 3-level hierarchical model partitioned the variance in these variables into between families, between family members, and between session components. For alliance and session depth, results showed a significant parent actor effect and a significant adolescent partner effect. Specifically, when parents saw a stronger alliance, they also saw the session as more valuable, but when adolescents saw a stronger alliance, their parents saw the session as less valuable. Both the parents' and the adolescents' improvement scores showed significant linear growth over time, and adolescents' alliance ratings were positively associated with their own and their parents' views of therapeutic progress.     

The Functional Analytic Psychotherapy Rating Scale: a Replication and Extension

Few theories of psychotherapy give direction to the therapist on a moment-to-moment level or make predictions about how specific therapist techniques change client behavior in session. Functional analytic psychotherapy (FAP, Kohlenberg and Tsai in Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. Plenum, New York 1991) provides this direction and prediction. Specifically, FAP claims that client problem behaviors will be displayed in the therapeutic relationship and that the therapist can improve client in-session behavior through differential, contingent responding. Further, it is assumed that these improvements in session can be generalized to out of session relationships. The FAP rating scale (FAPRS) was developed for the purpose of coding in-session client and therapist behaviors in an effort to test FAP’s purported mechanism of change. The current study seeks to replicate and extend initial FAPRS findings (Callaghan et al. in J Contemp Psychother 33:321–339, 2003) regarding mechanism of change and to address transportability. FAPRS coding data from a single successful case of an individual diagnosed with Borderline Personality Disorder and treated with FAP is presented. Results indicate that the FAPRS system is transportable and are generally supportive of the claim that therapist contingent responding leads to client improvement.     

The Development and Role of the Therapeutic Alliance in Supportive Psychotherapy with Adolescents

The formation of a therapeutic alliance is considered a central issue in therapy, and particularly crucial and challenging in work with adolescents. The relational and technical components of the therapeutic alliance were examined from the perspective of the adolescent client. 40 emotionally disturbed adolescent girls, aged 13 to 16 years, received brief supportive psychotherapy in the school setting. The alliance was assessed at sessions 3, 6 and 9, and outcome was evaluated on measures of internalizing problems, self-esteem, adjustment and client satisfaction. The results indicated the stability of the alliance between sessions 3 and 6, followed by significant linear increases between sessions 6 and 9. The strength of the alliance was most consistently related to reductions in internalising problems and client estimates of change. The implications for training and clinical practice with adolescent clients are discussed and future research avenues outlined.     

Parentification and the Impostor Phenomenon: An Empirical Investigation

The therapeutic alliance has consistently predicted client outcomes in psychotherapy. This study uses attachment theory as a resource in understanding the therapeutic alliance. Participants in this study were 27 mothers, 15 fathers, and 23 adolescents that participated in family therapy. Results indicate that mothers' reports of trust in their oldest child predicted the alliance, and adolescent ratings of trust in mothers and fathers moderated the relationship between therapy alliance and symptom distress. Implications for family therapy research and practice are discussed.     

Integrating clients' moment‐to‐moment ratings into psychotherapy research: A novel approach

Counselling and psychotherapy researchers have considerably advanced the field's understanding of psychotherapy processes and how they relate to treatment outcomes. Despite these advances, little is known about the client's perspective of changes in psychotherapy processes that occur throughout a given session (i.e. micro‐processes). To address this gap, this article describes the novel application of methods that assess participants' moment‐to‐moment ratings to psychotherapy research. This method entails recording psychotherapy session content that clients and other potential raters (e.g. therapists, researchers) later review while simultaneously providing continuous ratings of psychotherapy processes (e.g. helpfulness, alliance). In addition, moment‐to‐moment ratings can facilitate significant events research by prompting researchers to elicit client feedback about the moments that are rated the most and least positively. However, few studies have used these methods in the context of psychotherapy research. Studies incorporating these methods may yield findings that advance psychotherapy research, training efforts and clinical practice. For example, studies may examine how the magnitude and timing of clients' moment‐to‐moment ratings of psychotherapy processes are associated with treatment outcomes, therapist ratings and physiological processes (e.g. heart rate variability). Trainee therapists and their supervisors may also use clients' moment‐to‐moment ratings to facilitate attunement to verbal and non‐verbal indicators of moments perceived more positively and negatively. Last, these methods can produce findings that are highly relevant to clinical practice, where therapists routinely navigate fluctuations in psychotherapy processes (e.g. alliance ruptures) that can be assessed using moment‐to‐moment ratings.     

The “Activist Client”: Social Responsibility,the Political Self,and Clinical Practice in Psychotherapy and Psychoanalysis

The idea of the “activist client” is intended to be taken both literally and metaphorically—applying to some extent to a wider range of clients than actual activists. The paper develops a set of ideas about a “political turn” in psychotherapy and psychoanalysis, using the tag “the inner politician.” There is a focus on working directly with political material in the session, and the pros and cos of this practice are reviewed. Wider issues such as social responsibility and social spirituality are discussed, as well as an exploration of the limits of individual responsibility. Some specific topics covered in the paper include the political roots of depression, difficulties with the concept of the therapeutic alliance from the point of view of democratic perspectives on clinical work, and a challenge to the unquestioned valuing of empathy (based on a reading of therapy though a Brechtian lens). There are numerous clinical examples.     

Neurodynamics inside therapeutic interaction: a case study with simultaneous EEG recording / La neurodinámica en el contexto de la interacción terapéutica: un estudio de caso con una grabación simultánea de EEG

Recent research on processes of psychotherapy has focused on the study of patient-therapist regulation. Evidence concerning verbal and nonverbal coordination as predictors of therapeutic alliance and outcome in psychotherapy has been cumulating. These, along with others results in the field of social neuroscience, suggest that behavioural coordination may have neurophysiological correlates, which play a role in the regulatory process in psychotherapy. Here we introduce an observational paradigm and analytic method to assess the joint neurodynamic activity of patient and therapist. Additionally we report results from ongoing psychotherapy sessions. Our work highlights the involvement of brain activity in the psychotherapeutic process and provides novel insights on how psychotherapy works, in order to further the understanding of the embodied characteristic of the therapeutic interaction.     

The formation of the therapeutic alliance in couple therapy

This study examines the predictive validity of several clinical variables--including marital distress, individual symptomatology, and family-of-origin experiences--on the formation of the alliance in couple therapy. Eighty people who were treated with a naturalistic course of integrative conjoint psychotherapy at a large midwestern outpatient clinic were assessed on the clinical variables before session 1. They also completed ratings of the therapeutic alliance after sessions 1 and 8. Individual symptomatology did not predict alliance formation at either treatment stage. Higher levels of marital distress predicted poorer alliances to treatment between partners at session 1. Marital distress also predicted therapeutic alliance quality for men and women at session 8. Family-of-origin distress predicted alliance quality for men at session 1, and for women at session 8. Family-of-origin distress for men and women predicted split alliances early in treatment, and marital distress predicted split alliances for women at session 8. Clinical implications for the assessment and treatment of couples are discussed.