Comparing Alliance in Two Cognitive-Behavioural Therapies for Adolescents With ADHD Using a Randomized Controlled Trial

Alliance is defined as the client-therapist bond and their ability to collaborate on therapeutic activities. Treatment for adolescents with ADHD is rarely studied in terms of alliance. In this study, two cognitive-behavioral treatments (CBT; one structured treatment aimed at planning skills and one less-structured solution-focused treatment, both delivered in the style of Motivational Interviewing) were compared with regard to alliance and alliance-outcome association. The influence of therapist competence on this alliance-outcome association was also evaluated. The alliance between 69 adolescents diagnosed with ADHD and their therapists was measured early in treatment, using the Therapy Process Observational Coding System for Child Psychotherapy–Alliance scale. Observer-rated therapist competence was measured using the Motivational Interviewing Treatment Integrity scale (version 3.1.1.). Outcome variables were the adolescents’ reduction in planning problems and ADHD symptoms. The alliance, and, more specifically, collaboration on therapeutic activities, was significantly higher for the more structured CBT (p = .04; moderate effect size). Alliance was not related to outcome in the more structured CBT, while the alliance was positively related to the reduction in planning problems in the less structured CBT. Finally, alliance was a significant mediator between therapist competence and treatment outcome for the less-structured CBT. The clarity and structure of CBT may help facilitate alliance formation for adolescents with ADHD who often have difficulty implementing structure themselves. Therapists may need to invest more in alliance formation in less structured CBT as the alliance affects outcome. Moreover, enhancing therapist competence in less structured CBT may help improve outcomes in less structured CBT, as therapist competence may impact outcome through alliance.     

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.     

Homework Completion,Patient Characteristics,and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.     

Clinicians' fidelity to a manual-based family treatment as a predictor of the one-year course of bipolar disorder

This study assessed whether therapist adherence to the family focused treatment model for patients with bipolar disorder and their relatives was associated with patient outcomes at one year after treatment entry. A total of 78 videotaped sessions of FFT consisting of 26 families with a member with bipolar disorder (3 sessions/family) were rated on fidelity using the Therapist Competence/Adherence Scale (TCAS; see Endnote 1, p. 130). Patients' outcomes (relapse status) were assessed using the Brief Psychiatric Rating Scale (BPRS) and selected items from the Schedule of Affective Disorders and the Schizophrenia-Change (SADS-C) scale (measured at 3-month intervals for 12 months). Contrary to expectations, therapist fidelity was not related to overall outcome as assessed by the BPRS and the SADS-C. Among patients who did relapse, higher levels of cooperation among therapists predicted a later date for relapse than did lower levels of cooperation. Surprisingly, and in opposition to the study's hypotheses, patients who were hospitalized because of relapses had therapists who were rated as more competent in their ability to conduct the problem-solving module of FFT. Study implications are discussed.     

A Novel Approach to the Assessment of Fidelity to a Cognitive Behavioral Therapy for PTSD Using Clinical Worksheets: A Proof of Concept With Cognitive Processing Therapy

Fidelity monitoring is a critical indicator of psychotherapy quality and is central to successful implementation. A major barrier to fidelity in routine care is the lack of feasible, scalable, and valid measurement strategies. A reliable, low-burden fidelity assessment would promote sustained implementation of cognitive behavioral therapies (CBTs). The current study examined fidelity measurement for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) using clinical worksheets. External raters evaluated patient worksheets done as a part of treatment, both guided by the therapist and completed independently as homework. Results demonstrated that fidelity ratings from CPT session worksheets were feasible and efficient. Notably, they were strongly correlated with observer ratings of the fidelity of CPT strategies that were present on the worksheets. Agreement among ratings conducted by individuals with a range of experience with CPT was acceptable to high. There was not a main effect of therapist-guided, in-session worksheet ratings on PTSD symptom change. However, patient competence in completing worksheets independently was associated with greater PTSD symptom decline and in-session, therapist-guided worksheet completion was associated with larger symptom decreases among patients with high levels of competence. With further research and refinement, rating of worksheets may be an efficient way to examine therapist and patient skill in key CPT elements, and their interactions, compared to the gold standard of observer ratings of therapy video-recordings. Additional research is needed to determine if worksheets are an accurate and scalable alternative to gold standard observer ratings in settings in which time and resources are limited.     

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.     

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.     

Influence of Therapist and Client Behaviors on Therapy Alliance

This study considers the combined effect of therapist behaviors and couples interaction dynamics on therapeutic alliance because it seems to be a significant predictor of successful therapy outcomes. We measured therapeutic alliance using the Working Alliance Inventory, Observer Version (WAI-O), which includes three subscales: goals, tasks, and bond. We investigated the combined effect of therapist behaviors and couples interactions on therapeutic alliance. There were three significant findings: (1) the models better predicted therapeutic alliance for men clients than women clients; (2) combined consideration of partner behaviors and therapist behaviors provided the stronger prediction of therapeutic alliance; and (3) different variables predicted alliance for women clients versus men clients.     

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.     

Role of the working alliance in the treatment of delinquent boys in community-based programs

Examined the role of the working alliance in the treatment of delinquent boys in community-based residential programs, clarifying the relation between therapeutic process and behavioral change. Horvath and Greenberg's (1989) Working Alliance Inventory was used to assess the therapeutic alliance between youth and staff after 3 weeks in treatment and again after 3 months. Achenbach's (1991) Child Behavior Checklist (CBCL; Youth Self-Report [YSR] and Teacher Report Form [TRF]) and recidivism scores were used to assess treatment progress and outcome. Results indicated that a positive working alliance assessed after 3 months in treatment related to positive psychological changes and predicted lower rates of recidivism. Unexpectedly, a positive working alliance assessed early in treatment was associated with negative outcomes (increased internalizing and externalizing symptoms and higher rates of recidivism). This finding suggests that for some delinquent youth initially optimistic assessments may be prognostic of slow progress or treatment failure.     

The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.     

What Does the Alliance Predict in Group Interventions for Early Psychosis?

The therapeutic alliance is considered an essential component of any clinical or psychological intervention. The therapeutic alliance can however change over time, and therefore it is relevant to determine if the alliance and its variations are related to clinical outcomes. The present study had three objectives: (1) determine the impact of the alliance measured by the client and the therapist, on clinical and psychosocial outcomes of individuals with early psychosis receiving group interventions; (2) measure the concordance between the client and the therapists’ ratings of the alliance; and (3) determine the best predictor of the client’s alliance in our sample. A total of 36 individuals with early psychosis who participated in group interventions for symptom management answered the WAI three times, and so did the group therapists. Outcomes included measures of insight, symptoms (total, positive and negative), and self-esteem. Attendance and group participation were also measured. Results suggest that the overall client’s alliance predicted total symptoms and self-esteem at post-therapy, whereas both clients’ and therapists’ ratings predicted group attendance and participation. Greater variations in the alliance overtime for the clients were somewhat linked to worse negative symptoms at post-therapy. Alliance ratings were generally high and fairly concordant between therapists and clients. Only the baseline measure of capacity for attachment, predicted the client’s overall alliance scores. Clinical implications are discussed.     

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.     

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.     

Examining the Relation Between Technical and Global Competence in Two Treatments for Youth Anxiety

Although technical (quality of delivering techniques from a specific treatment) and global (general clinical expertise) competence are believed to be important ingredients of successful psychosocial treatment with youth, there have been few empirical efforts to measure both dimensions. Efforts to understand the role that each competence dimension plays in the process and outcome of youth treatment starts with determining whether the dimensions can be measured separately. This study examined whether scores from measures designed to assess technical and global competence were distinct. Treatment sessions (N = 603) from 38 youths (M age = 9.84 years, SD = 1.65; 60.5% White; 52.6% male) treated for primary anxiety problems within a randomized effectiveness trial were coded. Four coders used observational measures designed to assess technical competence, global competence, protocol adherence, and the alliance. Mean item interrater reliability was .70 (SD = .09) for technical competence and .66 (SD = .05) for global competence. While most components of global competence were distinct from technical competence scores, two components showed redundancy (r > .70). Scores on both competence measures were empirically distinct (r < .70) from scores on measures of protocol adherence and the alliance. Although the measures did not fully distinguish between technical and global competence, our findings do indicate that some components of technical and global competence may provide unique information about competence.     

Cognitive errors,coping patterns,and the therapeutic alliance: A pilot study of in‐session process

Aim: This exploratory study examined the association between clients’ assessment of the therapeutic alliance and their cognitive errors (CE) and coping action patterns (CAP). Method: Selected therapy sessions of clients (N = 26) were rated for cognitive errors and coping action patterns using the CERS and CAPRS methods (Drapeau, Perry, & Dunkley, 2008; Perry, Drapeau, & Dunkley, 2005). The therapeutic alliance was assessed using the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Results: Following Bonferroni corrections, no significant relationship was found between clients’ CEs and their ratings of the WAI. However, the ‘Negotiation’ CAP was associated with the total alliance score, and with the Task and Goal subscales. Implications: A better understanding of the cognitive processes presented by clients in session can enable clinicians to address these factors early on when the alliance is most critical.     

A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD

While cognitive processing therapy (CPT) is an effective evidence-based treatment for many veterans with military-related post-traumatic stress disorder (PTSD), not all veterans experience therapeutic benefit. To account for the discrepancy in outcomes, researchers have investigated patient- and research design-related factors; however, therapist factors (e.g. fidelity) have received less attention. The present study is a preliminary examination of the effect of psychotherapists’ fidelity during CPT on clinical outcomes during a randomized clinical trial (RCT) for military sexual trauma-related PTSD. PTSD symptoms, trauma-related negative cognitions (NCs), and depression symptoms were assessed for 72 participants at baseline, and 1-week, 2-month, 4-month, and 6-month posttreatment. Of the four CPT therapists, two were found to have significantly poorer (i.e. “below average”) treatment fidelity scores compared to the other two therapists who had “good” treatment fidelity scores. To examine possible therapist effects on outcomes, hierarchical linear modeling was utilized with therapist fidelity entered as a Level 2 predictor. Participants treated by a therapist with “good” treatment fidelity experienced significantly greater reductions in PTSD symptoms, NCs, and depression symptoms than patients treated by a therapist with “below average” treatment fidelity. Our preliminary findings highlight the importance of monitoring, maintaining, and reporting fidelity in psychotherapy treatment RCTs.