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Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341-355.

Over the past decades there has been increasing research on the efficacy of psychotherapy for children and adolescents, but outcomes have not always been positive. Treatment of children and adolescents comes with challenges that are unique from those experienced in therapy of adults. For example, unlike most adults, children and adolescents may not be the ones to choose to attend therapy - that decision is often made by adults in their lives. Furthermore, psychotherapists must also develop and maintain a collaborative relationship with parents, on whom the therapist and child/adolescent rely in order to be able to engage in treatment. Because of the unique characteristics of working with children and adolescents, negotiating, developing, maintaining, and repairing the therapeutic alliance is potentially complex. The therapeutic alliance is defined as an agreement on tasks of therapy, an agreement on goals of therapy, and the relational bond between therapist and client. In this meta-analysis, Karver and colleagues reviewed 28 studies of psychotherapy with children and adolescents. The mean age was about 12 years, most children/adolescents had internalizing problems, but others had problems with externalizing behaviors, and substance abuse. Almost two thirds of the studies involved a version of behavior or cognitive behavioral therapy. The therapeutic alliance was measured from the perspective of the client, therapist, and/or the parent. The overall mean effect size of the alliance-outcome relationship was small to moderate: r = .19 (p < .01, 95% confidence interval [CI] [0.13, 0.25]). Larger effect sizes were seen in those therapies of children and adolescents with internalizing disorders (r = .19), and when the therapist – parent alliance was measured and correlated with outcomes (r = .30). In other words, a positive alliance was most important for internalizing disorders, and for the relationship between therapist and parent.

Practice Implications

The findings of this meta-analysis indicate that the therapeutic alliance, especially with the parent, is important to the outcomes of children and adolescents in psychotherapy. Clinicians should not only develop an alliance with the youth, but also with the parent/caregiver. Therapists should also consider measuring the alliance regularly during therapy as a means of heading off any ruptures (with the youth or the parent) that might endanger the therapy. The authors recommended using the Therapeutic Alliance Scale for Children – Revised with children/adolescents, and the Working Alliance Inventory with parents.

Hill, C. E., Knox, S., & Pinto-Coelho, K. G. (2018). Therapist self-disclosure and immediacy: A qualitative meta-analysis. Psychotherapy, 55(4), 445-460.

Different writers and theorists in psychotherapy have disagreed on the need for or the wisdom of therapists disclosing about themselves during therapy. Recently, however, both humanistic therapists and some psychodynamic therapists tend to see therapist self-disclosure or immediate discussion of the therapeutic relationship more positively. Therapist self-disclosure is a therapist statement that reveals something personal about the therapist (“That makes me angry too”). On the other hand, immediacy refers to comments about and processing the therapeutic relationship by client and therapist in the here and now (“You said that people inevitably let you down, I wonder if you expect that I will let you down too”). Immediacy, also known as metacommunication, is particularly useful to address therapeutic alliance ruptures. In this qualitative meta-analysis, Hill and colleagues (2018) examined research that studied the effects of therapist disclosures and immediacy on subsequent client processes right after the disclosure or immediacy occurred. The authors included in their review 21 studies with a total sample of 184 cases. Five studies with 99 cases looked specifically at the effect of therapist disclosure. Therapist self-disclosure occurred relatively infrequently in 0% to 4% of all therapist responses. The most frequently occurring subsequent processes after therapist disclosure included an enhanced therapy relationship (reported in 64% of studies), greater client insight (reported in 46% of studies), and improved client mental health (reported in 45% of studies). Negative effects of therapist disclosure included negative client feelings or reactions (reported in 30% of studies) and impaired therapeutic relationship (reported in 16% of studies). Fifteen studies with 78 cases looked specifically at immediacy. Therapists used immediacy more extensively in between 12% to 38% of cases. The most frequently occurring subsequent processes following immediacy included an enhanced therapy relationship (reported in 40% of studies), and increased client self-disclosure (reported in 40% of studies). Negative effects of immediacy included a negative impact for the therapist (reported in 11% of studies) that referred to a heightened sense of therapist vulnerability.

Practice Implications

Reviews and theoretical guidelines stress that therapists should sparingly and deliberately use self-disclosure and immediacy. In fact, this review by Hill and colleagues indicated that therapist self-disclosure is relatively rare, whereas immediacy might be more common. Therapists might consider self-disclosure when the client is feeling alone and in need of support. But, as Hill and colleagues indicate, therapists must be thoughtful and strategic about self-disclosure, therapists should disclose only personally resolved material, and therapists must focus their disclosures exclusively on the client’s needs. On the other hand, immediacy may be a useful strategy to negotiate and address problems in the therapeutic relationship by talking about interactions and intentions in the relationship (i.e., metacommunicate about the relationship). Therapists have to consider that immediacy may require lengthy processing, and therapists should be attentive to the role of countertransference and seek consultation in order to be sure to act in the best interest of the client.

Author email: cehill@umd.edu

Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519.

It is difficult to over-state the importance of developing and maintaining a therapeutic alliance in order for patients to experience a good outcome from psychotherapy. The alliance is the collaborative agreement between therapist and patient on the tasks and goals of therapy, and the emotional bond between therapist and patient. A previous meta-analysis found a moderate but highly reliable association between a good alliance and patient outcomes. The alliance is a trans theoretical construct – that is, it is important to all types of therapy regardless of theoretical orientation. Sometimes deteriorations in the alliance occur manifested by a disagreement on the goals, a lack of collaboration on the tasks, or a strain in the relational bond. Other terms for this phenomenon include weakenings, misattunements, challenges, resistances, enactments, and impasses. Such deteriorations can vary from minor tensions to major ruptures in the relationship. Tensions and ruptures in the alliance are common occurrences in therapy with some studies showing 50% of therapy cases experience at least a minor tension within the first six sessions of therapy. There are two main types of alliance tensions/ruptures. (1) Withdrawal tensions/ruptures occur when the patient moves away from the therapist, such as when the patient changes the subject, goes silent, and cancels appointments. These tensions/ruptures are more subtle and harder for therapists to detect. (2) Confrontation tensions/ruptures occur when the patient moves against the therapist, such as when the patient expresses dissatisfaction with or pressures or tries to control the therapist. These tensions/ruptures are more obvious, but also difficult for therapists to manage because of the feelings they evoke. In this meta-analysis, Eubanks and colleagues reviewed 11 studies representing 1,314 patients. They found that the association between rupture repair episodes and patient outcomes was on average moderately large r = .29, d = .62, 95% CI [.10, .47], p = .003.

Practice Implications

The research on alliance tensions/ruptures and repairs is still new but points to some important therapist practices that could improve patient outcomes. Therapists must be attuned to indications of tensions and ruptures in the therapeutic relationship. Therapists immediately need to attend to confrontation tensions/ruptures, in which patients express dissatisfaction or hostility. Similarly, therapists must address more subtle withdrawal tensions/ruptures, in which patients go silent, evade, or appease. Therapists can acknowledge the tension/rupture directly and nondefensively by inviting patients to explore their experience of the rupture. If necessary, therapists might change the tasks or goals of the therapy to better match the patient’s concerns. Therapists should empathize with a patient’s negative feelings about the therapy, and validate the patient for bringing up their concerns. If appropriate, therapists should take responsibility for their part in the tension/rupture and not blame the patient. Also, if the tension/rupture is a repetition of an interpersonal pattern for the patient (e.g., the patient tends to withdraw in relationships), then the therapist might consider carefully exploring the tension/rupture as it occurs in the therapy with the understanding that it is a repetitive pattern. Mainly, therapists need to anticipate that tensions and ruptures will occur in therapy, that they can be destabilizing for the therapist and therapeutic relationship, and so therapists need to recognize and know how to explore their own and their patient’s negative feelings.

Author email: catherine.eubanks@einstein.yu.edu

Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372-383.

A key element of the therapeutic alliance is for therapists and clients to collaboratively come to a consensus about what they will work on. Goal consensus is part of the agreement between therapist and client, and in part it defines what will be the tasks of therapy. The tasks of therapy (i.e., what a therapist and client do in therapy to alleviate the problems or address issues) follow from the goals and conceptualization of the problems. At times goal consensus is straight forward. The client wants to feel less depressed and the therapist proposes certain therapeutic actions to help the client to be relieved of their depressive symptoms. However at other times, despite an agreement on the main symptoms, the client may not agree with a therapist’s conceptualization and tasks of therapy. For example, a therapist might believe that the client’s history of abuse and/or their current problem with alcohol may underlie the depression, but the client does not want to address these underlying issues. In such an example, the therapist and client only barely agree on a goal, and may not agree on how to go about alleviating the symptoms. In some cases there is outright disagreement, a misunderstanding, or vagueness about the goals, and so there is no consensus and therefore no basis for a collaboration. Collaboration and goal consensus are pan-theoretical processes that apply to all forms of therapy. However, research in the past decade has focused almost exclusively on behavioral or cognitive therapy studies using homework compliance as the index of collaboration. Tyron and colleagues conducted a meta-analysis of 54 studies of the association between goal consensus and client outcomes and found a moderate and significant correlation, r = .24 with 95% CI [.19, .28]. They also reported similar findings from a meta-analysis of 53 studies of therapist and client goal collaboration and client outcomes, in which they found a moderate and significant effect, r = .29, 95% CI [.24, .34].

Practice Implications

These meta-analyses show a positive link between goal consensus and collaboration with psychotherapy outcomes. Therapists should clarify clients’ goals for therapy, and therapists should share their conceptualization of the clients’ issues or symptoms. This conceptualization will determine to some extent the tasks or methods of therapy. For some clients, this process may take time and require revisiting throughout the course of treatment. Collaborative work to establish the goals and focus of therapy may in and of itself be therapeutic for those clients who have long standing interpersonal problems. Therapists should seek input from clients about the formulation and treatment plans, and be prepared to adjust their intentions according to client preferences. Therapists could invite continuous client feedback about the goals and tasks of therapy and monitor client progress. Then therapists can use this feedback to modify their interpersonal stances and treatment methods.

Author email: gtryon@gc.cuny.edu

Burlingame, G. M., McClendon, D. T., & Yang, C. (2018). Cohesion in group therapy: A meta-analysis. Psychotherapy, 55, 384-398.

Many writers consider group cohesion to be one of the most important concepts in group psychotherapy and that is a pre-requisite for positive patient outcomes. That is, patients in a group must feel a bond with the group and its members, must value the relationships in the group, and must see the group experience as a vehicle by which to achieve the change that they want. As Burlingame once noted, over time cohesion has become synonymous with the therapeutic relationship in group therapy. Although an important concept, cohesion has been elusive to define partly because of the complexity of group therapy itself. From the patient’s point of view, relationships in group therapy can take on three structural aspects in the form of member to member, member to group, and member to leader interactions. And so, cohesion may refer to the quality of the member’s relationship: to other members, to the group as a whole, and/or to the group leader. By “quality of group relationships”, clinicians and researchers often mean the positive affective bond (warmth, empathy, attraction, compatibility, trust) and working relationship (consensus on tasks and goals, willingness to work) that members have with other members, the group as a whole, and/or the group leaders. In this meta-analysis, Burlingame and colleagues identified 55 group therapy studies including over 6,000 patients that investigated the cohesion – outcome relationship. The average correlation of cohesion to patient outcomes in the 55 studies was statistically significant, r = .26 (95% CI [.20, .31], p = .01), suggesting a moderate effect. Leaders who had an interpersonal orientation had the highest cohesion – outcome relationship (r = .48), although leaders of other theoretical orientations also posted statistically significant but lower values. A greater group process orientation (r = .36), emphasizing greater interactions among group members (r = .36), composing groups of members with similar diagnoses or problems (r = .23), and groups lasting more than 20 sessions (r = .41) also each produced significantly higher cohesion – outcome correlations.

Practice Implications

The group cohesion – outcome relationship is highly reliable and suggests that clinicians of all theoretical orientations should routinely assess and enhance group cohesion to improve patient outcomes. Ways of increasing cohesion include emphasizing member to member interactions in a group, and discussing group processes as they occur. These processes may be related to members interacting with other members, with the group as a whole, or with the leader. In particular, group therapists should promote a positive emotional climate by handling conflict and avoidance when it arises in the group. This takes particular skills, training, and knowledge in group therapy processes, and so it is important for therapists to be aware of current practice guidelines for group therapy.

Author email: gary_burlingame@byu.edu

Morales, K., Keum, B. T., Kivlighan, D. M., Jr., Hill, C. E., & Gelso, C. J. (2018). Therapist effects due to client racial/ethnic status when examining linear growth for client- and therapist-rated working alliance and real relationship. Psychotherapy, 55(1), 9-19.

Racial and ethnic minority (REM) clients tend to have less access to health care services, are less likely to seek services for mental illness, and may receive lower quality care. It is also possible that REM clients may be treated differently by psychotherapists, so that REM clients may have a different experience from non-REM clients of the therapeutic alliance (i.e., the collaborative agreement on tasks and goals of therapy, and the bond with the therapist). The alliance is a well-known factor that is related to client outcomes. If there is such a difference in how REM and non-REM clients experience the alliance, it is likely because of the therapist’s ability to establish and grow the alliance. Previous research showed that therapists and not clients are largely responsible for the alliance – outcome association. Research also demonstrated that some therapists are less effective with REM than with non-REM clients, possibly because of the differing experiences of and development of the therapeutic alliance. In this study, Morales and colleagues measured the therapeutic alliance after every session of therapy for 144 clients seen in a counselling center, almost half of whom were REM clients. The clients saw one of 19 therapists, so that each therapist (10 of whom were REM therapists) saw at least two REM and two non-REM clients. So, the researchers were able to see how each therapist developed a therapeutic alliance differently with REM and non-REM clients. The study found that higher therapeutic alliance between therapists and clients early in therapy was associated with clients remaining in therapy longer, and that the therapeutic alliance statistically significantly increased across sessions. However, therapists varied significantly in the alliance growth depending on whether they were treating REM or non-REM clients. Some therapists showed significant growth in the alliance with REM clients but not with non-REM clients, whereas other therapists showed significant growth in the alliance with non-REM but not with REM clients.

Practice Implications

There were significant differences between therapists in how they were able to develop a therapeutic alliance with racial and ethnic minority (REM) clients vs non-REM clients. The authors speculated that this difference might be due to the therapists’ level of multicultural orientation. A multicultural orientation is a way of being with clients that consists of cultural humility, using opportunities to examine culture, and cultural comfort. Having a multicultural orientation likely increases the level of therapeutic alliance and promotes its growth over time. Research shows that a client benefits when the therapist integrates the client’s cultural narrative into the psychotherapy.

Author email: kmorales@umd.edu