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Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325.

The therapeutic alliance is often defined as the agreement between the client and therapist on the goals and tasks of treatment within the context of an affective bond. The alliance is associated with good treatment outcomes regardless of how it is measured, who measures it, when it is measured, and what type of therapy is offered. But researchers and theorists debate the causal role of the alliance in therapy. Is the therapeutic alliance simply a byproduct of an effective treatment (i.e. people begin feel better in therapy and therefore experience a better alliance)? Or is the alliance a client trait which is a necessary factor that enables effective treatments to work (i.e., some clients are better at developing an alliance which is required for therapeutic interventions to take hold). Or is the alliance a state-like factor that fluctuates over time and is therapeutic in and of itself (i.e., the growth in the alliance by itself is sufficient to induce symptom change). In this review of recent advanced methods to research the alliance, Zilcha-Mano provides an overview of statistics that model the session to session dynamic fluctuations and impacts of growth in the therapeutic alliance. She argues convincingly that for the most part, the alliance is not a byproduct of symptom improvement. Using this advanced methodology research indicates that session by session change in symptoms do not precede change in the alliance. The research supporting trait-like aspects of the alliance indicates that some clients are more adept than others at developing an alliance with their therapists. Therefore an early alliance in therapy indicates a client trait that provides a necessary context for effective therapies to do their work. However, research also shows that the alliance changes dynamically over the course of treatment, and that change in the alliance from a preceding session predicts change in symptoms in subsequent sessions. This indicates that alliance also has state-like elements that dynamically fluctuate and influence outcomes, which provides evidence that this aspect of the alliance is therapeutic in and of itself.

Practice Implications

The accumulating research evidence indicate that the therapeutic alliance is a key aspect of successful therapies. New research is showing how to best manage the alliance, like how to repair alliance ruptures. The research also indicates that the role of the alliance may differ according to client characteristics. Those clients who arrive for treatment with better trait-like characteristics (more adaptive representations of self, more adaptive relationships with others) may be better able to create a strong alliance early. For these clients, the alliance may not be highly therapeutic in itself, but rather set the context for therapy interventions to work. However, some clients find it difficult to maintain satisfying relationships with others including the therapist. For these clients, state-like changes in the alliance may be essential for treatment – that is, developing a strong alliance over the course of treatment may be therapeutic in itself to improve their interpersonal relationships outside of therapy.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270-277.

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel discuss the importance of client expectations on psychotherapy outcomes. In particular, they equate client expectations with the placebo effect. In the July, 2015 PPRNet blog, I discussed Wampold and Imel’s distinction between the Contextual Model of psychotherapy and the Medical Model of psychotherapy. One pathway of the Contextual Model indicates that patients who accept an explanation for their disorder and who agree with therapists about therapy interventions, experience expectations that have a powerful impact on patients’ emotions and cognitions. The placebo effect has long been known to improve patients’ response to medical interventions. The placebo effect is defined as the difference between a supposedly inert event or medication and the natural course of the disorder. By contrast, the specific effect of an intervention or medication (e.g., an antidepressant) is defined as the difference between the medication and the placebo (i.e., the effect of a medication over and above the effect of a placebo). In one important meta analysis, the placebo effect accounted for about 68% of the antidepressants’ impact on depression scores. In other words, the placebo effect (i.e., the expectation of receiving help) has a powerful impact on depression. Generating an expectation of improvement (“this pill is an antidepressant that will reduce your depression”) involves: (1) providing a plausible explanation for the disorder (“depression is biochemical imbalance, and this pill [actually an inert placebo] will help”), and (2) having a relationship with an empathic provider. Client expectations of improvement result in mental health outcomes that approach the effects of standard medical treatment for depression. In psychotherapy, creating expectations about the effectiveness of the intervention, providing an explanation of the disorder based on psychological and biological theories, and agreeing on the tasks and goals of therapy are an integral part of the treatment. In other words, the placebo response is part of what makes psychotherapy work, and good therapists capitalize on its effects.

Practice Implications

Patient expectations about the effectiveness of the therapy, their agreement with the therapist on the tasks and goals of therapy, and the therapist’s empathy toward the patient are key aspects that will increase the effectiveness of a therapeutic intervention. The explanation of the disorder and the treatment approach are embedded in psychological theories that typically underpin evidence-based psychotherapies.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, you can read the Handbook table of content and sections of the book on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client attachment. This month I focus on other factors like severity of distress and comorbidity, and level of motivation. Some authors argue that client factors predict 30% of variance in outcomes. That accounts for more of psychotherapy outcome than therapist effects and therapeutic techniques combined. Severity of symptoms of anxiety and depression and functional impairment caused by this distress leads to poorer client prognosis. Further, individuals with more severe symptoms need more sessions to show improvement. Some research shows that those with greater symptoms change more than those with fewer symptoms. However, even though those with higher levels of distress show the most change, they are less likely to achieve recovery in which they return to a normal level of functioning. In most cases, clients with comorbid problems are less likely to do well. For example, comorbidity for personality disorder or substance abuse negatively impact outcome. Client motivation is also related to psychotherapy outcomes. Motivation can be internal (those that arise from the individual’s intrinsic interests or values) or external (those that arise from external rewards or punishments). Generally, internal motives (i.e., greater readiness to change) are better predictors of sustained behaviour change. The stages of change model describes readiness to change as occurring in progressive stages that include: (1) precontemplation, in which clients are not internally motivated; (2) contemplation in which clients move to the next stage where they recognize a problem but are not ready to take action; and (3) preparation for action in which clients are more internally motivated to change. The next two stages of the model do not speak to motivation but to action and maintenance of change. Norcross looked at clients’ readiness to change prior to therapy and its relationship to outcome. Greater readiness to change was moderately and significantly associated with better treatment outcomes.

Practice Implications

The results on severity and comorbidity suggest that providers and policy makers must consider increasing the number of treatment sessions to take into account clients who have greater initial severity and comorbidities, especially for those with comorbid personality disorders. Results related to motivation indicate that when client motivation to work in therapy comes from within and they show progress in their readiness to change, they are more likely to do well. Therapists need to find ways of mobilizing clients’ internal reasons for change. Motivational interviewing may be one means of doing so.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Some authors argue that client factors account for 30% of variance in outcomes. That represents a greater association to psychotherapy outcome than therapist effects and therapeutic techniques combined. In this part of the Handbook chapter on client factors, Bohart and Wade discuss client attachment. Bowlby found that attachment relationships were important and were different from other relationships. Attachment figures confer a sense of security and safety to infants that allow children to explore their environment and experience the self. Attachment patterns that develop in childhood tend to be stable throughout the lifespan, but attachment style can change with positive (i.e., psychotherapy, romantic relationships) and negative (i.e., traumatic events) experiences. Attachment security is associated with adaptive affect regulation, positive view of self and others, and reflective functioning that is related to mentalizing. Attachment anxiety is associated with maladaptive up-regulation of emotions, positive view of others but negative view of self, and reduced reflective functioning likely due to preoccupation with relationships and emotion dysregulation. Attachment avoidance is associated with maladaptive down-regulation of emotions, negative view of others and positive view of self (or negative view of others and negative view of self in the case of fearful avoidant attachment), and limited reflective functioning due to dismissing of emotions and relationships. There are also disorganized attachment states related to traumatic events. Those with attachment avoidance tend to be distrustful and less likely to seek psychotherapy. A meta-analysis by Levy and colleagues (2011) of 19 studies including 1467 clients found that attachment security was associated with good psychotherapy outcomes and attachment anxiety was negatively associated with good outcomes. No relationship was found for attachment avoidance and outcomes. Diener and Monroe (2011) conducted a separate meta analysis on attachment and therapeutic alliance which included 17 studies with 886 clients. They found that clients with secure attachments had better alliances with their therapist and those with insecure attachments (anxious or avoidant) had weaker alliances.

Practice Implications

The research is clear that client attachment style influences how clients enter therapy, engage with the therapist, and experience outcomes. Attachment style likely affects specific therapy behaviors like self-disclosure and amount of exploration. In his book Attachment and Psychotherapy, David Wallin (2007) translates attachment theory into a framework for adult psychotherapy by tailoring interventions to specific attachment styles. For example, clients with greater attachment anxiety may do better in psychotherapy when the therapist: helps with down regulation of client emotional experiences, behaves in a way that does not evoke client fears of abandonment or loss, and helps clients improve reflective functioning by encouraging a thoughtful appraisal of their behaviors. On the other hand clients with greater attachment avoidance may require a therapist who: slowly introduces the client to greater attention to emotional experiences, does not demand too much from the client in terms of closeness in therapy at the outset, and encourages reflective functioning by helping the client understand the association between defensive avoidance of affect and relationship problems.