The Impact of Patients' and Therapists' Views of the Therapeutic Alliance on Treatment Outcome in Psychotherapy.

This article reports about the role of psychotherapists in creating a good enough therapeutic alliance as the basic task for other therapeutic factors come into play. Data from a naturalistic study involving 237 patients treated by 68 psychotherapists using 10 different psychotherapy approaches were analyzed in a process-outcome research design. The results show that therapists had to adapt their alliance perspectives to patients' level of alliance ratings as treatments progressed. Treatment concepts did not play a role in outcome. The view of a similar quality of the therapeutic alliance seems to be an indispensable precondition for favorable treatment outcomes. Successful treatments were conducted more often by therapists who showed significant convergence of alliance ratings over time, whereas discrepant alliance ratings correlated significantly with unsuccessful treatments.

Effects of sex and gender in ten types of psychotherapy.

OBJECTIVE: This paper addresses the results of two samples of a large naturalistic (effectiveness study) outpatient process-outcome study in Switzerland (Practice-Oriented Outpatient Psychotherapy Study). Ten different types of psychotherapy were investigated by looking at the role of the sex or gender of therapists and patients with regard to treatment outcome by including several nonspecific therapeutic factors. METHOD: Ten different types of psychotherapy, 237 patients, and 68 therapists were included in the study. A subsample of 116 cases was analyzed with regard to therapists' technical interventions. RESULTS: Sex and gender issues of both therapists and patients did not play a crucial role in any type of psychotherapy investigated. Gender issues appeared to play an indirect role. Female therapists intervene more empathically, whereas male therapists tend to use more confrontational techniques. CONCLUSIONS: Since the results show that therapists differ substantially with regard to their intervention techniques due to their sex, they should become more conscious of their interventions by considering patients' severity of psychological problems and patients' level of psychological functioning so as to not over or underchallenge them.

The role of therapists' treatment adherence, professional experience, therapeutic alliance, and clients' severity of psychological problems: Prediction of treatment outcome in eight different psychotherapy approaches. Preliminary results of a naturalistic study.

In this naturalistic study, 262 audiotaped psychotherapy sessions--randomly drawn from 81 individual therapies from eight different psychotherapy approaches--were rated completely on treatment adherence using a newly developed rating manual. In the therapy sessions, a relatively low percentage of treatment specific interventions (ranging from 4.2% to 27.8%) was found for all eight approaches, 50% to 73% of the interventions were nonspecific or common, and approximately 18% to 27% were intervention techniques from other approaches. Different types of psychotherapy differed highly significantly in levels of treatment adherence. There was no statistically significant association between the type of psychotherapy and its outcome, or between the degree of therapists' treatment fidelity and the treatment outcome. However, there were significant associations between therapists' degree of professional experience, clients' initial psychological burden, and treatment response. Clients' severity of psychological problems prior to treatment predicted quality of therapeutic alliance while therapists' treatment adherence was predicted by therapists' professional experience and by the quality of the therapeutic alliance. We discuss the seemingly indirect importance of treatment adherence for psychotherapy outcome that we found in this study in relation to findings from other studies and in the context of the role of schools within psychotherapy.

The Brief Symptom Inventory and the Outcome Questionnaire-45 in the Assessment of the Outcome Quality of Mental Health Interventions.

Self-report questionnaires are economical instruments for routine outcome assessment. In this study, the performance of the German version of the Outcome Questionnaire-45 (OQ-45) and the Brief Symptom Inventory (BSI) was evaluated when applied in analysis of the outcome quality of psychiatric and psychotherapeutic interventions. Pre-post data from two inpatient samples (N = 5711) and one outpatient sample (N = 239) were analyzed. Critical differences (reliable change index) and cut-off points between functional and dysfunctional populations were calculated using the Jacobson and Truax method of calculating clinical significance. Overall, the results indicated that the BSI was more accurate than the OQ-45 in correctly classifying patients as clinical subjects. Nonetheless, even with the BSI, about 25% of inpatients with schizophrenia attained a score at admission below the clinical cut-off. Both questionnaires exhibited the highest sensitivity to psychopathology with patients with personality disorders. When considering the differences in the prescores, both questionnaires showed the same sensitivity to change. The advantage of using these self-report measures is observed primarily in assessing outpatient psychotherapy outcome. In an inpatient setting two main problems-namely, the low response rate and the scarce sensitivity to psychopathology with severely ill patients-limit the usability of self-report questionnaires.

Sensitivity analysis in multiple imputation in effectiveness studies of psychotherapy.

The importance of preventing and treating incomplete data in effectiveness studies is nowadays emphasized. However, most of the publications focus on randomized clinical trials (RCT). One flexible technique for statistical inference with missing data is multiple imputation (MI). Since methods such as MI rely on the assumption of missing data being at random (MAR), a sensitivity analysis for testing the robustness against departures from this assumption is required. In this paper we present a sensitivity analysis technique based on posterior predictive checking, which takes into consideration the concept of clinical significance used in the evaluation of intra-individual changes. We demonstrate the possibilities this technique can offer with the example of irregular longitudinal data collected with the Outcome Questionnaire-45 (OQ-45) and the Helping Alliance Questionnaire (HAQ) in a sample of 260 outpatients. The sensitivity analysis can be used to (1) quantify the degree of bias introduced by missing not at random data (MNAR) in a worst reasonable case scenario, (2) compare the performance of different analysis methods for dealing with missing data, or (3) detect the influence of possible violations to the model assumptions (e.g., lack of normality). Moreover, our analysis showed that ratings from the patient's and therapist's version of the HAQ could significantly improve the predictive value of the routine outcome monitoring based on the OQ-45. Since analysis dropouts always occur, repeated measurements with the OQ-45 and the HAQ analyzed with MI are useful to improve the accuracy of outcome estimates in quality assurance assessments and non-randomized effectiveness studies in the field of outpatient psychotherapy.