The role of the therapeutic relationship in the association between interpersonal behaviors and outcome: Comparison of two competing models.

Objective: The patient-therapist relationship may be the mechanism behind the effect of pretreatment interpersonal patient behaviors on the outcome of psychotherapy for depression, or the factor determining for whom interpersonal behaviors affect outcome. We seek to establish which of these two alternatives receives empirical support. Method: We conducted a secondary analysis of the findings from the Treatment for Depression Collaborative Research Program to examine two alternative models. First, a deterministic model, in which clients' ability to create satisfactory interpersonal relationships affects their ability to build a strong therapeutic relationship, which in turn affects outcome; and second, a compensation model, in which patients in a treatment focusing on interpersonal mechanisms of change and not in placebo, who compensate for their maladaptive pretreatment interpersonal behaviors by building a strong therapeutic relationship, benefit from treatment more than do patients who cannot build such relationship. Results: The compensation, rather than the deterministic model, was supported, suggesting that the interpersonal behavior-outcome association is significantly moderated by the therapeutic relationship in interpersonal psychotherapy and not in placebo. Conclusions: Findings support an optimistic view whereby patients seeking treatment for maladaptive interpersonal behaviors can achieve good outcomes if work on interpersonal relationships is conducted in the presence of a strong therapeutic relationship. Clinical or methodological significance of this article: This study highlights an important optimistic view in which patients with maladaptive interpersonal style who can form a strong therapeutic relationship can benefit from treatment focusing on interpersonal relationships.

If you believe that breaking is possible, believe also that fixing is possible: a framework for ruptures and repairs in child psychotherapy.

Safran and Muran's classic theoretical framework of alliance rupture and repair suggests effective techniques for repairing alliance ruptures. Accumulating empirical evidence suggests that successful processes of rupture and repair result in better therapeutic outcome and reduced dropout rates. Although ruptures in the alliance in child psychotherapy are frequent, little is known about how to repair them. The present paper proposes a model for identifying and repairing ruptures in child psychotherapy based on Safran and Muran. It consists of four phases: i) identifying the rupture and understanding its underlying communication message, ii) indicating the presence of the rupture, iii) accepting responsibility over the therapists' part in the rupture and emphasizing the children's active role as communicators of their distress, and iv) resolving the rupture using change strategies and meta-communication by constructing a narrative story. The theoretical rationale of each phase is explained in detail, and practical clinical guidelines are provided. Empirical studies are needed to examine the effectiveness of the proposed framework.

Identifying the most suitable treatment for depression based on patients' attachment: study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments.

BACKGROUND: In the absence of one intervention that can cure all patients with major depressive disorder (MDD), the leading cause of disability worldwide, increased attention has been focused on selecting the best treatment based on patient characteristics. Theory-driven hypotheses for selecting the best treatments have not yet been adequately investigated. The present study tested the a priory hypothesis that attachment orientations may determine whether patients benefit more from a treatment where alliance provides a facilitative environment for the treatment to work, as in the case of supportive-expressive psychotherapy, vs. where alliance is conceptualized as an active ingredient in itself, as in the case of supportive psychotherapy. METHOD/DESIGN: To test the hypothesis that attachment orientation moderates the effect of treatment condition on outcome, we conduct a randomized controlled trial (RCT). One hundred patients are randomized to 16 sessions of either supportive-expressive or supportive psychotherapy for MDD, conducted by experienced psychologists. The primary outcome is change in the Hamilton Rating Scale for Depression. Secondary outcome measures include self-reported depressive and other symptoms, psychological and interpersonal functioning, quality of life, and the presence of the diagnosis of depression. Additional measures include hormonal levels, motion synchrony, and acoustic attributes, performance on cognitive tasks, and narrative material (collected from the sessions and from interviews). DISCUSSION: The RCT will expand our understanding of how the outcome of treatment can be optimized by identifying the most promising role of alliance in treatment, based on patients' pre-treatment attachment orientation. Results will contribute to the ongoing theoretical debate concerning the differential efficacy of various psychotherapeutic approaches for patients with different attachment orientations. The RCT will also contribute to progress toward personalized treatment by informing therapists about which of two approaches are most effective with patients based on their attachment styles. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02728557 submitted on the 15.3.16. FUNDING: The Israel Science Foundation. Trial status: Recruitment is ongoing.

The Development of the Working Alliance and Its Ability to Predict Outcome in Emotion-Focused Therapy for Social Anxiety Disorder.

The study focuses on the alliance of 12 patients receiving emotion-focused therapy for social anxiety. Anxiety symptoms and patient perception of the working alliance were examined weekly. The first eight sessions of each patient were coded for within- and between-sessions alliance levels (1008 segments were coded). At the sample level, the alliance shows linear development over time but high variability between individuals. More than half the patients showed alliance development consistent with the rupture-resolution pattern. Without accounting for the temporal relationship between alliance and symptoms, alliance significantly predicted symptoms across treatment. When we accounted for the temporal relationship between alliance and symptoms, we found that symptoms can predict alliance but alliance cannot predict symptoms. We obtained the same findings using patient-rated and coded alliance.

The Process of Change in Ethnic Minority Males Undergoing Psychodynamic Psychotherapy: A detailed comparison of two cases.

OBJECTIVE: Better understanding of the connection between therapeutic processes and outcomes in minority groups can help design and use culturally-adapted treatments. METHOD: To explore the active ingredient in the therapeutic process, the present case study compared two ethnic minority male clients, recruited as part of a randomized controlled trial (RCT), one with a good outcome, the other with a poor one. The 12-item Working Alliance Inventory-Observer (S-WAI-O) coding system was used to capture the process of change, alongside a qualitative analysis of content. The cases were identified based on their change in pre- to post-treatment scores on the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD). RESULTS: The findings suggest a rupture-resolution process in the good outcome case, including a process of negotiation of the alliance and work on issues of trust. In contrast, the poor outcome case showed strong and steady alliance, but context analysis pointed to withdrawal ruptures. CONCLUSIONS: Although it is difficult to generalize from a two-case study analysis, the present work suggests that building and negotiating alliance with minority clients has a potential for treatment success.

Patient demographics and psychological functioning as predictors of unilateral termination of psychodynamic therapy.

Approximately one in five patients drops out of treatment before its completion. Little is known about consistent predictors of dropout, and most studies focus on patients' demographic characteristics. A mass of information is collected daily at intake in clinical practice. Based on psychodynamic theoretical conceptualizations and accumulative clinical experience, this information may help predict dropout, and thereby expand the empirically based predictors of dropout. OBJECTIVE: The present study aims at bridging between scientific research and clinical practice by investigating potential predictors of unilateral termination collected at intake, before therapy, in addition to predictors already identified in the literature. METHOD: The study was based on data from 413 patients from a university consulting center. Each patient completed a pre-intake questionnaire collecting demographic information, and underwent an interview conducted by a professional intaker. RESULTS: Results indicate that the consistent predictors described in the literature, education, and age, were related to unilateral termination rates. Additionally, lower intrapsychic functionality, as evaluated by the intakers, was also found to contribute uniquely to higher unilateral termination rates. CONCLUSION: This finding attests to the unique value of professional evaluations of patients' intrapsychic functionality, frequently conducted in clinical practice, to detect patients at risk of unilateral termination of treatment.

Changes in causal attributions and relationship representations: Are they specific or common mechanisms in the treatment of depression?

BACKGROUND: The goal of the study was to examine two central theory-driven mechanisms of change, causal attributions and relational representations, to account for symptomatic improvement in psychodynamic treatment and supportive clinical management, combined with either pharmacotherapy or placebo, in a randomized control trial (RCT) for depression. METHOD: We used data from an RCT for depression, which reported non-significant differences in outcome among patients (N=149) who received supportive-expressive psychotherapy (SET), clinical management combined with pharmacotherapy (CM+MED), or clinical management with placebo pill (CM+PBO) (Barber et al., 2012). Mechanism and outcome measures were administered at intake, mid-treatment, end of treatment, and at a 4-month follow-up. RESULTS: Improvements in causal attributions and in relational representations were found across treatments. Changes in causal attributions did not predict subsequent symptomatic level when controlling for prior symptomatic level. In contrast, decrease in negative relational representations predicted subsequent symptom reduction across all treatments, and increase in positive relational representations predicted subsequent symptom reduction only in SET. LIMITATIONS: The study is limited by its moderate sample size. Additional studies are needed to examine the same questions using additional treatment orientations, such as cognitive treatments. CONCLUSIONS: Findings demonstrate that changes in negative relational representations may act as a common mechanism of change and precede symptom reduction across psychodynamic therapy and supportive case management combined with either pharmacotherapy or placebo, whereas an increase in positive relational representation may be a mechanism of change specific to psychodynamic therapy.