The Alliance-Outcome Association in Couple Therapy: A Common Fate Model.

The working alliance has been shown to be a robust predictor of couple therapy outcomes. However, there are still questions regarding the best way to conceptualize and analyze the association between the alliance and outcomes in the couple therapy context. This study presents results from a relatively novel analytic approach for evaluating the alliance and therapy outcomes via the shared influence model (i.e., common fate statistical methodology) with 93 couples who had at least three sessions. Examining the alliance in couple therapy this way allows for nuance in conceptualizing the process of the alliance among partners and the therapist in couple therapy. Empirically, the question that remains is whether the shared experience of the alliance between partners is a stronger predictor of therapy outcome as compared to the unique individual experiences of the alliance. This approach has not yet been utilized to model the couple alliance-outcome association. Results revealed that the shared influence model demonstrated a significant association between the alliance and therapy outcome. Specifically, the couple-level alliance construct was adequately represented from the partners' alliance ratings with the therapist, and couples that report higher shared alliance experiences were also likely to have better therapy outcomes. These findings suggest that conceptualizing and analyzing the alliance at the couple level may be strongly advantageous. Implications for research and practice are provided.

Se ha demostrado que la alianza terapéutica es un predictor fiable de los resultados de la terapia de pareja. Sin embargo, aún quedan preguntas con respecto a la mejor manera de conceptualizar y analizar la asociación entre la alianza y los resultados en el contexto de la terapia de pareja. Este estudio presenta resultados de un enfoque analítico relativamente innovador para evaluar la alianza y los resultados de la terapia mediante el modelo de influencia compartida (p. ej.: metodología estadística del destino común) con 93 parejas que tuvieron al menos tres sesiones. Analizar la alianza en la terapia de pareja de esta manera permite matices a la hora de conceptualizar el proceso de la alianza entre los integrantes de la pareja y el terapeuta en la terapia de pareja. Empíricamente, la pregunta que queda pendiente es si la experiencia compartida de la alianza entre los integrantes de la pareja es un predictor más fiable de los resultados de la terapia en comparación con las experiencias individuales únicas de la alianza. Este enfoque aún no se ha utilizado para interpretar la asociación entre la alianza de la pareja y los resultados. Los resultados revelaron que el modelo de influencia compartida demostró una asociación significativa entre la alianza y los resultados de la terapia. Específicamente, el constructo de la alianza a nivel de la pareja se representó adecuadamente a partir de las valoraciones de la alianza de los integrantes de la pareja con el terapeuta, y las parejas que informan más experiencias de alianza compartida también fueron propensas a tener mejores resultados en la terapia. Estos datos sugieren que puede ser enormemente ventajoso conceptualizar y analizar la alianza a nivel de la pareja. Se explican las consecuencias para la investigación y la práctica.

Effect size calculations for the clinician: methods and comparability.

OBJECTIVE: The measurement of clinical change via single-group pre-post effect size has become increasingly common in psychotherapy settings that collect practice-based evidence and engage in feedback-informed treatment. Different methods of calculating effect size for the same sample of clients and the same measure can lead to wide-ranging results, reducing interpretability. METHOD: Effect sizes from therapists-including those drawn from a large web-based database of practicing clinicians-were calculated using nine different methods. RESULTS: The resulting effect sizes varied significantly depending on the method employed. Differences between measurement methods routinely exceeded 0.40 for individual therapists. CONCLUSIONS: Three methods for calculating effect sizes are recommended for moderating these differences, including two equations that show promise as valid and practical methods for use by clinicians in professional practice.

The working alliance in treatment of military adolescents.

OBJECTIVE: Although the working alliance-outcome association is well-established for adults, the working alliance has accounted for 1% of the variance in adolescent therapy outcomes. How the working alliance unfolds in therapy and is modeled in therapy studies may substantially affect how much variance is attributed to the working alliance. METHOD: The sample included 2,990 military youth who were treated by 98 therapists and attended at least 8 therapy sessions. The average age was 14.91 years (SD = 1.79). Each session, clients completed the Outcome Rating Scale as a measure of psychological well-being/distress and the Session Rating Scale as a measure of working alliance. We utilized 3 models to examine the working alliance-outcome association in therapy: (a) mono-method model (i.e., 1 rating of working alliance correlated with outcomes), (b) aggregate-assessment model (i.e., multiple sessions aggregated and correlated with outcomes), and (c) change-based model (i.e., changes in working alliance scores correlated with outcomes). RESULTS: Findings supported the change-based model. The amount of variance explained in youth outcomes via growth in working alliance scores in the change-based model was approximately 9.8%, which suggests that a key mechanism of client-perceived change for adolescents in therapy may be the continual development of the working alliance over the course of treatment. CONCLUSIONS: The monitoring of and continual promotion of the working alliance among military youth in the early phases of therapy may help therapists improve treatment outcomes.

Beyond measures and monitoring: Realizing the potential of feedback-informed treatment.

More than a dozen randomized controlled trials and several meta-analyses have provided strong empirical support for routine outcome monitoring (ROM) in clinical practice. Despite current enthusiasm, advances in implementation, and the growing belief among some proponents and policymakers that ROM represents a major revolution in the practice of psychotherapy, other research has suggested that the focus on measurement and monitoring is in danger of missing the point. Any clinical tool or technology is only as good as the therapist who uses it. Failing to attend to the therapist's contribution, the long neglected variable in psychotherapy outcome, ensures that efforts to create, research, and refine new outcome measurement systems will inevitably fall short. Research from the field of expertise and expert performance provides guidance for realizing the full potential of ROM.

The role of deliberate practice in the development of highly effective psychotherapists.

Little empirical research exists about highly effective psychotherapists, and none about the factors that mediate the acquisition and maintenance of superior performance skills (e.g., Ericsson, 1996, 2006; Ericsson, Krampe, & Tesch-Romer, 1993). In the full sample, a 3-level multilevel modeling (Level 1: clients; Level 2: therapists; Level 3: organization types) of practitioner outcomes was used to examine the contribution of the therapist to treatment effectiveness. Consistent with prior research, in the full sample (n = 69 therapists; n = 4,580 clients) it was found that therapist effects explained 5.1% of the variance in outcome, after adjusting for initial severity. Therapist gender, caseload, and age were not found to be significant predictors. In a subsample of therapists, the relationship between outcome and therapist demographic variables, professional development activities, and work practices was analyzed (n = 17 therapists, n = 1,632 clients). Therapist characteristics (e.g., years of experience, gender, age, profession, highest qualification, caseload, degree of theoretical integration) did not significantly predict client-reported outcomes. Consistent with the literature on expertise and expert performance, the amount of time spent targeted at improving therapeutic skills was a significant predictor of client outcomes. Further, highly effective therapists indicated requiring more effort in reviewing therapy recordings alone than did the rest of the cohort. Caveats and implications for clinical practice, continuing professional development, and training are discussed.

The outcome of psychotherapy: yesterday, today, and tomorrow.

In 1963, the first issue of the journal Psychotherapy appeared. Responding to findings reported in a previous publication by Eysenck (1952), Strupp wrote of the "staggering research problems" (p. 2) confronting the field and the necessity of conducting "properly planned an executed experimental studies" to resolve questions about the process and outcome of psychotherapy. Today, both the efficacy and effectiveness of psychotherapy has been well established. Despite the consistent findings substantiating the field's worth, a significant question remains the subject of debate: how does psychotherapy work? On this subject, debate continues to divide the profession. In this paper, a "way out" is proposed informed by research on the therapist's contribution to treatment outcome and findings from studies on the acquisition of expertise.