Titles were merged in EndNote X,* and sources included books, theses, abstracts , Relation of the therapeutic alliance with outcome and other variables: a. Sep 28, The proposal of a therapeutic alliance characterized by a variable pattern over the . By combining items taken from other scales (VPPS, VTAS, and HAcs) . than the others, in relation to the type of therapy being considered. The importance of the client-therapist relationship has been recognised from the early The findings are discussed in relation to the definition of the therapeutic relationship and to .. therapist. Collaboration is usually defined as a joining of.
The shorter version consists of 12 item. Several studies have demonstrated the predictive validity of this instrument in a variety of treatments Horvath, ; Horvath and Greenberg, ; Howard et al.
California scales Gaston and Marmar, ; Marmar et al. The former derives from the TARS and focuses on the affective and attitudinal aspects of the alliance rather than on specific therapeutic interventions. Each item is rated on a seven-point scale. The TSR is a item structured-response instrument. Most of the item are scored in a binary fashion or on a 0—2 scale. Adequate internal consistency and inter-rater reliability Elvins and Green, ; Kolden, Therapeutic bond scales TBS Saunders et al.
This instrument consists of 50 item belonging to the following dimensions: Altogether, these subscales provide a Global Bond scale. Each item is rated on a point scale. All three scales and the Global Bond scale are related to patient ratings of session quality Martin et al.
The report is filled in by the therapist and consists of six items rated on a five-point scale. Patients also respond to 12 items that rate the level of therapist collaboration.
Alliance as measured by the PSR has been shown to be correlated with outcome in patients with severe and enduring mental illness such as schizophrenia Elvins and Green, ; Svensson and Hansson, The ARM was intended to describe components of the alliance in language designed to be acceptable within a wide range of theoretical orientations and was developed during the Second Sheffield Psychotherapy Project, a randomized comparison of cognitive—behavioural therapy and psychodynamic—interpersonal therapy for depression.
The ARM assesses five dimensions of the alliance: The ARM has five scales comprising 28 items rated on parallel forms by patients and therapists using a seven-point scale. The internal consistency of the Client Initiative scale was low 0. Some aspects of the alliance as measured by the ARM was correlated with psychotherapy outcome Stiles et al.
Kim alliance scale KAS Kim et al. The scale comprises the three dimension of the alliance originally proposed by Bordin plus a fourth dimension: The KAS is a self report measure consisting of item 8 collaboration item, 11 communication item, 5 integration item, and 6 empowerment item each of one rated on a four-point scale.
The alphas for the four dimensions ranged from 0. Highly correlated with the ARM. The scale has not been used in outcome research. Open in a separate window Any attempt to measure something as complex as therapeutic alliance involves a series of conceptual and methodological shortcomings, which have probably hindered the development of research in this field. Single-case research is one method used to investigate this theoretical construct, but implies some methodological drawbacks regarding the simultaneous treatment of several factors, the need for an adequate number of repeated measurements, and the generalizability of results.
Meta-analysis is a possible research strategy that can be used to obtain the combined results of studies on the same topic. However, it is important to remember that meta-analysis is more valid when the effect being investigated is quite specific.
According to Migoneanother hindrance is the so-called Rashomon effect named after the film by Akira Kurosawa: Di Nuovo et al. Though designed by independent research teams, there is often good correlation between the scales used to rate the therapeutic alliance, which reveal that these instruments tend to assess the same underlying process Martin et al.
None of their findings suggest that any one instrument was a stronger predictor of outcome than the others, in relation to the type of therapy being considered. It is interesting to note that although almost all of these scales were originally designed to examine the perspective of only one member of the patient—therapist—observer triad, they were later extended or modified to rate perspectives that were not previously considered.
The number of items included in the scales varies considerably between 6 and itemsas do the dimensions of the alliance investigated e.
According to Martin et al. Different approaches for the evaluation of alliance coexist in group psychotherapy. One of them is derived from individual psychotherapy. Although a comparison between different treatment modalities is a topic beyond the scope of this paper, it is worth noting that in the late s, some authors Marmar et al.
However, subsequently, Raue et al. This latter study compared 57 clients, diagnosed with major depression and receiving either psychodynamic—interpersonal or cognitive—behavioral therapy: They argue that these findings could reflect the effort in cognitive—behavioral therapy to give clients positive experiences and to emphasize positive coping strategies.
A more recent comparison was suggested by Spinhoven et al. Results obtained by evaluating alliance through WAI-Client and WAI-therapist after 3, 15, and 33 months, showed clear alliance differences between treatments, suggesting that the quality of the alliance was affected by the nature of the treatment.
Schema-focused therapy, with its emphasis on a nurturing and supportive attitude of therapist and the aim of developing mutual trust and positive regard, produced a better alliance according to the ratings of both therapists and patients. Ratings by therapists during early treatment, in particular, were predictive of dropout, whereas growth of the therapeutic alliance as experienced by patients during the first part of therapy, was seen to predict subsequent symptom reduction.
Phases of the Alliance during the Therapeutic Process and the Relationship with the Outcome There is much debate on the role of the therapeutic alliance during the psychotherapeutic process. It may in fact be a simple effect of the temporal progression of the therapy rather than an important causal factor. On the basis of this hypothesis, we would expect a development in the alliance to be characterized by a linear growth pattern over the course of the therapy, and alliance ratings obtained in the early phases to be weaker predictors of outcome than those obtained toward the end of the therapy.
However, according to the findings of numerous researchers, this is not the case. Horvath and Marx describe the course of the alliance in successful therapies as a sequence of developments, breaches, and repairs. According to Horvath and Symondsthe extent of the relationship between alliance and outcome was not a direct function of time: The results of these studies have led researchers to consider the existence of two important phases in the alliance.
The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session. During the first phase, adequate levels of collaboration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of confidence in the procedures that constitute the framework of the therapy.
The deterioration in the relationship must be repaired if the therapy is to be successful. This model implies that the alliance can be damaged at various times during the course of therapy and for different reasons. The effect on therapy differs, depending on when the difficulty arises. In this case, the patient may prematurely terminate the therapy contract. According to Safran and Segalmany therapies are characterized by at least one or more ruptures in the alliance during the course of treatment.
Randeau and Wampold analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies.
Although some studies are based on a very limited number of cases, the results appear consistent: While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used static measures of alliance.
There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: Few studies have analyzed alliance at different stages in the treatment process. According to the results proposed by Traceythe more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction high—low—high over the course of treatment.
When the outcome was worse, the curvilinear pattern was weaker. Kivlighan and Shaughnessy use the hierarchical linear modeling method an analysis technique for studying the process of change in studies where measurements are repeated to analyses the development of the alliance in a large number of cases.
According to their findings, some dyads presented the high—low—high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment.
In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development. Kivlighan and Shaughnessy distinguish three patterns of therapeutic alliance development: They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pattern, in that this appeared to be correlated with the best therapeutic outcomes.
In further studies of this development pattern, Stiles et al. Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative.
No significant correlation was observed between any of the four patterns and the therapeutic outcome. However, the authors observed a cycle of therapeutic alliance rupture—repair events in all cases: On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes. In particular, Stiles et al. The results of the study by De Roten et al. According to De Roten et al.
De Roten et al. According to Castonguay et al. This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon. Discussion and Conclusion According to their meta-analysis based on the results of 24 studies, Horvath and Symonds demonstrate the existence of a moderate but reliable association between good therapeutic alliance and positive therapeutic outcome.
To explore this question, 19 different therapist—client pairs were followed over 12 sessions of psychotherapy. Clients were evaluated with the Brief Symptom Inventory BSI after sessions 1 and 12 to determine psychotherapy outcome. In clinical psychology's quest to fulfill G. The study of therapist—client similarity has thus arisen.
Out of this tradition of research, two opposing schools of thought have developed: Therefore, the more similar the client—therapist dyad, the greater the likelihood of the communication being clear and readily understood. Strong support for this position comes from studies of length of psychotherapy as a function of client—therapist similarity. Mendelson and Geller 9 studied therapists and clients in a college counseling center. Dissimilarity was associated with increased dropout rates and increased premature termination rates.
Purportedly, clients were unable to build rapport with highly dissimilar therapists and left therapy because of dissatisfaction. Much of the support favoring dissimilarity comes from the perspective that psychotherapy is an educational experience. In psychotherapy, clients must be able to learn something novel and different from their therapists that they would not ordinarily learn on their own. Therefore, therapists who are too similar to their clients will be unable to present a different perspective or any new learning.
In the early s a flurry of research activity was generated on the topic of the A-B dichotomy. However, this theory has not been validated empirically.
This integrative model is based on four primary classes of events and variables, which therapists can consider and use to theoretically choose optimal psychotherapeutic techniques to maximize treatment outcome.
It is the third of these classes, Relationship Variables, that is most appropriate to this report. Among the dimensions of compatibility discussed by Beutler and Clarkin are demographics, interpersonal response patterns, personal beliefs, and attributions.
See their chapter 9 for a comprehensive discussion of therapist—client personal and personality matching in the optimization of psychotherapy outcome. People who score high on the Behaviors modality scale are generally described as active, energetic, and busy.
The Relationship Between Therapist–Client Modality Similarity and Psychotherapy Outcome
They are often goal-oriented and often choose to act on a problem rather than studying it in depth first. People who score high on the Affects modality consider themselves emotional. They feel things deeply and rely on their emotions and intuitions. People who score high in the Sensory modality are very tuned in to their physical sensations. They are keenly aware of smells, tastes, sights, kinesthetics, and sounds, similar to the conceptualization of the strongly right brain—dominant individual.
People who score high on the Imagery modality are good at thinking in pictures. They may be more likely to fantasize or daydream and can often think three-dimensionally.
People who score high in the Cognitions modality consider themselves logical, rational, and contemplative. People who score high in the Interpersonal modality derive energy from interpersonal relationships. People who score high in the Biochemical factors are health conscious. They avoid unhealthy habits and take care of their bodies. They do not resort to substance use to cope.
People who are having psychological problems will experience them across all modalities. Consequently, for optimal treatment outcome, therapy must focus on the significant manifestations in all seven modalities. In Multimodal therapy, clients are thoroughly assessed in all seven areas of functioning. All of their strengths and clinical symptoms in all modalities are carefully cataloged.
The Multimodal Treatment Plan is developed by matching specific, empirically documented psychotherapeutic techniques to each of the client's target clinical symptoms. Multimodal therapy agrees with other disciplines and psychological views 2021 in recognizing that it is the techniques that are of prime importance in psychotherapy. They determine an individual's functioning preferences. The implications of this finding for marital and other interpersonal relationships are that when individuals share dominant modalities, their communication will most likely be clearer and a more productive interpersonal relationship will result.
The Structural Profile was originally a verbally administered tool 25 that consisted of describing the seven modalities and requesting the client's self-rating for each. Straightforward in its approach, the Structural Profile is a quick and easy way to obtain a general and global picture of a client's modality functioning. However, to gain further insight into the nuances of a client's modality functioning, the item SPI was created.
Recently, the SPI has been shown to have even higher reliability scores than previously demonstrated, and, through a correlation with the Vocational Preference Inventory, validity has been established for the Affects, Sensations, Imagery, and Interpersonal Relations modalities, with some indication of validity established for the Behaviors modality. Herman 23 has already demonstrated that when therapists and clients differ in their modality structures, early psychotherapy impact suffers.
It is therefore intuitive to assume that psychotherapy outcome will suffer similarly. This is not a radical idea in psychotherapy research. McConnaughy 28 discussed in detail the impact of a therapist's personality style on the style, form, and content of the psychotherapy practiced.
Lazarus 29 has recently reviewed the necessity of approaching the client on his or her own terms. Rogers had covered this same topic extensively for years previously, 30 although employing a much more limited model. This study was designed to explore the importance of therapist—client similarity from the holistic and comprehensive viewpoint of multimodal therapy.
For this purpose, the SPI, the primary psychometric of multimodal therapy, was used to determine a measure of similarity. It was hypothesized that therapist—client similarity on the Multimodal Structural Profile Inventory would result in more successful psychotherapy outcomes than would therapist—client dissimilarity. Although initially 45 therapists agreed to participate, a total of only 19 therapist—client pairs did participate in this study.
The average age of the therapists was Their average age was Half of the clients were college students Several clients had master's degrees Of the nonstudents, some were employed and some were not. Clients were excluded from participation if they were actively psychotic, actively substance dependent, or organically impaired.
Clients had to be literate to the extent that they were capable of reading and answering the research questions in order to participate. Only clients 18 years or age or older were recruited for participation. Family and marital therapy clients were not recruited, so as to optimize concentration on the interactions between therapists and individual therapy clients.
Each therapist was asked to participate only once with one individual client. Procedures Therapist—client similarity was determined through administration of the Multimodal Structural Profile Inventory, Version 3.
The SPI assays an individual's functioning in the realm of Behaviors e. Scale scores can range from 5 indicating poor functioning in the modality area or a preference against using that sphere of functioning to 35 points indicating high functioning in the modality area or a preference to use that sphere of functioning, that is, a dominant modality.
The GSI provides information about the general level of psychological symptomatology the client is experiencing, whereas the PSDI provides information about the severity of the specific symptoms the client endorses.
All scales of the BSI can be analyzed by their raw scores which range from 0, indicating an absence of psychopathological symptoms, to 4, indicating high levels of psychopathological symptoms or can be converted to scaled scores, with a mean of 50 and a standard deviation of Both therapists and clients also completed a brief demographics questionnaire requesting information such as age, gender, race, occupation, and marital status.
In addition, the therapists' demographics questionnaire requested philosophical orientation, degree sought, and years of psychotherapeutic experience. Once therapists agreed to participate in this study, they were sent packets containing all the materials they would need.
The experimenter thus did not receive the names of any of the clients. Therapists were instructed to complete and return their own consent form, SPI, and demographics sheet upon receipt of the research materials. When therapists met with their next new client for the first time, they were instructed to explain the study and seek the client's consent for participation. Interested clients were then asked to read and sign both copies of the Client Consent Form, which described the study in detail.
Although there were no enforcement mechanisms to ensure that therapists would participate with their next new random client, many of the participants were recruited through training clinics where clinicians saw only one or two clients per year. This was one of the major causes of the high dropout rate: After the client signed the consent form, the therapist completed the Intake Consent Form described above and gave the client the Session 1 packet, which contained the BSI, the SPI, and the Client Demographics sheet in a self-addressed stamped envelope.
The Relationship Between Therapist–Client Modality Similarity and Psychotherapy Outcome
Clients were instructed to complete and return these questionnaires immediately after the first session. After the twelfth therapy session, the clinicians were instructed to remind their clients about the study and request that they complete the Session 12 packet, which contained the SPI and BSI in a self-addressed stamped envelope. Clients were instructed to complete these materials immediately after the twelfth therapy session.
According to the research protocol, therapists were instructed to administer exactly the same course of treatment that they would have followed had they not participated in the study. Clients were also informed that participation in this study would not alter the course or form of treatment that they would receive.
These steps are performed independently for both the therapist and client SPI scores. The reader is referred to Cronbach and Glesser 38 for a more in-depth description of the process and rationale for the use of this statistic.
This conversion process prevented contamination of the dependent measure the raw SPI scores. Uncorrected raw SPI modality scores have been found to be predictive of clients' symptomatology, as measured by BSI symptom scores, but SPI modality scores corrected for elevation and scatter have not.
In the analyses of therapeutic outcome, regression equations were computed by using the GSI scores from the session 12 BSI as the dependent measure of outcome. Only GSI scores were used in the analyses of outcome, rather than the nine different symptom clusters, in an attempt to avoid making a type I error. Because only 19 outcome packets were collected, it was determined that there were insufficient data for these nine separate analyses. Results Descriptively, therapist—client similarity scores SPI D-scores corrected for elevation and scatter were found to range from 1.
To demonstrate that this was a valid study of therapy and that the BSI was an appropriate instrument for examining outcome, t-tests for paired samples were computed on the GSI scores, comparing pretreatment to posttreatment. This is consistent with findings that SPI scores corrected for elevation and scatter are not predictive of psychopathology. Analyses of the relationship between client—therapist similarity on the Multimodal SPI and psychotherapy outcome confirmed the experimental hypothesis.