Christoph Flückiger

How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis

Prior meta-analyses have found a moderate but robust relationship between alliance and outcome across a broad spectrum of treatments, presenting concerns, contexts, and measurements. However, there continues to be a lively debate about the therapeutic role of the alliance, particularly in treatments that are tested using randomized clinical trial (RCT) designs. The purpose of this present study was to examine whether research design, type of treatment, or authors allegiance variables, alone or in combination, moderate the relationship between alliance and outcome. Multilevel longitudinal analysis was used to investigate the following moderators of the alliance-outcome correlation: (a) research design (RCT or other), (b) use of disorder-specific manuals, (c) specificity of outcomes, (d) cognitive and/or behavioral therapy (CBT) or other types of treatments, (e) researcher allegiance, and (f) time of alliance assessment. RCT, disorder-specific manual use, specificity of primary and secondary outcomes, and CBT did not moderate the alliance-outcome correlation. Early alliance-outcome correlations were slightly higher in studies conducted by investigators with specific interest in alliance than were those in studies conducted by researchers without such an allegiance. Over the course of therapy, these initial differences disappeared. Apart from this trend, none of the variables previously proposed as potential moderators or mediators of the alliance-outcome relation, alone or in combination, were found to have a mediating impact.

Therapist effects in the therapeutic alliance–outcome relationship: A restricted-maximum likelihood meta-analysis☆

OBJECTIVE Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. The purpose of this present meta-analysis was to (1) test for therapist effects in the alliance-outcome correlation and (2) extend the findings of previous research by examining several potential confounds/covariates of this relationship. METHOD A random effects analysis examined several moderators of the alliance-outcome correlation. These included (a) patient-therapist ratio (patient N divided by therapist N), (b) alliance and outcome rater (patient, therapist, and observer), (c) alliance measure, (d) research design and (e) DSM IV Axis II diagnosis. RESULTS The patient-therapist ratio (PTR) was a significant moderator of the alliance-outcome correlation. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance-outcome correlation. CONCLUSION Corroborating previous research, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship.

Working with patients’ strengths: A microprocess approach

Abstract Previous research has supported the immediate activation of patients’ strengths (resource activation) as an important change mechanism in psychotherapy. Two different studies of integrative cognitive–behavioral therapy (CBT) treatments demonstrated that fostered strengths-oriented CBT treatments were more effective than the control conditions. Within these two studies, the authors tested the effect of specific resource-activating strategies at the beginning of therapy (Sessions 2, 5, and 8) using a pairwise matched control group design. The in-session processes were measured by video observer ratings (N=96 sessions). Results indicate that in the strengths-fostering treatments therapists and patients focus more strongly on patient competencies and personal goals in comparison to the control groups. These in-session processes have a direct impact on session outcome (particularly self-esteem, mastery, and clarification experiences). Results are discussed in regard to actively implementing resource-activating behavior as superordinate principles of change and their relevance for therapy outcome.

Efficacy of new generation antidepressants: differences seem illusory.

Background Recently, Cipriani and colleagues examined the relative efficacy of 12 new-generation antidepressants on major depression using network meta-analytic methods. They found that some of these medications outperformed others in patient response to treatment. However, several methodological criticisms have been raised about network meta-analysis and Ciprianis analysis in particular which creates the concern that the stated superiority of some antidepressants relative to others may be unwarranted. Materials and Methods A Monte Carlo simulation was conducted which involved replicating Ciprianis network meta-analysis under the null hypothesis (i.e., no true differences between antidepressants). The following simulation strategy was implemented: (1) 1000 simulations were generated under the null hypothesis (i.e., under the assumption that there were no differences among the 12 antidepressants), (2) each of the 1000 simulations were network meta-analyzed, and (3) the total number of false positive results from the network meta-analyses were calculated. Findings Greater than 7 times out of 10, the network meta-analysis resulted in one or more comparisons that indicated the superiority of at least one antidepressant when no such true differences among them existed. Interpretation Based on our simulation study, the results indicated that under identical conditions to those of the 117 RCTs with 236 treatment arms contained in Cipriani et al.s meta-analysis, one or more false claims about the relative efficacy of antidepressants will be made over 70% of the time. As others have shown as well, there is little evidence in these trials that any antidepressant is more effective than another. The tendency of network meta-analyses to generate false positive results should be considered when conducting multiple comparison analyses.

Is the allegiance effect an epiphenomenon of true efficacy differences between treatments? a meta-analysis

Many meta-analyses of comparative outcome studies found a substantial association of researcher allegiance (RA) and relative treatment effects. Therefore, RA is regarded as a biasing factor in comparative outcome research (RA bias hypothesis). However, the RA bias hypothesis has been criticized as causality might be reversed. That is, RA might be a reflection of true efficacy differences between treatments (true efficacy hypothesis). Consequently, the RA-outcome association would not be indicative of bias but an epiphenomenon of true efficacy differences. This meta-analysis tested the validity of the true efficacy hypothesis. This was done by controlling the RA-outcome association for true efficacy differences by restricting analysis to direct comparisons of treatments with equivalent efficacy. We included direct comparisons of different versions of trauma-focused therapy (TFT) in the treatment of posttraumatic stress disorder (PTSD). RA was measured from the research reports. Relative effect sizes for symptoms of PTSD were calculated. Random effects meta-regression was conducted. Twenty-nine comparisons of TFTs from 20 studies were identified. Initial heterogeneity among relative effect sizes was low. RA was a significant predictor of outcome and explained 12% of the variance in outcomes. The true efficacy hypothesis predicted the RA-outcome association to be zero; however, a substantial association was found. Thus, this study does not support the true efficacy hypothesis. Given findings from psychotherapy research and other fields that support a biasing influence of researcher preferences, RA should be regarded as a causal factor and conceptualized as a threat to the validity of conclusions from comparative outcome studies.

In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy

Abstract Objective: Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia). Method: The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments. Results: When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies. Conclusion: Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Monitoring mindfulness practice quality: An important consideration in mindfulness practice

Abstract Mindfulness-Based Stress Reduction (MBSR) is an experientially based group intervention empirically supported to reduce psychological symptomology. Although MBSR has shown to be an effective intervention, little is known about which facets of the intervention are important in producing positive outcomes. This study tested several aspects of mindfulness practice (total practice duration, practice frequency and practice quality) with the primary focus being on validating (i.e., predictive and convergent validity) a new measure of mindfulness practice quality (PQ-M). The PQ-M fit a two-factor solution via a Maximum Likelihood Exploratory Factor Analysis (n=99). Using longitudinal multilevel modeling on a smaller subsample (n=19), preliminary support was found for changes in practice quality over the course of the MBSR intervention. Further, change in practice quality was associated with improvements in psychological symptoms. While this study was exploratory, these findings suggest that practice quality is a relevant factor to promote positive outcomes and may guide mindfulness instructors in providing highly tailored interventions.

Irrational Beliefs and Psychological Distress: A Meta-Analysis.

Background: Since the cognitive revolution of the early 1950s, cognitions have been discussed as central components in the understanding and treatment of mental illnesses. Even though there is an extensive literature on the association between therapy-related cognitions such as irrational beliefs and psychological distress over the past 60 years, there is little meta-analytical knowledge about the nature of this association. Methods: The relationship between irrational beliefs and distress was examined based on a systematic review that included 100 independent samples, gathered in 83 primary studies, using a random-effect model. The overall effects as well as potential moderators were examined: (a) distress measure, (b) irrational belief measure, (c) irrational belief type, (d) method of assessment of distress, (e) nature of irrational beliefs, (f) time lag between irrational beliefs and distress assessment, (g) nature of stressful events, (h) sample characteristics (i.e. age, gender, income, and educational, marital, occupational and clinical status), (i) developer/validator status of the author(s), and (k) publication year and country. Results: Overall, irrational beliefs were positively associated with various types of distress, such as general distress, anxiety, depression, anger, and guilt (omnibus: r = 0.38). The following variables were significant moderators of the relationship between the intensity of irrational beliefs and the level of distress: irrational belief measure and type, stressful event, age, educational and clinical status, and developer/validator status of the author. Conclusions: Irrational beliefs and distress are moderately connected to each other; this relationship remains significant even after controlling for several potential covariates.

A meta‐analysis of the relation between therapeutic alliance and treatment outcome in eating disorders

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

The enduring effects of psychodynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal meta-analysis

Although evidence suggests that the benefits of psychodynamic treatments are sustained over time, presently it is unclear whether these sustained benefits are superior to non-psychodynamic treatments. Additionally, the extant literature comparing the sustained benefits of psychodynamic treatments compared to alternative treatments is limited with methodological shortcomings. The purpose of the current study was to conduct a rigorous test of the growth of the benefits of psychodynamic treatments relative to alternative treatments across distinct domains of change (i.e., all outcome measures, targeted outcome measures, non-targeted outcome measures, and personality outcome measures). To do so, the study employed strict inclusion criteria to identify randomized clinical trials that directly compared at least one bona fide psychodynamic treatment and one bona fide non-psychodynamic treatment. Hierarchical linear modeling (Raudenbush, Bryk, Cheong, Congdon, & du Toit, 2011) was used to longitudinally model the impact of psychodynamic treatments compared to non-psychodynamic treatments at post-treatment and to compare the growth (i.e., slope) of effects beyond treatment completion. Findings from the present meta-analysis indicated that psychodynamic treatments and non-psychodynamic treatments were equally efficacious at post-treatment and at follow-up for combined outcomes (k=20), targeted outcomes (k=19), non-targeted outcomes (k=17), and personality outcomes (k=6). Clinical implications, directions for future research, and limitations are discussed.