Mark J. Hilsenroth

A review of therapist characteristics and techniques positively impacting the therapeutic alliance

The present review is a comprehensive examination of the therapists personal attributes and in-session activities that positively influence the therapeutic alliance from a broad range of psychotherapy perspectives. Therapists personal attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to contribute positively to the alliance. Therapist techniques such as exploration, reflection, noting past therapy success, accurate interpretation, facilitating the expression of affect, and attending to the patients experience were also found to contribute positively to the alliance. This review reveals how these therapist personal qualities and techniques have a positive influence on the identification or repair of ruptures in the alliance.

Interaction of therapeutic process and alliance during psychological assessment.

Utilizing a collaborative therapeutic assessment (TA) model proposed by Finn and Tonsager (1997), we examined the interaction between therapeutic alliance and in-session process during the assessment phase of treatment. This study compares the utility of the TA model (n = 38) versus a traditional information gathering model (n = 90) of assessment. The results of this study indicate that the use of a TA model may decrease the number of patients who terminate treatment against medical advice. The Session Evaluation Questionnaire (Stiles & Snow, 1984), Combined Alliance Short Form (Hatcher & Barends, 1996), and Penn Helping Alliance Questionnaire-Revised (Barber & Crits-Christoph, 1996) can reliably measure the patients experience of the assessment. The psychological assessment process may impact the patients experience of assessment feedback and aid in the development of a therapeutic alliance. The therapeutic alliance developed during the assessment was found to be related to alliance early in psychotherapy. We discuss the theoretical, clinical, and research implications of these findings.

The Development of Therapeutic Alliance During Psychological Assessment: Patient and Therapist Perspectives Across Treatment

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn & Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher & Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.

An Examination of Interrater Reliability for Scoring the Rorschach Comprehensive System in Eight Data Sets

In this article, we describe interrater reliability for the Comprehensive System (CS; Exner, 1993) in 8 relatively large samples, including (a) students, (b) experienced researchers, (c) clinicians, (d) clinicians and then researchers, (e) a composite clinical sample (i.e., a to d), and 3 samples in which randomly generated erroneous scores were substituted for (f) 10%, (g) 20%, or (h) 30% of the original responses. Across samples, 133 to 143 statistically stable CS scores had excellent reliability, with median intraclass correlations of .85, .96, .97, .95, .93, .95, .89, and .82, respectively. We also demonstrate reliability findings from this study closely match the results derived from a synthesis of prior research, CS summary scores are more reliable than scores assigned to individual responses, small samples are more likely to generate unstable and lower reliability estimates, and Meyers (1997a) procedures for estimating response segment reliability were accurate. The CS can be scored reliably, but because scoring is the result of coder skills clinicians must conscientiously monitor their accuracy.

The Rorschach: Facts, Fictions, and Future

A large body of empirical evidence supports the reliability, validity, and utility of the Rorschach. This same evidence reveals that the recent criticisms of the Rorschach are largely without merit. This article systematically addresses several significant Rorschach components: interrater and temporal consistency reliability, normative data and diversity, methodological issues, specific applications in the evaluation of thought disorder and suicide, meta-analyses, incremental validity, clinician judgment, patterns of use, and clinical utility. Strengths and weaknesses of the test are addressed, and research recommendations are made. This information should give the reader both an appreciation for the substantial, but often overlooked, research basis for the Rorschach and an appreciation of the challenges that lie ahead.

Therapist Affect Focus and Patient Outcomes in Psychodynamic Psychotherapy: A Meta-Analysis

OBJECTIVE The authors systematically examined the relationship between therapist facilitation of patient emotional experience/expression and outcome in psychodynamic psychotherapy. METHOD Computer and manual searches were conducted for relevant publications, and 10 independent samples of short-term dynamic psychotherapy were included in a meta-analysis. Data analysis included calculation of an overall effect size of the relationship between therapist affect focus and outcome, statistical significance, and test for homogeneity. In addition, moderator analyses were conducted to examine the potential impact of type of outcome construct used and the methodological quality of individual studies. RESULTS The overall average weighted effect size across all outcome types was statistically significant (r=0.30), and the homogeneity statistic was nonsignificant. Moderator analyses indicated a statistically significant relationship between therapist facilitation of patient emotional experience/expression and outcome when more than one outcome construct was included but not when either a single or an unclear outcome construct was used. There were no significant relationships between methodological quality and the size of the effects, although use of audio- or videotaping for supervision demonstrated a moderate effect. CONCLUSIONS These data indicate that therapist facilitation of patient affective experience/expression is associated with patient improvement over the course of psychodynamic psychotherapy. Although the size of this relationship was not significantly related to methodological quality, results suggest the importance of close supervision of actual techniques through the use of audio- or videotapes. Additionally, results highlight the importance of defining outcome in a multidimensional way to properly assess theoretically relevant effects.

A validity study of two projective object representations measures.

Two projective measures of object representations, the Concept of the Object on the Rorschach (H. Rorchach, 1942) and the Social Cognition and Object Relations Scales (D. Westen, 1993) were compared with each other, with measures of intelligence (Wechsler Adult Intelligence Scale-Revised; D. Wechsler, 1981), and measures of pathology (Millon Clinical Multiavial Inventory [T. Millon, 1983], Minnesota Multiphasic Personality Inventory [S. R. Hathaway & J. McKinley, 1983] Axis II diagnoses). Analyses focused on the construct validity of object representations and the implications of structural and affective aspects of object representations for psychopathology. Results support the construct validity of object representations and an affective, but not a cognitive-structural, linkage between object representations and pathology.

Evaluating the Phase Model of Change During Short-Term Psychodynamic Psychotherapy

This study examined the phase model of psychotherapy change (Howard, Lueger, Maling, & Martinovich, 1993; Howard, Moras, Brill, Martinovich, & Lutz, 1996) and assessed the domains of subjective well-being, symptomatic distress, and social/interpersonal functioning during short-term psychodynamic psychotherapy. Specifically, we assessed evaluation/third-session to ninth-session changes in a group of 20 treated patients. These three domains were examined for both statistical and clinically significant change (Jacobson & Truax, 1991). Treatment fidelity and credibility were also evaluated. Statistical and clinically significant improvement in the domains of subjective well-being and symptom distress were evident by the ninth session of short-term dynamic psychotherapy. Statistical and reliable improvement were observed in relational functioning during the same time period. In addition, changes in both subjective well-being and symptomatic distress contributed unique and separate variance to predicting changes in social/interpersonal functioning. The results with respect to the differential effects predicted by the phase model of change during the early course of treatment are discussed.

Borderline Pathology and the Personality Assessment Inventory (PAI): An Evaluation of Criterion and Concurrent Validity

Abstract In this study, we examined how patients diagnosed with borderline pathology (BP) would respond on the Personality Assessment Inventory (Morey, 1991) Borderline (BOR) scales in relation to patients without BP pathology. In addition, we examined whether the PAI BOR scales would be related to variables on the Social Cognition and Object Relations Scale (SCORS; Hilsenroth, Stein, & Pinsker, 2004; Westen, 1995) derived from early memory narratives. Results indicate that outpatients with a Diagnostic and Statistical Manual of Mental Disorders(4th ed. [DSM-IV]; American Psychiatric Association, 1994) diagnosis of BP scored significantly higher on the PAI BOR Total (BOR-Total) score, Identity Problems, and Self-Harm scales in comparison to a Non-BP clinical sample. The overall correct classification rate for the presence or absence of BP using the BOR Total scale (T ≥ 70) was 73%. In addition, there were several significant relationships between dimensional PAI BOR scales and the presence versus absence of DSM-IVBP. Moreover, both the BOR-Total and Affect Instability scales were significantly related to the SCORS variable Complexity of Representations. We provide clinical examples to illustrate these research findings in an applied manner.

short-term Psychodynamic Psychotherapy for Depression: An Examination of Statistical, Clinically Significant, and Technique-specific Change

Abstract This study investigates the effectiveness of short‐term psychodynamic psychotherapy (STPP) for depression in a naturalistic setting utilizing a hybrid effectiveness/efficacy treatment research model. Twenty‐one patients were assessed pre‐ and post‐treatment through clinician ratings and patient self‐report on scales representing specific DSM‐IV depressive, global symptomatology, relational, social, and occupational functioning. Treatment credibility, fidelity, and satisfaction were examined, all of which were found to be high. All areas of functioning assessed exhibited significant and positive changes. These adaptive changes in functioning demonstrated large statistical effects. Likewise, changes in depressive symptoms evaluated at the patient level utilizing clinical significance methodology were found to be high. A significant direct process/outcome link between STPP therapist techniques and changes in depressive symptoms was observed. Alternative treatment interventions within STPP were evaluated in relation to subsequent improvements in depression and were found to be nonsignificant. The present results demonstrate that robust statistical and clinically significant improvement can occur in a naturalistic/hybrid model of outpatient STPP for depression.