Rolf Holmqvist

Therapeutic Alliance Predicts Symptomatic Improvement Session by Session

The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation-Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory-Short form revised (Hatcher & Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy.

Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement

Abstract Objective: Although the working alliance as been found to be a robust predictor of psychotherapy outcome, critics have questioned the causal status of this effect. Specifically, the effect of the alliance may be confounded with the effect of prior symptom improvement. The objective of the present study was to test this possibility. Method: A large dataset from primary care psychotherapy was used to study relationships between alliance and outcome using piecewise multilevel path analysis. Results: Initial symptom level and symptom change up to session three predicted the alliance at session three. Working alliance significantly predicted symptom change rate from session three to termination, even while controlling for several possible confounds. Conclusions: The alliance predicts outcome over and above the effect of prior symptom improvement, supporting a reciprocal influence model of the relationship between alliance and symptom change.

Emotional reactions to psychiatric patients

In psychodynamic milieu treatment, the relations between patients and nurses are the main tools for understanding and helping the patients. For this reason, it is important to construct methods to follow the development of relations and to study characteristics of helpful and nonhelpful relations. In this article, a checklist with feeling words given to nurses and aides in psychiatric treatment facilities is presented and its measurement properties are described. The analysis showed that the checklist as a whole measures the amount of emotional arousal in a reliable way. The individual feeling words have acceptable variance. A factor analysis gave a limited number of factors that are clinically understandable. The checklist seems to be well worth further study.

Countertransference feelings and the psychiatric staff's self-image.

This paper presents a study of associations between psychiatric staffs habitual feelings towards their patients and the staffs self-image. At 22 psychiatric treatment homes for psychotic and other severely disturbed patients, 163 male and female staff recurrently rated their feelings towards the individual patients on a feeling checklist. At the beginning of the study period, they also rated different aspects of their self-image (the introject and the mother and father images) using Structural Analysis of Social Behavior (SASB). Over time and over patient, correlations between the individual staff ratings on the feeling checklist and ratings on the SASB were studied for all staff and for male and female staff separately. The analyses showed a number of associations between the staffs feelings and aspects of their self-image. Staff who habitually tended to feel helpful and autonomous towards their patients had a more positive image of mother, whereas staff who tended to feel more rejecting, unhelpful, and controlled had a combination of negative images of mother and father and a protecting introject. Some notable differences between male and female staff were found. Overall, self-image accounted for larger proportions of the male staffs feelings than of the female staffs. Negative feelings for male staff were associated more with a critical father image, whereas for female staff these feelings were associated more with an image of the father as a freedom giving.

Confirmatory Factor Analysis of the Patient Version of the Working Alliance Inventory–Short Form Revised

The working alliance concerns the quality of collaboration between patient and therapist in psychotherapy. One of the most widely used scales for measuring the working alliance is the Working Alliance Inventory (WAI). For the patient-rated version, the short form developed by Hatcher and Gillaspy (WAI-SR) has shown the best psychometric properties. In two confirmatory factor analyses of the WAI-SR, approximate fit indices were within commonly accepted norms, but the likelihood ratio chi-square test showed significant ill-fit. The present study used Bayesian structural equations modeling with zero mean and small variance priors to test the factor structure of the WAI-SR in three different samples (one American and two Swedish; N = 235, 634, and 234). Results indicated that maximum likelihood confirmatory factor analysis showed poor model fit because of the assumption of exactly zero residual correlations. When residual correlations were estimated using small variance priors, model fit was excellent. A two-factor model had the best psychometric properties. Strong measurement invariance was shown between the two Swedish samples and weak factorial invariance between the Swedish and American samples. The most important limitation concerns the limited knowledge on when the assumption of residual correlations being small enough to be considered trivial is violated.

Self-reported attachment style, trauma exposure and dissociative symptoms among adolescents

The aim of this study was to analyze whether self-reported attachment style (measuring avoidance and anxiety) among adolescents was associated with dissociative symptoms, in addition to self-reported potentially traumatic experiences. A group consisting of 462 adolescents completed three self-assessment questionnaires: Linkoping Youth Life Experience Scale (LYLES), Experiences in Close Relationships, modified version (ECR) and Dissociation Questionnaire Sweden (Dis-Q-Sweden). Self-reported attachment style had a stronger association with dissociative symptoms than self reported traumas. It was also found that scores on a dissociation questionnaire correlated strongly with scores on self-reported attachment style in adolescence. Discussion concerns reasons why self-reported attachment style is an important factor that may influence dissociative symptoms during adolescence.

Improvement of the Working Alliance in One Treatment Session Predicts Improvement of Depressive Symptoms by the Next Session

OBJECTIVE Developments in working alliance theory posit that the therapists attention to fluctuations in the alliance throughout treatment is crucial. Accordingly, researchers have begun studying the alliance as a time-varying mechanism of change rather than as a static moderator. However, most studies to date suffer from bias owing to the nonindependence of error term and predictors (endogeneity). METHOD Patients with major depressive disorder (N = 84) from a randomized trial comparing cognitive-behavioral therapy with interpersonal psychotherapy filled out the Beck Depression Inventory-II before each session. After each session, patients and therapists filled out the Working Alliance Inventory short forms. Data were analyzed using the generalized method of moments for dynamic panel data, a method commonly applied in econometrics to eliminate endogeneity bias. RESULTS Improvement of the alliance predicted significant reduction of depressive symptoms by the next session (patient rating: b = -4.35, SE = 1.96, p = .026, 95% confidence interval [CI] [-8.19, -0.51]; therapist rating: b = -4.92, SE = 1.84, p = .008, 95% CI [-8.53, -1.31]). In addition, there was a significant delayed effect on the session after the next (patient rating: b = -3.25, SE = 1.20, p = .007, 95% CI [-5.61, -0.89]; therapist rating: b = -5.44, SE = 1.92, p = .005, 95% CI [-9.20, -1.68]). CONCLUSION If the quality of patient-therapist alliance is improved in a given treatment session, depressive symptoms will likely decrease by the next session. The most important limitation of this study is its relatively small sample size. (PsycINFO Database Record

Client-identified important events in psychotherapy: Interactional structures and practices

Abstract This study describes interactional structures and practices in client-identified important events in psychotherapy sessions. Twelve of 16 events from seven client–therapist dyads were found to contain disagreement. A turn-by-turn investigation using conversation analysis displayed three different ways that therapists used to handle disagreement. The first was to orient to the clients disagreement cues by inviting the client to elaborate his or her point and to establish a shared understanding. The second was to orient to the clients disagreement cues but define the therapists point of view as more relevant to the project at hand. The third was a single case where the therapist did not orient to the clients disagreement cues. The results suggest that disagreement patterns may be an interesting focus for further exploration of microprocesses within therapy sessions.

The care of corporal punishment: Conceptions of early childhood discipline strategies among parents and grandparents in a poor and urban area in Tanzania:

This study investigates conceptions of early childhood discipline strategies discussed in focus groups with parents and grandparents in a poor urban area in Tanzania. A grounded theory analysis suggested a model that included four discipline strategies related to corporal punishment: to beat with care, to treat like an egg, as if beating a snake and the non-care of non-beating. In order to develop strategies to prevent corporal punishment in the home in accordance with the UN recommendation and article 19 in the Convention on the Rights of the Child, the power of caregiving needs further investigation.

Effects of Aggression Replacement Training in Young Offender Institutions

This article reports a study where aggression replacement training (ART), combined with token economy, was compared with relationally oriented treatment at four residential treatment units in a nonrandomized design. In all, 57 adolescents in the ages between 16 and 19 participated. Outcome was measured as weighted indices of sentences and police suspicion reports. The results show no differences between the treatment models. In a separate analysis, the hypotheses were tested that those adolescents would relapse less frequently who admitted their crimes at intake or who could talk about guilt for their criminal acts. These hypotheses were refuted as main effects, but an interaction effect was found that suggests that adolescents with less consciousness of guilt got better results at the ART institutions. Case descriptions suggest that a more individualized approach to treatment, where ART is used for those adolescents who are motivated for it, would give better results.