Sigal Zilcha-Mano

Does alliance predict symptoms throughout treatment, or is it the other way around?

OBJECTIVE Scholars increasingly recognize that therapeutic alliance and symptomatic change are associated with one another. A common assumption is that alliance predicts symptomatic change. However, the issue is far from settled. One challenge in determining the causality is the establishment of temporal precedence showing that alliance, as opposed to previous symptomatic change, drives subsequent symptomatic reduction. METHOD To make further advances in untangling this chicken-and-egg question, we employed autoregressive cross-lagged modeling over 4 time points in a sample of 149 depressive patients receiving supportive-expressive psychotherapy or clinical management combined with pharmacotherapy or clinical management combined with placebo. RESULTS Using this methodology, we found that both alliance and symptoms across treatment made significant and unique contributions in predicting subsequent symptomatic levels throughout treatment. Additionally, alliance, but not symptoms, predicted subsequent alliance levels. No differences were found between treatments. CONCLUSIONS Our findings imply that alliance temporally precedes symptomatic levels throughout treatment.

Psychometric development of the Problematic Pornography Use Scale

Despite the increased social acceptance and widespread use of pornography over the past few decades, reliable and valid instruments assessing problematic use of pornography are lacking. This paper reports the findings of three studies aimed at developing and validating a new scale measuring problematic pornography use. The Problematic Pornography Use Scale (PPUS) items showed high internal consistency, convergent validity, and construct validity. Exploratory and confirmatory factor analyses revealed four core factors relating to proposed domains of problematic pornography use. High PPUS scores were positively correlated with measures of psychopathology, low self-esteem and poor attachment. Although PPUS scores were related to other behavioral addictions, problematic pornography use as operationalized in the current paper appears to be uniquely distinguished from features of behavioral addictions relating to gambling and Internet use. Findings highlight the potential use of the PPUS for future research and possible clinical applications by defining problematic pornography use as a behavioral addiction.

A meta-analytic review of psychodynamic therapies for anxiety disorders

Recent randomized controlled trials (RCTs) suggest that psychodynamic therapy (PDT) may be useful in the treatment of anxiety disorders. This paper presents the most comprehensive meta-analysis to date examining the controlled effects of PDT for anxiety disorders. 14 RCTs totaling 1073 patients were included. PDT was found to be significantly more effective than control conditions (g=0.64). PDT did not differ significantly from alternative treatments at post-treatment (g=0.02), follow-up (FU) up to a year (g=-0.11), and FU past a year (g=-0.26). Medium-to-high levels of heterogeneity were detected, indicating significant differences between studies. Nevertheless, our findings remained unchanged when heterogeneity outliers were removed (termination g=-0.06/short FU g=-0.01/long FU g=-0.10). Power analyses indicated that large or medium effect size differences between PDT and other active treatments could be detected even with high heterogeneity. Exploratory moderator analyses found few significant predictors of effect (e.g., relative risk of dropout). No differences were found examining remission rates or relative risk of dropout. Overall, PDT was shown to be as efficacious as other active treatments that have been studied for anxiety disorders.

A wait-list randomized controlled trial of loving-kindness meditation programme for self-criticism.

UNLABELLED Self-criticism is a vulnerability risk factor for a number of psychological disorders, and it predicts poor response to psychological and pharmacological treatments. In the current study, we evaluated the efficacy of a loving-kindness meditation (LKM) programme designed to increase self-compassion in a sample of self-critical individuals. Thirty-eight individuals with high scores on the self-critical perfectionism subscale of the Dysfunctional Attitude Scale were randomized to an LKM condition (n = 19) or a wait-list (WL) condition (n = 19). Measures of self-criticism, self-compassion and psychological distress were administered before and immediately following the intervention (LKM or WL). WL participants received the intervention immediately after the waiting period. Both groups were assessed 3 months post-intervention. Intent-to-treat (n = 38) and per-protocol analyses (n = 32) showed significant reductions in self-criticism and depressive symptoms as well as significant increases in self-compassion and positive emotions in the LKM condition compared with the WL condition. A follow-up per-protocol analysis in both groups together (n = 20) showed that these gains were maintained 3 months after the intervention. These preliminary results suggest that LKM may be efficacious in alleviating self-criticism, increasing self-compassion and improving depressive symptoms among self-critical individuals. KEY PRACTITIONER MESSAGE Self-criticism plays a major role in many psychological disorders and predicts poor response to brief psychological and pharmacological treatments for depression. The current study shows that loving-kindness meditation, designed to foster self-compassion, is efficacious in helping self-critical individuals become less self-critical and more self-compassionate. The study also suggests that practising loving-kindness may reduce depressive symptoms and increase positive emotions.

Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances.

The therapeutic value of alliance is a contested supposition. Although many theorists and researchers believe that alliance is therapeutic in itself, others see it as a byproduct of effective treatment or as a common nonspecific factor enabling the truly effective ingredients of treatment to work. For many years, the debate was confined mainly to the domain of theory, and no studies were available to confirm which of these approaches is correct. The only empirical evidence that existed was studies showing a correlation between alliance and outcome, and advocates of the above conflicting opinions used the same correlation to prove the validity of their position. Over the last few years, however, a revolution has taken place in alliance research, which brings this theoretical debate into the realm of the empirical. Several recent alliance studies have applied advanced methodologies to achieve this aim. Based on an integration of these studies, the present article proposes a new model for understanding the potential therapeutic role of alliance as sufficient to induce change by itself. The model stresses the importance of differentiating between patients’ general tendencies to form satisfying relationships with others, which affect also the relationship with the therapist (“trait-like” component of alliance), and the process of the development of changes in such tendencies through interaction with the therapist (“state-like” component of alliance). The former enables treatment to be effective; the latter makes alliance therapeutic. Based on the literature, this article attempts to determine which of these components is the predictor of treatment outcome.

The relationship between alliance and outcome: Analysis of a two-person perspective on alliance and session outcome.

OBJECTIVE Better alliance is known to predict better psychotherapy outcomes, but the interdependent and interactive effects of both therapist- and patient-reported alliance levels have yet to be systematically investigated. METHOD Using actor-partner interdependence model analysis the authors estimated actor, partner, and 2 types of interactive effects of alliance on session outcome in a sample of 241 patient-therapist dyads across 30 sessions of cognitive-behavioral and alliance-focused therapy. RESULTS Findings suggest that the most robust predictors of session outcome are within-treatment changes in patient reports of the alliance, which predict both patient and therapist report on outcome. Within-treatment changes in therapist reports of the alliance, as well as differences between patients and between therapists in their average ratings of alliance levels across treatment, predict outcome as reported by the specific individual. Although alliance was found to be a significant predictor of outcome in both treatments, for therapist-reported alliance and outcome it had a stronger effect in alliance-focused therapy than in cognitive-behavioral therapy. Additionally, dyads with the highest pooled level of alliance from both partners fared best on session outcome. CONCLUSIONS The results are consistent with a 2-person perspective on psychotherapy, demonstrating the importance of considering the interdependent and interactive nature of both patient and therapist alliance levels on session outcome. (PsycINFO Database Record

The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder

Abstract Objective: To examine the associations between treatment/outcome expectations, alliance before and during treatment, and the impact of alliance on symptomatic improvement. Methods: One hundred and fifty-three depressed patients randomized to dynamic supportive-expressive psychotherapy (SET), antidepressant medication (ADM) or placebo (PBO) + clinical management completed ratings of treatment expectations, therapeutic alliance (CALPAS, WAI-S), and depressive symptoms (HAM-D). Results: Pretreatment expectations of the therapeutic alliance were significantly related to alliance later in therapy but did not differ across treatments and did not predict outcome. Alliance development over time differed between treatments; it increased more in SET than in PBO. After controlling for prior symptom improvement, early alliance predicted subsequent depression change. Conclusions: Expectations of alliance and of treatment outcome/improvement, measured prior to treatment onset, predicted subsequent alliance.

One size does not fit all: Examining heterogeneity and identifying moderators of the alliance-outcome association.

Although the alliance-outcome association is one of the most consistent findings in psychotherapy research, it is also highly heterogeneous. Little is known about the factors explaining this variability, and consequently there is a lack of adequate knowledge about how to utilize this association to improve treatment. The present study had the following objectives: (a) to examine the associations between within- and between-individual variability in alliance and outcome, controlling for previous symptomatic levels; (b) to examine the duration of the alliance-outcome association; and (c) to examine potential moderators of the alliance-outcome association. A total of 547 patients treated in a primary care psychotherapy setting in Chile were randomly assigned to 5 feedback conditions. The alliance-outcome association was analyzed using multilevel models, disentangling changes in alliance within-individuals from alliance between-individuals. Patient and therapist characteristics were examined as potential moderators. Findings suggest that patients who reported a better early alliance also reported a better outcome. Furthermore, patients reporting time-specific improvement in alliance also reported a greater reduction in symptoms. The unique effect of alliance on outcome at one point in time is maintained for a period of 2 weeks. Patients with more severe symptoms and longer treatments benefited more from a good alliance. Therapists identifying themselves as more integrative in their treatment orientation were able to better utilize good alliances for treatment success. Finally, the size of the alliance-outcome association can be manipulated by feedback to therapists.

Interpersonal problems as predictors of alliance, symptomatic improvement and premature termination in treatment of depression

BACKGROUND Previous studies reported inconsistent findings regarding the association of interpersonal problems with therapy outcome. The current study investigates if interpersonal problems predict process and outcome of three different treatments for depression. METHODS The data originate from a randomized clinical trial comparing supportive-expressive psychotherapy, antidepressant medication and pill-placebo for treatment of depression. Interpersonal problems were used as predictors of alliance, symptomatic improvement and premature termination of treatment. RESULTS Interpersonal problems related to communion predicted better alliances, but slower symptomatic improvement. Low agency predicted slower symptomatic improvement in supportive-expressive psychotherapy, but not in the medication or placebo condition. Lower interpersonal distress was associated with an increased likelihood to terminate treatment prematurely. LIMITATIONS The sample size did not allow the detection of small effects within the treatment groups. CONCLUSIONS Interpersonal problems are influential for the treatment of depression, but parts of their effects depend on the type of treatment.

Are there subtypes of panic disorder? An interpersonal perspective.

OBJECTIVE Panic disorder (PD) is associated with significant personal, social, and economic costs. However, little is known about specific interpersonal dysfunctions that characterize the PD population. The current study systematically examined these interpersonal dysfunctions. METHOD The present analyses included 194 patients with PD out of a sample of 201 who were randomized to cognitive-behavioral therapy, panic-focused psychodynamic psychotherapy, or applied relaxation training. Interpersonal dysfunction was measured with the Inventory of Interpersonal Problems-Circumplex (Horowitz, Alden, Wiggins, & Pincus, 2000). RESULTS Individuals with PD reported greater levels of interpersonal distress than that of a normative cohort (especially when PD was accompanied by agoraphobia), but lower than that of a cohort of patients with major depression. There was no single interpersonal profile that characterized PD patients. Symptom-based clusters (with vs. without agoraphobia) could not be discriminated on core or central interpersonal problems. Rather, as revealed by cluster analysis based on the pathoplasticity framework, there were 2 empirically derived interpersonal clusters among PD patients that were not accounted for by symptom severity and were opposite in nature: domineering-intrusive and nonassertive. The empirically derived interpersonal clusters appear to be of clinical utility in predicting alliance development throughout treatment: Although the domineering-intrusive cluster did not show any changes in the alliance throughout treatment, the nonassertive cluster showed a process of significant strengthening of the alliance. CONCLUSIONS Empirically derived interpersonal clusters in PD provide clinically useful and nonredundant information about individuals with PD.