The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also ...conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals .256, .299, p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices.
Clinical Impact Statement
Question: How robust is the correlation of the alliance (as a holistic, collaborative quality measured during therapy) with therapy outcomes? Findings: Based on over 300 studies, the positive relation of the alliance and outcome remains across assessor perspectives, alliance and outcome measures, treatment approaches, patient (intake-) characteristics, face-to-face and Internet-mediated therapies, and countries. Meaning: The alliance, which is of a mutual collaboration and partnership between therapist and client, is an important aspect of psychotherapy across various psychotherapy approaches. Next Steps: The universality of the alliance-outcome relation and the potential conceptual boundaries have to be investigated across cultural and biopsychosocial contexts inside but also outside of psychotherapeutic settings in a quantitative and in a qualitative manner.
The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or ...treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported alliance−outcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the alliance−outcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the alliance−outcome correlations: (a) intake characteristics (k = 35); (b) simultaneous processes, such as adherence or competence (k = 13); and (c) both intake and simultaneous processes (k = 24). We found moderate alliance−outcome correlations with or without adjustments for intake and simultaneous processes (range from r = .23 to r = .31). Our results provide robust empirical evidence for the assertion that the alliance−outcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes.
Public Significance Statement
The alliance is a robust predictor of outcome at the between-patients level. Patients who report a stronger alliance during treatment are also likely to report better treatment outcome. This association remains significant when controlling for patients' intake characteristics and therapists' adherence and competence. These results demonstrate that the alliance is an independent process-based factor with unique contribution to outcome across many psychotherapeutic contexts.
Objective: The relationship between the therapeutic alliance and outcome has been supported consistently over time. More recently, studies have examined therapist effects in the alliance-outcome ...relationship and came up with somewhat mixed findings. The purpose of this study was to replicate and extend previous meta-analytic work using a much larger data set, permitting not only the verification of the overall impact of the therapists' contribution but, at the same time, controlling for several potential covariates effecting this relationship. Method: We conducted two- and three-level mixed-effects meta-analyses (k = 152; 827 total effect sizes) to examine the significance of several potential moderators of the alliance-outcome correlation. These moderators included (a) Patient-Therapist Ratio (PTR; Patient N divided by therapist N to test therapist effects), (b) Alliance and Outcome Rater's contribution (patient, therapist, observer, and other), (c) Alliance Measures, (d) Research Design (RCT, Other) and (e) Personality Disorder. Results: The PTR, an index of the therapist's contribution to the alliance, was a significant moderator of the alliance-outcome correlation in both the two- and three-level models. When several potential confounds were simultaneously tested in a three-level multipredictor metaregression, including rater of alliance and outcome, research design, alliance measure, and personality disorder, PTR remained a significant moderator of the alliance-outcome correlation. Conclusion: Replicating and extending previous research, this study supported the significance of therapists' impact in the alliance-outcome relationship. These results remained significant even when, using three-level metaregressions, several potential covariates were simultaneously controlled.
What is the public health significance of this article?
Previous research has established that the therapeutic alliance between the
therapist and the patient is robustly related to the success of psychotherapy. This meta-analysis
strongly suggests that more effective therapists are better able to form a strong alliance with
their patients than less effective therapists. Regardless of treatment provided to patients,
therapists need to be able to form an alliance with a variety of patients.
Alliance in Individual Psychotherapy Horvath, Adam O; Del Re, A. C; Flückiger, Christoph ...
Psychotherapy (Chicago, Ill.),
03/2011, Letnik:
48, Številka:
1
Journal Article
Recenzirano
This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data ...sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as "alliance," "therapeutic alliance," "helping alliance," or "working alliance" were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was
r
= .275 (
k
= 190); the 95% confidence interval for this value was .25-.30. The statistical probability associated with the aggregated relation between alliance and outcome is
p
< .0001. The data collected for this meta-analysis were quite variable (heterogeneous). Potential variables such as assessment perspectives (client, therapist, observer), publication source, types of assessment methods and time of assessment were explored.
Objective: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better ...alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. Method: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge.
What is the public health significance of this article?
Improvements in the quality of the patient-rated alliance are associated with subsequent symptom reduction early in psychotherapy, and symptom reduction is associated with further improvement in the subsequent alliance. This meta-analysis provides empirical evidence for good clinical wisdom that collaborative qualities within the therapist-patient relationship and early distress remediation go "hand-in-hand." These results underscore the relevance of respectful, collaborative, and ethically sound care for mental health patients to positively impact therapy outcomes.
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 author's 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. (Contains 1 figure, 1 table, and 3 footnotes.)
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 Cipriani's analysis in particular which creates the concern that the stated superiority of some antidepressants relative to others may be unwarranted.
A Monte Carlo simulation was conducted which involved replicating Cipriani's 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.
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.
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.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Fire and explosion hazards represent a major barrier to the widespread adoption of lithium-ion batteries (LIBs) in electric vehicles and energy storage systems. Although mitigating the flammability ...of linear organic carbonate electrolytes in LIBs is an obvious solution to the thermal safety issue, it often comes at the expense of battery performance and cost. Herein, by combining alkyl-chain extension and alkoxy substitution, which simultaneously decreases solvent volatility and increases solvation ability, we demonstrate that molecular engineering of the linear carbonates presents a viable route to achieving thermally stable high-performance batteries. Although the tailored molecule bis(2-methoxyethyl) carbonate (BMEC) exhibits a flash point that is 90 °C higher than that of conventional electrolytes, the electrolyte quality is still maintained, enabling long-lasting cycling of the flagship electrode combination of graphite and Ni-rich layered oxide over 500 cycles in practical pouch cells. Furthermore, unlike a commercial electrolyte, we demonstrate that the BMEC electrolyte effectively alleviates heat and reactive-gas release under thermal/mechanical/electrical abuse conditions in the presence of charged electrodes, thereby preventing the thermal explosion of a 4 A h pouch cell upon nail penetration.
Concurrent modification of linear carbonates combining alkyl-chain extension and alkoxy substitution enables thermally stable high-performance batteries by decreasing volatility and increasing solvation ability simultaneously.
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.
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.
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.
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.
► Meta-analysis examining therapist effects in the alliance–outcome correlation. ► Therapist contribution to the alliance appears to be important for improved patient outcomes. ► Importance of therapist contributions are present when potential confounds are controlled. ► Effective therapists are able to form alliances across a range of patients.
For most of their existence, stars are fuelled by the fusion of hydrogen into helium. Fusion proceeds via two processes that are well understood theoretically: the proton-proton (pp) chain and the ...carbon-nitrogen-oxygen (CNO) cycle
. Neutrinos that are emitted along such fusion processes in the solar core are the only direct probe of the deep interior of the Sun. A complete spectroscopic study of neutrinos from the pp chain, which produces about 99 per cent of the solar energy, has been performed previously
; however, there has been no reported experimental evidence of the CNO cycle. Here we report the direct observation, with a high statistical significance, of neutrinos produced in the CNO cycle in the Sun. This experimental evidence was obtained using the highly radiopure, large-volume, liquid-scintillator detector of Borexino, an experiment located at the underground Laboratori Nazionali del Gran Sasso in Italy. The main experimental challenge was to identify the excess signal-only a few counts per day above the background per 100 tonnes of target-that is attributed to interactions of the CNO neutrinos. Advances in the thermal stabilization of the detector over the last five years enabled us to develop a method to constrain the rate of bismuth-210 contaminating the scintillator. In the CNO cycle, the fusion of hydrogen is catalysed by carbon, nitrogen and oxygen, and so its rate-as well as the flux of emitted CNO neutrinos-depends directly on the abundance of these elements in the solar core. This result therefore paves the way towards a direct measurement of the solar metallicity using CNO neutrinos. Our findings quantify the relative contribution of CNO fusion in the Sun to be of the order of 1 per cent; however, in massive stars, this is the dominant process of energy production. This work provides experimental evidence of the primary mechanism for the stellar conversion of hydrogen into helium in the Universe.
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