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 mARM-C excels, offering a dependable research tool in the digital mental health domain.•Validation of a five-component model confirms mARM-C's exceptional psychometric properties.•Strong ...internal consistency, test–retest reliability, and practical item discrimination boost the measurement tool's credibility.•Proven convergent and criterion-related validity underscores its role in advancing research at the intersection of digital mental health and human–computer interaction.
This research aims to test the reliability and validity of the Chinese version of the mobile Agnew Relationship Measure (mARM-C).
574 college students who had recently used meditation applications were included. 102 of them were chosen for retesting two weeks later. Standards for evaluation included the Digital Working Alliance Inventory (DWAI), Trust of Counseling Scale (TCS), and Client Satisfaction Questionnaire-8 (CSQ-8). The formal questionnaire was created after further modifications based on item analysis and exploratory factor analysis (EFA).
Confirmatory factor analysis (CFA) revealed that the five-component model fit the data well. The mARM-C has intense item discrimination, and each item is substantially and positively linked with the total score of each dimension and the total score of the measure. The mARM-C had fair to excellent internal consistency, split-half, and test–retest reliability. The convergent and criterion-related validity was acceptable.
In conclusion, the results of this study indicate that the Chinese version of the mARM-C has good validity and reliability. It is an effective self-report measure of the DTA.
The quality of the therapeutic alliance between a client and their clinician is thought to play an important role in healthcare but there is limited research about this concept in stroke ...rehabilitation. This study explored the core components of a therapeutic alliance and the factors perceived to impact on its development in a stroke rehabilitation unit.
Interpretive description methodology was used to gather and synthesise participants' experiences of their therapeutic relationships. Ten individual client interviews and one clinician focus group were conducted. Data was were analysed using conventional content analysis.
A therapeutic alliance appeared to consist of three overlapping core components: a personal connection, a professional collaboration, and family collaboration. Clients valued these components to different degrees and priorities could change over time. Alliance breakdowns were perceived to stem from a clinician's incorrect assumptions about their client's relationship preferences or lack of responsiveness to their needs. Recovery of the alliance seemed to depend on the strength of the pre-existing relationship and steps taken to repair it.
Establishing and maintaining a therapeutic alliance appears to be an individualised and complex process. A clinician's ability to use their personal attributes therapeutically, and professional skills flexibly, appeared integral to relationship quality.
IMPLICATIONS FOR REHABILITATION
Developing therapeutic relationships requires a person-centred and sometimes family/whānau-centred approach.
The judicious use of self-disclosure may achieve emotional proximity and yet maintain professional boundaries.
Maintaining relationship health requires a proactive approach to detect and manage relationship disruptions.
Fully automated mental health apps provide a promising opportunity for increasing access to mental health care and resources. Given this opportunity, continued research into the utility and ...effectiveness of mental health apps is crucial. Therapeutic alliance (TA) refers to the relationship between a client and a healthcare professional, and has been shown to be an important predictor of clinical outcomes in face-to-face therapy. Given the significance of TA in traditional therapy, it is important to explore whether the notion of a digital therapeutic alliance (DTA) in the context of fully automated mental health apps also plays an important role in clinical outcomes. Current evidence shows that the conceptualization of DTA in the context of fully automated mental health apps can be potentially different to TA in face-to-face therapy. Thus, a new DTA conceptual model is necessary for comprehensively understanding the mechanisms underpinning DTA for fully automated mental health apps. To the best of our knowledge, this is the first study that qualitatively explored the dimensions of a DTA in the context of fully automated mental health apps. We conducted interviews with 20 users of mental health apps to explore the key dimensions comprising DTA in the context of fully automated mental health apps. We found that although conceptualizations of DTA and TA have shared dimensions, flexibility and emotional experiences are unique domains in DTA. On the other hand, although agreement on goals between a therapist and a client is important in face to face therapy, we found that users can have an alliance with an app without a goal. The importance of goal needs further investigations.
Psychotherapy is an interpersonal process of collaboration toward specified treatment goals. The therapeutic alliance is well established as an important factor of psychotherapeutic change. However, ...the experience of distress in social interactions, commonly referred to as interpersonal problems, might be interfering with the collaborative process during psychotherapy. This study systematically reviews the literature and obtains an estimate of the relationship between pretreatment interpersonal problems and the quality of the therapeutic alliance. Overall, 27 studies with 48 correlation coefficients were included in the final analysis. Due to the nested structure of the data, a three-level meta-analytic approach with a restricted maximum likelihood estimator was applied. Alliance assessment phase, alliance rater, alliance measure instrument, and treatment type were tested as potential moderators. Heterogeneity and publication bias test were performed. The meta-analysis showed a small, but significant negative relationship between interpersonal problems at the beginning of psychotherapy and subsequent therapeutic alliance (
= -.12, SE = .02, 95% CI -.16, -.08,
< .001,
= -.27). Only alliance assessment phase accounted for significant variability. There were no indications for a substantial publication bias. Interpersonal problems of patients before psychotherapy are a robust predictor for lower therapeutic alliance quality, albeit a small effect size. Consequently, patients who experience interpersonal problems may face greater challenges in developing a strong alliance with their therapists, especially in early stages of the treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Although numerous studies have investigated the relationship between the therapeutic alliance and dropout, most have focused on the relationship between alliance quality and psychotherapy outcomes. ...Objective: To compare sessions with therapeutic alliance ruptures and two sessions prior to treatment dropout (pre-dropout) in terms of rupture subtypes, psychotherapists' behavior, attitudes, and session content. Method: We implemented quantitative methods to select the sessions and qualitative methods to analyze them. We analyzed 16 temporary rupture sessions from 12 therapist-patient dyads and 16 pre-dropout sessions from 8 different therapist-patient dyads. The sessions originate from clinical psychology Master's or Doctoral students under supervision in either cognitive behavioral or schema therapy. Pre-dropout sessions were considered unrepaired rupture sessions while rupture sessions were subsequently repaired. Results: Results revealed apparent differences and similarities between the session types in positive and negative psychotherapist behaviors, content intensity, and the type and frequency of ruptures. We explored three new rupture subtypes: attributing positive developments to other sources, indirect speech, and sarcastic hostility. Conclusions: A striking implication is that the frequency of positive and negative psychotherapist behaviors, ruptures, and session content is more likely to decrease in the pre-dropout sessions than in the temporary rupture sessions.
Objective: The study examined the effects of therapeutic alliance (TA; relational bond, task collaboration) on externalizing behavior outcomes, how TA can operate differently when children are seen ...in individual versus group sessions, and how therapist-child disagreement in perceptions of TA affects outcomes. Method: Three hundred sixty children (Ages 9.2-11.8; 65% male; 78.1% Black) identified as having high rates of aggressive behavior by the fourth-grade teachers, and their 20 elementary schools were randomized to group versus individual delivery of the cognitive behavioral intervention, Coping Power. TA ratings were collected from children and therapists at mid and end of intervention using the Therapeutic Alliance Scale for Children. Teacher ratings of children's externalizing and internalizing behavior problems were collected prior to intervention and at 1-year follow-up after intervention using the Behavior Assessment System for Children. Results: Children receiving the intervention individually reported significantly higher trait-like levels of task collaboration than did children seen in groups. Independent of intervention format, higher trait-like levels of therapist-rated bond and task collaboration predicted reduced levels of externalizing problems, and higher trait-like levels of child- and therapist-rated task-collaboration and therapist-rated bond predicted reduced levels of internalizing problems. Differences between therapist and child reports of bond predicted weaker reductions in internalizing behavior for children seen in groups. Conclusions: It is essential to train therapists to develop and assess for TA by midintervention with children with aggressive behavior problems, especially if they are seen in small groups, and to determine if therapists may misperceive the strength of TA.
What is the public health significance of this article?
Therapeutic alliance affects outcomes for children with aggressive behavior and findings add to the strength of the evidence-base for cognitive behavioral intervention. Therapeutic alliance is stronger in individual delivery of intervention to these children. Group-based delivery likely requires intensive training to assist therapists to establish strong task collaboration.
In this introduction to this issue on Rupture–Repair in Practice, we present our understanding of alliance ruptures using common language to appeal to all theoretical orientations. Specifically, we ...define withdrawal movements away from another or oneself (efforts towards isolation or appeasement) and confrontation movements against another (efforts towards aggression or control). In addition to these interpersonal markers, we suggest that therapist emotional experiences can be considered as intrapersonal markers indicating rupture. We emphasize understanding ruptures as relational phenomena. Then we present various pathways toward rupture–repair, highlighting renegotiation of therapy tasks or goals and exploration of patient and therapist contributions and needs. We explain how these paths can be understood as critical change processes that can transform obstacles in treatment into opportunities. We finish with some mention of our alliance‐focused training for self‐development. This issue represents an important step towards demonstrating the transtheoretical and practical potential of rupture–repair.
The components of clinical practice are complex, often ambiguous, and influenced by a wide variety of interrelated contextual factors. As appreciation grows for the impact of individuality, ...complexity, and uncertainty in health processes, effective translation into widespread clinical practice remains limited. In attempts to bring patients effective solutions, well-meaning physical therapists can get trapped in "idea cults," in which a favored idea is supported and others are disparaged. We recommend that physical therapists develop a practice of self-reflection marked by openness and humility to more successfully adapt to the unique needs, values, and preferences of each person. We highlight 4 ways physical therapists can cultivate a more mindful and adaptable clinical approach that can help recognize and navigate the complexities of everyday clinical practice.
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