nach oben

Cognitive Therapy and Research

Erschienen in:

05.08.2017 | Original Article

Not Just a Non-specific Factor: Moderators of the Effect of Within- and Between-Clients Alliance on Outcome in CBT

verfasst von: Sigal Zilcha-Mano, J. Christopher Muran, Catherine F. Eubanks, Jeremy D. Safran, Arnold Winston

Erschienen in: Cognitive Therapy and Research | Ausgabe 2/2018

Einloggen, um Zugang zu erhalten

Abstract

The working alliance is one of the most consistent predictors of outcome. Yet, little empirical knowledge exists on how therapists can use this association to maximize the outcome of cognitive behavioral therapy (CBT) for individual clients. The present study aimed to examine pre-treatment client interpersonal characteristics that determine what function the alliance should fulfill in order to maximize its effect on outcome. We did so by identifying moderators of the within- and between-clients effects on outcome. Data of 185 clients receiving CBT treatment was disaggregated to study the effects of the within- and between-clients alliance on outcome. Findings suggest that for clients who described themselves as overly cold and were described by their therapists as low on intrusiveness, state-like strengthening of alliance predicted better outcome, and that for clients not overly cold but overly exploitable, the general tendency of the client to report stronger alliance was associated with better outcome.

Severe major depression was diagnosed using the Structured Interview for DSM-IV-Axis I.

Conditional inference trees estimate a regression relationship by binary recursive partitioning within a conditional inference framework. The algorithm operates as follows: (a) test the global null hypothesis of independence between any of the predictors and the outcome; stop if this hypothesis cannot be rejected, otherwise select the input variable with the strongest association with the outcome; this association is measured by a p value corresponding to a test for the partial null hypothesis of a single predictor and of the response; (b) implement a binary split in the selected predictor; (c) recursively repeat steps (a) and (b).

Because the average correlation within the total score and the subscales was 0.37, the statistical methods used to search for moderators enabled us to introduce both the total and the subscale scores. Conceptually, the total score and the subscales represent distinct types of information regarding the client’s interpersonal tendencies and difficulties. The total score represents the client’s degree of interpersonal distress, whereas the subscales represent the nature of the client’s interpersonal problems, identifying the client’s specific area of interpersonal difficulty (Horowitz et al. 2000). We conducted a sensitivity analysis without the total score and obtained the same findings.

In a post hoc analysis, we examined the ability of the interaction between overly cold and overly exploitable pre-treatment characteristics to directly affect treatment outcome (rather than affect the association between the trait-like component of alliance and outcome). The analysis revealed that the interaction between overly cold and overly exploitable characteristics failed to significantly predict outcome [F _{(1, 3017)} = 0.5, p = .47].

Alden, L. E., Wiggins, S., & Pincus, A. L. (1990). Construction of circumplex scales for the inventory of interpersonal problems. Journal of Personality Assessment, 55, 521–536.CrossRefPubMed

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.CrossRef

Barber, J. P. (2009). Toward a working through of some core conflicts in psychotherapy research. Psychotherapy Research, 19(1), 1–12.CrossRefPubMed

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Publications.

Bergkvist, L., & Rossiter, J. R. (2007). The predictive validity of multiple-item versus single-item measures of the same constructs. Journal of Marketing Research, 44(2), 175–184.CrossRef

Bolger, N., & Laurenceau, J. P. (2013). Intensive longitudinal methods. New York, NY: Guilford.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252.CrossRef

Bowlby, J. (1988). Attachment, communication, and the therapeutic process. In A secure base: Parent-child attachment and healthy human development (pp. 137–157). New York: Basic Books.

Brady, J. P., Davison, G. C., Dewald, P. A., Egan, G., Fadiman, J., Frank, J. D., … Strupp, H. H. (1980). Some views on effective principles of psychotherapy. Cognitive Therapy and Research, 4, 271–306.CrossRef

Braun, J. D., Strunk, D. R., Sasso, K. E., & Cooper, A. A. (2015). Therapist use of Socratic questioning predicts session-to-session symptom change in cognitive therapy for depression. Behaviour Research and Therapy, 70, 32–37. doi:10.1016/j.brat.2015.05.004.CrossRefPubMedPubMedCentral

Castonguay, L. G. (1996). Integrative cognitive therapy for depression treatment manual. Pennsylvania: The Pennsylvania State University.

Castonguay, L. G., Constantino, M. J., McAleavey, A. A., & Goldfried, M. R. (2010). The therapeutic alliance in cognitive-behavioral therapy. In J. C. Muran & J. P. Barber (Eds.), The therapeutic alliance: An evidence-based guide to practice (pp. 150–171). New York, NY: Guilford Press.

Castonguay, L. G., Schut, A. J., Aikens, D. E., Constantino, M. J., Laurenceau, J. P., Bologh, L., & Burns, D. D. (2004). Integrative cognitive therapy for depression: A preliminary investigation. Journal of Psychotherapy Integration, 14(1), 4.CrossRef

Connors, G. J., Maisto, S. A., Schlauch, R. C., Dearing, R. L., Prince, M. A., & Duerr, M. R. (2016). Therapeutic alliances predict session by session drinking behavior in the treatment of alcohol use disorders. Journal of Consulting and Clinical Psychology, 84(11), 972–982.CrossRefPubMedPubMedCentral

Constantino, M. J., Marnell, M. E., Haile, A. J., Kanther-Sista, S. N., Wolman, K., Zappert, L., & Arnow, B. A. (2008). Integrative cognitive therapy for depression: A randomized pilot comparison. Psychotherapy: Theory, Research, Practice, Training, 45(2), 122–134.CrossRef

Crits-Christoph, P., Gibbons, M. B. C., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 298–340). New York NY: Wiley.

Cronin, T. J., Lawrence, K. A., Taylor, K., Norton, P. J., & Kazantzis, N. (2015). Integrating between-session interventions (homework) in therapy: The importance of the therapeutic relationship and cognitive case conceptualization. Journal of Clinical Psychology, 71(5), 439–450.CrossRefPubMed

Derogatis, L. R. (1983). Scl-90: Administration. Scoring and procedure manual-II for the revised version, Tawson, Clinical Psychometric Research.

DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005). A conceptual and methodological analysis of the nonspecifics argument. Clinical Psychology: Science and Practice, 12(2), 174–183.

DeRubeis, R. J., Cohen, Z. D., Forand, N. R., Fournier, J. C., Gelfand, L. A., & Lorenzo-Luaces, L. (2014). The personalized advantage index: translating research on prediction into individualized treatment recommendations. A demonstration. PLoS ONE, 9(1), e83875.CrossRefPubMedPubMedCentral

Falkenström, F., Ekeblad, A., & Holmqvist, R. (2016). Improvement of the working alliance in one treatment session predicts improvement of depressive symptoms by the next session. Journal of Consulting and Clinical Psychology, 84(8), 738.CrossRefPubMed

Falkenström, F., Granström, F., & Holmqvist, R. (2013). Therapeutic alliance predicts symptomatic improvement session by session. Journal of Counseling Psychology, 60(3), 317.CrossRefPubMed

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV axis II personality disorders, (SCID-II). Washington, D.C.: American Psychiatric Press.

Gardner, D. G., Cummings, L. L., Dunham, R. B., & Pierce, J. L. (1998). Single-item versus multiple-item measurement scales: An empirical comparison. Educational and Psychological Measurement, 58(6), 898–915.CrossRef

Goldfried, M. R. (1985). A paradigm shift in cognitive behavior therapy?. Psyccritiques, 30(7), 560.CrossRef

Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. Troy, MO: Holt, Rinehart & Winston.

Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press.

Greenberg, L. S., & Paivio, S. C. (2003). Working with emotions in psychotherapy, (vol. 13). New York, NY: Guilford Press.

Hill, C. E., Castonguay, L. G., Farber, B. A., Knox, S., Stiles, W. B., Anderson, T., … Caspar, F. (2012). Corrective experiences in psychotherapy: Definitions, processes, consequences, and research directions. In L. G. Castonguay & C. E. Hill (Eds.), Transformation in psychotherapy: Corrective experiences across cognitive-behavioral, humanistic, and psychodynamic approaches (pp. 355–370). Washington, DC: American Psychological Association.CrossRef

Hoffart, A. (2016). Cognitive models for panic disorder with agoraphobia: A study of disaggregated within-person effects. Journal of Consulting and Clinical Psychology, 84(9). doi:10.1037/ccp0000114.

Horowitz, L. M., Alden, L. E., Wiggins, J. S., & Pincus, A. L. (2000). IIP, inventory of interpersonal problems manual. New York, NY: The Psychological Corporation.

Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G., & Villaseñor, V. S. (1988). Inventory of interpersonal problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885–892.CrossRefPubMed

Horvath, A. O., Del Re, A., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. doi:10.1037/a0022186.CrossRefPubMed

Hothorn, T., Hornik, K., & Zeileis, A. (2006). Unbiased recursive partitioning: A conditional inference framework. Journal of Computational and Graphical Statistics, 15(3), 651–674.CrossRef

Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59(10), 877–883.CrossRefPubMed

Krull, J. L., & MacKinnon, D. P. (2001). Multilevel modeling of individual and group level mediated effects. Multivariate Behavioral Research, 36(2), 249–277.CrossRefPubMed

Laurenceau, J., & Bolger, N. (2012). Analyzing diary and intensive longitudinal data from dyads. Handbook of Research Methods for Studying Daily Life, 1, 407–422.

Littell, R. C., Milliken, G. A., Stroup, W. W., Wolfinger, R. D., & Schabenberger, O. (2006). SAS for mixed models (2nd ed.). Cary, NC: SAS Institute.

Loo, R. (2002). A caveat on using single-item versus multiple‐item scales. Journal of Managerial Psychology, 17(1), 68–75.CrossRef

Lorenzo-Luaces, L., DeRubeis, R. J., & Webb, C. A. (2014). Client characteristics as moderators of the relation between the therapeutic alliance and outcome in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 82(2), 368.CrossRefPubMedPubMedCentral

Lorenzo-Luaces, L., Driessen, E., DeRubeis, R. J., Van, H. L., Keefe, J. R., Hendriksen, M., & Dekker, J. (2017). Moderation of the alliance-outcome association by prior depressive episodes: Differential effects in cognitive-behavioral therapy and short-term psychodynamic supportive psychotherapy. Behavior Therapy, 48(5), 581–595.CrossRefPubMed

Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: The Analytic Press.

Muran, J. C. (2002). A relational approach to understanding change: Plurality and contextualism in a psychotherapy research program. Psychotherapy Research, 12(2), 113–138.CrossRef

Muran, J. C., Safran, J. D., Samstag, L. W., & Winston, A. (1992). Patient and therapist postsession questionnaires, version 1992. New York: Beth Israel Medical Center.

Muran, J. C., Safran, J. D., Samstag, L. W., & Winston, A. (2005). Evaluating an alliance-focused treatment for personality disorders. Psychotherapy: Theory, Research, Practice, Training, 42(4), 532.CrossRef

Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. Journal of Consulting and Clinical Psychology, 62(1), 185.CrossRefPubMed

Patton, M. J., Muran, J. C., Safran, J. D., Wachtel, P., & Winston, A. (1998). Treatment fidelity measure for three brief psychotherapies. New York: Beth Israel Center.

Raue, P. J., & Goldfried, M. R. (1994). The therapeutic alliance in cognitive–behavior therapy. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 131–152). New York, NY: Wiley.

Robins, R. W., Hendin, H. M., & Trzesniewski, K. H. (2001). Measuring global self-esteem: Construct validation of a single-item measure and the Rosenberg Self-Esteem Scale. Personality and Social Psychology Bulletin, 27(2), 151–161.CrossRef

Rubel, J. A., Rosenbaum, D., & Lutz, W. (2017). Patients’ in-session experiences and symptom change: Session-to-session effects on a within- and between-patient level. Behaviour Research and Therapy, 90, 58–66. doi:10.1016/j.brat.2016.12.007.CrossRefPubMed

Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective. Psychotherapy, 51(3), 381.CrossRefPubMed

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York, NY: Guilford Press.

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80–87.CrossRefPubMed

Santangelo, C., Safran, J., Muran, J., & Winston, A. (1994). Adherence to manualized brief psychotherapy treatments. In Poster presented at the annual meeting of the society for psychotherapy research, Pittsburgh, PA.

Sasso, K. E., Strunk, D. R., Braun, J. D., DeRubeis, R. J., & Brotman, M. A. (2015). Identifying moderators of the adherence-outcome relation in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 83(5), 976–984. doi:10.1037/ccp0000045.CrossRefPubMedPubMedCentral

Strasser, H., & Weber, C. (1999). On the asymptotic theory of permutation statistics. Mathematical Methods of Statistics, 8, 220–250.

Strunk, D. R., Brotman, M. A., & DeRubeis, R. J. (2010). The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. Behaviour Research and Therapy, 48(7), 599–606.CrossRefPubMedPubMedCentral

Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1(3), 207.CrossRef

Turner, A. E., & Muran, J. C. (1992). Cognitive – behavioral therapy for personality disorders: A treatment manual. San Diego, CA: Social & Behavioral Documents.

Wang, L. P., & Maxwell, S. E. (2015). On disaggregating between-person and within-person effects with longitudinal data using multilevel models. Psychological Methods, 20(1), 63.CrossRefPubMed

Wright, A. G., Hopwood, C. J., & Simms, L. J. (2015). Daily interpersonal and affective dynamics in personality disorder. Journal of Personality Disorders, 29(4), 503–525.CrossRefPubMedPubMedCentral

Zeileis, A., Hothorn, T., & Hornik, K. (2008). Model-based recursive partitioning. Journal of Computational and Graphical Statistics, 17(2), 492–514.CrossRef

Zilcha-Mano, S. (2016). New analytic strategies help answer the controversial question of whether alliance is therapeutic in itself. World Psychiatry, 15(1), 84–85.CrossRefPubMedPubMedCentral

Zilcha-Mano, S. (2017). Is alliance really therapeutic? A systematic answer based on recent methodological developments. American Psychologist, 72(4), 311–325.CrossRefPubMed

Zilcha-Mano, S., & Errázuriz, P. (2015). One size does not fit all: Examining heterogeneity and identifying moderators of the alliance–outcome association. Journal of Counseling Psychology, 62(4), 579.CrossRefPubMed

Zilcha-Mano, S., & Errázuriz, P. (2017). Early development of mechanisms of change as a predictor of subsequent change and treatment outcome: The case of working alliance. Journal of Consulting and Clinical Psychology, 85(5), 508–520.CrossRefPubMed

Zilcha-Mano, S., Dinger, U., McCarthy, K. S., & Barber, J. P. (2014). Does alliance predict symptoms throughout treatment, or is it the other way around? Journal of Consulting and Clinical Psychology, 82(6), 931.CrossRefPubMed

Zilcha-Mano, S., Muran, J. C., Hungr, C., Eubanks, C. F., Safran, J. D., & Winston, A. (2016). The relationship between alliance and outcome: Analysis of a two-person perspective on alliance and session outcome. Journal of Consulting and Clinical Psychology, 84(6), 484.CrossRefPubMedPubMedCentral

Zilcha-Mano, S., Solomonov, N., Chui, H., McCarthy, K. S., Barrett, M. S., & Barber, J. P. (2015). Therapist-reported alliance: Is it really a predictor of outcome? Journal of Counseling Psychology, 62(4), 568.CrossRefPubMedPubMedCentral

Titel: Not Just a Non-specific Factor: Moderators of the Effect of Within- and Between-Clients Alliance on Outcome in CBT
verfasst von: Sigal Zilcha-Mano
J. Christopher Muran
Catherine F. Eubanks
Jeremy D. Safran
Arnold Winston
Publikationsdatum: 05.08.2017
Verlag: Springer US
Erschienen in: Cognitive Therapy and Research / Ausgabe 2/2018
Print ISSN: 0147-5916
Elektronische ISSN: 1573-2819
DOI: https://doi.org/10.1007/s10608-017-9866-5

Neu im Fachgebiet Psychiatrie

18.04.2024 | Arterielle Hypertonie | Nachrichten

Update Psychiatrie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Live-Webinar: Aktuelle Leitlinien bei Herz-Kreislauf-Erkrankungen

Springer Medizin

Not Just a Non-specific Factor: Moderators of the Effect of Within- and Between-Clients Alliance on Outcome in CBT

Abstract

Neu im Fachgebiet Psychiatrie

Antihypertensiva schützen auch alte Menschen noch vor Demenz

Delir kann Demenz begünstigen

Zunahme von Geschlechtsinkongruenz und -dysphorie registriert

Vitiligo: Prävalenz steigt und viele Erkrankte werden spät behandelt

Update Psychiatrie

Live-Webinar: Aktuelle Leitlinien bei Herz-Kreislauf-Erkrankungen

Springer Medizin

Abstract

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 2/2018

Using Motivational Interviewing to Manage Process Markers of Ambivalence and Resistance in Cognitive Behavioral Therapy

Miles to Go Before We Sleep: Advancing the Understanding of Psychotherapy by Modeling Complex Processes

Process Factors Associated with Improved Outcomes in CBT for Anxious Youth: Therapeutic Content, Alliance, and Therapist Actions

Methods of Delivering Progress Feedback to Optimise Patient Outcomes: The Value of Expected Treatment Trajectories

Expectancies, Working Alliance, and Outcome in Transdiagnostic and Single Diagnosis Treatment for Anxiety Disorders: An Investigation of Mediation

When is it Effective to Focus on the Alliance? Analysis of a Within-Client Moderator

Neu im Fachgebiet Psychiatrie

Antihypertensiva schützen auch alte Menschen noch vor Demenz

Delir kann Demenz begünstigen

Zunahme von Geschlechtsinkongruenz und -dysphorie registriert

Vitiligo: Prävalenz steigt und viele Erkrankte werden spät behandelt

Update Psychiatrie