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William Ming Liu served as action editor. The American Psychological Association task force on empirically supported therapy relationships defined countertransference (CT) management (i.e., awareness of CT) as a "promising" element in psychotherapy research. The present study aimed to examine how changes in therapist CT and awareness of CT relate to therapy process and outcome. The data analysis was based on 41 treatments and used the core conflictual relationship theme to measure CT. We found that changes in therapists' Wishes from the relationship with the patient at the beginning of therapy were related to patients' working alliance and symptom changes at the end of treatment. Changes in therapist awareness of CT moderated the relationship between therapists' wishes from the therapy and patients' symptom changes during therapy. Last, we present a case study and discuss how awareness of CT can help the therapist handle the challenges that arise from it. Public Significance Statement: This study highlights the role of therapists' awareness of their own countertransference (their emotional responses to patients) in improving therapy outcomes. It shows that changes in how therapists understand and manage their feelings toward patients can positively affect the patient's progress and symptom improvement. [ABSTRACT FROM AUTHOR]

Changes in the individual's attachment orientation toward greater security are considered an important clinical goal. One promising underlying process of change in attachment orientation is shifting the emotion regulation tendency, in which the individual progresses from overreliance on the self or on the other to regulate emotional arousal. The present study utilized a computational approach to study shifts in the emotion regulation tendency as these manifest in the patient's and therapist's vocally encoded emotional arousal. The study examined whether shifts in the regulation tendency are associated with decreases in the level of insecure attachment and in strengthening of the therapeutic alliance. Shifts in the regulation tendency were examined throughout the early stages of treatment (Sessions 1–4) using 11,710 talk turns within 52 patient–therapist dyads. Findings suggest that shifts in the emotion regulation tendency are associated with greater strengthening of the therapeutic alliance and a decrease in the level of attachment avoidance. Public Significance Statement: This is the first study that examined the therapeutic importance of shifting the individual's emotion regulation tendency. The study used a computational approach to calculate shifts in the regulation tendency, as it manifests in vocally encoded emotional arousal. Findings suggest that progressing from overreliance on the self or on the other to regulate emotional arousal is associated with strengthening of the therapeutic alliance and with further decreases in attachment avoidance. [ABSTRACT FROM AUTHOR]

Therapists' in-session feelings in psychotherapy can be seen as indications of the development of the therapeutic relationship and the therapeutic process. To manage them appropriately, it is important to know to what extent they may be influenced by patients' pretreatment characteristics. This study aims to improve the understanding of therapists' emotional reactions in the psychotherapeutic setting by investigating if patients' pretreatment mentalization ability and attachment style predicted therapist in-session feelings. In a sample of 87 therapy dyads treated with interpersonal psychotherapy and cognitive behavioral therapy for depression, patient attachment was measured using self-reported Experiences in Close Relationships (ECR) and mentalization using Reflective Functioning (RF). ECR and RF were hypothesized to predict therapist feelings measured by the Feeling Word Checklist–24 at different treatment phases over the full course of treatment. Treatment method, patient age, gender, and pretreatment depression were evaluated as potential confounders. Multilevel modeling was used to analyze the data. Lower RF in patients predicted more negative therapist feelings in the mid- to late-treatment phases and less positive feelings in the late-treatment phase. Self-reported attachment anxiety or avoidance did not predict therapist feelings. Findings indicate that patients' ability to mentalize is important to consider when conducting psychotherapy, as it can influence therapists' feelings in the therapeutic process. Limitations of the present study's approach are discussed, and directions for future research are considered. Public Significance Statement: This study indicates that therapists treating depressed patients with less developed mentalizing capacity feel less positive and more negative feelings in sessions as treatment gets closer to its end compared to when treating patients with better mentalizing ability. However, patient self-reported attachment showed no relationship to therapist in-session feelings. [ABSTRACT FROM AUTHOR]

Research suggests that a client's achievement goal orientation and alliance are important for positive treatment outcomes. However, it is currently unknown how a member's goal orientation and alliance in tandem relate to members' improvement in group therapy, despite conceptual wisdom regarding the additive effect of a high alliance and a mastery or approach goal orientation. Therefore, this study sought to examine the congruence between members' goal orientation and the member–group alliance on members' perceived improvement in group therapy. Data for this study came from 99 clients across 10 interpersonal process groups. Polynomial regression and response surface analysis were used to test the congruent and discrepant effects of members' goal orientation (i.e., approach-performance, avoidance-performance, and mastery orientation) and group alliance on their perceived improvement in group therapy. As hypothesized, members who reported congruent high group alliance and high mastery orientation or approach orientation compared to congruent low alliance and low mastery or approach orientation reported high levels of improvement in group therapy. Regarding discrepant effects, discrepant high alliance and low avoidance orientation compared to low alliance and high avoidance was positively related to improvement in group therapy, and discrepant high alliance and low approach orientation compared to low alliance and high approach was positively related to improvement in group therapy. Last, discrepant high alliance and low mastery and low alliance and high mastery were positively related to improvement in group therapy, suggesting a compensatory effect between mastery orientation and alliance on improvement. Public Significance Statement: This study sought to examine if various levels of a group member's alliance to the group and their goal orientation (mastery orientation, performance-approach orientation, and performance-avoidance orientation) related to their perceived improvement in group therapy. Results indicated that a high alliance to the group and high mastery goal orientation or high approach goal orientation was related to high levels of improvement. Additionally, a low avoidance orientation and high alliance to the group was related to high levels of improvement. This study advances the group alliance literature by studying an understudied yet related construct, members' goal orientation. [ABSTRACT FROM AUTHOR]

The desire to die by suicide has been linked with interpersonal difficulties and impeded clinical outcomes. Despite the emphasis on the therapeutic relationship in clinical guidelines for working with suicidal clients, little is known about how suicidal clients' interpersonal difficulties manifest in clinical contexts. Additionally, there is limited understanding of the therapeutic relationship in single-session suicidal crisis contexts. Our aim was to examine the trajectory of the therapeutic bond in mediating clients' suicidal desire and outcome in single-session suicidal crisis intervention. Single-session online text-based crisis intervention sessions (N = 354; Mage = 29.43, SD = 9.15; 64.5% women) were coded for suicidal desire, therapeutic bond (each quarter), and outcome. We examined the proposed sequential mediating model (suicidal desire to early bond to bond change to outcome) using structural equation modeling. The proposed sequential mediation model fits the data well, χ2(11) = 22.030, p =.0241, root-mean-square error of approximation =.053, 90% CI [.019,.085], comparative fit index =.983, Tucker–Lewis index =.977, and was a better fit than several alternative models. Further, the indirect effect from suicidal desire to outcome through early bond and bond change was significant (b = −0.474, 99% CI [−0.782, −0.203]). Our findings indicate that therapeutic bonds were beneficial for clients with elevated suicidal desire—and—elevated suicidal desire was negatively associated with therapeutic bonds. These findings highlight the importance of training clinicians to navigate the unique challenges of developing therapeutic bonds with acutely suicidal clients. Public Significance Statement: Contemporary suicide theory has emphasized the interpersonal challenges that those with suicidal desire often experience. Our findings indicate that these challenges extend into the clinical context—greater suicidal desire was associated with poorer therapeutic bonds. Despite the difficulty in developing strong therapeutic relationships with suicidal clients, it is important that clinicians prioritize these relationships as we found a strong link between the therapeutic bond and suicidal clients' outcomes. [ABSTRACT FROM AUTHOR]

Using longitudinal client and therapist working alliance ratings, previous research examined how alliance: average value, linear growth, variability, stability (autocorrelation), and partner responsiveness were associated with client outcome. However, no research simultaneously examined all of these dimensions. Omitting important variables in analyses could lead to overestimation of related effects. Therefore, the purpose of this study was to examine these effects simultaneously. Therapists (N = 45) and clients (N = 236) rated alliance after every session (N = 10,720) and clients completed a measure of psychological distress after every eighth session. We used dynamic structure equation modeling to model longitudinal ratings using the longitudinal actor–partner interaction and location-scale models. Across sessions, there were significant linear growth and significant variability in client and therapist alliance ratings. The variability indicates multiple "V" patterns, which have been associated with alliance ruptures. Both actor effects were significant, showing session-to-session stability for client and therapist alliance. In addition, client–partner effect was significant, indicating higher-than-usual client alliance in a session predicting an increase in therapist alliance in the subsequent session. Growth in neither client-rated nor therapist-rated working alliances was significantly associated with client improvement. Lower variabilities (fewer fluctuations) in both client- and therapist-rated working alliances were associated with better outcomes. Higher therapist–actor and partner effects were associated with client improvement, but client–actor and partner effects were not associated with client improvement. Average working alliances were not associated with client improvement. Implications for practice and research were discussed. Public Significance Statement: Session-to-session ratings of how well clients and therapists are collaborating on the work of therapy can be used to enhance client improvement and therapist development; however, these session-to-session ratings contain a lot of different types of information that may be differentially informative about treatment progress. Our research shows that therapists should pay attention to the variability (how much the ratings go up and down) in the ratings over time and how therapist ratings of collaboration in a session are associated with client ratings of collaboration in the subsequent session. High variability in collaboration ratings and little association between therapist rating in one session and client rating in the next session are signs of problems in therapy. [ABSTRACT FROM AUTHOR]

We tested the process of change in Alliance Empowerment Family Therapy (AEFT; Escudero, 2013), a systemic, team-based approach for treating child welfare involved families. Since building and balancing strong personal and within-family therapeutic alliances are crucial for motivating and sustaining change in these multistressed, overburdened families, we assessed alliance perceptions over time in relation to two indices of therapy outcome, youth functioning, and family-specific goal attainment. Specifically, we administered the self-report version of the System for Observing Family Therapy Alliances (Friedlander et al., 2006) following Sessions 3, 6, and 9 to 156 Spanish families seen by 20 therapists in six agencies whose mission is to serve child welfare referred maltreated youth. Results showed that AEFT delivered in M = 11.04 sessions (SD = 3.29) was effective in attaining family-specific goals and improving child functioning, d = 1.16, as rated by the therapist team in coordination with the referring caseworker. A unique aspect of the study was the modeling, at each time point, of the shared therapeutic system alliance, a latent variable consisting of the therapist's rating of the alliance as well as the alliance ratings of the youth and primary caregiver. As we hypothesized, shared alliance perceptions strengthened with time and positively predicted posttreatment outcomes. Moreover, a comparison of linear growth models with and without the therapist's perspective showed that inclusion of the therapist ratings in the shared alliance variables improved the predictability of child and family outcomes. Public Significance Statement: We studied the process and outcomes of Alliance Empowerment Family Therapy (AEFT), a treatment specifically developed for child welfare referred families that emphasizes the therapeutic alliance as the central component of change. As we predicted, the shared alliance perceptions of youth, caregivers and therapists increased in strength over time and positively predicted improved child and family functioning. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the multilevel factor structure of the therapist and client versions of the 12-item Working Alliance Inventory–Short Revised (WAI; Hatcher & Gillaspy, 2006) in the United States and China, and to create a three-item brief version (WAI-B3) using multilevel factor analysis (M-FA) and multilevel item response theory (M-IRT). We gathered eight data sets from two samples each in United States and China with a total of 21,623 sessions from 376 therapists and 2,455 clients. M-FA results with the first four data sets (two American and two Chinese) suggested that the 12-item WAI across therapist and client versions, and in both United States and China showed a dominant general WA factor with three specific subgroup factors corresponding to the Goal, Task, and Bond items. We then constructed a three-item WAI-B3 by selecting items 11, 10, and 9 through M-IRT, as the best representative of Goal, Task, and Bond subscales, respectively, for both the therapist and client versions in United States and China. With the other four data sets (two American, two Chinese) to test the WAI-B3, we found adequate multilevel reliability, structural validity, and convergent validity with the original 12-item WAI scores. Multilevel measurement invariance tests provided tentative and mixed support for the equivalence of WAI-B3 between the American and Chinese data sets and between therapist and client versions. We recommend that the WAI-B3 be used in routine clinical practice to track therapy process, and that the WAI-B3 be tested with other client and therapist populations and cultures. Public Significance Statement: The 12-item Working Alliance Inventory–Short Revised (WAI-SR; Hatcher & Gillaspy, 2006) is best represented by a predominant general working alliance factor and its total composite score can be used to describe both between-session changes or conduct between-therapy-dyad comparisons. Items 11, 10, and 9 in WAI-SR form a brief version WAI-B3 that has solid psychometric properties. Measurement equivalence is supported for WAI-B3 client version across United States and China, and across its therapist and client versions in the United States. Mixed support for equivalence is found for WAI-B3–Therapist across United States versus China, and therapist versus client versions in China. It is recommended that researchers and practitioners incorporate this brief WAI-B3 into their routine clinical practice to continuously track both therapist and client perceptions of their working alliance over the treatment and conduct further cross-cultural investigations. [ABSTRACT FROM AUTHOR]

Meta-analyses have established the alliance as the most robust predictor of outcome in psychotherapy. A growing number of studies have evaluated potential threats to the conclusion that alliance is a causal factor in psychotherapy. One potential threat that has not been systematically examined is the possibility that the alliance--outcome association is driven by low alliance outliers. We examined the influence of removing low alliance outliers on the alliance--outcome association using data drawn from two large-scale, naturalistic psychotherapy data sets (Ns = 1,052; 11,029). These data sets differed in setting (university counseling center, community mental health center), country (United States and Canada), alliance measure (four-item Working Alliance Inventory Short Form Revised, 10-item Session Rating Scale), and outcome measure (Counseling Center Assessment of Psychological Symptoms--34, Outcome Questionnaire--45).We examined the impact of treating outliers in five different ways: retaining them, removing values three or two standard deviations from the mean, and winsorizing values three or two standard deviations from themean. We also examined the effect of outliers after disaggregating alliance ratings into within-therapist and between-therapist components. The alliance--outcome correlation and the proportion of variance in posttest outcomes explained by alliance when controlling for pretest outcomes were similar regardless of how lowalliance outliers were treated (change in r≤ .04, change in R² ≤ 1%). Results from the disaggregation were similar. Thus, it appears that the alliance--outcome association is not an artifact of the influence of low alliance outliers. [ABSTRACT FROM AUTHOR]

This study investigated how client working alliance changed after transferring from one therapist to another: (a) When pre- and post-transfer therapists' attachment anxiety/avoidance were congruently higher or lower and (b) when the pretransfer therapists' attachment anxiety/avoidance were more or less discrepant from the posttransfer therapists. A Tau-U analysis and a multilevel polynomial regression and response surface analysis were used to analyze longitudinal data about 23 transferred clients in open-ended psychodynamic psychotherapy with doctoral-level therapist trainees (n = 29). When first and second therapists' attachment anxiety/avoidance levels were congruent, the higher the two therapists' attachment anxiety and avoidance levels were, the greater was the decrement in clients' ratings of working alliance after transfers. When first and second therapists' attachment anxiety/avoidance levels were discrepant from each other, the more the first and second therapists' attachment were different from each other in terms of anxiety, the greater decrement in clients' ratings of working alliance there was after transfers. Meanwhile, the more the two therapists' attachment avoidance levels were different from each other, the less decrement in clients' ratings of working alliance there was after transfers. Therefore, the attachment orientations of the pre- and posttransfer therapists combined to influence client working alliance after transfers. Limitations and implications of the present research are discussed. [ABSTRACT FROM AUTHOR]

We examined how meaning in life was associated with working alliance (WA) and outcomes, all from the client perspective. Random intercept lagged cross-panel analyses were used to analyze data from intake and after every eight sessions for the first 24 sessions of open-ended individual psychodynamic psychotherapy from 94 clients nested within 12 therapists. We found that, for all four time periods, working alliance in one 8-week time period predicted both Meaning in Life Measure--Experience (MILM-E) and Meaning in Life Measure--Reflectivity (MILM-R) in the subsequent time period, and MILM-R in one 8-week time period predicted client outcome in the subsequent time period. These findings suggest that having a strong working alliance is associated with clients developing more meaning in life, and reflectivity about meaning in life is associated with clients improving in psychotherapy. Implications for practice and research are discussed. [ABSTRACT FROM AUTHOR]

The authors examined how stability/change in working alliance predicted subsequent symptoms, and how stability/change in symptoms predicted subsequent alliance in a sample of 188 adult clients with 44 doctoral student therapists over the course of 893 eight-session time periods of individual psychodynamic psychotherapy. Clients completed the Working Alliance Inventory--Short Revised (WAI-SR; Hatcher & Gillaspy, 2006) after every session and the Outcome Questionnaire--45 (OQ; Lambert et al., 1996) before intake and every eighth session. The authors used multilevel polynomial regression and response surface analyses to examine within-client effects. The authors found that change in the alliance across an eight-session period did not have an immediate temporal effect on symptoms, but when alliance was stable and stronger compared to other periods, subsequent symptoms were lower. Similarly, change in symptoms across an eight-session period did not have an immediate temporal effect on alliance, but when symptoms were stable and lower compared to other periods, subsequent alliance was stronger. These results suggest that sustained improvements in the alliance contribute to subsequent symptom improvements, and vice versa. The authors conclude that it is important to work to improve and maintain improvements in the working alliance and symptoms. Limitations and future directions are discussed. [ABSTRACT FROM AUTHOR]

The alliance has been a leading player in the long-running debate on whether therapeutic change is driven by factors common across distinct treatments or by treatment-specific factors. The present study disentangled between-patients differences in alliance strength from within-patient changes to investigate whether two treatments with identical goals but based on different roles of alliance differ in the within-patient effect of alliance on outcome. Both treatments are aimed at improving the patients' interpersonal abilities, but in the supportive treatment (ST) the alliance is the main specific factor, whereas in the supportive--expressive treatment (SET) it is conceptualized as a common factor. One hundred patients were randomized to receive either ST or SET. Treatment outcome and alliance were assessed weekly. Treatment condition significantly moderated the effect of within-patient changes in the alliance (relative to its mean) on subsequent treatment outcome, so that any increases in state-like alliance predicted lower levels of subsequent depressive symptoms in ST than in SET. [ABSTRACT FROM AUTHOR]

It is not yet fully understood how alliance, cohesion, and climate differentially correlate with client outcome in group therapy, especially when assessed simultaneously. This study aims to elucidate these relationships through an archival analysis of continuous Group Questionnaire (GQ) and Outcome Questionnaire-45 (OQ-45) data from 412 group therapy clients at college counseling centers, which were originally collected by Burlingame, Whitcomb, et al. (2018).We predicted that alliance, cohesion, and climate would each correlate with improvements in outcome and, further, that they would have similar relationships with change in outcome. Results indicate that greater alliance, cohesion, and climate are individually associated with lower distress. This relationship was significant regarding session-to-session fluctuations on individual client scores (p < .01), as well as regarding differences between clients in their personal averages across sessions (p < .01). However, when linear growth trajectories were considered, only alliance was significantly associated with improvement (p < .05). In other words, alliance, climate, and cohesion all correlate with outcome when time is ignored; however, alliance alone significantly correlates with outcome when change over time is taken into account. This study highlights the importance of the client--therapist relationship, emphasizing how alliance is significantly related to change in group therapy. Thus, therapists should prioritize a strong bond with clients. [ABSTRACT FROM AUTHOR]

We used a longitudinal actor--partner interdependence model to examine the codeveloping alliance in alliance empowerment therapy (AET; Escudero, 2013), a manualized team-based approach developed in Spain specifically for child welfare-involved youth. In this first evaluation of AET, we sampled 102 adolescents, 83% of whom had been removed from their homes due to abuse or neglect, and 40% of whom were in crisis at the time of referral. Before each session, clients rated their improvement-so-far; after each session, both clients and therapists completed a brief alliance measure, an adaptation of the System for Observing Family Therapy Alliances (SOFTA-s; Friedlander et al., 2006) for individual therapy. In terms of outcome, clients' improvement ratings were significantly associated with posttreatment changes in overall functioning and personal goal attainment. With respect to the change process, growth was observed in both clients' and therapists' ratings of the alliance over 12 sessions, and an increased similarity in alliance ratings was due to more rapid growth in the therapists' ratings than the clients' ratings. Dynamic structural equation modeling indicated that at higher levels of adolescent goal attainment, a stronger association was observed between increased therapist-rated alliance and goal attainment. In other words, in the most effective cases, therapists were more responsive to how the adolescents seemed to have experienced the alliance in the previous session. The cocreated alliance perceptions were due to therapist (rather than client) responsiveness, as well as to unspecified aspects of sharing a therapy environment over time, such as familiarity with the process, regular meetings, and so on. [ABSTRACT FROM AUTHOR]

This study investigated the interplay between agency and therapeutic bond in predicting patient symptoms in outpatient psychotherapy. A total of N = 731 patients provided measurements of agency (Therapeutic Agency Inventory; TAI), therapeutic bond (bond subscale of Working Alliance Inventory-Short Form Revised [WAI-SR]), and symptoms (Symptom Checklist Short Form [SCL-K11]) every fifth session of long-term treatment for up to 60 sessions. When investigated in separate models, both more agency and a stronger therapeutic bond predicted symptom improvement. However, within-person changes and between-person differences in agency predicted symptom improvement over and above the effects of therapeutic bond. Multilevel response surface analysis was used to further investigate the interplay between agency and therapeutic bond. When both agency and therapeutic bond levels were high, symptoms improved the most. When agency and therapeutic bond ratings differed, symptom ratings were significantly lower when agency exceeded therapeutic bond levels than when therapeutic bond ratings exceeded agency. Findings suggest that both agency and therapeutic bond are important treatment factors, but outcome could be improved when a strong therapeutic bond is combined with an equally strong sense of agency that empowers patients to pursue changes in their lives. When a strong therapeutic bond is present, but the patient feels less agentic, therapists may want to foster agency to improve outcomes. [ABSTRACT FROM AUTHOR]

Based on the social-cognitive theory, this study investigated the dynamic association between counseling trainees' self-efficacy and their clients' outcome (i.e., symptom distress), and the mediating effects of therapist- and client-rated working alliance and session quality. Data set included 1,352 sessions conducted by 87 master's level therapist trainees with their 317 clients in China. Before every session, therapists completed a measure of self-efficacy and clients reported their symptom distress; and after every session, both therapists and clients rated their working alliance and session quality. Results showed that, (a) over the course of therapy, the initial level of therapist self-efficacy did not predict how quickly client symptom declined; (b) the initial level of client distress did not predict how quickly therapist self-efficacy increased; and (c) client distress decline was not related to therapist self-efficacy increase over the course of therapy. However, at the session-to-session level, higher therapist self-efficacy before one session significantly predicted lower client distress before the next session, and higher client distress before one session significantly predicted lower therapist self-efficacy before the subsequent session. Therapist and client perceptions of working alliance were both significant mediators, while their session quality ratings were not. Findings supported the dynamic and reciprocal relationship between therapist self-efficacy and client distress at the immediate session-to-session level rather than the overall trajectory level, and revealed its specific mediating mechanism through the relationship building between therapist and client. [ABSTRACT FROM AUTHOR]

A central tenet of psychodynamic theory of depression is the role of avoided anger. However empirical research has not yet addressed the question of for which patients and via what pathways experiencing anger in sessions can help. The therapeutic alliance and acquisition of patient insight are important change processes in dynamic therapy and may mediate the anger--depression association. This study was embedded into a randomized trial testing the efficacy of Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression. In-session patient affect experiencing (AE) was coded for every available session (475/481) by blinded observers in 27 patients randomized to ISTDP. Dynamic Structural Equation Modeling was used to examine within-person associations between variation in depression scores session-by-session and both patient ratings (alliance) and observer ratings (AE and insight) of the treatment process. Alliance and insight were independent mediators of the effect of anger on next-session depression. However, the relative importance of these two indirect effects of anger on depression was conditional on pretreatment patient personality pathology (PP). In patients with higher PP, in-session anger was negatively related to depressive symptoms next session, with this effect operating through higher alliance. In patients with low PP, in-session anger was negatively related to depressive symptoms next session, with this effect operating through enhanced patient insight. These findings highlight an anger--depression mechanism of change in dynamic therapy. Depending upon patient personality, either an "insight pathway" or a "relational pathway" may promote the effectiveness of facilitating arousal and expression of patients' in-session feelings. [ABSTRACT FROM AUTHOR]

We examined how client working alliance (CWA) and therapist working alliance (TWA), and client-rated functioning (Outcome Rating Scale, ORS) related to client-perceived Cultural Humility (CH) of their therapist across the course of open-ended psychodynamic psychotherapy for 118 clients and 17 therapists. Clients and therapists completed measures of the WA after every session and clients completed the ORS prior to every session. Clients also judged their therapists' CH at Session 3, 8, and then every 8th session. CH data was partitioned into within-client, within-therapist, and between-therapists components and used to predict CWA, TWA, and ORS in a 4-level Hierarchical Linear Modeling (HLM) growth model. Between-therapist differences in CH were not related to next session CWA, TWA, or ORS, nor were these differences related to growth in CWA, TWA, and ORS. Within-therapist differences in CH were only related to the next session's CWA. At the within-client level, time-periods with higher CH, compared to clients' average CH, were associated with stronger next session (i.e., the immediate subsequent session) CWA and TWA, and time periods with lower CH, compared to clients' average CH, were associated with linear increase in CWA and TWA. Time-periods with high CH, compared to clients' average CH, were associated with significant increase in client functioning. Results suggest that lower CH weakens CWA and TWA in the next session but both CWA and TWA strengthen subsequently. By contrast, greater CH has no immediate effect on outcome but with greater CH psychological functioning increased over time. Implications for practice and research are discussed. [ABSTRACT FROM AUTHOR]

Several theorists (Bandura, 1969; Hackney & Goodyear, 1984; Searles, 1955) suggest parallels between the relationship in supervision and the relationship in therapy. We examined supervisor and therapist trainee ratings of supervisory working alliance (SWA) in 1 week predicting client-rated therapeutic working alliance (TWA) and client-rated therapy session evaluation (TSE) in the following week as well asTWAand TSE ratings in 1 week predicting SWA ratings in the following week. Our data included 663 weeks of therapy nested within 28 trainees nested within 15 supervisors, disaggregated into differences between supervisors, differences within supervisors, and differences within trainees. At the between-supervisor level, when supervisors' trainees rated the SWA higher on average compared with other supervisors' trainees' average SWA ratings, their clients' average TWA rating was higher. In contrast, when supervisors rated the SWA higher on average compared with other supervisors' average SWA ratings, their trainees' clients' average TSE rating was higher but the average TWA rating was lower. At the within-supervisor level, when trainees rated a higher SWA on average compared with other trainees' average SWA ratings with the same supervisor, their clients' average TSE rating was higher. The theoretical prediction of parallel relationships in supervision and therapy was supported, but only for between-supervisor and withinsupervisor differences in SWA. We found no evidence that week-to-week changes in SWA or client-rated TWA or TSE reflected parallel relationships. We provide suggestions for further research, including exploring the mechanisms through which supervision relates to the therapy process and outcome. [ABSTRACT FROM AUTHOR]

This review investigated whether ceiling effects on client-reported working alliance measures represent measurement artifacts or valid information related to the formation of the working alliance. Using data from two previously published meta-analyses, a total of 92 estimates of ceiling effects were calculated based on 37 studies with 6,439 participants. Analyses examined the size of ceiling effects, relation with demographic variables, type of alliance measure, and ceiling effect stability across sessions. Moderate to large ceiling effects appeared across score distributions of multiple measures of client-rated alliance, across time administered, and across different sample characteristics such as gender, age, and ethnicity. When examined with the Session Rating Scale (SRS), analyses indicated ceiling effects had a moderate correlation with session number. When SRS ceiling effects were examined in a single study with a large sample of complete cases (N = 2,990) across seven sessions, large initial ceiling effects continued to increase slightly in size across sessions. Higher ceiling effects were also observed with theWorking Alliance Inventory. Given the prevalence and relative stability of ceiling effects on score distributions, working alliance scores do not exhibit the characteristics of a normally distributed continuous variable. While the working alliance has typically been defined in terms of theoretical content such as tasks, goals, and bond, study findings suggest another key element may be a threshold structure where clients shift to an experience of the therapeutic relationship as established. Discussion focuses on directions for alliance research and clinical practice as well as study limitations. [ABSTRACT FROM AUTHOR]

The importance of interdependence processes of patients' and therapists' affect experiences (AEs) over the course of treatment has been highlighted by numerous therapeutic orientations. Yet, most studies have focused on snapshot observations and there is a dearth of knowledge regarding session-to-session patienttherapist AE interdependence, through which the dynamics of AE across treatment can be explored. Using actor-partner interdependence model analysis in a sample of 70 patient--therapist dyads across 16 sessions of psychodynamic treatment, the present study investigated whether (a) at the sample level, patients' and therapists' changes in positive and negative AEs are interdependent throughout treatment, and (b) whether individuals' differences in AE interdependence can be explained by patients' anticipated or general ability to form a strong therapeutic alliance, and by the actual alliance with the therapist during treatment. Findings suggest that patients' and therapists' changes in positive and negative AEs are interdependent throughout treatment. Moderation analysis suggests that when patients report stronger anticipated ability to form a strong alliance, an increase in therapists' negative AE from one session to another predicts a greater decrease in their patients' negative AE in the following session. Additionally, focusing on patients' actual alliance with the therapist during treatment, when patients report a stronger alliancewith their therapist, a subsequent increase in therapists' positive and negative AEs from one session to another predicts greater subsequent increases in their patients' positive and negative AEs in the next session. Taken together, findings suggest that patients' and therapists' AEs are interdependent throughout treatment, though individual differences exist. [ABSTRACT FROM AUTHOR]

Bordin's (1979) theory suggests that therapist techniques that call for client introspection and self-observation will be more effective when the working alliance (WA) is stronger. Psychodynamic therapists use expressive techniques to elicit this introspection and self-observation. We examined whether therapists' use of expressive skills (e.g., encouraging expression of thoughts and feelings; helping clients understand the reasons behind their thoughts, feelings, and behaviors)when theWAis high, versus low,was related to client outcome in open-ended, psychodynamic treatment. Ten therapists rated the WA with their 47 clients, who rated their perceptions of helping skills, after 2,284 counseling sessions. Clients also completed the Outcome Rating Scale (ORS) in reference to the week following each session. We examined time-ordered relationships by creating lagged variables forWA(T-2) and therapist expressive skills (TES; T-1) and used these scores to predictORS ratings (T) in a three-level Hierarchical Linear Modeling (HLM) analysis (sessions nested within clients, nested within therapists). Lagged WA (T-2) and expressive skills (T-1) were decomposed into between-therapist, withintherapist, and within-clients components. We found a 3-way interaction for within-therapist working alliance, within-client WA at T-2, and expressive skills at T-1 predicting ORS at T. When clients who had a weaker WA with their therapist than the therapists' other clients, had a session with a strongerWAthan the client's usualWA, then more expressive skills in the next session was related to better psychological well-being in the subsequent session. Implications and future directions are discussed. [ABSTRACT FROM AUTHOR]

We sampled routinely collected measures of role and outcome expectations, the expanded therapeutic alliance, and relationship satisfaction completed by 253 heterosexual couples seen by 35 therapists in the Marriage and Family Research Practice Network (Johnson et al., 2017) and investigated these variables as interdependent dyadic processes using the latent congruence model (Cheung, 2009) and the mediated actor-partner interdependence model (Ledermann et al., 2011). Taken together, we found a direct association between a couple's mean role and outcome expectation scores at Session 1 and individual partners' alliance perceptions at Session 3. Further, men rated the alliance more favorably when their outcome expectations were higher and the partners' outcome expectations were less discrepant. In terms of role expectations, both men and women began therapy expecting to be more actively engaged in the process than their partner. Whereas women rated the alliance more favorably when they had high role expectations for their partner as well as themselves, men rated the alliance more favorably when they had high expectations for their female partner's engagement in the therapy. Notably, alliance at Session 3 did not mediate the association between initial expectations and Session 4 relationship satisfaction due to a strong association ( r = 0.85) between relationship satisfaction rated prior to Sessions 1 and 4. In other words, although the best predictor of relationship status before the fourth session was how the relationship was perceived before couple therapy began, men's and women's initial role and outcome expectations were important contributors to the early alliance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The aim of this article was to introduce the Asymmetric Fixed Effects (AFE) model to psychotherapy mechanisms of change researchers as a novel way of studying the effects of improvements and deteriorations in the candidate mechanism(s) separately. Alliance-outcome research was used to illustrate the possibility of estimating separate effects of improvements and deteriorations in the alliance. Method: Two archival data sets were used. One was from community-based primary care services in Sweden using the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) and the Working Alliance Inventory-Short form (WAI-S, therapist form) each session with 1,096 patients. The other data set was from a university counseling center in China using the Session Rating Scale (SRS) and the Outcome Rating Scale (ORS) each session with 292 patients. Data were analyzed using the AFE model. Results: The findings indicated that with raw scores, improvements in alliance from one session to the next were followed by lower symptoms/distress scores by the next session, but alliance deteriorations had no effect on next-session symptoms/distress. With alliance deteriorations and improvements defined relative to the sample's average linear change over time, improvements, and deteriorations had equal but opposite effects on next session symptom level. Conclusions: Findings confirm the utility of the Asymmetric Fixed Effect model across two cross-national samples in showing that alliance deteriorations and improvements can predict next session symptoms separately at the within-person level. Findings raise new questions regarding the use of detrending in within-patient mechanism of change studies. [ABSTRACT FROM AUTHOR]

This study analyzed patient--therapist in-session interpersonal complementarity effects on the therapeutic alliance and depression severity during the initial and working phase of cognitive--behavioral therapy for depression. It also explored whether patients' interpersonal problems moderate those complementarity effects. We drew on a sample of 90 dyads derived from a randomized controlled trial of two cognitive--behavioral therapies for depression. Using an observer-based measure, we assessed patients' and therapists' interpersonal behavior in Sessions 1, 5, 9, and 13 and computed their complementarity regarding interpersonal affiliation (i.e., correspondence) and dominance (i.e., reciprocity). Patients completed measures of interpersonal problems at baseline and session-by-session measures of depression severity and quality of the therapeutic alliance. Response surface analyses based on polynomial regressions showed that patient--therapist complementarity in higher affiliative behaviors was associated with a stronger alliance. Interpersonal problems regarding agency moderated the complementarity effects of the dominance dimensions on depression severity. Overly dominant patients benefited more from a nonreciprocal relationship in the dominance dimension, whereas submissive patients benefited more from complementarity in that dimension. Furthermore, interpersonal problems of communion significantly moderated the effects of complementarity in affiliative behaviors on both the alliance and outcome. These results suggest the relevance of both interpersonal correspondence and reciprocity for the psychotherapy process, informing clinical practice in terms of interpersonal responsiveness. The moderation effects of interpersonal problems provide preliminary evidence, which should be replicated in future research, to determine relevant markers indicating for whom a complementary approach would be beneficial in cognitive therapy for depression. [ABSTRACT FROM AUTHOR]

Objective: The association between alliance and therapy outcome is one of the most investigated factors in psychotherapy research. However, even studies using advanced methods estimate effects over a specific time period (interval) between measurement occasions. Thus, it remains unknown how the magnitude and direction of effects depend on the considered time interval, resulting in limited comparability across studies. The current study examines the influence of time on the within-person relationship between alliance and symptom severity. Method: Alliance (WAI-SR) and symptom severity (SCL-K11) were assessed every fifth session in N = 650 patients receiving up to 100 weekly sessions (mode = 55; M = 41.03; SD = 27.23) of individual psychotherapy in a German outpatient clinic. Bivariate continuous-time (CT) structural equation modeling (SEM) was used to estimate within-person cross- and auto-effects. Results: Analysis revealed significant reciprocal within-person cross-effects with stronger relative effects of SCL-K11 on WAI-SR (a21) than vice versa (a12). CT analysis showed that both cross-lagged effects increased for longer time intervals with strongest effects for time intervals of about 40 sessions (a21 = -.47; a12 = --.19). Conclusions: Alliance and symptom severity showed a reciprocal relationship. Expanding current evidence, our analysis showed how the magnitude of these effects depends on the considered time interval. Applying CT-SEM on longitudinal data of the alliance outcome association complements current crosslagged panel analysis and allows to compare results of studies which are based on different time intervals between measurement occasions. Methodological, theoretical, and clinical implications are discussed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This study examined the effects of therapist interpersonal responsiveness on client-rated working alliance in their first psychotherapy session using the ordinary differential equations (ODE) model and multilevel data disaggregation. Responsiveness was operationally defined in this study as therapists adjusting their subsequent level of control/affiliation based on their clients' and their own current level of control/affiliation. Every 2-min segment of 111 first psychotherapy sessions for 111 clients nested within 38 therapists was rated by 11 trained raters on therapist and client levels of control and affiliation. An ODE model produced dynamic coefficients capturing therapists' responsiveness to clients and to themselves in that session, which were then disaggregated into between-therapist and within-therapist components. Hierarchical linear modeling revealed that for the control dimension, at the between-therapist level, therapist responsiveness to the client significantly predicted client-rated working alliance: Client-rated working alliance was (a) highest for therapists who generally increased their level of dominance/submission when their client was more dominant/submissive in the previous turn, and (b) lowest for therapists who generally increased their level of dominance/submission when their client was more submissive/dominant in the previous turn. None of the other associations were significant. Theoretical, methodological, and practical implications are discussed. Public Significance Statement: This study suggests that in the first therapy session, the therapist may benefit from (a) not going along with the client's lead all the time, and using some mildly dominant probing questions to facilitate deeper or broader exploration, and (b) withholding from client's interpersonal pull to be more directive when client is passive/submissive, and remaining a nondominant stance to provide space for the client to take lead. [ABSTRACT FROM AUTHOR]

The therapeutic alliance is one of the most consistent predictors of therapeutic change, including symptom reduction and improvement in wellbeing and quality of life, across a variety of mental health interventions. Yet, little is known about its biological mechanisms. Oxytocin (OT) has been suggested as a biological mechanism by which bonds are formed and strengthened across species. This article is intended to demonstrate the potential of OT as a biomarker of therapeutic change in psychotherapy and counseling psychology, especially of the therapeutic alliance. We delineate three main potential paths of investigation based on the most recent research on OT in parent–child and romantic partner dyads. For each path, we provide a detailed explanation for whom, when, and how OT should be measured. Each path is illustrated using data collected in a randomized controlled trial of psychotherapy for major depressive disorder. These illustrations demonstrate the great potential of OT as a biomarker of (a) trait-like characteristics of the patients and the therapists, (b) the processes of therapeutic change, and (c) the dyadic synchrony between patients and their therapists. The potential clinical contribution of OT as a biomarker for each of these three paths is further demonstrated using a case study. Practical suggestions and directions for future research are discussed. Public Significance Statement: The article highlights the promising potential of OT as a biomarker in psychotherapy research, through the most recent research on the role of OT in parent–child and romantic relationships, as well as through data from a randomized controlled trial of psychotherapy for major depressive disorder. The article provides practical suggestions on how this potential may be realized. Interdisciplinary studies integrating the two fields of inquiry, psychotherapy and OT research, can create new important knowledge that has the potential to make a substantial contribution to clinical practice and complement existing approaches for measuring the process of therapeutic change. [ABSTRACT FROM AUTHOR]

In an attempt to operationalize an implicit aspect of the therapeutic alliance, this article proposes the use of the innovative, objective, and time-efficient analysis of language style matching (LSM; Niederhoffer & Pennebaker, 2002). LSM, defined as the degree of similarity in rates of function words in dyadic interactions, is thought to reflect the extent to which conversational partners are automatically coordinating language styles to achieve a common goal. Although LSM has often been researched in the context of everyday conversations, little is known about the matching of clients and therapists' language style in the psychotherapy process. To demonstrate the clinical usefulness of the LSM approach in psychotherapy, 2 exploratory examples of the application of LSM in long-term psychoanalytic treatments are provided. First, LSM analyses per session and per speaking-turn are described for psychotherapy data of 140 sessions of 7 long-term psychoanalytic treatments in relation to outcome measures. Then, a case study is described in which LSM is triangulated with an observer-rated measure of working alliance in relation to outcome measures. These 2 demonstrative empirical examples were explorative in character and illustrate how LSM might tap into an implicit aspect of the therapeutic relationship, different from the working alliance measured by observers, and relevant for treatment outcome. Future larger-scale psychotherapy studies into the relationship between these implicit aspects of the alliance and treatment outcome and relevant clients and therapists' variables are warranted. Public Significance Statement: Language style matching may offer unique opportunities for the examination of therapist–client interactions within and between sessions, particularly those implicit aspects which elude conscious awareness of the therapist, client, or outside observer, that nonetheless exert an influence on treatment outcome. [ABSTRACT FROM AUTHOR]

Artificial intelligence generally and machine learning specifically have become deeply woven into the lives and technologies of modern life. Machine learning is dramatically changing scientific research and industry and may also hold promise for addressing limitations encountered in mental health care and psychotherapy. The current paper introduces machine learning and natural language processing as related methodologies that may prove valuable for automating the assessment of meaningful aspects of treatment. Prediction of therapeutic alliance from session recordings is used as a case in point. Recordings from 1,235 sessions of 386 clients seen by 40 therapists at a university counseling center were processed using automatic speech recognition software. Machine learning algorithms learned associations between client ratings of therapeutic alliance exclusively from session linguistic content. Using a portion of the data to train the model, machine learning algorithms modestly predicted alliance ratings from session content in an independent test set (Spearman's ρ =.15, p <.001). These results highlight the potential to harness natural language processing and machine learning to predict a key psychotherapy process variable that is relatively distal from linguistic content. Six practical suggestions for conducting psychotherapy research using machine learning are presented along with several directions for future research. Questions of dissemination and implementation may be particularly important to explore as machine learning improves in its ability to automate assessment of psychotherapy process and outcome. Public Significance Statement: Our study suggests that client-rated therapeutic alliance can be predicted using session content through machine learning models, albeit modestly. [ABSTRACT FROM AUTHOR]

Research indicates that patient outcome expectation (OE) correlates with improvement, and that this association may be mediated by better patient-therapist alliances. However, despite OE and alliance being dyadic and dynamic constructs, most research on these direct and indirect associations has assessed these variables from only one dyad member's perspective and at single time points. Addressing these gaps, we used a longitudinal actor-partner interdependence model to first examine OE-alliance associations. Namely, we assessed "actor" effects (relation between each member's OE at 1 session and his or her own next session alliance) and "partner" effects (relation between each member's partner's OE at 1 session and his or her own next session alliance). Second, we tested whether significant actor or partner effects of OE on alliance translated into better patient outcomes (indirect effects). Analyses were conducted at within- and between-dyad levels. Data derived from a generalized anxiety disorder trial in which 85 patients received 15 sessions of either cognitive-behavioral therapy (CBT) or CBT integrated with motivational interviewing. After every session, patients and therapists rated OE and alliance, and patients rated their worry. At the within-dyad level, there were OE-alliance actor effects for both patients and therapists. There was also a within-dyad partner effect; when patients had greater OE at one session their therapists reported better next-session alliances. Finally, all within-dyad effects in turn related to lower subsequent worry. Results reveal ways in which session-by-session fluctuations in both patient and therapist OE translate into better outcomes through their influence on alliance quality. When patients and therapists cultivate a shift toward more optimistic outcome expectation (OE) for a given treatment, it can translate into a better personal experience of their relationship; moreover, when patients shift toward higher OE, it can be contagious for their therapist's experience of the alliance. These OE-alliance "actor" and "partner" effects can also then be parlayed into symptom reduction in brief psychotherapy for generalized anxiety disorder. [ABSTRACT FROM AUTHOR]

Despite meta-analytic evidence showing that alliance is associated with posttreatment outcomes, several open questions still remain regarding this relation. First, we investigate whether (or not) the progressive aggregation of early alliance assessments increases the alliance–outcome relation across 2 distress and 4 subjective change measures. Second, we investigate whether the alliance–outcome relations using subjective change measures are independent from intake distress and early response. Third, we explore whether the progressive aggregation of the alliance on outcomes becomes particularly apparent between or within therapists again investigating these six outcome measures. Data were drawn from N = 430 patients treated by N = 151 therapists. Patient ratings of early alliance were assessed after Session 1 to 6. For outcome, 2 commonly used distress measures at intake and at posttreatment and 4 measures of retrospectively evaluated subjective change at posttreatment are integrated into a series of multilevel models. The proportion of variance in outcome predicted by alliance scores varied considerably depending on the number of alliance assessments which were aggregated, as well as on the type of outcome assessment (distress vs. subjective change measures) explaining up to 15% of outcome variance. Improvements in the strength of prediction with aggregated alliance assessments were most pronounced for subjective change measures for between-therapist components of the alliance. Examining associations with subjective change measures provides an additional, patient-centered perspective of the relation between early alliance and treatment outcomes. Despite ongoing encouragement to systematically consider patient-centered outcomes in clinical research, subjective change measures (i.e., how patients evaluate the change during psychotherapy) are still neglected in guidelines of how to conduct trial research. The present study shows that the alliance–outcome relation is dependent on the number of aggregated alliance assessments, the type of outcome assessment (i.e., distress vs. subjective change measures) and whether intake and early response are adjusted for or not. Aggregated early alliance assessments were shown to relate most strongly to retrospectively evaluated subjective change at posttreatment. Examining associations with subjective change measures provide additional clinical perspectives on process and outcomes when conducting clinical trials and routine outcome monitoring. [ABSTRACT FROM AUTHOR]

Client--therapist synchrony in various channels (e.g., self-reported affect or physical movement) has been shown as a key process in the construction and development of therapeutic alliance. However, psychophysiological synchrony between clients and therapists has been understudied, with the few extant studies typically relying on single-session data, and no studies examining it within the context of emotionfocused techniques. The main aim of the current paper is to examine the role of client-therapist physiological synchrony during segments of one emotion-focused technique--namely, imagery (IM) work--in predicting therapeutic alliance, and to compare it to the role of synchrony during segments of more traditional cognitive--behavioral (CB) techniques. We conducted an open-trial study in which 31 clients with test anxiety received a 6-session protocol-based treatment. Both clients' and therapists' electrodermal activity (EDA) were continuously assessed during sessions. The physiological measures for 5 sessions each (N = 128) were used to compute client--therapist synchrony in IM and CB segments. Therapeutic alliance was assessed using the Session Alliance Inventory. Client--therapist dyads' synchrony during IM and CB segments was, on average, greater than chance. Synchrony varied mostly at the session (vs. the dyad) level. Multilevel analyses revealed that the synchrony within IM segments (but not within CB segments) was significantly associated with the therapeutic bond aspect (but not the task/goal aspects) of alliance. Physiological synchrony during emotion-focused IM is tied to the bond component of the therapeutic alliance at the session level. [ABSTRACT FROM AUTHOR]

A correction to the article "The 'Roller Coaster Ride': A Longitudinal Investigation of the Dynamic Relationship Between Chinese Counseling Trainees' Self-Efficacy and Their Clients' Outcome and the Mediating Effects of Working Alliance and Session Evaluation," by Xu Li et al, that was published online on November 29, 2021, is presented.

The therapeutic alliance in individual and group psychotherapy is associated with treatment outcomes for a variety of disorders. However, debate persists about the centrality of the alliance in determining positive outcomes. We examined the alliance-outcome relationship across 20 sessions of emotionally focused group therapy (EFGT) for binge-eating disorder (BED). We hypothesized that (1) previous session alliance increase will predict lower subsequent session binge eating level while controlling for previous session binge eating level; and (2) previous session binge eating decline will predict higher subsequent session alliance level while controlling previous session alliance level. Participants were 118 individuals with BED who received 20 sessions of EFGT in 8 groups. Levels of binge eating and therapeutic alliance to the therapist were measured weekly. Linear growth in alliance during group therapy was associated with reduced binge eating at 6 months' posttreatment. We also found that the group's and the individual's alliance scores and binge-eating episodes were significantly associated across treatment, suggesting a mutual influence of the group's and individual's experience of the alliance with the therapist. Regarding the first hypothesis, previous session alliance increase was significantly associated with lower subsequent session binge eating. Regarding the second hypothesis, previous session binge-eating decline was not significantly related to higher subsequent session alliance. The findings provide evidence in a group therapy context for a model in which alliance change influences subsequent symptom levels, but not the other way around. [ABSTRACT FROM AUTHOR]

Using a novel approach to assess attachment to therapist from patient narratives (Patient Attachment to Therapist Rating Scale; PAT-RS), we investigated the relationships between secure attachment to therapist, patient-rated alliance, and outcome in a sample of 70 young adults treated with psychoanalytic psychotherapy. A series of linear mixed-effects models, controlling for length of therapy and therapist effects, indicated that secure attachment to therapist at termination was associated with improvement in symptoms, global functioning, and interpersonal problems. After controlling for the alliance, these relationships were maintained in terms of symptoms and global functioning. Further, for the follow-up period, we found a suppression effect indicating that secure attachment to therapist predicted continued improvement in global functioning, whereas the alliance predicted deterioration when both variables were modeled together. Although limited by the correlational design, this study suggests that the development of a secure attachment to therapist is associated with treatment gains as well as predictive of posttreatment improvement in functioning. Future research should investigate the temporal development of attachment to therapist and its interaction with alliance and outcome more closely. To ensure differentiation from patient-rated alliance, observer-based measurement of attachment to therapist should be considered. [ABSTRACT FROM AUTHOR]

Actor-partner interdependence modeling (APIM; Kashy & Kenny, 2000) was used to study the early therapeutic alliance in 74 clients being treated by 29 therapists to explore the relationship between the alliance and treatment progress, while prioritizing the dyadic nature of the alliance. The APIM examines collaboration/ influence by modeling the impact of one dyad member's alliance ratings on the other member's session impact rating (partner effects). In terms of the alliance, the results revealed significant client-actor effects for client ratings of session depth and positivity as well as significant therapist-actor effects for therapist ratings of session smoothness and positivity. For client-rated alliance, there were also significant client-partner effects for therapist ratings of session depth. For clients who made a reliable change in treatment, an increase in client-reported alliance was related to therapist reporting more arousal in the 3rd session. For clients who did not make a reliable change in treatment, client-reported alliance was not related to therapist arousal. Limitations of the study and implications of the findings are discussed. [ABSTRACT FROM AUTHOR]