Alliance prediction of outcome change in outpatient psychotherapy

Alliance prediction of outcome change in outpatient psychotherapy Aureliano Crameri Agnes von Wyl, Volker Tschuschke, Rainer Weber, Margit Koemeda, Peter Schulthess Zurich, Switzerland & Cologne, Germany 2010 Zürcher Fachhochschule

Interactions between main elements of the therapy process Outcome Therapeutic alliance Interventions

Data collection • Diagnostic assessment at the beginning of the therapy • Every session: Rating of performed interventions • Every 5th session: Rating of alliance and outcome • Diagnostic assessment at the end of the therapy and 1 year later (follow-up)

Measures (1): Diagnostic Assessment • Clinical Syndromes: • SCID-I • Personality Disorders: • SCID-II • Symptoms Distress: • BSI (Derogatis, 1993) • OQ-45 (Lambert et al., 1996) • Motivation for therapy: • FMP (Schneider et al, 1989)  German • CMOTS (Pelletier et al, 1997)  French • Motivational congruence / incongruence: • INK (Holtforth & Grawe, 2003)

Measures (2): Outcome Outcome Questionnaire (OQ-45) • Symptom distress • e.g. “I have trouble falling asleep or staying asleep” • Interpersonal Relations • e.g. “I am satisfied with my relationship with others” • Social Role • e.g. “I work/study to much”

Measures (3):Alliance Helping Alliance Questionnaire (HAQ; Luborsky et al, 1985) • Helpfulness (correlates highly with outcome measures) • e.g. “I can already see that I will eventually workout the problems I came to treatment for” • Cooperation • e.g. “I feel I am working together with the therapist in a joint effort” Patient’s and therapist’s judgment

Measure (4): Interventions Treatment fidelity • Therapist self-rated fidelity for each session by means of a single item measure (0 – 100%) • Example: „My work with this patient today was performed _____ % with the transaction analysis”

Measures (4): Interventions Generic interventions: • Directiveness (=0.80): Interventions with which the therapist structures the session and introduces information or attitudes not previously expressed by the patient • Support (=0.71): empathy, increases trust, enables the acceptance of feelings • Medication (single item): discussions related to the topic of medication

Sample • Therapies with at least 15 sessions

Sample characteristics 59% 45%

Severity of symptoms • BDI-Score of patients with affective disorders: mean=22, sd=8 mild to moderate depression • T-score on the anxiety scale (BSI) of patients with anxiety disorders: mean=70, sd=10

Data analysis Statistical software R 2.10 Number of observations: 1660

Proportion of missing data imputed • Multiple imputation with 3 chains • Longitudinal data was not subject to imputation

Results Zürcher Fachhochschule

Treatment fidelity Random effects

Treatment fidelity Significant fixed effects

Symptom distress Random effects

Symptom distress Significant fixed effects

Interpersonal relations Significant fixed effects

Clinical significance Relative Risk: 2.3 Congruence between alliance rupture and increase of interpersonal problems

Alliance Significant fixed effects Patient’s judgment as dep. variable Therapist’s judgment as dep. variable

Summary Psychopathology Working alliance Working alliance motivation Treatment fidelity Support Symptom distress Interpersonal relations Medication Directiveness & Support

Thank you for your attention Zürcher Fachhochschule

Alliance prediction of outcome change in outpatient psychotherapy