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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
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Interactions between
main elements of
the therapy process
Outcome
Therapeutic
alliance
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Interventions
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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)
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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)
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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”
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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
work out 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
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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”
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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
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Sample
• Therapies with at least 15 sessions
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Sample characteristics
Sex: female
Age
68%
39.5 (12.5)
Axis I (most frequent)
affective disorders
30%
anxiety disorders
13%
both
16%
59%
Axis II
cluster A (schizoid, etc)
5%
cluster B (narcissistic, etc)
17 %
cluster C (avoidant, etc)
23 %
Axis III (general medical
conditions)
11
45%
41 %
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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
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Data analysis
Statistical software R 2.10
Technique
Packages
Multiple imputation
mi
Linear mixed models nlme, lme4
Number of observations: 1660
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Proportion of
missing data imputed
Motivation
Demographic and
anamnestic data
Axis II diagnosis
BSI, BDI
Missing
proportion
19%
1 – 18%
12 %
4%
• Multiple imputation with 3 chains
• Longitudinal data was not subject to
imputation
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Results
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Treatment fidelity
Random effects
Likelihood
ratio
Sig (2 )
13377
320.5
<0.01
Therapist
12531
847.8
<0.01
Patient
12418
114.9
<0.01
Added
random effects
-
13696
Institute
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AIC
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Treatment fidelity
Significant fixed effects
t value
-3.4
sig (MCMC )
<0.01
Alliance (therapist’s judgment)
2.9
<0.01
Psychiatric treatment in the
last 2 years
-2,7
<0.01
Support
4.3
<0.01
Therapist age
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Symptom distress
Random effects
11702
Institute
11703
0.8
0.36
Therapist
11558
147.3
<0.01
Patient
11070
489.8
<0.01
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AIC
Likelihood
ratio
Sig (2 )
Added
random effects
-
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Symptom distress
Significant fixed effects
t value
4.4
sig (MCMC )
<0.01
Alliance (patient’s judgment)
-6.6
<0.01
Alliance (therapist’s judgment)
-4.4
<0.01
Directiveness
2.7
<0.01
Support
2.0
0.04
Medication
2.3
0.02
Anxiety disorder
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Interpersonal
relations
Significant fixed effects
t value
2.5
sig (MCMC)
<0.01
2.3
2.5
0.02
0.01
Motivational congruence
-2.9
<0.01
Alliance (patient’s judgment)
-7.4
<0.01
Alliance (therapist’s judgment)
-2.2
<0.01
Directiveness
3.2
<0.01
Support
2.3
0.02
Anxiety disorder
Cluster A (schizoid, etc)
Cluster C (avoidant, etc)
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Clinical significance
Congruence between alliance rupture and
increase of interpersonal problems
increase of interpersonal
problems
alliance
rupture
no
yes
no
140
44
yes
18 (11%)
16 (27%)
total
158 (100%)
60 (100%)
Relative Risk: 2.3
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Alliance
Significant fixed effects
Patient’s judgment as dep. variable
Session
Motivation for therapy
t value
-3.8
sig (MCMC)
<0.01
3.8
0.02
Therapist’s judgment as dep. variable
Session
Support
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t value
2.6
2.8
sig (MCMC)
0.01
<0.01
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Summary
Psychopathology
Working
alliance
Symptom
distress
Medication
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Working
alliance
motivation
Interpersonal
relations
Treatment
fidelity
Support
Directiveness
& Support
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Thank you
for your attention
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