Psychotherapy: Integration and alliance

Goldman et al. provides a unique voice to the ongoing discussion of effective psychotherapeutic

techniques by way of an analysis of an integrative psychotherapeutic model. They propose to

gauge the effectiveness of Psychodynamic-Interpersonal (PI) and Cognitive-

Behavioral (CB) techniques employed in a Short-Term Psychodynamic

Psychotherapy setting by measuring client’s perception of the strength of

the therapeutic alliance in early therapy.

Situating the state of the research, the authors provide background

and argue for the effectiveness of incorporating several theoretical models

into the psychotherapeutic process. Pure and undiluted forms of

psychotherapy may be archaic, as new research suggests that a combination

of therapeutic techniques from several theoretical orientations may indeed

serve the needs of the client more effectively. Gold and Stricker (2001), for

instance, employed an integration of Cognitive Behavioral, Relational and

Behavioral techniques within a Psychodynamic framework and found that

such a hybrid model is positively correlated with: 1) successful therapeutic

outcomes, 2) aiding the therapist to mediate on several levels of functioning,

and 3) may serve to strengthen the therapeutic alliance.

There is no shortage of research on the correlation of a strong

therapeutic alliance with positive therapeutic outcomes. Indeed, even a brief

Ebscohost search reveals well over 5,000 results. It is no surprise, then, that

the present researchers chose the therapeutic alliance as their moderating

construct. Specifically, the researchers attempted to measure the

effectiveness of therapeutic approaches by gauging the initial therapeutic

alliance of a PI versus a CB approach. The researchers predicted that the

mixture of CB and PI techniques would lead to higher patient ratings of the

therapeutic alliance than the use of PI techniques alone.

Curiously, however, the authors provided no operational definition of

the therapeutic alliance. It’s a tender thought to assume all psychologists

would all operate based on the same construct of therapeutic alliance. Yet

the reality of the theoretically diverse and fragmentary field of psychology

leads this author to wonder how definitional precision would affect research

findings. No doubt, the construct of therapeutic alliance is associated with

trust, bonding and rapport. A brief aside to research the therapeutic alliance,

however, reveals slightly nuanced differentiations in definitions and

approaches. Operational definition and theoretical justification on the use of

the therapeutic alliance as a construct in the present study would have made

for a stronger article.

The 91 (64 female; 27 male) participants in this study were admitted to

an out-patient, University-based Psychodynamic Psychotherapy Treatment

Team. Average age for the participants was 30. All 91 participants received a

DSM-IV Axis I mood disorder diagnosis, with another 55% also receiving an

Axis II diagnosis. The mean GAF score for all participants was 60 (SD= 5.7).

The attending clinicians were 28 (14 male; 14 female) PhD students in an

APA accredited program.

In terms of treatment, after an initial intake evaluation, the

participants remained for an average of 26 sessions over an 8 month period.

The intake evaluation consisted of a Therapeutic Model of Assessment (TMA).

As the authors explain, the TMA employs a multi-method assessment model,

by utilizing interviews, self-reports, performance tasks as well as free

response measures. A Short-Term Psychodynamic Psychotherapy (STPP)

approach was utilized in individual psychotherapy sessions. Briefly, STTP

consists of: 1) Attention to the client’s affect and expression of emotion; 2)

Investigation of topics that the client may seek to avoid, 3) identification of

notable patterns in cognitions, emotions, or inter-personal styles, 4) a

prominence to past experiences, 5) an emphasis on interpersonal

experiences, 6) a focus on the therapeutic relationship/alliance, and 7) an

examination of dreams and fantasies of the client (Goldman et al., 2013).

At the conclusion of the 26 sessions, participants were given a number

of measures, including: Global Assessment of Functioning (GAF), Brief Symptom

Inventory (BSI), Combined Alliance Short Form–Patient Version (CASF-P), and the

Comparative Psychotherapy Process Scale –External Rater Form (CPPS-ER). The CASF-P is

20 item self report measure based on a 7 point Likert scale. The CASF

purports to measure the client’s perception of the strength of the therapeutic

alliance. It consists of four subscales: 1) Idealized Relationship—the extent to

which the client recognizes her ability to disagree with the therapist 2)

Confident Collaboration—the degree of confidence the client experiences

with her therapist, 3) Goals & Task Agreement, and 4) Bond—the degree to

which a client perceives her therapist as trustworthy (Goldman et al., 2013).

Similarly, the CPPS-ER is also a 20 item self report measure based on a 7

point Likert scale, designed to assess the techniques and activities employed by the therapist.

The CPPS purports to measure characteristic features of the Psychodynamic-Interpersonal

(PI) and the Cognitive-Behavioral (CB) approach. Thus, the PI scales would

measure the seven domains of the STPP model outlined above. Conversely,

the CB scales attempt to measure standard CB interventions, such as 1) the

importance of recognizing maladaptive cognitive patterns, 2) instruction in

skills training to clients, 3) homework assignments outside of the therapeutic

setting, 4) providing clear information relating to treatment, symptoms and

diagnosis to the presenting client, 5) session activity direction on the part of

the therapist, and 6) a future oriented, goal directed approach to therapy

(Goldman et al., 2013).

Results indicate client’s overall level of satisfaction with the therapeutic alliance was not

affected by therapist techniques. Interestingly, however, the researchers did discover that those

therapists who employed more CB techniques—in particular CB techniques such as providing

information about the client’s disorder and the rationale of the therapeutic process—had patients

who reported greater scores on the Confident Collaboration scale of the CASF. The authors

suggest that this combination of CB techniques within a psychodynamic

framework would yield greater client confidence levels.

Further, the interaction effect (CB x PI) suggested that greater use of CB techniques were

correlated with higher levels of client—therapist agreement on the Goals and Tasks subscale of

the CASF. Conversely, lower levels of CB use were predictably associated with lower levels of

agreement on the same subscale. The implications for therapy, again, suggest that particularly

within a PI framework, explicit discussion of the nature of psychodynamic psychotherapy and its

personal relevance to the presenting client leads to greater therapeutic alliance satisfaction

scores. That is, the combination of active elements from both a CB and PI approach seem to aid

in the facilitation of strong therapeutic alliance in the initial phases of treatment.

As the authors note, this study was novel in its approach insofar as it

examined the integration of PI and CB techniques to gauge the strength of

the early therapeutic alliance. This innovation aside, the study, as the

authors rightly note, was limited by its low sample size. Although common in

empirical psychotherapeutic studies, this lack of a larger sample size may

limit the studies’ power to detect interaction effects. The distinct outpatient

population is a further limiting factor of the study inasmuch as the clients

experienced only mild to moderate distress in functioning. Finally, as the

sample population was compromised of a disproportionate amount of

Caucasian females, the results may not be absolutely generalizable.

Replication of this work in a more diverse population, including an inpatient

sample, would be highly desirable. These limitations notwithstanding, the

present study offers a worthwhile heuristic for the use of effective

therapeutic techniques that may lead to an increase in the formation of an

early therapeutic alliance.

References

Gold, J., & Stricker, G. (2001). A relational psychodynamic perspective on assimilative integration. Journal of Psychotherapy Integration, 11, 43–58. doi:10.1023/A:1026676908027

Goldman, R. E., Hilsenroth, M. J., Owen, J. J. & Gold, J. R. (2013). Psychotherapy Integration and alliance: Use of cognitive-behavioral techniques within a short-term psychodynamic treatment model. Journal of Psychotherapy Integration, 23(4), 373-385. doi: 10.1037/a0034363

Prepared by Phillip J. Kuna For John G. Kuna, PsyD and Associates Counselinghttp://johngkunapsydandassociates.com/john@johngkunapsydandassociates.com (570)961-3361