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This study examined the association between burnout, psychological distress, ward atmosphere, and working alliance (WA) among mental health workers treating patients with schizophrenia spectrum disorder (SSD). Data were collected from 345 patients with SSD and 151 mental health workers across 98 residential facilities (RFs) as part of the DiAPAson project from October 2020 to October 2021. Participants were excluded from the study if they exhibited patient‐operator matching errors, dropped out, or had many missing Maslach Burnout Inventory (MBI) scores. The final sample included 282 patients and 155 healthcare workers. Burnout was assessed using the MBI. Psychological distress was evaluated with the 12‐item version of the General Health Questionnaire. WA and ward atmosphere were evaluated with the WA Inventory and the Ward Atmosphere Scale, respectively, in both staff and patients. Sociodemographic and clinical data was also collected and analysed. Burnout was associated with a less supportive ward atmosphere, a weaker WA, and higher staff distress. Severe psychiatric symptoms evaluated with Brief Psychiatric Rating Scale in patients were also linked to staff burnout levels. Discrepancies in the perceptions of the ward atmosphere and the WA were observed between staff and patients, with patients reporting better perceptions in both domains. Our findings highlight the complex dynamics of well‐being within psychiatric care settings, emphasizing the importance of role clarity, professional autonomy, and a positive ward atmosphere in mitigating burnout. Interventions focused on such factors may help support mental health professionals involved in SSD patient care. ISRCTN registry ID ISRCTN21141466. [ABSTRACT FROM AUTHOR]

Introduction: Recent reports from the World Health Organization and the American Psychological Association have highlighted the gap between the growing need for mental health services and available resources. Even with additional funding, however, the high proportion of clients who drop out after only a few sessions presents a significant obstacle to providing effective help. Methods: Using archival data from the Research Consortium of Counseling and Psychological Services in Higher Education, this study examined relations between client attendance and two constructs of the early therapeutic environment model, working alliance and client distress. Results: Session count evidenced a floor effect, with the mean of the distribution (4.45) <1 standard deviation (SD; 4.11) from the lowest possible score. In contrast, clients' alliance scores (measured with the Working Alliance Inventory) displayed a ceiling effect, with the mean 1.48 SD units from the highest possible score. Analyses indicated that alliance and distress (measured via the Outcome Questionnaire—45) scores exhibit different nonlinear relations with session count. Working alliance scores exhibited a power function indicating that rapid increases in alliance scores during initial sessions were associated with larger session counts. In contrast, distress scores formed a funnel shape with session count such that moderate initial distress was associated with greater attendance. Clients whose alliance scores evidenced a ceiling effect accounted for most of the observed change on the distress measure. Conclusion: To enhance attendance, study findings suggest that, as early as possible, therapists should maximise the client–therapist alliance and moderate the level of client distress. [ABSTRACT FROM AUTHOR]

Purpose: Mental health suffered during the COVID‐19 pandemic lockdown in Scotland. While there was limited availability for face‐to‐face counselling, online counselling was available via telephone, videoconference, email, one‐to‐one chat and group basis. Existing research has failed to examine inter‐modality comparisons of client experiences of online counselling during the COVID‐19 pandemic. Methods: Scottish participants (n = 94) who received online counselling during the COVID‐19 pandemic completed an online survey using quantitative methodology, which explored their experiences of one of five online counselling modalities measured by two reliable scales: the Working Alliance Inventory‐Short Revised and factor one of the Satisfaction with Therapy and Therapist Scale. Additional exploratory analysis investigated whether age, gender, choice of online counselling modality and pre‐COVID‐19 pandemic familiarity with online counselling affected these outcomes. Results: Working alliance and satisfaction outcomes were positively correlated. No significant differences between working alliance and satisfaction scores were found between the five modalities. Female participants, and those who received their preferred choice of counselling modality, had significantly greater working alliance than those who did not. Conclusion: These findings provide insights to clients and practitioners about the variety of synchronous and asynchronous online platforms that can facilitate good therapeutic outcomes. The importance of participant choice of counselling modality was reiterated. The broader implications of the findings and the future direction of a hybrid online and face‐to‐face counselling model were discussed. [ABSTRACT FROM AUTHOR]

Purpose: This is the first of two articles that examine the psychometric properties and treatment outcomes associated with measures of the therapeutic alliance collected in naturalistic settings rather than clinical trials. These articles break new ground in understanding the relationship between measures of alliance and treatment outcome by performing detailed item analyses in order to assess the psychometric properties of each individual item, its propensity to change from session to session and its utility in predicting change in the outcome measure. Methods: Data were taken from the ACORN database for adults attending for psychotherapy treatment in naturalistic settings (N = 147,399). The sample, the largest to date, included only those completing both an alliance measure and an outcome measure at every session. Two sets of three different alliance items are used across three different treatment populations: general outpatient, substance use, and severe and persistent mental health difficulties. To investigate this possibility, the psychometric properties of each item were evaluated, including factor analysis, likelihood of change over time in treatment and correlations between changes in alliance and magnitude of client‐reported improvement in therapy. The predictive validity of each individual item is compared with the predictive validity of their respective three‐item measures. The problem of alliance scores being heavily skewed in a positive direction and the resulting lack of variability from session to session is addressed by categorising change in alliance as same, better or worse, regardless of the magnitude of change. Results: Findings tended to differ from those in clinical trials, with the last alliance score being most predictive of outcome. In this data set, the alliance accounted for, at most, 2% of the variance in outcomes. Measures of the therapeutic alliance demonstrate ceiling effects, and the alliance–outcome correlation is far from linear. Change in alliance score, rather than a single assessment, is more predictive of outcome, regardless of the magnitude of change in the alliance measure, with effect sizes of up to 50% more for those who rated the alliance as worse than for those rating it as no change or better. Conclusion: Therapists using therapeutic alliance questionnaires will benefit from being aware of how the psychometric properties of alliance measures impact outcomes. Even the smallest drop in alliance is predictive of significant clinically meaningful differences. Implications for practice, training and research are considered. [ABSTRACT FROM AUTHOR]

Borderline personality disorder (BPD) is characterized by a pathognomonic instability of interpersonal relationships. Therefore, a good working alliance in the treatment of BPD may go beyond qualitative aspects like agreement on goals and mutual trust, and in particular depend on a balancing of instability. Yet, little is known about working alliance dynamics in the treatment of BPD. Using daily ratings of the Therapy Process Questionnaire, we retrospectively investigated assessments of the stability of the therapeutic alliance during inpatient treatment in 51 patients with BPD and 66 patients with major depressive disorder. Regression analyses were used to investigate whether working alliance was more unstable in patients with BPD and how it was associated to outcome. The working alliance was found to be significantly more unstable in patients with BPD. Yet, a high dynamic complexity of the working alliance was found to be linked to better outcomes in BPD, possibly hinting at the importance of rupture and repair. [ABSTRACT FROM AUTHOR]

The Cultural Formulation Interview (CFI) is a semi-structured interview in the DSM -5 comprised of three parts: a core-16-item questionnaire, an informant version for relatives or relevant others, and 12 supplementary modules placing culture and context at the center of patient assessment and treatment to clarify diagnosis and treatment and ensure patients feel understood. The paper aims to synthesize the current quantitative evidence on CFI's favorability (i.e., whether it is feasible, acceptable, and valuable) for patients, clinicians, and relatives. A mixed-methods synthesis methodology was used to assess the impact of the favorability of the CFI for patients, clinicians and relatives, and clinicians' cultural competence. The synthesis included 10 studies on the clinician's competency, attitudes, training, and diagnosis, three studies on the views of the patients and clinicians about the CFI, and five studies with 34 estimates (n = 581) on the favorability of the CFI for patients, clinicians and relatives. Clinicians reported that the CFI increased their cultural knowledge across research, training, and practice settings. Patients reported that the CFI prioritized their perspective and increased rapport-building. A quantitative estimate from the five studies on the acceptability, utility, and feasibility of CFI from patients, relatives, and clinicians was favorable, suggesting that patients, relatives, and clinicians were satisfied with using the CFI. A protocol for standardizing CFI training and practice to inform future research using mixed-methods designs that include randomized control trials (RCTs) to examine the effect of the CFI on the clinician's cultural competence, working alliance, and patient's level of functioning was recommended. [ABSTRACT FROM AUTHOR]

Background: The abandonment of psychotherapeutic treatments is influenced by various factors, including patient characteristics, therapist traits, and the therapeutic relationship. Despite the well-documented importance of these factors, limited empirical research has focused on the role of the therapeutic relationship and the characteristics of therapist-patient dyads in predicting treatment dropout. This study protocol outlines a longitudinal research project aimed at predicting dropout and non-response in psychotherapy for individuals with personality disorders. The research seeks to identify predictive factors related to psychotherapy outcomes, focusing on patient, therapist, and dyadic elements. Specifically, the study will examine the influence of therapist characteristics (e.g., personality traits, countertransference, responsiveness) on treatment outcomes, explore the impact of relational factors (e.g., treatment expectations, epistemic trust, therapeutic alliance) on therapy effectiveness, and assess how the therapeutic alliance within therapist-patient dyads affects the likelihood of dropout and non-response. Methods: The longitudinal study will include 100 therapist-patient dyads (200 participants) recruited from various Mental Health Services in Milan, Italy. Validated instruments will be administered to both patients and therapists at four-time points: T0 (baseline), T1 (3 months), T2 (6 months), and T3 (1 year). Data will be collected at baseline and at the one-year mark to evaluate the relationships between therapist, patient, and dyadic factors and treatment outcomes. Discussion: Identifying predictive variables associated with high dropout rates can help preempt treatment discontinuation, reducing the financial and operational burdens on mental health services. Understanding these factors will enable the development of targeted interventions to improve treatment engagement and reduce attrition. This approach could enhance outcomes for individuals with personality disorders and lead to more efficient resource allocation and sustainable delivery of mental health care. [ABSTRACT FROM AUTHOR]

In medical settings, disagreement between doctors and patients frequently occurs, and it is considered a potential trigger to elicit conflicts. Hence, the point of departure for this study is the widely accepted view that these kinds of "face-threatening" and "dispreferred" acts need to be modified. Thus, this study sheds light on analyzing doctor-patient's discourse in 25 episodes of online radio medical consultation, reporting on Chinese doctors' mitigated disagreement forms and offering a novel perspective on how Chinese doctors use these mitigated disagreements to turn divergent ideas into alignment with patients in online radio medical consultation. The findings in this study provide preliminary empirical support for the idea that mitigated disagreements can be seen as a sign of relational work and may not destroy but rather strengthen doctor-patient's relations. [ABSTRACT FROM AUTHOR]

AbstractObjectiveMethodResultsConclusionCertain client characteristics are associated with early working alliance difficulties in psychotherapy. However, there is limited quantitative evidence on whether combinations of these characteristics (e.g., intersectional identities, prior treatment experiences) are related to alliance development. The present study leveraged a person-centered research approach to examine profiles of early alliance development and differences in the latent class structure of client characteristics among alliance development profiles.Individual psychotherapy clients (N = 2,579) rated the working alliance for their first four sessions and self-reported demographics, treatment history, and psychological distress. Therapists provided their assessment of clients’ primary presenting concerns at baseline.Latent profile analysis revealed three profiles of working alliance development: high and stable, moderate and increasing, and low and stable. Follow-up person-centered analyses (multigroup confirmatory latent class analysis) indicated that clients in the alliance profiles differed in their combinations of clinical and demographic characteristics. For example, women of color with high baseline distress and a history of prior psychotherapy were over-represented in the low and stable alliance profile.These results are consistent with recommendations to holistically consider how clients’ characteristics and experiences shape psychotherapy processes. Results also highlight the utility of person-centered quantitative methods in psychotherapy research. [ABSTRACT FROM AUTHOR]

Abstract Background The abandonment of psychotherapeutic treatments is influenced by various factors, including patient characteristics, therapist traits, and the therapeutic relationship. Despite the well-documented importance of these factors, limited empirical research has focused on the role of the therapeutic relationship and the characteristics of therapist-patient dyads in predicting treatment dropout. This study protocol outlines a longitudinal research project aimed at predicting dropout and non-response in psychotherapy for individuals with personality disorders. The research seeks to identify predictive factors related to psychotherapy outcomes, focusing on patient, therapist, and dyadic elements. Specifically, the study will examine the influence of therapist characteristics (e.g., personality traits, countertransference, responsiveness) on treatment outcomes, explore the impact of relational factors (e.g., treatment expectations, epistemic trust, therapeutic alliance) on therapy effectiveness, and assess how the therapeutic alliance within therapist-patient dyads affects the likelihood of dropout and non-response. Methods The longitudinal study will include 100 therapist-patient dyads (200 participants) recruited from various Mental Health Services in Milan, Italy. Validated instruments will be administered to both patients and therapists at four-time points: T0 (baseline), T1 (3 months), T2 (6 months), and T3 (1 year). Data will be collected at baseline and at the one-year mark to evaluate the relationships between therapist, patient, and dyadic factors and treatment outcomes. Discussion Identifying predictive variables associated with high dropout rates can help preempt treatment discontinuation, reducing the financial and operational burdens on mental health services. Understanding these factors will enable the development of targeted interventions to improve treatment engagement and reduce attrition. This approach could enhance outcomes for individuals with personality disorders and lead to more efficient resource allocation and sustainable delivery of mental health care.

Establishing trust and building a strong Working Alliance are crucial challenges when working with violent extremist offenders (VEOs). Extensive literature highlights the significance of these elements for effective interventions with this group. However, research has not yet approached the specific steps involved in creating a Working Alliance. This article fills this gap by drawing on in-depth interviews conducted with eight professionals from six European jurisdictions. The article also contrasts insights from practical work with academic state of the art. By offering these insights, the article aims to facilitate the creation of effective Working Alliances and contribute to the academic debates on the disengagement of VEOs.

This study examined how UK and Irish masters’ level coach education programmes cultivate learners’ coaching presence. A cross-section of coach educators and thought leaders from the UK and Ireland were interviewed regarding instructional approaches employed to cultivate learners’ coaching presence. Data were analysed using reflexive thematic analysis. The three main themes and nine sub-themes produced from the data analysis suggest that although coaching presence has been proven critical to coaching outcomes, its place in graduate coach education programmes is inconsistent. Recommendations for improving consistency are discussed.

BackgroundMethodsResultsDiscussionStudies of the alliance–outcome relationship in psychosocial treatments for early psychosis are limited both in number and design, with few utilizing subjective measures as outcomes, multiple alliance timepoints or existing benchmarks to distinguish high or low levels of the alliance. We addressed these gaps in the context of a pilot randomized controlled psychotherapy trial for early psychosis.Twenty-eight clients with early psychosis completed alliance ratings at mid-treatment (4.5 months) and post-treatment (9 months). We tested the alliance–outcome relationship through change scores between mid- and post-treatment and the use of a pre-defined benchmark to distinguish high versus low mid-treatment alliance. We also examined baseline differences between levels of the alliance. Outcomes included objective and subjective targets.Change in the alliance did not predict any outcomes at post-treatment. Clients with high mid-treatment alliance had lower perceived stress and higher psychological well-being at post-treatment. At baseline, clients with high alliance had lower negative symptoms and loneliness as well as higher community functioning and well-being.Use of an empirical alliance benchmark may help identify early psychosis clients who need additional support in alliance formation as well as facilitate positive psychotherapy outcomes [ABSTRACT FROM AUTHOR]

Working alliance is of particular importance in the treatment of hoarding due to high levels of stigma surrounding the diagnosis and low levels of insight in patients. Furthermore, clinician experiences of frustration when treating individuals with hoarding disorder may be a barrier to creating the necessary working alliance. However, evaluation of clinician experiences has been limited to self-reports or qualitative methods. Sentiment analysis of clinical case notes related to hoarding treatment may provide useful information on the relationship between clinician attitudes and patient outcomes. Sentiment analysis involves computerized scanning of text and subsequent ratings of emotional valence for each text string. The purpose of the current study was to use sentiment analysis to analyze clinical case notes from 41 participants who were enrolled in a clinical trial for hoarding disorder. When analyzed as a whole, sentiments spanned almost the entire possible range of values and showed insignificant changes over time, suggesting a stability in clinicians' overall sentiment towards patients. However, time emerged as a significant effect in specific categories, such that clinician sentiment became more negative across treatment sessions for notes relevant to barriers, successes, and concerns, and more positive for notes describing observations and assessments across sessions. The current study indicated that sentiment analysis of treatment notes is feasible; however, conclusions about working alliance are limited without additional input from clinicians (e.g., follow-up interviews). Future research should investigate which clinical interactions are reflected in clinical note sentiment, and whether change in clinician sentiment is associated with treatment outcomes. [ABSTRACT FROM AUTHOR]

This study examined the clinical effects of career counseling on psychological distress and the role of counselor adherence, working alliance, and client neuroticism in predicting these effects. The 239 participants received an average of 7.81 sessions at a university career counseling center. Among clients with a clinical level of psychological distress (n = 179) at the study's inception, 55.87% recovered, 22.35% improved, 19.55% experienced no change, and 2.23% saw an aggravation of their psychological distress. Results showed that a higher level of counselor adherence to the intervention manual significantly increased the probability that clients recovered or improved as compared to not experiencing significant change. Working alliance did not predict clinical change, nor did it moderate the effect of counselor adherence. Clients who improved had higher levels of neuroticism than clients who recovered. [ABSTRACT FROM AUTHOR]

Using stand-alone AI chatbot coaches in organisational coaching is becoming a reality promising to democratise, scale and enhance human coaching. However there is limited research on the hybrid use of human and AI coaching. Using the working alliance theory this paper reports on the perceptions of coaches and clients on the use of chatbot-assisted human coaching. In two qualitative studies coaches (study 1) and clients (study 2) were exposed to an AI chatbot coach assistant after which interviews were conducted and data analysed using thematic analysis. Themes were classified using working alliance theory. Coaches were concerned about the chatbot's potential negative interference in the coach-client relationship. Clients on the other hand described a more synergetic, psychologically safe experience provided the chatbot is endorsed by the human coach. Coaches and clients thought the chatbot was useful for goal tracking, accountability and convenience and stressed as a prerequisite the importance of the chatbot being flexible, reliable and humane. This study provides important initial insights into the under-researched, new frontier of human-AI collaboration in organisational coaching, highlighting the pivotal role of the coach's attitude towards this technology. This knowledge can help to operationalise the immense potential benefits of AI into organisational coaching practice. [ABSTRACT FROM AUTHOR]

In this study, we examined how four components of the therapeutic relationship—working alliance, real relationship, and positive and negative affective reactions of the patient toward their therapist—relate to each other and to the psychotherapy session outcome, from the patient’s point of view. Our simple comprised 700 adult patients in individual psychotherapy who were recruited and participated online. They underwent a baseline evaluation of their most recent therapy session, which encompassed a series of validated self-report measures focused on specific elements of the therapeutic relationship. The results revealed that, from the patient’s perspective, working alliance, real relationship, and positive affective reactions toward the therapist were positively correlated with session outcome, while negative affective reactions were negatively correlated. All components predicted session outcome when simultaneously included in a regression model. Collectively, these four components accounted for 30% of the variance in session outcome. Factor analysis revealed four distinct factors, underlying perceptions of the therapeutic relationship. Notably, the bond dimension of the alliance was sufficiently different from the task and goal dimensions, warranting consideration as a distinct construct. These findings, although cross-sectional, lay the groundwork for a more nuanced investigation of multiple dimensions of the therapeutic relationship. [ABSTRACT FROM AUTHOR]

AbstractObjective:Method:Results:Conclusions:Informed by the person-environment fit theory, this preliminary study examined if a fit between a group member’s treatment experience and their working therapy context (other group members’ aggregated treatment experiences) were related to their level of motivation within a group treatment for healing from internalized weight stigma.We examined the relationship between two types of within-member and between-member’s group cohesion, working alliance, and motivation. Specifically, we utilized the Actor-Partner Interdependence Model to operationalize the impact of actor’s within-member cohesion and alliance (personal changes over time) and between-member cohesion and alliance (individual differences) as well as partner’s within-member cohesion and alliance (contextual changes over time) and between-member cohesion and alliance (contextual differences) on group members’ motivation. This study utilized self-report data from 26 group members who participated in three online weight stigma psychotherapy groups.For cohesion, results suggested that the relationship between partner within-member cohesion and motivation was larger for members who reported low cohesion across all the sessions compared to the other members of their group. Additionally, an individual group member who perceived a group session more cohesive than they did on average, reported increased motivation in that session, and this relationship was stronger for members who on average perceived their group less cohesive than other group members. Lastly, session-level alliance was more strongly associated with an individual member’s motivation in that session when the other group members reported higher group alliance on average.These findings underscore the significance of member-group fit in group therapy and the reciprocal impact of individual members and the group on each other’s therapy outcomes. [ABSTRACT FROM AUTHOR]

AbstractObjective: Previous meta-analyses have shown that client-rated working alliance is negatively correlated with attachment anxiety and attachment avoidance. The purpose of this study is to provide an updated meta-analysis of the relation between alliance and the two dimensions of attachment insecurity. Method: Random effects models were used to examine the relation between the working alliance and attachment anxiety and the relation between the working alliance and attachment avoidance. Results: The overall relation between alliance and attachment anxiety was r = −.09 (p = .01, k = 33, I2 = 43.7%). The overall relation between alliance and attachment avoidance was r = −.13 (p < .001, k = 33, I2 = 44.7%). There was no evidence that these relations varied across study characteristics such as client race or the number of therapists in the study. Conclusion: The results support the negative relations between client-rated alliance and both dimensions of client-rated attachment insecurity. Further research is needed to identify the factors that moderate this relationship, using a more diverse sample of study characteristics and a wider range of measures. [ABSTRACT FROM AUTHOR]

Introduction: Extensive research has explored the incorporation of humor in therapy, revealing its potential positive effects on clients’ mental well-being and personal growth. However, limited research exists on how coaching could benefit from humor as an intervention and how its utilization impacts the interaction processes and outcomes for both the coachee and coach. Therefore, our research focuses on the use and effects of spontaneous humor within professional dialogues. This paper aims to extract insights from academic literature on humor in adjacent fields and apply these insights to the context of coaching. Methods: This paper offers implications for coaching theory and practice, alongside a proposed research agenda. The initial phase involves analyzing reviews on humor in professional contexts, and coaching. Secondly, following the PRISMA guidelines for review, we identified 13 empirical studies, which address the role of humor in counseling, psychotherapy, and mentoring. Results and discussion: Our findings suggest that humor serves as a valuable tool for establishing and deepening the working alliance, fostering adaptive coping mechanisms in clients, and enhancing the cognitive and behavioral process. Moreover, humor is shown to be advantageous for professionals in navigating challenging client relationships. These findings hold significance for the realm of coaching practice as well. In light of these insights, we propose the integration of humor use in education toolkits for coaching professionals. [ABSTRACT FROM AUTHOR]

This study explored the extent that Supervisory Working Alliance (SWA) scores may be subject to ceiling effect. A meta-analysis of 75 SWA scores found a mean ceiling effect estimate (CEE) of 1.51, indicating that scores averaged 1.5 SDs below the score cap. Approximately 92% of scores had evidence of ceiling bias. Supplementary analysis found significant differences in ceiling effect existed among common SWA scales and that international samples evidenced lower ceiling effect than U.S. samples. Authors concluded that SWA scores have been subject to attenuation effects caused by restricted range and the influence of the SWA has likely been underestimated. [ABSTRACT FROM AUTHOR]

Expressive suppression (ES; reducing emotional expression) is linked with reduced social connectedness in individuals with anxiety or depression. One implication is that people who use ES may have difficulty establishing a bond with their therapist which may impede clinical improvement. We examined this hypothesis in 33 adults with clinically elevated anxiety or depression receiving treatment focused on enhancing positive thoughts, emotions, and behaviors. At baseline, participants rated ES for positive and negative emotions during a standardized conversation task designed to generate connectedness. They also rated measures of early (session 3) perceived therapeutic bond and treatment outcomes (i.e. positive affect and social connectedness). ES of positive (r = -.39, p =.018), but not negative (r =.06, p =.747), emotions was negatively associated with therapeutic bond. Therapeutic bond mediated the relationship between greater ES of positive emotions during affiliation and lower post-treatment positive affect, 95% bias-corrected bootstrap confidence interval [−0.021, −0.000], adjusted for pre-treatment positive affect, as well as lower post-treatment social connectedness [−0.397, −0.015]; however, the indirect effect was not significant when accounting for pre-treatment social connectedness (p >.05). ES of positive emotions may be an important factor in the development of therapeutic bond and therefore treatment outcomes for individuals with anxiety or depression. [ABSTRACT FROM AUTHOR]

Objectives: Working alliance is considered an important determinant of outcome of psychotherapy. Patients with posttraumatic stress disorder (PTSD) following childhood abuse (CA-PTSD) may have challenges in building interpersonal relationships, including working alliance. Phase-based treatment provides an opportunity to strengthen alliance prior to trauma-focused treatment. This study aimed to compare the development of working alliance among patients with CA-PTSD in three variants of prolonged exposure (PE) therapy: standard PE, intensive PE (iPE), and skill training in affective and interpersonal regulation + prolonged exposure (STAIR + PE). We also examined the effect of alliance on treatment outcome and dropout. Method: Self-reported PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (Blevins et al., 2015) and patient-rated Working Alliance Inventory (Tracey & Kokotovic, 1989) were assessed in a clinical trial. We analyzed data from 138 adult patients (76.1% female; 42% non-Western). Analyses were performed using mixed-effects models. Results: Patients established a satisfactory alliance early in treatment, which increased over time. For PE and STAIR + PE, a larger decrease in PTSD symptom severity was related to a higher alliance in the subsequent session, but not the other way around. In STAIR + PE, a higher alliance in Phase 1 was related to lower PTSD symptoms in Phase 2. In all conditions, a higher initial working alliance was related to a lower chance of treatment dropout. Conclusion: In the treatment of CA-PTSD, all three variants of prolonged exposure foster positive development of the working alliance. Across conditions, working alliance did not precede symptom decline. Therapists should strive for a strong alliance at the beginning of treatment as this reduces the likelihood of dropout. What is the public health significance of this article?: This study demonstrates that individuals with PTSD report strong alliances with therapists in a variety of trauma-focused therapies. No clear evidence was found that alliance should be built prior to the start of exposure-based treatment sessions. Clinicians are advised to assess the patient's evaluation of the relationship with the therapist early in treatment, as a negative evaluation increases the chance of dropout. [ABSTRACT FROM AUTHOR]

Counselors make important contributions to the counseling relationship, and their attachment organizations can influence the strength, quality, and effectiveness of the working alliance (Bucci et al. 2015). This study explored first year counselor education doctoral students' (n = 7) experiences of being interviewed with the Adult Attachment Interview (AAI; George et al. 1996) as a means of supporting self-awareness and fostering effective counselor-client working alliances. Four superordinate themes emerged: (a) reactions to the AAI interview process, (b) process with AAI feedback, (c) AAI and intrapersonal process, and (d) AAI and interpersonal process. Findings suggest that the AAI is an effective tool in supporting counselor self-awareness regarding attachment strategies and can provide multiple personal and professional benefits, such as increased awareness of conflict and stress management strategies. Implications for clinical practice, counselor education, and future research are discussed. [ABSTRACT FROM AUTHOR]

The effects of traumatic stressors and adversity have implications for relationship outcomes in various professional settings, including clinical supervision. The high prevalence of traumatic experiences among counselors and counselors in training (CIT) suggests a need to explore how CITs experience the supervision relationship in the context of having experienced traumatic and/or adverse events. In recent years, researchers and practitioners have increased attention to trauma-informed practice and principles in clinical supervision, and many have suggested that applying these practices to supervision may improve the supervision relationship and related outcomes. This study explored factors related to CIT satisfaction with supervision and rapport with their supervisor, including adverse childhood experiences (ACEs) and the supervisor's use of trauma-informed practices. Results showed that higher instances of ACEs were associated with lower ratings of satisfaction and rapport in supervision. Hierarchical regression models indicated that students' perceptions of supervisors' application of trauma-informed practices were associated with stronger supervision working alliance and higher satisfaction with supervision. [ABSTRACT FROM AUTHOR]

In this article we explore some of the processes involved in dealing with Social Difference (SD) in coaching. Using examples from our own practice, we consider several factors, including the identity work involved in navigating the experience of SD in one-to-one coaching. Dealing with experiences of difference, including social class, gender, race, ability, and sexuality can invoke complicated and powerful feelings. Feelings of guilt, shame, anger, and isolation may cause impasses and ruptures in the coaching relationship. The article also sets out to test two hypotheses. Namely that working with questions of SD can enrich coaching if the Working Alliance (WA) is experienced as positive, and that issues of SD are better managed if they are discussed explicitly. We draw on social constructionist conceptions of identity, together with Rothberg’s work on the implicated subject, to facilitate inquiry into SD and identity for ourselves as coaches, as well as for our coachees. This is the work of re-examining ourselves, re-thinking who we are, and moving beyond the unwanted aspects of the self which may provoke existential feelings of guilt, shame, anger, and isolation, as accumulated through or aggravated by the current and historical woundings of oppression and social injustice. Our research tells us that it is by facing into the complicated emotions engendered by SD, that we can begin to embrace what we psychically and socially “disown.” We suggest that by recognizing our implicated selves, we may become better equipped psychologically, to be more sensitive and responsive to the impact that SD has on individuals, groups, and organizations. We discuss the ways in which a relational stance in coaching can help to provide a secure holding environment for critical and reflexive inquiry into SD, identity and the selves we enact. We conclude that a relational and implicated approach in coaching provides a wider perspective and extends the critical capacity of leaders to look within themselves and into their challenges with more congruence and ethical maturity.

Introduction: A depressive disorder during adolescence is a serious and disabling disorder, which has a high impact on the development of adolescents. Blended treatment, combining online and face-to-face sessions, is effective and can reduce some of the barriers for adolescents to use mental health care. There is a lack of knowledge about whether therapeutic alliance is established in blended treatment for adolescents and young adults suffering from a depressive disorder. This study examines whether the quality of the therapeutic alliance differs when cognitive behavior therapy (CBT) is delivered in combination with online intervention (b-CBT) compared to solely face-to-face (FtF-CBT) and the extent to which a stronger therapeutic alliance is associated with better treatment outcome. Methods: A pragmatic quasi-experimental design was used. Data collected within two separate studies were combined. A total of 85 participants (80 % female), aged 13–22 (mean = 16.63, SD = 1.92) were recruited within mental health care institutions and diagnosed with a depressive disorder (using K-SADS). Assessments were done at pre-treatment (T0), after five weeks (T1), after ten weeks (T2), post-treatment (T3) and one to four weeks after treatment (T4) and included measures of depressive symptomatology (CDI-2). The therapeutic alliance was measured at T1, T2 and T3 by the TASC. t-tests for independent samples were used to test differences in therapeutic alliance rates between b-CBT and FtF-CBT at post-treatment. A linear growth model for depressive symptoms based on five time points with Latent Growth Curve Analysis (LGCA) was used to test whether the therapeutic alliance is associated with depressive symptoms. Results: No differences in therapeutic alliance between b-CBT and FtF-CBT were found on either client-rated or therapist-rated therapeutic alliance. For both intervention groups, no significant association between the therapeutic alliance and depressive outcome was found. Discussion: This study shows that providing part of CBT using an online environment does not have a negative impact on the therapeutic alliance. In contrast to earlier research, no association was found between the therapeutic alliance and therapy outcome in neither the b-CBT nor the FtF-CBT intervention.

Abstract Background Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss. Methods 228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10). Results Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms. Conclusion The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions. Trial registration Not applicable.

The coaching literature emphasizes the role of the coach–coachee working alliance in obtaining positive coaching outcomes and proposes that a good match between coach and coachee promotes this working alliance. However, existing coaching research has some methodological shortcomings that limit drawing robust conclusions about the importance of coach–coachee fit and working alliance for coaching effectiveness. In this study, we investigate coach–coachee fit as an antecedent of the working alliance and its effects on coaching outcomes. Using a three‐wave study design, 184 coachees participating in a workplace coaching program in healthcare answered online surveys before, halfway‐through, and approximately one month after coaching. We measured both coachee‐rated and coach‐rated working alliance and, based on person‐environment fit theories, we included three measures of coach–coachee fit, that is similarity‐fit, general needs‐supplies fit, and idiosyncratic needs‐supplies fit. Multilevel path modelling revealed that only idiosyncratic needs‐supplies fit, where the coach fulfils a coachee's unique needs, related positively to coaching satisfaction through coachee‐rated working alliance and predicted improved goal attainment. Coachees’ similarity‐fit related positively to their assessment of the working alliance but, unexpectedly, predicted lower coaching satisfaction. Coach‐ and coachee‐rated working alliance related to coaching satisfaction but not goal attainment. These findings make a unique contribution to current debates in the coaching and person‐environment fit literatures and advance our understanding of the role of coach–coachee fit and working alliance for affective and behavioural coaching outcomes. [ABSTRACT FROM AUTHOR]

Objective Research has given limited attention to the distinction between patients from rural and urban areas, especially concerning the frequent overlap between rural living and low socio-economic status (SES). To shed more light on this, we explored the differential treatment processes between patients from rural and urban areas. Method Seven hundred and fourteen patients recruited from a university counseling center in China filled out the questionnaires for Outcome Expectation (OE), Session Alliance Inventory (SAI) and Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) each session. Data was analyzed using the disaggregated cross-lagged panel model and the asymmetric fixed-effect model. Results The findings indicated a reciprocal within-patient relation between OE and SAI for the whole sample. SAI mediated the effect of OE on next-session CORE-OM for patients from rural areas, with a significantly greater indirect effect than for patients from the urban areas. Asymmetric effects were found for OE among patients from urban areas, for whom drops in OE predicted worse next-session CORE-OM more strongly than improvements in OE predicted improved CORE-OM. Conclusion This study provided preliminary evidence for differential OE-alliance-outcome predictions between patients with different SES and affirmed a reciprocal OE-alliance relation in a Chinese sample during the transition period of college. [ABSTRACT FROM AUTHOR]

Objective: Although teletherapy is increasingly common, very little is known about its impact on therapeutic relationships. We aimed to examine differences between therapists' experiences of teletherapy and in-person therapy post-pandemic with regard to three variables pertinent to the therapeutic relationship: working alliance, real relationship, and therapeutic presence. Methods: In a sample of 826 practicing therapists, we examined these relationship variables, as well as potential moderators of these perceived differences including professional and patient characteristics and covid-related variables. Results: Therapists reported feeling significantly less present in teletherapy and their perceptions of the real relationship were somewhat impacted, but there were no average effects on their perceived quality of the working alliance. Perceived differences in the real relationship did not persist with clinical experience controlled. The relative reduction in therapeutic presence in teletherapy was driven by the ratings of process-oriented therapists and therapists conducting mostly individual therapy. Evidence for moderation by covid-related issues was also found, with larger perceived differences in the working alliance reported by therapists who used teletherapy because it was mandated and/or not by choice. Conclusion: Our findings might have important implications for generating awareness around the therapists' lowered sense of presence in teletherapy compared to in-person teletherapy. [ABSTRACT FROM AUTHOR]

In psychotherapy, emotional tears occur frequently but have received limited attention. We set out to replicate and extend findings of previous studies conducted in Italy (Genova et al., 2021) and Israel (Katz et al., 2022) with U.S. clients. We hypothesized that positive crying experiences would be associated with improvement and stronger alliance, as well as that insecurely attached patients would tend to view crying as more intense but also more meaningful. One hundred twenty-four patients completed an online survey about crying in therapy as well as measures assessing therapeutic change, working alliance, and attachment. Findings revealed that postcrying positive feelings were linked with greater reported improvement. Several crying experiences were related to both change and alliance. All significant relationships between crying experiences and change remained significant after partialing the effects of attachment, and all but one remained significant after partialing the effects of the alliance. Participants who cried in therapy reported greater improvement compared to those who denied crying in therapy. Despite greater discomfort, less securely attached clients tended to report feeling better understood by their therapists after crying. These findings replicate and extend previous international studies in a U.S. sample, providing support for their cross-cultural relevance and previous evidence that clients' crying experiences are related to both change and alliance. In conclusion, we suggest that therapists conceptualize instances of crying in therapy as a sensitive relational moment with potential positive or negative consequences, dedicate time to exploring experiences around crying, and specifically process crying experiences of insecurely attached patients. Public Significance Statement: This study demonstrates that patients' crying experiences in psychotherapy are linked with reported treatment change and the working alliance. In addition, those who endorse higher levels of insecure attachment tend to be more sensitive to how crying in therapy is experienced but also tend to find value in relation to being understood by their therapist. These findings are particularly important for psychotherapists in considering strategies responding to crying in psychotherapy as well as the value of exploring crying's experience and meaning with the client. [ABSTRACT FROM AUTHOR]

This study examined the reciprocal association between counseling trainees' trait and state anxiety and their clients' symptom distress and the mediating effects of working alliance. Data set included 6,888 sessions conducted by 211 master's level beginning therapists with their 1,216 clients in China. Trainees completed a measure of trait anxiety at the beginning of practicum. Before each session, trainees completed the state anxiety measure and clients reported their symptom distress; and after every session, both the trainees and clients rated their perceived working alliance. Multilevel modeling showed that (a) Therapist trainees' level of trait anxiety did not predict overall client outcome in terms of symptom reduction. (b) At the session-to-session level, higher therapist state anxiety before one session significantly predicted higher client distress before the next session, and higher client distress before one session significantly predicted higher therapist state anxiety before the subsequent session. (c) Therapist and client perceptions of working alliance were both significant mediators of the reciprocal relationship between therapist state anxiety and client distress. Findings suggested that it was trainees' state anxiety, instead of trait anxiety, that reciprocally related to client symptom outcome at the session-to-session level. Implications for clinical training were discussed. PRACTICAL IMPLICATIONS A generally more anxious therapist trainee does not seem to have worse overall clinical effectiveness compared with a generally less anxious trainee. From session to session, trainees who experience less state anxiety tend to establish a stronger working alliance with their clients, which leads to more client symptom relief. Evidence suggests against selecting trainees based on their trait anxiety level; but it is recommended that supervisors help trainees manage their state anxiety before a session. [ABSTRACT FROM AUTHOR]

The real relationship and working alliance are considered sister concepts, because, even though they are distinct elements of the therapeutic relationship, they seem to be highly interrelated, especially regarding the bond element of the relationship. Both concepts are considered to contribute significantly to the therapy outcomes, but some questions remain regarding their relationship, similarities, and conceptual differences. The present study aimed to examine the association of real relationship and working alliance across studies and analyze their contribution to treatment success. For this purpose, we conducted a meta-analysis on these two constructs and performed a quantitative analysis to differentiate the contribution of real relationship and working alliance for psychotherapy outcomes. Results from the meta-analysis confirmed the theorized association between real relationship and working alliance, revealing an overall correlation of r =.66. Based on our quantitative analysis, real relationship seems to be as good a predictor as the working alliance, although both benefit from each other. The research findings underline the importance of considering the contribution of these two concepts for therapeutic outcomes. Therapists should pay attention to both real relationship and the working alliance as key factors that improve therapy success. [ABSTRACT FROM AUTHOR]

Purpose: This is the second of two articles that examine the psychometric properties and treatment outcomes associated with two measures of the therapeutic alliance in naturalistic routine settings. Methods: Data were taken from the ACORN database for youth, and, where available, parent/carer, attending for psychotherapy treatment in naturalistic settings (N = 12,573). The sample, the largest to date, included only those completing both an alliance measure and an outcome measure at every session. Two sets of three different alliance items are used across the two populations in routine practice. Results: Analyses revealed that the alliance explained no more than 3% of the variance in outcomes. Alliance measures exhibit ceiling effects, and as such, drawing conclusions about correlations with outcomes can be difficult. Any drop in alliance score as rated by both youth and parent/carer is predictive of outcomes, with parent/carer ratings being marginally more predictive. Where the alliance is rated as better by youth or parent/carer in comparison with ratings as worse, effect sizes are up to 50% better for the youth. Conclusion: The therapeutic alliance remains an important non‐specific treatment component; however, measures of the alliance have ceiling effects. Both youth and their parent/carer can provide important feedback to the therapist, and any drop in alliance is predictive of clinically meaningful change. As such, therapists should monitor the alliance with both youth and parent/carer. Implications for practice, training and research are considered. [ABSTRACT FROM AUTHOR]

Objectives: Working Alliance (WA) is important in the care of patients with Schizophrenia Spectrum Disorders (SSD). This study aims to determine which sociodemographic and clinical factors are associated with WA, as assessed by patients and staff members in Residential Facilities (RFs), and may predict WA dyads' discrepancies. Methods: Three hundred and three SSD patients and 165 healthcare workers were recruited from 98 RFs and characterized for sociodemographic features. WA was rated by the Working Alliance Inventory (WAI) for patients (WAIP) and staff members (WAI- T). SSD patients were assessed for the severity of psychopathology and psychosocial functioning. Results: Pearson's correlation revealed a positive correlation (ρ = .314; p < .001) between WAI- P and WAI- T ratings. Linear regression showed that patients with higher education reported lower WAI- P ratings (β = -.50, p = .044), while not being engaged in work or study was associated with lower WAI- T scores (β = -4.17, p = .015). A shorter lifetime hospitalization was associated with higher WAI- P ratings (β = 5.90, p = .008), while higher psychopathology severity negatively predicted WAI- T (β = -.10, p = .002) and WAI- P ratings (β = -.19, p < .001). Better functioning level positively foresaw WAI- T (β = .14, p < .001) and WAI- P ratings (β = .12, p < .001). Regarding discrepancies, staff members' age was associated with higher dyads discrepancy in Total scale and Agreement subscale scores, which were also associated with more severe negative symptoms, while patients' age was negatively correlated to Relationship subscale discrepancy. Conclusions: This study provides insight into the factors that influence WA in SSD patients and health workers in RFs. The findings address interventions to improve WA and ultimately patient outcomes. [ABSTRACT FROM AUTHOR]

Working alliance theory describes the therapist–client relationship in psychotherapy and has been adapted to study workplace coaching effectiveness. The application of this theory in workplace coaching research has produced mixed results suggesting that additional factors could be at play. In workplace coaching, the organization often pays for and influences the coaching process. The role of the organization in the working alliance between coach and coachee has, however, not been studied sufficiently. his exploratory, hybrid deductive–inductive qualitative study used the Working Alliance Inventory as theoretical lens to examine coachees' perspectives on the organizational role in the coach–coachee working alliance. The findings indicate that organizations have a direct impact on the bond, task, and goals of the working alliance by facilitating the coaching process, influencing the coaching agenda and contract, and through coach selection. This tentative analysis suggests that measurements of the working alliance should be extended to include these organizational aspects. [ABSTRACT FROM AUTHOR]

The current study examined the self-reported working alliance of men attending a high intensity sexual offense treatment program and its associations with psychopathy, sexual violence risk, treatment change, and recidivism, in a Canadian sample of 317 incarcerated men followed up an average of approximately 10 years post release. Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) self-reported total, Task, Bond, and Goal scores were positively correlated with treatment related changes in risk, and inversely associated with Psychopathy Checklist-Revised (PCL-R; Hare, 1991 ; Wang & Hare, 2003) scores. The Affective facet of the PCL-R, representing the callous-unemotional features of the syndrome, uniquely predicted lower Bond and Goal scores controlling for the other facets. Cox regression survival analyses demonstrated that sexual violence risk predicted increased sexual recidivism while change predicted decreased sexual recidivism controlling for PCL-R total score; however, WAI scores (particularly the Goal component) were also unexpectedly associated with increased sexual recidivism. For violent recidivism, psychopathy, risk, and change incremented the prediction of general violence, while the WAI was not significantly associated with this outcome. A set of parallel analyses, stratified by Indigenous ethnocultural heritage, demonstrated some continuity, but also potential areas of difference, in substantive findings. Risk, need, responsivity implications of the working alliance for the treatment of high psychopathy correctional clientele, and how this may intersect with Indigenous heritage, are discussed. [ABSTRACT FROM AUTHOR]

Background: Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss. Methods: 228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10). Results: Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms. Conclusion: The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Objective: The therapeutic alliance is broadly linked with positive outcomes. However, nearly all research in this area involves in‐person therapy, whereas teletherapy has grown increasing common since the COVID‐19 pandemic. There is now a pressing need to establish whether the nature and importance of the therapeutic alliance is impacted by teletherapy. This study examined therapeutic alliance in families of youth with anorexia nervosa who were participating in a randomized controlled trial that transitioned from in‐person to telehealth visits during the COVID‐19 pandemic. Method: We analysed data from 53 adolescents and their parents (20 began in‐person, 33 began with telehealth). Both parents, youth and therapist completed the Working Alliance Inventory–Short Revised after 4 weeks of treatment. Results: We found no significant differences across telehealth and in‐person treatment for paternal or therapist reported data. However, both adolescents and mothers reported higher bond and goal‐related alliance for in‐person sessions compared to telehealth. Conclusions: Findings regarding alliance across telehealth and in‐person sessions were mixed, with some preference among mothers and youth for in‐person treatment. Future studies should determine whether possible adaptations can improve working alliance during family‐based treatment for anorexia nervosa via telehealth. [ABSTRACT FROM AUTHOR]

Clinicians and patients seeking electronic health applications face challenges in selecting effective solutions due to a high market failure rate. Conversational agent applications ("chatbots") show promise in increasing healthcare user engagement by creating bonds between the applications and users. It is unclear if chatbots improve patient adherence or if past trends to include chatbots in electronic health applications were due to technology hype dynamics and competitive pressure to innovate. We conducted a systematic literature review using Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology on health chatbot randomized control trials. The goal of this review was to identify if user engagement indicators are published in eHealth chatbot studies. A meta-analysis examined patient clinical trial retention of chatbot apps. The results showed no chatbot arm patient retention effect. The small number of studies suggests a need for ongoing eHealth chatbot research, especially given the claims regarding their effectiveness made outside the scientific literatures. [ABSTRACT FROM AUTHOR]

Factors such as the therapeutic relationship and working alliance have been shown to be important predictors for client outcomes in broad counseling settings with diverse client populations. The present study used linear multiple regression analysis to explore how relational factors such as in‐session empathy and mindfulness impact working alliance when providing sex offender counseling. Results from sex offender counselor participants (N = 109) showed that the perspective taking aspect of empathy was most impactful on working alliance and that in‐session mindfulness was less impactful on working alliance. [ABSTRACT FROM AUTHOR]

This scoping review provides an overview of empirical studies investigating therapeutic relationships between speech-language pathologists (SLPs), clients, and caregivers across all ages and clinical areas, and identifies areas of future research. The Joanna Briggs Institute's (JBI) scoping review method was employed. Systematic searches were conducted across seven databases and four grey literature databases. Research published in English and German until 3 August 2020 was included. Data were extracted for the primary aim, terminology and theoretical foundations, research design, and focus. Central findings concerning the input-, process-, outcome-, and output-level of speech-language pathology were categorised. Of 5479 articles, 44 articles were included in the analysis. Psychotherapy was the leading discipline for the theoretical foundation and measurement of relationship quality. Most findings focused on therapeutic attitudes, qualities, and relational actions to build the basis of a positive therapeutic relationship. A small number of studies indicated connections between clinical outcomes and the quality of the relationships. Future research needs to address precision of terminology, expansion of qualitative and quantitative research methods, development and psychometric examination of measuring instruments specific to SLPs and the development and evaluation of concepts to support professional relationship building in speech-language pathology training and everyday work. [ABSTRACT FROM AUTHOR]

[Background] Deliberate Practice (DP), which underscores the importance of expert mentorship, personalized learning objectives, feedback, and repetition, has been suggested as a method to enhance the effectiveness of therapists. [Method] The study tested the efficacy of an eight-week, structured, group-based online course, enriched with peer feedback, for 37 Cognitive Behavioral Therapists. The goal was to assess whether this intervention could boost the quality of therapist-patient alliances, as compared to a control group. To measure this, therapists had their patients anonymously fill out the Session Alliance Inventory both before and after the course. The trial encompassed 120 patient alliance ratings at baseline and 64 at the post-course measurement. The DP course was comprised of a 75-minute remote video workshop each week for eight weeks, supplemented by related study materials. Each workshop focused on a specific skill, such as responding to client resistance, and included 55 minutes of concentrated role-play activities, providing ample opportunities for repetition and feedback. [Results] Using a linear mixed model we did not find an effect on patient alliance ratings. However, we observed a trend (p = .054) indicating that the DP group decreased their alliance ratings (Cohen’s d = -0.40), while the control group demonstrated an increase in their scores (d = 0.49). [Conclusion] This pilot study did not find support for DP leading to better patient-rated alliance compared to a waitlist control. However, the study had several methodological limitations. Further and more rigorous investigation of the effects of DP on patient outcomes is recommended.

In this study, we examined how four components of the therapeutic relationship—working alliance, real relationship, and positive and negative affective reactions of the patient toward their therapist—relate to each other and to the psychotherapy session outcome, from the patient’s point of view. Our simple comprised 700 adult patients in individual psychotherapy who were recruited and participated online. They underwent a baseline evaluation of their most recent therapy session, which encompassed a series of validated self-report measures focused on specific elements of the therapeutic relationship. The results revealed that, from the patient’s perspective, working alliance, real relationship, and positive affective reactions toward the therapist were positively correlated with session outcome, while negative affective reactions were negatively correlated. All components predicted session outcome when simultaneously included in a regression model. Collectively, these four components accounted for 30% of the variance in session outcome. Factor analysis revealed four distinct factors, underlying perceptions of the therapeutic relationship. Notably, the bond dimension of the alliance was sufficiently different from the task and goal dimensions, warranting consideration as a distinct construct. These findings, although cross-sectional, lay the groundwork for a more nuanced investigation of multiple dimensions of the therapeutic relationship.