Therapeutic Alliance Formation: CBT or Psychodynamic? An Empirical Investigation
By Kenny Luck, M.A., Jul 8 2014 07:25PM
Goldman et al. (2013) 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.
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