To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.

Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review.

A review of therapist characteristics and techniques positively impacting the therapeutic alliance

The effectiveness of and adherence to eHealth interventions is enhanced by human support. However, human support has largely not been manualized and has usually not been guided by clear models. The objective of this paper is to develop a clear theoretical model, based on relevant empirical literature, that can guide research into human support components of eHealth interventions. A review of the literature revealed little relevant information from clinical sciences. Applicable literature was drawn primarily from organizational psychology, motivation theory, and computer-mediated communication (CMC) research. We have developed a model, referred to as “Supportive Accountability.” We argue that human support increases adherence through accountability to a coach who is seen as trustworthy, benevolent, and having expertise. Accountability should involve clear, process-oriented expectations that the patient is involved in determining. Reciprocity in the relationship, through which the patient derives clear benefits, should be explicit. The effect of accountability may be moderated by patient motivation. The more intrinsically motivated patients are, the less support they likely require. The process of support is also mediated by the communications medium (eg, telephone, instant messaging, email). Different communications media each have their own potential benefits and disadvantages. We discuss the specific components of accountability, motivation, and CMC medium in detail. The proposed model is a first step toward understanding how human support enhances adherence to eHealth interventions. Each component of the proposed model is a testable hypothesis. As we develop viable human support models, these should be manualized to facilitate dissemination.

Supportive Accountability: A Model for Providing Human Support to Enhance Adherence to eHealth Interventions

The therapeutic relationship.

Despite more than 50 years of research on client attrition from therapy, obstacles to the delivery and success of treatments remain poorly understood, and effective methods to engage and retain clients in therapy are lacking. This article offers a review of the literature on attrition, highlighting the methodological challenges in effectively addressing the complex nature of this problem. Current interventions for reducing attrition are reviewed, and recommendations for implementing these interventions into psychotherapy practice are discussed.

Early withdrawal from mental health treatment: implications for psychotherapy practice

Ninety-six patients requesting psychotherapy were studied prospectively at the time of screening interview by four senior psychiatrists using a variation on Luborsky's Helping Alliance questionnaire and the Osgood Semantic Differential. Significant differences were found at the time of screening between early dropouts and continuers, among screeners' rate of early dropouts, and among patients' perceptions of screeners. The screener with a high early dropout rate was seen as being more passive and less potent, and offering less new understanding than other screeners. Patients who dropped out early experienced a less strong helping alliance, felt they gained less new understanding, liked the clinician less well, felt less well liked and less respected, and saw the interviewer as more passive and psychotherapy as less potent than did continuers.

Early dropouts from psychotherapy.

OBJECTIVE: To review the tricyclic antidepressants, selective serotonin reuptake inhibitors, and dually acting antidepressants and their economic and treatment implications. SUMMARY: Major depressive disorder’s cost to the U.S. economy is staggering, but the selection of drugs available to treat it has expanded to include drugs that have better side-effect profiles. Regardless, remission rates are high, and, often, patients are not treated aggressively enough. Somatic presentations are more common than previously thought, and pain, in particular, may be associated with depression. Pain and depression are both regulated by serotonin and norepinephine, and several studies suggest that using dual-action antidepressants may be helpful in patients who have an element of pain to their disorder. Titration to an adequate dose of any antidepressant is important, as is sustaining treatment for months to years, depending on the patient’s history.

Pharmacologic considerations in treating depression: a patient-centered approach.

A model for selecting a psychiatry chief resident.

Examinations are an integral part of resident and program evaluation, but they are considered particularly stressful on residents. The department of psychiatry of the University of Texas Health Science Center at San Antonio administered the Psychiatry Resident-in-Training Examination (PRTTE) every other year to minimize stress and anxiety among residents. When questioned about their satisfaction with the PRTTE and its administration, the residents reported high levels of satisfaction and a desire to take the examination yearly. Dissatisfaction was limited to the physical environment in which the exam was administered.

Residents' Satisfaction With the PRITE.

Striving for an educational balance between psychodynamics and psychotherapy led to the creation of a Psychotherapy Service. Psychodynamic teaching was preserved while biological teaching was increased. The history, philosophy, and structure of this service, combined with a chart review, give a picture of the kind of clinical experience and training available on such a service.

Christopher B. Ticknor

Papers

Early dropouts from psychotherapy.

Pharmacologic considerations in treating depression: a patient-centered approach.

A model for selecting a psychiatry chief resident.

Residents' Satisfaction With the PRITE.

A Psychotherapy Service: Preserving a Place for Psychodynamic Teaching