Objectives
Clinical work involves psychological-relational factors that make up the background and framework for the development of therapeutic relationships. We used a novel assessment to examine the impact of patient-therapist relationship factors on treatment outcomes.
Methods
This study was conducted on patients with mood and/or anxiety disorders, seeking treatment at public and private outpatient settings. Patients received treatment as usual, including psychotherapy, pharmacotherapy, or their combination. The diagnostic assessment was carried out by therapists using the MINI Neuropsychiatric Interview. At baseline and after 3 and 9 weeks patients and therapists filled out the Work Alliance Inventory (WAI) and the Common Specific Therapeutic Factor (CSTF) Questionnaire, an instrument designed to assess therapist’s communication style, focus on patient history, supportive feedback/information, construction of the setting and therapist’s recall of patient. At the same time points, patients filled out the Work and Social Adjustment Scale. Linear regression models were used to examine the relation between CSTF- and WAI scores and treatment outcomes. Linear regression was used to analyze the relation between change in functioning and change in CSTF and WAI scores (both patient and therapist versions). Two separate models were fitted for the patient and therapist versions of the instruments. Age, gender and drug treatment (coded as yes/no) were forced into the model to adjust for their potential confounding effect and CSTF factors and WAI scores were entered using a stepwise procedure.
Results
The mean decrease in functional impairment from baseline to endpoint, measured using the WSAS, was 5.3 points (SD 8.7). Sixty-one percent (61%) of the participants rated their satisfaction with treatment as being “very good” to “excellent” (N = 57); a further 33% reported that it was “good” (N = 31). Forty-six point nine percent (46.9%) of the participants achieved remission.
In a linear regression model using scores from the patient versions of the instruments, improvement in communication skills was significantly associated with functional improvement after adjusting for the effects of gender, age and drug treatment (Table II). When the analyses were replicated in patients stratified by diagnosis (mood or anxiety/other diagnosis), changes in communication skills proved to be associated with functional improvement only in patients with mood disorders (b = 5.107, p = 0.026).
In a second model, using scores from the therapist versions of the instruments, increased focus on patient history was the only factor associated with functional improvement after controlling for gender, age and drug treatment. Changes in supportive feedback/information, recall, and in WAI scores (patient and therapist versions) were unrelated to changes in functioning in both models. Analyses carried out in diagnostic strata identified different CSFT predictors of functional improvement. In patients with mood disorders, changes in recall (b = 7.322, p = 0.019) and in patients with anxiety/bulimia changes in communication skills (b = 9.833, p < 0.001) were associated with functional improvement from baseline.
Increase in therapeutic alliance was significantly associated with higher levels of satisfaction in the patient model (Table III). No CSTF was associated with satisfaction with treatment. In the therapist model, no predictor of satisfaction with treatment was identified.
Conclusions
Communication style, focus on patient history, therapist’s recall of patients and therapeutic alliance were related to study outcomes. Further research involving therapists with different levels of experience is needed to shed light on whether and to what extent clinical experience mediates the CSTF-treatment outcome relation.