Therapist Adherence, Patient Alliance, and Depression Change in the NIMH Treatment for ...

139 Pages·2008·1.18 MB·English

Therapist Adherence, Patient Alliance, and Depression Change in the NIMH Treatment
for Depression Collaborative Research Program

by

Giovanni A. Minonne

A dissertation submitted in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
(Psychology)
in The University of Michigan
2008

Doctoral Committee:

Adjunct Associate Professor Robert L. Hatcher, Co-Chair
Assistant Professor Nnamdi Pole, Co-Chair
Professor Christopher M. Peterson
Adjunct Assistant Professor Heather A. Flynn
Adjunct Assistant Professor Michelle Van Etten-Lee
© Giovanni A. Minonne 2008
To Megan and Lia

ii
Acknowledgements

I would like to express my sincere gratitude to all the people who helped me to
achieve the goal of making this doctoral dissertation possible. In particular, I
express my deep appreciation and gratitude to Dr. Nnamdi Pole and to Dr. Robert
Hatcher, my advisors, for their invaluable guidance and for the dedication and
enthusiasm with which they have supported all the phases of this project. My
sincere gratitude goes equally to all the members of the dissertation committee,
who have generously given their time and expertise to help me develop a more
balanced and scholarly informed perspective and to enrich and refine the quality
of this dissertation. I also want to give special recognition to Irene Elkin and
Yvonne Smith, who generously provided the data for the study, and to Clara Hill
and Janice Krupnick, who gave permission to use this data. Without their
generous help this project would not have been possible. Finally, I want to thank
Laura Klem, who has generously devoted her time and her invaluable expertise to
help find the most appropriate method for analyzing the data. I am deeply grateful
to my wife, whose unconditional love and appreciation have given me the energy
to overcome difficulties and problems along the road, and to my daughter, who
has helped me to keep in touch with the joy and fun of life. I am grateful to my
parents for the strength and courage that they have taught me, to my step mother,
who raised me, to my family, and to all my friends who provide me with a very
much needed sense of belonging. I am finally grateful to my patients, my
colleagues and my clinical supervisors who have taught me to moderate my
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biases, and to expand my understanding of the complexity and variety of the
human needs addressed in psychotherapy.

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Table of Contents

Dedication…………………………………………………………………………………ii
Acknowledgements……………………………………………………………................iii
List of Appendices………………………………………………………………………..vi
Abstract………………………………………………………………………………......vii
Chapter 1: Introduction……………………………………………………………………1
Previous Studies on Therapist’s Adherence and Alliance in Manualized
Treatments………....................................................................................................4
Previous Studies on Adherence and Outcome in Manualized Treatments………15
Research Questions and Hypotheses………………………………………….....28
Chapter 2: Method……………………………………………………………………….35
Participants……………………………………………………………………….35
Patients…………………………………………………………………...35
Therapists………………………………………………………………...35
Design……………………………………………………………………………36
Treatments………………………………………………………………………..37
Measures…………………………………………………………………………40
Collaborative Study Psychotherapy Rating Scale………………………..40
Vanderbilt Therapeutic Alliance Scale…………………………………..41
Beck Depression Inventory ……………………………………………...42
Data Reduction and Analysis…………………………………………………….43
Chapter 3: Results………………………………………………………………………..46
Descriptive Statistics for Patient Alliance and Therapist Adherence……………46
Results of the Main Analysis…………………………………………………….50
Findings Across All Four Treatments……………………………………52
Cognitive Behavioral Psychotherapy…………………………………….54
Interpersonal Psychotherapy……………………………………………..55
Clinical Management Plus Imipramine………………………………….57
Clinical Management Plus Placebo……………………………………...58
Additional Exploratory Analysis………...………………………………………59
Cognitive Behavioral Psychotherapy…………………………………….59
Interpersonal Psychotherapy……………………………………………..60
Chapter 4: Discussion……………………………………………………………………61
Synthesis of the Main Findings………………………………………………….62
Limitations and Strengths of this Study and Suggestions for Future Research…75
Conclusion……………………………………………………………………….79
Appendices……………………………………………………………………………….82
Bibliography…………………………………………………………………………....123
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List of Appendices

Appendix

1 Figures Recording Therapist Adherence and Patient Alliance Predicting
Residual Change in Patient Depression………………………………………….83

2 Tables Recording Early and Late Therapist Adherence and Patient Alliance
Means and Standard Deviations………………………………………………...112

3 Summary of Results…………………………………………………………….118

4 Vanderbilt Therapeutic Alliance Scale (VTAS) (Patient Factor and Therapist
Factor) and Collaborative Study Psychotherapy Rating Scale
(CSPRS)………………………………………………………………………...119

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Abstract

Therapist Adherence, Patient Alliance, and Depression Change in the NIMH Treatment
for Depression Collaborative Research Program

by

Giovanni A. Minonne

Co-Chairs: Robert L. Hatcher and Nnamdi Pole

Using data from the National Institute of Mental Health Treatment of Depression
Collaborative Research Program (NIMH TDCRP), this dissertation examined the
relationship between the patient alliance (Vanderbilt Therapeutic Alliance Scale patient
factor) and therapist adherence to five subscales of the Collaborative Study
Psychotherapy Rating Scale: Cognitive Behavior Therapy (CBT), Interpersonal Therapy
(IPT), Clinical Management (CM), Facilitative Conditions (FC), and Explicit
Directiveness (ED) and their influence on depression change as measured by the Beck
Depression Inventory. Analyses were conducted using path models examining the
interrelationship between early and later alliance and adherence as predictors of
depression change for the full TDCRP sample (n = 239) and for each treatment
comprising the TDCRP: CBT (n = 59), IPT (n = 61), imipramine plus clinical
management (IMI-CM; n = 57), and placebo plus clinical management (PLA-CM; n =
62). The results indicate that, in each of the treatments, early patient alliance predicted
later patient alliance, and later patient alliance predicted depression change. Early
therapist adherence rarely predicted later therapist adherence and later therapist
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adherence rarely predicted depression change with the following exceptions. Later IPT
adherence predicted greater reductions in depression in IPT and later CBT adherence
predicted greater reductions in depression in both IPT and in PLA-CM. Across all the
treatments, there was a positive relationship between both IPT and FC adherence and
patient alliance, and a negative relationship between both ED and CM adherence and
patient alliance. In each treatment group, the relationship between adherence and the
patient alliance was different. In IPT, greater ED predicted reduced patient alliance. In
CBT and PLA-CM, greater CM adherence predicted reduced patient alliance. Early
patient alliance predicted: (a) greater later FC, IPT, and CBT adherence in CBT; (b)
greater IPT adherence in IPT; and (c) greater FC adherence in PLA-CM.
These results have important implications for psychotherapy training and clinical
practice. Particularly relevant are the findings that non-target techniques had a positive
influence on patient alliance and depression change, and that therapist directiveness
negatively influenced the patient alliance in IPT. In sum, this study highlights the
complex interrelationship of relational and technical dimensions of psychotherapy.

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Chapter 1

Introduction

Treatment manuals have produced a revolution in therapeutic research, training,
and clinical practice (Luborsky& DeRubeis, 1984). They are one of the most significant
results of the movement for an evidence-based psychotherapy which started in the early
1980s. This development was a response to problems like the excessive number of
therapeutic methods in use and their questionable scientific basis, and the ineffectiveness
and potential harmfulness of a psychotherapy based primarily on anecdotal evidence and
on the personal judgment of the clinician (Parry, 2000).
Psychotherapeutic manuals first appeared for behavioral (Wolpe, 1969) and
cognitive-behavioral (Beck et al., 1979) psychotherapies. Soon after, treatment manuals
were also developed for other therapeutic approaches, like interpersonal therapy
(Klerman et al., 1984), psychodynamic therapy (Davanloo, 1980; Strupp & Binder,
1984), and experiential psychotherapy (Greenberg & Goldman, 1988). Treatment
manuals are currently standard in clinical practice and extensive research supports the use
of manualized treatments for a broad range of psychological disorders (Nathan &
Gorman, 1998). In particular, the National Institute for Health and Clinical Excellence
(NICE) recently recommended structured psychological interventions for the treatment of
depression using Cognitive Behavioral and Interpersonal Psychotherapy (Timonen &
Liukkonen, 2008). However, some findings suggest a tension when applying a manually-
based psychotherapy treatment, between the requirement to follow specific guidelines
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