The Role of the Therapeutic Alliance in the Treatment of Schizophrenia Relationship to Arlene F.
Course and Outcome
Frank, PhD, John G. Gunderson, MD
\s=b\ This
study examined the relationship of the therapeutic allito the treatment course and outcome of 143 patients with nonchronic schizophrenia. Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not. These results underscored the prognostic value of assessing the alliance and the need to identify factors that contribute to its development and maintenance with schizophrenic patients. ance
(Arch Gen Psychiatry. 1990;47:228-236)
is that the success of any on the endeavor an open, collaborative or what has been referred to as a therapeutic,1 working,2,3 or helping4 alliance. Prior research has shown that the failure of a patient and therapist to form an alliance is strongly associated with patient noncompliance with treatment plans,5,6 premature ter¬ mination,7'10 and poor outcome.911"21 This highly influential body of research, nevertheless, has a number of limitations. One stems from the essentially correla¬ tional nature of the research. Although it is tempting to con¬ clude from prior studies that a good alliance is a prerequisite for a good treatment course and outcome, the possibility remains that it is a consequence of positive change. A related limitation is the difficulty in separating core features of the alliance from factors in the patient, therapist, and treatment situation that contribute to its development and maintenance. For example, it is unclear in many studies whether the predic¬ tive power of the alliance derives from its association with other good prognostic indicators and patient characteristics present at the start of treatment, reflects the skillful applica¬ tion of specific technical interventions by the therapist, or is
widely recognized therapeutic depends It participants establishing trusting, relationship, variously
Accepted for publication April 7,1989. From the Brookside Hospital, Nashua, NH (Dr Frank); the Department of Psychiatry, Harvard Medical School, Boston, Mass (Drs Frank and Gunderson); and the McLean Hospital, Belmont, Mass (Drs\ Frank and Gunderson). Reprint requests to Brookside Hospital, 11 Northwest Blvd, Nashua, NH
03063 (Dr Frank).
simply a product of the fortuitous pairing of a particular patient and therapist. Finally, generalizability is a problem. The existing research has focused largely on relatively healthy patients receiving short-term, individual psychotherapy. Clinical reports suggest that with sicker, personality-disor¬ dered or psychotic patients, the development of an alliance is not only especially critical but also difficult to achieve.22"28 Yet, few empirical studies of the alliance have been done with such patients, many of whom require long-term care and receive psychotherapy in conjunction with other treatments.2*32 This study examines the role ofthe alliance in the treatment of schizophrenic patients, a population that has been underrepresented in the alliance literature. By utilizing data that were collected as part of a long-term, psychotherapy study,3334 we explored the frequency with which schizophrenic patients form alliances and how the presence of a good alliance relates to the course and outcome of their treatment, both pharmaco¬ logically and psychologically. As such, this study fills a gap in knowledge that may link the past body of psychotherapy research to the ongoing and commonplace problems of psychi¬ atric practice with severely disturbed patients. BACKGROUND The Boston Psychotherapy Study was designed to evaluate the effects of two forms of individual psychotherapy on patients with nonchronic schizophrenia—exploratory-insight-oriented (EIO) and reality-adaptive-supportive (RAS)—when both were provided by experienced therapists in conjunction with antipsychotic medication. Patients were randomly assigned to one of the two therapy conditions and were followed up prospectively for 2 years. Comprehensive and multifaceted assessments of the patients, the therapists, and the treatment process were done at regular intervals throughout this
study.33
Results showed that during the 2-year study period, a large num¬ ber of the patients in both therapy groups unilaterally dropped out of treatment. Those patients who stayed in the study groups made some substantial gains; the longer they stayed, the more gains they made. However, even after 2 years, many of the serious incapacities that are associated with the diagnosis of schizophrenia were not resolved; this was true for EIO- and RAS-treated patients alike. Despite the fact that the two treatments differed in their theoretic underpinnings, objectives, foci, and technical ingredients, significant differences in the outcomes of the groups were few in number and modest in size.34
Downloaded From: http://archpsyc.jamanetwork.com/ by a Yale University User on 05/17/2015
These results, plus the finding that the level of improvement was only weakly related to antecedent characteristics of the patients,35 led us to search for common factors in the treatments that were associated with
change.
We focused on the therapeutic alliance because several prior studies of schizophrenic patients had suggested that it might be as robust a predictor of their treatment course and outcome as it has proved to be in numerous studies of nonschizophrenic patients. For example, in trying to understand their high dropout rate and their finding that individual psychotherapy added little to hospital treatment as usual for schizophrenic patients, Rogers et al36 noted that only a minority of the patients became actively engaged with their therapists. In fact, some questioned whether the patients had actually been "in therapy" at all. Grinspoon et al3' similarly reported that even after 2 years of treatment, only 5 of the 15 therapists thought that even weak alliances had been formed. They speculated that this may have contributed to the relatively poor performance of their patients who were undergo¬ ing psychotherapy and to the variability in outcomes observed among all patients. These reports must be regarded as tentative, however, because of the chronic condition of the patients, uncontrolled varia¬ tions in the treatments, and the retrospective, impressionistic nature of the alliance assessments. This study subjected the above observations to a more rigorous evaluation by using data that were collected prospectively from a larger and less chronic sample. The following hypotheses were tested: (1) Only a minority of schizophrenic patients will form good therapeu¬ tic alliances, and then only during a relatively long period. (2) Those patients who do form good alliances will be less likely to drop out of psychotherapy unilaterally, more likely to comply with their pre¬ scribed medication regimens, and more likely to make more gains over time than those patients who do not.
METHODS
earlier, the data for this study were drawn from a larger study that was completed in 1984. Because that study has been described in detail elsewhere,33 only those aspects of the design and procedures that bear directly on this study are included in this As noted
outcome
article.
Patients The patients in the study were 143 consenting adults who were selected from consecutive hospital admissions during a 7-year period (1974 to 1981). Selection procedures were designed to identify a representative sample of schizophrenic patients, between 18 and 35 years, who had minimal prior treatment, no history of alcohol depen¬ dency or drug abuse, no obvious organic impairments, and had been able to function outside of a hospital, in some major role, without medications for 4 consecutive months of the preceding 2 years. Diag¬ noses were established by three independent assessments. To be considered diagnostically suitable, patients had to (1) receive a clinical diagnosis of schizophrenia from the admitting psychiatrist, (2) receive a corroborating diagnosis from a research psychiatrist based on a standardized interview (the Psychiatric Status Schedule),38 and (3) fulfill five or more of the World Health Organization's Discriminat¬ ing Criteria for Schizophrenia.39,40 Failure to meet any one of these entry criteria automatically disqualified a patient from the outcome study, and resulted in the exclusion of the majority of the almost 2000 patients who underwent screening for it. Because criteria for the diagnosis of schizophrenia narrowed during the course of the project, a blind, repeated assessment was done on the first 48 patients in this study. Their clinical diagnoses had been made by using the then prevailing DSM-II standards. The use of the more stringent DSM-IIr standards that were applied to the rest of the sample resulted in the repeated diagnosis of 11 patients' conditions as schizophreniform and 2 patients' conditions as manic-depressive. Yet, even the conditions of these patients were diagnosable as schizo¬ phrenic by at least one other, equally stringent, modern criteria set42,43 and, hence, they were retained. An additional 21 patients who originally qualified for the study were not retained, either because administrative problems prevented their therapy from being implemented according to the study protocol (n 10) or because logistic problems (eg, family relocation) prevented their continuing in the study (n 11). Patients received no remunera¬ tion for participating in the research. However, any patient who =
=
lacked the resources to support long-term therapy was eligible to receive financial aid from the study. As a result, continuation in treatment was not influenced by a patient's ability to pay.
Therapists A total of 81 therapists participated in this research. All were selected based on their long-standing commitment to one of the two forms of psychotherapy being offered within the study design and their history of success in treating psychotic patients by this means. The majority (85%) of therapists had MD degrees and spent most of their professional time working on inpatient psychiatric units, with severely disturbed patients. On average, they had been in practice for 10.4 years and had treated 31 schizophrenic patients before joining the study. Additional information regarding the backgrounds, treatment orientations, and professional qualifications of the therapists can be ,44 found elsewhere.
Procedures When admitted to the hospital, all patients received an extensive baseline evaluation after which they were randomly assigned to either the EIO or RAS therapy condition. Although the psychotherapy was started while the patients were in the hospital, it was expected to continue well beyond discharge from the hospital. Patients were seen by the same therapist during their index hospitalization (mean 3.9 months, SD 4.8 months) and the outpatient phase of their treatment (mean 9.1 months, SD 9.9 months). Because the differential ef¬ fects of the EIO and RAS therapies were not expected to emerge before 6 months in treatment, this duration was imposed as an addi¬ tional requirement for inclusion in the follow-up phase of the project. Some outcome information was obtained from patients who left thera¬ py before then (n 48), but only those patients who remained (n 95) got systematic follow-up evaluations. These were done every 6 months by trained raters who were "blind" to the aims and hypotheses of the study and to the patients' treatment condition. The therapy process was monitored continuously, by means of therapist reports that were completed monthly and by audiotapes that were blindly rated every 6 months by independent judges. No specific constraints were placed on the pharmacotherapy that the patients received. Although all patients initially were treated with antipsychotic medication when admitted to the hospital, the choice of drugs and decisions about dosage and duration of drug treatment were left to the discretion of the prescribing physician. In accordance with the prevailing practices at the time, an administrative psychia¬ trist managed medications while the patients were in the hospital; after discharge, medications were handled by the therapist. This was true for RAS- and EIO-treated patients alike. Tb ensure that a high level of drug management and consistency was maintained across the therapy conditions over time, periodic medication reviews were done by an independent, senior consultant. Results of subsequent analyses confirmed that the pharmacotherapy provided to patients in the two treatment groups was equivalent and, in most cases (93%), continuous through the first year. =
=
=
=
=
=
Measures
Therapeutic Alliance. —Assessments ofthe alliance were obtained from the Psychotherapy Status Report,33 a 15-item questionnaire that therapists completed monthly. This instrument was used to quantify salient aspects of the ongoing psychotherapy process and supplement the process measures that were derived from audiotapes of the thera¬ py sessions. The Psychotherapy Status Report included the following six, Likert-type scales pertaining to the patients' in-therapy beha¬ viors that the clinical and research literature suggested would be indicative of an alliance in any form of psychotherapy: (1) stable, active, and collaborative participation in the treatment process; (2) full and spontaneous sharing of relevant material with the thera¬ pist and responsiveness to the therapist's interventions; (3) express valuing of the psychotherapy and optimism about its potential useful¬ ness; (4) maintenance of a sustained interest in understanding the illness and its influence on self and others, in problem solving, and in pursuing therapeutic goals; (5) presence of a generally clear and realistic picture of the therapist and the therapeutic relationship, and amenability to confrontation or interpretation of transference or oth¬ er distortions ofthat relationship; and (6) affective involvement in the
Downloaded From: http://archpsyc.jamanetwork.com/ by a Yale University User on 05/17/2015
Table 1 .—Measures of Therapeutic Alliance End Point
Descriptors
Good(1)
Poor (5)
Patient perceives treatment as clearly being in his/her interest and, despite anxiety, sticks to the therapeutic task without much interruption or denial of its unpleasantness
Patient has no perception that treatment is in his/her interest and shows only fleeting and confused or unpredictable participation in the treatment
Patient frequently volunteers relevant, personal material and is responsive on a meaningful level, giving feedback and
Patient refuses, even when probed, to share relevant, personal information and is silent and unresponsive, providing minimal feedback on verbal, postural, or gestural levels
Patient is consistently and expressly positive and regarding the usefulness of therapy
Patient is
Scale
elaborating on feelings and problems
consistently negative regarding the usefulness of therapy, and expressed feelings are of getting nowhere in
optimistic
treatment
Patient shows considerable interest in and understanding of his/her illness and the impact it has on self and others
Patient shows no interest in or understanding of his/her illness and the impact it has on self and others
Patient has clear and realistic perceptions of the therapist, including how the therapist feels about him/her, and is able to maintain this view for the most part
Patient has
Patient is clearly getting involved in the therapy in a meaningful way and is relating well to the therapist, giving rise to a consistently positive affective atmosphere
Patient clearly is not getting involved in the therapy in any meaningful way and is not relating well to the therapist, giving rise to a consistently negative affective atmosphere
therapist. Each scale had five levels defined by clinical descriptors. The end point descriptors for each are shown in Table 1. In form and content, these scales are similar to the questionnaire alliance measures that have been developed by oth¬ ers.12,13,15,18"20 Since ratings of the six scales were highly intercorrelated, and remained so over time, they were combined to form a single measure of the alliance that we termed active engagement (AE). The lower the AE score, the more actively engaged the patient was. Preliminary analyses revealed no significant differences between EIO- and RAS-treated patients in the mean AE ratings at any point in time. This indicated that, as intended, the AE measure was a generic measure, not specific to the type of therapy being provided. Those analyses also showed that the AE measure was highly internally consistent (Cronbach's .89) and had good test-retest reliability during a 3-month period (average r= .72). Evidence of the measure's validity was obtained from the significant correlation (r=.59, P
Course and Outcome
Frank, PhD, John G. Gunderson, MD
\s=b\ This
study examined the relationship of the therapeutic allito the treatment course and outcome of 143 patients with nonchronic schizophrenia. Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not. These results underscored the prognostic value of assessing the alliance and the need to identify factors that contribute to its development and maintenance with schizophrenic patients. ance
(Arch Gen Psychiatry. 1990;47:228-236)
is that the success of any on the endeavor an open, collaborative or what has been referred to as a therapeutic,1 working,2,3 or helping4 alliance. Prior research has shown that the failure of a patient and therapist to form an alliance is strongly associated with patient noncompliance with treatment plans,5,6 premature ter¬ mination,7'10 and poor outcome.911"21 This highly influential body of research, nevertheless, has a number of limitations. One stems from the essentially correla¬ tional nature of the research. Although it is tempting to con¬ clude from prior studies that a good alliance is a prerequisite for a good treatment course and outcome, the possibility remains that it is a consequence of positive change. A related limitation is the difficulty in separating core features of the alliance from factors in the patient, therapist, and treatment situation that contribute to its development and maintenance. For example, it is unclear in many studies whether the predic¬ tive power of the alliance derives from its association with other good prognostic indicators and patient characteristics present at the start of treatment, reflects the skillful applica¬ tion of specific technical interventions by the therapist, or is
widely recognized therapeutic depends It participants establishing trusting, relationship, variously
Accepted for publication April 7,1989. From the Brookside Hospital, Nashua, NH (Dr Frank); the Department of Psychiatry, Harvard Medical School, Boston, Mass (Drs Frank and Gunderson); and the McLean Hospital, Belmont, Mass (Drs\ Frank and Gunderson). Reprint requests to Brookside Hospital, 11 Northwest Blvd, Nashua, NH
03063 (Dr Frank).
simply a product of the fortuitous pairing of a particular patient and therapist. Finally, generalizability is a problem. The existing research has focused largely on relatively healthy patients receiving short-term, individual psychotherapy. Clinical reports suggest that with sicker, personality-disor¬ dered or psychotic patients, the development of an alliance is not only especially critical but also difficult to achieve.22"28 Yet, few empirical studies of the alliance have been done with such patients, many of whom require long-term care and receive psychotherapy in conjunction with other treatments.2*32 This study examines the role ofthe alliance in the treatment of schizophrenic patients, a population that has been underrepresented in the alliance literature. By utilizing data that were collected as part of a long-term, psychotherapy study,3334 we explored the frequency with which schizophrenic patients form alliances and how the presence of a good alliance relates to the course and outcome of their treatment, both pharmaco¬ logically and psychologically. As such, this study fills a gap in knowledge that may link the past body of psychotherapy research to the ongoing and commonplace problems of psychi¬ atric practice with severely disturbed patients. BACKGROUND The Boston Psychotherapy Study was designed to evaluate the effects of two forms of individual psychotherapy on patients with nonchronic schizophrenia—exploratory-insight-oriented (EIO) and reality-adaptive-supportive (RAS)—when both were provided by experienced therapists in conjunction with antipsychotic medication. Patients were randomly assigned to one of the two therapy conditions and were followed up prospectively for 2 years. Comprehensive and multifaceted assessments of the patients, the therapists, and the treatment process were done at regular intervals throughout this
study.33
Results showed that during the 2-year study period, a large num¬ ber of the patients in both therapy groups unilaterally dropped out of treatment. Those patients who stayed in the study groups made some substantial gains; the longer they stayed, the more gains they made. However, even after 2 years, many of the serious incapacities that are associated with the diagnosis of schizophrenia were not resolved; this was true for EIO- and RAS-treated patients alike. Despite the fact that the two treatments differed in their theoretic underpinnings, objectives, foci, and technical ingredients, significant differences in the outcomes of the groups were few in number and modest in size.34
Downloaded From: http://archpsyc.jamanetwork.com/ by a Yale University User on 05/17/2015
These results, plus the finding that the level of improvement was only weakly related to antecedent characteristics of the patients,35 led us to search for common factors in the treatments that were associated with
change.
We focused on the therapeutic alliance because several prior studies of schizophrenic patients had suggested that it might be as robust a predictor of their treatment course and outcome as it has proved to be in numerous studies of nonschizophrenic patients. For example, in trying to understand their high dropout rate and their finding that individual psychotherapy added little to hospital treatment as usual for schizophrenic patients, Rogers et al36 noted that only a minority of the patients became actively engaged with their therapists. In fact, some questioned whether the patients had actually been "in therapy" at all. Grinspoon et al3' similarly reported that even after 2 years of treatment, only 5 of the 15 therapists thought that even weak alliances had been formed. They speculated that this may have contributed to the relatively poor performance of their patients who were undergo¬ ing psychotherapy and to the variability in outcomes observed among all patients. These reports must be regarded as tentative, however, because of the chronic condition of the patients, uncontrolled varia¬ tions in the treatments, and the retrospective, impressionistic nature of the alliance assessments. This study subjected the above observations to a more rigorous evaluation by using data that were collected prospectively from a larger and less chronic sample. The following hypotheses were tested: (1) Only a minority of schizophrenic patients will form good therapeu¬ tic alliances, and then only during a relatively long period. (2) Those patients who do form good alliances will be less likely to drop out of psychotherapy unilaterally, more likely to comply with their pre¬ scribed medication regimens, and more likely to make more gains over time than those patients who do not.
METHODS
earlier, the data for this study were drawn from a larger study that was completed in 1984. Because that study has been described in detail elsewhere,33 only those aspects of the design and procedures that bear directly on this study are included in this As noted
outcome
article.
Patients The patients in the study were 143 consenting adults who were selected from consecutive hospital admissions during a 7-year period (1974 to 1981). Selection procedures were designed to identify a representative sample of schizophrenic patients, between 18 and 35 years, who had minimal prior treatment, no history of alcohol depen¬ dency or drug abuse, no obvious organic impairments, and had been able to function outside of a hospital, in some major role, without medications for 4 consecutive months of the preceding 2 years. Diag¬ noses were established by three independent assessments. To be considered diagnostically suitable, patients had to (1) receive a clinical diagnosis of schizophrenia from the admitting psychiatrist, (2) receive a corroborating diagnosis from a research psychiatrist based on a standardized interview (the Psychiatric Status Schedule),38 and (3) fulfill five or more of the World Health Organization's Discriminat¬ ing Criteria for Schizophrenia.39,40 Failure to meet any one of these entry criteria automatically disqualified a patient from the outcome study, and resulted in the exclusion of the majority of the almost 2000 patients who underwent screening for it. Because criteria for the diagnosis of schizophrenia narrowed during the course of the project, a blind, repeated assessment was done on the first 48 patients in this study. Their clinical diagnoses had been made by using the then prevailing DSM-II standards. The use of the more stringent DSM-IIr standards that were applied to the rest of the sample resulted in the repeated diagnosis of 11 patients' conditions as schizophreniform and 2 patients' conditions as manic-depressive. Yet, even the conditions of these patients were diagnosable as schizo¬ phrenic by at least one other, equally stringent, modern criteria set42,43 and, hence, they were retained. An additional 21 patients who originally qualified for the study were not retained, either because administrative problems prevented their therapy from being implemented according to the study protocol (n 10) or because logistic problems (eg, family relocation) prevented their continuing in the study (n 11). Patients received no remunera¬ tion for participating in the research. However, any patient who =
=
lacked the resources to support long-term therapy was eligible to receive financial aid from the study. As a result, continuation in treatment was not influenced by a patient's ability to pay.
Therapists A total of 81 therapists participated in this research. All were selected based on their long-standing commitment to one of the two forms of psychotherapy being offered within the study design and their history of success in treating psychotic patients by this means. The majority (85%) of therapists had MD degrees and spent most of their professional time working on inpatient psychiatric units, with severely disturbed patients. On average, they had been in practice for 10.4 years and had treated 31 schizophrenic patients before joining the study. Additional information regarding the backgrounds, treatment orientations, and professional qualifications of the therapists can be ,44 found elsewhere.
Procedures When admitted to the hospital, all patients received an extensive baseline evaluation after which they were randomly assigned to either the EIO or RAS therapy condition. Although the psychotherapy was started while the patients were in the hospital, it was expected to continue well beyond discharge from the hospital. Patients were seen by the same therapist during their index hospitalization (mean 3.9 months, SD 4.8 months) and the outpatient phase of their treatment (mean 9.1 months, SD 9.9 months). Because the differential ef¬ fects of the EIO and RAS therapies were not expected to emerge before 6 months in treatment, this duration was imposed as an addi¬ tional requirement for inclusion in the follow-up phase of the project. Some outcome information was obtained from patients who left thera¬ py before then (n 48), but only those patients who remained (n 95) got systematic follow-up evaluations. These were done every 6 months by trained raters who were "blind" to the aims and hypotheses of the study and to the patients' treatment condition. The therapy process was monitored continuously, by means of therapist reports that were completed monthly and by audiotapes that were blindly rated every 6 months by independent judges. No specific constraints were placed on the pharmacotherapy that the patients received. Although all patients initially were treated with antipsychotic medication when admitted to the hospital, the choice of drugs and decisions about dosage and duration of drug treatment were left to the discretion of the prescribing physician. In accordance with the prevailing practices at the time, an administrative psychia¬ trist managed medications while the patients were in the hospital; after discharge, medications were handled by the therapist. This was true for RAS- and EIO-treated patients alike. Tb ensure that a high level of drug management and consistency was maintained across the therapy conditions over time, periodic medication reviews were done by an independent, senior consultant. Results of subsequent analyses confirmed that the pharmacotherapy provided to patients in the two treatment groups was equivalent and, in most cases (93%), continuous through the first year. =
=
=
=
=
=
Measures
Therapeutic Alliance. —Assessments ofthe alliance were obtained from the Psychotherapy Status Report,33 a 15-item questionnaire that therapists completed monthly. This instrument was used to quantify salient aspects of the ongoing psychotherapy process and supplement the process measures that were derived from audiotapes of the thera¬ py sessions. The Psychotherapy Status Report included the following six, Likert-type scales pertaining to the patients' in-therapy beha¬ viors that the clinical and research literature suggested would be indicative of an alliance in any form of psychotherapy: (1) stable, active, and collaborative participation in the treatment process; (2) full and spontaneous sharing of relevant material with the thera¬ pist and responsiveness to the therapist's interventions; (3) express valuing of the psychotherapy and optimism about its potential useful¬ ness; (4) maintenance of a sustained interest in understanding the illness and its influence on self and others, in problem solving, and in pursuing therapeutic goals; (5) presence of a generally clear and realistic picture of the therapist and the therapeutic relationship, and amenability to confrontation or interpretation of transference or oth¬ er distortions ofthat relationship; and (6) affective involvement in the
Downloaded From: http://archpsyc.jamanetwork.com/ by a Yale University User on 05/17/2015
Table 1 .—Measures of Therapeutic Alliance End Point
Descriptors
Good(1)
Poor (5)
Patient perceives treatment as clearly being in his/her interest and, despite anxiety, sticks to the therapeutic task without much interruption or denial of its unpleasantness
Patient has no perception that treatment is in his/her interest and shows only fleeting and confused or unpredictable participation in the treatment
Patient frequently volunteers relevant, personal material and is responsive on a meaningful level, giving feedback and
Patient refuses, even when probed, to share relevant, personal information and is silent and unresponsive, providing minimal feedback on verbal, postural, or gestural levels
Patient is consistently and expressly positive and regarding the usefulness of therapy
Patient is
Scale
elaborating on feelings and problems
consistently negative regarding the usefulness of therapy, and expressed feelings are of getting nowhere in
optimistic
treatment
Patient shows considerable interest in and understanding of his/her illness and the impact it has on self and others
Patient shows no interest in or understanding of his/her illness and the impact it has on self and others
Patient has clear and realistic perceptions of the therapist, including how the therapist feels about him/her, and is able to maintain this view for the most part
Patient has
Patient is clearly getting involved in the therapy in a meaningful way and is relating well to the therapist, giving rise to a consistently positive affective atmosphere
Patient clearly is not getting involved in the therapy in any meaningful way and is not relating well to the therapist, giving rise to a consistently negative affective atmosphere
therapist. Each scale had five levels defined by clinical descriptors. The end point descriptors for each are shown in Table 1. In form and content, these scales are similar to the questionnaire alliance measures that have been developed by oth¬ ers.12,13,15,18"20 Since ratings of the six scales were highly intercorrelated, and remained so over time, they were combined to form a single measure of the alliance that we termed active engagement (AE). The lower the AE score, the more actively engaged the patient was. Preliminary analyses revealed no significant differences between EIO- and RAS-treated patients in the mean AE ratings at any point in time. This indicated that, as intended, the AE measure was a generic measure, not specific to the type of therapy being provided. Those analyses also showed that the AE measure was highly internally consistent (Cronbach's .89) and had good test-retest reliability during a 3-month period (average r= .72). Evidence of the measure's validity was obtained from the significant correlation (r=.59, P
