Training therapists to improve the therapeutic alliance: A randomized trial in a naturalistic setting

We know from research that psychotherapy is effective. But, meta analyses
suggest that 30-40% of patients fail to benefit from psychotherapy, which means
that there is room for improvement. More and more researchers share the opinion
that knowledge about underlying mechanism of change is the key factor in the
process of therapy improvement. Unfortunately these mechanisms that cause
therapeutic change are still largely unknown. The most important question in
the recent field of psychotherapy research is; how can we isolate and identify
the effective ingredients of therapy practice and how can we enhance their
influence. The therapeutic alliance is considered an essential ingredient of
psychotherapy by many scholars. More than 2000 studies have shown the influence
of the alliance on treatment outcome. But, research on the alliance has been
merely correlational and does not rule out reversed causality. We need new
lines of research to learn more about relational mechanism of change, since the
current body of evidence does not bring us any further when it comes to
learning more about how the alliance contributes to change. Research on the
alliance suggests that to enhance the influence of therapy, therapists need to
focus on the collaborative elements of the relationship. In this study we use a
specialized alliance training for therapists which focuses on these
collaborative elements, as an intervention. This will allow us to isolate and
directly manipulate the ingredients of effective therapy relationships and
collect data on their contribution to the treatment process and outcome.

Our primary aim is to conduct a large-scale study that investigates the impact
of a specialized alliance training and evaluates the effect of the alliance
training on the treatment process and outcome.
Our secondary aim is to learn more about the underlying mechanism of change
accountable for the effects of psychotherapy, through isolation and
manipulation of specific elements of effective therapy relationships.

The study is a Randomized Clinical Trial (RCT). We conduct the study in a
natural clinical setting. We want to investigate if the intervention works
(effectiveness) when used in normal practice. In the trial we will compare
three conditions with a training for therapists as intervention. The first
condition is with alliance training 1 (AT 1), the second with alliance training
2 (AT 2) and the third treatment as usual (TAU), without any alliance training.
In total this study will last about 1 year for each individual patient.

The patients who are randomly assigned to condition AT 1 and AT 2 will receive
TAU, but from a therapist who has finished alliance training 1 or 2 and who
will use relational reflection manuals during the treatment. Measurements will
be repeated throughout 15-20 weeks of every single treatment.

It is unlikely that general symptoms increase as a result of either the
treatment condition or the treatment as usual. As such, the study poses no risk
to the participants. However, the participants are asked to invest time into
this study. The screening will be conducted by telephone and will take
approximately 50 minutes. Furthermore, a set of questionnaires will be offered
via the internet after every session or after every third session.