Journal of Psychotherapy Integration © 2013 American Psychological Association

2013, Vol. 23, No. 4, 373–385 1053-0479/13/$12.00 DOI: 10.1037/a0034363

Psychotherapy Integration and Alliance: Use of Cognitive-

Behavioral Techniques Within a Short-Term Psychodynamic
Treatment Model

Rachel E. Goldman Jesse J. Owen

and Mark J. Hilsenroth University of Louisville
Adelphi University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Jerold R. Gold
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Adelphi University

This study examined the relationship between Psychodynamic-Interpersonal (PI) and

Cognitive-Behavioral (CB) techniques used in a Short-Term Psychodynamic Psycho-
therapy with the therapeutic alliance early in treatment. Ninety-one outpatient partic-
ipants rated their alliances, and independent videotape ratings of technique were made.
Our findings did not support the primary hypothesis of a relationship between technique
integration and overall patient-rated alliance. However, our findings did demonstrate a
significant association between the integration of PI and CB techniques with the two
alliance subscales Goals & Task Agreement and Confident Collaboration. In addition,
specific PI and CB techniques were significantly correlated with higher patient alliance
scores on these two subscales. Psychodynamic therapists who are more collaborative in
identifying specific goals and explicitly defining the focus of the treatment with their
patients, as well as providing a clear rationale for their model, may facilitate a stronger
therapeutic alliance specific to patient confidence in, and agreement with, the treatment
process.

Keywords: psychodynamic, cognitive-behavioral, technique, STPP, CPPS, therapeutic alliance,

psychotherapy integration

The therapeutic alliance has emerged as a cessful therapy outcomes (Horvath, Del Re,
significant process factor across different mo- Flückiger, & Symonds, 2011; Martin, Garske,
dalities of therapy that may contribute to suc- & Davis, 2000). Existing literature has de-
scribed the therapeutic alliance as an important
“barometer of therapeutic change” and a pan-
theoretical correlate of patient change across
This article was published Online First November 4, various psychotherapy orientations (Frieswyk et
2013.
Rachel E. Goldman and Mark J. Hilsenroth, Derner In- al., 1986; Gaston, 1990; Goldfried, 1991). The
stitute of Advanced Psychological Studies, Adelphi Univer- alliance has also consistently emerged as an
sity; Jesse J. Owen, Department of Educational and Coun- important construct in predicting treatment out-
seling Psychology, University of Louisville; Jerold R. Gold, comes across varying types of therapy regard-
Derner Institute of Advanced Psychological Studies, Adel-
phi University. less of the focus of therapy or treatment modal-
An earlier version of this study was presented at the 2012 ity (Horvath et al., 2011; Flückiger, Del Re,
Conference of the Society for Psychotherapy Research in Wampold, Symonds, & Horvath, 2012).
Virginia Beach, Virginia. Based on that earlier version of
this study, the first author received the Hans Strupp Memo-
There is likely a complex interplay between
rial Student Research Travel Award as well as the Lester different technical and relational aspects of the
Luborsky Award for the best student poster presented at the therapeutic alliance in mediating specific treat-
conference. ment effects (Hilsenroth, Cromer, & Ackerman,
Correspondence concerning this article should be addressed
to Rachel E. Goldman, Derner Institute, Adelphi University,
2012). “Pure” forms of psychotherapy may not
302 Weinberg Bldg., 158 Cambridge Avenue, Garden City, readily exist; rather, “treatment as usual” may
NY 11530. E-mail: rachelgoldman@mail.adelphi.edu be better conceptualized as various interven-
373
 374 GOLDMAN, HILSENROTH, OWEN, AND GOLD

tions, techniques, and therapeutic stance (STPP) model to examine treatment outcomes
(Ablon, Levy, & Katzenstein, 2006). The use of in relation to integrated therapeutic interven-
active ingredients integrated from a variety of tions. Patient ratings of session processes were
theoretical orientations may be better suited to significantly correlated with treatment out-
the patient’s needs during the therapeutic pro- comes. Specifically, the integration of CB tech-
cess (Ablon & Jones, 1998). As such, a range of niques in the STPP model was significantly
techniques from various psychotherapy orienta- associated with positive treatment outcomes in
tions, including cognitive– behavioral, interper- some areas of functioning. In contrast, Caston-
sonal, and psychodynamic models, have been guay and colleagues (2004) examined the use of
positively correlated with the alliance, including integrated cognitive therapy (ICT) in predicting
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the therapist’s ability to be supportive, affirm- patient-rated alliance and depressive symptom-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ing, using exploration, giving accurate interpre- atology. The traditional model of CT was sup-
tations, attending to the patient’s experience, plemented with certain interpersonal strategies
and being active within session (Hilsenroth et typically used to repair alliance ruptures in or-
al., 2012). In the literature on psychotherapy der to enhance the efficacy of CT. Findings
integration, such generic or cross-theoretical demonstrated that the addition of certain inter-
factors are considered to be common change personal procedures within CT led to greater
factors (Gold & Stricker, 2001). improvement in patients’ depressive symptoms.
Gold and Stricker (2001; Stricker & Gold, However, although patients evidenced signifi-
1996) proposed an assimilative model of inte- cant pre-post change, the treatment was superior
gration using cognitive, behavioral, experien- only to a waitlist control condition. Constantino
tial, and other techniques within a relational and colleagues (2008) further supported these
psychodynamic model. Active and exploratory findings through a RCT that examined the use
techniques may complement one another and
of ICT for depression. ICT was associated with
allow for more meaningful work within session;
enhanced treatment outcomes, more clinically
often, an integrative approach is recommended
significant change, and higher alliance scores,
to intervene at multiple levels of functioning.
than traditional CT.
This integration facilitates deeper experiences
Vocisano and colleagues (2004) conducted a
of personal growth, while also providing a di-
dactic structure for patients in order to target RCT of chronically depressed individuals who
behavior change and develop effective problem were given cognitive– behavioral analysis sys-
solving strategies. Gold and Stricker (2001, tem of psychotherapy (CBASP), the antidepres-
2012) also argue that early integration and an sant nefazodone, or a combination of the two.
assimilative use of active, cognitive– behavioral CBASP is a manualized protocol that focuses
techniques within a psychodynamic framework on effective problem solving and relationship
may often accelerate and strengthen the devel- skills. Although it is cognitive– behavioral by
opment of a positive therapeutic alliance. The nature, it includes a combination of therapeutic
shift by the therapist to use these methods may interventions, including the interpersonal role of
indicate a responsiveness to, and concern for, the therapist and transferential work (Swan &
the patient, that can prevent or repair alliance Hull, 2007). Patients had the most therapeuti-
strains or ruptures that derive from the patient’s cally effective outcomes when treated by ther-
perception of a lack of caring by the therapist. apists who blended CB and PI strategies. A
And, if the techniques are successful, the gains greater emphasis on the therapeutic relationship
might enhance the patient’s trust for, and con- was most strongly associated with positive out-
fidence in, the therapist. Likewise, the clarity comes, and being a psychodynamic-oriented
and relative ease with which patients use these therapist within the CBASP treatment led to
methods frequently leads to successful experi- greater symptom relief in patients. CB oriented
ences that in turn enhance the patient’s view of therapists who used the least amount of integra-
the therapist’s commitment and competence. tive strategies yielded significantly worse out-
Exploring the original Gold and Stricker comes. These findings substantiate the need for
(2001; Stricker & Gold, 1996) hypothesis, integrative approaches, even within manualized
DeFife, Hilsenroth, and Gold (2008) used a treatment protocols, to efficaciously target
Short-Term Psychodynamic Psychotherapy chronic symptoms and use the therapeutic alli-
 PSYCHOTHERAPY INTEGRATION AND ALLIANCE 375

ance as a means of navigating the patient’s Cases were assigned to treatment practicum and
interpersonal relationships. clinicians in an ecologically valid manner based
Given the success of this previous research, on real world issues regarding aspects of clini-
additional work on the integration of specific cian availability, caseload, and so forth. More-
therapeutic techniques may provide fruitful in- over, patients were accepted into treatment
formation related to positive therapeutic alli- regardless of disorder or comorbidity. In this
ance building. The current study seeks to extend sample of 91 individuals, 64 patients were fe-
this previous work and evaluate the integration male (70%) and 27 were male (30%). The mean
of CB techniques within a STPP treatment age for this sample was 30 (SD ⫽ 11.60); 55
model in relation to a patient’s experience of patients were single (60%), 21 married (23%),
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

early alliance. Specifically, independent clinical 14 divorced (15%), and 1 widowed (1%). All 91
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ratings of both Psychodynamic-Interpersonal patients (100%) in this study received a Diag-

and Cognitive-Behavioral therapist techniques nostic and Statistical Manual of Mental Disor-
will be examined in relation to patient-rated ders, fourth edition (DSM–IV) Axis I diagnosis
alliance early in treatment. Early session pro- (Mood Disorder ⫽ 48 [53%], V-Code Rela-
cesses have proven to be integral to initial alli- tional Problems ⫽ 15 [16%], Adjustment Dis-
ance development and demonstrate lasting ef- order ⫽ 12 [13%], Anxiety Disorder ⫽ 11
fects across treatment (Hilsenroth, Peters & [12%], Eating Disorder ⫽ 3 [3%], Impulse Con-
Ackerman, 2004; Horvath, 2001; Horvath et al., trol Disorder ⫽ 1 [1%], and Substance Related
2011). It is hypothesized that therapists practic- Disorder ⫽ 1 [1%]; American Psychiatric As-
ing from a STPP model who use some integra- sociation, 1994). Fifty patients (55%) also re-
tive techniques, that is, a combination of some ceived an Axis II diagnosis and 22 patients
CB with PI techniques, as opposed to a more (24%) were assessed to have subclinical, but
singular usage of PI techniques alone, will lead prominent Axis II features or traits (Cluster A ⫽
to higher ratings on the patient’s experience of 8 [9%], Cluster B ⫽ 37 [41%], Cluster C ⫽ 27
early alliance (Gold & Stricker, 2001). In other [30%]; American Psychiatric Association,
words, the use of an assimilative approach by 1994). Thus, this sample consisted of primarily
the therapist will facilitate a stronger therapeutic mood-disordered patients with relational problems
relationship and lead to higher alliance ratings manifested in either Axis II personality disorders,
than an alliance established through PI strate- or subclinical traits/features of Axis II personality
gies alone. Given the almost complete absence disorders. Mean scores for psychiatric severity
of extant research regarding the specific rela- consisted of the following: Intake GAF [Global
tionship between the integration of psychother- Assessment of Functioning] ⫽ 60 (SD ⫽ 5.70)
apy technique and patient alliance, the nature of and BSI-GSI [Global Severity Index of the Brief
this study is both preliminary and exploratory. Symptom Inventory] ⫽ 1.1 (SD ⫽ 0.58) (Amer-
ican Psychiatric Association, 1994).
Method
Therapists
The current study was developed within the
body of a larger programmatic process and out- Clinicians in the study were 28 advanced
come research study (Hilsenroth, 2007). The doctoral students (14 male and 14 female) en-
current research questions, hypotheses, and rolled in an APA-approved Clinical Psychology
goals were not formulated at the time of data Ph.D. program. Each therapist saw between one
collection, but were planned a priori specific to and six patients (M ⫽ 3.1; SD ⫽ 1.3). Each
this investigation. Thus, this research is a pro- clinician received a minimum of 3.5 hours of
spective analysis of archival data. supervision per week (1.5 hours of individual
and 2 hours of group) on the Therapeutic Model
Participants of Assessment (TMA, Finn & Tonsager, 1997;
Hilsenroth, 2007), clinical interventions, the or-
The participants in this study (n ⫽ 91) were ganization of collaborative feedback, psychody-
all admitted to a Psychodynamic Psychotherapy namic theory, and review of videotaped case
Treatment Team (PPTT) at a university-based material. Individual and group supervision fo-
community outpatient clinic (Hilsenroth, 2007). cused heavily on the review of videotaped case
 376 GOLDMAN, HILSENROTH, OWEN, AND GOLD

material and technical interventions. All clini- thus, the SI outlines potential outcomes (both
cians were trained in psychodynamic psycho- positive and negative) of this new insight.
therapy using guidelines delineated by Book Finally, the clinician and patient work to-
(1998), Luborsky (1984), McCullough et al. gether to develop treatment goals and negoti-
(2003), and Wachtel (1993), as well as selected ate an explicit treatment frame (i.e., schedul-
readings on psychological assessment, psy- ing session times, frequency of treatment
chodynamic theory, and psychodynamic psy- sessions, missed sessions, and payment plan).
chotherapy (for a more detailed description of In all cases, the clinician who carried out the
this training process, see Hilsenroth, DeFife, psychological assessment was also the clini-
Blagys, & Ackerman, 2006). cian who conducted the formal psychotherapy
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sessions.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Treatment Individual psychotherapy consisted of once

or twice weekly sessions of STPP treatment
Patients first received a psychological evalu- organized, aided, and informed (but not pre-
ation from a Therapeutic Model of Assessment scribed) by the technical guidelines delineated
(TMA; Finn & Tonsager, 1997; Hilsenroth, in the treatment manuals detailed above. Key
2007) that attempts to optimize the evaluation features of the STPP treatment model used in
phase with its use of a multimethod assessment these sessions included (Blagys & Hilsenroth,
(i.e., interview, self-report, performance tasks, 2000) the following: 1) Focus on affect and the
and free response measures). There is also a expression of emotion; 2) Exploration of at-
heightened focus on developing and maintain- tempts to avoid topics or engage in activities
ing empathic connections with patients (e.g., that may hinder the progress of therapy; 3) The
alliance fostering), factors contributing to the identification of patterns in actions, thoughts,
maintenance of life problems (often relational), feelings, experiences, and relationships; 4) Em-
collaboration to define individualized treatment phasis on past experiences; 5) Focus on inter-
goals and tasks, as well as sharing and exploring personal experiences; 6) Emphasis on the ther-
assessment results with patients. The TMA used apeutic relationship; and 7) Exploration of
in this study consisted of four steps including wishes, dreams, or fantasies. In addition, rela-
three meetings between the patient and clinician tional patterns, case presentations, and symp-
totaling approximately 4.5 hours, and one pa- toms were conceptualized in the context of cy-
tient appointment to complete a battery of self- clical patterns (Book, 1998; Luborsky, 1984;
report measures. The three meetings included McCullough et al., 2003; Wachtel, 1993). The
the following: 1) a semistructured diagnostic Safran and Muran (2000) model of intervention
interview (Westen & Muderrisoglu, 2003, was also used for treatment ruptures and repairs
2006); 2) interview follow-up; and 3) a collab- as they occurred in the therapeutic relationship.
orative feedback session. Treatment was open-ended in length rather than
During the collaborative feedback session, of a fixed duration. Whenever a termination
there is an emphasis on prominent inter/ date was set, this became a frequent area of
intrapersonal themes derived from the testing intervention, as issues related to the termination
results, the patient-therapist interaction, fac- were often linked to key interpersonal, affec-
tors that contribute to the maintenance of life tive, and thought patterns prominent in that pa-
problems, as well as an opportunity to explore tient’s treatment. Treatment goals were first ex-
these new understandings and apply them to plored during the assessment feedback session,
their current problems in living. The patient and a formal treatment plan was reviewed with
and clinician also review a Socialization In- each patient early in the course of psychother-
terview (SI) developed by Luborsky (1984) apy; this treatment plan was subsequently re-
on what to expect in psychodynamic psycho- viewed at regular intervals for changes, addi-
therapy and the patient and clinician roles tions, or deletions. Reassessment of patient
during formal treatment. The SI also high- functioning on a standard battery of outcome
lights the relational focus of the therapeutic measures as well as process ratings were com-
process, as well as the notion that he or she pleted by patients and therapists immediately
may become aware of issues that were not after selected sessions. Patients were informed,
known before the start of psychotherapy; both verbally and in writing, that their therapist
 PSYCHOTHERAPY INTEGRATION AND ALLIANCE 377

would not have access to their responses on any mean GSI for a normal population (n ⫽ 719,
psychotherapy process measure (i.e., alliance, nonpatients) was 0.30 [SD ⫽ 0.31], and test–
session process, etc.). Also, all sessions of these retest reliability was .90.
treatments were videotaped, not just the ses- Combined Alliance Short Form–Patient
sions during which reassessment ratings were Version (CASF-P; Hatcher & Barends,
completed. Patient process and independent 1996). The CASF-P is a client-rated alliance
technique ratings for this study were collected at measure that consists of 20 items rated on a
the same session early in treatment (3rd or 4th 7-point scale consisting of 1 (never), 2 (rarely),
session). The mean number of sessions attended 3 (occasionally), 4 (sometimes), 5 (often), 6
by these 91 patients was 26 sessions (SD ⫽ 22) (very often), and 7 (always). This measure con-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

over an average of 8 months. The median num- sists of a total score and four subscales: Ideal-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ber of sessions and length of treatment were ized Relationship (patient’s ability to acknowl-
somewhat shorter at 21 sessions and 6 months, edge disagreement with and negative feelings
respectively. toward the therapist; “How much do you dis-
agree with your therapist about what issues are
Measures most important to work on during these ses-
sions?”; reverse scored), Confident Collabora-
Global Assessment of Functioning (GAF; tion (level of confidence and commitment the
American Psychiatric Association, 1994). patient experiences regarding therapy as well as
Each patient was rated on the DSM–IV Axis V the degree to which therapy is worthwhile, re-
GAF (e.g., on a scale of 0 to 100) based on flects hopefulness of the patient; “What I am
patients’ level of functioning at the time of doing in therapy gives me new ways of looking
assessment before beginning treatment. An in- at my problems”), Goals & Task Agreement
dependent rater scored the GAF for each par- (clarity of duties and agreement on goals and
ticipant after viewing a videotape of the clinical tasks; “My therapist and I are working toward
interview/feedback sessions, reassessment ses- mutually agreed upon goals”), and Bond (ther-
sions, and those sessions or treatment review apeutic bond, aspects of mutual liking, respect,
representative of when 90% of the psychother- and trust; “My therapist and I trust each other”;
apy had been completed. For all cases, the Hatcher & Barends, 1996).
rating was completed without knowledge of pa- Hatcher and Barends (1996) also reported on
tient self-report data, or the assessing clinician’s the construct validity of the CASF-P through a
ratings for the GAF. Spearman-Brown correc- factor analysis by holding the outcome (pa-
tion for a one-way random effects model Intra- tients’ estimate of improvement) constant and
class Correlation Coefficient (ICC[1,2]) was examining the unique contribution of alliance
calculated for the study sample to examine the above and beyond outcome. Both Ackerman et
reliability of the mean score for the GAF and al. (2000) and Clemence, Hilsenroth, Acker-
was found to be .88, in the excellent range man, Strassle, and Handler (2005) report on
(Shrout & Fleiss, 1979, ICC ⬎ .74). For addi- convergent validity data with related measures
tional details regarding the reliability data of of psychotherapy process as well as criterion
this DSM–IV scale and related research design validity with regard to the prediction of treat-
procedures, see Hilsenroth and colleagues ment outcome using a sample of clients at the
(2000) and Peters and colleagues (2006). same university-based clinic as the clients in the
Brief Symptom Inventory (BSI; Derogatis, current study. For the current sample, the coef-
1993). The BSI is a 53-item self-report inven- ficient alpha was .89 and the mean CASF-P was
tory that assesses symptom distress in a number 6.14 (SD ⫽ 0.61; range ⫽ 4.45 to 7.00) from the
of different domains/problem areas using a Lik- early treatment sessions (i.e., 3rd or 4th) used in
ert scale of 0 (not at all) to 4 (extremely) and this study.
was collected at pre- and post-treatment. The Comparative Psychotherapy Process Scale –
psychometric properties, reliability, and validity External Rater Form (CPPS-ER; Hilsenroth,
of this measure, as well as description of spe- Blagys, Ackerman, Bonge, & Blais, 2005).
cific symptom subscale scores, a summary The CPPS is a brief descriptive measure de-
score, and the Global Severity Index (GSI) are signed to assess therapist activity and tech-
provided in the manual (Derogatis, 1993). The niques used during the therapeutic hour. It is
 378 GOLDMAN, HILSENROTH, OWEN, AND GOLD

based on the findings of two empirical reviews external raters demonstrated good to excellent
of the comparative psychotherapy process liter- reliability on the CPPS for the sessions utilized
ature (Blagys & Hilsenroth, 2000, 2002). Based in the current study (Stein et al., 2010). All
on these reviews, a list of interventions was Spearman-Brown corrected mean ICCs for the
developed that represents characteristic features individual CPPS-PI and CPPS-CB techniques
of Psychodynamic-Interpersonal (PI; defined were also in the good to excellent range (and
broadly to include psychodynamic, psychody- thus were examined individually) as were the
namic-interpersonal, and interpersonal thera- ICCs for the CPPS-PI and CPPS-CB subscale
pies) and Cognitive-Behavioral (CB; defined scores. Corrected average ICCs were reported
broadly to include items that are significantly for both CPPS technique items and subscales;
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

more characteristic of cognitive-behaviorally two external raters rated all of the sessions,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

oriented therapy [Blagys & Hilsenroth, 2002], allowing for their more reliable average ratings
cognitive, and behavioral therapies). The PI across their pair. In the current study, the mean
subscale measures the seven domains of thera- CPPS-PI subscale score for the rated sessions
pist activity previously described as key fea- was 3.31 (SD ⫽ 0.73) and the mean CPPS-CB
tures of the STPP treatment model (Blagys & subscale score was 1.26 (SD ⫽ 0.56), represent-
Hilsenroth, 2000). The CB subscale consists of ing a significant level of adherence to a psy-
items which include the following: 1) Emphasis chodynamic treatment model (degrees of free-
on cognitive or logical/illogical thought patterns dom [df] ⫽ 90, t ⫽ ⫺20.79, p ⬍ .0001, d ⫽
and belief systems; 2) Emphasis on teaching 3.2), in the same session that patient alliance
skills to patients; 3) Assigning homework to was rated. Coefficient Alphas for the CPPS-PI
patients; 4) Providing information regarding and CPPS-CB subscales from the 91 sessions
treatment, disorder, or symptoms; 5) Direction rated in this study were .82 and .75, respec-
of session activity; and 6) Emphasis on future tively.
functioning. The CPPS measure consists of 20 Videotapes of an early treatment session (3rd/
randomly ordered techniques rated on a 7-point 4th session) for each patient were arranged in
Likert scale ranging from 0 (not at all charac- random order and entire sessions were watched/
teristic), 2 (somewhat characteristic), 4 (char- rated by two raters independently. Raters were
acteristic), to 6 (extremely characteristic). The graduate students in Clinical Psychology. Im-
CPPS may be completed by a patient (P), ther- mediately after viewing a videotaped session,
apist (T), or an external rater (ER). Ten state- judges independently completed the CPPS;
ments are characteristic of PI interventions and each subscale (PI & CB) was coded in random
10 statements are characteristic of CB interven- order. Regular reliability meetings were held
tions. These interventions can then be organized during the coding process to prevent rater drift
into two scales: one measuring PI features (for a more detailed description of this rater
(CPPS-PI, 10 items) and one measuring CB training process, see Stein et al., 2010).
features (CPPS-CB, 10 items).
The reliability and clinical validity of the Results
CPPS has been well established (see Hilsenroth,
2007 for review). We have recently reported Preliminary Analyses
(Hilsenroth et al., 2005; Slavin-Mulford,
Hilsenroth, Weinberger, & Gold, 2011; Stein, Regarding the potentially confounding ef-
Pesale, Slavin, & Hilsenroth, 2010) on the ex- fects of patient symptoms, other control vari-
cellent interrater reliability and internal consis- ables were tested. Of note, patient self-report
tency of the CPPS, as well as validity analyses and independent clinician ratings of severity of
conducted across several different contexts and symptoms demonstrated a very limited (e.g., no
samples. The CPPS data we use in the current effect) relationship to patient alliance (BSI-GSI:
study are derived from these reports, follow r ⫽ .08, p ⫽ .44; GAF: r ⫽ ⫺0.02, p ⫽ .89;
procedures detailed there, and are rated by N ⫽ 91). Thus, there did not appear to be any
trained external raters who have demonstrated justification to include these variables in the
the ability to rate these individual techniques in final models, as it would have decreased power.
the good (ICC .60 –.74; Fleiss, 1981) to excel- MLM analyses were used to account for
lent range (.75; Fleiss, 1981). Several sets of therapist effects (Raudenbush, Bryk, Cheong,
 PSYCHOTHERAPY INTEGRATION AND ALLIANCE 379

& Congdon, 2005). Therapist effects (ICC) 0.90), only the amount of cognitive– behav-
were calculated for each variable in the study ioral techniques (CB) was significantly re-
and the following values were observed: PI ⫽ lated to this alliance subscale (b ⫽ ⫺0.19;
.38; CB ⫽ .06; CASF-Total ⫽ .20; Confident SE ⫽ .12; t ⫽ 3.37; df ⫽ 87; p ⫽ .001).2
Collaboration ⫽ .03; Goals & Task Agree- Therefore, those therapists using more CB inter-
ment ⫽ .13. ventions early in treatment were related to greater
Are different types of therapist techniques, levels of patient-rated collaboration.
or the integration of these techniques, related When examining the relationship between
to patient-rated overall alliance early in technique and the alliance subscale Goals &
treatment? We conducted a two-level ran- Task Agreement (M ⫽ 6.20, SD ⫽ 0.76),
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

dom intercept MLM (e.g., clients nested within results in Table 1 demonstrate that the inter-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

therapists). The level 1 equation was as follows: action term, PI ⫻ CB, was associated with
Goals & Task Agreement (b ⫽ ⫺0.24; SE ⫽
Alliance ⫽ B0ij ⫹ B1ij(PI) ⫹ B2ij(CB) .12; p ⫽ .057), whereas neither PI (b ⫽ 0.02;
SE ⫽ .08; p ⫽ .833) nor CB (b ⫽ .05; SE ⫽
⫹ B3ij(PIxCB) ⫹ e .08; p ⫽ .517) were significantly associated
with Goals & Task Agreement.3 Figure 1
where B0ij is the intercept for client i treated by shows the association between PI and CB
therapist j, B1ij is the estimate for the associa- with Goals & Task Agreement.4
tion between PI and alliance for client i treated
by therapist j, B2ij is the estimate for the asso- Exploratory Analyses
ciation between CB and alliance for client i
treated by therapist j, B3ij is the estimate for the What individual therapist techniques are
association between the interaction of PI and related to patient-rated Confident Collab-
CB and alliance for client i treated by therapist oration as well as Goals & Task Agreement
j, and e is the level 1 error. Note: PI and CB aspects of the alliance early in treatment?
were grand-mean centered prior to the creation To better understand the specific applied nature
of the interaction effect. The level 2 equation of which psychodynamic-interpersonal and
was as follows: cognitive– behavioral techniques were being in-
tegrated in relation to the Confident Collabora-
␤00 ⫽ ␥000 ⫹ u0j, tion and Goals & Task Agreement subscales,
␤01 ⫽ ␥010 ⫹ u1j,
␤02 ⫽ ␥020 ⫹ u2j,
1
OLS regressions were also conducted (n ⫽ 91) and
revealed that higher levels of CPPS-PI, CPPS-CB, and
␤03 ⫽ ␥030 ⫹ uj3. CPPS PI ⫻ CB early in treatment were not significantly
related to global patient self-reported alliance (CASF Total;
p ⫽ .29, p ⫽ .19, p ⫽ .14, respectively).
Of note, there were no level 2 predictors but 2
All CASF subscales were examined in the present anal-
the level 1 associations (e.g., the relationship yses in relation to the CPPS PI and CB subscales. The
between PI and alliance) were allowed to vary CASF subscales, Bond and Idealized Relationship, were not
across therapists. Additionally, we assumed that significantly related (p ⬎ .10) to any of the technique
the alliance (intercept) would vary across ther- variables and therefore were not examined further.
3
Intercept (Coeff ⫽ 6.20; SE ⫽ .09; p ⫽ ⬍.0001). Note:
apists. Inconsistent with our original hypothe- estimates above are the fixed effects in a MLM wherein all
ses, none of the technique variables (PI, CB, predictors were allowed to freely vary across therapists.
PI ⫻ CB) demonstrated a significant relation- 4
OLS regressions were also conducted (n ⫽ 91) and
ship with overall patient-rated alliance (p ⫽ .12, revealed that CPPS-PI was not significantly related to pa-
tient self-reported Confident Collaboration (p ⫽ .56) or
.22, .26, respectively).1 Goals & Task Agreement (p ⫽ .28). Higher levels of
Are different types of therapist techniques, CPPS-CB indicated a nonsignificant trend for patient self-
or the integration of these techniques, related reported Confident Collaboration (p ⫽ .05) as well as Goals
to patient-rated subscales of alliance early in & Tasks Agreement (p ⫽ .08). The interaction between
treatment? When accounting for therapist psychodynamic-interpersonal and cognitive– behavioral
techniques early in treatment (PI ⫻ CB) was significant and
effects and examining the relationship be- positively related to patient-self reported Confident Collab-
tween technique and the Confident Collabo- oration (p ⫽ .04) and demonstrated a nonsignificant trend in
ration alliance subscale (M ⫽ 5.88, SD ⫽ relation to Goals & Tasks Agreement (p ⫽ .06).
 380 GOLDMAN, HILSENROTH, OWEN, AND GOLD

Table 1 Goals & Task Agreement; specifically, “The

Summary of Fixed Effects From Multilevel Model therapist identifies recurrent patterns in pa-
Predicting Patient-Rated Goals and Task Agreement tient’s actions, feelings and experiences (#14)”
b (SE) p value (r ⫽ .18, p ⫽ .08). One CPPS-PI item was also
significant and negatively related to the patient-
Intercept 6.20 (.09) ⬍.0001
PI 0.02 (.08) .833 self reported Confident Collaboration alliance
CB 0.05 (.08) .517 subscale; “The therapist allows the patient to
PI ⫻ CB ⫺0.24 (.12) .057 initiate the discussion of significant issues,
events, and experiences (#16)” (r ⫽ ⫺.21, p ⫽
.05). The results of pairwise correlations also
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revealed that two CPPS-CB items were signif-

This document is copyrighted by the American Psychological Association or one of its allied publishers.

the relationships between particular

icant and positively related to the patient self-
therapist interventions with these patient ratings
reported Confident Collaboration alliance sub-
of alliance were further explored. The results of
these bivariate pairwise correlations (two- scale. The first was “The therapist actively
tailed; n ⫽ 91) revealed that two CPPS-PI items initiates the topics of discussion and therapeutic
were significant and positively related to the activities (#3)” (r ⫽ .22, p ⫽ .04) and the
patient self-reported Goals & Task Agreement second was “The therapist provides the patient
alliance subscale. The first was as follows: “The with information and facts about his or her
therapist links the patient’s current feelings or current symptoms, disorder, or treatment (#15)”
perceptions to experiences of the past (#4)” (r ⫽ (r ⫽ .28, p ⫽ .01). In addition, one CPPS-CB
.23, p ⫽ .03); the second was as follows: “The item demonstrated a nonsignificant trend in re-
therapist focuses attention on similarities lation to Confident Collaboration; specifically,
among the patient’s relationships repeated over “The therapist explains the rationale behind his
time, settings, or people (#5)” (r ⫽ .25, p ⫽ or her technique or approach to treatment (#11)”
.02). In addition, one CPPS-PI item demon- (r ⫽ .18, p ⫽ .09). Three CPPS-CB items were
strated a nonsignificant trend in relation to also significantly related to the patient self-

CB = 1 SD
CB = -1 SD

6.35

6.21
Goals and Tasks

6.07

5.93

5.78
-1.24 -0.59 0.05 0.70 1.35

PI

Figure 1. Fixed effects for PI and CB techniques in the prediction of patient-rated Goals &
Task Agreement.
 PSYCHOTHERAPY INTEGRATION AND ALLIANCE 381

reported Goals & Task Agreement alliance sub- demonstrated that the interaction effect (PI ⫻
scale. The first was “The therapist explains the CB) evinced a trend toward significance for the
rationale behind his or her technique or ap- alliance subscale, Goals & Task Agreement.
proach to treatment (#11)” (r ⫽ .24, p ⫽ .02); Simply, in the context of brief dynamic therapy,
the second was “The therapist provides the pa- higher levels of CB techniques were associated
tient with information and facts about his or her with greater agreement on Goals and Tasks,
current symptoms, disorder, or treatment (#15)” regardless of the level of PI techniques;
(r ⫽ .25, p ⫽ .02); and the third was “The whereas, lower levels of CB were associated
therapist explicitly suggests that the patient with lower agreement on Goals and Tasks only
practice behavior(s) learned in therapy between when PI techniques were also infrequently used.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sessions (#17)” (r ⫽ .22, p ⫽ .03). These find- Finally, exploratory analyses demonstrated that
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ings reveal that specific psychodynamic- specific psychodynamic-interpersonal and cog-

interpersonal and cognitive– behavioral tech- nitive– behavioral techniques were significantly
niques were significantly correlated with higher related to higher patient-rated alliance scores on
patient-rated alliance subscales, specific to the Confident Collaboration and Goal and Tasks
Goals & Task Agreement and Confident Col- Agreement subscales in clinically meaningful
laboration within treatment. ways.
Despite the useful applied clinical implica- Several interpretations can be made with re-
tions of these exploratory individual technique gard to the interaction effect (PI ⫻ CB) for
analyses, further replication is needed. Accord- Goals & Task Agreement. In brief psychody-
ing to Cohen’s (1988) criteria (r ⬎ .1 ⫽ small, namic therapy, CB techniques may be needed to
r ⬎ .30 ⫽ medium; r ⬎ .5 ⫽ large), the ma- establish Goals and Tasks aspects of the alliance
jority of these findings are considered small (e.g., high CB levels regardless of PI levels).
effects. Moreover, a Bonferroni adjustment for Thus, by increasing the use of CB techniques
these exploratory analyses on individual tech- within a psychodynamic session (in particular,
nique would lead to the more conservative level psychoeducation and increased therapist activ-
of significance of p ⬍ .0025. ity), the clinician can ensure a stronger empha-
sis on goals and tasks aspects of the alliance by
Discussion providing explanations for their approach. As
previously described, psychodynamic clinicians
This is one of the first studies of its’ kind to may want to consider having an explicit discus-
investigate the relationship between the integra- sion regarding how psychodynamic psychother-
tion of specific therapeutic techniques and pa- apy works and how this approach might offer
tients’ experience of alliance early in treatment. specific aid to aspects of patients’ functioning to
In exploring the impact of therapist effects on enhance the goals and task aspects of the alli-
the relationship between technique and patient- ance.
rated alliance, our findings revealed that overall Yet, in the face of limited CB use (e.g., low
alliance was not impacted by therapist tech- CB levels), more PI techniques may be needed
nique or technique integration. However, we to help establish agreement on the Goals and
did find that dynamic therapists who used more Tasks. For these patients, it may be necessary
CB techniques had patients who reported that the sessions contain more exploration of
greater Confident Collaboration, particularly patterned behavior. This would allow the ther-
when therapists provided information about the apist to properly evaluate what tasks would be
patient’s condition or the therapy process. That needed to ensure that both patient and therapist
is, when traditional cognitive– behavioral ele- are on the same page with regard to the direc-
ments, such as providing patients with explicit tion and goals of the treatment. Lastly, low
information and rationale about their symptoms levels of CB or PI may reflect a bad session (or
and treatment, are presented from a psychody- therapeutic process in general) and support pre-
namic perspective (i.e., relational, affective, in- vious findings that therapists need to be rela-
trapsychic; see TMA procedure), this may give tively active to promote positive session out-
patients more confidence to face their chal- comes (Owen, Hilsenroth, & Rodolfa, 2012).
lenges and a greater sense of collaboration with These findings provide significant clinical
their therapist. Additionally, our findings also implications for therapists by using certain
 382 GOLDMAN, HILSENROTH, OWEN, AND GOLD

psychodynamic-interpersonal and cognitive– changing their interpersonal dynamics with oth-

behavioral strategies to successfully predict as- ers (Gold & Stricker, 2001). Yet, in combina-
pects of a strong therapeutic alliance. Psychody- tion with cognitive– behavioral, systematic, and
namic therapists who collaboratively develop strategic interventions, this may allow for be-
patient goals, along with an explicit treatment havioral change and may deepen the psychody-
plan, may strengthen the early alliance by being namic exploration (Gold & Stricker, 2001;
an active participant in initiating discussions Stricker & Gold, 1996).
with the patient (Yeomanset et al., 1994). Like- These recommendations also fit with emerg-
wise, therapists who collaboratively develop ex- ing knowledge on between-session processes.
plicit goals and tasks of the treatment with their Intersession activity has been related to higher
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

patient may facilitate stronger early alliances by alliance scores, as patients may be more likely
This document is copyrighted by the American Psychological Association or one of its allied publishers.

specifically providing information about the pa- to practice therapeutic activities outside of ses-
tient’s symptomatology and treatment, as well sions based on their trust in the therapist about
as explaining the psychodynamic model, ratio- the goals set forth in treatment (Owen, Quirk,
nale, and approach to therapy (DeFife & Hilsen- Hilsenroth, & Rodolfa, 2012). A greater empha-
roth, 2011). Additionally, identifying significant sis on the integration of PI and CB techniques in
and persistent relational patterns over time increasing intersession activity may recipro-
(both past and present), as well as exploring cally strengthen the alliance as well (Owen,
various behavioral observations and different Quirk, Hilsenroth, & Rodolfa, 2012). To this
activities the patient might consider when faced end, one of our future aims is to identify
with these scenarios in-between sessions (i.e., whether the relationship between therapist tech-
anticipation, homework, etc. - see Stricker, nique integration and patient-rated alliance
2006) seem to have a positive association with transforms over the course of treatment; for
a greater sense of shared goals and tasks early in example, middle and late stages of treatment.
treatment. This will promote our understanding of how
The present work, in conjunction with the specific psychodynamic-interpersonal and cog-
DeFife et al. (2008) study that uses a subsample nitive– behavioral techniques can influence psy-
of the current data, offers consistent evidence chotherapy treatment outcomes. Yet, it is also
that supports the assimilative model of psycho- important to note that these process results
therapy integration (Stricker & Gold, 1996; come from a sample of patients who have dem-
Messer, 1992). In DeFife et al.’s findings of onstrated positive large effects for both process
patient-rated techniques, the integration of both and outcome data, including depressed patients
active and exploratory interventions appeared to (Hilsenroth et al., 2003), comorbid depressed
enrich the therapy work, leading to favorable and borderline personality disorder patients
treatment outcomes over time, whereas in the (Hilsenroth, DeFife, Blake, & Cromer, 2007),
present work, the use of assimilative integration and anxiety disorder patients (Slavin-Mulford et
of independently rated techniques had benefit in al., 2011). Within this sample, patients reported
the context of patient-rated alliance subscales. very high overall alliance scores with their ther-
Our investigation of independent clinical rat- apists (average scores ⬎6 on a 7-point scale).
ings of technique also demonstrated that the Despite its relevance as one of the first stud-
integration of some cognitive– behavioral inter- ies to empirically examine therapeutic integra-
ventions within a psychodynamic oriented tion in relation to patient-rated early alliance,
model early in therapy facilitated a stronger some limitations must be addressed. First and
therapeutic alliance specific to collaboration on foremost, the current study examined patients’
treatment focus and goals within therapy. Thus, experience of early alliance in treatment; as
active ingredients from both psychodynamic- such, we did not focus on subsequent treatment
interpersonal and cognitive– behavioral orienta- outcomes in relation to the interaction of ther-
tions appear to have a relationship in facilitating apeutic interventions. However, this does not
aspects of a strong alliance at the start of treat- detract from the unique psychotherapy process
ment. Through the exploration of cyclical findings that enhance our understanding of spe-
relational-affective patterns over time, psy- cific therapeutic interventions, all of which suc-
chodynamic techniques can aid the patient in cessfully influence aspects of the therapeutic
developing new perceptions of him/herself and alliance at the outset of treatment. Our findings
 PSYCHOTHERAPY INTEGRATION AND ALLIANCE 383

highlight the importance of certain techniques inpatient and other outpatient settings, and ex-
that therapists may draw upon to supplement amining the impact of patient characteristics.
their own clinical work and enhance the quality These limitations notwithstanding, this is one
of the therapeutic alliance, specific to collabo- of the first treatment studies to examine the
ration on treatment focus as well as the goals interaction between psychodynamic and cogni-
and tasks aspects of therapy. We hope to direct tive– behavioral techniques in the context of the
future efforts toward the exploration of early alliance. Our findings are among the very first to
alliance in mediating the relation between psy- shed light on the assimilation of some CB tech-
chotherapy technique integration and treatment niques within a larger Psychodynamic model
outcomes. early in treatment to facilitate a stronger thera-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Regarding the MLM analyses, we examined peutic alliance specific to collaboration on treat-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

therapist effects as a level 2 effect or nesting ment focus as well as the goals and tasks agreed
effect; this is where the variability is allocated upon within that therapy. These process results
and commonly referred to as such in the litera- also have therapeutic application, providing a
ture. Although effects exist at the therapist relevant framework for when and how specific
level, the reason for these specific effects is therapist techniques can be used to enhance
unknown and it is possible that they could be different aspects of alliance formation in clini-
unrelated to the therapists per se (e.g., lack of cal practice.
random assignment of patients). Likewise, the
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