Therapist Adherence/Competence and Treatment Outcome: A Meta-Analytic Review

Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104-1696, USA.
Journal of Consulting and Clinical Psychology (Impact Factor: 4.85). 04/2010; 78(2):200-11. DOI: 10.1037/a0018912
Source: PubMed


The authors conducted a meta-analytic review of adherence-outcome and competence-outcome findings, and examined plausible moderators of these relations.
A computerized search of the PsycINFO database was conducted. In addition, the reference sections of all obtained studies were examined for any additional relevant articles or review chapters. The literature search identified 36 studies that met the inclusion criteria.
R-type effect size estimates were derived from 32 adherence-outcome and 17 competence-outcome findings. Neither the mean weighted adherence-outcome (r = .02) nor competence-outcome (r = .07) effect size estimates were found to be significantly different from zero. Significant heterogeneity was observed across both the adherence-outcome and competence-outcome effect size estimates, suggesting that the individual studies were not all drawn from the same population. Moderator analyses revealed that larger competence-outcome effect size estimates were associated with studies that either targeted depression or did not control for the influence of the therapeutic alliance.
One explanation for these results is that, among the treatment modalities represented in this review, therapist adherence and competence play little role in determining symptom change. However, given the significant heterogeneity observed across findings, mean effect sizes must be interpreted with caution. Factors that may account for the nonsignificant adherence-outcome and competence-outcome findings reported within many of the studies reviewed are addressed. Finally, the implication of these results and directions for future process research are discussed.

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Available from: Jacques P. Barber
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    • "The alliance accounts for approximately 5 to 15% of the variance in therapy outcomes (Crits-Christoph et al., 2011; Horvath et al., 2011). While these estimates are modest in absolute terms, they are larger than the association between outcome and measures of therapist competence or adherence to specific treatments (Wampold, 2001; Webb et al., 2010). However, in adolescent psychotherapy the association between alliance and outcome has not been as robust as in adult therapy. "
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    ABSTRACT: Objective: Although the working alliance-outcome association is well-established for adults, the working alliance has accounted for 1% of the variance in adolescent therapy outcomes. How the working alliance unfolds in therapy and is modeled in therapy studies may substantially affect how much variance is attributed to the working alliance. Method: The sample included 2,990 military youth who were treated by 98 therapists and attended at least 8 therapy sessions. The average age was 14.91 years (SD = 1.79). Each session, clients completed the Outcome Rating Scale as a measure of psychological well-being/distress and the Session Rating Scale as a measure of working alliance. We utilized 3 models to examine the working alliance-outcome association in therapy: (a) mono-method model (i.e., 1 rating of working alliance correlated with outcomes), (b) aggregate-assessment model (i.e., multiple sessions aggregated and correlated with outcomes), and (c) change-based model (i.e., changes in working alliance scores correlated with outcomes). Results: Findings supported the change-based model. The amount of variance explained in youth outcomes via growth in working alliance scores in the change-based model was approximately 9.8%, which suggests that a key mechanism of client-perceived change for adolescents in therapy may be the continual development of the working alliance over the course of treatment. Conclusions: The monitoring of and continual promotion of the working alliance among military youth in the early phases of therapy may help therapists improve treatment outcomes. (PsycINFO Database Record
    Full-text · Article · Jan 2016 · Journal of Consulting and Clinical Psychology
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    • "Relatively few studies have simultaneously investigated the association between competence and alliance, and outcome from psychotherapy (Barber et al., 2008, 2006; Hoffart, Sexton, Nordahl, & Stiles, 2005; Trepka, Rees, Shapiro, Hardy, & Barkham, 2004). The findings from these studies are inconclusive ; however, there are some indications that the alliance and therapist competence overlap to some degree and explain some shared variance (Webb et al., 2010). It is therefore important to investigate alliance and competence simultaneously, and to control for other potential confounding factors such as early treatment gain and patient characteristics at baseline (Barber, 2009; Feeley et al., 1999; Kazdin & Whitley, 2006). "
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    ABSTRACT: Objective: The research on the association between the working alliance and therapist competence/adherence and outcome from cognitive behavioral therapy (CBT) is limited and characterized by inconclusive findings. This study investigates the working alliance and competence/adherence as predictors of outcome of CBT for social anxiety disorder (SAD) and panic disorder (PD). Method: Eighty-two clinically referred patients (58.5% female; age: M = 33.6 years, SD = 10.3) with PD (n = 31) or SAD (n = 51) were treated with 12 sessions of manualized CBT by 22 clinicians with limited CBT experience in a randomized controlled effectiveness trial. Independent assessors rated the CBT competence/adherence of the therapists using a revised version of the Cognitive Therapy Adherence and Competence Scale, and the patients rated the quality of the working alliance using the Working Alliance Inventory-short form in therapy sessions 3 and 8. The outcome was assessed by independent assessors as well as by patients self-report. A total of 20.7% of the patients (27.5% SAD, 9.7% PD) dropped out during treatment. The association between the alliance, competence/adherence, outcome and dropout was investigated using multiple regression analyses. Results: Higher therapist' competence/adherence early in the therapy was associated with a better outcome among PD patients, lower competence/adherence was associated with dropout among SAD patients. Higher rating of the alliance late in the therapy was associated with a better outcome, whereas lower alliance rating late in the therapy was associated with dropout. Conclusion: The findings indicate that the therapist competence/adherence and the working alliance have independent contributions to the outcome from CBT for anxiety disorders, but in different phases of the treatment.
    Full-text · Article · Dec 2015 · Behaviour Research and Therapy
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    • "Best practices involve ratings by therapists who have expertise in the intervention protocol and training in the rating system (Perepletchikova and Kazdin 2005). Although ratings of adherence to a protocol are typically reliable, ratings of competence have shown consistently low reliability across treatment modalities within individual therapy (Muse and McManus 2013; Webb et al. 2010) as well as family-centered intervention (Cross and West 2011). Although there are only a handful of studies, the reliability of observationally rated adherence is typically higher (r≥.80 Brody et al. 2004; ICC=.64 to .79 "
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    ABSTRACT: The valid and reliable assessment of fidelity is critical at all stages of intervention research and is particularly germane to interpreting the results of efficacy and implementation trials. Ratings of protocol adherence typically are reliable, but ratings of therapist competence are plagued by low reliability. Because family context and case conceptualization guide the therapist’s delivery of interventions, the reliability of fidelity ratings might be improved if the coder is privy to client context in the form of an ecological assessment. We conducted a randomized experiment to test this hypothesis. A subsample of 46 families with 5-year-old children from a multisite randomized trial who participated in the feedback session of the Family Check-Up (FCU) intervention were selected. We randomly assigned FCU feedback sessions to be rated for fidelity to the protocol using the COACH rating system either after the coder reviewed the results of a recent ecological assessment or had not. Inter-rater reliability estimates of fidelity ratings were meaningfully higher for the assessment information condition compared to the no-information condition. Importantly, the reliability of the COACH mean score was found to be statistically significantly higher in the information condition. These findings suggest that the reliability of observational ratings of fidelity, particularly when the competence or quality of delivery is considered, could be improved by providing assessment data to the coders. Our findings might be most applicable to assessment-driven interventions, where assessment data explicitly guides therapist’s selection of intervention strategies tailored to the family’s context and needs, but they could also apply to other intervention programs and observational coding of context-dependent therapy processes, such as the working alliance.
    Full-text · Article · Aug 2015 · Prevention Science
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