Wie wirkt Psychotherapie? Einflussfaktoren auf die therapeutische Beziehung

ZUSAMMENFASSUNG

Gegenstand und Ziel Die therapeutische Beziehung stellt einen zentralen Wirkfaktor in der Psychotherapie dar. Einflussfaktoren auf die therapeutische Beziehung sowie zugrunde liegende neurobiologische Marker sind wenig untersucht.

Material und Methoden Die Übersicht basiert auf einer Recherche in den zentralen Datenbanken (Pubmed und Psycinfo) zu den verschiedenen patienten-, therapeuten- und settingbezogenen Einflussfaktoren auf die therapeutische Beziehung und den Therapieerfolg sowie deren biologische Marker.

Ergebnisse Studienergebnisse zu den Einflussfaktoren auf die therapeutische Beziehung sind heterogen. Die Erfahrung von Kindesmisshandlung sowie die Diagnose einer Persönlichkeitsstörung stellen einen patientenbezogenen Einflussfaktor auf die therapeutische Beziehung dar, wobei beide Faktoren mit einer schlechteren therapeutischen Beziehung assoziiert sind. Die Passung zwischen den Persönlichkeiten von Patienten und Therapeuten scheint für den Therapieerfolg relevant zu sein. Erste Hyperscanning-Studien zeigen einen Zusammenhang zwischen einer besseren therapeutischen Beziehung und der neuronalen Synchronisierung zwischen dem Therapeuten und dem Patienten.

Schlussfolgerungen und klinische Relevanz Physiologische und neurobiologische Daten sowie detaillierte Videoanalysen können künftig die Auswahl von psychotherapeutischen Behandlungsmethoden, die Fallkonzeption und die Anpassung des therapeutischen Vorgehens verbessern.

ABSTRACT

Object The therapeutic relationship is an effective factor in psychotherapy. However, investigations on factors influencing the therapeutic alliance and underlying neurobiological markers are scarce so far.

Methods The overview is based on a research in central databases (Pubmed and Psycinfo), requesting the various patient-, therapist- and setting-related factors influencing the therapeutic alliance and therapy outcome as well as their biological markers.

Results The results of the factors influencing the therapeutic alliance are heterogeneous. Personality disorders and experiences of childhood maltreatment are patient related factors influencing the alliance; both factors are associated with an impaired alliance. The fit between the personalities of patients and therapists also seems to be relevant for therapy outcome. Hyperscanning studies show a positive association between the alliance and the neuronal synchronization between therapist and patient.

Conclusion Physiological and neurobiological data as well as video analyses can improve the selection of psychotherapeutic treatment methods, case conception and the adaptation of the therapeutic approach in the future.

Schlüsselwörter

Therapeutische Beziehung - Therapeuteneffekte - Neurobiologische Marker

Key words

Working alliance - therapist effects - neurobiological marker - therapeutic relationship

Publication History

Article published online:
10 October 2024

• Literatur

• 1 Rogers CR. A theory of therapy, personality, and interpersonal relationships, as developed in the client-centered framework. In: Koch S, Hrsg. Psychology: a study of a science. New York: McGraw Hill 1959: 184-256
• 2 Castonguay LG, Beutler LE. Principles of therapeutic change: A task force on participants, relationships, and techniques factors. J Clin Psychol 2006; 62: 631-638
• 3 Catty J. ‘The vehicle of success’: Theoretical and empirical perspectives on the therapeutic alliance in psychotherapy and psychiatry. Psychol Psychother Theory, Res Pract 2004; 77: 255-272
• 4 Flückiger C, Del AC, Wampold BE. et al The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy 2018; 55: 316-340
• 5 Flückiger C, Del Re AC, Wlodasch D. et al Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. J Couns Psychol 2020; 67: 706-711
• 6 Hentschel U. Die therapeutische allianz: Teil 1: Die entwicklungsgeschichte des konzepts und moderne forschungsansätze. Psychotherapeut 2005; 50: 305-317
• 7 Lambert MJ, Barley DE. Research summary on the therapeutic relationship and psychotherapy outcome. In: Psychotherapy. Washington: American Psychological Association Inc.; 2001: 357-361
• 8 Martin DJ, Garske JP, Katherine Davis M. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. J Consult Clin Psychol 2000; 68: 438-450
• 9 Murphy R, Hutton P. Practitioner Review: Therapist variability, patient-reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment – a systematic review and meta-analysis. J Child Psychol Psychiatry 2018; 59: 5-19
• 10 Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychother Theory, Res Pract 1979; 16: 252-260
• 11 Luborsky L, Crits-Christoph P, Alexander L. et al Two helping alliance methods for predicting outcomes of psychotherapy: a counting signs: vs.: a global rating method. J Nerv Ment Dis 1983; 171: 480-491
• 12 Horvath AO, Del Re AC, Flückiger C. et al Alliance in Individual Psychotherapy. Psychotherapy 2011; 48: 9-16
• 13 Horvath AO, Greenberg LS. Development and Validation of the Working Alliance Inventory. J Couns Psychol 1989; 36: 223-233
• 14 Marmar CR, Weiss DS, Gaston L. Toward the Validation of the California Therapeutic Alliance Rating System. Psychol Assess 1989; 01: 46-52
• 15 McCabe R, Priebe S. The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings. Int J Soc Psychiatry 2004; 50: 115-128
• 16 Del Re AC, Flückiger C, Horvath AO. et al Examining therapist effects in the alliance–outcome relationship: A multilevel meta-analysis. J Consult Clin Psychol 2021; 89: 371-378
• 17 Del Re AC, Flückiger C, Horvath AO. et al Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clin Psychol Rev 2012; 32: 642-649
• 18 Baier AL, Kline AC, Feeny NC. Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clin Psychol Rev 2020; 82: 101921
• 19 Coco G Lo, Gullo S, Albano G. et al The Alliance-Outcome Association in Group Interventions: A Multilevel Meta-Analysis. J Consult Clin Psychol 2022; 90: 513-527
• 20 Wilmers F, Munder T, Leonhart R. et al Die deutschsprachige Version des Working Alliance Inventory – short revised (WAI-SR) – Ein schulübergreifendes, ökonomisches und empirisch validiertes Instrument zur Erfassung der therapeutischen Allianz. Klin Diagnostik und Eval 2008; 01: 343-358
• 21 Simpson SG, Reid CL. Therapeutic alliance in videoconferencing psychotherapy: A review. Aust J Rural Health 2014; 22: 280-299
• 22 Greene CJ, Morland LA, MacDonald A. et al How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial. J Consult Clin Psychol 2010; 78: 746-750
• 23 Glueckauf RL, Fritz SP, Ecklund-Johnson EP. et al Videoconferencing-based family counseling for rural teenagers with epilepsy: Phase 1 findings. Rehabil Psychol 2002; 47: 49-72
• 24 Reese RJ, Mecham MR, Vasilj I. et al The effects of telepsychology format on empathic accuracy and the therapeutic alliance: An analogue counselling session. Couns Psychother Res 2016; 16: 256-265
• 25 Fletcher-Tomenius L, Vossler A. Trust in Online Therapeutic Relationships: The Therapist’s Experience. Couns Psychol Rev 2009: 24
• 26 Roy H, Gillett T. E-mail: A new technique for forming a therapeutic alliance with high-risk young people failing to engage with mental health services? A case study. Clin Child Psychol Psychiatry 2008; 13: 95-103
• 27 Simpson S. Psychotherapy via videoconferencing: A review. Br J Guid Couns 2009; 37: 271-286
• 28 Dunn K. The therapeutic alliance online. In: Psychotherapy 2.0. Routledge 2018: 75-88
• 29 Webb CA, Derubeis RJ, Amsterdam JD. et al Two aspects of the therapeutic alliance: Differential relations with depressive symptom change. J Consult Clin Psychol 2011; 79: 279-283
• 30 Gelso CJ, Carter JA. Components of the Psychotherapy Relationship: Their Interaction and Unfolding During Treatment. J Couns Psychol 1994; 41: 296-306
• 31 Gelso CJ, Carter JA. The Relationship in Counseling and Psychotherapy: Components, Consequences, and Theoretical Antecedents. Couns Psychol 1985; 13: 155-243
• 32 Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol 1993; 61: 561-573
• 33 Kivlighan DM, Shaughnessy P. Patterns of working alliance development: A typology of client’s working alliance ratings. J Couns Psychol 2000; 47: 362-371
• 34 Stevens CL, Muran JC, Safran JD. et al Levels and Patterns of the Therapeutic Alliance in Brief Psychotherapy. Am J Psychother 2007; 61: 109-129
• 35 Beck A, Steer R, Brown G. Beck-Depressions-Inventar–Revision (BDI-II). Deutsche Version. Frankfurt/Main: Harcourt Test Services 2006
• 36 Laws HB, Constantino MJ, Sayer AG. et al Convergence in patient–therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment. Psychother Res 2017; 27: 410-424
• 37 Moshe-Cohen R, Kivity Y, Huppert JD. et al Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder. Psychother Res 2024; 34: 28-40
• 38 Atzil-Slonim D, Bar-Kalifa E, Rafaeli E. et al Therapeutic bond judgments: Congruence and incongruence. J Consult Clin Psychol 2015; 83: 773-784
• 39 Johns RG, Barkham M, Kellett S. et al A systematic review of therapist effects: A critical narrative update and refinement to Baldwin and Imel’s (2013) review. Clin Psychol Rev 2019; 67: 78-93
• 40 Nienhuis JB, Owen J, Valentine JC. et al Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review. Psychother Res 2018; 28: 593-605
• 41 Prusiński T. Factors promoting alliance quality: Differentiation of therapeutic alliance according to the formal aspects of the psychotherapeutic process and demographic variables. Eur J Psychiatry 2023; 37: 190-198
• 42 Weck F, Grikscheit F, Jakob M. et al Treatment failure in cognitive-behavioural therapy: Therapeutic alliance as a precondition for an adherent and competent implementation of techniques. Br J Clin Psychol 2015; 54: 91-108
• 43 Pfeiffer E, Ormhaug SM, Tutus D. et al Does the therapist matter? Therapist characteristics and their relation to outcome in trauma-focused cognitive behavioral therapy for children and adolescents. Eur J Psychotraumatol 2020: 11
• 44 Wampold BE, Brown GS. Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. J Consult Clin Psychol 2005; 73: 914-923
• 45 Anderson T, Crowley MEJ, Himawan L. et al Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychother Res 2016; 26: 511-529
• 46 Schöttke H, Flückiger C, Goldberg SB. et al Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychother Res 2017; 27: 642-652
• 47 Coyne AE, Constantino MJ, Boswell JF. et al Therapist-Level Moderation of Within and Between-Therapist Process–Outcome Associations. J Consult Clin Psychol 2021; 90: 75-89
• 48 Shattock L, Berry K, Degnan A. et al Therapeutic alliance in psychological therapy for people with schizophrenia and related psychoses: A systematic review. Clin Psychol Psychother 2018; 25: e60-e85
• 49 Taber BJ, Leibert TW, Agaskar VR. Relationships among client-therapist personality congruence, working alliance, and therapeutic outcome. Psychotherapy 2011; 48: 376-380
• 50 Shir R, Tishby O. Therapy matchmaking: Patient-therapist match in personality traits and attachment style. Psychother Res 2024; 34: 353-365
• 51 Hersoug AG, Høglend P, Havik O. et al Therapist characteristics influencing the quality of alliance in long-term psychotherapy. Clin Psychol Psychother 2009; 16: 100-110
• 52 Mallinckrodt B, Jeong JS. Meta-analysis of client attachment to therapist: Associations with working alliance and client pretherapy attachment. Psychotherapy 2015; 52: 134-139
• 53 Bernecker SL, Levy KN, Ellison WD. A meta-analysis of the relation between patient adult attachment style and the working alliance. Psychother Res 2014; 24: 12-24
• 54 Fletcher AC, Delgadillo J. Psychotherapists’ personality traits and their influence on treatment processes and outcomes: A scoping review. J Clin Psychol 2022; 78: 1267-1287
• 55 Kushner SC, Quilty LC, Uliaszek AA. et al Therapeutic alliance mediates the association between personality and treatment outcome in patients with major depressive disorder. J Affect Disord 2016; 201: 137-144
• 56 Zuroff DC, Sotsky SM, Martin DJ. et al Relation of therapeutic alliance and perfectionism to outcome in brief outpatient treatment of depression. J Consult Clin Psychol 2000; 68: 114-124
• 57 Muran JC, Segal Z V, Samstag LW. et al Patient Pretreatment Interpersonal Problems and Therapeutic Alliance in Short-Term Cognitive Therapy. J Consult Clin Psychol 1994; 62: 185-190
• 58 Aerts JEM, Rijckmans MJN, Bogaerts S. et al Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance. Psychol Psychother Theory, Res Pract 2023; 96: 999-1014
• 59 Bond M, Banon E, Grenier M. Differential effects of interventions on the therapeutic alliance with patients with personality disorders. J Psychother Pract Res 1998; 07: 301-318
• 60 Culina I, Fiscalini E, Martin-Soelch C. et al The first session matters: Therapist responsiveness and the therapeutic alliance in the treatment of borderline personality disorder. Clin Psychol Psychother 2023; 30: 131-140
• 61 Kramer U, Flückiger C, Kolly S. et al Unpacking the effects of therapist responsiveness in borderline personality disorder: Motive-oriented therapeutic relationship, patient in-session experience, and the therapeutic alliance. Psychother Psychosom 2014; 83: 386-387
• 62 Sachse R. Persönlichkeitsstörungen verstehen: zum Umgang mit schwierigen Klienten. Psychiatrie Verlag, Imprint BALANCE buch + medien verlag 2020
• 63 Lorenzo-Luaces L, Derubeis RJ, Webb CA. Client characteristics as moderators of the relation between the therapeutic alliance and outcome in cognitive therapy for depression. J Consult Clin Psychol 2014; 82: 368-373
• 64 Nanni V, Uher R, Danese A. Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: A meta-analysis. Am J Psychiatry 2012; 169: 141-151
• 65 McLaughlin AA, Keller SM, Feeny NC. et al Patterns of therapeutic alliance: Rupture-repair episodes in prolonged exposure for posttraumatic stress disorder. J Consult Clin Psychol 2014; 82: 112-121
• 66 Aafjes-van Doorn K, Luo X, Kealy D. et al Interpersonal guilt and the working alliance in psychotherapy: The moderating role of childhood experience. Clin Psychol Psychother 2023; 30: 141-151
• 67 Birkhäuer J, Gaab J, Kossowsky J. et al Trust in the health care professional and health outcome: A meta-analysis. PLoS One 2017; 12: e0170988
• 68 Mende MA, Schmidt H. Psychotherapy in the Framework of Embodied Cognition—Does Interpersonal Synchrony Influence Therapy Success?. Front Psychiatry 2021; 12: 562490
• 69 Hernandez J, Riobo I, Rozga A. et al Using electrodermal activity to recognize ease of engagement in children during social interactions. In: UbiComp 2014 – Proceedings of the 2014 ACM International Joint Conference on Pervasive and Ubiquitous Computing. Association for Computing Machinery, Inc 2014: 307-317
• 70 Wang XW, Nie D, Lu BL. Emotional state classification from EEG data using machine learning approach. Neurocomputing 2014; 129: 94-106
• 71 Khodayari-Rostamabad A, Reilly JP, Hasey GM. et al A machine learning approach using EEG data to predict response to SSRI treatment for major depressive disorder. Clin Neurophysiol 2013; 124: 1975-1985
• 72 Hann DM, Osofsky JD, Barnard KE. et al Dyadic affect regulation in three caregiving environments. Am J Orthopsychiatry 1994; 64: 263-269
• 73 Isabella RA, Belsky J. Interactional Synchrony and the Origins of Infant-Mother Attachment: A Replication Study. Child Dev 1991; 62: 373-384
• 74 Reindl V, Wass S, Leong V. et al Multimodal hyperscanning reveals that synchrony of body and mind are distinct in mother-child dyads. Neuroimage 2022; 251: 118982
• 75 Miller JG, Vrtička P, Cui X. et al Inter-brain synchrony in mother-child dyads during cooperation: An fNIRS hyperscanning study. Neuropsychologia 2019; 124: 117-124
• 76 Voutilainen L, Henttonen P, Kahri M. et al Empathy, challenge, and psychophysiological activation in therapist-client interaction. Front Psychol 2018; 09: 332635
• 77 Bar-Kalifa E, Prinz JN, Atzil-Slonim D. et al Physiological synchrony and therapeutic alliance in an imagery-based treatment. J Couns Psychol 2019; 66: 508-517
• 78 Zhang Y, Meng T, Hou Y. et al Interpersonal brain synchronization associated with working alliance during psychological counseling. Psychiatry Res – Neuroimaging 2018; 282: 103-109
• 79 Reindl V, Gerloff C, Scharke W. et al Brain-to-brain synchrony in parent-child dyads and the relationship with emotion regulation revealed by fNIRS-based hyperscanning. Neuroimage 2018; 178: 493-502
• 80 Li L, Huang X, Xiao J. et al Neural synchronization predicts marital satisfaction. Proc Natl Acad Sci U S A 2022; 119: e2202515119