Patient coordination style during the first session of therapy: Relationship with early alliance, patient's characteristics and outcomes

Abstract

In the past two decades, psychotherapy researchers and clinicians postulated that the therapeutic alliance is a key component in psychotherapy. Meta-analyses confirm this assumption and conclude that alliance is a powerful predictor of therapeutic outcome for various forms of treatments, problems and patients. In the literature, various measures of alliance are mentioned but not much is known about the behavioural correlates and the nature of this process. The coordination construct is a way to analyse the micro-process involved in the interactional process. Defined by Westerman and Foote (Psychotherapy 1995;32:222-32) as "how well a patient relates his or her contributions in the exchange to the therapist's contributions and to the patient's own contributions at other points in time", the patient's coordination style (PCS) focuses on the complex interaction process and defensive pattern involved in the problematic patient's behaviour. Our hypothesis is that the coordination construct involves conversational collaboration needed to create a strong alliance. The aim of the study is to investigate this hypothesis by analysing the interaction between patient and therapist. Furthermore, the influence of patient's characteristic on patient's coordination style at the beginning of the therapy is explored. Moreover, in line with findings in the alliance literature, we expect to find a relationship between coordination style and therapeutic outcome. The data consisted in 60 self-referred outpatients with anxiety and depressive disorders (with/without cluser C personality disorders) that completed the Brief Psychodynamic Intervention in the Adult Psychiatry outpatient unit of the University of Lausanne (Switzerland). Coordination style was assessed at the first session by means of the coordination scales and alliance was measured by the Helping Alliance Questionnaire (Haq-I), patient's version administrated after each session of treatment. Patient's characteristics are measured in terms of global symptomatic distress (SCL-90), social adjustment (SAS), interpersonal problems (IIP) and overall level of defensive functioning (DMRS). Outcome of treatment consists of reduction in symptomatic distress (SCL-90, HAMA, HDRS) and positive evolution of social adjustment. As predicted, patient coordination style was closely related to the therapeutic alliance as assessed by the patient. Furthermore, patient's coordination style in the first session was a good predictor of the development of the alliance during early sessions of Brief Psychodynamic Intervention. Results showed that coordination was largely influenced by patient's characteristics. The global symptomatic distress, the level of social malad-justment and specific interpersonal problems (hostility and domineering) were correlated to a non-coordinated style. However, coordination was not related to outcome in Brief Psychodynamic Intervention. With regard to these results, the specific roles of therapist and patient in developing early alliance are discussed.