Physicians' and Patients' Ratings of the Physician-Patient Working Alliance, Adherence, Satisfaction, and Treatment Outcome.

The physician-patient relationship is important and essential to the delivery of effective healthcare. The current study examined a measure of this relationship, which we call the physician-patient working alliance (PPWA). We examined it from both perspectives of the medical dyad, simultaneously, which to date has not been done. Data were analyzed via the Actor Partner Interdependence Model to account for the possibility of interdependence in the ratings provided by each member of the dyad. The sample consisted of sixty-eight physician-patient dyads. Patients' ratings of the PPWA were significantly associated with their ratings of adherence to, and satisfaction with treatment. Physicians' ratings of the PPWA were significantly associated with their ratings of patient adherence and to their own satisfaction with treatment. Significant "partner" effects were uncovered, in that physicians' ratings of the PPWA were significantly associated with patients' ratings of adherence. Significant zero-order correlations were also observed for physician-rated outcome; particularly, significant correlations with patient-rated and physician-rated adherence. We conclude that the PPWA is a significant factor in patients' and physicians' ratings of adherence and satisfaction. This study also provides initial evidence that the PPWA is a dyadic phenomenon (e.g., the perception of the strength of the PPWA in one member of the medical dyad impacts the other member's perception) and that both parts of the medical dyad should be considered in future research and in clinical practice.

Social Support, Caregivers, and Chronic Kidney Disease.

The morbidity and mortality associated with chronic kidney disease remains unacceptably high. Psychosocial issues in CKD patients are frequently overlooked yet are often modifiable risk factors for mortality. Addressing patient perception of social support can potentially improve patient outcomes.

Psychological and relational factors in ESRD hemodialysis treatment in an underserved community.

OBJECTIVE: The researchers investigated the association of depression with treatment adherence, and examined the possible moderating roles of social support and of the physician-patient working alliance (PPWA) on treatment adherence, satisfaction with treatment, and quality of life. METHODS: The current study sampled ninety-five patients with End Stage Renal Disease who were receiving outpatient hemodialysis (HD) treatment. RESULTS: Findings indicated that higher levels of depression were significantly associated with lower ratings of adherence, quality of life, and social support. In contrast, higher levels of social support and of the PPWA were significantly associated with higher ratings of adherence, satisfaction with treatment, and quality of life. Analyses of moderation showed no effect for PPWA between depression and adherence, satisfaction, or quality of life; however, there was a significant moderation effect for social support. CONCLUSION: There are mild but significant associations between PPWA and social support. Positive associations between the PPWA and social support on adherence, satisfaction, and quality of life indicate that each one, PPWA and social support, plays its own role on patients' experiences of and behavior in treatment. Affective social support significantly limits the negative influence of depression on adherence. PRACTICE IMPLICATIONS: Assessment of depression and social support is essential in hemodialysis treatment.

A Training Program in Working Alliance Communication Skills.

The current paper presents the results from two studies. The first study examined the effectiveness of a training program designed to enhance medical residents' working alliance communication skills. The second study surveyed patients to examine if the resident training program resulted in significantly improved adherence and satisfaction for their patients. The first study used an experimental design, and 104 residents were randomly assigned to one of two groups: one group received working alliance training and the other served as a control and received no training. In the second study, after the training was completed, we surveyed one patient treated by each of the residents who participated in the first study to assess differences by resident group on patient self-reported adherence and satisfaction. In all, 68 patients participated and these patients were blind to whether the resident had participated in the training. For the first study, post-test data for the two groups showed that residents in the training group reported higher working alliance skills than residents in the control group. For the second study, patients cared for by residents who participated in the training reported better adherence and higher satisfaction with treatment than patients of residents in the control group. Thus, the training program appears to enhance residents' working alliance communication skills and is related to self-reported improvement in patient adherence and satisfaction. Further research is warranted to better understand these findings.

Therapists' and clients' ratings of real relationship, attachment, therapist self-disclosure, and treatment progress.

OBJECTIVE: While there has been much research on the role of the working alliance in psychotherapy, researchers only recently began investigating the role of the real relationship in treatment. METHODS: In the current study on therapist and client dyads, we used actor-partner interdependence modeling (APIM) to examine associations between therapists' and clients' ratings of the real relationship, therapist self-disclosure, attachment, and treatment progress. APIM analyses allowed for an examination into how therapists' and clients' views of a particular phenomenon might affect their own ratings (actor), as well as the others' (partner) ratings of that same phenomenon. RESULTS: Significant negative associations between therapist self-reported attachment anxiety and avoidance and therapist-rated real relationship and treatment progress. Significant positive associations were found between client-rated real relationship and client-rated treatment progress. These results and others are discussed in the context of the literature along with implications for future research in this area.

The Working Alliance in Psychiatric Care: Agreement Communication and Trust in Action.

The physician-patient working alliance has been associated with improved patient satisfaction and adherence. However, up until now there has only been a patient form with which to assess the working alliance in medicine. The current study presents the provider form of the physician-patient working alliance, along with psychometric evidence and support. Participants were 106 psychiatrists (61 men and 45 women). They were selected from a database of providers in the Northeast of the U.S. and were asked to complete a mailed survey and to return it in stamped addressed envelope. We found evidence that the provider form is reliable and valid, and that the providers' ratings' of the working alliance were closely and significantly associated with their satisfaction with the treatment and with ratings of treatment outcome. The provider form of the physician-patient working alliance appears to be a reliable and valid measure of the working alliance. Providers' ratings of the working alliance can now be assessed and examined along with patients' ratings of the working alliance. Use of the measures may inform the relationship in medical treatment and advance the quality of care provided to patients.

The Physician-Patient Working Alliance in Hemodialysis Treatment.

Over the past 20 years, the role of psychological and social factors, including the physician-patient working alliance, have emerged as integral components of medical care for patients with a myriad of health conditions. The current study examines a model comprised of psychological-interpersonal factors and the extent to which it explains patient satisfaction with and adherence to hemodialysis treatment. One hundred and seven adults with end-stage renal disease who were receiving regular outpatient hemodialysis participated in the study. Path analyses show that the physician-patient working alliance indirectly predicts patient adherence through patient satisfaction and patients' outcome expectations. The working alliance directly predicts patients' quality of life. It is concluded that consistent with previous research, the physician-patient working alliance is a significant factor in predicting key patient behaviors in medical care.

The physician-patient working alliance: Theory, research, and future possibilities.

OBJECTIVE: This article discusses the physician-patient working alliance and reviews the empirical research that has been generated on the working alliance to date. METHODS: The paper presents a brief history of the study of the physician-patient relationship, and discusses constructs that have examined aspects of the relationship, such as empathy, trust, and shared decision-making. Lastly, a meta-analysis was conducted based on the seven empirical studies (a total N of 1023 patients) that have examined the physician-patient working alliance. RESULTS: Results of the meta-analysis found medium to large effect sizes between the working alliance and various behavioral care indices. The working alliance is positively associated with patient adherence, satisfaction, and improved patient outcomes. CONCLUSION: Overall, the physician-patient working alliance provides researchers and medical-care providers with a unified construct that combines cognitive and affective dimensions inherent in the relationship in medical care. Furthermore, the PPWAI provides an efficient and inexpensive way to assess the physician-patient relationship in medical treatment. PRACTICE IMPLICATIONS: The present findings warrant the development of an intervention focused on working alliance training that could be offered to healthcare providers.

The physician-patient working alliance and patient psychological attachment, adherence, outcome expectations, and satisfaction in a sample of rheumatology patients.

Over the past twenty years, the physician-patient relationship (eg, the physician-patient working alliance) has emerged as an integral component to the treatment of patients for a myriad of health conditions. Psychological, emotional, and behavioral dimensions of patients' working alliance with their physicians, along with patients' attachment styles, were examined in relation to rheumatology patients' adherence to treatment plans, outcome expectations, and satisfaction. Study participants were 101 adult outpatients from a rheumatology clinic. Path analyses demonstrated that the physician-patient working alliance predicted outcome expectations (Standardized Beta [SB] = 0.27), and patient satisfaction (SB = 0.62), and that patient satisfaction in turn predicted patient adherence (SB = 0.48). Physicians' ratings of patient adherence were significantly and positively correlated with patients' ratings of the physician-patient working alliance. No significant paths were evident with respect to patient attachment. The physician-patient working alliance directly predicts patient satisfaction, and outcome expectations, and indirectly predicts adherence through patient satisfaction.

Transference and insight in psychotherapy with gay and bisexual male clients: the role of sexual orientation identity integration.

Clinical writing has suggested that the therapeutic process and relationship in work with lesbian, gay, and bisexual clients may be influenced by the extent to which clients have accepted their sexual orientation and developed a social network supportive of their sexual orientation, a construct we refer to as sexual orientation identity integration. The present cross-sectional study investigated this proposition by examining the identity integration ratings of 90 gay and bisexual male clients in relation to elements of treatment as rated by both the therapist (insight, negative transference, working alliance, session depth, and client improvement) and client (working alliance, session depth, and client improvement). Participants were male-male therapy dyads recruited from lesbian, gay, and bisexual-affirming practices. Client identity integration was negatively associated with transference, and positively associated with ratings of insight, alliance, depth, and improvement. Insight, but not transference, uniquely mediated the positive association between identity integration and most indicators of therapeutic quality. Results from an exploratory model suggested that transference may indirectly influence therapeutic quality by serving as a barrier to insight.

On the dissemination of clinical experiences in using empirically supported treatments.

This article addresses the long-standing gap that has existed between psychotherapy research and practice and the efforts that have been made to bridge it. It also introduces one such effort, which has consisted of 3 clinical surveys on the experiences of practitioners in using empirically supported treatments for panic disorder, social anxiety, and OCD. In contrast to attempts to close the gap by disseminating research findings to the clinician, the clinical surveys are intended to allow for practitioners to disseminate their clinical experiences to the researcher-and also to other clinicians. What we view as a "two-way bridge" initiative is a collaboration between the Society of Clinical Psychology, Division 12 of the APA, and the Psychotherapy Division of the APA-Division 29. The mechanism that has been established provides a way for clinicians to be a part of the research process, which we hope will provide evidence that can help to enhance our clinical effectiveness.

Gay and bisexual male clients' perceptions of counseling: the role of perceived sexual orientation similarity and counselor universal-diverse orientation.

A recurring question in multicultural counseling is whether client-counselor similarity on sociodemographic characteristics benefits counseling. A related issue is how counselor orientation to diversity relates to counseling process and outcome, both as a main effect and in interaction with counselor-client sociodemographic match. This cross-sectional study investigated these questions in relation to gay and bisexual male clients' counseling experiences by examining clients' perceived similarity to their counselor in sexual orientation, as well as counselors' self-reported orientation to diversity (assessed in terms of level of universal-diverse orientation [UDO]). Data were from 83 male-male client-counselor dyads recruited from lesbian/gay/bisexual-affirming counseling practices, where clients identified as gay or bisexual and counselors identified as gay, bisexual, or heterosexual. Counselor UDO was positively and uniquely associated with client ratings of the working alliance, session depth, and session smoothness. Perceived sexual orientation similarity was not directly related to any of the counseling-related criterion variables. Moreover, when counselors reported low levels of UDO, perceived similarity was negatively associated with the client-rated alliance and perceived improvement. Client religious commitment-a control variable in all analyses--was uniquely and negatively associated with client ratings of perceived improvement in counseling.

The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment.

OBJECTIVE: Researchers tested the hypothesis that patients' working alliance with their physicians, and patients' attachment styles would predict patients' adherence, satisfaction, and health-related quality of life. METHODS: One hundred ninety-three patients diagnosed with lupus participated in an online survey. They completed measures of the Physician-Patient Alliance Inventory, Experiences in Close Relationships Scale, SF-36, General Adherence Inventory, and the Medical Patient Satisfaction Questionnaire. RESULTS: Working alliance was significantly and positively associated with all three outcome variables of adherence, satisfaction, and quality of life. Attachment avoidance was significantly and negatively related to adherence, and attachment anxiety was significantly and negatively related to health-related quality of life. CONCLUSIONS: A working alliance between physician and patient, characterized by agreement communication on goals and tasks of treatment, along with trust and patient liking of his/her doctor, predicts patient adherence, satisfaction, and quality of life. Psychological dimensions of attachment also predict patient adherence and quality of life. PRACTICE IMPLICATIONS: Doctors and other health service providers ought to actively set goals and tasks of treatment, and foster patient trust and liking. A strong relationship with patients can increase treatment efficacy and effectiveness and improve outcomes for individuals with debilitating chronic illnesses such as lupus.

The real relationship inventory: development and psychometric investigation of the client form.

The development and validation of a client version of the Real Relationship Inventory (RRI-C) is reported. Using a sample of clients (n = 94) who were currently in psychotherapy, a 24-item measure was developed consisting of two subscales (Realism and Genuineness) and a total score. This 24-item version and other measures used for validation were completed by 93 additional clients. Results of the present study offer initial support for the validity and reliability of the RRI-C. The RRI-C correlated significantly in theoretically expected ways with measures of the client-rated working alliance and therapists' congruence, clients' observing ego, and client ratings of client and therapist real relationship on an earlier measure of the real relationship (Eugster & Wampold, 1996). A nonsignificant relation was found between the RRI-C and a measure of social desirability, providing support for discriminant validity. A confirmatory factor analysis supported the two theorized factors of the RRI-C. The authors discuss the importance of measuring clients' perceptions of the real relationship.

Behavioral indices in medical care outcome: the working alliance, adherence, and related factors.

BACKGROUND: The working alliance has been shown to be a consistent predictor of patient outcome and satisfaction in psychotherapy. This study examines the role of the working alliance and related behavioral indices in predicting medical outcome. OBJECTIVE: Cognitive and emotional dimensions of the physician-patient relationship were examined in relation to patients' ratings of physician empathy, physician multicultural competence, perceived utility of treatment, and patients' adherence self-efficacy. These factors were then examined as part of a theoretical framework using path analyses to explain patient self-reported adherence to and satisfaction with treatment. DESIGN: The study was based on an ex-post facto field correlation design. PARTICIPANTS: One hundred fifty-two adult outpatients from a neurology clinic at Bellevue Hospital, a large municipal hospital in New York City, participated in the study. INTERVENTIONS: Surveys given to participants. MEASUREMENTS: We used the following measurements: Physician-Patient Working Alliance Scale, Perceived Utility Scale, Treatment Adherence Self-Efficacy Scale, Medical Outcome Study Adherence Scale, Physician Empathy Questionnaire, Physician Multicultural Competence Questionnaire, Medical Patient Satisfaction Questionnaire. MAIN RESULTS: The effect sizes for adherence are between 0.07 and 0.21 and for satisfaction between 0.10 to >0.50. Regression and path analyses showed that ratings of physician multicultural competence and patient adherence self-efficacy beliefs predicted patient adherence (SB = 0.34) and (SB = 0.30) and satisfaction (SB = 0.18) and (SB = 0.12), respectively. Working alliance ratings also predicted patient satisfaction (SB = 0.49). CONCLUSIONS: Psychological and interpersonal dimensions of medical care are related to patient adherence and satisfaction. Medical care providers may be able to use these dimensions to target and improve health care outcomes.

The physician-patient working alliance.

OBJECTIVE: Cognitive and emotional dimensions of the physician-patient relationship (working alliance) were examined in relation to patients' beliefs about the usefulness of treatment (perceived utility), patients' beliefs about being able to adhere to treatment (adherence self-efficacy beliefs), patients' follow through on their treatment plan (adherence), and patients' satisfaction. METHODS: Participants were 51 men and 67 women who averaged 38.9 years of age (S.D.=12.28). Seventy-two were Euro-American, 23 African-American, 6 Asian-American, 11 Hispanic, and 6 "Other." They reported an average of 7.3 years (S.D.=7.48) since being diagnosed with a chronic medical illness and an average of 7.1 (S.D.=4.88) visits to their doctor within the last year. Patients' conditions included HIV+/AIDS, hypertension, diabetes, asthma, and cancer. RESULTS: Results show moderate to strong relationships between working alliance and perceived utility (r=0.63, P<0.001), self-efficacy (r=0.47, P<0.001), adherence (r=0.53, P<0.001), and satisfaction (r=0.83, P<0.001). Regression analyses showed that ratings of the working alliance (SB=0.25, P<0.005) and self-efficacy beliefs (SB=0.48, P<0.001) predicted patient adherence and that working alliance ratings (SB=0.83, P<0.001) also predicted patient satisfaction. CONCLUSION: The working alliance can be measured in medical care and appears to be strongly associated with patients' adherence to and satisfaction with treatment. PRACTICE IMPLICATIONS: The working alliance is important in medical treatment, as it is associated with patient adherence and satisfaction. Patients' self-efficacy ought to be assessed and promoted as it is also associated with treatment adherence.

"Therapist multicultural competency: a study of therapy dyads": correction.

Reports an error in "Therapist Multicultural Competency: A Study of Therapy Dyads" by Jairo N. Fuertes, Thomas I. Stracuzzi, Jennifer Bennett, Jennifer Scheinholtz, A. Mislowack, Mindy Hersh and David Cheng (Psychotherapy: Theory, Research, Practice, Training, 2006[Win], Vol 43[4], 480-490). The fifth author's name should be spelled as follows: Alexa Mislowack. (The following abstract of the original article appeared in record 2006-23019-010.) This study examined the role of therapist multicultural competence (TMC). Fifty-one therapy dyads completed measures of therapist multicultural competency, working alliance, and their satisfaction with therapy. Clients also completed measures of therapist attractiveness, expertness, trustworthiness, and empathy. Results showed strong associations between clients' ratings of TMC and ratings of the working alliance, therapist empathy, and satisfaction. Clients' combined rating of therapist expertness, attractiveness, and trustworthiness were not associated with their TMC ratings but were significantly associated with therapists' self-appraised TMC ratings. Therapists' ratings of their TMC were associated with their ratings of the working alliance and satisfaction with their work. Results are discussed in the context of the relevant literature, as are implications for training and research. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Therapist multicultural competency: A study of therapy dyads.

[Correction Notice: An erratum for this article was reported in Vol 44(1) of Psychotherapy: Theory, Research, Practice, Training (see record 2007-04278-014). The fifth author's name should be spelled as follows: Alexa Mislowack.] This study examined the role of therapist multicultural competence (TMC). Fifty-one therapy dyads completed measures of therapist multicultural competency, working alliance, and their satisfaction with therapy. Clients also completed measures of therapist attractiveness, expertness, trustworthiness, and empathy. Results showed strong associations between clients' ratings of TMC and ratings of the working alliance, therapist empathy, and satisfaction. Clients' combined rating of therapist expertness, attractiveness, and trustworthiness were not associated with their TMC ratings but were significantly associated with therapists' self-appraised TMC ratings. Therapists' ratings of their TMC were associated with their ratings of the working alliance and satisfaction with their work. Results are discussed in the context of the relevant literature, as are implications for training and research. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Effects of speech accents on interpersonal evaluations: implications for counseling practice and research.

This article reviews literature from the fields of psycholinguistics, communications, and social psychology that has examined the effects of speech accents (i.e., regional, national, and international variations in same-language use) on interpersonal attitudes, casual attributions, and subsequent behaviors. The authors link selected findings from this literature to the field of counseling to show that these findings can inform service delivery, particularly counseling conducted with ethnic minority and immigrant populations in the United States. Implications for practice and ideas for future research in this area are also discussed.

Clients' ratings of counselor multicultural competency.

Differences in perceptions between Euro American and ethnic minority respondents were examined to compare the role of counselor multicultural competency in multicultural versus traditional counseling. Results showed a strong positive correlation between clients' ratings of counselors' multicultural competencies and clients' ratings of counselors' general competency and empathy. However, when comparisons were made between Euro American and ethnic minority clients' on satisfaction, counselor multicultural competency explained a large and significant amount of variance for the ethnic minority sample only, above and beyond counselor general competency and empathy. Results are discussed in the context of relevant literature and suggestions for future research.