NRNP_6645 Week 10 Assignment: Psychotherapy with Multiple Modalities

The Role of the Therapeutic Relationship in Psychopharmacological Treatment Outcomes: A Meta-analytic Review

Christine M. Wienke Totura, Ph.D., Sherecce A. Fields, Ph.D., Marc S. Karver, Ph.D.

Efﬁcacious psychopharmacological treatments for a wide variety of mental disorders have been identiﬁed (1). Clini- cians are increasingly aware of these treatments to deliver the most effective services to their patients. However, pa- tient participation, engagement, and adherence to treatment regimens are essential components of effective treatment. A number of studies show that medical outcomes are poorer when patients receive an inadequate dose of treatment (2). Patient nonadherence to medication is a signiﬁcant problem throughout clinical medicine (3,4). Treatment adherence is even more problematic in psychiatric populations because mental health impairments lead to poor insight, reasoning difﬁculties, and low motivation to comply with treatment regimens (5). Therefore, to improve medication adherence and maximize the likelihood of achieving desirable out- comes, research should focus on identifying factors associ- ated with increasing patient engagement and participation in treatment.

Struggling to meet your deadline ?

Get assistance on

NRNP_6645 Week 10 Assignment: Psychotherapy with Multiple Modalities

done on time by medical experts. Don’t wait – ORDER NOW!

BUY A CUSTOM PAPER HERE

A number of studies examining patient-provider inter- actions have been conducted in the ﬁelds of medical and psychotherapy treatment. For example, in studies of both

general and specialty medical practitioners (including family medicine, internal medicine, and oncology), a positive physician-patient relationship and physician-patient com- munication have been moderately correlated with a variety of health outcomes, including decreased psychiatric symp- toms, resolution of general medical symptoms, improved functional status, decreased blood pressure, improved blood sugar levels, and better pain control (6,7). Similarly, in the psychotherapy treatment literature, the therapeutic re- lationship or alliance has been found to be one of the most robust predictors of adult and youth mental health treatment outcomes across various psychotherapy approaches (8,9).

Clearly, variables related to the therapeutic relationship are important components in many psychotherapeutic and general medical approaches with diverse patient pop- ulations. The therapeutic alliance may also be important for patients who receive psychopharmacological services for a wide variety of mental health issues. In fact, the therapeutic relationship may be more important for psychiatry than for general medicine. The effectiveness of psychopharmaco- logical treatment requires taking medications outside the

Psychiatric Services 69:1, January 2018 ps.psychiatryonline.org 41

treatment session, and the role of the therapeutic relationship may be critical in this regard. Some psychiatric medications take time before a therapeutic effect is evident, and many have side effects (10). Because adult patients are usually responsible for their medication compliance, alliance development seems a particularly relevant factor for managing effectiveness expec- tations and side effects that could mitigate adherence.

A strong therapeutic relationship may therefore encourage patient willingness to continue medication use despite unpleas- ant side effects or the lack of immediate therapeutic effect. In this study, we conducted a comprehensive literature review and meta-analysis of the association between the therapeutic relationship and psychopharmacological treatment outcomes among adult psychiatric patients. On the basis of previous studies, we expected to ﬁnd a signiﬁcant relationship between the ther- apeutic relationship and treatment outcome variables.

METHODS

Search Strategy The literature search included PubMed, PsycINFO, CINAHL, publication alerts from Ingenta, and Web of Science–Science Citation Index databases. Combinations of the following search terms were used: therapeutic relationship, therapy relationship, treatment relationship, relationship, patient, physician, psychiatrist, psychiatry, behavior, empathy, in- teraction, patient perception, communication, and alliance. Authors of relevant articles were searched in the afore- mentioned databases to determine whether they had pub- lished additional research, and the reference lists of found articles were searched for any studies not returned by the literature search. Finally, Google Scholar was used to search for studies that may have been harder to ﬁnd with the stan- dard databases and for unpublished manuscripts. Published journal articles or dissertations written in or translated into English until February 2014 were included. The search yielded 296 results.

Study Inclusion Criteria

The meta-analysis used the following inclusion criteria: empirically based studies examining the therapeutic re- lationship (that is, measures were administered explicitly assessing the therapeutic alliance or relationship) and ex- amining the association between the alliance measure and physician-related medication management outcomes for adult patients.

In cases in which abstracts provided insufﬁcient in- formation to adequately assess eligibility, the full article was reviewed to avoid elimination of appropriate articles. Nine articles that met criteria were retained. [A ﬂow diagram of study selection is presented in an online supplement to this article.] Two of these articles used data from the same study, and only one effect size was then computed. Therefore, eight studies were included in the ﬁnal meta-analysis, with 59 samples of data across multiple alliance and treatment measures.

Data Extraction

Data entry used a standardized form. For each of the eight studies, the following information was coded: author, pub- lication year, relationship variables, outcome variables, number of patients, patient age, type of prescribing health professional, sample size, and relationship to outcome effect size. Two independent raters (CMWT and SAF) coded each study. One of the authors (MK) discussed coding discrep- ancies with each rater, and all were resolved through re- peated review until consensus was reached.

Statistical Analysis

Fisher’s z was computed for small sample size by using the statistical software Comprehensive Meta-Analysis, Version 2 (11). Means and standard deviations (SDs) or correlations were preferred to compute effect sizes. When correlations were used, Fisher’s z was calculated from r. In the one other case, mean and SD values were used to calculate Fisher’s z. Positive z values indicate better outcomes as a function of increased alliance. All eight studies included sufﬁcient in- formation to calculate effect size. If a study employed more than one measure of alliance or outcome, involved different conditions and did not supply an overall effect, or involved distinct groups, then individual effect sizes were calculated and averaged to provide an overall effect size for the study. For studies reporting a nonsigniﬁcant relationship between alliance and outcome, the effect size was conservatively imputed to be zero. Inverse relationships were entered as negative values. Fifty-nine individual effect sizes were calculated across measures, samples, and conditions, which were pooled to providea composite effect size per study, or eight overall effect sizes weighted by sample size. Cochran’s Q homogeneity statistic was used to determine whether a random or ﬁxed-effects model would be required. We intended to examine potential moderators of the association between the therapeutic relationship and outcome (9), but we had too few studies to adequately power an analysis.

Meta-analysis typically involves accounting for publica-

tion bias (that is, studies with nonsigniﬁcant results are less likely to be published) (12). Two approaches examined publi- cation bias: funnel plot (Duval and Tweedie’s trim and ﬁll [13]) and fail-safe N (that is, the number of additional “negative” studies [with a zero intervention effect] needed to increase the p value above .05 [14]).

RESULTS

Study Characteristics

Participant demographic characteristics and effect sizes (eight different studies with 59 distinct samples) are reported in Table 1 and Figure 1. Four studies (ﬁve reports) involved treatment of affective disorders (depression or bipolar disor- der) (15–19), two involved treatment of schizophrenia (20,21), and two involved a mixed clinical population (22,23). Ther- apeutic alliance measures across studies included domains such as collaboration, shared goals, bonding with the therapist,

TABLE 1. Articles included in a meta-analysis of the association between the therapeutic relationship and psychopharmacological treatment outcomes

Measures

Participants

Article

Relationship

Timing of relationship measurement

Outcome

Patients

Health professionals

Study N

Overall effect size (z)

Beauford et al.,	Therapeutic alliance	Early treatment	Overt Aggression Scale	Adults; mixed clinical	Inpatient physicians	311	.49
1997 (22)	assessed by chart			population; mean
	review (6-point scale)			age=41.9
Blais, 2004 (23)	Inpatient Treatment	Early and middle	10-item Schwartz Outcome Scale,	Adults; mixed clinical	Psychiatrists	73	.11
	Alliance Scale	treatment	amount of trouble	population, primarily
				depression; mean
				age=47
Frank and Gunderson,	Psychotherapy Status	Early and middle	Psychiatric Status Scale, Inpatient	Adults; schizophrenia; age	Psychotherapists	48	.27
1990 (20)	Report	treatment	Multidimensional Psychiatric Scales,	range 18–35	with M.D.s
			Menninger Health-Sickness Rating
			Scales, Camarillo Dynamic
			Assessment Scales, Katz Adjustment
			Scales: Global psychopathology;
			paranoid hallucinations, delusions
			and expansiveness; agitation and
			hostility; anxiety and depression;
			withdrawal, retardation, and apathy;
			cognitive disorganization; primary
			process thinking; verbal-ideational
			productivity; ego weakness; denial
			of illness; adaptive regression;
			interpersonal relations; social
			dysfunction; behavioral disturbance;
			occupational functioning; self-
			sufﬁciency
Gaudiano and	Working Alliance	Early and middle	Bech-Rafaelsen Mania Scale, Hamilton	Adults; bipolar disorder;	Psychiatrists	61	.11
Miller, 2006 (15)	Inventory	treatment	Rating Scale for Depression, Global	mean age=42
			Assessment of Functioning
Krupnick et al.,	Modiﬁed Vanderbilt	Early, middle, and	Hamilton Rating Scale for Depression,	Adults; depression; mean	Psychologists and	225	.27
1996 (16); Meyer et al., 2002 (17)^a	Therapeutic Alliance Scale	late treatment	Beck Depression Inventory, composite outcome score	age=37.7	psychiatrists
McCabe et al.,	Modiﬁed Helping Alli-	Early treatment	Lancashire Quality of Life Proﬁle	Adults; schizophrenia;	Primary therapists	258	.39
1999 (21)	ance Scale			mean age=48.9
Strauss and Johnson,	Working Alliance	Early treatment	Hamilton Rating Scale for Depression,	Adults; bipolar disorder;	Psychiatrists	58	.25
2006 (18)	Inventory		Bech-Rafaelsen Mania Scale	mean age=44.09
Weiss et al., 1997 (19)	California Pharmaco-	Early treatment	Hamilton Rating Scale for Depression,	Adults; depression; mean	Psychiatrists	31	.46
	therapy Alliance Scale		Beck Depression Inventory	age=41.9
^a Same study, two articles

FIGURE 1. Meta-analytic plot of Fisher’s z effect sizes and 95% conﬁdence intervals in eight studies of the association between the therapeutic relationship and psychopharmacological treatment outcomes^a

Statistics for each study

Fisher’s Standard Lower Upper

Study Name Subgroup within study

z error Variance limit limit z p

Frank et al., 1990 Adults (schizophrenia) .266 .036 .001 .195 .337 7.365 .000

Blais, 2004 Adults (mixed clinical) .110 .042 .002 .027 .193 2.609 .009

Krupnick et al., 1996 Adults (depression) .270 .019 .000 .233 .306 14.485 .000

McCabe et al., 1999 Adults (schizophrenia) .393 .036 .001 .322 .464 10.800 .000

Weiss et al., 1997 Adults (depression) .463 .067 .004 .332 .594 6.932 .000

Strauss et al., 2006 Adults (bipolar) .249 .095 .009 .062 .436 2.610 .009

Guadiano et al., 2006 Adults (bipolar) .105 .054 .003 .000 .210 1.962 .050

Beauford et al., 1997 Adults (mixed clinical) .494 .033 .001 .429 .558 15.003 .000

.295 .048 .002 .202 .388 6.192 .000

–1.00

–.50 0

Favors A

.50 1.00

Favors B

^a Favors A results suggest a negative effect; favors B results suggest a positive effect. The diamond indicates the overall meta-analytic effect and 95% conﬁdence interval.

active participation, and perceived value of treatment. Psy- chopharmacology treatment outcomes measured included ag- gression, anxiety, depression, general well-being, and level of autonomous functioning. Four studies involved outpatient treatment (15–19), three involved inpatient treatment (21–23), and one hada mixed inpatient-outpatient sample (20). In seven studies, the therapeutic relationship was measured either early in treatment or both early and midtreatment, allowing for a prospective relationship to outcome (15,18–23). Some re- searchers measured the alliance three times: in early, middle, and late treatment (16,17; the data utilized in these articles are from the same study and therefore count in the analyses as only one study). Studies varied by treatment duration; the longest was up to 28 months (15).

Participant Characteristics

The meta-analysis sample consisted of 1,065 participants (mean6SD=1226101.7 participants per study), with a mean age of 41.2 (range 16–87 years). Only three studies provided information on the gender of patients; these studies were ap- proximately equally divided between males and females (19,22,23). Length of treatment varied across studies (range of inpatient treatment, 16 days to four months; range of outpatient treatment, 11 sessions to 28 months). Only three studies reported the number of treating clinicians (range of four to 81) (16,19,20).

Test of Study Heterogeneity

Cochran’s Q suggested heterogeneity (Q=44.49, p,.001). The error observed between studies was different from that explained by sampling error, suggesting the need for a random- effects model (24,25), which assumes that effects are randomly distributed within studies (26).

Effect of Publication Year on Effect Size

A moderate, nonsigniﬁcant correlation occurred for publi- cation year and sample size (r=.406, df=16, p=.118). A small, nonsigniﬁcant correlation between publication year and effect size occurred (r=–.078, df=16, p=.774). Sixty-eight percent of studies were published after 2010, and all were published after 2003.

Publication Bias

Studies with nonsigniﬁcant results are at risk of being un- published and thus excluded from meta-analyses (12). Publication bias was examined with the following two approaches.

Funnel plot. As expected, larger studies were clustered around the combined effect size toward the top of the plot, and smaller studies gathered toward the bottom of the plot (11). A plot of observed and inputted studies revealed no bias toward positive effect sizes (Figure 2). Duval and Tweedie’s trim-and-ﬁll analysis imputed no additional studies to the left or right of the mean with a random-effects model, leaving the effect size the same (z=.30, 95% conﬁdence in- terval [CI]=.20–.39, SE=.048, z=6.192, p,.05).

Classic fail-safe N. Fail-safe N analysis indicated that 65 nonsigniﬁcant studies would be needed to reverse the signiﬁcant positive effect size found in the eight studies (11). This is above the criterion benchmark of ﬁve times the number of studies plus ten (12)—in this case 50 studies—indicating that a ﬁle drawer problem is unlikely present.

Therapeutic Alliance and Psychiatric Medication Management

The point estimate (weighted mean) composite effect size was .30 (CI=.20–.39, SE=.048, z=6.192, p,.05). Effect sizes

ranged from –.11 to .49, a medium effect size (27). This in- dicates a statistically signiﬁcant association between the therapeutic alliance and outcomes of psychiatric medication management (Table 1).

DISCUSSION

This ﬁrst meta-analytic review examining the therapeutic relationship in psychiatric medication management in- dicated that a higher-quality physician-patient relationship was related to better mental health treatment outcomes. Across eight empirical studies, the average effect size was z=.30, a medium effect size commensurate with that found in

the literature on the therapeutic alliance or relationship in adult and child psychotherapy (8,28–30). The ﬁndings sug- gest that the therapeutic alliance is just as important in phar- macotherapy adherence as it is in psychotherapy participation. In addition, the effect size suggests that there is considerable variability in the association between the therapeutic re- lationship and the success of psychiatric medication man- agement. Many physicians form high-quality relationships with their patients, resulting in positive outcomes; however, many relationships need improvement, given the less-than- optimal treatment outcomes in some studies.

Successful psychopharmacological treatment relies on patients’ adherence to prescribed medications (31–34). Con- sidering that research has suggested that the therapeutic al- liance predicts outcomes across various clinicians and therapies (8), it should not be surprising that it is also im- portant in facilitating positive medication management outcomes, in particular with psychiatric patients (35–37). The results of this meta-analysis suggest a possible mechanism— namely, that a strong physician-patient alliance contributes to improved medication adherence, which may result in positive treatment outcomes. Because the meta-analysis did not assess medication adherence, future research should examine whether medication adherence mediates the re- lationship between alliance and treatment outcomes or whether the alliance has a more direct curative effect. An alternative possibility is that other unmeasured variables related to the therapeutic alliance may be the actual mech- anisms. Speciﬁc physician behaviors, such as providing ac- knowledgment and support (38) or a credible rationale for medication use (39), may be directly related to treatment adherence or outcome, but such behaviors may also result in patients’ experiencing positive feelings toward their treating physician. Other understudied variables that may be related to the association between therapeutic alliance and posi- tive treatment outcomes include treatment dose (length of sessions), time between sessions, early symptom change, patient empowerment in managing his or her psychiatric illness, patient motivation to change, or even organizational or agency factors (for example, warmth of the physician’s administrative staff ). In addition, development of attachments and empathy (40), patient misunderstanding or forgetting prescription instructions, economic barriers or barriers re- lated to the family or the environment, failure to remember to take medications consistently, and regular physician assessment of adherence may also contribute to medication adherence (41).

Given the signiﬁcant relationship between the thera- peutic alliance and outcomes found in a very small sample of studies, each study was carefully examined for limitations in methodological quality. First, the studies used diverse mea- sures to assess alliance, and most did not focus exclusively on the relationship between alliance and outcome in medi- cation management. Several studies included physicians who delivered both psychotherapy and pharmacotherapy (20,22,23), some studies combined data from individuals

FIGURE 2. Funnel plot of standard error by Fisher’s z in eight studies of the association between the therapeutic relationship and psychopharmacological treatment outcomes

.05

.10

.15

.20

–2.0 –1.5 –1.0 –.5 0 .5 1.0 1.5 2.0

Fisher’s z

who were receiving only psychotherapy with data from those also receiving pharmacotherapy (16), others focused on physicians delivering only medication management (15), and others reported alliance ratings for a treatment team, which included a prescribing psychiatrist (16,17,20–23). Thus it was difﬁcult to determine what aspects of the alli- ance were associated with favorable relationships and whether alliance in the context of psychotherapy or psy- chopharmacology with the psychiatrist or physician was responsible for treatment effects. However, the effect size found is consistent with that in the psychotherapy literature. If the studies had included only measures of the alliance in pharmacological treatment, the relationship between the alliance and medication management outcomes might have been stronger.

In addition, methodological issues might explain why two of the studies demonstrated weaker associations between alliance and outcomes (15,23). In the study by Blais (23), the aggregation of the alliance construct across the perspectives of multiple informants and helping professionals may have diluted the study’s ability to identify a stronger alliance-to-outcome effect size. Moreover, study effect sizes may have been attenuated as a result of the long time lag between assessment of the alliance and of discharge outcomes. In studies with long treatment duration, it might be more effective to assess patterns of alli- ance over time. This is an area for future research. Further- more, the effects were stronger for the relationship between the alliance and change in depression symptoms, compared with symptoms of mania, and for the relationship between the alliance and change in overall functioning scores. Additional studies are needed to provide adequate power to assess mod- erating effects such as these.

Many studies also did not provide information on the

physicians or on the number of physicians in the study. The alliance measures used in the studies also varied extensively. The Working Alliance Inventory was the most frequently used, but it was used in only two studies. This raises the question of whether each study measured the same con- struct. However, the consistently signiﬁcant ﬁndings across studies suggest that each measured the same alliance construct. Furthermore, sample heterogeneity existed in the eight studies.

However, the consistent results suggest the importance of the relationship between alliance and outcome despite the diversity in samples and measures. Unfortunately, the small number of studies did not allow for moderator analyses to examine patterns attributable to theoretical or methodological issues. For example, alliances may have more or less impact depending on the prob- lem or diagnosis treated, the outcome examined (which varied across studies), the alliance measures used, and the treatment settings (inpatient versus outpatient). Although this meta-analysis included a small sample of relevant work, the ﬁndings provide justiﬁcation for more research in this area. Furthermore, some ﬁndings may have been inﬂated because of shared method vari- ance or temporal similarity (in some studies, alliance measures were completed at the same time as outcome measures [15,16,20,23]). Variability in timing of alliance ratings may have had an impact on effect sizes. Alliance assessments in middle to late treatment may have inﬂated the relationship between alliance and outcomes, especially if the alliance assessments occurred after patients began experiencing potential improvements.

Despite some limitations, three studies were the most methodologically sound of those reviewed, with the clearest evidence of a moderate relation (average r=.26) between the therapeutic relationship and psychiatric medication man- agement (15,18,19). Higher-quality studies should be con- ducted to further elucidate outcomes.

The aforementioned limitations indicate several areas for future research. There is a need for more studies of psychia- trists across levels of experience, of clinicians delivering only pharmacotherapy, and in outpatient settings. The literature would beneﬁt from studies focusing on medication manage- ment for a variety of patients (for example, various diagnoses and stages of development) who are typically seen for brief appointments. If the alliance is found to serve a truly important role in pharmacotherapy, then research should examine its mechanisms in medication management and whether they vary depending on the characteristics of the patients being treated or the type of medication prescribed. Moreover, psy- chotherapy alliance measures have been developed on the basis of certain assumptions, such as one-hour therapy sessions, weekly meetings, and treatment success as assessed by con- versations between the therapist and the patient. Given that these assumptions do not typically apply to medication man- agement, treatment process measures are needed that reﬂect treatment considerations in psychiatric practice (such as brief appointments rather than weekly meetings and not consider- ing physician-patient conversations as the primary treatment ingredient). Finally, we conducted a thorough review of existing research and noted a lack of studies focused exclu- sively on the alliance-outcomes relationship in pharmaco- therapy, which suggests a major gap in the literature on the therapeutic alliance that needs to be addressed.

CONCLUSIONS

More high-quality studies on the role of the therapeutic al- liance in psychopharmacological treatment are needed. This

meta-analysis included some studies of lower quality and studies that were highly diverse. Nevertheless, it found ev- idence of a relationship between alliance and outcomes, suggesting that the therapeutic alliance is important in achieving optimal psychopharmacology outcomes. Thus the training of psychiatrists prescribing psychotropic medica- tions should emphasize communication skills to enhance the therapeutic alliance. Research is clearly needed to effectively develop the skills that will contribute to positive prescriber- patient relationships. This review contributes to the literature by encouraging better research on the therapeutic alliance in psychiatric medication management.

AUTHOR AND ARTICLE INFORMATION

Dr. Totura is with the Department of Psychology, Auburn University, Auburn, Alabama. Dr. Fields is with the Department of Psychology, Texas A&M University, College Station. Dr. Karver is with the Department of Psychology, University of South Florida, Tampa. Send correspondence to Dr. Totura (e-mail: christine.totura@auburn.edu).

The authors thank Sarah Tarquini for assistance with study coding.

The authors report no ﬁnancial relationships with commercial interests. Received March 8, 2017; revision received May 24, 2017; accepted June

22, 2017; published online September 15, 2017.

REFERENCES

Clinical Practice Guidelines. Arlington, Va, American Psychiatric https://www.psychiatry.org/psychiatrists/practice/clinical- practice-guidelines
DiMatteo MR: Variations in patients’ adherence to medical rec- ommendations: a quantitative review of 50 years of research. Medical Care 42:200–209, 2004
Bulloch AGM, Patten SB: Non-adherence with psychotropic medi- cations in the general population. Social Psychiatry and Psychiatric Epidemiology 45:47–56, 2010
Chappuy H, Tréluyer JM, Faesch S, et al: Length of the treatment and number of doses per day as major determinants of child ad- herence to acute Acta Paediatrica 99:433–437, 2010
Julius RJ, Novitsky MA Jr, Dubin WR: Medication adherence: a review of the literature and implications for clinical practice. Journal of Psychiatric Practice 15:34–44, 2009
Gabbay M, Shiels C, Bower P, et al: Patient-practitioner agree- ment: does it matter? Psychological Medicine 33:241–251, 2003
Street RL Jr, Makoul G, Arora NK, et al: How does communication heal? Pathways linking clinician-patient communication to health Patient Education and Counseling 74:295–301, 2009
Martin DJ, Garske JP, Davis MK: Relation of the therapeutic al- liance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology 68:438–450, 2000
Shirk SR, Karver M: Prediction of treatment outcome from re- lationship variables in child and adolescent therapy: a meta- analytic review. Journal of Consulting and Clinical Psychology 71: 452–464, 2003
Chew RH, Hales RE, Yudofsky SC: What Your Patients Need to Know About Psychiatric Medications, 2nd ed. Arlington, Va, American Psychiatric Publishing, 2009
Borenstein M, Hedges L, Higgins J, et al: Comprehensive Meta- analysis, Version Englewood, NJ, Biostat, 2005
Sharpe D, Rossiter L: Siblings of children with a chronic illness: a meta-analysis. Journal of Pediatric Psychology 27:699–710, 2002
Duval S, Tweedie R: A nonparametric “trim and ﬁll” method of accounting for publication bias in meta-analysis. Journal of the American Statistical Association 95:89–98, 2000
Rosenthal R: The “ﬁle drawer problem” and tolerance for null Psychological Bulletin 86:638–641, 1979
Gaudiano BA, Miller IW: Patients’ expectancies, the alliance in pharmacotherapy, and treatment outcomes in bipolar disorder. Journal of Consulting and Clinical Psychology 74:671–676, 2006
Krupnick JL, Sotsky SM, Simmens S, et al: The role of the ther- apeutic alliance in psychotherapy and pharmacotherapy outcome: ﬁndings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consul- ting and Clinical Psychology 64:532–539, 1996
Meyer B, Pilkonis PA, Krupnick JL, et al: Treatment expectancies, patient alliance, and outcome: further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 70:1051–1055, 2002
Strauss JL, Johnson SL: Role of treatment alliance in the clinical management of bipolar disorder: stronger alliances prospectively predict fewer manic symptoms. Psychiatry Research 145:215–223, 2006
Weiss M, Gaston L, Propst A, et al: The role of the alliance in the pharmacologic treatment of depression. Journal of Clinical Psy- chiatry 58:196–204, 1997
Frank AF, Gunderson JG: The role of the therapeutic alliance in the treatment of schizophrenia: relationship to course and out- Archives of General Psychiatry 47:228–236, 1990
McCabe R, Röder-Wanner UU, Hoffmann K, et al: Therapeutic relationships and quality of life: association of two subjective constructs in schizophrenia International Journal of So- cial Psychiatry 45:276–283, 1999
Beauford JE, McNiel DE, Binder RL: Utility of the initial thera- peutic alliance in evaluating psychiatric patients’ risk of American Journal of Psychiatry 154:1272–1276, 1997
Blais MA: Development of an inpatient treatment alliance scale. Journal of Nervous and Mental Disease 192:487–493, 2004
Hunter JE, Schmidt FL: Fixed effects vs random effects meta- analysis models: implications for cumulative research knowledge. International Journal of Selection and Assessment 8:275–292, 2000
Petitti DB: Approaches to heterogeneity in meta-analysis. Statistics in Medicine 20:3625–3633, 2001
Higgins JPT, Thompson SG, Spiegelhalter DJ: A re-evaluation of random-effects meta-analysis. Statistics in Society 172:137–159, 2009
Cohen J: Statistical Power Analysis for the Behavioral Sciences, 2nd Hillsdale, NJ, Erlbaum, 1988
Cummings CM, Caporino NE, Settipani CA, et al: The therapeutic relationship in cognitive-behavioral therapy and pharmacotherapy

for anxious youth. Journal of Consulting and Clinical Psychology 81:859–864, 2013

Horvath AO, Del Re AC, Flückiger C, et al: Alliance in individual Psychotherapy 48:9–16, 2011
Shirk SR, Karver MS, Brown R: The alliance in child and adoles- cent Psychotherapy 48:17–24, 2011
Post RM, Denicoff KD, Leverich GS, et al: Morbidity in 258 bipolar outpatients followed for 1 year with daily prospective ratings on the NIMH life chart method. Journal of Clinical Psychiatry 64: 680–690, 2003
De Nadai AS, Karver MS, Murphy TK, et al: Common factors in pediatric psychiatry: a review of essential and adjunctive mecha- nisms of treatment outcome. Journal of Child and Adolescent Psychopharmacology 27:10–18, 2017
Salloum IM, Cornelius JR, Daley DC, et al: Efﬁcacy of valproate maintenance in patients with bipolar disorder and alcoholism: a double-blind placebo-controlled study. Archives of General Psy- chiatry 62:37–45, 2005
Scott J, Pope M: Self-reported adherence to treatment with mood stabilizers, plasma levels, and psychiatric hospitalization. Ameri- can Journal of Psychiatry 159:1927–1929, 2002
Klein DN, Schwartz JE, Santiago NJ, et al: Therapeutic alliance in depression treatment: controlling for prior change and patient Journal of Consulting and Clinical Psychology 71: 997–1006, 2003
Meier PS, Barrowclough C, Donmall MC: The role of the thera- peutic alliance in the treatment of substance misuse: a critical review of the Addiction 100:304–316, 2005
Zeber JE, Copeland LA, Good CB, et al: Therapeutic alliance perceptions and medication adherence in patients with bipolar Journal of Affective Disorders 107:53–62, 2008
Perron BE, Zeber JE, Kilbourne AM, et al: A brief measure of perceived clinician support by patients with bipolar spectrum Journal of Nervous and Mental Disease 197:574–579, 2009
Gathchel RJ, Oordt MS: Hypertension; in Clinical Health Psy- chology and Primary Care: Practical Advice and Clinical Guidance for Successful Collaboration. Edited by Gatchel RJ, Oord MS. Washington, DC, American Psychological Association, 2003
Cameron KA, de Haes H, Visser A: Theories in health communi- cation research. Patient Education and Counseling 74:279–281, 2009
Velligan DI, Weiden PJ, Sajatovic M, et al: Assessment of adher- ence problems in patients with serious and persistent mental ill- ness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice 16:34–45, 2010

ORDER A PLAGIARISM-FREE PAPER HERE

Click here and follow the instructions to confirm you have read the entire Syllabus and will abide by the requirements described in order to successfully complete this course.

Student Support and Calendar Information

So you have all key information available to you off-line, it is highly recommended that you print the following items for your reference:

This Syllabus, including the Course Schedule that is linked on this page as a PDF
Course Calendar
Support, Guidelines, and Policies

Credit Hours

3 credits in 11 weeks

Walden University assigns credit hours based on the number and type of assignments that enable students to achieve the course learning objectives. In general, each semester credit equals about 42 hours of total student work and each quarter credit equals about 28 hours of total student work. This time requirement represents an approximate average for undergraduate work and the minimum expectations for graduate work. The number and kind of activities estimated to fulfill time requirements will vary by degree level and student learning style, and by student familiarity with the delivery method and course content.
Pre-requisites

NURS 6630: Psychopharmacological Approaches to Treatment of Psychopathology
NRNP 6635: Psychopathology and Diagnostic Reasoning
PRAC 6635: Psychopathology and Diagnostic Reasoning Practicum

Course Description

Psychotherapy involves giving more than â€œgood advice.â€ For the psychiatric-mental health nurse practitioner (PMHNP) to be effective, deliberate approaches to therapy must be consistent with evidence-based practices. Learners in this course examine a variety of therapeutic techniques that can be used during psychotherapy sessions with individuals, families, and groups across the lifespan. Emphasis is placed on evidence-based applications of various therapeutic approaches for a wide range of psychiatric issues.
Course Learning Outcomes

By the conclusion of this course, you should be able to:

Evaluate evidence-based psychotherapeutic counseling theories
Evaluate ethical and legal considerations related to psychotherapy
Apply psychotherapeutic counseling techniques and tools
Assess patients across the lifespan presenting for psychotherapy
Develop differential diagnoses for patients in mental health settings across the lifespan
Develop plans of care for patients that incorporate individual, family, or group psychotherapy interventions

College of Nursing Alignment of Learner Outcomes

Click on the following link to access the Alignment of Learner Outcomes:

Document: NRNP 6645 College of Nursing Alignment of Learner Outcomes (PDF)

Course Materials

Please visit the university bookstore via your Walden student portal to ensure you are obtaining the correct version of any course texts and/or materials noted in the following section. When you receive your materials, make sure that all required items are included.
Course Text
Required texts:

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

Note: This required text is available for purchase. It is also accessible through the Walden Library.

Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

Recommended text:

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

Note: If the print edition of these books are referenced here, electronic versions also may be available and may be acceptable for use in this course. If an electronic version is listed, no print version is available.

Other readings (journal articles, websites, book excerpts, etc.) are assigned throughout the course and may be found within each Module.
Media

Assigned course media elements may be found in one or more modules of the course and are available via a streaming media player or a hyperlink to the individual item.
Primary and Secondary Sources

Review the following information prior to selecting resources for assignments.

Primary: A primary source is an original document that is the first account of what happened. A research report is primary, and you can tell because it includes materials and methods demonstrating how the research was done. Some creative work is also primary, such as poetry, novels, and interviews of people who experienced something firsthand. In nursing, which is an evidence-based discipline, we strive to use primary research that is published in scholarly, peer-reviewed journals.

Scholarly, peer-reviewed journal: Scholarly journals publish papers by professional authors and experts in the field using a peer-review process to review the work and assure quality before publishing. The focus of a scholarly journal is to provide accurate information for scholars and other researchers. The focus is on content rather than advertising, a direct contrast to popular media. Scholarly journals publish both primary and secondary papers, the former usually noted as original research and the latter as reviews and commentaries. Letters to the editor may also be published but should be recognized as opinion pieces.

Note: When selecting articles for course assignments, you are advised (unless you are referencing seminal information) to focus on work published within the past five years.

Secondary: A secondary source is one step removed from the original source. This work interprets and often compiles other work, and it includes review articles, textbooks, fact sheets, and commentaries about a topic. It also includes news reports of original research. Secondary work is more prone to error and bias than primary work because it is being filtered through an additional person or persons. Review papers can be useful to glean information about a topic and to find other sources from the reference list, but it is the original, primary research that should be relied on most heavily in demonstrating scholarship, depth, and validation of factual information.
Course Assignments

Participation in Discussions: The exchange of ideas among colleagues engaged in scholarly inquiry is a key aspect of learning and is a requisite activity in this course. You are expected to participate in weeks with a Discussion by posting a response to a prompt or question in the weekly Discussion area. In addition, you are expected to respond to your fellow studentsâ€™ postings. To count as participation, responses need to be thoughtful; that is, they must refer to the weekâ€™s readings, relevant issues in the news, information obtained from other sources, and/or ideas expressed in the postings of other class members. You may ask questions or offer further information or links about the subject. Please pay attention to grammar and spelling, as consistently poorly written posts will receive grade penalties. In grading the required Discussion postings, your Instructor will be using the Discussion Posting and Response Rubric, located in the Course Information area.
Note: Unless otherwise noted, initial postings to Discussions are due on or before Day 3, and response postings are due on or before Day 6. You are required to participate in the Discussion on at least three different days (a different day for main post and each response). It is important to adhere to the weekly time frame to allow others ample time to respond to your posting. In addition, you are expected to respond to questions directed toward your own initial posting in a timely manner.

Assignments: The Assignments provide you the opportunity to apply the skills and knowledge gained through the Learning Resources. See the Assignment area of specific weeks for detailed descriptions of the Assignments. In grading the required Assignments, your Instructor will be using rubrics located in the Course Information area.
Note: The course Assignments will require that you completely and accurately demonstrate critical thinking via assimilation and synthesis of ideas when using credible outside and course-specific resources (i.e., video, required readings, textbook), when comparing different points of view, highlighting similarities, differences, and connections, and/or when lending support to your Assignment responses.

Academic Integrity Originality Policy

Walden encourages students to use critical thinking to produce original thoughts in discussion posts, assignments, and other scholarly work. This â€œâ€¦will require that you completely and accurately demonstrate critical thinking via assimilation and synthesis of ideas when using credible, outside and course specific resources (i.e., video, required readings, textbook); when comparing different points of view, highlighting similarities, differences, and connections; and/or when lending support to your responses.â€ Using too many direct quotes or ineffective paraphrasing does not demonstrate originality.

To demonstrate originality requires the use of paraphrasing. According to the Walden Writing Center (n.d.), â€œParaphrasing in academic writing is an effective way to restate, condense, or clarify another author’s ideas while also providing credibility to your own argument or analysisâ€ (â€œIntroduction to Paraphrasingâ€). â€œAs you discuss those sources, paraphrasing allows you to use your own words and sentence structure to talk about the information you gleaned from those sources.â€ (Walden Writing Center, n.d., â€œIntroduction to Paraphrasingâ€).

â€œIneffective paraphrasing occurs when authors paraphrase a source but do not use their own sentence structure or vocabulary to effectively reword that source. The issue here is often that the studentâ€™s paraphrase simply uses synonyms for the sourceâ€™s original wording and is not different enough from the original sourceâ€™s wording. Ineffective paraphrasing can occur when an author does not use his or her own wording or voice to paraphrase entire paragraphs or individual sentences.â€ (Walden Writing Center, n.d., â€œExamples of Paraphrasing,â€ slide 10).

For more information, refer to the Writing Centerâ€™s Introduction to Plagiarism & Intellectual Property at https://academicguides.waldenu.edu/writingcenter/modules/plagiarism#s-lg-box-8548804

Assignments, discussion posts, or other scholarly work that does not demonstrate originality and/or lacks proper citation to credit original sources/authors will receive a grade reduction amounting up to 10%.
Grading Criteria and Total Components of a Grade

Course grades will be based on participation (postings) and completion of assignments listed below.

Letter grades will be assigned as follows:

90%â€“100% = A
80%â€“89% = B
70%â€“79% = C
< 70% = F

Please see below for the policy on Incomplete (I) grades.

Assessment Total Points* Percentage (Weighted)
Discussions (x2) 200 10%
Assignments (x6) 600 40%
Exams (x2) 200 50%
Total 1,000 100%

*Each Assessment is graded on a 100-point scale.
Incomplete Grade Policy

Per university policy, Incomplete grades can be granted only to students who have already met the minimum criteria for active weekly participation in a course (including weekly postings in online courses) and have completed at least 80% of other coursework. Incompletes can be awarded when, because of extenuating circumstances, a student has not met additional course requirements, including but not limited to written assignments, group projects, and research papers, as applicable. All Incomplete grades are awarded at the discretion of the Course Faculty.

Students who are eligible for an Incomplete must contact the Course Faculty to request the grade as soon as possible. Students who do not meet the criteria listed above will not be allowed to earn an Incomplete. If the Incomplete is approved, the Faculty Member will work with the student to outline the due date(s) for remaining work. Under no circumstances will the new due dates extend beyond 50 days from the last day of the term. Faculty will then have 10 days to assess the work and post the permanent grade before the university-allotted Incomplete time limit of 60 days expires. All Incomplete grades not resolved within the time allotted will convert to permanent grades of F.
Instructor Feedback Schedule

The Instructor will log in to the course during the week to monitor the weekly Discussion area. Feedback will be provided via the My Grades area, the Discussion area, and/or the Announcements page.

You can expect your weekly assignment grades to be posted within 10 calendar days of a due date. Instructor feedback and explanation is provided whenever full credit is not achieved. Depending on the nature of the feedback, Instructor responses may be posted to the Discussion area or included in the My Grades area. Your Instructorâ€™s goal is to act as a discussion and learning facilitator rather than a lecturer. The Instructor will not respond to every posting by every individual, so please feel free to ask your Instructor if you would like some personal feedback on a particular assignment posting, or any time you have any questions regarding your assignments or your grade.
Course Procedures

All class Discussions take place in the Discussion areas.
You are encouraged to post course-related questions to the Contact the Instructor area, as they may be of interest to all; however, if your question is urgent, it is often best to email the Instructor. If your emailed question is thought to be of benefit to all, it may be responded to by the Instructor via email to all or posted as an announcement.
Instructor feedback on content and writing issues that is thought to be of benefit to the entire class may be posted to the Contact the Instructor area; however, most personal critique will be done privately in the Grade Center. Be sure to check the Grade Center for comments every week, even if you received full credit.
Please feel free to use the Class CafÃ© to initiate and participate in conversations not directly related to the course. This is an excellent opportunity to get to know other students better. The Instructor will browse the Class CafÃ© occasionally but generally will not respond to conversations posted there, unless students have specific questions for him or her.
Check the email account you use for official Walden University business on a regular basis. The expectation is that you are checking this email account daily during the week. If you experience difficulty sending or receiving Walden email, please contact the Student Support Team right away. Contact information for the Student Support Team is located in the Student Support area.
Review all materials in the Course Information area as well as the materials contained under each of the weekly buttons.
Resubmission of assignments is not permitted after due dates. Students are expected to review their work and submissions of work carefully prior to due dates. Faculty may open a second submission area for assignment resubmission prior to due dates if students report submission errors. Assignments are graded after due dates as the final product ready for grading. Errors in submissions noted after due dates may result in a grade of zero.

Note: There are Optional Readings located within the Learning Resources section of each week in the course. You are encouraged to explore these readings, as needed, in order to enhance your understanding of the course content.
Preferred Methods for Delivering Assignments

Be sure that you post to the correct Discussion area each week. Do not email postings to the Instructor. For all initial Discussion postings, make sure that the first sentence of your posting reads Main Question Post. For your responses to the response postings of others, make sure that the first sentence of your response reads Response. These actions will ensure easily identifiable subject lines for your postings and responses.
Assignments are submitted to the SafeAssign link and named according to the week in which the Assignment is submitted. Directions for naming each Application Assignment are included in each weekâ€™s Assignment area. Please be sure that all written Application Assignments are saved and submitted as a â€œ.docâ€ file.
All email correspondence must contain the subject line â€œNRNP 6645-XX-NAMEâ€ (XX is the section number) followed by a brief description of the subject. This subject line convention ensures that your email will be easily identified and responded to in a timely manner. It is required that the email contain a signature that matches the official name used in the course.

Late Assignment Policy

Students are expected to submit assignments by the due dates noted in the course. In extenuating circumstances, such as illness, the student must contact the Instructor as soon as possible to discuss the situation. In those circumstances, Faculty will determine the appropriate course of action for the student. Depending on the situation, these actions may include recommendations to drop the course (if within the university drop/withdrawal period), acceptance of some or all of the overdue assignments with or without penalties, or failure to accept assignments.

Assignments submitted late without the prior agreement of the Instructor, outside of an emergency absence, or in violation of agreements for late submission, will receive a grade reduction for the assignment amounting up to 20%. Each day late with result in a 4%-point deduction up to day 5. After 5 days, the assignment will be graded a zero. Students should be aware that late assignments may not receive the same level of written feedback as do assignments submitted on time.
Discussion Board, Midterm Exam, and Final Exam Late Policy

The late policy applied to discussion boards, midterms exams, and final exams are different than course assignments and are as follows. Students are expected to complete discussion boards, midterms exams, and final exams by the due dates noted in the course. If students do not complete the discussion boards or initiate exams by the due date, the grade will result in a zero. In the event of an extenuating circumstance, students must let the instructor know prior to the due date. If the student is unable to do so, he or she needs to notify the instructor as soon as possible and those circumstances will be reviewed on a case-by-case basis. Any exam that is permitted to be taken late or permitted a retake may be subject to proctoring with audio and video technology.
Keeping Your Coursework

You will have access to the course and your coursework from the course start date until 60 days after the course ends. After this time, you will no longer be able to access the course or related materials. For this reason, we strongly recommend that you retain copies of your completed assignments and any documents you wish to keep. The university is not responsible for lost or missing coursework.
Course Evaluation

At or near the end of the course, you will receive an email inviting you to submit an online evaluation of the course and instruction. All submitted course evaluations are confidential, and only aggregate data and comments will be shared with the Instructor and Program Director. Your feedback is vitally important to Walden University in its efforts to continuously improve programs.
Students With Disabilities

Students in this course who have a disability that might prevent them from fully demonstrating their abilities should contact the director of Student Wellness & Disability Services at disability@mail.waldenu.edu or at 1-800-925-3368, ext. 312-1205 and +1-612-925-3368 or https://www.waldenu.edu/contact-us for international toll-free numbers as soon as possible to initiate disability verification and discuss accommodations that may be necessary to ensure full participation in the successful completion of course requirements.
Classroom Participation

In accordance with U.S. Department of Education guidance regarding class participation, Walden University requires that all students submit at least one of their required Week 1 assignments (which includes posting to the Discussion Board) within each course(s) during the first 7 calendar days of class. For courses with two-week units, posting to the Discussion Board by Day 7 meets this requirement. The first calendar day of class is the official start date of the course as posted on your myWalden academic page.

Assignments submitted prior to the official start date will not count toward your participation.

Financial Aid cannot be released without class participation as defined above.

Students who are taking their first class with Walden and do not submit at least one of their required Week 1 assignments (or at least one Discussion post) by the end of the 7th day will be administratively withdrawn from the university.

Students who have already taken and successfully completed at least one or more class(es) with Walden, and who do not participate within the first 7 days, will be dropped from that class.

If you have any questions about your assignments, or you are unable to complete your assignments, please contact your Faculty Member.
Checklist

The module course checklist below outlines the assignments due for the course.

For full assignment details and directions, refer to each module of the course. All assignments are due by 11:59 p.m. Mountain Time (MT) on the day assigned (which is 1:59 a.m. Eastern Time (ET) the next day). The time stamp in the classroom will reflect Eastern Time (ET), regardless of your time zone. As long as your submission time stamp is no later than 1:59 a.m. Eastern Time (ET), you have submitted on time.
To View the Calendar

To view the Course Calendar:

Course Calendar

To View a Printable Course Schedule

For full assignment details and directions, refer to each Module of the course.

Click on the NRNP 6645 Course Schedule (PDF) link to access the Course Schedule.

Document: NRNP 6645 Course Schedule (PDF)

Checklist

Module Assignment Title

Module 1

Foundations of Psychotherapy With Multiple Modalities

Week 1

Foundations of Psychotherapy

Learning Resources

Required Readings
Required Media
Getting Started Analyzing Journal Articles

Discussion

Biological Basis and Ethical/Legal Considerations of Psychotherapy

Week 2

Family Assessment and Psychotherapeutic Approaches

Learning Resources

Required Readings
Required Media

Assignment

Family Assessment

Week 3

Foundations of Group Work and Types of Therapy

Learning Resources

Required Readings
Required Media

Assignment

Analyzing Group Techniques
Module 2 Theoretical Approaches to Psychotherapy

Week 4

Psychodynamic Psychotherapy