The document summarizes a study that examined the effectiveness of incorporating cognitive-behavioral techniques within a short-term psychodynamic psychotherapy model. The study measured clients' perceptions of the early therapeutic alliance when therapists used either psychodynamic-interpersonal or cognitive-behavioral techniques. Results showed that greater use of cognitive-behavioral techniques, like providing information about the client's diagnosis, led to higher client ratings of collaboration and agreement on treatment goals. However, overall client satisfaction with the alliance did not differ based on treatment approach. The study had some limitations but offers insights into how combining therapeutic techniques may strengthen the therapeutic alliance.

1. Psychotherapy: Integration and alliance
Goldman et al. provides a unique voice to the ongoing discussion of effective psychotherapeutic
techniques by way of an analysis of an integrative psychotherapeutic model. They propose to
gauge the effectiveness of Psychodynamic-Interpersonal (PI) and Cognitive-Behavioral (CB)
techniques employed in a Short-Term Psychodynamic Psychotherapy setting by measuring
client’s perception of the strength of the therapeutic alliance in early therapy.
Situating the state of the research, the authors provide background and argue for the
effectiveness of incorporating several theoretical models into the psychotherapeutic process.
Pure and undiluted forms of psychotherapy may be archaic, as new research suggests that a
combination of therapeutic techniques from several theoretical orientations may indeed serve the
needs of the client more effectively. Gold and Stricker (2001), for instance, employed an
integration of Cognitive Behavioral, Relational and Behavioral techniques within a
Psychodynamic framework and found that such a hybrid model is positively correlated with: 1)
successful therapeutic outcomes, 2) aiding the therapist to mediate on several levels of
functioning, and 3) may serve to strengthen the therapeutic alliance.
There is no shortage of research on the correlation of a strong therapeutic alliance with
positive therapeutic outcomes. Indeed, even a brief Ebscohost search reveals well over 5,000
results. It is no surprise, then, that the present researchers chose the therapeutic alliance as their
moderating construct. Specifically, the researchers attempted to measure the effectiveness of
therapeutic approaches by gauging the initial therapeutic alliance of a PI versus a CB approach.
The researchers predicted that the mixture of CB and PI techniques would lead to higher patient
ratings of the therapeutic alliance than the use of PI techniques alone.

2. Curiously, however, the authors provided no operational definition of the therapeutic
alliance. It’s a tender thought to assume all psychologists would all operate based on the same
construct of therapeutic alliance. Yet the reality of the theoretically diverse and fragmentary field
of psychology leads this author to wonder how definitional precision would affect research
findings. No doubt, the construct of therapeutic alliance is associated with trust, bonding and
rapport. A brief aside to research the therapeutic alliance, however, reveals slightly nuanced
differentiations in definitions and approaches. Operational definition and theoretical justification
on the use of the therapeutic alliance as a construct in the present study would have made for a
stronger article.
The 91 (64 female; 27 male) participants in this study were admitted to an out-patient,
University-based Psychodynamic Psychotherapy Treatment Team. Average age for the
participants was 30. All 91 participants received a DSM-IV Axis I mood disorder diagnosis, with
another 55% also receiving an Axis II diagnosis. The mean GAF score for all participants was 60
(SD= 5.7). The attending clinicians were 28 (14 male; 14 female) PhD students in an APA
accredited program.
In terms of treatment, after an initial intake evaluation, the participants remained for an
average of 26 sessions over an 8 month period. The intake evaluation consisted of a Therapeutic
Model of Assessment (TMA). As the authors explain, the TMA employs a multi-method
assessment model, by utilizing interviews, self-reports, performance tasks as well as free
response measures. A Short-Term Psychodynamic Psychotherapy (STPP) approach was utilized
in individual psychotherapy sessions. Briefly, STTP consists of: 1) Attention to the client’s affect
and expression of emotion; 2) Investigation of topics that the client may seek to avoid, 3)
identification of notable patterns in cognitions, emotions, or inter-personal styles, 4) a

3. prominence to past experiences, 5) an emphasis on interpersonal experiences, 6) a focus on the
therapeutic relationship/alliance, and 7) an examination of dreams and fantasies of the client
(Goldman et al., 2013).
At the conclusion of the 26 sessions, participants were given a number of measures,
including: Global Assessment of Functioning (GAF), Brief Symptom Inventory (BSI),
Combined Alliance Short Form–Patient Version (CASF-P), and the Comparative Psychotherapy
Process Scale –External Rater Form (CPPS-ER). The CASF-P is 20 item self report measure
based on a 7 point Likert scale. The CASF purports to measure the client’s perception of the
strength of the therapeutic alliance. It consists of four subscales: 1) Idealized Relationship—the
extent to which the client recognizes her ability to disagree with the therapist 2) Confident
Collaboration—the degree of confidence the client experiences with her therapist, 3) Goals &
Task Agreement, and 4) Bond—the degree to which a client perceives her therapist as
trustworthy (Goldman et al., 2013).
Similarly, the CPPS-ER is also a 20 item self report measure based on a 7 point Likert
scale, designed to assess the techniques and activities employed by the therapist. The CPPS
purports to measure characteristic features of the Psychodynamic-Interpersonal (PI) and the
Cognitive-Behavioral (CB) approach. Thus, the PI scales would measure the seven domains of
the STPP model outlined above. Conversely, the CB scales attempt to measure standard CB
interventions, such as 1) the importance of recognizing maladaptive cognitive patterns, 2)
instruction in skills training to clients, 3) homework assignments outside of the therapeutic
setting, 4) providing clear information relating to treatment, symptoms and diagnosis to the
presenting client, 5) session activity direction on the part of the therapist, and 6) a future
oriented, goal directed approach to therapy (Goldman et al., 2013).

4. Results indicate client’s overall level of satisfaction with the therapeutic alliance was not
affected by therapist techniques. Interestingly, however, the researchers did discover that those
therapists who employed more CB techniques—in particular CB techniques such as providing
information about the client’s disorder and the rationale of the therapeutic process—had patients
who reported greater scores on the Confident Collaboration scale of the CASF. The authors
suggest that this combination of CB techniques within a psychodynamic framework would yield
greater client confidence levels.
Further, the interaction effect (CB x PI) suggested that greater use of CB techniques were
correlated with higher levels of client—therapist agreement on the Goals and Tasks subscale of
the CASF. Conversely, lower levels of CB use were predictably associated with lower levels of
agreement on the same subscale. The implications for therapy, again, suggest that particularly
within a PI framework, explicit discussion of the nature of psychodynamic psychotherapy and its
personal relevance to the presenting client leads to greater therapeutic alliance satisfaction
scores. That is, the combination of active elements from both a CB and PI approach seem to aid
in the facilitation of strong therapeutic alliance in the initial phases of treatment.
As the authors note, this study was novel in its approach insofar as it examined the
integration of PI and CB techniques to gauge the strength of the early therapeutic alliance. This
innovation aside, the study, as the authors rightly note, was limited by its low sample size.
Although common in empirical psychotherapeutic studies, this lack of a larger sample size may
limit the studies’ power to detect interaction effects. The distinct outpatient population is a
further limiting factor of the study inasmuch as the clients experienced only mild to moderate
distress in functioning. Finally, as the sample population was compromised of a disproportionate
amount of Caucasian females, the results may not be absolutely generalizable. Replication of this

5. work in a more diverse population, including an inpatient sample, would be highly desirable.
These limitations notwithstanding, the present study offers a worthwhile heuristic for the use of
effective therapeutic techniques that may lead to an increase in the formation of an early
therapeutic alliance.
References
Gold, J., & Stricker, G. (2001). A relational psychodynamic perspective on assimilative
integration. Journal of Psychotherapy Integration, 11, 43–58.
doi:10.1023/A:1026676908027
Goldman, R. E., Hilsenroth, M. J., Owen, J. J. & Gold, J. R. (2013). Psychotherapy Integration
and alliance: Use of cognitive-behavioral techniques within a short-term psychodynamic
treatment model. Journal of Psychotherapy Integration, 23(4), 373-385. doi:
10.1037/a0034363
Prepared by Phillip J. Kuna
For John G. Kuna, PsyD and Associates Counseling
http://johngkunapsydandassociates.com/
john@johngkunapsydandassociates.com
(570)961-3361