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The role of alliance in the relationship between therapist competence and outcome in Brief Psychodynamic Psychotherapy
Despland, J.-N., de Roten, Y., Drapeau, M., Currat, T., Beretta, V., & Kramer, U. (2009). The role of alliance in the relationship between therapist competence and outcome in brief psychodynamic psychotherapy. Journal of Nervous and Mental Disease, 197(5), 362-367. doi: 10.1097/NMD.0b013e3181a20849
Therapist competence is a key variable for psychotherapy research. Empirically, the relationship between competence and therapeutic outcome has shown contradictory results and needs to be clarified, especially with regard to possible variables influencing this relationship. A total of 78 outpatients were treated by 15 therapists in a very brief 4-session format, based on psychoanalytic theory. Data were analyzed by means of a nested design using hierarchical linear modeling. No direct link between therapist competence and outcome has been found, however, results corroborated the importance of alliance patterns as moderator in the relationship between therapist competence and outcome. Only in dyads with alliance change over the course of treatment was it clear that competence is positively related to outcome. These findings are discussed with regard to the importance for outcome of therapist competence and alliance construction processes.
The results support to a large extent our 3 hypotheses. The results also indicate that no direct relationship exists between level of competence and outcome in BPI. This means that even after training in BPI and years of experience, a high level of therapist competence does not guarantee a positive outcome (Barber et al., 2006; Sandell, 1985). This also means that other variables, or variable combinations, account better for outcome variation. Results indicate that competent therapists tend to establish a growing alliance over the course of BPI, compared with less competent therapists. The highly significant coefficients indicate the important contribution of the therapist's level of competence in alliance construction processes. The latter are conceived as coconstruction processes, based on patient-dependent, therapist-dependent and dyad-specific variables. One could say that within the context of relational progression (growing alliance), the more competent the therapist, the better the outcome, whereas, paradoxically, within the context of relational stagnation (stable alliance), the more competent the therapist, the less positive the outcome (small symptom reduction, no change, or deterioration). For the latter, the exact opposite holds true; competence does have a direct effect on outcome, but no interaction effect has been found. Thus, the more competent the therapist is on the subscale of general psychotherapeutic attitude, the better the outcome. This result might reflect that the therapist's basic interactional and therapeutic skill of empathic, nonjudgmental consideration towards the patient is a necessary, but as such, an insufficient therapeutic ingredient in psychodynamic psychotherapy. It seems that alliance has an influence on the relationship between competence and outcome. We find, on the one hand, for the subsample with relational progression over the 4 sessions of BPI, therapist competence is of importance in the sense that low competence yields low outcome. As the level of training is related to competence, in the cases of relational change, more training in BPI, for example, in the form of more frequent case supervisions should help to produce a positive outcome. It also indicates that competence is certainly a necessary condition for treatment outcome, but as such insufficient; alliance evolution, as an emergent characteristic of a successful therapeutic process, needs to be taken into account. On the other hand, in cases stagnating in alliance over the 4 sessions of BPI, therapist competence is also important but in the opposite sense: low to moderate competence yields the best outcome and the more competent the therapist, the less positive the outcome. It could be said that, in the latter cases, the therapist does "more of the same" by delivering competent interventions, which finally have only a limited impact on symptom change. Two reasons might be at stake: (1) in these patients, the impact of the intervention is confined to an internal psychodynamic level, with no direct impact on our outcome measure (2) The patient–due to his dysfunctional relationship patterns- establishes a rigid level of alliance and is thus highly resistant to the therapeutic relationship and the therapist's interpretations, even more so if they are competently delivered. These results complete Barber et al's (2006) study on the moderator effect of adherence. For competence, as we defined it, a linear moderator model might be most accurate, compared with adherence, where a curvilinear yields similar effects of alliance. Using these approaches, we conclude that the highest competencescore is the optimal within the differential context of growing alliance, whereas for adherence, the median adherence is in any case the optimal (Barber et al., 2006).
Because context-embeddedness of the technique (e.g., "skillfulness" and "providing a therapeutic milieu") is the main difference between Barber et al's (2006) definition of adherence and ours of competence, we hypothesize that more outcome variance is explained with the wide concept of competence, compared with adherence, when taking into account the context of the applied psychodynamic technique. If this assumption holds true, it might also account for the absence of effect of the competence measure by Barber et al. (2006) who defined competence less broadly than it was done in our study (see Introduction section).
On the other hand, it might be argued that our definition of competence is so broad that risks of confounds with other context variables, such as the therapeutic alliance, are not excluded. Empirically, such a critic does not stand further examination, as the differential effect of stable alliance demonstrates: even if the therapist's competence varies in these dyads, alliance remains the same, indicating at least some independence between these variables. Several limitations of this study should be underlined. This is a naturalistic study; although the distribution of the patients between the therapists was controlled for, the patients were not randomly assigned to the therapists. Consequently, there was no controlled distribution of patients to therapists according to their number of years of training and experience. Such a control would have enabled us to partial out the influence of therapists' training and level of experience. In this study, it confounds with competence due to high correlations.
Jean-Nicolas Despland, Prof., Yves de Roten, PhD, Martin Drapeau, Prof., Thierry Currat, MD, Veronique Beretta, MPs, and Ueli Kramer, PhD
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Accuracy of therapist perceptions of patients' alliance: Exploring the divergence
Hartmann, A., Joos, A., Orlinsky, D.E., Zeeck, A. (2014). Accuracy of therapist perceptions of patients' alliance: Exploring the divergence. Psychotherapy Research, 25(4), 408–419. http://dx.doi.org/10.1080/10503307.2014.927601
The therapeutic alliance is a well-established predictor of psychotherapy outcome, yet much research has shown that therapists' and patients' views of the alliance can diverge substantially. Therapists systematically underestimate their patients' perceived level of alliance, and the correlation between therapist and patient estimates of patient alliance is only moderate. The present study explored the divergence between therapists' and patients' perspectives on patients' alliance experience, and its relations to therapists' concurrent work involvement and session process experiences.
The study sample includes 98 treatment cases, conducted by 26 psychodynamic psychotherapists of varying experience levels. Half of the sample consisted of individual outpatient treatments (private practice) and the other half were individual treatments in a day clinic setting (university hospital). Most of the 98 patients suffered from a major depressive disorder.
Therapist-patient divergence was significantly related to therapists' case-wise work involvement, but not to therapist's views of session process. The best predictor of therapist-patient divergence was therapists experiencing a "distressed practice" work involvement pattern.
Although therapists' work involvement experiences are not commonly investigated, they can be a relevant predictor of therapy processes.
Although the sample comprised 98 therapies, the nesting of therapies in 26 therapists limited the statistical power of the investigation and its results. Yet the findings already appear to have interesting and potentially clinically relevant if tentative implications.
Armin Hartmann
Department of Psychosomatic Medicine and Psychotherapy, University Clinic of Freiburg, Hauptstr.8, Freiburg 79104, Germany.
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Alliance in individual psychotherapy
Horvath, A. O.; Del Re, A. C.; Flückiger, C.; & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy 48(1): 9-16.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work (pp. 33-70). New York: Oxford University Press.
The concept of the alliance is currently one of the most intensely researched subjects in the psychotherapy research literature. This new research synthesis examines the relation between alliance and the outcomes of individual Psychotherapy, including over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as "alliance," "therapeutic alliance," "helping alliance," or "working alliance" were the inclusion criteria. Several potential moderators also were explored.
In terms of the research synthesis presented in this report, it is important to emphasize that the authors know about the lack of a precise consensual definition of the alliance construct. As a consequence, the alliance and its relation to outcome and other therapy variables has been gleaned from studies which, in practice, define the alliance by the diverse instruments used to measure it. Within the 201 studies in this collection of data, over 30 different alliance measures were used—not counting different versions of the same instruments. Similar to previous reports, the four "core measures": California Psycho-therapy Alliance Scale, (CALPAS), Helping Alliance Questionnaires (HAq), Vanderbilt Psycho-therapy Process Scale (VPPS), and Working Alliance Inventory (WAI) accounted for approximately 2/3 of the data. In research on the shared factor structure of the WAI, CALPAS and HAq, the concept of "confident collaborative relationship" was identified as the central common theme. Each of these four instruments has been in use for over 20 years and has demonstrated an acceptable level of internal consistency. Fifty-four of the research reports in this data set used less well validated instruments or assessment procedures; the relation of most of these measures to the core instruments, or to each other, are not well documented, and sometimes nonexistent. As noted, the diversity in the "de facto" definition of the alliance that has emerged via the use of a variety of assessment measures has become an important source of variability across studies.
For identifying studies published between 1973 and 2000, the authors relied on data from previous analyses (Horvath & Symonds, 1991 & Horvath & Bedi, 2002) but the effect sizes (ES) where recalculated (using more up-to-date methods) for all but 10 of the oldest unpublished studies which were no longer available. To locate data from the years 2000 to 2009, first electronic databases were searched (PsycINFO/EBSCO) using the same keywords as the Horvath and Bedi (2002) analysis. Next the bibliography of studies included in the analysis was cross-referenced. The criteria for inclusion in this report were: (1) the study author referred to the therapy process variable as "alliance" (including variants of the term); (2) the research was based on clinical as opposed to analogue data; (3) five or more adult patients participated in the study, and; (4) the data reported were such that we could extract or estimate a value indicating the relation between alliance and outcome. In contrast to previous meta-analyses, the literature search was extended to material available in Italian, German, or French, as well as English. The number of studies in the current study is roughly double the size of the data available for the previous (Horvath & Bedi, 2002) meta-analysis.
The analyses of this research synthesis were done using the assumptions of a random model and numerical estimates were calculated using restricted maximum likelihood (random effects) model. The aggregate effect size (ES), for the 190 independent alliance/outcome relations was r _ .275. The 95% confidence interval of this averaged ES ranged from .249 to .301. The magnitude of the relationship we found in the current meta-analysis is a little larger but similar to the values reported in previous research (Horvath & Symonds, 1991 r _ .26, k _ 26; Horvath & Bedi, 2002, r _ .21, k _ 100). The median effect size of ESs of the current data set was .28 suggesting that the group of effect sizes we collected was not strongly skewed. The overall effect size of .275 is statistically significant at p _ .0001 level indicating a moderate but highly reliable relation between alliance and psychotherapy outcome. In Addition, the impact of six categorical variables were investigated that have the potential of moderating the relation between alliance and outcome: alliance measure (CALPAS, VPPS, HAq, WAI, and Other); alliance rater (client, therapist, observer); time of alliance assessment (Early, Mid, Late, Averaged); outcome measure (BDI, SCL, Dropout); type of treatment (CBT, IPT, Psychodynamic, Substance Abuse); and publication source (journal, books/chapters, unpublished/thesis). There are several noteworthy features that apply to all of these results: All of the aggregate alliance-outcome correlations in each category are statistically significant beyond p _ .001. This result strongly supports the claim the impact of the alliance on therapy outcome is ubiquitous irrespective of how the alliance is measured, from whose perspective it is evaluated, when it is assessed, the way the outcome is evaluated, and the type of therapy involved.
The quality of the alliance matters. The next most common feature is the finding that, with very few exceptions, within each of these subsets of data, the ES are very diverse in magnitude. It was noted earlier that heterogeneity of the ESs in a large-scale meta-analysis is not unusual. However, these results indicate that the high degree of variability remains practically unchanged within each level of these potential moderators.
The positive relation between the quality of the alliance and diverse outcomes for many different types of psychological therapies is confirmed in this meta-analysis. While the overall ES of r _ .275 accounts for a relatively modest proportion of the total variance in treatment outcome, the magnitude of this correlation, along with therapist effects, is one of the strongest and most robust predictors of treatment success empirical research has been able to. By including all research in which the authors refer to the process variable as alliance, the study might have collected and summarized a number of different kinds of things. A practical response to this conceptual problem is to conclude that this meta-analysis reports the results of alliance-outcome relation as it is researched at this time. In general, Studies on the alliance construct are an important contribution to psychotherapy research by creating diverse implications for therapeutic practice.
Prof. Adam O. Horvath
Simon Fraser University, Faculty of Education
8888 University Drive, Burnaby, BC, Canada V5A 1S6
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The working alliance and the stability of therapeutic outcomes in the treatment of depressed patients: A process-outcome study
Huber, D., Henrich, G., Clarkin, J. & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry, 76(2), 132-149.
Huber, D., Zimmermann, J., Henrich, G. & Klug, G. (2012). Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients—A three-year follow-up study. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 58(3), 299-316.
In a process-outcome design comparing different forms of psychotherapy (psychoanalytic psychotherapy, psychodynamic psychotherapy, and cognitive-behavioral therapy) the study investigated whether the working alliance has differential impact on outcomes and their stability.
The working alliance is viewed as a mediator variable serving to explain the treatment process and its influence on different outcomes. We assume the working alliance to be one of three components constituting the therapeutic relationship that is, beyond the working alliance, the real relationship between patient and therapist and the transference.
Meta-analyses suggest working alliance as a robust predictor of different outcomes, however, the predictive power is relatively low, explaining only 7% of the outcome variance. Nevertheless, the working alliance can be regarded as a substantial predictor, taking into account that other curative factors explain rarely more than 15% of outcome variance.
The patient sample is derived from the prospective and partly randomized MPS sample consisting of 100 patients (intent-to-treat sample) who met the DSM-IV criteria for major depressive disorder (psychoanalytic psychotherapy=35, psychodynamic psychotherapy=31, cognitive-behavioral therapy=34); the completer sample comprises 85 patients. Therapy sessions of each patient have been audiotaped but 13 cases had to be excluded due to low audio quality (psychoanalytic psychotherapy=26, psychodynamic psychotherapy=24, cognitive-behavioral therapy=22).
Patients were assessed at pretreatment, at post-treatment and at follow-up each year after treatment termination up to three years. Self-rating questionnaires important for the study described here are the Beck-Depression Inventory (BDI) and the Inventory of Interpersonal Problems (IIP-short version).
As Stiles and Goldsmith (2010) recommended, we decided to measure the process in a multimodal way including patients, therapists and external rater assessments. For measuring the working alliance we choose the Working Alliance Inventory (WAI-observer rating short form). The WAI is a trans-theoretical instrument suitable for different treatment approaches, based on three dimensions: (1) agreement on tasks, (2) agreement on goals, (3) development of bond.
Measurement points for WAI are 6 and 12 months after beginning of treatment; ratings are performed by trained raters.
As a second process measure we use the Helping Alliance Questionnaire (patient and therapist version [HAQ-P and HAQ-T]). The inventory consists of 11 items assessing two aspects of the therapeutic working alliance: (1) perceived helpfulness by the therapist and (2) collaboration and bond with the therapist.
Measurement points for HAQ-P and HAQ-T are 6 and 12 months after beginning of treatment. In an explorative approach the following main research questions are addressed:
Does working alliance (WAI and HAQ) predict therapy outcomes (BDI and IIP) and their stability through follow-up?
Are there differences in the predictive power of working alliance as a function of the modality of measurement (patient, therapist, external rater)?
Do differences exist concerning the predictive power of working alliance as a function of treatment (psychoanalytic psychotherapy, psychodynamic psychotherapy, cognitive-behavioral therapy)?
Statistical analyses are performed by multiple regression analyses.
The study intends to contribute to the relevance of the working alliance as part of the therapeutic relationship. Within this frame, the treatment dependent impact of the working alliance will enhance a better understanding of different mechanisms of change.
Prof. D. Huber, M.D., Ph.D.
International Psychoanalytic University (IPU), Stromstrasse 3b, 10555 Berlin, Germany.
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Therapeutic alliance and psychotherapy process
Colli A., & Lingiardi V. (2009). The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy. Psychotherapy Research, 19, 718-734.
Lingiardi V., Colli A., Gentile D., & Tanzilli A. (2011). Exploration of session process: Relationship to depth and alliance. Psychotherapy, 48, 391-400.
Lingiardi V. (2013). Trying to be useful: Three different interventions for one therapeutic stance. Psychotherapy, 50, 413-418.
The goal of our studies was to investigate the relationship between psychotherapy process, therapeutic alliance, and therapist activity using an assessment method based on therapy sessions' transcripts. The research design implied that independent raters evaluated psychotherapy sessions of various theoretical approaches (mostly psychodynamic and cognitive– behavioral) with different process measures.
In a first study, we presented the validation and the application of a new rating system for the assessment of alliance ruptures and repairs in psychotherapy: the Collaborative Interactions Scale (CIS; Colli, Lingiardi, 2009). The CIS (composed of two main scales: one for the evaluation of patient rupture and collaborative processes, CIS-P, and one for the evaluation of therapist positive and negative contributions to the therapeutic relationship, CIS-T) furnishes a great deal of information about: 1) the patient capacity to self-disclose intimate and salient information in session, to experience emotions in a modulated fashion, to work actively with the therapist's comments, or to deepen the exploration of salient themes; and 2) two main aspects of therapist activities: the quality of the intervention (timing, attunement, tactfulness, comprehensibility) and their form (e.g., clarification, confrontation, interpretation).
The CIS is a reliable rating system, useful in both empirical research and clinical assessments. In the second study, we explored the relationship between the depth of elaboration, the therapeutic alliance, and some dimensions of psychotherapy process (including the therapist's interventions, the patient's contributions, and patient/therapist's patterns of interaction) evaluated with the Psychotherapy Process Q-Set (PQS; Jones, 1985, 2000). In line with the findings of Blagys and Hilsenroth (2000), our research showed the importance of therapist interventions that focus on the patient's affects (particularly those regarded as unacceptable emotions and feelings), recurring and enduring interpersonal patterns, and the "here and now" of the relationship in the increase of the depth of elaboration and patient/therapist alliance (see also Lingiardi, 2013).
The aims of these studies were to study in a clinically articulated and empirically grounded way the psychotherapy process in order to clarify what happens during the session, which kind of therapist interventions are more effective in relation to specific process factors (such as the depth of elaboration, or ruptures and resolutions processes), and which kind of patient/therapist dynamics are related to a good therapeutic relationship. The main limitations is that for the moment we studied only the observer perspective of evaluation; even if our findings are in line with previous studies that use both patient and therapist perspectives, in the future it will be necessary to investigate all the three perspectives simultaneously.
Prof. Vittorio Lingiardi, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi, 78 - 00185 Rome, Italy.
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Dr. Antonello Colli, Department of Human Science, Carlo Bo University of Urbino, Via Bramante, 17 - 61029 Urbino, Italy.
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Dr. Annalisa Tanzilli, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi, 78 - 00185 Rome, Italy.
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Dr. Daniela Gentile, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Via dei Marsi, 78 - 00185 Rome, Italy.
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Psychological intervention and change in depression process studies
Krause, M., Altimir, C., & Horvath, A. O. (2011). Deconstructing the therapeutic alliance: Reflections on the underlying dimensions of the concept, Clínica y Salud, 22(3), 267-283.
Krause, M., Altimir, C., Pérez, C., & de la Parra, G. (2015). Generic change indicators in therapeutic processes with different outcomes. Psychotherapy Research, 25(5), 533-545. .
Cumulative findings in psychotherapy research support the centrality of the therapeutic relationship, and especially of the alliance, for psychotherapy and change. This underscores the importance of examining the intrinsic relational character of the psychotherapeutic change process, through the study of the specific micro-processes involved in the dynamic construction and maintenance of the therapeutic relationship that ultimately bear influence over therapeutic change. It is of particular interest to further explore the ways in which patient and therapist mutually regulate and negotiate their affective exchange in the process of establishing and shaping the alliance.
1. Analysis of the underlying dimensions of the concept of alliance
2. Generic Change Indicators in therapeutic processes with different outcomes
3. A single case study of patient and therapist's verbal and nonverbal relational offers during rupture and resolution strategy episodes.
4. A single case study of patient and therapist's synchronic facial-affective regulation during ruptures and resolution strategies and its association with process outcome, alliance, and therapy evolution.
Research questions
1. What is the relationship between the processes that build up the elements of the therapeutic relationship that belong to different synchronic levels of analysis (micro, meso and macro) and how do they evolve along the psychotherapeutic process?
2. What are the implicit and explicit elements, expressed through facial and verbal behavior, respectively, of the affective regulation process between patient and therapist in episodes of rupture of the alliance and of resolution strategies, in a psychoanalytic psychotherapy?
Design and method
Subproject 1: Systematic qualitative study of former patients and therapists' reports of their experience in therapy; and qualitative analysis of the item contents of the most often used instruments of alliance. Subproject 2: transversal comparison of over 39 therapeutic processes regarding ongoing change, and final outcome. Subprojects 3 and 4: A single case study, systematically analyzed with qualitative and quantitative procedures, regarding nonverbal facial behavior and regulatory processes within the negotiation of the alliance. A nested analysis approach was implemented for the association between variables belonging to different levels of analysis.
Subproject 2: 39 therapeutic processes. Subprojects 3 and 4: 1 individual therapy
Subproject 2: Individual psychodynamic and gestalt, family social-constructionist, couples humanistic and group CBT. Subprojects 3 and 4: Individual short-term Psychodynamic focal therapy.
Outcome Questionnaire (OQ-45.2), Working Alliance Inventory (WAI), Rupture Resolution Rating System (3RS), Facial Action Coding System (FACS), Generic Change Indicators (GCI).
During the momentary deterioration of the alliance –expressed in rupture episodes–, patient facially expresses negative affect and attempts to regulate her emotional arousal, and the degree of affective contact and involvement with the therapist, while therapist attempts to down-regulate his own emotional expressions. Simultaneously, at the verbal level, therapist attempts relational offers such as proposing, questioning and being conciliator, while patient offers a receptive stance. Meanwhile, during therapist's reparatory attempts, patient nonverbally re-establishes contact and emotional involvement with the therapist, while therapist verbally offers the patient a friendly and validating attitude, at the same time that facially expresses patient's dissociated negative affects based on an active assessment of the patient's internal affective state. Finally, participants' synchronic smiles were observed in rupture and resolution strategies episodes, indicating a positive affective attunement and attempts to preserve the bond in the presence of relational conflict.
All studies indicate that clinical significant change is related to high-stage transformations of representations in the patient, particularly those referred to the construction and consolidation of new meanings, and a synergic relationship between initial-stage representational changes and higher-ordered ones was observed in these therapies.
Future studies require an accumulation of more in-session episodes and therapies, for the confirmation of the micro-facial affective patterns observed in the present study, and their evolution and change along the therapy process. Future studies should also attempt measuring the therapeutic alliance at the episode level, so that more clear associations can be made between the oscillations of the alliance and that of the facial-affective regulatory patterns, the ruptures and resolution strategies, and the process outcome indicators.
Carolina Altimir, Psicóloga, PhD
Investigadora Adjunta
Instituto Milenio para la Investigación en Depresión y Personalidad- MIDAP
Universidad de Las Américas
Centro de Investigación en Psicoterapia (CIPsi)
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Psychological intervention and change in depression. Adolescent psychotherapy: Therapeutic alliance, subjective change and relational patterns
The empirical study of psychotherapy with children and adolescents has fallen behind the studies with adults, being of recent development. These studies occur in artificial contexts, include only some types of psychotherapies (mostly CBT) at the expense of research in natural contexts. Studies that consider the children's and adolescents' own perspectives about the therapeutic process are scarce. Alliance is a central generic change factor.
The quality of the alliance relates consistently to outcome. The alliance observed during the first sessions, has a stronger relation with treatment outcomes than the alliance measured in the middle of treatment or the mean value of the alliance. In psychotherapy with adolescents there are contradictory evidence regarding which of the first sessions relates more to final outcome and which perspective relates stronger to outcome.
On the other hand, different psychoanalytic theories conceptualize adolescence as a vital moment in which it´s possible to define specific psychological conditions whit process qualities. These features are triggered with puberty and mobilize different relational tasks. In this context, it´s important to study the influence of relational characteristics of adolescents in the therapeutic process at different levels.
Research questions
This research has two sub-studies:
- In therapeutic processes with adolescents: How is the relation of the therapeutic alliance with change (process and outcome) and adherence, considering the perspective of the adolescents and their therapists and the differences of psychodynamic therapies compared to other therapies.
-Which are the characteristics of relational patterns of adolescents? What is the link between Prevalent Relational Patterns in adolescence, the change process and Therapeutic Alliance?
- Therapeutic alliance, communicative actions, and generic change indicators in the initial phase of psychotherapy with adolescents, and their connection with outcomes and adherence to treatment.
-Relational patterns in adolescents with depressive symptoms.
Design and method
The studies are multiple case study design. The studies use mixed designs that combined qualitative techniques and quantitative analysis. Process studies have a non-experimental design, with data obtained from natural intervention contexts.
-20 adolescents (15 female, 5 male); 13-17 years old. Disorders / complaints: Depression (8), Anxiety (3), Behavioral problems (3), Adaptation disorders (3) Developmental crisis (2), Others (1). Therapy approaches: psychodynamic, systemic, social-construccionist and CBT.
-10 individual Psychotherapies with adolescents with depressive symptoms (Approximately 8 sessions) videotaped. Were analyzed psychotherapies with psychodynamic, integrative and cognitive focus.
Horvath's Working Alliance Inventory - WAI (Chilean Version: Santibáñez, 2001) (first three sessions).
Outcome Questionnaire OQ 45.2 (Chilean Version: De la Parra & Von Bergen, 2001)
Generic Change Indicators (GChI, Krause, et al., 2007)
Relevant episodes: Change Episodes (Krause et al., 2006; Krause et al., 2007) and Rupture Episodes (Safran & Muran, 1996, 2000, 2006).
CCRT-LU (Luborsky, 1977; Albani, C., et al. 2002; CCRT-LU-S: López del Hoyo, et al., 2004)
Initially, therapeutic alliance (3rd session) correlates with final results (results OQ), both for adolescents (total score) and therapists (sub scale goals). There are no differences by theoretical orientation. Only the alliance perceived by therapists (not by adolescents) – of session 1 and 2 – relates to intermediate results (6th session). The alliance of session 2 (subscale goals) perceived by psychodynamic therapists, correlates with intermediate results.
Alliance, evaluated from the perspective of the adolescents in session 2, specifically on the task subscale, predicted the probability of finalizing the process. This was not observed when the alliance was measured from the perspective of the therapists. Alliance, perceived by the therapist in session 1 and 2, correlates with the Ongoing Change (GCI obtained in that session). Ongoing Change (higher GCI in the first three sessions) predicted adherence to therapy.
In the second sub-study, we have found a link between harmony in relationship narratives and the level of depressive symptoms and the Predominant Relational Patterns appear in relevant episodes of psychotherapy.
Therapists and adolescents perspectives on the alliance are related to the development of the process and the final outcome, but the therapists perspective relates specifically to ongoing change and intermediate outcome, while the adolescents perspective relates to adherence. The fact that ongoing change predicts adherence means that early changes (first three sessions) help adolescents to stay in therapy.
Olga Fernández
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H. Daniel Espinosa Duque / Doctor en Psicoterapia
Docente Investigador / Facultad de Psicología
Universidad CES / Calle 10A # 22-04 / Medellín, Colombia
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Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438-450.
Brief Summary
To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability.
Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study. In the past two decades, psychotherapy researchers and practitioners have postulated that the therapeutic alliance—defined broadly as the collaborative and affective bond between therapist and patient—is an essential element of the therapeutic process. The primary reason the alliance has grown in significance is the consistent finding that the quality of the alliance is related to subsequent therapeutic outcome. Another reason interest in the alliance has increased in the past 20 years is the inability of researchers to find a consistent difference in the effectiveness of psychotherapy across orientations. Consequently, many contemporary theories of psychotherapeutic change now emphasize the importance of the alliance, so much so that some theorists have referred to the alliance as the "quintessential integrative variable" (Wolfe & Goldfried, 1988, p. 449) of therapy. Although there are differences among the many alliance conceptualizations, most theoretical definitions of the alliance have three themes in common: (a) the collaborative nature of the relationship, (b) the affective bond between patient and therapist, and (c) the patient's and therapist's ability to agree on treatment goals and tasks (Bordin, 1979).
Using various techniques, this review indicates that alliance is moderately related to outcome (7 = .22). The average allianceoutcome correlation is within the range of many other effect sizes that are associated with psychotherapy outcome. In addition, the relation of alliance and outcome appears to be consistent, regardless of many of the variables that have been posited to influence this relationship. Indeed, the test of homogeneity suggests that the correlation represents a homogeneous population. In sum, the present metaanalysis indicates that the overall alliance-outcome correlation represents a single population of effects that cannot be reduced by a moderator variable into a more explanatory model of the relation of the alliance and outcome. This meta-analysis supports the belief that the relation of the therapeutic alliance with outcome is consistent within the psychotherapy literature. What is evident from this review is that the strength of the alliance is predictive of outcome, whatever the mechanism underlying the relation. From the empirical review of the reliabilities of the various alliance scales, it seems clear that all the alliance measures have adequate reliability. Although the overall reliability index for the various scales was somewhat lower than that found in the previous meta-analysis (.79 vs. .86), the present index still reaches an acceptable standard of consistency. Moreover, when the overall alliance index was separated by individual alliance scales, every alliance measure had an overall reliability index above .70. Surprisingly, even the scales that are not well established as measures of the alliance had adequate reliabilities. Given these results, all the alliance scales seem to have acceptable reliability. This meta-analysis did not implicate a specific alliance scale as being more reliable than the others, but it also failed to eliminate a scale from further consideration as a research tool because of its psychometric properties. These results suggest that researchers cannot base their choice of an alliance scale on its reliability indices; the scales all tend to receive strong support. The alliance ratings of patients, therapists, and observers all tended to have adequate reliability. Although the ratings of therapists seemed to be slightly less consistent than those of patients and observers, therapists' ratings of the alliance were still within the acceptable range. Across therapy sessions, patients tended to rate the alliance more consistently than did therapists or observers. On the basis of the present meta-analysis, it seems that patients tend to view the alliance as stable, whereas therapists and observers tend to indicate more change over time in their alliance ratings.
The implications of this finding are clear: Because patients tend to view the alliance consistently throughout treatment, they are more likely to view the alliance as positive at termination if their initial assessment was positive. Thus, therapists must be effective at establishing positive alliances with their patients early in the therapy process. However, because of the small sample size of this comparison, the greater consistency of patient ratings across alliance sessions should be considered a tentative finding.
Most of the alliance scales have been shown to be related to outcome. The Penn scales, the Vanderbilt scales, the WAI, and the CALPAS were moderately correlated with outcome, but the TARS failed to receive support. In addition, the Penn scales, the Vanderbilt scales, the WAI, and the CALPAS have received far more empirical scrutiny than any of the other alliance scales. Of these measures, the WAI is likely to be appropriate for most research projects. The scale was designed to measure alliance factors in all types of therapy and to measure the theoretical constructs underlying the alliance. The scale provides both an overall alliance score and also an assessment of Bordin's (1979) three aspects of the alliance: the bond, the agreement on goals, and the agreement on tasks. The WAI also provides an assessment of Horvath and Luborsky's (1993) two core aspects of the alliance measured by most scales: (a) therapist-patient affective attachments and (b) collaboration or willingness to invest in the therapy process. In addition, patient-, therapist-, and independent observerrated versions of the scale are available, as are shortened versions of these scales. The overall correlation of alliance and outcome did not seem to be influenced by publication status. Although the unpublished studies included in the meta-analysis had a slightly lower average correlation than did the published studies, the difference was not significant. Similarly, it is highly unlikely that enough unlocated studies with null results exist in file drawers to reduce the overall allianceoutcome correlation to a level of nonsignificance. Indeed, it would take 331 studies averaging null results to reduce the correlation of the alliance and outcome to .05.
Daniel J. Martin, John P. Garske, and M. Katherine Davis
Ohio University
Repairing alliance ruptures
Safran, J. D., & Muran, J. C. (2006). Has the concept of the alliance outlived its usefulness? Psychotherapy, 43, 286-291.
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48 (1). 80-87.
Safran, J. D., & Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work. New York, NY: Oxford University.
Brief Summary
One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance is a robust predictor of outcome across a range of different treatments and that, conversely, weakened alliances are correlated with unilateral termination by the patient. In the last two decades, there has emerged what we have characterized as a "second generation" of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur (Safran, Muran, Samstag, & Stevens, 2002). A rupture in the therapeutic alliance can be defined as a tension or breakdown in the collaborative relationship between patient and therapist (Safran & Muran, 2006). In this article, we provide a review of this research and metaanalyses of two different types of relevant studies.
The first set of analyses examined the association between the presence of rupture-repair episodes and treatment outcome in three studies including a total of 148 patients. The aggregated correlation was .24, z = 3.06, 95% CI [.09, .39], p = .002, a medium size effect that indicates that the presence of rupture-repair episodes was positively related to good outcome. The second set of analyses examined the impact of rupture resolution training or supervision on patient outcome in eight published studies including a total of 376 patients. Both prepost and group-contrast effect sizes were calculated. The mean weighted prepost r for the rupture resolution training studies was .65, z = 5.56, 95% CI [.46, .78.], p = .001. Given the particularly large effect sizes produced by two studies, the results were recalculated excluding these studies (leaving six studies with 252 patients), yielding an effect size of .52, z = 6.94, 95% CI [.40, .63], p = .001. These results provide evidence that rupture resolution training/supervision led to significant patient improvement; however, with a prepost design, we cannot determine whether this improvement was greater than what patients would experience with treatment from therapists who were not trained in rupture resolution. A meta-analysis of the between-groups effect sizes for the seven studies with control conditions (a total of 343 patients) yielded a mean weighted effect size of .15, z = 2.66, 95% CI [.04, .26], p = .01. When one outlier study was removed, leaving six studies with 321 patients, the mean weighted effect size was reduced to .11, z = 2.24, 95% CI [.01, .21], p =.03. These results indicate that rupture resolution training/supervision leads to small but statistically significant patient improvements relative to treatment by therapists who did not such training.
We have reviewed the growing body of evidence indicating that repairing ruptures in the therapeutic alliance is related to positive outcome. On the basis of this review, research supported implications for therapeutic practices are described.
Dr. J. Christopher Muran
Derner Institute for Adv Psy Studies
Associate Dean
Adelphi University
158 Cambridge Ave Garden City
New York 11530 United States
(516) 877-4803 (Phone); (516) 877-4805 (Fax)
Investigating the impact of alliance-focused training on interpersonal process and therapists´capacity for experiential reflection
Safran, J. D., & Muran, J. C. (2007). Therapist Relational Interview: Administration manual. Unpublished manuscript.
Safran, J. D., Muran, J. C., Demaria, A., Boutwell, C., Eubanks-Carter, C. & Winston, A. (2014). Investigating the impact of alliance-focused training on interpersonal process and therapists´ capacity for experiential reflection. Psychotherapy Research, 24(3), 269-285.
Brief Summary
In this article we present preliminary findings from a research program designed to investigate the value of alliance-focused training (AFT), a supervision approach designed to enhance therapists´ability to work constructively with negative therapeutic process. In the context of a multiple baseline design, all therapists began treating their patients using cognitive therapy and then joined AFT supervision groups at either session 8 or 16 of a 30 session protocol.
Study 1 investigated the impact of AFT on patient and therapist interpersonal process as assessed through the Structural Analysis of Social Behavior (SASB; Benjamin, 1974). Study 2 investigated the impact of AFT on therapists´tendency to reflect on their relationships with their patients in an experientially grounded fashion, as assessed via the Experiencing Scale (EXP). Since one of the goals of AFT is to train therapists to use their own emerging feelings as important clues regarding what may be taking place in the therapeutic relationship, we hypothesized that they would show increased levels of EXP after undergoing AFT. This dimension of therapists´reflective style was assessed with the use of a semi-structured interview designed to probe for therapists´tendency to reflect on their own internal experience when responding to questions about their relationships with the patients they were treating in the study. This interview, known as the Therapist Relationship Interview (TRI; Safran & Muran, 2007) was then coded with the Experiencing Scale (EXP).
The results of both studies 1 and 2 were for the most part consistent with hypotheses. In Study 1, several significant shifts in both therapist and patient interpersonal process emerged after CBT was augmented with AFT. All significant differences in therapist inter-personal process (except for Disclosing & Expressing) emerged on the"other" or"transitive" surface of the SASB (Surface 2). All significant differences in patient interpersonal process emerged on the"self-focused" or "intransitive" surface of the SASB (Surface 1). Consistent with our hypotheses, the majority of significant differences between training modalities in both therapist and patient interpersonal processes emerged regardless of time of implementation of AFT (session 8 or session 16).
In Study 2, results were consistent with the hypothesis that after receiving AFT, therapists would demonstrate a greater tendency during TRI interviews to reflect on their relationships with their patients in a personally involved, experientially grounded fashion than they did after receiving CBT training.
Taken together, the findings of studies 1 and 2 provide intriguing preliminary evidence regarding the potential of alliance-focused training to have a positive impact on both in-session interpersonal process, and on therapists´ capacity to reflect on the therapeutic relationship in a fashion that incorporates their own felt experience. Further research will be essential to evaluate whether differences in SASB and EXP ratings are related to ultimate outcome. Since all patients received some combination of CBT and AFT, we did not expect to find between-group differences in treatment outcome. It will, however, be critical to examine whether differences in treatment process are meaningfully related to one another and predictive of treatment outcome. At the present time, we continue to enter more patients and therapists into the larger, ongoing research project, and will be in the position to examine these questions in the future.
Dr. J. Christopher Muran
Derner Institute for Adv Psy Studies
Associate Dean
Adelphi University
158 Cambridge Ave Garden City
New York 11530 United States
(516) 877-4803 (Phone); (516) 877-4805 (Fax)


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Good morning everyone! Its 6:50AM, I still have time to make this post before I start preparing for work. How's your sleep guys? I hope you had enough rest and feeling energized as you face this another wonderful day.
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subset: commoncrawl


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France, Rated R, 108 Minutes Director: Olivier AssayasCast: Juliette Binoche, Guillaume Canet, Vincent Macaigne
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Peter S. Svensson, for reasons we can not fathom, is still writing for Bleeding Cool. Someone, quick, call him a doctor.
A new Witch Doctor: Mal Practice miniseries was the big announcement of the Skybound panel at Image Comics Expo, followed by the stealth announcement of a second Walking Dead novel in the follow-up Kirkman solo panel. Both panels effectively blended into one continuous whole as Kirkman held court first with fellow Skybound creators and later on his lonesome.
The Skybound panel featured Thief of Thieves co-writer Nick Spencer, Witch Doctor writer Brandon Seifert, Skybound editorial assistant Sina Grace (who also draws Lil' Depressed Boy) and a late arriving Robert Kirkman. Assume that I've just made a clever gag about timeliness and Kirkman and Image United. Or not.
Nick Spencer talked about the concept of Thief of Thieves, how a master criminal decides to go straight and deal with the consequences of not knowing where his professional life as a thief ends and his personal life begins. In a departure from the norm in comic writing, Kirkman and Spencer and several other writers yet to be announced are collectively working on the series similarly to how most TV shows are written via a writer's room. While the first arc that Spencer is writing was primarily done with just himself and Kirkman, later arcs had more writers involved, collaborating on the breakdowns of the plot, asking questions and assigning the actual scripting to different writers after everyone has gone over the idea and made appropriate suggestions. Kirkman added that this is a change of pace from his usual habit of sitting alone in front of a computer screen coming up with stories on his own. While he overall prefers the solitude of traditional comics writing, the experience he had with being on the writer's room for the Walking Dead inspired him to try it out on Thief of Thieves.
The series does not have a set ending, as Kirkman finds that starting off with an ending that you have preplanned feels like putting the cart before the horse. The series has been "broken" (a TV writing term that he hates but can't help but use) into arcs and stories and set up until at least issue 25. Spencer explained that Conrad is superlative at the job of stealing things, that he can see past the bullshit that keeps normal people from getting away with crimes. The real drama is that while stealing things is easy for him, it's living that's hard. Spencer admitted that after the carjacking scene in the sold-out first issue that people now look at him funny, because he did the research and knows these sorts of things now.
A fan asked Spencer about his newly announced Image series Bedlam. A criminally-insane mass murderer has been given a medical treatment, confirmed as cured, given a new identity through plastic surgery and in said new identity becomes a consultant for the very police forces that he used to foil. He now solves crimes in the town he used to terrorize. Spencer went on to describe how the setting of the series, the city of Bedlam was inspired by his youth growing up in America's rust belt, cities like Pittsburgh or Cincinnati on the brink of falling apart. He then gave a snappy summation of the series: "What if they cured the Joker?"
Last year Skybound published a rare Non-Kirkman written series, the occult medical drama Witch Doctor. There was a four-issue miniseries, and a one-shot follow up. With the success of those, writer Brandon Seifert announced a six issue miniseries follow-up, "Witch Doctor: Another Malpractice" which would focus more on the effects of magic in the dark occult world of the book. The conceit that this is a setting where magic is medicine and doctors deal with supernatural diseases allows him to explore concepts like what would it be like to treat a vampire. Seifert explained that in this world, vampirism is a condition that replaces your digestive tract and comes up through your throat, something that artist Lukas Ketner was able to properly render as horrifying. "If the first series was about the monsters, this one is about magic." said Seifert.
Seifert answered several fan questions about the series, explaining that many of the characters introduced in the first series weren't originally intended to appear more than once, but in response to how well the series has been received, several of them will make return appearances. Notably the demon-possessed boy from the first issue, and the medical board of directors. The enigmatic Penny received a bit of a backstory mainly because she was so mysterious that Seifert felt that the readers needed to get at least some information about her. The series will continue to be published as a series of miniseries mainly because Seifert and Ketner are so new to comics that they underestimated the workload that doing the series would entail. They plan on releasing as many issues as they can as swiftly as they can, but for now it will not graduate to an ongoing schedule unless they manage to get fast enough. There are a ton of stories that he has in mind, but no set schedule as to when each story will be told. For now he's organizing his thoughts alphabetically by monster, but admits that's not a viable publication strategy.
Kirkman showed a cover from an upcoming issue of The Walking Dead, featuring the new arc "Something to Fear." This arc, which follows the events of the current "A Larger World" arc has the cast discovering that there are more survivors out there, and that not all of them can be trusted. The story will begin in issue 97 set to ship in May, and will continue through the San Diego Comic Con-premiering issue 100. Kirkman related an anecdote about how he'd talked about the basic idea of this arc to former Image staffer and current Glory writer Joe Keatinge. Seven years ago. The comic will soon hit an Image record for the most issues released on time, which Kirkman credited to artist Charlie Adlard. The fact that zombies are less of a threat to the cast now that they've had a great deal of experience and knowledge in how to deal with them is something Kirkman acknowledged. There wouldn't be any new types of faster zombies introduced, though Kirkman joked about the potential for "LASER ZOMBIES."
The Walking Dead TV series continues apace, with a new episode having aired by the time you read this. Kirkman explained that while the TV series and the comic are two separate entities, the show is adapting the basic overall plot of the comic even if some of the characters differ. Likewise, characters who have yet to appear in the show may still show up in future seasons. "The comic is the roadmap for the show." elaborated Kirkman. "The show won't wind up with the cast living on sailboats and fighting frost giants." Kirkman prefers that the show be different from the comic, because a literal adaptation means that people who have read the comic will know exactly what is going on and thus there's no drama. You don't need to watch episode 2 because you'd already know what would happen in episode 10.
Kirkman commented on the casting of David Morrisey as the Governor for season three, and how he was present at Morrisey's screentest. Kirkman had to struggle not to make faces at him to relieve his stress. AMC has yet to give any notes asking them to make massive changes, which has surprised Kirkman as he'd thought several times that he'd gone too far. Kirkman explained that he tends to repeat jokes, and when watching the effects for Walking Dead would respond to "any suggestions?" with "Can you add a Dinosaur?" This lead to some of the effects artists redoing the scene where Lori hits a zombie with a car to instead be Lori hitting a raptor. Kirkman has the joke scene on his phone, and showed it to fans after the panels concluded. He will look into getting it released online in some form or another. This lead to him joking about putting Dinosaurs in all his books, given that they're in Invincible and Super Dinosaur. Which inspired him to think of stealing dinosaur bones for Thief of Thieves, and how there would be a black market for them and you could see the gears turning in Kirkman's brain as he seriously pondered the concept.
A fan asked about how they pulled off having Sophia as a zombie without using the actress in background shots so that you could go back and see it coming. Kirkman explained how the combination of no characters who knew her seeing her outside of incredibly dark conditions ensured that the secret remained intact, and that he and the other writers worked hard to ensure it all made sense. The next fan asked about the magical anti-zombie fence, which lead Kirkman to explain that yes, the farm seems much more secure than it should be but that's a plot point, and also that because the initial zombie infections would spread swifter in urban areas where people are more densely packed, that swiftly heading to rural areas would make it seem as if there were less zombies at first. The appearance of the blue meth from Breaking Bad was Kirkman's idea. T-Dog is not Tyrese, clarified Kirkman, and he will be getting more character development as the season progresses. Merle will be seen again.
"I'm a cog in the machine," explained Kirkman when asked about his role on the show. Starting with the second season he's been in the writer's room, helping to breakdown and adapt the episodes, giving suggestions and critiques when needed. There haven't been any major dramatic conflicts on the creative side, as the writers are all very calm and chill people. He pointed out that there are bits in episodes credited to him that he didn't write, as television scripts go through rounds of editing before and after the scripting process, and scenes from episodes get shifted around as needed, unlike in comics where the credits for writing are much more straight forward. Kirkman visits the sets, goes over approvals on the special effects giving advice on things like when more blood is needed or the like,
The upcoming Walking Dead video game was the next topic of discussion. Telltale Games approached Kirkman, and managed to convince him to let them have a shot at the franchise when they explained that they weren't interested in yet another game where people kill zombies, but in doing a character-driven game about survival. There are levels where you have to protect someone and only have so much food and have to decide if you will steal food from others and thus likely condemn them to death. Which characters live or die is something that will change in every playthrough depending on the player's choices, and thus you can get a different experience each time you play. The game will incorporate new characters, bits of backstory from the comic, specifically focusing on Glenn in Atlanta before he joins the main cast. The art in the game is inspired by the comic, which made Kirkman wary at first, as he didn't like that approach in Marvel vs Capcom 3, preferring the visual style used in Street Fighter IV, but when he saw it in action had a change of heart.
Kirkman came up with the title for the Walking Dead based on the phrase he'd heard describing zombies in the past, as it sounded cool. The conceit that the survivors are the real Walking Dead was something he felt was incredibly pretentious, but ended up using in the book anyways because it would make a nice ending to the first hardcover. When it ended up being used as dialog in the comic, the fans latched on to it, and AMC found it incredibly profound when they came aboard.
The Walking Dead Board Game had little creative input from Kirkman, because board games aren't something he's very knowledgeable in. The folks at Skybound had a day of pizza and playtesting the game which Kirkman was saddened he had to miss because he was on set for the show. There's a strong possibility that an expansion set for the game could be released later this year.
The next issue of Invincible, featuring the new black Invincible was Kirkman's next main topic. He explained how recent events in the comic have lead to Mark being infected with the Scourge Virus, putting him on the brink of death and requiring someone else to step up as the new Invincible. Kirkman explained that Mark is near death, and could die next issue. "He's not going to die." quipped Kirkman. The fate of his replacement wasn't going to be revealed at this panel, given that the comics featuring him have yet to be released to the public, but Kirkman suggested that introducing him just to kill him off would be rather disappointing. The Viltrumites who are hiding on Earth haven't been forgotten but will be on the back burner for the time being. They'll make a reappearance before issue 100. There won't be any Invincible novels to match the Walking Dead novel that recently came out, as Kirkman doesn't want to do Invincible without artist Ryan Ottley. There will be a second Walking Dead novel however.
A man with a baby had difficulty getting her to be quiet during the panel. Kirkman advised that a swift slap on the leg would help. Jokingly.
The kid-friendly title Super Dinosaur was the next of Kirkman's titles to be spotlighted. Kirkman felt that since he's now a father, he'd like to have books his children can actually be exposed to. His approach to writing the book was to make it kid-friendly but not kid-focused, remembering how he got into comics through old X-Men and Spider-Man issues that were aimed at an older audience but still acceptable for children to read. The ninth issue of Super Dinosaur will be out soon, and the second trade will be released in June. Kirkman finds that writing a more light-hearted book like Super Dinosaur is a change of pace from his normal dramatic workload, and who doesn't like dinosaurs shooting missiles?
Kirkman would one day like to bring back his other superhero titles such as Capes, Tech Jacket, Astounding Wolfman and the such, and said that seeing at least one of them again might be a possibility in the near future.
A fan who asked for a jumping on point for Invincible as he found the monthly comic to be hard to get into was advised to either pick up the first issue, try the Invincible Returns one-shot which was collected in the 14th trade, the 10th trade or even to just torrent the series. This began a digression as Kirkman knew that he probably should have been more aggressively against torrenting, but cares more about getting people to read his books. He has enough money, so it's okay right? He then told a story of back when he worked at Marvel he needed research on Annihilus and couldn't find the issues so it was off to torrent he went! (Also, he didn't get the pun of "Annihilate" and thus always pronounced it wrong as a child, and thus even today needs to pause a bit before saying the name.) Kirkman pointed out that he started reading comics with Amazing Spider-man 343 and had no clue who this Flash Thompson was, but slowly picked it up as he was reading. Also, that every guest to the Image Comics Expo received a free copy of Walking Dead #94 which also included a Comixology code redeemable for the first Invincible trade. Which he then admitted would soon be leaked onto the webs so that everyone could get a chance of reading it. Kirkman shrugged and joked that he's at least somewhat communist by nature.
Answering a fan queston, Kirkman explained that while he doesn't balance his heavy workload well, he usually doesn't work on weekends. He joked that his routine includes watching TV with his wife so that he doesn't have to talk to her. Kirkman now spends a good chunk of his weekdays in the writer's room for Walking Dead, and manages to squeeze in his comics work in between that. Knowing that he has to keep his artists with a steady supply of pages to work on helps keep him going, leading to occasional late Sunday nights where Kirkman stays up late so that Charlie Adlard can get more pages to work on before the morning in England. He gave a recent example of an intricate double page spread for an upcoming issue that requires hours of research, which Kirkman dreads as he prefers to just make stuff up and be wrong, and took him much longer than usual to get done, and Adlard had it done within a few hours.
The main criteria he looks for when selecting creators to work for Skybound is being handsome, joked Kirkman. Seifert was inordinately pleased with that, leading Kirkman to respond that occasionally he makes exceptions. For Nick Spencer. Seriously, Kirkman looks for people who have a proven track record in self-published work. He wouldn't have picked up Witch Doctor had it only been a written pitch, but the fact that they had self-published the book meant that he could trust their capacity to get the job done. Nick Spencer was chosen to work on Thief of Thieves because he'd done close to 900 Image comics on his own, exaggerated Kirkman. He went on to say that Skybound doesn't take submissions, but rather Skybound will find you.
An annoyed Kirkman yet again answered the question of whether he thinks he'd survive a zombie apocalypse, which he now gets asked at every appearance he makes, by saying no, he'd probably die and thus decide to quickly kill himself to prevent an even worse fate. There would be no holding up at Costco for him. He struggles with writing super intelligent characters such as Science Dog or Dinosaurus because he knows that he shouldn't just have them hit their enemies, but it's so much simpler to write that than coming up with an appropriate intelligent alternative. He's found that he's become softer since becoming a father, which now leads him to try and continue to push the envelope in his comics to prove that he's not just holding back because he's a dad.
When asked his opinion of the various .1 and .5 issues that have sprung up lately, Kirkman answered "They're ridiculous and no one wants them."
Savage Dragon made a cameo appearance in Battle Pope partially in response to the idea years ago that Savage Dragon would be appearing in comedic backup features in Joe Madureira's Battle Chasers "back when Joe Mad gave a shit about comics." explained Kirkman. He had been calling Erik Larsen up on a regular basis after having interviewed him for a friend's website, because A) he truly and honestly loved Savage Dragon and B) because he wanted to slowly endear himself to Larsen in the hopes of furthering his career, to the point where he'd keep track of how long it had been since the last time he'd talked to Larsen to ensure that he wasn't overdoing it. He totally was. In any case, Larsen explained that he approved of the silly proposed cameo because he felt that most crossovers were too worried about making sense, and that he wanted to see something like the Dragon being a hot dog vendor in someone else's comic. Which is why Kirkman made that literally happen in Battle Pope.
Kirkman told the story of how Image nearly passed on the Walking Dead as they felt that the story needed more of a hook to grab readers than just being set in a zombie apocalypse, which lead Kirkman to concoct a "Plan 9 From Outer Space"-esque tale of how the zombies were actually animated by an alien race that was preparing to invade Earth by disrupting its infrastructure. That was enough to get Image to sign off on it, though Kirkman had no intention of actually using that plot. When he tried to get Invincible launched, the first few issues weren't selling that strongly and it seemed as if Image might have to cancel the book. They asked if there was anything exciting that would be coming up that might increase sales, and Kirkman explained the entire concept of Mark's dad being evil and him having to fight against his father for the sake of the Earth. Which in Kirkman's original plans would have been revealed around issue 25. It was pointed out to Kirkman that if he didn't move it up and do it soon, there wouldn't BE an issue 25.
Part of the reason why Kirkman wants to do long running series is that in his mind's eye, Walt Simonson's seminal run on Thor was much longer than it really was. Likewise David Micheline's run on Amazing Spider-Man. Writing an ongoing series is easy, writing endings is hard because you have to wrap everything up and resolve all the issues. Kirkman pointed out that his difficulty at writing endings can be clearly seen in Astounding Wolfman, where the series doesn't as much end as introduce some new concepts and then stop. He does hope on following up the last minute introduction of Dracula to that series with an "Astounding Wolfman vs Dracula" miniseries in the future.
He has some vague ideas for endgame scenarios for Walking Dead and Invincible, so that if the sales begin to radically drop he can slowly start leading up towards them, but he's not actively leading up to an ending at this point. In fact, he worries about the fact that one day he'll have to end them, as he doesn't believe he'll be able to do them justice. To that end, he currently plans to keep on writing them until he dies. "Likely due to cholesterol. It's funny because it's true."
Peter S. Svensson writes for Bleeding Cool, manages SpaceCat Comics in San Jose, and still has yet to finish the first season of the Walking Dead. Supposedly it's a good show.


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#MeToo: Mumbai Police close Tanushree's case against Nana Patekar
Thursday - June 13, 2019 4:08 pm , Category : ENTERTAINMENT
Mumbai, June 13 (IANS) In a significant development, the Mumbai Police have filed a closure report in the alleged #MeToo sexual harassment case lodged by actress Tanushree Dutta against actor Nana Patekar, a top official said here on Thursday."Yes, we have filed a B-Summary Report before the court," Mumbai Police spokesperson, Deputy Commissioner of Police Manjunath Shinge told IANS.The police move comes after they reportedly did not find enough evidence in the matter, virtually ending the case as they cannot continue further investigations.Dutta's lawyer, Nitin Satpute said that they would challenge the police move in the matter."If the police file any B or C classification of Summary Report, that cannot be final. We shall oppose it before the court. After hearing, if the court is satisfied, then it can again direct the police to re-investigate," Satpute told IANS.He accused the police of conducting a shoddy probe in the entire matter, not recording the statements of many other witnesses, but relying on the evidence of only "one or two" witnesses in a bid to protect the accused."In view of this, we shall oppose the B Summary Report and also file a writ petition before Bombay High Court," Satpute added.Dutta had lodged the complaint against Patekar in September 2018 accusing him of allegedly sexually harassing her over a decade ago, in 2008 during a shoot, but he (Patekar) had stoutly denied the charges levelled by her.
--IANS qn/in
--IANS qn/in


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Exercise has long been linked to better sleep, according to a review article published in December 2014 in the American Journal of Lifestyle Medicine. Other research suggests exercise may improve sleep and mood in people with insomnia, too, according to a study published in October 2015 in the Journal of Sleep Research. Conversely, poor quality sleep has been linked to a wide array of health problems, including cardiovascular disease, diabetes, and depression. Given the fact that getting adequate sleep is so crucial for good health, and that exercise is a low-cost, easily accessible solution that offers lots of other health benefits with no risk or side effects, giving exercise a try to improve sleep is a no-brainer.
No matter what exercise routine you choose, use the time to meditate. You may wonder how marathon runners are able to put so many miles on their bodies. It's because the pain from running that you avoid is something they've learned to harness to enter a transcendental state. If you're aware of the benefits of meditation and exercise but don't have time to do both, you can combine them, killing two birds with one healthy stone.
The one arm tricep dips in an effective exercise to lose arm fat that primarily focuses on the triceps – the back portion of the arms where most of the fat gets deposited. Being a powerful toning exercise it can be included in the 1200 calorie diet and exercise plan. The best thing about this exercise is that absolutely no equipments are required for doing it. All you will need is some clear space in your room.
Before anyone's crowned Cap'n Crunch, remember form is key. Lie on your back with the knees bent and feet flat on the floor. With hands behind the head, place the chin down slightly and peel the head and shoulders off the mat while engaging the core. Continue curling up until the upper back is off the mat. Hold briefly, then lower the torso back toward the mat slowly.
For urban runners and power-walkers, one of the biggest obstacles is other people. It's difficult to get in your meditative zone and enjoy your music when you constantly have to dodge people. To resolve this vexing issue, Runbell, a startup in Tokyo, has developed the runner's version of the bicycle bell. With this lightweight brass bell warning people you're approaching from behind, you're free to maintain your transcendental state while continuing your workout. Head to their Kickstarter campaign to pledge your support.
Then, step your left foot directly behind you (about 2 feet) and bend both knees to lower into a reverse lunge, creating two 90-degree angles with your legs. In this positioning, your shoulders should be directly above your hips and your chest should be upright (not leaning forward or back). Your right shin should be perpendicular to the floor and your right knee should be stacked above your right ankle. Your butt and core should be engaged.
For an extra boost of self-love, take that workout outside. Exercising in the great outdoors can increase self-esteem even more The mental and physical health outcomes of green exercise. Pretty J, Peacock J, Sellens M, Griffin M. Department of Biological Sciences, University of Essex, Colchester, UK. International Journal of Environmental Health Research. 2005 October;15(5):319-37.. Find an outdoor workout that fits your style, whether it's rock-climbing, hiking, renting a canoe, or just taking a jog in the park. Plus, all that Vitamin D acquired from soaking up the sun (while wearing sunscreen, of course!) can lessen the likelihood of experiencing depressive symptoms. Why book a spa day when a little fresh air and sunshine (and exercise) can work wonders for self-confidence and happiness?
While a Bulgarian split squat isn't technically a zero-equipment move, they can still be done pretty much anytime, anywhere. "It activates many muscle groups and can be performed with any lifted surface, like a couch, bench, small table, or even an airport chair," says DiDomenico. The move is a major lower-body burner—you'll feel it in your quads, glutes, inner thighs, hamstrings, and even your calves.
Use small weights to do weighted punches. Pick up a small, 1 or 2 pound weight in each hand and stand with your feet hip-width apart. Bring your hands up in front of your face with your palms facing each other. Punch your right fist forward without locking your arm, then quickly pull it back as you shoot your left fist upward. Alternate the exercise this way for 60 seconds, as fast as you can.[5]
Starting on the hands and knees, keep a flat back and engage the core. Raise the left leg straight back, stopping when the foot is hip-level and the thigh parallel to the floor. Balance for as long as possible, then raise the bottom right toe off the floor, tightening the butt, back, and abs (try to be graceful here!). Hold for up to 10 seconds, then switch legs.
Back to the tricep pushups and really activating those tricep muscles for toned arms. If you need a rest, that's totally cool. Just take a break in the up position and maintain that plank form. This way you are still working your arm muscles just by holding your body weight up. So that's totally fine for some of our beginners out there. For those who are more advanced, we want you going as hard as you can and trying to hit that 15 to 20 reps. You're doing great.
No matter what exercise routine you choose, use the time to meditate. You may wonder how marathon runners are able to put so many miles on their bodies. It's because the pain from running that you avoid is something they've learned to harness to enter a transcendental state. If you're aware of the benefits of meditation and exercise but don't have time to do both, you can combine them, killing two birds with one healthy stone.
Start the clock, and immediately do 10 reverse lunges in perfect form. When you're done with the reverse lunges, go straight into jumping jacks until the clock reads 1:00 minute. Then move on to the next move. Do each move 10 times perfectly starting at the top of the minute, and finish out the minute with jumping jacks until it's time for the next move. For the single-leg deadlift, do 10 on only one side (don't change your standing leg during any set of 10 reps).
In addition to its other benefits, regular exercise helps older people remain independent by improving functional ability and by preventing falls and fractures (see also Exercise in the Elderly). It can strengthen the muscles of even the frailest older person living in a nursing or retirement home. It tends to increase appetite, reduce constipation, and promote quality sleep.
So, here's how to lose arm fat: Stand holding the dumbbells at your side, palms facing forward. Your posture and form is important, so keep your back straight and chest up. Lift your arms straight up until they're at a 90-degree angle to your trunk. Now curl the weights to your shoulder as you count to three, then straighten to a count of three. Lagree recommends doing three sets of 20 repetitions. Don't miss this 15-minute strength training routine that works your whole body.
Jessica Matthews, M.S., E-RYT500 is faculty in kinesiology and integrative wellness at Point Loma Nazarene University and professor of yoga studies at MiraCosta College, where she helps to grow and mentor the next generation of health and wellness professionals. A dynamic speaker, respected educator, fitness industry veteran and featured wellness expert, Jessica is a trusted and recognized go-to media resource, regularly contributing to numerous publications and outlines on topics ranging from fitness and yoga, to health coaching and career development. Additionally, she serves as ACE's senior advisor for health and fitness education, and is the lead editor and author of the ACE Group Fitness Instructor Handbook: The Professional's Guide to Creating Memorable Movement Experiences. You can connect with her at www.jessica-matthews.com, @fitexpertjess (Twitter and Instagram) and www.facebook.com/fitexpertjess.
Those buff lab rats might be smarter than we think. Various studies on mice and men have shown that cardiovascular exercise can create new brain cells (aka neurogenesis) and improve overall brain performance Aerobic exercise is the critical variable in an enriched environment that increases hippocampal neurogenesis and water maze learning in male C57BL/6J mice. Mustroph ML, Chen S, Desai SC, Cay EB, DeYoung EK, Rhodes JS. Neuroscience Program, The Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL, USA. Neuroscience. 2012 September 6;219:62-71. Aerobic exercise improves hippocampal function and increases BDNF in the serum of young adult males. Griffin EW, Mullally S, Foley C, Warmington SA, O'Mara SM, Kelly AM. Department of Physiology, School of Medicine, University of Dublin, Trinity College, Dublin, Ireland. Physiology & Behavior. 2011 October 24;104(5):934-41.. Ready to apply for a Nobel Prize? Studies suggest that a tough workout increases levels of a brain-derived protein (known as BDNF) in the body, believed to help with decision making, higher thinking, and learning. Smarty (spandex) pants, indeed.
Though some people actually love physical activity and look forward to it, for many of us, exercising is a mighty drag. Exercise has also had an added PR problem in recent years: A growing body of evidence has shown that it's not all that good for weight loss, which was probably many people's reason for doing it in the first place. It may help with weight a little, especially for maintenance, but by and large, if you want to drop pounds, the most effective way is to eat less, not necessarily to exercise more. That said, research in recent years has also illustrated quite persuasively what exercise is good for—and it is actually good for a number of things, including some very profound things, like reducing dementia risk. Here's what science tells us we should probably keep exercising for, even though we may not love every minute of it.
Everyone's genetics are different. Your friend may hold more body fat in their glutes and thighs, while you may hold extra body fat in your arms or in your hips. We're all different. We're all unique little snowflakes and we hold our body fat in different areas. But, no matter who you are, if you get a low enough body fat composition, we guarantee you that you're going to lose body fat everywhere including your arms.
You're protecting yourself against colds, flu, you name it. Exercise elevates your level of immunoglobulins, which are proteins that help bolster your immune system and ward off infection. "Every sweat session you do can help strengthen your immune function for about 24 hours," says Cedric Bryant, PhD, chief science officer for the American Council on Exercise.
Here's some quick physics fun: A body at rest tends to stay at rest. That's the fitness version of Newton's First Law, and it means that humans will find literally any excuse to not work out. I don't have time.... I felt a slight ache in my knee and don't want to make that worse... It's high tide. Somewhere. Probably. This happens to everyone—even the most dedicated, ruthless, disciplined gym-goers among us. (Like we said, it's science)
A new study from her lab shows that a 20-minute moderate workout has measurable effects on the immune system: Participants were asked to walk or jog on a treadmill, depending on their fitness level. They measured levels of TNF, an inflammatory marker, before and after the exercise, and found that there was a 5% reduction in the number of immune cells that produced the marker.


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