Alliance-Focused Training (AFT) as an integrative approach to improve therapists’ competencies in dealing with alliance ruptures and prevent negative outcome in psychotherapy for depression. A randomized controlled multicenter trial

抑郁症是最常见的疾病之一，也是全世界致残的主要原因。心理治疗被推荐为主要的循证治疗方法之一。然而，许多抑郁症患者并没有得到足够的好处，大约1/3的患者过早地终止了心理治疗。需要解决与结果和辍学密切相关的因素，例如治疗联盟。在任何心理治疗过程中，治疗联盟的破裂（即紧张或破裂的时期）不可避免地会发生。它们构成了过早终止治疗和不良治疗结果的高风险。治疗师往往没有注意到它们，或者缺乏建设性地处理它们的技能。尽管经常发生的联盟破裂和严重的影响，导致未能解决他们，心理治疗培训课程还没有系统地解决这个问题。以联盟为中心的培训（AFT）是一种很有前途的方法，可以提高治疗师处理联盟破裂的技能，独立于心理治疗取向，使用治疗过程的视频记录和角色扮演作为核心要素。先前的研究包括一项自己的试点研究（由海格尔基金会资助）强调了这种方法的潜力。然而，缺乏大规模试验的证据。本项目拟采用多中心随机对照试验，按合作中心（n=11家心理治疗培训机构）、治疗方式（CBT vs. PDT）和共病人格障碍分层，探讨AFT（与常规心理治疗训练相比，TAU）对抑郁症患者（计划n=232）及其培训治疗师（认知行为治疗，CBT或心理动力治疗，PDT，计划n=116）的疗效。每周进行一次治疗（50分钟），20周后进行后评估，35周后进行第一次随访。两个按等级顺序排列的主要假设是：与TAU相比，AFT在20周后预期有更强的自评抑郁症状减轻（第一主要终点）和更低的患者退出率（第二主要终点）。次要结局参数为：其他自评抑郁症状测量点、退评抑郁症状、观察者评抑郁症状；患者的自评焦虑、躯体抱怨、人格结构和人际问题、生活质量，以及治疗能力和对治疗师监督的更高满意度。此外，将调查以证据为基础的调解人。拟议的项目侧重于最普遍的疾病之一，致力于与日常实践高度相关的主题，并采用随机对照多中心设计，包括德国各地的11个培训机构。因此，该结果具有很大的潜力，可以为基于证据的心理治疗培训和改善抑郁症患者的预后做出实质性贡献。

Depressive disorders are among the most common disorders and constitute the leading cause for disability worldwide. Psychotherapy is recommended as one of the main evidence-based treatments. However, many patients with depression do not benefit enough and about 1/3 terminates psychotherapy prematurely. Factors closely linked to outcome and dropout, such as the therapeutic alliance, need to be addressed. Ruptures in the therapeutic alliance (i.e. periods of tension or breakdown) inevitably occur in the course of any psychotherapy. They constitute a high risk of premature treatment termination and poor therapy outcome. Therapists often fail to notice them or lack the skills to deal with them constructively. Despite the common occurrence of alliance ruptures and the serious implications resulting from failures to resolve them, the curricula of psychotherapy training do not systematically address the topic as of yet. The alliance-focused training (AFT) is a promising approach to enhance therapists’ skills in dealing with alliance ruptures, independent of psychotherapeutic orientation, using video recordings of therapy sessions and role play as central elements. Previous research including an own pilot study (funded by the Heigl Foundation) emphasizes the potential of the approach. However, evidence from large-scale trials is missing. The project intends to investigate the effectiveness of AFT (vs. psychotherapy training as usual, TAU) for depressed patients (planned n=232) and their trainee therapists (Cognitive-behavioral, CBT or Psychodynamic psychotherapy, PDT; planned n=116) in a randomized controlled multicenter trial, stratified by cooperating center (n=11 psychotherapy training institutes), treatment approach (CBT vs. PDT), and comorbid personality disorder. Therapy sessions (50 min.) will take place once a week, post-assessment will be performed after 20 weeks and 1st follow-up after 35 weeks. The two hierarchically ordered primary hypotheses are: In AFT compared to TAU, a stronger reduction of self-rated depressive symptoms (first primary endpoint) and a lower rate of patient dropout (second primary endpoint) is expected after 20 weeks. Secondary outcome parameters are: other measurement points of self-rated depressive symptoms and dropout, observer-rated depressive symptoms; self-rated anxiety, somatic complaints, personality structure and interpersonal problems, and quality of life for patients, as well as therapeutic competence and higher satisfaction with supervision for therapists. In addition, evidence-based mediators will be investigated. The proposed project focuses on one of the most prevalent disorders, is dedicated to a topic highly relevant to everyday practice, and uses a randomized-controlled multi-center design including 11 training institutes throughout Germany. Thus, the results have great potential to substantially contribute to an evidence-based psychotherapy training and improved outcomes for patients with depression.