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，是世界范围内导致残疾的主要原因。心理治疗被推荐为主要的循证治疗方法之一。然而，许多抑郁症患者没有得到足够的好处，大约三分之一的患者过早终止了心理治疗。与结果和退出密切相关的因素，如治疗联盟，需要加以解决。在任何心理治疗的过程中，治疗联盟的破裂(即紧张或破裂的时期)不可避免地发生。它们构成了过早终止治疗和治疗结果不佳的高风险。治疗师往往没有注意到这些问题，或者缺乏建设性地处理这些问题的技能。尽管联盟破裂的情况屡见不鲜，而且未能解决这些问题也会产生严重影响，但迄今为止，心理治疗培训的课程还没有系统地处理这一主题。以联盟为重点的培训(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，不受心理治疗取向的影响，以治疗过程的视频记录和角色扮演为核心要素。之前的研究包括自己的一项试点研究(由海格尔基金会资助)，强调了这种方法的潜力。然而，大规模试验的证据却不见踪影。本项目旨在通过随机对照的多中心试验，按合作中心(n=11个心理治疗培训机构)、治疗方法(CBT与PDT)和共病人格障碍分层，对232名抑郁症患者(计划n=232)及其见习治疗师(认知-行为、CBT或心理动力心理治疗，PDT；计划n=116)进行AFT(与往常一样的心理治疗训练)的有效性。治疗疗程(50分钟)每周进行一次，20周后进行后评估，35周后进行第一次随访。两个按等级排序的主要假设是：与TAU相比，AFT组20周后自评抑郁症状(第一个主要终点)的减少更明显，患者辍学率(第二个主要终点)较低。次要结果参数是：自我评定的抑郁症状和辍学、观察者评定的抑郁症状的其他测量点；自我评定的焦虑、躯体抱怨、人格结构和人际关系问题、患者的生活质量，以及治疗能力和对治疗师的监督更高的满意度。此外，还将对循证调解人进行调查。拟议的项目聚焦于最普遍的疾病之一，致力于一个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，这一结果具有极大的潜力，为以证据为基础的心理治疗培训和改善抑郁症患者的结果做出了实质性贡献。

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.