Modified Alliance-Focused Training with Doubling as an integrative approach to improve therapists’ competencies in dealing with alliance ruptures and prevent negative outcome in psychotherapy for depression. Study protocol of a randomized controlled multicenter trial

Introduction

Alliance ruptures constitute a high risk of premature treatment termination and poor psychotherapy outcome. The Alliance-Focused Training (AFT) is a promising transtheoretical approach to enhance therapists’ skills in dealing with alliance ruptures.

Methods and analysis

To evaluate the effectiveness of Modified AFT with doubling (MAFT-D), a randomized, patient and evaluator-blinded, multicenter trial was designed comparing MAFT-D (delivered to trainee therapists and supervisors) and psychotherapy training/ treatment as usual (TAU) for therapists (n=120) and their patients with depressive disorders (n=240). A total of 16 cooperating centers, each offering either cognitive-behavioral or psychodynamic psychotherapy training, will contribute to recruitment. Stratifcation by center (both for therapists and patients) and hence therapeutic approach (cognitive-behavioral vs. psychodynamic psychotherapies), and by comorbid personality disorder (yes vs. no, for patients) will be carried out. The two hierarchically ordered primary hypotheses are: In MAFT-D compared to TAU, a stronger reduction of depressive symptoms and a lower rate of patient dropout is expected from baseline to 20 weeks after baseline. Follow-up assessments are planned at 35 weeks, 20 months, and 36 months post-baseline to evaluate the persistence of effects. Secondary patient-and therapist-related outcomes as well as predictors, moderators, and mediators of change will be investigated. Mixed models with repeated measures will be used for the primary analyses.

Ethics and dissemination

Ethical approvals were obtained by the institutional Ethics review board of the main study center as well as by review boards in each federal state where one or more cooperating centers are located (secondary votes). Following the Consolidated Standards of Reporting Trials statement for non-pharmacological trials, results will be reported in peer-reviewed scientific journals and disseminated to patient organizations and media.

Trial registration number

DRKS00014842 (German Clinical Trial Register).

Strengths and limitations of this study

• This large randomized controlled multicenter trial aims to deepen our understanding of alliance-focused trainings and holds great potential to substantially advance evidence-based psychotherapy training across therapeutic approaches.

• The study is designed to assess the effects of MAFT-D (delivered to trainee therapists and supervisors) on both therapists and, most importantly, on their patients.

• Involving multiple psychotherapy training institutes not only ensures generalizability, but may also facilitate transfer into clinical training and practice.

• By focusing on depression while stratifying for comorbid personality disorders, the study also stands to clarify potential differential effects of MAFT-D depending on patients’ psychopathological characteristics.

• The supervision frequency (one session per four therapy sessions), aligned with local real-world practices, and the primary measurement point (20 weeks), chosen for comparability with other trials, together pose a risk of insufficient dose, with effects potentially becoming apparent only at later follow-ups.