Consistent with findings from numerous studies of the therapeutic alliance (Martin et al., 2000
) we found, in a sample of depressed patients in CT, that stronger alliances were associated with greater symptom reduction. Of the few studies that have included a control for temporal confounds (see Barber, 2009
), only two (Barber et al., 2000
; Klein et al., 2003
) have reported a significant association between alliance and subsequent outcome. To our knowledge, this is the first study of CT to find that subsequent symptom change is predicted by the alliance.
When we examined the relation between subsequent symptom change and the two factor-analytically derived components of the early WAI, Agreement and Relationship, Agreement appeared to account for most of the predictive variance. In contrast, both components of the late WAI were associated with prior symptom change. This pattern of findings may reflect the importance of therapist-patient agreement on the tasks and goals of CT, and that variation in the bond between therapist and patient plays a less prominent role in contributing to symptom improvement in CT. The bond did vary as a function of prior symptom change, consistent with the view that it may strengthen as a consequence of symptom improvement. It is important to note, however, that at the early session the Relationship factor was associated with subsequent symptom change at the level of a nonsignificant trend, when the Agreement factor was not included as a covariate. And although the standardized regression coefficient (.15) from the latter analysis may be considered “small,” it is by no means negligible, and is not much smaller than the mean alliance-outcome correlation of .22 reported in Martin et al.’s (2000)
In the current study we only examined the relation between the alliance assessed at the third session and subsequent outcome. It is possible that a significant relation between the therapist-patient bond and subsequent symptom change would have emerged if the alliance had been assessed earlier or later in treatment. On average, approximately one-third of the symptom change occurred prior to the early session, and thus before our alliance assessment. It may be that a different pattern of results would have emerged if the alliance had been assessed even earlier in treatment (see also Gelso & Carter, 1985
; Horvath & Greenberg, 1989
We examined a relatively highly structured form of therapy. It is unclear to what extent these findings would replicate in studies of other treatment modalities, such as dynamic therapy (Summers & Barber, 2010
). It may be that the symptom improvement observed in the current study is at least in part a result of the particular
goals and tasks that are emphasized and pursued in CT (e.g., those related to identifying, challenging and modifying negative cognitions). Motivational Interviewing (MI; Miller, & Rollnick, 2002
), with its empathic, client-centered approach may offer helpful tools for therapists to enhance their alliances (including agreement on the goals and tasks of treatment) with their patients, particularly those that are especially ambivalent about changing.
Several limitations of the present study should be noted. First, although it is fundamental to the concept of causal modeling, the “no omitted variables” assumption is impossible to verify with observational data. Thus, unmeasured third variable confounds could have influenced the results. Second, scores on the Agreement and Relationship factors were highly correlated, especially at the late session, posing problems for the multivariate approach we took to these data. We attempted to minimize problems that result from multicollinearity by using two factor-analytically-derived components of the WAI, rather than the three theory-derived subscales.
Findings from the present study raise several issues that should be addressed in future research. First, it will be important to examine whether the current findings can be replicated in other samples of depressed patients treated with CT, as well as samples comprising patients with conditions other than depression, and studies of treatment modalities other than CT. Tests of the robustness of the present findings should also examine alliance-outcome relations at different assessment timepoints, as well as with alternative methods of assessing the alliance. The results of such future investigations may lead to the specification of variables that play especially important roles in therapeutic improvement.