In this investigation of the alliance in cognitive therapy for personality disorders, better early alliances and rupture-repair episodes contributed to change in self-reported (WISPI) and interview-rated (SCID-II) personality symptoms and depression symptoms (BDI), even when the number of sessions completed and early change in depression were statistically controlled. Although this was a small open trial (n = 30) and alliance rupture-repair episodes could be assessed in only 25 of these patients, these findings suggest that the alliance might function in more than one way over the course of CT-PD to influence improvement in personality and depression symptoms.
The significant relation between early alliance and treatment outcomes is consistent with Horvath and Symonds’s (1991)
meta-analytic review and with Horvath and Luborsky’s (1993)
assertion that establishing collaboration and trust early on is integral to the therapy process. Our findings are also consistent with research on the importance of the early alliance in other chronic problems, such as recurrent depression (D. N. Klein et al., 2003
), childhood abuse-related PTSD (Cloitre et al., 2004
), and bulimia nervosa (Constantino et al., 2005
). We selected patients’ first alliance rating in an effort to assess the alliance before symptom change occurred, and we controlled statistically for early change in depression. Early alliance scores still predicted outcome. These findings differ from those of DeRubeis and Feeley (1990)
and Feeley et al. (1999)
in trials of CT for Axis I depression, where the alliance was no longer associated with treatment outcome when previous symptom reduction was controlled statistically. It is possible that the alliance is particularly important in Axis II populations, as hypothesized by Beck et al. (1990)
and Beck, Freeman, and Associates (2003)
. Indeed, stronger early alliances were associated with the completion of more sessions and with more early improvement in depression (Session 17), as well as with more improvement in personality and depression symptoms at posttreatment. It is also important to note that those with higher pretreatment WISPI scores, which assess the interpersonal dysfunction associated with personality disorders, reported lower alliances and were less likely to experience a rupture-repair episode. Higher pretreatment WISPI scores might indicate that extra attention needs to be paid to the alliance to obtain maximal benefit from the therapeutic relationship.
Our findings also suggest that the alliance can worsen over the course of therapy and that, if handled properly, ruptures may be therapeutic (Horvath, 1995
; Safran, 1993
; Safran, Crocker, Mc-Main, & Murray, 1990
; Safran & Muran, 1996
). Most of those who reported rupture-repair episodes also reported pre- to posttreatment symptom reductions of 50% or greater on all measures. These findings are consistent with recent advances in CT that emphasize in-session transactions to reveal patients’ core interpersonal schemata (Alford & Beck, 1997
; Newman, 1998
; Robins & Hayes, 1993
) and using the therapeutic relationship as a “corrective experience” to disconfirm maladaptive schemata (Beck et al., 1990
; Safran, 1998
; Safran & Segal, 1990
; Young et al., 2003
). In addition, our method of quantifying alliance ruptures, which is most similar to that of Stiles et al. (2004)
, provides another example of how the study of discontinuities in the course of therapy can reveal important change processes (Hayes, Laurenceau, Feldman, Strauss, & Cardaciotto, in press
Both early alliance strength and the rupture-repair process appear to contribute to therapy outcomes, but a number of patients experienced an alliance rupture that was not repaired or a linear decrease in the quality of the alliance. These patterns should be studied as carefully as ruptures that are repaired, as they can perhaps reveal mistimed interventions, or instances where some therapists do not attend to ruptures or respond ineffectively, as Castonguay and colleagues (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996
) noted in some sessions of CT for depression.
Although the results of this initial trial of CT for AVPD and OCPD are promising, there are important limitations to discuss. First, this is an open trial with no comparison condition, so within-group effects sizes were calculated. This method might yield overestimates of the effect sizes. Second, the sample size is small, but it is in line with the median sample sizes reported in recent reviews of therapies for personality disorders, which are typically of long duration and associated with significant rates of relapse (Perry et al., 1999
sample size = 25; Leichsenring and Leibing, 2003
: for psychodynamic therapies, Mdn
= 26; for cognitive–behavioral therapies, Mdn
= 16). This study of the role of the alliance in change was meant to contribute to treatment development efforts, and the findings will need replication and further study. Third, personality symptoms were not assessed until Session 17 after the intake interview; therefore we can only draw conclusions about those who remained in therapy until at least that point. Fourth, the clinical utility and generalizability of our findings must be strengthened by similar studies with different clinical problems and treatment approaches. It may be that alliance rupture-repair episodes are not as useful in Axis I problems or with Cluster A and B personality disorders.
In addition, although these findings are consistent with alliance rupture-repair models of change, they are topographical in nature. We describe shifts in alliance but did not directly examine in-session transactions. We can only infer that ruptures were captured by our quantitative method, which was most similar to the methods of Stiles et al. (2004)
and yielded similar findings. Another consideration is that the study included many therapists, but they treated too few patients to allow for analyses of therapist effects. However, therapist competence is an important variable, and in current work we are describing qualitatively and quantitatively the relations between alliance scores and ratings of therapist competence. We also note that the CALPAS (Marmar et al., 1989
) is one measure of the alliance and that the Working Alliance Inventory (Horvath & Greenberg, 1994
) might be more consistent with the format and goals of cognitive–behavioral therapies. The CALPAS, however, was an important predictor of symptom change, both as a measure of early alliance and of rupture-repair episodes.
The next phase of Adele M. Hayes’s treatment development research focuses on identifying therapist strategies associated with better and worse early alliances and rupture outcomes to improve treatment retention and treatment outcomes in this prevalent and challenging population. This work can complement the important work of Safran, Muran, and colleagues (reviewed in Muran, 2002
; Safran & Muran, 2000
) on markers of alliance ruptures and patient–therapist exchanges that inhibit and foster alliance repairs across types of therapy and clinical disorders. Together, such therapy process research can inform treatment development for the Cluster C personality disorders, which are among the most prevalent of the personality disorders in outpatient samples.