Abstract
Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings.Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD).Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome.Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings.Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.
Highlights
The working alliance, an important aspect of the therapeutic relationship, defined broadly as the “collaborative and affective bond between the therapist and patient” [1], has long been considered an essential component in the successful delivery of psychological therapy [2]
The current study is a secondary analysis of an effectiveness study of a cohort of 343 consecutive patients treated in routine clinical care (Ehlers et al, 2021)1 with CT-posttraumatic stress disorder (PTSD) [16]
Trauma Type Patients who experienced interpersonal traumas rated their therapeutic alliance after session 1 lower than patients who experienced other types of trauma, t(130.04) = −2.80, p = 0.006, whereas there was no significant difference for therapist ratings, t(154.46) = −1.74, p = 0.084
Summary
The working alliance, an important aspect of the therapeutic relationship, defined broadly as the “collaborative and affective bond between the therapist and patient” [1], has long been considered an essential component in the successful delivery of psychological therapy [2]. Effect sizes are often in the small to moderate range; Horvath et al [4] estimated an effect of r = 0.28 based on 190 alliance-outcome relationships reported in 201 studies. This is similar to results reported in previous meta-analyses with estimates of r = 0.26 [24 studies [3]] and r = 0.22 [79 studies [1]]. Patients’ ratings tend to be more consistent across therapy sessions than therapists’ [1], suggesting that patients view the alliance as more stable This finding requires replication, as few studies include ratings taken from both patient and therapist at multiple time points. Changes in outcome scores have been found to predict working alliance ratings
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