Alliance-outcome Association Research Articles

The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss

BackgroundWorking alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss.Methods228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10).ResultsData for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms.ConclusionThe results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions.Trial registrationNot applicable.

Process and outcome of outpatient psychotherapies under clinically representative conditions in Austria: protocol and feasibility of an ongoing study.

While most studies assessing psychotherapy efficacy are randomized-controlled trials conducted in research institutions or short clinical treatments, the understanding of psychotherapy effectiveness under regular, clinically representative conditions, particularly in outpatient practice, remains limited. Representative data examining the effectiveness of psychotherapy under real-world conditions in Austria is lacking. This paper introduces a naturalistic observational combined process- and outcome study, implementing a dual-perspective approach through standardised pre- and post-treatment questionnaires and evaluating changes in the therapeutic alliance after each session. Further, semi-structured qualitative interviews aim to illuminate the personal experiences of patients and therapists. The primary objective of the presented study is to discern whether symptoms markedly decrease following therapy. A significant secondary goal is to trace the therapeutic alliance's evolution from both patient and therapist viewpoints, emphasising the alliance-outcome association and gender dynamics within the pairs. This paper discusses the project's feasibility after three years and shares key insights. Recruitment for this study has posed substantial challenges due to psychotherapists' concerns regarding data protection, extensive documentation, and philosophical reservations about the study design. Consequently, we recruited fewer participants than initially planned. Despite these hurdles, qualitative data collection has shown notable success. Given psychotherapists' busy schedules and reluctance to participate, more potent external incentives or a legal obligation may be necessary to encourage participation in future studies.

The alliance-outcome association in borderline and obsessive-compulsive personality disorder.

Personality disorders are considered a possible factor affecting the relationship between therapeutic alliance and therapy outcome. The present study investigated the alliance-outcome effect in patient groups with borderline personality disorder (BPD) and obsessive-compulsive personality disorder (OCPD). Data derived from a sample of n = 66 patients, treated in a day care hospital setting with a dialectical-behavioral and schema therapeutic treatment concept. Patients rated their symptom severity at admission, early alliance after 4-6 therapy sessions and symptom severity as well as alliance at discharge. Results showed no significant differences between BPD and OCPD patients regarding symptom severity and alliance. Multiple regression analyses indicated that the alliance was a significant predictor of symptom reduction, however only in the OCPD group. Our results showed an exceptionally strong alliance-outcome relationship in OCPD patients, suggesting that focusing on building a strong alliance and measuring it early in therapy may be especially beneficial for this patient group. For patients with BPD, a more regular screening of the therapeutic alliance might be helpful.

A Three-level Meta-analysis on the Alliance-Outcome Association in Child and Adolescent Psychotherapy.

Previous meta-analyses have found small to moderate associations between child-therapist alliance and treatment outcomes. However, these meta-analyses have not taken into account changes in alliance (i.e., alliance shifts), alliance agreement (i.e., congruence or discrepancies between child-therapist ratings), and the role of alliance as a moderator in relation to treatment outcomes (i.e., an interaction effect of alliance and treatment condition on treatment outcomes). A series of multilevel meta-analyses of 99 studies was conducted to investigate several types of alliance-outcome associations in child and adolescent psychotherapy. Associations between child-therapist alliance and child outcomes (r = 0.17), changes in child-therapist alliance and child outcomes (r = 0.19), child-therapist alliance as a moderator of outcomes (r = 0.09), and parent-therapist alliance and child outcomes (r = 0.13) were small. Associations between child-therapist alliance agreement and outcomes (r = 0.21) and between parent-therapist alliance and parent outcomes (r = 0.24) were small to moderate. This meta-analysis provides the most updated and comprehensive overview of the alliance-outcome association in child and adolescent psychotherapy, showing that the alliance continues to show impact on treatment outcomes. Alliance research in youth psychotherapy has increasingly focused on several complex aspects of the alliance-outcome association, such as the role of changes in alliance, alliance discrepancies, client and therapist variability, and the reciprocal association between alliance and prior symptom change in relation to treatment outcomes. Implications for future research and clinical practice are discussed.

Threat alert: The effect of outliers on the alliance-outcome correlation.

Meta-analyses have established the alliance as the most robust predictor of outcome in psychotherapy. A growing number of studies have evaluated potential threats to the conclusion that alliance is a causal factor in psychotherapy. One potential threat that has not been systematically examined is the possibility that the alliance-outcome association is driven by low alliance outliers. We examined the influence of removing low alliance outliers on the alliance-outcome association using data drawn from two large-scale, naturalistic psychotherapy data sets (Ns = 1,052; 11,029). These data sets differed in setting (university counseling center, community mental health center), country (United States and Canada), alliance measure (four-item Working Alliance Inventory Short Form Revised, 10-item Session Rating Scale), and outcome measure (Counseling Center Assessment of Psychological Symptoms-34, Outcome Questionnaire-45). We examined the impact of treating outliers in five different ways: retaining them, removing values three or two standard deviations from the mean, and winsorizing values three or two standard deviations from the mean. We also examined the effect of outliers after disaggregating alliance ratings into within-therapist and between-therapist components. The alliance-outcome correlation and the proportion of variance in posttest outcomes explained by alliance when controlling for pretest outcomes were similar regardless of how low alliance outliers were treated (change in r ≤ .04, change in R² ≤ 1%). Results from the disaggregation were similar. Thus, it appears that the alliance-outcome association is not an artifact of the influence of low alliance outliers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supplemental Material for The Alliance-Outcome Association in Group Interventions: A Multilevel Meta-Analysis

Supplemental Material for The Alliance-Outcome Association in Group Interventions: A Multilevel Meta-Analysis

Intraindividual dynamics between alliance and symptom severity in long-term psychotherapy: Why time matters.

Objective: The association between alliance and therapy outcome is one of the most investigated factors in psychotherapy research. However, even studies using advanced methods estimate effects over a specific time period (interval) between measurement occasions. Thus, it remains unknown how the magnitude and direction of effects depend on the considered time interval, resulting in limited comparability across studies. The current study examines the influence of time on the within-person relationship between alliance and symptom severity. Method: Alliance (WAI-SR) and symptom severity (SCL-K11) were assessed every fifth session in N = 650 patients receiving up to 100 weekly sessions (mode = 55; M = 41.03; SD = 27.23) of individual psychotherapy in a German outpatient clinic. Bivariate continuous-time (CT) structural equation modeling (SEM) was used to estimate within-person cross- and auto-effects. Results: Analysis revealed significant reciprocal within-person cross-effects with stronger relative effects of SCL-K11 on WAI-SR (a₂₁) than vice versa (a₁₂). CT analysis showed that both cross-lagged effects increased for longer time intervals with strongest effects for time intervals of about 40 sessions (a₂₁ = -.47; a₁₂ = -.19). Conclusions: Alliance and symptom severity showed a reciprocal relationship. Expanding current evidence, our analysis showed how the magnitude of these effects depends on the considered time interval. Applying CT-SEM on longitudinal data of the alliance outcome association complements current cross-lagged panel analysis and allows to compare results of studies which are based on different time intervals between measurement occasions. Methodological, theoretical, and clinical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Alliance-Outcome Association in Couple Therapy: A Common Fate Model.

The working alliance has been shown to be a robust predictor of couple therapy outcomes. However, there are still questions regarding the best way to conceptualize and analyze the association between the alliance and outcomes in the couple therapy context. This study presents results from a relatively novel analytic approach for evaluating the alliance and therapy outcomes via the shared influence model (i.e., common fate statistical methodology) with 93 couples who had at least three sessions. Examining the alliance in couple therapy this way allows for nuance in conceptualizing the process of the alliance among partners and the therapist in couple therapy. Empirically, the question that remains is whether the shared experience of the alliance between partners is a stronger predictor of therapy outcome as compared to the unique individual experiences of the alliance. This approach has not yet been utilized to model the couple alliance-outcome association. Results revealed that the shared influence model demonstrated a significant association between the alliance and therapy outcome. Specifically, the couple-level alliance construct was adequately represented from the partners' alliance ratings with the therapist, and couples that report higher shared alliance experiences were also likely to have better therapy outcomes. These findings suggest that conceptualizing and analyzing the alliance at the couple level may be strongly advantageous. Implications for research and practice are provided.

The alliance-outcome association in the treatment of adolescent depression.

A growing body of research has consistently demonstrated a relationship between alliance and treatment outcomes in youth psychotherapy. However, previous research often suffered methodological issues that prevented detailed investigation of temporal relationships between alliance and symptomatology. The current study explored the directions of effect between alliance and outcome by examining the associations between early alliance and subsequent outcome while controlling for patients' baseline severity and prior symptom change. It also examined potential moderators of this association. Data were drawn from the IMPACT study, a randomized controlled trial comparing cognitive-behavioral therapy and short-term psychoanalytic psychotherapy versus a brief psychosocial intervention in the treatment of adolescent depression. Adolescents (N = 224) and therapist (n = 139) rated the alliance 6 weeks after randomization. Depression severity and overall psychopathology were assessed at baseline, 6, 12, 36, 52, and 86 weeks after randomization. Patients' age, gender, baseline depression severity, conduct disorder symptoms, and treatment type were examined as potential moderators of the alliance-outcome association. Data were analyzed using multilevel models. Findings suggested that higher early alliance ratings were associated with subsequent symptom reduction, even after controlling for prior symptom change and baseline severity. There was some evidence that the strength of this association was strongest in cognitive-behavioral therapy, weaker in short-term psychoanalytic psychotherapy, and statistically indistinguishable from zero in brief psychosocial intervention. These findings suggest that early therapeutic alliance with adolescents may influence subsequent outcome independent of prior symptom change and initial severity but that the effect of the alliance on outcome might vary across treatment types. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Supplemental Material for The Alliance–Outcome Association in the Treatment of Adolescent Depression

Supplemental Material for The Alliance–Outcome Association in the Treatment of Adolescent Depression

Assessing the alliance-outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons.

The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported alliance-outcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the alliance-outcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the alliance-outcome correlations: (a) intake characteristics (k = 35); (b) simultaneous processes, such as adherence or competence (k = 13); and (c) both intake and simultaneous processes (k = 24). We found moderate alliance-outcome correlations with or without adjustments for intake and simultaneous processes (range from r = .23 to r = .31). Our results provide robust empirical evidence for the assertion that the alliance-outcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Interpersonal agency as predictor of the within-patient alliance effects on depression severity.

Several studies have reported significant within-patient effects of the therapeutic alliance on outcome. However, it remains uncertain whether there are specific patient groups for whom an improved alliance might be particularly beneficial. The relational nature of the alliance makes patients' interpersonal problems a promising candidate for examining such differential effects. This study aims to analyze (i) between- and within-patient effects of the alliance on depression severity, (ii) the effects of patients' baseline interpersonal problems on the within-patient alliance-outcome association, and (iii) whether within-patient effects of the alliance remain significant when adjusting for patients' initial interpersonal problems. A sample of 141 patients with depression and undergoing outpatient psychotherapy completed the Inventory of Interpersonal Problems at baseline as well as a brief version of the Working Alliance Inventory and the Well-Being Index (as a proxy of depression severity) session by session. Multilevel models revealed both significant between- and within-patient effects of the alliance on improvements in depression severity. Patients' problems relating to agency had a significant effect on the within-patient effect of alliance, with more submissive patients benefiting more from an improved therapeutic alliance. Finally, the between- and within-patient effects of the alliance remained significant when adjusting for the patients' agentic interpersonal problems and treatment condition. The results provide evidence on which types of patients would particularly benefit from an improved therapeutic alliance. For patients suffering from low interpersonal agency and reporting problems with submissiveness, an enhanced alliance during the therapy process might improve treatment outcome. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial.

BackgroundTherapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes.ObjectiveThe aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties.MethodsA sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment.ResultsWe found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P<.001) and patient well-being (γ02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68).ConclusionsThe results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

Using Time-Lagged Panel Data Analysis to Study Mechanisms of Change in Psychotherapy Research: Methodological Recommendations.

The introduction of novel methodologies in the past decade has advanced research on mechanisms of change in observational studies. Time-lagged panel models allow to track session-by-session changes and focus on within-patient associations between predictors and outcomes. This shift is crucial, as change in mechanisms inherently takes place at a within-patient level. These models also enable preliminary casual inferences, which can guide the development of effective personalized interventions that target mechanisms of change, used at specific treatment phases for optimal effect. Given their complexity, panel models need to be implemented with caution, as different modeling choices can significantly affect results and reduce replicability. We outline three central methodological recommendations for use of time-lagged panel analysis to study mechanisms of change: a) Taking patient-specific effects into account, separating out stable between-person differences from within-person fluctuations over time; b) properly controlling for autoregressive effects; c) considering long-term time-trends. We demonstrate these recommendations in an applied example examining the session-by-session alliance-outcome association in a naturalistic psychotherapy study. We present limitations of time-lagged panel analysis and future directions.

Supplemental Material for Assessing the Alliance–Outcome Association Adjusted for Patient Characteristics and Treatment Processes: A Meta-Analytic Summary of Direct Comparisons

Supplemental Material for Assessing the Alliance–Outcome Association Adjusted for Patient Characteristics and Treatment Processes: A Meta-Analytic Summary of Direct Comparisons

The working alliance in manualized CBT for generalized anxiety disorder: Does it lead to change and does the effect vary depending on manual implementation flexibility?

The investigation of session-to-session effects of working alliance on symptoms and coping experiences in patients diagnosed with generalized anxiety disorder. In addition, investigating these effects dependent on whether therapists are primed to work with patients strength (resource priming) or to adhere to the treatment manual (adherence priming). Data was drawn from a randomized controlled trial in which 57 patients were randomly assigned to either the resource priming condition or the adherence priming condition. Within- and between patient associations were disentangled using dynamic structural equation modeling. The total score of the working alliance, as well as all its overlapping components (i.e., goal agreement, task consensus, bond) showed significant within-patient effects on next session coping experiences. More specifically, better alliance scores in one session were followed by more coping experiences in the subsequent session. With regard to anxiety symptoms, an association was found only with the working alliance total score as well as for the bonds component, but not for the goals and task components of the working alliance. The priming condition (resource priming vs. adherence priming) had no influence on the within-patient alliance-outcome association. Between-patient alliance associations were only present with coping experiences, but not with anxiety symptoms. The findings provide further empirical evidence for the hypothesis that the working alliance may be a robust facilitative factor for change in CBT treatments for generalized anxiety disorder, which evolves irrespective of the strictness with which therapists adhere to the treatment manual. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Interpersonal change as a mediator of the within- and between-patient alliance-outcome association in two treatments for generalized anxiety disorder.

Although a better therapeutic alliance associates with treatment outcome, it may do so in different ways. For example, alliance quality may promote improvement as it shifts over time (within-patient changes); alternatively, alliance quality may also, or instead, influence outcome when generally higher or lower for some patients relative to others (between-patient differences). Although both components have been linked to patient improvement, the distinct mechanisms of these associations have been rarely examined. Conceptually, it follows that within-patient alliance fluctuations (representing the changing nature of a current relationship intended to be ameliorative) may facilitate other interpersonal improvements that could, in turn, translate into symptom reduction. This path squares with the corrective relational experience notion. In contrast, whereas as patients' average alliances across therapy may generally facilitate or hinder improvement, the mechanism may not be other relationship functioning. This squares with the notion that when people generally experience good alliances with their therapist, it may reflect an existing relational ability that catalyzes the effectiveness of other nonrelational therapeutic means. This study tested these distinct hypotheses. Patients (N = 85) with generalized anxiety disorder were randomly assigned to cognitive-behavioral therapy, either alone or integrated with motivational interviewing. They rated alliance quality, interpersonal problems, and outcome repeatedly. Using multilevel structural equation modeling, both within- and between-patient alliances related to subsequent worry reduction. As predicted, change in interpersonal problems mediated the association only at the within-patient level. Results contribute to the literature on mechanisms of the within- and between-person alliance-outcome association. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Predicting personalized process-outcome associations in psychotherapy using machine learning approaches—A demonstration

Objective: Personalized treatment methods have shown great promise in efficacy studies across many fields of medicine and mental health. Little is known, however, about their utility in process-outcome research. This study is the first to apply personalized treatment methods in the field of process-outcome research, as demonstrated based on the alliance-outcome association. Method: Using a sample of 741 patients, individual regressions were fitted to estimate within-patient effects of the alliance-outcome association. The Boruta algorithm was used to identify patient intake characteristics that moderate the within-patient alliance-outcome association. The nearest neighbor approach was used to identify patients whose relevant pretreatment characteristics were similar to those of a target patient. The alliance-outcome associations of the most similar patients were subsequently used to predict the alliance-outcome association of the target patient. Results: Irrespective of the number of selected nearest neighbors, the correlation between the observed and predicted alliance-outcome associations was low and insignificant. According to the true error of the prediction, the demonstrated approach was unable to improve predictions made with a simple comparison model. Conclusion: The study demonstrated the application of personalized treatment methods in process-outcome research and opens many new paths for future research.

Supplemental Material for Interpersonal Change as a Mediator of the Within- and Between-Patient Alliance-Outcome Association in Two Treatments for Generalized Anxiety Disorder

Supplemental Material for Interpersonal Change as a Mediator of the Within- and Between-Patient Alliance-Outcome Association in Two Treatments for Generalized Anxiety Disorder

Meta-analysis of the alliance-outcome relation in couple and family therapy.

This article reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT), with implications for clinical practice. We begin by describing the unique features of CFT alliances and their measurement, followed by two case descriptions. We explain that due to the systemic context of CFT, each patient's personal alliance with the therapist affects and is affected by other family members' levels of collaboration. Because family members often seek help when they are in conflict with one another, "split" alliances are common, as are problematic within-system alliances, defined as the degree to which family members agree on the nature of their problems and value participating in therapy together to achieve shared goals. In our meta-analysis of 48 studies with 40 independent samples, we used a three-level random effects model (Ns = 2,568 families, 1,545 couples, and 491 effect sizes) and found r = .297. In another analysis with seven independent samples and 31 effect sizes, the split alliance-outcome association was also significant, r = .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance-outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared with involuntary or mandated families). The article concludes with research-informed strategies for building and sustaining strong systemic alliances in CFT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).