The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression

Abstract

Objective: This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP).

Method: 395 adults (57% female; Mage = 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16-20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change.

Results: A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) = 62.48, p < .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) = 8.31, p = .004.

Conclusions: The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies.

Figure 1

Mean HAM-D scores across the 12-week study Note: Error bars represent Standard Error of the Mean. Group means did not statistically differ at baseline (p = .44), Week 2 (p = .49), Week 4 (p = .58), Week 6 (p = .13) or Week 12 (p = .30). Those in CBASP + ADM showed lower mean HAM-D scores than those in BSP + ADM at Week 10, p = .05; M(SD)_BSP = 14.80(9.44); M(SD)_CBASP = 12.41(8.12).There was a trend for those in CBASP + ADM to show lower mean HAM-D scores at Week 8 (p = .06). BSP = Brief Supportive Therapy. CBASP = Cognitive Behavioral Analysis System of Psychotherapy. ADM = Antidepressant Medication. HAM-D = Hamilton Rating Scale for Depression.

Figure 2

Scores Across Treatment On the Working Alliance Inventory Note: Error bars represent Standard Error of the Mean. Early treatment n = 113 in BSP + ADM and 111 in CBASP + ADM; Middle treatment n = 73 in BSP + ADM and 63 in CBASP + ADM; Late treatment n = 99 in BSP + ADM and 94 in CBASP + ADM. BSP = Brief Supportive Therapy. CBASP = Cognitive Behavioral Analysis System of Psychotherapy. ADM = Antidepressant Medication. WAI = Working Alliance Inventory.