Sudden gains in the alliance in cognitive behavioral therapy versus brief relational therapy

Abstract

Objective: Two decades of empirical research suggest that changes in symptoms are not linear, and many patients gain much of their symptom reduction in one between-sessions interval. Theoretically, such gains are expected to be manifested in the working alliance as well, following a rupture session; however, no study to date has directly examined between-sessions sudden gains in the alliance. In the present study we examined whether ruptures predict subsequent sudden gains in the alliance, which in turn show an effect on outcome that is specific to the treatment in which the alliance is conceptualized as an active mechanism of change.

Method: In a sample of 241 patient-therapist dyads, patients received either brief relational therapy (BRT), in which the alliance is conceptualized as an active mechanism of change, or cognitive-behavioral therapy (CBT), in which it is not. We examined whether patient and therapist reports of ruptures predicted sudden gains in alliance in the subsequent session, and whether early sudden gains in alliance were significantly associated with treatment outcome in BRT versus CBT.

Results: Rupture sessions, as reported by therapists but not by patients, predicted a sudden gain in both patient and therapist-reported alliance in the subsequent session. Findings revealed a moderating effect of treatment condition on the association between sudden gains and treatment outcome, in which gains in alliance were associated with better treatment outcome in BRT than in CBT.

Conclusions: The findings support the potential role of gains in alliance as a specific mechanism of change in BRT versus CBT. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Figure 1.

Average sudden gain in alliance at the sample mean level, based on patients’ alliance self-report (1.a.) and therapists’ alliance self-report (1.b.). Similarly to the original figure by Tang and DeRubeis (1999), the working alliance inventory (WAI) scores shown for sessions n-2, n-1, n, n+1,n+2, and n+3 are the means (± SE) of the corresponding sessions of the patients showing sudden gains in alliance. Adapted from “Sudden gains and critical sessions in cognitive-behavioral therapy for depression,” by Tang, T. Z., & DeRubeis, R. J., 1999, Journal of Consulting and Clinical Psychology, 67.

Figure 2.

The mean of patient-rated treatment outcome stratified by sudden gains (SG) based on therapist-rated alliance, for each treatment condition (brief relational therapy and cognitive behavioral therapy).