Investigating the impact of early alliance on predicting subjective change at posttreatment: An evidence-based souvenir of overlooked clinical perspectives.

Abstract

Despite meta-analytic evidence showing that alliance is associated with posttreatment outcomes, several open questions still remain regarding this relation. First, we investigate whether (or not) the progressive aggregation of early alliance assessments increases the alliance-outcome relation across 2 distress and 4 subjective change measures. Second, we investigate whether the alliance-outcome relations using subjective change measures are independent from intake distress and early response. Third, we explore whether the progressive aggregation of the alliance on outcomes becomes particularly apparent between or within therapists again investigating these six outcome measures. Data were drawn from N ϭ 430 patients treated by N ϭ 151 therapists. Patient ratings of early alliance were assessed after Session 1 to 6. For outcome, 2 commonly used distress measures at intake and at posttreatment and 4 measures of retrospectively evaluated subjective change at posttreatment are integrated into a series of multilevel models. The proportion of variance in outcome predicted by alliance scores varied considerably depending on the number of alliance assessments which were aggregated, as well as on the type of outcome assessment (distress vs. subjective change measures) explaining up to 15% of outcome variance. Improvements in the strength of prediction with aggregated alliance assessments were most pronounced for subjective change measures for between-therapist components of the alliance. Examining associations with subjective change measures provides an additional, patient-centered perspective of the relation between early alliance and treatment outcomes. Public Significance StatementDespite ongoing encouragement to systematically consider patient-centered outcomes in clinical research, subjective change measures (i.e., how patients evaluate the change during psychotherapy) are still neglected in guidelines of how to conduct trial research. The present study shows that the alliance-outcome relation is dependent on the number of aggregated alliance assessments, the type of outcome assessment (i.e., distress vs. subjective change measures) and whether intake and early response are adjusted for or not. Aggregated early alliance assessments were shown to relate most strongly to retrospectively evaluated subjective change at posttreatment. Examining associations with subjective change measures provide additional clinical perspectives on process and outcomes when conducting clinical trials and routine outcome monitoring.

The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis.

“…We observed a general lack of assessing and reporting various symptoms and outcome measures simultaneously, somewhat neglecting further outcome components within the broad definition of the World Health Organization such as well-being or psychosocial functioning (Howard, Lueger, Maling, & Martinovich, 1993; WHO, 2019 for exceptions see Huppert et al, 2018 and Weiss et al, 2014). Further research is necessary to better understand to what extent the outcome definition and assessment method may affect the association between process-based psychotherapy factors such as the alliance and outcome (e.g., Flückiger et al, 2019).…”

Can we agree we just had a rupture? Patient-therapist congruence on ruptures and its effects on outcome in brief relational therapy versus cognitive-behavioral therapy.

“…Another important limitation is the use of single-item self-report measures, especially for session outcome, a choice that was aimed to mitigate the burden of session-by-session assessment over a 30-session period. This measure has the advantage of being a subjective measure of outcome, based on the individuals’ perceptions of their problems, and can provide an important patient-centered perspective of the process of therapeutic change (Flückiger, Hilpert, Goldberg, Caspar, Wolfer, Held, & Vîslă, 2019; Hill & Betz, 2005). Although the validity of this measure has been demonstrated before (Muran et al, 1992; Zilcha-Mano et al, 2016), it is critical to replicate the present findings using weekly measures of symptom severity, such as the Hamilton Rating Scale for Depression (Hamilton, 1967) and the Outcome Questionnaire (Lambert, Vermeersch, & Brown, 2004).…”

The Importance of the Working Alliance in the Treatment of Cluttering

“…The WAI-SR (Hatcher & Gillaspy, 2006) was used to evaluate the alliance. As per evidence from the field of psychotherapy, group-level results indicated that a strong working alliance between the participants and the SLP contributed to positive outcomes (Flückiger et al, 2018(Flückiger et al, , 2019Wampold, 2015). Although the findings confirmed significant associations between all three subscores on Bordin's (1979) model of the working alliance, they further indicated that the dimensions of goals and tasks were particularly relevant.…”