Patient and Clinician Perceptions of Therapeutic Alliance as Predictors of Improvement in Depression

Abstract

Background: Meta-analyses have consistently concluded that a positive therapeutic alliance is associated with better clinical outcomes and progress. To date, however, very few studies have focused on sociodemographic or clinical patient characteristics as moderators of alliance. Method: A multicenter longitudinal treatment outcome study was conducted to investigate the associations of patient and clinician perceptions of the therapeutic alliance with improvement in depression, and to investigate whether these associations were influenced by sociodemographic or clinical characteristics of the patient. Clinician-rated Montgomery Åsberg Depressive Rating Scale scores and both patient- and therapist-rated Helping Alliance Questionnaire (HAQ-I) scores were obtained from 567 outpatients with major depressive disorder who received 6 months of combined psycho- and pharmacotherapy. Results: Multilevel repeated-measures analyses indicated that patient- and therapist-rated HAQ-I scores, 4 weeks after treatment began, positively predicted subsequent clinical change, controlling for the effect of early improvement and a range of patient characteristics. Next to alliance, early improvement, initial depressive symptom severity, a history of psychiatric disorders, and occupational status affected the rate of clinical improvement. Personality pathology comorbidity, marital and occupational status, and the atypical character of the major depressive episode (MDE) moderated the alliance-outcome relationship, depending on the informant (patient or therapist) of therapeutic alliance. Conclusions: The present findings suggest that therapist and patient ratings of therapeutic alliance predict therapeutic progress, and that this relation may be moderated by client characteristics, including personality pathology comorbidity, marital status, occupational status, and the atypical character of the MDE.

Helping Alliance and Unmet Needs in Routine Care of People With Severe Mental Illness Across Europe

“…This confirms evidence from psychotherapy research of a stronger alliance-outcome relation when using patient-rated measures (Horvath and Symonds, 1991). In contrast, our finding that the rate of reduction of patient-rated unmet needs decelerated with higher patient-rated HA ratings was rather surprising at first, as previous research suggests that a better alliance is related to faster (De Bolle et al, 2010) or no change (Puschner et al, 2008) in subsequent clinical improvement. However, these studies used different alliance and outcome measures, and analyses applied absolute rather than mean-centered alliance scores.…”

“…The large majority of studies investigating the alliance-outcome relation used crosssectional or two time-point data only, limiting causal inferences. An exception is a study which reported that patient-and staff-rated HA predicted subsequent clinical improvement when controlling for prior symptom change (De Bolle et al, 2010). Another study, using a multilevel model controlled for confounders, showed that a reduction in outcome (unmet needs) preceded an increase of the patient-, but not of the staff-rated HA (Junghan et al, 2007).…”

Pharmacotherapy for social anxiety disorder: Interpersonal predictors of outcome and the mediating role of the working alliance

“…Research on the relationship psychiatrist- and patient-assessed alliance in pharmacotherapy is scant. Yet, in one study, both psychiatrist- and patient-assessed working alliances were predictive of outcome (De Bolle, Johnson, & Fruyt, 2010). Future pharmacotherapy research should use both patient and psychiatrist assessments of alliance to further tease apart whether there may be differences between the two modes of assessment.…”

The Relationship Between Change in Therapeutic Alliance Ratings and Improvement in Youth Symptom Severity: Whose Ratings Matter the Most?

“…While there is debate in the adult literature concerning if the client’s rating of TA is more predictive than the clinicians (De Bolle, Johnson, & De Fruyt, 2010; Horvath, 2001; Horvath, Del Re, Flückiger, & Symonds, 2011), in treatment with youth there is the added complexity of caregiver involvement in treatment (Green, 2009; Hawley & Garland, 2008). In the present study these three respondents’ (clinician, youth and caregiver) ratings of severity of mental health status (symptoms and functioning) are compared with three ratings of TA provided by them.…”