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Therapeutic Alliance and Psychotherapy Outcome

For decades, clinicians and investigators have debated the relative influence on outcome of modality-specific psychotherapeutic techniques versus the common elements of psychotherapy belonging to all techniques. Among the "common elements" of psychotherapy, the collaborative relationship between patient and therapist (therapeutic alliance) has long been considered one of the most important, but its importance relative to the type of treatment remains uncertain.

This analysis examined the relative importance of treatment type (cognitive, interpersonal, or imipramine or placebo plus clinical management) and therapeutic alliance in the outcome of 225 depressed outpatients seen for at least two sessions and enrolled in the large, multisite Treatment of Depression Collaborative Study. Trained raters used videotapes and a construct that included separate factors for patients' and therapists' behaviors to rate therapeutic alliance. Outcome was assessed by Hamilton and Beck Depression scale scores.

Therapeutic alliance was similar for all treatment types and accounted for more of the variance in treatment outcome (21%) than treatment method (1%). Alliance was just as important for drug therapy as for psychotherapy and remained important whether measured at early sessions or later (as an average of all sessions). The patient's contribution to the alliance -- but not the therapist's -- was the significant factor related to outcome.

Comment: This is the first empirical study to show the importance of therapeutic alliance in both psychotherapy and pharmacotherapy outcome, as well as in placebo responses (suggested by the good responses in patients who received placebo plus clinical management). While patients' behaviors were key to the effects of therapeutic alliance on outcome, it is unclear from this study whether alliance actually measured another patient characteristic related to good outcome (such as readiness to change; see JW for Psychiatry, vol. 1, p. 20). The importance of alliance in the outcome of pharmacotherapy may help explain the poorer outcomes of depressed patients in primary care settings, since these physicians have limited training and time for facilitating an alliance. More delineation of the important elements of therapeutic alliance is needed to determine whether it can be fostered or whether it merely measures a preexisting patient characteristic.

— P Roy-Byrne

Published in Journal Watch Psychiatry September 1, 1996

Citation(s):

Krupnick JL et al. The role of therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol 1996 64 532-539.

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