Session-to-session bidirectional associations of alliance with depressive symptoms and relationship satisfaction

The relationship between therapeutic alliance and treatment outcomes is one of the most widely studied topics in psychotherapy research. Research has primarily considered a unidirectional model whereby alliance predicts outcomes, which implies that building alliance early in therapy results in later symptom improvement and ignores the possibility that early symptom improvement could also subsequently lead to improved alliance. This study explored the bidirectional associations of alliance and outcomes session-to-session for 15 sessions among a sample of 24 couples randomized to emotionally focused therapy or treatment as usual for depression and relationship dissatisfaction. Multilevel models tested associations between the prior week's alliance and the following week's clinical outcomes (i.e., depressive symptoms and relationship satisfaction) and the prior week's clinical outcomes with the following week's alliance. Findings indicated that the prior week's alliance was associated with the following week's relationship satisfaction, but not depressive symptoms, when controlling for the prior week's depressive symptoms and relationship satisfaction in each respective model. In addition, the prior week's depressive symptoms and relationship satisfaction were both associated with the following week's alliance, when controlling for the prior week's alliance. Only one of these associations differed by sex: previous week's higher relationship satisfaction was associated with higher therapeutic alliance the following week for males than females. These bidirectional associations did not differ by treatment condition. This study contributes to the emerging empirical support suggesting bidirectionality among alliance and treatment outcomes.