Reevaluating the Alliance-Outcome Relationship in the Early Sessions of Cognitive Behavioral Therapy of Depression

The therapeutic alliance has been reliably associated with outcome across psychotherapies. We investigated the alliance-outcome relationship in the early sessions of cognitive behavioral therapy of depression using a model that disaggregates within- and between-person variance while estimating the reciprocal relation between variables. We utilized this model in a combined dataset from two studies totaling 191 patients. In our primary model, we found evidence for a predictive within-patient relationship between alliance and symptoms such that symptoms predicted regressed change in alliance and alliance predicted regressed change in symptoms. In a more conservative detrended model, these relationships were not significant. Given that a) most of the variability in alliance scores is between-patient; b) the size of the alliance-outcome relationship is modest; and c) the alliance-outcome relationship is not robust to detrending, our findings suggest the alliance plays at most a small role in improving patient outcomes in cognitive behavioral therapy of depression.