Sudden Gains in the Alliance in Cognitive Behavioral Therapy Versus Brief Relational Therapy

• Published in: Journal of consulting and clinical psychology 2019-06, Vol.87 (6), p.501-509
• Main Authors: Zilcha-Mano, Sigal, Eubanks, Catherine F, Muran, J. Christopher
• Format: Article
• Language: English
• Subjects: Behavior change; Behavior modification; Brief Relational Therapy; Clinical outcomes; Cognitive Behavior Therapy; Cognitive behavioral therapy; Cognitive therapy; Concept formation; Female; Human; Male; Patients; Psychotherapeutic Breakthrough; Therapeutic Alliance; Therapeutic alliances; Therapist patient relationships; Therapists; Therapy; Treatment Outcomes
• ISSN: 0022-006X; 1939-2117
• DOI: 10.1037/ccp0000397

Objective: Two decades of empirical research suggest that changes in symptoms are not linear, and many patients gain much of their symptom reduction in one between-sessions interval. Theoretically, such gains are expected to be manifested in the working alliance as well, following a rupture session; however, no study to date has directly examined between-sessions sudden gains in the alliance. In the present study we examined whether ruptures predict subsequent sudden gains in the alliance, which in turn show an effect on outcome that is specific to the treatment in which the alliance is conceptualized as an active mechanism of change. Method: In a sample of 241 patient-therapist dyads, patients received either brief relational therapy (BRT), in which the alliance is conceptualized as an active mechanism of change, or cognitive-behavioral therapy (CBT), in which it is not. We examined whether patient and therapist reports of ruptures predicted sudden gains in alliance in the subsequent session, and whether early sudden gains in alliance were significantly associated with treatment outcome in BRT versus CBT. Results: Rupture sessions, as reported by therapists but not by patients, predicted a sudden gain in both patient and therapist-reported alliance in the subsequent session. Findings revealed a moderating effect of treatment condition on the association between sudden gains and treatment outcome, in which gains in alliance were associated with better treatment outcome in BRT than in CBT. Conclusions: The findings support the potential role of gains in alliance as a specific mechanism of change in BRT versus CBT. What is the public health significance of this article? The findings suggest that for many patients much of the improvement in alliance occurs in a single between-sessions interval, following a session in which the therapist reported a rupture. Such alliance gains may show a specific association with treatment outcome in a treatment focusing on the alliance as a core mechanism of change. These findings are consistent with theoretical conceptualizations of gains in alliance as products of the therapists identifying and resolving ruptures, and attest to the important role such a rupture resolution process is expected to play in Brief Relational Therapy.