Building Strong Therapeutic Relationships Quickly: The Effect of the Perceived Working Alliance on Veterans' Intensive PTSD Treatment Outcomes

• Published in: Psychotherapy (Chicago, Ill.) Ill.), 2022-09, Vol.59 (3), p.470-480
• Main Authors: Held, Philip, Meade, Enya A., Kovacevic, Merdijana, Smith, Dale L., Pridgen, Sarah, Coleman, Jennifer A., Klassen, Brian J.
• Format: Article
• Language: English
• Subjects: Cognitions; Cognitive Behavioral Therapy - methods; Cognitive Processing Therapy; Female; Human; Humans; Major Depression; Male; Military Veterans; Posttraumatic Stress Disorder; Psychotherapy, Group; Stress Disorders, Post-Traumatic - psychology; Stress Disorders, Post-Traumatic - therapy; Symptoms; Therapeutic Alliance; Treatment Outcome; Treatment Outcomes; Veterans - psychology
• ISSN: 0033-3204; 1939-1536; 1939-1536
• DOI: 10.1037/pst0000447

Intensive treatment programs (ITPs) are successful at reducing posttraumatic stress disorder (PTSD) and depression symptoms in veterans. However, the role of the working alliance in the context of ITPs is largely unexplored. The purpose of this study was to examine veteran-rated working alliance with their individual cognitive processing therapy (CPT) provider as a predictor of changes in PTSD and depression symptoms as well as negative posttrauma cognitions in two unique ITP formats. Data were collected from 128 veterans who completed a 2-week ITP, involving 2× individual CPT/day, as well as 73 veterans who completed a 3-week ITP, involving 1× group CPT/day and 1× individual CPT/day. Both ITPs included adjunctive wellness, skills, and psychoeducation services in addition to CPT. Linear mixed-effects models were used to determine whether changes in working alliance predicted changes in PTSD and depression symptoms. Stronger veteran-reported working alliance with their individual CPT therapist, most notably agreement on tasks, predicted significant reductions in both the 2-week and 3-week programs in PTSD (ps = .012 and .002, respectively) and depression symptoms (ps = .009 and .007, respectively) and negative posttrauma cognitions (ps = .009 and .016, respectively). These results highlight the importance of veterans' perceived working alliance with their individual treatment therapists in ITPs. Results suggest that a strong working alliance that is meaningful for treatment outcomes can be developed quickly despite the brevity of this intensive treatment format. Future research should examine ways to facilitate the development of a strong working alliance prior to or as early as possible in ITPs. Clinical Impact Statement Question: Does veterans' perceived working alliance predict reduction in posttraumatic stress disorder (PTSD) and depression symptoms and negative posttrauma cognitions in intensive treatment programs (ITP) for PTSD? Findings: Veterans' perceived working alliance were associated with reductions in PTSD and depression symptoms as well as negative posttrauma cognitions across 2- and 3-week ITP formats. Meaning: Perceived working alliance should be assessed early and continuously throughout treatment, and barriers to establishing a strong working alliance should be reduced. Next Steps: Future research may examine ways to facilitate the working alliance as early as possible in treatment.