title: The therapeutic alliance in a naturalistic psychiatric setting: temporal relations with depressive symptom change.
abstract: OBJECTIVE
  Numerous studies have reported associations between the therapeutic alliance and depressive symptom improvement in outpatient samples. However, little is known regarding the temporal relationship between the alliance and symptom change among relatively severely depressed patients receiving treatment in naturalistic, psychiatric hospital settings.
  
  
  METHODS
  Adult patients with major depression (n = 103) receiving combined cognitive behavioral therapy and pharmacological treatment at a psychiatric hospital completed repeated assessments of the therapeutic alliance and depressive symptoms, as well as a pretreatment assessment of their expectation of symptom improvement.
  
  
  RESULTS
  Results indicated that the alliance and treatment outcome expectancies significantly predicted subsequent depressive symptom change. However, in a model in which prior symptom change and treatment outcome expectancies were statistically controlled, the alliance-outcome association was rendered nonsignificant. The alliance was significantly associated with prior symptom improvement.
  
  
  CONCLUSIONS
  Findings highlight the importance of controlling for plausible third variable and temporal confounds to minimize biased estimates of alliance-outcome associations in future studies. Overall, results were more consistent with the alliance being a consequence, rather than a cause, of symptom change. Finally, findings contribute to a growing body of evidence supporting the role of treatment outcome expectancies in predicting symptom improvement, even within our relatively severely depressed sample.
authors.affiliation: Center for Depression, Anxiety & Stress Research, Harvard Medical School, McLean Hospital, Department of Psychiatry, 115 Mill Street, Belmont, MA 02478, USA. Electronic address: cwebb@mclean.harvard.edu.
authors.forename: Christian A
authors.initials: CA
authors.lastname: Webb
authors.affiliation: Behavioral Health Partial Hospitalization Program, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA.
authors.forename: Courtney
authors.initials: C
authors.lastname: Beard
authors.affiliation: Center for Depression, Anxiety & Stress Research, Harvard Medical School, McLean Hospital, Department of Psychiatry, 115 Mill Street, Belmont, MA 02478, USA.
authors.forename: Randy P
authors.initials: RP
authors.lastname: Auerbach
authors.affiliation: Behavioral Health Partial Hospitalization Program, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA.
authors.forename: Eliza
authors.initials: E
authors.lastname: Menninger
authors.affiliation: Behavioral Health Partial Hospitalization Program, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA.
authors.forename: Thröstur
authors.initials: T
authors.lastname: Björgvinsson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003131:Combined Modality Therapy; D003863:Depression / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011369:Professional-Patient Relations; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000928:Antidepressive Agents
keywords: Alliance; Cognitive behavioral therapy; Depression; Expectancies; Hospital