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When is it Effective to Focus on the Alliance? Analysis of a Within-Client Moderator

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Abstract

Contemporary studies on the working alliance seek to move forward from demonstrating an association between alliance and outcome to investigating how alliance can be used to maximize treatment outcome by identifying the clients for whom state-like changes in alliance predict symptomatic change (between-clients moderators). Yet, very little is known empirically on when state-like changes in alliance predict outcome for individual clients (within-client moderators). The present study, based on a sample of 327 clients, demonstrates that state-like changes in alliance at a given session have a significant effect on subsequent session outcome only in the case of higher life satisfaction in that session. This finding suggests that strengthening in the state-like component of the alliance has a greater effect on outcome when the client suffers less from poor life satisfaction.

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Notes

  1. Various studies have used different models to examine this association, some showing that stronger alliance at a given time point predicted less severe symptoms at a subsequent time point, while controlling for previous symptomatic levels (e.g., Zilcha-Mano et al. 2014). Other studies used slightly different models, showing that patients who reported improvement in alliance over their expected level, are more likely to report greater reduction of symptoms, while controlling for previous symptomatic levels (e.g., Falkenström et al. 2013; Zilcha-Mano and Errázuriz 2015).

  2. It is important to stress that this value, although standardized, is by definition not comparable to other values taken from models that are not identical to the reported one (e.g., without log of time as both a fixed and a random effect, etc.).

  3. We repeated the analysis using a model that controlled for concurrent (time T) symptoms and prior change in symptoms (i.e., symptom change occurring before time T) as well as for log of time. This model revealed a significant interaction between within-client alliance and life satisfaction at the previous session in predicting outcome (β = −0.09, SE = 0.04, p = .02).

  4. To explore the question whether this moderating effect is specific to CBT, we performed a three-way interaction between within-client alliance and life-satisfaction at the last session with treatment condition (CBT and non-CBT therapists) to predict outcome for the entire sample (N = 547, CBT and non-CBT therapists). This interaction was not significant (F (1,2592) = 0.55, p = .46).

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  1. The Department of Psychology, University of Haifa, Mount Carmel, 31905, Haifa, Israel

    Sigal Zilcha-Mano & Ilana Lipsitz

  2. Psychology Department, Pontificia Universidad Católica de Chile, Santiago, Chile

    Paula Errázuriz

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  1. Sigal Zilcha-Mano
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Zilcha-Mano, S., Lipsitz, I. & Errázuriz, P. When is it Effective to Focus on the Alliance? Analysis of a Within-Client Moderator. Cogn Ther Res 42, 159–171 (2018). https://doi.org/10.1007/s10608-017-9867-4

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