Therapeutic alliance and adherence in cognitive therapy for depression

The relations between the therapeutic alliance, therapists\u27 adherence to cognitive therapy (CT) techniques, and patients\u27 responses to such techniques was examined in the reduction of depressive symptoms in a group of 51 patients receiving CT for depression. Several statistical methods were applied to examine the influence of in-session behaviors on symptom improvement. First, an attempt to replicate two earlier studies (R. J. DeRubeis & M. Feeley, 1990 and M. Feeley, R. J. DeRubeis, & L. A. Gelfand, 1999), using multiple regressions to assess the relation between in-session behaviors at session 2 and outcome, demonstrated a pattern opposite to prior findings. However, the repeated measures of the in-session behaviors over the first four sessions allowed more sophisticated analyses to be performed. Using longitudinal random coefficients analyses, therapist adherence predicted the rate of depressive symptom change from session 4 to the end of treatment at a trend level. Early measures of the therapeutic alliance did not lead to improvement at the end of treatment. In addition, therapist and patient concrete adherence aggregated across the first four sessions was predictive of symptom improvement in the following session, whereas the therapeutic alliance was not significantly related to short-term gains. Advantages of using longitudinal analyses over regressive approaches are reviewed, and implications for psychotherapy process research are discussed