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Not Just a Non-specific Factor: Moderators of the Effect of Within- and Between-Clients Alliance on Outcome in CBT

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Abstract

The working alliance is one of the most consistent predictors of outcome. Yet, little empirical knowledge exists on how therapists can use this association to maximize the outcome of cognitive behavioral therapy (CBT) for individual clients. The present study aimed to examine pre-treatment client interpersonal characteristics that determine what function the alliance should fulfill in order to maximize its effect on outcome. We did so by identifying moderators of the within- and between-clients effects on outcome. Data of 185 clients receiving CBT treatment was disaggregated to study the effects of the within- and between-clients alliance on outcome. Findings suggest that for clients who described themselves as overly cold and were described by their therapists as low on intrusiveness, state-like strengthening of alliance predicted better outcome, and that for clients not overly cold but overly exploitable, the general tendency of the client to report stronger alliance was associated with better outcome.

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Notes

  1. Severe major depression was diagnosed using the Structured Interview for DSM-IV-Axis I.

  2. Conditional inference trees estimate a regression relationship by binary recursive partitioning within a conditional inference framework. The algorithm operates as follows: (a) test the global null hypothesis of independence between any of the predictors and the outcome; stop if this hypothesis cannot be rejected, otherwise select the input variable with the strongest association with the outcome; this association is measured by a p value corresponding to a test for the partial null hypothesis of a single predictor and of the response; (b) implement a binary split in the selected predictor; (c) recursively repeat steps (a) and (b).

  3. Because the average correlation within the total score and the subscales was 0.37, the statistical methods used to search for moderators enabled us to introduce both the total and the subscale scores. Conceptually, the total score and the subscales represent distinct types of information regarding the client’s interpersonal tendencies and difficulties. The total score represents the client’s degree of interpersonal distress, whereas the subscales represent the nature of the client’s interpersonal problems, identifying the client’s specific area of interpersonal difficulty (Horowitz et al. 2000). We conducted a sensitivity analysis without the total score and obtained the same findings.

  4. In a post hoc analysis, we examined the ability of the interaction between overly cold and overly exploitable pre-treatment characteristics to directly affect treatment outcome (rather than affect the association between the trait-like component of alliance and outcome). The analysis revealed that the interaction between overly cold and overly exploitable characteristics failed to significantly predict outcome [F (1, 3017) = 0.5, p = .47].

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Authors and Affiliations

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

    Sigal Zilcha-Mano

  2. The Derner Institute of Advanced Psychological Studies, Adelphi University, Garden City, USA

    J. Christopher Muran

  3. Ferkauf Graduate School of Psychology, Yeshiva University, New York, USA

    Catherine F. Eubanks

  4. Psychology Department, New School For Social Research, New York, USA

    Jeremy D. Safran

  5. Mount Sinai Beth Israel, New York, USA

    J. Christopher Muran, Catherine F. Eubanks, Jeremy D. Safran & Arnold Winston

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  1. Sigal Zilcha-Mano
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  4. Jeremy D. Safran
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Correspondence to Sigal Zilcha-Mano.

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Sigal Zilcha-Mano, J. Christopher Muran, Catherine F. Eubanks, Jeremy D. Safran, and Arnold Winston, declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Zilcha-Mano, S., Muran, J.C., Eubanks, C.F. et al. Not Just a Non-specific Factor: Moderators of the Effect of Within- and Between-Clients Alliance on Outcome in CBT. Cogn Ther Res 42, 146–158 (2018). https://doi.org/10.1007/s10608-017-9866-5

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