Skip to main content
SpringerLink
Log in

The Relation between Improvement in the Therapeutic Alliance and Interpersonal Functioning for Individuals with Emotional Disorders

  • Published:
International Journal of Cognitive Therapy Aims and scope Submit manuscript

Abstract

Background: Individuals with emotional disorders often have comorbid relationship problems, and improving interpersonal functioning is a common goal of treatment. Research indicates that the therapeutic alliance is associated with broad symptom improvement; however, no study has examined whether the alliance promotes improved interpersonal functioning for individuals with emotional disorders and varying levels of interpersonal difficulties. The present study tested whether improvement in the alliance is associated with enhanced interpersonal functioning and examined whether this association is stronger for individuals with higher, relative to lower, relationship difficulties. Methods: Adults (ages 18–70; N = 251) with primarily major depressive disorder (55.4%) or generalized anxiety disorder (34.2%) received combined cognitive behavioral therapy and pharmacological treatment at a psychiatric hospital day program. At both pre- and post-treatment, participants completed self-report assessments of the alliance, relationship problems, and symptoms of depression and anxiety. Results: Across the full sample, improvement in alliance (bond, tasks, and goals) was associated with improved interpersonal functioning. Additionally, agreement on treatment goals more strongly predicted enhanced interpersonal functioning for individuals presenting to treatment with higher, relative to lower, relationship difficulties—controlling for depression and anxiety symptom severity. Conclusions: These findings contribute to research identifying ways to improve interpersonal functioning (i.e., strengthening the alliance) for individuals entering treatment with emotional disorders and varying levels of relationship difficulties.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  • Andresen, E. M., Malmgren, J. A., Carter, W. B., & Patrick, D. L. (1994). Screening for depression in well older adults: evaluation of a short form of the CES-D (center for epidemiologic studies depression scale). American Journal of Preventive Medicine, 10, 77–84.

    Article  PubMed  Google Scholar 

  • Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2009). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Personality Disorders, Theory, Research, and Treatment, 1, 80–89. https://doi.org/10.1037/1949-2715.S.1.80.

    Article  Google Scholar 

  • Barrett, M. S., & Barber, J. P. (2007). Interpersonal profiles in major depressive disorder. Journal of Clinical Psychology, 63, 247–266. https://doi.org/10.1002/jclp.20346.

    Article  PubMed  Google Scholar 

  • Beard, C., & Björgvinsson, T. (2013). Commentary on psychological vulnerability: an integrative approach. Journal of Integrative Psychotherapy, 23, 281–283.

    Article  Google Scholar 

  • Beard, C., & Björgvinsson, T. (2014). Beyond generalized anxiety disorder: psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. Journal of Anxiety Disorders, 28, 547–552. https://doi.org/10.1016/j.janxdis.2014.06.002.

    Article  PubMed  Google Scholar 

  • Beard, C., Kirakosian, N., Silverman, A. L., Winer, J. P., Wadsworth, L. P., & Björgvinsson, T. (2017). Comparing treatment response between LGBQ and heterosexual individuals attending a CBT- and DBT-skills-based partial hospital. Journal of Consulting and Clinical Psychology, 85, 1171–1181. https://doi.org/10.1037/ccp0000251.

    Article  PubMed  Google Scholar 

  • Beck, A. T., Rush, J. A., Sahw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press.

    Google Scholar 

  • Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books.

    Google Scholar 

  • Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium. Social Science & Medicine, 51, 843–857. https://doi.org/10.1016/S0277-9536(00)00065-4.

    Article  Google Scholar 

  • Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260.

    Article  Google Scholar 

  • Brown, P. D., & O'Leary, K.D. (2000). Therapeutic alliance: Predicting continuance and success in group treatment for spouse abuse. Journal of Counsulting and Clinical Psychology, 68, 340–345.

  • Cameron, I. M., Cunningham, L., Crawford, J. R., Eagles, J. M., Eisen, S. V., Lawton, K., Naji, S., & Hamilton, R. J. (2007). Psychometric properties of the BASIS-24© (behaviour and symptom identification scale-revised) mental health outcome measure. International Journal of Psychiatry in Clinical Practice, 11, 36–43.

    Article  PubMed  Google Scholar 

  • Cohen, S. (2004). Social relationships and health. The American Psychologist, 59, 676–684. https://doi.org/10.1037/0003-066X.59.8.676.

    Article  PubMed  Google Scholar 

  • Eng, W., & Heimberg, R. G. (2006). Interpersonal correlates of generalized anxiety disorder: self versus other perception. Journal of Anxiety Disorders, 20, 380–387. https://doi.org/10.1016/j.janxdis.2005.02.005.

    Article  PubMed  Google Scholar 

  • Hardy, G. E., Cahill, J., Shapiro, D. A., Barkham, M., Rees, A., & Macaskill, N. (2001). Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 69, 841–845. https://doi.org/10.1037//0022-006X.69.5.841.

    Article  PubMed  Google Scholar 

  • Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, J., & Conde, D. (2009). Research electronic data capture (REDCap) e a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42, 377–381.

    Article  PubMed  Google Scholar 

  • Hayes, A.F. (2013). Model templates for PROCESS for SPSS and SAS. Retrieved from http://www.afhayes.com/public/templates.pdf. Accessed 12 March 2016.

  • Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G., & Villaseñor, V. S. (1988). Inventory of interpersonal problems: psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885–892.

    Article  PubMed  Google Scholar 

  • Horvath, A. O., & Greenberg, L. S. (1986). The development of the working alliance inventory. In L. S. Greenberg & W. M. Pinsoff (Eds.), The psychotherapeutic process: a research handbook (pp. 529–556). New York: Guilford Press.

    Google Scholar 

  • Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561–573.

    Article  PubMed  Google Scholar 

  • Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: a meta-analysis. Journal of Counseling Psychology, 38, 139–149.

    Article  Google Scholar 

  • Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9.

    Article  Google Scholar 

  • Howard, I., Turner, R., Olkin, R., & Mohr, D. C. (2006). Therapeutic alliance mediates the relationship between interpersonal problems and depression outcome in a cohort of multiple sclerosis patients. Journal of Clinical Psychology, 62, 1197–1204. https://doi.org/10.1002/jclp.20274.

    Article  PubMed  Google Scholar 

  • Johnson, S. M., & Talitman, E. (1997). Predictors of success in emotionally focused marital therapy. Journal of Marital and Family Therapy, 23, 135–152.

    Article  PubMed  Google Scholar 

  • Klein, D. N., Schwartz, J. E., Santiago, N. J., Vivian, D., Vocisano, C., Castonguay, L. G., et al. (2003). Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics. Journal of Consulting and Clinical Psychology, 71, 997–1006. https://doi.org/10.1037/0022-006X.71.6.997.

    Article  PubMed  Google Scholar 

  • Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity and detection. Annals of Internal Medicine, 146, 317–326.

    Article  PubMed  Google Scholar 

  • Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.

    Google Scholar 

  • Mallinckrodt, B. (1996). Change in working alliance, social support, and psychological symptoms in brief therapy. Journal of Counseling Psychology, 43, 448–455.

    Article  Google Scholar 

  • Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: a clinician’s guide. New York: Guilford Press.

    Google Scholar 

  • Martin, D. J., Garske, J. P., & Davis, K. D. (2000). Relation of therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 6, 438–450.

    Article  Google Scholar 

  • Muran, J. C., Segal, Z. V., Samstag, L. W., & Crawford, C. E. (1994). Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy. Journal of Consulting and Clinical Psychology, 62, 185–190.

    Article  PubMed  Google Scholar 

  • Owen, J. J., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2011). The role of leaders’ working alliance in premarital education. Journal of Family Psychology, 25, 49–57. https://doi.org/10.1037/a0022084.

    Article  PubMed  PubMed Central  Google Scholar 

  • Pietromonaco, P. R., Uchino, B., & Dunkel Schetter, C. (2013). Close relationship processes and health: Implications of attachment theory for health and disease. Health Psychology, 32, 499–513.

    Article  PubMed  PubMed Central  Google Scholar 

  • Rosenberg, M. (2003). Voices from the group: Domestic violence offenders' experience of intervention. Journal of Aggression, Maltreatment, and Trauma, 7, 305–317.

  • Saunders, S. M. (2001). Pretreatment correlates of the therapeutic bond. Journal of Clinical Psychology, 57, 1339. https://doi.org/10.1002/jclp.1101.

    Article  PubMed  Google Scholar 

  • Sheehan, D. V., Lecrubier, Y., Sheehan, H. K., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The Mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59, 22–33.

    PubMed  Google Scholar 

  • Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166, 1092–1097.

    Article  Google Scholar 

  • Strunk, D. R., Brotman, M. A., & DeRubeis, R. J. (2010). The process of change in cognitive therapy for depression: predictors of early intersession symptom gains. Behaviour Research and Therapy, 48, 599–606. https://doi.org/10.1016/j.brat.2010.03.011.

    Article  PubMed  PubMed Central  Google Scholar 

  • Strunk, D. R., Cooper, A. A., Ryan, E. T., DeRubeis, R. J., & Hollon, S. D. (2012). The process of change in cognitive therapy for depression when combined with antidepressant medication: predictors of early intersession symptom gains. Journal of Consulting and Clinical Psychology, 80, 730–738.

    Article  PubMed  PubMed Central  Google Scholar 

  • Taft, C. T., Murphy, C. M., King, D. W., Musser, P. H., & DeDeyn, J. M. (2003). Process and treatment adherence factors in group cognitive-behavioral therapy for partner violent men. Journal of Consulting and Clinical Psychology, 71, 812–820.

  • Taft, C. T., Murphy, C. M., Musser, P. H., & Remington, N. A. (2004). Personality, interpersonal, and motivational predictors of the working alliance in group cognitive-behavioral therapy for partner violent men. Journal of Consulting and Clinical Psychology, 72, 349–354.

    Article  PubMed  Google Scholar 

  • Tichenor, V., & Hill, C. E. (1989). A comparison of six measures of working alliance. Psychotherapy, 26, 195–199.

    Article  Google Scholar 

  • Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the working alliance inventory. Psychological Assessment, 1, 207–210.

    Article  Google Scholar 

  • Uchino, B. N. (2009). Understanding the links between social support and physical health: a lifespan perspective with emphasis on the separability of perceived and received support. Perspectives in Psychological Science, 4, 236–255.

    Article  Google Scholar 

  • Webb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S. (2011). Two aspects of the therapeutic alliance: differential relations with depressive symptom change. Journal of Consulting and Clinical Psychology, 79, 279–283. https://doi.org/10.1037/a0023252.

    Article  PubMed  PubMed Central  Google Scholar 

  • Webb, C. A., Beard, C., Auerbach, R. P., Menninger, E., & Björgvinsson, T. (2014). The therapeutic alliance in a naturalistic psychiatric setting: temporal relations with depressive symptom change. Behaviour Research and Therapy, 61, 70–77. https://doi.org/10.1016/j.brat.2014.07.015.

    Article  PubMed  PubMed Central  Google Scholar 

  • Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books.

    Google Scholar 

  • Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116, 638–643.

    Article  PubMed  Google Scholar 

  • Yeomans, F. E., Gutfreund, J., Selzer, M. A., & Clarkin, J. F. (1994). Factors related to drop-outs by borderline patients: treatment contract and therapeutic alliance. The Journal of Psychotherapy Practice and Research, 3, 16–24.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Veterans Affairs Healthcare System, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA

    Chandra E. Khalifian

  2. University of California, San Diego, Department of Psychiatry, 9500 Gilman Dr, La Jolla, CA, 92093, USA

    Chandra E. Khalifian

  3. Behavioral Health Partial Hospitalization Program, Harvard Medical School, McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA

    Courtney Beard & Thröstur Björgvinsson

  4. Center for Depression, Anxiety & Stress Research, Harvard Medical School, McLean Hospital, Department of Psychiatry, 115 Mill Street, Belmont, MA, 02478, USA

    Christian A. Webb

Authors
  1. Chandra E. Khalifian
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Courtney Beard
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thröstur Björgvinsson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christian A. Webb
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chandra E. Khalifian.

Ethics declarations

Conflict of Interest

The authors declare that there is no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Khalifian, C.E., Beard, C., Björgvinsson, T. et al. The Relation between Improvement in the Therapeutic Alliance and Interpersonal Functioning for Individuals with Emotional Disorders. J Cogn Ther 12, 109–125 (2019). https://doi.org/10.1007/s41811-019-00045-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s41811-019-00045-7

Keywords

Search

Navigation