The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder

Esther T. Beierl; Hannah Murray; Milan Wiedemann; Emma Warnock-Parkes; Jennifer Wild; Richard Stott; Nick Grey; David M. Clark; Anke Ehlers

doi:10.3389/fpsyt.2021.602648

The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder

Esther T. Beierl^*, Hannah Murray, Milan Wiedemann, Emma Warnock-Parkes, Jennifer Wild, Richard Stott, Nick Grey, David M. Clark, Anke Ehlers

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

17 Citations (Scopus)

Abstract

Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.

Original language	English
Article number	602648
Journal	Frontiers in Psychiatry
Volume	12
DOIs	https://doi.org/10.3389/fpsyt.2021.602648
Publication status	Published - 16 Apr 2021

Keywords

cognitive therapy
cross-lagged associations
posttraumatic stress disorder
treatment outcome
working alliance

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10.3389/fpsyt.2021.602648

Cite this

@article{2011ea8365bd4633a4a09b4189382364,

title = "The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder",

abstract = "Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.",

keywords = "cognitive therapy, cross-lagged associations, posttraumatic stress disorder, treatment outcome, working alliance",

author = "Beierl, {Esther T.} and Hannah Murray and Milan Wiedemann and Emma Warnock-Parkes and Jennifer Wild and Richard Stott and Nick Grey and Clark, {David M.} and Anke Ehlers",

note = "Funding Information: We would like to thank Dr. David Veale for his support and Kelly Archer, Anna Bevan, Inga B?llinghaus, Georgina Bremner, Linda Horrell, Judith Kalthoff, Birgit Kleim, Ruth Morgan, Jennifer Readings, Catherine Seaman, Elizabeth Woodward, and Yvette Yeboah for their help with data collection and entry. We would also like to thank Margaret Dakin, Sue Helen, and Julie Twomey for their administrative support. Funding. This study was funded by Wellcome Trust grants 069777 and to 200796 to AE and DC, the Oxford Health NIHR Biomedical Research Centre and a Mental Health Research UK studentship awarded to AE and MW. It was supported by the NIHR South London and Maudsley Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders were not involved in planning or analyzing the study. Open access fees are funded through a block grant to Oxford University. Funding Information: This study was funded by Wellcome Trust grants 069777 and to 200796 to AE and DC, the Oxford Health NIHR Biomedical Research Centre and a Mental Health Research UK studentship awarded to AE and MW. It was supported by the NIHR South London and Maudsley Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders were not involved in planning or analyzing the study. Open access fees are funded through a block grant to Oxford University. Publisher Copyright: {\textcopyright} Copyright {\textcopyright} 2021 Beierl, Murray, Wiedemann, Warnock-Parkes, Wild, Stott, Grey, Clark and Ehlers. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",

year = "2021",

month = apr,

day = "16",

doi = "10.3389/fpsyt.2021.602648",

language = "English",

volume = "12",

journal = "Frontiers in Psychiatry",

issn = "1664-0640",

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T1 - The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder

AU - Beierl, Esther T.

AU - Murray, Hannah

AU - Wiedemann, Milan

AU - Warnock-Parkes, Emma

AU - Wild, Jennifer

AU - Stott, Richard

AU - Grey, Nick

AU - Clark, David M.

AU - Ehlers, Anke

N1 - Funding Information: We would like to thank Dr. David Veale for his support and Kelly Archer, Anna Bevan, Inga B?llinghaus, Georgina Bremner, Linda Horrell, Judith Kalthoff, Birgit Kleim, Ruth Morgan, Jennifer Readings, Catherine Seaman, Elizabeth Woodward, and Yvette Yeboah for their help with data collection and entry. We would also like to thank Margaret Dakin, Sue Helen, and Julie Twomey for their administrative support. Funding. This study was funded by Wellcome Trust grants 069777 and to 200796 to AE and DC, the Oxford Health NIHR Biomedical Research Centre and a Mental Health Research UK studentship awarded to AE and MW. It was supported by the NIHR South London and Maudsley Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders were not involved in planning or analyzing the study. Open access fees are funded through a block grant to Oxford University. Funding Information: This study was funded by Wellcome Trust grants 069777 and to 200796 to AE and DC, the Oxford Health NIHR Biomedical Research Centre and a Mental Health Research UK studentship awarded to AE and MW. It was supported by the NIHR South London and Maudsley Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders were not involved in planning or analyzing the study. Open access fees are funded through a block grant to Oxford University. Publisher Copyright: © Copyright © 2021 Beierl, Murray, Wiedemann, Warnock-Parkes, Wild, Stott, Grey, Clark and Ehlers. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/4/16

Y1 - 2021/4/16

N2 - Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.

AB - Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.

KW - cognitive therapy

KW - cross-lagged associations

KW - posttraumatic stress disorder

KW - treatment outcome

KW - working alliance

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U2 - 10.3389/fpsyt.2021.602648

DO - 10.3389/fpsyt.2021.602648

M3 - Article

AN - SCOPUS:85105128727

SN - 1664-0640

VL - 12

JO - Frontiers in Psychiatry

JF - Frontiers in Psychiatry

M1 - 602648

ER -

The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder

Abstract

Keywords

UN SDGs

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