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

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

Original languageEnglish
Article number602648
JournalFrontiers in Psychiatry
Volume12
DOIs
Published16 Apr 2021

Bibliographical 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: © Copyright © 2021 Beierl, Murray, Wiedemann, Warnock-Parkes, Wild, Stott, Grey, Clark and Ehlers. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

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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.

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