Is Cognitive Therapy or Therapeutic Alliance More Predictive of Depression Outcome?

Cognitive therapy (CT) is one of the most commonly used approaches for the treatment of major depression. The techniques used in CT are broad and diverse and allow for therapists to either adhere stringently to the traditional CT strategies or to use more liberal and abstract delivery methods. Also at the core of CT and many other therapies is the therapeutic alliance, which embodies the relationship bond between the client and therapist. This is seen as vital to the foundation of treatment and is the base from which all future progress is formed. There is a wealth of research that demonstrates the importance of the therapeutic alliance and some research that has shown the importance of CT adherence. But until recently, little research has focused on which factor impacts treatment outcome the most. To determine whether CT adherence or therapeutic alliance is more influential on depressive symptoms, Christian A. Webb of the Department of Psychology at the University of Pennsylvania recently conducted a study involving patients with depression.

Webb examined data collected from the Cognitive Pharmacotherapy–II study (CPT-II) and the University of Washington (UW) cognitive therapy study. He found mixed results among the 105 participants. Specifically, Webb discovered that among the individuals who had participated in the CPT-II study, CT adherence was the most influential factor relating to their acquisition of CT tools and knowledge. This was measured by assessing how often the participants used their new skills between sessions, an important indicator of future symptom reduction. However, Webb also found that in the UW study, the participants realized bigger gains as a direct result of the therapeutic alliance. After further examination, Webb found that this effect existed only in those participants with mild symptom severity. For the participants with significant depressive symptoms, CT adherence was the strongest predictor of symptom reduction in both studies. Webb believes these results, although somewhat contradictory, can expand the understanding of how to best help depressed clients. He added, “Such findings could ultimately yield important clinical implications for the treatment of depression with CT.”

Webb, C. A., DeRubeis, R. J., Dimidjian, S., Hollon, S. D., Amsterdam, J. D., Shelton, R. C. (2012). Predictors of patient cognitive therapy skills and symptom change in two randomized clinical trials: The role of therapist adherence and the therapeutic alliance. Journal of Consulting and Clinical Psychology. Advance online publication. doi: 10.1037/a0027663

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  • Gus


    April 20th, 2012 at 11:12 AM

    I guess I think that it is a litle bit of both, but truthfull we all work better and have more efficient outcomes when we are working with someone we like and trust. Not saying that the therapeutic alliance wins over CT, because we know that we need a good therapist to really help establish that bond, but I do think that the patient/ therapist relationship and bond is often overlooked and is not given the credit that it sometimes deserves for helping someone conquer those things that are troubling them.

  • Daniel


    April 20th, 2012 at 3:08 PM

    I am somewhat surprised that those with the highest levels of depression experienced the lowest level of success via therapeutic alliace. I would have thought that the creation of a strong working relationship like this one would have yielded more success for these patients.

  • Daniella


    April 21st, 2012 at 8:17 AM

    Working with depressed patients has to be a work in progress. Of course what works for one patient is not going to always work for another. But the important lesson here is that it does not have to be an all or nothing type of thing. Treatment can involve many different components, with some being stressed more heavily or not at different times in the patient’s therapy. It has to be something that the therapist is willing to change as well as the patient to fit their needs at a specific time.

  • nicholas


    April 22nd, 2012 at 4:36 AM

    it is all about finding a method that works for you and sticking to it
    it can’t be about going to therapy once a week or whatever and expecting to see real improvement
    like a diet (and i in no way think that this is like losing weight but i am just comparing the two)
    it has to be a total lifestyle change about how you act, the things that you do, the ways that you act and react and how you let other people treat you
    but most of all it is about making the choice that you are not going to allow this sadness to rule your life anymore

  • Lily


    April 24th, 2012 at 4:00 PM

    Wouldn’t it be about finding that perfect balance? One person might need a little more of one thing and a little less of the next, but someone else may need exactly the opposite.

    That’s what makes us us, that unique ability to have different needs and wants and the ability to thrive in multiple types if situations.

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