Investigating the Impact of Early Alliance on Predicting Subjective Change at Posttreatment: An Evidence-Based Souvenir of Overlooked Clinical Perspectives

Despite meta-analytic evidence showing that alliance is associated with posttreatment outcomes, several open questions still remain regarding this relation. First, we investigate whether (or not) the progressive aggregation of early alliance assessments increases the alliance-outcome relation across 2 distress and 4 subjective change measures. Second, we investigate whether the alliance-outcome relations using subjective change measures are independent from intake distress and early response. Third, we explore whether the progressive aggregation of the alliance on outcomes becomes particularly apparent between or within therapists again investigating these six outcome measures. Data were drawn from N = 430 patients treated by N = 151 therapists. Patient ratings of early alliance were assessed after Session 1 to 6. For outcome, 2 commonly used distress measures at intake and at posttreatment and 4 measures of retrospectively evaluated subjective change at posttreatment are integrated into a series of multilevel models. The proportion of variance in outcome predicted by alliance scores varied considerably depending on the number of alliance assessments which were aggregated, as well as on the type of outcome assessment (distress vs. subjective change measures) explaining up to 15% of outcome variance. Improvements in the strength of prediction with aggregated alliance assessments were most pronounced for subjective change measures for between-therapist components of the alliance. Examining associations with subjective change measures provides an additional, patient-centered perspective of the relation between early alliance and treatment outcomes. Public Significance Statement Despite ongoing encouragement to systematically consider patient-centered outcomes in clinical research, subjective change measures (i.e., how patients evaluate the change during psychotherapy) are still neglected in guidelines of how to conduct trial research. The present study shows that the alliance-outcome relation is dependent on the number of aggregated alliance assessments, the type of outcome assessment (i.e., distress vs. subjective change measures) and whether intake and early response are adjusted for or not. Aggregated early alliance assessments were shown to relate most strongly to retrospectively evaluated subjective change at posttreatment. Examining associations with subjective change measures provide additional clinical perspectives on process and outcomes when conducting clinical trials and routine outcome monitoring.