Psychotherapy Research 11(2) 221–233, 2001

© 2001 Society for Psychotherapy Research

THE WORKING ALLIANCE IN CLIENT-CENTERED

AND PROCESS-EXPERIENTIAL THERAPY
OF DEPRESSION
Priyanthy Weerasekera
Department of Psychiatry and Behavioral Neurosciences, McMaster University,
Hamilton, Ontario, Canada
Bruce Linder
Department of Psychology, McMaster University, Hamilton, Ontario, Canada
Leslie Greenberg
Department of Psychology, York University, North York, Ontario, Canada
Jeanne Watson
Ontario Institute for Studies in Education, University of Toronto, Toronto,
Ontario, Canada

This study examined the development of the working alliance in process-

experiential (PE) and client-centered therapy of depression. Thirty-four
randomly assigned individuals completed 16 to 20 sessions of manual-
based therapy. Results revealed the size of the alliance-outcome relation
to be dependent on alliance dimension (goal, task, or bond), outcome
measure (symptom improvement vs. self-esteem, relational problems), and
time in treatment alliance. Part correlational analyses revealed that early
alliance scores predicted outcomes that were not attributable to early mood
changes. Although no group differences were found for bond and goal
alliance, the PE group displayed higher task alliance scores in the midphase
of therapy. The level of pretreatment depression did not affect alliance
formation. The implications of these results are discussed.

The past two decades have witnessed an extensive body of research on the thera-
peutic alliance. This research found that the alliance predicted outcome as early as
Session 3. Controversy exists, however, as to whether early alliance or late alliance
(Sessions 16–20) is the better predictor of outcome (Horvath & Symonds, 1991).
Gaston, Marmar, Gallagher, and Thompson (1991) found a greater relationship be-
tween later (approximately Sessions 10 to 15) than early alliance and outcome in the
cognitive, behavioral, and brief dynamic therapy of depressed older adults. In this
study, alliance was measured at three points in time. By tracking the alliance across
treatment, Stiles, Agnew-Davies, Hardy, Barkham, and Shapiro (1998) also found later
rather than early alliance to be a better predictor of outcome. However, the alliance-
outcome relation was complex, depending on the outcome measure used, point in

Correspondence concerning this article should be addressed to Priyanthy Weerasekera, St. Joseph’s
Hospital, 50 Charlton Avenue East, Fontbonne Building, 4th floor F415, Hamilton, Ontario, Canada 18N
4A6. E-mail:weerasek@mcmaster.ca.

221
222 WEERASEKERA ET AL.

therapy at which alliance was measured, subscale of alliance measured, and point at
which posttreatment measures were taken. This study suggested that the alliance
and its components act differentially in predicting different outcomes. Replication of
these studies with alternate therapies may help elucidate a coherent theory about
the differential effects of alliance on outcome.
Controversy also exists as to whether a positive early alliance is simply a mea-
sure of early treatment gains and, therefore, an artifact of therapy (Horvath & Luborsky,
1993). The alliance-as-artifact hypothesis has been challenged by two pieces of evi-
dence. First, alliance follows a pattern that differs from response to treatment in that
it usually peaks early, by Session 3 or 4 (Horvath & Symonds, 1991). Therapeutic
response, in contrast, peaks later in treatment. Therefore, early alliance tends to predict
outcome before therapeutic progress or symptom reduction (Horvath & Luborsky,
1993). Second, Gaston et al. (1991) found that, after controlling for early treatment
gains, alliance still offered its own unique contribution to predicting outcome in three
diverse psychotherapies. Similar concerns have been expressed about alliance rat-
ings late in treatment, in that this may be measuring the effects of late treatment
gains on alliance. That is, as clients’ symptoms improve, their perception of the alli-
ance may move in a positive direction. However, it is the relationship between early
alliance and outcome that poses the more interesting question, because attempts can
be made to improve early alliance, to try to affect outcome.
The alliance-outcome relation appears to vary across different therapies and
different components of alliance. Although some investigators found no outcome
differences across treatments or across treatment by alliance combinations (Krupnick
et al., 1996), analyses examining different components of the alliance and different
forms of therapy have not been studied. Marmar, Gaston, Gallagher, and Thompson
(1989) found no differences in alliance on the California Psychotherapy Alliance Scale
(CALPAS) in the cognitive, behavioral, and dynamic therapy of depressed older adults.
However, in a later analysis, Gaston et al. (1991) found that the alliance uniquely
contributed to outcome variance, especially for cognitive–behavioral therapy (CBT).
Hatcher and Barends (1996), in their exploratory factor analysis of three alli-
ance measures (Working Alliance Inventory [WAI], CALPAS, the Penn Helping Al-
liance Questionnaire [HAQ]) and outcome in open-ended psychodynamic therapy,
found that a confident collaboration factor (patient’s confidence in the therapist)
was more predictive of mid-treatment estimates of progress. Various items from
the CALPAS, HAQ, and Task and Goal subscales of the WAI, but not the bond,
loaded on this collaboration factor, indicating that the bond, as measured by the
WAI, may not be as predictive of outcome as tasks and goals, even in more
relationally oriented therapies. This confidence dimension has also been demon-
strated by others (Stiles et al., 1998). More studies examining different components
of the alliance in different therapies will help identify which alliance dimensions
predict outcome in specific therapies.
Krupnick et al. (1996) found that in the National Institute of Mental Health col-
laborative study of depression, alliance was significantly related to outcome for both
interpersonal therapy (IPT) and cognitive–behavioral therapy (CBT), as well as for
the medication and placebo group. Alliance has also been related to outcome in other
comparative trials of depression (Gaston et al., 1991; Stiles et al., 1998). The rela-
tionship between depression severity and alliance formation however, has not been
extensively investigated. Rector, Zuroff, and Segal (1999) found pretreatment depres-
sion severity to be unrelated to alliance formation in a 20-week course of cognitive
therapy. However, severely depressed functionally impaired patients have been found
WORKING ALLIANCE IN DEPRESSION THERAPY 223

to be less responsive to brief psychotherapies (Elkin et al., 1995). However, it may

be functional impairment and not depression severity that affects alliance formation.
This has not been extensively investigated.
The purpose of this study was to explore the working alliance in the experiential
therapy of depression, with specific reference to the questions raised previously. We
drew data from a comparative study of experiential psychotherapies (Greenberg &
Watson, 1998), which found no differences in outcome between client-centered (CC)
and process-experiential (PE) therapy on measures of depression at the end of treat-
ment, although superior effects were found for the PE therapy on measures of self
esteem, and reduction of interpersonal problems. Given earlier findings, it was pre-
dicted that (a) the alliance would predict outcome by Session 3 and thereafter a com-
plex relationship would emerge as discussed by Stiles et al. (1998); (b) the alliance
would predict outcome independent of changes in mood from session to session; (c)
PE therapy, the more active and process-directive form of therapy, would show higher
scores on goal and task dimensions of the alliance; and (d) finally, depression severity
at pretreatment would affect alliance formation in a negative direction, with increasing
levels of depression having an adverse effect on alliance formation.

Method

This study investigated process issues in a sample that has already been reported
by Greenberg and Watson (1998) in their comparative trial on the differential effec-
tiveness of PE and CC therapies of depression. Although the methodology is described
in brief, the reader is referred to the Greenberg and Watson (1998) publication for a
more elaborate discussion of the methodology.

Clients

Clients (N = 34) met Structured Clinical Interview for Diagnostic and Statistical
Manual of Mental Disorders (third edition; SCID; Spitzer, Williams, Gibbons, & First,
1989) criteria for major depression and scored at least 50 on the Global Assessment
of Functioning Scale (GAS). The SCID interviews were conducted by a doctorate-
level psychologist and two graduate students in clinical psychology trained and su-
pervised on the SCID. A standard tape was used for the training, and random checks
revealed good agreement on diagnosis (r = .85). Because this was the first study to
investigate the effectiveness of two experiential therapies (PE and CC) for depres-
sion, both were considered “untested” treatments. Therefore, severely depressed,
functionally impaired patients were excluded because they were considered better
suited for rapid treatment with pharmacological interventions (Elkin et al., 1995).
Clients completed the Beck Depression Inventory (BDI; Beck, Steer, & Garbin,
1988) and the Symptom Distress Checklist-90-Revised (SCL-90-R; Derogatis, Rickels,
& Roch, 1976) 1 week before treatment. Intake scores revealed that, among the 34
patients, 6 (18%) were severely depressed (BDI score = higher than 31), 16 (47%)
were moderately depressed (BDI score = 21–30), 9 (26%) had borderline clinical
depression (BDI score = 17–20), and 3 (9%) were considered to have a mild mood
disturbance (BDI score = 11–16). Therefore, although all patients met criteria for major
depressive disorder on the SCID, on the BDI 35% did not rate themselves as so de-
pressed; however, 65% were in the moderate to severe range of depression but were
not functionally impaired.
224 WEERASEKERA ET AL.

After the initial screening process, clients matched on their SCL-90-R Depression
subscale scores were randomly assigned to one of two treatment groups. Mean SCL-
R-90 subscale scores were 2.45 (SD = 0.46), and 2.72 (SD = 0.45) for the CC and PE
groups, respectively. Demographics of the sample revealed that of the 34 clients 25
were women and 9 were men; 18 were married, 7 were separated or divorced, and
9 were single. With respect to educational status, 6 had completed high school,
7 some college, 17 were college graduates, and 4 had some postgraduate experi-
ence. Fourteen clients (41%) had at least one Axis II personality disorder diagnosis,
which was diagnosed according to the SCID: avoidant, 3; dependent, 1; passive-
aggressive, 4; schizoid, 1; obsessive-compulsive, 4; and paranoid, 1. The impact of
personality disorder and alliance formation was not explored in this study because it
is part of another project. There were no significant differences between groups on
any of the variables just discussed.
Exclusion criteria were assessed according to the SCID and a clinical interview.
Clients excluded from the study were those with a history of incest, suicide attempts,
loss of a significant other in the past year, involvement in a violent relationship, drug
or alcohol abuse, eating disorder, antisocial or borderline personality disorder, and
bipolar or psychotic disorder. These conditions were viewed as requiring acute in-
terventions such as use of shelters, family therapy, substance abuse programs, medi-
cations, admissions to psychiatric facilities, and other individual psychotherapies as
primary treatments or integrated with other interventions.
Two clients dropped out from each treatment condition. Dropouts were defined
as clients who prematurely ended treatment for personal reasons, such as inability
to make appointments, medical illness, or wish to seek alternate treatment. Data were
analyzed from all clients who completed a minimum of 15 sessions and the post
treatment battery.

Therapists

Eleven therapists, 8 female and 3 male, participated in the study. Six were ad-
vanced clinical psychology doctoral students, 4 had doctorates in clinical psychol-
ogy, and 1 was a psychiatrist. On average, the therapists had 5.5 years experience in
CC therapy, except for 1 whose previous training was in CBT. All therapists received
manual-based training and were monitored through audio- and videotapes for ad-
herence to treatment before and during therapy sessions.

Treatments

The two experiential therapies chosen for comparison differed in their use of
specific interventions (see Greenberg & Watson, 1998).

CC therapy. This was conducted according to manuals by Greenberg, Rice, and

Watson (1994) and readings of Rogers (1975). Attention was given to enacting the
necessary conditions of empathy, positive regard, and congruence. The manuals were
used as guides to enhance the therapist’s ability to convey empathic understanding
of the client’s internal frame of reference to the client and to check whether this
understanding fit and was received by the client.

PE therapy. This is an integration of CC therapy and marker-guided, process-

directive interventions. Greenberg, Rice, and Elliott (1993) developed a manual for
WORKING ALLIANCE IN DEPRESSION THERAPY 225

this. In brief, the first three sessions are performed according to CC therapy. After
this, specific markers of emotional problems are used to determine specific thera-
peutic interventions. Attention is given to accessing the underlying affective processes
and to changing dysfunctional emotional schemes. The three specific interventions
used are the two-chair dialogue at a marker of a self-evaluative conflict, empty chair
dialogue for unfinished business with a significant other, and systematic evocative
unfolding for problematic reactions.

Measures

WAI. The WAI (1984) is a 36-item inventory rated on a 7-point Likert scale made
up of three alliance subscales assessing bond, task, and goal. Internal consistency
for the whole scale is high (range = .87–.93) as it is for the subscales (.92 for Bond,
.92 for Task, and .89 for Goal; Horvath & Greenberg, 1989). The long form was used
for Sessions 4, 7, and 16. The short form of the scale, a 12-item inventory, was ad-
ministered after the remaining sessions. Comparable psychometric properties have
been found for the short form (Tracey & Kokotovic, 1989). The alpha reliability co-
efficients for this data set (based on Session 4) were .89, .92, .87, and .95 for goal,
task, bond, and total alliance, respectively.

Epstein’s Mood Measure. Three items relevant to depression were selected by

the researchers from the 33-item Epstein Mood Scale. These items were rated on a 9-
point scale and were used to assess depression after each session (session mood)
and before each session (intersession mood). Test–retest reliability coefficients range
from .79 for unpleasant emotions to .88 for both pleasant emotions and depression
(Epstein, 1979).

BDI. This 21-item inventory is widely used to assess depression. It has high in-
ternal consistency and correlates highly with other self-report measures of depres-
sion and with clinicians ratings of depression (r = .60–.90; Beck, Steer, & Garbin,
1988).

SCL-90-R. This is a widely used instrument that measures general symptom dis-
tress, with high internal consistency (range = .77–.90) and test–retest reliability (.80
and .90) over a 1-week interval (Derogatis et al., 1976). Both the Depression subscale
of the SCL-90-R and the Global Symptom Index were used as outcome measures.

Rosenberg Self-Esteem Inventory (RSE). This is a 10-item inventory and one of the
most widely used measures of self-esteem. It has shown good internal consistency (a
= .87; Rosenberg, 1979). It correlates significantly with the Low Self-Esteem subscale
of the Minnesota Multiphasic Personality Inventory-2 (McCurdy & Kelly, 1997).

Inventory of Interpersonal Problems (IIP). This measures distress arising from

interpersonal sources. The 127-item self-report version has demonstrated good test–
retest reliability (range = .89–.98) and internal consistency (range = .89–.94). In this
study, the overall mean index was used (Horowitz, Rosenberg, Baer, Ureno, &
Villaseno, 1988).

Barrett-Lennard Relationship Inventory (BLRI) Perceived Empathy. The 16-item

Empathy subscale of the BLRI was administered to both therapists and clients to
226 WEERASEKERA ET AL.

measure empathic attunement in sessions. This widely used measure has demon-
strated excellent psychometric properties (split-half reliability of .86 and test–retest
reliability of .89; Barrett-Lennard, 1962).

Truax Accurate Empathy Scale. This is a 9-point anchored rating scale that has
shown good construct validity; trained raters correlated .67 with nontrained raters
on accurate empathy. This scale also correlates with other scales purporting to mea-
sure the same construct (r = .49 with Porter’s Understanding Scale; Truss, 1967, 1972).
The interrater reliability in this study was significant (Pearson’s r = .80).

Treatment Adherence

Empathy was rated for both CC and PE therapies by rating 20-min random seg-
ments from Session 2 and the latter half of treatment from three randomly selected
sessions of each therapy on the Truax Accurate Empathy Scale. For CC therapy, the
average empathy level needed to exceed 5 on the BLRI, and none of the sessions
could drop below 4 (Greenberg & Watson, 1998).
In addition, three randomly selected PE sessions in which active interventions
were performed were selected from the last two thirds of therapy, and three com-
parison CC sessions, matched on session number and the presence of a marker in-
dicating a split, unfinished business, or a problematic reaction, were rated on active
intervention adherence measure appropriate to the marker. Each active-intervention
measure consisted of a seven-category checklist of specific therapist actions involved
in the intervention. The treatment adherence checks were performed by two trained
raters, who independently rated transcripts of a randomly selected 20 min of the
intervention after the marker from the three sessions. Each rater rated two thirds of
the segments, overlapping on one third, to establish reliability. At least one quarter
of the total sessions after the third session in the PE treatment needed to include
active interventions that adhered to the manual to be considered to have adhered to
the treatment protocol.

Procedure

Clients were recruited through mental health centers, newspapers, radio an-
nouncements, and the university where the research was conducted. Announcements
indicated that the university was conducting a study on depression, and those suffer-
ing from some of the symptoms listed were invited to participate. After telephone
screening of approximately 500 individuals, 107 were selected for further assessment.
Of this group, only 34 met inclusion criteria for the study and were able to partici-
pate. This recruitment process yielded a wide range of individuals with respect to all
demographic variables and depression scores, indicating this sample was represen-
tative of a community sample.
Individuals meeting SCID criteria for depression, having a GAS greater than 50,
and at least 1.00 on the Depression subscale of the SCL-90-R, were asked to partici-
pate in a further interview to rule out other Axis I and II disorders and to complete
the BDI, RSE, and IIP. After this, all clients were randomly assigned to the CC or PE
therapy group, for a total of 17 in each treatment condition. Therapists were ran-
domly assigned to two cases in each condition. Sixteen to twenty sessions of treat-
ment were offered in each treatment group. One PE client terminated after 15 ses-
sions because treatment goals had been reached.
WORKING ALLIANCE IN DEPRESSION THERAPY 227

Questionnaires were completed at the beginning and end of each session. The
WAI was administered after the end of each session with a completion rate of 95%.
Questionnaires were completed without the presence of the therapist. The BDI, RSE,
IIP, and SCL-90-R were completed 1 week before treatment, after Session 8, at ter-
mination (the last session), at the posttherapy interview (1 week after termination),
and at the 6-month follow-up. Therapists completed the therapist’s postsession ques-
tionnaire after every session and a posttherapy questionnaire after the final session.

Results

The interrelationships of the outcome measures were examined to elucidate what

they were measuring. All 34 clients completed all outcome measures. The pattern of
intercorrelations both at pretreatment and posttreatment suggested that we were tap-
ping two separable constructs: depression and relationship problems-self esteem. The
depression measures correlated highly (rs = .63 and .70); the IIP and RSE measures
correlated highly, although somewhat less so (rs = –.51 and –.50); and the RSE mea-
sure correlated moderately with the depression measures at pretreatment (rs = –.48
and –.45) and less so on posttreatment (rs = –.22 and –.36).
The relationship between alliance and outcome over time was examined by
correlating each session’s mean and subscale alliance scores, with residual treatment
gain scores for each outcome measure. The gain scores were calculated as the dif-
ference between the obtained posttreatment score and a predicted score, based on
regressing pretreatment scores on the posttreatment scores for each outcome mea-
sure. Thus, negative gain scores were associated with greater treatment gain. The
correlations were calculated by combining the patients from the two treatment groups,
because no treatment group differences were found either in overall session mean
alliance, F(1, 30) = 1.76, ns, or in correlations with outcome measures (z statistics
calculated comparing each group’s session alliance-outcome correlation). A conven-
tional statistical criterion for deciding whether a correlation coefficient was signifi-
cantly different from 0 or from other coefficients was not adopted because there were
320 correlations (16 sessions × five outcome measures × four alliance measures) to
consider. A Bonferroni adjusted value would be p < .00016, and this would have
seriously elevated Type II decision errors and overlooked real relationships evident
in the data. By this criterion, none of the correlations would have been statistically
significant. Therefore, similar to Stiles et al. (1998), visual inspection of the pattern
of correlations was used as a guide for hypothesizing about significant relationships
between the variables.
We found that the predictive relationship between alliance and outcome varied
depended on the type of alliance, and type of outcome measure, a finding similar to
Stiles et al. (1998). As can be seen in Table 1, mean alliance was more consistently
related to residual gain in depression than to relationship and self-esteem measures.
The correlations are negative because, as noted, greater gain in treatment is indi-
cated by larger negative numbers. With respect to depression gain, mean alliance
correlated with SCL-90-R Depression and BDI measures by Session 3 or 4 at values
of –.38 and –.40, respectively. Different patterns were seen for self-esteem and in-
terpersonal problem gain. For the IIP measure, correlations increased at the begin-
ning of treatment to comparable levels, –.38 by Session 5, but declined thereafter,
with a mean correlation during the second half of treatment of –.20. For the RSE
measure, correlations were generally lower with early treatment correlations at Ses-
228 WEERASEKERA ET AL.

TABLE 1. Correlations of the Working Alliance in Each Session With

Residual Gains on Outcome Measures
Depression
Session BDI SCL-90-R-D Relationships: IIP Self-Esteem: RSE Health: GSI
1 –.03 –.05 –.17 .09 –.10
2 –.15 –.28 –.13 .17 –.11
3 –.18 –.38* –.06 .31 –.21
4 –.40* –.44** –.33 .26 –.05
5 –.38* –.43* –.38* .23 –.12
6 –.24 –.30 –.27 .22 –.02
7 –.25 –.32 –.35* .30 –.02
8 –.45** –.43* –.28 .36 –.04
9 –.32 –.42* –.26 .32 –.03
10 –.28 –.31 –.28 .24 .07
11 –.31 –.35* –.15 .30 .03
12 –.40* –.40* –.16 .34* –.01
13 –.46** –.38* –.11 .27 –.05
14 –.46** –.36* –.23 .28 –.04
15 –.33 –.44* –.17 .32 .00
16 –.36 –.26 –.25 .35 .02
Note. Sample size varied from 30 to 34. BDI = Beck Depression Inventory; SCL-90-R-D = Symptoms
Distress Checklist-90-Revisied Depression subscale; IIP = Inventory of Interpersonal Problems; RSE =
Rosenberg Self-Esteem Inventory; GSI = Global Symptom Index of SCL-90-R.
*p < .05, two-tailed. **p < .01, two-tailed.

sions 4 and 5 of .26 and .23, respectively. Alliance-outcome correlations were con-
sistently lower for the General Symptom Index of the SCL-90-R, with a mean corre-
lation across all treatment sessions of –.04.
The patterns of correlations were similar for goal and task alliance to those found
with overall alliance scores but different for bond alliance. These alliance subscale
differences were not unexpected because goal and task alliance was more strongly
interrelated than either type of alliance was related to bond alliance: at midtreatment,
in Session 8, for goal and task r = .90, for bond and goal r = .54, and for bond and
task r = .67. The alliance-outcome correlations for goal and task alliance were gen-
erally stronger with gain on the depression measures than on the IIP or RSE mea-
sure. Mean correlations across treatment sessions for gain on the BDI and SCL-90-R
Depression with goal alliance were –.32 and –.34, whereas for gain on the IIP and
RSE they were –.22, .25. For task alliance they were –.40, –.43 for gain on the BDI
and SCL-90-R Depression and –.15 and .27 for IIP and RSE, respectively. In contrast,
for bond alliance the correlations were stronger with gain on the IIP and RSE mea-
sures than on the depression measures (–.25 and .23 vs. –.16 and –.19).
The second hypothesis explored in this study concerned whether the predictive
ability of early alliance was merely a reflection of early mood changes. This hypoth-
esis was tested by partialing out variance from each session alliance score that was
attributable to changes in mood made up to that session and correlating the residual
alliance variance with outcome (BDI residual gain scores). Mood change was esti-
mated by changes in intersession (IS on the Epstein Mood Scale) mood ratings across
sessions. IS mood ratings are related to treatment gains because they correlated sig-
nificantly with the BDI at the one point they were both administered (at midtreatment,
WORKING ALLIANCE IN DEPRESSION THERAPY 229

r = .41, p < .05). Using a technique similar to Gaston et al. (1991), a least-square
linear estimate of mood change for each patient was calculated for each session by
regressing previous IS mood ratings over session number to that point in treatment
(e.g., treatment gain to Session 5 was estimated by regressing IS ratings for Sessions
2 through 5). Mood change scores were subtracted from session alliance scores, and
the residual difference scores were correlated with overall treatment gain. These
correlations would be the semipartial or part correlations between session alliance
and overall treatment gain when mood change was partialed out.
Table 2 gives the semipartial or part correlations for mean alliance with BDI
residual gain scores. Significance levels of .05 and .01 and the Bonferroni adjusted
level of .0011 are provided as guidelines for interpretation. The session correlations
started at Session 3 because this was the first session in which there were two IS
mood ratings with which to calculate in-treatment gain. Overall, the part correla-
tions were very similar to the zero-order correlations. The early treatment goal alli-
ance- and task alliance–outcome correlations increased in Sessions 4 and 5, even
when removing estimated treatment gain (i.e., improvements in mood) at that early
point in treatment. Also, alliance continued to predict outcome later in treatment.
These results were also found when the semipartial correlational analysis was con-
ducted using residual gain scores in IS mood change, from Sessions 2 to 16 as an
estimate of outcome. Thus, no evidence could be found from this analysis that the
predictive relationship between alliance and depression treatment gain was attribut-
able to early improvements in mood or in fact to late improvements in mood.
Hypothesis 3 concerned the development of different types of alliance (goal,
task, bond) across the two forms of treatment. The PE group appeared to gain sig-
nificantly more in task alliance from early to midtreatment than the CC group. Re-
peated measure analyses of variance (ANOVAs) were conducted separately on goal,

TABLE 2. Subscale Alliance Part Correlations

With BDI Residual Gain Outcome Measure
Alliance subscale
Session Goal Task Bond
3 –.06 –.32 –.24
4 –.37* –.39* –.18
5 –.35* –.36* –.24
6 –.07 –.29 –.20
7 –.22 –.29 –.05
8 –.46** –.44 –.20
9 –.35 –.30 –.17
10 –.33 –.28 –.09
11 –.30 –.46** –.12
12 –.43* –.40 –.26
13 –.42* –.52** –.18
14 –.42* –.62*** –.23
15 –.32 –.46 –.13
16 –.21 –.28 –.00
Note. Sample size varied from 27 to 33. Linear estimates of mood
change removed (Intersession Epstein Mood Scale).
*p < .05. **p < .01. ***p < .0011, equivalent to p < .05 after Bonfer-

roni adjustment.
230 WEERASEKERA ET AL.

task, and bond alliance subscale scores, with treatment group as a between-subjects
variable. The sessions included in the analyses were restricted to three points in treat-
ment: early treatment (Sessions 1 and 2), middle treatment (Sessions 7 and 8), and
late treatment (Sessions 15 and 16). A mean score was calculated over the two ses-
sions at each point of treatment. Thirty-two of the 34 patients completed goal and
bond alliance measures on at least one of the two sessions at these three points; 31
did so for the task alliance measure. Separate repeated measures ANOVAs showed
that for all groups and subscales alliance improved significantly. No group differ-
ences were found for goal alliance. However, for task alliance, a significant Group ×
Session interaction was found, F (2, 58) = 4.74, MSE = 0.23, p = .012). The CC and PE
groups started treatment at comparable levels (M = 4.87, SD = 0.95 vs. 4.75, SD =
0.71, respectively). However, at midtreatment, the groups differed significantly, F (2,
44) = 3.51, p < .05, with mean scale values of 5.06 (SD = 1.08) and 5.65 (SD = 0.81).
Both groups continued to make task alliance gains until end of treatment, where the
differences of 5.54 (SD = 0.94) and 5.97 (SD = 0.70) were no longer significant, F(2,
44) = 1.84, ns). Thus, the PE group appeared to gain significantly more in task alli-
ance from early to mid-treatment, than the CC group. This is consistent with the
hypothesis that PE therapy, a more process-directive therapy, with its greater em-
phasis on specific interventions would affect task alliance more than CC therapy.
The final hypothesis concerned whether the severity of depression negatively
affected the development of alliance. No support was found for this hypothesis.
Correlations of pretreatment BDI and SCL-90-R Depression scores with session mean
and subscale alliance scores failed to reveal any significant correlations. In addition,
correlations computed between pretreatment BDI and SCL-90-R Depression scores,
with least-square linear slope estimates for change in mean alliance from Session 1
to 4 were nonsignificant (rs = .00 and –.15 for BDI and SCL-90-R Depression, re-
spectively). This indicates that a client’s level of depression before entering treat-
ment did not impact on alliance formation early in treatment.

Discussion

This study examined the pattern of the alliance in two experiential therapies of
depression. The finding that alliance was more consistently related to depression
than self-esteem, especially early in treatment, likely reflects the shorter time required
to produce changes in statelike depressive symptoms than in trait-like self-esteem, a
finding consistent with suggestions by Kopta, Howard, Lowry, and Beutler (1994).
Longer periods also seemed required to see changes in work and interpersonal func-
tioning in other treatments of depression (Mintz, Mintz, Arruda, & Hwang, 1992;
Weissman, 1994). In addition, the stronger correlation between goal and task alli-
ance and depression than bond alliance and depression may be attributed to the
greater role more active interventions play in the treatment of depression, as has
been seen in other successful active therapies for this disorder (CBT, IPT). This is
also consistent with the report by Hatcher and Barends (1996), who found that Goal
and Task subscales loaded significantly on a confident collaboration factor, found to
be more strongly predictive of patient assessment of progress at midtreatment.
The finding of a stronger relationship of bond than goal and task alliance with
interpersonal relations and self-esteem is consistent with the idea that in experien-
tial therapy it is the client–therapist relationship that promotes change in self-esteem
and subsequent interpersonal relations (Rogers, 1975). This is in keeping with other
WORKING ALLIANCE IN DEPRESSION THERAPY 231

relationally oriented therapies such as psychodynamic therapy, in which the thera-

peutic relationship is viewed as the major vehicle through which change occurs.
Therefore, the present study converges with results reported by Stiles et al. (1998),
suggesting that the alliance-outcome relationship is complex, that alliance dimen-
sions differentially predict outcome, and that this prediction is also affected by the
time required for different outcome measures to measure change.
The finding that alliance predicted outcome independent of early mood change
extends Gaston et al.’s (1991) results in showing this effect across all treatment ses-
sions and for two quite different experiential therapies. This is an important finding in
that it further validates the alliance construct and offers evidence against the alliance-
as-artifact hypothesis, which suggests that the alliance is simply a measure of early
treatment gains. In addition, the finding that alliance predicts outcome independent of
late mood changes suggests that late alliance is not an artifact of treatment gain.
We also found that for PE therapy (which placed greater emphasis on the use of
active intervention strategies) task alliance scores at midtreatment were higher than
for the less active task-oriented CC therapy. This is likely due to the greater per-
ceived relevance by midtreatment of the tasks in PE therapy, which explicitly targets
specific determinants of depression. Early in treatment both the PE and CC condi-
tions follow an empathic approach; however, by Session 4, PE therapy begins to
focus on specific determinants of depression, whereas CC therapy continues empathic
exploration. It is interesting that at the end of treatment there were no differences
between the two groups, suggesting that by the end of treatment the general task of
empathic exploration and the more specific PE tasks were perceived as relevant.
Perhaps it takes longer to build the task alliance using the more general task of ex-
ploration. Our findings also indicate that alliance subscales are able to tap specific
therapeutic ingredients that differentiate one therapy from another, and these active
ingredients appear to be important in predicting outcome. Further research is needed
to explore other alliance dimensions and their relation to the different active ingre-
dients in the different psychotherapies.
The finding that depression severity at intake did not affect change of alliance in
early therapy is an important finding given the social withdrawal and cognitive im-
pairment often associated with this condition, which might be expected to affect
alliance formation. However, it still may be that functional impairment is a factor in
alliance formation. Because this study did not include a functionally impaired group,
we are unable to answer this question. The findings in this study need to be repli-
cated with a larger sample before they can be generalized to a heterogeneous de-
pressed population.
The limitations of the study require that these findings be interpreted with cau-
tion. Given the small sample size, statistical power is low; therefore, caution should
be exercised in interpreting null results. Another problem in the study was the fre-
quent use of in-treatment self-report measures that could contribute to an inflation
of positive responses. Interviewer-rated measures at different points in time provide
a more objective measure of therapy variables.
Despite these limitations, this study demonstrated that the alliance continues to
be a robust construct in predicting treatment outcome, independent of treatment gains.
It was the first study to examine the alliance-outcome link in two separate experien-
tial therapies and demonstrates that a more task-oriented treatment leads to greater
levels of task alliance. It also reveals that the pattern of the alliance-outcome rela-
tionship is complex, requiring further research in alternate forms of therapy using
different alliance measures.
232
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Zusammenfassung
Diese Studie untersucht die Entwicklung der therapeutischen Allianz in Prozess-Erfahrungs- und
klientenzentrierter Therapie bei Depression. 34 nach dem Zufall zugeordnete Klienten folgten 16 bis
20 Sitzungen manual-unterstützter Therapie in einer der beiden Therapiearten. Die Ergebnisse zeigten,
daß die Korrelation zwischen Allianz und Ergebnis abhängig ist von der Allianzdimension (Ziel, Aufgabe,
Beziehung), dem Ergebniskriterium (Symptomverbesserung vs. Selbstwert, Beziehungsprobleme) und
dem Behandlungszeitpunkt, zu dem Allianz gemessen wurde. Partielle Korrelationen zeigten, daß früh
erhobene Allianzwerte geeignet sind, Therapieergebnisse vorherzusagen, die nicht auf frühe Stim-
mungsschwankungen zurückzuführen sind. Es wurden keine Gruppenunterschiede für Beziehungs-
und Ziel-Allianz gefunden, aber die Prozess-Erfahrungsgruppe wies höhere Aufgaben-Allianzwerte in
der mittleren Phase der Therapie auf. Der Schweregrad der Depression vor der Therapie hatte keinen
Einfluß auf die Allianzbildung. Auf die Bedeutung dieser Ergebnisse wird in der Diskussion näher
eingegangen.

Résumé
Cette étude a examiné le développement de l’alliance de travail au cours de thérapies de la dépression
par l’expérience du processus (PE) et centrée sur le client. Trente-quatre individus attribués au hasard
ont terminé une thérapie manualisée de 16 à 20 séances. Les résultats révèlent que la grandeur de la
relation alliance-résultat dépend de la dimension de l’alliance (objectif, tâche, ou lien), de la mesure du
résultat (amélioration des symptômes vs. estime de soi, problèmes relationnels), et du moment de
l’alliance de traitement. Des analyses de corrélations partielles révèlent que les scores de l’alliance précoce
non attribuables à des changements précoces de l’humeur prédisent les résultats. Alors que des différences
entre les groupes ne se trouvent ni pour l’alliance concernant le lien ni celle concernant le but, le groupe
PE montre des scores plus élevés pour l’alliance concernant la tâche au milieu de la thérapie. Le niveau
de la dépression avant le traitement n’a pas affecté la formation de l’alliance. Les implications de ces
résultats sont discutées.

Resumen
Este estudio examina el desarrollo de la alianza de trabajo en la terapia de proceso experiencial (PE) y
en la centrada en el cliente para la depresión. Treinta y cuatro individuos asignados al azar completaron
dieciséis a veinte sesiones de terapia manualizada. Los resultados revelaron que el valor de la relación
entre la alianza y el resultado de la terapia dependía de la dimensión de la alianza (en relación al objetivo,
la tarea o el vínculo), la medida del resultado (mejoría sintomática vs. auto estima y problemas rela-
cionales) el tiempo de alianza en el tratamiento. Los análisis parciales de correlación revelaron que los
puntajes de alianza tempranos no predijeron resultados atribuibles a cambios tempranos en la calidad
del humor. Si bien no se encontraron diferencias grupales en cuanto a la alianza en el vínculo y en el
objetivo, el grupo PE mostró puntajes más altos de la alianza de trabajo en la fase media de la terapia.
El nivel de depresión previo al tratamiento no afectó la formación de la alianza. Se discuten las
implicaciones de estos resultados.

Received October 2, 1998

Revision received December 15, 2000
Accepted December 15, 2000