Journal of Contemporary Psychotherapy, Vol. 32, No.

4, Winter 2002 (
C
2002)
Pretreatment Correlates of the Therapeutic Alliance
in the Chronically Depressed
Neil J. Santiago, Daniel N. Klein, Dina Viian, Carina Vocisano,
!ran" Do#ling, $ruce A. Arno#, %achel &an'er, John C. &ar"o#it(,
James P. &cCullough, Jr., )a#rence P. ). %iso, $ar'ara *.
%oth'aum, A. John %ush, &ichael +. Thase, and &artin $. Keller
We eamine! the relationship "et#een patient characteristics an! the #or$in%
alliance in a multisite trial for chronic !epression. Patients treate! #ith the
Co%&
niti'e (eha'ioral )nalysis *ystem of Psychotherapy (C()*P), alone (n = +,-)
or com"ine! #ith nefa.o!one (n = +-/), complete! the Wor$in% )lliance 0n'en&
tory !urin% the 2n! #ee$ of treatment. Within the C()*P alone %roup, a history
of
!ru% a"use1!epen!ence, lo#er pea$ social a!2ustment o'er the past fi'e years,
an! lo#er current social a!2ustment pre!icte! a si%nificantly poorer alliance.
Within the com"ination %roup, male %en!er an! a !istancin% copin% style
pre!icte! a si%nificantly poorer alliance. 3esults shoul! "e interprete! #ith
caution since they !i! not replicate across treatment %roups, an! the num"er of
si%nificant fin!in%s #ere not much %reater than chance epectations.
K+, -*%DS. therapeutic alliance; client characteristics; major depression; dysthymic disorder;
psychotherapy.
The therapeutic alliance
1
has emerged as one of the most significant
constructs in psychotherapy research. Attention to the alliance has increased as
studies have repeatedly demonstrated that it predicts treatment outcome across
varied therapies and client populations (Constantino, Castonguay, & Schut,
!!; "rupnic# et al.,
1$$%; &orvath & 'u(ors#y, 1$$); *artin, +ars#e, & ,avis, !!!-. An
important area of in.uiry that has resulted from the esta(lishment of the
alliance/outcome
Address correspondence to 0eil 1. Santiago, ,epartment of 2sychology, State 3niversity of 0e4
5or# at Stony 6roo#, Stony 6roo#, 05 117$8/9!!; e/mail: neil santiago;alumni.(r o 4n.edu.
1
<hile some authors have distinguished (et4een the terms =therapeutic alliance> and =4or#ing al/
liance,> using the former to refer to the more affective elements, and the latter to the tas#/oriented
aspects of the patient?therapist relationship (+aston, 1$$!-, 4e 4ill use the terms interchangea(ly
in this paper.
/01
!!/!11%@!@1!!/!A1@!
C
!! &uman Sciences 2ress, Bnc.
/2 Santiago et al.
relationship has (een the elucidation of factors that influence the development of
strong and 4ea# alliances (et4een clients and their therapists.
A num(er of investigations have eCamined the a(ility of pre/treatment
client characteristics to predict the therapeutic alliance. Such efforts have
included eC/ amination of demographic, clinical, intrapsychic, and interpersonal
varia(les. Bn general, demographic and clinical varia(les have not (een very
consistent in pre/ dicting the alliance (Constantino et al., !!-. Bnterpersonal
and intrapsychic fac/ tors have more fre.uently yielded significant relationships
4ith the therapeutic alliance, (ut effect siDes have generally (een small and
several findings have failed to replicate. 'o4 .uality social relationships
(+aston, *armar, Thompson, & +al/ lagher, 1$AA; &ersoug, *onsen, &avi#, &
&oglend, !!; "o#otovic & Tracey,
1$$!; *allinc#rodt, 1$$1; *allinc#rodt, Co(le, & +antt, 1$$9; *oras & Strupp,
1$A-, family relationships (&illiard, &enry, & Strupp, !!!; "o#otovic &
Tracey,
1$$!; *allinc#rodt, 1$$1; *allinc#rodt et al., 1$$9-, an under/involved
interper/ sonal style (&ardy et al., !!1; Saunders, !!1-, and poor o(ject
relations (2iper, ADim, 1oyce, & *cCallum, 1$$1; 2iper, ADim, 1oyce, *cCallum
et al., 1$$1; Eyan
& Cicchetti, 1$A9- have (een sho4n to negatively predict levels of the alliance.
3nassertiveness, eCploita(ility, and over/nurturance have (een reported to
predict higher ratings of the alliance (*uran, Segal, Samstag, & Cra4ford,
1$$8-. Bn con/ trast, defensiveness (+aston et al., 1$AA-, perfectionism (Furoff et
al., !!!-, and depressogenic attitudes (Eector, Furoff, & Segal, 1$$$- have
each (een found to predict poorer alliances. Ginally, severity of
emotional@physical a(use, emotional neglect, and physical neglect 4ere found to
predict a poorer early alliance in a sample of adult survivors of child a(use
(2aivio & 2atterson, 1$$$-. Gre.uently encountered limitations of the studies
that have sought to eCamine client correlates of the alliance have included small
sample siDes, informally defined or heteroge/ neous diagnostic groups, the use
of idiosyncratic measures, and the reliance on a single source (e.g. patient
report- for measurement of the alliance, outcome, and patient characteristic
varia(les, 4hich may have inflated the magnitude of associations due to shared
method variance.
The goal of the present study is to eCamine the relationship (et4een a (road
set of pre/treatment client characteristics and early levels of the therapeutic
alliance in a large sample of patients 4ith chronic depression. As reported
else4here ("lein et al., !!-, the early alliance significantly predicted
improvement in depressive symptoms in this sample even after controlling for
prior improvement and several patient characteristics. 'ittle is #no4n a(out the
therapeutic alliance or its pre/ dictors in this particular diagnostic population,
4hich displays greater levels of symptom severity, impairment, and comor(idity
than many of the client samples in previous studies of the alliance. Bn addition,
4hile some studies have eCam/ ined the alliance in the solely pharmacological
treatment of depression ("rupnic# et al., 1$$%; <eiss, +aston, 2ropst,
<ise(ord, & Ficherman, 1$$7-, no previ/ ous efforts have reported on the
alliance 4hen treatment included (oth therapy and medication. Ginally, this
Correlates of the Alliance in Chronic Depression /3
investigation possesses a more clearly defined and
/0 Santiago et al.
homogenous diagnostic group, larger sample siDe, and more eCtensive multi/
modal assessment (attery than many of the previous efforts aimed at eCploring
these po/ tential relationships.
&+T4*D
Participants
The participants in this study 4ere dra4n from the multisite clinical trial for
chronic depression descri(ed in "eller et al. (!!!-. 6riefly, %A1 patients 4ere
randomiDed at 1 academic centers to 1 4ee#s of treatment 4ith the Cognitive
6ehavioral Analysis System of 2sychotherapy (C6AS2; *cCullough, !!!,
!!1,
!!- alone, nefaDodone alone, or their com(ination. Eesults indicated that the
t4o monotherapies produced compara(le outcomes (overall response rates of
8AH for (oth groups- 4hile the com(ination treatment produced a significantly
(etter rate of response (7)H-. The present report is limited to the )%7
psychotherapy patients
in the C6AS2 alone ( N = 1%$- and the com(ination ( N = 1$A- conditions that
completed an assessment of their 4or#ing alliance 4ith their psychotherapist.
T4enty/siC percent of the A patients that 4ere assigned to the C6AS2 alone
group and 1)H of the 7 assigned to the com(ination condition did not
complete the <AB during the
nd
4ee# of treatment due to drop/out or missing
data.
All patients 4ere aged 1A?79 and met 4ia%nostic an! *tatistical 5anual
of 5ental 4isor!ers, 8
th
edition (,S*/BI; American 2sychiatric Association,
1$$8- criteria for a current episode of chronic major depressive disorder (*,,-,
*,, superimposed on a pre/eCisting dythymic disorder (dou(le depression-, or
recurrent *,, 4ith incomplete remission (et4een episodes and a total duration
of continuous illness of at least t4o years. Bn addition, patients had to score at
least ! on the 8/item &amilton Eating Scale for ,epression (&ES,;
&amilton,
1$%7- at screening and again at (aseline follo4ing a t4o/4ee# drug/free period.
JCclusion criteria included: an unsta(le medical condition, a history of
psychotic, (ipolar or o(sessive compulsive disorder; eating disorders 4ithin the
past year; su(stance a(use or dependence 4ithin the past siC months; antisocial,
schiDotypal, or severe (orderline personality disorder; dementia or seiDure
disorders; poorly controlled or serious medical disorders; and a history of failing
t4o different types of antidepressant medications or t4o different courses of
empirically supported psychotherapy for depression 4ithin the last three years.
Treatments
C6AS2 4as administered according to a treatment manual (*cCullough,
!!1- for 1% to ! sessions, 4ith t4ice/4ee#ly sessions throughout the first 8
4ee#s of treatment and 4ee#ly sessions thereafter. 2sychotherapists ( N = 9-
Correlates of the Alliance in Chronic Depression /5
had at least t4o years of eCperience after earning a 2h. ,. or *.,., or at least
five years eCperience after earning an *.S.<. All therapists 4ere doctoral level
psychologists eCcept for three master/level social 4or#ers and one psychiatrist.
0efaDodone 4as routinely initiated at 1!! mg (.i.d., 4ith a dose of )!!
mg@day re.uired after 4ee# ), and su(se.uent titration permitted up to %!!
mg@day in divided doses. 2harmacologists follo4ed a pu(lished manual
(Ga4cett, Jpstein, Giester, Jl#in, & Autry, 1$A7-. 2harmacotherapy visits 4ere
limited to 19?! minutes, and focused on symptoms and side effects. Gormal
psychotherapeutic interventions 4ere prohi(ited.
&easures
,iagnoses and +lo(al Assessment of Gunctioning (+AG- scores 4ere o(/
tained using a modified version of the Structured Clinical Bntervie4 for the
,S*/ BI (SCB,/2; Girst, SpitDer, +i((on, & <illiams, 1$$9- for ACis B
disorders and an a((reviated version of the SCB,/BB (Girst, +i((on, SpitDer,
<illiams, & 6en/ jamin, 1$$7- for ACis BB disorders during the screening
evaluation. The SCB,/ BB 4as limited to a su(set of personality disorders that
4ere re.uired to assess inclusion@eCclusion criteria, or are particularly common
in chronic depression (*ar#o4itD, 1$$9-: antisocial, (orderline, schiDotypal,
avoidant, dependent, and o(sessive/compulsive. A physical eCamination, routine
la(oratory tests, and urine toCicology screen 4ere also performed during
screening.
The early therapeutic alliance 4as assessed during the second 4ee# of
treat/ ment using the a((reviated version (Tracey & "o#otovic, 1$A$- of the
patient re/ port form of the <or#ing Alliance Bnventory (<AB; &orvath &
+reen(erg, 1$A$-. Self/report of the alliance 4as chosen for this study since
prior studies indicate that it is a stronger predictor of psychotherapy outcome
than therapist reports (Constantino et al., !!; &orvath, 1$$8; &orvath &
Symonds, 1$$1; although not *artin et al., !!!-. The <AB is one of the most
commonly used and (est/ esta(lished measures of the alliance. Bt is
pantheoretical, (ased on 6ordinKs (1$7$- model of the alliance, eChi(its good
relia(ility (&orvath & +reen(erg, 1$A$-, is moderately correlated 4ith other
measures of the alliance (&atcher & 6arends,
1$$%-, and has (een sho4n to predict outcome in many studies (&orvath, 1$$8;
&orvath & Symonds, 1$$1; *artin et al., !!!-. The a((reviated <AB retains
the same three su(scales as the original <AB, (ut reduces the num(er of items
on each su(scale from t4elve to four. The su(scales correspond to the elements
of the alliance delineated (y 6ordinKs (1$7$- model: the emotional "on!
(et4een therapist and client, agreement concerning the %oals of therapy, and
agreement on the use of particular tas$s that 4ill serve to achieve the desired
goals of therapy. Bn light of the evidence for a general factor (&ersoug, &oglend,
*onsen, & &avi#,
!!1- and high intercorrelations of the su(scales (r
goal, (ond
=
.%, r
goal, tas#
=
.71,
r
(ond, tas#
=
.7 at 4ee# - only the total score 4as employed in this report. The
67 Santiago et al.
<AB total scale eChi(ited a high degree of internal consistency in the present
study, 4ith a Cron(achKs alpha of .$ at 4ee# .
,epressive symptomatology 4as assessed using the 8/item &ES,
(&amilton, 1$%7-. AnCiety symptomatology 4as assessed using the &amilton
AnCiety Eating Scale (&AES; &amilton, 1$9$-. Bnformation on social
functioning 4as gathered from each su(ject through use of the 'ongitudinal
Bnterval Gollo4/ up Jvaluation ('BGJ; "eller et al., 1$A7-. JCperienced raters
4ho completed a training 4or#shop on these instruments administered the
intervie4s. Bn addition, all &ES, raters 4ere certified (y eCternal eCperts 4ho
evaluated a videotape of the raterKs &ES, assessment 4ith a depressed patient.
The )!/item version of the Bnventory of ,epressive SymptomatologyLSelf
Eeport (B,S/SE; Eush et al., 1$A%- served as a self/report measure of depression
severity. ,epressogenic thin#ing patterns 4ere assessed using the negative items
from the Attri(utional Style Muestionnaire (ASM; 2eterson, 1$A-. &ealthy and
unhealthy properties and transaction patterns in su(jectsK families 4ere assessed
using the Gamily Assessment ,evice (GA,; Jpstein, 6ald4in, & 6ishop, 1$A)-.
Su(jects completed the <ays of Coping Muestionnaire (<CM; Gol#man,
'aDarus, ,un#el/Schetter, ,e'ongis, & +ruen, 1$A%- as an indeC of the eCtent
to 4hich they employed particular coping styles and the Social Adjustment
ScaleLSelf Eeport version (SAS/SE; <eissman & 6oth4ell, 1$7%- as a
measure of general social adjustment. The glo(al satisfaction item from the
Eelationship Satisfaction Muestionnaire (ESAT; 6urns & Sayers, 1$AA- 4as
completed (y the !% su(jects 4ho indicated that they 4ere in a serious
romantic relationship.
%+S8)TS
The mean total score for the <AB at <ee# 4as %A.) (S.,. = 1!.9- for the
com(ination therapy group and %8.9 (S.,. = 1).)- for the C6AS2 monotherapy
group. The difference (et4een the means of the t4o treatment groups 4as statis/
tically significant, 6 (1, )%9- = $.)), p 7 .!1. Conse.uently, su(se.uent analyses
4ere conducted separately (y treatment group. 6aseline patient characteristics
and their correlations 4ith the <AB are listed in Ta(le B.
<ithin the com(ination therapy group, gender 4as significantly correlated
4ith total scores on the <AB, 4ith females demonstrating stronger initial
alliances. Also, the <AB 4as significantly negatively correlated 4ith the
,istancing Gactor Score from the <CM, 4hich reflects a tendency to detach
oneself from, ignore, or ma#e light of stressful events.
<ithin the C6AS2 monotherapy group, a lifetime history of drug a(use or
dependence 4as associated 4ith significantly lo4er scores on the <AB. Signifi/
cantly lo4er scores on the <AB 4ere also associated 4ith lo4er intervie4er
ratings of (est social adjustment 4ithin the past five years from the 'BGJ, and
lo4er total scores on the SAS/SE.
Correlates of the Alliance in Chronic Depression 61
Ta'le 9. Correlations 6et4een the Jarly <or#ing Alliance and 6aseline 2atient Characteristics
Com(ination therapy C6AS2 monotherapy
Iaria(le *ean (S.,.- r *ean (S.,.- r
Continuous:
Age 88.8 (1!.)- .!) 8). (1!.7- .!!
&ES, 7.) (9.1- .!7 %.9 (8.$- .!)
H Change in &ES, 1A.% (.)- .1) 1!.9 (9.7- .!%
B,S/SE )$.$ (A.8- .!) )A.$ (A.9- .!)
&ESA 1A.7 (%.1- .!A 1A. (%.!- .!9
*,, Age of Nnset 7.) (1).- .!! 7.9 (1).)- .!%
,, Age of Nnset !.% (18.)- .17 1$.$ (18.- .11
,uration of *ood ,isorder 17. (18.$- .1 1%.1 (18.9- .1!
Total 0um(er of *ajor ,epressive 7.9 (1.A- .!A 9.7 (17.$- .!7
Jpisodes
'BGJ Social Adjustment 2ast *onth ).$ (!.7- .11 ).$ (!.7- .!$
'BGJ Social Adjustment 6est *onth .% (!.A- .!8 .9 (!.$- .17

from 2ast 9 5ears

SAS Nverall Summary Score .% (!.8- .1! .9 (!.8- .1$

+AG Score at Screening 9).7 (9.%- .!) 9).$ (9.7- .!$

<CM Confrontive !.7 (!.%- .!8 !.7 (!.9- .!A
<CM ,istancing !.7 (!.9- .1A

!.A (!.9- .!!
<CM Self/controlling 1. (!.9- .1! 1. (!.9- .!
<CM See#ing Social Support !.A (!.%- .!A !.$ (!.%- .!
<CM Accepting Eesponsi(ility 1.1 (!.7- .!8 1.1 (!.7- .!9
<CM Jscape/Avoidance 1.! (!.%- .! 1.! (!.%- .!%
<CM 2lanful 2ro(lem Solving !.$ (!.%- .!$ !.$ (!.9- .!)
<CM 2ositive Eeappraisal !.9 (!.9- .!% !.% (!.9- .!7
ASM Nverall Score 9.! (!.A- .!% 8.$ (!.A- .!8
GA, Total Score .% (!.%- .!9 .9 (!.%- .!7
ESAT Nverall Satisfaction 4ith ).) (1.A- .! ).) (1.7- .!%
Eomantic Eelationship
Cate%orical8
+ender (*ale, Gemale = !,1-, H *ale )!.A .1%

)7.) .1
Eace (<hite, 0on4hite = !,1-, H <hite $.9 .!9 $1.7 .1)
AnCiety ,isorder (current-, H %.! .!) 17.9 .!1
AnCiety ,isorder ('&-, H )%.1 .!) A.9 .!8
Alcohol A(use or ,ependence ('&-, H 7.) .!) $.A .19
,rug A(use or ,ependence ('&-, H 1). .18 19.8 .1%

Jating ,isorder ('&-, H 8.! .! .% .!9

2ersonality ,isorder ('&-, H )$.% .1! $.8 .!
2arental 'oss 6efore Age 19, H )1.7 .!% )9.1 .1)
&istory of SeCual A(use, H 1A.9 .!7 19.8 .!7
&istory of 2hysical A(use .$ .!! 1A.8 .18
or 0eglect, H
Note. C6AS2 = Cognitive 6ehavioral Analysis System of 2sychotherapy; *,, = *ajor ,epressive
,isorder; ,, = ,ysthymic ,isorder; 'BGJ = 'ongitudinal Bnterval Gollo4/up Jvaluation; +AG =
+lo(al Assessment of Gunctioning; &ES, = &amilton Eating Scale for ,epression; B,S/SE = Bn/
ventory of ,epressive Symptomatology (Self Eeport-; &ESA = &amilton Eating Scale for AnCiety;
ESAT = Eelationship Satisfaction Muestionnaire; <CM = <ays of Coping Muestionnaire; ASM =
Attri(utional Style Muestionnaire; SAS/SE = Social Adjustment ScaleLSelf Eeport; '& = 'ifetime
&istory. Categorical varia(les 4ere coded as a(sent = ! and present = 1 unless other4ise noted.

p

.!9, t4o/tailed.
6/ Santiago et al.
D9SC8SS9*N
The results of this study provide little evidence that pretreatment client
charac/ teristics can predict the early therapeutic alliance for patients suffering
from chronic depression. Bndeed the num(er of significant associations 4as only
slightly greater than 4ould (e eCpected (y chance, no findings 4ere replicated
across treatment conditions, and the strengths of the o(served correlations 4ere
lo4. The o(served relationship (et4een gender and the early alliance in the
com(ination therapy group 4as inconsistent 4ith previous reports (&orvath,
1$$8-. Although this find/ ing 4as not replicated in the C6AS2 monotherapy
group, the direction of the association 4as the same and the effect remained
statistically significant 4hen the t4o groups 4ere com(ined. Thus, it may reflect
an association that is particular to the population of chronic depressives, the
treatment implemented in this study, or to the high (approCimately t4o/thirds-
proportion of female therapists in the study. Although not surprising, the
o(served relationship (et4een a poorer early alliance and a lifetime history of
drug a(use or dependence 4ithin the C6AS2 alone group has not (een reported
previously. Bn this case, the association in the com(ina/ tion therapy group
4as in the same direction, reached the trend level ( p 7 .1!-, and remained
significant 4hen the t4o treatment groups 4ere com(ined. The im/ plications of
this finding are unclear, ho4ever, since the a(ility of the alliance to predict
treatment outcome has not (een replicated in clinical trials for drug a(users
(6ar(er et al., !!1; 6elding, Bguchi, *orral, & *c'ellan, 1$$7; 2etry &
6ic#el,
1$$$-.
<ithin the com(ination therapy group, none of the interpersonal varia(les,
including those related to family factors, 4ere significantly associated 4ith the
early alliance as might (e eCpected from previous reports (&illiard et al., !!!;
"o#otovic & Tracey, 1$$!; *allinc#rodt, 1$$1; *oras & Strupp, 1$A-. <hile
family factors 4ere also non/significant in the C6AS2 monotherapy group, there
4as miCed support for the set of interpersonal varia(les. Bn particular, current
social adjustment on the SAS/SE and the highest level of social functioning in
the past 9 years on the 'BGJ 4ere each significantly associated 4ith early
levels of the therapeutic alliance. Bn contrast, current social functioning on the
'BGJ and overall satisfaction on the ESAT did not predict the early alliance.
The only intrapsychic varia(le that displayed a significant correlation 4ith
the early alliance 4as the ,istancing factor score from the <ays of Coping
Muestion/ naire 4ithin the com(ination therapy group. This finding is consistent
4ith earlier studies that have found a tendency to4ards detachment and under/
involvement to (e negatively associated 4ith the alliance (&ardy et al., !!1;
Saunders, !!1- (ut should (e interpreted 4ith caution, as it did not replicate
for the C6AS2 alone group. Jarlier findings related to depressogenic (eliefs
(Eector et al., 1$$$- and childhood a(use@neglect (2aivio & 2atterson, 1$$$-
4ere not replicated in this sample.
Correlates of the Alliance in Chronic Depression 66
Several limitations eCist in this study. The alliance 4as only assessed via
self/ report, so results could not (e calculated for therapist or o(server rated
measures of the alliance. Bn addition, since the short form of the <AB 4as used,
and its su(/scales 4ere so highly intercorrelated, it 4as not feasi(le to test for
associations among client characteristics and particular aspects of the
therapeutic alliance, 4hich is often conceived as a multifaceted construct
(6ordin, 1$7$; +aston, 1$$!-. Ginally, multiple significance tests 4ere
employed 4ithout correcting for the su(se.uent inflation of Type/B error across
the set of analyses, 4hich may introduce spurious findings.
The results of this study imply that only a small proportion of the variance
in the early therapeutic alliance is predicted (y the characteristics that a client
(rings 4ith them to therapy, even in this severely impaired population. Bn light
of these findings, clinicians should (e hesitant to forecast the alliance (ased
solely upon pre/eCisting client characteristics. Bnstead, it appears li#ely that the
alliance is an emergent property of specific eCperiences that occur during a
patientKs initial involvement 4ith their therapist and the conteCt in 4hich
treatment is provided. Gu/ ture studies should eCplore ho4 other such factors,
including the nature of adjunct pharmacological treatment, therapist
characteristics, therapist/client matching, and the early client/therapist
interactions, influence the development of the alliance in patients 4ith chronic
forms of depression as 4ell as in other specific diagnostic groups.
%+!+%+NC+S
American 2sychiatric Association. (1$$8-. 4ia%nostic an! statistical manual of mental !isor!ers
(4th e!.). <ashington, ,C, 3S: American 2sychiatric Association.
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6elding, *. A., Bguchi, *. 5., *orral, A. E., & *c'ellan, A. T. (1$$7-. Assessing the helping
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%!.
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