Does alliance predict symptoms throughout treatment, or is it the other way around?

Sigal Zilcha-Mano, Ulrike Dinger, Kevin S. McCarthy, Jacques P. Barber

Research output: Contribution to journalArticlepeer-review


Objective: Scholars increasingly recognize that therapeutic alliance and symptomatic change are associated with one another. A common assumption is that alliance predicts symptomatic change. However, the issue is far from settled. One challenge in determining the causality is the establishment of temporal precedence showing that alliance, as opposed to previous symptomatic change, drives subsequent symptomatic reduction. Method: To make further advances in untangling this chicken-and-egg question, we employed autoregressive cross-lagged modeling over 4 time points in a sample of 149 depressive patients receiving supportive- expressive psychotherapy or clinical management combined with pharmacotherapy or clinical management combined with placebo. Results: Using this methodology, we found that both alliance and symptoms across treatment made significant and unique contributions in predicting subsequent symptomatic levels throughout treatment. Additionally, alliance, but not symptoms, predicted subsequent alliance levels. No differences were found between treatments. Conclusions: Our findings imply that alliance temporally precedes symptomatic levels throughout treatment.

Original languageEnglish
Pages (from-to)931-935
Number of pages5
JournalJournal of Consulting and Clinical Psychology
Issue number6
StatePublished - 2014
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2013 American Psychological Association.


  • Alliance
  • Depression
  • Psychodynamic psychotherapy
  • Psychotherapy outcome

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Clinical Psychology


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