How Do Supportive Techniques Bring About Therapeutic Change: The Role of Therapeutic Alliance as a Potential Mediator

Although supportive techniques play an important role in supportive– expressive psychodynamic psychotherapy, little is known about the mechanisms responsible for their effect on treatment success. In this study, we propose and investigate a model according to which the mechanism of change underlying the effect of supportive techniques on therapeutic improvement is the strengthening of the therapeutic alliance. According to the proposed mediation model, the implementation of supportive techniques brings about strengthening in the alliance, which in turn results in subsequent reduction in symptoms. The present study was designed to test the proposed mediation model. Analyses were conducted on a sample of 61 patients diagnosed with major depressive disorder and enrolled in an ongoing psychotherapy trial. For each patient, Session 4 of the supportive– expressive treatment was coded for therapist adherence to supportive techniques, using the Penn Adherence–Competence Scale. The therapeutic alliance was assessed using a self-report scale, and the Hamilton Rating Scale for Depression was used to assess the subsequent change in symptoms. The analyses suggest a significant mediation model, according to which the implementation of supportive techniques resulted in improvements in the alliance, which in turn resulted in reduction in symptoms at the subsequent session (bootstrapping for the indirect effect, 95% confidence interval [―1.96, ―0.16]). The findings support the proposed mediation model, suggesting that the alliance may act as a mechanism of change underlying the effect of supportive techniques on treatment success.