The therapeutic alliance in a naturalistic psychiatric setting: Temporal relations with depressive symptom change

•The therapeutic alliance is understudied in naturalistic psychiatric settings.•We tested whether the alliance predicts depressive symptom change in a hospital.•The alliance and pretreatment expectations of change predicted improvement.•The alliance did not predict outcome after statistically controlling for confounds.•The alliance was predicted by the degree of prior symptom improvement.

ObjectiveNumerous studies have reported associations between the therapeutic alliance and depressive symptom improvement in outpatient samples. However, little is known regarding the temporal relationship between the alliance and symptom change among relatively severely depressed patients receiving treatment in naturalistic, psychiatric hospital settings.MethodAdult patients with major depression (n = 103) receiving combined cognitive behavioral therapy and pharmacological treatment at a psychiatric hospital completed repeated assessments of the therapeutic alliance and depressive symptoms, as well as a pretreatment assessment of their expectation of symptom improvement.ResultsResults indicated that the alliance and treatment outcome expectancies significantly predicted subsequent depressive symptom change. However, in a model in which prior symptom change and treatment outcome expectancies were statistically controlled, the alliance-outcome association was rendered nonsignificant. The alliance was significantly associated with prior symptom improvement.ConclusionsFindings highlight the importance of controlling for plausible third variable and temporal confounds to minimize biased estimates of alliance-outcome associations in future studies. Overall, results were more consistent with the alliance being a consequence, rather than a cause, of symptom change. Finally, findings contribute to a growing body of evidence supporting the role of treatment outcome expectancies in predicting symptom improvement, even within our relatively severely depressed sample.