Therapeutic alliance : exploration of the construct validity of the concept

Background: Repeated meta-analyses have established that there exists a robust association between therapeutic alliance and outcome at end of treatment; still, there is a lack of coherent theory regarding the concept and lack of agreement on how to interpret and understand research results. Further support of the construct validity of the concept is needed.

Aim: The aim of the present thesis was to explore the construct validity of the concept therapeutic alliance. Paper I aimed at studying the adaptation of an established alliance measure to a group psychotherapy setting. Paper II aimed at exploring the association between alliance and outcome in treatment for young adults. Paper III aimed at testing prediction and moderation of early alliance in psychodynamic psychotherapy (ORP) and dialectical behavior therapy (DBT). Paper IV aimed at predicting growth of alliance from relational personality variables.

Methods: Paper I is based on data from a randomized controlled study on patients on sick leave diagnosed with work related depression and/or stress reactions participating in psychodynamic group psychotherapy (n = 18). Paper II and IV are based on data from a prospective, naturalistic outcome study on young adults receiving long-term psychoanalytic psychotherapy (n = 115, n = 79). Paper III is based on data from a randomized controlled study on female, suicidal patients diagnosed with borderline personality disorder (n = 59). Analyses were performed on data for patients for whom patients and/or therapists had filled out relevant questionnaires.

Results: Study I: Reliability for the alliance questionnaire was acceptable. Average alliance was associated with outcome, while dismissing attachment, level of interpersonal problems, problems being exploitable, and problems being overly nurturant were associated with growth of alliance. Dismissing attachment was also predictive of early alliance. Paper II: Therapist-rated alliance was negatively associated with symptom change in patients with high levels of initial suffering. Paper III: Patients and therapists in DBT rated early alliance higher than their counterparts in ORP. Somatic anxiety moderated discrepancy in therapist/patient-rated alliance between the two treatments. Study IV: Two measures of object and self-representations predicted growth of patient-rated alliance, while interpersonal problems within the friendly-submissive domain predicted fluctuations in therapist-rated alliance.

Conclusion: The present thesis found some support for the construct validity of the concept therapeutic alliance. However, the lack of coherent theory of the concept makes it difficult to interpret diverging results other than from a clinical perspective.

List of scientific papers

I. Lindgren, A., Barber, J. B., & Sandahl, C. (2008). Alliance to the group-as-a- whole as a predictor of outcome in psychodynamic group psychotherapy. International Journal of Group Psychotherapy (58), 163-184.
https://doi.org/10.1521/ijgp.2008.58.2.163

II. Lindgren, A., Werbart, A., & Philips, B. (2010). Long-term outcome and post-treatment effects of psychoanalytic psychotherapy with young adults. Psychology and Psychotherapy: Theory, Research and Practice, (83), 27-43.
https://doi.org/10.1348/147608309X464422

III. Lindgren, A., Wilczek, A., Nilsonne, Å., Kåver, A., Åsberg, M., & Barber, J. P. Early alliance in dialectical behavior and psychodynamic psychotherapies for suicidal women with borderline personality disorder. [Submitted].

IV. Lindgren, A., & Werbart, A. Object representations predict growth of alliance in psychoanalytic psychotherapy with young adults. [Submitted].