The Evolution of Patients' Concept of the Alliance and Its Relation to Outcome: A Dynamic Latent-Class Structural Equation Modeling Approach

Public Significance Statement This study provides empirical evidence that the majority of clients who indicate that their condition is improving from session to session, also evolve their conceptualization of the nature of their alliance with the therapist. In other words, most of the potentially good outcome patients see their collaborative relation to their therapist as a more integrated concept. If what was observed in this study can be generalized, it would imply that therapist also need to adjust their relational focus to accommodate such, more integrated notion of the alliance during therapy. The working alliance (WA) has been widely identified as the key concept for psychotherapy and allied health care services. The WA, measured at different phases of diverse kinds of therapies, has been shown to robustly predict posttreatment outcomes. But the way the clients' conceptualization of the alliance evolves overtime, and the relation between this kind of conceptual change and subsequent symptom improvements, has not been investigated. Dynamic Latent Class Structural Equation Models (DLC-SEM) were applied to data drawn from two randomized clinical trials of cognitive-behavioral therapy for generalized anxiety disorder (N = 57 and 80) to evaluate several potential models of the relation between the conceptual/structural changes in patients' self-reports of the quality of the alliance and subsequent treatment outcomes. Inspection of the DLC-SEM models suggests that, overtime, between 63% and 66% of the better session-level outcome clients switched from three factors (task, goal, bond) to an integrated single factor conceptualization of the therapeutic alliance. The study indicates that the majority of patients evolve their concept of the alliance overtime: The previously distinct alliance elements become integrated into a single factor construct. These findings suggest that if such overtime development is generalizable across diverse patient/treatment populations, future research ought to take these developments into account both methodologically (i.e., how alliance is measured) and in analyzing time-series data (e.g., using DLC-SEM). By modeling the patient's dynamic concept evolution, this initial study shows a potential to empirically explore prior theoretical propositions of the evolutions (or stability) of the alliance overtime.

Automated summary

This study indicates that the majority of patients evolve their concept of the alliance over time, with previously distinct alliance elements becoming integrated into a single factor construct. If these developments are generalizable across diverse patient/treatment populations, future research should take them into account both methodologically (i.e., how alliance is measured) and in analyzing time-series data (e.g., using DLC-SEM).