The role of alliance and symptomatic change within cognitive behaviour therapy for depression : a thesis presented in partial fulfillment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand

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Massey University
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This thesis explores the role of alliance processes and symptomatic change within Cognitive Behaviour Therapy for depression (A. T., Beck, Rush, Shaw, & Emery, 1979). Archived session data from The Depression Outcome Study conducted at Massey University, Albany (2006-2009) and a single-case research design with multiple assessments was used to determine temporal relations between alliance and depression severity. An observer version of the Working Alliance Inventory-Short Revised (WAI-SR-O) was utilized to rate the alliance of ten client-therapist dyads every session over the first ten sessions of therapy. Symptomatic change was assessed every session with the Beck Depression Inventory–II. Increasing inter-rater reliability of the current research involved seeking guidelines for rating the WAI from researchers overseas. These guidelines were modified and expanded to rate the WAI-SR-O within CBT. A rater reliability study was conducted in two stages to provide a forum to train the raters for the current research and establish inter-rater reliability. Similar to previous research, results of the current research demonstrated that an early strong alliance may predict a positive outcome and poor early alliance may lead to premature termination of therapy. It was difficult to draw definite conclusions as to whether alliance precedes symptomatic change. However, findings suggested that a reciprocal relationship between alliance and symptomatic change may start in the assessment stages of therapy. The current research demonstrated a clear reciprocal relationship between Total Alliance scores and depression severity in some sessions in some cases. A strong alliance contributed to a decrease in depression severity which subsequently increased the alliance. However, in other sessions the reciprocal relationship was not as clear. Furthermore, definite conclusions could not be drawn about the reciprocal effects between the components of the alliance (i.e., Goal, Task and Bond subscales) and depression severity. However, symptomatic change was found to be greater in the context of a strong bond between the client and therapist. There was also some evidence of subscale scores increasing following a decrease in depression severity and decreasing following an increase in depression severity in the same session that the depression severity was rated. Furthermore, there was evidence that findings were related to variability of data, nature of the alliance and time and environmental factors.
Cognitive Behaviour Therapy, Depression, Psychotherapy, Therapeutic alliance