The Norway Couple Project: Lessons Learned

Session-to-session bidirectional associations of alliance with depressive symptoms and relationship satisfaction

The relationship between therapeutic alliance and treatment outcomes is one of the most widely studied topics in psychotherapy research. Research has primarily considered a unidirectional model whereby alliance predicts outcomes, which implies that building alliance early in therapy results in later symptom improvement and ignores the possibility that early symptom improvement could also subsequently lead to improved alliance. This study explored the bidirectional associations of alliance and outcomes session-to-session for 15 sessions among a sample of 24 couples randomized to emotionally focused therapy or treatment as usual for depression and relationship dissatisfaction. Multilevel models tested associations between the prior week's alliance and the following week's clinical outcomes (i.e., depressive symptoms and relationship satisfaction) and the prior week's clinical outcomes with the following week's alliance. Findings indicated that the prior week's alliance was associated with the following week's relationship satisfaction, but not depressive symptoms, when controlling for the prior week's depressive symptoms and relationship satisfaction in each respective model. In addition, the prior week's depressive symptoms and relationship satisfaction were both associated with the following week's alliance, when controlling for the prior week's alliance. Only one of these associations differed by sex: previous week's higher relationship satisfaction was associated with higher therapeutic alliance the following week for males than females. These bidirectional associations did not differ by treatment condition. This study contributes to the emerging empirical support suggesting bidirectionality among alliance and treatment outcomes.

The Gap Between Couple Therapy Research Efficacy and Practice Effectiveness

Meta-analyses of randomized controlled trials of couple therapy find large improvements in couple adjustment, but published evaluations of the effectiveness of couple therapy in routine practice find only small-to-moderate effects. The current study analyzes possible explanations for the research-efficacy to practice-effectiveness gap and offers suggestions for enhancing couple therapy effectiveness. Major recommendations are that therapists should clarify whether couples' therapy goal is to clarify commitment to the relationship or to improve the relationship; use standardized assessment of the individual partners and the relationship; and use systematic monitoring of therapy progress and the therapeutic alliance. It is also possible that the greater use of evidence-based therapies when treating couple relationship distress could enhance couple therapy outcome.

Therapeutic Alliance and Retention in Brief Strategic Family Therapy: A Mixed-Methods Study

We explored how the therapeutic alliance contributed to retention in Brief Strategic Family Therapy by analyzing videotapes of eight-first sessions in which four therapists worked with one family that stayed in treatment and one family that dropped out. Although behavioral exchange patterns between clients and therapists did not differ by retention status, positive therapist alliance-related behavior followed negative client alliance behavior somewhat more frequently in the retained cases. In the qualitative aspect of the study, four family therapy experts each viewed two randomly assigned sessions and commented on their quality without knowing the families' retention status. A qualitative analysis of the audiotaped commentaries revealed 18 alliance-related themes that were more characteristic of either the retained or the nonretained cases.