Therapeutic Alliance--Especially challenging in CT?

I felt compelled to throw my two cents worth into this discussion topic. I was a cognitive therapist in the now infamous NIMH Collaborative study of depression. Many of you probably know that CT fared more poorly in that study than it has in almost all others to date. Close analysis of the data suggest that CT produced unusually variable results in that study. In fact, three of us obtained excellent results, while five CT therapists landed in the "Less effective" group depicted in a recent article by Blatt, Sanislow, Zuroff, and Pilkonis (1996) in the Journal of Consulting and Clinical Psychology 64, 1276-1284. Not one CT therapist showed up in the "Moderately effective" group. Why? I disagree with the authors conclusions--you can read the article for what they had to say (not that anyone has wanted to listen to what the therapists in the study have to say).

I truly believe that the training of therapists in that study focused too much on technique as opposed to "process" and alliance issues. Cognitive therapy that pushes change too aggressively can easily result in very poor outcome. Unfortunatley, many neophytes to CT can all too easily focus on technique and attempts to change the client prematurely. The techniques are great; they work. Yet, they will not work if one has not acquired sophisticated skills in maintaining a good, collaborative relationship with the client. By the way, I realize that data from the study have not especially supported my suppositions. However, I think this is a very subtle issue, that was not readily detected by the therapy rating scales used in the study. Even brief breaches of the therapeutic alliance can result in "disaster." I think not enough attention has been paid to such breaches.

Alliance isn't the whole story, of course. Some of us in the study did things a bit differently than others. I plan to write a letter to the editor of Behavior Therapy or some such publication soon detailing a bit more about these issues. Several times in the last decade I offered my thoughts to those who conducted this study, but no interest was shown in interviewing the therapists. I wonder why....

chelliott@worldnet.att.net

Replies:

Technique vs Alliance in CT, by Jim Pretzer, 2/14/97 Therapeutic Alliance and the NIMH study on depression by Elkin, by Brian O'Neill, 2/15/97 Measurement of Alliance, by Chuck Elliott, 2/21/97

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