{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T07:13:40Z","timestamp":1776410020336,"version":"3.51.2"},"reference-count":53,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,4,16]],"date-time":"2021-04-16T00:00:00Z","timestamp":1618531200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100013373","name":"NIHR Oxford Biomedical Research Centre","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100013373","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009981","name":"Mental Health Research UK","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100009981","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Psychiatry"],"abstract":"<jats:p><jats:bold>Background:<\/jats:bold> Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings.<\/jats:p><jats:p><jats:bold>Objective:<\/jats:bold> To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD).<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold> Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings.<\/jats:p><jats:p><jats:bold>Conclusions:<\/jats:bold> Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.<\/jats:p>","DOI":"10.3389\/fpsyt.2021.602648","type":"journal-article","created":{"date-parts":[[2021,4,16]],"date-time":"2021-04-16T16:59:03Z","timestamp":1618592343000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":20,"title":["The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder"],"prefix":"10.3389","volume":"12","author":[{"given":"Esther T.","family":"Beierl","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hannah","family":"Murray","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Milan","family":"Wiedemann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emma","family":"Warnock-Parkes","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jennifer","family":"Wild","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard","family":"Stott","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nick","family":"Grey","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David M.","family":"Clark","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anke","family":"Ehlers","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2021,4,16]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"438","DOI":"10.1037\/0022-006X.68.3.438","article-title":"Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review","volume":"68","author":"Martin","year":"2000","journal-title":"J Consult Clin Psychol"},{"key":"B2","volume-title":"Forms of Feeling: The Heart of Psychotherapy","author":"Hobson","year":"1985"},{"key":"B3","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1037\/0022-0167.38.2.139","article-title":"Relation between working alliance and outcome in psychotherapy: a meta-analysis","volume":"38","author":"Horvath","year":"1991","journal-title":"J Couns Psychol"},{"key":"B4","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1037\/a0022186","article-title":"Alliance in individual psychotherapy","volume":"48","author":"Horvath","year":"2011","journal-title":"Psychotherapy"},{"key":"B5","doi-asserted-by":"publisher","first-page":"469","DOI":"10.1007\/BF01172968","article-title":"Determinants of change in cognitive therapy for depression","volume":"14","author":"DeRubeis","year":"1990","journal-title":"Cognit Ther Res"},{"key":"B6","doi-asserted-by":"publisher","first-page":"635","DOI":"10.1037\/a0020051","article-title":"The alliance in couple therapy: partner influence, early change, and alliance patterns in a naturalistic sample","volume":"78","author":"Anker","year":"2010","journal-title":"J Consult Clin Psychol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1037\/a0023668","article-title":"The dependability of alliance assessments: the alliance\u2013outcome correlation is larger than you might think","volume":"79","author":"Crits-Christoph","year":"2011","journal-title":"J Consult Clin Psychol"},{"key":"B8","doi-asserted-by":"publisher","first-page":"584","DOI":"10.1037\/ccp0000302","article-title":"Common change factors and mediation of the alliance\u2013outcome link during treatment of depression","volume":"86","author":"Schwartz","year":"2018","journal-title":"J Consult Clin Psychol"},{"key":"B9","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1037\/a0023252","article-title":"Two aspects of the therapeutic alliance: differential relations with depressive symptom change","volume":"79","author":"Webb","year":"2011","journal-title":"J Consult Clin Psychol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"578","DOI":"10.1037\/0022-006X.67.4.578","article-title":"The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression","volume":"67","author":"Feeley","year":"1999","journal-title":"J Consult Clin Psychol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"599","DOI":"10.1016\/j.brat.2010.03.011","article-title":"The process of change in cognitive therapy for depression: predictors of early inter-session symptom gains","volume":"48","author":"Strunk","year":"2010","journal-title":"Behav Res Ther"},{"key":"B12","doi-asserted-by":"publisher","first-page":"1027","DOI":"10.1037\/0022-006X.68.6.1027","article-title":"Alliance predicts patients' outcome beyond in-treatment change in symptoms","volume":"68","author":"Barber","year":"2000","journal-title":"J Consult Clin Psychol"},{"key":"B13","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1080\/15374416.2012.723261","article-title":"The reciprocal relationship between alliance and symptom improvement across the treatment of childhood anxiety","volume":"42","author":"Marker","year":"2013","journal-title":"J Clin Child Adolesc Psychol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"351","DOI":"10.1037\/cou0000089","article-title":"Reciprocal influence model of working alliance and therapeutic outcome over individual therapy course","volume":"62","author":"Xu","year":"2015","journal-title":"J Couns Psychol"},{"key":"B15","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1080\/15299732.2017.1329771","article-title":"The role of evidence-based therapy relationships on treatment outcome for adults with trauma: a systematic review","volume":"19","author":"Ellis","year":"2018","journal-title":"J Trauma Dissociation"},{"key":"B16","doi-asserted-by":"publisher","first-page":"413","DOI":"10.1016\/j.brat.2004.03.006","article-title":"Cognitive therapy for post-traumatic stress disorder: development and evaluation","volume":"43","author":"Ehlers","year":"2005","journal-title":"Behav Res Ther"},{"key":"B17","doi-asserted-by":"publisher","first-page":"319","DOI":"10.1016\/S0005-7967(99)00123-0","article-title":"A cognitive model of posttraumatic stress disorder","volume":"38","author":"Ehlers","year":"2000","journal-title":"Behav Res Ther."},{"key":"B18","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1016\/j.brat.2015.10.001","article-title":"Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder","volume":"75","author":"Brady","year":"2015","journal-title":"Behav Res Ther"},{"key":"B19","doi-asserted-by":"publisher","first-page":"974","DOI":"10.1037\/a0020758","article-title":"Understanding factors associated with early therapeutic alliance in PTSD treatment: adherence, childhood sexual abuse history, and social support","volume":"78","author":"Keller","year":"2010","journal-title":"J Consult Clin Psychol"},{"key":"B20","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1002\/jcad.12297","article-title":"The influence of trauma symptoms on the therapeutic alliance across treatment","volume":"98","author":"Lawson","year":"2020","journal-title":"J Counsel Dev"},{"key":"B21","doi-asserted-by":"publisher","first-page":"445","DOI":"10.1037\/1040-3590.9.4.445","article-title":"The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale","volume":"9","author":"Foa","year":"1997","journal-title":"Psychol Assess"},{"key":"B22","volume-title":"Diagnostic and Statistical Manual of Mental Disorders. Fourth edition, DSM-IV","year":"2000"},{"key":"B23","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1037\/1040-3590.1.3.207","article-title":"Factor structure of the working alliance inventory","volume":"1","author":"Tracey","year":"1989","journal-title":"Psychol Assess"},{"key":"B24","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1037\/0022-0167.36.2.223","article-title":"Development and validation of the working alliance inventory","volume":"36","author":"Horvath","year":"1989","journal-title":"J Couns Psychol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"252","DOI":"10.1037\/h0085885","article-title":"The generalizability of the psychoanalytic concept of the working alliance","volume":"16","author":"Bordin","year":"1979","journal-title":"Psychother Theory Res Pract"},{"key":"B26","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1348\/014466599162836","article-title":"PTSD symptoms, response to intrusive memories, and coping in ambulance service workers","volume":"38","author":"Clohessy","year":"1999","journal-title":"Br J Clin Psychol"},{"key":"B27","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1192\/bjp.180.4.363","article-title":"Dissociation and posttraumatic stress disorder: two prospective studies of road traffic accident victims","volume":"180","author":"Murray","year":"2002","journal-title":"Br J Psychiatry"},{"key":"B28","volume-title":"Latent curve models: A structural equation approach","author":"Bollen","year":"2006"},{"key":"B29","doi-asserted-by":"crossref","DOI":"10.1002\/9781118619179","volume-title":"Structural Equations with Latent Variables","author":"Bollen","year":""},{"key":"B30","doi-asserted-by":"publisher","first-page":"183","DOI":"10.1007\/BF02289343","article-title":"A general approach to confirmatory maximum likelihood factor analysis","volume":"34","author":"J\u00f6reskog","year":"1969","journal-title":"Psychometrika"},{"key":"B31","doi-asserted-by":"publisher","first-page":"238","DOI":"10.1037\/0033-2909.107.2.238","article-title":"Comparative fit indexes in structural models","volume":"107","author":"Bentler","year":"1990","journal-title":"Psychol Bull"},{"key":"B32","article-title":"Statistically based tests for the number of common factors","volume-title":"Paper presented at the Annual Meeting of the Psychometric Society","author":"Steiger","year":"1980"},{"key":"B33","volume-title":"Analysis of Linear Structural Relationships by Maximum Likelihood and Least Squares Methods (Report No. 81-88)","author":"J\u00f6reskog","year":"1981"},{"key":"B34","volume-title":"Mplus User's Guide","author":"Muth\u00e9n","year":""},{"key":"B35","first-page":"243","article-title":"Full information estimation in the presence of incomplete data","volume-title":"Advanced Structural Equation Modeling","author":"Arbuckle","year":"1996"},{"key":"B36","volume-title":"RStudio: Integrated development for R","year":"2021"},{"key":"B37","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v048.i02","article-title":"lavaan: An R package for structural equation modeling","volume":"48","author":"Rosseel","year":"2012","journal-title":"J Stat Software"},{"key":"B38","unstructured":"RevelleW\n          20392272Evanston, ILNorthwestern Universitypsych: Procedures for Personality and Psychological Research2020"},{"key":"B39","doi-asserted-by":"publisher","first-page":"754","DOI":"10.21105\/joss.00754","article-title":"sjmisc: Data and variable transformation functions","volume":"3","author":"L\u00fcdecke","year":"2018","journal-title":"J Open Source Software"},{"key":"B40","unstructured":"WaringE\n            QuinnM\n            McNamaraA\n            Arinode la Rubia E\n            ZhuH\n            EllisS\n          skimr: Compact and Flexible Summaries of Data2020"},{"key":"B41","unstructured":"LenthRV\n          emmeans: Estimated Marginal Means, aka Least-Squares Means2021"},{"key":"B42","doi-asserted-by":"publisher","first-page":"1686","DOI":"10.21105\/joss.01686","article-title":"Welcome to the tidyverse","volume":"4","author":"Wickham","year":"2019","journal-title":"J Open Source Software"},{"key":"B43","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1037\/a0031290","article-title":"Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder","volume":"81","author":"Kleim","year":"2013","journal-title":"J Consult Clin Psychol"},{"key":"B44","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1007\/s10608-018-9938-1","article-title":"A review of the role of negative cognitions about oneself, others, and the world in the treatment of PTSD","volume":"43","author":"Brown","year":"2019","journal-title":"Cognit Ther Res"},{"key":"B45","doi-asserted-by":"publisher","first-page":"1067","DOI":"10.1037\/0022-006X.70.5.1067","article-title":"Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse","volume":"70","author":"Cloitre","year":"2002","journal-title":"J Consult Clin Psychol"},{"key":"B46","doi-asserted-by":"publisher","first-page":"695","DOI":"10.3109\/10826084.2012.659789","article-title":"Helping alliance, retention, and treatment outcomes: a secondary analysis from the NIDA clinical trials network women and trauma study","volume":"47","author":"Ruglass","year":"2012","journal-title":"Subst Use Misuse"},{"key":"B47","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1002\/jts.20315","article-title":"Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder","volume":"21","author":"Forbes","year":"2008","journal-title":"J Trauma Stress"},{"key":"B48","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1016\/S0005-7967(01)00024-9","article-title":"Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout","volume":"40","author":"Van","year":"2002","journal-title":"Behav Res Ther"},{"key":"B49","volume-title":"Cognitive Therapy of Depression","author":"Beck","year":"1979"},{"key":"B50","doi-asserted-by":"publisher","first-page":"22676","DOI":"10.3402\/ejpt.v5.22676","article-title":"The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders","volume":"5","author":"Cronin","year":"2014","journal-title":"Eur J Psychotraumatol"},{"key":"B51","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1037\/a0038889","article-title":"A critique of the cross-lagged panel model","volume":"20","author":"Hamaker","year":"2015","journal-title":"Psychol Methods"},{"key":"B52","doi-asserted-by":"publisher","first-page":"672","DOI":"10.1002\/jts.21968","article-title":"Psychophysiological predictors of working alliance among treatment-seeking women with complex trauma exposure","volume":"27","author":"Doukas","year":"2014","journal-title":"J Trauma Stress"},{"key":"B53","doi-asserted-by":"publisher","first-page":"809","DOI":"10.1080\/10705511.2018.1431046","article-title":"Drawing conclusions from cross- lagged relationships: re-considering the role of the time-interval","volume":"25","author":"Kuiper","year":"2018","journal-title":"Struct Equat Model"}],"container-title":["Frontiers in Psychiatry"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2021.602648\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,4,16]],"date-time":"2021-04-16T16:59:16Z","timestamp":1618592356000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2021.602648\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,4,16]]},"references-count":53,"alternative-id":["10.3389\/fpsyt.2021.602648"],"URL":"https:\/\/doi.org\/10.3389\/fpsyt.2021.602648","relation":{},"ISSN":["1664-0640"],"issn-type":[{"value":"1664-0640","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,4,16]]},"article-number":"602648"}}