ORIGINAL ARTICLE
Interaction Between Alliance and Technique in Predicting Patient
Outcome During Psychodynamic Psychotherapy
Jesse Owen, PhD* and Mark J. Hilsenroth, PhDÞ
Abstract: The current study examined whether alliance interacted with psy-
chodynamic interventions to predict patients’ psychotherapy outcomes. A
prospective study of psychodynamic psychotherapy with 68 outpatients who
were treated by 23 therapists was used. The patients rated the alliance with their
therapist early in treatment. Therapist use of psychodynamic techniques was
reliably rated by independent clinicians for the same sessions. The therapy
outcomes were measured at the end of treatment based on the patients’ global
symptomatology as well as estimate of improvement across a broad range of
functioning. In all models, we controlled for the patients’ pretherapy psychi-
atric severity. Analyses were conducted using multilevel modeling to account
for therapist effects. Results revealed that patient rated alliance was signifi-
cantly related to improvement on a measure of broad band functioning. In
addition, alliance and psychodynamic interventions interacted to predict this
scale of multidimensional therapy outcome. Further, results showed that sev-
eral individual psychodynamic techniques interacted with alliance that were
meaningfully related to this measure of broad band outcome including (1) link-
ing current feelings or perceptions to the past; (2) focusing attention on simi-
larities among patient’s relationships repeated over time, settings, or people; and
(3) identifying recurrent patterns in patient’s actions, feelings, and experiences.
In this sample of outpatient psychodynamic treatments, the dynamic techniques
were most effective when provided in the context of strong alliances.
Key Words: Alliance, psychodynamic, technique, therapy outcome,
therapy process.
(J Nerv Ment Dis 2011;199: 384Y389)
T he therapeutic alliance has a long history within psychodynamic
theory (Gelso, 2009; Greenson, 1965). Extending this foundation
pantheoretically, the model of alliance by Bordin (1979) defined al-
liance as the agreement between the therapist and the patient on the
goals of the therapy, the methods to be used to reach those goals, and
the degree to which the therapy dyad has fostered an emotional or
relational bond. In hundreds of studies, the patients’ rating of alliance
has been a positive predictor of therapy outcomes across therapy
modalities, accounting for approximately 5% to 8% of the variance
in therapy outcomes (Horvath et al., 2011; Martin et al., 2000;
Orlinsky et al., 2004), which is consistent with the role of specific
interventions in predicting therapy outcomes (8%; Wampold, 2001).
Several psychodynamic scholars have suggested that alliance
and psychodynamic techniques are intertwined (Luborsky, 1984;
Malan, 1976; Strupp and Binder, 1984). Although this position is
intuitive, there are few empirical studies addressing this premise
(Barber, 2009). For instance, Gaston et al. (1994, 1998) found that
the greater use of exploratory techniques (e.g., processing clients’
*Department of Educational and Counseling Psychology, University of Louisville,
Louisville, KY; and †Derner Institute of Advanced Psychological Studies,
Adelphi University, Garden City, NY.
Send reprint requests to Jesse J. Owen, PhD, Department of Educational and
Counseling Psychology, University of Louisville, Louisville KY, 40292.
E-mail: jesse.owen@louisville.edu.
Copyright * 2011 by Lippincott Williams & Wilkins
ISSN: 0022-3018/11/19906-0384
DOI: 10.1097/NMD.0b013e31821cd28a
384 www.jonmd.com The Journal of Nervous and Mental Disease
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reactions) interacted with alliance to predict better therapy outcomes
in dynamic treatment. In psychodynamic therapies for cocaine de-
pendency, two studies have found contrasting results. Crits-Christoph
et al. (1988) found no support for the interaction between the accu-
racy of interpretations and alliance in predicting outcomes in psy-
chodynamic therapy. More recently, Barber et al. (2008) found that
strong alliance coupled with fewer dynamic techniques was asso-
ciated with better therapy outcomes in a sample of cocaine-dependent
patients. However, one limitation of these studies is that they did not
account for the interdependencies that arise from patients who are
treated by the same therapist (i.e., therapist effects) because therapists
have been shown to account for a significant proportion of the variance
in patient ratings of alliance and therapy outcomes (Marcus et al., 2009;
Wampold and Brown, 2005). Multilevel modeling is an effective way
of accounting for these interdependencies among patients who are
treated by the same therapist, ultimately limiting statistical errors (e.g.,
type I; Marcus et al., 2009). This study will be the first, to our knowl-
edge, to use multilevel modeling in examining the relationship between
alliance and dynamic technique with patient outcomes.
Although having a strong alliance with patients may be partic-
ularly important in the delivery of psychodynamic techniques, patient
factors may influence the formation of the alliance as well as the
therapists’decisions to use particular interventions. For instance, some
studies have shown that more symptomatic patients may have worse
outcomes and alliance in psychodynamic therapies (Leichsenring and
Leibing, 2007). Therefore, it is also important to account for the
patients’ psychiatric severity when exploring how alliance and psy-
chodynamic techniques relate to therapy outcomes. We hypothesized
that higher ratings of alliance coupled with more psychodynamic
interventions early in treatment would be significantly related to better
therapy outcomes at the end of treatment, after controlling for patient
pretherapy levels of psychopathology. In doing so, we will use mul-
tilevel modeling to account for the potential dependencies in patient
ratings, thus also accounting for therapist effects.
METHODS
Patients
The participants (N = 68) were patients admitted to a psy-
chodynamic psychotherapy treatment team at a university-based
community outpatient clinic, regardless of disorder or comorbidity
(Hilsenroth, 2007). Table 1 displays the demographic information and
the distribution of the patients’ primary axes I and II diagnoses in
accordance with the DSM, 4th edition (American Psychiatric Asso-
ciation, 1994). This sample consisted of primarily mood-disordered
patients with relational problems manifested in either axis II person-
ality disorders or subclinical traits/features of axis II personality dis-
orders, generally in the mild to moderate range of psychopathology.
Therapists
The therapists were 23 advanced doctoral students (12 men and
11 women) enrolled in an American Psychological AssociationY
approved clinical PhD program. Each therapist received a minimum
of 3.5 hours of supervision per week (1.5 hours of individual and
2 hours of group) on a therapeutic model of assessment (Hilsenroth,
& Volume 199, Number 6, June 2011
The Journal of Nervous and Mental Disease & Volume 199, Number 6, June 2011 Alliance and Technique in Therapy

aided, and informed by the technical guidelines delineated in the

TABLE 1. Demographic Information on the Patient
Sample (N = 68) treatment manuals detailed previously. Key features of the psycho-
dynamic treatment model used in these sessions included a) focus on
n % affect and the expression of emotion; b) exploration of attempts to
Sex avoid topics or engage in activities that may hinder the progress of
Men 18 26 therapy; c) the identification of patterns in actions, thoughts, feelings,
experiences, and relationships; d) emphasis on past experiences;
Women 50 74
e) focus on interpersonal experiences; f ) emphasis on the therapeutic
Age, mean (SD), yrs 29.8 (11.00) relationship/alliance; and g) exploration of wishes, dreams, or fan-
Marital status tasies (Blagys and Hilsenroth, 2000). In addition to these areas of
Single 42 62 treatment focus, relational patterns, case presentations, and symptoms
Married 16 24 were conceptualized in the context of cyclical patterns (Book, 1998;
Divorced 10 14 Luborsky, 1984; McCullough et al., 2003; Strupp and Binder, 1984;
Primary axis I diagnosis Wachtel, 1993). Also, the Safran and Muran (2000) model of inter-
Adjustment disorder 9 13 vention was used for treatment ruptures and their repair as they oc-
Anxiety disorder 10 15 curred in the therapeutic relationship.
Eating disorder 1 1.5 The treatment was open-ended in length rather than fixed in
duration. All sessions of these treatments were videotaped. The
Impulse disorder 1 1.5
patients included in the present analyses had attended a minimum of
Mood disorder 35 51.5 nine sessions and had completed, at least, a ninth session reassessment
Substance-related disorder 1 1.5 battery. The mean number of sessions attended by these 68 patients
V code relational problems 11 16 was 27 sessions over an average of 9 months (median, 21 sessions). In
Axis II diagnosis 38 56 all cases, the therapist who carried out the psychological assessment
Axis II trait/features 18 27 also conducted the formal psychotherapy sessions.

2007; Finn and Tonsager, 1997), clinical interventions, the organiza-
tion of collaborative feedback, psychodynamic theory, and a review of
videotaped case material. All therapists were trained in psychody-
namic assessment, case formulation, and psychotherapy (Hilsenroth
et al., 2006, for detailed review). On average, the therapists treated
2.96 patients, with all therapists treating at least two patients.
Treatment
Case Assignment and Intake Procedures
The cases were assigned to therapists in an ecologically valid
manner based on the therapists’ availability and caseload. After case
assignment, the patients received a psychological evaluation based
on the therapeutic model of assessment (TMA; Hilsenroth, 2007;
Finn and Tonsager, 1997). The TMA is a multimethod assessment
that includes an initial interview, completion of self-report, and free-
response measures. In this process, the therapists worked collabora-
tively with patients to develop a) an empathic connection (i.e., alliance
fostering), b) an understanding of factors contributing to the mainte-
nance of life problems (often relational), and c) treatment goals and
negotiate an explicit treatment frame (i.e., scheduling session times,
frequency of treatment session(s), and payment plan). Furthermore,
the therapist shared and explored the results from the assessment with
patients. The final aspect of the TMA was to emphasize the promi-
nent interpersonal/intrapersonal themes derived from the testing
results, the therapist/patient interaction, the factors that contribute
to the maintenance of life problems, and an opportunity to explore
these new understandings and apply them to their current problems
in living. The patient and therapist also reviewed a socialization
interview developed by Luborsky (1984) on what to expect in psy-
chodynamic psychotherapy, such as the patient’s and therapist’s roles
during treatment (i.e., focusing on relational processes), interpersonal
learning (i.e., insight), and potential outcomes (both positive and
negative).
Treatment Phase
The treatment consisted of sessions of psychodynamic psy-
chotherapy treatment conducted once or twice weekly; organized,
Measures
Combined Alliance Short FormYPatient Version
The Combined Alliance Short FormYPatient Version (CASF-P;
Hatcher and Barends, 1996) is a patient-rated alliance measure cre-
ated from a factor analysis of the responses of 231 outpatients at a
university-based community clinic from three widely used measures
of alliance. The CASF-P consists of 20 items rated on a 7-point scale
ranging from 1 (never) to 7 (always). Previous research has sup-
ported the reliability (e.g., > = 0.91 for the total score) and validity
of this measure using a subset of the current participants (Ackerman
et al., 2000). The patients were informed, both verbally and in writing,
that their therapist would not have access to their responses on any
psychotherapy process measure (i.e., alliance). For the current sample,
the mean (SD) CASF-P score was 6.16 (0.62; range, 4.45 to 7.00) from
the early treatment sessions (i.e., third or fourth) used in this study.
Comparative Psychotherapy Process Scale
The Comparative Psychotherapy Process Scale (CPPS) is based
upon the findings of two empirical reviews of the comparative psy-
chotherapy process literature (Blagys and Hilsenroth, 2000; Hilsenroth
et al., 2005). It is a brief descriptive measure designed to assess
therapist activity and the techniques used and occurring during the
therapeutic hour. Based on these reviews, a list of interventions was
developed from the empirical literature that represents the character-
istic features of psychodynamic-interpersonal (PI) and cognitive-
behavioral (CB) treatments. The measure consists of 20 randomly
ordered techniques rated on a 7-point scale ranging from 0 (not at
all characteristic), through 2 (somewhat characteristic), 4 (character-
istic), to 6 (extremely characteristic). Ten statements are characteristic
of PI interventions (CPPS-PI), and 10 statements are characteristic of
CB interventions (CPPS-CB). The CPPS may be completed by a
patient, therapist, or an external rater. The reliability and clinical va-
lidity of the CPPS has been well established (Hilsenroth, 2007, for
review). Recently, Hilsenroth et al. (2005) reported on the interrater
reliability for the CPPS-PI and CPPS-CB scale scores, ranging from
good (intraclass correlation coefficient [ICC], 0.60 to 0.74) to ex-
cellent (90.75), and on significant results on six separate validity
analyses conducted across several different contexts and samples. In
the current study, we used the CPPS-PI subscale, which was based on

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Owen and Hilsenroth The Journal of Nervous and Mental Disease
independent clinic ratings of videotape from an early (i.e., third or
fourth) treatment session, the same session in which patient alliance
was rated (CPPS-PI: mean (SD), 32.45 (7.06); CPPS-CB: mean (SD)
12.53 (5.46); t = 17.37, p G 0.001, d = 3.2). Accordingly, the treatment
was largely psychodynamically focused, and the scores on the CPPS-
PI were approximately at the midpoint of the rating scale.
Brief Symptom Inventory
The Brief Symptom Inventory (Derogatis and Melisarotas,
1983) is a patient-rated symptomatic checklist addressing issues such
as somatic complaints, obsessive-compulsive behaviors or thoughts,
interpersonal sensitivity, depression, anxiety, hostility, phobic reac-
tions, paranoia, and psychotic thought processes using a 5-point scale
ranging from 0 (not at all) to 4 (extremely). This measure contains a
summary score, the Global Severity Index (GSI), which is considered
the best single indicator of the current level of symptomatic distress.
In the current study, we used the patients’ pre- and post-GSI scores,
with the post-GSI scores being an indicator of therapy outcomes (after
controlling for pretherapy functioning). The pretreatment and post-
treatment GSI means (SDs) for the sample were 1.40 (0.58) and
0.70 (0.62), respectively (t = 4.40, p G 0.001, d = 1.2).
Patient’s Estimate of Improvement
The Patient’s Estimate of Improvement (PEI; Hatcher and
Barends, 1996) is 16-item questionnaire assessing improvement dur-
ing psychotherapy across a broad range of patient functioning (i.e.,
beyond only symptomatic change). This measure is modeled after the
items developed by Alexander and Luborsky (1986) to assess the de-
gree of the patient’s change that was caused by psychotherapy. The
questions assess the change in one’s general functioning, symptom
distress, intimate and social relationships, work or school, feelings
about oneself, behavior, control of life, and tolerance for and ability to
share painful feelings, as well as the helpfulness and benefit of and
productivity and satisfaction with psychotherapy. Fourteen of these
items were rated on a 9-point bipolar scale ranging from 1 (very much
worse) to 9 (very much better) with 5 (no change) as the midpoint value;
one item (‘‘To what extent have your original complaints or symptoms
improved?’’) was rated on a 7-point scale ranging from 1 (not at all) to
7 (very much) with 4 (moderately) as the midpoint value, and one free-
response item regarding treatment (not analyzed here). The patients’
mean (SD) posttherapy ratings on this measure were 104.58 (13.18;
range, 57.00 to 127.00; possible range, 15.00 to 133.00).
RESULTS
The patients were treated as nested within therapist, creating
two levels: the therapist level (level 2) and the patient level (level 1). A
two-level multilevel regression model (MLM) was conducted using
Hierarchical Linear Modeling 6.04 software (Raudenbush et al.,
2005). The MLM is generally indicated when significant variances in
the variables are attributable to the therapist, suggesting patient ratings
are not independent. That is, it is likely that patients who were treated
by the same therapist would be more similar than patients who were
treated by other therapists. To quantify the variability caused by the
therapist in PEI, CASF-P, CPPS-PI, and GSI, we conducted four
random-intercept only models (e.g., each variable was entered as
the outcome variable with no predictors; however, in the baseline
model predicting GSI, we controlled for pretherapy GSI; Wampold
and Brown, 2005). In doing so, we calculated the ICCs for the four
variables, respectively, by dividing the level 2 variance by the total
variance (level 1 variance plus level 2 variance). The ICC describes
the proportion of total variance in the variable (i.e., alliance or therapy
outcomes) that is attributable to therapists. The ICCs for the PEI,
CASF-P, CPPS-PI, and GSI were 0.38, 0.24, 0.31 and 0.10 (P-values
for all analyses were G 0.01, except for GSI, where p = 0.17), re-
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spectively, suggesting that who the therapist is has a consistent role in
his or her patients’ experiences in psychotherapy.
Because there was not true random assignment of cases, we
also conducted a baseline model for GSI at pretherapy to ascertain
whether therapists’ had different levels of severity before therapy. The
ICC for GSI at pretherapy was less than 0.001, suggesting that the
therapists did not differ in their patients’ pretherapy distress and that,
therefore, equivalent levels of psychiatric severity were observed
across therapists. Consistent with traditional regression analyses, we
centered alliance and CPPS-PI scores to create the interaction effect
(Aiken and West, 1991).
First, we examined whether alliance, psychodynamic techniques,
and their interaction-predicted GSI at posttherapy, after controlling for
GSI at pretherapy (all variables were grand-mean centered). All of
the variables were entered at level 1 (patient level), and there were
no therapist level variables. None of the predictor variables were sta-
tistically significant. These results suggest that the patient ratings of
alliance (B = 0.01, SE = 0.08, p = 0.94), the independent clinical
ratings of the therapists’ use of PI techniques (B = j0.002, SE = 0.02,
p = 0.89), or their interaction was not significantly associated with the
patients’ GSI at posttherapy (B = j0.03, SE = 0.02, p = 0.15). As
expected, the patients’ GSI at pretherapy was significantly associated
with GSI scores at posttherapy (B = 0.54, SE = 0.14, p G 0.001).
Although alliance, psychodynamic techniques, and their interaction
did not predict posttherapy GSI, we would note that the sample
demonstrated significant ( p G 0.001) and large effect (d = 1.2)
changes on GSI across the course of treatment.
Second, we tested whether the patients’ PEI scores would be
predicted by their ratings of alliance, by the independent clinical
ratings of the therapists’ use of PI techniques, and the interaction
effect between alliance and PI, after controlling for pretherapy GSI
ratings (all variables were grand-mean centered). The use of pre-
therapy GSI ratings will help account for the patients’ initial level of
distress in this model. The results from the model are presented in
Table 2. The patients’ rating of alliance was significantly related to
therapy outcomes; independent clinical ratings of PI techniques were
not associated with therapy outcomes. However, there was a signifi-
cant interaction effect between alliance and PI techniques (Fig. 1).
Given the significant interaction effect, we also tested the simple
slopes. The results demonstrated that, for patients who received one
standard deviation more PI techniques, alliance was significantly
related to therapy outcomes (B = 13.95, SE = 3.67, t = 3.80, p G 0.01,
d = 1.06). However, for patients who received one standard deviation
fewer PI techniques, their alliance was not significantly associated
with therapy outcomes (B = 2.37, SE = 1.77, t = 1.34, p = 0.19,
TABLE 2. Summary of Multilevel Model Predicting PEI by
Alliance, CPPS-PI, and Alliance  CPPS-PI, Controlling for
Pretherapy GSI (N = 68)
Fixed Effects Coefficient (SE) t
Intercept for PEI (F00) 104.48 (1.93) 54.27**
PreYGSI-control variable (B10) 1.65 (1.97) 0.84
Alliance (B20) 8.15 (2.15) 3.79**
CPPS-PI (B30) j0.04 (0.19) j0.20
Alliance  CPPS-PI (B40) 0.82 (0.27) 3.01*
Random Effects Variance W2
Therapist variance (R2ther ) 53.25 50.50**
Client variance (R2e ) 103.32
PEI indicates Patient’s Estimate of Improvement; CPPS-PI, Comparative Psycho-
therapy Process ScaleYPsychodynamic-Interpersonal; GSI, Global Severity Index.
*p G 0.01.
**p G 0.001.
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The Journal of Nervous and Mental Disease & Volume 199, Number 6, June 2011
FIGURE 1. Interaction effect for alliance  CPPS-PI in the Prediction of Patient Outcome. The scores for alliance reflect the
centered values (z-scores). PEI indicates Patient’s Estimate of Improvement; CPPS-PI, Comparative Psychotherapy Process
ScaleYPsychodynamic-Interpersonal.
d = 0.18). These results suggest that alliance is positively related to
broadband patient functioning outcomes and that alliance is an even
stronger predictor of therapy outcomes for patients who received more
PI techniques, and this is the case controlling for both therapist effects
and pretreatment symptom severity.
In a post hoc analysis, we tested individual techniques  alli-
ance interactions in the prediction of PEI. The following three items
had significant interaction effects ( p G 0.05): ‘‘The therapist links the
patient’s current feelings or perceptions to experiences of the past,’’
‘‘The therapist focused attention on similarities among the patient’s
relationships repeated over time, settings, or people,’’ and ‘‘The ther-
apist identifies recurrent patterns in the patient’s actions, feelings,
and experiences.’’
DISCUSSION
The therapeutic alliance has been a robust predictor of therapy
outcomes, yet the ways in which alliance helps facilitate the therapy
process and therapists’ techniques has been less understood. For in-
stance, in a review of psychodynamic techniques and alliance, Crits-
Christoph and Gibbons (2003) concluded that ‘‘the common clinical
notion that techniques will have their greatest impact in the context of
a positive alliance has yet to receive much empirical support’’ (p. 341).
Accordingly, the current study sought to understand the interrela-
tionship between alliance and psychodynamic techniques in outpa-
tient therapy. The results revealed that the patients’ perceptions of the
alliance with their therapist when coupled with more PI techniques
were a stronger predictor of therapy outcomes based on the PEI
compared with the patients’ alliance when their therapists used fewer
PI interventions, and this is the case after accounting for therapist
effects and controlling for pretreatment symptom severity (i.e., GSI
pretherapy scores). These findings are consistent with and extend the
studies of Gaston et al. (1994, 1998), who also tested the interaction
between dynamic techniques and alliance in outpatient settings and
found a relation between these variables with symptom-based out-
comes. That is, the PEI assesses improvement during psychotherapy
across a broad range of patient functioning, which may not be cap-
tured with purely symptom-based measures.
Conceptually, dynamic techniques aim to promote insight and
affective experiencing, navigate maladaptive coping strategies (i.e.,
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Alliance and Technique in Therapy
defenses), and facilitate repair of core conflictual relational concerns
(Blagys and Hilsenroth, 2000; Luborsky, 1984; McCullough et al.,
2003; Strupp and Binder, 1984). In doing so, the exploration of patient
history, emotions, wishes, and cyclical relation patterns can be a del-
icate therapeutic process to navigate, especially those interventions
that focus on the in-session patient-therapist relationship. Therefore,
the context of strong working alliance may provide a safe collabora-
tive environment for patients and therapists to do this work and make
progress toward treatment goals. Furthermore, post hoc analyses dem-
onstrated that several individual PI techniques were meaningfully
related to outcome in a manner that is highly consistent with the model
of treatment used in this study (i.e., Luborsky, 1984; McCullough
et al., 2003; Strupp and Binder 1984; Wachtel, 1993). These results
showed that, in conjunction with alliance, the individual PI tech-
niques focused on identifying, exploring, and understanding cyclical
relational-affective patterns were related to broadband functional out-
comes that include self, other, relational, occupational, and behavioral
changes, in addition to symptom improvement.
Moreover, these effects were evident after controlling for the
patients’ initial psychiatric symptom severity. Indeed, most patients in
the current study had axes I and II comorbidity, with a significant
degree of mood and personality disorders. This provides a great deal
of generalizability for the results of this study in applied practice and
may provide more support for the use of dynamic interventions when
coupled with high alliance in the treatment of comorbid axis I and II
(i.e., complex disorder) patients (Heroug et al., 2003; Siefert et al.,
2006). However, some research has found that the use of certain
psychodynamic techniques early in therapy should be used cautiously
with patients demonstrating poor object-relatedness (Connolly et al.,
1999). In addition, some caution should be given to this interpretation
because we lacked experimental control of implementing dynamic
techniques (i.e., randomized controlled trial). However, we do present
independent clinical ratings of specific treatment techniques that were
found to represent excellent levels of interrater reliability, and our
findings are consistent with recent studies that have used such designs
(HLglend et al., 2008).
We did not find any significant associations among patient
ratings of alliance, independent ratings of dynamic techniques, or
their interaction with changes in psychiatric symptoms based on the
GSI. However, clients reported large effects in the decrease of their
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Owen and Hilsenroth The Journal of Nervous and Mental Disease
symptom change. Given that alliance is commonly associated with
patient outcomes, it was surprising that the patients’ ratings of alliance
were also not significantly associated with their global symptom
change. This finding is not without precedent in dynamic therapies
(Crits-Christoph and Gibbons, 2003, for a review). For instance, pre-
vious research highlights that the timing and accuracy of the psycho-
dynamic techniques are an important consideration in treatment
outcomes (Crits-Christoph et al., 1998). In contrast with the exclusive
symptom-focus of the GSI, the PEI represents outcomes across a
broad range of self, relational, social and occupational functioning in
addition to target complaints and symptoms. Accordingly, the even-
tual impact of dynamic techniques may be best assessed by defining
outcome in a multidimensional manner to properly assess theoretically
relevant effects, a finding that also has previous empirical support
(Diener et al., 2007; Leichsenring and Rabung, 2008).
The use of multilevel modeling also provides new insights in
the ways that we might understand patient alliance, outcome, and
therapists’ use of technique. Therapists accounted for a sizable pro-
portion of the variance in their patients’ rating of alliance, use of
dynamic techniques, and therapy outcomes. This suggests that some
therapists, on average, are able to form stronger alliances, use more
dynamic techniques, and have patients who report better therapy
outcomes compared with other therapists. It is unclear why some
therapists are eliciting stronger alliances or providing a greater degree
of dynamic techniques, for instance, than other therapists. The mag-
nitude of therapist effects here are consistent to slightly higher than in
previous studies (e.g., Wampold and Brown, 2005), which may be
caused by the number of therapists in the study (Maas and Hox, 2005)
or their level of training. As graduate trainees acquire the requisite
ability to establish a therapeutic relationship and use technique, this
may represent a time of asymmetric development regarding profes-
sional skills and competencies. Nonetheless, our findings suggest that
these therapists had a pivotal role in their patients’ experiences and
improvements across treatment.
The merits of the current study should be interpreted along with
its methodological limitations. First, the study was conducted at an
outpatient training clinic where graduate trainees conducted the
therapy. Future research is needed to test whether these findings will
generalize with more experienced therapists and in other treatment
settings. Regarding other issues related to generalizability and exter-
nal validity, some might object to our inclusion of the 11 patients who
entered treatment using medication (seven antidepressant and four
antianxiety medication users) in the analyses. These patients were
included because this medication regimen had been stabilized upon
entry to treatment (at least 3 months use) and remained so throughout
the course of treatment (i.e., consistent at each assessment point), yet
these patients still desired additional treatment beyond medication to
address their personal goals. Second, our study was naturalistic and
included patients with various clinical syndromes. Although this facet
may increase the external validity of the study, it also limits our ability
to detect differences in our findings based on specific diagnoses. We
did not implement experimental controls over treatment, thus we
cannot definitively rule out other potential confounds. For instance,
we do not know whether therapists used other techniques, beyond the
20 specific PI and CB interventions assessed in this study, that may
have assisted in the delivery of PI techniques. However, based on the
reliable independent clinical ratings of PI and CB techniques it was
clear that PI was the primary approach to therapy. Furthermore, this
does not detract from the specific alliance and technique interactions
that were found to be significantly related to multidimensional out-
comes. In addition, we assessed alliance and techniques early in
therapy; therefore, we do not know whether the changes in the alliance
or the use of techniques were related to patient improvement.
Third, similar to previous studies, the scores on the alliance
measure demonstrated a ceiling effect (mean score over 6 on a 7 point
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& Volume 199, Number 6, June 2011
scale). Although ceiling effects typically limit the ability to find sig-
nificant effects (not realized here), our findings should be understood
as the differences between patients who reported excellent alliances
with their therapists and those who had good alliances with their
therapists (but not poor alliances). Fourth, we do not have follow-up
data for these clients; therefore, we do not know whether the gains
reported would sustain over time. Fifth, our multilevel models, al-
though they are appropriate, were limited to address more complex
questions. We had a relatively large number of therapists, which was
necessary to estimate therapist effects (Maas and Hox, 2005). How-
ever, the estimates of random slopes (i.e., testing whether the rela-
tionship between alliance and outcome varied across therapists) were
deemed unreliable because of a limited number of patients per ther-
apist. As such, we chose a fixed effect model (e.g., the association
between CPPS-PI  alliance and therapy outcomes) to examine our
data, and these effects were adequate and less biased than traditional
regression models (Maas and Hox, 2005). Accordingly, future studies
with more therapists and patients may be able to test to whether the
association between techniques and outcomes are consistent across
therapists.
CONCLUSIONS
The patients’ report of the therapeutic alliance and indepen-
dent clinical ratings of psychodynamic interventions early in treat-
ment (third or fourth session) interacted to predict therapy outcomes
as measured by the PEI. This suggests that psychodynamic techniques
coupled with a strong alliance was a positive predictor of therapy
outcomes. Consequently, for outpatient psychodynamic treatments,
dynamic techniques were most effective when provided in the context
of strong alliances.
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