Depression fix feeds off patient-therapist bond.

In an era of intense competition for health-care dollars, psychotherapists often characterize their techniques as scientifically grounded and capable of alleviating specific mental ailments. These professionals increasingly consult manuals that describe specific procedures for treating depression and other conditions.

However, much of psychotherapy's power in quelling chronic depression comes from a less-formal aspect of therapy, according to a new study. A 3-month course of cognitive-behavioral psychotherapy proves most beneficial if the therapist and patient establish an emotional bond early on and work toward common goals, say psychologist Daniel N. Klein of the State University of New York at Stony Brook and his colleagues.

Some researchers argue that there's no solid evidence that this facet of psychotherapy, known as the therapeutic alliance (SN: 1/11/97, p. 21), alleviates any mental disorders. These scientists contend that a therapeutic alliance may develop only after patients have started to improve.

The new investigation counters much of that skepticism, in Klein's view. "The therapeutic alliance is probably more important to psychotherapy's effectiveness than specific techniques are," he says. Klein and his coworkers present their findings in the December Journal of Consulting and Clinical Psychology.

The researchers studied 367 people who had suffered from major depression for at least 2 years. Participants received 16 sessions of cognitive-behavioral therapy over 3 months. In such sessions, psychotherapists help a patient identify his or her harmful thinking patterns so as to develop better coping strategies and social skills. More than half the patients were also prescribed an antidepressant.

At weeks 2, 6, and 12, patients completed surveys that asked whether a mutually agreed-upon plan existed for achieving goals in the therapy and that gauged the perceived quality of the patient-therapist relationship.

Depressed participants who, on the survey, reported a strong therapeutic alliance by week 2 exhibited the most improvement by the end of treatment. This pattern held after the team accounted for factors that could have influenced whether a patient formed a therapeutic alliance, such as sex, the severity and length of the depression, childhood abuse, and anxiety symptoms.

Patients receiving medication and psychotherapy reported slightly stronger therapeutic alliances than the others did. Added attention from a pharmacologist for people taking medication may have contributed to this effect, the scientists suggest.

"This is an important study," remarks psychologist Bruce E. Wampold of the University of Wisconsin-Madison. He supports the view that psychotherapy works primarily through general influences, such as the therapeutic alliance.

In the same journal, he and his coworkers report that in well-controlled studies of depression and other conditions, placebo therapies such as supportive counseling have achieved results comparable to those of specific psychotherapies. The therapeutic alliance influences this placebo effect, Wampold says.

Psychologist Scott O. Lilienfeld of Emory University in Atlanta advises caution in interpreting Klein's findings. "It's still difficult to know whether the therapeutic alliance directly causes improvement in depression symptoms," says Lilienfeld. Patients who possessed positive characteristics that the researchers didn't measure, such as emotional resilience and optimism, may have most readily formed therapeutic alliances and also most successfully fought the depression, he asserts.