Treatment failure in cognitive-behavioural therapy: therapeutic alliance as a precondition for an adherent and competent implementation of techniques

Objectives: Treatment failure is a common phenomenon, but little is known about the reasons. Therapeutic alliance, therapist adherence, and therapist competence are considered important aspects of treatment success and formed the focus of the current investigation.

Design: Three randomized controlled trials for the treatment of depression, social phobia, and hypochondriasis were the basis of the current study.

Methods: The role of therapeutic alliance, as well as therapist adherence and competence, were investigated in 61 patients, which were classified either as treatment failure or as treatment success. Process variables were evaluated by independent raters on the basis of videotapes of the first three treatment sessions.

Results: Therapists' adherence and therapeutic alliance differed significantly between successful treatments and those classified as failures, whereas therapists' competence did not. In cross-sectional analysis, we found a moderating effect of adherence with alliance on treatment outcome, indicating that the better the therapeutic alliance, the stronger the effect of adherence on treatment outcome. Moreover, higher therapists' competence was found to affect treatment outcome positively, only mediated by therapeutic alliance. Higher therapists' adherence affected treatment outcome positively, only mediated by the competence-alliance relationship. In additional longitudinal analyses, we found evidence that the therapeutic alliance within one session influences therapists' adherence and competence in the subsequent session, but not the other way around.

Conclusions: Therapeutic alliance proved to be an important variable for the prediction of treatment failure. Furthermore, in our longitudinal analyses, we found evidence that the therapeutic alliance is a precondition for the adherent and competent implementation of therapeutic techniques, which questions the results of our cross-sectional analysis and of previous research.

Practitioner points: Clinical implications Treatment failure is associated with a lower therapeutic alliance in cognitive-behavioural treatment. Therapeutic alliance seems to be an important precondition for the adherent and competent implementation of therapeutic techniques. Therapeutic alliance should be monitored during psychotherapeutic treatment. Cautions or limitations Results are limited to cognitive-behavioural therapy and may not be representative for other treatment approaches. Process analyses are based on highly standardized randomized controlled trials and may not be generalizable to routine care.