Can you see what I see? A comparison of client and observer perspectives of the alliance and group cohesion in CBT.

Both therapeutic alliance and group cohesion have been identified as "demonstrably effective" relationship elements in therapy. However, the overwhelming majority of process-outcome research has relied on clients as raters of the therapeutic relationship. A lack of convergence between client, therapist, and observer perspectives has raised questions regarding how best to measure relationships in therapy. Interest in observational measures has grown, as they may offer more objective and reliable measurements of process. This study compared the predictive validity of client and observer ratings of the alliance (Agreement and Bond) and group cohesion in the context of group cognitive behaviour therapy (CBT) for anxiety disorders. Results showed that client and observer ratings of process were not significantly correlated, and regarding the alliance, only client-rated Agreement predicted client-rated treatment gains. In contrast, both client and observer-ratings of group cohesion were found to uniquely contribute to treatment outcomes. If replicated, the findings from the present study suggest that (1) while client ratings of alliance consistently predict client-rated outcomes, the predictive validity of observer measures has yet to be established, and (2) both clients and observers provide meaningful and distinct information about group cohesion in therapy.

Which, who and when? Therapeutic processes in group cognitive behaviour therapy for anxiety disorders.

The evidence for the effect of therapeutic alliance in group cognitive behaviour therapy (CBT) for anxiety disorders is unclear. Identifying whether the alliance-outcome relationship depends on (1) which components are assessed, (2) who is measuring the alliance and (3) when the alliance is measured will help to clarify the role of the client-therapist relationship in therapy. The present study explored the effects of alliance component (agreement vs. bond), rater perspective (client vs. therapist) and timing (early vs. late therapy) on the alliance-outcome relationship. Individuals with an anxiety disorder enrolled into transdiagnostic group CBT were studied, with n = 78 at early therapy and n = 57 at late therapy. Results showed that greater client-rated agreement significantly predicted improved post-treatment outcomes throughout the course of therapy, while stronger client-rated bond in late therapy predicted reduced treatment gains. In contrast, therapist perceptions of agreement and bond were not associated with post-treatment outcomes at any point in therapy. Client-reported group cohesion also was not associated with additional variance in outcome after accounting for client-rated alliance. Overall, the findings highlight the importance of prioritizing the client's perception of the client-therapist relationship in CBT for anxiety disorders, as well as distinguishing the effects of component, rater and timing in future process-outcome studies.

Elements of the therapeutic relationship in CBT for anxiety disorders: A systematic review.

To optimise the effects of cognitive behaviour therapy (CBT) for anxiety disorders, research has increasingly focussed on understanding mechanisms of change. Specifically, the therapeutic relationship has been identified as a potential "active ingredient" of therapy. The evidence for the effects of eleven elements of the therapeutic relationship (alliance, collaboration, goal consensus, group cohesion, empathy, positive regard, feedback, emotional expression, outcome expectations, treatment credibility, alliance rupture-repair) on treatment outcomes in CBT for anxiety disorders was systematically reviewed. Fifty unique studies were included, and findings were qualitatively reviewed and summarised. Results revealed consistent and sizeable evidence for the cohesion-outcome and expectation-outcome relationships. There was emerging evidence for the effects of collaboration, empathy, and alliance rupture-repair on outcomes. However, the evidence for goal consensus and credibility on outcomes was limited. Notably, review of the alliance literature revealed substantial inconsistencies across studies. No studies were identified for positive regard, feedback, and emotional expression. Overall, further research is needed to clarify the role of the therapeutic relationship in CBT for anxiety disorders. These findings will contribute to the conceptual integration of therapeutic relationship constructs in cognitive behavioural models, and help to improve treatments and outcomes for individuals.