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. Author manuscript; available in PMC: 2021 Nov 1.
Published in final edited form as: Psychol Serv. 2019 Feb 11;17(4):452–460. doi: 10.1037/ser0000329

Therapeutic alliance across trauma-focused and non-trauma-focused psychotherapies among veterans with PTSD

Jessica A Chen 1, John C Fortney 2, Hannah E Bergman 3, Kendall C Browne 4, Kathleen M Grubbs 5, Teresa J Hudson 6, Patrick J Raue 7
PMCID: PMC6689461  NIHMSID: NIHMS1011535  PMID: 30742471

Abstract

Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are not widely utilized. Clinicians report concerns that direct discussion of traumatic experiences could undermine the therapeutic alliance, which may negatively impact retention and outcome. Studies among adolescents with PTSD found no difference in alliance between trauma-focused and non-trauma-focused psychotherapies, but this has not been tested among adults. The present study is a secondary analysis of a randomized trial of collaborative care, also known as care management, for PTSD. We examined patient-reported therapeutic alliance among 117 veterans with PTSD who participated in Cognitive Processing Therapy (CPT, now called CPT+A; n = 54) or non-trauma-focused supportive psychotherapy for PTSD (n = 73) at VA community outpatient clinics. We tested the hypothesis that alliance in CPT would be non-inferior to (i.e., not significantly worse than) non-trauma-focused psychotherapy using patient ratings on the Revised Helping Alliance Questionnaire. Patients’ therapeutic alliance scores were high across both groups (CPT: M = 5.13, SD = 0.71, 95% CI: 4.96–5.30; non-trauma-focused psychotherapy: M = 4.89, SD = 0.64, 95% CI: 4.73–5.05). The difference between groups (0.23, 95% CI −0.01–0.48) was less than the “noninferiority margin” based on suggested clinical cutoffs (0.58 points on a 1–6 scale). These results held even after adjusting for veterans’ demographic and clinical characteristics and change in PTSD symptoms from baseline to follow-up. Although there are concerns that direct discussion of traumatic experiences could worsen therapeutic alliance, patients report similar levels of alliance in CPT and non-trauma-focused supportive psychotherapy.

Keywords: Posttraumatic Stress Disorder, Cognitive Behavioral Therapy, Treatment, Empirically Supported Treatments, Clinical Trials

Introduction

The most commonly used behavioral treatments for posttraumatic stress disorder (PTSD) in community practice settings are unstructured psychotherapies (e.g., supportive psychotherapy or process groups), psychoeducation, and management of symptoms associated with PTSD (e.g., treatment for anger or sleep; Allen, Wilson, & Armstrong, 2014; Cook et al., 2013; Finley et al., 2015). PTSD psychotherapies that have been developed and tested in randomized clinical trials, such as Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016), Prolonged Exposure (PE; Foa, Hembree, & Rothbaum, 2007), and Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2001), are not widely utilized (Kolko, Cohen, Mannarino, Baumann, & Knudsen, 2009; Shiner et al., 2014). Many of these PTSD psychotherapies involve processing traumatic experiences through the use of exposure and/or cognitive restructuring techniques (Institute of Medicine, 2014; Jonas et al., 2013; Schnurr, 2017; Watts et al., 2013). A common concern among providers is that directly addressing trauma-related material has the potential to harm or destabilize patients (Ruzek et al., 2017), undermine patients’ trust (Hoffart, Øktedalen, Langkaas, & Wampold, 2013), and damage therapeutic alliance (Becker, Zayfert, & Anderson, 2004; van Minnen, Hendriks, & Olff, 2010). There have been concerns that direct discussion of traumatic experiences may increase the likelihood of dropout from PTSD psychotherapy, although no clear association has been found (Goetter et al., 2015; Imel, Laska, Jakupcak, & Simpson, 2013). An additional critique is that structured, manualized protocols overemphasize technique and compromise rapport building (Addis, Wade, & Hatgis, 1999; Hamblen et al., 2015). Concerns about poor alliance may be one reason that trauma-focused psychotherapies are used less frequently than other types of psychotherapy for PTSD.

Therapeutic alliance, typically defined as the emotional bond between the provider and the patient, their collaboration on therapeutic tasks, and their agreement on therapeutic goals (Bordin, 1979), is an important predictor of psychotherapy completion (Sharf, Primavera, & Diener, 2010) and outcome (Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012; Horvath, Del Re, Flückiger, & Symonds, 2011). Therapeutic alliance may be particularly important for PTSD treatment, which often relies on establishing a trusting therapeutic relationship (Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004; Keller, Zoellner, & Feeny, 2010; Ormhaug, Jensen, Wentzel-Larsen, & Shirk, 2014; Wagner, Brand, Schulz, & Knaevelsrud, 2012). Given the importance of therapeutic alliance to treatment completion and outcome and the concern that trauma focus could negatively impact alliance, it is crucial to better understand the relationship between trauma-focused psychotherapies and patient-reported alliance.

Clinical trials of CPT and PE have reported high patient ratings of therapeutic alliance (Aguirre McLaughlin, Keller, Feeny, Youngstrom, & Zoellner, 2014; Greene et al., 2010; Keller et al., 2010; Morland et al., 2014), but no study has directly compared alliance in trauma-focused PTSD psychotherapy to other types of PTSD psychotherapy in an adult sample. Among adolescents with PTSD, no difference has been found in alliance between trauma-focused psychotherapies and client-centered or brief psychodynamic psychotherapies (Capaldi, Asnaani, Zandberg, Carpenter, & Foa, 2016; Gilboa-Schechtman et al., 2010; Ormhaug et al., 2014). Among adults with PTSD, it remains unknown whether the strength of therapeutic alliance is better or worse in trauma-focused psychotherapy compared with non-trauma-focused psychotherapy.

The present study involved a secondary analysis of a pragmatic randomized effectiveness trial of collaborative care, also known as care management, for PTSD. The parent trial compared usual care in nonurban Veterans Affairs Community Based Outpatient Clinics (VA CBOCs) to telemedicine-based collaborative care (Fortney et al., 2015). Patients were not randomized to psychotherapy condition, so the goal of this study was to compare alliance between two naturalistic groups who would typically receive different types of PTSD psychotherapy in VA community clinics. Although trauma-focused PTSD psychotherapies are thought to be potentially destabilizing for therapeutic alliance and rapport (Becker, Zayfert, & Anderson, 2004; Cook, Schnurr, & Foa, 2004), given the lack of between-treatment differences in alliance seen among adolescents with PTSD (Capaldi et al., 2016; Gilboa-Schechtman et al., 2010; Ormhaug et al., 2014), we hypothesized that therapeutic alliance in CPT would be non-inferior to nontrauma-focused psychotherapy for PTSD.

Materials and Methods

Participants

Participants were outpatient veterans aged 18 or older who were receiving primary care at one of 11 nonurban CBOCs affiliated with three VA medical centers across the south central and western United States. Patients were identified via self-referral (n = 186) or a diagnosis of PTSD in their electronic health record (n = 2,273). Of the 2,459 veterans identified, 456 (18.5%) opted out prior to being contacted. 654 (26.6%) declined to participate, and 288 (11.7%) could not be reached.

Inclusion criteria consisted of meeting DSM-IV diagnostic criteria for current PTSD as established by a structured clinical interview, the Clinician-Administered PTSD Scale (CAPS; Weathers, Ruscio, & Keane, 1999). Exclusion criteria included: already receiving specialty PTSD treatment; diagnoses of schizophrenia, bipolar disorder, or active substance dependence; life-threatening illness; hearing impairment; having no telephone; and lacking capacity to consent. Of the 1,061 veterans screened for eligibility, 144 (13.6%) were ineligible due to receiving specialty PTSD treatment and 466 (43.9%) were ineligible due to other exclusion criteria (see additional details in Fortney et al., 2015). Following screening, 451 veterans were consented, 275 were eligible based on their CAPS interview, and 265 completed baseline measures. Written informed consent was obtained via interactive video.

Procedure

The present study used baseline and six-month follow-up data from a large, multi-site randomized trial comparing telemedicine-based collaborative care for PTSD (n = 133) to usual care (n = 132). Collaborative care, also known as care management, is a specific type of integrated care that seeks to improve access to evidence based mental health treatments for primary care patients. Collaborative care is team based and involves care managers (e.g., nurses, social workers) and other mental health specialists (e.g., psychiatrists, psychologists) who collaborate with a primary care team by providing consultation and treatment recommendations for patients who are not achieving clinical goals. Collaborative care is measurement based (involves monitoring of patient-reported outcomes), population based (utilizes a registry to monitor treatment engagement), and patient centered (uses proactive outreach to engage patients and coordinate services).

The parent trial was approved by the institutional review boards at each VA medical center. Details of the larger trial have been published elsewhere (Fortney et al., 2015), but briefly, veterans with PTSD were enrolled between November 2009 and September 2011 from VA CBOCs and randomized to receive either telemedicine-based collaborative care or usual care. Participants in the telemedicine-based collaborative care arm (Telemedicine Outreach for PTSD [TOP]) had a telephone nurse care manager who monitored symptoms and adverse events and promoted pharmacotherapy adherence and engagement in CPT. If TOP participants elected to participate in CPT, they were referred to an off-site psychologist at the affiliated VA medical center who delivered CPT through interactive video. The parent trial found that telemedicine-based collaborative care resulted in greater PTSD symptom reduction at six- and twelve-month follow-ups compared with usual care, and this effect was mediated by receipt of eight or more sessions of CPT.

In the present study, participant ratings of alliance were compared between two naturalistic groups, individuals who received CPT and individuals who received non-trauma-focused psychotherapy offered in usual care. CPT is an evidence-based, protocol-driven cognitive therapy for PTSD that has been found to significantly reduce PTSD symptoms among veterans (Monson et al., 2006). The CPT protocol utilized at the time of the study consisted of 12 weekly sessions and involved identifying and challenging problematic trauma-related cognitions (“stuck points”) through Socratic questioning as well as writing detailed trauma accounts and reading the accounts daily (Monson et al., 2006). At the conclusion of the study, CPT treatment fidelity for TOP participants was assessed retrospectively via chart notes by dichotomously classifying sessions as per protocol or not; on average, 79.8% of sessions were classified as per protocol. CPT was delivered by providers who worked in specialty mental health clinics at the affiliated VA medical centers.

The comparison condition was individual, non-trauma-focused psychotherapy for PTSD delivered in usual care. All enrolled veterans, including those in the TOP condition, were eligible to receive any usual care services offered at the local CBOC or the distant VA medical center. Detailed chart review was used to classify psychotherapy sessions as individual, non-trauma-focused psychotherapy for PTSD using the following criteria: 1) all CPT, PE, EMDR, and Acceptance and Commitment Therapy (ACT) were coded as separate categories; 2) any remaining psychotherapy sessions were classified as treatment for PTSD when PTSD was in the progress note title, when there was discussion of PTSD symptoms, or if there was psychoeducation about PTSD (Grubbs et al., 2017). In the present study, eight participants received CPT in usual care and they were categorized as part of the CPT group (Figure 1). No instances of PE or EMDR were identified by chart review in this sample, and ACT was only offered in group format. The research team did not dictate the length, frequency, or timing of sessions in usual care. Usual care psychotherapy was delivered by CBOC mental health providers, all of whom were licensed clinical social workers.

Figure 1.

Figure 1.

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Breakdown of Patients Receiving CPT and Non-Trauma-Focused PTSD

Psychotherapy By Study Arm

One of the primary differences between psychotherapy in TOP and usual care was that TOP participants had access to a telepsychologist who delivered CPT, whereas participants in usual care typically had to present in-person to receive any psychotherapy. Because several studies have found no difference in therapeutic alliance between telemedicine-delivered and in-person CPT (Morland et al., 2014), psychotherapy for depression (Preschl, Maercker, & Wagner, 2011), or psychotherapy for anxiety disorders (Klein, Richards, & Austin, 2006), we did not expect mode of delivery to systematically impact alliance ratings. CPT was delivered remotely by one of three doctoral-level psychologists trained and certified in CPT by VA’s national training program; all worked in either specialty general mental health or specialty PTSD clinics at the affiliated VA medical centers. All non-trauma-focused psychotherapy and any CPT delivered as part of usual care were provided at the CBOCs by one of 11 licensed clinical social workers. All usual care psychotherapy providers had the option of participating in VA’s nationwide CPT training, but no data were collected on usual care therapists’ training in evidence-based psychotherapies.

At baseline and six-month follow-up, participants completed telephone interviews with research assistants blinded to study condition. Demographics, treatment history, psychiatric diagnoses, symptom severity, and social support were measured at baseline. Therapeutic alliance was assessed at six-month follow-up for participants who had attended at least one psychotherapy appointment in the past month to ensure that alliance ratings were relevant to recent psychotherapy and to minimize retrospective bias. Psychotherapy appointments were identified through chart review and confirmed by the participant over the phone. In this pragmatic trial, participants could engage in multiple psychotherapies simultaneously (e.g., individual and group psychotherapy); therefore, questions about alliance were asked separately for each type of therapy and were anchored to the specific therapist’s name for the treatment in question. Psychotherapy attendance was also assessed for all participants at the six-month follow-up. Number of sessions attended in the past four weeks was assessed for those still attending treatment, whereas number of sessions in the past six months was assessed for those who completed or discontinued treatment.

Measures

Revised Helping Alliance Questionnaire (HAq-II; Luborsky et al., 1996).

The HAq-II is a 19-item self-report questionnaire that assesses three theoretical domains of therapeutic alliance: agreement on goals, collaboration on tasks, and bond (Bordin, 1979). Responses were made on a 6-point Likert scale from 1 (strongly disagree) to 6 (strongly agree) and total score was calculated by averaging all 19 items, with higher scores indicating stronger alliance. The HAq-II has good test-retest reliability (.78), excellent internal consistency (.90), and convergent validity with the California Psychotherapy Alliance Scale (.59-.69) (Luborsky et al., 1996), and has been used to assess therapeutic alliance in randomized clinical trials (Barber et al., 2001; Zlotnick, Najavits, Rohsenow, & Johnson, 2003). Only patient-reported alliance was assessed in this study.

PTSD severity.

PTSD symptom severity was assessed at baseline using patient self-report (Posttraumatic Diagnostic Scale [PDS]; Foa, Cashman, Jaycox, & Perry, 1997) and clinician-administered interviews (CAPS; Weathers et al., 1999). The PDS consists of seventeen items rated on a 4-point scale from 0 (not at all or only one time) to 3 (5 or more times a week/almost always) to assess DSM-IV PTSD symptom severity and frequency in the past month, with higher scores indicating more severe/frequent PTSD symptoms. The PDS has good psychometric properties, including 82.0% agreement with a structured clinical interview for PTSD (Foa et al., 1997). The CAPS is a clinician-administered interview measure that assesses PTSD diagnostic criteria and severity. Frequency and intensity ratings are made on a 5-point scale and a PTSD symptom is considered present if it occurs at least once or twice in the past month with at least moderate severity (Weathers et al., 1999). The CAPS is considered the “gold standard” for PTSD diagnostic assessment (Blake et al., 1995; Weathers, Keane, & Davidson, 2001).

Other psychiatric diagnoses and symptoms.

Participants were assessed at baseline for current diagnoses of major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder using a structured diagnostic interview for DSM-IV (Mini-International Neuropsychiatric Interview [MINI]; Sheehan et al., 1998). Depression symptom severity was assessed using the Hopkins Symptom Checklist (SCL-20; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). Alcohol use severity was assessed using the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001), which produces four zones of treatment recommendations, ranging from providing alcohol education to referral to specialty addictions care, based on the severity of reported alcohol use.

Social support.

Social support was assessed at baseline using the 19-item Medical Outcomes Study Social Support Survey (MOS; Sherbourne & Stewart, 1991), which assesses patients’ perceptions of five domains of social support: emotional support, informational support (e.g., advice), tangible support (e.g., behavioral assistance with daily activities when needed), positive social interaction, and affectionate support.

Data Analysis

Noninferiority analyses involve a one-sided test to determine if one intervention, typically a novel treatment or one that is not yet part of routine practice, is no worse than a standard intervention (Greene, Morland, Durkalski, & Frueh, 2008). In noninferiority analyses, the null hypothesis is that the “novel” intervention is inferior to the standard treatment by a prespecified amount, whereas the alternative hypothesis is that the difference between the two treatments is smaller than the prespecified amount. To test the hypothesis that patient-reported alliance in CPT was not significantly worse than non-trauma-focused psychotherapy offered as part of routine care, we utilized a confidence interval (CI) approach to noninferiority testing (Greene, Morland, Durkalski, & Frueh, 2008; Piaggio et al., 2006). We prespecified a “noninferiority margin” based on the measure developers’ recommended difference of 0.58 points for a cutoff that distinguishes good alliance from poor alliance (Center for Psychotherapy Research, n.d.).

Multiple linear regression was used to estimate the difference in mean therapeutic alliance scores between psychotherapies after adjusting for sociodemographic characteristics (e.g., age, gender, race), prior treatment history, individual differences associated with PTSD treatment outcome (e.g., social support, combat trauma exposure), as well as baseline PTSD, depression, and alcohol use severity. We additionally adjusted for repeated observations among a subset of patients (n = 10) who participated in both CPT and non-trauma-focused psychotherapy for PTSD simultaneously, which was not prohibited in this pragmatic trial. A 95% CI was constructed around the difference in mean alliance scores between the two treatments (CPT minus non-trauma-focused); if the 95% CI overlapped with the noninferiority margin (−0.58), we rejected the null hypothesis that therapeutic alliance was worse in CPT. A sensitivity analysis was conducted in which baseline PTSD severity was replaced with change in PTSD symptoms between baseline and six-month follow-up so that we could compare alliance after adjusting for treatment response, given that alliance and outcome are associated (Cloitre et al., 2004; Ormhaug et al., 2014). Missing values were multiply imputed in SAS 9.4 using the PROC MI Markov chain Monte Carlo method; the 25 imputed datasets were combined using PROC MIANALYZE.

Results

At the six-month follow-up, 140 veterans had attended at least one session of CPT (n = 56) or individual non-trauma-focused psychotherapy for PTSD (n = 84) since study enrollment, which yielded a final sample of 117 veterans who answered questions about therapeutic alliance because they attended CPT (n = 54) or non-trauma-focused psychotherapy (n = 73) in the past month. Of the 54 veterans in CPT, 82.5% (n = 46) were in the collaborative care arm and 14.8% (n = 8) were in the usual care arm (Figure 1). Of the 73 participants in the non-trauma-focused psychotherapy group, 54.8% (n = 40) were in the usual care arm and 45.2% (n = 33) were in the collaborative care arm. Ten participants received both CPT and non-trauma-focused psychotherapy for PTSD simultaneously and therefore completed the alliance questions twice, once for each therapy type/treatment provider.

The sample was primarily middle-aged (M = 48.7 years, SD = 14.25), male (82.9%), White (59.0%) or African-American (26.5%), married (66.7%), and unemployed (75.2%) (Table 1). Nearly half (46.5%) reported combat trauma as their worst trauma via the CAPS. PTSD symptom severity was high (CAPS M = 74.8, SD = 12.95) as was diagnostic comorbidity for MDD (82.1%), GAD (69.2%), and panic disorder (51.3%). Most participants had a history of prior psychotherapy (89.7%) and prior PTSD treatment (77.8%). With two exceptions, patients who received CPT were similar to those who received non-trauma-focused psychotherapy for PTSD. Patients who received CPT were significantly (p < .01) less likely to have an approved claim for PTSD-related disability and were significantly (p < .05) more likely to have an annual income <$20,000 compared with those who received non-trauma-focused psychotherapy.

Table 1.

Baseline Characteristics of Veterans Receiving CPT and Non-Trauma-Focused PTSD Psychotherapy

CPT Non-Trauma-Focused PTSD Therapy Total Study Samplea
n = 54 n = 73 N = 117
Characteristic Mean or % SD Mean or % SD Mean or % SD
Age, years 48.52 14.87 48.49 14.00 48.72 14.25
Gender, female 16.7 16.4 17.1
Race/ethnicity
 White 57.4 61.6 59.0
 African American 29.6 24.7 26.5
 Hispanic 7.4 6.9 7.7
 Other 5.6 6.9 6.8
Married 63.0 68.5 66.7
Income (<$20,000)* 31.5 15.1 23.1
High school graduate 94.4 97.3 95.7
Employed 25.9 26.0 24.8
VA PTSD disability statusb ***
 Never applied 16.7 4.2 9.6
 Applied, denied 9.3 7.0 7.8
 Applied, pending 38.9 18.3 27.0
 Approved 35.2 70.4 55.7
OEF/OIF/OND service era 35.2 39.7 38.5
Combat trauma 46.3 49.3 46.5
Prior psychotherapy 87.0 93.2 89.7
Prior PTSD treatment 72.2 83.6 77.8
Social support, MOS social support scale scorec 3.45 1.02 3.53 0.95 3.52 0.98
PTSD severity (CAPS) 74.07 11.79 74.29 14.48 74.78 12.95
PTSD severity (PDS) 34.33 7.83 35.16 7.67 35.05 7.58
Current GAD 63.0 72.6 69.2
Current panic disorder 51.9 52.1 51.3
Current MDD 75.9 84.9 82.1
Depression severity (SCL-20) 2.16 0.69 2.25 0.59 2.22 0.63
AUDIT treatment recommendationb
 Alcohol education 74.5 70.8 73.5
 Simple advice 15.7 16.7 15.9
 Brief counseling and continued monitoring 3.9 2.8 1.8
 Referral to specialist 5.9 9.7 8.9
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Note: Percentages do not always sum to 100.0 due to rounding. AUDIT = Alcohol Use Disorders Identification Test; CAPS = Clinician-Administered PTSD Scale; CPT = Cognitive Processing Therapy; GAD = generalized anxiety disorder; MDD = major depressive disorder; MOS = Medical Outcomes Study; OEF/OIF/OND = Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn; PDS = Posttraumatic Diagnostic Scale; PTSD = posttraumatic stress disorder; SCL-20 = Hopkins Symptom Checklist.

a

10 individuals received both CPT and non-trauma-focused individual PTSD therapy. For bivariate, between-group comparisons of demographic characteristics, individuals who received any CPT were analyzed as part of the CPT group.

b

Total n may vary for some characteristics due to missing values: VA PTSD disability status (n missing = 2 [non-trauma-focused]); AUDIT treatment recommendation (n missing = 3 [CPT] and 1 [non-trauma-focused]).

c

The MOS Social Support Scale ranges from 1 (least social support) to 5 (most social support).

*

p < .05.

**

p < .01.

***

p < .001

By the six-month follow-up, 26 CPT participants (48.1%) had either completed or discontinued psychotherapy and reported attending a mean of 8.4 sessions (SD = 5.7) in the past 6 months, while 28 CPT participants (51.9%) were still attending psychotherapy and reported attending a mean of 2.0 sessions (SD = 1.1) in the past 4 weeks. Among those who received non-trauma-focused psychotherapy, 17 participants (23.3%) had either completed or discontinued psychotherapy and reported attending a mean of 4.7 sessions (SD = 4.5) in the past 6 months, while 56 participants (76.7%) were still attending psychotherapy and reported attending a mean of 1.3 sessions (SD = 1.4) in the past 4 weeks.

Mean therapeutic alliance scores for CPT (M = 5.13, SD = 0.71, 95% CI [4.96, 5.30], minimum = 2.79, maximum = 6.00) and non-trauma-focused psychotherapy (M = 4.89, SD = 0.64, 95% CI [4.73, 5.05], minimum = 2.16, maximum = 6.00) were high across both groups, where the maximum score for the measure is 6 and the suggested cutoff for good versus poor alliance is 4.57 (Center for Psychotherapy Research, n.d.). The mean between-group difference obtained from the unadjusted regression model (M = 0.24, 95% CI [0.00, 0.47]) was well above the noninferiority margin (−0.58), and these results held after adjusting for demographic and clinical characteristics (M = 0.23, 95% CI [−0.01, 0.48]; Table 2). Results did not differ in a sensitivity analysis that removed the 10 participants who received both CPT and non-trauma-focused psychotherapy (M = 0.16, 95% CI [−0.13, 0.45]) or after adjusting for change in PTSD symptoms between baseline and six-month follow-up (M = 0.25, 95% CI [0.00, 0.50]). Because the 95% CI of the difference did not overlap with the prespecified noninferiority margin of −0.58 points (Figure 2), we rejected the null hypothesis that therapeutic alliance in CPT was inferior to alliance in non-trauma-focused psychotherapy for PTSD.

Table 2.

Regression Results for Patient-Reported Therapeutic Alliance Scores

Variable β 95% CI
Unadjusted model (t-test)
 Treatment type, CPT 0.24 0.00, 0.47
Adjusted model
 Treatment type, CPT 0.23 −0.01, 0.48
Demographic characteristics
 Age −0.01 −0.02, 0.00
 Sex, female −0.23 −0.59, 0.14
 Race, White/Caucasian −0.09 −0.34, 0.15
 Married −0.04 −0.35, 0.27
 Period of wartime service, OIF/OEF/OND 0.24 −0.13, 0.62
 Trauma type, combat −0.09 −0.34, 0.15
 PTSD service connection (ref. group = Approved)a
  Never applied 0.14 −0.30, 0.58
  Denied 0.09 −0.38, 0.56
  Pending −0.13 −0.42, 0.16
 Social support score (MOS)b * 0.18 0.04, 0.31
 Any past psychotherapy 0.00 −0.40, 0.41
Clinical characteristics
 Baseline PTSD severity (PDS) −0.02 −0.04, 0.00
 Baseline depression severity (SCL-20) 0.13 −0.13, 0.38
 Baseline alcohol use severity (AUDIT treatment recommendation zone, ≥3)c 0.00 −0.03, 0.04
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Note: AUDIT = Alcohol Use Disorders Identification Test; CPT = Cognitive Processing Therapy; MOS = Medical Outcomes Study; OEF/OIF/OND = Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn; PDS = Posttraumatic Diagnostic Scale; PTSD = posttraumatic stress disorder; SCL-20 = Hopkins Symptom Checklist.

a

PTSD service connection categories: Never applied; Applied, denied; Applied, pending; Approved.

b

For the Medical Outcomes Study Social Support scale, 1 indicates the least social support and 5 indicates the most.

c

The AUDIT produces four treatment recommendations based on severity of alcohol use: 1 = Alcohol education, 2 = Simple advice, 3 = Brief counseling and continued monitoring, 4 = Referral to specialist.

*

p < .05.

Figure 2.

Figure 2.

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Mean Differences and 95% Confidence Intervals for Therapeutic Alliance Scores Between CPT and Non-Trauma-Focused PTSD Psychotherapy

Abbreviations: CPT, Cognitive Processing Therapy; PTSD, posttraumatic stress disorder

Discussion

In clinical practice settings, there are often concerns that trauma-focused psychotherapies may underemphasize rapport building or jeopardize the patient-provider relationship. The present study found high alliance ratings for both CPT and non-trauma-focused psychotherapy when delivered in routine practice settings and found that alliance in CPT was non-inferior to non-trauma-focused psychotherapy. These results corroborate previous findings that patient-reported alliance in protocol-driven cognitive-behavioral therapies tends to be as good as or better than alliance in psychotherapies that explicitly focus on the therapeutic relationship, such as psychodynamic or interpersonal therapies (e.g., Arnow et al., 2013; Raue, Goldfried, & Barkham, 1997; Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, 2007). Our results add to the literature by directly comparing alliance across two treatments among adults and military veterans with PTSD. Overall, our results suggest that CPT can be delivered in VA community outpatient settings without negative consequences for the therapeutic relationship.

There are several limitations to the present study. The larger parent trial was not designed to compare CPT with other PTSD psychotherapies or to test specific hypotheses about therapeutic alliance. Patients were not randomized to psychotherapy type and, despite statistical adjustment for observed patient characteristics, it is possible that there were unobserved differences between patients self-selecting into the two types of therapy. While the present study lacks the internal validity that would allow for causal or mechanistic inferences, a strength of the study is its ecological validity and pragmatic design, including the use of existing VA providers and minimal exclusion criteria. The psychotherapists were a diverse mix of psychologists and social workers who delivered care across specialty PTSD, specialty general mental health, and CBOC/primary care mental health settings, and the study sample was diverse and representative of the patient population at these clinics, thus increasing the generalizability of these findings to therapists and patients with PTSD typically seen in the VA setting. The two groups were primarily made up of different therapists, except 8/54 (14.8%) of the CPT participants received CPT from a licensed clinical social worker as part of usual care in the CBOC (Figure 1). It is possible that, on average, the TOP CPT therapists had more training and experience in treating PTSD than those providing supportive psychotherapy, which could positively impact alliance, although years of training and experience do not predict patient-reported alliance in the general psychotherapy literature (Dunkle & Friedlander, 1996; Hersoug, Høglend, Monsen, & Havik, 2001). We also cannot rule out the possibility that alliance was influenced by provider characteristics (e.g., theoretical orientation) that affect therapists’ likelihood to deliver trauma-focused treatments (Ruzek et al., 2014).

The two comparison groups differed on a number of other dimensions. Most patients receiving CPT also received other intervention components as part of the TOP collaborative care intervention (e.g., phone calls from a care manager), which may have positively affected patients’ reported alliance, treatment adherence, and outcome. Due to the pragmatic nature of this trial where psychotherapy was offered as part of routine clinical care, we were not able to control for the number of sessions that patients received between study enrollment and assessment of alliance. Patients’ self-reported attendance in sessions indicated that those receiving CPT saw their therapist more frequently leading up to the study assessment, which is consistent with a manualized treatment approach. On the other hand, psychotherapy in usual care was typically not time-limited and patients could have been seeing their therapist prior to study enrollment. Because alliance generally strengthens in a linear fashion over time (Stiles et al., 2004; Stiles & Goldsmith, 2010), this would have given an advantage to non-trauma-focused psychotherapy and resulted in lower average alliance ratings in CPT, which we did not find. Therefore, any bias this might introduce makes our findings conservative.

Additionally, the majority of patients who received CPT received psychotherapy over video teleconferencing, while most of the non-trauma-focused psychotherapy was delivered in-person. While the mode of delivery could have confounded our results, previous research has found that alliance in group CPT delivered via video teleconferencing was non-inferior to traditional, in-person delivery (Morland et al., 2014), suggesting that mode of delivery alone is not likely to have a significant impact on alliance ratings.

Another limitation is that alliance was measured only for patients who received psychotherapy in the month prior. While restricting assessment of alliance to patients recently involved in psychotherapy limited the influence of retrospective bias, it is possible that we failed to capture important information about alliance for patients who stopped attending in months 1–5 of the study due to dropout, completion, or other reasons. However, the number of patients in this category is small (n = 2 for CPT and n = 11 for non-trauma-focused psychotherapy).

To our knowledge, this is the first study to compare therapeutic alliance between trauma-focused and non-trauma-focused psychotherapies among adults with PTSD. While this study cannot answer casual or explanatory questions about the mechanisms underlying PTSD treatment and therapeutic alliance, the present study answers a pragmatic question about the relationship between CPT and working alliance when delivered in routine care settings. Based on our results and the existing research literature, there is no indication at this point that, from the patient’s perspective, psychotherapies that explicitly focus on trauma processing are associated with a weaker therapeutic relationship than non-trauma-focused psychotherapies. For practicing clinicians, these results should help alleviate concerns that using a manualized protocol or explicitly confronting trauma-related material will negative impact the patient-provider relationship.

Acknowledgments

Data collection was supported by a research grant (MHI 08-098) from the Department of Veterans Affairs to J. Fortney. Manuscript preparation is the result of work supported by resources from Denver-Seattle VA HSR&D COIN for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, University of Washington, VA San Diego Healthcare System, and the Central Arkansas Veterans Healthcare System. Dr. Chen was supported by the VA Office of Academic Affiliations’ Advanced Fellowship in Health Services Research (TPH 61-000-14). Dr. Fortney was supported by grants from the Patient Centered Outcomes Research Institute (PCS-1406-19295) and the Department of Veterans Affairs (QUE 15-282). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Contributor Information

Jessica A. Chen, Health Services Research & Development (HSR&D) Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System and Department of Health Services, University of Washington

John C. Fortney, HSR&D COIN for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System and Department of Psychiatry & Behavioral Sciences and Department of Health Services, University of Washington

Hannah E. Bergman, VA Puget Sound Health Care System

Kendall C. Browne, Center of Excellence in Substance Abuse and Treatment (CESATE), VA Puget Sound Health Care System and Department of Psychiatry & Behavioral Sciences, University of Washington

Kathleen M. Grubbs, VA San Diego Health Care System

Teresa J. Hudson, HSR&D, Central Arkansas Veterans Healthcare System and Department of Psychiatry, University of Arkansas

Patrick J. Raue, Department of Psychiatry & Behavioral Sciences, University of Washington.

References

  1. Addis ME, Wade WA, & Hatgis C (1999). Barriers to dissemination of evidence-based practices: Addressing practitioners’ concerns about manual-based psychotherapies. Clinical Psychology: Science and Practice, 6, 430–441. 10.1093/clipsy.6.4.430 [DOI] [Google Scholar]
  2. Aguirre McLaughlin A, Keller SM, Feeny NC, Youngstrom EA, & Zoellner LA (2014). Patterns of therapeutic alliance: Rupture–repair episodes in prolonged exposure for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 82, 112–121. 10.1037/a0034696 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Allen B, Wilson KL, & Armstrong NE (2014). Changing clinicians’ beliefs about treatment for children experiencing trauma: The impact of intensive training in an evidence-based, trauma-focused treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 384–389. 10.1037/a0036533 [DOI] [Google Scholar]
  4. Arnow BA, Steidtmann D, Blasey C, Manber R, Constantino MJ, Klein DN, … Kocsis JH (2013). The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression. Journal of Consulting and Clinical Psychology, 81, 627–638. 10.1037/a0031530 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG, World Health Organization, & others. (2001). AUDIT: The alcohol use disorders identification test: Guidelines for use in primary health care.
  6. Barber JP, Luborsky L, Gallop R, Crits-Christoph P, Frank A, Weiss RD, … others. (2001). Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Journal of Consulting and Clinical Psychology, 69, 119 10.1037/0022-006X.69.1.119 [DOI] [PubMed] [Google Scholar]
  7. Becker CB, Zayfert C, & Anderson E (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277–292. 10.1016/S0005-7967(03)00138-4 [DOI] [PubMed] [Google Scholar]
  8. Bordin ES (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. 10.1037/h0085885 [DOI] [Google Scholar]
  9. Capaldi S, Asnaani A, Zandberg LJ, Carpenter JK, & Foa EB (2016). Therapeutic alliance during prolonged exposure versus client-centered therapy for adolescent posttraumatic stress disorder. Journal of Clinical Psychology, 72, 1026–1036. 10.1002/jclp.22303 [DOI] [PubMed] [Google Scholar]
  10. Center for Psychotherapy Research. (2018, April 30). HAQ-II scoring. University of Pennsylvania; Retrieved from http://www.med.upenn.edu/cpr/assets/user-content/documents/HAQ-II_scoring.pdf. [Google Scholar]
  11. Cloitre M, Stovall-McClough KC, Miranda R, & Chemtob CM (2004). Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72, 411–416. 10.1037/0022-006X.72.3.411 [DOI] [PubMed] [Google Scholar]
  12. Cook JM, O’Donnell C, Dinnen S, Bernardy N, Rosenheck R, & Hoff R (2013). A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs. Journal of Traumatic Stress, 26, 56–63. 10.1002/jts.21769 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, & Covi L (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19, 1–15. 10.1002/bs.3830190102 [DOI] [PubMed] [Google Scholar]
  14. Dunkle JH, & Friedlander ML (1996). Contribution of therapist experience and personal characteristics to the working alliance. Journal of Counseling Psychology, 43, 456–460. [Google Scholar]
  15. Finley EP, Garcia HA, Ketchum NS, McGeary DD, McGeary CA, Stirman SW, & Peterson AL (2015). Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics. Psychological Services, 12, 73–82. 10.1037/ser0000014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Flückiger C, Del Re AC, Wampold BE, Symonds D, & Horvath AO (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59, 10–17. 10.1037/a0025749 [DOI] [PubMed] [Google Scholar]
  17. Foa EB, Cashman L, Jaycox L, & Perry K (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445–451. 10.1037/1040-3590.9.4.445 [DOI] [Google Scholar]
  18. Foa EB, Hembree EA, & Rothbaum BO (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. New York, NY: Oxford University Press. [Google Scholar]
  19. Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, … Schnurr PP (2015). Telemedicine-based collaborative care for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 72, 58–67. 10.1001/jamapsychiatry.2014.1575 [DOI] [PubMed] [Google Scholar]
  20. Gilboa-Schechtman E, Foa EB, Shafran N, Aderka IM, Powers MB, Rachamim L, … Apter A (2010). Prolonged exposure versus dynamic therapy for adolescent PTSD: A pilot randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 1034–1042. 10.1016/j.jaac.2010.07.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Goetter EM, Bui E, Ojserkis RA, Zakarian RJ, Brendel RW, & Simon NM (2015). A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans. Journal of Traumatic Stress, 28(5), 401–409. 10.1002/jts.22038 [DOI] [PubMed] [Google Scholar]
  22. Greene CJ, Morland LA, Durkalski VL, & Frueh BC (2008). Noninferiority and equivalence designs: issues and implications for mental health research. Journal of Traumatic Stress, 21, 433–439. 10.1002/jts.20367 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Grubbs KM, Fortney JC, Kimbrell T, Pyne JM, Hudson T, Robinson D, … Schnurr PP (2017). Usual care for rural veterans with Posttraumatic Stress Disorder. The Journal of Rural Health 10.1111/jrh.12230 [DOI] [PubMed] [Google Scholar]
  24. Hamblen JL, Bernardy NC, Sherrieb K, Norris FH, Cook JM, Louis CA, & Schnurr PP (2015). VA PTSD clinic director perspectives: How perceptions of readiness influence delivery of evidence-based PTSD treatment. Professional Psychology: Research and Practice, 46, 90–96. 10.1037/a0038535 [DOI] [Google Scholar]
  25. Hersoug A, Høglend P, Monsen J, & Havik O (2001). Quality of working alliance in psychotherapy: therapist variables and patient/therapist similarity as predictors. The Journal of Psychotherapy Practice and Research, 10(4), 205–216. [PMC free article] [PubMed] [Google Scholar]
  26. Hoffart A, Øktedalen T, Langkaas TF, & Wampold BE (2013). Alliance and outcome in varying imagery procedures for PTSD: A study of within-person processes. Journal of Counseling Psychology, 60, 471–482. 10.1037/a0033604 [DOI] [PubMed] [Google Scholar]
  27. Horvath AO, Del Re AC, Flückiger C, & Symonds D (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. 10.1037/a0022186 [DOI] [PubMed] [Google Scholar]
  28. Imel ZE, Laska K, Jakupcak M, & Simpson TL (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 394–404. 10.1037/a0031474 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Institute of Medicine. (2014). Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. 10.17226/18724 [DOI] [PubMed] [Google Scholar]
  30. Jonas DE, Cusack K, Forneris CA, Wilkins TM, Sonis J, Middleton JC, … others. (2013). Psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD). Rockville, MD: Agency for Healthcare Research and Quality; (Comparative Effectiveness Reviews, No. 92.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK137702/ [PubMed] [Google Scholar]
  31. Keller SM, Zoellner LA, & Feeny NC (2010). Understanding factors associated with early therapeutic alliance in PTSD treatment: Adherence, childhood sexual abuse history, and social support. Journal of Consulting and Clinical Psychology, 78, 974–979. 10.1037/a0020758 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Klein B, Richards JC, & Austin DW (2006). Efficacy of internet therapy for panic disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37, 213–238. 10.1016/j.jbtep.2005.07.001 [DOI] [PubMed] [Google Scholar]
  33. Kolko DJ, Cohen JA, Mannarino AP, Baumann BL, & Knudsen K (2009). Community treatment of child sexual abuse: A survey of practitioners in the National Child Traumatic Stress Network. Administration and Policy in Mental Health and Mental Health Services Research, 36, 37–49. 10.1007/s10488-008-0180-0 [DOI] [PubMed] [Google Scholar]
  34. Luborsky L, Barber JP, Siqueland L, Johnson S, Najavits LM, Frank A, & Daley D (1996). The revised Helping Alliance questionnaire (HAq-II): psychometric properties. The Journal of Psychotherapy Practice and Research, 5(3), 260. [PMC free article] [PubMed] [Google Scholar]
  35. Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, & Stevens SP (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898–907. 10.1037/0022-006X.74.5.898 [DOI] [PubMed] [Google Scholar]
  36. Morland LA, Mackintosh M-A, Greene CJ, Rosen CS, Chard KM, Resick PA, & Frueh BC (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: A randomized noninferiority clinical trial. Journal of Clinical Psychiatry, 75, 470–476. 10.4088/JCP.13m08842 [DOI] [PubMed] [Google Scholar]
  37. Ormhaug SM, Jensen TK, Wentzel-Larsen T, & Shirk SR (2014). The therapeutic alliance in treatment of traumatized youths: relation to outcome in a randomized clinical trial. Journal of Consulting and Clinical Psychology, 82, 52–64. 10.1037/a0033884 [DOI] [PubMed] [Google Scholar]
  38. Piaggio G, Elbourne DR, Altman DG, Pocock SJ, Evans SJ, Group C, & others. (2006). Reporting of noninferiority and equivalence randomized trials: an extension of the CONSORT statement. JAMA : The Journal of the American Medical Association, 295, 1152–1160. 10.1001/jama.295.10.1152 [DOI] [PubMed] [Google Scholar]
  39. Preschl B, Maercker A, & Wagner B (2011). The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression. BMC Psychiatry, 11 10.1186/1471-244X-11-189 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Raue PJ, Goldfried MR, & Barkham M (1997). The therapeutic alliance in psychodynamic-interpersonal and cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology, 65, 582 10.1037/0022-006X.65.4.582 [DOI] [PubMed] [Google Scholar]
  41. Resick PA, Monson CM, & Chard KM (2016). Cognitive Processing Therapy for PTSD: A Comprehensive Manual. New York, NY: Guilford Press. [Google Scholar]
  42. Ruzek JI, Eftekhari A, Crowley J, Kuhn E, Karlin BE, & Rosen CS (2017). Posttraining beliefs, intentions, and use of prolonged exposure therapy by clinicians in the veterans health administration. Administration and Policy in Mental Health and Mental Health Services Research, 44, 123–132. 10.1007/s10488-015-0689-y [DOI] [PubMed] [Google Scholar]
  43. Schnurr PP (2017). Focusing on trauma-focused psychotherapy for posttraumatic stress disorder. Current Opinion in Psychology, 14, 56–60. 10.1016/j.copsyc.2016.11.005 [DOI] [PubMed] [Google Scholar]
  44. Shapiro F (2001). Eye movement desensitization and reprocessing: basic principles, protocols and procedures. New York: Guilford Press. [Google Scholar]
  45. Sharf J, Primavera LH, & Diener MJ (2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 47(4), 637–645. 10.1037/a0021175 [DOI] [PubMed] [Google Scholar]
  46. Sheehan D, Lecrubier Y, Sheehan KH, Sheehan K, Amorim P, Janavs J, … Dunbar G (1998). Diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33. [PubMed] [Google Scholar]
  47. Sherbourne CD, & Stewart AL (1991). The MOS social support survey. Social Science & Medicine, 32, 705–714. 10.1016/0277-9536(91)90150-B [DOI] [PubMed] [Google Scholar]
  48. Shiner B, Tang C, Trapp AC, Konrad R, Bar-On I, & Watts BV (2014). The provision of mental health treatment after screening: exploring the relationship between treatment setting and treatment intensity. General Hospital Psychiatry, 36, 581–588. 10.1016/j.genhosppsych.2014.07.009 [DOI] [PubMed] [Google Scholar]
  49. Spinhoven P, Giesen-Bloo J, van Dyck R, Kooiman K, & Arntz A (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75, 104–115. 10.1037/0022-006X.75.1.104 [DOI] [PubMed] [Google Scholar]
  50. Stiles WB, Glick MJ, Osatuke K, Hardy GE, Shapiro DA, Agnew-Davies R, … Barkham M (2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51, 81 10.1037/0022-0167.51.1.81 [DOI] [Google Scholar]
  51. Stiles W, & Goldsmith JZ (2010). The alliance over time In Muran JC & Barber JP (Eds.), The therapeutic alliance: An evidence-based guide to practice (pp. 44–62). New York, NY. [Google Scholar]
  52. van Minnen A, Hendriks L, & Olff M (2010). When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors. Behaviour Research and Therapy, 48, 312–320. https://doi.org/10.1016/j.brat . https://doi.org/10.1016/j.brat2009.12.003. 2009.12.003 [DOI] [PubMed] [Google Scholar]
  53. Wagner B, Brand J, Schulz W, & Knaevelsrud C (2012). Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab war-traumatized patients. Depression and Anxiety, 29, 646–651. 10.1002/da.21962 [DOI] [PubMed] [Google Scholar]
  54. Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, & Friedman MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of Clinical Psychiatry, 74, 541–550. 10.4088/JCP.12r08225 [DOI] [PubMed] [Google Scholar]
  55. Weathers FW, Ruscio AM, & Keane TM (1999). Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychological Assessment, 11, 124–133. 10.1037/1040-3590.11.2.124 [DOI] [Google Scholar]
  56. Zlotnick C, Najavits LM, Rohsenow DJ, & Johnson DM (2003). A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: Findings from a pilot study. Journal of Substance Abuse Treatment, 25, 99–105. 10.1016/S0740-5472(03)00106-5 [DOI] [PubMed] [Google Scholar]

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