The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder.

OBJECTIVE To examine the associations between treatment/outcome expectations, alliance before and during treatment, and the impact of alliance on symptomatic improvement. METHODS One hundred and fifty-three depressed patients randomized to dynamic supportive-expressive psychotherapy (SET), antidepressant medication (ADM) or placebo (PBO) + clinical management completed ratings of treatment expectations, therapeutic alliance (CALPAS, WAI-S), and depressive symptoms (HAM-D). RESULTS Pretreatment expectations of the therapeutic alliance were significantly related to alliance later in therapy but did not differ across treatments and did not predict outcome. Alliance development over time differed between treatments; it increased more in SET than in PBO. After controlling for prior symptom improvement, early alliance predicted subsequent depression change. CONCLUSIONS Expectations of alliance and of treatment outcome/improvement, measured prior to treatment onset, predicted subsequent alliance.