Using data from the National Institute of Mental Health Treatment for Depression Collaborative Research Program, the authors examined the impact on treatment outcome of the patient's perception of the quality of the therapeutic relationship and contribution to the therapeutic alliance. Shared variance with early clinical improvement was removed from these relationship measures. Multilevel modeling demonstrated that a perceived positive therapeutic relationship early in treatment predicted more rapid decline in maladjustment subsequent to the relationship assessment. This effect occurred equally across all 4 treatment conditions. A positive early therapeutic relationship also predicted better adjustment throughout the 18-month follow-up as well as development of greater enhanced adaptive capacities (EAC). Controlling a wide range of patient characteristics did not eliminate the effects of the therapeutic relationship on rate of improvement during treatment and on EAC. Thus, independent of type of treatment and early clinical improvement, the therapeutic relationship contributes directly to positive therapeutic outcome.
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