Journal of Marital and Family Therapy

April 2007, Vol. 33, No. 2, 245–257

THERAPEUTIC ALLIANCE AND TREATMENT

PROGRESS IN COUPLE PSYCHOTHERAPY
Lynne M. Knobloch-Fedders, William M. Pinsof, and Barton J. Mann
The Family Institute at Northwestern University

This study examined the ability of the therapeutic alliance to predict treatment progress
on individual- and relationship-level variables from the early to middle phase of couple
treatment. Although alliance did not predict progress in individual functioning, it accoun-
ted for 5–22% of the variance in improvement in marital distress. Women’s mid-
treatment alliance uniquely predicted improvement in marital distress, over and above
early treatment alliance. When men’s alliances with the therapist were stronger than their
partners’ at session 8, couples showed more improvement in marital distress. Treatment
response was also positively associated with women’s ratings of their partners’ alliance.
Results confirm that the therapeutic alliance in conjoint treatment is composed of distinct
client subsystems that are useful predictors of treatment progress.

Empirical evidence has accumulated over the last several decades suggesting that the thera-
peutic alliance is a strong predictor of outcome in individual psychotherapy (Horvath & Bedi,
2002; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Therapeutic alliance has also
been shown to predict outcome in couple therapy across diverse treatment orientations and
modalities (Bourgeois, Sabourin, & Wright, 1990; Brown & O’Leary, 2000; Holtzworth-
Munroe, Jacobson, DeKlyen, & Whisman, 1989; Johnson & Talitman, 1997; Quinn, Dotson, &
Jordan, 1997; Raytek, McGrady, Epstein, & Hirsch, 1999). Using marital distress as the depen-
dent variable, the proportion of variance explained by the therapeutic alliance in conjoint treat-
ment outcome has ranged from 5–7% (Bourgeois et al., 1990) to 22% (Johnson & Talitman,
1997). The predictive validity of the therapeutic alliance on individual-level outcome variables
(i.e., individual functioning or psychological symptomatology) in conjoint treatment has not
been investigated.
Investigators have recently turned their attention toward exploring mediators and modera-
tors of the relationship between therapeutic alliance and outcome (Horvath & Bedi, 2002).
However, most of this emerging body of research has been conducted in individual therapy
contexts, and it is unknown how well these findings apply to couple therapy.
For example, it is unclear whether the therapeutic alliance remains relatively stable over
the course of conjoint treatment or whether it evolves over time. In research on brief individual
therapy, Sexton, Hembre, and Kvarme (1996) found that the formation of the alliance occurred
by the completion of the first session and remained relatively stable over the course of 10 ses-
sions. However, other studies report that alliance measurements taken during different phases
of individual psychotherapy do not correlate with each other (Crits-Christoph, Cooper, &
Luborsky, 1988; Gaston, Piper, Debbane, Bienvenu, & Garant, 1994).

Lynne M. Knobloch-Fedders, PhD, and William M. Pinsof, PhD, Center for Applied Psychological and
Family Studies, The Family Institute at Northwestern University; Barton J. Mann, PhD, American Orthopaedic
Society for Sports Medicine. Barton J. Mann was formerly Coordinator of Research at The Family Institute at
Northwestern University.
The authors would like to thank the Burton D. Morgan Foundation’s support of this research through a
fellowship awarded to the first author. They also thank Emily Durbin and Richard Zinbarg for their assistance
with data analysis.
Address correspondence to Lynne M. Knobloch-Fedders, Center for Applied Psychological and Family
Studies, The Family Institute at Northwestern University, Bette D. Harris Center, 618 Library Place, Evanston,
Illinois 60201; E-mail: l-knobloch@northwestern.edu

April 2007 JOURNAL OF MARITAL AND FAMILY THERAPY 245

 Conflicting evidence also exists about whether therapeutic alliance measured early in treat-
ment or at mid-therapy is a better predictor of outcome in individual therapy (Horvath & Bedi,
2002). Typically, couple therapy researchers have measured therapeutic alliance formation once,
after the third session (Bourgeois et al., 1990; Heatherington & Friedlander, 1990; Johnson &
Greenberg, 1985; Mamodhoussen, Wright, Tremblay, & Poitras-Wright, 2005). However, longi-
tudinal investigations in which the alliance is measured over time, in order to determine
whether early or mid-treatment alliance more strongly predicts outcome, have not been
conducted.
Evidence has accumulated suggesting that the strength of the therapeutic alliance’s relation-
ship with outcome may show differential gender effects. Several studies have found that the
strength of the therapeutic alliance in conjoint treatment is a more powerful predictor of posi-
tive outcome among men than among women (Bourgeois et al., 1990; Brown & O’Leary, 2000).
However, Quinn et al. (1997) found that when wives’ alliance scores were higher than hus-
bands’ scores the outcome of therapy was reported to be more positive than when husbands’
alliance scores were higher than wives’ scores. This effect was found when wives’ raw scores
were higher than their husbands’ on two specific subscales of the Couple Therapy Alliance
Scale (CTAS; Pinsof & Catherall, 1986), the Task subscale and the Other subscale.
Pinsof and Catherall (1986) proposed that a ‘‘split alliance’’ may occur if both members of
the couple do not agree on their perceptions of the therapeutic alliance (as opposed to an
‘‘intact alliance,’’ in which both members of the couple perceive the quality of the alliance simi-
larly). This concept has been empirically supported (Heatherington & Friedlander, 1990; Quinn
et al., 1997). Pinsof (1994) hypothesized that split alliances may be related to poorer outcomes,
although this has never been tested.
This study was designed to examine the ability of the therapeutic alliance to predict change
in both individual-level and couple-level variables. The therapeutic alliance was measured twice,
after sessions 1 and 8, in order to determine the stability of the alliance across time, as well as
test the relative predictive power of early versus mid-treatment alliance on therapeutic progress.
Gender differences in the therapeutic alliance’s ability to predict change were investigated.
Finally, the possibility that split alliances may be related to poorer outcome was tested.
This study was conducted as part of a larger naturalistic investigation of the process of
change in systemically oriented psychotherapy. One of the goals was to begin to assess empiri-
cally informed treatment: that is, treatment in which the therapist makes use of information
regarding client change as treatment unfolds to guide and improve the quality of intervention
(also called ‘‘progress research,’’ Pinsof & Wynne, 2000; or ‘‘client-focused research,’’ Howard,
Moras, Brill, Martinovich, & Lutz, 1996). Clients were informed before beginning treatment
that their therapists would have access to the clinical information collected during the study. In
this way, the study differs from previous alliance research, most of which has been designed to
keep client alliance ratings confidential from therapists in order to preserve the independence of
ratings.

METHOD

Participants
All couples who presented for treatment at a large midwestern outpatient clinic specializing
in couple and family therapy were asked to participate in a naturalistic study of change in psy-
chotherapy; the final sample included a total of 80 people who attended at least eight sessions
of conjoint treatment. The sample included 35 couples for whom complete data existed for both
partners, as well as 10 additional participants who were included although their partners were
excluded due to missing data. Participants’ mean age at intake was 34 years (SD = 9.64; range:
21–74 years). Fifty-eight percent of couples were married, 23% were single, 17% were cohabi-
ting, and 3% were engaged. Seventy-seven percent of the sample was Caucasian, 6% were

246 JOURNAL OF MARITAL AND FAMILY THERAPY April 2007

Hispanic, 3% were Asian, 3% were African American, and 4.5% were biracial; an additional
6% did not indicate their racial background. The median income per household was $50,000.
Couples presented for conjoint treatment with a variety of problems, including difficulties with
communication, conflict, intimacy, problem solving, and parenting.
Twenty-nine therapists, 25 women and 4 men, participated in the study; their mean age
was 31 years. They were a relatively inexperienced group, comprised of 18 students in the sec-
ond year of a master’s program in marital and family therapy, three doctoral students in coun-
seling or clinical psychology, and eight postgraduate clinical fellows. Twenty-eight of the
therapists were Caucasian; one therapist was Asian. Their mean level of clinical experience was
3 years. Therapists participated in weekly group supervision conducted by senior clinicians, all
highly experienced family therapists.
Treatment was conducted using a systemic model of psychotherapy called integrative prob-
lem-centered therapy (IPCT; Pinsof, 1995). IPCT focuses on changing the couple’s presenting
problem by prescribing a sequence of interventions derived from various treatment orientations,
including behavioral, biological, experiential, family-of-origin, psychodynamic, and self-
psychology. Treatment was not time limited, and averaged 18.26 sessions (SD = 9.74; range:
8–44 sessions).

Measures
COMPASS Treatment Assessment System. The COMPASS Treatment Assessment System
(COMPASS Information Services, 1996; Sperry, Brill, Howard, & Grissom, 1996) is a question-
naire designed to assess patient characteristics and response to psychotherapy. It contains three
subscales: Current Well-Being, Current Symptoms, and Current Life Functioning, all of which
are rated on 5-point Likert scales.
The seven-item Current Well-Being scale includes items assessing distress, energy and
health, emotional and psychological adjustment, and current life satisfaction; higher scores indi-
cate greater well-being. The 33-item Current Symptoms scale is designed to assess the frequency
of symptoms characteristic of seven diagnoses represented in the Diagnostic and Statistical
Manual of Mental Disorders–IV (DSM–IV; American Psychiatric Association, 1994): depres-
sion, anxiety, obsessive-compulsive, adjustment, bipolar, phobia, and substance abuse disorders;
higher scores indicate greater symptomatic distress. The 17-item Current Life Functioning scale
measures six areas of life functioning, including self-management, work ⁄ school ⁄ homemaker,
social ⁄ leisure, intimacy, family, and health; higher scores indicate better life functioning. The
COMPASS subscales show excellent internal consistency and reliability. In a sample of 423 out-
patients, the internal consistency (alpha) of the COMPASS subscales ranged from .79 (Current
Well-Being) to 95 (Current Symptoms), while 3–4 week test–retest reliability ranged from .76
(Current Life Functioning) to .85 (Current Symptoms; Grissom & Howard, 2000).
Marital Satisfaction Inventory–Revised. The Marital Satisfaction Inventory–Revised (MSI-
R; Snyder, 1997) is a 150-item self-report measure of relationship distress. It includes two
validity scales, a global distress scale, and 10 additional scales assessing specific relationship
dimensions, including affective communication, problem-solving communication, aggression,
time together, disagreement about finances, sexual dissatisfaction, role orientation, family his-
tory of distress, dissatisfaction with children, and child rearing. The latter three are excluded
from analyses in this study. The family of origin distress subscale was not included because it
does not represent an area for potential improvement in couple treatment, and the parenting
subscales were excluded because less than half of participants had children between the ages of
4–17.
Items are scored true–false; higher scores on all subscales indicate greater distress. The
MSI-R subscales have been shown to discriminate well between community and clinical
samples, and demonstrate adequate internal consistency ([alphas] range from .70 to 93, while
test–retest correlation coefficients range from .74 to .88; Snyder, 1997).

April 2007 JOURNAL OF MARITAL AND FAMILY THERAPY 247

 For the purpose of this study, in order to increase the likelihood of response variability for
the purpose of detecting change in treatment, the response format of the MSI-R was converted
from true–false into a 5-point Likert scale with the following anchors: (a) strongly agree; (b)
agree; (c) neither agree nor disagree; (d) disagree; and (e) strongly disagree.
Couple Therapeutic Alliance Scale–Revised. The Couple Therapeutic Alliance Scale–
Revised (CTAS-R; Pinsof, 1994) is a 40-item self-report questionnaire designed to measure the
therapeutic alliance in conjoint treatment; it is completed by each partner separately. It is rated
on a 5-point Likert scale ranging from (1) ‘‘strongly agree’’ to (5) ‘‘strongly disagree.’’
The CTAS-R measures three components of the alliance identified by Bordin
(1979)—tasks, goals, and bonds—for each of the four possible alliance subsystems in conjoint
psychotherapy: (a) self–therapist (the ‘‘Self’ subscale); (b) partner–therapist (the ‘‘Other’’ sub-
scale); (c) couple–therapist (the ‘‘Group’’ subscale); and (d) self–partner (the ‘‘Within’’ sub-
scale). The latter can be conceptualized as the couple’s ability to form a congruent ‘‘orientation
to treatment’’ with each other (for example, agreeing on the tasks and goals of therapy). All
the items can also be summed to create a CTAS-R total score.
These two dimensions (alliance component and subsystem) form a 3 · 4 matrix that is used
to assess each system’s alliance across the content domains of tasks, goals, and bonds, creating
seven possible subscales (Self, Other, Group, Within, Tasks, Bonds, and Goals). All items load
both onto one content and one interpersonal subscale. Sample items in the CTAS-R include
the following: ‘‘The therapist cares about me as a person’’ (Self and Bonds subscales), ‘‘The
therapist understands my partner’s goals for this therapy’’ (Other and Goals subscales), ‘‘The
therapist cares about the relationship between my partner and myself’’ (Group and Bonds
subscales), and ‘‘My partner and I are not pleased with the things that each of us does in this
therapy’’ (Within and Tasks subscales).
In this article, analyses were limited to the interpersonal dimension of the CTAS-R (i.e.,
the Self, Group, Other, and Within subscales) in order to focus the results on the interpersonal
dimension of the alliance in conjoint treatment, as well as to reduce the number of analyses to
limit the possibility of Type I error.

Procedure
Before the first session began, the therapist met with the couple briefly, described the study,
and solicited their informed consent to participate. Couples then completed the pretreatment
measures of individual and couple functioning (the COMPASS and MSI-R), met with the ther-
apist for their initial appointment, and directly afterwards completed the CTAS-R. After ses-
sion 8, participants completed the COMPASS, MSI-R, and CTAS-R. Couples completed the
measures separately, did not discuss their answers with each other, and returned their assess-
ments directly to the therapist.

RESULTS

For comparison purposes, the 80 participants (40 men and 40 women) who completed at least
eight sessions of conjoint treatment were contrasted with 88 others (42 men and 46 women) who
were assessed at session 1 but ended treatment before session 8. Participants who completed at
least eight sessions rated the alliance significantly higher on the CTAS-R Total subscale
(X = 3.86, SD = .41) than those who did not (X = 3.71, SD = .43), t(146) = 2.20, p = .029.
There were no significant differences between these two groups on demographic variables such as
age or income. However, a Chi-square analysis revealed that the groups differed in terms of racial
background, X 2(4) = 15.437, p = .0038. The group of participants who completed at least eight
sessions contained fewer African Americans (2 to 16) and more Caucasians (63 to 51) compared
with the group that ended treatment before session 8. A one-way analysis of variance was conduc-
ted to determine whether CTAS-R Total scores at intake differed by racial background, but this

248 JOURNAL OF MARITAL AND FAMILY THERAPY April 2007

was not significant, F(4, 141) = .799, p = .528, while the post hoc contrast between Caucasians
and African Americans also showed no significant difference, t(131) = 1.61, p = .109.

Descriptive Statistics
For the 80 participants who completed at least eight sessions, descriptive statistics for the
COMPASS, MSI-R, and CTAS-R are displayed in Table 1, including internal reliability (alpha)
coefficients calculated at session 1 for each subscale. Alpha coefficients ranged from .54 on the
COMPASS Well-Being subscale to .96 on the CTAS-R Total subscale.
For comparison purposes, gender differences in ratings on all measures were assessed using
t-tests, corrected for Type I error using the Bonferroni approach. No significant differences
emerged between men and women on the COMPASS, MSI-R, or CTAS-R. Analyses were also
conducted to determine whether alliance ratings correlated with age or household income; how-
ever, no relationship was found between alliance and these demographic variables.
Because data collected from both members of a couple are not independent, all analyses
were conducted separately for men and women.

Stability of the Alliance From Early to Mid-treatment

Correlations between CTAS-R subscales measured after session 1 and session 8 for men
and women are presented in Table 2; they range from .32 (CTAS-R Within subscale for

Table 1
Descriptive Statistics for the COMPASS, MSI-R, and CTAS-R at Session 1 and
Session 8 for Men and Women

Session 1 Session 8
Men Women Men Women
Alpha Mean SD Mean SD Mean SD Mean SD

COMPASS
Well-being .54 21.46 3.04 20.31 3.19 22.29 3.25 21.91 3.66
Life functioning .93 58.17 13.67 57.02 13.68 65.27 13.50 64.36 12.20
Current symptoms .94 57.28 17.19 64.82 18.63 53.96 16.59 56.99 16.10
Composite total .86 136.92 20.17 142.15 18.56 141.51 18.78 143.26 10.41
MSI-R
Global distress .92 68.54 13.28 73.88 13.90 63.99 16.17 68.17 16.67
Affective communication .81 40.41 7.98 41.22 8.17 38.67 9.81 41.14 9.48
Problem solving .87 64.11 10.94 64.68 11.06 60.46 12.37 61.58 12.92
Time together .86 30.45 6.70 32.01 7.52 28.81 8.04 30.26 8.60
MSI
Sexual dissatisfaction .89 42.13 10.39 40.23 9.38 42.01 11.85 39.65 10.10
Role orientation .95 31.62 11.35 29.75 14.33 26.90 9.86 23.89 10.18
Composite total .95 333.62 47.72 335.33 49.02 314.40 63.17 314.27 53.37
CTAS-R
Self .88 3.89 .43 3.93 .58 4.09 .47 4.12 .55
Group .88 3.85 .42 4.00 .59 4.10 .48 4.13 .52
Other .89 3.78 .46 3.75 .52 3.92 .49 3.89 .54
Within .89 3.81 .50 3.95 .51 3.88 .57 3.88 .56
Composite total .96 3.83 .40 3.90 .49 3.98 .46 3.99 .48

April 2007 JOURNAL OF MARITAL AND FAMILY THERAPY 249

 Table 2
Bivariate Correlations Between the CTAS-R Subscale
Scores at Session 1 and Session 8

Men Women

CTAS-R
Self .410** .374*
Group .586** .359*
Other .543** .480**
Within .668** .323*
Composite total .605** .422**

*p < .05. **p < .01.

women) to .67 (CTAS-R Within subscale for men). All correlations are significant at the
p < .05 level.

Predictive Validity of Early Treatment Alliance

In order to test the predictive validity of the therapeutic alliance on change in individual-
and relationship-level variables, a series of separate hierarchical linear regressions were calcula-
ted. To assess the unique contribution of the alliance on therapeutic change beyond that of
initial distress, intake scores on the dependent variable were entered into the regression on the
first step, and therapeutic alliance scores were entered on the second step.
To control for the possibility of Type I error, initial hierarchical regression equations were
calculated in order to predict the change in COMPASS and MSI-R Total scores using CTAS-R
Total alliance scores; these total scores represent composites derived by summing the various
subscale scores. Only if the initial hierarchical multiple regression equation reached significance
at the p < .05 level were further analyses conducted to predict change based on the various
CTAS-R subscale scores.
Predictive validity of early treatment alliance on individual functioning. Pretreatment levels
of individual functioning accounted for 35% of the variance in individual functioning at session
8 for men and 22% for women. Next, therapeutic alliance scores at intake were added to the
hierarchical regression models in step two in order to predict change in individual functioning
from session 1 to session 8. For both men and women, the second step in these regression mod-
els did not reach significance, F change (1, 37) = .052, p = .821 for men and F change
(1, 37) = .01, p = .983 for women.
Predictive validity of early treatment alliance on marital distress. CTAS-R Total scores at
session 1 predicted change in marital distress from session 1 to session 8 for both men and
women (see Table 3). For men, pretreatment levels of marital distress accounted for 61% of the
variance in marital distress at session 8, F(1, 38) = 60.22, p < .001. After controlling for pre-
treatment marital distress, therapeutic alliance accounted for an additional 5% of the variance
in marital distress change, F change (1, 37) = 5.94, p = .020. For women, pretreatment levels
of marital distress accounted for 33% of the variance in marital distress at session 8, F(1,
38) = 18.60, p < .001. After controlling for pretreatment marital distress, therapeutic alliance
accounted for an additional 9% of the variance in marital distress change, F change
(1, 37) = 5.40, p = .026.
To determine whether any alliance subscale showed a unique ability to predict change in
marital distress, a hierarchical regression analysis was conducted using marital distress at

250 JOURNAL OF MARITAL AND FAMILY THERAPY April 2007

 Table 3
Summary of Hierarchical Linear Regressions Predicting Change in Marital Distress
From CTAS-R at Session 1

B SE B B sr2 t p

Men
Self )1.23 33.28 ).008 <.001 ).037 .971
Group )19.41 34.31 ).130 .003 ).566 .575
Other )4.14 23.36 ).030 <.001 ).177 .861
Within )12.73 21.75 ).100 .003 ).585 .562
Total )36.98 15.18 ).234 .053 )2.44 .202*
Women
Self 14.32 27.75 .156 .004 .516 .609
Group )38.95 27.72 ).432 .031 )1.41 .169
Other )21.64 27.22 ).210 .010 ).795 .432
Within 20.97 19.80 .202 .018 1.06 .297
Total )31.82 13.70 ).292 .085 )2.32 .026*

*p < .05. **p < .01.

Note. Two separate regressions, using (a) CTAS-R Self, Group, Other, and Within subscales;
and (b) the CTAS-R Total score, were calculated.

session 8 as the dependent variable. Marital distress at session 1 was entered on the first step,
and postsession 1 CTAS-R Self, Other, Group, and Within subscale scores were simultaneously
entered on the second step. Step two of this regression was nonsignificant for both men
[F change (4, 34) = 1.44, p = .24] and women [F change (4, 34) = 2.147, p = .096], suggest-
ing that change in marital distress from session 1 to session 8 can be accounted for by what is
common among the early treatment alliance subscales.

Predictive Validity of Mid-treatment Alliance

Predictive validity of mid-treatment alliance on individual functioning. Separate hierarchical
regression equations were calculated for men and women in order to determine whether thera-
peutic alliance at session 8 predicted change in individual functioning from session 1 to session
8. For both men and women, these regression equations were nonsignificant, F change
(1, 37) = .17, p = .683 for men and F change (1, 37) = 1.00, p = .324 for women.
Predictive validity of mid-treatment alliance on marital distress. CTAS-R Total scores at
session 8 predicted change in marital distress from session 1 to session 8 for both men and
women (see Table 4). After controlling for pretreatment marital distress, therapeutic alliance
accounted for an additional 6% of the variance in change in marital distress, F change
(1, 37) = 7.11, p = .011. For women, after controlling for pretreatment marital distress, thera-
peutic alliance accounted for an additional 15% of the variance in change in marital distress,
F change (1, 37) = 10.34, p = .003.
To assess whether specific mid-treatment alliance subscales predict change in marital dis-
tress, hierarchical regression analyses were conducted using marital distress at session 8 as the
dependent variable. Marital distress at session 1 was entered on the first step, and CTAS-R
Self, Other, Group, and Within subscale scores at session 8 were simultaneously entered on the
second step. Step two resulted in a significant increase in variance explained for women, F
change (4, 34) = 6.28, p < .001, R2 change = .285, but just missed significance for men, F

April 2007 JOURNAL OF MARITAL AND FAMILY THERAPY 251

 Table 4
Summary of Regressions Predicting Change in Marital Distress From CTAS-R at
Session 8

B SE B B R2 change t p

Men
Self 31.61 32.74 .234 .008 .965 .341
Group )36.12 40.98 ).272 .007 ).882 .384
Other )5.66 28.24 ).044 <.001 ).200 .842
Within )27.22 19.57 ).247 .017 )1.39 .173
Total )37.48 14.06 ).275 .062 )2.67 .011*
Women
Self )12.85 25.81 ).133 .003 ).498 .622
Group 42.99 33.59 .416 .027 1.28 .209
Other )15.87 21.21 ).160 .006 ).748 .459
Within )59.31 18.17 ).624 .121 )3.26 .003**
Total )42.78 13.31 ).383 .147 )3.22 .003**

*p < .05. **p < .01.

Note. Information provided above is taken from two separate regressions, using (a) CTAS-R
Self, Group, Other, and Within subscales entered simultaneously; and (b) the CTAS-R
Total score.

change (4, 34) = 2.55, p = .057, R2 change = .089. For women, the CTAS-R Within subscale
was the only unique predictor that reached significance, accounting for 12% of the variance on
this step, t(39) = )3.26, p = .003.

Predictive Validity of Mid-treatment Alliance Over and Above Early Treatment Alliance
In order to determine whether mid-treatment alliance makes a unique contribution to the
prediction of marital distress change from session 1 to session 8 beyond that accounted for by
early treatment alliance, separate hierarchical regression equations were calculated (see
Table 5). Intake scores for marital distress were entered on the first step of the regression equa-
tion, CTAS-R Total scores measured at session 1 were entered second, and CTAS-R Total
scores measured at session 8 were entered on the third step. The third step of this regression
equation did not reach significance for men, F change (1, 36) = 2.18, R2 change = .02,
p = .149. However, for women session 8 alliance accounted for an additional 8% of the vari-
ance in marital distress change beyond intake marital distress and session 1 alliance scores, F
change (1, 36) = 5.85, p = .021.
To assess whether specific mid-treatment alliance subscales have a unique ability to predict
change in marital distress over and above early treatment alliance, hierarchical regression analy-
ses were conducted using marital distress at session 8 as the dependent variable. Marital distress
at session 1 was entered on the first step; CTAS-R Self, Other, Group, and Within subscale
scores at session 1 were simultaneously entered on the second step; and CTAS-R subscales at
session 8 were simultaneously entered on the third step. This third step was nonsignificant for
men, F change (4, 30) = 1.03, p = .41, but significant for women, F change (4, 30) = 4.73,
p = .004, R2 change = .21.
Because the CTAS-R Total score at session 8 predicted change in marital distress over
and above CTAS-R early alliance Total score, specific alliance subscales were evaluated to

252 JOURNAL OF MARITAL AND FAMILY THERAPY April 2007

 Table 5
Summary of Regressions Predicting Change in Marital Distress From CTAS-R From
Session 8 Over and Above CTAS-R Session 1 Scores

B SE B B R2 change t p

Men
Total )25.99 17.62 ).190 .019 )1.48 .149
Women
Self 32.64 34.89 .241 .008 ).935 .357
Group )32.28 46.35 ).243 .005 ).696 .492
Other )6.66 33.25 ).052 <.001 ).200 .843
Within )22.55 23.28 ).204 .009 ).968 .341
Total )35.28 14.58 ).316 .082 )2.42 .021*

*p < .05. **p < .01.

Note. Information provided above is taken from two separate regressions, using (a) CTAS-R
Self, Group, Other, and Within subscales entered simultaneously; and (b) the CTAS-R
Total score.

determine whether they uniquely predict women’s change in marital distress. Hierarchical
regression analyses were conducted using marital distress at session 8 as the dependent variable.
Marital distress at session 1 was entered on the first step; CTAS-R Self, Other, Group, and
Within subscales at session 1 were simultaneously entered on the second step; and CTAS-R
Self, Other, Group, and Within subscales at session 8 were simultaneously entered on the third
step. This third step of the regression model was not significant for women, F change
(4, 30) = 1.02, R2 change = .04, p = .410.

Differential Outcome Based on Gender Differences in Alliance Ratings

In order to test whether women’s or men’s higher alliance ratings were differentially associ-
ated with therapeutic change, independent sample t-tests were performed. From the original
sample of 80 individuals, 10 participated without their partners; their data were omitted from
this analysis, leaving 35 couples. Separate groups were formed based on whether the man’s
CTAS-R Self raw score was higher than the woman’s, or vice versa.
For women, t-tests indicated that the group in which men’s CTAS-R Self subscale alliance
rating at session 8 was higher than their partners’ showed greater improvement in women’s
marital distress, t(33) = 2.17, p = .037. This relationship was not significant for men’s marital
distress, t(33) = 0.32, p = .752.

Relationship of Split Alliance to Outcome

Following previous research (e.g., Heatherington & Friedlander, 1990), split alliances were
empirically defined as a difference of one standard deviation or more between partners’ CTAS
subscale scores. For the sake of conceptual simplicity, we examined only those alliance sub-
scales that involved the therapist and the member of the couple providing the rating (i.e., the
CTAS Self and Group subscales) for split alliances. From the original sample of 80 individuals,
split alliance analyses were conducted on the 35 couples (70 individuals) who provided data
from both partners. After session 1, 28 couples (40%) had a split alliance on the CTAS-Self
subscale, while 24 couples (34.3%) had a split alliance on the CTAS-Group subscale. After

April 2007 JOURNAL OF MARITAL AND FAMILY THERAPY 253

session 8, the frequency of split alliances had increased slightly, to 30 couples (42.9%) on the
CTAS-Self subscale and 28 (40%) on the CTAS-Group subscale.
Independent sample t-tests were conducted in order to determine whether couples with a
split alliance showed less reduction in marital distress than those with intact alliances. These
analyses were conducted on the 35 couples (70 individuals) who provided data from both part-
ners. For men and women, these t-tests were not significant at the p < .05 level.

DISCUSSION

This study investigated the predictive validity of the therapeutic alliance on change on both
individual- and relationship-level variables. Alliance was measured both very early in treatment
(after session 1) and during the middle phase of treatment (after session 8) in order to deter-
mine whether early alliance, mid-treatment alliance, or both predicted change in conjoint
treatment.
This study was not designed to measure treatment outcome per se — if outcome is defined
as improvement from intake to termination—because data on change in marital distress and
individual functioning were gathered at session 8 although the average length of treatment was
18 sessions. Therefore, this study is properly regarded as an investigation into the relationship
between therapeutic alliance and treatment progress from the early to middle phase of couple
treatment.
Compared to previous research on the alliance in couple therapy, we expected that our
sample would rate the therapeutic alliance relatively highly, because clients’ awareness that
their therapist would have access to their alliance ratings might influence them to make their
ratings more socially desirable. However, the mean alliance ratings and frequency of split alli-
ances obtained in the present study were similar to those found in previous studies in which
therapists were blind to alliance ratings (Heatherington & Friedlander, 1990).
In theory, the fact that alliance data was fed back to therapists during treatment should
reduce its ability to function as a reliable predictor and criterion. This phenomenon, labeled
responsiveness (Stiles, 1988, 1994), means that as outcome information is fed back into therapy
it influences the process such that therapists adjust their interventions accordingly. This respon-
siveness tends to attenuate process–outcome correlations. Therefore, the possibility exists that
therapist response to clients’ initial alliance assessments after session 1 might have influenced
their interventions, which in turn affected client change. Given this possibility, the current study
is a particularly stringent test of whether the therapeutic alliance can predict change in couple
therapy.
This study suggests that the therapeutic alliance formed quickly, and remained relatively
stable from the first session to the eighth session of treatment. It appears that couples’ immedi-
ate perceptions of their therapists (formed during the first session) remain well established, at
least as the therapy moves into the mid-treatment phase. In addition, couples who remained in
psychotherapy through session 8 developed stronger alliances with their therapists after the first
session compared with those who terminated earlier. This is consistent with previous research
which found that couples who failed to complete a conjoint treatment program for alcoholism
had weaker first-session therapeutic alliances (Raytek et al., 1999). Clinically, these suggest that
alliance building may be one of the most important therapeutic tasks of the first conjoint ses-
sion.
No differences emerged on initial alliance scores based on participants’ racial background.
However, the therapists in this study were predominantly Caucasian, and the group of partici-
pants who terminated early contained more African Americans and less Caucasians than those
who completed at least eight sessions. Although evidence has not supported the idea that ethnic
minorities achieve differential treatment outcomes when treated by Caucasian therapists
(Sue, 1988), previous research has found perceived racial similarity aids the formation of the

254 JOURNAL OF MARITAL AND FAMILY THERAPY April 2007

therapeutic alliance, whereas dissimilarity in racial status between clients and therapists makes
initial alliance development more difficult (Coleman, Wampold, & Casali, 1995; Gelso & Mohr,
2001). Unfortunately, because all but one of the therapists in the sample was Caucasian, the
effect of client–therapist racial matching on therapeutic alliance formation and treatment out-
come cannot be tested in this sample. However, this is an important area for continuing
research, especially in conjoint treatment contexts.
The results of this study suggest that therapeutic alliance in couple therapy is not a useful
predictor of therapeutic progress in individual functioning. Perhaps, because individual symp-
toms may not be the specific focus of treatment in conjoint therapy, therapeutic alliance is not
a relevant predictor in this treatment context.
Therapeutic alliance is a strong predictor of progress in marital distress, however. The per-
centage of variance in improvement in marital distress accounted for by the therapeutic alliance
(that is, the sum total of the predictive validity of session 1 and session 8 alliance) was 5% for
men and 17% for women.
Despite the therapeutic alliance’s relative stability, it does appear that subtle shifts in the
alliance through mid-treatment are associated with treatment responsiveness, at least for
women. Women’s alliance scores at mid-treatment made a unique contribution to the prediction
of improvement in marital distress, over and above their early treatment alliance scores. Clini-
cally, this implies that therapists must continue to foster the development of the therapeutic
alliance with couples throughout the early and middle phases of treatment.
Another interesting finding suggests that the relationship between therapeutic alliance and
treatment responsiveness may be different for men and women. For men, the CTAS-R sub-
scales (Self, Other, Group, and Within) did not significantly predict change in marital distress
at either session 1 or session 8, suggesting that what is common among the alliance subscales is
important rather than the specific subsystem being measured. In contrast, women’s ratings of
the couple’s alliance to treatment (i.e., the Within subscale) was a strong and unique predictor
of couple change at session 8. Given this finding, it is somewhat surprising that women’s own
alliance with the therapist (measured by the CTAS-R Self and Group subscales) did not con-
tribute substantially to the prediction of treatment response by session 8. It appears that,
beyond women’s initial positive perception of their relationship with the therapist, a unique pre-
dictor of successful change is women’s perception that the couple’s alliance to treatment with
each other is positive.
Previous research on conjoint treatment has obtained mixed results concerning whether
stronger alliance ratings for husbands or wives are associated with more successful outcome;
the CTAS-R’s ability to distinguish between different client subsystems becomes particularly
useful when trying to make sense of these conflicting findings. The results of this study suggest
that when men’s alliances with the therapist are stronger than their partners’ at session 8, cou-
ples show significantly more improvement in relationship distress. In a similar vein, when
women rate their partners’ alliances with the therapist more positively, successful treatment
response is more likely (also found by Quinn et al., 1997).
We do not have a ready explanation for why these different, and gender-linked, patterns
emerged; however, the existence of these patterns suggests that gender influences the therapeutic
alliance’s association with change in conjoint treatment. Clinically, knowledge about such fac-
tors, including gender, that influence the development of the alliance at different treatment sta-
ges may help therapists better target their alliance-building strategies across treatment.
These results also support the notion that the therapeutic alliance in conjoint treatment is
composed of distinct client subsystems, and that these subsystem alliances are useful predictors
of client change. The CTAS-R’s ability to measure subsystem alliances contributes to a more
refined understanding of the alliance in conjoint treatment.
Because theorists have speculated that a split alliance may lead to poorer outcomes in
conjoint treatment (Pinsof & Catherall, 1986), the fact that split alliances were found to be

April 2007 JOURNAL OF MARITAL AND FAMILY THERAPY 255

unrelated to treatment response was surprising and somewhat disappointing. It makes intuitive
sense that men and women who do not agree on their perceptions of the therapeutic alliance
may struggle to achieve treatment gains. However, the small sample size may have limited this
study’s ability to detect any differential treatment response between those couples with split ver-
sus intact alliances.
Besides the constraints imposed by its relatively small sample size, which may have limited
the study’s statistical power and ability to detect effects, the findings may not generalize to
other samples, treatment settings, or therapists. Selection effects are possible because partici-
pants volunteered to participate in the study and were not randomly selected. Although the
sample was representative of couples seeking marital therapy in an outpatient treatment setting,
it was relatively young, Caucasian, and affluent; therapists were also predominantly Caucasian,
female, and inexperienced. Because of limited variability in the therapist sample, the effects of
therapist gender and experience level on the alliance were not examined. In addition, although
therapists were trained and supervised using the Integrative Problem-Centered Therapy model,
treatment adherence was not measured.
Other limitations concern the measurement strategies employed in this study. Because the
internal consistency of the COMPASS Well-Being subscale (a = .54) was low, error variance
may have reduced the validity of this subscale. Secondly, in order to increase the likelihood of
response variability for the purpose of detecting change in treatment, the response format of the
MSI-R was converted from true–false into a 5-point Likert scale. Although it is possible that the
results may have been affected by this response format change, work by Wainer (1976) suggests
that our results are probably not substantially different than those obtained if the original true–
false format had been used (D. Snyder, personal communication, August 8, 2005). Wainer (1976)
presented a statistical proof demonstrating that forming linear composites by using 0 or 1 to
reflect true or false yields almost identical results compared with those obtained using linear
composites formed by adding weighted coefficients per item (1, 2, 3, 4, or 5) as we did.
Despite these limitations, the conclusions drawn from this study highlight several interest-
ing avenues for future research. Longitudinal studies that measure both the alliance and thera-
peutic responsiveness several times over the course of treatment are necessary in order to
determine the relative influence of the alliance on client outcome as treatment unfolds. The
effect of gender differences on the link between alliance and treatment process and outcome is
an important area for investigation with many clinical implications. Future research aimed at
helping clinicians identify clients at risk for developing poor alliances, as well as suggesting
appropriate targets of intervention to improve outcomes for these couples, is also an important
next step.

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