Temporal sequencing of change in trauma-related beliefs and therapeutic alliance during prolonged exposure and sertraline for chronic PTSD

Abstract

Objective:

Changes in trauma-related beliefs and therapeutic alliance have been found to temporally precede symptom reduction; however, it is likely these processes do not act in isolation but rather in interactive ways.

Methods:

The present study examined the temporal relationships between negative posttraumatic cognitions (PTCI) and therapeutic alliance (WAI) in 142 patients who were part of a randomized trial comparing prolonged exposure (PE) to sertraline for chronic PTSD.

Results:

Using time-lagged mixed regression models, improvements in the therapeutic alliance predicted subsequent improvements in trauma-related beliefs (d = 0.59), an effect accounted for by between-patient variability (d = 0.64) compared to within-patient variability (d = .04) giving weaker support to the causal role of alliance on outcome. Belief change did not predict improvements in alliance and neither model was moderated by treatment type.

Conclusion:

Findings suggest alliance may not be an independent driver of cognition change and point to the need for additional study of the impact of patient characteristics on treatment processes.

Keywords:

• PTSD
• mediators
• cognitive beliefs
• alliance
• prolonged exposure
• sertraline

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Supplemental data

Supplemental data for this article can be accessed at https://doi.org/10.1080/10503307.2023.2184733.

Notes

1 To confirm the stability of findings, we reanalyzed the data using latent curve modeling with structured residuals (LCM-SR; Curran et al., 2014). Consistent with the MLM findings, the final model revealed nonsignificant, lagged within-person associations between PTCI and subsequent WAI and between WAI and subsequent PTCI, and a significant between-person association between better average alliance at session 2 and greater overall change in cognitions across treatment. All other between-person associations were nonsignificant. Additional details are summarized in Supplemental Table 1.

Additional information

Funding

Preparation of this manuscript was supported by grants to Drs. Zoellner and Feeny from the National Institute of Mental Health [R01 MH066347, R01 MH066348] and the William T. Dahms, M.D. Clinical Research Unit, funded under the Cleveland Clinical and Translational Science Award [UL1 RR024989]. Additional funding was provided by the Abraham W. Wolf Endowed Fund for Psychotherapy Research at Case Western Reserve University awarded to Dr. Baier.