Psychotherapy, Cognitive-Behavior Therapy, Drug Therapy and Placebo Are Compared

by Janice L. Krupnick, Ph.D., Stuart M. Stotsky, M.D., Sam Simmens, Ph.D.,
Janet Moyer, M.A., John Watkins, Ph.D., Irene Elkin, Ph.D.
and Paul A. Pilkonis, Ph.D.

The therapeutic bond formed between therapist and patient has been found to be a leading influence on a patient's recovery regardless of type of treatment used. "This is the first empirical study to compare the therapeutic alliance established between therapist and patient and its effect on improving depressive symptoms in not only different types of psychotherapy but also in pharmacotherapy," said psychologist and lead author Janice L. Krupnick, Ph.D. Dr. Krupnick and six other researchers determined whether the therapeutic bond had an influence on a patient's depression regardless of the treatment modality. These researchers examined 225 depressed outpatients who received either interpersonal psychotherapy, cognitive-behavior therapy, an antidepressant medication (imipramine) in a supportive environment or a placebo pill in a supportive environment by 28 therapists (10 psychologists and 18 psychiatrists).

To improve the validity of the study, videotapes of the 619 sessions were watched by trained clinical observers who rated the depressive symptoms of the patients and the strength of the therapeutic alliance at the third, ninth and fifteenth session. Specifically, the clinical observers rated how much the patient's and therapist's own contribution to the therapeutic relationship helped reduce the patient's depression. "This study's methodology is an improvement over previous alliance studies," said Dr. Krupnick, "because ratings on observations of full-session videotapes were used versus using ratings from clinical observers of only brief segments."

In all the treatment groups, the trained evaluators reported that improvement in the patient's mental state was attributed to the good therapeutic relationship. And that the degree to which a patient could be engaged in a good relationship with his/her therapist was the leading force in reducing a patient's depression.

These findings, said Dr. Krupnick, "especially the strong association between alliance and reduced depression in the imipramine and placebo groups give further support to how important the therapist-patient bond is in improving a patient's mental state." From these conclusions and other research in this area, Dr. Krupnick warns about the dangers of primary care doctors treating depression with drugs when there is no therapeutic relationship. "This could really impede a person's chance of getting better," she said.


Janice L. Krupnick, Ph.D., Stuart M. Stotsky, M.D., Sam Simmens, Ph.D., Janet Moyer, M.A., John Watkins, Ph.D., Irene Elkin, Ph.D., Paul A. Pilkonis, Ph.D. (1998). The Role of the Therapeutic Alliance in Psychotherapy and Pharmacotherapy Outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.
Journal of Consulting and Clinical Psychology, Vol. 64, No. 3, pp 532-539.


The American Psychological Association (APA), in Washington, DC, is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists. APA's membership includes more than 159,000 researchers, educators, clinicians, consultants and students. Through its divisions in 50 subfields of psychology and affiliations with 58 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting human welfare.


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