The therapeutic alliance is seen as an important dimension in any type of psychotherapy. But patient, therapist, or observers can have different views on the therapeutic alliance. The question is which perspective best represents the therapeutic alliance, and what are the differences between these alternative views. In the present study, the therapist-patient alliance (TPA, the view of the therapist), patient-therapist alliance (PTA, the view of the patient), and mutual therapeutic alliance (MTA, the view of an observer) were measured simultaneously in cognitive behavior therapy of patients suffering from generalized anxiety disorder. Additionally, the concordance between patient and therapist ratings (TPC) was calculated. Cognitive behavior therapists attained high positive scores in all perspectives for all dimensions of the therapeutic alliance, such as empathy, cooperation, transparency, focusing, and assurance of progress. Correlations were consistently higher for ratings between therapist and patient than between observer and patient. A relation with outcome (Hamilton Anxiety Scale) was only found for observer ratings. It was concluded that cognitive behavior therapists can achieve good alliances with their patients. Different perspectives on the therapeutic alliance should be distinguished and taken into account separately in studies on the therapeutic process and outcome.

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Background: Generalized anxiety disorders (GAD) are amongst the most prevalent mental disorders. Recent studies have suggested that cognitive behaviour therapy (CBT) is an effective treatment for GAD. A controlled clinical trial was done to evaluate the efficacy of CBT treatment in outpatients with pure GAD who were treated by a therapist working in routine care. Methods: Seventy-two outpatients, fulfilling GAD criteria according to DSM-IV, were included in the study. From this group, 36 patients (CBT-A) were randomly assigned to 25 sessions of CBT and the other 36 formed a contact control group (CCG). After the contact control period (CC period), these patients were also treated with CBT (CBT-B), allowing not only a parallel group comparison but also an A-B comparison. Therapists were licensed full-time psychologists who worked routinely in outpatient care and had a professional training in CBT. Treatment was done in accordance with a manual, and treatment conformity was controlled by several methods. Results: The reduction in the score on the Hamilton Anxiety Observer Rating Scale was 6.4% (1.5 points) in the CCG, 35.4% (9.5 points) in the CBT-A and 47.3% (10.3 points) in the CBT-B. In the self-rating Spielberger State-Trait Anxiety Inventory, a reduction of 2.7% was seen in CCG, 14.6% in CBT-A, and 11.6% in CBT-B. According to the Clinical Global Impression Rating, 65.6% of patients were still at least moderately ill at the end of the CC period, while this rate was 33.4% at the end of CBT-A, or 15.7% at the end of CBT-B. All these differences between treatment and control group are statistically highly significant. The clinical improvement remained stable over a follow-up period of 8 months. Conclusions: CBT is an effective method of treatment for GAD. Differences between control and treatment group are comparable to or larger than those reported in studies on antidepressant drugs.

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