Supplementary Material for: Therapeutic change may begin before the therapist and patient ever meet: Pre-treatment alliance changes predict clinical outcomes

Mechanisms of change are widely assumed to be activated by the onset of treatment. This foundational premise underlies decades of psychotherapy research and guides the timing of measurement and intervention in clinical science. The present study challenges this assumption by demonstrating that one of the most well-established predictors of treatment outcome—the therapeutic alliance—not only changes before therapy begins, but that these early, pre-treatment changes predict both alliance development and symptom reduction throughout treatment. In a randomized controlled trial for depression (N=100), the therapeutic alliance was assessed twice before patients met their therapist, and weekly thereafter. The pre-treatment change in alliance significantly predicted subsequent alliance dynamics and clinical improvement, above and beyond baseline levels. The findings remained robust even after controlling for pre-treatment outcome expectations and previous treatment experience. These findings suggest that mechanisms traditionally viewed as the result of treatment targeting may, in fact, be antecedents. By revealing pre-treatment shifts in a mechanism once thought to be non-existent prior to patient–therapist contact, this work may challenge fundamental assumptions in clinical psychology and highlights the need to reconceptualize therapeutic change as a dynamic, temporally extended process that may begin before any intervention has occurred. Such a shift has implications for how we define, measure, and intervene on core mechanisms of human change.

学界普遍认为，改变的机制会在治疗启动时被激活。这一基础性前提支撑了数十年来的心理治疗研究，并指导了临床科学中测量与干预的时机选择。本研究对此假设提出了挑战：研究证实，作为治疗结局最可靠的预测指标之一的治疗联盟（therapeutic alliance），不仅会在治疗开始前就发生变化，且这些治疗前的早期变化能够预测整个治疗过程中的联盟发展与症状缓解情况。在一项针对抑郁症的随机对照试验（N=100）中，研究人员在患者与治疗师会面之前对治疗联盟进行了两次评估，之后则每周进行一次评估。治疗前的联盟变化显著预测了后续的联盟动态与临床改善情况，其预测效力超出了基线水平所能解释的范围。即使在控制了治疗前结局预期与既往治疗经历的影响后，上述研究结果依然稳健。这些研究结果表明，传统上被视为针对性治疗产物的改变机制，实际上可能是先行因素。本研究揭示了此前被认为在患者与治疗师接触前不存在的机制，在治疗前就已发生变化，这或许会挑战临床心理学中的基础性假设，并凸显出将治疗性改变重新概念化为一种可能在任何干预实施前就已启动的、具有时间延展性的动态过程的必要性。这一范式转变将对我们如何定义、测量以及干预人类改变的核心机制产生深远影响。