The therapeutic relationship has been theorised as a core process across many psychotherapies, from a focus on transference within psychoanalysis1 to the humanistic concept of the ‘real relationship’ examining the authentic and personal client-therapist relationship2. While different models vary in their conceptualisations of the relationship, the therapeutic or working alliance has emerged as a pan-theoretical construct. The most common definition of the therapeutic alliance includes an affective bond between the client and therapist, as well as their agreement on the goals and tasks of therapy3. The current review will evaluate the contribution of the therapeutic alliance to adult psychotherapy outcomes, including an examination of recent meta-analyses and implications for clinical practice.
THE RISE OF COMMON FACTORS
Common factors are processes shared by all or most therapies, such as the therapeutic relationship, empathy and expectations about treatment4. There has been an increasing focus on common factors since Lambert’s review in 1992 examined the various influences on psychotherapy outcomes5. It was estimated that 15% of the variation in outcomes could be attributed to specific therapeutic techniques, with a larger 30% of the variance attributed to common factors (most of the remaining variance was explained by extra-therapeutic factors). A subsequent review by Wampold concluded that treatment factors as a whole accounted for 13% of the variance in outcomes, with the therapeutic alliance identified as the most effective component6. Such findings are consistent with the contextual model which proposes that therapy operates within a social context, with the relationship between the client and therapist forming the foundation of all therapeutic processes 7, 8.
THE ALLIANCE-OUTCOME ASSOCIATION
While narrative reviews of the literature have indicated an influential role of the therapeutic alliance, meta-analyses are required to establish the alliance-outcome effect with accuracy. One of the most recent and comprehensive meta-analyses examined 295 independent studies with more than 30,000 clients from the years 1978 to 20179. An overall moderate correlation of .278 was observed between the therapeutic alliance and clinical outcomes, explaining approximately 7.7% of the variation in clinical outcomes. The magnitude of the relationship is largely consistent with previous meta-analyses which have observed associations in the range of .28 to .2910, 11. As such, the association is robust and does not appear to be influenced by the type of meta-analytic strategy.
The meta-analysis of Flückiger et al. (2018) included an analysis of the alliance-outcome effect across various moderators (see Table 1 for effect sizes across moderators). A number of the variables analysed showed no moderating effect, including the type of therapy, alliance measure and the rater of the alliance. The alliance-outcome association also showed no significant difference for internet-based therapies (r = .257, k= 23). The type of client group did show a moderating effect. Those with substance abuse disorder and eating disorder showed a lower alliance-outcome association relative to other presentations. With regard to the type of outcome measure used, the alliance showed a lower association with measures of dropout and risk. However, these measures tended to be used in treatment studies of substance use disorder and therefore the lower association may be a consequence of the client group. Another factor showing a moderating effect was the time the alliance was measured, with measurements later in therapy showing a stronger association with outcomes than earlier measures. As will be discussed, this difference may have implications when considering the directionality of the alliance-outcome association.
The role of the alliance in preventing dropout represents an important consideration, given that those who fail to complete therapy show worse outcomes than completers12, 13. Furthermore, dropout can have a negative impact on service functioning and the morale of staff14, 15. As previously discussed, the meta-analysis of Flückiger et al. (2018) showed a small association between the alliance and dropout, although this effect may have been confounded by the large number of substance use disorder studies underlying the effects. A previous meta-analytic review with a more diagnostically varied client group has also examined this question, analysing 11 studies with 1,301 cases16. A moderate alliance-dropout relationship was observed (d = .55, r = .27), with larger effects for therapies of longer duration and within inpatient settings. This appears to be of a similar magnitude to the effect of the alliance on symptom reduction. As such, the alliance appears to have a robust and wide-ranging effect across clinical outcomes. However, the magnitude of the association may not be high enough to suggest that the alliance has a role in all therapeutic processes, as would be predicted from the contextual model7, 8.
THE DIRECTION OF THE ALLIANCE-OUTCOME ASSOCIATION
As research on the alliance-outcome association is correlational, the directionality of the association cannot be established17. The potential for outcomes to influence ratings of the alliance is plausible, with the finding that the alliance-outcome association is greater when the alliance is measured later in therapy supporting this influence9 (i.e., when the alliance and outcome are measured closer in time). As the alliance is typically measured early in therapy, an alliance to outcome effect is more probable. However, it is possible that early symptom improvement acts as a confounding variable by influencing both the early alliance and final outcome.
A number of studies have sought to address this methodological limitation by controlling for early symptom improvement. While a non-significant effect of the alliance has been found in some of these studies18, 19, the majority have observed the alliance-outcome association to persist20, 21. This includes a study of 646 clients in primary care which found that the alliance predicted symptom improvement session to session, controlling for prior symptom change22. The meta-analysis by Fluckinger et al. (2018) also included a sub-analysis examining the alliance-outcome association for 66 studies which controlled for both client demographics and early symptom change. No statistically significant difference was found in these studies between the overall alliance-outcome correlation (r = .25) and the partial-correlation controlling for confounds (r = .22). Thus, the existing evidence is supportive of an alliance to outcome effect, although the mechanisms underlying a direct causal pathway have yet to be established.
COMPARING THE ALLIANCE WITH OTHER COMMON FACTORS
The magnitude of the alliance-outcome association has been described as moderate based on general effect size criteria for the behavioural sciences23. However, it is also necessary to evaluate the effect of the alliance relative to the effects of other therapeutic factors observed in meta-analyses. For example, some common factors show larger effects, such as goal consensus and collaboration each explaining 11% of the variation in clinical outcomes24. Other common factors have explained variance similar to the alliance, such as empathy25 (9%) and genuineness/congruence26 (6%); lower effects have been observed for treatment expectations27 (1.4%), specific treatment techniques and adherence28, 29 (< 1%). The alliance would therefore appear to be moderately effective in the context of other common factors. However, it is difficult to make an accurate comparison across common factors as many will have a high degree of shared variance30. There is also evidence to suggest that the therapeutic alliance facilitates the effects of other treatment factors, consistent with the contextual model. For example, it has been found that early expressions of empathy by the therapist result in a stronger alliance, which subsequently has a direct positive effect on outcomes31, 32. Thus, the association between empathy and outcomes25, as previously referred to, may be partly mediated through the therapeutic alliance. There is also evidence to suggest that the alliance mediates the link between treatment expectations and clinical outcomes33, 34. Although it is difficult to isolate the nature of such interactions, the alliance does appear to have a role in facilitating the effects of other common factors.
INFLUENCE OF THERAPIST AND CLIENT FACTORS
In examining the factors that contribute to a positive alliance, much research has examined the influence of therapist and client factors. One study attempted to compare the contribution of the therapist and client to the alliance-outcome association35. It was found that therapists who formed stronger alliances had better outcomes, with client variability in the alliance having no influence on outcomes. Furthermore, the better outcomes of some therapists were explained by their ability to form stronger alliances. The influence of therapist factors was further supported by a meta-analysis which found that a lower client to therapist ratio within a study (an indicator of therapist variability relative to client variability) was a moderator of the alliance-outcome association36. Thus, some therapists appear to have alliance-enhancing characteristics which result in better outcomes for their clients. In comparison, some clients may form better alliances but this does not appear to impact outcomes.
Therapists who form stronger alliances tend to be those viewed by their clients as warm, empathetic, trustworthy, confident and friendly37. Qualitative research can be particularly valuable in this area, identifying the more subtle alliance-enhancing behaviours of therapists. For example, clients have described how therapist behaviours such as good eye contact, smiling, self-disclosure, encouragement and personalisation of therapy can contribute to the alliance38, 39. In contrast, alliance-hindering factors include superficial, critical and non-responsive behaviours, a cold/detached interpersonal style and therapists with a high personal burden40-42. These barriers to the alliance would appear to be associated with a lack of therapist empathy.
As previously discussed, client factors have not been shown to influence the alliance-outcome association35, 36. Furthermore, there has been far less consistency in identifying client factors that contribute to the alliance. However, one relatively reliable client predictor of the alliance is that of a secure attachment style, with this finding supported by meta-analyses43, 44. Other less reliable client predictors of the alliance include dependent personality characteristics45, and a higher level of interpersonal problems has been associated with a greater scope to improve the alliance over time46. Client factors showing a negative association with the therapeutic alliance include hostile/dominant interpersonal problems and maladaptive defence mechanisms47, 48. However, with the exception of attachment style, the results overall do not present a consistent picture of clients most likely to develop a strong alliance.
THE ALLIANCE AS A DYADIC AND DYNAMIC PROCESS
Despite the alliance being conceptualised as a dyadic process3, there is limited research on the interaction between the client and therapist. As there is only a moderate correlation between client and therapist ratings of the alliance49 (r = .36), variation in their level of agreement may influence outcomes. For example, greater similarity of alliance ratings have been associated with greater symptom reduction, although initially this appeared specific to high alliance dyads50. However, a more recent study also observed this effect for low alliance dyads, suggesting that agreement on alliance difficulties can provide a basis for therapeutic effects51. Such results would support the value of therapists being attuned to the ongoing nature of the therapeutic relationship.
Another dyadic dimension of the alliance to consider is its development over time, in particular how changes in the ‘state alliance’ influences outcomes52. For example, a recent study using dyadic multilevel monitoring found that therapist-client congruence in alliance ratings did not predict symptom reduction, but greater convergence in alliance ratings over time did show an effect53. Furthermore, another study showed that time-specific improvements in client’s alliance ratings were predictive of both clients’ and therapists’ rated outcomes in the following session54. Such research supports the value of measuring the alliance as a dynamic process. It also suggests that therapists need to be concerned not only about the current alliance, but also its development over time.
It has been proposed that ruptures to the alliance are an inevitable part of psychotherapy, with the management of these ruptures a key determinant of outcomes55. Ruptures can range from ‘withdrawal’ associated with silences and non-compliance to ‘confrontation’ associated with anger and dissatisfaction. Where ruptures are not effectively managed, the therapeutic alliance will deteriorate and client outcomes will be poorer56, 57. However, when ruptures are effectively managed, it can contribute to positive outcomes and provide the client with greater insight on how they relate to others58.
There is evidence to suggest that the process of ‘rupture and repair’ can have therapeutic effects. For example, clients who show a ‘U’ or ‘V’ shaped pattern of high-low-high alliance tend to have more positive clinical outcomes than those with a stable alliance or a linearly improving alliance59-61. Early rupture repair dynamics in therapy have also been associated with the strengthening of the alliance over time51. Quantifying the effect of this process, one meta-analysis found that rupture-repair episodes had a moderate correlation with client outcomes62 (r = .24), although the reliability with which rupture-repair episodes were measured was questionable (based on fluctuations in alliance measures). There is also some evidence that alliance-focused therapy, which includes rupture resolution training, leads to better client outcomes62-64. With such research however, it is difficult to distinguish the effects of rupture resolution training from the more generic alliance-building techniques.
HOW VALID IS THE ALLIANCE AS A CONSTRUCT?
Despite the therapeutic alliance having a robust association with outcomes, there remains a question about the validity of the construct itself. For example, there is still a lack of consensus about the mechanisms underlying the therapeutic benefits of the alliance65. It could be argued that the alliance is simply a label for a range of highly correlated therapeutic processes that have distinct influences on outcomes (e.g., goal consensus, affective bond, empathy). Indeed, one meta-analysis showed a strong association of the alliance with empathy (r = .50) and genuineness (r = 59), potentially suggesting many shared processes within these constructs30. A second critique of the alliance is the proposal that the goal/task consensus component is measuring compliance rather than collaboration66. There is some evidence to support this idea as those with submissive or dependent personality types tend to have stronger alliances with their therapists45, 67. Another challenge to the alliance comes from the concept of the ‘real relationship’, defined as the personal and genuine relationship between the client and the therapist68. While this real relationship is proposed as distinct from the therapeutic alliance69, the high level of shared variance would question this difference70. Thus, there are many challenges to the construct of the therapeutic alliance and future research needs to go beyond basic alliance-outcome associations.
Research on the therapeutic alliance needs to be considered in terms of its implications for clinical practice. As meta-analyses have established that the alliance is one of the leading therapeutic processes, it needs to be given extensive focus during clinical training. While evidence-based alliance training has yet to be developed, a number of recommendations for such training can be made from the existing research. First, alliance-enhancing behaviours need to be given focus in training, including techniques to facilitate empathy, warmth and an environment of psychological safety. Second, there is a need to develop skills that can adapt to the dynamic nature of the alliance, including rupture resolution. Lastly, techniques relating to goal consensus and collaboration should be given particular focus during alliance training, given the large therapeutic effects of these processes.
A limited number of studies exist which have evaluated alliance-enhancing techniques in practice. In one of the initial studies, a small group of therapists were trained in alliance promoting activities, such as collaboratively reviewing goals and displaying empathy71. Moderate to large effect sizes for increases in the alliance were observed (therapists acted as their controls), although the difference was non-significant due to the small sample size. There is also some preliminary evidence to support alliance-focused training64, 72. Such training has a particular emphasis on rupture resolution, but also involves teaching therapists to actively monitor the relationship, to identify their own contribution to the relationship and to utilise their own feelings. This training has been shown to enhance therapist-client interpersonal processes, including reduced client dependence, increased client responsiveness and increased therapist affirmations and expressiveness. These improved therapeutic processes have in turn been associated with better treatment outcomes72. Such preliminary research is encouraging in translating alliance-enhancing skills into improved clinical outcomes.
An additional way the alliance may be enhanced is through explicit monitoring of the relationship. For example, there is emerging evidence to suggest that clients whose therapists overtly check-in on the alliance have better outcomes73. Furthermore, the alliance-outcome association is stronger for therapists who receive feedback on the alliance74. Such monitoring of the alliance may aid in the identification of misalignments and ruptures75 and is a core process of feedback-informed treatment76. However, questionnaire-based monitoring should only be used in combination with observational skills which can identify less conspicuous aspects of the alliance (e.g., withdrawal type ruptures associated with excessive compliance).
As meta-analyses have consistently established the effect of the therapeutic alliance, the focus of future research should move beyond simple alliance-outcome correlational studies. In this respect, there is a need for research to focus on how the dyadic and dynamic nature of the relationship contributes to outcomes. The use of the actor-partner interdependence model may be valuable here, statistically examining bidirectional effects within interdependent relationships77. Such research can be supported by qualitative research methods and single case studies which provide a more detailed description of these dynamic processes. Another line of future research is the validation of measures which assess the process of alliance rupture and repair. Efforts have been made to develop such measures and may have an important role in guiding clinicians through the resolution process78.
The therapeutic alliance has been shown to have a moderate and robust effect on clinical outcomes across a range of treatment contexts. While the effect of the alliance is consistent, it is also complex with dyadic and dynamic influences. The alliance-outcome association has undergone robust testing, although the exact processes underlying the association remain unclear. The alliance is likely to have a curative effect in itself, but also a mediating or facilitative effect for other common factors. Whether the concept of the alliance survives in its current form is unclear, although the underlying processes will undoubtedly be the subject of future attempts to enhance psychotherapy outcomes.
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Patrick McHugh, Clinical Psychologist, HSE Midwest. firstname.lastname@example.org