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Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325.

The therapeutic alliance is often defined as the agreement between the client and therapist on the goals and tasks of treatment within the context of an affective bond. The alliance is associated with good treatment outcomes regardless of how it is measured, who measures it, when it is measured, and what type of therapy is offered. But researchers and theorists debate the causal role of the alliance in therapy. Is the therapeutic alliance simply a byproduct of an effective treatment (i.e. people begin feel better in therapy and therefore experience a better alliance)? Or is the alliance a client trait which is a necessary factor that enables effective treatments to work (i.e., some clients are better at developing an alliance which is required for therapeutic interventions to take hold). Or is the alliance a state-like factor that fluctuates over time and is therapeutic in and of itself (i.e., the growth in the alliance by itself is sufficient to induce symptom change). In this review of recent advanced methods to research the alliance, Zilcha-Mano provides an overview of statistics that model the session to session dynamic fluctuations and impacts of growth in the therapeutic alliance. She argues convincingly that for the most part, the alliance is not a byproduct of symptom improvement. Using this advanced methodology research indicates that session by session change in symptoms do not precede change in the alliance. The research supporting trait-like aspects of the alliance indicates that some clients are more adept than others at developing an alliance with their therapists. Therefore an early alliance in therapy indicates a client trait that provides a necessary context for effective therapies to do their work. However, research also shows that the alliance changes dynamically over the course of treatment, and that change in the alliance from a preceding session predicts change in symptoms in subsequent sessions. This indicates that alliance also has state-like elements that dynamically fluctuate and influence outcomes, which provides evidence that this aspect of the alliance is therapeutic in and of itself.

Practice Implications

The accumulating research evidence indicate that the therapeutic alliance is a key aspect of successful therapies. New research is showing how to best manage the alliance, like how to repair alliance ruptures. The research also indicates that the role of the alliance may differ according to client characteristics. Those clients who arrive for treatment with better trait-like characteristics (more adaptive representations of self, more adaptive relationships with others) may be better able to create a strong alliance early. For these clients, the alliance may not be highly therapeutic in itself, but rather set the context for therapy interventions to work. However, some clients find it difficult to maintain satisfying relationships with others including the therapist. For these clients, state-like changes in the alliance may be essential for treatment – that is, developing a strong alliance over the course of treatment may be therapeutic in itself to improve their interpersonal relationships outside of therapy.

Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.

In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.

Practice Implications

Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270-277.

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

The conduct of psychotherapy trials almost always requires that therapists be adherent and competent in delivering a manualized therapy intervention. Treatment adherence usually refers to the extent to which a therapist used the intervention prescribed by a treatment manual. Therapist competence refers specifically to a therapist’s skill in delivering the therapy. So “competence” in the context of psychotherapy research typically refers only to performing a certain type of treatment. Wampold and Imel argue that these definitions are consistent with a Medical Model of psychotherapy that emphasizes delivering specific active ingredients of a treatment. The Contextual Model of psychotherapy, on the other hand might define a therapist as competent to the extent that the therapist is interpersonally skilled, empathic, and able to engage clients in the actions of the therapy. Wampold and Imel report on a meta analysis of 28 studies conducted by Webb and colleagues (2010) who found a small and non-significant relationship between therapist adherence and patient outcomes (r = .02), and a small and non-significant relationship between therapist competence and patient outcomes (r = .07). Type of treatment (e.g., CBT, IPT, dynamic) did not affect these associations – in other words adherence and competence were not more important to CBT than to other treatments. However, competence seemed to be more important for the treatment of depression (r = .28). Perhaps depression responds better to specific techniques. The finding that competence was generally not related to outcomes was surprising, however generally competence is narrowly defined as how well a therapist delivered the treatment not how well the therapist was able to establish a therapeutic context. Previous researchers concluded that when clients liked working with a therapist, clients got better, and therapists were rated as more competent as a result. A number of studies appear to indicate that therapist competence is really a function of the client’s characteristics not to what the therapist does. For example, clients with more severe personality problems could make a therapist appear less competent, and these clients may have poorer outcomes. If this is the case, it would create a paradoxical situation in which therapists’ appearance of competence (i.e., ability to deliver a manualized intervention well) is largely determined by the client and not by the therapist.

Practice Implications

In contrast to the findings about adherence and competence, the therapeutic alliance is robustly related to patient outcomes. Also in contrast, the size of the alliance-outcome relationship is almost entirely due to the skills of the therapist, not the client’s characteristics. In other words, therapist competence is not a matter of whether they can do a good job of following a manual, but rather therapist competence is likely a matter of creating the right conditions (i.e., interpersonal skill, alliance, empathy, etc.) for delivering evidence-based interventions by which many clients improve. However, some therapists are better at these facilitative interpersonal skills than others.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel reviewed the research literature on the therapeutic alliance. The therapeutic alliance is considered a pan-theoretical construct that is critical to the success of all psychotherapies. Alliance is defined as the: (a) agreement on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the bond between therapist and client. Numerous meta analyses across several decades demonstrate a robust relationship between the alliance and therapy outcome. For example, Horvath and colleagues (2011) conducted a meta analysis with 190 studies that included over 14, 000 clients in which the average effect size was r = .28, indicating a moderate and significant association between alliance and outcomes. Some researchers argued that this is an under-estimation of the alliance outcome relationship. In Horvath and colleagues’ meta analysis, they found no difference between type of psychotherapy (CBT, interpersonal, dynamic) and the alliance – outcome relationship. However, the alliance may work differently in some therapies. For example, in CBT there is some evidence that the collaborative bond is not related to outcomes, but rather the agreement on tasks and goals is related to patient outcomes. This highlights that an alliance cannot happen without techniques; in other words, if techniques fail to engage the patient in the work of therapy, then the technique is not working properly. Wampold and Imel also reviewed the research on whether the therapist or the patient is most influential in developing an alliance. Using sophisticated statistical techniques, they were able to disentangle the effects of therapists and clients. More effective therapists were those who had stronger alliances with patients, and their patients had better outcomes. However, the patient’s contributions to developing an alliance were not significant. Finally, Wampold and Imel reviewed the research on whether early alliance causes good outcomes, or whether early outcomes causes a good alliance. If the latter were true, then the therapeutic alliance would simply be an artifact of early improvement – that is, the alliance would not be necessary for patients to improve. Most of the studies, which were conducted by researchers of different theoretical orientations, concluded that early alliance predicts outcomes and not the other way around. There is some evidence that change in the alliance and change in symptoms have a reciprocal impact – as the alliance grows the patient subsequently improves and as the patient improves the alliance subsequently grows.

Practice Implications

Clearly, developing and maintaining a therapeutic alliance is important to achieving good patient outcomes in psychotherapy. The alliance is not independent from techniques of psychotherapy. In other words, therapists and clients have to agree on the tasks and goals of treatment, and this agreement is fundamental to all treatment modalities offered to patients. If there is no agreement, then therapists have to consider changing course or discussing with the client ways of achieving an agreement. Over and above that, therapists and clients must have some interpersonal bond that is likely underpinned by the therapist’s empathy, positive regard, and concern for the client. The research is clear that it is the therapist who most strongly contributes to the development of an alliance, and so it is the therapist’s responsibility to nurture a positive working alliance.

Safran , J. D. & Kraus , J. (2014). Alliance ruptures, impasses and enactments: A relational perspective. Psychotherapy, 51, 381-387.

In this clinically oriented review, Safran and Kraus discuss the evidence related to alliance ruptures, repairing alliance ruptures, and methods of training in alliance rupture repair. Safran’s work represents “second generation” research on the therapeutic alliance. The therapeutic alliance refers to the relational bond between client and therapist and their agreement on tasks and goals of therapy. A positive alliance is associated with good client outcomes across a variety of therapeutic approaches. Therapeutic alliance ruptures in psychotherapy are inevitable, such that the alliance is continually being re-negotiated, both implicitly and explicitly, throughout the therapy. Such ruptures might include strains, tensions, or breakdowns that could interfere with the ongoing collaboration between therapist and client. Ruptures are associated with re-enactments of dysfunctional relational patterns, but they also may provide opportunities for change and growth in therapy. Safran’s model of alliance ruptures and repairs sees the processes in the client-therapist relationship as key to understanding the client’s relationship problems. Collaboratively addressing tensions in the alliance allows the client to develop more flexible ways of being in relationships and of experiencing themselves. Research by Safran and Muran (2000) suggest that it is rare not to have some minor strain occurring in the therapeutic alliance. Ruptures may occur in half of therapy cases within the first six sessions. Research indicates that unresolved ruptures are associated with deterioration in the alliance, poor outcome, and patients dropping out. In a meta-analysis, repairing alliance tensions by using evidence-based strategies was associated with improved patient outcomes and the effect was large. Alliance ruptures occur across theoretical orientations. For example, research on cognitive therapy showed an improvement in therapist-client interpersonal processes after therapists were trained in techniques to resolve alliance ruptures.

Practice Implications

Alliance ruptures can range in intensity from minor tensions to major rifts in collaboration. They may occur at any time in treatment, and may be present in single or across multiple sessions. Safran and Kraus describe two general types of ruptures. First, withdrawal ruptures occur when clients deal with ruptures or misunderstandings by falling silent. The resolution may involve the therapist exploring the client’s interpersonal fears, reasons for inhibiting negative feelings, and providing the client with an opportunity to communicate their needs. Second, confrontation ruptures occur when clients directly express anger, resentment or dissatisfaction with the therapist or therapy in a blaming manner. The resolution may involve the therapist empathically engaging with the client to facilitate feelings of disappointment, hurt, and vulnerability. Key to this process is the therapist’s meta-communication or mindfulness abilities. The therapist must be aware of the behavior associated with the rupture, collaboratively explore the rupture experience, help the client overcome avoidance of feelings related to the rupture, and explore the client’s needs and wishes that emerge while working through the rupture.