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Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22, 25–41. https://doi.org/10.1002/wps.21035

The therapeutic alliance is possibly the most researched concept in psychotherapy. The alliance consists to a collaborative agreement patient and therapist on the goals of therapy, a collaborative agreement on the tasks of therapy (how therapy should proceed), and the relational bond between therapist and patient (mutual liking and trust). The most recent meta-analysis of almost 300 studies showed that the correlation between the therapeutic alliance and patient outcomes was moderate in size (r = .29) and very stable across studies, treatment modalities, and patient populations. Another meta-analysis of studies that assessed outcomes and therapeutic alliance after every session showed that there is a reciprocal relationship between alliance and outcomes, demonstrating that the alliance is not simply a consequence of symptom improvement. In this sweeping review of the therapeutic alliance research and clinical literature, Wampold and Fluckiger asked “who is most responsible for the effects of the alliance – the patient or the therapist?”. The alliance is a dyadic construct about the interaction between therapist and patient. It could be that the patient contribution to the alliance is most important to their outcomes. A patient with insecure attachment, more symptoms, comorbid personality disorder, or low motivation might experience a poorer alliance with any therapist. Conversely, some therapists might be able to form a better alliance than other therapists across a wide range of patients, and this might be what results in better outcomes. Studies that disaggregate the total correlation of the alliance and outcome into patient and therapist contributions generally demonstrate that it is the therapist that is primarily responsible for the alliance-outcome association. That is, therapists who can form a stronger alliance with a wide range of patients also generally have better outcomes than other therapists. Even patients who tend to form a weaker alliance with therapists will develop a stronger alliance with therapists who generally have the skills to develop a strong alliance.

Practice Implications

When it comes to the therapeutic alliance, the therapist matters even for patients who struggle to form an alliance. It turns out that gender, age, ethnicity, profession, and theoretical orientation of the therapist do not matter as much as their interpersonal skills. These interpersonal skills include a therapist’s capacity to communicate hope and positive expectations, persuasiveness, emotional expression, warmth, understanding, acceptance, empathy, and ability to repair alliance ruptures. If a therapist wants to make the most of the therapeutic alliance to help their patients, then the therapist should develop and nurture these interpersonal skills for themselves.

Zilcha-Mano, S., Fisher, H. (2022). Distinct roles of state-like and trait-like patient–therapist alliance in psychotherapy. Nature Reviews Psychology, 1, 194–210.

Research and understanding of the role of the therapeutic alliance in helping patients get better is evolving quickly. The therapeutic alliance is composed of patient-therapist collaborative agreement on the tasks and goals of therapy, and their relational bond. It is the most consistent predictor of patient outcomes. Much of the recent evolution in the research and theory of the alliance is driven by advances in statistical methods that disentangle (1) trait-like alliance from (2) state-like alliance. Trait-like alliance refers to the patient’s characteristic capacity to cooperate and make use of a therapeutic opportunity. State-like alliance refers the patient’s session by session increase or decrease in their alliance to the therapist regardless of their characteristic capacity. In this review of advances in research and theory on trait-like and state-like alliance, Zilcha-Mano and colleagues discuss the roles of these differing aspects of the alliance in helping to determine what therapist interpersonal stances will work best for which patient. The authors review research indicating that trait-like alliance (patients’ and therapists’ pre-therapy interpersonal capacity to cooperate and form a bond) provides a context for therapeutic interventions. That is, therapists with better interpersonal skills and patients with fewer interpersonal problems (i.e., alliance traits) tend to quickly and easily form a therapeutic alliance that provides a fertile ground for therapeutic interventions to take root. For these patients and therapists, a good alliance allows specific interventions of CBT (exposure and response prevention), psychodynamic therapy (transference interpretations), EFT (two chair technique) and others to work. The authors also review research indicating that state-like alliance (session by session growth in the therapeutic alliance) may be the key therapeutic tool for patients who begin therapy with greater interpersonal problems and lower trait alliance capacity. For these patients, an increase in their trust and bond with the therapist results in better treatment outcomes. Strengthening the alliance across therapy sessions may be a mechanism by which a corrective interpersonal experience with the therapist produces change in how the patient sees themselves (as deserving positive regard from others) and sees others (as caring and trustworthy).

Practical Implications

Clinicians working with patients who have lower interpersonal problems and a higher characteristic trait-like capacity to cooperate will do well to come to a collaborative agreement with the patient on a treatment plan and goals early in therapy. Such patients will do well with many types of therapeutic interventions. However, for patients with greater interpersonal problems (difficulties trusting, problems with interpersonal boundaries, lower reflective capacity), the key to effective therapy may be to grow the alliance from session to session. Therapists may engage in supportive interpersonal stances that include warmth, positive regard, empathy, and active listening. Therapists should focus their training on increasing their responsiveness to patients based on patient characteristics, and to assess the level of the therapeutic alliance at the start of therapy and from session to session.

Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

Simpson, S., Richardson, L., Pietrabissa, G., Castelnuovo, G., Reid, C. (2020). Videotherapy and therapeutic alliance in the age of COVID-19. Clinical Psychology and Psychotherapy, https://doi.org/10.1002/cpp.2521

The therapeutic alliance is one of the most robust predictors of patient outcomes in psychotherapy. The alliance refers to the patient’s and therapist’s agreement on the goals of therapy (what the patient wants for an outcome), the tasks of therapy (what to do in therapy to achieve these goals), and the relational bond between the patient and therapist. Despite the importance of the therapeutic alliance, psychotherapists tend to rate it lower in videoconferenced psychotherapy compared to face to face therapy. That is, psychotherapists are skeptical that one can develop and maintain the same quality of alliance in videoconferenced psychotherapy compared to face to face therapy. In this review, Simpson and colleagues evaluate the research on the alliance in videoconferenced psychotherapy. The authors argue that videoconference psychotherapy provides greater access for some patients, and also creates therapeutic opportunities that are not possible in face to face therapy. For example, those with PTSD, agoraphobia, social avoidance, and severe anxiety may find engaging in videoconferenced psychotherapy to be easier. Younger individuals who feel more at home with social interactions on a video screen may also engage better with videoconferenced psychotherapy. Simpson and colleagues reviewed 24 studies that examined the therapeutic alliance in the context of video therapy. There was a wide range of technologies and clinical groups, thus making meaningful comparisons difficult. Generally, both clients and therapists rated the alliance highly. There is some evidence that for a few patients, like those concerned with privacy and stigma, videoconferenced psychotherapy may be less threatening. However, it must be noted that most of these studies were surveys, analogue studies not including real therapeutic contexts, or single case reports. Currently, there appears to be no high quality randomized controlled trial comparing videoconferenced versus face to face therapy on the quality of the alliance.

Practice Implications

As is the case with treatment efficacy studies, high quality trials looking at the therapeutic alliance in videoconferenced psychotherapy lag far behind practice. As a result, the research provides little guidance to therapists. Small studies and anecdotal reports suggest that the alliance may be as good in videoconferenced psychotherapy as in face to face therapy, and that some patient, especially those with high levels of avoidance and anxiety, may find videotherapy to be less threatening. Given the ubiquitous nature of technology, and the likelihood that videoconferenced psychotherapy will continue well into the future, it is important that researchers turn to examining what works in videotherapy and for whom.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., Van Tongeren, D. R., Worthington, E. L., Jr., & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89–100.

Studies have shown that many therapists have better outcomes with White clients than with racial and ethnic minority (REM) clients. Also the prevalence of racial/ethnic microaggressions in therapy is high, with as many as 81% of REM clients reporting at least one experience in which a therapist said or did something that was insensitive or offensive. Microaggressions can be understood as instances of therapeutic alliance ruptures that if unrepaired could lead to poor client outcomes. In this practice review of the existing research, Davis and colleagues consider the multicultural orientation framework to help therapists to be more sensitive and effective when working with REM clients. A key feature of the multicultural orientation framework is cultural humility, which refers to a therapist’s interpersonal stance that is open in relation to aspects of cultural identity that are important to the client. Another important concept is cultural opportunities, or the events in therapy in which the client’s cultural beliefs, values, and identity can be explored. Finally, cultural comfort refers to the therapist’s thoughts and feelings that emerge as a result of conversations about the client’s cultural identity. The review found two large and well-designed studies that looked at the association between a multicultural orientation and client outcomes. Therapist cultural humility predicted better therapy outcomes, and lower therapist cultural comfort resulted in client premature termination from therapy. In separate studies, cultural humility was associated with higher therapeutic alliance and fewer microaggressions by therapists. Finally, missed opportunities to discuss cultural identity was associated with more negative therapy outcomes for clients.

Practice Implications

Repairing alliance ruptures caused by microaggressions involves therapists: identifying the event, validating the client’s perspective, discussing the microaggression with appropriate humility, taking responsibility and making amends, and asking the client to inform the therapist about the best way forward. One study showed that the therapeutic alliance improved substantially after therapists and clients discussed and repaired a microaggression. A multicultural orientation involves therapists creating a culturally inclusive setting by overtly discussing the importance of culture and what might cause ruptures.

Timuluk, L. & Keogh, D. (2017). The client’s perspective on (experiences of) psychotherapy: A practice-friendly review. Journal of Clinical Psychology, 73, 1556-1567.

Psychotherapy studies that ask clients for their perspective on the treatment or therapist are surprisingly rare. Researchers have conducted such studies over many decades, but there exist very few of them. This is curious given that respecting clients’ preferences for types of therapy or for therapists’ behaviors is predictive of good mental health outcomes. Giving voice to clients’ perspectives is consistent with the notion that psychotherapy is a co-constructed endeavour rather than something that a therapist does to a client (as is the case for a medical intervention). In this review, Timuluk and Keogh review the research in which patients were interviewed for their perspective on a wide range of aspects of psychotherapy. The research indicates a number of things that clients value, that help, and that hinder their progress in therapy. Clients value a number of therapist traits like friendliness, warmth, respect, offering appropriate guidance, and understanding. This research showed that clients recognize that the relationship (i.e., the alliance) has therapeutic effects. Clients report that many forms of therapist behaviors help to develop a therapeutic alliance including eye contact, smiling, warm personalized greetings, paraphrasing, identifying client feelings, and referring to material from previous sessions. Clients find some events in therapy to be unhelpful or that hinder their progress, like feeling exposed and unprotected, being emotionally overwhelmed, and feeling misunderstood by the therapist.

Practice Implications

Although clients do value therapist expertise in applying therapeutic techniques, they hold therapist personal qualities like warmth, authenticity, honesty, and dedication as necessary prerequisites for therapy. Clients view the therapist’s interpersonal manner as key to forming a therapeutic relationship. It is important that therapists are aware of how they feel towards a client (countertransference), and how these feelings might impact the way in which they communicate through body language, tone of voice, and behaviors. Effective therapists are willing to seek their client’s perspectives, and are open and non-defensive about what a client has to say about the therapy or therapist, even if negative. Therapist openness to feedback will inevitably lead to a stronger relationship and collaboration with the client, and to better outcomes for the client.