The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Whose contribution (therapist or patient?) to the alliance mostly leads to change?
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.
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.
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2022, December 8). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, Women of Color clients. Professional Psychology: Research and Practice. Advance online publication.
A lack of culturally competent care can have negative impacts on therapy outcomes for Black, Indigenous, People of Color (BIPOC) and for women who experience discrimination based on gender. Often these negative outcomes occur because of microaggressions – which are a form of alliance rupture in the therapeutic relationship caused by subtle, intentional, or unintentional messages that degrade BIPOC, women, and other historically excluded groups. The majority of BIPOC clients (81%) and women (53%) report experiencing a therapist microaggression over the course of psychotherapy. A therapist’s cultural humility (valuing the importance of culture in their client’s experience) and the therapeutic alliance (client-therapist collaborative agreement on tasks and goals of therapy) may reduce the negative impact of microaggressions committed by the therapist. This study by DeBlaere and colleagues looked at the association between microaggressions experienced by BIPOC women and therapy outcomes, and whether this association was reduced by higher levels of therapist cultural humility and therapeutic alliance. The clients were 288 BIPOC women who were treated by a psychotherapist (81% had a female therapist, and 46% had a White therapist). Both racial and gender microaggressions were associated with worse outcomes. Using structural equation modeling to assess indirect effects, the authors found a significant indirect effect of racial microaggressions (−.12, 95% CI [−.35, −.07]) and gender microaggressions (−.10, 95% CI [−.36, −.05]) on positive therapy outcomes, through both cultural humility and working alliance, accounting for 24% of the variance in outcomes. That is, the effect of microaggressions on outcomes was partly explained by the level of therapist cultural humility and by the therapeutic alliance. The most common racial microaggression reported by clients was: “My counselor avoided discussing or addressing cultural issues in our sessions”, and the most common gender microaggression was: “My therapist encouraged me to be less assertive so that I do not present myself as being aggressive”.
Unfortunately, therapist racial and gender microaggressions are common. However, therapists who practice cultural humility and who work at developing a therapeutic alliance may commit fewer microaggressions and can more easily mitigate the negative effects of microaggressions should they occur. Taking steps to develop cultural humility, strengthening the alliance, and repairing alliance ruptures through professional development may be ways of improving therapy outcomes for BIPOC women.
Can Psychotherapists be Trained to Maintain a Therapeutic Alliance?
Tasca, G. A., Ravitz, P., Hunter, J., Chyurlia, L., Baker, S., Balfour, L., Mcquaid, N., Pain, C., Compare, A., Brugnera, A., & Leszcz, M. (2022, November 10). Training community-based psychotherapists to maintain a therapeutic alliance: A Psychotherapy Practice Research Network study. Psychotherapy. Advance online publication.
The therapeutic alliance refers to a collaborative agreement between therapist and patient on the tasks and goals of therapy, and their relational bond. Research demonstrates that the alliance is one of the most reliable predictors of patient outcome. Much of the research on the alliance focused on asking either the patient or the therapist to rate the alliance. But the alliance is a dyadic concept, that is, it involves the shared perceptions of the therapeutic relationship by patient and therapist. More recent research has focused on patient-therapist congruence (degree of agreement or disagreement) of their perceptions of the alliance. The Psychotherapy Practice Research Network (PPRNet) recently completed a study in which community-based psychotherapists were trained to develop and maintain a therapeutic alliance. We examined if trained therapists were more congruent with their patients’ experience of the alliance than untrained therapists, and whether congruence in alliance ratings in one session of therapy was associated with better outcomes in the following session. Forty community-based psychotherapists were randomly assigned to be trained to develop and maintain the alliance or to receive no training. Patients were 117 adults who were seen in their therapists’ community-based practices. Training focused on helping therapists to understand and be responsive to their own and their patient’s mental states (intentions, feelings, thoughts) to be better attuned to their patient’s experience of the therapeutic relationship. The training included workshops and ongoing case consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. The results indicated that compared to untrained therapists, trained therapists and their patients were significantly more congruent in their alliance ratings. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association was not significant among untrained therapists and their patients.
This study suggests that therapists can be trained to be more attuned to their patients’ experience of the therapeutic relationship, and that this congruence may make the alliance a more potent change agent. Training may make therapists more sensitive to their patients’ experience of the alliance across sessions. Therapists should be particularly attentive to the state of the therapeutic alliance from session to session and to track their patients’ experience of the alliance using skills like mentalizing. The PPRNet has converted this training program into a virtual self-paced platform, and we will test this new format in a study starting in 2023. We encourage community-based clinicians to receive the free training by participating in this new study. For more information about the training and new study, email email@example.com.
The Therapeutic Alliance in Child and Adolescent Psychotherapy
Roest, J.J., Welmers-Van de Poll, M.J., Van der Helm, G.H.P., Stams, G.J.J.M., & Hoeve, M. (2022). A three-level meta-analysis on the alliance-outcome association in child and adolescent psychotherapy. Research on Child and Adolescent Psychopathology.
Much of the research and writing about the therapeutic alliance has focused on adult individual psychotherapy. However, there have been several recent meta-analyses of the alliance-outcome association in child populations. In one meta-analysis of 28 studies, for example, the mean alliance-outcome correlation was r = .19, which represents a small but positive effect. Most of these previous meta-analyses only looked at alliance rated at one time point (usually early in therapy) rather than focusing on the growth in the alliance across sessions. These previous meta-analyses also did not investigate the effect of alliance agreement on treatment outcomes (i.e., whether therapist and child were congruent in their ratings of the alliance). In this meta-analysis by Roest and colleagues, the authors tried to parse out these various factors that might affect the alliance-outcome association in studies of child and adolescent psychotherapy. The authors included 99 studies representing 8,496 children and 3,442 parents. They found that associations between child-therapist alliance and child outcomes (r = .17), growth in child-therapist alliance across sessions and child outcomes (r = .19), and parent-therapist alliance and child outcomes (r = 0.13) tended to be positive but small. However, associations between child-therapist alliance agreement (i.e., their congruence in alliance ratings) and child outcomes (r = .21) and the association between parent-therapist alliance and parent outcomes (r = 0.24) were positive and moderately large.
It appears that the therapeutic alliance plays a role in positive outcomes for child and adolescent patients. Overall, the effects seem to be small, indicating that developing a good alliance may have a modest effect on a child’s outcomes. A more important effect might be noted in the agreement or congruence between therapist and child or adolescent client on their experience of the alliance. That is, a therapist who is more attuned to their patient’s experience of the therapeutic relationship might promote better outcomes. Attunement might require therapists to accurately reflect on the child’s experience of the relationship and of the therapist. Mentalizing (understanding oneself and others in terms of intentions and mental states) may be a key skill to develop for a therapist who works with children and adolescents.
How and for Whom Does the Therapeutic Alliance Work?
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).
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.
An Alliance Rupture in One Session Leads to Greater Symptoms in the Next Session
Babl, A., Berger, T., Gómez Penedo, J. M., Grosse Holtforth, M., Caspar, F., & Eubanks, C. F. (2022). Disaggregating between- and within-patient effects of ruptures and resolutions on the therapeutic alliance and symptom severity. Psychotherapy. Advance online publication.
The therapeutic alliance is the collaborative agreement between patient and therapist on the tasks and goals of therapy, and their affective bond. Meta-analyses of over 200 studies show clearly that a higher overall level of the alliance is a reliable predictor of better patient outcomes at the end of treatment. The research is also more specific about how the alliance works - patients whose alliance ratings in one session is higher than their own overall average tend to have fewer symptoms in the next session. During treatment, the state of the alliance may be characterized by rupture and repair episodes. That is, therapists and patients commonly have minor or major disagreements on the tasks and goals of therapy or a disruption in their relational bond, and therapists often try to repair this disagreement or disruption. Confrontation ruptures occur when patients directly show their concern, and withdrawal ruptures occur when patients might have difficulty either recognizing their feelings or directly expressing them. Ruptures are ubiquitous - they occur in every form of therapy and with therapists of every skill level. Resolutions, when done well by therapists, allow the patient and therapist to come to a stronger collaboration on the tasks and goals of therapy or to strengthen their bond. A meta-analysis showed that patients who experience resolution episodes after a rupture had better treatment outcomes. However, most of these studies focused on the effects of higher or lower overall levels of ruptures relative to resolutions on post-treatment outcomes. Few of the studies looked at the impact of a rupture and/or resolution during a session on the outcome or the level of the alliance at the end of the session. In this study, Babl and colleagues specifically looked at whether a rupture during a session is associated with poorer alliance and poorer outcomes after the session, and if a resolution of the rupture is related to a better alliance and better outcomes. The study included 56 patients who received 25 sessions of integrative cognitive therapy for depression or anxiety and who were treated by one of 33 therapists. Independent coders rated alliance ruptures and resolutions from video recordings of 4 therapy sessions throughout treatment. Therapeutic alliance and patient outcomes were assessed after each session with reliable questionnaires. Higher intensity ruptures overall were associated with lower alliance ratings across all sessions. Sessions with more intense confrontation ruptures were associated with poorer alliance ratings after the session. Alliance ruptures and repairs were not associated with patient outcomes.
It may be important for therapists to continuously monitor the state of the therapeutic alliance with each patient and to identify any instances in which the patient is engaging in a confrontation or withdrawal rupture. Therapists may successfully address such ruptures by openly and non-defensively discussing a rupture should it occur, taking responsibility for the rupture if appropriate, regularly talking with patients about the state of the therapeutic relationship, and re-negotiating the tasks and goals of therapy if necessary.