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
Is the Therapeutic Alliance Therapeutic? It Depends.
Zilcha-Mano, S., & Ben David-Sela, T. (2022, August 4). Is Alliance Therapeutic in Itself? It Depends. Journal of Counseling Psychology. Advance online publication.
The therapeutic alliance is the most studied concept in psychotherapy and is perhaps the most reliable predictor of patient outcomes. But there are two possible explanations for this finding. First, meta-analyses indicate that patients who report higher overall levels of the alliance tend to experience better outcomes at the end of therapy. Second, other meta-analyses report that if a patient’s alliance improves from one session to the next, regardless of their overall level of the alliance, they report a better outcome. The distinction between the two explanations is important. In the first case, one could argue that some patients who have a general tendency to develop a strong alliance also have a general ability to benefit from any treatment. In the second case, one could argue that a patient’s general tendency to develop an alliance does not matter as much as experiencing a growth in their alliance with the therapist from one session to the next. In other words, is the effect of the therapeutic alliance due to a general capacity of the patient to engage in any therapeutic relationship, or is the effect due to growth in the alliance itself being an active mechanism of change in therapy? In this study, Zilcha-Mano and colleagues compared two treatments for depression from a randomized controlled trial: (1) supportive expressive therapy (SET) that relied on primarily specific interventions and secondarily on the overall level of the alliance to help patients change, and (2) supportive therapy (ST) that primarily relied on growth in the alliance as the main therapeutic factor for change. The authors used sophisticated statistical modelling of session-to-session change in depression and change in the alliance to separate out the effects of a patient’s general tendency to develop a good alliance from the growth of the alliance session to session. The researchers also compared SET and ST on the effects of general tendency to develop an alliance versus growth in the alliance from session to session. The findings indicated that the general tendency of patients to experience a good alliance predicted better outcomes in both therapies. That is, patients who already had a capacity to engage in the therapeutic relationship got better regardless of the type of therapy. However, growth in the alliance predicted better outcomes only in ST and not SET. That is, for ST in which the alliance itself was considered a mechanism of change, patients’ symptoms improved when there was growth in the alliance from one session to the next independent of their general capacity to engage.
The results of the study, like previous meta-analyses, suggested that patients who have a higher general capacity to develop a therapeutic alliance have better outcomes regardless of the therapy. This is a “rich get richer” finding, in which more agreeable patients tend to get better with any treatment they receive. However, the findings also suggested that it is also possible for patients with a lower general capacity for a good therapeutic alliance to improve. For such patients, therapists might prioritize developing and maintaining the alliance on a session-to-session basis. This might be accomplished by taking a more supportive approach, by identifying and acknowledging alliance ruptures, and by repairing such ruptures through negotiating new tasks and goals or strengthening the therapeutic bond.
The Therapeutic Alliance in Treating Posttraumatic Stress Disorder
Howard, R., Berry, K., & Haddock, G. (2021). Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology and Psychotherapy.
The therapeutic alliance is a key therapeutic factor with a lot of research support. The alliance is the collaborative agreement between patient and therapist on the goals and tasks of therapy, and their emotional bond. A meta-analysis of 295 studies reported that the alliance is moderately and reliably related to patient outcomes, and that this effect cuts across therapy modalities, orientations, and diagnoses. Some clinical writers expressed concern that the alliance is more difficult to develop with patients with posttraumatic stress disorder (PTSD) because of psychological consequences of PTSD like avoidance, mistrust, emotion regulation problems that pose a barrier to developing an alliance. Further, the disrupted interpersonal relationships that is part of the PTSD experience may also inhibit the development of an alliance with a therapist. However, one could also argue that a strong therapeutic alliance that is characterized by an emotional bond between client and therapist might be highly therapeutic for patients with PTSD. This meta-analysis by Howard and colleagues is the first to systematically review the research on the association between the therapeutic alliance and patient outcomes following PTSD treatment. The meta-analysis included 12 studies of adults receiving treatment for PTSD. The aggregated correlation effect size was r = -.339 (95% CI: -0.436, -0.234) with low levels of heterogeneity among the studies indicating that the findings are reliable. The average effect size was moderate in size, robust to effects of an outlier, and there was little evidence of publication bias. The authors also conducted a sub analysis that indirectly compared in-person therapy (k = 8; r = -.323) to remote therapy (k = 4; r = -.390) in which they found no significant differences (Q(1) = 0.41, p = .524) in the alliance-outcome association.
The findings add support to the larger research literature in psychotherapy about the importance of the therapeutic alliance to patient outcomes. In particular, the findings suggest that clinicians should develop a good therapeutic alliance when treating patients with PTSD in order to promote better outcomes. That is, therapists and clients must come to a collaborative agreement on what the goals of the therapy are and how the therapy will be conducted. In addition, developing an interpersonal therapeutic bond will help the patient to weather the challenges that are associated some PTSD treatments. The findings also suggested that the effect of the alliance was as strong when therapy was in-person versus remote – but this finding is not as reliable given the indirect nature of the comparisons.
Patients Crying in Psychotherapy
Genova, F., Zingaretti, P., Gazzillo, F., Tanzilli, A., Lingiardi, V., Katz, M., & Hilsenroth, M. (2021). Patients’ crying experiences in psychotherapy and relationship with working alliance, therapeutic change and attachment styles. Psychotherapy, 58(1), 160–171.
Crying often reflects deep feeling and may play a role in the expression of these feelings. In psychotherapy, crying may be an important experience in helping patients to experience and express their emotions. In previous research, patients who had a strong therapeutic alliance with their therapist also felt that crying allowed them to communicate feelings that they could not express verbally. Researchers also report that patients cry in 14% to 21% of sessions, and that crying may be an indicator of healing when it is assisted by therapist interventions. In this study, Genova and colleagues explored the association between patients’ crying during therapy and the therapeutic alliance and therapeutic change. In a survey, 106 adult patients (mean age = 30.94 years, SD = 8.74) were asked to complete several questionnaires about crying in therapy, crying in their lives in general, the therapeutic alliance, and their outcomes in therapy. Of all patients, 83% reported crying at least once in therapy, suggesting that patient crying during therapy is a common event. Most patients (67.4%) talked to their therapist about crying. Many patients reported negative feelings like sadness (53.5%), frustration (38.4%), or powerlessness (28.2%) after crying in therapy. However, other patients also reported positive feels after crying like relief (45.3%), feeling emotionally touched (34.1%), or a sense of warmth (24.7%). Some patients (41.9%) reported that crying in therapy improved their relationship with their therapist, and no patient reported that crying worsened their therapeutic relationship. There was a significant positive correlation between feeling relieved after crying and the therapeutic alliance (r = .29), but a significant negative correlation between feeling depressed after crying and the therapeutic alliance (r = -.30). Positive feelings after crying were also associated with patient rated improvement in therapy (r = .29 to r = .34). However, negative feelings, such as more tension after crying, were related to poorer outcomes (r = -.27).
When patients and therapists have a strong therapeutic alliance (collaborative agreement on the goals and tasks of therapy, and a relational bond), patients experience their crying as a useful event to resolve negative feelings. This is especially true when crying leads to greater awareness and new realizations and when the therapist is supportive. It is critical for therapists to explore their patients’ crying in therapy as it represents an opportunity to deepen the therapeutic relationship and the patient’s self-awareness and self-efficacy.
Therapists Are Mostly Responsible for the Therapeutic Alliance
Del Re, A. C., Flückiger, C., Horvath, A. O., & Wampold, B. E. (2021). Examining therapist effects in the alliance–outcome relationship: A multilevel meta-analysis. Journal of Consulting and Clinical Psychology. Advance online publication.
The therapeutic alliance has been consistently found to be a reliable predictor of patient outcomes. The alliance in therapy refers to the patient and therapist collaborative agreement on the tasks of therapy and the goals of therapy, as well as their emotional bond. Previous research suggested that the therapist contribution to the alliance accounted for a significant proportion of patient outcomes. That is, some therapists are better than others at forming a good alliance across a variety of patients, and those therapists who can form a good alliance have patients that achieve better outcomes. If therapists are responsible for most of the effects of a positive therapeutic alliance, then efforts should be directed toward training therapists to improve the alliance. In this meta-analysis of 152 studies, Del Re and colleagues used Patient-Therapist Ratio (PTR) as a proxy to estimate the contribution of the therapist to the alliance. Large PTR refers to many patients per therapist, whereas a low PTR refers to few patients per therapist. A significant effect of low PTR on the alliance – outcome relationship would indicate that most of the effect of the alliance on outcomes was due to the therapist. The overall effect of the alliance on patient outcomes was moderately large (r = .275, 95% CI = .247, .302) and similar to what was found in previous research. In other words, a higher therapeutic alliance between patient and therapist was related to better patient outcomes. PTR was a significant moderator of the alliance – outcome relationship (ß = −0.006, 95% CI = −0.010, −0.002). That is, the therapist had a significant contribution to the alliance – outcome association. There was no evidence of publication bias in the research, and other potential confounds did not significantly reduced the effect of the therapist on the alliance and outcomes.
The strength of the relationship of the therapeutic alliance to patient outcomes is mostly due to the therapist’s characteristics or actions. That is, therapists are largely responsible for the therapeutic alliance and its impact on patient outcomes. Previous research suggested that more effective therapists have the interpersonal skills to manage interpersonally challenging situations. More effective therapist interpersonal skills include: verbal fluency, instilling hope, persuasiveness, emotional expression, warmth, empathy, and the capacity to repair alliance ruptures. Therapists who are capable of engaging in these facilitative interpersonal behaviors across a range of patients are more likely to achieve outcomes for their patients.
Therapeutic Alliance Predicts Patient Outcomes Over and Above Other Factors
Flückiger, C., Del Re, A. C., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020, March 26). Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. Advance online publication.
The therapeutic alliance is probably the most researched concept in psychotherapy. The alliance refers to a collaborative agreement on the tasks of therapy (what patients and therapists do in therapy, like homework, or examine the past or relationship issues), a collaborative agreement on the goals of therapy (what the desired outcomes might be), and the relational bond between patient and therapist (liking and respect for one another). The most recent meta-analysis of the alliance included 296 studies. The meta-analysis showed a moderate and robust relationship between higher alliance and better patient outcomes regardless of type of therapy, who rated the alliance, or how it was rated. Nevertheless, some still think that the alliance is a byproduct of other factors like patient symptom severity (less symptomatic patients may report a better alliance with therapists) or adherence to treatment manuals (higher therapist adherence may lead to a better alliance). In other words, some argue that the alliance may not directly affect outcomes and may not be that important. In this meta-analysis, Fluckiger and colleagues examined 60 studies with over 6,000 patients that reported the alliance-outcome relationship, and also the effects of patient characteristics like symptom severity and adherence to treatment manuals. Overall, the therapeutic alliance was significantly related to patient outcomes, r = .304 (95% CI [.253, .354], p < .001, k = 53). When the authors of the primary studies controlled for patient characteristics like symptom severity, the adjusted alliance - outcome correlation remained significant, r = .286 (95% CI [.226, .344], p = .001, k = 35). When the authors of primary studies controlled for the effects of therapist adherence to a treatment manual, the adjusted alliance – outcome correlation still remained significant, r = .242 (95% CI [.179, .306], p = .001, k = 13). The slight reduction in the alliance-outcome correlation caused by the effects of patient symptom severity or therapist adherence to a manual was not significant.
Therapists’ capacity to develop a therapeutic alliance is a key factor to patients experiencing a good outcome from psychotherapy. This is true for many types of patients with differing levels of symptom severity, and also true regardless of type of therapy or level of therapist adherence to a treatment protocol. Developing shared treatment goals and agreeing on the tasks of therapy are important first steps. In addition, therapists and clients who like working together and share a sense of mutual respect are more likely to experience a successful therapy. Maintaining the alliance throughout therapy is also important. The alliance fluctuates across time indicating subtle or obvious ruptures or tensions that occur. Therapists’ skills at identifying and repairing alliance ruptures is critical to an ongoing collaborative relationship and to patients achieving the best possible outcomes.
Social Support and Therapeutic Bond Interact to Predict Client Outcomes
Zimmermann, D., Wampold, B.E., Rubel, J., Schwartz, B., Poster, K., … & Lutz, W. (2020) The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome, Psychotherapy Research, DOI: 10.1080/10503307.2020.1847344
Researchers have known for many years that the number of social supports and the size of a patient’s social network have a positive impact on patient outcomes in psychotherapy. Social supports reduce loneliness, and higher loneliness is an important cause of distress. Research has also demonstrated quite convincingly that the relationship in psychotherapy plays an important role in patient mental health outcomes. The therapeutic alliance, for example, is one of the most researched concepts in psychotherapy and shows a clear and positive association with client improvement across a number of theoretical orientations and client problems. The therapeutic alliance is the collaborative agreement between client and therapist on the tasks and goals of therapy, and also their relational bond. The bond includes trust, respect, and confidence in the therapist. This is important because aspects of mental health, like emotion regulation, develop partly in social and intimate relationships, including in the therapeutic relationship. If the therapeutic relationship works to reduce loneliness and improve emotion regulation, then a positive therapeutic relationship will be particularly important for clients with less social support. In this study, Zimmerman and colleagues examined if an extra-therapeutic factor (social support) interacted with an intra-therapeutic factor (therapeutic alliance) to predict client outcomes. Over 1200 adult clients were treated by 164 experienced therapists who were guided by CBT manuals. Patients received 42.77 sessions on average (SD = 19.97), social support was assessed at the start of treatment, and alliance and outcomes were monitored after every session. On average, clients improved throughout treatment. Clients who had more social supports and who reported a better bond with their therapist improved the most. Of particular interest was the interaction between social support and bond. Those clients with lower social supports benefitted more if they also had a good therapeutic bond, and clients with a good therapeutic bond did well regardless of their level of social support.
Both extra-therapeutic social support and intra-therapeutic bond with the therapist uniquely contributed to better outcomes for clients. However, a good therapeutic bond with the therapist appears to be particularly important for all clients, especially those with low levels of social supports. Psychotherapists would do well to assess the level and quality of their clients’ social support. And in all cases, especially for clients with low social support, therapists should work to develop and maintain a supportive and trusting therapeutic bond with their clients.