The therapeutic alliance—the bond between therapist and client—has been consistently linked to better outcomes in therapy. In a new study, researchers found that a significant part of that alliance is determined by the therapist’s skill at connecting with clients.
They write, “It appears that some therapists are consistently (i.e., across each of their clients) better at forming alliances than others and those therapists tend to have better overall treatment outcomes with their patients.”
As the discourse of a mental health crisis in society continues to grow, especially in response to uncertain times including the COVID pandemic and political and economic instability, many people are looking for treatment. In a new study, published in the Journal of Consulting and Clinical Psychology, an international research team investigates whether therapist effects moderate the relation between therapeutic alliance and treatment outcomes. The researchers included Bruce Wampold, renowned in counseling psychology for his work on the common factors that make therapists effective.
The authors note, “The therapeutic alliance refers to the mutual collaboration between patient and therapist on goals and tasks of psychotherapy, along with the therapeutic bond between the dyad. Several large-scale meta-analyses have demonstrated that the therapeutic alliance is a robust predictor of treatment success…. The impact of the alliance has also been demonstrated across several mental health conditions.”
What’s known as the “therapist effect” is another consistent finding in psychotherapy research, in that therapists differ in their effectiveness of influencing treatment outcomes. While many of the therapist attributes that lead to better outcomes have not been thoroughly studied, research has shown a positive effect of therapist empathy. Even while clinicians and patients often disagree on their assessment of therapy, therapist effects as rated by patients still accounted for a significant portion of the alliance. They also cite the repeated finding that therapists with an ability to form strong alliances with their clients tend to have better treatment outcomes.
As previous findings of therapist effects on the alliance-outcome relationship have been mixed, the researchers wanted to update the science by conducting a meta-analysis. Replicating and extending previous research done on the topic a decade ago, across 153 studies the researchers calculated an index of therapist effect, the Patient-Therapist Ratio (PTR). To account for other variables that could influence therapist effect, the researchers controlled for personality disorder diagnosis, a measure used to assess therapeutic alliance, the source of measurement of alliance and outcome (patient-, therapist- or observer-rated), and research design.
The authors write, “If most of the variance in the quality of the alliance is due to clients’ influence, therapists’ efforts and treatment methods will have a limited impact on the outcome accounted for by the alliance. However, if the therapists are responsible for the lion’s share of the alliance variance, then our efforts to enhance therapists’ skills in developing strong alliances and designing treatments that focus on enhancing the alliance will have major pay-back results.”
After using multi-level meta-analytic models to statistically analyze the impact of therapist effect (PTR) on therapeutic alliance and outcome, they found that it still had a statistically and clinically significant impact even when controlling for other variables previously mentioned. The authors say their results provide evidence that training therapists in relationship skills will improve the therapeutic alliance, and therefore their treatments will be more effective.
While concluding that therapist effects as a whole are significant, the authors mention the need for more research to be done on what makes therapists more or less effective. They cite some evidence that more effective therapists exhibit interpersonal skills in challenging situations, verbal fluency, positive expectations for treatment outcome, persuasiveness, emotional expression, warmth, acceptance, and understanding, capacity to bond with patients, and being responsive during ruptures in the alliance.
The authors report that there still may be other variables that impact the alliance-outcome that haven’t been controlled for yet. Considering alternative explanations for why the PTR index of therapist effects are predictive of alliance-outcome, they mention that more effective therapists did not have smaller caseloads. Though with mental health clinicians and systems overwhelmed with demand, taking the time to find a good psychotherapist could still be worth it for more effective treatment.
“In conclusion,” the authors write, “therapists who generally form strong alliances across a range of patients were more likely to have positive patient outcomes compared to therapists who generally had poorer alliances across patients. That is, therapist variability in the alliance was supported meta-analytically to be more relevant than patient variability for improved post treatment outcomes.”
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, 89(5), 371–378. https://doi.org/10.1037/ccp0000637 (Abstract)