The therapeutic alliance is the relationship between the patient and the psychotherapist or psychologist. It is considered as one of the most important aspects of the efficient outcomes of the psychological therapy as it results in positive changes in symptoms. The alliance has been found to be associated with the outcomes irrespective of the types of treatment, clinical conditions, alliance rater, and timing of alliance measurement. The decrease in therapeutic alliance could be linked to the absence of mutual clarity between the patients and psychotherapists or the reduction in the shared understanding of the therapeutic goals. This decrease in the alliance could be caused by the differences in the views of the patients and psychotherapists in spite of the agreement on the tasks and goals. The decrease in the perceived quality of alliance could also result in the poorer outcomes of the treatment (Laws et al., 2017). Therefore, the study of therapeutic alliance could be considered important in the optimal outcomes of the psychotherapeutic interventions.
Therapeutic alliance has been found to be correlated positively with improved outcomes in case of several psychotherapies, such as group therapy, individual therapies, and family therapy (Edalati Shateri & Fathali Lavasani, 2018). Higher alliance scores are associated with fewer problems in interpersonal relationships, decreased levels of severe clinical issues, and improvements during therapy (Lorenzo-Luaces, DeRubeis, & Webb, 2014). The alliance helps the patients in developing an appropriate level of trust on the professional abilities of the psychotherapists. The trust on the psychotherapist helps the patients in developing an agreement with the psychotherapists regarding common therapeutic goals, and the methods and strategies to achieve these goals (Edalati Shateri & Fathali Lavasani, 2018). In the clinical practice, therapeutic alliance could be considered in the efficient outcomes related to therapy.
Edalati Shateri and Fathali Lavasani (2018) conducted a study in which they worked on the therapeutic alliance and its association with the improved outcomes in the treatment of depression. The researchers noted that the working alliance has been described by several studies. It can change with sessions. Therefore, the primary purpose of the study was to assess the use of the methods of supportive techniques and improvement of working alliance in the starting sessions of the supportive–expressive (SE) short-term psychodynamic psychotherapy. The study was especially related to the change in the symptoms of the patients with depression (Edalati Shateri & Fathali Lavasani, 2018).
The research design consisted of an experiential single case study. The researchers worked with 6 female participants who had major depressive disorder. The participants of the study were selected by the method of purposive sampling. The instruments and questionnaires used in the study consisted of the Quality of Life Scale, the Working Alliance Inventory-12, and Beck Depression Inventory II. The researchers found that the severity of the depression did not significantly change (p=0.65) on the baseline and during the evaluation sessions. However, the quality of life of the patients significantly improved (p=0.01) after the start of the sessions. Moreover, the different components of working alliance increased with the sessions. For instance, the bond subscale scores significantly improved (p=0.003) with the advancing sessions. The researchers concluded that the improvements in the working alliance and the development of the supportive and empathic feelings can help the patients in improving the mental experience regarding the quality of life. These feelings, although different from the initial feelings of the improvement of symptoms, could influence the treatment outcomes. However, an important limitation of the study is that it was a single-case study, and it could not be generalized to a large population. Therefore, researchers noted that the findings of the study have to be interpreted with caution (Edalati Shateri & Fathali Lavasani, 2018).
Laws et al. (2017) worked on the relation of the therapeutic alliance with the chronic depression treatment. The objective of the study was to test whether the discrepancy in the ratings of the therapeutic alliance of the patients and pscyhotherapists, and the convergence in the alliance ratings of the patients and psychotherapists with the passage of time could influence the treatment of chronic depression. The researchers performed the study in two phases. In the first phase of 12 weeks, 808 patients of chronic depression received the medication for chronic depression. Among those patients, 491 did not respond, who were then entered into the phase two. In this phase, the patients were divided into two groups and received the medication for depression either alone in one group or in combination with psychotherapy, such as brief supportive psychotherapy or cognitive-behavioral analysis system of psychotherapy in the second group. The researchers utilized different instruments and questionnaires to work on their objective. They used Working Alliance Inventory-short form to evaluate the quality of alliance; Quick Inventory of Depressive Symptomatology-Clinician (QIDS-C) version to assess the symptoms of depression, and Hamilton rating scale for depression (HAMD, Laws et al., 2017).
The researchers found that the alliance ratings of the patients and psychotherapists either remained similar or come close to each other during psychotherapy. They also noted that higher alliance convergence was related to an increased level of the decrease in QIDS-C depression during the psychotherapeutic sessions. Moreover, the increase in alliance convergence was found to be associated with a decrease in HAMD scores at a 3-month follow-up. The researchers concluded that the results were in partial agreement that an increase in alliance quality during psychotherapy could also help in improving the treatment outcomes. However, the researchers noted that an important limitation of the study was the work on chronically depressed patients; therefore, the findings have to be interpreted with caution for the non-chronically depressed patients or for larger population. Moreover, the effect size found for alliance convergence is small, so for clinical importance of the alliance-convergence, further studies are still required (Laws et al., 2017).
In another study, Lorenzo-Luaces et al. (2014) worked on the effect of client characteristics on therapeutic alliance and treatment outcomes in case of cognitive therapy for depression. In this regard, the researchers explored the personality traits and personality problems; demographic variables, such as age, gender, and marital status, and some other clinical features, such as severity of mental health problems, and the presence of comorbid health problems, such as anxiety. The study was conducted on 60 clients who were receiving cognitive therapy for depression. The researchers used the Beck Depression Inventory—Second Edition (BDI–II) for the assessment of depressive symptoms, and Working Alliance Inventory–Short Observer-Rated version (WAI–O) for the assessment of alliance. They also worked on demographics, personality, severity of problem of depression, and some other clinical features (Lorenzo-Luaces et al., 2014).
The researchers found that the interaction between the number of the previous episodes of depression and the WAI–O could significantly predict the symptom change. They also noted that the correlation of an overall alliance to outcome relationship was about 0.23. Moreover, the size of the relation of the alliance and outcome changed significantly in association with the number of the previous episodes of depression. For instance, in case of the clients with fewer than three episodes of depression, the correlation of alliance and outcome was significantly higher than that of the previous studies, and in case of the clients with three or more previous episodes of depression, the alliance was not of significant help in changing the symptoms. The relationship of alliance and outcome also strengthened with an increased level of self-reported conscientiousness, and decreased scores on measured IQ. An important limitation of the study is that it was conducted on 60 participants. Therefore, the researchers noted that the study could be considered underpowered, and further studies are still required on personal characteristics (Lorenzo-Luaces et al., 2014).
The literature review shows that the therapeutic alliance plays a role in the improved outcomes of a psychological intervention (Edalati Shateri & Fathali Lavasani, 2018). This alliance usually develops between the patient and the psychotherapist from the start of the study, but it may increase in strength with the increase in the number of sessions as also noted by Laws et al. (2017). However, the client characteristics, such as previous episodes of anxiety, lower IQ scores, and increased level of self-reported conscientiousness, could also influence the outcomes even in case of an appropriate alliance as described by Lorenzo-Luaces et al. (2014). It is important to note that the study by Laws et al. (2017) had been conducted on a sufficiently large number of participants. However, the study by Edalati Shateri & Fathali Lavasani (2018) has been conducted on very small number of participants; therefore, further studies could be conducted with a larger sample size.
After considering the findings of these studies, it can be suggested that psychotherapists have to develop such an environment in which the clients keep on working with the psychotherapists as each passing session improves alliance. Moreover, psychotherapists have to fully understand the different characteristics of the patients for better clinical outcomes. In the future, randomized controlled trials with a sufficiently large sample size could be conducted, so that the statistically significant findings of the studies could be obtained utilizing the most powerful research design.