One size does not fit all: Examining heterogeneity and identifying moderators of the alliance–outcome association.

Abstract

Although the alliance-outcome association is one of the most consistent findings in psychotherapy research, it is also highly heterogeneous. Little is known about the factors explaining this variability, and consequently there is a lack of adequate knowledge about how to utilize this association to improve treatment. The present study had the following objectives: (a) to examine the associations between within- and between-individual variability in alliance and outcome, controlling for previous symptomatic levels; (b) to examine the duration of the alliance-outcome association; and (c) to examine potential moderators of the alliance-outcome association. A total of 547 patients treated in a primary care psychotherapy setting in Chile were randomly assigned to 5 feedback conditions. The alliance-outcome association was analyzed using multilevel models, disentangling changes in alliance within-individuals from alliance between-individuals. Patient and therapist characteristics were examined as potential moderators. Findings suggest that patients who reported a better early alliance also reported a better outcome. Furthermore, patients reporting time-specific improvement in alliance also reported a greater reduction in symptoms. The unique effect of alliance on outcome at one point in time is maintained for a period of 2 weeks. Patients with more severe symptoms and longer treatments benefited more from a good alliance. Therapists identifying themselves as more integrative in their treatment orientation were able to better utilize good alliances for treatment success. Finally, the size of the alliance-outcome association can be manipulated by feedback to therapists.

The relationship between alliance and outcome: Analysis of a two-person perspective on alliance and session outcome.

“…Greater mindfulness of the alliance may have resulted in buffering any adverse effects of alliance disagreement. Some support for this post hoc explanation, arguing for the existence of moderators of the association between differences in alliance and outcome, may come from studies demonstrating significant moderators of the alliance-outcome association (e.g., Lorenzo-Luaces, DeRubeis, & Webb, 2014; Falkenström, Granström, & Holmqvist, 2013, Zilcha-Mano & Errázuriz, 2015). Future studies should test potential moderators of the association between differences in alliance and outcome and consider additional patterns of interactive effects, rather than focus strictly on the difference models that have been the subject of most of the research attention to date.…”

“…Studies support the psychometric properties of WAI measure (Elvins & Green, 2008). Research has shown that the WAI show a process of development over time for both patients (Falkenström, Granström, & Holmqvist, 2013; Zilcha-Mano & Errázuriz, 2015) and therapists (Zilcha-Mano, Solonomov, Chui, McCarthy, Barrett, & Barber, 2015), and that changes in alliance over time can significantly predict outcome for patient rating of alliance (Falkenström et al, 2013), and in some instances also for therapist rating (Zilcha-Mano et al, 2015). In the current study the internal reliability range across time points was .88–.94 for patients and .83–.93 for therapists.…”

“…The strength of the working alliance is a consistent predictor of outcome in psychotherapy, with stronger alliance predicting better therapeutic outcomes (Horvath, Del Re, Flückiger, & Symonds, 2011). Recent studies have shown that this association is significant even after adjusting for temporal precedence between alliance and symptoms (Falkenström, Granström, & Holmqvist, 2013; Zilcha-Mano, 2016; Zilcha-Mano, Dinger, McCarthy, & Barber, 2014; Zilcha-Mano & Errázuriz, 2015). …”

Therapist-reported alliance: Is it really a predictor of outcome?

“…Studies in which therapists received feedback on the therapeutic alliance found a lower dropout rate and better outcomes in the feedback condition (Harmon et al, 2007; Whipple et al, 2003). Support for the potential contributions of systematic feedback on the alliance comes from a recent study showing that feedback on the alliance contributes to a stronger alliance-outcome association (Zilcha-Mano & Errázuriz, in press). …”

Client and therapist match on gender, age, and income: Does match within the therapeutic dyad predict early growth in the therapeutic alliance?

“…Regardless of feedback condition of therapists, all clinicians worked according to their own style and theoretical orientation, with no design control over treatment delivery or adherence. The rationale, procedures, and main outcomes of the original RCT are reported elsewhere (for example, Zilcha‐Mano & Errázuriz, ).…”