The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review

Abstract

It is well established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6472 studies, of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalizability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.

Suicidal Behavior and Difficulty of Patients, as Perceived by Community Mental Health Nurses

“…Systematic research has shown an association between a strong therapeutic alliance and fewer suicidal thoughts; this finding was reported in longitudinal studies in which the alliance with a mental health professional was evaluated 35. The therapeutic alliance, therefore, requires special attention when treating patients with some level of suicidality 36…”

“…35 The therapeutic alliance, therefore, requires special attention when treating patients with some level of suicidality. 36…”

Psychological intervention priorities according to perinatal women who experienced suicidal thoughts and perinatal mental health professionals: a Q-methodology study

“…Hence, some mothers might have never received the support of a therapist and could not therefore draw on that experience to assist them in their judgement of how important the therapeutic alliance might be to the outcome of an intervention. Furthermore, a recent systematic review of 19 quantitative studies summarised the relationship between the therapeutic alliance in psychotherapy and suicidal experiences prior to, during and following psychotherapy ( 52 ). The authors failed to identify a significant association between suicidal experiences prior to, or during, the psychotherapy and the strength of the therapeutic alliance.…”

Dynamic suicide topic modelling: Deriving population‐specific, psychosocial and time‐sensitive suicide risk variables from Electronic Health Record psychotherapy notes

“…In a related domain, countertransference, what has been broadly conceptualized as the therapist's emotional reactions to the therapeutic encounter (Gelso & Kline, 2022), has also been shown to be more negative when therapists are working with suicidal patients (Barzilay et al, 2020) and that these adverse countertransference patterns may impact suicide outcomes (Michaud et al, 2021). While therapeutic alliance and counter transference are known to impact suicide prevention (Dunster‐Page et al, 2017; Huggett et al, 2022), effectively measuring this impact over time remains difficult (Ryu et al, 2021; Tishby & Wiseman, 2022).…”