The alliance -outcome relationship revisited: A session -by -session perspective

Psychotherapy research has documented that the quality of the therapeutic alliance is consistently related to outcome across a variety of diverse treatments and modalities. In order to build on previous research and to further test systemic theory about the alliance in individual therapy, it is important to understand better the session-by-session relationship between alliance and outcome, the extent to which clients differ in the types of alliances they form with their therapists, and what factors might account for these differences. Distinguishing within-person from between-person variability is also essential in understanding stability and change in the alliance-outcome relationship. While many previous studies only take one or two alliance measurements throughout treatment, this study used multilevel modeling techniques to explore the association between alliance and outcome at each session. 296 participants, consisting of predominantly highly-educated Caucasians, were enrolled in this naturalistic study. The role of the direct and indirect system was examined in relation to alliance-outcome relationships in an integrative, systemic-based, individual therapy. The overall relationship between alliance and outcome was consistent with previous research documenting the positive alliance-outcome association. This finding was applicable both within and between clients. Although several client and therapist variables were examined, no specific predictor variables that could moderate this alliance-outcome relationship were conclusively identified. Future research should continue to explore potential moderating relationships with important social support structures that reside in the indirect system. The results highlight the importance of studying therapeutic alliance on a micro- rather than a macro-level. On a micro-level, it is possible to examine both the within- and between persons variation instead of the crude total correlation of the macro approach