The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also ...conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals .256, .299, p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices.
Clinical Impact Statement
Question: How robust is the correlation of the alliance (as a holistic, collaborative quality measured during therapy) with therapy outcomes? Findings: Based on over 300 studies, the positive relation of the alliance and outcome remains across assessor perspectives, alliance and outcome measures, treatment approaches, patient (intake-) characteristics, face-to-face and Internet-mediated therapies, and countries. Meaning: The alliance, which is of a mutual collaboration and partnership between therapist and client, is an important aspect of psychotherapy across various psychotherapy approaches. Next Steps: The universality of the alliance-outcome relation and the potential conceptual boundaries have to be investigated across cultural and biopsychosocial contexts inside but also outside of psychotherapeutic settings in a quantitative and in a qualitative manner.
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