The relationship quality between therapist and patient is a therapeutic factor that can lead to better patient outcomes. One of the key elements of the therapeutic relationship is the therapeutic alliance. The alliance is the agreement between patient and therapist on the goals of therapy, the tasks or type of work done in therapy, and their emotional bond. There is a positive association between a strong therapeutic alliance and patient mental health outcomes. There is also substantial research showing how ruptures in the alliance can lead to poorer outcomes and that repairing these ruptures may build an even stronger alliance. Establishing an alliance is a collaborative process in which patients and therapists affect each other’s interpersonal behaviours. If one person in the interaction has interpersonal difficulties, this might negatively impact their alliance. Individuals with psychological problems often experience interpersonal distress and have difficulty navigating social interactions. Even well-trained and experienced therapists may have issues working with patients with significant interpersonal problems. In this meta-analysis, Iovoli and colleagues were interested in how patients’ interpersonal problems at the beginning of therapy were associated with the quality of the therapeutic alliance during treatment. Their systematic review of the existing research revealed 27 studies representing 6,334 patients. The studies included patients with various diagnoses or problems and therapists working within different therapeutic orientations. The correlation between interpersonal problems at the beginning of therapy and the subsequent therapeutic alliance resulted in r = −.124, SE = .019, 95% CI [−.162, −.082], t(26) = −6.311, p < .001. This small but statistically significant effect indicates that patients with greater interpersonal problems tend to have a weaker therapeutic alliance with their therapists. The effect was more substantial when the alliance was measured early in therapy. The interpersonal problem–alliance association did not differ significantly depending on the type of therapy provided by the therapist.
Practice Implications
Individuals with higher interpersonal problems may face more significant challenges in developing a solid therapeutic alliance with their therapists. Therapists should identify and address these interpersonal problems. Patient’s interpersonal difficulties have a more substantial impact on developing an alliance early on in therapy, which could set the stage for therapeutic relationship difficulties throughout treatment. One could expect more alliance ruptures with such patients (disagreements on the tasks and goals of therapy or a strained relational bond). Therapists should learn to identify when an alliance rupture has occurred and learn skills to repair these ruptures. The PPRNet is currently conducting a study in which community-based therapists receive evidence-based training to identify and repair alliance ruptures. Go to https://researchpprnet.ca/ for more information on how to obtain this free training.
Iovoli, F., Flückiger, C., Gómez Penedo, J. M., Engelhardt, J. H., Kaschlaw, H. H., Lauterbach, R., Wester, R. A., & Rubel, J. A. (2024). The relationship between interpersonal problems and therapeutic alliance in psychotherapy: A three-level mixed-effects meta-analysis. Psychotherapy, 61(3), 198–211. https://doi.org/10.1037/pst0000534
To learn more about the Psychotherapy Practice Research Network, visit www.pprnet.ca.
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