The therapeutic alliance represents the collaborative agreement between therapist and patient on the goals of therapy, the tasks of therapy (how therapy is conducted), and their relational bond. The level of the therapeutic alliance is a highly reliable predictor of patient outcomes. But how does the alliance result in positive outcomes, for which patients is it a good predictor, and what can therapists do with this information? Zilcha-Mano and Fisher address some of these important questions by differentiating between trait alliance and state alliance and review research that disentangles the effects of trait vs state alliance on outcomes. Trait alliance refers to patients' capacity at the outset of therapy to develop a good alliance with a therapist. Higher trait alliance is related to fewer interpersonal problems, lower attachment avoidance, and higher self-esteem. Research indicates that patients with higher trait alliance tend to have better outcomes. State alliance refers to session-by-session changes in the alliance independent of the patient’s capacities or traits at the start of therapy. Perhaps the most important result from this line of research is that changes in the alliance from one session to the next were associated with better treatment outcomes in subsequent sessions. This effect was more pronounced for those patients with more significant interpersonal problems. In other words, those patients whose underlying issues involved interpersonal difficulties and who had more interpersonal deficits before treatment benefitted most from strengthening the alliance across therapy sessions. Research also suggests that general training in psychotherapy skills may not be enough to improve therapists’ capacity to repair alliance ruptures and grow the alliance. However, few therapists receive alliance training as most training programs view the alliance as a patient trait that works in the background instead of a therapeutic state-like mechanism of change.
Practice Implications
Patients who start with a relatively lower capacity or trait to develop an alliance (i.e., those with more significant interpersonal problems) might benefit the most from a therapist who is sensitive to strengthening the alliance and repairing alliance ruptures throughout therapy. An improving alliance from one session to the next can provide the corrective emotional experience key to successful therapy for patients who struggle to develop and maintain satisfying relationships. This corrective interpersonal experience can change how patients perceive themselves (as deserving of others’ positive regard) and others (as having benevolent intentions). Specific alliance-related training may be necessary for psychotherapists to develop and hone these skills. Therapists can also use patient feedback in questionnaires at the end of each therapy session to assess the patient’s level of alliance in one session relative to previous sessions. A precipitous decline in the alliance from one session to the next would alert the therapist to a possible alliance rupture and the need for repair strategies.
Zilcha-Mano, S., & Fisher, H. (2022). Distinct roles of state-like and trait-like patient-therapist alliance in psychotherapy. Nature Reviews: Psychology, 1, 194–210. https://doi.org/10.1038/s44159-022-00029-z
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