Although the therapeutic alliance is well known to be related to patient outcomes, it is less clear how and why it leads to these outcomes. Is it that some patients have a natural capacity (or trait) to develop an alliance with any therapist, or is it that their alliance capacity grows over time within a particular therapeutic relationship (state-like fluctuations) regardless of the patient’s general capacity? A key element of the alliance is the emotional bond that can develop between patient and therapist. Some patients with more secure attachments and fewer interpersonal problems have a greater capacity to form a bond than those with more insecure attachment and interpersonal problems. However, the therapeutic bond can be state-like as well – it can change during therapy despite patients’ trait-like capacities. In this study, Malka and colleagues use a unique statistical approach, the social relations model, to disentangle the effects of trait-like and state-like therapeutic bonds on patient outcomes. The study included 118 patients with depression who received psychodynamic therapy. Patients rated the therapeutic bond after each of 16 therapy sessions, and a therapist also rated the bond with the patient after each session. In this way, the researchers could estimate the effects of the patient’s bond capacity in general (the patient’s trait), the therapist’s overall level of bond with their patients (the therapist’s trait), and the patient and therapist change in the bond across sessions (state-like fluctuations). Overall, there was strong evidence that some therapists and patients had a stronger trait-like capacity to form better therapeutic bonds than others. But the most interesting finding was that patients with better treatment outcomes developed increasingly stronger bonds as sessions progressed relative to other patients of the same therapist. In other words, regardless of where patients started in their capacity to form a bond (their trait), it was the session-to-session state-like fluctuation in the bond within their unique therapeutic relationship that predicted outcomes.
Practice Implications
The unique therapist-patient relationship appears to be a key mechanism of change in treatment. While a patient’s and therapist’s personal tendencies may shape their potential for a strong alliance, once treatment begins, it is the quality and growth of their bond that contributes to therapy outcomes. Therapists would do well to enhance their ability to perceive fluctuations in the therapeutic alliance across sessions with each patient. This will help therapists respond to and repair alliance ruptures when they occur.
Malka, M., Sayda, D., Ben-David Sela, T., Moggia, D., Altmann, U., & Zilcha-Mano, S. (2026): It takes two to heal: Trait-like and state-like contributions to the therapeutic bond and their association with therapeutic change, Psychotherapy Research, https://doi.org/10.1080/10503307.2026.2619106.
The director of the Psychotherapy Practice Research Network (PPRNet) is Dr. Giorgio Tasca. Dr. Tasca is an Associate Professor with the School of Psychology, in the Faculty of Social Sciences at the University of Ottawa. His research is centered around psychotherapy process, mechanisms of change, and outcomes, as well as eating disorders.
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PPRNet Clinical summary: It Takes Two to Heal: Within Dyad Change in the Alliance Predicts Outcomes
Although the therapeutic alliance is well known to be related to patient outcomes, it is less clear how and why it leads to these outcomes. Is it that some patients have a natural capacity (or trait) to develop an alliance with any therapist, or is it that their alliance capacity grows over time within a particular therapeutic relationship (state-like fluctuations) regardless of the patient’s general capacity? A key element of the alliance is the emotional bond that can develop between patient and therapist. Some patients with more secure attachments and fewer interpersonal problems have a greater capacity to form a bond than those with more insecure attachment and interpersonal problems. However, the therapeutic bond can be state-like as well – it can change during therapy despite patients’ trait-like capacities. In this study, Malka and colleagues use a unique statistical approach, the social relations model, to disentangle the effects of trait-like and state-like therapeutic bonds on patient outcomes. The study included 118 patients with depression who received psychodynamic therapy. Patients rated the therapeutic bond after each of 16 therapy sessions, and a therapist also rated the bond with the patient after each session. In this way, the researchers could estimate the effects of the patient’s bond capacity in general (the patient’s trait), the therapist’s overall level of bond with their patients (the therapist’s trait), and the patient and therapist change in the bond across sessions (state-like fluctuations). Overall, there was strong evidence that some therapists and patients had a stronger trait-like capacity to form better therapeutic bonds than others. But the most interesting finding was that patients with better treatment outcomes developed increasingly stronger bonds as sessions progressed relative to other patients of the same therapist. In other words, regardless of where patients started in their capacity to form a bond (their trait), it was the session-to-session state-like fluctuation in the bond within their unique therapeutic relationship that predicted outcomes.
Practice ImplicationsThe unique therapist-patient relationship appears to be a key mechanism of change in treatment. While a patient’s and therapist’s personal tendencies may shape their potential for a strong alliance, once treatment begins, it is the quality and growth of their bond that contributes to therapy outcomes. Therapists would do well to enhance their ability to perceive fluctuations in the therapeutic alliance across sessions with each patient. This will help therapists respond to and repair alliance ruptures when they occur.
By Dr. Giorgio Tasca
The director of the Psychotherapy Practice Research Network (PPRNet) is Dr. Giorgio Tasca. Dr. Tasca is an Associate Professor with the School of Psychology, in the Faculty of Social Sciences at the University of Ottawa. His research is centered around psychotherapy process, mechanisms of change, and outcomes, as well as eating disorders.Also Read