PPRNet Clinical summary: Therapeutic Alliance Improvement is Important for Clients with Childhood Adversity

The therapeutic alliance is the agreement between therapist and client on the goals of therapy (what to change) and the tasks of therapy (how to work together), as well as the relational bond between them. There are hundreds of studies showing that higher alliance is reliably associated with better client outcomes. However, these are often correlational studies that show an association but do not necessarily indicate that the alliance causes better outcomes. Establishing cause is key to making a more definitive scientific statement about the alliance's role in psychotherapy. One way to support the claim that the alliance leads to (causes) a better outcome is to show that a change in the alliance in one session is associated with a better outcome in the immediately subsequent session. Another important practical issue is to understand which clients benefit most from the therapeutic alliance. This might help therapists personalize the client's treatment. One such client characteristic may be a history of childhood adversity (abuse, neglect, bullying), which can affect adult clients’ abilities to trust in the therapeutic relationship and therapists’ interventions. Therapists’ repair of alliance ruptures (inevitable tensions in the therapeutic relationship) may be a corrective experience for clients, especially those who experienced childhood adversity. In this study, Østergård and colleagues assessed symptom severity before each therapy session and the therapeutic alliance after each session for 162 clients seen at a university counselling centre. Therapists were supervised trainees who provided short-term psychodynamic therapy. The researchers also assessed the number of childhood adverse experiences of each client. Using advanced time-lagged statistical methods for longitudinal data analysis, the authors found that higher alliance in a prior session was reliably associated with better outcomes in a subsequent session. The effect of the alliance leading to better outcomes grew over time and was strongest around session 8. Further, the effect of the previous session alliance on subsequent session outcomes was most pronounced for clients who experienced greater childhood adversity. This suggested that these clients needed a strong alliance and that therapists should repair ruptures in the alliance to provide the corrective emotional experience necessary for a good outcome.

Practice Implications 

This study points to the importance of consistently working to improve the therapeutic alliance to enhance therapy outcomes, particularly for those clients who experienced adverse childhood events. Developing and repairing the alliance can contribute to corrective emotional experiences with a reliable therapist. This process might dispel negative expectations about oneself and others that are often prevalent among clients with adverse childhood experiences. Providing therapists with training focused on developing their ability to build and repair the therapeutic alliance would help to develop this key skill and improve client outcomes.

Østergård, O. K., Nilsson, K. K., & Falkenström, F. (2026). The working alliance predicts session-by-session change in problems and functioning in short-term psychodynamic psychotherapy. Journal of Counseling Psychology. Advance online publication. https://dx.doi.org/10.1037/cou0000867