Therapist and Client Perceptions of the Working Alliance: Codevelopment, Linear Growth, Variability, and Client Functioning

• Published in: Journal of counseling psychology Vol. 71; no. 1; pp. 63 - 76
• Main Authors: Lin, Shihong, Kivlighan, Dennis M., Hill, Clara E.
• Format: Journal Article
• Language: English
• Published: United States American Psychological Association 01-01-2024
• Subjects: Alliances; Clients; Databases, Factual; Female; Human; Humans; Male; Outpatient; Partners; Professional-Patient Relations; Psychological Distress; Psychotherapy - methods; Ratings & rankings; Resistance (Psychology); Responsiveness; Therapeutic Alliance; Therapeutic alliances; Therapist Attitudes; Therapists; Treatment Outcomes; Variability; working alliance change; linear growth; codevelopment; variability; therapy outcome
• ISSN: 0022-0167; 1939-2168
• DOI: 10.1037/cou0000715

Using longitudinal client and therapist working alliance ratings, previous research examined how alliance: average value, linear growth, variability, stability (autocorrelation), and partner responsiveness were associated with client outcome. However, no research simultaneously examined all of these dimensions. Omitting important variables in analyses could lead to overestimation of related effects. Therefore, the purpose of this study was to examine these effects simultaneously. Therapists (N = 45) and clients (N = 236) rated alliance after every session (N = 10,720) and clients completed a measure of psychological distress after every eighth session. We used dynamic structure equation modeling to model longitudinal ratings using the longitudinal actor-partner interaction and location-scale models. Across sessions, there were significant linear growth and significant variability in client and therapist alliance ratings. The variability indicates multiple "V" patterns, which have been associated with alliance ruptures. Both actor effects were significant, showing session-to-session stability for client and therapist alliance. In addition, client-partner effect was significant, indicating higher-than-usual client alliance in a session predicting an increase in therapist alliance in the subsequent session. Growth in neither client-rated nor therapist-rated working alliances was significantly associated with client improvement. Lower variabilities (fewer fluctuations) in both client- and therapist-rated working alliances were associated with better outcomes. Higher therapist-actor and partner effects were associated with client improvement, but client-actor and partner effects were not associated with client improvement. Average working alliances were not associated with client improvement. Implications for practice and research were discussed.
Public Significance Statement
Session-to-session ratings of how well clients and therapists are collaborating on the work of therapy can be used to enhance client improvement and therapist development; however, these session-to-session ratings contain a lot of different types of information that may be differentially informative about treatment progress. Our research shows that therapists should pay attention to the variability (how much the ratings go up and down) in the ratings over time and how therapist ratings of collaboration in a session are associated with client ratings of collaboration in the subsequent session. High variability in collaboration ratings and little association between therapist rating in one session and client rating in the next session are signs of problems in therapy.