The therapist–client relationship

Introduction: The therapeutic alliance is the working relationship between a therapist and a client: how much they trust each other and agree on the goals and tasks of therapy. Researchers combined the results of many earlier studies to see whether a stronger alliance is related to greater improvement in symptoms.

Studies included: The researchers searched research databases for studies published between 2000 and 2024. To be included, a study had to measure the alliance with a standardized client questionnaire (12 statements, such as "My therapist and I agree on what is important to work on", each rated 1 to 7, for a total from 12 to 84) completed by the client at the third session, and measure symptoms at the start and end of treatment. Studies of children, couples or group therapy were left out. The researchers included only studies whose authors reported approval by an ethics board and informed consent from clients. They used only the summary results published in each study, so no individual client could be identified.

Participants: The 58 included studies had a total of 9,840 adult clients (aged 18 to 74; 66% women) receiving individual outpatient therapy for a depressive disorder or an anxiety disorder. Fifty-four studies were conducted in the United States, Canada, Western Europe or Australia, and four in East Asia. Many studies did not report clients' race/ethnicity.

Results and Discussion: Across all 58 studies, alliance scores were positively correlated with symptom improvement (r = +0.28), a statistically significant relationship. The table shows the correlations for each type of therapy. In six studies that measured the alliance at several points, clients whose symptoms improved early in treatment tended to report a stronger alliance later. The researchers noted that a strong alliance may help clients improve, but early improvement may also strengthen the alliance.