The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported allian-ceϪoutcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the allianceϪoutcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the allianceϪoutcome correlations: (a) intake characteristics (k ϭ 35); (b) simultaneous processes, such as adherence or competence (k ϭ 13); and (c) both intake and simultaneous processes (k ϭ 24). We found moderate allianceϪoutcome correlations with or without adjustments for intake and simultaneous processes (range from r ϭ .23 to r ϭ .31). Our results provide robust empirical evidence for the assertion that the allianceϪoutcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes. Public Significance StatementThe alliance is a robust predictor of outcome at the between-patients level. Patients who report a stronger alliance during treatment are also likely to report better treatment outcome. This association remains significant when controlling for patients' intake characteristics and therapists' adherence and competence. These results demonstrate that the alliance is an independent process-based factor with unique contribution to outcome across many psychotherapeutic contexts.

Most of the literature on the alliance-outcome association is based exclusively on differences between patient reports on alliance. Much less is known about the unique contribution of the therapist’s report to this association across treatment, that is, the association between therapist-reported alliance and outcome over the course of treatment, after controlling for the patient’s contribution. The present study is the first to examine the unique contribution of the therapist-reported alliance to outcome, accounting for reverse causation (symptomatic levels predicting alliance), at several time points in the course of treatment. Of 156 patients randomized to dynamic supportive-expressive psychotherapy, antidepressant medication with clinical management, and placebo with clinical management, 149 were included in the present study. Alliance was assessed from the perspective of both the patient and the therapist. Outcome measures included the patients’ self-reported and diagnostician-rated depressive symptoms. Overall, the findings demonstrate that the therapists’ contribution to the alliance-outcome association was explained mainly by prior symptomatic levels. However, when a time lag of several sessions was introduced between alliance and symptoms, a positive association emerged between alliance at one time point and symptomatic distress assessed several sessions later in the treatment, controlling for previous symptomatic level. The findings were similar whether or not we controlled for the patient’s perspective on the alliance. Taken together, the findings attest to the importance of improving therapists’ ability to detect deterioration in the alliance.

The primary aim of this study was to investigate the effects of the 2016 United States presidential election and ensuing political climate on patients' experiences in psychotherapy. A sample of 604 self-described Democrat and Republican patients from 50 states participated in the study. Results showed that most therapists disclosed their political stance (explicitly or implicitly) and most patients discussed politics with their therapists. 64% of Clinton supporters and 38% of Trump supporters assumed political similarity with their therapist. Stronger patient-reported alliance levels were found for patients who (a) perceived political similarity; (b) reported implicit therapist political disclosure; and (c) found in-session political discussions helpful. Additionally, Clinton (but not Trump) supporters reported significant pre-post-election decreases in expression of positive emotions and increases in both expression of negative emotions and engagement in discussions about socio-political topics. Our findings suggest that the current political climate infiltrates the therapeutic space and affects therapeutic process and content.

The introduction of novel methodologies in the past decade has advanced research on mechanisms of change in observational studies. Time‐lagged panel models allow us to track session‐by‐session changes and focus on within‐patient associations between predictors and outcomes. This shift is crucial as change in mechanisms inherently takes place at a within‐patient level. These models also enable preliminary casual inferences, which can guide the development of effective personalised interventions that target mechanisms of change, used at specific treatment phases for optimal effect. Given their complexity, panel models need to be implemented with caution, as different modelling choices can significantly affect results and reduce replicability. We outline three central methodological recommendations for use of time‐lagged panel analysis to study mechanisms of change: (a) taking patient‐specific effects into account, separating out stable between‐person differences from within‐person fluctuations over time; (b) properly controlling for autoregressive effects; and (c) considering long‐term time trends. We demonstrate these recommendations in an applied example examining the session‐by‐session alliance–outcome association in a naturalistic psychotherapy study. We present limitations of time‐lagged panel analysis and future directions.

In the past few decades there has been an increasing movement toward adopting integrative perspectives. Although the levels of psychotherapy integration shown by therapists in naturalistic and experimental settings have been investigated, not much is known about the levels of integration among psychotherapy experts. The current study examines the levels of psychotherapy integration in psychotherapy sessions of known experts from different orientations, at different time points in history. Ratings of prototypical demonstrations of 9 psychotherapy experts from different therapeutic orientations and from different generations were examined to determine the extent of integration. Psychotherapy integration was observed in all prototypical demonstrations. Experts tended to integrate techniques from other approaches within their own "family"-similarities in the use of techniques were found among experts who identified with an 'exploratory' orientation as well as among experts who identified with a 'directive' orientation. The current findings show that experts "stay in the family"they integrate techniques from approaches similar to their own. Furthermore, experts from different generations showed similar levels of psychotherapy integration.