A meta-analysis of client-therapist perspectives on the therapeutic alliance: Examining the moderating role of type of measurement and diagnosis

Abstract

Background: Clients and therapists often have different perspectives on their therapeutic alliance (TA), affecting the process and outcome of therapy. The aim of the present meta-analysis was to assess the mean differences between clients’ and therapists’ estimations of TA among clients with severe disturbances, while focusing on two potential moderators: client diagnosis and alliance instrument. Method: We conducted a systematic literature search of studies examining both client perspective and therapist perspective on TA in psychotherapy among people with schizophrenia spectrum disorders, personality disorders, and substance misuse disorders. We then analyzed the data using a random-effects meta-analytic model with Cohen’s d standardized mean effect size. Results: Heterogeneity analyses (k = 22, Cohen’s d = −.46, 95% confidence interval = .31–1.1) produced a significant Q-statistic (Q = 94.96) and indicated high heterogeneity, suggesting that moderator analyses were appropriate. Conclusions: Our findings show that the type of TA instrument moderates the agreement on TA between client and therapist, but there was no indication of the client’s diagnosis moderating the effect. The agreement between client and therapist estimations seems to be dependent on the instrument that is used to assess TA. Specific setting-related instruments seem to result in higher agreement between clients’ and therapists’ estimations than do more general instruments that are applied to assess TA.

Longitudinal changes in therapeutic alliance with people with psychosis: Relationship between client and therapist assessments

“…A meta‐analytic examination of diverse mental conditions has shown client and therapist TA ratings were only moderately correlated ( r = .36) (Tryon et al, 2007). Furthermore, a recent meta‐analysis has shown that within the category of severe mental illnesses, diagnosis is not a moderator for lack of agreement or incongruence in ratings (Igra et al, 2020); thus, other factors are related to it.…”

“…The authors suggested that these findings reflected a ‘better safe than sorry’ pattern in which therapist caution may contribute to a greater likelihood of therapist underestimation of TA relative to the client, and better ability to track temporal changes more accurately. A meta‐analysis on studies among people with serious mental illness has confirmed a general trend for clients to rate the alliance somewhat higher than therapists (Igra et al, 2020).…”

The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review

“…Such qualities are reflective of Rogers' (1957, 1965) seminal work and the person‐centred literature whereby the constructs of empathy (Elliott et al, 2018), unconditional positive regard (Farber et al, 2018) and genuineness (Kolden et al, 2018) have been linked to psychotherapy outcome. Furthermore, client–therapist agreement on the therapeutic alliance can be integral to positive (Marmarosh & Kivlighan, 2012) or negative therapeutic outcomes (Rubel et al, 2018), although dependent on which outcome measure is used to assess alliance (Igra et al, 2020).…”

A dyadic session‐by‐session assessment of therapeutic alliance and short‐term outcome among clients with schizophrenia in comparison with clients with emotional disorders

“…Therapeutic alliance can be assessed by both client and therapist, but these assessments can differ. Interestingly, a pattern in which therapists systematically assess the alliance as lower than do their clients has been shown across different therapeutic approaches and different populations (Atzil‐Slonim et al, 2015; Hasson‐Ohayon et al, 2021; Igra et al, 2020; Marmarosh & Kivlighan, 2012; Shick Tryon et al, 2007). This discrepancy has been coined a ‘better safe than sorry’ approach on the part of therapists, as it implies a cautious attitude not to overestimate the TA and consequently fail to recognize ruptures (Atzil‐Slonim et al, 2015).…”

“…Thus, empirically assessing TA with dyadic indices, that is from both client and therapist points of view, is important as it allows us to broaden our understanding regarding TA and its effects (Coyne et al, 2018; Laws et al, 2017; Zilcha‐Mano et al, 2016). In addition, an aspect which seems particularly important in the assessment of TA effects on psychotherapy outcome is the effect of TA congruence—that is the level of agreement between client and therapist regarding TA across time (Igra et al, 2020)—on outcome.…”