Influence of patient and therapist agreement and disagreement about their alliance on symptom severity over the course of treatment: A response surface analysis.

Abstract

The alliance is dyadic in its nature with both the patient and the therapist contributing. Relatively little is known about the effects of congruence between patient and therapist perception of alliance on treatment outcome. The current study investigated how patient and therapist agreement and disagreement about the alliance predict symptom severity over the course of long-term psychotherapy. We investigated N ϭ 361 patients nested within N ϭ 102 therapists longitudinally every 5th session across long-term treatment. Multilevel polynomial regression with response surface analysis was used to predict symptom severity five sessions later from congruence of the alliance ratings. Throughout treatment, patient and therapist agreement about stronger alliances significantly predicted lower subsequent patient-reported symptom distress. Patient and therapist disagreement was a marginally significant predictor of subsequent symptom distress. There was no significant difference in the effects of alliance agreement and disagreement on symptoms across time in long-term treatment. Findings support the importance of alliance agreement and disagreement as predictors of subsequent patient symptom severity. Public Significance StatementThis study suggests that agreement between therapists and patients about the quality of their alliance may be related to lower patient symptoms later in treatment, while disagreement about the alliance quality could be related to more severe symptoms later in treatment. The study further suggests that alliance agreement and disagreement affect later symptoms steadily over the course of long-term psychotherapy. Thus, therapists need to direct their attention toward patients' potentially diverging perspective on the alliance and take appropriate actions to foster better agreement on their working relationship throughout treatment.

Does it make a difference to be more “on the same page”? Investigating the role of alliance convergence for outcomes in two different samples

“…Such findings indicate that there might not be a direct, one-to-one relationship between high alliance and evidence of explicit agreement on tasks and goals in the actual therapy dialogue (see also Jennissen et al, 2020). Instead, high alliance ratings may reflect an underlying sense of commitment and understanding rather than the active agreement on what to do and what to achieve in treatment.…”

“…While some divergence is inevitable-even constructive, Safran and colleagues argue that substantial ruptures are not, and their idea is that breaches in the alliance produce a chance for re-coordination, re-attunement and eventually repair which in turn leads to productive change. This negotiation process is assumed to be a central change process throughout treatment (Jennissen et al, 2020). There are empirical indications to suggest that alliance ruptures and subsequent repair can benefit the change process (Safran et al, 2013).…”

“…Since only one of four studies on alliance convergence unambiguously supports the idea that convergence is a promising process variable, we may speculate that an increased patient-therapist alignment in more fundamental experiential or relational dimensions, such as non-verbal synchrony, emotional attunement and affective co-regulation, are more essential than an increasing consensus in dyadic alliance or alliance convergence (see Atzil-Slonim & Tschacher, 2020;Jennissen et al, 2020).…”

“…However, this may be an oversimplification of the complex nature of the Psychotherapy Research 13 therapy relationship and likely a too literal translation of the positive alliance-outcome association (such as findings on alliance congruence and/or convergence over time) into practical guidelines for therapeutic action. As Jennissen et al (2020) recently put it: it should be noted that in clinical practice, high consensual alliance ratings may not be a result of explicit discussions on the tasks and goals of therapy. Instead, an automatic process of attunement and a sense of communion between the patient and the therapist might create high agreement in the alliance ratings.…”

“…In a study of the bond aspect of the alliance, Atzil-Slonim et al (2015) found that when clients reported more symptoms, therapist and client ratings of the emotional bond were more divergent. Moreover, Jennissen et al (2020), using multilevel polynomial regression with response surface analysis, found that congruence in therapist-patient alliance predicted less symptom severity five sessions later.…”