The paper is dedicated to a discussion of the links between the relational factors in therapy on patient outcomes. Empathy and goal consensus between, the core elements of the client-therapist alliance, are the strongest predictors of favorable intervention outcomes. However, such patient-specific factors as severity and chronicity of mental problems are found to modify the intensity of the alliance-outcome association. Along with aiming to enhance their relationship-building skills, therapists are advised to explore the mediators and modifiers of the alliance-outcome associations through independent research.
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The quality of interpersonal relationships taking place between therapists and their patients has been viewed as one of the core elements defining the effectiveness of psychological and psychiatric therapies. It is considered that strong emotional bond and mutual agreement between a patient and a therapist on intervention goals and strategies used to attain them are key to productive therapeutic relationships. The type of patient-therapist interaction that meets these criteria is frequently referred to as the working alliance and is considered to largely contribute to the therapy success and the overall patient outcome (Constantino et al., 2017).
Within a period of a few past decades, the links between these two variables – working alliance and patient outcomes – have become of significant interest to practitioners and researchers in the field of psychology. The present paper will discuss available evidence regarding the role of the working alliance and other relationship-associated factors in the promotion of positive therapeutic outcomes in patients.
The choice of the right and effective methods is undeniably an essential predictor of psychotherapy success. However, as noted by Norcross and Lambert (2014), “the impact of treatment methods is inextricably bound to the relationship context in which they are applied” (p. 399). According to Wampold and Imel (2015), the most influential (and most commonly studied) relational factors affecting patient outcomes in therapy include alliance, empathy, goal consensus/collaboration, positive regard/affirmation, congruence/genuineness, therapy-related expectation, and cultural adaptation of methods.
Noteworthily, goal consensus and empathy (two basic components of the working alliance as per the definition by Constantino et al. (2017)) are statistically proven to be the most significant among all other factors (Wampold & Imel, 2015; Norcross & Lambert, 2014).
It is fairly easy to comprehend why these two attributes are very important. Firstly, providing a patient perceives that they are criticized by a therapist and that the latter does not understand their innermost feelings, they will most certainly be discouraged and mistrusting. At the same time, Norcross and Lambert (2014) note that as a result of a social experience based on empathy, a client “comes to consider new knowledge from another person as trust-worthy, generalizable, and relevant to the self” (p. 400).
Additionally, trustful relationships allow guiding patients through interventions in the situations of psychological resistance to change that frequently occur in individuals with a strong internal locus of control (Goldfried & Davila, 2005). Thus, without empathy on part of a therapist, patients will likely find it difficult to believe in the effectiveness of the therapy.
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Secondly, the agreement on goals and objectives of the therapy, as well as specific techniques that must be utilized, may be regarded as the sign of a mutual understanding between a therapist and a patient. The consensus indicates that the former takes into account patient needs and interests and that the latter is aware of the purposes and other nuances of the recommended therapeutic practices and fully realizes the overall orientation of the intervention (Wampold & Imel, 2015). It means that with the help of goal consensus, the promotion of patient motivation and adherence can be largely facilitated. Therefore, by influencing patient perceptions of the therapy, both empathy and agreement of goals/collaboration may affect therapy outcomes.
Nevertheless, the links between the alliance and patient outcomes are not always strong and can be influenced by multiple variables. For instance, the number of previously experienced depressive episodes can affects the alliance-outcome association. According to Constantino et al. (2017), the working alliance contributes to better outcomes in case a patient had 0-2 of prior episodes and fails to impact the outcomes in individuals who had 3 or more prior episodes (Constantino et al. 2017).
In addition, it is observed that relations between the alliance and the outcome become stronger along with a rise in the severity of patients’ baseline anxiety (Constantino et al. 2017). These findings indicate that particular patient characteristics, as well as the intensity and the chronicity of one’s psychological condition, can substantially modify outcomes even when evidence-based relationship-building/practice methods are employed by a practitioner.
Regarding the controversies in the findings on the alliance-outcome links, it is pivotal for therapists to fully comprehend the factors modifying the degree of therapy effectiveness. However, research evidence dedicated to this problem is scarce so far, and the study by Constantino et al. (2017) is one of just a few studies exploring it. At the same time, the majority of experts tend to agree that practitioners should pay equal attention to both the selection of treatment methods and the quality of therapist-patient relationships (Goldfried & Davila, 2005; Norcross & Wampold, 2011). Therefore, it is highly recommended for therapists to focus on developing and improving their relationship-building and communication skills and concentrate on such relational factors as goal consensus and empathy.
In conclusion, it must be added that practitioners should be encouraged to engage in further investigation of the alliance-outcome associations. To enhance own understanding of moderators/mediators of correlations between the outcomes and the working alliance and improve the efficacy of own therapeutic decisions respectively, one may systematically observe their patients’ reactions to certain aspects of therapeutic relations. However, large-scale dissemination of findings on this matter can help to advance the theory and practice of psychotherapy to a substantial degree.
Constantino, M. J., Coyne, A. E., Luukko, E.K. Newkirk, K., Benecker, S. L., Ravitz, & McBride, C. (2017). Therapeutic alliance, subsequent change, and moderators of the alliance-outcome association in interpersonal psychotherapy for depression. Psychotherapy Theory Research & Practice, 54(2), 125-135.
Goldfried, M. R., & Davila, J. (2005). The role of relationship and technique in therapeutic change. Psychotherapy: Theory, Research, Practice, Training, 42(4), 421-430.
Norcross, J. C., & Lambert, M. J. (2014). Relationship science and practice in psychotherapy: Closing commentary. Psychotherapy, 51(3), 398-403.
Norcross, J. C., & Wampold, B. E. (2011). Evidence based therapy relationships: Research conclusions and therapy practices. Psychotherapy, 48(1), 98-102.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York, NY: Routledge.