Development of working alliance over the course of psychotherapy

The goal was to investigate patients' rating of working alliance in longer-term individual psychotherapy (N=201), in order to determine different patterns of development and predictors of positive versus negative development.

The study explored patient factors that might be associated with positive versus negative development of the alliance, from early in treatment until the end. Subgroups of patients with different alliance development were compared, in order to identify predictors of these groups.

The data analyses identified patients who demonstrated significant change in the perceived quality of alliance using the reliable change index. Most patients were expected to have a stable alliance, and fewer were expected to have improving or deteriorating alliance.

We found three patterns: stable alliance, improving alliance, and deteriorating alliance. Seventy per cent of the therapies had a stable alliance, which was maintained throughout the treatment, supporting the assumption that the quality of the early alliance is important for the therapy process. We observed different pre-treatment scores of Target Complaint and Expectation of Change in Target Complaint between the subgroups with different development of the working alliance. Higher Expectation of Change was associated with improving alliance, whereas the combination of higher Target Complaint scores and lower Expectation of Change was associated with deteriorating alliance. Also, lower score on Global Assessment Scale (<50) was associated with deteriorating alliance. Clinical case vignettes illustrate the developments of improving and deteriorating alliance.

Several pre-treatment patient characteristics were associated with development of alliance in positive versus negative directions. Clinical implications are discussed.