Therapist predictors of early patient-rated working alliance: a multilevel approach

The present study investigated whether and how various therapists' (N = 68) self-reported characteristics relating to their therapeutic work predicted patients' (N = 335) early ratings of the working alliance in a naturalistic psychotherapy study. Results from multilevel modeling demonstrated that certain self-reports accounted well for the therapist effect in the early alliance. The effect of therapists' experiences of difficulties in practice was particularly strong: a negative influence of difficulties termed negative personal reaction (NPR) and a surprising positive influence of another factor, professional self-doubt (PSD), were found. The latter was interpreted as reflecting an attitude of therapist humbleness and sensitivity, which seems to facilitate alliance development. A negative impact of self-reported skills in using one's own and the patients' emotional reactions in the therapeutic relationship (advanced relational skills) was found when controlling for a warm interpersonal style. The negative effect of advanced relational skills depended on the level of NPR difficulties. The findings suggest that therapists should be cautious in using this kind of relational skill unless they experience relating to patients in a warm manner and report low levels of NPR in their practice.