Does congruence between therapist and patient in session-by-session bond ratings predict change in symptoms?

The working alliance is a robust predictor of psychotherapy outcomes, and recent theories suggest that congruence between therapist and patient perceptions of the alliance may further enhance outcomes. This study examined whether session-by-session congruence in emotional bond ratings predicted next-session symptom improvement.

Data were drawn from 2,575 patients (82,641 patient-by-session observations) receiving feedback-informed cognitive-behavioral therapy by 194 trainee therapists in a university outpatient clinic. Patients and therapists rated the emotional bond after each session. Symptoms were assessed with the Hopkins Symptom Checklist-11. Dynamic within-patient cross-lagged panel models with polynomial coefficients and response surface analysis were used to test congruence and incongruence effects, while accounting for temporal dynamics.

Contrary to hypotheses, congruence between patient- and therapist-bond ratings did not predict better outcomes, nor was there a stronger congruence effect at higher levels of alliance. Instead, a small curvilinear main effect of alliance quality was found, with stronger effects at higher levels. Both patient and therapist ratings contributed to this, though patient ratings showed the stronger effect. Incongruence effects were observed: outcomes were better when therapists rated the bond lower than patients than when the reverse pattern occurred.

Bond congruence did not predict short-term symptom improvement. Instead, findings showed that a cautious therapist appraisal of the bond was associated with better outcome. The findings challenge prevailing assumptions about the value of congruence. Results call for a reconsideration of how therapist-patient agreement on the alliance is conceptualized and used in practice. (PsycInfo Database Record (c) 2026 APA, all rights reserved).