Patient-Rated Existential Isolation, Therapy Alliance Quality and Outcome in Naturalistic Psychotherapy

Existential isolation (EI)-a feeling that one's experience of reality differs from others-is positively associated with maladaptive psychological consequences. Higher EI is also a risk factor for poorer psychotherapy outcomes. Conversely, EI may be an important during-treatment relational experience that, if improved, could be therapeutic. Supporting this idea, one prior study demonstrated a mediational pathway in which higher patient-reported therapy alliance quality predicted better treatment outcomes through lower EI. However, that study was limited by its focus on men only, cross-sectional design and reliance on retrospective recall. Addressing these limitations, the present novel secondary analysis examined-in temporal sequence-the indirect association of patient-rated early alliance quality and post-treatment outcome through EI (assessed after the early alliance period and before post-treatment) in the context of current naturalistic psychotherapy for adults with diverse gender identities. Data derived from a community-based outpatient psychotherapy trial for adults. The present effective sample included 157 patients and 44 therapists. Patients rated their EI, alliance and symptomatic/functional impairment across up to 16 weeks of therapy. We used multilevel structural equation modelling to test the research question. Neither the direct effect of early alliance nor its indirect effect through subsequent EI on post-treatment symptomatic/functional impairment was significant. However, patients with lower EI reported significantly better post-treatment outcome. Lower EI may be a facilitative factor in naturalistically administered therapies that did not target this experience. Future research could examine whether explicit interventions to reduce EI could amplify its ameliorative effect on treatment outcome.