Clinical Psychology Review 82 (2020) 101921

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Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

Therapeutic alliance as a mediator of change: A systematic review and T

evaluation of research
Allison L. Baier , Alexander C. Kline1, Norah C. Feeny
⁎

PTSD Treatment and Research Program, Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, OH 44106-7123,
USA

HIGHLIGHTS

• We evaluated studies examining the alliance as a mediator of change in psychotherapy.

• Alliance plays an important role pantheoretically.
• Studies displayed methodological and statistical heterogeneity.
• Steps for improving future mediation research are proposed.

ARTICLE INFO ABSTRACT

Keywords: The alliance-outcome relationship has been consistently linked to positive treatment outcomes irrespective of
Alliance psychotherapy modality. However, beyond its general links to favorable treatment outcomes, it is less clear
Mediator whether the alliance is a specific mediator of change and thus a possible mechanism underlying psychotherapy
Mechanism response. This systematic review evaluated research examining the alliance as a potential mediator of symptom
Psychotherapy
change, reviewing study characteristics of 37 relevant articles examining the alliance-outcome relationship and
Systematic review
the extent to which these studies met recommended criteria for mechanistic research. Alliance mediated ther­
apeutic outcomes in 70.3% of the studies. We observed significant heterogeneity across studies in terms of
methodology, including timing of alliance assessment, study design, constructs used in mediation models, and
analytic approaches. Building on recent methodological advancements, we propose directions for future research
examining the putative mediational role of alliance, such as greater uniformity in and attention to study design
and statistical methodology. This review highlights the importance of alliance in therapeutic change and dis­
cusses how adhering to requirements for process research will improve our ability to more precisely estimate
how and to what extent alliance drives therapeutic change.

1. Introduction Institute of Medicine has called for research to identify elements of

The past several decades have seen the development and advance­
ment of a range of psychotherapies, including an increasing number of
evidence-based psychotherapies with well-defined treatment manuals
and effectiveness in treating a range of mental health disorders (Pincus
& England, 2015). Despite this, dropout and nonresponse remain sig­
nificant concerns even among the most effective treatments, affecting
an estimated 20–50% of patients (Nathan & Gorman, 2015; Saxon,
Firth, & Barkham, 2017; Wang et al., 2005). Improving patient ad­
herence and outcomes in psychotherapy will be aided by a greater
understanding of how psychotherapy works. In line with this, the
therapeutic change to better understand the mechanisms underlying
treatment response (Weissman, 2015). A more nuanced awareness of
processes driving therapeutic change would enable clinicians to further
attend to the therapeutic elements actively contributing to treatment
response or nonresponse, thereby optimizing treatments and ultimately
providing more personalized, effective care.
One hypothesized process underlying treatment response is the
therapeutic alliance. Modern definitions of the term center on the al­
liance as a collaborative relationship between therapist and patient that
is influenced by the extent to which there is agreement on treatment
goals, a defined set of therapeutic tasks or processes to achieve the

⁎
Corresponding author at: Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, Ohio 44106, USA.
E-mail address: alb184@case.edu (A.L. Baier).
1
Present address: VA San Diego Healthcare System, 3350 La Jolla Village Drive, MC116B, San Diego, CA, USA 92161.

https://doi.org/10.1016/j.cpr.2020.101921
Received 25 November 2019; Received in revised form 6 August 2020; Accepted 14 September 2020
Available online 17 September 2020
0272-7358/ © 2020 Elsevier Ltd. All rights reserved.
A.L. Baier, et al.
stated goals, and the formation of a positive emotional bond (Bordin,
1979, 1994). Stronger alliance is consistently associated with positive
treatment outcomes across a range of psychotherapies as evidenced by
multiple meta-analyses on the subject, with fairly stable correlations
between studies (Fluckiger, Del Re, Wampold, & Horvath, 2018:
r = 0.28, k = 295; Horvath & Bedi, 2002: r = 0.21, k = 100; Horvath,
Del Re, Flückiger, & Symonds, 2011: r = 0.28, k = 190; Horvath &
Symonds, 1991: r = 0.28; k = 190; Martin, Garske, & Davis, 2000:
r = 0.22, k = 79).
Although alliance has consistently been linked to better outcomes
across psychotherapies, there is ongoing debate with regard to the
putative nature of alliance as an actual mechanism of change. Some
argue alliance is simply a precondition necessary for any successful
therapy (Hatcher & Barends, 2006; Raykos et al., 2014; Weck,
Grikscheit, Jakob, Höfling, & Stangier, 2015). As a consequence, some
methodologists argue alliance is a nonspecific treatment factor that is
important across all psychotherapies and thus is largely independent of
psychotherapy “type”. In contrast, others argue that alliance is a spe­
cific treatment factor that drives therapeutic change itself and may be
of greater significance in some psychotherapies (e.g., relational thera­
pies) over others (e.g., cognitive behavioral therapy; Siev, Huppert, &
Chambless, 2009). Whether a nonspecific or specific factor, therapeutic
alliance is well studied, with over 306 studies in the most recent meta-
analysis on the alliance-outcome relationship alone (Fluckiger et al.,
2018). Although it is well established that strong alliance is generally
associated with better psychotherapy outcomes, the extent to which
this process is itself specifically driving therapeutic change remains
unclear. Randomized controlled trials (RCTs) offer one way to examine
the question of whether alliance is a specific or nonspecific factor; if
alliance is a specific factor, there should be treatment effects such that
alliance plays a more prominent role in one therapy over another
whereas if alliance is a nonspecific factor, studies would find no
treatment effects. A resolution to this debate is important for better
understanding the therapeutic alliance's impact on psychotherapy
outcomes, as well as how this process impacts outcomes. Additionally, a
greater understanding of the alliance's role in psychotherapy will en­
able researchers to examine its potential interactive effects on other
possible mediators, thereby providing greater clarity regarding the
mechanistic processes by which treatments lead to change.
1.1. Requirements for a mediator
Mediators help to explain why and how change is occurring and are
considered the first step in elucidating potential mechanisms of ther­
apeutic change (Laurenceau, Hayes, & Feldman, 2007). Given that a
subset of patients will drop out or not benefit from even the most ef­
fective psychological treatments, identifying the processes underlying
change will help implement treatments in a manner emphasizing the
most “essential” treatment components responsible for positive out­
comes and also unveil ways to optimize such components for specific
patients (Kraemer, Wilson, Fairburn, & Agras, 2002). Notably, while the
terms ‘mediator’ and ‘mechanism’ are often used interchangeably, they
are substantively different in that not all mediators are mechanisms and
researchers cannot necessarily make inferential conclusions from
mediation analyses (Kazdin, 2007).
A mediator (variable M) is an intervening variable that statistically
explains or accounts for the relationship between two other variables:
the independent variable (variable X) and dependent variable (variable
Y) (MacKinnon, Fairchild, & Fritz, 2007). Three major approaches are
often used to assess mediation including: causal steps (Baron & Kenny,
1986; Judd & Kenny, 1981), difference in coefficients (Mackinnon &
Dwyer, 1993), and product of coefficients (Alwin & Hauser, 1975). The
causal approach outlined by Baron and Kenny (1986) is most widely
used; however, it is limited by attenuated power and requires as­
sumptions and study requirements (e.g., normal distribution, large
sample sizes) that can be hard to achieve in clinical research (Hayes &
2
Clinical Psychology Review 82 (2020) 101921
Scharkow, 2013; MacKinnon, Lockwood, Hoffman, West, & Sheets,
2002; Shrout & Bolger, 2002). Methodologists have put forth a number
of alternative approaches to use in conjunction with the major ap­
proaches or as new stand-alone methods. These include bootstrap and
other resampling methods that help deal with violations of the nor­
mality assumption (Preacher & Hayes, 2004), the extension of single-
mediator models to multiple mediator models to examine the potential
interactive effects of multiple variables (Hayes, 2013), multilevel
mediation models to handle hierarchical data (Bauer, Preacher, & Gil,
2006; Krull & MacKinnon, 2001), and longitudinal mediation models to
examine how variables change or remain stable over the course of time
(Cheong, MacKinnon, & Khoo, 2003; Curran & Bauer, 2011; Curran &
Bollen, 2001; Curran, Lee, Howard, Lane, & MacCallum, 2012). While
there are advantages and disadvantages to each method, multilevel
longitudinal mediation methods offer the most robust statistical options
for examining mediation in treatment data because these models are
equipped to handle the nested nature and time-course of the data. For a
comprehensive discussion of mediation analysis and the various pros
and cons of different methods, readers are directed to MacKinnon and
colleagues' review (2007).
In addition to the mechanics of the mediation analysis, methodol­
ogists are increasingly advocating for researchers to disentangle within-
patient and between-patient effects in process research (Curran &
Bauer, 2011). That is, how do the intraindividual and interindividual
variation in scores contribute to outcome over the course of time? Re­
searchers often make conclusions about within-patient processes from
between-patient data. However, the between-patient relationship be­
tween a process variable (e.g., alliance) and outcome (e.g., depression
symptoms) could in fact be a proxy for some other patient variable (e.g.,
diagnosis, personality), creating difficulties when drawing inferential
conclusions (Curran & Bauer, 2011). Thus, an increased focus on
longitudinal mediation methods that disaggregate the within-patient
and between-patient variation in alliance scores, is an important con­
sideration for process research that seeks to uncover why and how
change occurs.
In sum, methodological approaches are integral to identifying and
assessing proposed mediators. Specifically, the precision and con­
fidence of conclusions drawn are closely affected by the types of ana­
lyses employed in studying this process.
1.2. Advances in assessing mediation
Mediators are an important first step in understanding hypothesized
change processes; however, the identification of a mediator does not
necessarily explain the underlying cause of change (Kazdin & Nock,
2003; Laurenceau et al., 2007). In addition to the statistical require­
ment for mediation, Kazdin (2007) proposed six other criteria for
drawing inferential conclusions from studying change processes that
can ultimately yield important clinical information about psy­
chotherapy. First, in addition to statistical mediation, researchers must
be mindful of the temporal relationship (termed ‘timeline’; Kazdin,
2007) between the mediator and outcome, a criterion that has in­
creasingly been discussed and advocated (Johansson & Høglend, 2007;
Kazdin, 2007; Kraemer et al., 2002). That is, does the mediator precede
and predict the outcome variable over the course of time? Second, re­
searchers must rule out other explanations for the observed relationship
between the mediator and outcome. For example, what other com­
peting mediators need to be examined? Could the mediator in question
simply be a proxy for some other variable or patient trait (e.g., per­
sonality)? Or, if the mediator precedes outcome, might the outcome
variable also exert an influence over the hypothesized mediator (i.e.,
reverse causality)? Kazdin (2007) refers to this criterion as ‘specificity’.
Third, studies ought to manipulate the hypothesized mediator through
experimental designs (termed, ‘experimental manipulation’) to demon­
strate the relationships between the proposed mediator and outcome.
Such experimental methods would help determine Kazdin's fourth
A.L. Baier, et al.
criteria, ‘gradient’, wherein stronger “doses” of the proposed mediator
lead to greater change in outcome. Fifth, research findings must fit
within the broader scientific theory (‘plausibility/coherence’), and sixth,
research must consistently demonstrate a relationship between the
mediator and outcome across replication studies, including different
patient populations and varying treatment conditions (‘consistency’;
Kazdin, 2007). While all criteria are important to the study of mediators
in the quest of identifying mechanisms of change, some experts suggest
that in statistical mediation, temporality, specificity, and experimental
manipulation should be considered the most important (Kazdin, 2007;
Kazdin & Nock, 2003). Accordingly, studies and reviews of mediation
research have begun to focus on these particular criteria (e.g., Lemmens
et al., 2017).
In addition to the criteria for studying mediators, researchers have
put forth recommended designs for process research, including rando­
mized controlled trials (RCTs), comparisons with an adequate control
group, sufficient power (e.g., sample size), and spaced repeated mea­
sures (e.g., assessments at different timepoints throughout treatment) to
allow for adequate assessment of temporality (Kazdin, 2007; Kazdin &
Nock, 2003; Laurenceau et al., 2007). Researchers have begun to
evaluate the state of the literature with regard to these recommenda­
tions for process research for both posttraumatic stress disorder
(Cooper, Clifton, & Feeny, 2017) and depression treatments (Lemmens
et al., 2017). Clinically, such reviews provide greater specificity re­
garding treatment processes that appear to be most effective in driving
therapeutic change. These reviews also shape future research on med­
iation by assessing limitations in research to date and articulating re­
search recommendations (e.g., study design, statistical methodology) to
better understand mediators in psychotherapy.
To date, meta-analyses have examined the alliance-outcome re­
lationship as well as potential moderators of the relationship, such as
treatment type and patient characteristics (Fluckiger et al., 2018;
Horvath et al., 2011; Horvath & Bedi, 2002; Horvath & Symonds, 1991;
Martin et al., 2000). In a re-analysis (Flückiger, Del Re, Wampold,
Symonds, & Horvath, 2012) of data included in a previous meta-ana­
lysis (Horvath et al., 2011; k = 190 studies), the authors used multi­
level, longitudinal meta-analytic procedures to examine moderators of
the alliance-outcome correlations over the course of therapy (e.g., de­
sign characteristics, therapy type). While moving toward better un­
derstanding the nuance of the alliance-outcome relationship, like all
other meta-analyses on the subject, the authors examined moderators of
the alliance-outcome correlation. Beyond this relationship, the extent to
which alliance serves as a potential mediator of change in psychother­
apy—and whether alliance may be a specific or nonspecific factor—­
remains unclear, reflecting a critical next step in more precisely un­
derstanding the specific change processes occurring in treatment.
1.3. Aims of current review
The primary aim of this study was to provide a systematic review of
research on the potential role of the therapeutic alliance as a mediator
of change in psychotherapy. As therapy change processes are better
understood, clinicians will be better equipped to optimize these
“treatment drivers,” which ultimately should improve patient out­
comes. Studies were selected that examined the therapeutic alliance as
a mediator between an independent variable and treatment outcome
with a statistical test of mediation (e.g., Baron & Kenny, 1986). In an
effort to better understand whether alliance is a specific factor on
nonspecific factor, a broad range of in-person, individual, outpatient
psychotherapy was included. The resulting review presents the char­
acteristics of 37 studies examining alliance as a mediator of change and
the extent to which alliance is supported as a possible mediator of
therapeutic change.
3
Clinical Psychology Review 82 (2020) 101921
2. Method
2.1. Search strategy
The search process occurred in two phases. First, PsycInfo was
systematically searched for potentially relevant papers published in
peer-review journals. Limiters applied in the search were publication
date (January 1, 1980 and July 15, 2020), language (English only), and
age group (adulthood, defined as 18 years and older). The following
search terms were used: “alliance” OR “therapeutic alliance” OR
“helping alliance” OR “working alliance” AND “psychotherapy” OR
“therapy” OR “cognitive (behavior(u)ral) therapy” OR “psychological
treatment(s)/intervention(s)” OR “Interpersonal (psycho)therapy” OR
“psychodynamic/analytic therapy” OR “client centered therapy” OR
“acceptance commitment therapy” AND “mechanism” OR “mechanisms
of change/action” OR “working mechanisms (of psychotherapy)” OR
“processes of therapy” OR “process research” OR “change” OR “med­
iation” OR “mediator” OR “mediating effects”. Following the initial
search, reference lists of prior meta-analyses of the alliance-outcome
relationship (e.g., Fluckiger et al., 2018; Horvath et al., 2011) were
reviewed as well as reference lists of potentially suitable papers.
2.2. Inclusion criteria
Studies were eligible for inclusion if they met the following criteria:
(a) the study consisted of adult patients; (b) the study was empirical and
quantitative (i.e., reviews, commentaries, theoretical essays, meta-
analyses, systematic reviews, and qualitative studies were excluded);
(c) the study was not a case report; (d) patients received in-person,
outpatient, individual psychotherapy (i.e., group, inpatient, and tele­
health modalities were excluded); (e) the analytic method of the study
included statistical mediation with the alliance as the hypothesized
mediating variable; (f) the study included a validated clinical symptom
outcome measure as the dependent variable in the mediation model(s)
(e.g., Beck Depression Inventory; Beck, Steer, Ball, & Ranieri, 1996); (g)
the study used a validated measure of therapeutic alliance (e.g.,
Working Alliance Inventory; Hatcher & Gillaspy, 2006); and (h) the
study was reported in English. Inclusion criteria adhered to the pre­
cedent of prior alliance reviews examining in-person, individual psy­
chotherapy (e.g., Smith, Msetfi, & Golding, 2010) and reviews of pro­
cess mediation research (e.g., Lemmens et al., 2017). Given that the
goal of this review was to evaluate the state of the literature, studies
were not excluded for poor study quality (Cuijpers, van Straten,
Bohlmeijer, Hollon, & Andersson, 2010; Hedges & Pigott, 2004); how­
ever, if more than one study used an identical dataset, we chose to
include the study with the strongest methodology and study quality as
defined by our coding criteria below.
2.3. Coding procedures
Key study characteristics and variables related to process research
were coded by the first author (ALB) and a trained, independent rater.
Interrater reliability between coders was excellent (κ = 0.93), and
minimal differences in coding were resolved by consensus. Study
characteristics included: psychotherapy intervention type(s), primary
diagnosis of the sample, setting of study, validated measure of the
therapeutic alliance, validated clinical symptom outcome measure,
statistical method(s) used to examine mediation, and main study find­
ings. Additionally, papers were assessed on whether or not they met key
criteria for process research following the methodology of Lemmens
et al. (2017) including: the use of an RCT design, use of a control group,
sufficient sample size for mediation analyses (defined as n ≥40 in line
with other reviews evaluating process research), examination of mul­
tiple mediators within one study, assessment of temporality (defined as
2 or more assessments of the therapeutic alliance during the treatment
phase that were examined over the course of time, not as an average),
A.L. Baier, et al. Clinical Psychology Review 82 (2020) 101921

Unique records identified Additional records identified

Identification through PsycINFO database through reference lists of other
searching with initial screening reviews, meta-analyses, and
criteria manuscripts
(n = 1,613) (n = 59)

Records after duplicates removed and

screened on the basis of title (n = 1,651)

Records excluded (n = 287):

Screening

- No mediation (n = 28)
- Case study (n = 38)
Records screened on basis
- Group treatment (n = 7)
of abstract
- Not adult (n = 14)
(n = 479)
- Not empirical (n = 137)
- Not psychotherapy (n = 59)
- Telehealth (n = 4)
Eligibility

Full-text articles excluded (n = 155):

Full-text articles assessed - No mediation (n = 77)
for eligibility - Case study (n = 1)
(n = 192) - Group treatment (n = 13)
- Inpatient treatment (n = 4)
- No validated alliance measure (n =
5)
- Not adult (n = 3)
- No validated symptom outcome
measure (n = 13)
Included

- Not empirical (n = 17)

- Not psychotherapy (n = 4)
Studies included in present - Telehealth (n = 8)
review - Same data as another study (n =
(n = 37) 10)

Fig. 1. PRISMA flow diagram of study identification and selection process.

and direct experimental manipulation of alliance. We chose to follow 3. Results

guidelines outlined by Lemmens and colleagues in an effort to maintain
consistency with the literature; however, we also wanted to ensure
maximum relevancy of criteria to the study of alliance as a mediator of
change. Consequently, we chose to collapse two criteria—RCT design
and use of a control group—into one criterion due to overlap (i.e., all
studies in the review with a control group were also an RCT). As pre­
viously stated, the direct comparison of two treatments can yield in­
teresting information regarding whether alliance is a specific or non­
specific mediator of change. Additionally, we elected to add in a
criterion regarding whether or not researchers adequately disentangled
within and between-patient effects specifically for the mediation ana­
lysis, bringing the total criteria to six. Studies were rated as either
meeting the criteria (1) or not (0).
3.1. Study selection
Study selection followed PRISMA guidelines (Moher, Liberati,
Tetzlaff, Altman, & The, 2009) and is presented in Fig. 1. The initial
PsycINFO search yielded 1613 citations, which were screened on the
basis of title. Reference lists from meta-analyses and studies deemed
potentially eligible for inclusion were also reviewed, which provided an
additional 59 citations for review. Following this initial screening, a
total of 479 studies with potential to meet inclusion criteria were re­
tained. Each abstract was then closely reviewed, followed by the full
text (n = 192) if necessary to determine eligibility. A total of 442
studies were excluded, with the most common reasons for exclusion
including lack of empirical study and lack of mediation. Ultimately, 37
studies met full inclusion criteria and are denoted with asterisks in the
references.

4
 Table 1
Characteristics and results of 37 identified studies aimed at examining the potential role of the therapeutic alliance as a mediator of treatment outcomes and the extent to which they meet requirements for process
research.
A.L. Baier, et al.

Study Characteristics and Results Requirements for Process Research

Primary Author, Date Setting & Intervention(s)* Diagnosis Alliance Timepoint of Statistical Main Finding(s) RCT Disentangled N≥40 Multiple Temporality Manipulation
Measure Alliance Measure Mediation Effects Mediator
Method

DeRubeis & Feeley, Outpatient Center; CT MDD PHAS Session 2 plus Temporal No significant correlation 0 0 0 1 1 0
1990 (n = 25) (observer) one tape from correlations between alliance and
each of the subsequent change or prior
following change scores.
periods: weeks
4–6; 7–9; 10–12

Feeley, DeRubeis, & RCT data; Combined MDD PHAS Same as Temporal No significant correlation 0a 0 0 1 1 0
Gelfand, 1999 sample: CT & CT + ADM (observer) DeRubeis & correlations between alliance and
(n = 25) Feeley, 1990 subsequent change or prior
change scores.

Barber et al., 2000 Combined data from four Mixed CALPAS End of sessions 2, Temporal Alliance predicted symptom 0 0 1 1 1 0
open trials; Supportive- (patient) 5, 10, and each correlations change. Depression predicted
Expressive Dynamic 5th session late alliance but not early
Therapy (n = 88) thereafter alliance.
a
Zuroff et al., 2000 RCT data; Combined MDD VTAS Sessions 3 & 15 Causal steps Increase in alliance partially 0 0 1 0 1 0
sample: IPT, CBT, (observer) mediated the relationship
ADM + CM & placebo + between perfectionism and
CM (n = 149) outcome.

5
Wilson, Fairburn, RCT data; Combined BN HRQ (patient) End of session 4 Causal steps Alliance did not mediate the 1 0 1 1 0 0
Agras, Walsh, & sample: CBT & IPT relationship between treatment
Kraemer, 2002 (n = 154) type and outcome.

Klein et al., 2003 RCT data; CBASP (n = 169) MDD WAI- Weeks 2 (after Mixed effects Early alliance predicted change 1 0 1 1 1 0
vs. CBASP + ADM Abbreviated 4- 3–4 sessions), 6 growth modeling in depressive symptoms, no
(n = 198) items (patient) (after 8–12 treatment moderation. The
sessions), and 12 reverse relationship was not
(after 16–20 observed.
sessions)

Baldwin, Wampold, & Naturalistic database Mixed WAI (patient) Prior to session 4 Multilevel Therapist variability in alliance, 0 1 1 0 0 0
Imel, 2007 collected from 45 mediation model but not patient variability,
University counseling accounted for the relationship
centers; Various between pretreatment scores
psychotherapy treatment and outcome.
(n = 331)

Spinhoven, Giesen- RCT data; SFT (n = 44) vs. BPD WAI-SF After 3, 15, and Longitudinal Alliance predicted change in 1 0 0 1 1 0
Bloo, van Dyck, TFP (n = 34) (patient and 33 months multilevel model symptoms. The reverse
Kooiman, & Arntz, therapist) relationship was not observed.
2007

Forbes et al., 2008 Academic treatment center; PTSD WAI-SF 3 weeks post Causal steps Alliance did not mediate the 0 0 1 1 0 0
Unspecified psychotherapy (patient and intake relationship between anger at
treatment (n = 103) therapist) intake and post treatment
symptoms

Byrd, Patterson, & Naturalistic database from a Mixed WAI-SF After session 3, 4, Causal steps with Alliance mediated the 0 0 1 0 0 0
Turchik, 2010 University training clinic; (patient) or 5 Sobel test relationship between comfort
Various psychotherapy with closeness (attachment)
treatment (n = 66) and outcome
Clinical Psychology Review 82 (2020) 101921

(continued on next page)

 Table 1 (continued)

Study Characteristics and Results Requirements for Process Research

A.L. Baier, et al.

Primary Author, Date Setting & Intervention(s)* Diagnosis Alliance Timepoint of Statistical Main Finding(s) RCT Disentangled N≥40 Multiple Temporality Manipulation
Measure Alliance Measure Mediation Effects Mediator
Method

Crits-Christoph, Data from a study on MDD CALPAS After sessions Longitudinal Alliance predicted next session 0 0 1 1 1 0
Gibbons, Hamilton, training therapists; (patient) 3–16 multilevel model symptom change. The reverse
Ring-Kurtz, & Alliance-Fostering Therapy relationship was observed only
Gallop, 2011 (n = 45) in later treatment sessions.

Owen et al., 2011 Naturalistic database from
University counseling
center; Various
psychotherapy treatment
(n = 232)
Mixed ITASr-SF End of academic Causal steps with Alliance mediated the 0 0 1 0 0 0
(patient) quarter bootstrap method relationship between clients'
perceptions of microaggressions
and therapy outcomes

Webb et al., 2011 RCT data; CT (n = 105) MDD WAI-SF Session 3 and 3rd Multiple Early alliance significantly 0 0 1 0 1 0
(observer) to last session regressions with predicted depressive symptom
change scores improvement

Hirsh, Quilty, Bagby, & Subsample RCT data; DBT BPD WAI-SF Baseline, 4, 8, Causal steps with Alliance mediated the 1 0 1 0 1 0
McMain, 2012 (n = 43) vs. GPM (n = 44) (patient) and 12 months product of relationship between
coefficient agreeableness and outcome in
method DBT only
a
Strunk, Cooper, Ryan, RCT data; CT + ADM arm MDD WAI-SF Sessions 1–3 Longitudinal Alliance scores did not predict 0 0 1 1 1 0
DeRubeis, & (n = 176) (observer) model subsequent symptom change
Hollon, 2012

6
Falkenström, Primary Care; Various Mixed WAI-SF After every Longitudinal Within-patient alliance 0 1 1 1 1 0
Granström, & psychotherapy treatment (patient) session multilevel model predicted next session symptom
Holmqvist, 2013 including supportive, change and vice versa. There
psychodynamic, and CBT was no treatment moderation.
(n = 646)

Patterson et al., 2014 University training clinic; Mixed WAI-SF After session 3 Causal steps with Alliance did not mediate the 0 0 1 0 0 0
Unspecified psychotherapy (patient) Sobel test relationship between treatment
(n = 68) expectancy and outcome

Yoo, Hong, Sohn, & Data from 13 University Mixed WAI-SF After the 3rd Multilevel Alliance mediated the 0 0 1 0 0 0
O'Brien, 2014 counseling centers, 4 (patient) session mediation model relationship between treatment
community counseling with bootstrap expectancy and outcome
centers, and 7 private method
practices; Various
psychotherapy treatment
(n = 284)

Zilcha-Mano, Dinger, RCT data; SET (n = 49) vs. MDD WAI (patient) Weeks 2, 4, 8, AR longitudinal Alliance predicted subsequent 1 0 1 1 1 0
McCarthy, & CM + ADM (n = 51) vs. and 16 multilevel model symptom levels, an effect not
Barber, 2014 CM + PBO (n = 49) moderated by treatment type.
a
Burns et al., 2015 RCT data; Combined Chronic Pain WAI-SF Week 4 and week Cross-lagged Alliance was associated with 0 0 1 1 1 0
sample: Enhanced CBT & (patient) 8 panel subsequent symptom change.
CBT (n = 94) correlations

McClintock, Anderson, Naturalistic database from
& Petrarca, 2015 University clinic; Various
psychotherapy treatment
(n = 116)
Mixed WAI-SF Average of Causal steps with Alliance mediated the 0 0 1 1 0 0
(patient) Sessions 3–9 bootstrap method relationship between
expectancy and outcome
(continued on next page)
Clinical Psychology Review 82 (2020) 101921
 Table 1 (continued)

Study Characteristics and Results Requirements for Process Research

A.L. Baier, et al.

Primary Author, Date Setting & Intervention(s)* Diagnosis Alliance Timepoint of Statistical Main Finding(s) RCT Disentangled N≥40 Multiple Temporality Manipulation
Measure Alliance Measure Mediation Effects Mediator
Method

Xu & Tracey, 2015 Naturalistic sample from Mixed WAI-SF Prior to each Latent change Alliance predicted subsequent 0 0 1 0 1 0
university training clinic; (patient) session starting score modeling symptom improvement and vice
Various psychotherapy with session 3 versa
treatment (n = 638)

Falkenström, Ekeblad, RCT data from community- MDD WAI-SR After every Dynamic panel Alliance predicted next session 1 1 1 1 1 0
& Holmqvist, 2016 based psychiatric clinic; (patient) & session data model symptom change. Results were
CBT (n = 43) vs. IPT WAI-SF not moderated by treatment
(n = 41) (therapist) and the reverse relationship
was not observed.

Klug, Zimmermann, & Data from comparative trial MDD HAQ (patient Every 3 months Multilevel Alliance did not mediate the 1 0 0 1 0 0
Huber, 2016 in outpatient university and therapist) (CBT) and mediation model relationship between treatment
clinic; PA (n = 35) vs. 6 months (PA, type and outcome
PD (n = 31) vs. CBT PD)
(n = 34)

Kushner, Quilty, RCT data; ADM (n = 74) vs. MDD CALPAS 3rd and 12th Serial multiple Alliance mediated the 1 0 1 0 1 0
Uliaszek, McBride, IPT (n = 65) vs. CBT (patient and session mediation model relationship between
& Bagby, 2016 (n = 70) therapist) with bootstrap agreeableness and symptom
method change, an effect not moderated
by treatment

7
Maitland et al., 2016 RCT data; FAP (n = 11) vs. Mixed WAI-SF Average of Causal steps with Alliance mediated the 1 0 0 0 0 0
WW (n = 11) (patient) sessions 1–3 bootstrap method relationship between treatment
condition symptom change.
a
Sasso et al., 2016 RCT data; CT arm (n = 60) MDD WAI-SF Sessions 1–4 Longitudinal Within-patient and between- 0 1 1 1 1 0
(observer) model patient alliance scores did not
predict subsequent symptom
change early in treatment

Lawson, Stulmaker, & University training clinic;
Tinsley, 2017 Integrated Relationship and
Trauma-Based CBT
(n = 76)
Zilcha-Mano & RCT data; Various
Errázuriz, 2017 psychotherapy treatment
(n = 166) with therapists
randomized to different
feedback conditions
PTSD ITA-RS Session 3 or 4 Causal steps with Alliance mediated the 0 0 1 0 0 0
(patient) bootstrap method relationship between baseline
interpersonal problems and
dissociation posttreatment, but
not between interpersonal
problems and trauma symptoms
posttreatment
a
Mixed WAI (patient) Sessions 1–4 Multilevel Early alliance development 0 0 1 0 1 0b
mediation model predicted treatment outcome
for patients with pretreatment
interpersonal problems

Renner et al., 2018 Specialized care facility; MDD SRS (patient) After every AR longitudinal Alliance did not predict change 0 0 0 1 1 0
SFT (n = 20) session multilevel model in depressive symptoms nor
vice versa.

Sauer-Zavala et al., RCT data; UP (n = 77) vs. Mixed WAI-SF After session 4 Causal steps with Alliance mediated the 1 0 1 0 0 0
2018 SDP (n = 76) Anxiety (patient) bootstrap method relationship between treatment
Disorders expectancy and change in
symptoms in SDP but not UP.
(continued on next page)
Clinical Psychology Review 82 (2020) 101921
 Table 1 (continued)

Study Characteristics and Results Requirements for Process Research

A.L. Baier, et al.

Primary Author, Date Setting & Intervention(s)* Diagnosis Alliance Timepoint of Statistical Main Finding(s) RCT Disentangled N≥40 Multiple Temporality Manipulation
Measure Alliance Measure Mediation Effects Mediator
Method

Brattland et al., 2019 Naturalistic RCT; various Mixed WAI-SF At Session 1 and Multilevel Alliance mediated the 1 0 1 0 0 0
psychotherapy treatment (patient) after 2 months of mediation model relationship between treatment
with patients randomized to treatment condition and outcome.
TAU (n = 74) or ROM
(n = 69)

Rubel et al., 2019 RCT data; CBT (n = 57) GAD WAI-SF After every Dynamic Within-patient alliance scores 1 1 0 0 1 0
with patients randomized to (patient) session structural were associated with reduction
three different priming equation in anxiety and increase in
conditions (n = 19 per modeling coping experiences during the
condition) following session. Results were
not moderated by condition.

Santoft et al., 2019 RCT data; CBT (n = 40) vs. Exhaustion WAI-SF After every Multilevel Therapeutic alliance did not 1 0 1 1 1 0
RTW-I (n = 42) Disorder (patient) session mediation model mediate the relationship
between condition and burnout.

Gómez Penedo et al., RCT data; EBCT (n = 70) MDD WAI-SF After every Hybrid random Within-patient and between- 1 1 1 0 1 0
2020 vs. CBT (n = 71) (patient) session effects model patient alliance predicted next
session symptomatology even
when adjusting for treatment
condition

8
Leibovich, Front, RCT data; combined sample MDD WAI-SF Session 4 Causal steps with Alliance mediated the 0a 0 1 0 0 0
McCarthy, & of supportive therapy vs (patient) bootstrap method relationship between
Zilcha-Mano, 2020 supportive-expressive supportive techniques and
therapy (n = 61) outcome

Sullivan, Lawson, & Naturalistic database from a Mixed ITA-RS Early (session 3 Causal steps with Alliance did not mediate the 0 0 1 1 0 0
Akay-Sullivan, University training clinic; or 4); middle bootstrap method relationship between early
2020 trauma-based CBT and (between interpersonal distress and
relational-based CBT sessions 6–8); outcome
(n = 137) late (between
sessions 16–24)

Note: Column Headings: RCT = Randomized Controlled Trial; n ≥40 = Sample size per treatment arm is at least 40 or, combined is at least 40 if study did not examine treatment effects; Control = Control Group;
Multiple Mediators = Study included more than alliance as a potential mediator; Temporality = Study included two or more assessments of alliance during treatment phase; Manipulation = Manipulation of Alliance;
0 = Absent/No; 1 = Present/Yes. *Denotes reported sample size used in analysis; a Denotes data comes from RCTs but authors do not make use of RCT design in analyses such as by looking at treatment moderation; b
Study randomized clinicians to different kind of feedback pertaining to the alliance but did not examine this manipulation in the analyses. Interventions: CT = Cognitive Therapy; ADM = Antidepressant Medication;
IPT = Interpersonal Therapy; CBT = Cognitive Behavioral Therapy; EBCT = Exposure-Based Cognitive Therapy; CM = Clinical Management; CBASP = Cognitive Behavioral Analysis System of Psychotherapy;
SFT = Schema Focused Therapy; TFP = Transference Focused Psychotherapy; PA = Psychoanalytic; PD = Psychodynamic; DBT = Dialectical Behavior Therapy; GPM = General Psychiatric Management;
FAP = Functional Analytic Psychotherapy; WW = Watchful Waiting; UP = Unified Protocol; SDP = Single Disorder Protocols (empirically supported); RTW-I = Return to Work Intervention; ROM = Routine Outcome
Monitoring. Diagnosis: MDD = Major Depressive Disorder; BN = Bulimia Nervosa; BPD = Borderline Personality Disorder; PTSD = Posttraumatic Stress Disorder; GAD = Generalized Anxiety Disorder. Alliance
Measures: WAI = Working Alliance Inventory; WAI-SF = Working Alliance Inventory Short Form; WAI-SR = Working Alliance Inventory Scale Revised; CALPAS = California Psychotherapy Alliance Scale;
PHAS = Penn Helping Alliance Scale; VTAS = Vanderbilt Therapeutic Alliance Scale; HRQ = Helping Relationship Questionnaire; HAQ = Helping Alliance Questionnaire; HAQ-R = Helping Alliance Questionnaire-
Revised; HAq-II = Helping Alliance Questionnaire-II; ITASr-SF = Individual Treatment Alliance Scale Revised-Short Form; ITA-RS = Individual Therapy Alliance Revised/Shortened; SRS = Session Rating Scale.
AR = autoregressive.
Clinical Psychology Review 82 (2020) 101921
A.L. Baier, et al.
3.2. Study characteristics
Table 1 provides an overview of study characteristics and the extent
to which each study met predetermined criteria for process research.
Thirty-seven studies were included in the review with data from 5530
patients. Studies were published between 1990 and 2020 with sample
sizes ranging between 20 and 646 (median = 103; M = 149;
SD = 144.1). The majority of studies were conducted in the United
States (59.5% vs. 24.3% in Europe, and 16.2% in other parts of the
world). Study settings were mixed with 10 studies (27.0%) utilizing
data from training clinics or counseling centers and the remaining
studies utilizing data from RCTs, hospitals, and/or specialized treat­
ment centers. Almost half (17 studies; 45.9%) were published in the last
five years, including the years 2015 to 2020. Eighteen of the 37 studies
examined the alliance within the context of cognitive therapy (CT),
cognitive behavioral therapy (CBT), or a combined sample that in­
cluded at least one arm of CT or CBT. Ten studies examined various
forms of psychotherapy, often in the context of community mental
health clinics or university counseling centers. Other treatments ex­
amined either in isolation or, in a combined sample with CT/CBT in­
cluded Interpersonal Therapy (IPT, k = 4), Supportive Therapy (k = 2),
Supportive Expressive Therapy (SET, k = 3), Schema Focused Therapy
(SFT, k = 2), Psychoanalytic Therapy (PA, k = 1), Psychodynamic
Therapy (PD, k = 1), Cognitive Behavioral Analysis System of Psy­
chotherapy (CBASP, k = 1), Transference Focused Psychotherapy (TFP,
k = 1), Functional Analytic Psychotherapy (FAP, k = 1), Dialectical
Behavior Therapy (DBT, k = 1), Unified Protocol (UP, k = 1), Single
Disorder Protocols (SDP, k = 1), and Return to Work Intervention
(RTW-I, k = 1). Six studies included a combined treatment or phar­
macologic treatment.
The most common disorders studied were major depressive disorder
(MDD; 15/37 studies, 40.1%) and mixed diagnostic samples (37.8%),
followed by posttraumatic stress disorder (PTSD; 5.4%), borderline
personality disorder (BPD; 5.4%), chronic pain (2.7%), and bulimia
nervosa (2.7%), and exhaustion disorder (2.7%). Consequently, out­
come measures varied widely; the most commonly used outcome
measure was the self-report Beck Depression Inventory (Beck et al.,
1996), used in 11 of the 37 studies. The Working Alliance Inventory or
one of its short-form or revised versions (Hatcher & Gillaspy, 2006;
Horvath & Greenberg, 1989; Tracey & Kokotovic, 1989) was the alli­
ance measure used most often (25/37 studies; 67.6%) followed by
versions of the Helping Alliance (Alexander & Luborsky, 1986;
Luborsky et al., 1996; Morgan, Luborsky, Crits-Christoph, Curtis, &
Solomon, 1982), which was used in 4 studies (10.8%). In terms of who
reported the quality of alliance, the majority of studies (26/37) used
patient ratings, six studies used independent observer ratings, and five
used patient and therapist ratings (e.g., ran two separate models, one
with patient ratings and one with therapist ratings). The timing of al­
liance assessments also varied widely across studies as can be seen in
Table 1.
The three earliest studies (⁎Barber, Connolly, Crits-Christoph,
Gladis, & Siqueland, 2000; DeRubeis & Feeley, 1990; Feeley et al.,
1999) used temporal correlations to examine the relationship between
alliance and residualized symptom change at different time points in
therapy. Only one of these three (Barber et al., 2000) found evidence
that alliance mediated symptom change. However, the methodology
used in these first three studies limits the ability to draw strong con­
clusions about the role of alliance on outcome. The most common
statistical method used to examine mediation was through a causal step
approach utilizing linear regressions (Baron & Kenny, 1986). Of the 13
studies using this method, eight relied on bootstrapping methods to
examine the size of the indirect effect (Preacher & Hayes, 2004) - a
method that can account for violation of normality assumptions
(MacKinnon et al., 2007). Taken together, the majority of studies using
a causal step approach found support for alliance as a mediator (10/13
studies).
9
Clinical Psychology Review 82 (2020) 101921
Over the course of time, in line with advances in methodology,
statistical methods used in the identified studies became more sophis­
ticated and included multilevel mediation (Krull & MacKinnon, 2001),
growth modeling (Cheong et al., 2003), and various forms of long­
itudinal modeling (Curran & Bollen, 2001). Indeed, ten of the 17 studies
published in the past five years (including 2015) used one of these
methods (e.g., Falkenström et al., 2016; Renner et al., 2018; Santoft
et al., 2019). Of the 20 studies using more advanced statistical meth­
odology (e.g., multilevel and longitudinal modeling compared to simple
mediation models), the majority (15/20) found at least some evidence
supporting alliance as a potential mediator. As presented in Table 1,
studies were substantially different from one another in terms of design
(e.g., different populations, psychopathology, treatment-type) as well
as the extent to which they met requirements for process research.
Furthermore, studies differed with how they handled missing data.
Studies largely used available data (20/37), often in conjunction with
imputation methods and in line with analytic requirements or theore­
tical rationale (e.g., to be included in analyses, patients needed at least
“x” number of data points or patients needed to attend at least “x”
number of treatment sessions). Six studies used completer samples. The
remaining studies did not report how missing data were handled or,
identifed an intent-to-treat approach (e.g., last observation carried
forward) and did not specify if they included patients with no data.
Conclusions regarding alliance as a mediator even among the most
statistically advanced studies should thus be interpreted in the context
of the variability noted across studies.
3.3. Process characteristics
For an overview on the number of studies meeting each of the re­
quirements for process research, readers are directed to Table 2. The
majority of studies (81.1%) had sample sizes greater than 40 patients
and are thus likely sufficiently powered for appropriate inclusion in
systematic reviews or meta-analyses on the basis of sample size and
power (Hedges & Pigott, 2004; Kazdin & Bass, 1989). Fewer than two-
thirds of the studies (59.5%) included more than two assessments of
alliance, and only half examined other putative mediators in addition to
the alliance (51.4%). While 20 studies (54.1%) examined patients from
RCTs, only 14 studies (37.8%) made use of the RCT design in examining
differential treatment effects. Finally, six studies (16.2%) adequately
disentangled within and between-patient effects.
As noted, mediation analyses alone are not sufficient for drawing
conclusions about change processes. The strength of the argument for
the mediator in question is proportional to the number of criteria met
for process research (Kazdin, 2007). No study met all six criteria. Only
one study met five criteria. Falkenström et al. (2016) conducted an RCT
comparing CBT (n = 43) to IPT (n = 41) in a sample of patients with
major depressive disorder. The authors utilized multilevel longitudinal
models and additionally disaggregated within and between-patient ef­
fects (Curran et al., 2012; Wang & Maxwell, 2015), finding a reciprocal
relationship between the alliance and change in depressive symptoms.
That is, alliance predicted next session change in depression scores and
vice-versa, suggesting mutual influence of alliance and symptoms.
Table 2
Number (%) of studies meeting criteria for process research (n = 37).
Requirement n studies (%)
RCT, yes, n (%) 14 (37.8)
Disaggregated within and between-patient effects, yes, n (%) 6 (16.2)
Sample size per condition ≥40, yes, n (%) 30 (81.1)
Multiple mediators, yes, n (%) 19 (51.4)
Temporality, yes, n (%) 22 (59.5)
Manipulation of mediator, yes, n (%) 0 (0.00)
Note. RCT = randomized controlled trial; n = number of studies, % = percent
of studies.
A.L. Baier, et al.
These results did not differ between treatments suggesting that the two-
way movement of alliance and symptom change was important across
both treatment modalities providing support for alliance as a common
factor across treatments.
Six studies met four criteria and therefore seem to be promising
with regard to meeting process research requirements for under­
standing drivers of therapeutic change. Klein et al. (2003) examined
CBASP (n = 228) to CBASP plus antidepressant medication (n = 227)
for the treatment of depression. The authors utilized mixed effects
growth modeling on treatment initiators with baseline data to examine
the temporal relationship between alliance and change in depressive
symptoms. The study found alliance at week 2 predicted subsequent
improvement in depressive symptoms after controlling for prior change.
The authors found no evidence of reverse causality (i.e., symptoms
predicting improvements in alliance) and treatment condition did not
moderate the findings.
In a large study of primary care patients (N = 646), Falkenström
et al. (2013) used longitudinal multilevel models to examine whether
alliance predicted symptom improvement or vice versa. The authors
additionally disentangled effects following procedures recommended
by Curran and Bauer (2011) and found that within-patient alliance
predicted next session symptom change and vice versa. While this was a
naturalistic sample, the authors additionally examined whether the
alliance-outcome relationship differed between treatment type, namely
supportive, psychodynamic, or CBT finding no difference between
groups lending support for alliance as a nonspecific factor.
Sasso, Strunk, Braun, DeRubeis, and Brotman (2016) re-examined
data from the CT arm of a treatment trial for depression by dis­
aggregating within-patient and between-patient variance in alliance
scores as predictors of session to session symptom change early in
treatment. The authors found that neither within-patient nor between-
patient variation in scores predicted subsequent symptom change. The
authors noted their limited sample size (N = 60) as a possible ex­
planation for their null findings.
In an RCT comparing SET (n = 49) to clinical management (e.g.,
supportive interventions) and pharmacotherapy (n = 51) or clinical
management and placebo (n = 49) for patients diagnosed with de­
pression (Zilcha-Mano et al., 2014), alliance temporally predicted
subsequent symptoms. The reverse relationship (symptom scores pre­
dicting next session alliance scores) was not observed. No significant
treatment interaction was observed suggesting alliance was an im­
portant predictor of change across these treatment modalities.
Santoft et al. (2019) compared CBT (n = 40) to RTW-I (n = 42) for
the treatment of “exhaustion disorders” or burnout, a disorder found in
the International Statistical Classification of Diseases and Related
Health Problems (ICD-10; Organization, 2004). Over half of the sample
(57.3%) met criteria for a comorbid disorder. The authors used a
multilevel mediation model, finding no association between the alli­
ance and subsequent symptom changes over time. Additionally, alliance
did not mediate the relationship between treatment type and outcome.
Finally, Gómez Penedo et al. (2020) compared the alliance as a pre­
dictor of next session symptomatology in exposure-based cognitive
therapy and CBT for patients with depression. The authors used a hy­
brid random effect model finding both within-patient and between-
patient alliance predicted next session symptomatology even when
adjusting for treatment condition.
Thus, of these seven studies scoring highest (4 or 5 out of 6 criteria)
with regard to meeting requirements for process research, findings are
mixed. Five studies found evidence for the mediating role of alliance
whereas two studies did not. Additionally, four studies investigated
reciprocity (i.e., alliance predicting symptoms and symptoms predicting
alliance); two found support for this two-way movement between the
alliance and symptom change. All five studies finding support for alli­
ance as a mediator of change also found support for alliance as a
nonspecific or “common” factor suggesting alliance is an important
construct irrespective of psychotherapy modality. Three studies
10
Clinical Psychology Review 82 (2020) 101921
(Falkenström et al., 2016; Santoft et al., 2019; Sasso et al., 2016) had
modest sample sizes under 100 patients which may have impacted
findings; however, all studies were adequately powered.
In addition, 9 studies (24.3%) met exactly half of the criteria for
process research and 14 studies (37.8%) only met two criteria. Finally,
7 studies (18.9%) only met one of the six criteria. While the combina­
tion of criteria met varied between studies, most met the sample size
(30/37 studies) and temporality criteria (22/37 studies). It should be
noted that the temporality criterion did not mandate testing for re­
ciprocity or reverse causation, but only that the study included two or
more assessments of alliance during the active phase of treatment.
Taken together, 26 of the 37 studies (70.3%) found some evidence for
the mediating role of alliance. Of note, only seven studies (18.9%)
could be considered of “highest quality” with respect to meeting at least
4 criteria for process research. Given the small number of studies
meeting these requirements, results should be interpreted with caution.
4. Discussion
Of all papers identified in this systematic review, the majority
(70.3%; 26 of 37 studies) found evidence for alliance as a mediator of
change despite significant heterogeneity between study designs, sta­
tistical analytic procedures, and overall quality. Although additional,
more targeted research is needed to more comprehensively unpack the
alliance-outcome relationship, results of this review reinforce that al­
liance likely plays an important role pantheoretically in effective psy­
chotherapy (Weck et al., 2015). The studies were critiqued with regard
to the extent to which they met six criteria for process research (Kazdin,
2007), in line with prior methodology used to evaluate change me­
chanisms in clinical research (Lemmens et al., 2017) while adapted to
best meet this particular review. Only seven studies met four or more
criteria for process research pointing to clear future directions for the
study of alliance as a change mechanism. Nevertheless, an increasing
number of research groups over the past five years made use of robust
analytic techniques that adequately deal with assumption violations,
hierarchical data, and longitudinal methods to include disaggregating
within-patient and between-patient effects, evidencing the promising
advancements of recent research and methodological approaches.
Given the positive alliance-outcome correlation that has con­
sistently been observed in treatment research, alliance indeed seems to
play some role in promoting symptom reduction, either mechanistically
or by facilitating mechanistic processes. To answer the question of how
the alliance contributes to change, mediation analyses are needed
coupled with robust research designs that utilize RCTs to further in­
vestigate the question of whether the alliance is a specific or nonspecific
factor of change. If the alliance is a nonspecific factor as the research to
date supports, then RCTs comparing different therapies should find no
differences between treatments in the role of alliance on treatment
outcome. However, some continue to argue alliance as a specific change
factor more important for certain psychotherapies (e.g., relational) than
others (e.g., exposure therapy). Additionally, studies should aim for
large sample sizes to ensure adequate power, multiple assessments of
both validated alliance measures and validated outcome measures to
assess temporality, and the study of multiple constructs in concert. We
further acknowledge that given ethical and clinical demands of opti­
mizing the therapeutic alliance in treatment, the manipulation of alli­
ance within a clinical research framework is challenging, if not im­
possible. However, the ability to study if the magnitude of the mediator
influences outcome is a critical step in identifying mechanisms of
change. It may be that the alliance is one purported change process that
will be difficult to unequivocally ascertain as a mechanism, whereas
other constructs (e.g., Socratic dialogue, exposure activities, behavioral
activation) can be manipulated ethically. However even when omitting
this criterion, of the 37 included papers, less than half (16 studies,
43.2%) met at least three of the other five requirements, evidencing the
paucity of literature adhering to stringent criteria for understanding
A.L. Baier, et al.
mediators and drivers of treatment change.
The 37 studies included in this review varied widely with regard to
the extent to which they met requirements for process research in ad­
dition to mediation method used and sample size. Ultimately, research
aimed at uncovering possible change processes—including the allian­
ce—must move toward inclusion of requirements for process research
beginning with mediation analyses. While the statistical methodology
used in the included studies largely improved over the course of time to
account for more advanced models, future research will need to focus
on using methodologically robust methods that are specific to the data
in question. For example, most mediation models examine linear
changes; however, change is not always linear (Hayes, Laurenceau,
Feldman, Strauss, & Cardaciotto, 2007). Patients often show sudden
gains (Jun, Zoellner, & Feeny, 2013) and experience ruptures and re­
pairs in the alliance throughout the course of treatment (McLaughlin,
Keller, Feeny, Youngstrom, & Zoellner, 2014), which may not be ac­
curately reflected in linear models. Notably, we explicitly omitted such
papers from this review (e.g., Zilcha-Mano, Eubanks, Bloch-Elkouby, &
Muran, 2020) for methodological consistency and interpretation, as
well as our focus in examining the links between outcomes and alliance
throughout the entire course of therapy. Thus, future studies should
explore the use of nonlinear and curvilinear models, which could help
elucidate the temporal patterns associated with change processes.
Perhaps the alliance is critical early in the therapeutic process and less
susceptible to ruptures later on in treatment. In order to study temporal
patterns, research must make use of repeated measurement of alliance
and symptoms over the course of treatment. Identifying a time course of
possible mediators, such as the alliance, will help clinicians better un­
derstand when and where in treatment they might wish to direct their
focus. Indeed, a recent meta-analysis of session-by-session data found
that early in therapy, alliance and symptoms were reciprocally related
to one another (Fluckiger et al., 2020).
Identifying mediators ultimately relies on sound study designs in­
cluding RCTs and careful assessment of putative mediators to allow for
an examination of temporality and specificity. It will be important for
future research to make use of these study designs. Better under­
standing the mechanistic role of alliance will be assisted by research on
alliance that is crafted during study design rather than being a sec­
ondary analysis of treatment data. Approaching the study of alliance
from the outset will enable researchers to ensure inclusion of important
aspects of sound process research such as multiple assessments of alli­
ance and other putative change processes that might interact with al­
liance throughout the duration of treatment.
Finally, as the alliance-outcome relationship is better understood,
research should continue to examine possible moderators of the re­
lationship, such as therapist effects or patient characteristics. Recent
research, for example, has demonstrated that impact of alliance on
outcomes may be more relevant for some patients than others.
Specifically, the impact of alliance on symptom change in patients re­
ceiving treatment for depression has been affected by chronicity of
depression, whereby the effects of alliance on outcome were greatest
among patients with fewer prior depressive episodes (e.g., Lorenzo-
Luaces et al., 2017; Lorenzo-Luaces, DeRubeis, & Webb, 2014). It is thus
likely that alliance drives therapeutic change to a greater degree for
certain patients.
Clinically, cultivation of alliance should be prioritized at the earliest
stages of treatment. In addition to being broadly associated with op­
timal treatment outcomes, a stronger alliance appears to also itself re­
flect an independent contributor to symptom reduction and likely be
one of the many processes driving change across therapy types, patient
characteristics, and treatment settings. Notably, while alliance appears
to mediate change for some patients, it is also clear that other treatment
processes and techniques impact outcomes as well. Treatment process
research studying psychotherapy mechanisms has consistently im­
plicated the role of specific processes on symptom reduction (e.g.,
change in posttraumatic cognitions and fear reduction; Cooper et al.,
11
Clinical Psychology Review 82 (2020) 101921
2017) in prolonged exposure for posttraumatic stress disorder). The
current review suggests however that, in addition to these specific
treatment components, alliance itself often also contributes to ther­
apeutic change for patients. It is thus possible alliance independently
drives therapeutic change; however, it is likely more plausible that the
alliance does not act in isolation but rather facilitates other treatment
processes (Lorenzo-Luaces & DeRubeis, 2018; Rothman, 2013). For
example, the alliance between a patient and provider likely impacts the
design and assignment of homework, creation of exposure exercises, or
receptivity to Socratic dialogue. Finally, in addition to alliance being
particularly salient for symptom change among certain patients, it is
also likely that the alliance may be more relevant for the im­
plementation of certain techniques rather than others (Tschacher,
Junghan, & Pfammatter, 2014). Thus, perhaps the quest to resolve the
debate between whether specific or common factors are responsible for
therapeutic change is misguided. Research efforts that consider the
complexity of the therapeutic change process between specific and
common factors and that capitalize on recent methodological and sta­
tistical advances would further propel our scientific understanding of
change processes.
Given the importance of the alliance, clinicians should consider
introducing routine and systematic ways of monitoring the alliance
such as with brief, validated patient-rated measures (e.g., WAI;
(Horvath & Greenberg, 1989). It is well-documented that there are
benefits to monitoring patient progress throughout the course of psy­
chotherapy to track gains or setbacks and make adjustments to the
therapy as needed (Knaup, Koesters, Schoefer, Becker, & Puschner,
2009; Lambert & Lo Coco, 2013; Lambert & Shimokawa, 2011; Sapyta,
Riemer, & Bickman, 2005). In addition to symptom monitoring, clinical
outcomes across treatment are bolstered by patient feedback related to
the alliance (MacDonald, 2014; McClintock, Perlman, McCarrick,
Anderson, & Himawan, 2017; Norcross & Wampold, 2011). System­
atically monitoring the alliance would also assist clinicians' attention to
potential therapeutic ruptures, which have been shown not to nega­
tively affect outcome so long as they are repaired (McLaughlin et al.,
2014). Furthermore, studies have found that alliance scores are not
inflated due to the presence of a therapist or knowing that the scores
would be reviewed by a therapist, which should relieve clinician con­
cerns regarding demand characteristics or social desirability of regular
administration of alliance measures within psychotherapy (Reese et al.,
2013).
Key strengths of this review include its systematic search adherent
to PRISMA guidelines, with a comprehensive examination of ther­
apeutic alliance through mediation analyses and thus a mechanistic
viewpoint. A diverse range of patients, primary diagnoses, psy­
chotherapies, and treatment settings were included enhancing the
generalizability of the findings. However, findings should be inter­
preted in the context of several limitations. As presented in Table 1,
study characteristics varied widely which should be considered in the
context of this review's conclusions. Given the variability in methodo­
logical design implemented across studies, we elected not to conduct a
meta-analysis. We also note that the variables in the relationships with
alliance as a mediator (i.e., “X” and “Y” variables) were not uniform.
The heterogeneity of factors precluded the possibility of reliably and
meaningfully evaluating the size of effects related to alliance as a
mediator. Advancements in methodology ultimately equate to ad­
vancements in what can be reliably concluded regarding processes of
change and, more broadly, how treatments work (Zilcha-Mano, 2019).
Notably, this review highlights significant advancements in analytic
approaches and methodology in recent years, with roughly half of in­
cluded studies published within the last five years. Recent papers have
shifted from correlational analyses taken at a snapshot during treatment
to more advanced longitudinal models that provide more precise esti­
mates of the relationship between alliance and outcomes. Additional
progress in design and methodology will better illuminate the role that
alliance plays in driving therapeutic change and enable future meta-
A.L. Baier, et al.
analytic studies.
Results of the current review suggests that alliance itself may be an
independent driver of therapeutic change. In the majority of studies
included in the current review, alliance mediated symptom reduction,
supporting the alliance as a potential causal process, either in­
dependently or in conjunction with other change processes. This effect
was observed across a broad range of patients, disorders, and settings
that were included in this review. Alliance likely impacts psy­
chotherapy in complex ways, reflecting the need for future targeted
research to untangle these complex interactions and better elucidate
when, how, for whom, and the extent to which alliance serves as a
mediator of outcome.
Contributors
ALB developed the concept for the study and reviewed the litera­
ture. ACK and NCF consulted on scope of the review and relevant
methodology such as search terms and inclusion/exclusion criteria. ALB
wrote the first draft of the manuscript and all three authors contributed
to and have approved the final manuscript.
Declaration of Competing Interest
All authors declare that they have no conflicts of interest.
Acknowledgements
The authors wish to thank Alexandra Bowling for her diligent re­
view of articles included in this review.
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Allison L. Baier, M.A., is a doctoral candidate at Case Western Reserve University. Her
research interests include understanding mechanisms underlying treatment outcomes and
effectively increasing dissemination and implementation of evidence-based interventions
for PTSD.
Alexander C. Kline, Ph.D., is a graduate of Case Western Reserve University and current
Postdoctoral Fellow at UCSD/VA San Diego Healthcare System. His research focuses on
interventions for PTSD and related comorbidities, with emphasis on processes and pre­
dictors linked to clinical outcomes.
Norah C. Feeny, Ph.D., is a Professor in the Department of Psychological Sciences at Case
Western Reserve University. Her research interests include examining patient preferences,
evaluating interventions for PTSD, and understanding what predicts who will benefit
from these treatments.