The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta-analytic review
Open accessAbstract
Research consistently provides evidence for the relationship between the therapeutic alliance (TA) and outcome across various therapies and presenting problems. Depression is considered the leading cause of disability worldwide, and there is substantial evidence for the efficacy for Cognitive Behaviour Therapy (CBT) in its treatment. At present, there is lack of clarity specifically about the relationship between the TA and outcome in CBT for depression. The present review is the first meta‐analytic review to explore this relationship and also considering moderators. Within a random‐effects model, an overall mean effect size of r = 0.26 (95% CI [.19–.32]) was found, indicating that the TA was moderately related to outcome in CBT for depression. The mean TA–outcome correlation is consistent with existing meta‐analysis that looked across a broad range of presenting problems and psychological therapies. A secondary exploratory analysis of moderators suggested the TA–outcome relationship varied according to the TA rater, where the relationship was weaker for therapist raters compared with clients and observer raters. Additionally, the results indicated that the TA–outcome relationship marginally increased over the course of CBT treatment. The results of the meta‐analysis are discussed in reference to the wider body of research, methodological limitations, clinical implications, and future directions for research.
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TL;DR
This first meta-analytic review of the therapeutic alliance (TA) and outcome in CBT for adult depression found a moderate overall TA–outcome correlation of r = 0.26 (95% CI .19–.32) across 13 studies. Exploratory moderator analyses suggested the relationship was weaker for therapist-rated TA and marginally stronger later in treatment.
Key findings
- Across 13 studies conducted between 1989 and 2015, with sample sizes from n = 21 to n = 128 and study correlations from r = 0.06 to r = 0.59, the overall mean TA–outcome correlation was r = 0.26 (95% CI .19–.32).
- Effect sizes were homogeneous (Q = 9.66, df = 13, p = 0.646; I² = 0%), and Orwin’s failsafe N indicated 155 null-result studies would be needed to reduce the correlation to r < 0.01.
- In exploratory moderator analyses, TA–outcome correlations were r = 0.21 (95% CI .12–.31) for early, r = 0.28 (95% CI .11–.43) for mid, r = 0.27 (95% CI .13–.40) for late, and r = 0.42 (95% CI .22–.59) for average time points; the average-time-point estimate had high heterogeneity (I² = 70.5%).
- By TA rater, correlations were r = 0.27 (95% CI .19–.36) for client, r = 0.19 (95% CI .03–.33) for therapist, and r = 0.41 (95% CI .22–.58) for observer ratings; the observer estimate had higher heterogeneity (I² = 54.7%).
Methods
- Systematic review and random-effects meta-analysis of correlational studies reporting a TA–outcome relationship in individual, face-to-face CBT for adults (18+) with depression as the main target and depressive symptoms as the primary outcome.
- Electronic database searches (MEDLINE, Embase, PsycINFO, Scopus to December 2015) plus author, journal, reference, ProQuest, and Google Scholar searches yielded 13 included papers after screening and exclusion of shared datasets.
- One independent effect size per study was entered into Comprehensive Meta-Analysis; effect sizes were coded as positive correlations, with mean effect sizes calculated when studies reported multiple measures, raters, or time points. Moderator analyses used disaggregated effect sizes for TA time point and rater, weighted by original sample size.
Limitations
- The paper states that synthesizing partial correlations is a limitation because partial correlations may inflate magnitude or alter direction, though it was done to control for prior depression severity.
- The paper states that moderator analyses broke the meta-analytic assumption of independent effect sizes, did not test significance between groupings, and had small, unbalanced rater subgroups: client n = 9, therapist n = 4, observer n = 4.
- The paper cautions that the “average” time-point and observer-rater findings had higher heterogeneity (I² = 70.5% and 54.7%, respectively), so those results should be interpreted more cautiously.
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0 of 25 cited sources checked · 0 supported · 0 flagged
- Findingown data§ Time point of therapeutic alliance measure · p. 15
When the therapeutic alliance was measured at various time points and an average was presented, the relationship with outcome was r = 0.42 (95% CI .22 - .59).
“When the TA was measured at various time points and an average was presented in the study, the relationship with outcome was r = 0.42 (95% CI .22 - .59).”
Quote in the paperSubstantial claim - Findingown data§ Results · p. 14
The overall mean correlation between therapeutic alliance and outcome was r = 0.26 (95% CI .19 - .32).
“The overall mean correlation between TA and outcome was r = 0.26 (95% CI .19 - .32).”
- Also stated in: § Abstract · p. 3 · plain
“an overall mean effect size of r = 0.26 (95% CI .19 - .32) was found”
Quote in the paperSubstantial claim - Also stated in: § Abstract · p. 3 · plain
- Findingown data§ Time point of therapeutic alliance measure · p. 15
The mean effect size for the therapeutic alliance-outcome relationship measured mid-treatment was r = 0.28 (95% CI .11 -.43).
“The mean effect sizes for the relationship between TA and outcome measured at early, mid and late in treatment were r = 0.21 (95% CI .12 - .31); r = 0.28 (95% CI .11 -.43) and r = 0.27 (95% CI .13 - .40).”
Quote in the paperNot a substantial claim - Findingown data§ Publication bias · p. 15
Orwin's failsafe N identified that 155 studies that accepted the null hypothesis would be required to reduce the correlation to a trivial value (r = <0.01).
“Orwin's failsafe N (Orwin, 1983) was used also to account for publication bias, which identified that 155 studies that accepted the null hypothesis would be required to reduce the correlation to a trivial value, i.e. r = <0.01.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Orwin, 1983
Not checked in the free run.
- Findingown data§ Time point of therapeutic alliance measure · p. 15
The mean effect size for the therapeutic alliance-outcome relationship measured early in treatment was r = 0.21 (95% CI .12 - .31).
“The mean effect sizes for the relationship between TA and outcome measured at early, mid and late in treatment were r = 0.21 (95% CI .12 - .31); r = 0.28 (95% CI .11 -.43) and r = 0.27 (95% CI .13 - .40).”
Quote in the paperSubstantial claim
- Findingown data§ Time point of therapeutic alliance measure · p. 15
The mean effect size for the therapeutic alliance-outcome relationship measured late in treatment was r = 0.27 (95% CI .13 - .40).
“The mean effect sizes for the relationship between TA and outcome measured at early, mid and late in treatment were r = 0.21 (95% CI .12 - .31); r = 0.28 (95% CI .11 -.43) and r = 0.27 (95% CI .13 - .40).”
Quote in the paperNot a substantial claim - Findingown data§ Results · p. 14
The effect sizes were homogeneous (Q = 9.66, df 13, p = 0.646).
“The effect sizes were homogeneous ( Q = 9.66, df 13, p = 0.646)”
Quote in the paperNot a substantial claim - Findingown data§ Results · p. 14
The I2 statistic suggested heterogeneity was low within the group of effect sizes overall (I2 = 0%).
“The I 2 statistic was computed and suggested that heterogeneity was low within the group of effect sizes overall ( I 2 = 0%).”
Quote in the paperNot a substantial claim - Findingown data§ Rater of therapeutic alliance · p. 16
Client ratings of the therapeutic alliance had an effect size of r = 0.27 (95% CI .19 - .36).
“The effect sizes according to TA rater were: client ( r = 0.27, 95% CI .19 - .36), therapist ( r = 0.19, 95% CI .03 - .33) and observer ( r = 0.41, 95% CI .22 - .58).”
Quote in the paperSubstantial claim - Findingown data§ Discussion · p. 20
The therapeutic alliance-outcome relationship varied according to the rater of the therapeutic alliance.
“A secondary exploratory analysis of moderators suggested that the TAoutcome relationship varied according to TA rater”
- Also stated in: § Discussion · p. 18 · hedged
“It appears that the rater has some influence on the TA-outcome relationship.”
Quote in the paperNot a substantial claim - Also stated in: § Discussion · p. 18 · hedged
- Findingown data§ Rater of therapeutic alliance · p. 16
Observer ratings of the therapeutic alliance had an effect size of r = 0.41 (95% CI .22 - .58).
“The effect sizes according to TA rater were: client ( r = 0.27, 95% CI .19 - .36), therapist ( r = 0.19, 95% CI .03 - .33) and observer ( r = 0.41, 95% CI .22 - .58).”
Quote in the paperNot a substantial claim - Findingown data§ Discussion · p. 20
The overall mean effect size of the therapeutic alliance-outcome relationship in CBT for depression is r = 0.26 (95% CI .19-.32).
“this meta-analytic review provides evidence of a moderate relationship between the TA and outcome in CBT for depression, with an overall mean effect size of r = 0.26 (95% CI .19 - .32).”
Quote in the paperSubstantial claim - Findingown data§ Discussion · p. 17
The strength of the therapeutic alliance-outcome relationship when measured mid and late in treatment was marginally higher than early treatment ratings.
“These results suggest that the strength of the TA-outcome relationship when measured mid and late in treatment was marginally higher than early treatment ratings.”
- Also stated in: § Discussion · p. 20 · hedged
“the results indicated that the TA-outcome relationship marginally increased over the course of CBT treatment.”
Quote in the paperNot a substantial claim - Also stated in: § Discussion · p. 20 · hedged
- Findingown data§ Discussion · p. 17
The therapeutic alliance-outcome relationship is weaker for therapist ratings than for client and observer ratings.
“For TA rater, the TA-outcome relationship was weaker for therapist ratings, when compared with client and observer ratings.”
- Also stated in: § Discussion · p. 20 · plain
“the relationship was weaker for therapists than clients and observer raters.”
Quote in the paperSubstantial claim - Also stated in: § Discussion · p. 20 · plain
- Findingown data§ Time point of therapeutic alliance measure · p. 15
There was a higher level of heterogeneity for the average time point effect size (I2 = 70.5%).
“Although for the 'average' time point the TAoutcome was strongest, there was a higher level of heterogeneity I 2 = 70.5%, therefore this finding should be interpreted with more caution.”
Quote in the paperSubstantial claim - Findingown data§ Rater of therapeutic alliance · p. 16
Therapist ratings of the therapeutic alliance had an effect size of r = 0.19 (95% CI .03 - .33).
“The effect sizes according to TA rater were: client ( r = 0.27, 95% CI .19 - .36), therapist ( r = 0.19, 95% CI .03 - .33) and observer ( r = 0.41, 95% CI .22 - .58).”
Quote in the paperNot a substantial claim - Findingown data§ Rater of therapeutic alliance · p. 16
There was a higher level of heterogeneity for the observer effect size (I2 = 54.7%).
“Although, again, there was a higher level of heterogeneity for the observer effect size ( I 2 = 54.7%), therefore this finding should be interpreted with more caution.”
Quote in the paperNot a substantial claim - Interpretationown data§ Publication bias · p. 14
The funnel plot showed studies distributed almost symmetrically at the top of the graph, suggesting absence of publication bias.
“The studies are distributed almost symmetrically at the top of the graph, suggesting absence of publication bias.”
Quote in the paperNot a substantial claim - Premisecitation§ Introduction · p. 8
The most recent review in this area was in year 2000.
“The most recent review in this area was some time ago, in year 2000, and therefore an update is pertinent.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Keijsers, Schaap and Hoogduin (2000)
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- Interpretationown data§ Time point of therapeutic alliance measure · p. 15
The strength of the therapeutic alliance-outcome relationship when measured mid and late in treatment is marginally higher than early ratings.
“These results suggest that the strength of the TA-outcome relationship when measured mid and late in treatment is a marginally higher than early ratings.”
- Also stated in: § Abstract · p. 3 · hedged
“Additionally, the results indicated that the TA-outcome relationship marginally increased over the course of CBT treatment.”
Quote in the paperSubstantial claim - Also stated in: § Abstract · p. 3 · hedged
- Interpretationown data§ Key practitioner message · p. 20
Development of the therapeutic alliance may promote clinical outcomes in CBT for depression.
“Development of the therapeutic alliance may promote clinical outcomes in CBT for depression.”
Quote in the paperSubstantial claim- Rests on an assumption: The association between therapeutic alliance and outcome in CBT for depression is at least partly causal, such that improving the alliance can improve outcomes.
- Interpretationown data§ Rater of therapeutic alliance · p. 16
The therapeutic alliance-outcome relationship for therapist ratings was weaker compared with client and observer ratings.
“The TA-outcome relationship for therapist ratings was weaker, when compared with client and observer ratings.”
- Also stated in: § Abstract · p. 3 · hedged
“A secondary exploratory analysis of moderators suggested the TA-outcome relationship varied according to the TA rater, where the relationship was weaker for therapist raters compared to clients and observer raters.”
Quote in the paperSubstantial claim - Also stated in: § Abstract · p. 3 · hedged
- Interpretationown data§ Discussion · p. 16
The therapeutic alliance is moderately related to outcome in CBT for depression.
“This suggests that the TA is moderately related to outcome in CBT for depression.”
- Also stated in: § Abstract · p. 3 · hedged
“indicating that the TA was moderately related to outcome in CBT for depression”
Quote in the paperSubstantial claim - Also stated in: § Abstract · p. 3 · hedged
- Interpretationreasoning§ Key practitioner message · p. 4
Therapists and clients may hold different views of their therapeutic alliance.
“Therapists and clients may hold different views of their therapeutic alliance.”
- Also stated in: § Key practitioner message · p. 20 · hedged
“Therapists and clients may hold different views of their therapeutic alliance.”
Quote in the paperSubstantial claim- Rests on an assumption: Differences in the therapeutic alliance-outcome relationship by rater reflect genuine differences in perspective between therapists and clients rather than measurement artifacts.
- Also stated in: § Key practitioner message · p. 20 · hedged
- Premisecitation§ Discussion · p. 16
Previous meta-analyses by Horvath et al (2001, 2011) found a high level of heterogeneity across studies.
“Previous meta-analyses by Horvath et al (2001, 2011) found a high level of heterogeneity across studies, which is very different to this review.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Horvath et al (2001, 2011)
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- Study design and conductown data§ Discussion · p. 18
In the moderator analyses, the meta-analytic assumptions of independence were broken.
“In the moderator analyses the meta-analytic assumptions of independence were broken.”
Quote in the paperNot a substantial claim - Premisecitation§ Discussion · p. 17
Observer and self-report rated therapeutic alliance measures are superior predictors of therapy outcomes compared to therapist-rated therapeutic alliance measures.
“The findings in this review are similar to previous research that suggests it is both observer and self-report rated TA measures are the superior predictors of therapy outcomes compared to therapist-rated TA measures (Horvath and Symonds, 1991).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Horvath and Symonds, 1991
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- Interpretationcitation§ Discussion · p. 16
The mean therapeutic alliance-outcome correlation is consistent with existing meta-analyses that looked across various presenting problems and psychological therapies.
“The mean TA-outcome correlation is consistent with existing meta-analyses that looked across various presenting problems and psychological therapies (e.g. Martin et al , 2000, r = .22, k = 79; Horvath et al , 2011, r = .275, k = 190).”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Martin et al, 2000
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- cites Horvath et al, 2011
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- Classified as probably not a substantial claim. 30
- May combine two claims. 15
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Findingown data§ Meta-Analytic Method · p. 11Thirteen papers were included in the meta-analysis.
“Thirteen papers were included in the meta-analysis.”
- Also stated in: § Results · p. 14 · plain
“Thirteen studies were included in the investigation of the relationship between TA and outcome in CBT for depression.”
Quote in the paperSubstantial claim- Also stated in: § Results · p. 14 · plain
Classified as probably not a substantial claim.
Study design and conductreasoning§ Moderator analysis · p. 13Differences between groupings due to moderators were not examined for significance because the effect sizes were not independent.
“Differences between groupings due to moderators were not examined for significance because the effect sizes were not independent.”
- Also stated in: § Moderator analysis · p. 15 · plain
“Significance between groupings within the moderators were not examined due to the effect sizes being non-independent of each other.”
Quote in the paperSubstantial claim- Also stated in: § Moderator analysis · p. 15 · plain
Classified as probably not a substantial claim.
Premisecitation§ Introduction · p. 5The therapeutic alliance has been consistently proposed to have a relationship with positive outcomes across various psychological therapies, with moderate effect sizes in meta-analyses.
“The TA has been extensively investigated in general adult samples and a strong TA has been consistently proposed to have a relationship with positive outcomes across various psychological therapies, with moderate effect sizes found in meta-analyses (e.g. Martin et al , 2000, r = .22, k = 79; Horvath et al , 2011, r = .275, k = 190).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Martin et al, 2000
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- cites Horvath et al, 2011
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Study design and conductown data§ Method · p. 8The search terms were broad and resulted in a wide range of studies, including those relevant to the research question, as indicated by an initial pilot review.
“The pilot review indicated that the search terms were broad and resulted in a wide range of studies, including those that were relevant to the research question.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Introduction · p. 7Keijsers, Schaap and Hoogduin (2000) proposed there was evidence of a relationship between therapeutic alliance in CBT and outcome for depression.
“This review proposed there was evidence of relationship between TA in CBT and outcome for depression.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Keijsers, Schaap and Hoogduin (2000)
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Premisenone given§ Abstract · p. 3The present review is the first meta-analytic review to explore the therapeutic alliance-outcome relationship in CBT for depression whilst also considering moderators.
“The present review is the first meta-analytic review to explore this relationship whilst also considering moderators.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Introduction · p. 6Meta-analyses have suggested there are no differences in the strength of the therapeutic alliance-outcome relationship across therapies.
“However, meta-analyses have suggested that there are no differences in the strength of the TA-outcome relationship across therapies, e.g. Horvath et al (2011) looked at the alliance-outcome relationship across psychological therapies and problems.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Horvath et al, 2011
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Premisecitation§ Introduction · p. 5CBT for depression has a strong evidence base and is highly efficacious.
“CBT for depression has a strong evidence-base and is deemed to be highly efficacious (e.g. Gloaguen, 1998; Tolin, 2010).”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Gloaguen, 1998
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- cites Tolin, 2010
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Study design and conductown data§ Meta-Analytic Method · p. 11A second-rater coded a sample of six final papers and there was 100% agreement between the raters.
“a second-rater coded a sample of the final papers (six papers) and there was 100% agreement between the raters.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S4 (based).
Premisenone given§ Introduction · p. 8There is no existing meta-analysis of the therapeutic alliance-outcome relationship in CBT for depression.
“Moreover, there is no existing meta-analysis in this area.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Premisecitation§ Introduction · p. 6The therapeutic alliance is considered necessary to promote change in CBT, but not sufficient without the actual therapeutic techniques.
“It is considered necessary to promote change, but not sufficient without the actual therapeutic techniques (Beck, 1995).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Beck, 1995
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Premisecitation§ Introduction · p. 6Horvath et al (2011) reported an effect size of r = .35 for CBT as a subgroup in the alliance-outcome relationship.
“CBT was examined as a subgroup and reported an effect size of r = .35, and there were no significant difference across different therapies (e.g. psychodynamic, interpersonal therapies).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Horvath et al, 2011
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Premisecitation§ Introduction · p. 6The therapeutic alliance has been increasingly acknowledged as a key process within CBT.
“Although the TA was more traditionally associated with psychodynamic therapies, it has been increasingly acknowledged as a key process within Cognitive Behaviour Therapy (CBT; Raue, 1997).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Raue, 1997
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Premisecitation§ Introduction · p. 7Webb et al suggested that the therapeutic alliance assessed at late sessions was predicted by prior symptom change.
“In addition, Webb et al suggested that the TA assessed at late sessions was predicted by prior symptom change.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Webb et al
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Premisecitation§ Introduction · p. 6Raue (1997) found the therapeutic alliance was significantly higher in CBT compared to psychodynamic psychotherapy.
“For example, Raue (1997) found the TA was significantly higher in CBT compared to psychodynamic psychotherapy.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Raue (1997)
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Interpretationcitation§ Discussion · p. 17Although the therapeutic alliance-outcome finding may appear modest, it could be considered large in comparison to the relationship between other process variables and outcome in CBT.
“Although this finding may appear modest, it could be considered large in comparison to the relationship between other process variables and outcome in CBT.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Premisenone given§ Introduction · p. 7There are key differences between psychological therapies which could influence each therapy's association with the therapeutic alliance.
“Additionally, there are key differences between psychological therapies which could influence each therapy's association with the TA.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Premisenone given§ Introduction · p. 7Previous meta-analyses have provided effect sizes for the relationship between alliance and outcome in CBT across different problems.
“Previous meta-analyses have provided effect sizes for the relationship between alliance and outcome in CBT across different problems.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationown data§ Discussion · p. 16The effect sizes in the main analysis were homogeneous, suggesting that the correlation represents a single population of effects.
“The effect sizes in the main analysis were homogeneous, suggesting that the correlation represents a single population of effects.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Premisenone given§ Abstract · p. 3At present there is lack of clarity specifically about the relationship between the therapeutic alliance and outcome in CBT for depression.
“At present there is lack of clarity specifically about the relationship between the TA and outcome in CBT for depression.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown data§ Discussion · p. 18For the therapeutic alliance rater analysis, two of the subgroups were small and it was unbalanced: Client (n = 9), Therapist (n = 4), and Observer (n = 4).
“It should also be noted that for the TA rater analysis, two of the subgroups were small and it was unbalanced, where n represent the number of effect sizes; Client ( n = 9), Therapist ( n = 4) and Observer ( n = 4).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Study design and conductnone given§ Discussion · p. 18Effect sizes from the same study were weighted appropriately to ensure their contribution was not overemphasised.
“In addition, effect sizes from the same study were weighted appropriately to ensure their contribution was not overemphasised.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Introduction · p. 6Research suggests that the strength and nature of the therapeutic alliance differs across therapy types.
“There is research that suggests that the strength and nature of TA differs across therapy types (Barber et al , 2006).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Barber et al, 2006
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Study design and conductown data§ Discussion · p. 18The therapeutic alliance-outcome relationship was principally calculated using partial correlations, either between therapeutic alliance and post-treatment depression controlling for pre-treatment depression, or between therapeutic alliance and residualised change in depression scores controlling for the most recent session's depression score.
“It was identified that the TA-outcome was principally calculated by partial correlation, either between TA and post-treatment depression, controlling for pre-treatment depression or between TA and residualised change in depression scores over treatment, controlling for the most recent session's depression score.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Premisecitation§ Introduction · p. 6Beck (1995) emphasized that the therapeutic alliance is one of six basic principles of CBT and facilitates change.
“Indeed, Beck (1995) emphasized that the TA is one of six basic principles of CBT and facilitates change.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Beck, 1995
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Interpretationown data§ Key practitioner message · p. 4The therapeutic alliance is related to outcome at all stages of therapy, although it may be strongest at late stages of therapy.
“The therapeutic alliance is related to outcome at all stages of therapy, although it may be strongest at late stages of therapy.”
- Also stated in: § Key practitioner message · p. 20 · hedged
“The therapeutic alliance is related to outcome at all stages of therapy, although it may be strongest at late stages of therapy.”
Quote in the paperSubstantial claim- Also stated in: § Key practitioner message · p. 20 · hedged
Probably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Discussion · p. 17Webb et al (2010) reported mean effect sizes of the relationships between therapist adherence to treatment protocol and therapist competence with therapy outcome as r = 0.02 and r = 0.07 respectively.
“For example, Webb et al (2010) reported mean effect sizes of the relationships between therapist adherence to treatment protocol and therapist competence with therapy outcome as r = 0.02 and r = 0.07 respectively.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Webb et al (2010)
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Study design and conductown data§ Discussion · p. 18Significant differences between groupings in the moderator analyses were not investigated because the effect sizes were not independent.
“These analyses were exploratory and significant differences between groupings were not investigated because the effect sizes were not independent.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationown data§ Discussion · p. 16The finding that therapeutic alliance is moderately related to outcome in CBT for depression is robust because Orwin's failsafe N identified that approximately 155 studies that accepted the null hypothesis would be needed to reduce the correlation to a trivial value (r = <0.01).
“This finding is robust as Orwin's fail safe N statistic identified that approximately 155 studies that accepted the null hypothesis would be needed to reduce the correlation to a trivial value ( r = <0.01).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Orwin, 1983
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Premisecitation§ Introduction · p. 5The therapeutic alliance is viewed as a factor common to all treatments that is integral in determining positive therapy outcomes, at times considered as more significant than the treatment itself.
“The TA is viewed as a factor common to all treatments that is integral in determining positive therapy outcomes, at times considered as more significant than the treatment itself (Messer & Wampold, 2002).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Messer & Wampold, 2002
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Interpretationreasoning§ Discussion · p. 16The difference in heterogeneity between this review and previous meta-analyses may be due to the present meta-analysis focusing on a specific presenting problem (depression) and therapy (CBT).
“This may be due to the present meta-analysis focusing on a specific presenting problem (depression) and therapy (CBT).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Premisecitation§ Introduction · p. 7Webb et al (2011) found that the therapeutic alliance predicted greater depressive symptom reduction in participants with depression engaged in CBT, controlling for temporal confounds.
“Webb et al (2011) found that the TA predicated greater depressive symptom reduction in participants with depression engaged in CBT, controlling for 'temporal comfounds'”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Webb et al (2011)
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Premisenone given§ Introduction · p. 7Although CBT contains common elements across problems, there are disorder-specific models and the components of CBT for different problems can have differing emphasis.
“Although CBT contains common elements across problems, there are disorder-specific models and the components of CBT for different problems can have differing emphasis.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim. May combine two claims.
Premisecitation§ Introduction · p. 7DeRubeis and Feeley (1990) found that prior depressive symptom improvement was related to a stronger therapeutic alliance, whereas they did not find a significant relationship between the therapeutic alliance and subsequent depression change.
“They found that prior depressive symptom improvement was related to a stronger TA, whereas they did not find a significant relationship between the TA and subsequent depression change.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites DeRubeis and Feeley (1990)
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Premisecitation§ Discussion · p. 18The use of partial correlations in meta-analyses can inflate the magnitude and alter the direction of the effect.
“The difficulties of using partial correlations in meta-analyses are acknowledged, including the potential influence on inflating the magnitude and altering the direction of the effect (Aloe, 2014).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Aloe, 2014
Not checked in the free run.
The paper relies on this without support.
The association between therapeutic alliance and outcome in CBT for depression is at least partly causal, such that improving the alliance can improve outcomes.
“Development of the therapeutic alliance may promote clinical outcomes in CBT for depression.”
The paper relies on this without support.
Differences in the therapeutic alliance-outcome relationship by rater reflect genuine differences in perspective between therapists and clients rather than measurement artifacts.
“Therapists and clients may hold different views of their therapeutic alliance.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
It has been demonstrated in many studies that therapeutic relationship and related concepts such as therapeutic alliance and rapport are important factors in determining treatment success.
“It has been demonstrated in many studies that therapeutic relationship and related concepts such as therapeutic alliance and rapport, are important factors in determining treatment success.89-91”
From Best Practice Recommendations for Conducting and Reporting Controlled Trials in Clinical Hypnosis Research (2024) · cites this paper as [89]
The Introduction (p. 5) describes therapeutic relationship and therapeutic alliance as related constructs and reports evidence linking a strong alliance with positive outcomes. The review finds a moderate alliance–outcome association in CBT for depression (Discussion, p. 19), but the Introduction (p. 7) says the direction of that relationship is debated. The copy does not establish rapport specifically as a determinant of treatment success. (LLM, conf=0.84)
Experimental — accuracy not yet measuredTherapeutic relationship, alliance, or rapport variables can be assessed with various measures with established validity and reliability.
“These variables can be assessed with various measures with established validity and reliability.89,90,93-95”
From Best Practice Recommendations for Conducting and Reporting Controlled Trials in Clinical Hypnosis Research (2024) · cites this paper as [89]
The Note (p. 32) lists numerous measures of therapeutic alliance, supporting the claim that these variables can be assessed in various ways. The copy does not establish that the listed measures generally have established validity and reliability; the References (p. 24) include a study on those properties for one scale, but do not substantiate that broader qualification. (LLM, conf=0.85)
Experimental — accuracy not yet measuredTherapeutic alliance is one of the most important variables predicting the outcome of psychotherapy.
“Considering that therapeutic alliance, which depends also on the characteristics of the psychotherapists, is one of the most important variables predicting the outcome of psychotherapy (119, 120)”
There is clear evidence that better therapeutic relationship is associated with better outcomes.
“There is clear evidence that better therapeutic relationship is associated with better outcomes (Cameron, Rodgers, & Dagnan, 2018), but does it follow that therapeutic relationship is the key mechanism of change in all therapy?”
From A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model (2020) · cites this paper as Cameron, Rodgers, & Dagnan, 2018
TA is moderately associated with better treatment outcomes in face-to-face therapy, regardless of the therapeutic framework or patient characteristics.
“Several meta-analyses have found that TA is moderately associated with better treatment outcomes in face-to-face therapy [1,2], regardless of the therapeutic framework or patient characteristics, among other aspects [3].”
Therapeutic alliance (TA) between the patient and therapist has a relevant influence on therapeutic outcomes.
“Evidence shows that the therapeutic alliance (TA) (also called the working alliance) has a relevant influence on therapeutic outcomes [1].”
There is a positive relationship between patient-therapist TA and therapeutic outcomes in face-to-face therapy and IBIs.
“Consequently, the relationship between “patient-online program TA” and therapeutic outcomes is also in line with the positive relationship found between the “patient-therapist TA” and the therapeutic outcomes in face-to-face therapy [1,2] and IBIs [3,21].”
The relationship between patient-online program TA and therapeutic outcomes is in line with the positive relationship found between patient-therapist TA and therapeutic outcomes in face-to-face therapy and IBIs.
“Consequently, the relationship between “patient-online program TA” and therapeutic outcomes is also in line with the positive relationship found between the “patient-therapist TA” and the therapeutic outcomes in face-to-face therapy [1,2] and IBIs [3,21].”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Average time-point subgroup is counted as both eight and four
MinorThe results text assigns eight effect sizes to the average time-point subgroup, whereas Table 2 assigns it four. Four also makes the time-point subgroup counts sum to the stated total of 23.
“The number of effect sizes for the TA-outcome relationship according to the time point of TA measurement in treatment was as follows; early ( n = 8), mid ( n = 5), late ( n = 6) and average ( n = 8).”
“| | Average | 4 | 0.42 | [ .23 - .59] | 4.01 | 0.000 | 10.2 | 3 | 0.02 | 70.5% |”
Average time-point confidence interval differs between text and table
MinorThe results text gives the lower 95% confidence limit as .22, while Table 2 gives .23 for the same mean effect size.
“the relationship with outcome was r = 0.42 (95% CI .22 - .59).”
“| | Average | 4 | 0.42 | [ .23 - .59] | 4.01 | 0.000 | 10.2 | 3 | 0.02 | 70.5% |”
Homogeneity test has the wrong degrees of freedom
MinorThe analysis includes 13 independent effect sizes, so the Q test has 13 − 1 = 12 degrees of freedom, not 13.
Reported 13 · recomputed 12
“The effect sizes were homogeneous ( Q = 9.66, df 13, p = 0.646)”
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- Authors
- Cameron, S. K., Rodgers, J., & Dagnan, D.
- Affiliations
- NHS Lanarkshire (GB)
- Newcastle University (GB)
- Cumbria Partnership NHS Foundation Trust (GB)
- Corresponding author
- Cameron, Sarah Kate
- Venue
- Clinical Psychology & Psychotherapy
- Publisher
- Wiley
- Published
- 2018-02-26
- Volume
- 25
- Issue
- 3
- Pages
- 446-456
- ISSN
- 1063-3995 (ISSN-L)
- 1099-0879
- OpenAlex
- W2792161256
- Semantic Scholar
- 2e49c40b1734132ec2693407aa692ffffbf66aee
- Cited by
- 128
- References
- 61
- Citations by year
- 2026: 29 · 2025: 17 · 2024: 17 · 2023: 15 · 2022: 16 · 2021: 15 · 2020: 12 · 2019: 5 · 2018: 2
- FWCI
- 1.44
- Type
- journal article
- Language
- en
- Open access
- green
- doi.org
- Locations
- Clinical Psychology & Psychotherapy (publishedVersion)
- PubMed (publishedVersion)
- Insight (University of Cumbria) (acceptedVersion)
- Newcastle University ePrints (Newcastle Univesity)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Counseling Practices and Supervision
- Keywords
- therapeutic relationship, cognitive behavioral therapy, depression, treatment outcomes, rater differences, moderators
- MeSH terms
- Adult, Depressive Disorder, Humans, Professional-Patient Relations, Cognitive Behavioral Therapy, Treatment Outcome
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