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

Baier, Allison L., Kline, Alexander C., Feeny, Norah C.·2020·Clinical Psychology Review

DOI 10.1016/j.cpr.2020.101921

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Abstract

The alliance-outcome relationship has been consistently linked to positive treatment outcomes irrespective of psychotherapy modality. However, beyond its general links to favorable treatment outcomes, it is less clear whether the alliance is a specific mediator of change and thus a possible mechanism underlying psychotherapy response. This systematic review evaluated research examining the alliance as a potential mediator of symptom change, reviewing study characteristics of 37 relevant articles examining the alliance-outcome relationship and the extent to which these studies met recommended criteria for mechanistic research. Alliance mediated therapeutic 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 discusses how adhering to requirements for process research will improve our ability to more precisely estimate how and to what extent alliance drives therapeutic change.

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Authors: Baier, A. L., Kline, A. C., & Feeny, N. C.
Affiliations: Case Western Reserve University (US)
Corresponding author: Baier, Allison L.
ORCID: Baier, Allison L.
Kline, Alexander C.
Feeny, Norah C.
Venue: Clinical Psychology Review
Publisher: Elsevier BV
Published: 2020-12
Volume: 82
Pages: 101921
ISSN: 0272-7358 (ISSN-L)
DOI: 10.1016/j.cpr.2020.101921
OpenAlex: W3087180323
Cited by: 441
References: 118
Citations by year: 2026: 79 · 2025: 111 · 2024: 105 · 2023: 74 · 2022: 60 · 2021: 12
FWCI: 2.89
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Clinical Psychology Review (publishedVersion)
PubMed (publishedVersion)
Funders: National Institute of Mental Health (R01 MH066348)
Topics: Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Social Sciences › Psychology › Clinical Psychology › Counseling Practices and Supervision
Keywords: therapeutic relationship, psychotherapy outcome, symptom change, process research, mechanistic research, mediation analysis, psychotherapy response
MeSH terms: Therapeutic Alliance, Humans, Professional-Patient Relations, Psychotherapy, Research Design, Treatment Outcome

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

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