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Distinct roles of state-like and trait-like patient–therapist alliance in psychotherapy

Nature Reviews Psychology volume 1, pages 194–210 (2022)Cite this article

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Abstract

Hundreds of studies suggest that the patient–therapist alliance is the most consistent predictor of treatment outcome across patients, therapists, types of treatment and settings. Yet, the context-insensitive nature of this prediction makes it difficult to optimize alliance to benefit individual patients. To elucidate the potential roles of alliance in treatment, research published mainly in the past five years has distinguished between state-like strengthening of alliance throughout treatment from trait-like differences between individuals in alliance strength. In this Review, we synthesize the literature on state-like and trait-like alliance to shed light on for whom, when and why alliance predicts treatment outcome. Trait-like alliance is a product of patients’ and therapists’ intrapersonal and interpersonal characteristics, whereas state-like alliance reflects the therapeutic process evolving between them. Trait-like alliance mediates the effects of patient and therapist baseline characteristics on outcome, whereas state-like alliance is the mechanism by which alliance might drive therapeutic change. This synthesis reveals the importance of putting alliance into context for making progress toward personalized psychotherapy, in which the alliance is not merely a non-specific factor but an individual-specific mechanism of change.

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Fig. 1: The trait-like and state-like components of alliance and their origins.
Fig. 2: A continuum of treatments.
Fig. 3: The mechanisms underlying the association between trait-like and state-like alliance and treatment outcome.

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Acknowledgements

S.Z.-M. was supported by the Israeli Science Foundation grant no. 395/19 and the US–Israel Binational Science Foundation (BSF) grant no. 2017263. The authors thank R. Hatcher, S. Ziv-Baiman, J. Rubel, N. Solomonov, the members of the Psychotherapy Research Lab at the University of Haifa for their feedback on earlier drafts of the manuscript, and M. Malka for her help in creating drafts of the figures.

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    Sigal Zilcha-Mano & Hadar Fisher

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Glossary

Cognitive behavioural therapy

(CBT). A form of therapy aimed at modifying maladaptive thought processes and problematic behaviours through cognitive restructuring and behavioural techniques to achieve change.

Moderator

Variable that influences (statistically) the direction or magnitude of the relationship between an independent and a dependent variable.

Brief relational therapy

A form of therapy that involves ongoing tracking and exploring of patient–therapist interactions, and focuses on rupture resolution in their relationship.

Integrative cognitive therapy

A form of therapy that integrates humanistic and interpersonal interventions with cognitive therapy to resolve problems in the therapeutic relationship.

Alliance fostering therapy

A form of therapy that combines interpersonal-psychodynamic interventions with techniques used to enhance the alliance.

Mediation model

A model testing the effect of an intervening variable that accounts (statistically) for the association between the independent and the dependent variables.

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Zilcha-Mano, S., Fisher, H. Distinct roles of state-like and trait-like patient–therapist alliance in psychotherapy. Nat Rev Psychol 1, 194–210 (2022). https://doi.org/10.1038/s44159-022-00029-z

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