What Makes Therapy Work? New Insights on the Therapeutic Alliance

The Research

A landmark 2023 meta-analysis published in Psychotherapy examined over 300 studies spanning 40 years of therapy research, including data from more than 30,000 clients. The researchers sought to answer a fundamental question: What actually makes therapy effective?

The findings challenge some common assumptions and confirm others:

The therapeutic alliance—the collaborative relationship between therapist and client—accounted for more variance in outcomes than the specific type of therapy used. In fact, the strength of the alliance predicted success across CBT, psychodynamic therapy, humanistic approaches, and other modalities.

Even more striking: therapist effects (individual therapist skill and qualities) accounted for 5-9% of outcome variance, which is actually larger than the variance explained by specific treatment models (less than 1% in most comparative studies).

Key Findings

✓ Therapeutic alliance predicts 7-10% of therapy outcomes
✓ Individual therapist effects are larger than therapy type effects
✓ Alliance strength can be reliably measured as early as session 3
✓ When alliance is strong, dropout rates decrease by 40%
✓ Client perception of alliance matters more than therapist perception

What is the Therapeutic Alliance?

The therapeutic alliance has three core components, first identified by researcher Edward Bordin:

1. The Bond: The emotional connection, trust, and mutual respect between therapist and client

2. The Goals: Agreement on what therapy is trying to achieve

3. The Tasks: Agreement on the activities and methods used to reach those goals

When all three align, therapy becomes a collaborative partnership rather than an expert-fixing-a-patient dynamic.

What Creates a Strong Alliance?

Therapist Qualities That Matter

Research identified specific therapist characteristics associated with better outcomes:

Empathic Attunement

Accurately understanding the client’s experience
Communicating that understanding back effectively
Not just sympathy, but deep comprehension

Positive Regard

Genuine warmth and acceptance
Non-judgmental stance toward all client disclosures
Belief in the client’s capacity for change

Authenticity

Being genuine rather than performing a therapist role
Appropriate self-disclosure when it serves the client
Acknowledging when uncertain or making mistakes

Cultural Humility

Recognizing limits of one’s own cultural knowledge
Actively learning about client’s cultural context
Adapting approach to fit client’s values and worldview

What Clients Bring

Alliance isn’t just about the therapist—clients contribute too:

Willingness to Engage: Clients who actively participate in therapy tasks show better outcomes

Hope and Expectancy: Belief that therapy can help predicts actual improvement

Honesty: Clients who can be vulnerable and honest (even about doubts regarding therapy) form stronger alliances

Feedback: Clients who share when something isn’t working allow therapists to adjust

Practical Applications

For People Seeking Therapy

Evaluate the Alliance Early

Research shows alliance quality is evident by session 3. Ask yourself:

Do I feel heard and understood?
Does my therapist seem genuinely interested in me?
Do we agree on what we’re working toward?
Do the homework assignments or exercises make sense for my goals?
Can I be honest about my concerns?

If Something Feels Off, Say So

Studies show that clients who voice concerns about the therapy relationship often experience strengthened alliances. Good therapists welcome this feedback.

Red Flags for Poor Alliance

Feeling judged or criticized
Therapist doing most of the talking
Goals feeling imposed rather than collaborative
Consistent misunderstanding of your concerns
Dismissal of cultural or identity factors important to you

Remember: Fit Matters

A highly skilled therapist who’s wrong for you will be less helpful than a good-enough therapist who’s a great fit. Trust your gut.

For Counselors & Practitioners

Measure Alliance Routinely

Use validated brief measures like the Session Rating Scale or Working Alliance Inventory every 3-4 sessions. Research shows therapists often overestimate alliance strength.

Repair Ruptures Quickly

Alliance ruptures happen—what matters is addressing them:

Notice signs: increased silence, intellectualization, arriving late
Name it directly: “I’m sensing some distance today. Did something not sit right last session?”
Take responsibility: “I may have moved too fast” or “I might have misunderstood”
Collaborate on repair: “How can we get back on track?”

Studies show successful rupture repair often strengthens alliance beyond baseline.

Adapt Your Approach

Research found that effective therapists adjusted their style to match client preferences:

Some clients want directive guidance; others need space to explore
Some value emotional expression; others prefer problem-solving
Some seek expert advice; others want collaborative discovery

Ask directly: “What are you hoping to get from our time together?” and “What approach has felt helpful to you before?”

Mind the Gap

Therapists and clients often have different perceptions of alliance strength. When in doubt, check in: “How are you feeling about our work together?”

Common Alliance Pitfalls

1. The “Expert” Trap

Operating from an expert-fixing-broken-client stance undermines collaboration. Research shows better outcomes when therapists position themselves as expert guides while clients remain experts on their own experience.

2. Technique Over Relationship

Following a treatment manual rigidly while ignoring alliance cues predicts poorer outcomes. The relationship is the foundation; techniques are the tools.

3. Cultural Misattunement

Studies show that when therapists don’t acknowledge cultural factors, racial/ethnic minority clients experience weaker alliances and drop out more frequently. Cultural responsiveness isn’t optional—it’s essential.

4. Avoiding Negative Feedback

Therapists who become defensive when clients express concerns damage the alliance. Research shows the best therapists actively solicit feedback about what’s not working.

Key Takeaways

The relationship matters more than the method: A strong alliance in any therapy type beats a weak alliance in “the best” therapy type
Alliance forms early: By session 3, you’ll know if it’s a good fit
It’s collaborative: Both people contribute to alliance quality
Ruptures are normal: What matters is noticing and repairing them
Speak up: Sharing concerns often strengthens the bond

For Researchers and Future Directions

Current research is exploring:

How alliance-focused training for therapists improves outcomes
The role of neurobiology in therapeutic connection
Alliance patterns in digital and teletherapy contexts
How to maintain alliance across cultural divides
Moment-to-moment alliance fluctuations within sessions

Final Thoughts

After decades of research comparing therapy approaches, the evidence points to a humbling truth: the relationship between therapist and client is one of the most powerful healing forces we have.

Technique matters. Training matters. Evidence-based practices matter. But without a foundation of trust, collaboration, and genuine human connection, even the most sophisticated interventions fall flat.

Whether you’re seeking therapy or providing it, investing in the quality of that relationship is one of the highest-leverage decisions you can make.

The research is clear: therapy works best when two people genuinely connect in service of growth and healing.