One size does not fit all: Examining heterogeneity and identifying moderators of the alliance-outcome association

Sigal Zilcha-Mano, Paula Errázuriz

Research output: Contribution to journalArticlepeer-review


Although the alliance-outcome association is one of the most consistent findings in psychotherapy research, it is also highly heterogeneous. Little is known about the factors explaining this variability, and consequently there is a lack of adequate knowledge about how to utilize this association to improve treatment. The present study had the following objectives: (a) to examine the associations between within-and between-individual variability in alliance and outcome, controlling for previous symptomatic levels; (b) to examine the duration of the alliance-outcome association; and (c) to examine potential moderators of the alliance-outcome association. A total of 547 patients treated in a primary care psychotherapy setting in Chile were randomly assigned to 5 feedback conditions. The alliance-outcome association was analyzed using multilevel models, disentangling changes in alliance within-individuals from alliance between-individuals. Patient and therapist characteristics were examined as potential moderators. Findings suggest that patients who reported a better early alliance also reported a better outcome. Furthermore, patients reporting time-specific improvement in alliance also reported a greater reduction in symptoms. The unique effect of alliance on outcome at one point in time is maintained for a period of 2 weeks. Patients with more severe symptoms and longer treatments benefited more from a good alliance. Therapists identifying themselves as more integrative in their treatment orientation were able to better utilize good alliances for treatment success. Finally, the size of the alliance-outcome association can be manipulated by feedback to therapists.

Original languageEnglish
Pages (from-to)579-591
Number of pages13
JournalJournal of Counseling Psychology
Issue number4
StatePublished - 1 Oct 2015

Bibliographical note

Publisher Copyright:
© 2015 American Psychological Association.


  • Alliance
  • Feedback
  • Moderation
  • Outcome
  • Psychotherapy processes

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Clinical Psychology
  • Social Psychology


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