Within-patient perceptions of alliance and attunement: Associations with progress in psychotherapy

Katie Aafjes-van Doorn, Avigail Bar-Sella, Sigal Zilcha-Mano, Xiaochen Luo, George Silberschatz, David Kealy, James McCollum, John Snyder

Research output: Contribution to journalArticlepeer-review


The most frequently examined aspect of the therapeutic relationship is the working alliance, which reflects the conscious collaborative bond, and agreement on task and goal. In addition to the established importance of the working alliance, the therapists' attunement and responsiveness might reflect another important aspect of the therapeutic relationship that can be considered in relation to session-by-session progress over treatments. Emerging research suggests that the quality of the working alliance not only differs between patients but also within patients over time. However, little is known about the quality of the therapeutic relationship between and within patients in relation to progress in psychotherapy. We examined fluctuations of the working alliance measure (WAI) and the newly developed measure of the Patients' Experiences of Attunement and Responsiveness (PEAR) during treatment in a naturalistic sample of patients in an outpatient psychotherapy clinic. Multilevel modelling was used to examine the respective contribution of these measures to subsequent improvement in psychological functioning longitudinally. Results suggest that the within-patient effect, instead of between-patient effect, was significant for WAI (and did not reach significance for PEAR), indicating that the fluctuation of WAI was predictive of psychological functioning in the subsequent month. Based on these findings, therapists and their patients might benefit from regular tracking of the patient-reported working alliance. The findings underscore the importance of the alliance, specifically at the within-patient level. It also highlights the challenge for research to tap into other aspects of the therapeutic relationship that can help explain progress in therapy. Given the breadth and accessibility of the working alliance construct, more work is needed for researchers to examine the construct of attunement and responsiveness.

Original languageEnglish
Pages (from-to)1717-1727
Number of pages11
JournalClinical Psychology and Psychotherapy
Issue number5
StatePublished - 1 Sep 2022

Bibliographical note

Publisher Copyright:
© 2022 John Wiley & Sons, Ltd.


  • OQ
  • attunement
  • psychotherapy change
  • responsiveness
  • working alliance

ASJC Scopus subject areas

  • Clinical Psychology


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