How Does the Therapeutic Relationship Contribute to Change?

Collaboration, empathy, rupture repair and the evidence for relational change

Level: Introductory
Reading load: 10 core readings in 5 units
Prerequisites: No clinical training is required. How Does Psychotherapy Produce Change? and How Do We Know When Psychotherapy Helps—or Harms? provide useful preparation. Several statistical papers are demanding; the guides explain the comparisons that matter.
Last reviewed: September 2026

Introduction

Feeling understood, agreeing on a goal, and working together are related experiences, though any one may exist without the others. Improvement can strengthen a therapeutic relationship; the relationship may also help make improvement possible. The familiar phrase therefore contains several research questions. To understand its contribution, we must distinguish what is shared, whose perspective is measured, and which direction an influence takes.

This path begins by defining and measuring the working alliance: goals, tasks and bonds. It then distinguishes empathy from alliance and examines the evidence linking both with outcomes. A conceptual model and a synthesis of studies that follow relationships and outcomes over time ask whether changes within a person support a stronger account than comparisons between people. The next pair examines how strains or breakdowns in collaboration might be repaired, contrasting clinicians’ judgments with an intervention on training. Finally, therapist-level analysis and randomized client allocation ask what explains differences among those providing care.

By the end, you should be able to distinguish different aspects of the relationship and the perspectives from which they are assessed, separate prediction from explanation, identify what an intervention actually changed, and propose a stronger test of a relational claim. Clinical examples give the questions substance; the syllabus is about understanding evidence, not learning to deliver therapy.

Unit 1 of 5

What is the alliance, and how can it be measured?

Bordin gives collaboration a structure that extends beyond warmth. Horvath and Greenberg then show the choices involved in making that structure measurable. Keep a useful conceptual distinction separate from evidence that questionnaire subscales capture distinct things.

Reading
1 of 10
Goals, Tasks and Bonds
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885
Foundational argument · Moderate · Full work: 9 pages
Connect goals, tasks and bonds to a concrete disagreement about therapy.
Why you’re reading it. Give the later studies a clearly defined claim to investigate.
A question to consider. A client trusts the therapist but sees no point in a proposed activity: which parts of the alliance are implicated, and what would you need to ask before interpreting the disagreement?
Reading
2 of 10
Measuring the Working Alliance
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223–233. https://doi.org/10.1037/0022-0167.36.2.223
Methodological contribution · Moderate · Full work: 11 pages
Compare the theory’s three components with the evidence about their measured overlap.
Why you’re reading it. See what is gained and lost when a relational idea becomes a score.
A question to consider. If client and therapist total scores agree but their task ratings differ, what would be obscured by reporting only the totals?

Unit 2 of 5

Which relationship qualities are associated with improvement?

Empathy and alliance overlap but answer different questions. These syntheses let you compare definitions, perspectives and bodies of evidence without treating their correlations as independent shares of a treatment’s causal effect.

Reading
3 of 10
Understanding Another Person in Therapy
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410. https://doi.org/10.1037/pst0000175
Major synthesis · Contemporary update · Moderate · Full work: 12 pages
Distinguish feeling understood from agreement about therapeutic work, and compare the different empathy measures.
Why you’re reading it. Extend the relationship beyond alliance while keeping measurement precise.
A question to consider. How could someone feel understood but reject the treatment’s goals, and what evidence would establish each part of that account?
Reading
4 of 10
Alliance and Outcome Across Adult Psychotherapies
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172
Major synthesis · Challenging · Full work: 25 pages
Track how population, assessment timing, rater and outcome enter the pooled association.
Why you’re reading it. Judge the breadth of an empirical pattern before assigning it a cause.
A question to consider. Why could you not add the empathy and alliance correlations to calculate how much of improvement the relationship causes?

Unit 3 of 5

Does collaboration produce change, follow it, or both?

Zilcha-Mano separates stable relational tendencies from changes during treatment. The individual-participant synthesis then follows alliance and symptoms over early sessions. Ask what repeated measurement resolves and what it leaves dependent on assumptions.

Reading
5 of 10
Is Alliance Itself Therapeutic?
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72(4), 311–325. https://doi.org/10.1037/a0040435
Foundational argument · Methodological contribution · Challenging · Full work: 15 pages
Treat the trait-like/state-like distinction as a model with testable commitments.
Why you’re reading it. Specify an account of relational change that goes beyond a general association.
A question to consider. State one prediction that distinguishes the proposed change process from a stable tendency to rate both relationships and life circumstances favorably.
Reading
6 of 10
Alliance and Symptoms: Which Changes First?
Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., Compare, A., Falkenström, F., Ekeblad, A., Errázuriz, P., Fisher, H., Hoffart, A., Huppert, J. D., Kivity, Y., Kumar, M., Lutz, W., Muran, J. C., Strunk, D. R., … Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843. https://doi.org/10.1037/ccp0000594
Methodological contribution · Major synthesis · Challenging · Full work: 15 pages
Use the timing diagram to compare both directions and the intervals they span.
Why you’re reading it. Apply the conceptual distinction to repeated observations without treating temporal order as randomization.
A question to consider. If a client’s alliance and symptoms both improve after an outside stressor resolves, what could the fitted temporal associations still fail to identify?

Unit 4 of 5

What could repair a rupture, and can therapists learn it?

A strained alliance need not announce itself as an argument. Eubanks and colleagues make clinicians’ proposed responses inspectable, including their judgments about timing. Muran’s training study changes the process itself. Distinguish a plausible response, a changed interaction and an improved final outcome.

Reading
7 of 10
How Clinicians Propose Repairing Ruptures
Eubanks, C. F., Burckell, L. A., & Goldfried, M. R. (2018). Clinical consensus strategies to repair ruptures in the therapeutic alliance. Journal of Psychotherapy Integration, 28(1), 60–76. https://doi.org/10.1037/int0000097
Methodological contribution · Moderate · Full work: 17 pages
Compare withdrawal and confrontation situations, then separate expert ratings from evidence of what actually helped clients.
Why you’re reading it. Use clinical knowledge to generate testable ideas about repair.
A question to consider. A client becomes agreeable but stops discussing important concerns: what competing interpretations should be considered before calling the alliance repaired?
Reading
8 of 10
Can Training Change Therapeutic Interactions?
Muran, J. C., Safran, J. D., Eubanks, C. F., & Gorman, B. S. (2018). The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders. Journal of Consulting and Clinical Psychology, 86(4), 384–397. https://doi.org/10.1037/ccp0000284
Methodological contribution · Landmark empirical study · Challenging · Full work: 14 pages
Identify the staggered introduction of training and the specific process measures that changed.
Why you’re reading it. Evaluate an intervention intended to improve collaboration.
A question to consider. How would you extend this design to test whether the training improves clients’ valued outcomes, including retention and unwanted effects?

Unit 5 of 5

What explains differences among therapists and dyads?

Baldwin’s analysis separates variation across therapists from variation among their patients. Anderson’s study adds randomized client allocation to selected therapist conditions. Close by stating exactly which comparison supports each inference, while keeping individual fit and the limits of the samples visible.

Reading
9 of 10
Separating Therapist and Patient Variability
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842–852. https://doi.org/10.1037/0022-006x.75.6.842
Methodological contribution · Challenging · Full work: 11 pages
Translate the multilevel comparison into therapist averages and patients’ deviations from those averages.
Why you’re reading it. Avoid assigning one overall correlation to a single participant or process.
A question to consider. If therapists with stronger average alliances have better outcomes, how could case assignment still explain part of the pattern?
Reading
10 of 10
Therapist Interpersonal Skills in a Randomized Comparison
Anderson, T., Crowley, M. E. J., Himawan, L., Holmberg, J. K., & Uhlin, B. D. (2016). Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychotherapy Research, 26(5), 511–529. https://doi.org/10.1080/10503307.2015.1049671
Landmark empirical study · Methodological contribution · Moderate · Full work: 19 pages
Distinguish randomized allocation from pre-existing therapist characteristics and from an intervention that teaches skills.
Why you’re reading it. Bring the causal argument to a design with a stronger comparison and explicit limits.
A question to consider. What does this study add to Baldwin’s design, and what further experiment would establish that improving a particular interpersonal skill improves outcomes?

Scope and omissions

The emphasis is individual adult psychotherapy and the relationship within treatment. It covers collaboration, empathy, measurement, temporal evidence, rupture repair, training and therapist variability. It does not equate the relationship with alliance or provide an exhaustive account of genuineness, positive regard, transference or all forms of responsiveness; an optional conceptual extension addresses that broader terrain.

Much of the evidence comes from Western settings, including university samples and a specialist outpatient programme. Children, families, groups, mandated care, cultural differences and digital treatment require additional evidence. These limits matter to the meaning of collaboration as well as to effect estimates. The later paths in this area develop several of those settings. Neither a strong alliance nor a high empathy score guarantees useful, safe or lasting treatment.

Synthesis

The therapeutic relationship contains several possible contributions to change: agreement on goals and tasks, bonds, empathy, responsiveness, and repair. Their associations with outcomes invite explanation without settling causal direction. Repeated observations, training interventions, and comparisons among therapists add different evidence. A strong account identifies the relational process, the perspective from which it is measured, and the valued outcome it is proposed to influence.

Choose one claim about how a therapeutic relationship contributes to change. Name the construct, whose perspective measures it, the desired outcome and the time interval. Describe the proposed process in ordinary language.

Give an alternative account based on earlier improvement, a shared influence, or differences in patient assignment. State which unit of comparison is needed: people, occasions within a person, therapists, or randomized conditions. Propose a feasible test and explain what even a favorable result would leave uncertain.

Add a disagreement or rupture to your example. Distinguish a clinician’s plausible response from evidence of successful repair and from evidence that the repair changed a valued outcome. Include a way to notice withdrawal, unwanted effects or a strong relationship that is not helping.

Return to How Do We Know When Psychotherapy Helps—or Harms? to develop the outcome and comparator in your proposed test. How Does Psychotherapy Produce Change? places relational explanations alongside other accounts of therapeutic change.

To examine activity, exposure, appraisal and the evidence distinguishing therapeutic procedures from mechanisms, continue with How Do Behavioral and Cognitive Interventions Produce Change?.