Back to overview

The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis.

Type of publication Peer-reviewed
Publikationsform Original article (peer-reviewed)
Author Flückiger Christoph, Rubel Julian, Re A. C. Del, Horvath Adam O., Wampold Bruce E., Crits-Christoph Paul, Atzil-Slonim Dana, Compare Angelo, Falkenström Fredrik, Ekeblad Annika, Errázuriz Paula, Fisher Hadar, Hoffart Asle, Huppert Jonathan D., Kivity Yogev, Kumar Manasi, Lutz Wolfgang, Muran John Christopher, Strunk Daniel R., Tasca Giorgio A., Vîslă Andreea, Voderholzer Ulrich, Webb Christian A., Xu Hui, Zilcha-Mano Sigal, Barber Jacques P.,
Project Design development in randomized clinical trials - Psychological treatment in generalized anxiety
Show all

Original article (peer-reviewed)

Journal Journal of Consulting and Clinical Psychologa
Volume (Issue) 88(9)
Page(s) 829 - 843
Title of proceedings Journal of Consulting and Clinical Psychologa
DOI 10.1037/ccp0000594

Open Access

Type of Open Access Repository (Green Open Access)


Objective: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. Method: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge.