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

Christoph Flückiger*, Julian Rubel, A. C. Del Re, Adam O. Horvath, Bruce E. Wampold, Paul Crits-Christoph, Dana Atzil-Slonim, Angelo Compare, Fredrik Falkenström, Annika Ekeblad, Paula Errázuriz, Hadar Fisher, Asle Hoffart, Jonathan D. Huppert, Yogev Kivity, Manasi Kumar, Wolfgang Lutz, John Christopher Muran, Daniel R. Strunk, Giorgio A. TascaAndreea Vîslă, Ulrich Voderholzer, Christian A. Webb, Hui Xu, Sigal Zilcha-Mano, Jacques P. Barber

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

127 Scopus citations


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.

Original languageAmerican English
Pages (from-to)829-843
Number of pages15
JournalJournal of Consulting and Clinical Psychology
Issue number9
StatePublished - Sep 2020

Bibliographical note

Publisher Copyright:
© 2020 American Psychological Association.


  • Early response
  • Individual participant data meta-analysis
  • Process-based therapy
  • Within-patient effects
  • Working alliance


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