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.
Bibliographical noteFunding Information:
There is no prior manuscript that analyzed this set of data. Furthermore, there is no manuscript submitted or in pipeline that is based on the present dataset. We do not intend to further publish any manuscript with the same set of data. This study was supported by the Swiss National Science Foundation (Grant PP00P1_163702) and the Foundation for Research in Science University of Zurich (Grant: STWF-19-018; Principal investigator: Christoph Flückiger). We are very thankful for the investigators and authors of the primary studies for their contribution to this meta-analysis. The authors’ list and its alphabetic order do not represent the sequence of engagement of the primary study investigators to collect their datasets, and it does not represent the conceptual and methodological innovations of all the authors engaged in the primary manuscripts. More explicit standards are necessary on how to conduct meta-analysis that investigates individual participant datasets, particularly when integrating future open source datasets.
© 2020 American Psychological Association.
- Early response
- Individual participant data meta-analysis
- Process-based therapy
- Within-patient effects
- Working alliance