Matching Clinician and Patient Traits to Improve the Therapeutic Alliance

Therapeutic alliance was a strong predictor of treatment outcomes, highlighted Loren Martin, PhD.¹ The patient’s own willingness to change was the number 1 predictor and the alliance was number 2, so strengthening the alliance could indirectly influence willingness to change, he said. Patients with a strong bond followed through on homework assignments and worked on tasks tied to their therapy goals.

Martin said the bond between care provider and patient drove that engagement. “It’s really because of that relationship, the bond that’s formed, that it really gets the client to buy into the therapy.” Not every clinician in training was prepared to form that bond. Therapist effects were first reported by David Ricks in a case study contrasting a “supershrink” with outstanding outcomes against a “pseudoshrink” with very poor outcomes. Okiishi and colleagues later followed outcomes in a larger group of therapists and identified a supershrink cohort and a pseudoshrink cohort.² This literature prompted Martin’s interest in leveraging therapists’ personal attributes to improve the alliance. Personality factors were among the attributes predictive of a strong alliance and positive outcomes. Some attributes were easier to modify than others. Secure attachment was important for a strong alliance but harder to change, and therapists may have needed to work on it for some time to develop a more secure attachment style. Martin noted that clinicians remained malleable and could change over time.

Pairing also affected the alliance, and some therapist-patient combinations were simply not the right fit. Martin’s group had identified therapist attributes predictive of a strong alliance and was now identifying the patient profiles that paired with them. The work was motivated by help-seeking patterns. “The data shows us that most people who need mental health support never seek it. And out of those that do, most of them shop around for a therapist,” Martin said. Identifying compatible traits could make patients who did seek care more likely to bond with their initial therapist rather than cycle through several.

Dr Martin is vice provost of research, innovation, and partnerships and the George B. and Joy Rathmann Endowed Professor at Keck Graduate Institute, as well as an adjunct professor in the doctoral program in clinical psychology at Azusa Pacific University.

References

1. Okiishi J, Lambert MJ, Nielsen SL, et al. Waiting for supershrink: an empirical analysis of therapist effects. Clin Psychol Psychother. 2003;10(6):361-373.

2. Flückiger C, Del Re AC, Wampold BE, et al. The alliance in adult psychotherapy: a meta-analytic synthesis. Psychotherapy (Chic). 2018;55(4):316-340.