The therapeutic alliance is one of the most studied therapeutic variables with an undisputed importance for psychotherapy—both from a clinical and scientific point of view (e.g. Norcross & Lambert, 2018
). In line with findings that different treatment approaches yield similar outcomes, analyzing potential differences in alliance between treatment forms has not revealed significant differences either (Doran, 2016
; Flückiger et al., 2012
; Horvath et al., 2011
). Therefore, a number of empirical studies have investigated specific elements (e.g. therapist self-disclosure: for an overview see Köhler et al., 2017
) in relation to the therapeutic alliance (for an overview see Norcross & Lambert, 2018
). To our knowledge, however, there are no studies so far that have looked into the formation of an initial alliance in a realistic, face-to-face counseling setting in dependence of counselors’ interpersonal style in the context of an experimental design. As a first step, it seems important to look more closely at the possibility for counselors to actively and deliberately shape their interpersonal style and thus stimulus character. Such an experimental variation is needed initially in order to gain differential insight into the formation of a viable alliance. By connecting alliance formation to interpersonal behavior of the therapist, we can address a central question in psychotherapy research—what works for whom?
—which has been raised repeatedly since its first mention by (Gordon L. Paul in 1969
; Hofmann & Hayes, 2019
; Kazdin, 2007
; Norcross & Wampold, 2010
). It is essential to unravel the mechanisms behind the working alliance in order to better tailor its formation and use to the individual patient’s needs.
For the present study, we refer primarily to the pan-theoretical model of the working alliance by Bordin (1979
) and focus on its definition and operationalization. We will thus use this terminology throughout the article. According to Bordin, three components must be fulfilled in order to achieve a good working alliance: (a) agreement regarding goals between patient and therapist, (b) agreement about tasks in order to reach these goals, and (c) a strong emotional bond. Bordin's conceptualization of the working alliance has provided one of the most robust, well empirically grounded, and widely used to date (Doran, 2016
Within the contextual model formulated by Wampold and Imel (2015
) and the ongoing debate of specific vs. nonspecific factors of psychotherapy, the alliance is discussed as a common factor among others such as patients’ expectations regarding treatment or therapist effects (Mulder et al., 2017
; Wampold, 2015
). A reciprocal link has been proven between alliance and outcome, showing a moderate, robust correlation (Ardito & Rabellino, 2011
; Horvath et al., 2011
; Martin et al., 2000
) of approximately 8% of shared variance (Flückiger et al., 2018
; Horvath et al., 2011
). A recent meta-analysis has found evidence for the causal link of better early alliance prediciting better outcome, which advocates alliance as a main mechanism of change (Flückiger et al., 2020
The Role of the Therapist and Therapeutic Interpersonal Style
Descriptions of alliance emphasize the collaboration between both therapist and patient—making it a dyadic phenomenon to which both contribute (Barber et al., 2010
). There is sound evidence regarding the impact of the therapist’s role in relation to the alliance-outcome link (Baldwin et al., 2007
; Del Re et al., 2012
; Flückiger et al., 2018
). Wampold and Imel (2015
) consider the therapist one of the most influential therapeutic factors (see also Dinger et al., 2017
). In their meta-analysis, Del Re et al. (2012
) showed that variance in the therapist's ability to form an alliance with the patient is more important regarding therapy outcome than variance between patients. In other words, there are therapists who—due to their behavior or specific characteristics—can build strong relationships across many patients, and others, who are less able to do so (also see Dinger et al., 2017
). As the therapeutic alliance is formed in the early stages of therapy and thus has an early impact on therapy outcome, the client’s first impression of the psychotherapist may have a direct impact on client satisfaction and seems to be quite consistent over time (Bar et al., 2006
; Flückiger et al., 2020
; Wampold, 2015
). The therapist’s behavior is a prerequisite for how the relationship between patient and therapist is formed at this early stage. Competence and skill of therapists are key influencing factors, while treatment and in-session processes have an inherently nested nature. For current literature, please see Kazantzis (2018
) for an introduction and overview to a special issue on processes of CBT and Kazantzis et al. (2018
) for a review of meta-analyses on the matter.
There is a growing body of literature that addresses the question of how interpersonal behavior or the interpersonal stimulus of a therapist relates to the formation and maintenance of alliance and outcome, embedded into interpersonal theory by classifying the therapeutic interpersonal impression in the Interpersonal Circumplex (Kiesler, 1983
). Within the model, interpersonal behavior is characterized on two main axes within a circumplex model: (a) the communion/affiliation/warmth axis and (b) the axis of agency/dominance. The first axis addresses the extent to which a person portrays approach behavior, with opposite poles (warm behavior vs. cold/hostile behavior). Warmth/friendliness can be considered a key component of empathy. It grasps perceived intention and motives, friendliness, helpfulness, sincerity, trustworthiness, and morality and when considering the interpersonal circumplex, the way we perceive a person’s warmth determines our approach-avoidance behavioral tendencies towards them (also see Fiske et al., 2006
). For example, a person’s friendly interpersonal style increases the chance for others to behave in a friendly manner in turn. The agency axis considers dominant vs. submissive behavior. Based on these axes, the model consists of eight dimensions of interpersonal behavior that are in a circular relationship to each other. As such, a category is positively correlated with adjacent categories and less positively correlated with more distant categories, with opposite categories being negatively correlated (Kiesler, 1983
). Complementary response tendencies can be derived from here, i.e., how we behave towards others under certain conditions (e.g., friendly behavior entailing friendly behavior in return).
So far, studies that aim to examine different therapeutic styles and its contribution to a facilitative alliance-outcome relation have mostly concentrated on therapists’ agency (e.g. Choi et al., 2020
; Karno & Longabaugh, 2005
). Since the distinction between a directive and non-directive style can be traced back to the different psychotherapeutic orientations of Albert Ellis and Carl Rogers (see Kiesler & Goldston, 1988
), this concept has been historically more consolidated than the distinction based on affiliation. Moreover, in dismantling and investigating specific variances in therapeutic styles, studies to date have used analogue experimental designs with no direct interpersonal contact between a counselor/therapist and client/patient. For example, Moors and Zech (2017
) investigated the effects of psychotherapists’ interpersonal styles when interacting with patients. In a laboratory experiment, videos with distinctive therapeutic behaviors were used to simulate a first psychotherapy session with participants. The results showed that besides agency, warmth was identified as an additional predictor of client satisfaction. These effects depended on the clients’ own interpersonal agentic profiles, but therapists’ warmth seems to be essential regarding client satisfaction. In addition, empirical evidence suggests that therapists’ or counselors’ warmth positively impacts the therapeutic alliance (Ackerman & Hilsenroth, 2003
; Dinger et al., 2007
). Studies also show that friendliness and perceived empathy as well as authenticity of the therapist are important aspects for patients when rating the therapeutic alliance (Bedi et al., 2005
; Nienhuis et al., 2018
). Warmth and thus validation may also have an impact on the emotional state of patients, as Benitez et al. (2019
) were able to show that—in ongoing psychotherapy—therapist’s use of validation strategies was linked to a decrease in negative affect for patients, while experiencing invalidation increased perceived negative affect after the session. This line of research is still in the early stages, but may indicate that for clients or patients, perceived warmth may present a key facilitator in an initial therapeutic encounter for a viable alliance and therapeutic success. In turning to placebo research in medicine, there are isolated studies that modulated the therapeutic style experimentally regarding perceived empathy (Kaptchuk et al., 2008
) as well as both warmth and competence (Howe et al., 2017
), showing a positive, independent effect on the placebo response for both factors.
Purpose of the Present Study
Building on these initial findings, it seems relevant to further explore the effects of therapists’ interpersonal behavior—especially with regard to the affiliation/warmth axis—on patient perception. Although the alliance concept is a broadly investigated variable, previous methodological approaches are limited in taking a closer look at the actual process of the alliance formation under realistic, face-to-face conditions and have not sufficiently considered the role of therapists’ interpersonal behavior. It should be kept in mind that dismantling studies regarding the alliance in clinical samples are difficult to realize due to ethical reasons (Flückiger et al., 2018
). Therefore, unraveling how a therapist’s interpersonal style should be shaped in a first contact to be positively perceived by both patient and therapist seems an important, promising perspective. To our knowledge, no studies have yet pursued this path by experimentally varying the therapeutic style in a non-laboratory, realistic setting. This study presents a novel experimental approach under realistic conditions to contribute as to how interpersonal therapeutic behavior might facilitate good alliance formation and overall outcomes by examining its effects on client perception of alliance.
Therefore, we sought to actively manipulate two interpersonal therapeutic styles—with regard to the affiliation/warmth axis in the interpersonal circumplex—by means of an experimental pilot project. In a single psychological counseling session regarding interpersonal conflicts of university students, counselors took on (a) a warm, friendly, and self-disclosing style (high affiliation relational style) or (b) a more psychoeducative and neutral role (neutral/distant relational style). The two styles were classified and verified according to the Interpersonal Circumplex (Kiesler, 1983
) and were realized in a randomized two-group design in order to compare the two conditions. Our primary aim was to test whether our specific experimental variation of the interpersonal style was feasible under non-laboratory, realistic conditions in the context of a single counseling session. In an exploratory fashion, we wanted to further investigate whether the style influenced the perception of the client-rated working alliance. Due to the above described limited research on which style is helpful for which client as well as the fact that basic therapeutic principles such as empathy were met in both conditions and these were based on evidence-based treatment guidelines as described in more detail in the methods section, we did not specify any predictions. In addition, we expected symptom severity of clients to decrease by means of the session and we investigated whether there were differences between the conditions.
To our knowledge, the present study is the first to look into the formation of an initial alliance in (a) a realistic, face-to-face counseling setting and (b) in dependence of counselors’ interpersonal style in the context of an experimental design. We were able to demonstrate the feasibility of an experimental variation of the therapeutic style that created different interpersonal impressions of counselors concerning their warmth/affiliation (i.e., friendliness and hostility). Their successful realization of the two styles was confirmed by an extensive rating. In addition, alliance was rated highly in both styles by clients.
Realization of the Two Styles
Ratings of the degree of affiliation by objective and trained raters speak to counselors’ successful realization of the two styles. In line with our theoretical assumptions in the interpersonal circumplex and the proposed conceptual differences, observers evaluated counselors friendlier and less hostile in the high affiliation condition. The friendlier counselors were rated, the higher the ratings of the degree of affiliation, indicating intended behavior in the defined area of action of the high affiliation condition (and vice versa for the hostile dimension and neutral/distant condition). These results underpin the theoretical interpersonal framework of varying the styles along the affiliation axis (see Fig. 1
Differences Between the Two Styles
Counselors’ Areas of Action and Perceived Interpersonal Impressions
Observers rated counselor behavior differently between the styles concerning friendliness and hostility in the interpersonal circumplex, while clients only rated it as such on a descriptive level. Interestingly, clients’ own interpersonal behavior was also not rated differently between the two styles by raters and observers. Since counselors were instructed to act with a friendly and empathic therapeutic stance per se and independent of the condition, we speculate that clients may have felt understood and supported to a similar extent. Thus, they may not have perceived counselors differently on the affiliation axis, e.g., not less friendly in the neutral/distant condition, especially since they had no comparison. Further, they may have intuitively reacted complementary to the perceived stimulus character of counselors, as proposed by the interpersonal complementarity principle (Kiesler, 1983
). A closer look at the interpersonal profiles reveals that they were indeed congruent in their mutual ratings of the other party, independent of the therapeutic style (also see Fig. 3
). Both counselors and clients showed similar high affiliation ratings, which is an important finding, considering that a therapist’s warmth has a large impact on client satisfaction and is necessary for initiating a good alliance, especially in the beginning of psychotherapy (Ackerman & Hilsenroth, 2003
; Moors & Zech, 2017
). This can be further underlined by findings of Dinger and colleagues (2007), who were able to show that higher affiliation values of clients also lead to an improved alliance. Counselors in our study were also perceived as being more agentic than clients—in accordance with the complementary principle—which is in line with research by Moors and Zech (2017
), who showed that it seems helpful for counselors to show some assertive instead of nonassertive behavior in a first session in order to increase client satisfaction. In considering agency and affiliation with regard to alliance formation, our results suggest that feelings of warmth may be more important for clients than feeling agentic (also see Cuddy et al., 2008).
Perception of the Therapeutic Alliance and Symptom Severity
The qualitatively high consistent alliance suggests that counselors were able to build a first viable therapeutic alliance in a single counseling session. We speculate that missing differences for clients may be explained by a high overall intrinsic motivation regarding the session, which can be linked to expectation effects and a rather positive perception of the session in general and its benefits (e.g., therapeutic alliance) (Kube et al., 2019
; Wampold, 2015
). Furthermore, clients showed more facilitative affiliation tendencies in both conditions (measured via the IIP), which can be linked to a good overall ability of our sample in realizing satisfying relationships with others and subsequently forming a viable alliance with their counselor. Also, basic Rogerian therapeutic principles such as empathy were similarly applied in both styles, presumably entailing a positive effect on clients’ alliance perception. As we controlled for possible counselor effects, the positively rated alliance and non-significant differences as rated by clients cannot be traced back to a missing conceptual differentiation of the styles or insufficient counselor adherence.
Our results suggest that a consistently good alliance and symptom reduction seem to be established regardless of the two manualized interpersonal styles in a single counseling session as long as basic Rogerian principles are met, from which we can cautiously assume its effectiveness for healthy university students with interpersonal problems. As especially early alliance is positively associated with consecutive therapeutic success (e.g. Zilcha-Mano et al., 2016
), our results could provide preliminary evidence for positive longer-term effects of such a single counseling session. The alleviation of symptom severity can be very well integrated into study findings on single-session psychotherapy, where effectiveness has been well established for intrapsychic and interpersonal problems, parenting factors, crisis interventions, and as an additional treatment component for medical conditions (Bloom, 2001
; Cardamone-Breen et al., 2018
; Pinkerton & Rockwell, 2010
). In particular, single-session approaches to interpersonal conflicts have been shown to be efficient and effective in studies (Brown, 1984
; Schwebel, 1985
), matching our results.
Strengths and Limitations
We want to point to the novel experimental design, which we carefully developed on the basis of the already discussed practical and theoretical considerations. In order to minimize the risk of bias and thus enhance validity of the study, we conducted a computer-based randomization by an independent trained student assistant and our objective raters were blinded trained student assistants. We also took a closer look at the three subscales of the WAI-SR, yielding more differential results, as this three-factor structure has been validated in previous studies (e.g. Munder et al., 2010
), but is oftentimes not considered.
At the same time, we wish to address several limitations with regard to the study design. The generalizability of our results is limited, as the study sample was healthy by pre-selection and comprised of rather young students. As participants self-selected into the study, it is not truly representative of realistic clinical conditions such as psychotherapy, so that results must be interpreted against this backdrop. Despite these slight constraints, we would like to emphasize that we conducted actual counseling sessions with real clients, counselors, and interpersonal problems, and did not employ analogue experimental designs with no direct interpersonal contact between client and counselor (e.g., using video simulation; also see Moors & Zech, 2017
). Another limitation of our study arises from the sample size, which limits statistical power and may be inadequate to detect an effect, as we did not calculate an a-priori power analysis. We would also like to note that counselors were not blinded to the session and we did not assess their preferences and expectations towards the styles, so we cannot rule out possible preferences for one condition or the other (also see perceived fit). In addition, only four counselors conducted the sessions, which limits the statistical power. As we did not conduct a prior study of the psychometric properties of the ratings of the degree of affiliation, we have to label it as a non-validated scale with possible underlying circular reasoning. However, moderate to excellent internal consistencies and ICC scores can be considered positive indicators of this scale. A further limitation stems from the complexity of the therapeutic process, as the interaction between client/patient and counselor/therapist can only be partially depicted within our study design. A multitude of interacting and interdependent variables have to be considered and the experimental variation (a) only targeted one specific variable and (b) could not control and account for dynamic, natural forces within the therapeutic process. Another shortcoming relates to the single nature of the session and the single alliance assessment. In addition, we did not include a follow-up measurement. Accordingly, temporal implications are limited regarding alliance, symptom change, and especially their stability.
Albeit our study consists of a non-clinical sample, our results hold promising research and clinical implications we wish to address. The question of whether they can be transferred to a clinical population remains open for now and poses some ethical issues. However, we argue that although our study sample was healthy, the results may also be of interest to clinical practice (particularly psychotherapy), as the interpersonal conflict was perceived as a psychological burden by clients.
In clinical practice, the first encounter between client and counselor is decisive and guiding for clients, especially in light of the oftentimes high burden of client suffering. In this context—and while considering a possible underpowering of the study—it is interesting that it may not be as important to clients what interpersonal style counselors use with regard to their perception of alliance and symptom relief. As such, counselors and therapists may have more freedom in choosing an interpersonal style that seems fitting with their own characteristics and stance and in consequence seems fitting for the client. Other variables, such as personality, trait/state like alliance, or the interpersonal stimulus character may be more important and should be considered. Also, counselors’ interpersonal style may not be so relevant in a single session with regard to clients’ alliance perception but may become more important for longer-term encounters and therapies. Zuroff et al. (2007
) were able to show that the perceived friendliness of therapists increases the autonomous motivation of patients, which in turn is positively linked to alliance and outcome. Hence, increasing therapists’ friendliness to a certain extent may prove beneficial, especially in a first contact or in clinical settings—with limited time to attend to the patient and alliance formation. As there is a call of therapists for training with regard to adequately delivering therapeutic interventions to patients (Fairburn & Cooper, 2011
), starting points could be interpersonal behavior and impressions of therapists. This could increase patients’ autonomous motivation for planned interventions and thus strengthen therapeutic alliance (De Nadai et al., 2014
), as well as enrich empirical input for already existing alliance focused trainings (Eubanks-Carter et al., 2015
). We should also consider that it may not be as important.
As our results suggest the effectiveness of a one-time psychological counseling session for healthy individuals with an interpersonal burdened conflict, this entails that such sessions may serve as stand-alone interventions and provide the possibility of an easily accessible, cost-effective approach as primary and secondary prevention strategies. It has been shown that time-limited psychotherapy offers, such as short-term therapy or one-time interventions, seem to be equally effective as time-unlimited offers (Bloom, 2001
). This should be kept in mind and seems a promising alternate and additional approach, considering the continuously rising costs in our health care systems. Another argument for single-session or short-term psychotherapy is that therapeutic progress occurs in the initial phase of therapy and the curve flattens over time (Bloom, 2001
). Patients who show an early response in treatment also show better and more stable treatment outcomes compared to patients who show delayed or no response (Lambert, 2005
In clinical practice, alliance must always be seen within the context of therapists’ ability to form alliances, patients’ features that facilitate or hinder its formation, and their interaction. Our experimental design provides a feasible way and basis to examine and compare different aspects of the alliance in relation to the therapeutic interpersonal style and characteristics of clients and counselors in future studies. The differentiation between a trait-like component of alliance, comprising the patient’s ability to form sustainable social relationships, and a state-like component of alliance, defined as changes within the therapeutic alliance, should also be considered (see Zilcha-Mano, 2017
). It is suggested that state-like changes in alliance can result in trait-like changes within patients regarding symptomatology, quality of life, and perception of interpersonal relationships (Crits-Christoph et al., 2006
). In the present study, the nature of the single alliance assessment most probably targeted the trait-like alliance. We demonstrated the possibility of actively shaping different therapeutic styles. Longitudinal study designs with multiple alliance measures are needed to reveal differential results. This may yield an important clinical implication to keep in mind—the effect of changes in state-like alliance on further trait-like alliance as a possible therapeutic tool and change mechanism for counseling sessions and therapy—as it is done in specific treatment forms such as the Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000
) or Dialectic-Behavioral Therapy (DBT; Linehan, 1993
Conclusion and Outlook
Our results underline the possibility for counselors to actively and deliberately shape their interpersonal style and thus stimulus character, which may have consequences for the perception of the working alliance (Grosse-Holforth et al., 2014
; Zilcha-Mano et al., 2018
). Clearly, counselors and therapists integrate a large number of methods and techniques in their everyday clinical practice, and a dynamic structure emerges in which they adapt intuitively to the needs and behavior of the patient. However, precisely for this reason, it seems important to disentangle the two styles in this experimental design. As Norcross and Wampold (2018
) highlighted that therapists and counselors are indeed capable of adapting their style to fit patient and client characteristics, the present study can be seen as a supplemental experimental proof-of-concept and may present a small additional piece to the puzzle. With this experimental design, we are able to contribute methodologically to the current research landscape. It seems promising to investigate the effects of therapeutic behavior on patients’ perceptions and thus alliance and outcome and to explore how certain behavior might facilitate the formation of a sustainable alliance. Such an experimental variation is important as a first step to gain differential insights into this very formation and shaping of the alliance. By linking alliance formation to interpersonal therapeutic behavior, we can address the question of what works for whom.
It seems essential to decipher the underlying mechanisms of the alliance to better tailor it to the individual patients’ needs. Our design should encourage future research to unravel variables and active ingredients involved in the building and perception of the therapeutic alliance. Results may also indicate what variables to include in naturalistic settings. We are planning to provide more detailed information on differential relationship forming by analyzing possible mediating and moderating client and counselor characteristics such as personality traits, expectations and interpersonal problems. The focus on specific variables in this new experimental approach may present an important contribution to personalized treatment. Our novel experimental design may be helpful in regard to the question of an optimal individualized relationship style in the sense of what works for whom,
by taking a closer look at specific aspects of the therapeutic alliance itself as well as client/patient and counselor/therapist characteristics. The design may also be applied for specific research questions such as the possible role and function of interpersonal expectations as part of dismantling studies.
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