The Alliance as a Prerequisite to Emotional Processing in Psychotherapy

Abstract

The quality of the therapeutic alliance has been shown to predict treatment outcomes across approaches to psychotherapy. However, the underlying mechanism by which the alliance leads to improvement remains to be clarified. In the emotion-focused therapy framework, it is theorized that a strong alliance facilitates emotional processing, which in turn leads to outcome. The hypothesis that a strong alliance creates the conditions for emotional processing has not been tested. Additionally, while research on emotion-focused therapy has shown that emotional processing predicts outcome over and above the alliance, this finding has not been evaluated within cognitive-behavioural therapy. The primary goals of this study were to 1) test the hypothesis that high levels of emotional processing primarily occur in the context of a strong alliance and 2) examine whether emotional processing predicts outcome over and above the alliance in cognitive-behavioural therapy. Observer-rated measures were used to assess emotional processing and the alliance in working phase psychotherapy sessions from adults who completed cognitive-behavioural therapy at a graduate training clinic. Interquartile ranges and results from one-way ANOVA (n = 31) showed higher means and lower variability in the alliance at high levels of emotional processing, suggesting a threshold. A Pearson correlation yielded a remarkably high association between emotional processing and treatment gains (r = .597). Additionally, hierarchical regression analyses (n = 19) indicated that working phase peak emotional processing predicted treatment gains over and above working phase alliance. The implications of these results for psychotherapy research and practice are discussed.