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Trustful Collaboration Critical for Outcome of Therapy

A trusting therapeutic relationship and outcome-oriented collaboration between therapist and patient are critical for the successful treatment of mental illness. And it pays to start early in therapy, a series of meta-studies by a task force of the American Psychological Association (APA) led by UZH psychology professor Christoph Flückiger shows.


Psychotherapeut im Gespräch mit Patient
Within the so-called working alliance, therapist and patient agree on the tasks, approach and goals of therapy, and collaborate to reach them. (Bild: Ames)

Depression, anxiety, addiction – 30 percent of the world’s population experience mental illness at least once in their lifetime. Times of uncertainty and isolation such as the current coronavirus pandemic bear a particular risk. According to the World Health Organization (WHO), mental illness is one of the greatest and most stigmatized problems of modern societies. Intense efforts are under way in the healthcare sector to improve the relevant treatment options and make them as cost-efficient as possible. Psychotherapy has been shown to be a flexible and low-threshold primary treatment option.

International meta-analyses of 400 studies

The relationship between therapist and patient and how it influences treatment success has long been neglected in medicine. In recent years, however, this topic has received more and more attention. “The therapist-patient relationship is especially significant when it comes to treating mental disorders,” says Christoph Flückiger, professor of psychological interventions and psychotherapy at the University of Zurich. “The therapeutic process can trigger unpleasant emotions and require patients to consciously confront their experiences and behaviors.”

Led by Flückiger and featuring researchers from 17 countries, a task force of the American Psychological Association (APA) has now conducted a series of meta-analyses. They investigated almost 400 empirical studies with regard to how the therapeutic relationship affects treatment outcome. Their analyses show that in practically all of the included studies, it was possible to predict the outcome of the therapy from the quality of the therapeutic relationship, and that held true across all treatment approaches, outcome measurements, patient characteristics and countries.

Significance of working alliance more than mere side effect

“Treatments for mental disorders are particularly successful when the therapist and the patient work together in a trusting, outcome-oriented relationship,” summarizes Flückiger. Within this so-called working alliance, both parties agree on the tasks, approach and goals of therapy, and collaborate to reach them.

Some voices in the scientific discourse have suspected that the working alliance between therapist and patient and the accompanying treatment success were merely a side effect brought about by other factors. Some of the factors believed to play a role include previous treatment experience, symptom severity, therapeutic approach or progress made during the therapeutic process. However, the task force led by Christoph Flückiger found no evidence whatsoever that these factors detracted from the working alliance’s significance for the outcome of therapy.

Early alliance is crucial

The findings highlight the importance of the early phase of treatment for the outcome. “Early in treatment, there is a positive reciprocal link between severity of symptoms and working alliance, and this often results in a positive upward spiral,” explains Flückiger. In other words, a strong mutual relationship between a therapist and a patient helps reduce symptoms, which in turn reinforces the therapeutic relationship.

“Our studies provide evidence that it is worth investing in a respectful, trusting therapeutic collaboration, especially when it comes to treating mental illness,” says Flückiger. While this idea is also demanded in other medical fields, implementation and training is often insufficient.


Flückiger, C., Rubel, J., Del Re et al. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88 (9), 829-843. DOI: 10.1037/ccp0000594

Flückiger, C., Del Re, A. C., Horvath, A. O. et al. Assessing the alliance-outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. 26 March 2020, DOI: 10.1037/cou0000424

Probst, G. H., Berger, T. & Flückiger, C. Alliance predicts outcome in internet-based therapy – A correlational meta-analysis (English and German versions). Verhaltenstherapie. 27 July 2019. DOI: 10.1159/000501565

Flückiger, C., Del Re, A.C., Horvath, A. O. & Wampold, B. E. The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy. 24 May 2018. DOI: 10.1037/pst0000172 (Award: “Most Valuable Paper in Psychotherapy” 2019)

Weiterführende Informationen


Prof. Dr. Christoph Flückiger

Department of Psychology – Psychological Interventions and Psychotherapy

University of Zurich

Phone: +41 44 635 74 39