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A strong therapeutic alliance has a direct impact of the likelihood of successful outcomes of treatment.

Previous research has focused largely on reports of patient perceptions.

A new 2025 study provides empirical evidence that the therapeutic alliance impacts the success of treatment.

Patients often report a lack of measurable progress in symptom relief despite months or years in therapy. Why is this so common, especially given the development of multiple new evidence-based treatment modalities?

The answer is that many things can go wrong. Among the most central factors affecting treatment outcome is the alliance between the patient and therapist. This therapeutic relationship is the core foundation for successful treatment. It has long been known that a strong therapeutic alliance is highly predictive of treatment outcomes (Fitch et al, 2025). A recent review of 37 studies showed that over 70% of these demonstrated that the strength of the therapeutic relationship has a direct impact on positive outcomes (Baier et al, 2020). This holds true independent of the modality of treatment (Baier et al, 2020).

Much of the existing literature focuses largely on reports of patient perceptions. A new study published in 2025 in The Journal of Behavioral Health and Psychology provides empirical evidence to support the positive impact of the therapeutic alliance on treatment success (Fitch et al, 2025). This study used a 234-item scale called the Care Predictive Index (CPI) to measure therapist-related predictors of treatment outcomes. It included five mental health centers that use diverse treatment modalities. Results showed that the profiles of therapists, as measured by the CPI, lead to improved patient outcomes (Fitch et al, 2025). This statistical evidence reinforces the need to prioritize the strength of the therapeutic alliance.

It therefore is clear how critical it is to seek out the right therapist to optimize the likelihood of success. Whether you decide to start therapy or are already in therapy, pay attention to the process, the therapeutic alliance, and your instincts. Are you and your therapist aligned with your goals? Does your therapist maintain professional boundaries while creating a safe space free of judgment, criticism, or blame in which you can process emotions and experiences? It is not realistic to expect a major breakthrough each session, but are you making incremental progress?

Take time to reflect on the therapeutic alliance. Here are some red flags indicating that the relationship may be flawed or has ruptured. If any of these warning signs apply then it may be time to seek another opinion or change direction.

You dread going to therapy or dislike your therapist.

The goals of the treatment are not identified in the initial stages of treatment and periodically reassessed.

The sessions meander in a haphazard way or simply degenerate into a weekly recap.

Lack of gradual measurable progress or feeling stuck.

The therapist is not well-versed in modalities of treatment that are relevant for your condition.

You feel judged, criticized, or blamed.

The therapist seems distracted or falls asleep during sessions.

The therapist does not remember important details that you discussed.

They run late or answer calls or texts during sessions.

They do not clearly communicate policies regarding contact between sessions, cancellation policies, or billing issues.

The therapist overshares personal details about themselves.

They act in a flirtatious manner or make sexual innuendos.

The therapeutic relationship is unique and it can feel one-sided with a power imbalance. Professional boundaries are essential for the safety and protection of patients. Patients share highly personal material, which often makes them feel vulnerable. Poor boundaries on the part of the therapist can harm patients.

Do not ignore it if something feels wrong. Pay attention and trust your instincts. Therapy should not be an oblique or mysterious process. You should understand how it works and feel free to discuss concerns with your therapist.

How do you know when to end therapy? Ideally you and your therapist decide this together. You should not feel pressured or obligated to continue when it no longer serves you. Sometimes it becomes clear that a different modality of treatment would be more beneficial. When this occurs, your therapist should recognize and support a transition. It is customary for the therapist to leave the door open for you to return as needed.

To find a therapist, please visit the Psychology Today Therapy Directory.

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Baier, A.L., Kline, A.C., Feeny, N.C., (2020). Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clinical Psychology Review, 82(101921). https://doi.org/10.1016/j.cpr.2020.101921

Fitch, N.D., Krause, M., Moukamal, K., Castanon, M., (2025). The Impact of Therapeutic Alliance on AMA Rates. Journal of Behavioral Health and Psychology, 14(6). https://www.researchgate.net/publication/399244391_The_Impact_of_Therapeutic_Alliance_on_AMA_Rates

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