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The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance–outcome association for face-to-face psychotherapy was r .278 (95% confidence intervals [.256, .299], p .0001; equivalent of d .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r .275, k 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices.

Keywords: therapeutic alliance, psychotherapy relationship, working alliance, meta-analysis, psychotherapy, outcome


Dr. Christoph Flückiger received his Doctorate in Clinical Psychology, with an emphasis in Psychotherapy Research from the University of Bern, Switzerland. He was post-doctoral researcher at the Department of Counseling Psychology at the University of Wisconsin-Madison. Recently, he is professor and head of a psychotherapy research lab for generalized anxiety disorder at the University of Zürich, Switzerland. Christoph Flückiger is licensed psychotherapist and supervisor in Switzerland and Germany. He is Editor-Elect of the journal Psychotherapy Research.

Cite This Article

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy.Psychotherapy, 55(4), 1-25.



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