The sister concepts of working alliance and real relationship: A meta-analysis

Figures & data

Figure 1. PRISMA flow diagram of the study selection process.

Table 1. Studies characteristics and key findings.

Author, year; country	Design	Objectives	Participants	N	Key measures	Key findings
Gelso et al. (2005); USA	Cross-sectional	Develop and validate the RRI-T.	Therapists	210	WAI-S; SEQ – Depth andSmoothness	The RRI – T total score and one or both subscale scores correlated significantly with the WAI, the SEQ Depth and Smoothness subscales, emotional insight, intellectual insight, and negative transference.
Fuertes et al. (2007); USA	Cross-sectional	Examine therapist and client ratings of the RR in relation to their WA ratings; Examine the role of therapist and client attachment in the formation of the RR.	Therapists and clients	118	WAI-S; RRI; COM	For both therapists and clients, there was a positive relationship between their ratings of the RR and the WA. With respect to progress, client and therapist ratings of the RR, and not their ratings of the WA, were predictive of their ratings of client progress.
Marmarosh et al. (2009); USA	Longitudinal	Understand how the RR relates to important process and outcome variables (attachment, WA, transference, and treatment outcome) from both the clients’ and therapists’ perspectives.	Therapists and clients	52	WAI-S; RRI; SCL-90-R	Clients’ perceptions of the RR correlated with both therapist and client ratings of WA. Therapist ratings of the RR correlated with only therapist ratings of WA. Therapists’ perceptions of the RR did not correlate with clients’ perceptions of the alliance at the third session of therapy. Therapist-rated RR was the only significant predictor of outcome.
Kelley, Gelso, Fuertes, Marmarosh, and Lanier (2010); USA	Cross-sectional	Develop and validate the RRI-C.	Clients	187	WAI-S	The RRI-C was positively correlated with a measure of clients’ observing ego functions and WA; it was negatively correlated with a scale that measures clients’ tendency to hide their true feelings and to change their behavior to fit in or meet others’ expectations.
Owen, Tao, Leach, and Rodolfa (2011); USA	Cross-sectional	Examine whether clients’ perceptions of their psychotherapists’ multicultural orientation (MCO) were associated with their psychological functioning, WA, and RR scores.	Clients	176	WAI-SR; RRI; SOS-10	Clients’ perceptions of their psychotherapists’ MCO were positively related to the WA and WA significantly mediated the relationship between clients’ perceptions of their psychotherapists’ MCO and client psychological well-being. Clients’ perceptions of the RR was not a significant mediator for the association between clients’ ratings of their psychotherapists’ MCO and psychological well-being, but a strong and positive association was found between clients’ perceptions of their psychotherapists’ MCO and the RR.
Lo Coco, Gullo, Prestano, and Gelso (2011); Italy	Longitudinal	Association of the client- and therapist-rated strength of the RR to the outcome of brief psychotherapy; Extent to which the RR predicts outcome above and beyond the predictive power of the WA.	Therapists and clients	54	WAI-S; RRI; OQ-45	From the clients’ perspective, both the Genuineness of the RR and the Bond scale of the WA were found to relate significantly to treatment outcome when these variables were measured early in treatment. However, neither the therapist-rated RR nor the therapist-rated WA, when measured early in treatment, were significantly associated with outcome.
Hill et al. (2015); USA	Longitudinal	Investigate changes over 12 to 42 months in 23 predoctoral trainees during their externship training in a psychodynamic/interpersonal psychotherapy clinic.	Therapists and clients	191	WAI-SR; RRI; OQ-45.2	Over their time in the clinic, trainees were able to form stronger WA (as rated by both clients and therapists) and stronger RR (as rated by clients).
Kelley (2015); USA	Cross-sectional	Investigate the role of therapy practices and the therapy relationship on lesbian and gay clients’ feelings about their current therapist.	Clients	116	WAI-SR; RRI	Clients’ perceptions of their therapists’ therapy practices, the RR, and the WA were significantly positively related to these clients’ feelings about their therapists. The RR and the WA were strongly correlated.
Kivlighan, Hill, Gelso, and Baumann (2016); USA	Longitudinal	Examine the dyadic associations of clients and therapists in their evaluations of WA, RR, session quality, and client improvement over time in ongoing psychodynamic or interpersonal psychotherapy.	Therapists and clients	97	WAI-SR; RRI; OQ-45	Clients’ and therapists’ ratings of the WA and the RR were significantly and uniquely related to their own ratings of session quality. Client-rated WA and RR were associated with therapist-rated session quality.
Doran, Safran, and Muran (2016); USA	Cross-sectional	Investigate the utility and psychometric properties of the Alliance Negotiation Scale (ANS).	Clients	212	WAI; RRI	The relationship between the ANS and WAI was positive and statistically significant; the ANS and RRI were significantly positively correlated. The correlations point to a substantial overlap between the three measures.
Shafran, Kivlighan, Gelso, Bhatia, and Hill (2017); USA	Longitudinal	Examine the relationship between amount of therapist immediacy in sessions and client post-session ratings of WA, RRI, and session quality, using hierarchical linear modeling (HLM).	Therapists and clients	25	WAI-SR; RRI	More immediacy in a session was related to higher client ratings of session quality for that session. Whereas more immediacy in a session was related to lower client ratings of WA early in treatment, more immediacy in a session was related to higher client ratings of WA later in treatment. No relationship was found between immediacy and RR.
Kivlighan, Kline, Gelso, and Hill (2017); USA	Longitudinal	Examine how congruence and discrepancy in clients’ and therapists’ ratings of the WA and RR were related to client-rated session quality.	Therapists and clients	167	WAI-SR; RRI; SES	RR – WA discrepancy is a common occurrence at the session level. More than 50% of sessions had discrepant client RR – WA scores, and almost 45% of the sessions had discrepant therapist ratings.
Bhatia and Gelso (2017); USA	Cross-sectional	Examine how 3 elements of the therapy relationship (WA, RR, and transference) during the termination phase relate to perceived client sensitivity to loss, termination phase evaluation, and overall treatment outcome.	Therapists	233	WAI-SF; RRI; COM	Therapists perceiving a stronger WA and RR during the termination phase were also likely to view the termination phase as effective and overall treatment as successful. Only therapists’ perceptions of the WA during the termination phase contributed to overall treatment outcome, when all three components were examined together.
Bhatia and Gelso (2018); USA	Cross-sectional	Examine the components of the tripartite model in terms of how they relate to one another and to the outcome of a psychotherapy session, from the therapists’ perspective.	Therapists	249	WAI-SR; RRI; SES	WA, RR, transference and countertransference contributed 27% of the variance in session outcome as rated by therapists of varying theoretical orientations. From the therapist’s perspective, the WA, RR and transference configuration were associated with session outcome. Only the RR and the WA predicted session outcome when all the components were looked at simultaneously in a regression model.
Pérez-Rojas and Gelso (2020); USA	Cross-sectional	Assess how acculturation may impact international student therapists’ experiences in cross-cultural counseling.	Therapists	104	WAI-S; RRI: SES	The self-reported quality of counseling relationships (RR and WA) and of counseling sessions with U.S. clients was unrelated to international counseling students’ levels of acculturative stress and perceptions of cultural distance.
Aafjes-van Doorn, Békés, and Prout (2020); USA	Cross-sectional	Explore therapists’ experiences of video therapy after switching from in-person to video sessions during the pandemic.	Therapists	141	WAI-SF; RRI	Higher rated WA and RR were associated with more positive attitudes towards video therapy. Scores on the RR and WA were positively correlated. Neutral WA online, albeit lower than those reported in previous studies on video therapy. Relatively strong RR online, similar to levels reported in studies of in-person therapy.

RR: Real Relationship; WA: Working Alliance; WAI-SF: Working Alliance Inventory – Short Form; WAI-SR: Working Alliance Inventory – Short Revised; SEQ: Session Evaluation Questionnaire; COM: Counseling Outcome Measure; SCL-90-R: Symptom Checklist-90-Revised; SOS-10: Schwartz Outcome Scale-10; OQ-45: Outcome Questionnaire-45; IIP: Inventory of Interpersonal Problems; SES: Session Evaluation Scale.

Figure 2. Forest plot of effect sizes and confidence intervals for the meta-analysis of real relationship and working alliance.

“Box” size is relative to sample size, with larger boxes indicating a larger sample. “Favors A” indicates a negative correlation, whereas “Favors B” indicates a positive correlation. The last line of the table is the estimated results (random effects) for the meta-analysis.

Table 2. Comparison of correlations between working alliance and outcomes and real relationship and outcomes from dependent samples.

Study (Author, year)	Raters	N	r WA-outcomes^1	r RR-outcomes^2	Z	p
Gelso et al. (2005)	Therapists (SEQ – Depth)	92	0.14	0.36	−2.112	0.017
	Therapists (SEQ – Smoothness)		0.16	0.43	−2.647	0.004
Fuertes et al. (2007)	Therapists	59	0.27	0.36	−0.72	0.236
	Clients	59	0.14	0.29	−1.518	0.064
Marmarosh et al. (2009)	Therapists	21	0.02	0.01	0.051	0.479
	Clients	31	0.07	0.2	−1.361	0.087
Lo Coco, Gullo, Prestano, and Gelso (2011)	Therapists	4	0.14	0.14	0.409	0.341
	Clients	50	0.18	0.21	−0.215	0.415
Owen, Tao, Leach, and Rodolfa (2011)	Clients	176	0.34	0.27	1.302	0.096
Kivlighan, Hill, Gelso, and Baumann (2016)	Therapists	23	0.61	0.51	0.693	0.244
	Clients	74	0.61	0.5	1.473	0.07
Bhatia and Gelso (2017)	Therapists	233	0.45	0.29	2.785	0.003
Bhatia and Gelso (2018)	Therapists	249	0.5	0.42	1.687	0.046
Pérez-Rojas and Gelso (2020)	Therapists	104	0.42	0.47	−0.677	0.249
Total Weighted Mean		1175	0.37	0.356	0.623	0.267

¹Correlation values between Working Alliance and outcomes; ²Correlation values between Real Relationship and outcomes.

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