Therapeutic Alliance and Dropout in CPT

Most clinicians rightly assume that therapeutic alliance is part of an effective therapy. However, how it is effective is still a question to be answered. The link between an alliance and completion of therapy in the PTSD context is assumed to be important.

Sijercic and colleagues (2021) examined Therapeutic Alliance and Dropout in CPT, as measured by independent raters. They described that early drop out in CPT is a particularly important. This is because in the CPT model of PTSD, symptom reduction is thought to occur via the modification of unhelpful cognitions and emphasis on approaching, rather than avoiding, thoughts and feelings related to trauma.

They reported that there are several studies that have found that individuals who drop out of CPT generally do so before their fourth session. Hence these clients may not have the chance to examine how their cognitions may be keeping them stuck with PTSD symptoms.

Similarly, Sijercic and colleagues (2021) reported on PTSD research showing that clients who drop out of PTSD treatment are more likely to have poorer treatment outcomes and that they also often continue to experience high levels of PTSD symptoms after they cease treatment.

Managing dropout is particularly important in a treatment such as CPT given that skills build upon one another over the sessions, and clients who drop out do not have an opportunity to build a “complete skill set” that may be helpful to them. For example, if someone drops out in session four, they do not get to learn about identifying unhelpful patterns in their thinking.

Sijercic and colleagues (2021) questioned whether initial alliance, late alliance, mean alliance, or change in alliance predicted treatment dropout.

They found that initial alliance scores, late alliance scores, and alliance score change did not predict dropout, although mean alliance scores across sessions did.

They reported that this effect may be viewed in a positive light such that the first impressions of alliance may not determine who drops out, providing therapists many chances over the course of CPT to strengthen their alliance.

A caveat – Sijercic and colleagues (2021) research was by independent raters. Most clinical settings do not have independent raters and ratings are either done by client, therapist or both. One would assume that the most important rating would be that of the client who makes the choice to stay or leave therapy. It will be interesting to see the research.


“Keeping our alliance up” throughout therapy is an important way to prevent drop out. Which means we have the opportunity to repair ruptures, or that a “rocky start” might not be the worse thing in the world. Hence it is important ask your clients about the process of therapy, and the alliance.

Some definitions

Definitions used by Sijercic and colleagues (2021) were that therapeutic alliance consists of three components:
(a) an affective bond between the client and therapist,
(b) mutually agreed-upon goals between the client and therapist, and
(c) collaboration between the client and therapist on assigned tasks


Sijercic, I., Liebman, R. E., Stirman, S. W., & Monson, C. M. (2021). The Effect of Therapeutic Alliance on Dropout in Cognitive Processing Therapy for Posttraumatic Stress Disorder. Journal of traumatic stress, 34(4), 819–828.