Therapeutic Alliance in posttraumatic stress disorder (PTSD) how important?

CPT for PTSD and Therapeutic Alliance

What is the therapeutic alliance

Sijercic and colleagues 2021 reported that several definitions of therapeutic alliance exist. They also outlined that most researchers agree the alliance consists of three components that were defined by Bordin, (1979): (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

A bit more about bond

Items (b) and (c) in Bordin’s (1979) conceptualisation, are self-explanatory. In order to move forward with therapy, we need goals in terms of what we want to change and tasks for that change to happen. Naturally, collaboration in both these areas make sense, as it keeps everyone “on the same page.”  Bond has a little more to it. Bordin, (1979) defined the various aspects of the bond as containing trust and attachment. Furthermore, he explained that this bond could differ in kind (but not strength) depending on the types of interactions between the therapist and client. He described examples of different types of bonds. Such as when a therapist asks a client to make a daily record of his submissive and assertive acts and of the circumstances surrounding them compared with when a therapist shares his or her feelings with a patient, in order to provide a model.

A systematic review and meta-analysis of the therapeutic alliance

Howard et al., (2022) completed a systematic review and meta-analysis of the therapeutic alliance during psychological therapy for posttraumatic stress disorder: They found that strong therapeutic alliances can be developed among people with PTSD and PTSD symptoms in therapy. They reported several significant points related to this.

  1. Average client-rated alliance was high. This was as measured by the WAI (6.05 )  and WAI-SF (5.79), a commonly used  long form and short form measure of alliance. These scores are out of seven.  Comparatively, Hersoug et al. (2001) measured WAI scores among 270 psychotherapy clients with minimal inclusion criteria and found an average of 4.94.

This is important because PTSD symptoms like avoidance, difficulty with trust and difficulty with positive emotion could be thought to be barriers to a therapeutic alliance (Cloitre et al., 2004; Keller et al., 2010).

  • Alliance was high regardless of delivery method or modality of delivery. This included individual therapy, group therapy, inpatient therapy, internet-based therapy, remote videoconferencing therapy, or telephone therapy.  It also included when mixed modalities such as, remote and face-to-face therapies were used.
  • Alliance was high across the different therapeutic approaches used. The predominant approaches in their analysis were CBT, PE and CPT.

What about the types of trauma? Aren’t more traumatised clients more likely to have difficulty with the alliance?

Howard et al., (2022) reported on six studies that looked at this area. Many people assume that some traumas are worse than others and may have differing effects. The six studies examined trauma type and the effect on the clients experience of alliance.

Howard’s team reported there was one study of 33 participants with childhood sexual trauma, where they found alliance was significantly predicted by presence of emotional and or physical abuse or neglect. However, the study also found that alliance was NOT associated with childhood sexual abuse or with total childhood maltreatment. In contrast, they described five other studies that reported no significant associations with alliance and trauma type.

This included trauma variables such as:

  • The age of trauma onset
  • Number of trauma types
  • The presence of childhood trauma
  • The number of traumas
  • The presence of re-traumatization
  • Interpersonal trauma versus a non-interpersonal trauma

Others have found that there is no difference in alliance between trauma-focussed therapies than non-trauma-focussed therapies (Chen et al., 2020) .

Does alliance predict outcome in PTSD treatment

Howard’s team described that client-rated alliance during therapy significantly predicted PTSD symptoms at the end of therapy across 12 of 20 studies. For those of you who like effect size, they reported an aggregated moderate effect size of r = .339.

Similarly, rupture in alliance, might be important to attend to. McLaughlin et al. (2014) explored the differences in PTSD outcomes across three groups, no rupture in alliance, an unrepaired rupture, and a repaired rupture. They reported unrepaired ruptures predicted worse treatment outcome.

Does alliance predict drop out in PTSD treatment

Sijercic et al., (2021) examined therapeutic alliance and dropout in CPT they found that initial alliance scores, late alliance scores, and alliance score change did not predict dropout. However, mean alliance scores across sessions did.

They suggested that their findings may mean that alliance has room to grow and change across different phases of treatment. They noted that the results of their study also indicated that changes in alliance did not significantly predict treatment dropout.


Therapeutic alliance includes a bond, tasks and goals. It is an important part of PTSD therapy and appears to be associated with outcomes. The effect size of the therapeutic alliance is moderate. Clients with PTSD can form therapeutic alliances including a bond with the therapist regardless of the type or number of traumas they have had. Attending to any ruptures in alliance is important in PTSD treatment. A low overall alliance – as in mean alliance across therapy has been linked with drop out in Cognitive Processing Therapy. However, because it is the alliance across therapy, this may mean there are opportunities for change in the alliance to occur.


Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16(3), 252–260.

Chen, J. A., Fortney, J. C., Bergman, H. E., Browne, K. C., Grubbs, K. M., Hudson, T. J., & Raue, P. J. (2020). Therapeutic alliance across trauma focused and non-trauma-focused psychotherapies among veterans with PTSD. Psychological Services, 17(4), 452–460.

Cloitre, M., Chase Stovall-McClough, K., Miranda, R., & Chemtob, C. M. (2004). Therapeutic Alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72(3), 411–416.

Gaston, L. (1990). The concept of the alliance and its role in psychotherapy: Theoretical and empirical considerations. Psychotherapy, 27(2), 143–153.

Hersoug, A. G., Høglend, P., Monsen, J. T., & Havik, O. E. (2001). Quality of working alliance in psychotherapy: therapist variables and patient/therapist similarity as predictors. The Journal of psychotherapy practice and research, 10(4), 205–216.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy:A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149.

Keller, S. M., Zoellner, L. A., & Feeny, N. C. (2010). Understanding factors associated with early therapeutic alliance in PTSD treatment: Adherence, childhood sexual abuse history, and social support. Journal of Consulting and Clinical Psychology, 78, 974–979.

McLaughlin, A. A., Keller, S. M., Feeny, N. C., Youngstrom, E. A., & Zoellner, L. A. (2014). Patterns of therapeutic alliance: Rupture-repair episodes in prolonged exposure for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 82(1), 112–121.

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.