ORIGINAL RESEARCH

published: 31 January 2022

doi: 10.3389/fpsyt.2022.827321

The Strength of Alliance in Individual

Psychotherapy and Patient’s
Wellbeing: The Relationships of the
Therapeutic Alliance to
Psychological Wellbeing, Satisfaction
With Life, and Flourishing in Adult
Patients Attending Individual
Psychotherapy
Tomasz Prusiński*
Department of Personality Psychology, Institute of Psychology, The Maria Grzegorzewska University, Warsaw, Poland

Objectives: The central aim of the research was to verify and determine the strength
of the relationships of therapeutic alliance to wellbeing, life satisfaction, and flourishing
Edited by: in patients attending individual psychotherapy. The relationships were assessed based
Takeshi Terao,
on different sources of information about the quality of the working alliance: patient’s
Oita University, Japan
evaluation and patient’s and psychotherapist’s joint evaluations.
Reviewed by:
Hikaru Hori, Design: The author applied Bordin’s pantheoretical model of alliance and two different
Fukuoka University, Japan
Nobuko Kawano,
conceptions of wellbeing, operationalized as hedonistic and eudaimonic.
Oita University, Japan Methods: The 411 participants included 252 patients and 159 psychotherapists. To
*Correspondence: test the hypotheses, 16 joint and separate models of structural relations were built and
Tomasz Prusiński
tomasz.prusinski@op.pl analyzed empirically using SEM. Correlations were analyzed between alliance factors and
those of wellbeing, satisfaction, and flourishing.
Specialty section:
This article was submitted to
Results: The actual impact of working alliance quality on psychological wellbeing
Psychological Therapies, proved to be stronger compared to the relations between alliance and satisfaction or
a section of the journal
flourishing. The results of analyses revealed low, though usually positive and significant,
Frontiers in Psychiatry
correlations between the dimensions of alliance and those of wellbeing, life satisfaction,
Received: 01 December 2021
Accepted: 03 January 2022 and flourishing.
Published: 31 January 2022
Conclusions: The empirical data and the strategy of analyses brought the expected
Citation:
results, confirming that patient’s and psychotherapist’s perception of a strong therapeutic
Prusiński T (2022) The Strength of
Alliance in Individual Psychotherapy alliance is crucial for the optimization of patient’s functioning and wellbeing. It turns out
and Patient’s Wellbeing: The that the therapeutic alliance is, above all, a factor of wellbeing understood more deeply
Relationships of the Therapeutic
Alliance to Psychological Wellbeing, than merely as current pleasure. The study also showed that no factor isolated from
Satisfaction With Life, and Flourishing other components of alliance increased the quality of patient’s mental functioning more
in Adult Patients Attending Individual
than others.
Psychotherapy.
Front. Psychiatry 13:827321. Keywords: therapeutic alliance, psychological well-being, life satisfaction, flourishing, pantheoretical model of
doi: 10.3389/fpsyt.2022.827321 alliance, psychotherapeutic process, adult psychotherapy, structural equation models

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Prusiński Working Alliance and Patient’s Wellbeing

INTRODUCTION for recovery, some sense of helplessness or inadequacy, and a

conscious need for cooperation with the psychotherapist.
Previous research has established a belief that psychotherapy is Bordin suggests that alliance comprises three integrated
an effective way of treating mental disorders and optimizing components: agreement on goals, the assignment of tasks, and the
individuals’functioning (1–3). Less is known, however, about how development of bonds. The first two dimensions are specified at
psychotherapy works and what mechanisms are responsible for the initial meetings, which, for psychotherapists, are also sessions
its outcomes (4, 5). Identifying the components of the therapeutic aimed at assessing the patient. The third dimension—though
process that play the key role in recovery is important because built during the entire period of meetings, as it is impossible to
it results in a better optimization of treatment and in a better agree on mutual trust during the first sessions—is a condition of
understanding of the causal mechanisms that lead to disorders achieving the goals and performing the tasks. Bordin emphasizes
(6, 7). Researchers continue to investigate the significance of that the quality of these three dimensions of the therapeutic
specific elements of psychotherapy and to identify its active alliance is what the success of psychotherapy and its short-
components (8–10)—those that allow for achieving positive term as well as final outcomes depend on. Thus understood, the
outcomes, operationalized both with objective indicators (the alliance ensures the conditions necessary for the patient to build
abatement of symptoms) and with subjective ones (an increase trust with respect to the proposed treatment, to accept it, and
in patient’s wellbeing) (11). to adhere to the working rules agreed on in the further stages
Studies on psychotherapy effectiveness are usually focused of psychotherapy.
on reducing symptoms and interpersonal, cognitive, and social
deficiencies in functioning (12). The improvement of overall
quality of life is also often an implicit or explicit goal of Therapeutic Alliance and Psychotherapy
psychotherapy. Frisch (13) defines the increase in quality of life Outcomes
or satisfaction with life as the subjective evaluation of the degree The main meta-analyses identifying the components of
to which individual needs, goals, and wishes have been fulfilled. psychotherapy responsible for its positive outcomes (16)
In psychotherapy, increased positive satisfaction with life or an revealed no significant paths of relations. This finding
improvement in wellbeing may be something more than merely induced some researchers to suspect that psychotherapy
a by-product of the alleviation of problems and symptoms: outcomes were unrelated to specific techniques used in various
they may be an integral part of the transition from dysfunction psychotherapeutic orientations and that they were more
to adaptation. Reporting a decrease in symptoms impairing a probably linked with non-specific, more universal factors
person’s functioning is valuable, but it seems to be insufficient. common to different modalities of psychotherapy (17, 18). The
The development of a healthy individual proceeds not only due classic results concerning the determinants of psychotherapy
to the decrease or absence of negative experiences or sensations, effectiveness, reported by Wilson and Lipsey (19), confirmed that
but also because the individual begins to experience themselves as the variance in the final outcome of psychotherapy was a product
a person having specific resources. It therefore seems important of non-specific factors.
to determine what positive experiences, attitudes, and beliefs— A frequently considered factor of this kind is the therapeutic
generally, what change in wellbeing—an individual gains thanks relationship (14, 20, 21). Also referred to in the literature as
to the process of psychotherapy. the therapeutic alliance (22, 23), “goodness of fit” between the
therapist and the patient (24), the therapeutic partnership (25),
The Pantheoretical Model of Therapeutic or the working alliance (14, 15, 23), it is currently considered
Alliance the most important determinant of effective psychological
In the literature devoted to the issues of alliance in psychotherapy intervention, independent of psychologist’s or psychotherapist’s
there is no single agreed-upon definition of the construct (14). theoretical orientation (26). The therapeutic alliance is an
The theory of the alliance commonly regarded as canonical is the important and powerful predictor of treatment outcomes,
one proposed by Bordin (15). Bordin calls the patient–therapist explaining an estimated 7.5% of the total variance in the
relationship the working alliance. The value of his model stems outcomes of psychotherapy (20, 27).
both from the essence of how alliance is understood in it and The working alliance is considered to be an important
from the fact that it was thoroughly analyzed by the author of the determinant of psychotherapy success (28, 29) because it
construct and has been used in a number of research studies. In builds a framework for various methods and strategies used
other words, the model has a strong empirical basis. This way of by psychotherapists. It builds communication between the
understanding the therapeutic relationship that has been adopted psychotherapist and the stable part of patient’s personality,
for the purposes of the current publication. helping the latter to remain in the process of change despite the
The working alliance can be defined as committed fluctuating level of subjective discomfort or perceived difficulties
cooperation between patient and psychotherapist which is in functioning. Establishing an optimal relationship with the
based on mutual trust and whose basic perspective is determined patient enables the psychotherapist to adjust to those of the
by the goals that have been agreed on and set to be pursued. It is patient’s characteristics that, for various reasons, could make it
emphasized that the working alliance is the most rational part of difficult to take a positive attitude toward them (30).
the patient–therapist relationship. A necessary condition for an Studies indicate that a well-established therapeutic alliance is
alliance to emerge is that the patient must have a directed desire a determinant of positive treatment outcomes, on the condition

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Prusiński Working Alliance and Patient’s Wellbeing

that alliance is evaluated not only by the psychotherapist but also realistic attitude toward oneself, support the rebuilding of the
by the patient and that these evaluations coincide (21). Botella et patients’ undermined agency, develop the ability of building deep
al. (31) found that, with an increase in the number of sessions, relationships, and promote independence and self-directedness,
the relationship between alliance and symptoms changed in such thus reducing helplessness.
a way that a stronger alliance was accompanied by a decrease
in symptoms. Likewise, the analyses performed by Zuroff and The Present Study
Blatt (32) indicatedthat the decrease in depressive symptoms was The main aims of the study were:
fasterin the patients who evaluated the quality of the therapeutic
1. to investigate the links and determine the strength of
relationship as high.
the relations of the therapeutic alliance to wellbeing, life
Although the overall quality of life, wellbeing, and present
satisfaction, and flourishing (12, 14, 36);
life satisfaction are often both implicit and explicit aims of
2. to check if these relations change depending on who is the
psychotherapy, there are few studies assessing such positive
source of information about alliance quality: the patient alone
changes during treatment (12). Scarce empirical material is still
or both patient and psychotherapist (42, 43).
cited that links the process of psychotherapy with outcomes in
the form of life satisfaction and social or psychological wellbeing. To accomplish these aims, I tested the following hypotheses:
Frisch et al. (33) found a moderate relationship (0.42–0.57) of H1: A higher quality of alliance reported by a patient leads to
quality of life and wellbeing to treatment using psychotherapy. higher psychological wellbeing.
Seligman et al. (34) established that positive psychotherapy, H2: A higher quality of alliance reported by a therapist–patient
aimed at increasing overall life satisfaction, led to greater changes dyad leads to higher psychological wellbeing.
in happiness among students with depression than ordinary H3: A higher quality of alliance reported by a patient leads to
treatment. There are also studies that go beyond the mental higher satisfaction with life.
health context and suggest that the doctor–patient alliance, H4: A higher quality of alliance reported by a therapist–patient
characterized by agreement on treatment goals and tasks and dyad leads to higher satisfaction with life.
by mutual trust and liking, predict the maintenance of patients’ H5: A higher quality of alliance reported by a patient leads to
present life satisfaction and an increase in their quality of life higher quality of functioning (flourishing) in life.
(35, 36). H6: A higher quality of alliance reported by a therapist–patient
Studies are lacking that would show that the isolated dyad leads to higher quality of functioning (flourishing) in life.
therapeutic alliance factor enhances quality of life—both I tested which structural factor of alliance was the leading one
temporarily (wellbeing) and in a more long-term perspective in terms of impact on life satisfaction, wellbeing, and flourishing.
(further healthy development, psychological wellbeing, and The hypothesis was:
flourishing). Looking for relations between the working alliance H7: The tasks assigned, the goals agreed on, and the
and wellbeing is consistent with the current paradigm of psychotherapeutic bonds developed are positively correlated with
positive psychology, according to which wellbeing results from the dimensions of wellbeing, life satisfaction, and flourishing.
the dialectics of various positive and negative experiences or In the present study, I relied on Bordin’s pantheoretical model
landmark moments in life (37). Although the psychotherapeutic of alliance and on diverse approaches to wellbeing. Wellbeing was
alliance is the most often estimated determinant of success operationalized in two ways, derived from different philosophical
in psychotherapeutic treatment, little is known about the traditions: hedonistic and eudaimonic. According to the former,
explanatory value of its components (38, 39). wellbeing can be the experience of pleasure, contentment, and
The use of the concept of therapeutic alliance as a factor subjective satisfaction with life (44), while according to the
regulating the effects of psychotherapy with regard to the latter it is the long-term experience that accompanies the
enhancement of wellbeing makes sense because it is supported fulfillment of one’s potential and life in harmony with nature
by relational mechanisms (40) and by self-determination (45). Eudaimonic wellbeing is defined as the stable experience
theory (41). The presence of alliance is not associated with of optimal functioning manifesting itself in a positive attitude
demonstrating to patients that following recommendations or toward oneself, the ability to build deep relationships, a sense of
accomplishing tasks is good for their health and that it is autonomy, the ability to control one’s environment, and having a
in their best interest. A strong alliance, in turn, results in firm belief about the direction of one’s life.
the development of a kind of non-instrumental social bond, The model of hypothesized relationships among the analyzed
based on respect for and trust in the proposed treatment and constructs, verified based on empirical data, is shown in
allowing for the acceptance of the recovery process (the bond Figures 1, 2.
effect). Finally, the way the alliance is implemented allows the
individual to feel important and included in the decision-making MATERIALS AND METHODS
process concerning their health (the agency effect). It should
be expected that a properly built alliance, which is, by its very Participants and Procedure
nature, based on a close relationship and on the autonomy of Empirical research was conducted between February 2019 and
the patient’s actions, will be reflected in the quality of his or June 2020. A total of 440 individuals were invited to take
her functioning. Based on the mechanisms outlined above, I part in the study: 270 patients and 170 psychotherapists.
therefore assumed that the alliance should enhance a positive and The final sample consisted of 411 participants: 252 patients

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Prusiński Working Alliance and Patient’s Wellbeing

FIGURE 1 | Model of direct relations of working alliance to well-being, life satisfaction, and flourishing. WAI-PA, isolated assessment of alliance based on patient’s
evaluation; WAISUM, assessment of alliance based on patient’s and psychotherapist’s evaluations; WAI, FS, TSWL, PWB, measures of the variables; e, random
component.

and 159 psychotherapists. In the study testing the relations Statistical Methods
between the variables, the assessment of therapeutic alliance I used the SPSS 25 and IBM SPSS AMOS 25 statistical packages.
and wellbeing was based on evaluations collected from 252 Preliminary analyses of the participants’ sociodemographic data
psychotherapist–patient dyads. The study dropout rate was 0.069 and correlation analyses were performed by means of SPSS 25.
(6.9%) in the case of therapists and 0.071 (7.1%) in the case To analyze SEM models, I used the AMOS 25 package.
of patients.
Participation in the study was voluntary and anonymous. The
participants—both patients and psychotherapist—were recruited Measures
from private and public psychotherapy offices. Information The Working Alliance Inventory
about the study was first given to the psychotherapist and then To assess working alliance quality, I used the full version of
to the patient. The participants—the psychotherapist and the the WAI. The WAI is available in three versions: patient’s
patient—were informed about the purpose of the study and version (WAI-PA), psychotherapist’s version (WAI-PT), and a
asked to give their consent to take part in it. After granting the version estimating the working alliance by summing patient’s
consent, the psychotherapist completed the Working Alliance and psychotherapist’s evaluations (WAI-SUM) (46). Each version
Inventory and a survey sheet with questions about demographic consists of 36 analogous items operationalizing the construct
variables and psychotherapeutic work context variables. The of working alliance, which the respondent rates on a Likert
patient began with completing the Working Alliance Inventory scale as accurately or inaccurately describing the cooperation
and went on to complete a battery of scales concerning the in the patient–psychotherapist dyad being evaluated. The WAI
evaluation of wellbeing and a sociodemographic survey. In score can be computed for three subscales; it is also possible
this study, I analyzed data collected in a single measurement. to determine alliance quality by computing the total score.
The respondents received no remuneration for participation in Each subscale is composed of 12 items: 6 positive and 6
the study. negative ones.

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Prusiński Working Alliance and Patient’s Wellbeing

FIGURE 2 | Model of correlations detailed for the dimensions of explanatory variables.

In my study I administered two versions of the measure: to assess the short-term outcomes of psychotherapy, understood
WAI-PA and WAI-SUM. The WAI-PA was used because it was as the current sense of satisfaction or contentment.
the patient’s mental state and wellbeing that were estimated,
which made it reasonable to ask about the patient’s evaluation of The Psychological WellBeing Scale
the working alliance. The WAI-SUM was used because patient’s This scale (48) consists of 18 items and measures long-term
and psychotherapist’s weighted evaluation of alliance corrects integrated psychological wellbeing as a whole. Respondents give
the possible overestimations or underestimations that may occur their answers on a 6-point scale from strongly disagree to strongly
when evaluation is performed exclusively by the patient. agree. The measure allows for the estimation of six components of
The reliability of the total score is αWAI−PA = 0.97 and wellbeing: autonomy, environmental mastery, personal growth,
αWAI−SUM = 0.98, and for the subscales it is as follows: αWAI−PA positive relations with others, purpose in life, and self-acceptance.
= 0.93 and αWAI−SUM = 0.95 for Goals; αWAI−PA = 0.93 and TSWLS and PWBS have good and very good reliability and
αWAI−SUM = 0.95 for Tasks; αWAI−PA = 0.93 and αWAI−SUM = validity (49).
0.96 for Bonds. CFA showed that measurement using the WAI
was valid.
The Flourishing Scale
The Flourishing Scale (FS) (50) is an 8-item measure of
The Temporary Satisfaction With Life Questionnaire the quality of functioning in important domains, such as
The TSWLS (47) measures integrated evaluation of life as relationships, self-esteem, purpose, and optimism. It yields a
a whole that existed, continues to exist, and will exist. It single score (αFS = 0.91). Respondents give their answers on a
consists of 15 items. The overall score is the sum of item 7-point scale from strongly disagree to strongly agree.
scores. Respondents give their answers on a 7-point scale from The data that support the findings of this study are available on
completely disagree to completely agree. TSWLS scores were used request from the corresponding author. The data are not publicly

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Prusiński Working Alliance and Patient’s Wellbeing

FIGURE 3 | Structural and measurement model with 11 latent variables postulating the direction of relations between the working alliance and psychological
well-being, tested with SEM.

available due to privacy or ethical restrictions. The collection 960 (0.4%) sessions (M = 37.01, SD = 82.71). A hundred and
of data that served as the basis for the analyses performed was eighty-nine participants (75%) attended psychotherapy once a
financially supported by state institutions and the university. week, and most of the psychotherapeutic sessions (76.6%) took
50–60 min.
RESULTS The type of disorder experienced by the participants in the
group of patients was a variable controlled for to a limited
Participants’ Sociodemographic degree. A few patients had more than one diagnosis; others were
Characteristics unable to give an unambiguous one. As regards the disorders
On the side of patients there were 252 Polish participants, that patients’ were treated for, the largest group were individuals
including 129 women (51.2%) and 123 men (48.8%). Female diagnosed with affective and mood disorders (32.9%). Mental
participants were 17 to 80 years old (M = 35.37, SD = 11.81), and behavioral disorders caused by the use of alcoholic and
and male participants’ age ranged from 18 to 70 (M = 37.34, SD = psychoactive substances were diagnosed in 23.4% of patients and
9.85). Most patients had higher (55.2%) or secondary education adaptation disorders were diagnosed in 13.5% of cases; 9.5% of
(42%) and lived in cities with a population above 100,000 (61.1%). psychotherapies were conducted due to personality disorders,
In the whole sample, 86 participants (34.1%) were single and schizophrenia, schizotypal disorders, and delusional disorders.
166 (65.9%) were married or had a partner. By the time of the In 7.5% of patients the reported reason for psychotherapeutic
measurement, the patients had attended between 2 (1.2%) and work was anxiety disorders and phobias, and 1.2% of patients

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Prusiński Working Alliance and Patient’s Wellbeing

FIGURE 4 | Structural and measurement model with eight latent variables postulating the direction of relations between the working alliance and satisfaction with life,
tested with SEM.

needed psychotherapy due to an experience of trauma in the Preliminary SEM Analyses

pretherapeutic period. To test the hypotheses (H1–H6), I built structural models with 11
On the psychotherapists’ side of the dyads, the participants latent variables (H1–H2), with 8 latent variables (H3–H4), with
were Polish, 109 women and 50 men, aged 27–64 (M = 5 latent variables (H5–H6), and with 16 latent variables (joint
42.98, SD = 9.48). The psychotherapists taking part in the model for H1, H2, H3, H4, H5, and H6). Thus, I constructed four
study worked in the following modalities: psychoanalytic SEM models, which are presented in Figures 3–6.
or psychodynamic (25.4%), cognitive-behavioral (31.7%), To check if the relationships between the therapeutic alliance
Ericksonian (12.3%), systemic (10.3%), humanistic (4.4%), and the explained variables would change depending on who was
and Gestalt (9.1%); 35.7% of therapies were conducted the source of information about allianc equality, I changed the
by psychotherapists with 1–5 years of work experience, measurement model within the framework of the same structural
while 63.9% were conducted by psychotherapists with more model defining the relations for the latent variables entered.
than 5 years of experience. 92.1% of the psychotherapists The measurement of working alliance was based either on the
were doing or had completed at least 2-year training sum of patient’s and psychotherapist’s evaluations (WAI-SUM)
in psychotherapy; 52.7% had a certificate from a Polish or exclusively on the patient’s evaluation (WAI-PA). Each of
psychotherapeutic associations. the SEM models was analyzed in the form of both full and

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Prusiński Working Alliance and Patient’s Wellbeing

FIGURE 5 | Structural and measurement model with five latent variables postulating the direction of relations between the working alliance and flourishing, tested with
SEM.

simplified structures. A simplified model is unaffected by small expected that they would mutually support the relationships
sample size bias, which decreases the likelihood of the first type tested. Thus, the further verification of the hypotheses, based
of error: rejecting a correct model. Such a model does not lose on results from multiple models, would rest on strong
the postulated multidimensionality of the construct in any way empirical support.
(51). In the preliminary analyses estimating model fit, I tested 16
models. The results are presented in Table 1. Main SEM Analyses
Using the criteria for assessing fit indices (52, 53) for SEM The hypotheses postulating cause-and-effect relations
models (χ2 /df < 2.5; RMSEA ≤ 0.80; GFI and CFI values close to between the working alliance as the explanatory variable
or exceeding 0.90; TLI values close to 0.95; ECVI and MECVI: the and psychological wellbeing, life satisfaction, and flourishing
best model is considered to be the one for which the values are the as explained variables (H1–H6) were tested using structural
lowest) and analyzing the values of the indices showing the fit of equation modeling. SEM results are presented in Table 2.
the theoretical model with the measurement model, I concluded The factor loadings were significant in each of the
that the models with very good and sometimes even excellent analyzed models. The actual effect of the working
fit were simplified separate ones, estimating the relationship alliance quality on wellbeing proved to be the
between alliance and each of the explained variables separately. strongest (Mβ SEPARATE SIMPLIFIED AND FULL MODELS =
Full separate models have acceptable or barely acceptable values 0.38 and Mβ JOINT SIMPLIFIED AND FULL MODELS = 0.65)
of some of the fit indices (RMSEA, CFI, TLI). The joint structural compared to the effects between alliance and satisfaction
models, including all relationships, demonstrate the poorest fit, (Mβ SEPARATE SIMPLIFIED AND FULL MODELS = 0.29 and
though RMSEA values in their case are acceptable. Mβ JOINT SIMPLIFIED AND FULL MODELS = 0.49) or flourishing
I therefore decided to consider all models when testing the (Mβ SEPARATE SIMPLIFIED AND FULL MODELS = 0.16 and
hypotheses. The structural models are not alternative for one Mβ JOINT SIMPLIFIED AND FULL MODELS = 0.40). Likewise, the
another, in the sense that they are not mutually exclusive. I values of the multiple correlation coefficient R2 were the highest

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Prusiński Working Alliance and Patient’s Wellbeing

FIGURE 6 | Structural and measurement model with 16 latent variables postulating the direction of the relations of the working alliance to psychological well-being, life
satisfaction, and flourishing, tested with SEM.

for the models that presented wellbeing as determined by alliance The results also show that the strength the relations
quality. The alliance–wellbeing models explain an average of between the therapeutic alliance and the explained
15% (MR2SEPARATE MODELS = 0.15) to 45% (MR2JOINT MODELS = variables slightly changes depending on who is the source
0.45) of the variance in the explained variable. These values are of information about alliance quality. If the alliance is
higher than the corresponding values for alliance–satisfaction evaluated by the patient, the relationships are stronger
(MR2SEPARATE MODELS = 0.08, MR2JOINT MODELS = 0.27) and (Mβ SEPARATE PA MODELS = 0.30, Mβ JOINT PA MODELS = 0.54)
alliance–flourishing models (MR2SEPARATE MODELS = 0.03, than when evaluations come from both sides of the alliance
MR2JOINT MODELS = 0.20). (Mβ SEPARATE SUM MODELS = 0.25, Mβ JOINT SUM MODELS =

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TABLE 1 | Fit indices of the tested models.

Hypotheses SEM model χ2 Df χ2 /df p RMSEA GFI CFI TLI ECVI MECVI

H1, H2 WAI-PA Full 3161.76 1367 2.31 0.01 0.072 0.65 0.81 0.80 13.54 13.80
WAI-PA Simplified 4.064 4 1.02 0.40 0.008 0.99 0.99 0.99 0.10 0.11
WAI-SUM Full 3357.36 1367 2.46 0.01 0.076 0.59 0.83 0.82 14.32 14.58
WAI-SUM Simplified 6.505 4 1.63 0.16 0.050 0.99 0.99 0.99 0.11 0.12
H3, H4 WAI-PA Full 2432.14 1217 2.00 0.01 0.063 0.70 0.88 0.87 10.56 10.78
WAI-PA Simplified 22.22 8 2.78 0.01 0.084 0.97 0.91 0.83 0.19 0.19
WAI-SUM Full 2653.71 1217 2.18 0.01 0.069 0.65 0.88 0.88 11.44 11.67
WAI-SUM Simplified 12.04 8 1.88 0.06 0.059 0.98 0.96 0.92 0.16 0.17
H5, H6 WAI-PA Full 1979.25 898 2.20 0.01 0.069 0.71 0.88 0.87 8.62 8.78
WAI-PA Simplified 2.14 4 0.53 0.71 0.001 0.99 0.99 0.99 0.10 0.10
WAI-SUM Full 2142.72 898 2.39 0.01 0.074 0.66 0.89 0.89 9.27 9.43
WAI-SUM Simplified 1.425 4 0.36 0.84 0.001 0.99 0.99 0.99 0.09 0.09
H1–H6 WAI-PA Full 5,902.35 2834 2.09 0.01 0.066 0.59 0.77 0.76 24.86 24.47
WAI-PA Simplified 410.73 167 2.46 0.01 0.076 0.84 0.41 0.33 1.98 2.01
WAI-SUM Full 6091.26 2834 2.15 0.01 0.068 0.56 0.79 0.79 25.61 26.22
WAI-SUM Simplified 402.35 167 2.41 0.01 0.075 0.84 0.42 0.34 1.95 1.98

χ2 , chi2 model fit statistic; df, degrees of freedom; χ2 /df, chi2 statistics divided by degrees of freedom; RMSEA= root mean square error of approximation; GFI, index of variance
explained by the path model; CFI, comparative fit index; TLI, Tucker–Lewis index; ECVI and MECVI, information criteria for comparing the quality of models.

0.48). In all of the analyzed structural conditions, these relations experience themselves as a person having developmental
are positive. potential, and on the fact that the active factor in
To sum up, the values of coefficients yielded by SEM psychotherapy—the therapeutic alliance—may be related to
supported hypotheses H1, H2, H3, H4, H5, and H6. The six this potential.
hypotheses were therefore accepted. The collected empirical data and the strategy of testing the
research objectives brought the expected results, confirming that
Correlations patient’s and psychotherapist’s perceptions of a strong therapeutic
To test hypothesis H7, postulating positive relations between alliance is crucial for the optimization of patient’s functioning
the dimensions of alliance (the assignment of tasks, agreement and wellbeing.
on goals, the development of bonds) and those wellbeing, life Importantly, the research plan in which alliance measurement
satisfaction, and flourishing, I performed correlation analyses. based on patient’s separate evaluation was enhanced with
Table 3 presents the obtained results. weighted estimation elicited from the recruited patient–
The results of the analyses revealed low but mostly positive psychotherapist dyad provides a strong empirical basis
and significant correlations between the variables. This makes it for conclusions. Supplementing separate evaluation with
reasonable to accept hypothesis H7. joint evaluation—elicited from two individuals: patient
All three working alliance factors correlate with flourishing and psychotherapist—is also theoretically justified. An
and with present and future life satisfaction, but they do important characteristic of Bordin’s working alliance is
not correlate with the evaluations of satisfaction experienced the mutuality of agreement. The strength of the alliance
in the past. The therapeutic alliance is associated with in this model is built by mutual consent to the actions
nearly all dimensions of psychological wellbeing. None of the undertaken and by maintaining a relationship of cooperation.
dimensions of alliance is the leading one in terms of the The indicators of change are the goals achieved through
number and strength of significant relations to the explained specific tasks, which is possible thanks to the bond
variables (Mrho TASKS = 0.24, MrhoGOALS = 0.24, Mrho BONDS created between patient and psychotherapist. Therefore,
= 0.23). if the alliance stems from the active participation of both
individuals involved in the therapeutic process, then it is
DISCUSSION reasonable to take the opinion of both parties into account in
its evaluation.
The analyses presented in this study explored the relationships Introducing psychotherapist’s evaluation of allianceis
of the non-specific and universal factor in psychotherapy valuable, considering the potential limitations of the present
(17, 18), the alliance, to the important though not always study, such as the fact that the psychiatric symptoms
explicit aims of psychotherapy: wellbeing, life satisfaction, experienced by the patients or the type of pharmacotherapy
and flourishing. In the current study I focused on the may have influenced their evaluation of the alliance
fact that, during psychotherapy, an individual may and wellbeing. Supplementing the analyzed models with

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Prusiński Working Alliance and Patient’s Wellbeing

TABLE 2 | Standard estimators of the tested models.

Models Hypotheses SEM model β p R2 Mβ MR2

Separate models H1, H2 WAI-PA Full 0.50 0.01 0.25 0.38 0.15
WAI-PA Simplified 0.34 0.01 0.12
WAI-SUM Full 0.42 0.01 0.18
WAI-SUM Simplified 0.26 0.01 0.07
H3, H4 WAI-PA Full 0.28 0.01 0.08 0.29 0.08
WAI-PA Simplified 0.30 0.01 0.09
WAI-SUM Full 0.28 0.01 0.08
WAI-SUM Simplified 0.28 0.02 0.08
H5, H6 WAI-PA Full 0.19 0.01 0.04 0.16 0.03
WAI-PA Simplified 0.20 0.01 0.04
WAI-SUM Full 0.13 0.05 0.02
WAI-SUM Simplified 0.13 0.03 0.02
Joint (Comprehensive) models H1–H6 WAI-PA Full WAI → Wellbeing 0.51 0.01 0.26
WAI → Satisfaction 0.30 0.01 0.09
WAI → Flourishing 0.21 0.01 0.04
WAI-PA Simplified WAI → Wellbeing 0.86 0.01 0.74
WAI → Satisfaction 0.70 0.01 0.49
WAI → Flourishing 0.66 0.01 0.43
WAI-SUM Full WAI → Wellbeing 0.42 0.01 0.18
WAI → Satisfaction 0.29 0.01 0.08
WAI → Flourishing 0.14 0.04 0.02
WAI-SUM Simplified WAI → Wellbeing 0.80 0.01 0.64
WAI → Satisfaction 0.66 0.01 0.44
WAI → Flourishing 0.58 0.01 0.33

β, standardized path coefficient; R2 , multiple correlation coefficient; M β and MR2 , mean values.

psychotherapist’s evaluation of alliance ensured a correction similar and sometimes (as in the case of wellbeing) higher values
of the patient’s underestimations or overestimations in this indicating the strength of these relationships.
regard. One should still be careful, however, when using The study also showed that no factor isolated from other
the results of the analyses and conclusions presented in components of alliance increased the quality of patient’s mental
this study. functioning more than others (38, 39) and that at the level of the
Alliance is a correlate of the maintenance of patients’ analyzed components of alliance these relations were rather weak.
wellbeing, present satisfaction, and flourishing. Of all Importantly, however, the results of analyses showed
the dimensions considered, I have identified those that significant associations between the dimensions of the
alliance is most strongly related to. An improvement therapeutic alliance (agreement on goals, the assignment of
in psychological wellbeing accompanied by a strong tasks, and the development of bonds) and the dimensions
alliance proved to be the main finding. It turns out of wellbeing. High working alliance quality is accompanied
that the therapeutic alliance is, above all, a factor of by an increase in current life satisfaction. Also the future is
wellbeing understood more deeply than merely as perceived by the patient as more pleasant and its conditions
current pleasure. as more acceptable. A strong therapeutic relationship is not
The present study supports the conclusions reached before related to the patient putting their past in order so as to make
by teams who analyzed the relations between the alliance sure that it is no longer a source of suffering and negative
and positive outcomes of psychotherapy (12, 21), confirming feelings in the present life. This is an important finding,
that these relations are increasingly positive with an increase which allows for concluding that the process of psychotherapy
in correspondence between patient’s and psychotherapist’s improves present functioning and, possibly, makes it possible
evaluations of the alliance. It also extends the previous findings to discover resources and develop strategies to optimize
by indicating that the relationships of working alliance to future functioning. The “strong alliance effect” is not a factor
wellbeing, present satisfaction, and flourishing remain positive motivating for changing the past. This may stem from the
and significant if the alliance is evaluated by the patient alone. fact that the past is treated by the patient as a temporally
Compared to earlier analyses (33), the present study revealed closed space impossible to change. The association found in

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Prusiński Working Alliance and Patient’s Wellbeing

TABLE 3 | Spearman’s rho correlation coefficients between the dimensions of on the significant conditions of recovery and to facilitate
alliance and the dimensions of wellbeing, life satisfaction, and flourishing. these conditions.
Variable Assignment Agreement Development
Two other dimensions, autonomy and self-acceptance,
of tasks on goals of bonds are also related to the quality of the therapeutic alliance,
though less strongly so. Thus, the working alliance—
Satisfaction Past 0.07 −0.10 −0.02 understood, after all, as an optimally built relationship
Present 0.25* 0.20* 0.21* in the process of psychotherapy—turns out to co-occur
Future 0.22* 0.20* 0.22* with the main characteristics of mental health: with a
Psychological Self-acceptance 0.13* 0.10 0.11 positive but also realistic attitude toward oneself, and
wellbeing with autonomy, enabling the effective intrinsic regulation
Purpose 0.05 0.06 −0.01 of behavior. The therapeutic relationship seems to be an
Relations 0.28* 0.26* 0.21* important stabilizing condition of maturation and development
Growth 0.21* 0.20* 0.16* despite the fact that what is often the case, particularly in
Mastery 0.33* 0.34* 0.30* the psychotherapeutic process, is a fluctuating increase in the
Autonomy 0.30* 0.26* 0.24* subjective sense of discomfort or the subjective experience of
Flourishing Flourishing 0.21* 0.19* 0.18* various difficulties.
The alliance sometimes accounts for a considerable percentage
PAST, satisfaction with the past life; PRESENT, satisfaction with the present life; FUTURE,
satisfaction with the future life; PURPOSE, purpose in life; RELATIONS, positive relations of the variance in scores on the explained variables measured in
with others; GROWTH, personal growth; MASTERY, environmental mastery. * p < the study. The analyses yielded higher estimates in this respect
0.01 (one-tailed). compared to earlier findings (20, 27).
To sum up, the seven hypotheses tested based on the
results of statistical analyses were supported and accepted. The
actual relationship between the quality of working alliance and
the study can also be explained as showing that the working psychological wellbeing proved to be the strongest. The relations
alliance is not a consultative or advisory relationship, which of the therapeutic alliance to satisfaction with life and the
means it does not consist in the psychotherapist indicating quality of flourishing in life are weaker, though their values
actions to be performed (54), and that patients themselves are moderate.
may be focused on improving their current health condition The therapeutic alliance is an important factor accompanying
rather than on putting the past in order in an appropriate and the positive outcomes of psychotherapy, operationalized by
satisfying manner. This result is consistent with the popular means of subjective indicators—namely, wellbeing.
assumption about what psychotherapy is. Since, as Haley (55) The relations of the therapeutic alliance to wellbeing, life
pointed out, the main aim of psychotherapy is for people to satisfaction, and flourishing vary slightly depending on who is
start functioning appropriately to the reality in which they the source of information about the quality of the alliance: the
currently live, efforts associated with revising their emotional patient alone or the patient and the psychotherapist (weighted
attitude to the past do not necessarily have to be a condition of evaluation by two individuals). If the alliance is evaluated by the
successful psychotherapy. patient alone, the relations are stronger.
As regards the associations of alliance dimensions with
the dimensions of psychological wellbeing, it should be noted
that all components of alliance are similarly related to the Constraints on Generality
ability to build deep and trust-based relations with others Various limitations of the present study should be mentioned.
(correlation between the dimensions of alliance and positive In future studies the sample size should be increased, so that
relations with others). The working alliance accompanies empirical support for SEM models can be stronger. Researchers
agency—which is crucial for recovery—and coping with complex should make sure that people with different characteristics
environmental factors (correlation between the dimensions of in terms of extraneous variables are strongly represented,
alliance and environmental mastery); it also accompanies the so that analyses taking their the impact of these variables
feeling that the search for a further path of development into account can be performed. The current sample was
and the challenges undertaken will lead to an increase too small and too heterogeneous to allow for distinguishing
in personal abilities (correlation between the dimensions homogeneous subgroups of subjects. It becomes necessary in
of alliance and personal growth). This is consistent with the future to identify the potential moderators of the analyzed
previous findings. Ryff (48) stresses that what is crucial relationships. What would also be valuable is longitudinal
for the improvement of health and for human development analyses, which, using at least two measurements performed
is an increase in the sense of self-directedness and the at different stages of working alliance consolidation, could
ability to transform the environment in accordance with one’s determine the dynamics of the relationships of alliance to
values and needs. It turns out that that a properly set-up wellbeing, satisfaction, and flourishing. This study had a cross-
alliance makes it possible to organize the therapeutic space sectional design, and the treatment relationship and alliance may
in such a way as to support the process of intense work have fluctuated over time in ways that this kind of design does

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Prusiński Working Alliance and Patient’s Wellbeing

not detect. Given these limitations, the research project should consent to participate in this study was provided by the
be continued. participants’ legal guardian/next of kin.

DATA AVAILABILITY STATEMENT AUTHOR CONTRIBUTIONS

The raw data supporting the conclusions of this article will be The author confirms being the sole contributor of this work and
made available by the authors, without undue reservation. has approved it for publication.

ETHICS STATEMENT FUNDING

The studies involving human participants were reviewed This research results presented in this article come from
and approved by the Research Ethics Board at the Maria research project BSTP 32/19-I, financed by the Maria
Grzegorzewska University (APS) in Warsaw. Written informed Grzegorzewska University.

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