Patient versus therapist alliance: whose perception matters?

Development of working alliance was examined for 25 opioid-abusing pain patients and their therapists. Patients participated in an eight-session intervention based on adherence strategies and employment of a supportive, psychoeducational approach; methadone was prescribed for pain. Treatment goals included opioid analgesic adherence and decreasing pain, functional interference, and substance abuse. Patients and therapists completed the Helping Alliance Questionnaire-II following each treatment session. At baseline, scores of patients and therapists indicated good alliance. Patient alliance grew significantly over time regardless of addiction severity and independent of treatment outcomes. In contrast, therapist alliance grew only for patients without substance abuse comorbidity and/or who had good outcomes. Patients' and therapists' alliance scores were consistent during sessions focused on emotional bonds but diverged during sessions that demanded behavior change, suggesting that therapists may have reacted negatively to patients' lack of progress. Whether therapists' reactions to poor performers impacted subsequent patient outcomes is unknown but should be investigated.