The relationship between clinician responsiveness, therapeutic alliance, and depth of elaboration in psychotherapy: A network analysis

Background: Several psychotherapeutic approaches are effective for a range of mental health conditions (Cristea et al., 2017; Cuijpers et al., 2023), but it remains unclear which active ingredients promote successful treatments. It is well established that relational factors, particularly the therapeutic alliance, predict good outcomes (Fluckinger et al., 2018; Norcross & Lambert, 2019). More recently, models that focus on the impact of therapist variables are receiving particular attention. However, further studies are needed to understand their implications on the therapeutic process in clinical practice. The present work stems from an effort to apply complex systems theories in psychotherapy research by capturing the opportunity to look at the therapeutic process holistically. This study aims to identify and emphasize the interconnectedness of the elements underlying the dynamics that develop between clinician and patient and to shed light on the processes that promote patient changes through the network approach (cf., Borsboom et al., 2021). This empirical investigation aimed to explore the network structure involving the dimensions of therapist responsiveness (e.g., Kramer & Stiles, 2015), therapeutic alliance (i.e., bond, task, and goal; Bordin, 1979), and depth of elaboration (e.g., Stiles et al., 2022) in psychotherapy sessions. Methods: 77 therapist-patient dyads completed the Patient’s Experience of Attunement and Responsiveness (PEAR; Snyder & Silberschatz, 2017, the Working Alliance Inventory-Short Form (WAI-SF; Tracey & Kokotovic, 1989), and the Session Evaluation Questionnaire (SEQ; Stiles & Snow, 1984) Depth Scale. We applied network analysis to examine interconnections between variables. We calculated centrality metrics and assessed the robustness of estimates by evaluating the accuracy of edge weights and the stability of centrality indices through the correlation stability coefficient (CS). Results: The most central therapist node was the task, while the most central patient node was the goal. The patient nodes were closely interconnected with each other. Several interconnections also emerged among the therapist nodes. The bond (therapist) was connected to the bond (patient), and the task (patient) was connected to the task (therapist). Depth showed a range of interconnections in both the patient and the therapist, but this variable closely correlated only to therapist responsiveness in the group of therapists. The CS was .36. Discussion: Our results seem to show that the depth of content elaboration that emerges in psychotherapy sessions is closely related to the responsiveness of the therapist, especially in the clinician group (e.g., Harrington et al., 2021). In addition, clinician responsiveness is associated with both task and bond in both the patient and therapist groups (e.g., Culina et al., 2023; Hatcher, 2021;). These two alliance dimensions are crucial because they enable mutual interaction between clinicians and patients, supporting evidence of the exquisitely intersubjective nature of clinical exchange and the impact of relational variables on successful psychotherapies.