The therapeutic alliance in single-session therapy

The therapeutic alliance in single-session therapy

One of the most debated topics when it comes to Brief Therapies is undoubtedly that of the therapeutic alliance, when the debate then focuses on the way in which this factor affects Single Session Therapy, the comparison takes on even more heated tones.

With today ‘s article we will focus on a study carried out by Chrystal T. Fullen (2019) which describes precisely the process of co-construction of the therapeutic alliance in the context of SST starting from the analysis of some therapeutic conversations.


What exactly is the therapeutic alliance?

The therapeutic alliance is one of the most studied therapeutic factors in the field of psychology (Gelso, 2014). Although researchers and professionals do not agree on its definition, the importance it covers in the therapeutic process is universally recognized (Bordin, 1979). Often the words alliance and relationship are used interchangeably to describe the connection that develops between the therapist and client during therapy . However Chrystal T. Fullen (2019) in the research cited in this article has chosen to use the word alliance to highlight the widely held hypothesis thatthe strength of the therapeutic alliance correlates with positive outcomes of therapy (Arnow et al ., 2013).



Why does the therapeutic alliance arouse so much interest?

Historically , research on therapeutic factors has occupied an important role in psychology . Researchers have shown an ongoing interest in the mechanisms that influence change in psychotherapy (Liebert & Dunn-Bryant, 2015). Such attention is not surprising when one considers the existence of over four hundred models of psychotherapy , many of which are in strong competition with each other (Behan, 2019).



Are there factors of change common to all psychotherapies?

In 1936 Rosenzweig postulated that all models of psychotherapy are effective and that the success of all therapies lies in the commonalities between the models and not in their differences. Since then, researchers have continued to identify common factors in an effort to create a universal theory that highlights the specific factors responsible for therapy success (Frank, 1961; Wampold, 2001).



What conclusions did the researchers come to?

The most widely accepted theory to date is the common factor theory formulated by Lambert (1999) which Duncan, Hubble, and Miller (2010) expanded on in 2010 by relating factors contributing to therapeutic change to treatment outcomes. . This study found that the positive outcomes of a therapy are:

  • 40% directly connected to the client’s extra-therapeutic resources
  • 30% to the therapeutic alliance
  • 15% to the customer’s hope
  • 15% to the theoretical approach of the therapist (Duncan, Hubble and Miller, 2010).

 While this theory is widely accepted, some contest its validity (de Felice et al ., 2019), identifying other common factors (Brown, 2015; Drisko, 2014; Frank & Frank, 1993; Horvath & Luborsky, 1993). However, regardless of which theory is favored, all agree that the therapeutic alliance is fundamental to all therapeutic approaches (Del Re & Wampold, 2012; Wampold, 2015).



What happens when the theme of the therapeutic alliance enters the debate on the duration of the therapy?

Interest in the duration of psychotherapy is strongly linked to the assumption that the therapeutic alliance between therapist and client is established over multiple sessions. The controversy over length of therapy stems from the belief of some researchers and practitioners that in order to create a strong working alliance and ensure client satisfaction , a therapist required a large number of sessions (Glebova et al. , 2011). .



But what has other scholars observed?

Howard, Kopta, Krause and Orlinksy (1986) have published a study which highlights how the number of sessions and the outcomes of psychotherapy are negatively correlated . The authors also suggested that the greatest benefit from psychotherapy occurs in the first six sessions , with no significant improvement over time. Clients often show satisfaction with a psychotherapy service regardless of the number of sessions attended (Littlepage et al ., 1976) just as the therapeutic alliance along with positive outcomes and client satisfaction are independent of treatment duration(Ardito & Rabellino, 2011; Arnow et al., 2013; Horvath & Symonds, 1991).



What about Fullen’s research?

Fullen conducted his investigation using conversation analysis (CA) , a qualitative method of analysis developed by Harvey Sacks (1995) , a leading sociologist, through which he analyzed a single therapy session. The use of CA in psychotherapy research is well established and constitutes a valid method of analysis (Couture & Sutherland, 2006; Muntigl & Horvath, 2016; Sutherland & Strong, 2011).



What were the results?

The analysis concerned the study of single-session therapies carried out with adults between 18 and 75 years of age. Conversation excerpts provided clear evidence supporting co-building of a therapeutic alliance throughout the session . Fullen identified the moments of the transcription in which the therapist and the client engaged in definition of meaning, collaboration, analyzing the paralinguistic characteristics of the conversation. Subsequently she associated the extracts of the transcripts with the aspects of the relationship already defined previously by the original theory of Bordin (1979) who defined the therapeutic alliance as a mutual agreement regarding the Objectives (Goal ) of the change and the Tasks ( Task) necessary to reach them, together with the establishment of Bonds which maintain the collaboration between the participants in the therapeutic work.

Below are the elements found in the conversations that allowed the co-building of the alliance :

  • Spontaneity of the relationship
  • Positive and unconditional regard by the therapist towards the client
  • Empathy
  • Agreement on achieving a work goal
  • Tasks necessary to achieve the goal
  • Professional relationship between client and therapist built on trust created through spontaneity and unconditional respect
  • Client satisfaction with therapy




With today’s article we wanted to provide evidence to support the idea that a single therapy session may be sufficient to create a stable and positive therapeutic alliance . The research cited in the article highlights how SST is based on the same principles as other therapeutic approachesthat is, to help the client improve the quality of life through the co-construction of a therapeutic alliance useful to amplify the positive therapeutic results. As healthcare and treatment costs rise, SST becomes a cost-effective and effective treatment option. The study results also support any research that believes that TSS is as effective as other forms of evidence-based therapy. These results also challenge researchers who suggest that long-term models are more effective simply because they are longer without considering all the research supporting that how often people have therapy is often one or only a few sessions. and with satisfaction for the results achieved.


Angelica Giannetti
Team Psychotherapist of the Italian Center
for Single Session Therapy




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Rosita Del Medico

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