The relationship between patient object relations and the therapeutic alliance in a naturalistic psychotherapy sample

Objectives
This study examined the relationship between patients' object relations and interpersonal process in psychotherapy. Namely, we tested the hypothesis that the quality of patients' object relations is positively associated with both patient- and therapist-rated alliance quality.
Design

Psychotherapy was administered naturalistically, with quantitative data collection before and during treatment.

Methods
Participants included 73 adult outpatients and 23 therapists at two mental health clinics. Using the Bell Object Relations and Reality Testing Inventory, we measured four dimensions of patients' object relations at baseline—alienation, insecure attachment, egocentricity, and social incompetence. Using the Working Alliance Inventory, we measured alliance from patient and therapist perspectives. Control variables included time, patient demographics, symptom severity, and clinic. We employed hierarchical linear modelling to analyse data with a nested structure, with 138 sessions at Level 1, 73 patients at Level 2, and 23 therapists at Level 3.

Results
Patient alienation and insecure attachment were associated with lower patient-rated alliance, while egocentricity was associated with higher patient-rated alliance. Patients' object relations were not significantly associated with therapist-rated alliance. On average, patients perceived the alliance more positively than their therapists, with a weak positive correlation between the alliance perspectives.

Conclusions
The results suggest that object relation dimensions may be important patient characteristics for forecasting therapeutic relationship quality. They also call for more attention to differences between alliance rating perspectives.
Practitioner points

Treatment may benefit from more attention to the quality of patients' object relations.
If patients present with high levels of alienation and insecure attachment, therapists may need to pay especially close attention to the therapeutic alliance, and prudently address any ruptures in its quality.

When monitoring the alliance quality, it is important to consider that patients and therapists may have different perspectives. Therapists relying solely on their own perceptions are at risk of missing alliance difficulties, and patients' object relations may be uniquely predictive of their own sense of the alliance. Therefore, it may be helpful to ask patients in session and through standardized measures for feedback on how they perceive the goals and tasks of treatment and the emotional bond with their therapist. Again, any alliance tensions could then be addressed directly as a means to maintaining engagement in the service of better outcome.