Between- and within-client associations of working alliance with therapeutic outcomes in non-western contexts: Multilevel evidence from China and a comparison with the United States.

Abstract

Objective: Working alliance is widely regarded as a central process variable across therapeutic orientations. However, alliance research remains predominantly informed by findings from Western contexts. Thus, the current study aimed to elucidate the multilevel roles of working alliance (client-rated) in non-Western settings. Method: Utilizing naturalistic data from a Chinese master's training program alongside a comparable US training program, this study conducted multilevel analyses to investigate both between-client alliance-outcome associations and within-client alliance-outcome associations in China, while also comparing these findings to those from the US. Results: The findings indicated that client-contributed alliance negatively predicted subsequent symptom levels in China (β = -.31, 95% CI [-.39, -.24], p < .001), and session-by-session alliance variations negatively predict subsequent symptom levels in China (β = -.04, 95% CI [-.07, -.00], p = .028). Additionally, the between- and within-client predictions of alliance for outcomes in China were equivalent to those observed in the US. Conclusions: This study contributes cross-cultural insights into the multilevel roles of alliance in individual therapy and enriches the discourse surrounding state- and trait-like aspects of alliance.