The first sessions of psychotherapy: a qualitative meta-analysis of alliance formation processes

Although the effect of the therapeutic alliance on psychotherapy outcome is well documented in the research literature, less is known about how the alliance is developed during the first sessions of therapy. This qualitative meta-analysis aimed to summarize and reanalyze the existing qualitative research literature on alliance-formation processes from the perspectives of therapists and clients. Research articles were obtained through systematic searches in the following databases: PsycINFO, MEDLINE, and Web of Science. Initially, 1,006 nonduplicate articles were screened, resulting in 15 articles that explored early alliance-formation processes from the perspectives of therapists and clients. These articles were analyzed using an existing framework of meta-analyzing qualitative research. Nine articles that studied the client perspective revealed 5 overarching metathemes: (1) meeting a competent and warm therapist; (2) being understood as a whole person; (3) feeling appreciated, tolerated, and supported; (4) gaining new strength and hope for the future; and (5) overcoming initial fears and apprehension about psychotherapy. Seven articles that studied the therapist perspective revealed 6 overarching metathemes: (1) balancing technical interventions and interpersonal warmth; (2) showing a genuine desire to understand; (3) openly supporting client agency; (4) adjusting to create a sense of safety; (5) paying attention to body language; and (6) providing helpful experiences during the first session. As the first of its kind, this meta-analysis of the dual perspectives of therapists and clients shows thematic commonalities and divergences in how alliance development is experienced. Clinical implications of how alliance development can be promoted in clinical practice are discussed.