Lately, you've been feeling down and depressed. While you've certainly felt this way before, you've never felt so fatigued that you feel weighed down. Feeling worthless and hopeless, you decide to see a therapist in the hopes of getting help. You tell a friend, who suggests that you call their therapist. According to your friend, this is the best therapist in the world. Thankful for the referral, you call and make an appointment. However, after several appointments, you just don't feel as though you and your therapist have connected. But because your friend simply loves this therapist, you wonder if trying out a different therapist is the right thing to do. Maybe the lack of connectedness is just in your head. Or maybe it's just the depression getting in the way of connecting with your therapist.

Make a Real Connection

While it's certainly true that symptoms of depression can interfere with connecting with others1, it's important to not just dismiss the lack of connection, particularly if it's your first experience with therapy. In fact, a large body of research indicates that the therapeutic alliance, or the extent to which you feel connected to your therapist, is one of the primary mechanisms leading to change in depressive symptoms across several types of psychotherapy.2, 3 Additionally, research indicates that the therapeutic alliance is particularly important to the outcome for those who have had a history of fewer depressive episodes.4

In a new study conducted from the University of Pennsylvania, Brown University, VU University Amsterdam, and Akrin Mental Health Care, a team of researchers examined the effect of the therapeutic alliance on the relations between the number of prior depressive episodes and treatment outcome between two types of therapy: cognitive behavior therapy (CBT) and psychodynamic therapy.5 In the study, individuals meeting criteria for depression completed surveys about their alliance with their therapist and their depressive symptoms over the course of 16 sessions of either CBT or psychodynamic therapy.

The results of the study indicated that, although the number of prior depressive episodes did not affect treatment outcome of either treatment, having a strong therapeutic alliance predicted positive treatment outcomes. Additionally, although having a strong therapeutic alliance was an important factor in both treatments, how important the alliance was differed based on the type of therapy and number of prior episodes. Specifically, for those individuals undergoing psychodynamic therapy, the alliance had a large effect on treatment outcome, regardless of the number of prior depressive episodes. In contrast, for those undergoing CBT, having a strong therapeutic alliance had a larger effect on treatment outcome in those with a history of fewer prior depressive episodes. Depending on the treatment and the number of prior depressive episodes, having a strong therapeutic alliance was an important mechanism of change in depressive symptoms.

The results of this study point to the importance of considering not only a therapist match to areas of expertise and type of therapy, but also to your interpersonal fit and feeling of connectedness. While it may be frustrating and time-consuming to shop around for a therapist, finding someone that you feel connected to may increase the likelihood of reducing your symptoms of depression.


Date of original publication:


1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

2. Arnow, B. A., Steidtmann, D., Blasey, C., Manber, R., Constantino, M. J., Klein, D. N., … Fisher, A. J. (2013). The relationship between the working alliance and treatment outcome in two distinct psychotherapies for chronic depression. Journal of Consulting and Clinical Psychology, 81, 627-638. Doi: 10.1037/a0031530

3. Ulvenes, P.G., Berggraf, L., Hoffart, A., Stiles, T. C., Svartberg, M., McCullough, L., & Wampold, B. E. (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy, 49, 291-302. doi: 10.1037/a0027895

4. Lorenzo-Luaces, L., DeRubeis, R. J., & Webb, C. A. (2014). Client characteristics as moderators of the relation between the working alliance and outcome in cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 82, 368-373. Doi: 10.1037/a0035994.

5. Lorenzo-Luaces, L., Driessen, E., DeRubeis, R. J., Van, H. L., Keefe, J. R., Hendriksen, M., & Dekker, J. (2017). Moderation of the alliance-outcome association by prior depressive episodes: differential effects in cognitive-behavioral therapy and short-term psychodynamic supportive psychotherapy. Behavior Therapy, 48(5), 581-595.