Goals, Tasks, and Bonds: Toward the Computational Assessment of Therapist Versus Client Perception of Working Alliance

Early client dropout is one of the most significant challenges facing psychotherapy: recent studies suggest that at least one in five clients will leave treatment prematurely. Clients may terminate therapy for various reasons, but one of the most common causes is the lack of a strong working alliance. The concept of working alliance captures the collaborative relationship between a client and their therapist when working toward the progress and recovery of the client seeking treatment. Unfortunately, clients are often unwilling to directly express dissatisfaction in care until they have already decided to terminate therapy. On the other side, therapists may miss subtle signs of client discontent during treatment before it is too late. In this work, we demonstrate that nonverbal behavior analysis may aid in bridging this gap. The present study focuses primarily on the head gestures of both the client and therapist, contextualized within conversational turn-taking actions between the pair during psychotherapy sessions. We identify multiple behavior patterns suggestive of an individual's perspective on the working alliance; interestingly, these patterns also differ between the client and the therapist. These patterns inform the development of predictive models for self-reported ratings of working alliance, which demonstrate significant predictive power for both client and therapist ratings. Future applications of such models may stimulate preemptive intervention to strengthen a weak working alliance, whether explicitly attempting to repair the existing alliance or establishing a more suitable client-therapist pairing, to ensure that clients encounter fewer barriers to receiving the treatment they need.

I. Introduction

Previous research has established that the strength of the relationship between a client and their therapist is a robust predictor of positive therapy outcomes [24], [29], [32]. Much of the current psychological literature on the client-therapist relationship pays particular attention to what is known as the working alliance. Although many variations on the definition of ‘working alliance’ can be found, there is a consensus on the central idea that the working alliance captures the collaborative aspect of the therapist-client relationship [3], [24]. Higher therapist-reported and especially client-reported ratings of the working alliance have been strongly associated with reduction of the client's symptoms and concerns [14], [23], [24], but also with other positive therapy outcomes such as reduced drug abuse and recidivism [30] and improved medication compliance [13]. Of particular note is the recognized relationship between the strength of the working alliance and client dropout [13], [27], [41]. Proactive detection is especially valuable in this case: by the time a client has decided to quit therapy, the time for potential intervention has already passed. Understanding the complexity of the therapist-client relationship is crucial for informed treatment decision-making.