The benefits of being on the same page about the “work” of therapy.

In psychotherapy research, the quality of the therapeutic relationship is consistently associated with outcomes, regardless of the specific techniques that are utilized. There are multiple aspects to that relationship and an important one is the level of collaboration and clarity on the goals for therapy and the methods that will be used to achieve them. Also associated with the benefit of sessions is emotional distress; patents who enter treatment with higher levels of distress generally report poorer therapy experiences. An important question, however, is whether distress affects session quality directly or whether its impact occurs through the therapeutic relationship itself.

A 2026 study examined this question using data from over a thousand adults receiving psychotherapy. Participants completed measures of recent anxiety and depressive symptoms, the personal connection with their therapists, agreement on goals and tasks, and overall session quality. The researchers found that patients experiencing greater distress tended to report weaker therapeutic relationships and less agreement with their therapists about the tasks of therapy. Much of the connection between psychological distress and poorer session experiences appeared to operate through these relational factors rather than distress alone. Distressed clients were less likely to feel aligned with their therapists about what they were working on in treatment, and this lack of alignment was strongly associated with lower session quality. Although correlational, the findings suggest that maintaining a collaborative understanding of therapy's purpose and process may be especially important when patients are most distress.

The authors concluded that the working alliance, particularly agreement about the concrete activities that comprise the “therapeutic work”, helps explain why some patients experience therapy sessions as more beneficial than others. Their findings add to a growing body of evidence that effective psychotherapy depends not only on symptom change but also on developing a shared understanding of treatment goals and the work required to achieve them.

Citation:

Stefana, A. (2026). How recent psychological distress relates to session quality in psychotherapy: The mediating roles of the real relationship and working alliance. Psychology and Psychotherapy: Theory, Research and Practice, 99, 751-764. https://doi.org/10.1111/papt.70049