Therapeutic alliance and suicidal ideation during therapy and the role of racial/ethnic identity

Psychother Res. 2026 Jun 1:1-13. doi: 10.1080/10503307.2026.2674016. Online ahead of print.

ABSTRACT

OBJECTIVE: Research has shown a robust relationship between the quality of a therapeutic alliance early in treatment and subsequent symptomatic outcome. However, findings are mixed regarding other kinds of outcome across treatment. The current study aimed to examine the association between alliance and suicidal ideation (SI) throughout treatment and whether that association varies depending on marginalized race/ethnicity.

METHODS: Structural equation modeling was used to examine 1,099 clients at a university counseling center. Alliance and SI were measured at every session. Analyses tested the relationship between alliance and SI across five sessions, regarding between-client associations and within-client time-lagged predictions. Moderation of marginalized race/ethnicity on the relationship between alliance and SI was tested.

RESULTS: Across treatment, clients who reported more SI had lower alliance scores. When clients reported higher alliance ratings than they usually did in a session, their reported SI tended to decline in the following session. There was no evidence that when clients reported lower SI in a session, alliance ratings increased in the following session. Clients of marginalized race/ethnicity reported lower alliance and higher SI compared to non-marginalized clients. However, the association between alliance and SI scores did not vary depending on marginalized race/ethnicity.

CONCLUSION: Future research directions and clinical implications are discussed.

PMID:42220082 | DOI:10.1080/10503307.2026.2674016