Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation

Shira Barzilay, Allison Schuck, Sarah Bloch-Elkouby, Zimri S. Yaseen, Mariah Hawes, Paul Rosenfield, Adriana Foster, Igor Galynker

Research output: Contribution to journalArticlepeer-review


Background: Mental health clinicians frequently experience intense negative emotional responses to suicidal patients, which have been related to treatment outcome. This study examines the therapeutic alliance as a mediator of the relationship between clinicians' negative emotional responses at the initial encounter and patients' suicidal ideation (SI) concurrently and 1 month later. Methods: We assessed 378 adult psychiatric outpatients (62.7% female; mean age = 39.1 ± 14.6 years) and their 61 treating clinicians. Following the initial encounter, self-report questionnaires assessed clinicians' emotional responses to their patients, patients' and clinicians' perception of the therapeutic alliance, and patients' SI. The SI was reassessed 1 month after the initial visit. Multilevel mediation analyses were performed. Results: Patients' (but not clinicians') perception of the therapeutic alliance mediated the relationship between clinicians' negative emotional responses to patients and patients' SI 1 month following the initial visit (indirect effect estimate = 0.015; p <.001). Conclusions: The association between clinicians' negative emotional response and patients' prospective SI appears to be transmitted, at least partly, through the patients' perception of the poorer early quality of the therapeutic alliance. Thus, clinicians' awareness and management of their emotional states appear essential both for the identification of suicidal risk and to enhance therapeutic alliance and treatment outcomes.

Original languageAmerican English
Pages (from-to)214-223
Number of pages10
JournalDepression and Anxiety
Issue number3
StatePublished - 1 Mar 2020
Externally publishedYes


  • Adult
  • Emotions
  • Female
  • Humans
  • Male
  • Prospective Studies
  • Suicidal Ideation
  • Suicide, Attempted
  • Therapeutic Alliance
  • countertransference
  • suicidal ideation
  • suicide
  • suicide prevention
  • therapeutic alliance

All Science Journal Classification (ASJC) codes

  • Psychiatry and Mental health
  • Clinical Psychology


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