Research suggests that the therapeutic alliance—the working relationship between a person and their therapist—plays a meaningful role during Eye Movement Desensitization and Reprocessing (EMDR) therapy.
Studies have examined how this relationship develops, whether it is associated with improvements in trauma-related symptoms, and how it functions during different treatment approaches.
The findings suggest that a stronger therapeutic alliance is often associated with greater symptom improvement during EMDR and other trauma-focused treatments. However, researchers have not established that a strong alliance alone causes better outcomes.
EMDR uses a structured approach to processing distressing memories, but this does not make the therapist-client relationship unimportant. Research indicates that collaboration, trust, and agreement about treatment goals remain relevant throughout the process.
What Is the Therapeutic Alliance?
The therapeutic alliance is the collaborative relationship between a therapist and the person receiving treatment.
It involves more than simply liking or feeling comfortable with a therapist.
Researchers commonly describe three main components:
Agreement on treatment goals: Both people understand what the treatment is intended to address and what meaningful progress might involve.
Agreement on treatment tasks: Both understand and agree on the activities and procedures used during treatment.
Emotional bond: The relationship includes trust, respect, understanding, and a sense of being supported.
These components are based on a widely used model of therapeutic alliance developed by psychologist Edward Bordin.
A strong therapeutic alliance does not require constant agreement or a close personal relationship. Instead, it involves a shared understanding of the treatment process and a working relationship that supports participation.
Why Is the Therapeutic Alliance Relevant to EMDR?
EMDR uses a structured eight-phase treatment approach involving preparation, assessment, memory processing, and reevaluation.
During treatment, a person may focus on a distressing memory while engaging in bilateral stimulation, such as guided eye movements, alternating sounds, or tapping.
Unlike some forms of traditional talk therapy, EMDR does not necessarily require extensive verbal discussion of every memory detail.
However, communication and collaboration remain relevant.
For example, a person may want to understand why a particular memory has been selected, what to expect during processing, or when to pause and review their experience.
The therapeutic alliance provides a framework for these conversations.
Researchers are interested in whether a collaborative relationship helps people remain engaged with the treatment process and whether differences in relationship quality are associated with differences in outcomes.
What Do Studies Find About Therapeutic Alliance and EMDR Outcomes?
A 2026 study by Peji and Perez, published in Cureus, directly examined the relationship between therapeutic alliance and symptom improvement during EMDR-centered psychotherapy.
The researchers analyzed clinical records from 138 adults with post-traumatic stress disorder (PTSD) who received treatment at an outpatient psychological clinic in the Philippines between 2022 and 2025.
The treatment involved EMDR alone or EMDR combined with additional therapeutic interventions.
Researchers measured PTSD symptoms at three points:
Before treatment.
During the middle of treatment.
After treatment.
They also measured therapeutic alliance at the midpoint using a brief relationship questionnaire.
What did the study find?
Average PTSD symptom scores decreased during treatment:
| Assessment point | Average PTSD symptom score |
|---|---|
| Before treatment | 43.7 |
| Mid-treatment | 37.8 |
| After treatment | 30.0 |
Lower scores indicated fewer reported PTSD symptoms.
The researchers found that stronger therapeutic alliance ratings at the midpoint were associated with greater overall symptom improvement.
The association was particularly noticeable during the later part of treatment.
However, therapeutic alliance did not significantly predict symptom changes between the beginning and midpoint of treatment.
The researchers also found that the number of completed treatment sessions was independently associated with symptom improvement.
What do these findings mean?
The results suggest that both the working relationship and continued participation may be relevant to outcomes during EMDR-centered psychotherapy.
However, this was a retrospective observational study rather than a randomized experiment investigating the effects of therapeutic alliance.
The findings therefore establish an association, not proof that a stronger alliance directly caused greater symptom improvement.
Because some participants also received other interventions, the results cannot be attributed exclusively to EMDR.
Does the Therapeutic Alliance Become More Important as EMDR Progresses?
The 2026 study by Peji and Perez provides some evidence that the relationship between therapeutic alliance and symptom improvement may vary across treatment stages.
The researchers found no significant association between midpoint alliance ratings and symptom changes during the earlier treatment period.
However, stronger midpoint alliance ratings were associated with greater symptom reduction during the later treatment period.
This suggests that the alliance may become particularly relevant as treatment progresses.
One possible explanation is that collaboration and communication help support continued engagement with structured therapeutic activities.
For example, during later sessions, people may be working through different aspects of their experiences or reviewing how their responses have changed.
A positive working relationship may help support participation in these activities.
However, the study did not establish why the association was stronger later in treatment.
The results also do not mean that the therapeutic alliance is unimportant during the early stages.
Further studies measuring alliance repeatedly throughout EMDR would help clarify how its role changes over time.
What Has Research Found About Therapeutic Alliance and Attachment?
A 2023 pilot study by Barazzone and colleagues, published in the Journal of EMDR Practice and Research, examined therapeutic alliance alongside changes in attachment security.
Attachment security refers to a person's sense of trust, connection, and confidence in close relationships.
The researchers studied 18 adults receiving EMDR for symptoms of PTSD or complex post-traumatic stress disorder, a condition involving additional difficulties that can develop following prolonged or repeated trauma.
Participants completed approximately 15 EMDR sessions on average.
Researchers collected self-report measures of:
Attachment security.
PTSD symptoms.
Complex PTSD symptoms.
Therapeutic alliance.
What did the study find?
Participants showed reductions in attachment insecurity during the treatment period.
The researchers also found that changes in attachment security were partly associated with the quality of the therapeutic alliance and changes in trauma-related symptoms.
These findings suggest that the working relationship may be relevant to broader psychological changes during EMDR.
However, the study involved only 18 participants and did not include a comparison group.
It cannot establish whether the observed attachment changes resulted directly from EMDR, the therapeutic alliance, other influences, or a combination of factors.
The findings are useful for understanding possible relationships between treatment experiences and psychological functioning, but larger studies are needed to clarify these associations.
Can a Therapeutic Alliance Develop When Different Therapists Deliver EMDR?
A 2026 study by Hoogeveen and colleagues, published in the European Journal of Psychotraumatology, investigated therapeutic alliance during an intensive trauma-focused treatment program involving therapist rotation.
Therapist rotation means that participants work with different therapists across treatment sessions rather than seeing the same therapist throughout the program.
The study included 133 adults with PTSD who received a four-day intensive treatment program in the Netherlands.
The program combined EMDR with prolonged exposure therapy, physical movement-based activities, and psychoeducation.
Participants interacted with different therapists during treatment.
Researchers measured therapeutic alliance and PTSD symptoms at several points.
What were the findings?
The study reported that:
Participants were able to develop positive therapeutic alliances despite working with different therapists.
Alliance ratings increased modestly from the early treatment period to the midpoint.
Alliance ratings then remained relatively stable.
Stronger earlier alliance ratings were associated with greater subsequent reductions in PTSD symptoms.
Unresolved difficulties in the therapeutic relationship were associated with less favorable outcomes.
The researchers described a small relationship in both directions: earlier alliance ratings were related to later symptom changes, while earlier symptom severity was also related to subsequent alliance ratings.
Why is this relevant?
The findings suggest that a therapeutic alliance can develop within a structured treatment program even when participants do not work with the same therapist throughout.
They also show that the relationship between alliance and symptom improvement can be investigated over multiple treatment stages.
However, this study examined a combined program rather than EMDR alone.
The results cannot establish whether the same patterns would occur during standard individual EMDR sessions or whether they were influenced by other components of the intensive treatment program.
Does EMDR Training Influence the Therapeutic Alliance?
Researchers have also examined whether training in EMDR is associated with how therapists develop collaborative relationships.
A 2022 study by Plantade-Gipch, Rotonda, and Tarquinio investigated the contribution of EMDR training to therapeutic alliance.
The researchers compared three groups involving 20 psychotherapists:
Six therapists trained only in EMDR.
Four therapists trained in EMDR and another therapeutic approach.
Ten therapists trained in other therapeutic methods.
The researchers used patient ratings from the Working Alliance Inventory, a questionnaire designed to measure the therapeutic relationship.
What did the study find?
Patients working with therapists trained in EMDR reported improvements in therapeutic alliance ratings, particularly in agreement about treatment goals.
This finding suggests that the structured approach used in EMDR training may be associated with how therapists communicate treatment goals and establish collaborative expectations.
However, the study was small and used a quasi-experimental design rather than randomized assignment to therapist-training conditions.
Differences in therapist experience, patient characteristics, and other factors may have influenced the findings.
The study therefore does not establish that EMDR training independently produces stronger therapeutic alliances than other forms of training.
What Does Broader PTSD Research Say About Therapeutic Alliance?
Research on therapeutic alliance is not limited to EMDR.
A systematic review and meta-analysis by Howard, Berry, and Haddock, published in Clinical Psychology & Psychotherapy in 2022, examined therapeutic alliance across psychological treatments for PTSD.
A systematic review gathers and evaluates research on a specific question. A meta-analysis combines results from eligible studies to examine patterns across the evidence.
The review included 34 studies, with 12 contributing to the statistical meta-analysis of alliance and PTSD outcomes.
What did the researchers find?
The analysis identified a statistically significant association between stronger therapeutic alliance and better PTSD outcomes.
The combined correlation was approximately −0.34.
A correlation describes how closely two variables are related. In this case, the negative value indicated that stronger alliance ratings were associated with lower PTSD symptom severity.
The researchers also found that therapeutic alliance was associated with outcomes in both in-person and remote psychological treatments.
However, this review covered several forms of PTSD psychotherapy.
Its findings cannot be interpreted as an EMDR-specific estimate of the therapeutic alliance's effect.
The review also identified methodological limitations, including generally weak-to-moderate study quality and potential selection bias.
Nevertheless, it provides broader evidence that therapeutic alliance is relevant to treatment outcomes among people receiving psychological care for PTSD.
How Do Researchers Measure the Therapeutic Alliance During EMDR?
Researchers use structured questionnaires to assess how participants experience their working relationship with a therapist.
These questionnaires may be completed by the person receiving treatment, the therapist, or both.
Some studies also assess the alliance repeatedly to investigate how it changes.
| Assessment method | What it measures |
|---|---|
| Working Alliance Inventory | Agreement on treatment goals, agreement on tasks, and emotional bond |
| Agnew Relationship Measure | Aspects of the working relationship, including collaboration and relational quality |
| Client-rated questionnaires | How the person receiving treatment experiences the relationship |
| Therapist-rated questionnaires | How the therapist evaluates the working relationship |
| Repeated assessments | Whether alliance ratings change throughout treatment |
For example, the 2026 study by Peji and Perez used the five-item Agnew Relationship Measure to evaluate alliance at the midpoint of treatment.
The 2026 study by Hoogeveen and colleagues used the short form of the Working Alliance Inventory to assess the relationship with the rotating therapist team.
Researchers can then compare these ratings with changes in PTSD symptoms and other outcomes.
This helps identify whether relationship quality is associated with treatment progress.
However, a questionnaire score does not capture every aspect of a therapeutic relationship.
The timing of the assessment and whether it reflects the client's or therapist's perspective can also influence the findings.
Does a Strong Therapeutic Alliance Cause Better EMDR Outcomes?
The research does not establish a simple cause-and-effect relationship.
Several studies have found that stronger therapeutic alliance ratings are associated with better outcomes.
However, there are different possible explanations for this association.
A stronger alliance may support treatment participation.
A collaborative relationship may help people remain engaged with the treatment process and communicate their preferences or concerns.
Symptom improvement may influence alliance ratings.
Someone who notices progress may also begin to evaluate the treatment relationship more positively.
Other factors may influence both outcomes.
Personal expectations, treatment preferences, therapist characteristics, and other aspects of care could influence both relationship ratings and symptom changes.
Researchers use repeated assessments and statistical analyses to investigate these possibilities.
However, observational studies cannot fully establish whether the alliance causes improvement or whether both change together for other reasons.
The most accurate interpretation is that therapeutic alliance appears to be an important factor associated with outcomes, while its precise causal role during EMDR remains under investigation.
Does EMDR Require a Strong Relationship Before Memory Processing Can Begin?
Research does not establish a specific therapeutic alliance score that every person must reach before progressing through EMDR.
The structured EMDR approach includes preparation activities that help establish treatment goals, explain procedures, and support participation.
These activities can contribute to a collaborative working relationship.
However, people develop trust and comfort at different rates.
A positive therapeutic alliance does not necessarily mean that someone feels completely comfortable discussing every personal experience.
Similarly, EMDR does not require a person to describe every detail of a memory aloud.
The collaborative aspect of treatment is more accurately understood as having enough shared understanding to participate meaningfully in the chosen procedures.
Research supports the relevance of therapeutic alliance, but it does not establish one required level of emotional closeness or a single pattern of relationship development for everyone.
Can EMDR Work Without Extensive Verbal Discussion?
EMDR may involve less detailed verbal discussion of distressing memories than some traditional talk-based therapies.
During memory processing, attention is often directed toward internal experiences while bilateral stimulation is used.
The person may briefly describe what they notice rather than explaining every thought or memory in detail.
However, this does not mean that communication is absent.
Treatment goals, memory selection, pacing, and responses to the procedures can still involve collaboration.
A therapeutic alliance can therefore develop through shared understanding and participation, not only through extended conversations.
This distinction is important because therapeutic alliance measures assess the quality of the working relationship rather than the amount of talking that occurs.
The available research does not establish that more verbal discussion automatically produces a stronger alliance or better EMDR outcomes.
What Are the Limitations of Research on Therapeutic Alliance During EMDR?
Although published studies provide useful information, several limitations affect how confidently the findings can be interpreted.
1. Some studies use small samples
The 2023 pilot study examining attachment security involved 18 participants.
Small studies can identify potentially meaningful patterns but provide limited information about how consistently they apply to larger populations.
2. Some studies examine combined treatments
The 2026 therapist-rotation study included both EMDR and prolonged exposure therapy.
The findings describe the combined treatment setting rather than the independent effects of EMDR.
3. Observational studies cannot establish causation
The 2026 retrospective study found significant associations between alliance ratings and PTSD improvement.
However, it cannot determine whether stronger alliance directly caused the changes.
4. Alliance is measured differently across studies
Some researchers use client-rated questionnaires, while others include therapist ratings or repeated assessments.
Differences in measurement methods can make findings difficult to compare.
5. The relationship may change over time
An alliance rating collected during early treatment may not represent the relationship later in the process.
More research is needed to understand how these changes relate to specific phases of EMDR.
These limitations do not suggest that the therapeutic alliance is unimportant. They indicate where more precise research would help clarify its role.
What Questions Could Future EMDR Research Explore?
Future studies could examine therapeutic alliance during individual EMDR using repeated assessments throughout treatment.
Researchers could investigate whether particular components of the alliance—such as trust, agreement on goals, or collaboration during processing—are more strongly associated with outcomes.
Studies could also compare how the alliance develops during EMDR and other established trauma-focused therapies.
Another useful question involves whether changes in the therapeutic alliance occur before, after, or alongside changes in PTSD symptoms.
Larger studies that account for treatment preferences, therapist characteristics, and previous treatment experiences could help distinguish these possibilities.
Research could also investigate alliance during therapist-guided online EMDR and other treatment formats.
These studies would provide a clearer understanding of how the therapeutic relationship contributes to the overall treatment experience.
What Is the Main Takeaway?
Research suggests that the therapeutic alliance is a meaningful part of EMDR and trauma-focused psychotherapy.
Studies have examined the relationship between alliance quality, PTSD symptom improvement, attachment security, treatment participation, and different ways of delivering therapy.
A 2026 retrospective study involving 138 participants found that stronger therapeutic alliance ratings were associated with greater symptom improvement, particularly during later treatment.
Other studies have shown that therapeutic alliances can develop during intensive treatment involving rotating therapists and that relationship quality may be associated with changes in attachment security.
Broader PTSD research also supports an association between stronger therapeutic alliance and better treatment outcomes.
The overall conclusion is that collaboration, trust, and agreement on treatment goals remain relevant during EMDR, even though the treatment uses structured procedures that may not require extensive verbal discussion.
At the same time, researchers have not established that therapeutic alliance alone causes better EMDR outcomes.
Further studies are needed to clarify how the relationship develops and how its different components contribute to treatment progress.
References
Peji, R. G. A., & Perez, J. A. (2026). Therapeutic alliance, treatment intensity, and symptom change in post-traumatic stress disorder: A retrospective study of eye movement desensitization and reprocessing-centered psychotherapy. Cureus, 18(2), e103603.
https://doi.org/10.7759/cureus.103603Hoogeveen, M., de Jongh, A., Matthijssen, S. J. M. A., & Voorendonk, E. M. (2026). Therapeutic alliance in intensive PTSD treatment with a therapist rotation model. European Journal of Psychotraumatology, 17(1), 2664272.
https://doi.org/10.1080/20008066.2026.2664272Barazzone, N. A., Santos, I., McGowan, J. F., Crowley, M., Chamberlain, A. R., & Donaghay-Spire, E. G. (2023). Eye movement desensitization and reprocessing therapy and change in attachment security: A pilot study. Journal of EMDR Practice and Research, 17(1), 38–52.
https://doi.org/10.1891/EMDR-2022-0053Plantade-Gipch, A., Rotonda, C., & Tarquinio, C. (2022). The contribution of EMDR to psychotherapists' training in the alliance: A quasi-experimental study. Psychology and Education, 59(2), 1092–1099.
https://psychologyandeducation.net/pae/index.php/pae/article/view/7533Howard, R., Berry, K., & Haddock, G. (2022). Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology & Psychotherapy, 29(2), 373–399.
https://doi.org/10.1002/cpp.2642Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260.
https://doi.org/10.1037/h0085885
