The Therapeutic Alliance In Substance Use Disorder Treatment: An Integrative Review Of Relational Mechanisms And Self Determination Theory

Author: Jacob Rosedale, PhD, LPC (affiliation National University, Bellevue University)

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Abstract

The therapeutic alliance is one of the most reliable predictors of engagement and treatment outcome across psychotherapies, yet its role becomes especially consequential in substance use disorder (SUD) treatment, where ambivalence, shame, and fluctuating motivation are common. This integrative review synthesizes contemporary alliance research, process-outcome findings, and motivational science to clarify how relational mechanisms function as active ingredients in addiction treatment. Drawing from evidence across psychotherapy, motivational interviewing, and addiction science, the article identifies key therapist behaviors—empathic attunement, motivational calibration, relational transparency, collaborative structure, emotional presence, and rupture repair—as mechanisms that shape alliance quality and influence treatment engagement. Self-Determination Theory (SDT) is presented as a unifying framework linking these relational processes with core psychological needs for autonomy, competence, and relatedness. An SDT informed cyclical model is proposed in which therapist behaviors support psychological need fulfillment, enhancing motivation, deepening engagement, and strengthening the alliance in an ongoing, iterative process. Clinical implications and directions for future research are discussed to advance a relationally grounded understanding of effective SUD treatment.

Keywords: therapeutic alliance; substance use disorders; self-determination theory; motivation; autonomy support; therapist behaviors; addiction treatment; engagement; relational processes

Introduction

Substance use disorder (SUD) treatment unfolds within a complex and often emotionally charged interpersonal landscape. Clients frequently begin treatment with diminished self-efficacy, conflicted motivation, and a history of relational ruptures that shape how they perceive helpers and institutions (Love et al., 2020; Reyre et al., 2017). Decades of psychotherapy research demonstrate that the therapeutic alliance—defined as the collaborative bond, mutual agreement on goals, and shared engagement in therapeutic tasks—is one of the most consistent predictors of treatment outcome across modalities (Flückiger et al., 2018; Horvath et al., 2011; Wampold & Flückiger, 2023). In the context of addiction, alliance quality assumes even greater significance. Clients entering SUD treatment often experience heightened shame, mistrust, and fluctuating readiness to change, making the relational environment a central determinant of whether treatment becomes sustainable or ends prematurely (Urbanoski et al., 2012; Kan et al., 2014).

Although alliance research has expanded substantially in the last decade, the addiction field continues to struggle with the consistent application of alliance principles. Many treatment programs emphasize symptom reduction, compliance, and behavioral outputs at the expense of relational depth (Dellazizzo et al., 2023; Norcross & Lambert, 2019). As a result, therapists may focus on “doing” more rather than “connecting” better, despite evidence that relational processes often exert a greater influence on long-term outcomes than specific techniques (Miller & Rollnick, 2023; Wampold & Imel, 2015). This disconnect between what the field knows and what it routinely prioritizes creates a persistent gap in clinical practice.

At the same time, the mechanisms by which the alliance facilitates change remain insufficiently articulated in many addiction-focused models. While countless studies affirm that strong alliances predict reduced substance use, improved psychological functioning, and lower dropout rates, fewer studies clearly identify how therapist behaviors shape the motivational and relational conditions through which change occurs. Recent work within psychotherapy process research has begun to address this gap by specifying microprocesses—moment-to-moment therapist behaviors—that signal safety, agency, and collaboration (Finsrud et al., 2022; Del Río Olvera et al., 2022). Yet these insights remain scattered across diverse theoretical traditions.

Self-Determination Theory (SDT; Ryan & Deci, 2017) provides a compelling unifying framework for understanding these processes. SDT posits that human psychological growth and motivation depend on the fulfillment of three basic psychological needs: autonomy, competence, and relatedness. These needs are profoundly activated in addiction treatment, where clients’ sense of agency, capability, and relational trust is often compromised. When therapeutic interactions support these needs, clients experience greater intrinsic motivation, deeper engagement, and more stable recovery trajectories (Chan et al., 2023; Herchenroeder et al., 2024). Conversely, when clinical interactions are controlling, invalidating, or ambiguous, clients may experience reduced autonomy and competence, increasing the likelihood of disengagement or relapse.

Integrating SDT with alliance research provides a theoretically grounded explanation of why certain therapist behaviors—empathic attunement, transparency, calibration to motivation, collaborative structure—enhance engagement and outcomes. These behaviors are not merely relational courtesies; they are mechanisms that support core psychological needs and thereby generate motivation for change. This integrative lens clarifies how the alliance functions not as a static “prerequisite” for intervention but as an active, dynamic process shaping every therapeutic encounter.

This article synthesizes four major domains of scholarship:

(1) empirical research on the alliance in SUD treatment;

(2) process-outcome studies identifying therapist behaviors that strengthen or weaken the alliance;

(3) SDT-based literature on motivation and behavior change; and

(4) emerging microprocess research examining moment-to-moment relational signals.

The goal is to produce a cohesive conceptual model that illustrates how therapist behaviors support alliance processes, how these processes fulfill core psychological needs, and how need fulfillment enhances motivation, engagement, and treatment outcomes in a cyclical and self reinforcing manner.

This review advances the field by:

• clarifying relational mechanisms of change in addiction treatment;

• linking alliance processes to SDT’s motivational architecture;

• proposing a cyclical curved-arrow conceptual model;

• offering clinical implications that prioritize relational pacing, attunement, and autonomy support;

• identifying future research directions that integrate process research with motivational science.

The following sections review key empirical findings, outline the therapist behaviors most consistently associated with strong alliances in SUD treatment, and present an SDT-informed model that situates the alliance as a central mechanism of motivational change.

The Alliance as a Mechanism in Substance Use Disorder Treatment

Alliance Strength Predicts Engagement and Outcome

Across several decades of psychotherapy research, the therapeutic alliance has proven to be one of the most robust predictors of client engagement, retention, and symptom improvement. In SUD treatment specifically, alliance quality consistently predicts reduced substance use, improved psychological functioning, and lower dropout rates—even after controlling for early symptom change or baseline motivation (Campbell et al., 2015; Gelinas & James, 2022; Kan et al., 2014). These findings indicate that the alliance operates not merely as a correlate of improvement but as an active mechanism supporting change.

Recent studies strengthen this conclusion. Meta-analytic work by Hammarberg et al. (2023) and Dellazizzo et al. (2023) reconfirmed that early-session alliance ratings predict whether clients remain engaged long enough to benefit from treatment. In youth and young adults—groups at high risk for premature dropout—the first-session alliance appears disproportionately influential, predicting both short- and long-term treatment adherence (van Benthem et al., 2020; Urbanoski et al., 2012). When clients perceive therapists as empathic, collaborative, and emotionally present early in the process, they are significantly more likely to return for subsequent sessions.

Why the Alliance Matters More in Addiction Treatment

SUD treatment introduces unique relational challenges that elevate the importance of a strong therapeutic alliance. Many clients enter treatment under conditions of external pressure—legal mandates, family ultimatums, employment concerns—or following multiple failed attempts to change. These experiences often erode trust, diminish self-efficacy, and heighten sensitivity to perceived judgment or coercion (Andersson et al., 2023; Winograd et al., 2022).

In this context, the therapeutic alliance serves several functions simultaneously:

1. Regulating emotional distress

Clients commonly experience shame, fear of judgment, and heightened anxiety during early sessions. A strong alliance provides emotional containment and models relational safety.

2. Stabilizing engagement

The alliance anchors clients in treatment despite ambivalence or external pressure, reducing the likelihood of early dropout.

3. Supporting motivation for change

When therapists communicate respect for client autonomy, competence, and dignity, clients display higher intrinsic motivation—aligning with SDT’s principles.

4. Modulating perceived therapist intent

Addiction clients are often hypervigilant to signs of control, disappointment, or frustration. Attuned relational signals can counteract this sensitivity.

5. Strengthening resilience after setbacks

Relapse or lapses frequently threaten engagement. A secure alliance helps clients tolerate setbacks without disengaging from treatment. Together, these functions position the alliance not as a backdrop but as a central pathway through which change processes occur.

Ruptures and Repairs as Predictors of Outcome

Addiction treatment is especially prone to alliance ruptures—moments of withdrawal, tension, disagreement, or misattunement—which often reflect clients’ struggles with shame, mistrust, or autonomy (Klein et al., 2024). Importantly, ruptures are not inherently harmful; rather, it is the therapist’s response to them that shapes outcome trajectories.

Process research consistently shows that effective rupture repair predicts improved symptoms, greater trust, and stronger long-term engagement (Finsrud et al., 2022; Saraiya et al., 2023).

Therapists who respond to ruptures with curiosity, emotional presence, and collaborative inquiry strengthen the alliance more than therapists who avoid addressing relational tension.

In SUD treatment, rupture repair may involve:

• acknowledging emotional intensity (“I can see how much pressure you’re under right now”);

• validating ambivalence as normal;

• slowing down and re-establishing collaboration;

• avoiding defensive or directive responses;

• re-affirming respect for the client’s pace and autonomy.

Rupture repair also aligns with SDT principles: resolving relational disruptions restores clients’ sense of relatedness and autonomy, strengthening motivation.

Alliance Variability Matters More Than Alliance Level

A growing body of moment-to-moment alliance research reveals that how the alliance fluctuates across sessions may predict outcomes better than static average alliance scores (Gibbons et al., 2010; Falkenström et al., 2014). In many cases, modest drops in alliance quality followed by successful repair predict better outcomes than a superficially “smooth” alliance with no emotional depth.

This dynamic view supports the notion that alliance is not a stable trait of the relationship, but an iterative process continually shaped by therapist behaviors, client responses, and contextual factors. In addiction treatment, where crises and emotional fluctuations are common, this perspective is especially relevant. Therapists must attend not only to initial alliance formation but to its maintenance across changing motivational states, treatment phases, and environmental stressors.

Alliance as a Motivational Mechanism

Although the alliance is often conceptualized as a relational phenomenon, multiple studies indicate that its primary power in addiction treatment lies in its capacity to shape motivation. When clients experience connection, collaboration, and emotional safety, they are more willing to consider change, tolerate discomfort, disclose ambivalence, and re-engage after setbacks (Meier et al., 2020; Chan et al., 2023).

From an SDT standpoint, the alliance supports motivation in three primary ways:

• Autonomy: Clients experience agency when therapists avoid controlling language and emphasize choice.

• Competence: Clients feel more capable when therapists highlight strengths, normalize difficulty, and scaffold challenges.

• Relatedness: Clients feel understood and valued when therapists display empathy, emotional presence, and attuned responsiveness.

Empirical research in 2023–2025 further underscores that autonomy-supportive therapeutic environments predict better engagement and decreased dropout in addiction programs, especially during the early weeks of treatment (Chan et al., 2023; Herchenroeder et al., 2024).

Summary

Taken together, alliance research reveals that:

• the alliance is a mechanism of change, not a prerequisite;

• early alliance formation predicts retention;

• rupture repair strengthens outcomes;

• variability across sessions offers meaningful clinical information;

• alliance power derives from its motivational impact;

• relational processes can be understood through the lens of SDT.

The next section elaborates the specific therapist behaviors that most reliably strengthen the alliance in SUD treatment.

Therapist Relational Mechanisms that Shape the Alliance

A central finding across alliance and motivational research is that therapist behaviors—not therapist personality or modality—are what most reliably predict alliance quality and treatment retention. In SUD treatment, specific relational behaviors consistently emerge as mechanisms that enhance safety, deepen collaboration, and support clients’ motivational needs (Flückiger et al., 2018; Del Río Olvera et al., 2022; Chan et al., 2023). These behaviors create the relational climate through which psychological needs are met and motivational change becomes possible.

The following relational mechanisms are consistently supported across empirical research, process-outcome studies, and clinicians’ experiential knowledge.

Empathic Attunement and Emotional Presence

Empathy remains the single most robust therapist predictor of alliance quality. In SUD settings— where shame, fear of judgment, and perceived stigma are common—clients report that empathic presence allows them to disclose more honestly, tolerate vulnerability, and experience the therapeutic relationship as safe (Kim, 2018; Afshan, 2024).

Empathic attunement involves:

• accurately mirroring emotional tone;

• tracking shifts in affect;

• slowing the session pace when distress rises;

• communicating a nonjudgmental stance;

• conveying emotional steadiness during the client’s shame or frustration.

Attuned empathy is not passive; rather, it is responsive. It signals to clients: “You are safe. I am here. I can handle your distress without pushing you or pulling away.”

Because many SUD clients have histories of relational rupture, empathic attunement helps restore the sense of belonging central to SDT’s construct of relatedness.

Motivational Calibration

Motivation fluctuates throughout addiction treatment. Therapists who adapt to these fluctuations demonstrate “motivational calibration”—the ability to recognize where clients are in their readiness to change and respond accordingly (Ingersoll, 2024; Chan et al., 2023).

This involves:

• honoring ambivalence without prematurely pushing action;

• adjusting the level of direction versus exploration;

• noticing and amplifying change talk;

• avoiding coercive or pressuring language;

• responding to sustain talk with curiosity instead of confrontation.

Motivational calibration directly supports autonomy, enhancing clients’ sense of agency. It communicates, “You are in control of this process,” preventing treatment from feeling imposed.

Research from 2023–2024 demonstrates that autonomy-supportive communication decreases psychological reactance, increases intrinsic motivation, and improves treatment retention in SUD populations (Herchenroeder et al., 2024; Chan et al., 2023).

Relational Transparency and Collaborative Structure

Transparency is essential for clients who carry hypersensitivity to betrayal, misalignment, or hidden expectations. Transparent communication includes:

• explaining the rationale for interventions;

• making goals explicit;

• checking regularly for alignment;

• discussing therapist intentions openly;

• sharing the decision-making process.

Clients report that these behaviors reduce anxiety, clarify expectations, and enhance trust, particularly in early sessions (Reyre et al., 2017).

Collaborative structure—the ongoing negotiation of goals and tasks—further enhances alliance formation by reinforcing autonomy and competence. Research indicates that collaborative goal setting predicts higher engagement and lower dropout rates across multiple addiction treatment modalities (Dellazizzo et al., 2023; Teixeira et al., 2022).

These behaviors satisfy SDT’s psychological need for competence, helping clients feel capable and oriented in the therapeutic process.

Emotional Presence and Tolerance of Vulnerability

Many clients arrive with fear of being judged, rejected, or emotionally overwhelmed. When therapists display emotional availability and tolerance for clients’ vulnerability, they model relational safety and containment.

Emotional presence includes:

• sitting with client emotion rather than redirecting prematurely;

• tolerating silence;

• responding with grounded calm when clients become ashamed or discouraged;

• acknowledging emotional intensity without pathologizing it.

Research demonstrates that emotional presence predicts stronger bonds and deeper disclosure, especially in addiction recovery where guilt and shame often inhibit engagement (Hammarberg et al., 2023).

This presence reinforces the SDT need for relatedness, inviting the client into a relational experience of “being held in mind.”

Rupture Recognition and Repair

Ruptures occur frequently in SUD treatment. Clients may withdraw, become defensive, or express frustration.

Effective therapists respond by:

• naming the rupture gently;

• validating the client’s emotional experience;

• exploring the meaning of the rupture;

• repairing misunderstandings;

• reaffirming collaboration.

Studies show that rupture repair predicts treatment retention more strongly than initial alliance strength (Saraiya et al., 2023; Finsrud et al., 2022). Repair not only stabilizes the relationship but enhances clients’ willingness to take emotional risks, vital for recovery.

In the SDT framework, repair restores autonomy and relatedness simultaneously—clients feel respected (autonomy) and emotionally connected (relatedness).

Responsiveness and Flexibility

Responsiveness refers to the therapist’s ability to shift strategies based on client cues—pacing, emotional tone, readiness, and cognitive capacity. High responsiveness predicts better outcomes across psychotherapy (Anderson et al., 2009) and is especially important in addiction contexts where clients cycle rapidly between openness and defensiveness.

Responsive therapists demonstrate:

• flexibility in session flow;

• fluid movement between emotions, cognition, and behavior;

• respect for client limits;

• willingness to abandon an intervention if it threatens alliance safety.

Responsiveness supports competence by helping clients feel understood and capable within the therapeutic interaction.

Summary of Relational Mechanisms

Across studies, the therapist behaviors most associated with strong alliances in SUD treatment consistently involve:

• empathic attunement (relatedness),

• motivational calibration (autonomy),

• transparency and collaboration (competence + autonomy),

• emotional presence (relatedness),

• rupture repair (relatedness + autonomy),

• responsiveness (competence + relatedness).

These behaviors closely map onto SDT’s three psychological needs and generate the relational climate through which motivation and engagement can flourish. The next section explains how SDT integrates these relational mechanisms into a coherent motivational framework.

Self-Determination Theory as Integrative Framework

Self-Determination Theory (SDT; Ryan & Deci, 2017) provides a powerful framework for understanding why specific therapist behaviors strengthen the therapeutic alliance and promote change in addiction treatment. SDT posits that human motivation and psychological growth depend on the fulfillment of three basic needs: autonomy, competence, and relatedness. When these needs are supported, individuals internalize motivations more deeply, persist longer in difficult tasks, and demonstrate greater resilience. When these needs are thwarted, motivation becomes externally driven, fragile, and vulnerable to disruption.

SUD treatment activates all three needs. Clients commonly enter treatment with compromised autonomy (due to addiction or external pressure), diminished competence (due to repeated unsuccessful attempts to change), and fractured relatedness (due to stigma, ruptured relationships, or distrust of helpers). Therapist behaviors that support these needs therefore function not merely as relational niceties but as mechanisms of motivational repair.

Autonomy Support

Autonomy support refers to therapist behaviors that enhance clients’ sense of agency. It includes:

• acknowledging ambivalence as normal;

• avoiding coercive or prescriptive language;

• offering choices and rationales;

• exploring client values and goals;

• calibrating pressure to match readiness.

Research consistently shows that autonomy-supportive communication predicts stronger treatment engagement and lower dropout in addiction programs (Chan et al., 2023; Herchenroeder et al., 2024). It counters the shame and external pressure that often accompany SUD treatment, helping clients experience change as self-chosen rather than externally imposed.

Competence Support

Competence support involves helping clients feel capable and effective within treatment.

Therapists strengthen competence by:

• affirming strengths and efforts;

• highlighting past successes; • breaking tasks into manageable steps;

• collaboratively structuring sessions;

• providing clear guidance without overwhelming.

When clients feel competent, they become more willing to try new behaviors, face cravings, and tolerate distress. Competence support also protects against demoralization after lapses, enabling clients to re-engage rather than withdraw.

Relatedness Support

Relatedness refers to the need to feel seen, understood, and valued within meaningful relationships. In SUD treatment, relatedness may be the most fragile psychological need due to the intense stigma, shame, and relational ruptures associated with addiction.

Therapist behaviors that foster relatedness include:

• empathic attunement;

• emotional presence;

• nonjudgmental stance;

• reliable responsiveness;

• effective rupture repair.

Research shows that when clients feel connected and emotionally safe, they disclose more honestly, confront ambivalence more openly, and sustain treatment longer (Finsrud et al., 2022; Hammarberg et al., 2023).

SDT Explains Why the Alliance Works

SDT clarifies that the alliance functions primarily as a need-supportive environment. When therapists support autonomy, competence, and relatedness, clients internalize treatment goals, sustain engagement, and tolerate emotional challenges. The alliance is therefore not simply a “bond” but a motivational engine.

This perspective reframes the alliance as:

• a dynamic process, shaped by moment-to-moment interactions;

• a relational mechanism, not merely a predictor;

• a motivational catalyst, transforming external pressures into internal commitment.

SDT + Alliance = A Unified Mechanism of Engagement

Integrating SDT with alliance research reveals a clear pattern:

• Therapist behaviors →

• Alliance processes (bond, collaboration, trust) →

• Psychological need satisfaction →

• Enhanced motivation, engagement, and retention →

• Strengthened alliance →

• Continued need satisfaction

This cyclical feedback loop forms the basis for the conceptual model presented in the next section.

A Cyclical, Need-Supportive Model of Alliance Formation

Building on alliance research and SDT, this article proposes a curved-arrow cyclical model illustrating how therapist behaviors initiate a repeating, self-reinforcing process that deepens engagement and supports long-term change. Rather than functioning as a linear progression, the alliance operates as a dynamic motivational cycle continuously shaped by interactional exchanges.

The model consists of five interconnected components:

1. Therapist Relational Behaviors

2. Alliance Processes

3. Psychological Need Satisfaction (Autonomy, Competence, Relatedness)

4. Motivation and Engagement

5. Strengthened Alliance → returning to Therapist Behaviors

Each component feeds into the next through curved, bidirectional arrows, representing a fluid relational system rather than discrete stages.

1. Therapist Relational Behaviors

The cycle begins with therapist behaviors already established in earlier sections: empathic attunement, motivational calibration, transparency, collaborative structure, emotional presence, responsiveness, and rupture repair. These behaviors form the foundation of alliance construction.

2. Alliance Processes

These behaviors activate alliance processes—bond, trust, collaboration, and shared purpose. Alliance is conceptualized as an emergent relational property rather than a static characteristic. When therapists are attuned and responsive, clients experience the relationship as safe and predictable, allowing deeper engagement.

3. Psychological Need Satisfaction

Alliance processes, in turn, satisfy the SDT needs that drive intrinsic motivation:

• Autonomy: Clients feel respected, not controlled.

• Competence: Clients feel capable and supported.

• Relatedness: Clients feel seen and valued. Satisfaction of these needs is the mechanism that transforms the relational environment into motivational energy. Without need satisfaction, alliance alone is insufficient to sustain change.

4. Motivation and Engagement

As needs are met, motivation becomes more internalized. Clients begin to:

• attend sessions consistently;

• disclose more openly;

• tolerate discomfort;

• take greater ownership of change;

• view setbacks as part of learning rather than failure.

These shifts reflect the transition from external or introjected motivation toward more autonomous forms of regulation (Ryan & Deci, 2017; Herchenroeder et al., 2024).

5. Strengthened Alliance (Cycle Renewal)

As motivation and engagement increase, clients:

• deepen trust,

• show greater relational openness,

• allow more therapeutic influence,

• participate more actively in tasks and goals.

This strengthens the alliance further, which then feeds back into the therapist’s ability to employ more nuanced relational behaviors—completing the cycle and allowing it to repeat at higher levels of depth and stability (Flückiger et al., 2018; Falkenström et al., 2014; Wampold & Flückiger, 2023).

Summary of the Model

This cyclical model reframes the therapeutic alliance as a dynamic motivational engine rather than a preliminary condition.

It clarifies that:

Therapist behaviors → shape alliance quality

Alliance → supports psychological needs Need satisfaction → fuels motivation

Motivation → strengthens engagement and the alliance

A strengthened alliance → enables deeper therapeutic work

Figure 1 Cyclical model of relational mechanisms and motivational processes in substance use disorder treatment.

This integrative cycle aligns with SUD-specific challenges and provides a coherent theoretical blueprint for training, supervision, and clinical practice (Ryan & Deci, 2017; Flückiger et al., 2018; Chan et al., 2023).

Re-Centering Relational Processes in Treatment

This review highlights that therapist relational behaviors—rather than techniques—form the backbone of engagement in SUD treatment. Programs must re-center alliance processes as core clinical labor. Time spent on attunement, collaboration, pacing, and repair is not ancillary; it is the mechanism through which treatment becomes effective.

Training and Supervision

Training programs should:

• explicitly model alliance microprocesses;

• teach therapeutic stance before technique;

• emphasize attunement, transparency, and responsiveness;

• incorporate role-play and video analysis to highlight moment-to-moment interaction patterns;

• train rupture recognition and repair.

Supervision must shift from case-focused problem-solving to relationship-focused inquiry.

Supervisors should help clinicians track how their language, tone, pace, and emotional presence influence client experience and motivational readiness.

Clinical Culture and Systems of Care

Institutional environments often inadvertently undermine alliance-building by pressuring therapists toward rapid assessment, documentation, and intervention.

Clinical systems must:

• protect relational time;

• reduce productivity pressures that sacrifice attunement;

• reward alliance-centered outcomes such as retention, engagement, and session depth;

• normalize emotional labor as legitimate clinical work.

Implications for Evidence-Based Practice

Alliance-enhancing behaviors are compatible with all major SUD modalities, including MI, CBT, ACT, and contingency management. Rather than competing with techniques, relational mechanisms enhance their effectiveness. Integrating SDT clarifies why certain interventions work: they support psychological needs while avoiding coercive dynamics that increase dropout risk.

Future Directions

Future research should continue integrating SDT with psychotherapy process methods, including sequential coding of session behavior, moment-to-moment linguistic analysis, and physiological measures of relational attunement.

Studies are needed to:

• examine how alliance fluctuations predict relapse risk;

• identify therapist behaviors most influential during early sessions;

• explore SDT-informed rupture repair strategies;

• investigate alliance development across diverse cultural contexts;

• evaluate training programs that explicitly teach relational microprocesses.

There is also an urgent need for longitudinal designs that examine how early relational patterns shape long-term recovery trajectories—particularly as SUD treatment increasingly incorporates telehealth, digital platforms, and hybrid care models.

Conclusion

The therapeutic alliance remains one of the strongest predictors of treatment engagement and outcome in substance use disorder treatment. Yet its role extends beyond providing a relational backdrop; it functions as a motivational mechanism through which change becomes possible. Integrating alliance research with Self-Determination Theory clarifies how therapist behaviors support clients’ autonomy, competence, and relatedness, strengthening intrinsic motivation and enhancing engagement. The cyclical model presented here illustrates how alliance processes and motivational need satisfaction reinforce one another across treatment episodes. Therapists who attune, collaborate, calibrate, repair, and remain emotionally present create relational environments that catalyze change—even for clients entering treatment with ambivalence, shame, or external pressure. Re-centering relational mechanisms in clinical practice, training, and institutional culture is not merely a theoretical preference; it is an ethical and practical imperative. Effective addiction treatment begins with relationship—not as preparation for “real work,” but as the work itself.

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