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Research in Psychotherapy : Psychopathology, Process, and Outcome logoLink to Research in Psychotherapy : Psychopathology, Process, and Outcome
. 2026 Aug 31;29(2):899. doi: 10.4081/ripppo.2026.899

Process and outcome in university counseling: the role of epistemic trust and working alliance

Contributions: Costanza Franchini, Alexandro Fortunato, Alice Fiorini Bincoletto: conceptualization and design of the study, theoretical framework, interpretation of findings, writing – original draft; Gaetano Maria Sciabica, Mara Morelli, Silvia Andreassi: data collection, revision; Antonio Chirumbolo: statistical analyses, interpretation of results; Anna Maria Speranza: supervision, interpretation of findings, critical revision of the manuscript. All authors read and approved the final version of the manuscript and agreed to be accountable for any aspect of the work.: Costanza Franchini 1, Alexandro Fortunato 1, Alice Fiorini Bincoletto 1,✉, Gaetano Maria Sciabica 1, Mara Morelli 1, Antonio Chirumbolo 2, Silvia Andreassi 1, Anna Maria Speranza 1
PMCID: PMC13637446  PMID: 42708169

Abstract

University counseling services are increasingly recognized as effective interventions for promoting students’ psychological well-being, yet the psychological mechanisms underlying their effectiveness are still poorly understood. The present study examined the role of epistemic stances (epistemic trust, mistrust, and credulity) and therapeutic alliance in predicting changes in psychological distress among students undergoing a brief psychodynamic counseling intervention. The sample included 93 university students who participated in a brief psychodynamic counseling intervention consisting of four sessions and a 3-month follow-up. Data were analyzed using hierarchical linear mixed-effects models. Psychological distress was assessed using the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at pre-treatment (T1), post-intervention (T2), and follow-up (T3). Epistemic stances were measured with the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ) at T1, and therapeutic alliance was assessed at T2 with the Working Alliance Inventory – Short Form Revised (WAI-SR). Psychological distress significantly decreased from pre-treatment to post-intervention and remained stable at follow-up. Higher baseline epistemic trust predicted lower levels of distress, whereas higher epistemic mistrust and credulity were associated with poorer outcomes. A stronger therapeutic alliance was associated with lower distress levels. Moreover, the therapeutic alliance moderated the relationship between epistemic mistrust and psychological distress, such that higher alliance was associated with lower distress. Findings suggest that both epistemic stances and the therapeutic alliance contribute to counseling effectiveness. A strong alliance may partially buffer the negative impact of epistemic mistrust, highlighting the importance of fostering a mentalizing environment in brief counseling interventions.

Key words: university counseling, epistemic trust, working alliance, outcome, process

Introduction

University counseling services have gained increasing recognition as vital contexts for promoting students’ psychological well-being and facilitating their adaptation to developmental and academic challenges (Cerolini et al., 2023). Originally conceived as short-term interventions aimed at supporting students facing emotional, relational, or academic difficulties (Kirk et al., 1971), these services have shown consistent evidence of effectiveness in reducing symptoms of distress and enhancing general functioning (Collins et al., 2025; Speranza et al., 2023).

A growing body of research has highlighted their effectiveness in reducing symptoms such as anxiety, depression, somatization, withdrawal, and attentional difficulties, as well as enhancing self-efficacy, sense of belonging, and emotional well-being (Bani et al., 2022; Ghilardi et al., 2017; Stallman et al., 2016). Furthermore, university counseling has been linked to greater satisfaction and academic performance, as well as lower dropout rates (Biasi et al., 2017; Franzoi et al., 2022; Speranza et al., 2023). Beyond these symptomatic and academic outcomes, university counseling interventions appear to foster broader psychological changes.

Recent studies have highlighted their role in improving reflective functioning, mentalized affectivity, and time perspective (Esposito et al., 2020; Fortunato et al., 2023; Franchini et al., 2024; Sciabica et al., 2025). These findings suggest that such interventions may promote not only relief from distress but also broader processes of personal growth and self-understanding. This is particularly relevant in psychodynamic counseling, thereby helping individuals integrate emotional experiences into a more coherent personal narrative. Especially in young adulthood, it provides a symbolic space for mean-making, supporting the elaboration of transitional challenges and promoting continuity and integration in the development of the self (Caldarelli et al., 2024; Pizzo et al., 2025).

However, despite the growing evidence supporting the effectiveness of university counseling, much less is known about why and how these interventions work, and through which psychological processes they exert their effects. Thus, the literature calls for a better understanding of how these interventions work and for whom they are most effective, in order to clarify their supportive function and inform clinical practice.

An emerging line of research has highlighted the central role of epistemic trust as a psychological condition underlying change and learning in therapeutic contexts (Li et al., 2026; Riedl, Kampling, et al., 2023; Riedl, Rothmund, et al., 2023).

Epistemic trust refers to the individual’s receptiveness to accepting information from others as reliable, personally relevant, and generalizable (Fonagy & Allison, 2014; Fonagy & Campbell, 2017). It represents a fundamental human capacity that allows individuals to benefit from social communication, integrate new interpersonal meanings, and revise representations of themselves. Within a therapeutic or counseling relationship, epistemic trust allows individuals to perceive the clinician’s communications as authentic and meaningful, thus facilitating openness to new perspectives and personal growth. When such trust is limited, on the contrary, people may find it difficult to recognize others as reliable sources of knowledge, which can limit their ability to benefit from interpersonal exchanges. Through relational experiences characterized by mirroring, attunement and authenticity, it is possible to restore the individual’s epistemic openness, reactivating the ability to learn from others, and internalize new ways of thinking, feeling, and relating (Campbell et al., 2024; Protopapa et al., 2024).

In the context of university counseling, this process can take the form of renewed trust in one’s emotional world and in the possibility of receiving meaningful input from others: an evolutionary change that supports both psychological change and adaptive functioning. According to Fonagy and Allison (2014), mentalization can be seen as the mechanism through which epistemic trust is restored and thus as a common factor in the effectiveness of different therapeutic approaches. By being recognized and understood as intentional agents, patients can lower their epistemic vigilance and reopen themselves to the social environment as a credible source of knowledge. In this sense, mentalization does not operate as a specific technique, but as a relational process that restores trust in communication and, thus, the possibility of learning from relational experience.

This reactivation of epistemic trust allows individuals to reinterpret their experiences, expand self-understanding, and generalize new ways of relating beyond therapy (Fonagy & Campbell, 2017; Fonagy et al., 2019).

Among the nonspecific factors associated with therapeutic outcomes, the therapeutic alliance has received considerable attention and is widely recognized as playing a central role (Horvath & Symonds, 1991; Martin et al., 2000; Norcross & Lambert, 2019). In the present study, the therapeutic alliance is conceptualized according to Bordin’s (1979) pantheoretical model, which defines it as the degree of agreement between patient and therapist regarding therapeutic goals and tasks, together with the collaborative bond between them. Several meta-analyses have highlighted the relevance and strength of this variable in influencing the positive outcome of treatments, regardless of the clinicians’ theoretical orientation (Flückiger et al., 2018; Flückiger et al., 2020; Horvath & Symonds, 1991).

Within the framework proposed by Fonagy and colleagues (2019), the therapeutic alliance and epistemic trust can be understood as closely intertwined dimensions involved in therapeutic change. Rather than representing two separate processes, the alliance may provide the experiential and relational context in which epistemic stances are expressed, modulated, and potentially revised. When clients perceive the therapist as reliable, emotionally attuned, and genuinely interested in their mental states, communications may become more likely to be perceived as personally relevant and trustworthy. In turn, increased epistemic trust may reinforce this reciprocal dynamic, promoting engagement, openness, and psychological change through interpersonal learning (Fonagy et al., 2019; Li et al., 2022).

These processes may be particularly relevant in university counseling, which often takes place during emerging adulthood, a developmental period marked by ongoing consolidation of identity, autonomy, and interpersonal functioning (Arnett, 2004, 2016). These considerations also point to the relevance of overall personality functioning, insofar as students’ capacities for self-other understanding, affect regulation, and relational engagement may shape both epistemic stances and the development of a collaborative alliance.

Studies have shown that improvements in epistemic trust during therapy predict better outcomes in both adolescents and adults (Li et al., 2022; Riedl, Rothmund, et al., 2023), while higher levels of epistemic mistrust and credulity have been linked to premature dropout and poor engagement in university counseling (Franchini et al., 2025). These findings suggest that epistemic trust may serve as a precondition for forming a strong alliance and for benefiting from the interpersonal learning that counseling aims to promote.

Conversely, clients with high epistemic mistrust may find it difficult to establish a collaborative bond, limiting their capacity to integrate new emotional and cognitive perspectives offered by the therapist. Taken together, this theoretical framework positions epistemic trust as a key psychological process underlying the effectiveness of counseling, with mentalizing as the mechanism that enables its restoration and the therapeutic alliance as its experiential correlate.

In brief psychodynamic counseling, where time is limited, these processes may be especially salient: the clinician’s capacity to mentalize the student’s inner world can quickly establish a trustworthy relationship that reopens the student’s ability for social learning and personal change.

Aims and hypothesis

Building on these premises, the present study aims to examine the role of epistemic stances (trust, mistrust, and credulity) and therapeutic alliance in predicting changes in psychological distress across a brief psychodynamic counseling intervention for university students. Specifically, it was tested whether baseline epistemic stances and the quality of the therapeutic alliance predicted improvements in psychological distress.

Consistent with Fonagy and Allison’s (2014) model, which conceptualizes epistemic trust as a fundamental precondition for openness to social learning and change, we expected that higher baseline epistemic trust and lower epistemic mistrust and credulity would be associated with greater reductions in psychological distress at the end of the counseling intervention (post-test) and at the 3-month follow-up.

Given the established role of the therapeutic alliance as a key non-specific factor in psychotherapy (Horvath & Symonds, 1991; Norcross & Lambert, 2019), we also hypothesize that a stronger therapeutic alliance would predict greater improvements in psychological functioning after the intervention. In line with previous evidence suggesting a reciprocal relationship between alliance and epistemic trust (Fonagy et al., 2019; Li et al., 2022), we further expect that the therapeutic alliance would moderate the association between epistemic stances and counseling outcome, both at posttest and at follow-up measurements. Specifically, a strong alliance is hypothesized to buffer the negative effects of epistemic mistrust and to amplify the positive effect of epistemic trust on reductions in psychological distress.

Materials and Methods

Participants and procedure

In the present study, the sample included 93 university students (Mage=22.5; SDage=2.7; F=64%) who underwent a university counseling intervention at the “Sapienza” University of Rome, Italy. The counseling center at our university offers a brief psychodynamic intervention, organized into four weekly counseling sessions and a follow-up session 3 months later. When students first contact the service, they are scheduled for an appointment at the hub service for an intake assessment, to assess their request and direct them to the most appropriate service. Before attending the intake interview, they are asked to provide informed consent and to complete an online questionnaire to collect autobiographical data. Students already engaged in psychotherapy at the time of request are not admitted to counseling, while those presenting with severe psychiatric disorders during intake are referred to specialized mental health services. For students undergoing counseling, assessments are administered throughout the process to evaluate changes across the different dimensions of interest before and after the intervention. Specifically, assessments were carried out at three time points: pre-treatment (T1, immediately before the first counseling session), post-intervention (T2, after the fourth session), and follow-up (T3, three months after the end of counseling). The clinical team consisted of 26 psychologists in training as psychotherapists, enrolled in different schools of specialization at the “Sapienza” University of Rome, who had also completed a specific training program in university counseling. Data was collected online using the Qualtrics platform. Each participant was identified by an anonymous alphanumeric code to ensure confidentiality. Ethical approval for the study was granted by the Ethics Committee of the “Sapienza” University of Rome (protocol n. 96/2023).

Measures

Epistemic Trust, Mistrust and Credulity Questionnaire

The Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ; Campbell et al., 2021; Liotti, Milesi, et al., 2023) is a self-report questionnaire consisting of 15 items measuring three epistemic stances on a 7-point Likert scale (from 1=not true to 7=very true). The factors assessed are: Epistemic Trust (5 items; e.g., “I usually ask people for advice when I have a personal problem”), Epistemic Mistrust (5 items; e.g., “If you put too much faith in what people tell you, you are likely to get hurt”), and Epistemic Credulity (5 items; “I have too often taken advice from the wrong people”). The Italian validation showed high internal consistency for both the adult and adolescent versions (Liotti, Milesi, et al., 2023; Liotti, Fiorini Bincoletto, et al., 2023). In the present study, the Trust subscale showed values of Cronbach’s α=.75 and McDonald’s ω=.76, the Mistrust subscale yielded Cronbach’s α=.63 and McDonald’s ω=.65, and the Credulity subscale Cronbach’s α=.79 and McDonald’s ω=.80.

Working Alliance Inventory – Short Form Revised

The Working Alliance Inventory – Short Form Revised (WAI-SR; Hatcher & Gillaspy, 2006) is a 12-item self-report instrument based on Bordin’s (1994) conceptualization of the therapeutic alliance as the mutual agreement on treatment goals and the tasks required to achieve them, together with the affective bond that sustains the therapeutic work. In line with the theoretical ground, the measure assesses three dimensions: agreement on the goals of therapy (4 items; e.g., “My therapist and I agree on what I need to do in counseling to improve my situation”); agreement on the tasks necessary to achieve those goals (e.g., 4 items; “My therapist and I are working together toward mutually agreed-upon goals”); and the bond, referring to the emotional and interpersonal connection established between client and therapist (4 items; e.g., “I believe my therapist likes me”). The revised version retains the structure of the original WAI (Horvath & Greenberg, 1986) and the subsequent short form (WAI-S; Tracey & Kokotovic, 1989). The Italian translation of the instrument was developed by Lingiardi (2002). In the present study, the client version of the questionnaire was used. Cronbach’s α and McDonald’s ω for the total scale were .83 and .87, respectively.

Clinical Outcomes in Routine Evaluation-Outcome Measure

The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM; Evans et al., 2002; Palmieri et al., 2009) is a 34-item self-report questionnaire widely used to assess psychological distress and the effectiveness of psychological interventions. The measure was developed by the CORE System Trust (Evans et al., 2002) and covers four main domains rated on a 5-point Likert scale (from 0=not at all to 4=almost all the time). The domains are: Well-being (4 items assessing overall psychological well-being; e.g., “I have felt like crying”), Problems/Symptoms (12 items assessing psychological distress such as anxiety, depression, and physical symptoms; e.g., “Tension and anxiety have prevented me doing important things”), Functioning (12 items assessing everyday functioning in social, occupational, and interpersonal contexts; e.g., “I have thought I have no friends”), and Risk (4 items on self-harm and 2 items on harm to others; e.g., “I made plans to end my life”). A mean score can be calculated for each domain, as well as for the total score and the total score excluding risk items. Lower scores correspond to better clinical outcomes. The Italian validation of the CORE-OM maintains the structure and psychometric properties of the original questionnaire (Palmieri et al., 2009). In the present research, Cronbach’s α and McDonald’s ω for the total score were .84 and .87, respectively.

Statistical analysis

All statistical analyses were conducted using Jamovi version 2.4.11 (The jamovi project, 2023; Gallucci, 2019, 2020). Preliminary descriptive statistics were calculated to examine participants’ demographic characteristics and the main study variables.

To test the study hypotheses, two hierarchical linear mixed-effects models were estimated using restricted maximum likelihood. This approach allows the analysis of repeated measures while accounting for the non-independence of observations due to multiple assessments per participant and clustering by counselor. Participants’ age and biological sex were included as covariates, and both participants and counselors were modeled as random intercepts to account for within-subject and within-therapist variability.

The first model examined changes in psychological distress (CORE-OM total scores) across time, including Time (T1, T2, T3) as a within-subject factor, while controlling for age and biological sex. The second model tested the predictive role of epistemic stances and the therapeutic alliance on counseling outcome. Specifically, baseline levels of epistemic trust, mistrust, and credulity (ETMCQ subscales at T1) were entered as fixed effects, together with the total score of the WAI-SR assessed at T2. To test moderation effects, the two-way interaction terms between each epistemic stance and the therapeutic alliance (e.g., Trust×Alliance, Mistrust×Alliance, Credulity×Alliance) were included. In this model, the therapeutic alliance was conceptualized as a moderator of the relationship between epistemic stances and psychological distress, in line with the hypothesis that a stronger alliance may buffer the negative impact of epistemic mistrust and amplify the positive effect of epistemic trust on counseling outcomes.

The dependent variable for both models was the CORE-OM total score, representing overall psychological distress (lower scores indicating better outcomes). Marginal and conditional R2 values were calculated to estimate the variance explained by fixed effects and by the full model including random effects. Intraclass correlation coefficients were computed to estimate the proportion of variance attributable to participants and counselors. Statistical significance was set at p<.05 (two-tailed). When the main effect of Time was significant, Bonferroni-adjusted pairwise comparisons were conducted. For significant interaction effects, simple slope analyses were performed to clarify the moderating role of the therapeutic alliance.

Results

Descriptive statistics for the sample are presented in Table 1.

Table 1.

Descriptive statistics (total sample, N=93).

Characteristics % (n)
Biological sex 62.4 F (58)
Mean age (±SD) 22.6 (±2.71)
University courses
   Architecture 2.2(2)
   Economics 4.3(4)
   Pharmacy and medicine 11.8(11)
   Law 5.4(5)
   Civil and industrial engineering 12.9(12)
   Information engineering, computer science and statistics 6.5(6)
   Literature and philosophy 12.9(12)
   Medicine and dentistry 9.7(9)
   Medicine and psychology 5.4(5)
   Mathematical, physical and natural sciences 24.7(23)
   Political sciences, sociology and communication 4.3(4)
Degree program
   Bachelor’s degree 63.4(59)
   Master’s degree 7.5(7)
   Single cycle 25.8(24)
   PhD course 3.2(3)
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SD, standard deviation. Biological sex was coded as: 0=female, 1=male.

The first mixed-effects model tested changes in psychological distress across the three time points. A significant main effect of time emerged, F(2, 171.3)=17.22, p<.001, indicating a reduction in distress from pre- to post-intervention that was maintained at follow-up (see Table 2 for full statistics). Post-hoc comparisons confirmed that CORE-OM scores significantly decreased from T1 to T2 (t=4.977, pBonferroni<.001) and from T1 to T3 (t=5.246, pBonferroni<.001), with no significant difference between T2 and T3 (t=0.248, pBonferroni=1.000). Neither age nor biological sex was significantly related to distress. The model accounted for 6% of the variance in distress explained by fixed effects (R2m=.056) and 62% when random effects were included (R2c=.622). Means and the standard deviations of CORE-OM total score at the three time points are reported in Table 3. See Figure 1 for a graphical representation of the decrease in CORE-OM scores over time.

Table 2.

Linear mixed model: change in CORE-OM total score over time.

CORE-OM total score
Confidence intervals
Effect Estimate SE Lower Upper df t p
Fixed coefficients
Intercept 1.407 0.075 1.258 1.555 18.4 18.646 <.001
T1 T2-T1 -0.303 0.061 -0.423 -0.183 171.4 -4.977 <.001
T2 T3-T1 -0.318 0.061 -0.437 -0.199 171.1 -5.246 <.001
Biological sex 1-0 -0.071 0.114 -0.295 0.152 78.3 -0.627 0.532
Age 0.012 0.021 -0.029 0.052 80.8 0.576 0.566
Random components Variance SD ICC
Subjects’ intercept 0.172 0.414 0.518
Counselors’ intercept 0.068 0.260 0.297
Residual 0.160 0.400
Model fit R2 df LRT X2 p
Conditional 0.622 6 102.344 <.001
Marginal 0.056 4 32.864 <.001
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CORE-OM, Clinical Outcomes in Routine Evaluation-Outcome Measure; SE, standard error; SD, standard deviation; ICC, intraclass correlation coefficients; LRT, likelihood ratio test. Biological sex was coded as follows: 0=female, 1=male.

Table 3.

Means and SDs of CORE-OM total score at each time point.

Outcome T1M (SD) T2M (SD) T3M (SD)
CORE-OM total score 1.62 (.559) 1.30 (.680) 1.29 (.626)
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M, mean; SD, standard deviation; CORE-OM, Clinical Outcomes in Routine Evaluation-Outcome Measure.

Figure 1.

Figure 1.

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Significant decrease in CORE-OM total score over time.

The second model, which included epistemic stances and therapeutic alliance, showed a substantial improvement in fit (R2m=.259; R2c=.625). The effect of time remained significant, F(2, 170.0)=12.87, p<.001. Among fixed predictors, higher epistemic trust predicted lower psychological distress (β=-0.022, p=.017), whereas higher epistemic mistrust (β=0.033, p=.006) and credulity (β=0.019, p=.034) were associated with higher distress levels. Consistent with expectations, a stronger therapeutic alliance was associated with lower distress (β=-0.009, p=.028). Most notably, a significant interaction between epistemic mistrust and therapeutic alliance was found (β=-0.0015, p=.010), indicating that the alliance moderated the relationship between mistrust and psychological distress. Simple slope analyses revealed that the negative association between alliance and distress was strongest at low levels of mistrust (-1 SD), weaker at average levels, and non-significant at high levels of mistrust (+1 SD) (Figure 2). Thus, when students reported high epistemic mistrust, the protective effect of a good alliance on psychological well-being was attenuated. The interactions between alliance and epistemic trust or credulity were not significant. Overall, the final model explained approximately 26% of the variance in psychological distress through fixed effects and 63% when including random effects, suggesting that both epistemic and relational factors contributed to improvements in psychological functioning across the counseling process. Full statistics are reported in Table 4.

Table 4.

Linear mixed model: change in CORE-OM total score over time with ETMCQ scales and WAI total scores as predictors.

CORE-OM total score
Confidence intervals
Effect Estimate SE Lower Upper df t p
Fixed coefficients
Intercept 1.423 0.058 1.308 1.538 15.7 24.449 <.001
T1 T2-T1 -0.303 0.061 -0.424 -0.183 170.0 -4.964 <.001
T2 T3-T1 -0.317 0.061 -0.438 -0.197 170.0 -5.193 <.001
Biological sex 1-0 -0.088 0.105 -0.295 0.119 71.6 -0.835 0.406
Age 0.041 0.019 0.004 0.078 76.0 2.182 0.032
ETMCQ T -0.022 0.009 -0.040 -0.004 75.3 -2.431 0.017
ETMCQ M 0.03255 0.01144 0.01002 0.05507 74.4 2.846 0.006
ETMCQ C 0.019 0.009 0.002 0.037 74.6 2.160 0.034
T2 WAI TOT -0.009 0.004 -0.017 -0.001 75.6 -2.242 0.028
ETMCQ T * T2 WAI TOT -0.000 0.001 -0.002 0.001 73.8 -0.308 0.759
ETMCQ M * T2 WAI TOT -0.002 0.0006 -0.003 -0.0004 75.0 -2.647 0.010
ETMCQ C * T2 WAI TOT -0.002 0.0009 -0.003 0.0001 72.8 -1.881 0.064
Random components Variance SD ICC
Subjects’ intercept 0.135 0.368 0.457
Counselors’ intercept 0.022 0.147 0.118
Residual 0.161 0.401
Model fit R2 df LRT X2 p
Conditional 0.625 13 133.635 <.001
Marginal 0.259 11 64.517 <.001
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CORE-OM, Clinical Outcomes in Routine Evaluation-Outcome Measure; SE, standard error; ETMCQ, Epistemic Trust, Mistrust, and Credulity Questionnaire; WAI_TOT, Working Alliance Inventory total score; SD, standard deviation; ICC, intraclass correlation coefficients; LRT, likelihood ratio test. Biological sex was coded as follows: 0=female, 1=male.

Discussion

The present study aimed to evaluate the role of epistemic stances (trust, mistrust, and credulity) and the therapeutic alliance in predicting changes in psychological distress among a sample of university students who underwent a brief psychodynamic counseling intervention. Drawing on the model proposed by Fonagy and Allison (2014), which conceptualizes epistemic trust as a foundation for social learning and for the processes of change fostered within the therapeutic relationship, the study sought to examine how different configurations of epistemic functioning might influence the effectiveness of counseling. More specifically, it investigated whether baseline levels of epistemic trust, mistrust, and credulity predicted reductions in distress following counseling, whether the quality of the therapeutic alliance was directly associated with outcomes, and whether the therapeutic alliance moderated the relationship between epistemic stances and distress reduction over time.

Consistent with our first hypothesis, psychological distress significantly decreased from the beginning to the end of the intervention, and this improvement was maintained at follow-up. These findings align with previous research demonstrating the effectiveness of brief psychodynamic counseling in reducing distress and enhancing students’ general functioning and well-being (Cerolini et al., 2023; Fortunato et al., 2025; Speranza et al., 2023). This pattern of findings supports the effectiveness of brief university counseling interventions in fostering not only reductions in psychological distress but also improvements in general functioning and a stronger perception of subjective well-being, by providing a structured space for emotional reflection and relational engagement (Bani et al., 2022; Broglia et al., 2023; Celia et al., 2022; Connell et al., 2008; McKenzie et al., 2015; Murray et al., 2016; Strepparava et al., 2016). The absence of significant differences based on biological sex or age further suggests that this intervention model operates effectively across diverse student groups, offering an accessible, safe, and transformative relational space for a heterogeneous university population.

As predicted, epistemic stances at baseline were associated with counseling outcomes. Higher epistemic trust predicted lower levels of psychological distress, while higher epistemic mistrust and credulity were linked to poorer outcomes. This pattern supports Fonagy and Allison’s (2014) conceptualization of epistemic trust as a psychological precondition for openness to social learning and therapeutic change. Individuals who are able to perceive others as reliable sources of personally relevant information may more readily engage in the counseling process and internalize new meanings about themselves and their relationships. Taken together, these findings suggest that university counseling may be usefully framed within a person-centered and developmentally informed perspective, consistent with the framework of the Psychodynamic Diagnostic Manual, Third Edition (PDM-3; Lingiardi & McWilliams, 2026), which emphasize the need to understand symptoms within the broader context of mental functioning, personality patterns, and developmental trajectories (Tanzilli et al., 2021).

Figure 2.

Figure 2.

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Interaction between baseline Mistrust (ETMCQ) and Therapeutic Alliance (WAI-TOT) in predicting CORE-OM total score. Lines represent predicted CORE-OM scores at low (-1 SD), mean, and high (+1 SD) levels of therapeutic alliance. Shaded areas indicate 95% confidence intervals.

Conversely, those characterized by high epistemic mistrust, marked by skepticism and defensive withdrawal, may find it difficult to engage with the counselor’s communications and thus derive less benefit from the process. This interpretation may be further understood within a broader personality-functioning perspective. Epistemic mistrust and credulity should not be considered direct measures of personality pathology; however, they may reflect more enduring difficulties in interpersonal functioning. Recent evidence indicates that epistemic disruptions are associated with impairments in personality functioning and with more severe psychopathological outcomes (Kampling et al., 2022), while clinical studies have shown that impairments in epistemic trust are particularly pronounced in patients with personality disorders and are associated with the severity of personality pathology, especially borderline, paranoid, and avoidant features (Knapen et al., 2025). Consistently, epistemic mistrust and credulity have also been linked to borderline features, attachment insecurity, childhood adversity, and relational difficulties (Campbell et al., 2025). In line with these findings, previous research has shown that epistemic disruptions are associated with more severe interpersonal problems, less adaptive defensive functioning, and greater symptomatology, suggesting that epistemic stances may be embedded in broader patterns of self-other representation, affect regulation, and relational organization (Fiorini Bincoletto et al., 2024; Liotti et al., 2025).

Our third hypothesis was also confirmed: the quality of the therapeutic alliance was inversely related to psychological distress, indicating that students who perceived a stronger bond with their counselor experienced greater symptom reduction. This result corroborates the extensive literature identifying the alliance as one of the most robust predictors of psychotherapy outcome (Horvath & Symonds, 1991; Norcross & Lambert, 2019). In the context of brief university counseling, where time is limited, the rapid establishment of a collaborative and emotionally attuned relationship appears particularly crucial.

The most noteworthy finding concerns the moderating role of the therapeutic alliance, which qualified the association between epistemic mistrust and psychological distress. Specifically, the negative effect of mistrust on outcomes was weaker when the alliance was strong, that is, when students reported feeling understood, validated, and supported by their counselor. In contrast, when the alliance was weak, higher epistemic mistrust was associated with greater levels of psychological distress at post-intervention and follow-up. This interaction suggests that the alliance partially attenuates the negative impact of epistemic mistrust: while higher mistrust is associated with greater distress across all levels of alliance, this association becomes weaker as the quality of the therapeutic relationship increases. Importantly, the magnitude of this moderating effect should be interpreted with caution. Although statistically significant, the interaction coefficient was small in magnitude, suggesting that the moderating effect of the therapeutic alliance on the association between epistemic mistrust and psychological distress was limited. Consistently, the interaction terms accounted for a limited proportion of additional variance explained by fixed effects. Therefore, these findings suggest that a strong therapeutic alliance may partially mitigate the negative association between epistemic mistrust and psychological distress, but that elevated mistrust may continue to represent a relevant challenge for treatment engagement and change processes.

Thus, a strong alliance may function as a protective factor, attenuating the detrimental association between epistemic mistrust and psychological distress.

Importantly, the clinical interpretation of this finding also requires caution. Although the therapeutic alliance was associated with lower distress, the simple slope analyses indicated that this association was strongest at low levels of epistemic mistrust, weaker at average levels, and non-significant at high levels of mistrust. Thus, when epistemic mistrust is elevated, the beneficial association of a strong alliance with symptom reduction may be limited, particularly within a brief four-session counseling format. This suggests that high levels of epistemic mistrust may represent a relevant challenge for therapeutic engagement and change processes.

Clinically, this finding underscores the crucial role of the counselor’s relational competence in fostering a mentalizing environment perceived as trustworthy, coherent, and emotionally responsive. The ability to convey attunement and authenticity may compensate for the client’s initial mistrust, allowing the therapeutic relationship to serve as a corrective interpersonal experience. Within Fonagy’s framework (e.g., 2019), such experiences may progressively restore epistemic trust, enabling the internalization of new meanings and perspectives. Conversely, when mistrust remains unaddressed – either because the alliance fails to develop or because the intervention ends prematurely – this epistemic stance may continue to inhibit change.

The absence of moderation effects for trust and credulity suggests that the therapeutic alliance plays a particularly relevant role only when communicative openness is inhibited. Students with initially high levels of epistemic trust are already predisposed to regard the counselor as a reliable source of information and can thus benefit from the intervention regardless of the degree of perceived attunement. Credulity, by contrast, does not represent a deficit of trust but rather an unregulated form of openness, often lacking critical thinking. In such cases, a strong alliance may not be sufficient to promote meaningful change unless accompanied by a process of cognitive-emotional integration. Mistrust, instead, constitutes a direct obstacle to the formation of the therapeutic bond and to the very possibility of receiving the counselor’s communications as reliable and relevant. It is therefore unsurprising that this dimension benefits most from the quality of the alliance.

From a clinical standpoint, these findings offer important insights. In university counseling settings, students with high levels of epistemic mistrust may struggle not only to ask for help but also to maintain a collaborative stance throughout the intervention, risking early dropout or reduced therapeutic gains (Franchini et al., 2025).

In such cases, the counselor’s primary task should be to cultivate a climate of relational safety and to validate the student’s subjective experience, rather than relying on interpretive or directive interventions. A mentalizing stance – marked by curiosity, flexibility, and communicative coherence – can facilitate the reduction of mistrust and restore the student’s openness to learning from personal experience. This foundational work constitutes a prerequisite for any form of psychological change and helps explain why, even within brief interventions, the quality of the therapeutic relationship can exert a transformative effect (Fonagy et al., 2019).

Taken together, these results support a dynamic and reciprocal view of therapeutic change in which epistemic and relational dimensions jointly shape outcomes. Epistemic trust provides the cognitive-affective readiness to learn from interpersonal exchanges, while the alliance offers the relational context in which this openness can take form. This interplay seems particularly relevant in time-limited interventions, where the rapid creation of a trustworthy and attuned relationship may determine whether the counseling process facilitates a deeper understanding of one’s and others’ minds beyond symptoms’ relief.

Limitations and future developments

Despite its relevant contributions, the study presents some limitations. First, all variables were assessed using self-report measures, which may have introduced response biases and inflated associations because of shared method variance. Future studies would benefit from integrating clinician-rated, observational, or interview-based measures, particularly for assessing therapeutic processes such as the working alliance.

Second, the study did not include a control or comparison group. Although psychological distress significantly decreased over the course of the intervention, the absence of a comparison condition prevents definitive conclusions about the extent to which these improvements can be attributed specifically to the counseling intervention rather than to spontaneous remission, regression to the mean, or other contextual factors. Controlled studies will therefore be necessary to strengthen causal inferences regarding the effectiveness of brief psychodynamic university counseling.

Another limitation concerns the characteristics of the counselors. All counseling sessions were conducted by psychologists undergoing psychotherapy training. Although this reflects the organization of many university counseling services and enhances the ecological validity of the study, differences in clinical experience, therapeutic competence, and theoretical orientation may have contributed to variability in treatment outcomes. While counselor clustering was statistically modeled through random effects, future research should explicitly examine therapist-level variables as potential moderators of counseling effectiveness.

The characteristics of the sample also limit the generalizability of the findings. Participants were university students presenting primarily with mild to moderate psychological distress, whereas individuals with severe psychiatric disorders were referred to specialized mental health services. Consequently, the present findings cannot be generalized to students with more severe, chronic, or highly comorbid clinical conditions, who may require more intensive or longer-term interventions than the four-session counseling model examined here.

Another important limitation relates to the temporal structure of the study design. Although epistemic stances were assessed before treatment initiation, therapeutic alliance and post-treatment psychological distress were both measured at T2. Therefore, the observed moderation effect should not be interpreted as evidence of a causal process at post-treatment, as the moderator and the outcome were assessed contemporaneously. The temporal ordering is more appropriate for the follow-up assessment, where therapeutic alliance temporally precedes psychological distress measured at T3. Future research would benefit from assessing therapeutic alliance across multiple stages of treatment to better examine its dynamic relationship with clinical outcome. In future research, it could also be valuable to include the clinician’s perspective in the assessment of the therapeutic alliance, providing a more comprehensive understanding of the relational dynamics that support change.

A further limitation concerns the sample size available for the moderation analyses. Although the study was adequately powered to detect the main longitudinal effects, the relatively modest sample size may have limited the statistical power to detect small interaction effects. Therefore, the non-significant Trust×Therapeutic Alliance and Credulity×Therapeutic Alliance interactions should be interpreted with caution and should not be considered evidence that these moderation effects are absent. Future studies based on larger samples are needed to clarify whether these interactions emerge under conditions of greater statistical power.

Finally, the present study assessed epistemic stances only at baseline and therefore could not examine whether epistemic trust, mistrust, and credulity changed throughout the counseling process. Future longitudinal studies should investigate the evolution of epistemic stances during counseling interventions and their potential role as mechanisms of change. A further conceptual limitation concerns the absence of a direct assessment of personality functioning or personality organization. Although the present study focused on epistemic stances as predictors of counseling outcome, epistemic disruptions may partly overlap with difficulties in personality functioning. Therefore, the present findings suggest that these may function as indirect markers of difficulties in navigating the relational world. Future studies should incorporate dimensional assessments of personality functioning and personality organization, drawing on contemporary frameworks such as the PDM-3 (Lingiardi & McWilliams, 2026), which may be particularly useful in this regard, as its Mental Functioning Axis conceptualizes trust, empathy, and intimacy as core capacities involved in adaptive interpersonal functioning. Such an approach would help clarify the interface between epistemic functioning, personality structure, and therapeutic alliance to brief psychodynamic counseling interventions.

Conclusions

In conclusion, this study provides empirical evidence that the effectiveness of university counseling depends not only on the establishment of a strong therapeutic alliance but also on the client’s epistemic functioning. When the alliance is sufficiently strong, it may act as a “buffer” against epistemic mistrust, supporting engagement and facilitating change. These findings highlight the importance of fostering a relational stance grounded in mentalizing, reciprocity, and validation, conditions that may reopen the student’s epistemic channel and allow the counseling relationship to become a context for growth, learning, and psychological change.

Availability of data and materials

Data supporting the findings of this study are available from the corresponding author upon request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data supporting the findings of this study are available from the corresponding author upon request.

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