Therapeutic relationship

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The therapeutic alliance, (also called the helping alliance, the therapeutic relationship, and the working alliance}, refers to the relationship between a healthcare professional and a patient. It is the means by which the professional hopes to engage with, and effect change in a patient.

Research

Research has shown that the quality of the relationship between the therapist and the client has a greater influence on client outcomes than the specific type of psychotherapy used by the therapist (this was first suggested by Saul Rosenzweig in 1936). Accordingly, most contemporary schools of psychotherapy focus on the healing power of the therapeutic relationship.

This research is extensively discussed (with many references) in The Heart and Soul of Change: What Works in Therapy, Mark A. Hubble, Barry L. Duncan, Scott D. Miller (Eds), American Psychological Association (1999) ISBN 155798557X (quotes in this section are from this book) and in "The great psychotherapy debate" by Bruce Wampold (2001).

In 2001 Bruce Wampold, Ph.D. of the University of Wisconsin published "The Great Psychotherapy Debate." In it Wampold, a former statistician studying primarily outcomes with depressed patients, reported that (1) psychotherapy can be more effective than placebo, (2) no single treatment modality has the edge in efficacy, and (3) factors common to different psychotherapies, such as whether or not the therapist has established a positive working alliance with the client/patient, account for much more of the variance in outcomes than specific techniques or modalities. Some report that by attempting to program or manualize treatment psychotherapists may actually be reducing efficacy, although the unstructured approach of many psychotherapists cannot appeal to patients motived to solve their difficulties through the application of specific techniques different from their past "mistakes."

While much early work on this subject was generated from a psychodynamic perspective, researchers from other orientations have since investigated this area. It has been found to predict treatment adherence (compliance) and concordance and outcome across a range of patient diagnoses and treatment settings. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings. A literature review by M. J. Lambert (1992) estimated that 40% of client changes are due to extratherapeutic influences, 30% are due to the quality of the therapeutic relationship, 15% are due to expectancy (placebo) effects, and 15% are due to specific techniques. Extratherapeutic influences include client motivation and the severity of the problem:

Components of the therapeutic relationship

The therapeutic relationship has been theorized to consist of three parts: the working alliance, transference/countertransference, and the real relationship. Evidence on each component's unique contribution to outcome has been gathered, as well as evidence on the interaction between components.

Working alliance

Also known as the therapeutic alliance, working alliance is not to be confused with the therapeutic relationship, of which it is theorized to be a component.

The working alliance may be defined as the joining of a client's reasonable side with a therapist's working or analyzing side. Bordin conceptualized the working alliance as consisting of three parts: tasks, goals, and bond.

Goals are what the client hopes to gain from therapy, based on his or her presenting concerns. Tasks are what the therapist and client agree need to be done to reach the client's goals. The bond forms from trust and confidence that the tasks will bring the client closer to his or her goals.

Research on the working alliance suggests that it is a strong predictor of psychotherapy or counseling client outcome. Also, the way in which the working alliance unfolds has been found to be related to client outcomes. Generally, an alliance that experiences a rupture that is repaired is related to better outcomes than an alliance with no ruptures, or an alliance with a rupture that is not repaired. Also, in successful cases of brief therapy, the working alliance has been found to follow a high-low-high pattern over the course of the therapy.

Operationalization and measurement

Several scales have been developed to assess the patient-professional relationship in therapy, including the

• Barrett-Lennard Relationship Inventory,
• California Psychotherapy Alliance Scales (CALPAS).
• Therapeutic Alliance with Clinician (TAC) Questionnaire
• The Scale To Assess Relationships (STAR) was specifically developed to measure the therapeutic relationship in community psychiatry, or within care in the community settings..
• Working Alliance Inventory (WAI),

See also

• Dodo bird verdict
• Nonspecific factors in psychological therapy
• Psychotherapeutic processes
• Psychotherapeutic transference

Key texts

Books

• Bender, D. S. (2005). Therapeutic Alliance. Washington, DC: American Psychiatric Publishing, Inc.
• Hick, S. & Bien, T. (2009). Mindfulness and the therapeutic relationship. Guildford Press.

Papers

• Bachelor, A. (1991) Comparison and relationship to outcome of diverse dimensions of the helping alliance as seen by client and therapist. Psychotherapy Theory Research and Practic. 28 534-539.
• Bachelor, A. (1995) clients’ perception of the therapeutic alliance: a qualitative analysis. Journal of Counselling Psychology. 42 3 323-337.
• Bambling M., & King R., (2001) Therapeutic alliance and clinical practice. Psychotherapy in Australia. 8 1 38-47
• Bordin, E. (1976) The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory Research and Practice. 16 252-260.
• Bordin, E. S. (1994) Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory research, and practice, New York: Wiley.
• Eaton, T. I, Abeles, N., & Guttreund, M. (1988) Therapeutic alliance and outcome: Impact of treatment length and pretreatment symptomology Psychotherapy Research and Practice. 25 536-542.
• Foreman, S., & Marmar, R. C. (1985) Therapist actions that address initially poor therapeutic alliances in psychotherapy. American Journal of Psychiatry 4 922-926.
• Gaston, L. (1990) The concept of the alliance and its role in psychotherapy: theoretical and empirical considerations, Psychotherapy 27, 143-153.
• Gaston, L. (1991) Reliability and criterion-related validity of the california psychotherapy alliance scales—patient version. Psychological Assessment. 3, 68-74.
• Gaston, L., Marmar, C R., Gallager, D., & Thompson, L. W (1988) Relation of patient pretreatment characteristics to the therapeutic alliance in diverse psychotherapies. Journal of Consulting and Clinical Psychology. 56 483-489.
• Gaston, L., Marmar, C. R., Thompson, L. W & Gallager, D. (1991) Alliance prediction of outcome beyond in-treatment symptomatic change as psychotherapy progresses. Psychotherapy Research. 1 104-1 12.
• Hartley, D. E., & Strupp, H. H. (1983) The therapeutic alliance: Its relationship to outcome in brief psychotherapy. In I Masling (Ed.), Empirical studies in analytic theories (pp. 1-37). Hillside, NJ: Erlbaum.
• Hatcher, R., Barends, A., Hansell, J., & Gutfreund, M. (1995) Patient’s and therapists’ shared and unique views of the therapeutic alliance: an investigation using confirmatory factor analysis in a nested design. Journal of Consulting and Clinical Psychology. 63 636-643.
• Hatcher, R., & Barends, A. (1996) Patient’s view of the alliance in psychotherapy: exploratory factor analysis of three alliance measures. Journal of Consulting and Clinical Psychology. 64 1326-1336
• Henry W R. & Strupp, H. (1994) The therapeutic alliance as an interpersonal process. In A. O. Horvath & L. S. Greenberg (Eds.) The working alliance: Theory, research and practice, New York: Wiley.
• Horvath, A. O. (1981) An exploratory study of the working alliance: Its measurement and relationship to outcome Unpublished doctoral dissertation, University of British Columbia. Quoted in: Horvath, A. O. (1994). Empirical research on the alliance. Horvath & Greenberg (Eds.), The working alliance theory research and practice. New York: Wiley
• Horvath, A. O. (1982) Working Alliance Inventory (Revised). Instructional Psychology Research Group, 82 (1). Simon Fraser University Burnaby, British Columbia, Canada.
• Horvath, A. O. (1991) What do we know about the alliance and what do we still have to find out? Paper presented at the annual meeting of the Society for Psychotherapy Research, Lyon, France.
• Horvath, A. O. (1994) Empirical research on the alliance. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance theory research and practice. New York: Wiley.
• Kivlighan, D., Angelone, E., & Swafford, K. (1991) Live supervision in individual psychotherapy: effects on therapists’ intention use and client’s evaluation of session effect and working alliance. Professional Psychology: Research and Practice. 22 6 489-495.
• Kivlighan, D., & Shaughnessy, P. (1995) Analysis of the development of the working alliance using hierarchical linear modeling. Journal of Counselling Psychology. 42 3 338-349.
• Kivilghan, D. M., Jr., & Schmitz, P. (1992). Counselor technical activity in cases with improving working alliances and continuing-poor working alliances. Journal of Counseling Psychology. 39 32-38.
• Kokotovic, A., & Tracey, I. (1990) Working alliance in the early phase of counseling. Journal of Counseling Psychology. 37 16-21.
• Krupnick, I. (1990, June) The relationship of therapeutic alliance and outcome in interpersonal psychotherapy and cognitive behavioral therapy. Paper presented at the annual meeting of the Society for Psychotherapy Research, Wintergreen, VA.
• Krupnick, J., Stotsky, S., Simmens, S., & Moyer, J. (1996) The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the MIMH treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology. 64 3 532-539.
• Luborsky, L. (1976) Helping alliances in psychotherapy. In I L. Cleghhorn (Ed.), Successful psychotherapy, New York: Brunner/Mazel, 92 - 116.
• Luborsky, L., & Auerbach, A. (1985) The therapeutic relationship in psychodynamic psychotherapy: The research evidence and its meaning for practice. In R. Hales & A. Frances (Eds.), Psychiatry update annual review (pp. 550 - 561). Washington, VC: American Psychiatric Association.
• Mallinckrodt, B., & Nelson, M. (1991) Counselor training level and the formation of the therapeutic working alliance. Journal of Counseling Psychology, 38 14-19.
• Mallinckrodt, B., Gantt, G., & Coble, H. (1995) Attachment patterns in the therapy relationship: development of the client attachment to therapist scale. Journal of Counselling Psychology. 42 307-317.
• Mallinckrodt, B. (1996) Change in working alliance, social support, and psychological symptoms in brief therapy. Journal of Counselling Psychology. 43 4 448-455.
• Marmar, C., Gaston L., Gallagher, D, & Thompson l., (1989) Alliance and outcome in late life depression. Journal of Nervous and Mental disease. 177 464-472.
• Marmar, C. R., Horowitz, M. J., Weiss, D. S., & Marziali, E. (1986) The development of the therapeutic alliance rating system. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook. New York: Guilford Press, 367 - 390.
• Marmar, C., Weiss, D. S., & Gaston, L. (1989) Toward the validation of the California Therapeutic Alliance Rating System. Psychological Assessment: Journal of Consulting and Clinical Psychology. 1 46 - 52.
• Martin D, J., Garske J, P., & Davis, M, K. (2000) Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology. 68 3 438-50.
• Morgan, R., Luborsky, L., Crits-Cristoph, P., Curtis, H., & Solomon, J. (1982) Predicting the outcomes of psychotherapy by the Penn Helping Alliance Rating Method. Archives of General Psychiatry. 39 397 - 401.
• Pinsof, W. (1994) Integrative systems perspective on the therapeutic alliance: theoretical, research and clinical implications. In A. Horvath & Greenberg (ed), The working alliance: theory research and practice. New York: Wiley, 173-189.
• Piper, W. E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (1991 [a]) Transference interpretations, therapeutic alliance and outcome in short-term individual therapy. Archival of General Psychiatry. 48 946-953.
• Piper, W. E., Azim, H. F. A., Joyce, A. S., MacCallum, M., Nixon, G. W. H., & Segal, P. S. (1991 [b]) Quality of object relations vs. interpersonal functioning as a predictor of therapeutic alliance and psychotherapy outcome. Journal of Nervous and Mental Disease. 17 9 432-438.
• Raue, P. & Goldfried, M. (1997) The therapeutic alliance in psychodynamic – interpersonally and cognitive - behavioral therapy. Journal of Consulting and Clinical Psychology. 65 4 582-587.
• Raue, P., Castonguay, L., & Goldfried, M. (1993) The working alliance: a comparison of two therapists. Psychotherapy Research. 3 197-207.
• Raue, P., & Godfried, M. (1994) The therapeutic alliance in cognitive-behavior therapy. In A. Horvath & L. Greenberg (Eds) The working alliance: theory, research and practice. New York: Wiley.
• Reandeau, S., & Wampold, B. (1991) Relationship of power and involvement to working alliance: a multiple case sequential analysis of brief therapy. Journal of Counselling Psychology. 38 107-114
• Rector, N., Zuroff, D., & Segal, Z. (1999) Cognitive change and the therapeutic alliance: the role of technical and nontechnical factors in cognitive therapy. Psychotherapy. 36 320-328.
• Safran, J., Crocker, P., McMain, S., & Munay, P. (1990).Therapeutic alliance rupture as a therapy event for empirical investigation. Psychotherapy. 27 154164.
• Safran, J., Muran, J., Wallner, S., & Samstag, L. (1992, June) A comparison of therapeutic alliance rupture resolution and nonresolution events. Paper presented at the annual meeting of the Society for Psychotherapy Research, Berkeley, CA.
• Safran, J., Muran, J., & Samstag, L. (1994) Resolving therapeutic ruptures: a task analytic investigation. In A. O. Horvath & L. S. Greenberg (Eds.), The Working Alliance: Theory,Rresearch, and Practice. New York: Wiley.
• Safran J., & Muran J. (1996) The resolution of ruptures in the therapeutic alliance. Journal of Consulting and Clinical Psychology. 64 3 447-58.
• Safran J., & Muran J. (2000) Resolving therapeutic alliance ruptures: diversity and integration. Journal of Clinical Psychology. 56 2 233-43.
• Satterfield, W., & Lyddon, W. (1995) Client attachment and perception of the therapeutic alliance with counselor trainees. Journal of Counseling Psychology. 42 187-189.
• Stiles, W., Agnew-Davies, R., Hardy, G., Barkham, M., & Shapiro, D. (1998) Relations of the alliance with psychotherapy outcome: findings in the second sheffield psychotherapy project. Journal of Consulting and Clinical Psychology. 66 791-802.
• Weerasekera, P., Linder, B., Greenberg, L., & Watson, J. (2001) The working alliance in client-centered and process-experiential therapy of depression. Psychotherapy Research. 11 2 221-233.

Additional material

Papers

• Google Scholar
• Allen, J., Szollos, S., & Williams, E. (1986). The penn helping alliance scales. In Greenberg & Pinsof (Eds). The psychotherapeutic process: A research handbook. 325-3666. New York: Guilford.
• Dozier, R., Hicks, M., Cornille, T., & Peterson, G. (1998) The effect of Tomm’s therapeutic questioning styles on therapeutic alliance: a clinical analogue study. Family Process. 37 2 189-200.
• Efstation, J., Patton, M., & Kardash, C. (1990) Measuring the working alliance in counsellor supervision. Journal of Counselling Psychology. 37 322-329.
• Fenton, L., Cecero, J., Nich, C., Frankforter, T., & Carroll, K. (2001) Perspective is everything: the predictive validity of six working alliance instruments. Journal of Psychotherapy Practice and Research. 10 262-268.
• Marziali, E. (I984 [b]) Three viewpoints on the therapeutic alliance scales: Similarities, differences and associations with psychotherapy outcome. Journal of Nervous and Mental Disease. 172 417-423.
• The Penn Helping Alliance Scales (1993) In L., S. Greenberg & W., M. Pinsof (Eds.), The Psychotherapeutic Process A Research Handbook. New York: Guilford Press, 325-366.
• Tichenor, V., & Hill, C. (1989) A comparison of six measures of working alliance. Psychotherapy: Research and Practice. 26 195-199

Further references

Abend, S. M. (1996). The problem of therapeutic alliance: Journal of Clinical Psychoanalysis Vol 5(2) 1996, 213-240.

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