Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research

This paper proposes a historical excursus of studies that have investigated the therapeutic alliance and the relationship between this dimension and outcome in psychotherapy. A summary of how the concept of alliance has evolved over time and the more popular alliance measures used in literature to assess the level of alliance are presented. The proposal of a therapeutic alliance characterized by a variable pattern over the course of treatment is also examined. The emerging picture suggests that the quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. In our opinion, with regard to the relationship between the therapeutic alliance and outcome of psychotherapy, future research should pay special attention to the comparison between patients’ and therapists’ assessments of the therapeutic alliance. This topic, along with a detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects.

[1]  G. Burlingame,et al.  Cohesion in group therapy. , 2011, Psychotherapy.

[2]  Bryce D. McLeod,et al.  Relation of the alliance with outcomes in youth psychotherapy: a meta-analysis. , 2011, Clinical psychology review.

[3]  N. Kanas.  The theory and practice of group psychotherapy. , 2011, International journal of group psychotherapy.

[4]  J. Smit,et al.  Implementation of outpatient schema therapy for borderline personality disorder: study design , 2009, BMC psychiatry.

[5]  Jonathan Green,et al.  The conceptualization and measurement of therapeutic alliance: an empirical review. , 2008, Clinical psychology review.

[6]  T. Crowe,et al.  Is therapist alliance or whole group cohesion more influential in group psychotherapy outcomes? , 2008, Clinical psychology & psychotherapy.

[7]  S. Lorentzen.  Cohesion, Alliance, and Outcome in Group Psychotherapy: Comments on Joyce et al. (2007) and Johnson (2007) , 2008, International journal of group psychotherapy.

[8]  J. Markowitz.  The Therapeutic Alliance in Schema-Focused Therapy and Transference-Focused Psychotherapy for Borderline Personality DisorderSpinhoven P, Giesen-Bloo J, van Dyck R, et al (Leiden Univ, The Netherlands; Univ Maastricht, The Netherlands; Vrije Universiteit Amsterdam; et al) J Consult Clin Psychol 75:1 , 2008 .

[9]  R. R. Greenson.  The working alliance and the transference neurosis. 1965. , 2008, The Psychoanalytic quarterly.

[10]  A. Arntz,et al.  The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. , 2007, Journal of consulting and clinical psychology.

[11]  D. Mohr,et al.  Therapeutic alliance mediates the relationship between interpersonal problems and depression outcome in a cohort of multiple sclerosis patients. , 2006, Journal of clinical psychology.

[12]  P. Pilkonis,et al.  The Role of the Therapeutic Alliance in Psychotherapy and Pharmacotherapy Outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program , 2006 .

[13]  M. Drapeau,et al.  New, but improved? Comparison between first and revised version of the Helping Alliance questionnaire , 2006 .

[14]  Y. D. Rotena,et al.  New, but improved? Comparison between first and revised version of the Helping Alliance questionnaire , 2006 .

[15]  Michael J. Constantino,et al.  The working alliance: Where are we and where should we go? , 2006, Psychotherapy.

[16]  M. Witty.  Client-centered therapy. , 2006, The Harvard mental health letter.

[17]  Sherecce Fields,et al.  Meta-analysis of therapeutic relationship variables in youth and family therapy: the evidence for different relationship variables in the child and adolescent treatment outcome literature. , 2006, Clinical psychology review.

[18]  Joseph A. Olsen,et al.  Group Climate, Cohesion, Alliance, and Empathy in Group Psychotherapy: Multilevel Structural Equation Models. , 2005 .

[19]  U. Hentschel.  Therapeutic alliance: The best synthesizer of social influences on the therapeutic situation? On links to other constructs, determinants of its effectiveness, and its role for research in psychotherapy in general , 2005 .

[20]  N. Favre,et al.  Is one assessment enough? Patterns of helping alliance development and outcome , 2004 .

[21]  David A. Shapiro,et al.  Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped? , 2004 .

[22]  J. Markowitz,et al.  Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics. , 2003, Journal of consulting and clinical psychology.

[23]  I. Weiner.  Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients , 2003, Psychotherapy research : journal of the Society for Psychotherapy Research.

[24]  S. Shirk,et al.  Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. , 2003, Journal of consulting and clinical psychology.

[25]  W. Goldstein.  A Primer of Transference-Focused Psychotherapy for the Borderline Patient , 2003 .

[26]  M. Weishaar,et al.  Schema Therapy: A Practitioner's Guide , 2003 .

[27]  O. Kernberg,et al.  A Primer of Transference-Focused Psychotherapy for the Borderline Patient , 2002 .

[28]  B. Adinoff,et al.  Group Alliance and Cohesion as Predictors of Drug and Alcohol Abuse Treatment Outcomes , 2002 .

[29]  John C. Norcross,et al.  Psychotherapy relationships that work : therapist contributions and responsiveness to patients , 2002 .

[30]  H. Strupp.  Implications of the Empirically Supported Treatment Movement for Psychoanalysis , 2001 .

[31]  S. Kim,et al.  The Kim Alliance Scale: Development and Preliminary Testing , 2001, Clinical nursing research.

[32]  K. Carroll,et al.  Perspective is everything: the predictive validity of six working alliance instruments. , 2001, The Journal of psychotherapy practice and research.

[33]  D. Kivlighan,et al.  Comparison of therapeutic factors in group and individual treatment processes. , 2000 .

[34]  D. Kivlighan,et al.  Patterns of working alliance development: A typology of client's working alliance ratings. , 2000 .

[35]  J. Garske,et al.  Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. , 2000, Journal of consulting and clinical psychology.

[36]  A. Horvath,et al.  The therapeutic relationship: from transference to alliance. , 2000, Journal of clinical psychology.

[37]  J. Safran,et al.  Negotiating the Therapeutic Alliance: A Relational Treatment Guide , 2000 .

[38]  L. Hansson,et al.  Rehabilitation of schizophrenic and other long-term mentally ill patients. Results from a prospective study of a comprehensive inpatient treatment program based on cognitive therapy , 1999, European Psychiatry.

[39]  S. Saunders.  Clients' assessment of the affective environment of the psychotherapy session: relationship to session quality and treatment effectiveness. , 1999, Journal of clinical psychology.

[40]  W. Stiles,et al.  Relations of the alliance with psychotherapy outcome: findings in the Second Sheffield Psychotherapy Project. , 1998, Journal of consulting and clinical psychology.

[41]  W. Stiles,et al.  Alliance structure assessed by the Agnew Relationship Measure (ARM). , 1998, The British journal of clinical psychology.

[42]  L. Mccleary,et al.  The contribution of group cohesion and group alliance to the outcome of group psychotherapy. , 1997, International journal of group psychotherapy.

[43]  M. Barkham,et al.  The therapeutic alliance in psychodynamic-interpersonal and cognitive-behavioral therapy. , 1997, Journal of consulting and clinical psychology.

[44]  P. Pilkonis,et al.  The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. , 1996, Journal of consulting and clinical psychology.

[45]  J. Safran,et al.  The resolution of ruptures in the therapeutic alliance. , 1996, Journal of consulting and clinical psychology.

[46]  Paolo Migone.  La ricerca in psicoterapia: storia, principali gruppi di lavoro, stato attuale degli studi sul risultato e sul processo , 1996 .

[47]  D. Kivlighan,et al.  Analysis of the Development of the Working Alliance Using Hierarchical Linear Modeling , 1995 .

[48]  J. Carter,et al.  Components of the psychotherapy relationship: Their interaction and unfolding during treatment. , 1994 .

[49]  A. Horvath.  Empirical validation of Bordin's pantheoretical model of the alliance: The Working Alliance Inventory perspective. , 1994 .

[50]  C. Marmar,et al.  The California Psychotherapy Alliance Scales. , 1994 .

[51]  A. Horvath,et al.  The role of the therapeutic alliance in psychotherapy. , 1993, Journal of consulting and clinical psychology.

[52]  G. Kolden.  The generic model of psychotherapy: An empirical investigation of patterns of process and outcome relationships , 1991 .

[53]  Jeremy D. Safran,et al.  The relative predictive validity of two therapeutic alliance measures in cognitive therapy , 1991 .

[54]  A. Horvath,et al.  Relation between Working Alliance and Outcome in Psychotherapy: A Meta-Analysis. , 1991 .

[55]  B. Wampold,et al.  Relationship of power and involvement to working alliance: A multiple-case sequential analysis of brief therapy. , 1991 .

[56]  R. Marx,et al.  The Development and Decay of the Working Alliance During Time-limited Counselling , 1990 .

[57]  Thinking about thinking in therapy: an examination of clients' understanding of their therapists' intentions. , 1990, Journal of consulting and clinical psychology.

[58]  J. Gunderson,et al.  The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome. , 1990, Archives of general psychiatry.

[59]  L. Gaston,et al.  The concept of the alliance and its role in psychotherapy: Theoretical and empirical considerations. , 1990 .

[60]  J. Safran,et al.  Therapeutic alliance rupture as a therapy event for empirical investigation. , 1990 .

[61]  Z. Segal,et al.  Interpersonal process in cognitive therapy , 1990 .

[62]  K. Howard,et al.  The Therapeutic Bond Scales: Psychometric Characteristics and Relationship to Treatment Effectiveness , 1989 .

[63]  T. Tracey,et al.  Factor structure of the Working Alliance Inventory. , 1989 .

[64]  P. Kerrigan.  Process and outcome. , 1989, The Practitioner.

[65]  S. Soldz,et al.  Cohesion, alliance and outcome in group psychotherapy. , 1989, Psychiatry.

[66]  C. Marmar,et al.  Alliance and outcome in late-life depression. , 1989, The Journal of nervous and mental disease.

[67]  D. Weiss,et al.  Toward the validation of the California Therapeutic Alliance Rating System. , 1989 .

[68]  A. Horvath,et al.  Development and validation of the Working Alliance Inventory. , 1989 .

[69]  T. Tracey.  Client and therapist session satisfaction over the course of psychotherapy. , 1989 .

[70]  E. Gilliéron.  Short psychotherapeutic interventions (four sessions). , 1989, Psychotherapy and psychosomatics.

[71]  M. Goldfried,et al.  Research on psychotherapy integration: recommendations and conclusions from an NIMH workshop. , 1988, Journal of consulting and clinical psychology.

[72]  W. Pinsof,et al.  THE INTEGRATIVE PSYCHOTHERAPY ALLIANCE: FAMILY, COUPLE AND INDIVIDUAL THERAPY SCALES* , 1986 .

[73]  A. Horvath,et al.  The development of the Working Alliance Inventory. , 1986 .

[74]  L. Luborsky,et al.  The Penn Helping Alliance Scales. , 1986 .

[75]  H. Strupp,et al.  The Vanderbilt process measures: The Psychotherapy Process Scale (VPPS) and the Negative Indicators Scale (VNIS). , 1986 .

[76]  A T McLellan,et al.  Therapist success and its determinants. , 1985, Archives of general psychiatry.

[77]  E. Marziali.  Three Viewpoints on the Therapeutic Alliance: Similarities, Differences, and Associations with Psychotherapy Outcome , 1984, The Journal of nervous and mental disease.

[78]  H. Strupp,et al.  Psychotherapy In A New Key: A Guide To Time-limited Dynamic Psychotherapy , 1984 .

[79]  H. Strupp,et al.  The Vanderbilt Psychotherapy Process Scale: a report on the scale development and a process-outcome study. , 1983, Journal of consulting and clinical psychology.

[80]  P. Crits-Christoph,et al.  Two Helping Alliance Methods for Predicting Outcomes of Psychotherapy: A Counting Signs Vs. a Global Rating Method , 1983, The Journal of nervous and mental disease.

[81]  C. Marmar,et al.  Therapeutic alliance scales: development and relationship to psychotherapy outcome. , 1981, The American journal of psychiatry.

[82]  H. Strupp,et al.  Specific vs nonspecific factors in psychotherapy. A controlled study of outcome. , 1979, Archives of general psychiatry.

[83]  E. Bordin.  The generalizability of the psychoanalytic concept of the working alliance. , 1979 .

[84]  L. Horwitz.  Clinical Prediction in Psychotherapy , 1974 .

[85]  S. Strong.  Counseling: An interpersonal influence process. , 1968 .

[86]  R. R. Greenson.  The Working Alliance and The Transference Neurosis , 1965, The Psychoanalytic quarterly.

[87]  E. Zetzel.  Current concepts of transference. , 1956, The International journal of psycho-analysis.

[88]  H. Eysenck.  The effects of psychotherapy: an evaluation. , 1952, Journal of consulting psychology.

[89]  C. Rogers,et al.  Client-Centered Therapy , 1951 .