Between Therapist and Client

Product Information

Horvath A. O., Symonds B. D. (1991). Relation between working alliance and outcome in psychotherapy: a meta-analysis. J. Couns. Psychol. 38, 139–149 10.1037/0022-0167.38.2.139 [ CrossRef] [ Google Scholar] It is the collaborative relationship between these two parties engaged in the common fight to overcome the patient’s suffering and self-destructive thoughts and behaviors, and effect beneficial change. Frank A. F., Gunderson J. G. (1990). The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome. Arch. Gen. Psychiatry 47, 228–236 [ PubMed] [ Google Scholar]

Kim S. C., Boren D., Solem S. L. (2001). The Kim alliance scale: development and preliminary testing. Clin. Nurs. Res. 10, 314–331 10.1177/10547730122158950 [ PubMed] [ CrossRef] [ Google Scholar]By this stage, positive transference and regressive forms of dependence have been resolved. The client has been handed permission and rights to develop their life independently. Orlinsky D. E., Howard K. I. (1966). Psychotherapy Session Report, Form P and form T. Chicago: Institute of Juvenile Research [ Google Scholar] Safran J. D., Wallner L. K. (1991). The relative predictive validity of two therapeutic alliance measures in cognitive therapy. Psychol. Assess. 3, 188–195 10.1037/1040-3590.3.2.188 [ CrossRef] [ Google Scholar]

According to Safran and Segal ( 1990), many therapies are characterized by at least one or more ruptures in the alliance during the course of treatment. Randeau and Wampold ( 1991) analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies. Although some studies are based on a very limited number of cases, the results appear consistent: the therapist’s focus on the patient’s conflictual behavior patterns and the patient’s involvement rather than avoidance in responding to these challenges, are factors that contribute to improving the therapeutic alliance. Fluctuations in the alliance, especially in the middle phase, thus appear to reflect the re-emergence of the patient’s dysfunctional avoidant strategies and the task of the therapist is to recognize and resolve these conflicts.

In further studies of this development pattern, Stiles et al. ( 2004) analyzed therapeutic alliance growth during the course of short-term treatment of depressed patients, drawn from the Second Sheffield Psychotherapy Project, who received cognitive–behavioral and psychodynamic–interpersonal therapy. Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative. Cluster analysis yielded four therapeutic alliance development patterns, two of which matched Kivlighan and Shaughnessy’s patterns: stable alliance; linear alliance growth with high variability between sessions; negative growth with high variability between sessions; and positive growth with low variability between sessions. No significant correlation was observed between any of the four patterns and the therapeutic outcome. However, the authors observed a cycle of therapeutic alliance rupture–repair events in all cases: very frequent ruptures followed by rapid resolution processes, that is, V-shaped patterns. On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes. In particular, Stiles et al. ( 2004) provide the first statistical demonstration of the hypothesis previously formulated by Safran and Muran ( 2000) and Samstag et al. ( 2004), where the alliance ruptures represented opportunities for clients to learn about their problems relating to others, and repairs represented such opportunities having been taken in the here-and-now of the therapeutic relationship. A widely studied and validated tool used by psychologists is the Outcome Questionnaire-45.2 (OQ®-45.2), developed by Brigham Young University professor Michael Lambert, PhD. Patients complete the 45-question instrument before each session to assess psychological symptoms such as depression, anxiety and substance use, as well as problems in interpersonal functioning and social roles. Any score indicating a propensity toward suicide, violence or substance use is a red flag that calls for immediate follow-up, while high scores on one or more of the subscales suggest key areas for treatment focus, Lambert explains. Other psychologists have since developed shorter measures for the same purpose, notably the Outcome Rating Scale and the Session Rating Scale, developed by Scott D. Miller, PhD, Barry L. Duncan, PsyD, and colleagues. In our opinion, regarding the relationship between the therapeutic alliance and the outcome of psychotherapy, future research should pay special attention to the comparison between patients’ and therapists’ assessments of the therapeutic alliance: these have often been found to differ, and evidence suggests that the patient’s assessment is a better predictor of the outcome of psychotherapy (Castonguay et al., 2006). In Horvath’s ( 2000) opinion, this might be explained by the limitations of assessment procedures, since the rating scales are usually validated on the basis of patient data, whereas the therapist views the relationship through a “theoretical lens,” thus tending to assess the relationship according to what the theory suggests is a good therapeutic relationship or according to the assumptions about the signs that indicate the presence or absence of the desirable relationship qualities. On the other hand, the patients’ assessments tend to be more subjective, atheoretical, and based on their own past experiences in similar situations. This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants. In a helpful contribution, Hentschel ( 2005) points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: if the therapist is instructed, for instance, on methods of increasing the level of alliance, and is then asked to rate the alliance, this can lead to a contamination of the results. The use of neutral observers or the creation of counterintuitive studies is therefore recommended. Empathetic responses are key to establishing a strong therapeutic alliance in early stages of therapy. Agnew-Davies R., Stiles W. B., Hardy G. E., Barkham M., Shapiro D. A. (1998). Alliance structure assessed by the Agnew Relationship Measure (ARM). Br. J. Clin. Psychol. 37, 155–172 10.1111/j.2044-8260.1998.tb01291.x [ PubMed] [ CrossRef] [ Google Scholar]

Horvath A. O. (1994). “Empirical validation of Bordin’s pantheoretical model of the alliance: the working alliance inventory perspective,” in The Working Alliance: Theory, Research, and Practice, eds Horvath A. O., Greenberg L. S. (New York: Wiley; ), 109–128 [ Google Scholar] During this stage, the client “graduates.” The therapist and client can recognize each other as autonomous and independent individuals.McLeod B. D. (2011). Relation of the alliance with outcomes in youth psychotherapy: a meta-analysis. Clin. Psychol. Rev. 31, 603–616 10.1016/j.cpr.2011.02.001 [ PubMed] [ CrossRef] [ Google Scholar]