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The concept of the Alliance and its Role in Psychotherapy: Theoretical and Empirical Considerations

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Louise Gaston at TRAUMATYS
Louise Gaston
  • TRAUMATYS
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Abstract

Reviews definitions of the alliance (ALI) concept and proposes 4 relatively independent ALI dimensions that are complementary and compatible. These include (1) the therapeutic ALI, (2) the working ALI, (3) the therapist's empathic understanding and involvement, and (4) the patient–therapist agreement on the goals and tasks of treatment. There is evidence to support the predictive validity of the ALI in psychotherapy, with observations available across a variety of psychotherapy approaches, symptomatic disorders in outpatient samples, and sources of information (patient, therapist, clinical judges). A lack of association between ALI and outcome was, however, observed in some studies. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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... The quality of the relationship between healthcare professional and patient, often referred to as the therapeutic alliance, is a predictor of treatment outcomes for a range of mental health conditions [1][2][3][4]. For example, there is good evidence that a strong therapeutic alliance is associated with positive outcomes, particularly engagement and retention, in the treatment of alcohol and other drug (AOD) use [4][5][6]. ...
Inpatient detoxification for alcohol and other drug use: qualitative study of patients' accounts of their relationships with staff
Article
Full-text available
  • Dec 2024
Background The therapeutic alliance is an important predictor of treatment outcomes but people who use alcohol and other drugs report mixed views of treatment providers. We analysed patients’ accounts of inpatient detoxification staff to ascertain whether, and if so how, relationships with them, and thus the therapeutic alliance, might be improved. Methods Semi-structured qualitative interviews were conducted (in 2022/2023) with 20 people (14 males; 6 females) who had just completed inpatient detoxification in sixteen different facilities. Interviews were part of a larger longitudinal qualitative evaluation of an initiative to increase inpatient detoxification capacity across England. Results Patients described how treatment was delivered by professionals with diverse roles. They rated staff highly and appreciated their personal qualities; the standard of medical care and non-medical services they provided; their willingness to provide privacy, freedom and choice; the support given at key points in the treatment journey; and the positive impact staff relationships had on their substance use and lives more generally. Criticisms of staff were infrequent, mostly related to specific individuals or events, and potentially more common when detoxification occurred within general hospitals rather than within specialist services. Conclusions Patients’ accounts of staff in this study were more positive than documented in previous literature. However, the characteristics that patients appreciated (and disliked) were consistent with earlier research. There was scope to improve in some services and patient groups not interviewed may have held more negative views of staff. Overall, the holistic and patient-centred approach that staff adopted, and patients valued, appears to contribute to a good therapeutic alliance.
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... The process of recovery takes place through achieving set goals -the cognitive component of the alliance -and completing tasks -the behavioural component of the alliance (Horvath & Greenberg, 1989). Mutual agreement and cooperation on goals and objectives, and the effectiveness of their implementation, are made possible by the developing bond-affective component of the alliance: the feeling of being accepted, understood and liked (Gaston, 1990). The first two dimensions are usually, though not exclusively, specified in the first meetings, which for psychotherapists are also sessions that diagnose the patient's health problem (Klajs, 2017). ...
Mutual understanding and cooperation between patient and psychotherapist in psychotherapy. Evaluation of the goodness-of-fit of measurement by means of the Working Alliance Inventory (WAI) questionnaire
Article
Full-text available
  • Dec 2022
Objective This article presents the results of the efforts on the Polish adaptation of the WAI questionnaire, gathered from several publications to date and from the current analysis. The tool, after several years of research with its application and estimation of psychometric properties, can be recommended to take measurement of the quality of the psychotherapeutic relationship. Theses The focus is on the key function of the psychotherapeutic relationship towards generating positive performance in the treatment of health problems. Globally there are many tools to assess the quality of a psychotherapeutic relationship. To date the Polish psychologists and psychotherapists have not had such tools at their disposal. Conclusions Analysis of the reliability of three of the four versions of the questionnaire (WAI-PC, WAI-PT, WAI-R, WAI-SUM) showed that the measurement made by the scale can be considered reliable. Evidence is presented verifying the alliance structure in action. Confirmatory factor analysis confirmed the three-dimensional structure of the psychotherapeutic alliance. The WAI questionnaire showed satisfactory theoretical validity. The WAI questionnaire in its 36-item version is a consistent tool that can be successfully used in research.
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Danışanlar ve terapistler kendi kültürlerinin, yaşam deneyimlerinin ve dünya görüşlerinin kesişimine karşılık gelen sosyal kimliklerini psikoterapi sürecine getirir. Mevcut derleme sosyal kimlikler bakımından terapist-danışan eşleşmesinin danışanın bakış açısından psikoterapist seçimi ve terapötik sonuçlarla ilişkisini incelemeyi amaçlamıştır. Öncelikle sosyal kimlik teorisi tanıtılmış ve etkileşim ortakları arasındaki sosyal kimlik benzerliğinin veya eşleşmesinin empati, güven, kendini açma ve anlayış gibi olumlu kişiler arası süreçler için önemi vurgulanmıştır. Ardından benzer kişiler arası süreçlerin psikoterapinin başarısı için de son derece önemli olduğunun altı çizilerek, danışan deneyimleri açısından özellikle ırk/etnisite, din, cinsiyet ve yaş bakımından danışan-terapist eşleşmesini ele alan görgül çalışmaların bulguları gözden geçirilmiştir. Danışan-terapist sosyal kimlik eşleşmesinin danışanların psikoterapist seçimini, memnuniyetini, psikoterapiye devamlılığını ve tedavi sonuçlarını etkilediği çıkarımına gidilebilir. Ancak danışan-terapist kimlik uyumuna ilişkin bulguların tutarlı olduğunu söylemek güçtür. Bu karmaşık sonuçlar, aynı sosyal gruptaki üyeler arası farklılıkların ve çalışmalar arasındaki metodolojik farklılıkların göz ardı edilmesiyle ilişkili olabilir. Danışanlar özellikle terapinin ilk aşamalarında terapistin yaş, cinsiyet, din, sosyoekonomik düzey ve ırk/etnik köken gibi görece kolayca fark edilebilir özelliklerine göre terapiste güven geliştiriyor olabilseler de farklılıklarla bir arada yaşamanın kaçınılmaz olduğu günümüz toplumlarında kültürel açıdan duyarlı psikoterapi yaklaşımlarını yaygınlaştırmak daha önemlidir.
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Wzajemne porozumienie i współpraca pacjenta i psychoterapeuty w psychoterapii. Ocena dobroci pomiaru kwestionariuszem Przymierza w działaniu
Article
Full-text available
  • Dec 2022
Cel Niniejszy artykuł prezentuje zebrane z kilku dotychczasowych publikacji oraz z obecnie przeprowadzonych analiz efekty pracy nad polską adaptacją kwestionariusza WAI. Narzędzie po kilku latach prowadzonych badań z jego użyciem i estymacji właściwości psychometrycznych może być rekomendowane do prowadzenia pomiaru jakości relacji psychoterapeutycznej. Tezy Podkreśla się ważną funkcję relacji psychoterapeutycznej wobec uzyskiwania pozytywnych efektów leczenia problemów zdrowotnych. Na świecie istnieje wiele narzędzi pozwalających oszacować jakość relacji psychoterapeutycznej. Polscy psychologowie i psychoterapeuci nie dysponowali do tej pory takimi narzędziami. Konkluzje Analiza rzetelności trzech spośród czterech wersji kwestionariusza (WAI-PC, WAI-PT, WAI-R, WAI-SUM) wykazała, że pomiar dokonany skalą można uznać za rzetelny. Przedstawiono dowody weryfikujące strukturę przymierza w działaniu. Konfirmacyjna analiza czynnikowa potwierdziła trzydymensjonalną strukturę przymierza psychoterapeutycznego. Kwestionariusz WAI wykazał się zadowalającą trafnością teoretyczną. Kwestionariusz WAI w wersji 36-itemowej jest spójnym narzędziem, które z powodzeniem może być stosowane w badaniach naukowych.
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Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy
Article
Full-text available
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Background The therapeutic alliance (TA) is a robust and pantheoretical predictor of treatment outcome in Face-to-Face- (F2F-) and Online-psychotherapy (Online-PT). Many authors have proposed several conceptualizations of TA, which are oftentimes operationalized. The resulting diversity of conceptualizations and measures is presented in this review. Methods We performed a three-parted literature search for self-report-instruments of TA in individual, voluntary F2F-PT with adults (1. utilization of past reviews, 2. systematic literature search yielding 5,205 articles, 3. reference lists). Analogously, we conducted a systematic literature search for instruments of TA in the Online-setting (yielding 200 articles). Additionally, we analyzed the content of the instruments qualitatively. Results A current overview of 48 instruments for measuring TA (46 for F2F-PT, 2 for Online-PT) including their conceptual backgrounds, characteristics and main content aspects is presented. Most instruments (n = 24) operationalize one or more theoretical conceptualizations of TA. Other instruments are adaptation/syntheses of existing measures (n = 14), based on literature searches (n = 3) or on an empirical survey (n = 3) and two instruments provide no conceptual background information. The content of the instruments mainly focused on the following aspects: 1. Self-disclosure and authenticity; 2. Agreement; 3. Active participation, motivation and compliance; 4. Trust and secure attachment; and 5. Considering needs/abilities/wishes of the patient. Additionally, a narrative review of various approaches to conceptualize TA is presented and linked to respective corresponding instruments. Discussion The broad variety of conceptualizations and measures of TA makes coherent research on TA difficult. There are conceptual challenges such as the role of attachment style in TA that remain to be clarified. The current conceptualizations and measures do not incorporate the practical experience and expertise of psychotherapists and patients sufficiently. A metatheoretical conceptualization and measure of TA based on an empirical survey of psychotherapists and patients could address these issues.
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Research on Psychotherapy Integration: Recommendations and Conclusions From an NIMH Workshop
Article
Full-text available
  • Jun 1988
Although the trend toward psychotherapy integration and eclecticism has gathered momentum, research on eclectic approaches to psychotherapy has lagged behind. To address this gap, the National Institute of Mental Health (NIMH) held a 2-day workshop in March 1986 on psychotherapy integration. Fourteen psychotherapy researchers were invited to consider the key issues associated with psychotherapy integration in order to advise the NIMH on guidelines for launching a program to stimulate relevant empirical research. Recommendations were developed to initiate such a research program that encompassed (a) conceptual clarification, (b) efficacy studies of systematic eclectic therapies, (c) the role of traditional psychotherapy process research, and (d) the training of integrative or eclectic therapists.
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Effective ingredients in psychotherapy: Prediction of outcome from process variables
Article
Full-text available
  • Oct 1978
Examined the impact of (a) exploration of the psychodynamic roots of patients' conflicts, (b) warmth and friendliness of the therapist-offered relationship, and (c) positiveness of patients' attitudes toward working in therapy on the outcome of brief therapy with 35 college males exhibiting symptoms of depression, anxiety, and social introversion. Symptoms were confirmed by elevated scores on the Depression, Psychasthenia, and Social Introversion scales, respectively, of the MMPI. Analyses of process ratings for audiotaped segments from 4 sessions throughout the course of therapy revealed that the activities of therapists of differing theoretical orientations and of professional vs untrained, "inherently helpful" therapists could be distinguished. Although patients' attitudes toward the therapist and patient involvement in the therapy process did not differ as a function of the type of therapist, the process dimension that most consistently predicted therapy outcome was patient involvement. Exploratory processes and therapist-offered relationship had a lesser influence on outcome. (71 ref)
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Factor Structure of the Working Alliance Inventory
Article
Full-text available
  • Sep 1989
The Working Alliance Inventory (WAI) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI.
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Use of Structural Equation Modeling in Counseling Psychology Research
Article
Full-text available
  • Oct 1987
Structural equation modeling (multivariate analysis with latent variables, also called causal modeling or covariance structure analysis) is a valuable methodological tool for use in counseling psychology research. Essentially the broad framework that subsumes many well-known procedures (e.g., multiple linear regression, factor analysis, path analysis), structural equation modeling allows for analysis of causal patterns among unobserved variables represented by multiple measures. It permits testing of causal hypotheses and theory, examination of psychometric adequacy, and enhancement of the explanatory power of correlational data that characterize counseling psychology research. I present and illustrate structural equation modeling, followed by a discussion of (a) issues and problems related to the use of this methodology, (b) possible applications of structural equation modeling to counseling psychology research, and (c) resources for those wanting further study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Development and Validation of the Working Alliance Inventory
Article
Full-text available
  • Apr 1989
Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualizaton of the alliance. Results from 3 studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. Data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations were also observed between the WAI and other relationship indicators. Results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in the reviewed studies are encouraging, the high correlations between the 3 subscales of the inventory bring into question the distinctness of the alliance components. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Toward the Validation of the California Therapeutic Alliance Rating System
Article
Full-text available
  • Mar 1989
The California Therapeutic Alliance Rating System, CALTARS, was used by judges to rate four therapy sessions for each of 52 subjects treated in brief dynamic psychotherapy for pathological grief. A principal-components analysis provided support for the theoretically proposed domains of alliance. The interrater reliability at the treatment level was satisfactory for the five component-based scales. As hypothesized, scores reflecting positive contribution to the alliance were positively related to educational attainment, motivation for psychotherapy, pretreatment interpersonal functioning, patient experiencing in therapy, symptom improvement, and gains in interpersonal functioning but negatively associated with stressful life events and greater therapist emphasis on addressing patient resistances. As further hypothesized, scores reflecting negative contribution to the alliance were positively associated with greater therapist emphasis on addressing resistances. Alliance ratings were largely independent of pretreatment symptomatology. These findings build toward the construct validity of the CALTARS. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Therapeutic alliance and outcome: Impact of treatment length and pretreatment symptomatology
Article
Full-text available
  • Jan 1988
  • PSYCHOTHERAPY
Studied data collected in 1978–1982 in a research project at a university psychological clinic that provides low-cost services to families in the community. Data consisted of pre- and posttherapy written measures and audiotapes from selected sessions with 40 patients (aged 20–57 yrs). Findings indicate that (1) strength of therapeutic alliance was established within the 1st 3 sessions of therapy with little change over the course of therapy, (2) short length therapy cases had lower levels of therapist positive alliance, (3) therapeutic alliance was predictive of outcome, and (4) therapeutic alliance was adversely affected by pretreatment symptomatology. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The Relationship in Counseling and Psychotherapy: Components, Consequences, and Theoretical Antecedents
Article
  • Apr 1985
  • COUNS PSYCHOL
This two-part article suggests ingredients in the therapy relationship that are common to all interventions. It then examines similarities and differences in how the relationship works within the three dominant approaches to therapy. The overall aim of the article is to restimulate research and theory on the relationship. The first part defines the relationship and proposes three components to all therapeutic relationships: a working alliance, a transference configuration, and a real relationship. Five propositions are offered about the operation of each component within and across theoretical orientations. The second part examines how views of the relationship in perspectives broadly labeled psychoanalytic, humanistic, and learning vary according to three theoretical dimensions: the centrality, real-unreal, and means-end dimensions. Central research findings are reviewed for each theoretical perspective, the current state of research is examined for each, and suggestions are offered for future directions.
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A Cognitive-Behavioral Response and a Modest Proposal
Article
  • Apr 1985
  • COUNS PSYCHOL
Responds to C. J. Gelso and J. A. Carter's (see record 1986-09708-001) article on the client–therapist relationship in counseling and psychotherapy, particularly their suggestion that learning-oriented approaches (including cognitive and behavioral responses) have been notably silent on the importance of relationships in therapy. It is argued that cognitive-behavior therapists do not generally deny the existence or even potential importance of transference phenomena but that they would disagree on the automatic importance of the phenomena. (7 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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