KeywordsTherapeutic Alliance Psychodynamic Psychotherapy Unconditional Positive Regard Interpersonal Schema Good Alliance
What Is Therapeutic Alliance?
The concept of the therapeutic alliance originated in psychoanalytic theories (e.g., Freud 1912/1958, 1913; Greenson 1965). Now it has become a pan-theoretic concept (Ackerman and Hilsenroth 2003). Therapeutic alliance is broadly defined as the overall bond between therapist and client evolving during the process of therapy (Horvath et al. 2011). Although there are different conceptualizations of therapeutic alliance, three often-highlighted aspects include patient’s and therapist’s ability to agree on treatment goals and tasks, the collaborative nature of the relationship, and the affective bond between patient and therapist (Bordin 1979; Gaston 1990; Horvath and Symonds 1991; Saunders et al. 1989).
What Can We Learn About Therapeutic Alliance from Different Theoretical Orientations?
Different theoretical orientations in psychotherapy, such as psychoanalytic, psychodynamic, humanistic, and cognitive, have contributed to our understanding of therapeutic alliance in their own ways. Psychoanalysis stresses that therapeutic alliance cannot be explained as some simple, conflict-free, motivating force; rather, it involves a complex interaction of several factors (Freebury 1989). For example, the building of therapeutic alliance depends on a relatively intact part of the patient’s ego to sustain the difficult work of psychoanalysis, especially when dealing with communications between therapist and patient which are the consequence of transference. The patient’s early childhood development has an impact on therapeutic alliance building. The therapist’s reciprocal reactions also add onto the therapeutic dyad, either strengthening or undermining the therapeutic alliance. Led by psychoanalytic thinkers, therapeutic alliance is considered as a process of intersubjective negotiation over the tension between two basic and yet conflicting needs of human beings: needs for relatedness (intimacy, closeness) as well as agency (independence, autonomy) (Safran and Muran 2001).
Like psychoanalysis, psychodynamic psychotherapy considers that therapeutic alliance is formed early in treatment possibly as early as when the therapist makes the initial contact with the patient (e.g., when calling to schedule or in the first session). The early alliance is a predictor of treatment outcome, as good as or better than later assessment (Horvath 2005). Therefore, psychodynamic psychotherapists generally take alliance building seriously starting from the first few sessions by listening sensitively, conveying a sense of warmth and understanding, inviting discussions on the in-session process, and exploring the patient’s affect in a safe, nonjudgmental way (Hilsenroth and Cromer 2007).
In the humanistic orientation, Carl Rogers emphasized the central role of the therapeutic alliance and identified three necessary and sufficient conditions required for therapeutic alliance building (Overholser 2007). The first is congruence, which requires the therapist to remain genuine, open, and honest. The second is unconditional positive regard, which helps to create a warm, accepting, and safe environment. The third is empathy, that is, to understand the patient’s subjective phenomenological experience.
Therapeutic alliance, in cognitive-behavioral psychotherapy, is considered as a reflection of interpersonal schemas, emotional processing, and earlier attachment (including the experiences or lack of the experiences in validation and compassion) which provides the foundation for interpersonal schemas and emotional processing (Leahy 2008).
How Does Therapeutic Alliance Impact Treatment Outcome?
Recent studies with meta-analysis (e.g., Martin et al. 2000; Sharf et al. 2010) have indicated that therapeutic alliance has a moderate effect on treatment outcome. Moreover, the effect of therapeutic alliance on treatment outcome appears to be consistent, and does not depend on many of the variables that have been posited to influence the alliance-outcome relationship, such as therapy orientation, time of assessment, alliance measures, and rating perspectives. Ardito and Rabellino (2011), in a historical excursus of studies on alliance and outcome, also have asserted that alliance is a reliable predictor of positive treatment outcome independent of psychotherapy approaches and outcome measures. The positive connection between therapeutic alliance and treatment outcome has been demonstrated in a variety of mental disorders and among diverse patient populations. For example, patients with schizophrenia who formed a good alliance with their therapists within the first 6 months of treatment are significantly more likely to remain in psychotherapy, comply with medication regimens, achieve better outcomes, and rely on less medications after 2 years of the treatment, in comparison to patients who did not form a good alliance with their therapists (Frank and Gunderson 1990). For patients with substance-related and addictive disorders, ratings of the therapeutic alliance, whether provided by the client or therapist, are found to be significant predictors of treatment participation and drinking behavior during the treatment and 12-month posttreatment periods (Meier et al. 2005). Studies of therapeutic alliance in psychosocial treatments for most child and adolescent disorders suggest that therapeutic alliance is likely as important for younger patients as it is for adults (Shirk et al. 2011). Recent meta-analysis of youth-focused emotional and behavioral treatment has found that therapeutic alliance is correlated to outcomes (Karver et al. 2006; McLeod 2011).
Interestingly, therapeutic alliance has a significant effect on clinical outcome not only for psychotherapy and active pharmacotherapy but also for placebo treatment. Different types of psychotherapy (e.g., interpersonal psychotherapy, cognitive-behavioral therapy, minimally supportive condition) can achieve comparable levels of therapeutic alliance (Krupnick et al. 1996; Marmar et al. 1989). Moreover, therapeutic alliance may be established in similar ways even when the therapeutic approaches are different (Thurer and Hursch 1981).
The direct relationship between the therapeutic alliance and treatment outcome regardless of treatment modalities supports the theoretical idea that alliance may be therapeutic in and of itself (Henry and Strupp 1994). That is, if a proper alliance is established between a patient and therapist, the patient will experience the relationship as therapeutic, regardless of other psychological interventions (Lambert and Barley 2001). Furthermore, it suggests that it is important to work directly with the alliance – to establish it early in treatment, to maintain it when the alliance is strong, and to repair it if the alliance is poor (Safran and Muran 2000).
How May a Therapist Influence Therapeutic Alliance?
Certain personal attributes of the therapist have been found to positively impact the therapeutic alliance, such as being respectful, trustworthy, honest, warm, interested, open, flexible, and confident (Ackerman and Hilsenroth 2003). In contrast, therapist characteristics such as being rigid, critical, distant, uncertain, tense, and distracted contribute negatively to the alliance (Ackerman and Hilsenroth 2001). In terms of the therapist’s interventions during the session, the activities that contribute positively to the alliance include exploring, reflecting, interpreting accurately, attending to the patient’s experience, facilitating the patient to express his/her affect, as well as noting past therapy success (Ackerman and Hilsenroth 2003). On the other hand, overstructured therapy, inappropriate self-disclosure, insensitive use of silence, as well as rigid interpretation of transference are found to negatively impact the alliance (Ackerman and Hilsenroth 2001).
How to Improve Therapeutic Alliance?
Falkenström et al. (2013) have indicated that it seems important for therapists to monitor and work with the alliance not only in the beginning of treatment but in each session; because when the alliance is worse than usual for a given patient, symptoms are likely to get worse in the next session. The constant effort in strengthening the alliance can be particularly crucial if that patient has personality problems. One way to monitor and work with the alliance is the use of metacommunication interventions. As Flückiger and colleagues (2012) have pointed out, some institutes encourage patients’ feedback in various aspects of the therapy process, such as “What are useful goals? What are useful tasks or instruments to achieve the goals? What behaviors of the therapist are helpful? Do you feel confident in your therapeutic relationship? What aspects of the therapy do you hold in high regard? What is possibly missing in your treatment?” This feedback-seeking intervention promotes a proactive role of the patients in treatment and can produce lasting benefits in the growth and development of the therapeutic alliance.
What if There Is a Rupture in Therapeutic Alliance?
Therapeutic alliance can experience deterioration. The decline in the quality of the relationship between patient and therapist is known as alliance rupture (Safran and Muran 2000). Ruptures can occur when the therapist makes a mistake, therapy reaches an impasse, hidden negative feelings based on maladaptive interpersonal schema emerge (Safran et al. 2002), or the therapist challenges the patient’s thoughts or behaviors in a way that comes across as too strong so that the patient feels judged or imposed upon or becomes defensive (Hayes et al. 2007). Given therapy is a sophisticated process with uncertainties and trials and errors, ruptures are hardly avoidable, and they are not necessarily detrimental. What’s more important than avoiding ruptures is repairing them.
Ruptures should not be taken lightly. It is crucial for the therapist to seek supervision or consultation in order to work through one’s own difficulties in the rupture, to regain empathy, and to thoughtfully resolve the rupture. Safran and Muran (1996) proposed a model of alliance rupture resolution that features the following stages of repairing: stage 1, attending to the rupture marker; stage 2, exploration of rupture experience focused on response to self; stage 3, exploration of avoidance, including response to self and expected response of other; and stage 4, self-assertion of wish. The model also stresses that it is necessary to alternate back and forth between stages 2 and 3 and that such exploration would open the patient up for more expression of his/her underlying wish and thus facilitating stage 4.
When handled with competency, not only will the negative feelings be resolved and the alliance be recovered, but also the alliance will be strengthened because candid dialogues have been conducted and therapeutic trust has been tested. Having experienced a repaired rupture, the patient and the therapist can feel more connected. The patient can feel being seen, being understood, and being accepted at a deeper level, which in turn can motivate the patient to challenge oneself and to establish a new adaptive way of living. Therefore, when a rupture happens, it may open up critical opportunities for strengthening the therapeutic alliance and catalyzing changes. As a matter of fact, empirical studies have shown that compared to a stable alliance pattern (little change across sessions) and a linear growth pattern (increasing alliance across sessions), a quadratic growth pattern (a rupture-and-repair sequence across sessions) is associated with a higher level of improvement over the course of treatment (Castonguay et al. 2006; Gelso and Carter 1994; Kivlighan and Shaughnessy 2000). The presence of a repaired rupture episode, compared to those patterns that did not demonstrate a sharp decrease and subsequent increase in alliance levels, is associated with better treatment outcome among patients with depression (Stiles et al. 2004), personality disorder (Strauss et al. 2006), as well as post-traumatic stress disorder (McLaughlin et al. 2014).
How Would Religion and Spirituality Assist Therapeutic Alliance Building and Repair?
Religion and spirituality are important psychosocial factors that may serve as a powerful resource for healing. To be ethical and multiculturally competent in practice, therapists cannot underestimate the impact of religion and spirituality on therapeutic alliance building or rupture as well as on treatment outcome. The majority of patients, as evidence suggests (Rose et al. 2001), want to be able to discuss religion and spirituality, and yet their ability to openly discuss these issues is often limited by a sense of fear. Patients may fear that religious therapists will try to alter and convert them to their own religious faith (Quackenbos et al. 1985) and that secular therapists will misunderstand, ignore, or ridicule their beliefs (Keating and Fretz 1990). In situations where religiosity is integrated in therapy (Morrison et al. 2009), most patients indicated that it had been helpful in making progress toward goals, with only 10 % indicating it was neither helpful nor unhelpful, and no report that the integration of religiosity in therapy was unhelpful.
Whether or not the therapist has a religious or spiritual background, it is possible to honor the patient’s religion and spirituality at each stage of the therapeutic process. For example, therapists taking a spiritual history at the intake stage help develop a comprehensive understanding of the patients and build the therapeutic alliance. Later in treatment, therapists may work on supporting healthy religious beliefs and challenging unhealthy beliefs in a respectful, nonjudgmental, and explorative manner. In rare occasions, therapists may choose to pray with patients in sessions, which strengthens the therapeutic bond as well. According to Bishop (1992), therapists should increase their awareness about their own beliefs and values, avoid unconsciously imposing their own values on patients, and evaluate how these values affect them as a therapist. Therapists are advised to be knowledgeable about the world’s major religions. More importantly, after patients have revealed their beliefs, the therapists should educate themselves through research and consultation about these beliefs and be mindful about and discuss with the patients about how the patients’ individual beliefs may be similar to or different from the universally or stereotypically held beliefs (Richards and Bergin 1997). According to the ACA Code of Ethics (2014), therapists must accept a patient’s interpretations of the meanings of the words religious or spiritual, understanding what spirituality or non-spirituality means to each patient and validating their experience as significant (D’Andrea and Sprenger 2007). When therapists realize their limitations and obstacles in understanding or dealing with the religious/spiritual issues, they should consult or have joint therapy with trained clergy or refer the patients to trained clergy if desired by the patients (Koenig 2007).
- American Counseling Association. (2014). ACA code of ethics. Alexandria: Author.Google Scholar
- Freud, S. (1913). On the beginning of treatment: Further recommendations on the technique of psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (pp. 122–144). London: Hogarth Press.Google Scholar
- Freud, S. (1958). The dynamics of transference. In J. Starchey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (pp. 99–108). London: Hogarth Press. (Original work published 1912).Google Scholar
- Greenson, R. R. (1965). The working alliance and the transference neurosis. Psychoanalysis Quarterly, 34, 155–181.Google Scholar
- Henry, W. P., & Strupp, H. H. (1994). The therapeutic alliance as interpersonal process. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research and practice (pp. 51–84). New York: Wiley.Google Scholar
- Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). 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. Clinical Psychology Review, 26(1), 50–65.CrossRefPubMedGoogle Scholar
- Koenig, H. G. (2007). Spirituality in patient care (2nd ed., pp. 161–174). Philadelphia: Templeton Foundation Press.Google Scholar
- Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. A. (1996). 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. Journal of Consulting and Clinical Psychology, 64(3), 532–539.CrossRefPubMedGoogle Scholar
- Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance ruptures. In J. C. Norcorss (Ed.), Psychotherapy relationships that work (pp. 235–254). New York: Oxford University Press.Google Scholar
- Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., Rees, A., & Barkham, M. (2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped? Journal of Counseling Psychology, 51(1), 81–92.CrossRefGoogle Scholar
- Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., Laurenceau, J., & Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337–345.CrossRefPubMedPubMedCentralGoogle Scholar
- Thurer, S., & Hursch, N. (1981). Characteristics of the therapeutic relationship. Clinical practice of psychology, 62–82.Google Scholar