The therapeutic alliance

2011-08-04 by smapg

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.

Contents

ResearchEdit

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.[1] 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.[2][3][4] Evidence on each component's unique contribution to outcome has been gathered, as well as evidence on the interaction between components.[5]

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.[6] Bordin[7] 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.[8]

Operationalization and measurement

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

Barrett-Lennard Relationship Inventory,[9]

California Psychotherapy Alliance Scales (CALPAS).[10]

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.[11].

Working Alliance Inventory (WAI),[12]