DCP3

REVIEW ARTICLE published: 18 October 2011

doi: 10.3389/fpsyg.2011.00270

Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research Rita B. Ardito* and Daniela Rabellino

Department of Psychology, Center for Cognitive Science, University of Turin, Turin, Italy

Edited by:

Susan G. Simpson, University of South Australia, Australia

Reviewed by:

Susan G. Simpson, University of South Australia, Australia Michiel V. Vreeswijk, Psychiatric Hospital, Netherlands

*Correspondence:

Rita B. Ardito, Department of Psychology, University of Turin, via Po, 14 – 10123 Turin, Italy. e-mail: rita.ardito@unito.it

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 sum- mary 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 psychother- apy 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.

Keywords: alliance measures, evaluation of psychotherapeutic process, outcome of psychotherapy, thera-

pist/patient relationship, therapeutic alliance, working alliance

INTRODUCTION The main aim of this paper is to propose a historical excursus of the most relevant literature which has investigated the relationship between the therapeutic alliance and outcome in psychotherapy.

A challenge by Eysenck (1952), who claimed that the effi- cacy of psychotherapy had not been demonstrated and that any improvements were the result of so-called spontaneous remission, stimulated significant developments in the study of outcomes in psychotherapy. Furthermore, research into the relationship between the process and outcome of psychotherapy has frequently attempted to explain the non-specific factors theorized by Strupp and Hadley (1979) which can have a significant impact on the out- come of different treatments. This viewpoint was more recently confirmed by Strupp (2001), who showed that the outcome of a psychotherapeutic process is often influenced by so-called non- specific factors, namely, the personal characteristics of the therapist and the positive feelings that arise in the patient – feelings which can lead to the creation of a positive therapeutic climate from an emotional and interpersonal perspective.

From a different perspective, Orlinsky and Howard (1986), in their review of the research into process and outcome in psy- chotherapy, seek to respond to the following question: what is effectively therapeutic about psychotherapy? Here, it is important to note that research in the field of psychotherapy is usually clas- sified as outcome research and process research. Outcome research analyses the results of the therapy, whereas process research investi- gates the various aspects of the therapeutic process, which can also be measured during the course of therapy regardless of outcome. This process is what takes place between, and within, the patient

and therapist during the course of their interaction (Orlinsky and Howard, 1986). These two areas of research should not really be considered as separate, but rather as two sides of a coin. Migone (1996) distinguishes three partially overlapping phases in the his- tory of psychotherapy research: a first phase, between the 1950s and 1970s, when research focused on the outcome of psychother- apy and there was a proliferation of meta-analysis; a second phase between the 1960s and 1980s in which there was a growing inter- est for research into the relationship between process and outcome (the Vanderbilt Project is the most famous example of this); and a third phase from the 1970s onward, in which interest shifted to the therapeutic process and the desire for a greater understanding of the “micro-processes” involved in therapy.

Before examining the most influential instruments designed to measure the therapeutic alliance and their correlations with out- come, we will summarize the concept of alliance as it has evolved over time.

EVOLUTION OF THE CONCEPT OF THERAPEUTIC ALLIANCE According to Horvath and Luborsky (1993), the concept of ther- apeutic alliance can be traced back to Freud’s (1913) theorization of transference. Initially regarded as purely negative, Freud, in his later works, adopted a different stance on the issue of transference and considered the possibility of a beneficial attachment actually developing between therapist and patient, and not as a projec- tion. Along the same lines, Zetzel (1956) defines the therapeutic alliance as a non-neurotic and non-transferential relational com- ponent established between patient and therapist. It allows the patient to follow the therapist and use his or her interpretations.

www.frontiersin.org October 2011 | Volume 2 | Article 270 | 1

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

Similarly, Greenson (1965) defines the working alliance as a reality- based collaboration between patient and therapist. Other authors (Horwitz, 1974; Bowlby, 1988), expanding on the concept of Bib- ring (1937), considered the attachment between therapist and patient as qualitatively different to that based on childhood expe- riences. These authors made a distinction between transference and the therapeutic (or working) alliance, and this distinction later extended beyond the analytical framework (Horvath and Luborsky, 1993).

Rogers (1951) defines what he considered to be the active components in the therapeutic relationship: empathy, congru- ence, and unconditional positive regard. These were seen as the ideal conditions offered by the therapist but were later shown to be specifically essential for client-centered therapy (Horvath and Greenberg, 1989; Horvath and Luborsky, 1993). While Rogers stressed the therapist’s role in the relationship, other works focused on the theory of the influence of social aspects. The work of Strong (1968) was based on the hypothesis that if the patient is con- vinced of the therapist’s competence and adherence, this will give the latter the necessary influence to bring about changes in the patient.

Recognition of the fact that different types of psychotherapy often reveal similar results gave rise to the hypotheses regarding the existence of variables common to all forms of therapy, rekindling interest in the alliance as a non-specific variable. Luborsky (1976) proposes a theoretical development of the concept of alliance, sug- gesting that the variations in the different phases of therapy could be accounted for by virtue of the dynamic nature of the alliance. He distinguished two types of alliance: the first, found in the early phases of therapy, was based on the patient’s perception of the ther- apist as supportive, and a second type, more typical of later phases in the therapy, represented the collaborative relationship between patient and therapist to overcome the patient’s problems – a shar- ing of responsibility in working to achieve the goals of the therapy and a sense of communion.

The definition of the therapeutic alliance proposed by Bordin (1979) is applicable to any therapeutic approach and for this reason is defined by Horvath and Luborsky (1993) as the “pan-theoretical concept.” Bordin’s formulation underlines the collaborative rela- tionship between patient and therapist in the common fight to overcome the patient’s suffering and self-destructive behavior. According to the author, the therapeutic alliance consists of three essential elements: agreement on the goals of the treatment, agree- ment on the tasks, and the development of a personal bond made up of reciprocal positive feelings. In short, the optimal therapeutic alliance is achieved when patient and therapist share beliefs with regard to the goals of the treatment and view the methods used to achieve these as efficacious and relevant. Both actors accept to undertake and follow through their specific tasks. The other two components of the alliance can only develop if there is a per- sonal relationship of confidence and regard, since any agreement on goals and tasks requires the patient to believe in the therapist’s ability to help him/her and the therapist in turn must be confident in the patient’s resources. Bordin also suggests that the alliance will influence outcome, not because it is healing in its own right, but as an ingredient which enables the patient to accept, follow, and believe in the treatment. This definition offers an alternative

to the previous dichotomy between the therapeutic process and intervention procedures, considering them interdependent.

Only a few studies have examined the relationship between alliance and outcome in group psychotherapy. One conceptu- alization of therapeutic alliance in group psychotherapy follows Bordin’s theory, transferring this multifactorial construct from an individual to a group setting. The first difference is that in group psychotherapy we have multiple therapeutic agents: the therapist (usually two co-therapists), the members of the group, and the group as a whole. Thus, we have to consider more than one rela- tional level within the group: member to therapist alliance (the same as individual therapy), member to member alliance, group to therapist alliance, and member to other members as a whole alliance. Under this complexity of adapting the alliance concept to a group context, some authors have found a solution: the sys- temic model of alliance according to Pinsof (1988) Pinsof and Catherall (1986). These authors have adapted Bordin’s model to multiple interpersonal subsystems. These subsystems involve (a) a self-to-therapist alliance, (b) group-to-therapist alliance, (c) self- to-members alliance, and (d) other-to-therapist alliance. Under this point of view, an alliance can be conceptualized as the totality of the alliances formed (Gillaspy et al., 2002).

In a comparison of therapeutic factors in group and individual treatment processes by Holmes and Kivlighan (2000), relationship components have emerged as being more prominent in group psychotherapy, whereas emotional awareness–insight and prob- lem definition change are more central to the process of individual treatment. As such, we can say that clients in group therapies may attach greater importance to relationship factors.

When defining therapeutic alliance in a group context, it is necessary to take into account the comparison with group cohe- sion, another central construct that is often confused with alliance. Definitions of cohesion have covered a wide range of features, sometimes overlapping the alliance construct.Yalom (1995) speaks of a sense of support, trust, belonging in the group, and also “the analog of relationship in individual therapy”; Budman et al. (1989) refer to cohesion as working together toward a therapeu- tic goal and engagement around common themes. They found that alliance and group cohesion were closely related and that both were strongly related to improved self-esteem and reduced symptomatology. Crowe and Grenyer (2008) make a distinction between cohesion and alliance, stating that group cohesion refers to the relationship between all members of the group, including the therapists (Burlingame et al., 2011), while working alliance, by contrast, refers to the relationship between the therapist and group member. Marziali et al. (1997) tested the contribution of thera- peutic alliance and group cohesion (both based on self-report) to outcome in group therapies for borderline personality disorder. Cohesion and alliance were correlated significantly and both pre- dicted a successful outcome, although the alliance accounted for more outcome variance.

MEASURING THE ALLIANCE Table 1 shows the alliance measures more frequently used to assess the level of alliance and their correlations with outcome. Most of them are based on the theoretical assumptions previously described.

Frontiers in Psychology | Psychology for Clinical Settings October 2011 | Volume 2 | Article 270 | 2

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

T a

b le

1 |T

h e

m o

s t

c o

m m

o n

a ll

ia n

c e

m e

a s u

re s

a v a

il a

b le

in li

te ra

tu re

fo r

a d

u lt

p s y c h

o th

e ra

p y .

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a s u

re T

h e

ra p

e u

ti c

m o

d e

l

a n

d d

e s c ri

p ti

o n

S c o

ri n

g s y

s te

m T

h e

ra p

is ts

’, c li

e n

ts ’,

a n

d /o

r c li

n ic

a l

o b

s e

rv e

rs ’

p e

rs p

e c ti

v e

P s y c h

o m

e tr

ic p

ro p

e rt

ie s

C o

rr e

la ti

o n

s w

it h

o u

tc o

m e

Pe nn

sy lv

an ia

(P en

n) sc

al es

(A le

xa nd

er an

d

Lu bo

rs ky

,1 98

6;

Lu bo

rs ky

et al

.,

19 85

;L ub

or sk

y

et al

., 19

83 ).

Lu bo

rs ky

’s (1

97 6)

ps yc

ho dy

na m

ic

co nc

ep t

of th

e tw

o ty

pe s

of he

lp in

g

al lia

nc e

(i. e.

,p at

ie nt

’s pe

rc ep

tio n

of th

e

th er

ap is

t as

su pp

or tiv

e, an

d

re pr

es en

tin g

th e

co lla

bo ra

tiv e

re la

tio ns

hi p

be tw

ee n

pa tie

nt an

d

th er

ap is

t to

ov er

co m

e th

e pa

tie nt

’s

pr ob

le m

s) .T

he se

sc al

es ra

te th

e

al lia

nc e

an d

co ns

is t

of th

e H

A cs

(H el

pi ng

A lli

an ce

C ou

nt in

g S

ig ns

M et

ho d)

,H A

r (H

el pi

ng A

lli an

ce R

at in

g

M et

ho d)

,a nd

H A

q (H

el pi

ng A

lli an

ce

Q ue

st io

nn ai

re M

et ho

d) .

A sc

or e

on a

5- (H

A cs

), a

10 -

(H A

r) ,a

nd a

6- (H

A q)

po in

t

ra tin

g sc

al e

is as

si gn

ed to

a

se rie

s of

ite m

s gr

ou pe

d in

to

su b-

sc al

es ac

co rd

in g

to th

e

ty pe

of al

lia nc

e be

in g

co ns

id er

ed .F

or ea

ch sc

al e,

th e

al lia

nc e

sc or

e is

th e

su m

of th

e su

bs ca

le ra

tin gs

.

Th er

ap is

ts

(H A

r) /c

lie nt

s

(H A

q) /c

lin ic

al

ob se

rv er

s (H

A cs

)

H ig

h le

ve lo

f in

te rn

al

co ns

is te

nc y

(0 .9

3) an

d le

ss

ro bu

st co

nv er

ge nt

va lid

ity

co m

pa re

d w

ith ot

he r

m ea

su re

m en

ts of

al lia

nc e

(E lv

in s

an d

G re

en ,2

00 8)

.

Th es

e sc

al es

ha ve

be en

sh ow

n to

be m

od er

at el

y co

r-

re la

te w

ith ou

tc om

e (r

= 0.

29 ;

Lu bo

rs ky

et al

., 19

83 ;

M ar

tin ,

G ar

sk e

an d

D av

is ,

20 00

)

al so

in de

pe nd

en tly

of pr

e-

tr ea

tm en

t ch

ar ac

te ris

tic s

su ch

as se

ve rit

y of

ill ne

ss (L

e B

lo ch

et al

., 20

06 ).

Va nd

er bi

lt sc

al es

(H ar

tle y

an d

S tr

up p,

19 83

;

O ’M

al le

y et

al .,

19 83

;S uh

et al

.,

19 86

)

S tr

up p’

s dy

na m

ic an

d in

te gr

at iv

e

co nc

ep tu

al iz

at io

ns of

al lia

nc e

(S tr

up p

an d

B in

de r,

19 84

). Th

e V

P P

S

(V an

de rb

ilt P

sy ch

ot he

ra py

Pr oc

es s

S ca

le )m

ea su

re s

th e

re la

tio ns

hi p

be tw

ee n

th er

ap is

t an

d pa

tie nt

an d

th e

ps yc

ho th

er ap

y pr

oc es

s. Th

is sc

al e

w as

la te

r m

od ifi

ed to

be co

m e

th e

V TA

S

(V an

de rb

ilt Th

er ap

eu tic

A lli

an ce

S ca

le )

m or

e sp

ec ifi

ca lly

de si

gn ed

to m

ea su

re

th e

th er

ap eu

tic al

lia nc

e.

In th

e V

P P

S ra

tin g

is

pe rf

or m

ed on

a se

gm en

t of

th e

th er

ap y,

us in

g a

fiv e-

po in

t

sc al

e to

m ea

su re

80 ite

m s.

In

th e

V TA

S ta

pe s

of tr

ea tm

en t

se ss

io ns

ar e

ra te

d us

in g

a

si x-

po in

t sc

al e

to m

ea su

re 44

ite m

s.

C lin

ic al

ob se

rv er

s A

fa ct

or an

al ys

is co

nd uc

te d

on th

e tw

o sc

al es

fo un

d th

at

th e

V P

P S

an d

th e

V TA

S ha

d

si m

ila r

fa ct

or st

ru ct

ur es

(H ar

tle y

an d

S tr

up p,

19 83

).

Th e

V TA

S ha

s de

m on

st ra

te d

so lid

in te

r-r at

er re

lia bi

lit y,

in te

rn al

co ns

is te

nc y,

an d

co nv

er ge

nt va

lid ity

w ith

ot he

r

al lia

nc e

m ea

su re

s (K

ru pn

ic k

et al

., 19

96 ).

Th es

e sc

al es

ha ve

be en

sh ow

n

to be

m od

er at

el y

co rr

el at

e

w ith

ou tc

om e

(r =

0. 25

; M

ar -

tin et

al .,

20 00

).

To ro

nt o

sc al

es

(M ar

zi al

i, 19

84 ;

M ar

zi al

ie t

al .,

19 81

).

C la

ss ic

ps yc

ho dy

na m

ic

co nc

ep tu

al iz

at io

ns of

th e

al lia

nc e

as

w el

la s

B or

di n’

s (1

97 9)

in te

gr at

iv e

m od

el .S

pe ci

fic fo

cu s

on th

e af

fe ct

iv e

as pe

ct s

of th

e al

lia nc

e. B

y co

m bi

ni ng

ite m

s ta

ke n

fr om

ot he

r sc

al es

(V P

P S,

V TA

S, an

d H

A cs

)M ar

zi al

ia nd

co lle

ag ue

s de

ve lo

pe d

th e

TA R

S

(T he

ra pe

ut ic

A lli

an ce

R at

in g

S ca

le ).

Th er

e ar

e th

re e

ve rs

io ns

of th

e TA

R S

ac co

rd in

g to

th e

ra te

r’s pe

rs pe

ct iv

e

A ll

of th

e th

re e

ve rs

io ns

of

th e

TA R

S co

ns is

t of

42 ite

m s

(2 1

pe rt

ai ni

ng to

th e

pa tie

nt

an d

21 pe

rt ai

ni ng

to th

e

th er

ap is

t) .E

ac h

ite m

is ra

te d

on a

si x-

po in

t sc

al e.

Th er

ap is

ts /c

lie nt

s/

cl in

ic al

ob se

rv er

s

A de

qu at

e in

te rn

al

co ns

is te

nc ie

s an

d co

nv er

ge nt

va lid

ity w

ith se

lf re

po rt

ve rs

io ns

of th

e Pe

nn sc

al es

an d

V P

P S

(E lv

in s

an d

G re

en ,

20 08

).

Th es

e sc

al es

do no

t ap

pe ar

to be

re la

te d

to ou

tc om

e

(r =

0. 07

;M ar

tin et

al .,

20 00

).

(C on

tin ue

d)

www.frontiersin.org October 2011 | Volume 2 | Article 270 | 3

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

T a

b le

1 |

C o

n ti

n u

e d

M e

a s u

re T

h e

ra p

e u

ti c

m o

d e

l

a n

d d

e s c ri

p ti

o n

S c o

ri n

g s y

s te

m T

h e

ra p

is ts

’, c li

e n

ts ’,

a n

d /o

r c li

n ic

a l

o b

s e

rv e

rs ’

p e

rs p

e c ti

v e

P s y c h

o m

e tr

ic p

ro p

e rt

ie s

C o

rr e

la ti

o n

s w

it h

o u

tc o

m e

W or

ki ng

al lia

nc e

in ve

nt or

y (W

A I)

H or

va th

an d

G re

en be

rg (1

98 6,

19 89

)

Th e

W A

Im ea

su re

s th

e qu

al ity

of th

e

al lia

nc e

on th

e ba

si s

of th

e th

re e

as pe

ct s

of th

e al

lia nc

e th

eo riz

ed by

B or

di n’

s (1

97 9)

:t he

bo nd

,t he

ag re

em en

t on

go al

s, an

d th

e

ag re

em en

t on

ta sk

s. Th

er e

ar e

th re

e

ve rs

io ns

of th

e W

A Ia

cc or

di ng

to th

e

ra te

r’s pe

rs pe

ct iv

e. Tr

ac ey

an d

Ko ko

to vi

c (1

98 9)

ha ve

de ve

lo pe

d a

sh or

te ne

d ve

rs io

n of

th es

e sc

al es

.

Th e

W A

Ii s

a se

lf- re

po rt

sc al

e

co ns

is tin

g of

36 ite

m ea

ch of

on e

ra te

d on

a se

ve n-

po in

t

sc al

e. Th

e sh

or te

r ve

rs io

n

co ns

is ts

of 12

ite m

.

Th er

ap is

ts /c

lie nt

s/

cl in

ic al

ob se

rv er

s

S tr

on g

su pp

or t

fo r

th e

re lia

bi lit

y of

th e

W A

Is ca

le s

an d

so m

e su

pp or

t fo

r its

va lid

ity .S

ev er

al st

ud ie

s ha

ve

de m

on st

ra te

d th

e pr

ed ic

tiv e

va lid

ity of

th is

in st

ru m

en t

in a

va rie

ty of

tr ea

tm en

ts

(H or

va th

,1 99

4; H

or va

th an

d

G re

en be

rg ,1

98 9;

H ow

ar d

et al

., 20

06 ;K

le in

et al

., 20

03 ;

M ar

tin et

al .,

20 00

;S af

ra n

an d

W al

ln er

,1 99

1) .

Th es

e sc

al es

ha ve

be en

sh ow

n

to be

m od

er at

el y

co rr

el at

e

w ith

ou tc

om e

(r =0

.2 4;

M ar

tin

et al

., 20

00 ).

C al

ifo rn

ia sc

al es

(G as

to n

an d

M ar

m ar

,1 99

4;

M ar

m ar

et al

.,

19 89

a; M

ar m

ar

et al

., 19

89 b)

Th e

C al

ifo rn

ia S

ca le

s co

m pr

is e

th e

C A

LT A

R S

(C al

ifo rn

ia Th

er ap

eu tic

A lli

an ce

R at

in g

S ca

le )a

nd th

e C

A LP

A S

(C al

ifo rn

ia P

sy ch

ot he

ra py

A lli

an ce

S ca

le ).

Th e

fo rm

er de

riv es

fr om

th e

TA R

S an

d fo

cu se

s on

th e

af fe

ct iv

e an

d

at tit

ud in

al as

pe ct

s of

th e

al lia

nc e

ra th

er

th an

on sp

ec ifi

c th

er ap

eu tic

in te

rv en

tio ns

.T he

C A

LP A

S is

a re

vi se

d

ve rs

io n

of th

e C

A LT

A R

S an

d w

as

de si

gn ed

to ra

te th

e fo

ur as

pe ct

s of

th e

al lia

nc e

id en

tifi ed

by G

as to

n (1

99 0)

:

pa tie

nt w

or ki

ng ca

pa ci

ty ,p

at ie

nt

co m

m itm

en t,

th er

ap is

t un

de rs

ta nd

in g

an d

in vo

lv em

en t,

pa tie

nt –t

he ra

pi st

ag re

em en

t on

go al

s, an

d st

ra te

gi es

.

Th e

C A

LT R

A S

co ns

is ts

of 41

ite m

s, 20

of w

hi ch

re fe

r to

th e

th er

ap is

t, an

d 21

to th

e

pa tie

nt .T

he C

A LP

A S

is a

se lf-

re po

rt 24

-it em

qu es

tio nn

ai re

.E ac

h ite

m is

ra te

d on

a se

ve n-

po in

t sc

al e.

Th er

ap is

ts /c

lie nt

s/

cl in

ic al

ob se

rv er

s

Fa ct

or an

al yt

ic st

ud ie

s ha

ve

sh ow

n co

nfi rm

at io

n fo

r th

e

fo ur

as pe

ct s

of th

e al

lia nc

e

id en

tifi ed

(M ar

m ar

et al

.,

19 89

a, b)

.T he

C A

LP A

S is

hi gh

ly co

rr el

at ed

w ith

th e

W A

I.

Th es

e sc

al es

ha ve

be en

sh ow

n

to be

m od

er at

el y

co rr

el at

e

w ith

ou tc

om e

(r =

0. 17

; M

ar -

tin et

al .,

20 00

; S

af ra

n an

d

W al

ln er

,1 99

1) .

Th er

ap eu

tic

se ss

io n

re po

rt

(T S

R )

O rli

ns ky

an d

H ow

ar d

(1 96

6,

19 86

)

Th e

TS R

m ea

su re

s th

e th

re e

di m

en si

on s

of th

e th

er ap

eu tic

bo nd

as

de fin

ed by

O rli

ns ky

an d

H ow

ar d

(1 98

6) :w

or ki

ng al

lia nc

e (in

ve st

m en

t of

pa tie

nt an

d th

er ap

is t

in to

th ei

r

re sp

ec tiv

e ro

le s)

,e m

pa th

ic re

so na

nc e

Th e

TS R

is a

14 5-

ite m

st ru

ct ur

ed -r

es po

ns e

in st

ru m

en t.

M os

t of

th e

ite m

ar e

sc or

ed in

a bi

na ry

fa sh

io n

or on

a 0–

2 sc

al e.

Th er

ap is

ts /c

lie nt

s A

de qu

at e

in te

rn al

co ns

is te

nc y

an d

in te

r-r at

er re

lia bi

lit y

(E lv

in s

an d

G re

en ,2

00 8;

Ko ld

en ,1

99 1)

.T he

re su

lts

sh ow

th at

th e

pa tie

nt ’s

in -s

es si

on em

ot io

na l

N o

co rr

el at

io ns

be tw

ee n

al lia

nc e

an d

ou tc

om e

(E lv

in s

an d

G re

en ,2

00 8)

.

Frontiers in Psychology | Psychology for Clinical Settings October 2011 | Volume 2 | Article 270 | 4

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

(t he

pa rt

ic ip

an ts

’j oi

nt se

ns e

of be

in g

un de

rs to

od by

ea ch

ot he

r) an

d m

ut ua

l

af fir

m at

io n

(t he

ex pe

rie nc

e of

a

re ci

pr oc

al ,c

ar in

g at

tit ud

e) .I

n

de ve

lo pi

ng th

is in

st ru

m en

t, O

rli ns

ky

an d

H ow

ar d

w er

e in

flu en

ce d

by th

e

R og

er s’

s (1

95 1)

no tio

n of

un co

nd iti

on al

po si

tiv e

re ga

rd .

ex pe

rie nc

e is

a

va lid

in di

ca to

r of

al lia

nc e

qu al

ity

(S au

nd er

s, 19

99 ).

Th er

ap eu

tic bo

nd

sc al

es (T

B S

)

(S au

nd er

s et

al .,

19 89

)

B as

ed on

O rli

ns ky

an d

H ow

ar d’

s (1

98 6)

ps yc

ho th

er ap

eu tic

m od

el .T

he TB

S ar

e

de ve

lo pe

d fr

om th

e th

eo re

tic al

as su

m pt

io ns

of th

e TS

R .

Th is

in st

ru m

en t

co ns

is ts

of 50

ite m

be lo

ng in

g to

th e

fo llo

w in

g di

m en

si on

s: 15

ite m

s co

m po

se th

e W

or ki

ng

A lli

an ce

sc al

e, 17

ite m

s

co m

po se

th e

E m

pa th

ic

R es

on an

ce sc

al e,

an d

18

ite m

s co

m po

se th

e M

ut ua

l

A ffi

rm at

io n

sc al

e. A

lto ge

th er

,

th es

e su

bs ca

le s

pr ov

id e

a

G lo

ba lB

on d

sc al

e. E

ac h

ite m

is ra

te d

on a

21 -p

oi nt

sc al

e.

C lie

nt s/

cl in

ic al

ob se

rv er

s

Th e

in te

rn al

re lia

bi lit

ie s

of

ea ch

su bs

ca le

is ad

eq ua

te ,a

s

is th

e in

te rn

al re

lia bi

lit y

of th

e

G lo

ba lB

on d

sc al

e. A

ll th

re e

sc al

es an

d th

e G

lo ba

lB on

d

sc al

e ar

e re

la te

d to

pa tie

nt

ra tin

gs of

se ss

io n

qu al

ity

(M ar

tin et

al .,

20 00

;S au

nd er

s

et al

., 19

89 ).

Th e

G lo

ba l

B on

d sc

al e

is

re la

te d

to ou

tc om

e (r

= 0.

37 )

bu t

th er

e ar

e lim

ite d

co rr

e-

la tio

ns st

ud ie

s (M

ar tin

et al

.,

20 00

).

P sy

ch ot

he ra

py

st at

us re

po rt

(P S

R )

(F ra

nk an

d

G un

de rs

on ,1

99 0)

Th e

P S

R w

as no

td ev

el op

ed fo

llo w

in g

a

sp ec

ifi c

th eo

re tic

al vi

ew po

in t

an d

ev al

ua te

s th

e pa

tie nt

’s in

-t he

ra py

be ha

vi ou

r th

at m

ay po

in t

to th

e

ex is

te nc

e of

a th

er ap

eu tic

al lia

nc e:

co lla

bo ra

tiv e

an d

ac tiv

e pa

rt ic

ip at

io n,

sp on

ta ne

ou s

an d

fu ll

ag re

em en

t,

af fe

ct iv

e in

vo lv

em en

t, de

si re

to

ac hi

ev e

go al

s, co

nfi de

nc e,

cl ea

r, an

d

re al

is tic

re pr

es en

ta tio

n of

th e

th er

ap eu

tic re

la tio

ns hi

p.

Th e

re po

rt is

fil le

d in

by th

e

th er

ap is

t an

d co

ns is

ts of

si x

ite m

s ra

te d

on a

fiv e-

po in

t

sc al

e. Pa

tie nt

s al

so re

sp on

d

to 12

ite m

s th

at ra

te th

e le

ve l

of th

er ap

is t

co lla

bo ra

tio n.

Th er

ap is

ts Th

e sc

al e

ha s

sh ow

n a

hi gh

le ve

lo f

in te

rn al

co ns

is te

nc y

(C ro

nb ac

h’ s

al ph

a =

0. 89

), an

d

ha s

de m

on st

ra te

d go

od

te st

–r et

es t

re lia

bi lit

y du

rin g

a

3- m

on th

pe rio

d (a

ve ra

ge

r =

0. 72

;F ra

nk an

d

G un

de rs

en ,1

99 0)

.

A lli

an ce

as m

ea su

re d

by th

e

P S

R ha

s be

en sh

ow n

to

be co

rr el

at ed

w ith

ou tc

om e

in pa

tie nt

s w

ith se

ve re

an d

en du

rin g

m en

ta l

ill ne

ss su

ch

as sc

hi zo

ph re

ni a

(E lv

in s

an d

G re

en ,

20 08

; Sv

en ss

on an

d

H an

ss on

,1 99

9) .

(C on

tin ue

d)

www.frontiersin.org October 2011 | Volume 2 | Article 270 | 5

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

T a

b le

1 |

C o

n ti

n u

e d

M e

a s u

re T

h e

ra p

e u

ti c

m o

d e

l

a n

d d

e s c ri

p ti

o n

S c o

ri n

g s y

s te

m T

h e

ra p

is ts

’, c li

e n

ts ’,

a n

d /o

r c li

n ic

a l

o b

s e

rv e

rs ’

p e

rs p

e c ti

v e

P s y c h

o m

e tr

ic p

ro p

e rt

ie s

C o

rr e

la ti

o n

s w

it h

o u

tc o

m e

A gn

ew

re la

tio ns

hi p

m ea

su re

(A R

M )

(A gn

ew -D

av ie

s

et al

., 19

98 ).

Th e

A R

M w

as in

te nd

ed to

de sc

rib e

co m

po ne

nt s

of th

e al

lia nc

e in

la ng

ua ge

de si

gn ed

to be

ac ce

pt ab

le w

ith in

a

w id

e ra

ng e

of th

eo re

tic al

or ie

nt at

io ns

an d

w as

de ve

lo pe

d du

rin g

th e

S ec

on d

S he

ffi el

d P

sy ch

ot he

ra py

Pr oj

ec t,

a

ra nd

om iz

ed co

m pa

ris on

of

co gn

iti ve

–b eh

av io

ur al

th er

ap y

an d

ps yc

ho dy

na m

ic –i

nt er

pe rs

on al

th er

ap y

fo r

de pr

es si

on .T

he A

R M

as se

ss es

fiv e

di m

en si

on s

of th

e al

lia nc

e: bo

nd ,

pa rt

ne rs

hi p,

co nfi

de nc

e, op

en ne

ss ,

an d

cl ie

nt in

iti at

iv e.

Th e

A R

M ha

s fiv

e sc

al es

co m

pr is

in g

28 ite

m s

ra te

d on

pa ra

lle lf

or m

s by

pa tie

nt s

an d

th er

ap is

ts us

in g

a se

ve n-

po in

t

sc al

e.

Th er

ap is

ts /c

lie nt

s In

te rn

al co

ns is

te nc

ie s

of fo

ur

sc al

es w

er e

al la

cc ep

ta bl

e

(a lp

ha s

ra ng

ed fr

om 0.

77 to

0. 87

). Th

e in

te rn

al

co ns

is te

nc y

of th

e C

lie nt

In iti

at iv

e sc

al e

w as

lo w

(0 .5

5;

A gn

ew et

al .,

19 98

).

S om

e as

pe ct

s of

th e

al lia

nc e

as m

ea su

re d

by th

e A

R M

w as

co rr

el at

ed w

ith ps

yc ho

th er

ap y

ou tc

om e

(S til

es et

al .,

19 98

). A

qu al

ita tiv

e st

ud y

us in

g an

ou t-

co m

e m

ea su

re m

en t

(C O

R E

N et

)i n

co rr

el at

io n

w ith

a m

od -

ifi ed

fiv e-

po in

t sc

al e

of th

e

A R

M co

nfi rm

s th

at th

e cl

ie nt

’s

ra tin

g of

th e

al lia

nc e

is on

e of

th e

be st

pr ed

ic to

r of

en ga

ge -

m en

ta nd

ou tc

om e

(U ns

w or

th ,

20 08

).

K im

al lia

nc e

sc al

e

(K A

S )

(K im

et al

., 20

01 )

Th e

K A

S w

as de

ve lo

pe d

to ra

te th

e

qu al

ity of

th e

th er

ap eu

tic al

lia nc

e fr

om

th e

pa tie

nt ’s

pe rs

pe ct

iv e.

Th e

sc al

e

co m

pr is

es th

e th

re e

di m

en si

on of

th e

al lia

nc e

or ig

in al

ly pr

op os

ed by

B or

di n

(1 97

9) pl

us a

fo ur

th di

m en

si on

:t he

pa tie

nt ’s

em po

w er

m en

t, i.e

., th

e

pa tie

nt be

co m

in g

m or

e re

sp on

si bl

e fo

r

hi s/

he r

ow n

ca re

an d

m or

e in

vo lv

ed in

m ak

in g

ch oi

ce s.

Th e

K A

S is

a se

lf re

po rt

m ea

su re

co ns

is tin

g of

30 -it

em (8

co lla

bo ra

tio n

ite m

,

11 co

m m

un ic

at io

n ite

m ,5

in te

gr at

io n

ite m

,a nd

6

em po

w er

m en

t ite

m )e

ac h

of

on e

ra te

d on

a fo

ur -p

oi nt

sc al

e.

C lie

nt s

H ig

h le

ve lo

f in

te rn

al

co ns

is te

nc y

fo r

th e

to ta

lK A

S

(C ro

nb ac

h’ s

al ph

a =

0. 94

). Th

e

al ph

as fo

r th

e fo

ur

di m

en si

on s

ra ng

ed fr

om 0.

71

fo r

em po

w er

m en

t to

0. 87

fo r

co m

m un

ic at

io n

(K im

et al

.,

20 01

). H

ig hl

y co

rr el

at ed

w ith

th e

A R

M .

Th e

sc al

e ha

s no

tb ee

n us

ed in

ou tc

om e

re se

ar ch

.

Frontiers in Psychology | Psychology for Clinical Settings October 2011 | Volume 2 | Article 270 | 6

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

Any attempt to measure something as complex as therapeu- tic alliance involves a series of conceptual and methodological shortcomings, which have probably hindered the development of research in this field. Single-case research is one method used to investigate this theoretical construct, but implies some method- ological drawbacks regarding the simultaneous treatment of sev- eral factors, the need for an adequate number of repeated mea- surements, and the generalizability of results. Meta-analysis is a possible research strategy that can be used to obtain the combined results of studies on the same topic. However, it is important to remember that meta-analysis is more valid when the effect being investigated is quite specific. According to Migone (1996), another hindrance is the so-called Rashomon effect (named after the 1950 film by Akira Kurosawa): each single aspect of therapeutic alliance may be perceived very differently by the therapist, patient, and clinical observer, which raises the question of objectivity.

Di Nuovo et al. (1998) propose some methodological changes to increase the utility of research findings, namely, omitting the use of methodological “control” techniques with comparisons between groups, re-evaluating single-case research, reconsidering the use of longitudinal studies, and using systematic replication and meta-analysis to guarantee the generalizability of results, even with single cases.

In spite of the difficulties involved in this type of research, Table 1 shows that numerous instruments have been developed to analyses the therapeutic alliance. Though designed by indepen- dent research teams, there is often good correlation between the scales used to rate the therapeutic alliance, which reveal that these instruments tend to assess the same underlying process (Martin et al., 2000). Fenton et al. (2001) compared the predictive validity of six instruments (CALPAS, Penn Scale, VTAS, WAI-Observer, WAI-therapist, WAI-Client) and found that all the measurement instruments used by raters (six trained clinicians served as inde- pendent raters for this study) were strong predictors of outcome. None of their findings suggest that any one instrument was a stronger predictor of outcome than the others, in relation to the type of therapy being considered.

It is interesting to note that although almost all of these scales were originally designed to examine the perspective of only one member of the patient–therapist–observer triad, they were later extended or modified to rate perspectives that were not previ- ously considered. In short, some scales analyses specific theoret- ical concepts of the alliance (Penn scales, WAI, CALPAS, TBS), whereas others use a more eclectic construct (VPPS,VTAS, TARS). The number of items included in the scales varies considerably (between 6 and 145 items), as do the dimensions of the alliance investigated (e.g., two in the Penn scales; three in the WAI, TSR, and TBS; four in the CALPAS and KAS; and five in the ARM). Accord- ing to Martin et al. (2000), the most frequently used scales in individual psychotherapy are the WAI, CALPAS, and Penn scales, followed by the Vanderbilt scales, TARS, and TBS.

Different approaches for the evaluation of alliance coexist in group psychotherapy. One of them is derived from individ- ual psychotherapy. Johnson et al. (2005) used the WAI to refer to relationships with other group members; it was called the Member–Member WAI. The WAI-based scale used to measure relationships with group leaders was called the Member–Leader

WAI. The CALPAS Group used by Crowe and Grenyer (2008) consisted of four subscales: patient working capacity, patient com- mitment, working strategy consensus, and member understanding and involvement.

Although a comparison between different treatment modali- ties is a topic beyond the scope of this paper, it is worth noting that in the late 1980s, some authors (Marmar et al., 1989a,b) failed to demonstrate significant differences between behavioral, cognitive, and brief psychodynamic therapies in the level of alliance as measured by CALPAS. However, subsequently, Raue et al. (1997), when comparing psychodynamic–interpersonal and cognitive–behavioral therapy sessions, found that observers rated the cognitive–behavioral group significantly higher on the WAI. This latter study compared 57 clients, diagnosed with major depression and receiving either psychodynamic–interpersonal or cognitive–behavioral therapy: the cognitive–behavioral sessions were rated as having better therapeutic alliances than the psy- chodynamic ones. They argue that these findings could reflect the effort in cognitive–behavioral therapy to give clients positive expe- riences and to emphasize positive coping strategies. A more recent comparison was suggested by Spinhoven et al. (2007), whose aim was to evaluate the therapeutic alliance in schema-focused therapy (Young et al., 2003; Nadort et al., 2009) and transference-focused psychotherapy (Yeomans et al., 2002). Results obtained by evalu- ating alliance through WAI-Client and WAI-therapist after 3, 15, and 33 months, showed clear alliance differences between treat- ments, suggesting that the quality of the alliance was affected by the nature of the treatment. Schema-focused therapy, with its emphasis on a nurturing and supportive attitude of thera- pist and the aim of developing mutual trust and positive regard, produced a better alliance according to the ratings of both thera- pists and patients. Ratings by therapists during early treatment, in particular, were predictive of dropout, whereas growth of the therapeutic alliance as experienced by patients during the first part of therapy, was seen to predict subsequent symptom reduction.

PHASES OF THE ALLIANCE DURING THE THERAPEUTIC PROCESS AND THE RELATIONSHIP WITH THE OUTCOME There is much debate on the role of the therapeutic alliance during the psychotherapeutic process. It may in fact be a simple effect of the temporal progression of the therapy rather than an important causal factor. On the basis of this hypothesis, we would expect a development in the alliance to be characterized by a linear growth pattern over the course of the therapy,and alliance ratings obtained in the early phases to be weaker predictors of outcome than those obtained toward the end of the therapy. However, according to the findings of numerous researchers, this is not the case. Safran et al. (1990) conclude that the positive outcome of therapy was more closely associated with the successful resolution of ruptures in the alliance than with a linear growth pattern as the therapy proceeds. Horvath and Marx (1991) describe the course of the alliance in successful therapies as a sequence of developments, breaches, and repairs. According to Horvath and Symonds (1991), the extent of the relationship between alliance and outcome was not a direct function of time: they find that measurements obtained during the earliest and most advanced counseling sessions were stronger

www.frontiersin.org October 2011 | Volume 2 | Article 270 | 7

Ardito and Rabellino Therapeutic alliance and psychotherapy outcome

predictors of outcome than those obtained during the middle phase of therapy.

The results of these studies have led researchers to consider the existence of two important phases in the alliance. The first phase coincides with the initial development of the alliance dur- ing the first five sessions of short-term therapy and peaks during the third session. During the first phase, adequate levels of collab- oration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of con- fidence in the procedures that constitute the framework of the therapy. In the second phase the therapist begins to challenge the patient’s dysfunctional thoughts, affects, and behavior patterns, with the intent of changing them. The patient may interpret the therapist’s more active intervention as a reduction in support and empathy, which may weaken or rupture the alliance. The deterio- ration in the relationship must be repaired if the therapy is to be successful.

This model implies that the alliance can be damaged at vari- ous times during the course of therapy and for different reasons. The effect on therapy differs, depending on when the difficulty arises. In the early phases, it may create problems in terms of the patient’s commitment to the process of therapy. In this case, the patient may prematurely terminate the therapy contract. In more advanced phases of therapy, an interruption in the alliance may be triggered by a number of therapeutic scenarios, including when patients’ thoughts and emotions have been invalidated in some way. Within a transference-focused psychotherapy framework, the patient’s expectations of the therapist may be unrealistic and ide- alized, which may therefore hinder their ability to use the therapy to deal with important issues. In situations such as this, the actual therapeutic alliance regularly and repetitively reflects the patient’s unresolved conflicts.

According to Safran and Segal (1990), many therapies are char- acterized 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 conflict- ual behavior patterns and the patient’s involvement rather than avoidance in responding to these challenges, are factors that con- tribute 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 strate- gies and the task of the therapist is to recognize and resolve these conflicts.

While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used sta- tic measures of alliance. There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: the first comprises those addressing transitional fluctuations in alliance levels, while the second con- sists of those concerned with the more global dynamics of the development of the alliance.

Few studies have analyzed alliance at different stages in the treatment process. Hartley and Strupp (1983) examined ratings obtained during the first session and then during sessions repre- senting 25, 50, 75, and 100% of the treatment, over the course of short-term therapies. Among patients who completed the therapy successfully, there was an increase in the alliance rating between the first session and the session representing the 25% mark, whereas among unsuccessful patients, the alliance rating declined over the same period. According to the results proposed by Tracey (1989), the more successful the outcome, the more curvilinear the pat- tern of client and therapist session satisfaction (high–low–high) over the course of treatment. When the outcome was worse, the curvilinear pattern was weaker.

Horvath et al. (1990) posit an initial phase in which the alliance was strong, followed by a period of decline, and a subsequent period of repair. Kivlighan and Shaughnessy (1995) use the hierar- chical linear modeling method (an analysis technique for studying the process of change in studies where measurements are repeated) to analyses the development of the alliance in a large number of cases. According to their findings, some dyads presented the high–low–high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment.

In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development. Kivlighan and Shaughnessy (2000) distinguish three patterns of therapeutic alliance development: stable alliance, lin- ear alliance growth, and quadratic or “U-shaped pattern” alliance growth. They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pat- tern, in that this appeared to be correlated with the best therapeutic outcomes.

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 thera- peutic bond, partnership, and confidence, disclosure, and patient initiative. Cluster analysis yielded four therapeutic alliance devel- opment patterns, two of which matched Kivlighan and Shaugh- nessy’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 res- olution 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 demon- stration of the hypothesis previously formulated by Safran and Muran (2000) and Samstag et al. (2004), where the alliance rup- tures represented opportunities for clients to learn about their

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problems relating to others, and repairs represented such oppor- tunities having been taken in the here-and-now of the therapeutic relationship.

The results of the study by De Roten et al. (2004) produced two patterns of alliance development (linear and stable), but no quadratic (U-shaped) or rapid rupture–repair (V-shaped) pat- terns emerged. The authors provided a possible explanation for these results by attributing them to the type of psychotherapy being investigated (the Brief Psychodynamic Investigation pro- posed by Gilliéron, 1989, which is a manual on a very brief psychotherapeutic four-session intervention) and the type of sam- ple (psychiatric patients). Moreover, a new rating scale, the HAq, had replaced those that were used previously (WAI and ARM). According to De Roten et al. (2004), these results were in line with Horvath’s view of the alliance as a constructive process, rather than with the views of Gelso and Carter (1994) and Safran and Muran (1996) concerning the rupture and repair of alliances, in which change was a better predictor of stability outcomes. De Roten et al. (2004) suggest that a process characterized by ruptures and repairs was more likely to occur in long-term psy- chodynamic treatment, particularly during phases of in-depth work.

According to Castonguay et al. (2006), patterns of therapeu- tic alliance development require further investigation, in order to understand how and whether the various patterns are a cause, effect, or manifestation of improvement. This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon.

DISCUSSION AND CONCLUSION According to their meta-analysis based on the results of 24 studies, Horvath and Symonds (1991) demonstrate the existence of a mod- erate but reliable association between good therapeutic alliance and positive therapeutic outcome. More recent meta-analyses of studies examining the linkage between alliance and outcomes in both adult and youth psychotherapy (Martin et al., 2000; Shirk and Karver, 2003; Karver et al., 2006) have confirmed these results and also indicated that the quality of the alliance was more pre- dictive of positive outcome than the type of intervention (but for slightly different results in youth psychotherapy see McLeod, 2011).

Some theorists have defined the quality of the alliance as the “quintessential integrative variable” of a therapy (Wolfe and Gold- fried, 1988), and in the present state, it seems possible to affirm that the quality of the client–therapist alliance is a consistent predictor of positive clinical outcome independent of the variety of psy- chotherapy approaches and outcome measures (Horvath and Bedi, 2002; Norcross, 2002). Thus, it is not by chance that in their meta- analysis, Horvath and Luborsky (1993) conclude that two main aspects of the alliance were measured by several scales regardless of the theoretical frameworks and the therapeutic models: personal attachments between therapist and patient, and collaboration and desire to invest in the therapeutic process.

In our opinion, regarding the relationship between the thera- peutic 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 psychother- apy (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 “the- oretical 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 investigat- ing 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 increas- ing 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.

From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. The development of a dynamic vision of the concept of therapeutic alliance is also apparent. The work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in 1956. Research aimed at analyzing the components that make up the alliance continues to flour- ish and develop. Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: from that of the patient, therapist, and observer. Attention has recently turned toward the role of the therapeutic alliance in the vari- ous phases of therapy and the relationship between alliance and outcome.

So far, few studies have regarded long-term psychotherapy involving many counseling sessions. This topic, along with a more detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the sub- ject of future research projects. Equally important, in our opinion, will be the findings of studies regarding drop-out and therapeutic alliance ruptures, which must necessarily consider the differences between that perceived by the patient and that perceived by the therapist.

ACKNOWLEDGMENTS The authors thank Mauro Adenzato for his valuable comments and suggestions to an earlier version of this article. This work was supported by University of Turin (Ricerca scientifica finanziata dall’Università).

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Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Received: 29 June 2011; accepted: 28 Sep- tember 2011; published online: 18 Octo- ber 2011. Citation: Ardito RB and Rabellino D (2011) Therapeutic alliance and out- come of psychotherapy: historical excur- sus, measurements, and prospects for research. Front. Psychology 2:270. doi: 10.3389/fpsyg.2011.00270 This article was submitted to Frontiers in Psychology for Clinical Settings, a specialty of Frontiers in Psychology. Copyright © 2011 Ardito and Rabellino. This is an open-access article subject to a non-exclusive license between the authors and Frontiers Media SA, which permits use, distribution and reproduc- tion in other forums, provided the original authors and source are credited and other Frontiers conditions are complied with.

www.frontiersin.org October 2011 | Volume 2 | Article 270 | 11

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