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relaçao terapeutica, Horvath

relaçao terapeutica, Horvath

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ORIGINAL ARTICLES
The therapeutic relationship: Research and theory
An introduction to the Special Issue
ADAM O. HORVATH
Simon Fraser University, Burnaby, Canada
(Received 16 November 2004; revised 7 December 2004; accepted 8 December 2004)
Abstract
The place of the therapeutic relationship in psychotherapy research is presented in a historical framework, followed by abrief review of the major research themes within this topic and a review of what is covered in this special section. Some of thestrengths of this body of work, as well as the potential challenges arising out of the re-emergence of the alliance as a pan-theoretical concept capturing the relational dynamics of therapy, are discussed. Recommendations for renewing theempirical
 Á 
/
conceptual dialogue on what constitutes the therapeutic relationship in different therapeutic contexts anddifferent phases of therapy are provided.
Keywords:
Therapeutic relationship, alliance, therapy process research
Research on the relationship in therapy
The dedication of a special issue of 
PsychotherapyResearch
to the topic of the therapeutic relationshipmarksasignificantmilepostinthehistoryofempiricalresearch on psychotherapy process. The editors’decisionto devotethis extended format tothe topic issymbolicofagrowingrecognitionofthematurityandvalueofthisbodyofwork.Thispresentsanimportantopportunitytoshowcaseanewgenerationofscientificinquiries highlighting some of the issues challengingthoseofuswhodesiretomovetheempiricalinvestiga-tionoftherelationalaspectofpsychotherapyforward.As a framework for this overview of the currentrelationship research agenda, thehistorical context of thisbodyofresearchwillbebrieflyreviewed,followedby a summary of the empirical investigations of thealliance in psychotherapy in the past three decades,andmorespecificallyinthisspecialsection.Finally,thechallengeslyingaheadarediscussed.
Historical context
The relationship between therapist and client hashistorically occupied a prominent role in the theoriesof therapeutic process. In a brief paper, Freud laidthe foundation of what would be later elaborated asthe concept of the alliance by noting the importanceof the development of ‘‘the [patient]
. . .
attach[ing]himself 
. . .
to the doctor
. . .
and link [him] withimages of people by whom he was accustomed tobe treated with affections’(Freud, 1913). WhileFreud’s insights have done much to enable thesystematic investigation of mental processes, by thebeginning of the nineteenth century it becameapparent that if psychotherapy was to become a‘‘scientifically based profession’’, it needed a theorythat could generate robust, refutable, hypotheses.The challenge of developing an empirically testa-ble model of human change was first taken up by thebehaviorists (Skinner, 1974). The advantages andopportunities offered by a model based on observa-ble behaviors were significant. However, excludingall phenomena beyond that which could be observedand verified at the time meant that not only thetherapy relationship, but cognitive processes as wellwere moved beyond the domain of empirical re-search. By the middle of the twentieth century,technological innovations made it possible and
Correspondence: Adam O. Horvath, Counselling Psychology Program, Simon Fraser University, 8888 University Way, Burnaby, BC,V5A 1S6. E-mail: horvath@sfu.ca
Psychotherapy Research
, January 2005; 15(1
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2): 3
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/
7
ISSN 1050-3307 print/ISSN 1468-4381 online
#
2005 Society for Psychotherapy ResearchDOI: 10.1080/10503300512331339143
 
practical to produce live recordings of therapysessions opening the way to empirically reliableexploration of the process of psychotherapy. Thisnew technology, and Rogers’ interest in the relation-ship, broadened the horizon of psychotherapy re-search. The therapeutic relationship became onceagain the focus of attention of some researchers.While much of the post-war research focused onfinding specific ingredients responsible for positivetherapeutic gains, advances in research synthesis(Luborsky, Singer, & Luborsky, 1975; Smith &Glass, 1977) yielded compelling empirical evidencethat an element or elements common to the broadcross section of therapeutic practices are responsiblefor a large portion of healing effects. This findingrenewed interest in role of the relationship betweentherapist and client. An essential component in thesubsequent momentum behind research on thetherapeutic relationship was the theoretical work of Luborsky (1976) and Bordin (1976, 1980, 1994).Their elaboration and extension of Greenson (1965)and Zetzels (1956) work on the psychodynamicconcept of the therapeutic and working allianceresulted in a pan-theoretical formulation of therelational component of therapy.Between 1975 and 1986 there were a number of measures developed to quantify the quality of thealliance in helping relationships. While the instru-ment development and refinement projects openedthe way to investigate this concept, there remained asignificant residual ambiguity about the theoretical/conceptual definition of the alliance (Hentschel,2004; Horvath & Greenberg, 1989; Horvath &Luborsky, 1993).
Research accomplishments
It is useful to reflect on the growing volume of research on the alliance as representing two some-what chronologically and topically overlappingphases: initially much of the investigators’ energyfocused on exploring the relation between thealliance and therapy outcome across various helpingcontexts. The variety of contexts explored in thisphase included different types of treatments, diversepopulations and diagnostic categories, gender ef-fects, as well as some therapist factors such as levelsof therapist training and experience. Another area of interest from the beginning was the relation betweenoutcome and alliance assessed from different per-spectives (i.e., client, therapist, and observer) as wellas the magnitude of the alliance/outcome relation atdifferent phases of therapy (see Horvath & Bedi,2002; Horvath & Symonds, 1991; Martin, Garske,& Davis, 2000). At a risk of ignoring complexity, areasonable summary is that the relationships re-ported across reviews have been quite consistent: thealliance-outcome correlation is moderate but signifi-cant (ranges from .22 to .29), client’s assessmentstend to be more predictive of outcome than are othersources, early alliance is as good or better predictorof outcome than assessments taken later, and thealliance as measured appears to be related but notidentical to parallel therapeutic gains.Somewhat overlapping in terms of chronology butdistinct in thematic interests is the second phase of alliance research; these investigations place lessemphasis on the outcome/alliance relation, as such,and focus more on the role, development, andmanagement of the alliance in therapy itself. Forexample, researchers have examined Bordin’s (1980)propositions about fluctuations (‘‘tears and repairs’’)in the alliance as core opportunities for therapeuticgain (e.g., Safran & Muran, 2000), differences acrossclients in terms of the kind of relation they desirewith their therapist (e.g., Batchelor, 1988), exam-ination of therapist qualities and behaviors that areassociated with client perceptions of good alliance(e.g., Henry & Stupp, 1994; Hilsenroth, Ackerman,Clemence, Strassle, & Handler, 2002).
Challenges ahead
Giventherichness andaccomplishmentofthislineof research, what are the challenges we might antici-pate? Firstly, we need more theoretical debate aboutthe construct of the relationship. The relatively brief period between the initial theoretical/conceptualformulation and the development of measuringprocedures that in practice defined the construct forresearch that followed likely foreclosed the opportu-nity to examine the implications and possible limita-tions of the concept as first presented by Luborsky(1976) and Bordin (1979). Moreover, moving theconcept from its original psychodynamic context andframing it as a pan-theoretical variable isolated thealliance from a broad theoretical framework of therapy and change. Bordin (1994) began the workof exploring how aspects of the alliance mightarticulate with other aspects of therapy, but thesefirst steps were not taken up by others, and a numberof important unresolved issues remain. Most ob-viously, the question whether the alliance is in itself acurative component of therapy, or whether therelationship creates the interpersonal context neces-sary for other therapeutic elements to come to bearon the client’s problems. In addition the dynamicevolution of the therapeutic relationship over timeend perhaps its unique unfolding within particulardiagnostic context needs to be investigated.Second, the field needs to struggle with thequestion of how therapists can be trained to develop4
A. O. Horvath
 
better alliances with their clients. Initial efforts totrain therapists resulted in paradoxical effect. Henryand colleagues, (1993) reported the results of whatappeared to be an excellent training program; but itfailed to improve the quality of alliance in therapy. Ina recent review of research on training therapists todevelop strong alliances, Horvath (2004) reportedthat less than half of the projects surveyed obtained apositive relationship between alliance training andthe quality of the alliance assessed by the client or anindependent rater. The review also indicated thatinvestigators were more consistent in identifyingtherapist
attributes
(such as flexibility, interest, andwarmth) than therapists
activities
associated withpositive or improving alliances. It was also noted thatall of the successful training projects involvedindividual supervision of trainees, most often withina structured format (of both supervision and treat-ment), and these successful training programs eachmade use of the therapist current problematicrelationship with their clients. These findings appearto suggest that it is important to more clearly identifythe interactive elements between therapist and clientrelated to the alliance, and we need to find methodsto identify and manage therapists’ problematic reac-tions to clients in order to improve their relationaleffectiveness (Henry & Strupp, 1994; Safran &Muran, 2000).Third, we need to examine changes in the qualityof the alliance over time. The majority of theavailable research is based on the assumption thata positive alliance has the same quality over thelength of treatment. Progressive enrichment andcomplexity is a characteristic of all intimate relation-ship over time, so why should we assume that this isnot the case in therapy? The qualities of agreementor consensus on bonds and tasks, the formation of acaring and trusting relationship, and even emergenceof a collaborative stance, are likely reasonably uni-form requirements typical of the beginning phase of most therapies. It is also reasonable to assume thatthese issues retain some relevance in later phases.But as the relationship evolves and becomes morecomplex and as therapy evolves and the clientexposes more sensitive material, the processes likeagreement on tasks and goals become increasinglyembedded in the therapy routine itself. It has beensuggested (Horvath, 2003) that qualities such asmutual reflexivity and the permission to criticallyand mindfully engage in a discourse about theimmediate here and now relational pattern in thetherapy room may be more appropriate in discrimi-nating the mature phase of the therapeutic alliance.The lack of success in identifying what Bordin(1980) predicted as ‘‘different [patterns of] alliancescorresponding to different kinds of treatments’’ maybe due to such ‘homogeneity myth’. A moredetailed and discriminating examination of clients’experience of the therapeutic relationship in laterphases of the work, especially within medium andlonger term treatments might reveal distinctionsuseful in clinical practice, research, and training.Fourth, we need to examine the similarity anddistinctiveness of the alliance concept compared toother relationship variables. A recent ‘‘state of theart’’ summary of empirical evidence on the efficacyof therapistscontribution to the therapeutic rela-tionship (Norcross, 2002) identified 11 relationshipfactors as potential contributors to therapy efficacy:Alliance, Cohesion, Empathy, Goal Consensus andCollaboration, Positive Regard, Congruence, Feed-back, Repair of Alliance Ruptures, Self Disclosure,Counter Transference (management of), and Rela-tional Interpretation. The significant overlap evidentamong these ‘elements’’, and the lack of a con-ceptual model knitting these elements into a cohesiveframework, suggests that there is a need to makesome clarifications and distinctions.The time is approaching to renew vigorous dialo-gue to clarify what we mean by the concepts listedabove. What do these notions share, and what usefuldistinctions may be made between them?
Conclusions
The larger context of the research on the therapeuticrelationship is the overarching goal of understandinghow therapy works, and of using what we glean tofrom a clearer understanding of the psychotherapyprocess leading to better practice. The more weunderstand how clients absorb, store, and retrievefeatures of the relationship with their therapist anduse it to re-imagine their situation and expand theoptions they have available, and the better weunderstand how the therapist can create opportu-nities to enhance this process, the more we fill theblanks in the puzzle of human change and growthprocess.As several papers in this volume illustrate, researchon the relationship can lead us to better identifypatterns that locate specific micro processes whichcan fill important gaps in our understanding of howtherapy works. Examples of investigations reportedin this section with theory building potential includepapers on how clients interpret therapist’s behaviors(Benecke et al., 2004; Caspar et al., 2004), cognitiveprocess that play a formative and maintenance rolein forming a positive relationship with the therapist(Casey et al., 2004; Rumpold et al., 2004; Sexton etal., 2004), as well as the identification of clinicallyimportant treatment challenges specific to person-ality and diagnostic features (Lingiardi et al., 2004).
Relationship research and theory
5

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