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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 a brief review of the major research themes within this topic and a review of what is covered in this special section. Some of the strengths of this body of work, as well as the potential challenges arising out of the re-emergence of the alliance as a pantheoretical concept capturing the relational dynamics of therapy, are discussed. Recommendations for renewing the empirical Á/conceptual dialogue on what constitutes the therapeutic relationship in different therapeutic contexts and different 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 Psychotherapy Research to the topic of the therapeutic relationship marks a significant milepost in the history of empirical research on psychotherapy process. The editors’ decision to devote this extended format to the topic is symbolic of a growing recognition of the maturity and value of this body of work. This presents an important opportunity to showcase a new generation of scientific inquiries highlighting some of the issues challenging those of us who desire to move the empirical investigation of the relational aspect of psychotherapy forward. As a framework for this overview of the current relationship research agenda, the historical context of this body of research will be briefly reviewed, followed by a summary of the empirical investigations of the alliance in psychotherapy in the past three decades, and more specifically in this special section. Finally, the challenges lying ahead are discussed. Historical context The relationship between therapist and client has historically occupied a prominent role in the theories
of therapeutic process. In a brief paper, Freud laid the foundation of what would be later elaborated as the concept of the alliance by noting the importance of the development of ‘‘the [patient] . . . attach[ing] himself . . . to the doctor . . . and link [him] with images of people by whom he was accustomed to be treated with affections’’ (Freud, 1913). While Freud’s insights have done much to enable the systematic investigation of mental processes, by the beginning of the nineteenth century it became apparent that if psychotherapy was to become a ‘‘scientifically based profession’’, it needed a theory that could generate robust, refutable, hypotheses. The challenge of developing an empirically testable model of human change was first taken up by the behaviorists (Skinner, 1974). The advantages and opportunities offered by a model based on observable behaviors were significant. However, excluding all phenomena beyond that which could be observed and verified at the time meant that not only the therapy relationship, but cognitive processes as well were moved beyond the domain of empirical research. 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: firstname.lastname@example.org ISSN 1050-3307 print/ISSN 1468-4381 online # 2005 Society for Psychotherapy Research DOI: 10.1080/10503300512331339143
A. O. Horvath ported across reviews have been quite consistent: the alliance-outcome correlation is moderate but significant (ranges from .22 to .29), client’s assessments tend to be more predictive of outcome than are other sources, early alliance is as good or better predictor of outcome than assessments taken later, and the alliance as measured appears to be related but not identical to parallel therapeutic gains. Somewhat overlapping in terms of chronology but distinct in thematic interests is the second phase of alliance research; these investigations place less emphasis on the outcome/alliance relation, as such, and focus more on the role, development, and management of the alliance in therapy itself. For example, researchers have examined Bordin’s (1980) propositions about fluctuations (‘‘tears and repairs’’) in the alliance as core opportunities for therapeutic gain (e.g., Safran & Muran, 2000), differences across clients in terms of the kind of relation they desire with their therapist (e.g., Batchelor, 1988), examination of therapist qualities and behaviors that are associated with client perceptions of good alliance (e.g., Henry & Stupp, 1994; Hilsenroth, Ackerman, Clemence, Strassle, & Handler, 2002). Challenges ahead Given the richness and accomplishment of this line of research, what are the challenges we might anticipate? Firstly, we need more theoretical debate about the construct of the relationship. The relatively brief period between the initial theoretical/conceptual formulation and the development of measuring procedures that in practice defined the construct for research that followed likely foreclosed the opportunity to examine the implications and possible limitations of the concept as first presented by Luborsky (1976) and Bordin (1979). Moreover, moving the concept from its original psychodynamic context and framing it as a pan-theoretical variable isolated the alliance from a broad theoretical framework of therapy and change. Bordin (1994) began the work of exploring how aspects of the alliance might articulate with other aspects of therapy, but these first steps were not taken up by others, and a number of important unresolved issues remain. Most obviously, the question whether the alliance is in itself a curative component of therapy, or whether the relationship creates the interpersonal context necessary for other therapeutic elements to come to bear on the client’s problems. In addition the dynamic evolution of the therapeutic relationship over time end perhaps its unique unfolding within particular diagnostic context needs to be investigated. Second, the field needs to struggle with the question of how therapists can be trained to develop
practical to produce live recordings of therapy sessions opening the way to empirically reliable exploration of the process of psychotherapy. This new technology, and Rogers’ interest in the relationship, broadened the horizon of psychotherapy research. The therapeutic relationship became once again the focus of attention of some researchers. While much of the post-war research focused on finding specific ingredients responsible for positive therapeutic gains, advances in research synthesis (Luborsky, Singer, & Luborsky, 1975; Smith & Glass, 1977) yielded compelling empirical evidence that an element or elements common to the broad cross section of therapeutic practices are responsible for a large portion of healing effects. This finding renewed interest in role of the relationship between therapist and client. An essential component in the subsequent momentum behind research on the therapeutic relationship was the theoretical work of Luborsky (1976) and Bordin (1976, 1980, 1994). Their elaboration and extension of Greenson (1965) and Zetzel’s (1956) work on the psychodynamic concept of the therapeutic and working alliance resulted in a pan-theoretical formulation of the relational component of therapy. Between 1975 and 1986 there were a number of measures developed to quantify the quality of the alliance in helping relationships. While the instrument development and refinement projects opened the way to investigate this concept, there remained a significant 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 somewhat chronologically and topically overlapping phases: initially much of the investigators’ energy focused on exploring the relation between the alliance and therapy outcome across various helping contexts. The variety of contexts explored in this phase included different types of treatments, diverse populations and diagnostic categories, gender effects, as well as some therapist factors such as levels of therapist training and experience. Another area of interest from the beginning was the relation between outcome and alliance assessed from different perspectives (i.e., client, therapist, and observer) as well as the magnitude of the alliance/outcome relation at different phases of therapy (see Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). At a risk of ignoring complexity, a reasonable summary is that the relationships re-
Relationship research and theory better alliances with their clients. Initial efforts to train therapists resulted in paradoxical effect. Henry and colleagues, (1993) reported the results of what appeared to be an excellent training program; but it failed to improve the quality of alliance in therapy. In a recent review of research on training therapists to develop strong alliances, Horvath (2004) reported that less than half of the projects surveyed obtained a positive relationship between alliance training and the quality of the alliance assessed by the client or an independent rater. The review also indicated that investigators were more consistent in identifying therapist attributes (such as flexibility, interest, and warmth) than therapists activities associated with positive or improving alliances. It was also noted that all of the successful training projects involved individual supervision of trainees, most often within a structured format (of both supervision and treatment), and these successful training programs each made use of the therapist current problematic relationship with their clients. These findings appear to suggest that it is important to more clearly identify the interactive elements between therapist and client related to the alliance, and we need to find methods to identify and manage therapists’ problematic reactions to clients in order to improve their relational effectiveness (Henry & Strupp, 1994; Safran & Muran, 2000). Third, we need to examine changes in the quality of the alliance over time. The majority of the available research is based on the assumption that a positive alliance has the same quality over the length of treatment. Progressive enrichment and complexity is a characteristic of all intimate relationship over time, so why should we assume that this is not the case in therapy? The qualities of agreement or consensus on bonds and tasks, the formation of a caring and trusting relationship, and even emergence of a collaborative stance, are likely reasonably uniform requirements typical of the beginning phase of most therapies. It is also reasonable to assume that these issues retain some relevance in later phases. But as the relationship evolves and becomes more complex and as therapy evolves and the client exposes more sensitive material, the processes like agreement on tasks and goals become increasingly embedded in the therapy routine itself. It has been suggested (Horvath, 2003) that qualities such as mutual reflexivity and the permission to critically and mindfully engage in a discourse about the immediate here and now relational pattern in the therapy room may be more appropriate in discriminating the mature phase of the therapeutic alliance. The lack of success in identifying what Bordin (1980) predicted as ‘‘different [patterns of] alliances corresponding to different kinds of treatments’’ may
be due to such ‘‘homogeneity myth’’. A more detailed and discriminating examination of clients’ experience of the therapeutic relationship in later phases of the work, especially within medium and longer term treatments might reveal distinctions useful in clinical practice, research, and training. Fourth, we need to examine the similarity and distinctiveness of the alliance concept compared to other relationship variables. A recent ‘‘state of the art’’ summary of empirical evidence on the efficacy of therapists’ contribution to the therapeutic relationship (Norcross, 2002) identified 11 relationship factors as potential contributors to therapy efficacy: Alliance, Cohesion, Empathy, Goal Consensus and Collaboration, Positive Regard, Congruence, Feedback, Repair of Alliance Ruptures, Self Disclosure, Counter Transference (management of), and Relational Interpretation. The significant overlap evident among these ‘‘elements’’, and the lack of a conceptual model knitting these elements into a cohesive framework, suggests that there is a need to make some clarifications and distinctions. The time is approaching to renew vigorous dialogue to clarify what we mean by the concepts listed above. What do these notions share, and what useful distinctions may be made between them? Conclusions The larger context of the research on the therapeutic relationship is the overarching goal of understanding how therapy works, and of using what we glean to from a clearer understanding of the psychotherapy process leading to better practice. The more we understand how clients absorb, store, and retrieve features of the relationship with their therapist and use it to re-imagine their situation and expand the options they have available, and the better we understand how the therapist can create opportunities to enhance this process, the more we fill the blanks in the puzzle of human change and growth process. As several papers in this volume illustrate, research on the relationship can lead us to better identify patterns that locate specific micro processes which can fill important gaps in our understanding of how therapy works. Examples of investigations reported in this section with theory building potential include papers on how clients interpret therapist’s behaviors (Benecke et al., 2004; Caspar et al., 2004), cognitive process that play a formative and maintenance role in forming a positive relationship with the therapist (Casey et al., 2004; Rumpold et al., 2004; Sexton et al., 2004), as well as the identification of clinically important treatment challenges specific to personality and diagnostic features (Lingiardi et al., 2004).
A. O. Horvath
Horvath, A. O. (2003). Phases of therapy, phases of alliance . Paper presented at the Annual Conference of Psychiatrists and Psychotherapists, Renaca, Chile. ˜ Horvath, A. O. (August, 2004). What the Dodo bird forgot to tell you about common factors . . . . Paper presented at the annual meeting of the American Psychological Association , Honolulu, Hawaii. Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions responsiveness to patients . New York: Oxford University Press. Horvath, A. O., & Greenberg, L. S. (1989). The development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36 , 223 Á/233. Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61 , 561 Á/573. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A metaanalysis. Journal of Counseling Psychology, 38 , 139 Á/149. Lingiardi, V., Fillippucci, L., & Baicco, R. (2004). Therapeutic alliance evaluation in personality disorders psychotherapy. Psychotherapy Process , 15 , 45 Á/53. Luborsky, L. (1976). Helping alliances in psychotherapy. In J. L. Cleghhorn (Ed.), Successful psychotherapy (pp. 92 Á/116). New York: Brunner/Mazel. Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies: ‘‘Is it true that everybody has won and all must have prizes’’? Archives of General Psychiatry, 32 , 995 Á/1008. Martin, D. J., Garske, J. P., & Davis, K. M. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta analytic review. Journal of Consulting and Clinical Psychology, 68 (3), 438 Á/450. Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions responsiveness to patients . New York, NY: Oxford University Press. Rumpold, G., Doering, S., Smrekar, U., Schubert, C., Koza, R., Schatz, D. S., et al. (2004). Changes in motivation and the therapeutic alliance during a pretherapy diagnostic and motivation-enhancing phase among psychotherapy outpatients. Psychotherapy Process , 15 , 117 Á/127. Safran, J. D., & Muran, C. (2000). Negotiating the therapeutic alliance: A relational treatment guide . New York: Guilford. Sexton, H., Littauer, H., Sexton, A., & Tommeras, E. (2004). Building an alliance: Early process and client Á/therapist connection. Psychotherapy Research , 15 , 103 Á/116. Skinner, B. F. (1974). About behaviorism . New York: Knopf. Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist , 32 , 752 Á/ 760. Zetzel, E. R. (1956). Current concepts of transference. International Journal of Psychoanalysis , 37 , 369 Á/376.
It is hoped that the body of research that has accumulated over the last three decades will serve as a platform for a renewed dialogue resulting in a clarification of the concept of the alliance as a dynamic, situated entity with both generic and specific elements. Perhaps, as the conceptual/empirical dialogue progresses, we will be able to rise above the current dichotomy of relational versus technical elements in therapy and come to understand both the relationship and the intervention as mutually co-determined. Such re-visioning of the substantive elements of therapy, if warranted, would offer a new perspective on possible research agendas.
Batchelor, A. (1988). How clients perceive therapist empathy: A content analysis of ‘‘received’’ empathy. Psychotherapy: Theory/ Research/Practice/Training , 25 , 227 Á/240. Benecke, C., Peham, D., & Banninger-Huber, E. (2004). Nonverbal relationship regulation in psychotherapy. Psychotherapy Research , 15 , 81 Á/90. Bordin, E. S. (1976). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory/Research/ Practice/Training , 16 , 252 Á/260. Bordin, E. S. (1980, June). Of human bonds that bind or free . Paper presented at the Society for Psychotherapy Research, Paciﬁc Grove, CA. Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice . New York: Wiley. Casey, L., Oei, T. P. S., & Newcombe, P. A. (2004). Looking beyond the negatives: A time period analysis of positive cognitions, negative cognitions, and working alliance in CBT for panic disorder. Psychotherapy Research , 15 , 55 Á/68. Caspar, F., Grossmann, C., Unmussig, C., & Schramm, E. (2004). Complimentary therapeutic relationship: Therapist behavior, interpersonal patterns, and therapeutic effects. Psychotherapy Research , 15 , 91 Á/102. Freud, S. (1913). On the beginning of treatment: Further recommendations on the technique of psychoanalysis. In J. Strachey (Ed.), Standard edition of the complete psychological works of Sigmund Freud (Original work published 1913, Vol. 12, pp. 122 Á/144). London: Hogarth Press. Greenson, R. R. (1965). The working alliance and the transference neuroses. Psychoanalysis Quarterly, 34 , 155 Á/181. Henry W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., & Binder, J. L. (1993). The effects of training in time-limited dynamic psychotherapy: Mediators of therapist’s response to training. Journal of Clinical and Consulting Psychology, 61 (3), 441 Á/447. 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 . New York: Wiley. Hilsenroth, M. J., Ackerman, S. J., Clemence, A. J., Strassle, C. G., & Handler, L. (2002). Effects of structured clinician training on patient and therapist perspectives of alliance early in psychotherapy. Psychotherapy: Theory/Research/Practice/Training , 39 (4), 309 Á/323.
Zusammenfassung Therapeutische Beziehung: Forschung und Theorie Die therapeutische Beziehung wird in einem historischen Rahmen behandelt, gefolgt durch eine Kurzubersicht der ¨ wichtigsten Forschungsthemen in diesem Bereich und eine ¨ Ubersicht zu den Themen dieses Doppelheftes. Einige starke Punkte dieser Arbeiten werden diskutiert, ebenso wie die moglichen Herausforderungen einer wiederer¨ wachten Auffassung von Allianz als pantheoretischem
Relationship research and theory
Konzept zur Erfassung der Beziehungsdynamik in der Therapie. Es werden Empfehlungen gegeben zu einer Erneuerung des Empirie-Theoriedialoges, zu dem, was therapeutische Beziehung in verschiedenen therapeutischen Kontexten und verschiedenen Therapiephasen ausmacht. Resumo ˆ A relacao terapeutica: Investigacao e teoria ¸˜ ¸˜
´ ´ Resume ´ ´ La relation therapeutique: recherche et theorie La place de la relation therapeutique dans la recherche ´ en psychotherapie est presentee dans un cadre historique ´ ´ ´ suivi d’une breve revue des themes majeurs de la recherche ` ` dans ce domaine et d’un resume de ce qui sera traite dans ´ ´ ´ cette section speciale. Il sera question des forces de ce ´ corpus de travail ainsi que des defis potentiels emanant ´ ´ de la reemergence de l’alliance comme un concept ´´ pan-theorique saisissant la dynamique relationnelle de ´ la therapie. Des recommandations sont fournies pour ´ un renouveau du dialogue empirique et conceptuel sur ce qui constitue la relation therapeutique dans des ´ contextes therapeutiques varies et des phases de therapie ´ ´ ´ differentes. ´
´ E apresentado o lugar da relacao terapeutica na investigaˆ ¸˜ cao em psicoterapia num perspectiva historica, seguido de ´ ¸˜ uma revisao breve dos principais temas de investigacao ˜ ¸˜ ligados ao topico e uma revisao daquilo que e abordado ´ ´ ˜ nesta seccao especial. Sao discutidos alguns dos pontos ˜ ¸˜ fortes deste corpo de trabalho, bem como os potenciais desafios que resultam da re-emergencia da alianca como ˆ ¸ conceito panteorico que capta a natureza relacional da ´ terapia. Sao fornecidas recomendacoes para a renovacao ˜ ¸˜ ¸˜ do dialogo conceptual em que consiste a relacao terapeu´ ˆ ¸˜ tica em diferentes contextos terapeuticos e diferentes fases ˆ da terapia.
Sommario La relazione terapeutica: ricerca e teoria Attraverso un excursus storico viene presentato il ruolo della relazione terapeutica nella ricerca in psicoterapia; segue una breve revisione dei temi principali di ricerca all’interno di quest’ambito e degli argomenti trattati in questa sezione speciale. Sono discussi i punti di forza di questo lavoro come pure le potenziali sfide nate dal riemergere dell’alleanza come concetto panteoretico che cattura le dinamiche relazionali in terapia. Vengono fornite indicazioni per rinnovare il dibattito empirico/concettuale su che cosa costituisce la relazione terapeutica nei differenti contesti terapeutici e nelle differenti fasi della terapia.
Resumen ´ ´ ´ ´ La relacion terapeutica. Investigacion y teorıa Se presenta un marco historico para ubicar el lugar de la ´ relacion terapeutica en la investigacion en psicoterapia, ´ ´ ´ seguido de una breve revista de los temas principales de investigacion dentro de este topico y de una revision de lo ´ ´ ´ que se aborda en esta seccion especial. Se debate sobre ´ algunos de los puntos fuertes de estos estudios, a la par que se senala el desafıo potencial que surge de la reemergencia ´ ˜ de la alianza como concepto pan-teorico que rige la ´ relacion dinamica de la terapia. Se dan recomendaciones ´ ´ para renovar el dialogo empırico-conceptual en lo referente ´ ´ a la relacion terapeutica en diferentes fases y contextos ´ ´ terapeuticos de la terapia. ´
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