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Psychotherapy Research
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The therapeutic alliance: An evidence-based guide to

practice
a
Michael J. Lambert
a
Department of Psychology, Brigham Young University Provo, UT, USA
Published online: 16 Apr 2015.

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To cite this article: Michael J. Lambert (2015): The therapeutic alliance: An evidence-based guide to practice,
Psychotherapy Research, DOI: 10.1080/10503307.2015.1031200

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 Psychotherapy Research, 2015
BOOK REVIEW
The therapeutic alliance: An evidence-based
guide to practice, edited by J. Christopher Muran
and Jacques P. Barber, New York, NY, Guilford
Press, 2010, 368 pp., $41.65 (hardback), ISBN
9781606238738
Change in psychotherapy can be partially under-
stood to be a function of the degree to which the
therapist is able to provide a positive bond and
collaborate with a client on the goals and processes
of treatment, commonly referred to as the thera-
peutic alliance (TA). The TA is arguably the most
important common factor influencing patient out-
come, and thus a comprehensive summary of its
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contribution is a must read. Muran and Barber
(Chapter 1) provide the context and history of the
alliance concept and its evidence base, noting that
TA has an empirical history dating back at least
40 years with much of this research demonstrating
its predictive validity for treatment outcomes.
The editors assembled a panel of experts who have
an established record of scholarship that includes
theoretical work as well as empirical exploration.
Chapters are organized into three sections: expoun-
ding on: (1) critical studies (e.g., measurement,
prediction, change over time); (2) implications for
routine practice (e.g., negative experiences, repair
of alliance ruptures, important chapters from
psychodynamic, interpersonal, cognitive/behavioral,
and perspectives from modalities such as family,
group, and couple therapy); and (3) the development
of training programs and their effects.
The authors and editors consistently note that of
all the variables that have been correlated with
treatment outcome the alliance remains the most
consistent and strongest predictor. They also suggest
that providing evidence-based practice to those who
have psychological disorders cannot be done in the
absence of a strong alliance and that the field of
mental health cannot afford to overlook the TA or
assume that maximizing its contribution can be done
in the absence of considerable attention and devo-
tion in training programs and routine care.
Chapters in this volume summarize basic quantit-
ative and qualitative findings documenting the con-
tribution of both the client and therapist to the TA,
showing that it is diminished when clients have low
expectations for therapy, histories of negative inter-
personal relationships, hostile affiliative styles, insec-
ure attachment, and the like. Among the more
important therapist contributions chapters suggest
the importance of solid technical ability, flexibility,
and ability to regulate negative emotions. In addition,
they note the importance of being sensitive to inter-
personal processes, and delivering therapy character-
ized by low levels of critical and demanding style as
well as avoiding tendencies to over or understructure
therapy.
Sage wisdom is provided in many chapters for
recognizing these problem alliances. For example,
Tsai, Kohlenberg, and Kanter (Chapter 9) suggest
that clinicians practicing functional analytic psycho-
therapy ask themselves a series of questions about the
patient’s clinically relevant behavior. Since the treat-
ment is a here and now approach with a strong
relationship focus that analyzes the way in which
everyday relationship problems are manifest with the
therapist, they suggest the therapist ask themselves:
Does the client frustrate you because he procrasti-
nates doing his homework assignment? Does your
attention wander because you experience him as
droning on and on? Does she say one thing and do
another? Does she seem to have no interest or
curiosity about you as a person? The answers to
these questions help the therapist be more attuned to
the relationship and open a door for improving it.
Using oneself as a barometer of how others might
react to the client requires a therapist to constantly
engage in their own personal work to recognize and
deal with their own deficits, a tall task, but one that is
typically engaged in within some schools of therapy,
and one that places the alliance at the center of the
healing process.
Readers will be pleased with the various chapters
on training, some of which approach manuals in
their precision. But here the authors are stronger in
proposing training methods than in routine care
applications. In this author’s opinion, training out-
comes eventually rely too much on therapist intu-
ition and reflection. Outside of training programs
where trainees see few cases and supervision is
readily available and intense, routine care is char-
acterized by practices in which therapists see many
cases, and work without supervision. More formal
methods are needed to recognize problem alliances.
It is possible to use assessment information on the
TA to improve outcomes in routine care. Such
methods make use of the quantitative and qualitative
findings presented in this book and can be recom-
mended for clinical practice. For example, Miller,
Duncan, Sorrell, and Brown (2005) have developed
an ultra-brief (four item) measure of the alliance that
 2 Book Review
is completed near the end of each therapy session
and then discussed with clients, thus ensuring that
the clients perception of TA is provided to the
therapist in a timely manner, while leaving time for
discussion of any problems that exist.
Lambert and Shimokawa (2011) have shown that
tracking patients’ mental health status on a weekly
basis while identifying patients at risk of treatment
failure can reduce deterioration rates and enhance
positive outcomes. In their system, the alliance is
measured only for these off-track cases. The alliance
information is presented at the level of a total score
with a cut-off indicating alliance problems; subscale
scores that assess the affective bond, task, and goal
agreement with cut-off scores for each alliance area;
and then item level feedback based on cut-off scores
for each problematic item. Such procedures enable
therapists to examine the alliance from the client’s
point of view by inspecting specific information and
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in so doing help themselves to understand where
alliance problems exist. For example one item in
their alliance measure asks the patient to rate the
statement: “My therapist seems glad to see me.”
This type of feedback is seen as much more helpful
and actionable than an overall alliance score or
therapist intuition alone because it makes use of
normative values (and corresponding cut-scores) on
the TA ratings of a large number of individuals. In
addition, Lambert and colleagues provide sugges-
tions and guidelines for improving the alliance based
on the research presented in this book (e.g., chapters
by Eubanks-Carter, Muran, & Safran, 2010; Muran,
Safran, & Eubanks-Carter, 2010).
Muran and Barber’s book is an invaluable con-
tribution to an evidence-based practice of psy-
chotherapy, providing many examples of the
contribution of the alliance across psychotherapy
systems and modalities. In order to fully integrate
the evidence and make use of it to improve treat-
ment, alliance ratings can be quickly measured
through client self-report measures that include
specific cut-off scores for problematic perceptions
of the ongoing relationship. Without these methods,
therapists may be too likely to rely on their own
overly optimistic perception of the therapeutic rela-
tionship. These methods also have the advantage of
not relying on general training and supervision, but
instead identify problems in ongoing cases. Appar-
ently clinicians are quite capable of improving the
alliance and outcome when they are informed about
problems. Similar methods have been employed in
cognitive behavioral treatments (Burns & Auerbach,
1996) as well as a host of others systems, and are
worth considering. We need not simply promote the
importance of the TA as a central aspect of evidence-
based practice, but can make use of information
on the alliance with each patient we are treating,
especially if they are failing to make expected
progress. Clients clearly benefit when such interven-
tions are employed.
Because this is an edited book the editors have
thoughtfully included a final chapter summarizing
consensual findings across quantitative and qualitat-
ive studies summarized by chapter authors, noting
that the alliance is at the core of professionalism and
competence across medical practice as well as psy-
chological treatment. The editors and authors bring
to our attention the fact that TA training and
practice guidelines lag behind basic scientific studies
on the alliance and that studies of training have an
important place in future research. I can highly
recommend this book to the practicing professional
and to psychotherapy researchers, but especially
students in training. It is loaded with wisdom about
the many things that affect collaboration in psycho-
therapy and how to maximize the TA and patient
outcomes.
References
Burns, D. D., & Auerbach, A. (1996). Therapeutic empathy in
cognitive behavior therapy. Does it really make a difference? In
P. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 135–164).
New York, NY: Guilford Press.
Eubanks-Carter, C., Muran, J. C., & Safran, J. D. (2010).
Alliance rupture and resolution. In J. Christopher Muran &
J. P. Barber (Eds.), The therapeutic alliance: An evidence-based
guide to practice (pp. 74–96). New York: Guilford Press.
Lambert, M. J., & Shimokawa, K. (2011). Collecting client
feedback. Psychotherapy, 48(1), 72–79. doi:10.1037/a0022238
Miller, S. D., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005).
The partners for change outcome management system. Journal
of Clinical Psychology, 61, 199–208. doi:10.1002/jclp.20111
Muran, J. C., Safran, J. D., & Eubanks-Carter, C. (2010).
Developing therapist abilities to negotiate alliance ruptures. In
J. Christopher Muran & J. P. Barber (Eds.), The therapeutic
alliance: An evidence-based guide to practice (pp. 320–340). New
York: Guilford Press.
Michael J. Lambert
Department of Psychology, Brigham Young University
Provo, UT, USA
Michael_Lambert@byu.edu
© 2015, Michael J. Lambert
http://dx.doi.org/10.1080/10503307.2015.1031200