See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/14828157

The role of the therapeutic alliance in Psychotherapy

Article  in  Journal of Consulting and Clinical Psychology · September 1993

DOI: 10.1037//0022-006X.61.4.561 · Source: PubMed

CITATIONS READS
867 48,545

2 authors, including:

Adam O Horvath
Simon Fraser University
67 PUBLICATIONS   13,176 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Ruptures in affiliation: An examination of the discursive-interactional practices used to damage and repair social cohesion between speakers. View project

Alliance in Individual Psychotherapy View project

All content following this page was uploaded by Adam O Horvath on 19 January 2015.

The user has requested enhancement of the downloaded file.

Journal of Consulting and Clinical Psychology Copyright 1993 by the American Psychological Association, Inc.
1993, Vol. 61, No. 4,561-573 0022-006X/93/S3.00

The Role of the Therapeutic Alliance in Psychotherapy

Adam O. Horvath and Lester Luborsky

The article traces the development of the concept of the therapeutic working alliance from its
psychodynamic origins to current pantheoretical formulations. Research on the alliance is re-
viewed under four headings: the relation between a positive alliance and success in therapy, the
path of the alliance over time, the examination of variables that predispose individuals to develop a
strong alliance, and the exploration of the in-therapy factors that influence the development of a
positive alliance. Important areas for further research are also noted.

Over the last 3 decades, the dynamic concept of the therapeu-
tic alliance (Freud, 1912; Greenson, 1967; Sterba, 1934; Zetzel,
1956) has taken root in other models of psychotherapy, leading
to several related explanations of the role of the alliance within
the therapeutic process (Bordin, 1976; Bowlby, 1988; Luborsky,
1976; Rogers, 1957; Strong, 1968). The central aim of this article
was to review the theoretical issues and the research results
relevant to each of four aspects of the role of the alliance in
psychotherapy: The relation between a positive alliance and
success in therapy; the path of the alliance over time; the vari-
ables that predispose individuals to develop a strong alliance;
and the in-therapy factors that influence the development of a
positive alliance.
The terms therapeutic alliance, working alliance, and helping
alliance have been used in the past to refer to specific aspects of
the alliance or as synonyms for the alliance as a whole. Because
the use of these terms has not been consistent, the term the
alliance is used here generically to refer to all of the aforemen-
tioned constructs, unless otherwise specified.
Development of the Concept of the Alliance
Psychodynamic Origins
In The Dynamics ofTransference, Freud (1912) discussed the
value of the analyst's maintaining "serious interest" in and
"sympathetic understanding" of the client to permit the
healthy part of the client's self to form a positive attachment to
the analyst. Later, Freud (1913) speculated that, as a result of
the supportive attitude of the analyst, the patient would uncon-
sciously link the therapist with the "images of people by whom
he was accustomed to be treated by affection" (pp. 139-140).
Two slightly different conceptualizations of the therapist-
Adam O. Horvath, Faculty of Education and Department of Psy-
chology, Simon Eraser University, Burnaby, British Columbia, Canada;
Lester Luborsky, Department of Psychiatry, University of Pennsyl-
vania.
Some of the material presented in this article will appear as a
chapter by A. O. Horvath, L. Gaston, and L. Luborsky in the Handbook
of Psychodynamic Psychotherapy: Theory and Research.
Correspondence concerning this article should be addressed to
Adam O. Horvath, Faculty of Education, Simon Fraser University, Bur-
naby, British Columbia V5A 1S6.
561
client relationship are evident in Freud's writings: In his early
papers, this attachment is described as a form of beneficial
(positive) transference. This form of transference had the effect
of "[the client's] clothing the doctor with authority" (Freud,
1913, pp. 99-108). Freud saw this aspect of the relationship as
the source of the client's "belief in his [analyst's] communica-
tions and explanations" (Freud, 1913, pp. 99-108). Positive
transference involves a distortion of the real relationship and,
like its negative counterpart, needs to be to interpreted by the
analyst. However, in his later papers, Freud appeared to have
modified this positive transference view of the therapeutic rela-
tionship to include the possibility of a beneficial client-thera-
pist attachment grounded in reality. The implication of this
later perspective is that, although interpretation of the client's
projections or unresolved prior experiences is central to ther-
apy, the ability of the intact portion of the client's conscious,
reality-based self to develop a covenant with the "real" thera-
pist makes it possible to undertake the task of healing.
Greenson (1965) elaborated on this concept of a reality-based
collaboration between therapist and client and coined the term
working alliance. He proposed a model that has three compo-
nents: transference, the working alliance, and the real relation-
ship (Gelso & Carter, 1985). Zetzel (1956) clarified some of the
distinctions between transference and alliance, suggesting that,
in effect, the nonneurotic component of the client-therapist
relationship (the alliance) permits the client to step back and
use the therapist's interpretations to better distinguish between
remnants of past relationships and the real association between
himself or herself and the therapist. She argued that, in success-
ful analysis, the client oscillates between periods when the rela-
tionship is dominated by transference and periods dominated
by the working alliance.
A related conceptualization of the therapeutic alliance was
offered by Bibring (1937), who suggested that the therapeutic
situation represents a "new-object relationship." This position
was further developed by Gitleson (1962) and Horwitz (1974)
and, more recently, by Bowlby (1988). In essence, the object-re-
lationists propose that the client, as part of the therapy process,
develops the capacity to form a positive, need-gratifying rela-
tionship with the therapist. This attachment is qualitatively dif-
ferent from those based on early childhood experiences and
thus represents a new class of events. The therapist's task is to
maintain a positive, reality-grounded stance toward the patient
562 ADAM O. HORVATH AND LESTER LUBORSKY
and to provide an opportunity for the client to reflect on the
discrepancies between the distorted and reality-based aspects
of the relationship (Frieswyk et al., in press).
These theorists argue that the alliance and transference are
distinct constructs, but there are others who maintain that all
aspects of the therapist-client relationship are manifestations
of the transference neurosis and should be interpreted as such.
They claim that the client's alliance fulfills an unconscious
wish to gain the therapist's approval as a parental figure or,
alternatively, the apparent alignment or collaboration is actu-
ally a form of covert competition. This logic leads some (e.g.,
Brenner, 1979; Curtis, 1979) to conclude that using the alliance
construct may be counterproductive because it will result in a
watering down of the central thrust of the analytic work—the
interpretation of transference.
Whether transference distortions are part and parcel of the
alliance has been one of the ongoing controversies in dynamic
therapy. The central practical issue is the degree to which the
alliance is dependent on the here-and-now motivation, skill,
and "fit" of the client and the therapist, as opposed to the
concept that the quality of the therapeutic relationship is (at
least initially) predestined by the client's unconscious projec-
tions based on past experiences (Gelso & Carter, 1985; Gut-
freund, 1992).
The alliance-as-transference perspective implies that emo-
tions and thoughts associated with unresolved relationships
with significant others are bound to be displaced (transferred)
onto the relationship with the therapist. Thus, the relationship
"entails a misperception or misinterpretation of the therapist
. . . [and] is an unreal relationship in this sense" (Gelso &
Carter, 1985, p. 170). Accordingly, authors with this perspective
(e.g., Brenner, 1979) see the alliance as aim-softened transfer-
ence and, therefore, not a relationship properly speaking.
Others argue that all relationships, in the broadest sense, are
prejudiced by previous interpersonal experiences and that the
alliance is not a separate or distinct variable but an alternative
perspective on the same phenomenon as the positive transfer-
ence (Hatcher, 1990). Proponents of this view tend to maintain
that the therapeutic alliance is based on the quality of the
current interpersonal synergy of therapist and client yet it is
also a reflection of the client's previous unresolved relation-
ships. The key issue debated among researchers sympathetic to
this position (Piper, Azim, Joyce, & McCallum, 199la) is the
degree to which the client's past relationships influence the
alliance.
More recently, the impact of countertransference (i.e., the in-
fluence of the therapist's early relationships or relational capaci-
ties) on the formation of a viable alliance has also been raised.
The theoretical and empirical parameters of this question are
currently not clear. If countertransference is a factor influenc-
ing the development of the alliance, is it most usefully conceptu-
alized as a therapist variable (i.e., as a relational capacity that is
somewhat constant across clients) or with a more traditional
definition of countertransference (i.e., as an interactional phe-
nomenon)? If the latter is the correct view, then its influence on
the alliance will be apparent only if specific client behaviors or
characteristics are present. In either case, a clear theoretical
model is needed to relate countertransference to the develop-
ment of the alliance and thus facilitate the empirical investiga-
tion of the possible impact of therapist distortions. Research
on the role of therapist distortions is in its early stages; data
currently available on this topic is presented later in this article
(see Client and Therapist Factors Influencing the Development
of the Alliance).
Despite the differences of view on the role of transference, it
seems that we are witnessing the development of a growing
consensus among dynamic theorists: Most feel that a compre-
hensive definition of the alliance needs to take account of the
influence of past experiences (we include transference under
this heading) and, at the same time, delineate the alliance as a
distinct aspect of the current relationship (Gaston, 1990).
Conceptual work on the alliance as an independent (i.e., non-
transference) factor has taken place both within and outside the
analytic framework. The main contributions to this position
within the psychodynamic perspective were reviewed earlier.
To put the nonpsychodynamic position in proper light, we will
first present a brief review of some alternative conceptualiza-
tions of the therapeutic relationship.
The Client-Centered Concept of the Therapeutic
Relationship
Rogers (1951,1957) asserted that the therapist's ability to be
empathic and congruent and to accept the client uncondition-
ally were not only essential but sufficient conditions for thera-
peutic gains. Although client-centered theory is often regarded
as a quintessentially humanistic position emphasizing the "I
and Thou" aspect of therapy, Rogers' propositions do not ad-
dress the possibility of variations in the clients' ability and mo-
tivation to respond to the offer of such a relationship. There is a
presumption of a fated response to the correct attitude of the
therapist.
During the past 3 decades, many investigations were
launched to explore the effects of the Rogerian Therapist-Of-
fered Conditions (TOC). The initial findings were strongly sup-
portive of the original hypotheses: Therapists who provided
high levels of TOCs were more successful than those who pro-
vided less of these conditions (Barrett-Lennard, 1985; Rogers,
Gendlin, Kiesler, & Truax, 1967). Some of the later reviews of
the research results (e.g., Mitchell, Bozart, & Krauft, 1977; Or-
linsky & Howard, 1986), however, noted that the relation be-
tween the TOCs and outcome were not uniform across differ-
ent therapy modalities. Moreover, the majority of findings indi-
cate that it is the client's perception of the therapist as an
empathic individual, rather than the actual therapist behavior,
that yielded the most robust correlation with outcome.
Although there are clear theoretical differences between the
TOC and the alliance, research results indicate a moderate-to-
strong correlation between client-perceived empathy and some
aspects of the alliance, particularly in early stages of therapy
(Greenberg & Adler, 1989; Horvath, 1981; Jones, 1988; Moseley,
1983). However, in each of these investigations, the alliance was
more predictive of outcome than empathy. In a more recent
study, the relation between the alliance and all four TOC di-
mensions were examined during the mature phase (Session 20)
of therapy (Salvio, Beutler, Wood, & Engle, 1992). The results of
this investigation confirmed the close association among the
TOC and alliance components. The researchers used these data
to develop a composite Strength of Therapeutic Alliance score
using principle-component analysis. The factor loading on this
 SPECIAL SECTION: THERAPEUTIC ALLIANCE IN PSYCHOTHERAPY
index for the four TOC components (regard, empathy, uncondi-
tionally, and congruency) ranged from .82 to .72, whereas the
values for the alliance dimensions (task, bond, and goal) ranged
from .96 to .92. Some interpret the close relationship between
these concepts by noting that the TOCs, and empathy in partic-
ular, may be instanciations of the alliance (e.g., Watson &
Greenberg, in press); others suggest that the TOCs may be im-
portant preconditions for alliance development (e.g., Horvath,
in press). A direct examination of the temporal and causal rela-
tion between these variables is an important task; either path
analytic or structural modeling approaches could reveal impor-
tant causal or temporal connections among these constructs
and help us to develop better therapeutic strategies.
The Social Influence Concept of the Therapeutic
Relationship
The mediating effect of the client's judgments of the thera-
pist's attributes was explored by LaCrosse (1980) and Strong
(1968). Their theory extended the work of social psychologists
Hovland (Hovland, Janis, & Kelley, 1953) and Cartwright
(1965). The central hypothesis of this group was that the client's
impressions of the therapist as expert, trustworthy, and attrac-
tive provides the helper with leverage (social influence [SI]) to
promote change. Because the strength of the therapist's influ-
ence is proportional to these client attributions, these beliefs
are directly related to the benefits the client is likely to accrue
from therapy.
This body of work may be seen, in part, as a reaction to
Rogers' exclusive emphasis on the therapist's role in the rela-
tionship. During the 1970s and the 1980s, a substantial corpus
of empirical research accumulated relating the SI dimensions
of attractiveness, expertness, and trustworthiness to positive
therapy outcome. Most of the early studies reported in the liter-
ature involved the artificial manipulation of the three SI vari-
ables in analog settings. The results of these investigations sug-
gested a reliable relation between the SI variables and outcome
(LaCrosse, 1980). However, the results of subsequent clinical
trials did not corroborate the analog studies, which indicates
that the impact of these variables on therapeutic gains may be
quite modest and inconsistent across therapy modalities
(Greenberg & Adler, 1989; Horvath, 1981).
The Pantheoretical Concept of the Alliance
A major discovery in psychotherapy research of the past 2
decades has been the consistent finding that, broadly speaking,
different therapies produce similar amounts of therapeutic
gains (Luborsky, Singer, & Luborsky, 1975; Smith & Glass, 1977;
Stiles, Shapiro, & Elliott, 1986). In spite of some of the criticism
that raised the possibility of methodological shortcomings in
some of these research syntheses (Luborsky, in press; Shadish &
Sweeney, 1991) and suggestions that systematic differences
among therapies may be just lurking below the surface of these
broad general conclusions (Beutler, 1979), many researchers
have interpreted these results as an indication that variables
common to all forms of psychotherapy may be responsible for a
large part of a client's improvement. This renewed interest in
the generic elements common to all forms of therapy refocused
interest on the alliance as a pantheoretical factor that may be
563
responsible for a significant proportion of this common vari-
ance.
One of the early refinements of the concept of the alliance,
based on transcripts from the Penn Psychotherapy Project, was
developed by Luborsky (1976). He suggested that the alliance is
a dynamic rather than a static entity responsive to the changing
demands of different phases of therapy. Two types of helping
alliances were identified: Type 1, more evident in the beginning
of therapy, and Type 2, more typical of later phases of treat-
ment. Type 1 alliance is "A therapeutic alliance based on the
patient's experiencing the therapist as supportive and helpful
with himself as a recipient" (p. 94); Type 2 alliance is " . . . a
sense of working together in a joint struggle against what is
impeding the patient... on shared responsibility for working
out treatment g o a l s . . . a sense of'we-ness'" (p. 94). Luborsky
(1976) observed that the strength of both Type 1 and Type 2
alliances were associated with the likelihood of improvement
in psychodynamic therapy.
In a series of pioneering articles, Bordin(1976,1980,1989, in
press) proposed a broader definition of the working alliance.
His definition builds on Greenson's (1967) earlier work and
further clarifies the distinctions between the unconscious pro-
jections of the client (i.e., transference) and what he defines as
the working alliance. This pantheoretical formulation empha-
sizes the client's positive collaboration with the therapist
against the common foe of pain and self-defeating behavior. He
identified three components of the alliance: tasks, bonds, and
goals. The definitions of these components may be summa-
rized thus: Tasks refer to the in-counseling behaviors and cogni-
tions that form the substance of the counseling process. In a
well-functioning relationship, both parties must perceive these
tasks as relevant and efficacious; furthermore, each must ac-
cept the responsibility to perform these acts. A strong working
alliance is characterized by the therapist and the client mutu-
ally endorsing and valuing the goals (outcomes) that are the
target of the intervention. The concept of bonds embraces the
network of positive personal attachments between client and
therapist that includes issues such as mutual trust, acceptance
and confidence.
Bordin also theorizes on how the alliance enhances the effi-
cacy of therapy (Bordin, 1989; in press). Positive alliance is not,
in and of itself, curative; rather, the working alliance is seen as
the ingredient that ". . . makes it possible for the patient to
accept and follow treatment faithfully" (Bordin, 1980, p. 2).
Bordin's formulations also offer an alternative to the traditional
dichotomous perspective of technical and process factors in
therapy. He proposes that these two aspects are not separate but
interdependent and that the positive developments in each pro-
vide a necessary facilitative base for the growth of the other
(Bordin, in press). This synergetic aspect of the model implies
that the client forms attachments to the therapist, in part,
based on his or her assessment of the relevance and potency of
the interventions offered. This contrasts with Rogers' sugges-
tion that clients in therapy respond automatically to a thera-
pist's positive attitude.
Recent research on clients' cognitions during therapy seem to
support the idea that clients' assessments of therapy are based,
in part, on their own expectations of therapy and are ultimately
interactive rather than merely responsive to therapist factors
(Hill & O'Grady, 1985; Horvath, Marx, & Kamann, 1990; Mar-
 564 ADAM O. HORVATH AND LESTER LUBORSKY
tin, Martin, & Slemon, 1989). The results of these investiga-
tions, however, do not imply that approval of a therapist's style
will necessarily result in a stronger alliance. It appears that the
therapist has to (a) communicate to the client the important
links between therapy-specific tasks and the overall goals of
treatment and (b) maintain an awareness of the client's commit-
ment to these activities and effectively intervene if resistance is
present.
In a parallel fashion, the client's assessment of the therapy
tasks are partially predicated on a sense of agreement on what
are accepted as reasonable goals of the therapy: Although it is
likely that therapists and clients almost invariably have some
agreement on the global, long-term goals, it has been argued
that the short- and medium-term expectations of client and
therapist may be quite different: "Clients seek speedy relief
from the pain that brought them to therapy, whereas the thera-
pist perceives treatment as a process which will lead to the
eventual but not necessarily immediate relief of the client's suf-
fering" (Horvath & Symonds, 1991, p. 620). The therapist's
goals are informed by theory and may not be readily available
to the client. To establish a good alliance, it is important for the
therapist to negotiate these immediate and medium-term ex-
pectations and link these to the client's wish to obtain lasting
relief from suffering. By developing such linkages, the therapist
can obtain the client's active consent to pursue these objectives
(i.e., an alliance). The presence of a strong alliance helps the
patient to deal with the immediate discomforts associated with
the unearthing of painful issues in therapy and makes it possi-
ble to postpone immediate gratification by using both cogni-
tive (i.e., endorsements of the tasks of therapy) and affective (i.e.,
personal bonds) components of the relationship.
Luborsky's research suggests that the client's initial response
to the therapist might well be dominated by a judgment con-
cerning whether the helper seems caring, sensitive, sympa-
thetic, and helpful (i.e., Type 1 helping alliance; Luborsky,
1976). Such judgments may be influenced by levels of per-
ceived warmth and care (e.g., empathy), external features (e.g.,
attractiveness), contextual information (e.g., expertness), and
the client's past experiences in similar relationships (LaCrosse,
1980). Subsequently, the influence of these initial impressions
are augmented or even supplanted by the more cognitive (evalua-
tive or collaborative) components of the alliance and the capac-
ity to form a reciprocal relationship (Luborsky et al., 1985).
Research Results
The current significance of the alliance concept rests, in
part, on the growing body of research linking the quality of the
alliance with therapeutic outcome and on the more recent find-
ings relating the alliance to specific change processes. The re-
sults of these empirical investigations are summarized and orga-
nized topically below.
Measurement of the Alliance and Operational Definitions
The recent increase in studies of the alliance was supported
by the development of reliable methods of measuring the con-
cept. Because these measures operationally define the alliance,
we begin this discussion by reviewing these instruments.
Currently, there are at least 11 alliance assessment methods.
Horvath and Symonds (1991) identified five clusters of related
measures used in the majority of the investigations: the Califor-
nia Psychotherapy Alliance Scales, (CALPAS/CALTRAS1;
Gaston & Ring, 1992; Marmar, Weiss, & Gaston, 1989); the
Penn Helping Alliance scales (Penn/HAQ/HAcs/HAr; Alex-
ander & Luborsky, 1987; Luborsky, 1976); the Therapeutic Alli-
ance Scale (TAS; Marziali, 1984a); the Vanderbilt Therapeutic
Alliance Scale (VPPS/VTAS; Hartley & Strupp, 1983); and the
Working Alliance Inventory (WAI; Horvath, 1981,1982). Each
of these instruments is available in several versions, and most
have been adapted for use as an observer's rating scale or as a
self-report measure. In addition to assessing the global level of
alliance, these measures also yield scores on a variety of alli-
ance components. Overall, these scales appear to have accept-
able psychometric properties. Horvath and Symonds (1991)
have reported that the therapist-based measures are the most
stable (r « .93), and observers' ratings of the alliance are the
least reliable (r « .82).
Differences Among Alliance Assessment Methods
Most of these alliance measures were developed indepen-
dently and each progressed through several stages of refine-
ments. Given the relatively large number of instruments, it is
not surprising that they measure related, but not identical, un-
derlying constructs. In the next section, we will examine the
following questions: How closely related are the constructs un-
dergirding these measures? How much variance is common
among the measures? Do these instruments predict outcome
equivalently?
It seems that two core aspects of the alliance—personal at-
tachments and collaboration or willingness to invest in the ther-
apy process—are common elements among each of the instru-
ments. Beyond these core components, the following con-
structs are monitored by two or more of the instruments:
therapists' and clients' positive or negative contributions (e.g.,
CALPAS, TAS), shared or agreed goals for the therapy (e.g.,
CALTRAS, WAI, Penn), capacity to form a relationship (e.g.,
Penn, VTAS, CALTRAS), acceptance or endorsement of ther-
apy tasks (e.g., CALTRAS, WAI), and active participation in
therapy (e.g., Penn, CALTRAS, VTAS). The weight or emphasis
given to these compohents, however, varies among measures
(Hansell, 1990; Hartley, 1985; Horvath, in press; Marziali,
1984b).
Tichenor and Hill (1989) investigated the relation between
four observer-rated instruments (Penn, VTAS, CALPAS, and
WAI0). They observed that there was a 12%-71 % overlap among
the scales (Tichenor & Hill, 1989). In another study (Safran &
Wallner, 1991), two self-report scales were compared (WAI and
CALPAS). The overall shared variance was reported as 76%.
However, at the subscale level, overlap ranged from 0%-67%,
1
CALPAS and CALTRAS both refer to the California Psychother-
apy Alliance Scales. The two versions of the instrument are quite simi-
lar but yield slightly different subscales. To avoid confusion, we gener-
ally use the abbreviation CALTRAS, except where a specific study or
result is referenced; in those cases, the abbreviation reported by the
original authors is used.
 SPECIAL SECTION: THERAPEUTIC ALLIANCE IN PSYCHOTHERAPY
with an average value of 37%. Information available on another
group of self-report measures (Penn, VPPS2, and TAS) suggests
that there is a wide range of commonalities at the subscale level
(0%-69%), with an average overlap of approximately 21% for
client-rated instruments and of 18% for the therapists' scales
(Bachelor, 1991).
The data suggest that, at the global level, a generous overlap
exists between measures. This may be interpreted as proof that
each is assessing a similar underlying process. However, most
instruments also attempt to capture distinct components of the
alliance with subscales embedded in the instrument. Low sub-
scale correlations within instruments indicate independent un-
derlying factors and are cited as evidence of the scales' validity
(Gaston & Ring, 1992). It can be argued, therefore, that low
correlations across subscales of different instruments are to be
expected and that a more proper test of similarity would entail
comparison of parallel subscales only. Unfortunately, there has
been no agreement across instruments as to the underlying
structure of the alliance; each instrument has different sub-
scales, making such comparison impossible at this time.
Theoretical diversity is also reflected in the instruments: The
Penn scales arose from a psychodynamic perspective and are
influenced by Luborsky's work on the alliance (Luborsky,
McLellan, Woody, O'Brien, & Auerbach, 1985); VPPS repre-
sents a blend of dynamic and eclectic frameworks that has been
influenced by the work of Strupp and his colleagues at Vander-
bilt University (Henry & Strupp, in press; Strupp, 1974); the
TAS and CALPAS scales are influenced by both traditional
psychodynamic concepts of the alliance and the subsequent
work of Bordin (Gaston & Ring, 1992); the WAI was designed
to capture Bordin's pantheoretical perspective and was vali-
dated using his definitions of the alliance dimensions of goals,
tasks, and bonds (Horvath & Greenberg, 1989). Two of the
scales (Penn and WAI) are theoretically homogeneous, and the
remaining instruments represent a more eclectic position. The
homogeneous scales tend to have higher subscale correlations,
whereas blended scales (particularly the CALTRAS) appear to
have more independent subscales (Gaston, & Ring, 1992; Hor-
vath & Symonds, 1991).
Across all instruments, therapists' alliance scales have pro-
vided significantly poorer predictions of all types of outcomes
than clients' or observers' assessments (Horvath & Symonds,
1991). This appears to be true irrespective of the outcome indi-
ces predicted. There may be several interacting reasons for this.
The fault could lie in the fact that the therapists' scales are
direct rewordings of client instruments; thus far, no effort has
been made to investigate the specific impressions and experi-
ences that therapists associate with the clients' experience of
positive alliance. Another reason for the poor predictive power
of therapists' alliance scores may be that some therapists signifi-
cantly misjudge the relationship. Countertransference could
also account for a significant portion of these errors. Also, the
therapists' own early object relations may bias their judgment
of the alliance (Henry & Strupp, in press). Whatever the reason
for the apparent discrepancy between clients' and therapists'
evaluations of the relationship, a better understanding of the
factors influencing the therapist's (mis)perception of the alli-
ance is essential for more effective use of the alliance construct
to improve therapy.
565
The Relation Between the Quality of the Alliance and
Outcome in Psychotherapy
During the past 2 decades, there has been a marked increase
in both the number of empirical investigations of the alliance
and the breadth of issues covered by these studies. There have
been several recent reviews of this research (Gaston, 1990; Hor-
vath & Symonds, 1991; Luborsky, in press). The following is a
summary of the most salient findings.
Horvath and Symonds (1991) used meta-analytic techniques
to synthesize the quantitative research that links the relation-
ship between alliance and outcome. On the basis of the 24
studies included3 in the review, they found an average effect size
(ES), which linked quality of alliance to therapy, of r = .26.
However, the actual influence of the alliance may be greater
because the calculation was based on the cautious assumption
that all relations observed but not reported by researchers, or
reported as not significant, were actually r= .0. This is likely an
overly pessimistic assumption, resulting in an underestimation
of the actual ES.
Research confirming the relation between good alliance and
positive outcome has underlined the importance of the con-
struct, but in order to offer a more focused perspective on the
function of the alliance, we need to examine more closely the
factors that influence the relation between the alliance and
outcome.
Factors Influencing Alliance-Outcome Relations
Type of treatment. Alliance research covers a broad variety
of treatments and client problems. The impact of the alliance
has been examined in the context of behavioral therapy (DeRu-
beis & Feeley, 1991; Krupnick, Stotsky, Simmens, & Moyer,
1992), cognitive therapy (Krupnick et al., 1992; Raue, Castun-
guay, & Goldfried, 1991; Rounsaville et al., 1987; Svartberg &
Stiles, 1992), gestalt therapy (Horvath & Greenberg, 1989), and
psychodynamic therapy (Eaton, Abeles, & Gutfreund, 1988;
Horowitz & Marmar, 1985; Krupnick et al., 1992; Luborsky,
1976; Luborsky & Auerbach, 1985; Marmar, Horowitz, Weiss,
& Marziali, 1986; Marziali, Marmar, & Krupnick, 1981; Piper,
DeCarufel, & Szkrumelack, 1985; Saunders, Howard, & Or-
linsky, 1989; Windholz & Silbershatz, 1988). A strong alliance
appears to make a positive contribution in all of these therapies
(Horvath & Symonds, 1991). Moreover, neither meta-analysis
of cross-study differences (Horvath & Symonds, 1991) nor most
studies that directly contrasted alliance-outcome relations
across different treatment approaches (e.g., Krupnick et al.,
1992) could identify significant differences in alliance-out-
come relations among treatments.
Variety of outcomes. Alliance measurements have been used
to predict many different kinds of therapy outcomes ranging
2
The VPPS was originally developed as an observer-rated instru-
ment. However, in the study referenced, it was modified for use as a
self-report scale.
3
The five inclusion criteria were (a) the investigator identifying the
independent variable as "therapeutic," "working," or "helping" alli-
ance; (b) a time lapse between the measurement of alliance and the
outcome; (c) analog studies were excluded; (d) a minimum of five sub-
jects in the study; and (e) only individual treatments were included.
566 ADAM O. HORVATH AND LESTER LUBORSKY
from drug use (Luborsky et al., 1985) to social adjustment
(Rounsaville et al., 1987) to clients' and therapists' subjective
ratings of global improvement (Eaton et al., 1988). In general,
the alliance measures appear to be more efficient at predicting
outcomes tailored to the individual client such as the Target
Complaints (TC; Battle et al., 1966) than broad-range symptom-
atic change such as the Symptom Distress Check List—90
(SCL-90; Derogatis, Rickels, & Rock, 1976). The average corre-
lation of alliance rating and outcome rated on the TC was .30 (TV
of 8 studies); the same correlation for the SCL-90 was .09 (N of
6 studies) (Horvath, Gaston, & Luborsky, in press). At first
glance, the self-rated outcome may appear to be a softer index
of improvement in that the clients rate both process and out-
come, and thus a bias toward convergence may be part of the
design. Inspection of the research results suggest, however, that
this is not the case: The average relation between observers'
alliance rating and therapists' judgment of outcome is as strong
as the relation obtained when both measures are rated by
clients, and the relation between clients' alliance rating and
observers' outcome is nearly as large (Horvath & Symonds,
1991).4
Treatment length. The impact of the alliance has been dem-
onstrated in treatments ranging from 4 to over 50 sessions. The
length of treatment, however, does not appear to influence the
relation between the quality of the alliance and therapy out-
come (Horvath & Symonds, 1991).
Early versus late alliance. Gaston et al. (1992) report that
the strength of alliance remains relatively stable over time when
the measures are averaged across cases. However, there is evi-
dence that the strength of the alliance fluctuates systematically
within individual treatment dyads (Horvath & Marx, 1991).
Others (e.g., Adler, 1988) report a positive slope of the alliance
over time, but the incremental gain in alliance strength is appar-
ently not related to outcome.
Horvath and Symonds (1991) reported that early alliance is a
slightly more powerful prognosticator of outcome (ES = .3)
than alliance measures averaged across sessions or taken to-
ward the middle of treatment (ES = .2). Although the differ-
ences between these values are small, subsequent investigations
(i.e., DeRubeis & Feeley, 1991; Piper et al., 1991 a; Piper, Azim,
Joyce, & McCallum, 1991b; Plotnicov, 1990) appear to confirm
this trend. The apparent anomaly that we can better predict
success on the basis of early alliance than by using later assess-
ments may be explained by examining the course of the alli-
ance over time. Longitudinal analyses of the levels of the alli-
ance in more and less successful therapy (e.g., Horvath & Marx,
1991; Safran, Crocker, McMain, & Murray, 1990; Safran,
Muran, & Wallner Samstag, 1992) appear to confirm a rup-
ture-repair cycle in successful therapies predicted by Zetzel
(1956) and Bordin (1989). The alliance in this phase of therapy
may be, of necessity, quite labile between or even within ses-
sions. This fluctuation in alliance level may account for the
modest correlation between outcome and alliance averaged
across sessions. The significant index of success in the later
phases of therapy may be more related to the degree of success
in resolving these ruptures. Thus, it may be interesting to ex-
plore the relation between the overall level of the alliance, the
relative strengths of the components at different points in the
therapy, and the final outcome within individual dyads.
The relation between alliance and early benefits of therapy.
One of the important debates concerning the validity and use-
fulness of relationship variables in general, and the alliance in
particular, is whether there is a clear distinction between early
session-level benefits and the alliance. Are what we currently
identify as indications of good alliance simply aspects of early
therapeutic progress?
If we were to discover that the alliance is a by-product of
therapeutic gains, this would seriously challenge both the theo-
retical and practical usefulness of the concept (Horvath, 1991).
This scenario of "alliance as an artifact" can be tested by exam-
ining the following hypotheses: (a) If the alliance is a by-product
of successful therapy, its development ought to follow therapeu-
tic progress (i.e., in an idealized successful treatment situation,
its quality ought to grow from poor to better); (b) because thera-
peutic gains accumulate and stabilize over time, early measures
of the alliance ought to be less efficient predictors of outcome
than measures obtained later in therapy (Gelso & Carter, 1985);
and (c) the alliance's unique contribution to prediction of the
final therapeutic success may be more directly examined if the
variance associated with early therapy gains were statistically
controlled (partialed out) before alliance-outcome relations
were computed.
There is emerging evidence mitigating against the theory of
alliance as an artifact. The relevant data will be reviewed in the
same order as the hypotheses were listed earlier. Safran and his
colleagues have found that positive outcome was most closely
associated with successful repairs of alliance ruptures (break-
down of the relationship) rather than with a linear or parallel
development throughout therapy (Safran, Crocker, et al., 1990;
Safran et al, 1992). Horvath and Marx (1991) likewise de-
scribed the course of the alliance in successful therapy as a
series of developments, decays, and repairs.
Kokotovic and Tracey (1990) and Plotnicov (1990) reported
that very early (first-session) alliance measures were predictive
of therapy dropouts. Horvath and Symonds (1991) found that
the magnitude of the alliance-outcome relation was not a direct
function of time: Both the early and late alliance measures pre-
dict outcome better than alliance assessments obtained in the
middle phase of therapy.
Gaston and her colleagues (1991) computed partial correla-
tions (controlling for therapy gains) associated with alliance
and posttherapy outcome. She found that alliance predicted
36% to 57% of the variance in posttherapy outcome beyond
short-term improvements. Similar results were found in a re-
cent investigation of the impact of psychodynamic interven-
tions by Barber, Crits-Cristoph, and Luborsky (1992).
Client and Therapist Factors Influencing the
Development of the Alliance
It is likely that both clients' and therapists' personal histories
have some influence on the capacity to develop a good thera-
peutic alliance. Moreover, some of these client-therapist quali-
ties could interact to produce particularly propitious or poor
alliance patterns. Horvath (1991) summarized 11 studies re-
porting on the impact of client characteristics on the alliance.
4
For a full discussion of the possible "halo effect" in alliance-
outcome relations, see Horvath and Symonds (1991, pp. 143-144).
 SPECIAL SECTION: THERAPEUTIC ALLIANCE IN PSYCHOTHERAPY
To make the interpretation of a broad spectrum of potential
client variables easier, Horvath sorted factors into three catego-
ries: interpersonal capacities or skills, intrapersonal dynamics,
and diagnostic features. The interpersonal capacities category
included measures of the quality of the clients' social relation-
ships (e.g., Moras & Strupp, 1982) and family relations (e.g., Ko-
kotovic & Tracey, 1990), and indices of stressful life events (e.g.,
Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen,
1983). The intrapersonal dynamics category subsumes indices
of clients' motivation (e.g., Marmar et al, 1989), psychological
status (e.g., Ryan & Cicchetti, 1985), quality of object relations
(e.g., Piper et al., 199 Ib), and attitudes (e.g., Kokotovic & Tracey,
1990). Diagnostic features refers to the severity of the client's
symptoms in the beginning of treatment (e.g., Luborsky et al.,
1983) or to prognostic indices (e.g., Klee, Abeles, & Muller,
1990).
It appears that both intrapersonal and interpersonal client
variables have similar and significant effects on the alliance.
The average correlation coefficients (rs, weighted by sample
size) between these variables and alliance were .3 and .32, re-
spectively. Thus, clients who have difficulty maintaining social
relationships (e.g., Moras & Strupp, 1982) or have poor family
relationships (e.g., Kokotovic & Tracey, 1990) are less likely to
develop strong alliances. Similarly, patients with little hope for
success (e.g., Ryan & Cicchetti, 1985), who have poor object
relations (e.g., Piper et al., 1991b), who are defensive (e.g., Gas-
ton, Marmar, Thompson, & Gallagher, 1988), and who are not
psychologically minded (e.g., Ryan & Cicchetti, 1985) are often
associated with poor alliance in therapy. Severity of symptoms,
on the other hand, had but a small impact on the ability to
develop a good therapeutic relationship.
In a recent study, Piper and his colleagues (Piper et al., 1991 a)
investigated the relations among clients' quality of object rela-
tions (QOR), six aspects of current interpersonal functioning,
the level of the alliance, and three posttreatment and follow-up
outcome indicators. Their results support the link between the
client's early object relations and the ability to develop a positive
alliance—QOR had a statistically significant relation with alli-
ance as well as outcome (these correlations were similar in mag-
nitude, r KK .23)—but they found no significant relations be-
tween the quality of the client's current relationships and the
alliance. However, the alliance was a superior predictor of out-
come, compared with the QOR, suggesting that the quality of
the alliance is influenced but not determined by early relation-
ship experiences. Unfortunately, no information was provided
on the partial correlations among QOR, alliance, and outcome
to help us decide the important question of whether QOR and
alliance were predicting overlapping or distinct portions of the
outcome. Also, the alliance measure used in this investigation
was specifically developed for the project; thus, the results may
not be generalizable.
An important but unanswered question with respect to the
impact of the client pretreatment factors remains: Do these
variables affect the alliance only at the beginning phase of
treatment or throughout therapy? This question has crucial
practical implications. Therapists' strategies would depend on
whether the deleterious effects of poor object relations affect
only the initial building of the alliance or its subsequent mainte-
nance also.
Information on the impact of the therapists' pretreatment
567
characteristics is just emerging: Henry and Strupp (in press)
analyzed therapist-client transactions using a circumplex
model (the Structural Analysis of Social Behavior [SASB]; Ben-
jamin, 1974) and concluded that "the central theoretical mecha-
nism which underlies an interpersonal definition of the alli-
ance is clearly the process of introjection whereby [therapists]
intrapsychically represent past interpersonal relationships. In-
ternal representations of others guide not only actions toward
the self, but also tend to re-create the original interpersonal
patterns in current relationships." In a study currently in pro-
gress, the relation between therapist attachment styles and the
ability to develop the bond aspect of the alliance will be di-
rectly assessed for the first time (G. M. McKee, personal com-
munication, June 1992).
Another gap in our current knowledge is the effect of specific
therapist-client variable combinations on the development of
the alliance. An examination of the interaction of some of these
client-therapist variables may throw light on the configura-
tions that result in the therapist's misjudging the true status of
the alliance. Do some specific combinations of factors make
dropping out early from therapy more likely? We have some
evidence indicating that successful alliance may not be a matter
of direct matching of therapist-client characteristics but a prod-
uct of complementarity (Blumenthal, Jones, & Krupnick, 1985;
Goren, 1991; Kiesler & Watkins, 1989; Vervaeke & Vertommen,
1991). The investigation of these therapist and therapist-client
factors (including the investigation of the possible impact of
countertransference) represent an important new challenge in
alliance research.
Clinical Implications
Critical Alliance Phases
Current findings lead us to speculate that there might be two
important alliance phases. The first is the initial development
of the alliance, which takes place within the first five sessions
and probably peaks during Session 3 (Horvath, 1981; Saltzman,
Leutgert, Roth, Creaser, & Howard, 1976). During this phase,
satisfactory levels of collaboration and trust must be estab-
lished; the client needs to join the therapist as a participant in
the therapeutic journey, agree on what needs to be accom-
plished, and develop faith in the procedures that provide the
framework of the therapy. The second critical phase occurs as
the therapist begins to challenge old neurotic patterns. The
client may experience the therapist's more active interventions
as reduction of sympathy and support; this could reactivate the
client's past dysfunctional relational beliefs and behaviors, thus
weakening or rupturing the alliance. Such deterioration of the
relationship must be repaired if therapy is to continue success-
fully (Crits-Cristoph, Barber, & Kurcias, 1991; Safran et al.,
1992; Safran, Muran, & Wallner Samstag, in press).
This model implies that alliance may be damaged at differ-
ent times for different reasons. Depending on when such failure
occurs, therapy will be affected in diverse ways. Difficulties in
developing a supportive relationship and problems with con-
sensual endorsement of the therapeutic procedures can occur
in the beginning of therapy. In such cases, it is unlikely that the
client will adhere to the therapeutic regime, and premature
termination is probable (DeClericq, Goffinet, Hoyois, & Brus-
568 ADAM O. HORVATH AND LESTER LUBORSKY
selmans, 1991; Horvath, 1991; Kokotovic & Tracey, 1990).
Later, failure to experience interruptions in the alliance may be
a sign either that the therapy is "coasting" (i.e., dysfunctional
thoughts, affects, or behavior patterns are not challenged) or
that the client is responding to the therapist in an unrealistic,
idealized manner and is failing to use the therapeutic en-
counter to deal with important issues (i.e., there is positive trans-
ference but no alliance present). In these cases, therapy itself
becomes cyclical insofar as the in-therapy events have a regular
repetitive structure that may mirror past unresolved conflicts
(Henry & Strupp, in press). Therapy may also fail if the chal-
lenges to the alliance in the second phase are too severe or not
attended to properly and, as a result, the alliance rupture does
not heal (Safran et al, 1990, in press).
The model we are proposing draws on the concepts proposed
by Luborsky (1976), Bordin (1975,1976), Horvath (1991), and
Safran et al. (1990). There appears to be some evidence support-
ing the presence of the first alliance phase: Some researchers
have found that failure to develop these initial levels of the
alliance has a deleterious impact on outcome and may disrupt
therapy (i.e., DeClericq et al., 1991; Frank & Gunderson, 1990;
Kokotovic & Tracey, 1990; Plotnicov, 1990; Saunders et al.,
1989).
Empirical support for the second critical alliance phase is
emerging. Safran and his colleagues (1990) suggested that
"most therapy cases . . . are characterized by at least one or
more ruptures in the therapeutic alliance over the course of
therapy" (p. 154). Luborsky (1976) found that the strength of
the Type 2 alliance was related to the quality of outcome in
dynamic therapy. Similarly, Foreman and Marmar (1985) re-
ported that therapists were able to improve the level of alliance
by addressing the conflicted in-therapy relationships. Gaston
and her colleagues (1991) found that therapists who focused on
a client's problematic relationship improved the alliance, in
contrast with those who focused on problem content.
Reandeau and Wampold (1991) examined verbal transactions
of high- and low-alliance therapist-client dyads and found that
high-alliance clients responded to therapist-challenging inter-
ventions with nonreactive high-involvement statements,
whereas low-alliance clients used avoidance (low-involvement)
responses in these situations. Although some of the studies
cited here are based on small samples, the findings appear to be
consistent: The therapist's focus on the conflictual relationship
patterns in therapy and the client's ability to respond to these
challenges by involvement, as opposed to avoidance, contribute
to better alliance.
Therapist Interventions
Most studies of the alliance deal with the impact of the qual-
ity of the alliance on therapy outcome; we have much less re-
search data on the specific therapist techniques that improve
the relationship (Horvath & Symonds, 1991). This state of af-
fairs is hardly surprising. Therapy involves such a multitude of
contextual contingencies that isolating therapy techniques that
reliably affect the alliance across this broad range of situations
is very difficult (Butler & Strupp, 1986). Nonetheless, research
is unlikely to provide guidance to clinical practice unless the
relations between clearly defined therapist actions in specific
contexts and the effect of these interventions on process or
outcome can be demonstrated. Although this inquiry is in its
early stage, we will present some preliminary findings that ad-
dress these issues.
Collaboration
There is empirical support of Freud's original proposition
that a friendly, sympathetic attitude toward the client is benefi-
cial for the initial development of the alliance (Greenberg &
Adler, 1989; Horvath, 1981; Jones, 1988; Kokotovic & Tracey,
1990). This proposition is further confirmed by the finding that
early alliance measures are significantly correlated with mea-
sures of empathy as well as with outcome (Adler, 1988; Horvath
& Greenberg, 1989; Moseley, 1983). However, some of the re-
search on early alliance also suggests that the endorsements of
the tasks involved in therapy and a sense of collaboration with
the therapist are the factors most closely associated with posi-
tive outcome (Adler, 1988; Horvath & Greenberg, 1989). These
results seem to indicate that the clients' perception of the thera-
pists as accepting and supporting is closely linked with the
clients' perception of the appropriateness of technical aspects
of treatment and with the therapists' apparent willingness to
negotiate treatment goals. On one hand, the clients "clothe the
therapist with authority" (Freud, 1913, pp. 99-108), but on the
other hand, they also need to feel that this power and authority
is shared. This sense of collaboration and participation may
importantly contribute to a sense of safety that is essential for
the development of trust between therapist and client and deep
commitment to the therapeutic journey.
Using the Therapy Relationship
Safran and his colleagues (Safran et al., in press) developed a
theoretical model of the function of the alliance during therapy.
Their schema is congruent with Luborsky's (1977) work on the
Core Conflictual Relationship and also with Bordin's (1976)
model of the alliance. Briefly, they suggest that the client brings
dysfunctional interpersonal relationship schemas into the thera-
peutic situation that are reactivated during therapy. If the thera-
pist responds in a manner that confirms the schema, the cycle
is maintained or even exacerbated. If, on the other hand, the
pattern is recognized and the client's negative feelings toward
the therapist are examined, it is possible to disrupt the cycle
and assist the client to gain a better grasp of his or her patho-
genic ideas.
There is some empirical support for this model: Reandeau
and Wampold (1991) found that clients who responded with
high engagement to strong therapist intervention developed
better alliances than those patients who withdrew or used avoid-
ance maneuvers. Kivlighan and Schmitz (1992) described thera-
pists' equivalents of these findings: Therapists who were more
challenging and oriented toward addressing the therapeutic re-
lationship were more likely to improve the alliance than those
who did not address the current relationship or who were less
focused. There is some support for the view that the alliance is
not a steady state or linear phenomenon. Such regular varia-
tions in alliance levels were observed in a small-scale study
(Horvath & Marx, 1991). Other investigators, however, did not
report such cycles over time (Gomes-Swartz, 1978; Hartley &
Strupp, 1983; Krupnick, 1990; Marmar et al., 1989; Morgan,
 SPECIAL SECTION: THERAPEUTIC ALLIANCE IN PSYCHOTHERAPY
Luborsky, Crits-Cristoph, Curtis, & Solomon, 1982). The fail-
ure to observe variations over time in these investigations may
be due to the fact that, whereas Horvath and Marx (1991) moni-
tored individual alliance scores over time, the other investiga-
tors averaged scores across individuals, possibly masking
asynchronous fluctuations.
The clinical implications of this model are worth noting: It
follows from these principles that negative client sentiments,
avoidance, or even high levels of compliance may be signs of
disruption in the alliance. Safran et al. (in press) argue that the
therapist should attend carefully to these signals and provide
support and empathy for the client in order for him or her to
bring these conflicted feelings into full awareness. The proposi-
tion that direct attention to the vicissitudes of the in-therapy
relationship has a salutary impact fits well with Bordin's (in
press) notion that the alliance directly taps into the client's past
pathogenic relationships. There is also preliminary empirical
evidence, provided by Foreman and Marmar (1985), that thera-
pists may be able to strengthen the alliance by focusing on the
therapy relationship directly. These investigators found that ini-
tially poor alliances improved as a result of such action. Al-
though they interpret their findings with caution, noting that
the clients in the study had broadly heterogeneous symptoms
before therapy, other researchers (i.e., Coady, 1988; Marziali,
1984a) also noted that therapists' attention to negative in-ther-
apy experiences improved the alliance.
Interpretation
The research on the impact of interpretation on the alliance
presents a complex picture. Gaston (manuscript in preparation)
investigated the effect of frequency of interpretation on the
alliance and failed to find evidence of significant benefits.
Crits-Cristoph et al. (1991) researched the impact of the accu-
racy of interpretations and observed that there was a relation
between a specific type of interpretation (involving the ele-
ments of wish and response) and the quality of the alliance but
other interpretations appeared unrelated to the alliance. Also,
Piper (1991 b) discovered a curvilinear relationship between fre-
quency of interpretations and the quality of the alliance. It
seems likely that the type of interpretation, timing, and the
client's response potentials are important factors in determin-
ing whether this particular therapist intervention will
strengthen the alliance. At least one recent study appears to
verify elements of such reciprocity (Hentschel & Bijleved,
1991).
Some of the research results suggest that the relevance of the
interpretation to the current relationship between the therapist
and client is a factor in its efficacy: Addressing current stress in
the therapeutic relationship is more likely to improve the alli-
ance (repair the rupture) and result in therapeutic gains than
interpretations addressing out-of-therapy (past) events (Fore-
man & Marmar, 1985; Reandeau & Wampold, 1991).
Additional evidence supporting the intricacy of the relation
between therapist activity and the alliance is provided by Mal-
linckrodt and Nelson (1991), who studied the alliance ratings of
therapists with more advanced and less advanced levels of
training. The therapists with more advanced levels of training
had higher ratings on the Task and Goal scales of the Working
Alliance Inventory but were not rated differentially on the
569
Bond scale. These results suggest that more and less trained
therapists were equally liked and trusted; however, the better
trained, more experienced therapists who, presumably, were
more adept at the timing and pacing of their interventions, were
better able to engage the clients as collaborators and as capable
of selecting appropriate goals.
Training Implications
Although there is strong evidence that development and
maintenance of a strong alliance is helpful in keeping clients in
therapy as well as being a likely contributor to positive out-
come, the most effective curriculum and method of training
therapists to use this information in clinical practice is not yet
clear. Our increasing knowledge of therapists' actions that are
likely to contribute to alliance improvements do not necessar-
ily translate directly to effective training paradigms. For exam-
ple, Henry and Strupp (in press) have reported that training
specifically designed to sensitize therapists to the importance
of maintaining a positive alliance did not result in the kinds of
therapist's verbal behavior that, as they predicted, would lead
to better alliance. Similar findings were also reported by Babin
(1991). Henry and Strupp's data, in particular, seem to suggest
that the therapist's ability to respond accurately to the demands
of the therapeutic relationship may be blocked by her or his
own relational issues. Whether these therapist factors are uni-
form across clients or specifically reactive to specific client is-
sues is currently unclear.
Conclusions
Current Status of Alliance Research
Recent developments of the alliance concept made it possible
to use this construct in a variety of theoretical frameworks.
Some of the current alliance formulations also facilitate the
bridging of the traditional distinctions between the relation-
ship and technique aspects of therapy and thus help us to better
understand the interactive nature of all aspects of treatment.
Much of the impetus for alliance research can be traced to
the development of measures that operationalized the alliance.
These measures show evidence of reliability, and there are some
data supporting their validity. Most of the support for these
instruments' validity, however, comes from the positive relation
between the measures and outcomes of psychotherapy. Less
evidence is available on how well these instruments represent
the various theoretical definitions. A variety of alliance compo-
nents have also been operationalized by the development of
these instruments, and there is emerging evidence that these
components may be of different importance at different points
of therapy. However, there is limited agreement across instru-
ments on the identity of these components; thus, the evidence
has yet to converge on what elements of the alliance play an
important role at particular stages of different therapies.
The positive relation between good alliance and successful
therapy outcome is reasonably well documented across a vari-
ety of different therapies. We are adequately certain that alli-
ance in the beginning of the therapy is a good prognosticator of
premature termination. There is also data to support the hy-
pothesis that good alliance is supported by somewhat different
570 ADAM O. HORVATH AND LESTER LUBORSKY
factors in the beginning and later stages of therapy. Moreover,
fluctuations in the alliance, particularly in the middle phase,
appear to reflect the reemergence of the client's dysfunctional
relationship patterns and the therapist's skill in recognizing
and resolving these issues. A related finding is that the client's
(and perhaps the therapist's) pretherapy interaction patterns or
capacities influence, but do not determine, the course of alli-
ance development.
Future Directions for Alliance Research
Although the past 15 years of research has verified the useful-
ness of the alliance construct, we need to further develop the
broader theoretical framework of therapeutic change in which
this concept may be fruitfully embedded. Models describing
specific alliance-related client experiences leading to predict-
able change patterns are needed. Also, to make the alliance
more useful in clinical practice, we must explore not only the
pretherapy variables that influence each participant's potential
to forge an alliance but also the specific therapist activities that
address the different aspects of the alliance at different phases
of therapy.
The most urgent priorities to achieve these goals are (a) a
better understanding of the overlap and differences among the
various measures of the alliance and the alliance components;
(b) more fine-grained studies aimed at identifying specific ther-
apist actions that facilitate alliance development or the repair
of a disrupted alliance in specific treatments and at different
stages of therapy; (c) investigation of the differences between
the therapist's and the client's assessment of the alliance to
identify the factors that lead to therapist misjudgment of the
quality of the alliance; (d) investigation of the relation between
the clients' and therapists' relational issues and development of
a good alliance; and (e) examination of the relation between
therapeutic gains and subsequent changes in the level of the
alliance throughout the course of therapy.
References
Adler, J. V (1988). A study of the working alliance in psychotherapy.
Unpublished doctoral dissertation, University of British Columbia.
Alexander, L. B., & Luborsky, L. (1987). The Penn Helping Alliance
Scales. In L. S. Greenberg& W M. Pinsof (Eds.), Thepsychotherapeu-
tic process: A research handbook (pp. 325-366). New 'York: Guilford
Press.
Babin, R. J. (1991). Basic counselor skills scoring method as a predictor
of the counselor trainee's effectiveness in establishing a working alli-
ance. Unpublished master's thesis, Nicholls State University, Thibo-
daux, LA.
Bachelor, A. (1991). Comparison and relationship to outcome of di-
verse dimensions of the helping alliance as seen by client and thera-
pist. Psychotherapy: Theory Research and Practice, 28, 534-539.
Barber, J., Crits-Cristoph, P., & Luborsky, L. (1992, June). "Purified"
helping alliance, early symptomatic improvement and outcome in dy-
namic psychotherapy for depression. Paper presented at the annual
meeting of the Society for Psychotherapy Research, Berkeley, CA.
Barrett-Lennard, G. T. (1985). The helping relationship: Crisis and ad-
vance in theory and research. The Counseling Psychologist, 13, 278-
294.
Battle, L. C., Imber, S. D., Hoen-Saric, R., Stone, A. R., Nash, E. H., &
Frank, J. D. (1966). Target complaints as criteria of improvement.
American Journal of Psychotherapy, 20,184-192.
Benjamin, L. S. (1974). Structural analysis of social behavior. Psychol-
ogical Review, 81, 392-425.
Beutler, L. E. (1979). Toward specific psychological therapies for spe-
cific conditions. Journal of Consulting and Clinical Psychology, 47,
882-897.
Bibring, E. (1937). On the theory of the results of psychoanalysis. Inter-
national Journal of'Psycho-Analysis, 18, 170-189.
Blumenthal, S. J., Jones, E. E., & Krupnick, J. L. (1985). The influence
of gender and race on the therapeutic alliance. Psychiatry Update
Annual Review, 4, 586-601.
Bordin, E. S. (1976, September). The working alliance: Basis for a gen-
eral theory of psychotherapy. Paper presented at the Annual Conven-
tion of the American Psychological Association, Washington, DC.
Bordin, E. S. (1976). The generalizability of the psychoanalytic con-
cept of the working alliance. Psychotherapy: Theory Research and
Practice, 16, 252-260.
Bordin, E. S. (1980, June). Of human bonds that bind or free. Paper
presented at the annual meeting of the Society for Psychotherapy
Research, Pacific Grove, CA.
Bordin, E. S. (1989, April). Building therapeutic alliances: The base for
integration. Paper presented at the annual meeting of the Society for
the Exploration of Psychotherapy Integration, Berkeley, CA.
Bordin, E. S. (in press). Theory and research on the therapeutic work-
ing alliance: New directions. In A. O. Horvath & L. S. Greenberg
(Eds.), The working alliance: Theory, research, and practice. New
York: Wiley.
Bowlby, J. (1988). A secure base: Clinical applications of attachment
theory. London: Routledge & Kegan Paul.
Brenner, C. (1979). Working alliance, therapeutic alliance, and transfer-
ence. Journal of the American Psychoanalytic Association, 27, 136-
158.
Butler, S. E, & Strupp, H. H. (1986). Specific and nonspecific factors in
psychotherapy: A problematic paradigm for psychotherapy re-
search. Psychotherapy: Theory Research and Practice, 23, 30-40.
Cartwright, D. S. (1965). Influence leadership and control. In J. G.
March (Ed.), Handbook of organizations (pp. 1-47). Chicago: Rand
McNally.
Coady, N. (1988, June). Prediction of outcome from interpersonal pro-
cess: A study of the worker-client relationship. Paper presented at the
annual meeting of the Society for Psychotherapy Research, Santa Fe,
NM.
Crits-Cristoph, P., Barber, J., & Kurcias, J. S. (1991). The accuracy of
therapists'interpretations and the development of the therapeutic alli-
ance. Manuscript submitted for publication.
Curtis, H. C. (1979). The concept of the therapeutic alliance: Implica-
tions for the "widening of scope." Journal of the American Psychoan-
alytic Association, 27, 159-192.
DeClericq, M., Goflmet, S., Hoyois, P., & Brusselmans, M. (1991,
June). Crisis intervention in emergency: Project design and prelimi-
nary outcome data. Paper presented at the annual meeting of the
Society for Psychotherapy Research, Lyon, France.
Derogatis, L. R., Rickels, K., & Rock, A. F. (1976). The SCL-90 and the
MMPI: A step in the validation of a new self-report scale. British
Journal of Psychiatry, 128, 280-289.
DeRubeis, R. J., & Feeley, M. (1991). Determinants of change in cogni-
tive therapy for depression. Cognitive Therapy and Research.
Eaton, T. T, Abeles, N., & Gutfreund, M. J. (1988). Therapeutic alli-
ance and outcome: Impact of treatment length and pretreatment
symptomology. Psychotherapy: Research and Practice, 25, 536-542.
Foreman, S., & Marmar, R. C. (1985). Therapist actions that address
initially poor therapeutic alliances in psychotherapy. American
Journal of Psychiatry, 922-926.
Frank, A. E, & Gunderson, J. G. (1990). The role of the therapeutic
alliance in the treatment of schizophrenia. Archives of General Psy-
chiatry, 47, 228-236.
Freud, S. (1958). The dynamics of transference. In J. Starchey (Ed.), The
 SPECIAL SECTION: THERAPEUTIC ALLIANCE IN PSYCHOTHERAPY
standard edition of the complete psychological works of Sigmund
Freud (pp. 99-108). London: Hogarth Press. (Original work pub-
lished 1912)
Freud, S. (1913). On the beginning of treatment: Further recommenda-
tions on the technique of psychoanalysis. In J. Strachey (Ed. and
Trans.), The standard edition of the complete psychological works of
Sigmund Freud(pp. 122-144). London: Hogarth Press.
Frieswyk, S. H., Gabbard, G. O., Horwitz, L. Allen, J. G, Colson, D. B.,
Newsom, G. E., & Coyne, L. (in press). The role of the working
alliance in psychoanalytic therapy with borderline patients. In A. O.
Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, re-
search and practice. New York: Wiley.
Gaston, L. (1990). The concept of the alliance and its role in psycho-
therapy: Theoretical and empirical considerations. Psychotherapy,
27, 143-153.
Gaston, L. (1991). Reliability and criterion-related validity of the Cali-
fornia Psychotherapy Alliance Scales—Patient version. Psychologi-
cal Assessment, 3, 68-74.
Gaston, L., Marmar, C. R., Thompson, L. W, & Gallager, D. (1988).
Relation of patient pretreatment characteristics to the therapeutic
alliance in diverse psychotherapies. Journal of Consulting and Clini-
cal Psychology, 56, 483-489.
Gaston, L., Marmar, C. R., Thompson, L. W, & Gallager, D. (1991).
Alliance prediction of outcome beyond in-treatment symptomatic
change as psychotherapy progresses. Psychotherapy Research, 1,
104-112.
Gaston, L., & Ring, J. M. (1992). Preliminary results on the Inventory
of Therapeutic Strategies. Journal of Psychotherapy Research and
Practice, 1,1-13.
Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling and
psychotherapy: Components, consequences, and theoretical ante-
cedents. The Counseling Psychologist, 2,155-243.
Gitleson, M. (1962). The curative functions in psychotherapy. Interna-
tional Journal of Psychoanalysis, 43,194-205.
Gomes-Swartz, B. (1978). Effective ingredients in psychotherapy: Pre-
diction of outcome from process variables. Journal of Consulting and
Clinical Psychology, 46,1023-1035.
Goren, L. (1991). The relationship of counselor androgyny to the working
alliance. Unpublished doctoral dissertation, University of Southern
California.
Greenberg, L. S., & Adler, J. (June 1989). The working alliance and
outcome: A client report study. Paper presented at the annual meeting
of the Society for Psychotherapy Research. Toronto, Ontario.
Greenson, R. R. (1965). The working alliance and the transference
neuroses. Psychoanalysis Quarterly, 34, 155-181.
Greenson, R. R. (1967). Technique and practice of psychoanalysis. New
York: International University Press.
Gutfreund, M. J. (1992, June). A close-up look at the alliance in a single
case. Paper presented at the annual meeting of the Society for Psycho-
therapy Research, Berkeley, CA.
Hansell, J. (1990, June). The relationship of the California Psychotherapy
Alliance Scales to other measures of the alliance. Paper presented at
the annual meeting of the Society for Psychotherapy Research, Win-
tergreen, VA.
Hartley, D. (1985). Research on the therapeutic alliance in psychother-
apy. In R. Hales & A. Frances (Eds.), Psychiatry update annual review
(pp. 532-549). Washington, DC: American Psychiatric Press.
Hartley, D. E., & Strupp, H. H. (1983). The therapeutic alliance: Its
relationship to outcome in brief psychotherapy. In J. Masling (Ed.),
Empirical studies in analytic theories (pp. 1-37). Hillside, NJ: Erl-
baum.
Hatcher, R. (1990, June). Transference and the therapeutic alliance.
Paper presented at the annual meeting of the Society for Psychother-
apy Research, Wintergreen, VA.
Henry, W P., & Strupp, H. H. (in press). The therapeutic alliance as
571
interpersonal process. In A. O. Horvath & L. S. Greenberg (Eds.),
The working alliance: Theory, research and practice New York: Wiley.
Hentschel, U, & Bijleved, C. J. H. (1991). It takes two to therapy: On
differential aspects in the formation of therapeutic alliance (Leiden
Psychological Reports: Personality Psychology No. 03-91). Leiden
University, the Netherlands.
Hill, C. E., & O'Grady, K. E. (1985). List of therapist intentions illus-
trated in a case study and with therapists of varying theoretical
orientations. Journal of Counseling Psychology, 32, 3-22.
Horowitz, M., & Marmar, C. (1985). The therapeutic alliance with
difficult patients. In R. Hales & A. Frances (Eds.), Psychiatry Update
Annual Review (pp. 573-584). Washington, DC: American Psychiat-
ric Press.
Horvath, A. O. (1981). An exploratory study of the working alliance: Its
measurement and relationship to outcome. Unpublished doctoral dis-
sertation, University of British Columbia.
Horvath, A. O. (1982). Working Alliance Inventory (Revised). Instruc-
tional Psychology Research Group, 82 (1). Simon Fraser University,
Burnaby, British Columbia, Canada.
Horvath, A. O. (1991). What do we know about the alliance and what do
we still have to find out? Paper presented at the annual meeting of the
Society for Psychotherapy Research, Lyon, France.
Horvath, A. O. (in press). Empirical research on the alliance. In A. O.
Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, re-
search and practice. New York: Wiley.
Horvath, A. O., Gaston, L., & Luborsky, L. (in press). The role of the
alliance in psychotherapy. In N. Miller, L. Luborsky, J. Barber, & J.
Docherty (Eds.), Handbook of psychodynamic psychotherapy:
Theory and research. New York: Basic Books.
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation
of the Working Alliance Inventory. Journal of Counseling Psychology,
36, 223-233.
Horvath, A. O., & Marx, R. W (1991). The development and decay of
the Working Alliance during time-limited counselling. Canadian
Journal of Counselling, 24, 240-259.
Horvath, A. O, Marx, R. W, & Kamann, A. M. (1990). Thinking about
thinking in therapy: An examination of clients' understanding of
their therapists' intentions. Journal of Consulting and Clinical Psy-
chology, 55,614-621.
Horvath, A. O, & Symonds, B. D. (1991). Relation between working
alliance and outcome in psychotherapy: A meta-analysis. Journal of
Counseling Psychology, 38,139-149.
Horwitz, L. (1974). Clinical prediction in psychotherapy. Northvale, NJ:
Jason Aronson.
Hovland, C. I, Janis, I. L., & Kelley, H. H. (1953). Communication and
persuasion: Psychological studies of opinion change. New Haven, CT:
Yale University Press.
Jones, S. S. (1988). An exploration of the relationship between client ex-
pectations and the working alliance. Unpublished doctoral disserta-
tion, University of Mississippi.
Kiesler, D. J., & Watkins, L. M. (1989). Interpersonal complementarity
and the therapeutic alliance: A study in relationship in psychother-
apy. Psychotherapy: Research and Practice, 26, 183-194.
Kivlighan, D. M., Jr., & Schmitz, P. J. (1992). Counselor technical activ-
ity in cases with improving working alliances and continuing-poor
working alliances. Journal of Counseling Psychology, 39, 32-38.
Klee, M. R, Abeles, N., & Muller, R. T. (1990). Therapeutic alliance:
Early indicators, course, and outcome. Psychotherapy: Research and
Practice, 27,166-174.
Kokotovic, A. M., & Tracey, T. J. (1990). Working alliance in the early
phase of counseling. Journal of Counseling Psychology, 37, 16-21.
Krupnick, J. (1990, June). The relationship of therapeutic alliance and
outcome in interpersonal psychotherapy and cognitive behavioral ther-
apy. Paper presented at the annual meeting of the Society for Psycho-
therapy Research, Wintergreen, VA.
 572 ADAM O. HORVATH AND LESTER LUBORSKY
Krupnick, J., Stotsky, S., Simmens, S., & Moyer, J. (1992, June). The role
of therapeutic alliance in psychotherapy and pharmacotherapy out-
come: Findings in the NIMH Treatment of Depression Collaborative
Research Program. Paper presented at the annual meeting of the
Society for Psychotherapy Research, Berkeley, CA.
LaCrosse, M. B. (1980). Perceived counselor social influence and coun-
seling outcomes: Validity of the Counselor Rating Form. Journal of
Counseling Psychology, 27, 320-327.
Luborsky, L. (1976). Helping alliances in psychotherapy. In J. L. Clegh-
horn (Ed.), Successful psychotherapy (pp. 92-116). New York: Brun-
ner/Mazel.
Luborsky, L. (1977). Measuring a persuasive psychic structure in psy-
chotherapy: The core conflictual relationship theme. In N. Freed-
man & S. Grand (Eds.), Communicative structures and psychic struc-
tures (pp. 367-395). New York: Plenum.
Luborsky, L. (in press). Therapeutic alliance measures as predictors of
future benefits of psychotherapy. In A. O. Horvath & L. S. Greenberg
(Eds.), The working alliance: Theory, research and practice. New York:
Wiley.
Luborsky, L., & Auerbach, A. (1985). The therapeutic relationship in
psychodynamic psychotherapy: The research evidence and its
meaning for practice. In R. Hales & A. Frances (Eds.), Psychiatry
update annual review (pp. 550-561). Washington, DC: American
Psychiatric Association.
Luborsky, L., Crits-Cristoph, P., Alexander, L., Margolis, M., & Cohen,
M. (1983). Two helping alliance methods for predicting outcomes of
psychotherapy: A counting signs vs. a global rating method. Journal
of Nervous and Mental Disease, 171, 480-491.
Luborsky, L., McLellan, A. T, Woody, G. E., O'Brien, C. P., & Auerbach,
A. (1985). Therapist success and its determinants. Archives of Gen-
eral Psychiatry, 42, 602-611.
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, 995-1008.
Mallinckrodt, B., & Nelson, M. L. (1991). Counselor training level and
the formation of the psychotherapeutic working alliance. Journal of
Counseling Psychology, 38,133-138.
Marmar, C. R., Horowitz, M. J., Weiss, D. S., & Marziali, E. (1986). The
development of the therapeutic alliance rating system. In L. S.
Greenberg & W M. Pinsof (Eds.), The psychotherapeutic process: A
research handbook (pp. 367-390). New York: Guilford Press.
Marmar, C., Weiss, D. S., & Gaston, L. (1989). Toward the validation of
the California Therapeutic Alliance Rating System. Psychological
Assessment: A Journal of Consulting and Clinical Psychology, 1, 46-
52.
Martin, J., Martin, W, & Slemon, A. G. (1989). Cognitive-mediational
models of action-act sequences in counseling. Journal of Counseling
Psychology, 36, 8-16.
Marziali, E. (1984a). Prediction of outcome of brief psychotherapy
from therapist interpretive interventions. Archives of General Psychi-
atry, 41, 301-305.
Marziali, E. (1984b). Three viewpoints on the therapeutic alliance
scales similarities, differences and associations with psychotherapy
outcome. Journal of Nervous and Mental Disease, 172, 417-423.
Marziali, E., Marmar, C, & Krupnick, J. (1981). Therapeutic alliance
scales: Development and relationship to psychotherapy outcome.
American Journal of Psychiatry, 138, 361-364.
Mitchell, K. M., Bozart, J. D, & Krauft, C. C. (1977). Reappraisal of
the therapeutic effectiveness of accurate empathy, non-possessive
warmth, and genuineness. In A. S. Gurman & A. M. Razin (Eds.),
Effective psychotherapy (pp. 482-502). New York: Pergamon Press.
Moras, K., & Strupp, H. H. (1982). Pretherapy interpersonal relations,
patients' alliance and the outcome in brief therapy. Archives of Gen-
eral Psychiatry, 405-409.
Morgan, R., Luborsky, L., Crits-Cristoph, P., Curtis, H., & Solomon, J.
(1982). Predicting the outcomes of psychotherapy by the Penn Help-
ing Alliance Rating Method. Archives of General Psychiatry, 39,397-
402.
Moseley, D. (1983). The therapeutic relationship and its association with
outcome. Unpublished master's thesis, University of British Colum-
bia, Vancouver, Canada.
Orlinsky, D. E., & Howard, K. I. (1986). The psychological interior of
psychotherapy: Explorations with the Therapy Session Report
Questionnaires. In L. S. Greenberg & W M. Pinsof (Eds.), The psy-
chotherapeutic process: A research handbook. New York: Guilford
Press.
Piper, W E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (199la).
Transference interpretations, therapeutic alliance and outcome in
short-term individual psychotherapy. Archives of General Psychiatry,
48, 946-953.
Piper, W E., Azim, H. F. A., Joyce, A. S., McCallum, M., Nixon,
G. W H., & Segal, P. S. (1991b). Quality of object relations vs. inter-
personal functioning as predictor of therapeutic alliance and psycho-
therapy outcome. Journal of Nervous and Mental Disease, 179, 432-
438.
Piper, W E., DeCarufel, F L., & Szkrumelack, N. (1985). Patient pre-
dictors of process and outcome in short-term individual psychother-
apy. Journal of Nervous and Mental Disease, 173, 726-733.
Plotnicov, K. H. (1990). Early termination from counseling: The client's
perspective. Unpublished doctoral dissertation, University of Pitts-
burgh, PA.
Raue, P. J., Castunguay, L. G., & Goldfried, M. R. (1991, July). The
working alliance: A comparison of two therapies. Paper presented at
the annual meeting of the Society for Psychotherapy Integration,
London.
Reandeau, S. G., & Wampold, B. E. (1991). Relationship of power and
involvement to working alliance: A multiple-case sequential analysis
of brief therapy. Journal of Counseling Psychology, 38, 107-114.
Rogers, C. R. (1951). Client-centered therapy. Cambridge, MA: River-
side Press.
Rogers, C. R. (1957). The necessary and sufficient conditions of thera-
peutic personality change. Journal of Consulting andClinical Psychol-
ogy, 22, 95-103.
Rogers, C. R., Gendlin, G. T, Kiesler, D. V, & Truax, L. B. (1967). The
therapeutic relationship and its impact: A study of psychotherapy with
schizophrenics. Madison: University of Wisconsin Press.
Rounsaville, B. J., Chevron, E. S., Prusoff, B. A., Elkin, L, Imber, S.,
Sotsky, S., & Watkins, J. (1987). The relation between specific and
general dimensions of the psychotherapy process in interpersonal
psychotherapy of depression. Journal of Consulting and Clinical Psy-
chology, 55, 379-384.
Ryan, E. R., & Cicchetti, D. V(1985). Predicting quality of alliance in
the initial psychotherapy interview. Journal of Nervous and Mental
Disease, 717-725.
Safran, J. D, Crocker, P., McMain, S., & Murray, P. (1990). The therapeu-
tic alliance rupture as a therapy event for empirical investigation.
Psychotherapy, 27,154-165.
Safran, J. D, Muran, C. J., & Wallner Samstag, L. (1992, June). A com-
parison of therapeutic alliance rupture resolution and nonresolution
events. Paper presented at the annual meeting of the Society for
Psychotherapy Research, Berkeley, CA.
Safran, J. D, Muran, J. C., & Wallner Samstag, L. (in press). Resolving
therapeutic ruptures: A task analytic investigation. In A. O. Horvath
& L. S. Greenberg (Eds.), The working alliance: Theory, research, and
practice. New \brk: Wiley.
Safran, J. D., & Wallner, L. K. (1991). The relative predictive validity of
two therapeutic alliance measures in cognitive therapy. Psychologi-
cal Assessment: A Journal of Consulting and Clinical Psychology, 3,
188-195.
Saltzman, C., Leutgert, M. J., Roth, C. H., Creaser, J., & Howard, L.
(1976). Formation of a therapeutic relationship: Experiences during
 SPECIAL SECTION: THERAPEUTIC ALLIANCE IN PSYCHOTHERAPY 573

the initial phase of psychotherapy as predictors of treatment dura-
tion and outcome. Journal of Consulting and Clinical Psychology, 44,
546-555.
Salvio, M. A., Beutler, L. E., Wood, J. M., & Engle, D. (1992). The
strength of the therapeutic alliance in three treatments for depres-
sion. Psychotherapy Research, 2, 31-36.
Saunders, S. M., Howard, K. I., & Orlinsky, D. E. (1989). The therapeu-
tic bond scales: Psychometric characteristics and relationship to
treatment effectiveness. Psychological Assessment: A Journal of Con-
sulting and Clinical Psychology, 1, 323-330.
Shadish, W. R., Jr., & Sweeney, R. B. (1991). Mediators and moderators
in meta-analysis: There's a reason we don't let dodo birds tell us
which psychotherapies should have prizes. Journal of Consulting and
Clinical Psychology, 59, 883-893.
Smith, M. L., & Glass, G. V (1977). Meta-analysis of psychotherapy
outcome studies. American Psychologist, 32, 752-760.
Sterba, R. F. (1934). The fate of the ego in analytic therapy. Interna-
tional Journal of Psychoanalysis, 115, 117-126.
Stiles, W B., Shapiro, D., & Elliott, R. (1986). Are all psychotherapies
equivalent? American Psychologist, 41,165-180.
Strong, S. R. (1968). Counseling: An interpersonal influence process.
Journal of Counseling Psychology, 15, 215-224.
Strupp, H. H. (1974). On the basic ingredients of psychotherapy. Psy-
chotherapy and Psychosomatics, 24, 249-260.
Svartberg, M., & Stiles, T. C. (1992, June). Therapeutic alliance and
treatment competence: Their relations to patient change in short-term
anxiety provoking psychotherapy. Paper presented at the annual
meeting of the Society for Psychotherapy Research, Berkeley, CA.
Tichenor, Y, & Hill, C. E. (1989). A comparison of six measures of
working alliance. Psychotherapy, 26, 195-199.
Vervaeke, G., & Vertommen, H. (1991, July). Similarity, acceptability
and convergence: Specific and non-specific factors. Paper presented at
the annual meeting of the Society for the Exploration of Psychother-
apy Integration, London.
Watson, J. C., & Greenberg, L. S. (in press). The alliance in experiential
therapy: Enacting the relationship conditions. In A. O. Horvath &
L. S. Greenberg (Eds.), The working alliance: Theory and research
New York: Wiley.
Windholz, M. I, & Silbershatz, G. (1988). Vanderbilt psychotherapy
process scale: A replication with adult outpatients. Journal of Con-
sulting and Clinical Psychology, 56, 56-60.
Zetzel, E. R. (1956). Current concepts of transference. International
Journal of Psychoanalysis, 37, 369-376.
Received April 18,1992
Revision received December 16,1992
Accepted February 26,1993 •

Low Publication Prices for APA Members and Affiliates

Keeping You Up-to-Date: All APA members (Fellows; Members; Associates, and Student
Affiliates) receive—as part of their annual dues—subscriptions to the American Psychologist and
APA Monitor.
High School Teacher and International Affiliates receive subscriptions to the APA Monitor,
and they can subscribe to the American Psychologist at a significantly reduced rate.
In addition, all members and affiliates are eligible for savings of up to 60% (plus a journal
credit) on all other APA journals, as well as significant discounts on subscriptions from coop-
erating societies and publishers (e.g., the American Association for Counseling and Develop-
ment, Academic Press, and Human Sciences Press).
Essential Resources: APA members and affiliates receive special rates for purchases of APA
books, including the Publication Manual of the APA, the Master Lectures, and Journals in Psychol-
ogy: A Resource Listing for Authors.
Other Benefits of Membership: Membership in APA also provides eligibility for low-cost
insurance plans covering life, income protection, office overhead, accident protection, health
care, hospital indemnity, professional liability, research/academic professional liability, stu-
dent/school liability, and student health.
For more information, write to American Psychological Association,
Membership Services, 750 First Street, NE, Washington, DC 20002-4242, USA

Viewpublicationstats