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Psychotherapy: Theory, Research, Practice, Training 2006, Vol. 43, No.

3, 258 263

Copyright 2006 by the American Psychological Association 0033-3204/06/$12.00 DOI: 10.1037/0033-3204.43.3.258


Simon Fraser University

Research on the alliance is reviewed in a historic context. Different conceptualizations of the nature and role of the alliance are examined within the framework of theories about the role and function of the relationship in treatment. The evolution of these concepts is cast in the broader context of the current debate concerning an appropriate conceptual framework for empirically supported therapy. Using these perspectives, several persistent challenges are highlighted: the need to develop a clearer denition of the alliance; the challenge of reaching a broad consensus about the alliances relation to other elements in the therapeutic relationship; and the task of more clearly specifying the role and function of the alliance in different phases of treatment. The paper concludes with an examination of how such a historically informed perspective might offer useful indicators for future research. Keywords: psychotherapy process, therapeutic relationship, alliance
Empirical research on the therapeutic relationship in general, and the alliance in particular, has been growing exponentially for over

The preparation of this article was supported, in part, by Grant 41204-1816 from the Social Sciences and Humanities Research Council of Canada. Correspondence regarding this article should be addressed to Adam O. Horvath, Faculty of Education Counseling Psychology Program, Simon Fraser University, Burnaby, British Columbia, Canada. E-mail:

20 years (Horvath, 2001). Much has been accomplished over the past 2 decades, particularly in documenting the positive links between the quality of the alliance and therapy outcome. The results of these investigations have been summarized and synthesized on a number of occasions (Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Nonetheless, on reviewing the accumulated literature, it appears that some questions about the role and function of the alliance may not have been fully resolved. In addition, there has been relatively little discussion about how the research on the alliance may be related to some of the overarching issues currently debated in the eld. In particular, it may be instructive to re-examine how the literature on the alliance may parallel some aspects of the current search to identify the most appropriate level for developing empirical support for psychotherapy practice: treatments, relationships, or principles (Castonguay & Beutler, 2005; Chambless & Hollon, 1998; Norcross, 2002). It seems timely, therefore, to take a step back to re-examine this growing body of work in its broader context. In this article, I will attempt to explore whether such a birds eye perspective might help to guide us in charting future research directions. The notion that the relationship between therapist and client has a profound effect on the therapeutic journey reaches back to the middle period of Freuds writings (Freud, 1913). Although the importance of the relationship has never been seriously challenged (except perhaps by the earliest proponents of behavior modication), the exact nature of the alliance (i.e., What is it made of?) and how these elements affect therapy outcome has been a matter of considerable debate from the beginning. Some of the questions debated are as follows: Is the alliance a conscious real relationship, or transference based (Gelso & Carter, 1985)? Is the effect on therapy outcomes directly impacted by the quality of the alliance, or might the alliance be better thought of as


The Alliance in Context providing the opportunity to put into effect efcacious strategies that are, in turn, responsible for the positive changes? The place of the relationship within the overall conceptualization of the therapeutic change process has also been a matter of some controversy from the start (Abend, 2000; Ferenczi, 1932; Sterba, 1934). Early analytical writers tended to see the alliance as facilitative rather than directly responsible for change. They also emphasized the unconscious (positive) transference conceptualization (Zetzel, 1956). A different perspective on the nature of the therapeutic relationship emerged in the 1950s, most powerfully voiced by Rogers (1957; Rogers, Gendlin, Kieser, & Truax, 1967) but also endorsed by authors sympathetic to the experiential/ humanistic perspective (e.g., Gendlin, 1964; Watson, Greenberg, & Lieter, 1998; Yalom, 2002). This line of thinking treats the therapeutic relationship as real and based primarily on the here and now of the therapist client encounter. A variety of ideas were proposed within this conceptualization about the essential components of the positive therapeutic relationship and the nature of the psychological mechanism through which the relationship actually heals. The common core of these arguments is that the quality of the therapist client relationship directly contributes to therapy outcome; the relationship is curative in and of itself. There are also conceptual challenges within this position: An extensive body of research on Rogerss therapist-offered facilitative conditions indicates thatrather than observable, objective, evidence of therapists empathy, congruence, and positive regard, which Rogers argued are the actual quanta of the relational qualityit is the clients construal of the relationship that is most closely related to therapy effectiveness (Mitchell, Bozart, & Krauft, 1977). Moreover, it has become evident that the qualities of the therapeutic relationship that clients experience as empathic are not uniform (Bachelor, 1988), and the proposed underlying client process of self-actualizing tendency has proven difcult to document empirically. Most important, from the clinical as well as the empirical perspective, each of the proposed models for the role of relationship in therapy the unconsciousfacilitative conceptualization, and the here-and-now, conscious, effective ingredient formulationseems incomplete without the other. The revival of interest in the alliance was triggered by the work of Luborsky (Alexander & Luborsky, 1987; Luborsky, 1976) and Bordin (1976, 1994). It seems that both of these researchers grasped the difculties with previous conceptualizations and strived to bridge the gaps between the consciousrational versus unconscioustransferential as well as the facilitative versus active-ingredient dichotomies. Both Luborsky and Bordin were clearly informed by psychodynamic theories, but they cast the alliance in a much broader framework encompassing all types of helping relationships and, in the process, tacitly moved the historical transference element into the background. These formulations emphasized the conscious, reality-based aspects of the alliance. Theoretically, Bordin and Luborskys explications of the alliance represented a major step forward both in resolving the troubling divisions noted earlier and in moving the concept of the alliance on to theoretically neutral or pantheoretical grounds. However, it is important to note that these formulations neither dealt with the problem of delineating clearly the alliance from other aspects of the relationship nor (also important to note) anticipated the emerging dichotomy between relationship and technique that surfaced in the literature around this time. Likewise, the facilitative versus active ingredient issue remained somewhat ambiguous. Although Bordin appeared to lean more toward the active ingredient side (Bordin, 1994), and Luborsky seemed to favor slightly a facilitative hypothesis (Luborsky, 1984), no explicit resolution of this question was attempted at this time. This ambiguity, it appears, left the alliance concept and indeed the relationship theory somewhat incoherent and disconnected from other aspects of theorizing about the therapy process. Although researchers had shown that the alliance played a signicant role in just about any form of therapy (Horvath, 1994; Horvath & Bedi, 2002; Martin et al., 2000), the questions of how the alliance would articulate with the healing process in general and how it would interact with specic healing practices were less often addressed directly. It is also important to note that, in this revisioning of the alliance, the concept was, in practice, treated as a uniform phenomena in two senses: It was similar across different therapies


Horvath and also uniform across time.1 The idea that the relationship plays an important role across different helping contexts was central to the new understanding of the alliance. However, the notion that the optimal therapeutic relationship has uniform qualities across time bears careful examination. Progressive enrichment and complexity are characteristics of all intimate relationships: Why should we assume that such is not the case in therapy? The qualities of agreement or consensus on goals and tasks, the formation of caring and trusting personal bonds, and even the emergence of a collaborative stance, are relatively uniform characteristics typical of the beginning or engagement phase of most therapies. It is also reasonable to assume that these issues retain some relevance in later phases. However, as the relationship evolves and becomes more complex, processes like agreement on tasks and goals become increasingly embedded in the therapy routine itself. It was argued elsewhere (Horvath, 2003) that qualities such as freedom to share negative emotional responses and the permission to critically and mindfully engage in a metadiscourse about the immediate here-and-now relational pattern may be more appropriate and discriminating landmarks of the quality of the mature phase of the therapeutic alliance. Last, tacit assumptions about the nature of the alliance in therapy have not yet been fully examined. Is the alliance essentially an intrapersonal process? Formulations of the alliance based on classical notions of transference would be one example of such a viewpoint (Greenson, 1965), as are narrative and other postmodern perspectives that emphasize the importance of the individuals internal contextualization of relational events (Gonclaves, 1994). Alternatively, the alliance may be construed as an essentially interpersonal phenomenon. Bordins (1994) emphasis on collaboration as well as some of the more recent formulations of transference (Mitchell, 1993) are consistent with this notion. It is interesting to note that the evidence appears to support both these perspectives: The consistent superiority of the clients self-reported perspective as contrasted with observational measures in predicting outcome may be interpreted as indirect support for the intrapersonal position (Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin et al., 2000). On the other hand, large-scale investigations have indicated that, across a wide range of populations and types of assessment methods, enthusiastic collaboration emerged as the single most consistent indicator of a positive alliance, supporting the interpersonal view of the concept (Hatcher, 1999; Hatcher, A. Barends, Hansell, & Gutfreund, 1995; Hatcher & A. W. Barends, 1996). Supporting this perspective, but in a somewhat different vein, Henry and Strupp (1994) found that components of therapists and clients internalized self (introject) interact, unconsciously, and inuence the quality of the alliance. Thus, it seems likely that each of these processes, interand intrapersonal, contributes to the overall quality of a positive alliance. Further clarication of how these processes work should help therapists to more effectively establish and repair their alliances with their clients. For instance, it seems important to investigate whether these elements gain import sequentially (Horvath, 2003), play different roles in diverse treatments (Safran & Muran, 1998), or have a consistent, possibly synergic, relation to each other. The quest to better understand the structure and role(s) of the alliance raises a related challenge: to more clearly situate the alliance within the larger concept of the therapeutic relationship. Recently, Division 29 of the American Psychological Association (APA) initiated a comprehensive review of research on the relationship in therapy. The results of this unique multidisciplinary effort, Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients (Norcross, 2002), listed 11 elements and eight processes within the framework of therapeutic relationships. The list of the elements of the therapy relationships was as follows: the alliance, cohesion, empathy, goal consensus and collaboration, positive regard, congruence, feedback, repair of alliance ruptures, selfdisclosure, countertransference (management of), and relational interpretation. There appears to be a signicant overlap among these elements. Although some commonalities across concepts within the relationship domain are likely unavoidable, there are different levels of conceptual aggregation among the elements, and the logic of
1 Luborsky proposed a two-phase alliance in his early works (Luborsky, 1976), but this distinction is seldom explored in the empirical literature. Bordin spoke of different alliances appropriate to different treatments (1989) but did not elaborate explicitly on the nature of these distinctions, and there have been few attempts to specify these unique qualities.


The Alliance in Context dividing up the relationship pie is not yet fully clear. Equally challenging is the task of developing a conceptual model that could knit these elements into a cohesive framework.2 This suggests that there is a need for clarication and drawing of distinctions among these elements, as well as a move toward consensus on a conceptual map of the therapeutic relationship and how the pieces on this map dynamically relate to each other. The situation is similar within the body of research on the alliance itself; researchers use an ever-growing number of assessment devices that, for the lack of a broadly accepted clear conceptual denition, de facto dene the alliance in each investigation. Although there is evidence that many of these measures overlap (Bachelor & Horvath, 1999; Tichenor & Hill, 1989), there are also important differences among them (Horvath & Bedi, 2002). There is considerable debate within APA and in the profession-at-large about the most appropriate conceptual category that can be rigorously associated with therapeutic effectiveness. It is good to remember that, before the current debates about whether treatments, relationships, or principles can be empirically supported as efcacious, there were attempts to provide evidence that some theories were host to more effective therapies than others (see Luborsky, Singer, & Luborsky, 1975; Smith & Glass, 1977). It seems, in hindsight, that at such a broad level of aggregation (i.e., theories) there was little hope to document consistent superiority. Given the nding that, at most, 15% of the outcome variance is linked to techniques, and many of these ingredients appear to be shared across a number of different treatments (Lambert & Barley, 2002; Wampold, 2001), it may be the case that the concept of treatment is also too high a level of aggregation to serve as a discriminating notion to determine what is effective in therapy. It also remains to be seen whether empirically supported principles, as suggested by Castonguay and Beutler (2005), are sufciently narrow and specic to serve as discriminators between what is useful and what is not in therapy. On the other hand, Lambert and Barley (2002) report that common factors account for as much as 30% of the variance associated with patient improvement. It is likely that various components of the relationship account for the lions share of this impact. However, as noted earlier, although a number of relationship components reviewed by the APAs Division 29 may be empirically supported, the overlap among these elements is yet unclear; thus it seems unlikely that the identication of the body of research supporting each of the overlapping elements will aggregate to counterbalance the current research and clinical emphasis on empirically supported treatments. It seems possible, however, that if the research on the alliance (or indeed on the therapeutic relationship) evolves in the direction of identifying relationship processes situated in contexts of specic therapy practices (and associated with specic in-therapy small o outcomes), the work on the alliance and the relationship might lead to conceptually and clinically practical ways to identify the units of practice that lead to positive client change. There is a strong convergence of evidence that components of the therapeutic relationship bear close links to positive client change. The concept of the alliance has served a uniquely useful purpose in illustrating the importance of this element across all psychotherapy practices. It also seems to be true, however, that empirical research on the alliance, by applying a exible approach based on a variety of measures rather than a consensual denition of the construct, leveraged the strength of this nding at the expense of a clear framework for the therapeutic relationship, its components, and dynamics. This ecumenical status of the alliance makes it much more difcult to distill clinically useful guidance and training for the therapist (Horvath, 2004). One possible solution to the denitional dilemma would be to focus research on the relationship on a microrather than a macrolevel. The goal would be the identication of small-scale interpersonal events anchored within therapy tasks and leading to specic short-term goals. (An example might be the therapist and client reecting on the shifts within their relationship, with the goal of discovery of a recurrent interactional pattern for the client.) It may be the case that a cluster of empirically supported relationship processes is at the core of the effective alliance. Given the variety of therapeutic changes sought in different therapy con2 There have been impressive attempts to create such model (see, e.g., Gelso, 1985, and Orlinsky & Howard, 1986, 1987), but the bulk of the research published on the alliance and on the relationship has not yet adopted a consistent overarching model.


Horvath texts, it may be possible to identify a limited range of relational process that are most facilitative in reaching some of those objectives. It might also come to light that, across different practices, some subset of alliance processes is responsible for engaging and binding the client to the work of therapy while other, perhaps slightly different, subsets might be synergistic in facilitating particular client change events. References
ABEND, S. (2000). The problem of therapeutic alliance. In S. T. Levy (Ed.), The therapeutic alliance (pp. 116). Madison, WI: International Universities Press. ALEXANDER, L. B., & LUBORSKY, L. (1987). The Penn Helping Alliance Scales. In L. S. Greenberg & W. M. Pinsoff (Eds.), The psychotherapeutic process: A research handbook (pp. 325356). New York: Guilford Press. BACHELOR, A. (1988). How clients perceive therapist empathy: A content analysis of received empathy. Psychotherapy: Theory, Research, Practice, Training, 25, 227240. BACHELOR, A., & HORVATH, A. (1999). The therapeutic relationship. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 133179). Washington, DC: American Psychological Association. BORDIN, E. S. (1976). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, Practice Training, 16, 252260. BORDIN, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 1337). New York: Wiley. CASTONGUAY, L. G., & BEUTLER, L. E. (Eds.). (2005). Principles of therapeutic change that work. New York: Oxford University Press. CHAMBLESS, D. L., & HOLON, S. D. (1998). Dening empirically supported therapies. Journal of Consulting and Clinical Psychology, 64, 497504. FERENCZI, S. (1932). The clinical diary of Sandor Ferenczi (M. Balint & N. Z. Jackson, Trans.). Cambridge, MA: Harvard University Press. FREUD, S. (1913). On the beginning of treatment: Further recommendations on the technique of psychoanalysis. In J. Strachey (Ed.), Standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 122144). London: Hogarth Press. GELSO, C. J., & CARTER, J. A. (1985). The relationship in counseling and psychotherapy: Components, consequences, and theoretical antecedents. Counselling Psychologist, 2, 155243. GENDLIN, E. T. (1964). A theory of personality change. In P. Worchel & D. Byrne (Eds.), Personality change (pp. 102148). New York: Wiley. GONCLAVES, O. F. (1994). Cognitive narrative psychotherapy: The hermeneutic construction of alternative meanings. New York: Springer. GREENSON, R. R. (1965). The working alliance and the transference neuroses. Psychoanalytic Quarterly, 34, 155181. HATCHER, R. L. (1999). Therapists view of treatment alliance and collaboration in therapy. Psychotherapy Research, 9, 405 423. HATCHER, R. L., BARENDS, A., HANSELL, J., & GUTFREUND, M. J. (1995). Patients and therapists shared and unique views of the therapeutic alliance: An investigation using conrmatory factor analysis in a nested design. Journal of Consulting and Clinical Psychology, 63, 636 643. HATCHER, R. L., & BARENDS, A. W. (1996). Patients view of the alliance in psychotherapy: Exploratory factor analysis of three alliance measures. Journal of Consulting and Clinical Psychology, 64, 1326 1336. HENRY, W. P., & STRUPP, H. H. (1994). The therapeutic alliance as interpersonal process. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research and practice (pp. 51 84). New York: Wiley. HORVATH, A. O. (1994). Research on the alliance. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research and practice (pp. 259 287). New York: Wiley. HORVATH, A. O. (2001). The alliance. Psychotherapy: Theory, Research, Practice, Training, 38, 365372. HORVATH, A. O. (2003, November). Alliance at the crossroad: An assessment of what has been achieved and the signicant challenges that lie ahead. Paper presented at the annual meeting of the Society for Psychotherapy Research, Newport, RI. HORVATH, A. O. (2004, August). Training and supervision for the common factors. Paper presented at the 112th Annual Convention of the American Psychological Association, Honolulu, HI. HORVATH, A. O., & BEDI, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 3770). New York: Oxford University Press. 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. LAMBERT, M. J., & BARLEY, D. E. (2002). Research summary on the therapeutic relationship and psychotherapy outcome. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 1732). New York: Oxford University Press. LUBORSKY, L. (1976). Helping alliances in psychotherapy. In J. L. Cleghhorn (Ed.), Successful psychotherapy (pp. 92116). New York: Brunner/Mazel. LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy. New York: Basic Books. 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, 9951008. MARTIN, D. J., GARSKE, J. P., & DAVIS, K. M. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438 450. 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.), Effec-


The Alliance in Context

tive psychotherapy (pp. 482502). New York: Pergamon Press. MITCHELL, S. A. (1993). Hope and dread in psychoanalysis. New York: Basic Books. NORCROSS, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press. 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 psychotherapeutic process: A research handbook. New York: Guilford. ORLINSKY, D. E., & HOWARD, K. I. (1987). A generic model of psychotherapy. Journal of Integrative and Eclectic Psychotherapy, 6, 6 27. ROGERS, C. R. (1957). The necessary and sufcient conditions of therapeutic personality change. Journal of Consulting and Clinical Psychology, 22, 95103. ROGERS, C. R., GENDLIN, G. T., KIESLER, D. V., & TRAUX, L. B. (1967). The therapeutic relationship and its impact: A study of psychotherapy with schizophrenics. Madison: University of Wisconsin Press. SAFRAN, J. D., MURAN, J. C., & SAMSTAG, W. L. (1994). Resolving therapeutic raptures: A task analytic investigation. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice. New York: Wiley. SMITH, M. L., & GLASS, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752760. STERBA, R. F. (1934). The fate of the ego in analytic therapy. International Journal of Psychoanalysis, 115, 117126. TICHENOR, V., & HILL, C. E. (1989). A comparison of six measures of working alliance. Psychotherapy: Theory, Research, Practice, Training, 26, 195199. WAMPOLD, B. E. (2001). The great psychotherapy debate. Mahwah, NJ: Erlbaum. WATSON, J. C., GREENBERG, L. S., & LIETAER, G. (1998). The experiential paradigm unfolding: Relationship and experiencing in therapy. In L. S. Greenberg, J. C. Watson & G. Lietaer (Eds.), Handbook of experiential psychotherapy (pp. 327). New York: Guilford. YALOM, I. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: HarperCollins. ZETZEL, E. R. (1956). Current concepts of transference. International Journal of Psychoanalysis, 37, 369 376.