The therapeutic alliance is the trusting relationship between a therapist and client that allows them to work collaboratively throughout the therapeutic process. A strong therapeutic alliance facilitates a client’s beliefs that their therapist has their best interest at heart in order for them to work productively with their therapist towards a goal. It has been postured that some clients report having made improvements between making the initial call to schedule their first session and arriving for their first session.16
Factors such as empathy, warmth, and the therapeutic relationship seem to correlate more significantly with therapeutic outcome than specialized treatment interventions.13 When therapy begins, there are a multitude of factors that may strengthen or weaken the therapeutic alliance. In a strong alliance, a therapist is often able to non-verbally validate their client, identify and avoid obstacles that may hinder the progress of their client, critically formulate and apply judgment, and help their patient reach their goals in therapy, whereas a weak alliance may result when a therapist is unable to convey that they are listening attentively, or when a therapist uses inappropriate self-disclosure, or is overly structured, rigid, or uninvolved.8 Some literature suggests that the extent to which the relationship between the therapeutic alliance and treatment outcomes is due to the shared sense of purpose within the alliance, an indicator that seems to improve over the course of the relationship.6
The strength of the therapeutic alliance has consistently been shown to be related to treatment outcomes – a stronger alliance being associated with superior treatment outcomes.14 In fact, has been found to significantly improve clinical outcomes, for both psychotherapy and pharmacotherapy,12 in depressed individuals.2,12,17 The therapeutic relationship has also frequently been cited as being associated with improvements of anxiety-related disorders, especially in anxious youth4,9,11 regardless of the treatment type. Interestingly, the direction of this relationship is debated. While some literature suggests the therapeutic alliance results in greater clinical improvements, others have found that not only is this the case, but that positive treatment outcomes may also result in an improved therapeutic alliance.7 For example, one study found that both a greater therapeutic alliance predicted greater reductions in bulimic behavior while reductions in bulimic behavior also predicted improved therapeutic alliance.1
A positive therapeutic alliance has shown to be especially beneficial for patients seeking treatment for substance use disorders. Ratings of the alliance, for example have been thought to be predictors of both treatment participation and drinking behavior in those with an alcohol use disorder (AUD)3 and a strong therapeutic alliance early in treatment has demonstrated efficacy as a predictor of a client’s dedication to, and maintenance of drug treatment.15 For this reason, it has been suggested that a strong therapeutic alliance may be particularly useful for patients with substance use disorders who also have low motivation.10
It should be noted that some evidence, although it supports that the therapeutic alliance is predictive of positive outcomes, it has been proposed that the strength of the relationship between these variables may vary by patient due to individual, personality and lifestyle differences.5 That is, for certain individuals, it may be that the therapeutic alliance is more or less critical to their overall therapeutic progress.
1. Accurso, E., Fitzsimmons-Craft, E., Ciao, A., Cao, L., Crosby, R., Smith, T., . . . Nezu, Arthur M. (2015). Therapeutic Alliance in a Randomized Clinical Trial for Bulimia Nervosa. Journal of Consulting and Clinical Psychology, 83(3), 637-642.
2. Arnow, B. A., Steidtmann, D., Blasey, C., Manber, R., Constantino, M. J., Klein, D. N., … Kocsis, J. H. (2013). The Relationship Between the Therapeutic Alliance and Treatment Outcome in Two Distinct Psychotherapies for Chronic Depression. Journal of Consulting and Clinical Psychology, 81(4), 627–638.
3. Connors, G., Carroll, K., DiClemente, C., Longabaugh, R., Donovan, D., & Kendall, Philip C. (1997). The Therapeutic Alliance and Its Relationship to Alcoholism Treatment Participation and Outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-598.
4. Cummings, C. M., Caporino, N. E., Settipani, C. A., Read, K. L., Compton, S. N., March, J., Sherrill, J., Albano, A. M., Moira, R., Birmaher, B., Saklosky, D., Gosch, E., Keeton, C., Kendall, P. C., Nezu, A. M. (2013). The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth. Journal of Consulting and Clinical Psychology, 81(5), 859-864.
5. De Bolle, M., Johnson, J. G., & De Fruyt F. (2010) Patient and Clinician Perceptions of Therapeutic Alliance as Predictors of Improvement in Depression. Psychotherapy and Psychosomatics, 79(1), 378–385.
6. Escudero, V., Friedlander, M., Varela, N., & Abascal, A. (2008). Observing the therapeutic alliance in family therapy: Associations with participants’ perceptions and therapeutic outcomes. Journal of Family Therapy, 30(2), 194-214.
7. Falkenström, Granstrom, & Holmqvist. (2013). Therapeutic Alliance Predicts Symptomatic Improvement Session by Session. Journal of Counseling Psychology, 60(3), 317-328.
8.. Gurton, A. (2015). Understanding the Therapeutic Alliance. Retrieved from https://www.mentalhelp.net/blogs/understanding-the-therapeutic-alliance/
9. Hughes, A. A. & Kendall, P. C. (2007). Prediction of Cognitive Behavior Treatment Outcome for Children with Anxiety Disorders: Therapeutic Relationship and Homework Compliance. Behavioral and Cognitive Psychotherapy, 35(4), 487-494.
10. Ilgen, Mckellar, Moos, & Finney. (2006). Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder. Journal of Substance Abuse Treatment, 31(2), 157-162.
11. Keeley, M. L., Geffken, G. R., Ricketts, E. Mcnamara, J. P. H. & Storch, E. A. (2011). The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive–compulsive disorder. Journal of Anxiety Disorders, 25(7), 855-863.
12. Krupnick, J., Sotsky, S., Simmens, S., Moyer, J., Elkin, I., Watkins, J., . . . Beutler, Larry E. (1996). The Role of the Therapeutic Alliance in Psychotherapy and Pharmacotherapy Outcome: Findings in the National Institute Of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64(3), 532-539.
13. Lambert, M., Barley, D., Silverman, Wade H., & Norcross, John C. (2001). RESEARCH SUMMARY ON THE THERAPEUTIC RELATIONSHIP AND PSYCHOTHERAPY OUTCOME. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357-361.
14. Martin, D., Garske, J., Davis, M., & Kendall, Philip C. (2000). Relation of the Therapeutic Alliance With Outcome and Other Variables: A Meta-Analytic Review. Journal of Consulting and Clinical Psychology, 68(3), 438-450.
15. Meier, P., Barrowclough, C., & Donmall, M. (2005). The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. 304-316. ISSN 0965-2140.
16. Wampold, B.E., (1997), Methodological Problems in identifying efficacious psychotherapies, Psychotherapy Research, Vol 7, pp 21-44
17. Webb, C. A., Beard, C., Auerbach, R. P., Menninger, E., Bjorgvinsson, T. (2014). The therapeutic alliance in a naturalistic psychiatric setting: Temporal relations with depressive symptom change. Behaviour Research and Therapy, 61(1), 70-78.
by Callie Patterson
Callie Patterson is a graduate student pursuing a degree in psychological sciences at Northern Arizona University.
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