In spite of the difficulties involved in this type of research, Table 1 shows that numerous instruments have been developed to analyses the therapeutic alliance. A Secure Base: Clinical Applications of Attachment Theory. Therapist success and its determinants. The resolution of ruptures in the therapeutic alliance. The patient may interpret the therapist’s more active intervention as a reduction in support and empathy, which may weaken or rupture the alliance. Arch. Clin. Clin. Raue, P., Goldfried, M., and Barkham, M. (1997). B., Fields, S., and Bickman, L. (2006). From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. (2000), the most frequently used scales in individual psychotherapy are the WAI, CALPAS, and Penn scales, followed by the Vanderbilt scales, TARS, and TBS. Svensson, B., and Hansson, L. (1999). Kivlighan, D. M., and Shaughnessy, P. (2000). Valutare le psicoterapie: La ricerca italiana. According to Horvath and Symonds (1991), the extent of the relationship between alliance and outcome was not a direct function of time: they find that measurements obtained during the earliest and most advanced counseling sessions were stronger predictors of outcome than those obtained during the middle phase of therapy. 120, 182–238. Psychotherapy, 48(3), pp.237-248. Factor structure of the working alliance inventory. In our opinion, regarding the relationship between the therapeutic alliance and the outcome of psychotherapy, future research should pay special attention to the comparison between patients’ and therapists’ assessments of the therapeutic alliance: these have often been found to differ, and evidence suggests that the patient’s assessment is a better predictor of the outcome of psychotherapy (Castonguay et al., 2006). Alien. Sper. (2008). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Do baseline client characteristics predict the therapeutic alliance in the treatment of schizophrenia? Alliance structure assessed by the Agnew Relationship Measure (ARM). Q. Numerous studies have shown that the therapeutic alliance is one of the strongest predictors of treatment outcomes. J. (2007). Current concepts of transference. Psychiatry 14, 325–332. Kivlighan and Shaughnessy (1995) use the hierarchical linear modeling method (an analysis technique for studying the process of change in studies where measurements are repeated) to analyses the development of the alliance in a large number of cases. De Roten, Y., Fischer, M., Drapeau, M., Beretta, V., Kramer, U., Favre, N., and Despland, J.-N. (2004). 2006 Jan;194(1):10-4. doi: 10.1097/01.nmd.0000195315.39196.52. Rev. Zetzel, E. R. (1956). J. Psychoanal. Meta-analysis is a possible research strategy that can be used to obtain the combined results of studies on the same topic. In fact, many studies indicate that the therapeutic alliance is the best predictor of treatment outcome (3-5). In psychodynamic psychotherapy, verbal (structures and intents) and non-verbal (voice and interruptions) dimensions of communication intertwine conveying information and determining the mutual regulation between therapist and patient through conversational sequences. Strong, S. R. (1968). Samstag, L. W., Muran, J. C., and Safran, J. D. (2004). 28, 1167–1187. According to Martin et al. Psychol. A., Wright, A. R., Campbell, C., Stokes, S., and Adinoff, B. Holmes, S. E., and Kivlighan, D. M. (2000). This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants. This is an open-access article subject to a non-exclusive license between the authors and Frontiers Media SA, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and other Frontiers conditions are complied with. J. Integr. Here, it is important to note that research in the field of psychotherapy is usually classified as outcome research and process research. Therapeutic Alliance Ruptures | Psychology Today Research sheds light on what to do when therapy isn't working. Johnson, J. E., Burlingame, G. M., Olsen, J. However, it is important to remember that meta-analysis is more valid when the effect being investigated is quite specific. Clin. Orlinsky, D. E., and Howard, K. I. “Defining and identify alliance ruptures,” in Core Processes in Brief Psychodynamic Psychotherapy: Advancing Effective Practice, ed. Psychology & Psychiatry; August 28, 2020 Why therapeutic alliance is important in psychotherapy. 2019 Jun 11;10:364. doi: 10.3389/fpsyt.2019.00364. Clin. (2004) suggest that a process characterized by ruptures and repairs was more likely to occur in long-term psychodynamic treatment, particularly during phases of in-depth work. J. Couns. Yalom (1995) speaks of a sense of support, trust, belonging in the group, and also “the analog of relationship in individual therapy”; Budman et al. Therapeutic alliance scales: development and relationship to psychotherapy outcome. Int. (1994). 1, 62–73. (2007), whose aim was to evaluate the therapeutic alliance in schema-focused therapy (Young et al., 2003; Nadort et al., 2009) and transference-focused psychotherapy (Yeomans et al., 2002). J. Couns. On the other hand, the patients’ assessments tend to be more subjective, atheoretical, and based on their own past experiences in similar situations. J. The relationship between adult attachment style and therapeutic alliance in individual psychotherapy: A meta-analytic review. Bibring, E. (1937). (1952). The work of Strong (1968) was based on the hypothesis that if the patient is convinced of the therapist’s competence and adherence, this will give the latter the necessary influence to bring about changes in the patient. A Primer for Transference Focused Psychotherapy for the Borderline Patient. Psychol. Assess. Psychotherapy (Chic.) Horvath, A. O., and Bedi, R. P. (2002). *Correspondence: Rita B. Ardito, Department of Psychology, University of Turin, via Po, 14 – 10123 Turin, Italy. Psychol. None of their findings suggest that any one instrument was a stronger predictor of outcome than the others, in relation to the type of therapy being considered. Clients’ assessment of the affective environment of the psychotherapy session: relationship to session quality and treatment effectiveness. The authors provided a possible explanation for these results by attributing them to the type of psychotherapy being investigated (the Brief Psychodynamic Investigation proposed by Gilliéron, 1989, which is a manual on a very brief psychotherapeutic four-session intervention) and the type of sample (psychiatric patients). Psychiatry 52, 339–350. J. Nerv. 15, 9–23. J. Similarly, Greenson (1965) defines the working alliance as a reality-based collaboration between patient and therapist. Clin Psychopharmacol Neurosci. Patterns of working alliance development: a typology of client’s working alliance ratings. Only a few studies have examined the relationship between alliance and outcome in group psychotherapy. Development and validation of the working alliance inventory. Some sum this up by saying the therapeutic alliance is the ‘bond’ that develops in the therapy room. The first difference is that in group psychotherapy we have multiple therapeutic agents: the therapist (usually two co-therapists), the members of the group, and the group as a whole. The Vanderbilt psychotherapy process scale: a report on the scale development and a process-outcome study. 16, 319–324. Psychol. According to Migone (1996), another hindrance is the so-called Rashomon effect (named after the 1950 film by Akira Kurosawa): each single aspect of therapeutic alliance may be perceived very differently by the therapist, patient, and clinical observer, which raises the question of objectivity. Research on psychotherapy integration: recommendations and conclusions from an NIMH workshop. Ment. J. Freniatr. Br J Clin Psychol. Psychol. 3. e-mail: rita.ardito@unito.it, Front. Migone (1996) distinguishes three partially overlapping phases in the history of psychotherapy research: a first phase, between the 1950s and 1970s, when research focused on the outcome of psychotherapy and there was a proliferation of meta-analysis; a second phase between the 1960s and 1980s in which there was a growing interest for research into the relationship between process and outcome (the Vanderbilt Project is the most famous example of this); and a third phase from the 1970s onward, in which interest shifted to the therapeutic process and the desire for a greater understanding of the “micro-processes” involved in therapy. The emerging picture suggests that the quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures. Clin Psychol Rev. (1986). 18, 170–189. Alliance and outcome in late-life depression. Most of them are based on the theoretical assumptions previously described. Psychol. Psychology 2:270. doi: 10.3389/fpsyg.2011.00270. For example, poorer insight and previous sexual abuse were associated with worse client-rated alliance, whereas baseline negative symptoms were associated with worse therapist-rated alliance. Although a comparison between different treatment modalities is a topic beyond the scope of this paper, it is worth noting that in the late 1980s, some authors (Marmar et al., 1989a,b) failed to demonstrate significant differences between behavioral, cognitive, and brief psychodynamic therapies in the level of alliance as measured by CALPAS. Clin.  |  Neurol. Consult. 3, 188–195. 172, 417–423. Initially regarded as purely negative, Freud, in his later works, adopted a different stance on the issue of transference and considered the possibility of a beneficial attachment actually developing between therapist and patient, and not as a projection. 37, 369–375. 27, 143–153. They found that alliance and group cohesion were closely related and that both were strongly related to improved self-esteem and reduced symptomatology. London: Routledge and Kegan Paul. The therapeutic alliance forms the foundation for almost all of the work done in couple and family therapy (CFT). (1990). Psychol., 18 October 2011 He distinguished two types of alliance: the first, found in the early phases of therapy, was based on the patient’s perception of the therapist as supportive, and a second type, more typical of later phases in the therapy, represented the collaborative relationship between patient and therapist to overcome the patient’s problems – a sharing of responsibility in working to achieve the goals of the therapy and a sense of communion. On the theory of the results of psychoanalysis. Safran, J. D., Crocker, P., McMain, S., and Murray, P. (1990). On links to other constructs, determinants of its effectiveness, and its role for research in psychotherapy in general. 47, 475–497. CORE Net and ARM-5: are they worth using? Safran, J. D., and Segal, Z. Psychother. The therapeutic relationship, also called the therapeutic alliance, refers to how a therapist and a client connect, behave, and interact with each other in the therapy room. (1989) refer to cohesion as working together toward a therapeutic goal and engagement around common themes. Dis. According to the results proposed by Tracey (1989), the more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction (high–low–high) over the course of treatment. 15, 239–246. Safran, J. D., and Muran, J. C. (2000). The WAI-based scale used to measure relationships with group leaders was called the Member–Leader WAI. Luborsky, L., Crits-Cristoph, P., Alexander, L., Margolis, M., and Cohen, M. (1983). Without a therapeutic alliance, CFT would be nothing more than a collection of ideas in books. However, according to the findings of numerous researchers, this is not the case. The therapeutic alliance (also referred to as the working alliance) is a description of the interaction between the physiotherapist and their patients. (2004) analyzed therapeutic alliance growth during the course of short-term treatment of depressed patients, drawn from the Second Sheffield Psychotherapy Project, who received cognitive–behavioral and psychodynamic–interpersonal therapy. Dis. Psychol. 26, 50–65. Models and their interventions either come alive or die in their delivery by the therapist via the therapeutic alliance. J. Meta-analysis of therapeutic relationship variables in youth and family therapy: the evidence for different relationship variables in the child and adolescent treatment outcome literature. Eur. Epub 2019 May 21. Although some studies are based on a very limited number of cases, the results appear consistent: the therapist’s focus on the patient’s conflictual behavior patterns and the patient’s involvement rather than avoidance in responding to these challenges, are factors that contribute to improving the therapeutic alliance. Psychoanalysis is the therapeutic approach that was originally developed by Sigmund Freud. J Clin Psychol. The number of items included in the scales varies considerably (between 6 and 145 items), as do the dimensions of the alliance investigated (e.g., two in the Penn scales; three in the WAI, TSR, and TBS; four in the CALPAS and KAS; and five in the ARM). Fenton et al. J. Couns. eCollection 2019. Please enable it to take advantage of the complete set of features! Crowe, T. P., and Grenyer, B. F. S. (2008). The role of the therapeutic alliance in Psychotherapy. Horvath, A. O., and Greenberg, L. S. (1986). (2006), patterns of therapeutic alliance development require further investigation, in order to understand how and whether the various patterns are a cause, effect, or manifestation of improvement. The foundation for therapy is called the therapeutic alliance (1, 2). 1, 323–330. 1, 207–210. Strupp, H. H. (2001). 12, 213–229. Consult. The Kim alliance scale: development and preliminary testing. Greenson, R. R. (1965). The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session. Two helping alliance methods for predicting outcomes of psychotherapy: a counting signs vs. a global rating method. Along the same lines, Zetzel (1956) defines the therapeutic alliance as a non-neurotic and non-transferential relational c… The effects of psychotherapy: an evaluation. It may in fact be a simple effect of the temporal progression of the therapy rather than an important causal factor. Luborsky, L. (1976). 15, 215–224. Received: 29 June 2011; HHS Eysenck, H. J. The therapeutic relationship in CBT for psychosis: client, therapist and therapy factors. Dis. 157, 23–28. Therapeutic alliance in depression treatment: controlling for prior change and patient characteristics. doi: 10.2196/17204. (2002). 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