The therapeutic alliance is considered one of the main factors influencing the treatment process in counseling. There are numerous definitions of the therapeutic alliance. However, it can be broadly defined as “the collaborative and affective bond between therapist and patient- the collaborative and affective bond between therapist and patient” (Martin, Gaske & Davis, 2000). In 1979 Bordin identified three main components of the successful therapeutic alliance: an agreement on goals, the development of bonds, and an assignment of a task or a series of tasks (Ackerman & Hilsenroth, 2003). Studying and understanding various factors influencing therapeutic alliance is essential because it is the core concept in counseling. By identifying what factors contribute to a stronger therapeutic alliance, it is possible to develop an effective methodology focused on reducing the time needed to make a strong empathetic connection between the patient and the psychotherapist. Effective psychotherapy is impossible when a patient lacks trust in a psychotherapist. Psychotherapists use numerous micro skills focused on improving empathetic connection and fostering psychological alliance, which indicates that this aspect of psychotherapy is highly important. Previous research has found that a strong therapeutic alliance helps treat various psychological disorders and is highly valued by patients. The literature review by Ackerman & Hilsenroth (2003) has found that most studies emphasize the importance of various elements of the therapeutic alliance, such as trustworthiness, lucid communication, accurate interpretation, interest, exploration, involvement, and many others. All these elements are directly related to the connection between two people that provides relief from suffering. The facts provided above show that therapeutic alliance plays one of the major roles in influencing treatment outcomes. This paper will explore various aspects of the therapeutic alliance, including its components and core conditions, and analyze the relationship between therapeutic alliance and the effectiveness of treatment.
Carl Roger’s Conditions Necessary For Therapy
Before discussing new studies, it is necessary to mention the conditions necessary for therapy identified by Carl Rogers. The conditions were described in 1957 in the article “The necessary and sufficient conditions of therapeutic personality change.” The first condition, which Rogers calls a precondition, is psychological contact between two persons. All the following conditions are impossible without this precondition. The second condition is that the patient must be in a state of incongruence, which makes him vulnerable and anxious. According to Rogers (1957), incongruence refers to “a discrepancy between the experience of the organism and the self-picture of the individual insofar as it represents this experience.” The third condition states that the therapist must be congruent or integrated in the relationship. In other words, a psychologist must be aware of his feelings within the client’s relationship. The fourth condition is that the therapist must experience unconditional positive regard for the client. A therapist must warmly accept various aspects of the client’s experience. It is essential to accept the client’s negative and positive experiences without having negative emotions, biases, or prejudices. The fifth condition is the empathetic understanding by the therapist of clients’ feelings, emotions, attitudes, and motivations. It is needed to feel what the client feels without having anger, fear, confusion, and other negative emotions. Finally, the client should perceive acceptance and acceptance and empathy experienced by the therapist for him to the minimum degree. All these conditions are equally important for successful therapy and positive changes contributing to the client’s welfare.
Importance of Congruence and other Factors in Therapy
Though these conditions were described more than 50 years ago, many are considered important even nowadays. For instance, numerous studies prove that empathy, congruence, and positive regard affect the strength of the therapeutic alliance (Ackerman & Hilsenroth, 2003). Congruence, one of the main concepts described by Rogers, is highly important for the patient and the therapist. The patient asks for help because he wants to achieve unity. At the same time, the therapist must be genuine and congruent in his feelings during therapy.
Additionally, congruence must exist between the goals set by the client and the goals set by the therapist. The level of agreement on the therapy perspective and goals between the patient and therapist affects therapeutic alliance. It is correlated with the outcomes of the therapy. The study by Zilcha-Mano, Snyder, and Silberschatz (2016) that involved 87 female and 40 male participants with different mental health issues discovered interesting findings related to the effects of unity on therapy outcomes. The therapeutic alliance was assessed with 12-item Working Alliance Inventory-Short Form, and outcomes were measured with a 45-item patient-rated version of the OQ. It was found that when the congruence is high, and alliance is strong, it makes the patient feel comfortable and makes the therapy process more effective. It is interesting, but when congruence is high, and alliance is weak, it also results in quite good outcomes, which can be explained by the fact that the patient coaches the therapist when the alliance is problematic (Zilcha-Mano et al., 2016). Another interesting finding is that higher agreement on moderate alliance levels predicted the poorest outcomes. The authors explain this by claiming that a moderate level of the alliance is “the least conducive to action for both patients and therapists” (Zilcha-Mano et al., 2016). Though the study has some limitations, including specific treatment orientations used by therapists, specific mental health disorders, and low outcome measurements, it still provides valuable findings. It supports the theory created by Rogers in 1957.
Another study supporting these findings was conducted by Laws et al. in 2016. The study involved 395 participants suffering from chronic depression. During therapy, the patient’s and therapist’s perceptions of the therapeutic alliance were measured three times. The study has found that convergence of alliance ratings has a significant predictive ability on treatment outcomes. For instance, patients with higher convergence had better treatment results at a 3-month follow-up (Laws et al., 2016). This study also has certain limitations that could affect the results. The first limitation is that patients were also treated with medications; hence they could have made a higher impact on treating depression than the therapeutic alliance.
Additionally, the generalizability of results is quite doubtful because only chronically depressed patients participated in the study. However, it should be noted that depression is one of the most widespread psychological disorders in the world. A similar study on the effects of therapeutic alliance on depression was conducted by Kushner et al. (2016), who found that patient-rated therapeutic alliance is correlated with treatment outcomes. Other studies, like the study by Ilgen, McKellar, Moos, and Finney, show that therapeutic alliance can also help treat alcohol use disorder (2006). Therefore, strong therapeutic alliances can positively influence the treatment of various mental disorders, addictions, and other unhealthy conditions.
Another interesting aspect that should be mentioned is that therapist ratings of alliance have better predictive ability of treatment outcome; this is stated in the study by (Zilcha-Mano et al., 2016) and in the study by (Zilcha-Mano et al., 2015). However, it is quite questionable whether therapist ratings of alliance measure therapeutic alliance. Possibly therapists rate the alliance based on the severity of symptoms they observe during treatment. Therapists may have better therapeutic alliances with patients showing certain improvements. Hence it is essential to use the ratings of both clients and therapists to measure the strength of the therapeutic alliance.
Additionally, other studies, like the study by Krupnick et al., (1996), claim that patient-rated alliance is a better predictor for positive treatment outcomes. Interestingly, the study by Zilcha-Mano et al. (2015) found that the true predictor of positive outcomes is not a therapeutic alliance but a change in symptoms in the course of treatment, which influences therapeutic alliance. However, this study has numerous limitations, such as a small sample size (n=49) and lacks statistical power. Additionally, the authors noted that their findings contradict to findings of previous studies that had bigger samples (Zilcha-Mano et al., 2015).
Another interesting article providing detailed information on the therapeutic alliance is by (Martin et al., 2000). The authors analyzed 79 studies on therapeutic alliance and found that the alliance may be therapeutic in and of itself. Meaning that it can directly influence the effectiveness of treatment. Moreover, the analysis has indicated that the alliance’s ” strength is predictive of outcome” (Martin et al., 2000). Hence, most articles on therapeutic alliance prove that it is the strongest predictor of treatment.
Alliance deterioration is another factor that can influence treatment outcomes. It may be assumed that deterioration may hurt therapy outcomes. However, various studies have shown that deterioration maybe even better for the patient than constant moderate therapeutic alliance (Zilcha-Mano et al., 2016). The literature review by Ackerman and Hilsenroth (2014) also supports this claim by stating that alliance ruptures and deterioration provide an opportunity for deepening alliance and making it more productive, resulting in better treatment outcomes. Ruptures are “interpersonal markers indicating critical points in therapy for exploration.” (Crits-Christoph et al., 1993). Hence the therapist must use these points to treat the patient and to establish a better empathetic connection.
So is The Alliance the Best Predictor of Treatment Outcomes?
Numerous issues related to the therapeutic alliance and treatment outcomes require further research. Numerous studies show contradictory results of therapist-rated or patient-rated alliance being the best predictor for treatment outcomes. Possibly, this can be explained by the different treatment orientations of psychologists taking part in the research or by different measurement scales that measure therapeutic alliance by evaluating different factors. Hence it is necessary to develop effective measurement instruments for assessing the strength of the therapeutic alliance. Additionally, there is still a lack of information about the factors contributing the most to the therapeutic alliance. Research should be focused on identifying these factors because they can be quite helpful in developing effective strategies for creating a strong therapeutic alliance quite fast and with clients having different disorders, personalities, goals, and needs.
References:
Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical psychology review, 23(1), 1-33.
Crits-Christoph, P., Barber, J., & Kurcias, J. (1993). The accuracy of therapists’ interpretations and the development of the therapeutic alliance. Psychotherapy Research, 3(1), 25-35.
Ilgen, M. A., McKellar, J., Moos, R., & Finney, J. W. (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.
Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. A. (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.
Kushner, S. C., Quilty, L. C., Uliaszek, A. A., McBride, C., & Bagby, R. M. (2016). Therapeutic alliance mediates the association between personality and treatment outcome in patients with major depressive disorder. Journal of affective disorders, 201, 137-144.
Laws, H. B., Constantino, M. J., Sayer, A. G., Klein, D. N., Kocsis, J. H., Manber, R., … & Arnow, B. A. (2016). Convergence in patient–therapist therapeutic alliance ratings and its Relation to outcome in chronic depression treatment. Psychotherapy Research, 1-15.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3), 438.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of consulting psychology, 21(2), 95.
Zilcha-Mano, S., Snyder, J., & Silberschatz, G. (2016). The effect of congruence in patient and therapist alliance on patient’s symptomatic levels. Psychotherapy Research, 1-10.
Zilcha-Mano, S., Solomonov, N., Chui, H., McCarthy, K. S., Barrett, M. S., & Barber, J. P. (2015). Therapist-reported alliance: Is it a predictor of outcome? Journal of counseling psychology, 62(4), 568.
