Therapeutic alliance

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Therapeutic Alliance

The therapeutic relationship, also called the helping alliance, the therapeutic alliance, and the working alliance, refers to the relationship between a healthcare professional and a client or patient. It is the means by which the professional hopes to engage with, and effect change in a client.

Alliance factors are a critical aspect of therapeutic outcome. Substantial research is showing that the quality of the therapeutic alliance between the patient and psychotherapist is necessary to achieve a satisfactory outcome.


While much early work on this subject was generated from a psychodynamic perspective, researchers from other orientations have since investigated this area. It has been found to predict treatment adherence (compliance) and concordance and clinical outcome across a range of client/patient diagnoses and treatment settings. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings.[1]

Components of the therapeutic relationship

The therapeutic relationship has been theorized to consist of three parts: the working alliance, transference/countertransference, and the real relationship.[2][3][4] Evidence on each component's unique contribution to outcome has been gathered, as well as evidence on the interaction between components.[5]

Working alliance

Also known as the therapeutic alliance, working alliance is not to be confused with the therapeutic relationship, of which it is theorized to be a component.

The working alliance may be defined as the joining of a client's reasonable side with a therapist's working or analyzing side.[6] Bordin[7] conceptualized the working alliance as consisting of three parts: tasks, goals, and bond.

Goals are what the client hopes to gain from therapy, based on his or her presenting concerns. Tasks are what the therapist and client agree need to be done to reach the client's goals. The bond forms from trust and confidence that the tasks will bring the client closer to his or her goals.

Research on the working alliance suggests that it is a strong predictor of psychotherapy or counseling client outcome. Also, the way in which the working alliance unfolds has been found to be related to client outcomes. Generally, an alliance that experiences a rupture that is repaired is related to better outcomes than an alliance with no ruptures, or an alliance with a rupture that is not repaired. Also, in successful cases of brief therapy, the working alliance has been found to follow a high-low-high pattern over the course of the therapy.[8]

Operationalization and measurement

Several scales have been developed to assess the patient-professional relationship in psychotherapy, including the Working Alliance Inventory (WAI),[9] the Barrett-Lennard Relationship Inventory,[10] and the California Psychotherapy Alliance Scales (CALPAS).[11] The Scale To Assess Relationships (STAR) was specifically developed to measure the therapeutic relationship in community psychiatry, or within care in the community settings.[12].


  1. Orlinsky, D. E., Ronnestad, M. H., Willutski, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In M. J. Lambert (Ed.) Handbook of psychotherapy and behaviour change (5th Ed.). New York: John Wiley & Sons.
  2. Greenson, R.R. (1967) The technique and practice of psychoanalysis. (Vol.1). New York: International Universities Press.
  3. Gelso, C.J. & Carter, J. (1985). The relationship in counseling and psychotherapy: Components, cnsequences, and theoretical antecedents. Counseling Psychologist, 13, 155-243.
  4. Gelso, C.J. & Carter,J. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296-306.
  5. Gelso, C.J. & Samstag, L.W. (2008). A Tripartite Model of the Therapeutic Relationship. Handbook of Counseling Psychology (4th ed.). (pp. 267-280).
  6. Gelso, C.J. and Hayes, J.A. (1998). The Psychotherapy Relationship: Theory, Research and Practice. (p. 22-46): John Wiley & Sons: New York.
  7. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252-260.
  8. Stiles, W.B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., Rees, A. & Barkham, M. (2004). Patterns of alliance development and the rupture-repair hypothesis: Are productive relationships U-shaped or V-shaped). Journal of Counseling Psychology, 51, 81-92.
  9. Horvath, A. O., Greenberg, L. (1986). The development of the Working Alliance Inventory: A research handbook. In L. Greenberg and W. Pinsoff (Eds.) Psychotherapeutic Processes: A Research Handbook, New York: Guilford Press.
  10. Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in therapeutic change. Psychological Monographs: General and Applied, 76, 1-33.
  11. Gaston L., Marmar, C. R. (1991). Manual for the California Psychotherapy Alliance Scales - CALPAS Unpublished manuscript. Department of Psychiatry McGill University, Montreal, Canada.
  12. *McGuire-Snieckus, R., McCabe, R, Catty, J., Hansson, L., and Priebe, S. (2007). A new scale to assess the therapeutic relationship in community mental health care: STAR. Psychological Medicine, 37, 85-95.