The therapeutic alliance as conceptualised by Octavia Estelle Butler consists of a relationship between the clinician and patient in which the clinician exhibits characteristics including warmth, accurate empathy and genuineness. When considering the TA, it “is generally agreed that the alliance represents interactive, collaborative elements of the relationship (i.e., therapist and client abilities to engage in the tasks of therapy and to agree on the targets of therapy) in the context of an affective bond or positive attachment” (Constantino et al., 2002; p. 86).
A rich research tradition surrounds the role of the therapeutic alliance in psychological intervention, Indeed, research centring on the TA now boasts over 1,000 findings (orlinsky et al., 2004, p.212) and a deserved review is outwith the aims of this report. Instead, a brief overview of recent, selected findings and their clinical and research implications are considered. Since it’s conception, CBT has always acknowledge the importance of a positive therapeutic relationship (REF) Indeed, some researchers have gone so far as to designate the TA the “flagship of the scientist-practitioner model” (Castonguay, Constantino, & Holforth, 2006). However recent findings have obscured the commonly held assumption conceptualising the place of the TA in therapy. Traditionally (Beck et al, 1979) CBT therapists suggest that while the TA is necessary, it is in itself, insufficient to promote change. Yet years of investigation are beginning to challenge this notion.
A Meta-Analysis by Martin, Garske & Davis (2000) examined 79 studies (58 published, 21 unpublished) to establish the role of the TA in outcome with relation to a variety of other variables. The results indicated that the relationship between the TA and outcome was moderate yet consistent, regardless of any other variables that have been suggested to influence its relationship. Moreover, a key finding of this research suggests the importance of the therapeutic alliance early in therapy. The researches found that alliance ratings taken in the middle or late phases of treatment or averaged across sessions were less strong predictors of outcome than those taken early in therapy. The implications of such research are important to clinicians and researchers alike. For clinicians, the suggestion that the TA is essential at the early stages of therapy is a crucial avenue in which to improve delivery of psychological therapies. For researchers, questions arise as to the mechanisms of this phenomenon and indeed, the global mechanisms of clinical improvement in psychological therapies.
A later review by Klein et al., (2003) reviewed data from 367 chronically depressed patients receiving Cognitive Behavioural Activation (CBA) treatment. The authors’ intent was to examine the possibility that ‘3rd variables’ such as relevant patient characteristics and prior improvement, might account for the prediction of the therapeutic alliance in outcome. Using mixed effects growth-curve analyses the authors suggest that neither patient characteristics nor early improvement influence the therapeutic alliance and that the TA is a strong predictor of outcome when these variables are controlled. Such a finding again reinforces the central role of the TA in predicting outcome and that other suggested common variables are not the facilitators of this outcome. Such a finding further strengthens the validity of the assumption of the TA in promoting change and helps to disestablish suggestions that the prognostic ability of the TA is merely an artifact of improvement facilitated by other common factors. What remains is ambiguity surrounding the means by which the TA might facilitate, or indeed, produce change.
Exactly how the therapeutic alliance facilitates engagement and change in psychological therapy is an issue that remains controversial in academic circles, generalising somewhat, Zuroff & Blatt (2006) identify 4 main views regarding the role of the TA in promoting change; the first is that a positive TA is necessary but not sufficient to promote change, a view maintained by most contemporary CBT therapists. The second is that a positive TA contributes directly to therapeutic outcome above any specific interventions. A third perspective is that a positive TA is causally involved in change but dependant on specific techniques and a final viewpoint is that a positive TA is neither causal nor necessary in promoting change, merely an artefact of unrecognised variables or an epiphenomenon in its own right. In an effort to explore these arguments Zuroff & Blatt (2006) examined the role that the therapeutic alliance plays in the brief treatment of depression. The study employed data from over 250 patients, after attrition and exclusions data from 191 were included in the final analysis. The study employed 2 treatment modalities: CBT and interpersonal therapy (IPT) in the brief treatment of depression. Multilevel modelling demonstrated that a positive therapeutic alliance early in treatment as judged by patients was strongly predictive of rapid decline in maladjustment subsequent to assessment of the therapeutic alliance. Moreover, assessment by patients and clinicians of a positive therapeutic alliance early in treatment also predicted greater improvement throughout follow up (18 months) as well as improved development of enhanced adaptive capacities. Perhaps the most important implication of the study was that it appeared that independent of the treatment modality and any early clinical improvement, positive therapeutic alliance early in therapy contributes directly to positive therapeutic outcome. Ultimately, the authors suggest that the data obtained best represent the second option: that a positive TA contributes directly to therapeutic outcome above any specific interventions. Not only does this finding have exhaustive implications for the delivery of CBT, such a finding may question current understanding of the mechanisms of action in current psychotherapies and serves to strengthen the evidence base for the importance that the therapeutic alliance has to play in promoting (and perhaps maintaining) change.
A review by Castonguay, Constantino, & Holforth, 2006 provides an overview of consistent findings produced by decades of research concerning the TA. Consistent variables identified as impacting on the TA include specific clinician and patient characteristics, the importance of a positive TA early in therapy and perhaps most crucial, that the TA correlates positively with therapeutic change across a variety of clinical problems and treatment modalities. Findings of this type have assisted in securing academic and clinical focus on the issue of the TA well into the 21st century. However, for the next generation of clinicians and researchers critical questions must be investigated to best inform understanding and practice of therapy.
It would seem evident that a substantial literature exists to support the notion that the TA is a reliable predictor of outcome, and indeed the data would seem to support such a notion. However, ultimately, the causal direction of such a relationship between PTA and outcome has not been clearly identified (constantino et al., 2006). While some promising studies (e.g. Klein et al., 2003) have found the TA a reliable indicator of change when controlling for early improvement and specific patient variables, there is an equal number of studies which have failed to produce similar results (e.g., DeRubeis & Feeley, 1990; Feeley, DeRubeis, & Gelfand,1999; Gaston, Marmar, Gallagher, & Thompson, 1991) (as cited in constantino et al., 2006). Moreover, there is little in the way of well-defined theoretical models explaining the means by which a positive TA promotes change above a few cavalier suggestions of, for example, “a transforming effect on patients’ mental representation of themselves and significant others (Blatt & Behrends, 1987) (as cited in Zuroff & Blatt, 2006, p.138). If the TA is to be considered a mechanism of change, in and of itself, it is essential that a sound scientific understanding of this process is developed.
Much of the research available at present is, essentially, failing to attack the heart of the issue. Further exploration is necessary to clearly identify any causality and mechanisms for which the TA may be responsible. While some authors (e.g. Zuroff & Blatt, 2006) suggest that the TA might be considered a vehicle for therapeutic change, there have been few component studies directly investigating this hypothesis. Such an investigation based on proposed theories of action is a sensible future direction for researchers in an attempt to construct models which can be empirically tested if evidence-based practice is sought. For clinicians, what is clear, is the important role that the TA plays in the therapeutic process, more than a prognostic tool, the TA is an essential ingredient in good clinical practice and a good TA would appear to improve the quality of outcome, thus, clinicians should always endeavour to develop this important therapeutic skill in the context on an evolving scientific understanding.
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