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The working alliance: Where have we been, where are we going? Jennifer M. Doran

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Department of Psychology, The New School for Social Research, New York, NY, USA Published online: 10 Sep 2014.

Click for updates To cite this article: Jennifer M. Doran (2014): The working alliance: Where have we been, where are we going?, Psychotherapy Research, DOI: 10.1080/10503307.2014.954153 To link to this article: http://dx.doi.org/10.1080/10503307.2014.954153

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Psychotherapy Research, 2014 http://dx.doi.org/10.1080/10503307.2014.954153

EMPIRICAL PAPER

The working alliance: Where have we been, where are we going?

JENNIFER M. DORAN Department of Psychology, The New School for Social Research, New York, NY, USA

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(Received 1 February 2014; revised 16 June 2014; accepted 6 August 2014)

Abstract Objective: This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptualization. Method: Major research efforts on the topic are reviewed. The review includes both theoretical and empirical literature on the working alliance and related constructs, such as alliance ruptures and repair, and therapeutic negotiation. Existing measures of the working alliance are also reviewed. Results: The working alliance is critiqued on both theoretical and empirical grounds, including the strengths and limitations of current approaches and assessments. Recent theoretical developments are reviewed, among them work on alliance rupture and repair and the reconceptualization of the alliance as a process of therapeutic negotiation. Emerging applications of advanced statistical techniques to measure the working alliance are also considered. Conclusion: The review concludes by supporting recent efforts that have attempted to increase the sophistication of measurement tools and statistical approaches, and encouraging future research in these areas. Keywords: working alliance; literature review; rupture and repair; alliance negotiation; multilevel modeling

The Working Alliance History The central importance of the quality of relationship between a patient and therapist has been a cornerstone of psychological theory dating back to the early 1900s and the height of psychoanalytic thinking. As early as 1912, Freud made the claim that the friendly and affectionate aspects of the transference”1 were the “vehicle for success in psychoanalysis” (p. 105), and stated that rapport between a patient and analyst was the initial aim of treatment (Freud, 1913). While much has changed in psychological theory since this time, the emphasis on the therapeutic relationship has remained a stable force in the literature. In 1940, Sterba wrote that the therapeutic relationship emerged out of positive transference to the analyst, and that this was a necessary prerequisite for successful treatment. Fenichel (1941) spoke of the importance of a trusting analytic atmosphere and the development of positive transference in treatment. In 1956, Zetzel made the distinction between transference as therapeutic

alliance—the relationship between the patient and therapist, and the transference neurosis—a manifestation of resistance to treatment. Her work initiated a differentiation between the therapeutic relationship and transference feelings in therapy. The modern construct of the working alliance now refers to specific components of the professional therapeutic relationship that are conceptually distinct from transference in therapy (Meissner, 1996). As the therapeutic relationship emerged as a salient component of therapy, attention began to shift to investigating this relationship in greater depth. Loewald (1960) and Stone (1961) observed different types of relating that occurred in treatment and identified complexities inherent in the patient-analyst relationship. By this time, a range of terminology was being used to describe this relationship—the therapeutic alliance (Zetzel, 1956), rational transference (Fenichel, 1941), and mature transference (Stone, 1961). In 1965, Greenson introduced the term working alliance, using it to encompass what he believed were similar concepts described by existing diverse

Correspondence concerning this article should be addressed to Jennifer M. Doran, The New School for Social Research, 80 5th Avenue, 6th Floor, New York, NY 10011, USA. Email: [email protected] © 2014 Society for Psychotherapy Research

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terminology. In his definition, the working alliance referred to the non-neurotic, rational rapport between a patient and analyst, and was deemed as essential to psychoanalytic therapy as transference neurosis (Greenson, 1965, 1967). While the concept of the working alliance originated in the psychoanalytic literature, the centrality of the therapeutic relationship has origins in the humanistic and cognitive-behavioral traditions as well. In Rogers’ (1951) client-centered therapy, he viewed the real relationship between a counselor and client as critical to therapeutic change. The therapeutic relationship was also viewed as an important construct in early cognitive-behavioral theories, dating back to its inception in the literature (Beck, Rush, Shaw, & Emery, 1979; Goldfried & Davison, 1974). In the past several decades, contemporary cognitive-behavioral theorists have increasingly recognized the importance of the working alliance in manualized treatment (Arnkoff, 1995; Newman, 1998). Seminal work by Bordin (1979) was responsible for developing the modern definition of the alliance, and for galvanizing an interest in examining the role that alliance plays across diverse theoretical traditions. His pan-theoretical conceptualization defines the working alliance as a collaborative stance between the patient and therapist, and posits that its development is fostered by three interrelated processes: agreement on therapeutic goals, agreement on therapeutic tasks, and the quality of the relational bond between the patient and therapist. Bordin’s pan-theoretical definition of the alliance is the most widely used definition to date, and may have allowed this construct to proliferate despite shifting theoretical dominance in the field. Measurement In 1976, in an effort to add empirical understanding to the theoretical construct of the alliance, Luborsky operationalized the construct with the creation of two measures: the Helping Alliance Counting Signs (HAcs) and the Helping Alliance Rating (HAr) scale. These measures involved having an outside rater use a manual and their clinical judgment to determine the strength of the alliance on multiple indicators (Luborsky, 1976). This seminal work found differences in the strength of the alliance for patients who were the most and least improved on outcome measures, demonstrating an important link between therapeutic process (strength of the alliance) and treatment outcome. Similar to the theoretical growth of the construct of the alliance, a number of measures of the alliance have been developed and refined since Luborsky’s efforts. A meta-analysis by Horvath, Del Re,

Fluckiger, and Symonds (2011) included 201 studies using more than 30 different alliance measures to examine the relationship between working alliance and psychotherapy outcome. Across studies, the most commonly used measures were the California Psychotherapy Alliance Scale (CALPAS; Marmar & Gaston, 1988; Marmar, Weiss, & Gaston, 1989), the Helping Alliance Questionnaire (HAq; Alexander & Luborsky, 1986), the Vanderbilt Psychotherapy Process Scale (VPPS; Gomes-Schwartz, 1978), and the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989). The CALPAS, HAq, and WAI are considered pure measures of the working alliance. The CALPAS is rated by outside clinical judges and contains subscales designed to reflect four dimensions of the alliance: therapist positive contributions, therapist negative contributions, patient positive contributions, and patient negative contributions (Marmar et al., 1989). The HAq is part of the larger Penn Helping Alliance Scales (Alexander & Luborsky, 1986) and is a self-report measure of the strength of the alliance from the perspective of the patient. The HAq contains two subscales: the patient’s experience of the therapist as being competent and able to provide help (Type 1); and the patient’s experience of the treatment as a process of working with the therapist toward shared treatment goals (Type 2). The Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) and its short form (WAI-S; Tracey & Kokotovic, 1989) have the largest empirical base and are the most widely used measures of the working alliance. There are three versions of the WAI, each of which contains 36 items that are rated on a 7-point Likert scale. There are two self-report versions, one that is filled out by the patient (Form C) and one that is filled out by the therapist (Form T). There is also a version that is completed by an outside rater (Form O). The development of the WAI was heavily influenced by four psychological theories— Roger’s (1951) client-centered therapy, Strong’s (1968) social influence theory, Greenson’s (1967) non-neurotic transference model of the therapeutic relationship, and Bordin’s (1979) transtheoretical formulation of the working alliance (Horvath & Greenberg, 1986, 1989). The items on the WAI fall into three subscales—Task, Goal, and Bond—which directly correspond to the three major components of Bordin’s (1979) theory. The WAI-S was designed to be an update of the WAI and to provide a more parsimonious measure for assessing working alliance. The WAI-S contains 12-items and retains 4 items from each subscale (Tracey & Kokotovic, 1989). A more recent attempt to update the WAI involved minor item and wording changes, and the retention of only positively worded items (WAI-SR; Hatcher &

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Psychotherapy Research Gilaspy, 2006). Of note, measures also exist that extended beyond the individual psychotherapy paradigm, including the Couple Therapy Alliance Scale and the Family Therapy Alliance Scale (CTAS and FTAS; Pinsof & Catherall, 1986). The most recently revised versions of these measures include the CTAS RevisedShort Form (CTASr-SF) and FTAS Revised-Short Form (FTASr-SF), which include interpersonal dimensions of the alliance and assess the perception of significant others of the therapeutic relationship (Pinsof, Zinbarg, & Knobloch-Fedders, 2008). In addition to specific measures of the working alliance, several instruments combine the alliance with more general psychotherapy processes. The VPPS (Gomes-Schwartz, 1978) has its roots in the Therapeutic Session Report (Orlinsky & Howard, 1967), and includes patient, therapist, and observer-rated versions. The measure consists of seven subscales that reflect different components of psychotherapy process, including general change mechanisms (Gomes-Schwartz, 1978). Two newly developed instruments, the Scale for the Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACiP; Mander et al., 2013) and the Individual Therapy Process Questionnaire (ITPQ; Mander et al., 2014), integrate existing alliance measures with specific common factors change mechanisms. The SACiP integrated items from the Bernese Post Session Report (BPSR; Fluckiger, Regli, Zwahlen, Hostettler, & Caspar, 2010), a measure of Grawe’s (2004) mechanisms of change, and the German WAI-SR (Munder, Wilmers, Leonhart, Linster, & Barth, 2010). The ITPQ integrated the SACiP with the Scale of Therapeutic Alliance—Revised (STA-R; Brockmann et al., 2011). Of note, these newer measures reflect both positive and negative therapeutic processes. Empirical Research The working alliance is now seen as the “quintessential integrative variable” in psychotherapy (Wolfe & Goldfried, 1988) and the essential ingredient in promoting change (Horvath & Bedi, 2002; Lambert & Simon, 2008). As such, it is one of the most frequently investigated topics in psychotherapy research. The surge of interest in investigating the relationship between the patient and therapist can be at least partially explained by the large body of research demonstrating a lack of significant differences across treatment conditions. In response to a body of literature demonstrating the general comparative effectiveness of a number of treatments across theoretical orientations, some researchers have argued that all mainstream psychotherapies are equally effective (Lambert & Bergin, 1994; Stiles,

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Shapiro, & Elliot, 1986; Wampold, Imel, & Miller, 2009). This finding has often been referred to as the dodo bird effect (Luborsky, Singer, & Luborsky, 1975; Rosenzweig, 1936), a term borrowed from a literary fable in which the conclusion of an athletic competition is “everyone has won, and all must have prizes” (Carroll, 1965). While the dodo bird effect is not without controversy (Carroll & Roundsaville, 2010; DeRubeis, Brotman, & Gibbons, 2005; Siev & Chambless, 2009; Tarrier, 2002), studies continue to support its conclusion (Wampold et al., 1997, 2009). For researchers who contend that all psychotherapies are equally effective, its equivalence is usually attributed to what are referred to as “common factors” in treatment (Imel & Wampold, 2008, p. 249). Common factors are elements of psychotherapy that are ubiquitous across treatments, and advocates of the common factors model believe that these shared aspects of all psychotherapy treatments contribute to positive treatment outcome (Wampold, 2001, 2007). While a number of common factors have been identified (Tracey, 2010), the working alliance is the most robust factor to date. Numerous studies have shown that the strength of the alliance is a significant predictor of outcome across treatment conditions (for a review, see Horvath & Bedi, 2002; Lambert & Barley, 2002). The strength of the alliance demonstrates a modest but consistent impact on psychotherapy outcome, with meta-analytic effect sizes ranging from .22 to .27 (Horvath et al., 2011; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Additionally, metaanalytic findings (Tryon & Winograd, 2011) have demonstrated that patient and therapist agreement on the goals and tasks of therapy enhance treatment outcome (p. 34), as does engagement in an active cooperative relationship (p. 33). Researchers have concluded that the working alliance is an essential ingredient in producing therapeutic change (Horvath & Greenberg, 1986; Lambert & Barley, 2001; Lambert & Simon, 2008; Norcross, 2002). These conclusions have resulted in recommendations that clinicians focus on establishing a strong and positive working relationship with their patients from the beginning of treatment (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Horvath & Bedi, 2002). Critiques of the Working Alliance Despite the popularity and empirical validation of the working alliance, the construct is not without critiques. Horvath (1994) has noted a gap in knowledge in being able to determine which factors facilitate or hinder the development and maintenance of the working alliance, and states that as the therapeutic relationship progresses it becomes increasingly

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difficult to capture the components of the alliance with a generic model. Empirical efforts to identify the specific components of the alliance that are helpful at different points in treatment have produced unclear results (Elvins & Green, 2008; Horvath, 2005; Wallner-Samstag et al., 2008). Safran and Muran (2006) have argued that there are problems in the current conceptualization of the working alliance, and have gone so far as to say that the construct may have outlived its usefulness in psychotherapy research. Their perspective is that, rather than abandoning the alliance construct altogether, the construct needs to evolve and be refined in light of new theoretical and empirical developments. These and other factors have led researchers to call for further clarification of the alliance concept in order to stimulate additional re‐ search on the relationship between alliance, process, and outcome (Castonguay, Constantino, & Holtforth, 2006; Gelso, 2009; Hatcher, 2009; Horvath, 2005).

therapist and patient defer to the needs of the other at the exclusion of their own, or when they agree with the other in order to maintain harmony and avoid disruption the relationship. Empirical support for these ideas comes from research that links pre-treatment patient characteristics to the strength of the working alliance. A study by Muran, Segal, Wallner-Samstag, and Crawford (1994) found that patient pre-treatment friendly and submissive interpersonal problems positively predicted the strength of the working alliance. This prompted the authors to question if attempts to measures the alliance were actually capturing patient compliance and willingness to adhere to the pre-set parameters of treatment. Research also demonstrates that patients with dependency problems and submissive interpersonal styles provide higher alliance ratings early in treatment, suggesting that alliance ratings by dependent and submissive individuals may be artificially over-inflated (Bender, 2005; Blatt, 2004; Bornstein, 1993; Soygut, Nelson, & Safran, 2001).

Alliance as Compliance One of main theoretical critiques of the working alliance is its emphasis on collaboration and consensus. According to Bordin’s (1979) definition, a substantial portion of the working alliance is the degree of agreement between the patient and therapist on the tasks and goals of therapy. A number of psychoanalytic theorists have raised the concern that the construct does not include enough emphasis on potential conflicting or negative feelings that underlie the patient’s alliance with the therapist (Brenner, 1979; Curtis, 1979). In an article on the impact of managed care on psychotherapy, Cushman and Gilford (2000) argue that the current system positions therapists as distributors of knowledge and patients as compliant recipients of technique. They state that the working alliance construct has become conflated with the notion of agreement, which neglects to consider other avenues for relationship development and minimizes the importance of conflict and working through confrontation. Cushman and Gilford (2000) state that a constructive therapeutic process should involve an “examination of therapist-patient relationship: disagreements, complaints, arguments, the voicing of hurt or angry feelings, the exploration of misunderstandings or puzzlements, or the challenging on monetary arrangements, roles, and power distributions within the hour” (p. 990). Some consequences of the emphasis on agreement and collaboration are mistaking patient compliance for a true working alliance (Cushman & Gilford, 2000; Safran & Muran, 2006), or the risk of what appears to be a strong alliance actually reflecting a pseudo-alliance (Bender, 2005; Wachtel, 2008). Two processes that underlie a pseudo-alliance are when the

Alliance: Not the Whole Story Another argument in the literature is that the working alliance is only one component of the relationship between the patient and therapist. Greenson (1971) conceptualized the relationship as consisting of three components: the working alliance, the transference and countertransference feelings between patient and therapist, and the “real relationship” between them. This latter component was expanded on by Gelso and colleagues, who argue that the real relationship is the most important relational component, and contributes to the change process over and above the impact of the working alliance (Gelso, 2011; Gelso & Hayes, 1998). Gelso defines the real relationship as the personal relationship existing between two people that reflects both the degree of genuineness present and the realistic perception of each other. He views the real relationship as qualitatively different than the working alliance, existing on a personal level and outside of the therapeutic work (Gelso, 2009, 2011). While there is some support for the predictive validity of the real relationship (Fuertes et al., 2007), most research finds substantial overlap and no empirical distinction between the real relationship and the working alliance (Greenberg, 1994; Horvath, 2009; Kelly, Gelso, Fuertes, Marmarosh, & Lanier, 2010; Marmarosh et al., 2009). Further problems are evident in research that inquires about what was helpful to patients in the therapeutic relationship. Such questioning has produced variables that do not directly correspond to the components of the working alliance—patients

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Psychotherapy Research seem to focus less on their own involvement and the mutuality of the relationship, and more on individual therapist characteristics. Aspects of the relationship that were seen as helpful included therapist friendliness, use of humor, and positive comments or compliments (Bedi, Davis, & Arvay, 2005; Bedi, Davis, & Williams, 2005; Fitzpatrick, Janzen, Chamodraka, & Park, 2006). Research by DeRubeis and Feeley (1990) found that specific in-session changes were more important than a strong working alliance and contributed more to overall treatment outcome. Finally, there is disagreement about the directional relationship between alliance and change, and debate about the causal inferences drawn from research on the alliance. While researchers have most commonly attributed change in therapy to the working alliance, an opposing viewpoint has found evidence for the alliance as a product or outcome of change, rather than a contributing factor or causal agent (Asay & Lambert, 2001; DeRubeis et al., 2005; DeRubeis, Tang, Gelfand, & Feeley, 2000; Horvath & Symonds, 1991; Norcross, 2002). In the absence of statistical controls for temporal effects, the alliance–outcome correlation can be interpreted as symptom improvement (good outcome) producing strong working alliances in therapy (DeRubeis et al., 2005). It remains unclear the degree to which a strong alliance facilitates treatment outcome versus how much early symptom change contributes to a positive therapeutic relationship. These conflicting viewpoints highlight a lack of empirical clarity about the bidirectional or reciprocal nature or these two constructs. Empirical evidence bolsters the perspective that the working alliance is only a small piece of the puzzle in accounting for therapeutic change. While research evidence consistently shows that the quality of the working alliance is associated with treatment outcome, meta-analytic studies find that the magnitude of this relationship is relatively small. Correlations between the strength of the working alliance and outcome in psychotherapy have ranged from .22 to .27 (Horvath et al., 2011; Horvath & Symonds, 1991; Martin et al., 2000), a small effect size that indicates that the working alliance explains less than 10% of the variance in treatment outcome. Nonetheless, the magnitude of this effect is comparable to the effect for treatment conditions (Luborsky et al., 2001), indicating that the alliance plays just as much of a role as a specific set of techniques. The Alliance–outcome Relationship: More Complex than It First Appears The working alliance is often examined in a general and non-specific manner, in the absence of adequate

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empirical scrutiny regarding therapist and patient behaviors or characteristics. Research on the working alliance has failed to account for a variety of factors that may also be contributing to treatment outcome, like specific patient diagnoses or personality. The patient’s presenting problem may make a difference on the strength of the working alliance–outcome relationship. For example, while research has found that working alliance predicted outcome in samples of depressed and anxious patients (Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000), a causal relationship did not emerge for a sample of cocaine-dependent patients, suggesting that the working alliance may not be as important of a variable in this population (Barber et al., 1999, 2001). The relationship between exposure to trauma and psychotherapy has also been investigated, with the impact of trauma hypothesized to play a role in treatment process (Cloitre, Koenen, Cohen, & Han, 2002; Keller, Zoellner, & Feeny, 2010). Individuals with a complex trauma history have been found to be mistrustful of others and hold negative beliefs about interpersonal relationships (Keller et al., 2010), which likely impacts their ability to form a trusting emotional relationship, or working alliance, with their therapist (Ford, Courtois, Steele, van der Hart, & Nijenhuis, 2005). Research on individuals with trauma histories found that the strength of the working alliance predicted treatment adherence in therapy (Keller et al., 2010), and that early alliance predicted reduction in posttraumatic stress symptomatology at termination (Cloitre et al., 2002). Research on a complex trauma sample also found that pre-treatment patient psychophysiology and reactivity, such as lower skin conductance and higher respiratory sinus arrhythmia, predicted higher working alliance in brief psychotherapy (Doukas, Doran, D’Andrea, & Pole, in press). As a relational construct, it seems intuitive that patient personality may impact the development and maintenance of a working alliance, a variable of interest in some process and outcome studies (Ablon & Jones, 1999; Barber et al., 2000; Blatt, Quinlan, Pilkonis, & Shea, 1995). While some research has investigated the impact of particular patient traits (Bender, 2005; Blatt, 2004; Bornstein, 1993; Muran et al, 1994; Soygut et al., 2001), there is a dearth of research regarding the role of specific personality pathology on the strength of the alliance. It has been postulated that patients with severe personality pathology pose several challenges to psychotherapy. The difficulties in emotion regulation and longstanding interpersonal problems typical of these disorders have been viewed as an impediment to the working alliance (Benjamin, 1993; Benjamin & Karpiak, 2001; Kiesler, 1996; Millon & Davis, 1996). However, the

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relationship is not as straightforward as simply linking particular disorders to either a positive or negative therapeutic relationship. For example, some research on borderline personality disorder (BPD) has found that different characteristics within this presentation have a differential impact on the working alliance and treatment outcome. Factors like age, agreeableness, and harm avoidance have demonstrated a relationship with the strength of the working alliance, and increases in the alliance over time—rather than at a fixed point—have demonstrated a positive impact on treatment outcome (Hirsch, Quilty, Bagby, & McMain, 2012; Piero, Cairo, & Ferrero, 2013). These inter-disorder differences highlight the complexities inherent in attempting to link specific pathologies to the working alliance. Additionally, research has demonstrated that personality similarity between patient and therapist may be an important factor, with more similar personalities resulting in a stronger working alliance (Taber, Leibert, & Agaskar, 2011). There are additional complexities beyond patient diagnosis or personality. Barber and colleagues have noted that, even when ratings are blind, patients typically rate therapists very highly, resulting in ceiling effects in the data (Barber et al., 1999, 2000). Studies utilizing temporal analyses of the alliance–outcome relationship have found limited stability of the alliance–outcome relationship, with alliance rarely predicting subsequent symptom change (Barber, 2009). In studies that have found a temporally causal relationship, the magnitude of the obtained correlations were generally relatively small (Barber et al., 2000; Klein et al., 2003). Additionally, the studies that yielded statistically significant relationships analyzed therapy that was interpersonallyoriented in nature, which suggests that the mutative impact of the working alliance may only occur in similar types of therapy (Barber et al., 2000). There is general lack of clarity regarding the role of theoretical orientation and type of treatment on the strength or importance of the working alliance construct. DeRubeis et al. (2005) have cautioned psychotherapy researchers about interpretation of typical alliance–outcome correlations. In this article, they argue that the effect of specific treatment techniques may be stronger than has been previously believed, and that global equivalence of outcomes does not mean that the outcomes were produced by similar mechanisms. Research has demonstrated inconsistent findings of the relationship between working alliance and outcome across specific treatments (Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998). For example, some studies have found the alliance to be important in cognitive-behavioral therapies (Castonguay et al., 1996;

Raue, Goldfried, & Barkham, 1997), while others have failed to find such a relationship (DeRubeis & Feeley, 1990; Feeley, DeRubeis, & Gelfand, 1999). Additionally, variability in the working alliance has been attributed to several sources, including measurement error, therapist factors, patient factors, the statistical interaction between patient and therapist factors, and early symptom improvement (DeRubeis et al., 2005). While ample controversy exists over these conclusions (Castonguay & Grosse, 2005; Wampold, 2005), what remains clear is that the psychotherapy literature to date has not sufficiently examined contributing or confounding variables to the alliance–outcome relationship.

Problems with Measurement and Methodology There are also criticisms of the way standard scales measure the strength of the working alliance. Horvath et al. (2011) have pointed out that the proliferation of alliance measures that occurred in the 1970s and 1980s were derived from different or ambiguous conceptual definitions, rendering metaanalytic reports somewhat confounded and opaque. Researchers have also noted that the way patients perceive the therapy relationship is not fully captured by existing scales (Bachelor, 1995; Bedi, 2006; Mohr & Woodhouse, 2001; Owen, Reese, Quirk, & Rodolfa, 2013). Bachelor (1995) and Bedi (2006) have found varying endorsement of specific relationship qualities across patients, concluding that there is an underrepresentation of critical components of the working alliance on existing scales. As different components of the alliance have been shown to have varying levels of subjective relevance across patients, standard self-report scales may inaccurately reflect how patients perceive the strength of the alliance (Bachelor, 1995). Bedi (2006) has argued that, in order to adequately measure patient experience of the working alliance, scales need to include components that are reported by the patient as being important to them, including therapist characteristics, therapist behavior and the therapeutic environment. Additionally, analyses of the different components of the working alliance have found differential relationships across the dimensions of task, goal, and bond. Webb, DeRubeis, Amsterdam, Shelton, and Hollon (2011) have argued that, in cognitive therapy, agreement between the patient and therapist on the tasks and goals of therapy is more important than the quality of the relational bond, and has suggested that the therapeutic relationship may be more a consequence than a cause of symptom change in cognitive therapy (Webb, DeRubeis, Amsterdam, Shelton, & Hollon, 2011). Along similar lines, Hatcher and Gilaspy (2006) found a stronger relationship

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Psychotherapy Research between agreement on tasks and overall improvement in therapy, with the goal and bond subscales having more modest correlations. While mutuality and collaboration are central to most theoretical and empirical formulations of the working alliance (Horvath & Bedi, 2002), research has shown that patients typically focus less on mutuality and more on the therapist, not typically reporting collaboration as an important part of alliance development (Bedi, 2006). Doran, Safran, Waizmann, Bolger, and Muran (2012) have argued that the majority of existing scales tend to overemphasize agreement and collaboration, missing critical information about disagreement and tension in the therapy process. In reviewing the history and definition of the alliance construct Horvath et al. (2011) stated that “the most distinguishing feature of the modern pan-theoretical alliance construct is its emphasis on collaboration and consensus” (p. 10). Along similar lines, research on the factor structure of the WAI, CALPAS, and HAq has suggested that the shared variance across these measures can be conceptualized as a confident, collaborative relationship (Hatcher & Barends, 1996; Hatcher, Barends, Hansell, & Gutfreund, 1995). Doran et al. (2012) have pointed out that, while existing measures like the WAI typically include some negatively worded items, there are a lack of items that directly assess the degree to which tension and disagreement are addressed and worked through in the therapeutic relationship. The patient may report experiencing anger or frustration with their therapist on existing scales, but the items provide no direct assessment of if these concerns are able to be expressed to the therapist in the course of treatment. One potential danger of focusing exclusively on positive outcome (agreement), and ignoring the process of expressing and working through negative feelings is that patients and therapists may endorse disagreement but be unwilling to express it, which may hinder authentic relatedness and impede therapeutic progress in subtle ways (Safran & Muran, 2000). Of specific concern is the lack of negative items on short versions of the WAI, including the WAI-S and WAI-SR. As research has not directly examined what is lost in their elimination, the effects of their absence remain unclear. Of note, recently developed measures that expand beyond the construct of the alliance and incorporate more general mechanisms of change do assess more negatively valenced processes (Mander et al., 2013, 2014). Taken together, the above critiques suggest that both the construct of the working alliance and the way in which it is measured are in need of revision.

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Reconceptualizing the Working Alliance Rupture and Repair With the hermeneutic turn in psychoanalytic theory and the ascendance of the relational model (Aron, 1996; Mitchell, 1988, 1993; Mitchell & Aron, 1999) came the realization that the experience of a constructive therapeutic relationship is central to the change process. As the psychoanalytic sensibility began to shift away from the idealized therapeutic stance of abstinence and neutrality (a one-person psychology), and toward an emphasis on mutuality in the therapeutic dyad (a two-person psychology), the importance of tension in the therapeutic relationship emerged as an important topic of study (Safran, Crocker, McMain, & Murray, 1990). In 1993, Safran stated that problems, or ruptures, in the working alliance are inevitable events that offer important opportunities for the patient and therapist to work through disagreements in the therapeutic relationship. Safran and Muran (2000) define a rupture as “strains in the alliance … consisting either of disagreements about the tasks or goals of therapy or of problems in the bond dimension” (p. 16). It is worth noting that the term “rupture” dates back to the 1940s and the concept of corrective emotional experiences in psychotherapy (Alexander & French, 1946). Alexander and French saw psychotherapy as an opportunity for a patient to relive experiences from the past, particularly problematic experiences with early caregivers, in the therapeutic relationship which allowed for a different and reparative emotional experience. Later, Kohut (1971) described ruptures as the result of the analyst’s inevitable failures in empathy in the therapeutic relationship. He saw ruptures as disrupting therapeutic progress, and believed that once empathy is restored and the rupture is repaired, the patient’s therapeutic development resumes (Kohut, 1971). This line of thinking paralleled work by developmental theorists in their efforts to understand early interactions between infants and their caregivers (Beebe & Lachmann, 2002; Tronick, 1989). Tronick (1989) characterized infant-mother interactions as a sequence of ruptures and repairs, facilitated by periods of misattunement and empathic coordination. Winnicott (1969) applied the mother-infant metaphor to the therapeutic relationship and investigated the area of intersection between the subjective worlds of both the analyst and patient. Relational theorists continued to build on this work, applying the pattern of rupture and repair to an understanding of the therapeutic process, ushering in a new line of research on negative events and tension in psychotherapy (Safran et al., 1990; Safran & Muran, 2000).

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Alliance as Negotiation As the notion of rupture and repair became more salient in psychotherapy research, several theorists turned their attention to how moments of tension were handled in therapy and emphasized the negotiation of ruptures as the critical factor in alliance strength and the change process. The term negotiation first appeared in the literature in 1960, when Loewald stated that the therapeutic action in psychoanalysis was engagement in a dyadic process of negotiation, with negotiation itself an intervention targeted at meaningful psychic change. The construct can also be found in Greenson’s (1965) early writing on the working alliance, in which he states “the constant scrutiny of how the patient and the analyst seem to be working together, the mutual concern with the working alliance, in itself serves to enhance it” (p. 174). Additionally, models of complementarity (Tracey & Ray, 1984) have assessed the ways in which patient and therapist follow or diverge from each other in therapy, with more shared autonomy and responsibility resulting in more positive therapeutic exchanges. Mitchell (1991, 1993), a leading theorist in the relational movement, stated that coexisting with another necessarily requires an ongoing process of negotiation, specifically arguing that negotiation was a central factor in therapy for facilitating patient change. Pizer (1992) saw negotiation as ongoing and recurrent, consisting of both implicit and explicit processes, and the intrinsic vehicle for therapeutic action. With these theoretical developments, the conceptualization of the working alliance itself began to subtly shift from emphasizing agreement and collaboration to an increasing focus on intersubjective negotiation (Aron, 1996; Benjamin, 1990; Mitchell, 1988, 1993).

Implications for Research Safran and Muran (2000, 2006) have put forth a theoretical argument for reconceptualizing the working alliance. Heavily influenced by relational psychoanalytic thinking, they have suggested augmenting the working alliance construct to include the management and repair of alliance ruptures in psychotherapy. Their suggested modification of the alliance construct prioritizes negotiation over collaboration in psychotherapy process, on the grounds that focusing on agreement and collaboration can mask withdrawal ruptures and subtle patient compliance. From their perspective, the process of negotiation both establishes the necessary conditions for change to occur and is itself a central component of the change process. Emphasizing the critical role of

negotiation shifts focus away from collaboration and agreement to a consideration of how disagreement and tension are worked through in the therapeutic relationship. It is noteworthy that Bordin himself, in his later work, argued for conceptualizing the working alliance not just in terms of therapist and patient collaboration, but in terms of their ability to identify and repair strained alliance ruptures (Bordin, 1983, 1994). In the last two decades, there has been a growing empirical support for the importance of investigating ruptures. Research has suggested that fluctuations in the quality of the alliance over the course of treatment is common, and the process of repairing strains or ruptures in the alliance has been shown to be related to therapeutic gains and positive treatment outcome (Horvath & Luborsky, 1993; Muran, 2002; Muran et al., 2009; Norcross & Wampold, 2011a, 2011b; Safran, Muran, & Eubanks-Carter, 2011; Stiles et al., 2004; Strauss et al., 2006). There is now broad consensus in the literature that disruptive rupture events are important components of the therapy process, with the resolution of therapeutic conflicts a catalyst for change (Norcross & Wampold, 2011a, 2011b; Safran et al., 2011; Strauss et al., 2006). If the reconceptualization of the working alliance as a process of negotiation is to be of value for psychotherapy researchers, it will be necessary to have empirical means for operationalizing and measuring the construct as it occurs in the process of psychotherapy. Despite the fact that the concept of negotiation has been present in the literature for several decades, there is a lack of validated assessment instruments to measure it. Previous work on negotiation has largely involved qualitative analyses of in-session processes or the use of factor analytic techniques (Czogalik & Russell, 1995; Ogrodniczuk, Joyce, & Piper, 2005), or has examined explicit negotiation of treatment parameters before the therapy process began (Epperson, Bushway, & Warman, 1983; Rainer & Campbell, 2001; Reiss & Brown, 1999; Tracey, 1988). As a result, negotiation has remained largely a theoretical construct and has not been subject to proper empirical scrutiny. Validation efforts are under way of two instruments being used to identify and examine ruptures in the therapeutic alliance (Eubanks-Carter, Mitchell, Muran, & Safran, 2009; Safran, Muran, & Proskurov, 2009), which focus on identifying the presence and nature of ruptures in therapy. Recent efforts have argued that it may be fruitful to develop instruments that explicitly assess negotiation itself. The Alliance Negotiation Scale (ANS; Doran et al., 2012) was specifically designed to capture the degree of

Psychotherapy Research negotiation present in the therapeutic relationship. This measure was created in the context of a critique of current measures of the working alliance, in line with Safran and Muran’s (2000, 2006) proposed augmentation of the alliance construct to include negotiation. While preliminary data on the reliability and validity of the measure is promising (Doran et al., 2012), including validation of a Spanish version in an Argentinean sample (Waizmann, Bolger, Doran, Safran, & Roussos, 2012), additional studies are needed to validate the measure and to investigate the relationship between negotiation and psychotherapy outcome.

Empirical Advances

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Nested Data and Multilevel Modeling In recent years, increased attention has been given to the complexity and confounds inherent in measuring a dyadic process like the alliance (Baldwin & Imel, 2013; Crits-Christoph, Gibbons, Hamilton, RingKurtz, & Gallop, 2011), and more advanced ways of analyzing psychotherapy data have emerged in the literature (Baldwin & Imel, 2013; Kivlighan & Shaughnessy, 1995; Tasca, Illing, Joyce, & Ogrodniczuk, 2009). Psychotherapy process and outcome data typically have a hierarchical, nested structure. Nested data refers to data that has multiple levels or a hierarchy of variables (Tasca et al., 2009). In psychotherapy research, clients are often nested by group (treatment condition), and therapist. Psychotherapy data is often measured over time in a repeated-measures format (e.g., working alliance measured after each therapy session; symptoms measured at intake and termination), with the “time” variable nested within individual clients (Singer & Willett, 2003). Process–outcome studies of the working alliance typically employ hierarchical data and a repeated-measures design (Kivlighan & Shaughnessy, 1995). When data is nested, the statistical assumption of independence—that individual data points are separate from and do not influence each other (Field, 2009)—may not be met (Tasca et al., 2009). If this assumption is not met, the data violates the sphericity assumption for ANOVA tests—commonly used to analyze group treatment data—resulting in increased Type I error rates. Even moderate dependence in nested data can have a large impact on Type I error rates, which can produce “false-positive” results (Kenny & Judd, 1986). Using multilevel modeling (MLM) is one way of assessing the degree of dependence in the data. Multilevel models (MLMs) include statistical techniques that are more appropriate for nested data (Tasca et al., 2009). More specifically, three-level growth MLMs

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are ideal for measuring change across time, and are appropriate for addressing the complexity of hierarchical, nested, repeated-measures designs (Tasca et al., 2009). Examples of MLMs in clinical research have emerged in recent years (Baldwin, Wampold, & Imel, 2007; Crits-Christoph et al., 2009; Imel, Baldwin, Bonus, & MacCoon, 2008), with MLMs used to examine variables like therapist effects on outcome (Lutz, Leon, Martinovich, Lyons, & Stiles, 2007) and the supervisory alliance— the working alliance between a therapist and their clinical supervisor (Patton & Kivlighan, 1997). Despite the growing popularity of these analytic techniques, the large majority of group treatment research has not adequately assessed or adjusted for dependence in their data (Baldwin, Murray, & Shadish, 2005), typically employing generic statistical techniques (e.g., ANOVA) that are based on a general linear model. The dearth of working alliance research employing MLMs (Tasca et al., 2009) suggests that this finding extrapolates to process– outcome studies. Another problem with the traditional ways of analyzing working alliance data is the inability to parse out different sources of variance in the total process–outcome correlation. Baldwin and Imel (2013) has pointed to social relations modeling as an example for psychotherapy research. The social relations model (SRM; Kenny, Kashy, & Cook, 2006) is a framework for partitioning sources of variance in relational data. In this model, three potential sources of variance in interpersonal patterns are identified that correspond with the therapeutic dyad—the individual (patient), their partner (therapist), and the relationship between them. In SRM research, total correlations are separated into between- and within- components, examining the strength of these different sources of variability on the end product. This has various applications for psychotherapy research, such as attempting to parse out the influence of patient/patient characteristics, therapist effects/the therapist factor, or the unique dyadic relationship between a particular patient and therapist (Baldwin & Imel, 2013). Baldwin and Imel (2013) have stated that existing meta-analytic evidence on the working alliance is relatively clear and have argued against continuing to examine generic alliance–outcome correlations. Instead, they advocate for a more sophisticated analytic approach that involves partitioning the variance of the alliance– outcome relationship into its component parts, in an attempt to better understand and control for confounds in the alliance–outcome relationship. In their own work, Baldwin and Imel (2013) have employed MLMs to estimate the percentage of variability in the

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alliance–outcome relationship that occurs between therapists relative to the proportion of variability that occurs within therapists (e.g., therapists who see multiple clients in a single research study).

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Confounding Variables and Hierarchical Linear Modeling The variable of time in working alliance studies points to additional complexities in the data. Working alliance ratings have shown variability over time in a number of studies, with several findings pointing to linear increases over time (Kramer, de Roten, Beretta, Michel, & Despland, 2009; Paivio & Patterson, 1999; Piper, Ogrodniczuk, Lamarche, Hilscher, & Joyce, 2005), and others failing to demonstrate this pattern (Hilsenroth, Peters, & Ackerman, 2004; Klee, Abeles, & Muller, 1990; Sexton, Hembre, & Kvarme, 1996). Despite the knowledge that the working alliance fluctuates and varies over time, the majority of research has employed single-session measurements or has collapsed ratings over an arbitrary number of sessions to form average ratings in different “phases” of treatment (Kivlighan & Shaughnessy, 1995). Meta-analytic studies have found that the majority of studies have used working alliance measurements from the third session of treatment (Horvath & Symonds, 1991). While early alliance ratings have demonstrated increased predictive capability on treatment outcome when compared with mid- or late-treatment ratings (Martin et al., 2000), the third session preference has been criticized as an arbitrary process marker (Kivlighan & Shaughnessy, 1995). Different studies have found support for strong process–outcome correlations for both early (Horvath & Symonds, 1991) and late (Stiles, Agnew-Davies, Hardy, Barkham, & Shapiro, 1998) working alliance scores, though research has also demonstrated relatively small correlations between both patient- and therapist-rated alliance scores in early and late phases of treatment (Brossart, Willson, Patton, Kivlighan, & Multon, 1998). The linear trajectory of working alliance patterns has also been found to be associated with outcome. Kivlighan and Shaughnessy (2000) identified three general patterns of the working alliance: (i) a stable pattern, with little change across sessions, (ii) a linear growth pattern, with increasing strength in the relationship over time, and (iii) a quadratic growth, “U-shaped” pattern, with high alliance ratings in the early and late phases of treatment, and a drop in scores in mid-treatment sessions. They found that the quadratic growth pattern predicted significantly better treatment outcomes than dyads with other patterns (Kivlighan & Shaughnessy,

2000). A subsequent replication effort instead identified a “V-shaped” pattern that consisted of brief deflections/drops in working alliance scores that seemed to be markers of rupture and repair episodes in treatment, and found that this pattern was associated with increased treatment gains (Stiles et al., 2004). A review of alliance measurement over time (Stiles & Goldsmith, 2010) described the great variation in temporal patterns found throughout the literature, including specific types of trends emerging in different patient populations. In general, the review found support for improvement in the alliance over the course of therapy, and for some association between this improvement and treatment outcome. However, the authors noted that the effects are small, variable, and inconsistent across studies (Stiles & Goldsmith, 2010). The rater of the working alliance also plays a role in the process–outcome relationship. Alliance ratings can be derived from the perspective of the client, the perspective of the therapist, through rating of an outside observer, or through concordance between individual client and therapist ratings (Langhoff, Baer, Zubraegel, & Linden, 2008). Research has generally found a lack of statistically significant relationships between client, therapist, and observer ratings (Hersoug, Hoglend, Monsen, & Havik, 2001; Tichenor & Hill, 1989), and client-rated alliance has typically demonstrated superior predictive capability on treatment outcome when compared to therapist ratings (Horvath & Symonds, 1991; Piper, Azim, Joyce, & McCallum, 1991). Of note, these confounding variables—time, pattern, and rater—can interact in important ways, and should therefore be analyzed or controlled for in process–outcome studies. Hierarchical linear modeling (HLM; Bryk, Raudenbush, Seltzer, & Congdon, 1988; Francis, Fletcher, Stuebing, Davidson, & Thompson, 1991; Willett, 1988) a type of MLM, has been used to analyze alliance development over time and is particularly well-suited for examining change in repeated-measures studies. Procedures like HLM can be useful in examining the interaction between variables in process–outcome research. For example, Kivlighan & Shaughnessy (1995) found a strong relationship between therapist-rated working alliance that followed a linear pattern (increasing over time), and client-rated outcome. This study demonstrated that the linear pattern in the alliance accounted for more variance in outcome than therapist alliance ratings at the third session of treatment, the middle phase of treatment, or the final session of treatment. The authors concluded that it is not sufficient to know the strength of the alliance at a static point in time, but that information about the trajectory of the

Psychotherapy Research alliance is critical to best predict treatment outcome. Furthermore, they pointed to HLM as a sophisticated analytic technique for measuring the working alliance as a dynamic, rather than static, process variable (Kivlighan & Shaughnessy, 1995).

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Generalizability Theory Analysis Research has recently begun to holistically examine confounding variables. In an effort to examine the dependence in alliance scores, evaluate the causal direction of session-to-session changes, and examine the impact of aggregating alliance scores over sessions, Crits-Christoph and colleagues (2011) employed generalizability theory analysis. Building on process– outcome studies that used MLM techniques, and incorporating client and therapist levels into the structure of the data, generalizability theory (Cronbach, Rajaratman, & Gleser, 1963; Shavelson & Webb, 1991) was employed to examine what quantity of session data was necessary to produce a stable measure of the working alliance, and generalize from a sample of sessions to the complete set of sessions from which the sample was drawn. Generalizability coefficients were calculated to assess the accuracy of extrapolating from an individual session score to the hypothetical mean score that would have been obtained across observation at all sessions. Clientlevel generalizability coefficients demonstrated that a single assessment of the alliance was only marginally acceptable, and that appropriate stability was achieved through aggregating alliance ratings from four or more therapy sessions. The study found that, while static session 3 alliance ratings explained about 5% of the variance in treatment outcome, evaluating sessions 3– 9 in aggregate explained nearly 15%. Evaluating all of the relevant data, the authors concluded that adequate assessment of the working alliance requires multiple raters (clients and therapists) and data from a minimum of four (and up to seven) treatment sessions. The findings also suggested a complex interplay between the working alliance and symptom change, with session-to-session alliance changes predicting subsequent session-to-session symptom changes (Crits-Christoph et al., 2011). The alliance–outcome relationship, while robust and well established, is more complicated than it first appears, with several variables potentially contributing to the strength of the observed relationship. The structure of the data (nested, repeated-measures), time of measurement (session number), patterns in the data over time (linear, quadratic), and rater (client, therapist) all potentially impact or confound the observed alliance–outcome relationship. Furthermore, meta-analytic studies have aggregated studies

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that have employed different measures, methods, and statistical procedures, making the conclusions somewhat confounded and opaque. Sophisticated statistical techniques—such as MLM, hierarchical linear modeling, and generalizability theory analysis— represent significant empirical advances and point the way toward further clarification and elucidation of the alliance–outcome relationship.

Conclusion In the current climate of evidence-based treatments (American Psychological Association, 1995; Department of Health, 1996), it is crucial that psychotherapy researchers identify and understand the factors that contribute to psychotherapeutic change (Garfield, 1990; Stiles, 1980). While decades of research on the working alliance have demonstrated its critical role in the change process, the proportion of treatment outcome that it explains remains relatively low. Despite what appears to be a relatively minor contribution, the therapeutic relationship remains the most investigated and robust predictor of treatment outcome in the psychotherapy literature to date. The working alliance is typically assessed by measures conceptually grounded in Bordin’s (1979) pantheoretical definition of the construct. Despite decades of research and several important theoretical developments, the definition of the working alliance, from an empirical standpoint, has been slow to evolve. Given the wealth of information that has accumulated since Bordin’s time, continuing attachment to his definition may be outdated. The factors that contribute to the establishment and maintenance of a strong alliance, particularly in regard to the presence of strains that perturb the system, need to be identified and understood in more depth. The components of the working alliance, the stability of the alliance in the presence of strain, and the nature of its relationship to change all require further explication. A fundamental issue in alliance research is the tension between clinical constructs and scientific endeavors. Stiles & Goldsmith (2010) describe the fallacy of treating the working alliance as a stable, unidimensional construct, suggesting that aggregate and global reports oversimplify the complexities of the therapeutic relationship. They point to methodological variations and poor articulation of underlying theory for the failure to produce clearly delineated results. The working alliance is complex, dynamic, and more nuanced than existing measures reflect (Stiles & Goldsmith, 2010). Qualitative research and mixed methods approaches have much to offer, with case studies providing a more individualized way of

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examining global psychotherapy process patterns (Hill, 2006; Stiles & Goldsmith, 2010). In the past several decades, important theo‐ retical developments have emerged, among them acknowledging the role of ruptures and their repair, and the postulated importance of therapeutic negotiation for producing interpersonal change. Despite theoretical attention to these constructs in recent years, a lack of validated measures exist to evaluate their utility in treatment process (Norcross & Wampold, 2011a). Additional work is needed to further incorporate these constructs into psychotherapy research and devise and validate measures for investigating their role and impact on psychotherapy process and outcome. Recent empirical advances offer opportunities to evaluate the process–outcome relationship in more sophisticated ways. The ability to parse out sources of variance in alliance–outcome correlations requires advanced statistical techniques and helps to break down the more generic observed relationship. Such analyses can assist in understanding the alliance–outcome correlation, the predictive validity of its component parts, and what factors contribute to or confound the strength of the relationship. Taken together, clearer articulation of underlying theory, more individualized measurement approaches, and psychometric and statistical advances all have great potential to increase the clarity of the working alliance literature. Limitations of this review include a lack of attention to the working alliance construct in specific populations or types of therapy, including child/ adolescent (McLeod, 2011) and couples and family therapy (Pinsof et al., 2008). An in-depth discussion of the impact of different reporters and the convergence of patient, therapist, and observer-based measures was also beyond the scope of this paper. Finally, given the vast literature on the topic, metaanalytic reviews (e.g., Horvath & Symonds, 1991; Martin et al., 2000) were cited to summarize large bodies of research where appropriate. It is recommended that the next generation of psychotherapy researchers devote attention to furthering these important initiatives. Qualitative approaches should be utilized to examine existing theory and to better understand empirical inconsistencies that have emerged. Research needs to more proactively employ advanced statistical techniques to parse out questions regarding temporal effects, causality, patient and therapist characteristics, and the role of other contributing or confounding variables. Despite the long tradition of theory and research related to the therapeutic relationship, ample critiques, controversies, and questions remain. A deeper

understanding of the alliance construct will require continued and rigorous empirical evaluation. Note 1

Transference has been historically defined as the displacement of feelings, attitudes, or defenses toward a person in the present (e.g., the therapist) which are inappropriate and originate in the past, usually in regard to a significant person in the patient’s early life (Freud, 1912). Freud distinguished between positive and negative transference, and referred to the therapeutic relationship in the context of the former.

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The working alliance: Where have we been, where are we going?

This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptu...
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