Elsevier

Clinical Psychology Review

Volume 28, Issue 7, October 2008, Pages 1167-1187
Clinical Psychology Review

The conceptualization and measurement of therapeutic alliance: An empirical review

https://doi.org/10.1016/j.cpr.2008.04.002Get rights and content

Abstract

Therapeutic alliance constitutes a major variable in explaining the outcome of treatment. However, meta-analytic, narrative, and theoretical reviews have all begun to comment on significant deficiencies in both conceptualization and measurement of alliance. While the evidence on the overall impact of alliance on treatment outcomes is impressive, we know much less about its components, modelling and discrete measurement.

We review the conceptual and methodological underpinning of current alliance concepts and measures with the aim of identifying the current status of the methods and clarifying the conceptual and measurement tasks ahead.

The review makes clear the diversity of concepts and measures available to address treatment alliance; however there is no one current measure of alliance that meets all the predefined criteria in either adult or child populations. We discuss the most successful measures to date, and recommend future developments in the field of alliance, including conceptual and experimental approaches, developmental issues, and analytic techniques.

Section snippets

Introduction — strengths and shortcomings of the alliance concept

Gathering evidence within empirical studies of mental health interventions suggest that the therapeutic alliance constitutes an important variable in explaining the outcome of treatment (Priebe & McCabe, 2006). Meta-analysis of studies in both adult (Martin, Garske, & Davis, 2000) and child (Shirk & Karver, 2003) mental health research have shown a consistent if modest association between measures of therapeutic alliance, and treatment outcome; particularly when alliance is measured at early

Genealogy

Treatment alliance (TA) is a summary term referring to a number of interpersonal processes at play in psychological treatment which can generally be considered to act in parallel to (and theoretically independently of) specific manualized treatment techniques (Green, 2006). Hypothesis testing and modeling of such effects depends in the end on the robustness of the concepts being measured. The plethora of measures in current use may reflect an uncertainty about this conceptualization.

A genealogy

Analysis of alliance in treatment

Measurement of therapeutic alliance has been approached both by external observation of relevant interpersonal behaviors (e.g. rating video or audio tapes of treatment sessions) or by eliciting attitudes of the client and therapist at various time points during treatment. Each of these measurement methods raises methodological problems.

Summary

Available evidence supports that view that alliance is an important concept and that its measurement should be part of future well designed treatment trails in mental health across the age range (Green, 2006). The purpose of this review has been to take a critical look at current concepts and measurement in alliance with a view to identifying how the investigation of alliance should proceed in future treatment research.

The review makes clear the diversity of measures available to measure

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