Adam O. Horvath

The therapeutic relationship: From transference to alliance

A variety of conceptualizations of the relationship between therapist and client, as well as the impact the quality of this relationship has on the client, are reviewed. Different hypotheses about bow the alliance might influence therapeutic progress are also presented. The review pays attention to both the historical and conceptual dimensions of this issue, and provides a summary of the empirical bases of the claims made of the value of a good alliance. The article concludes with a discussion of an integrated model of the alliance and a discussion of the clinical and training implications of our current understanding of this concept.

How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis

Prior meta-analyses have found a moderate but robust relationship between alliance and outcome across a broad spectrum of treatments, presenting concerns, contexts, and measurements. However, there continues to be a lively debate about the therapeutic role of the alliance, particularly in treatments that are tested using randomized clinical trial (RCT) designs. The purpose of this present study was to examine whether research design, type of treatment, or authors allegiance variables, alone or in combination, moderate the relationship between alliance and outcome. Multilevel longitudinal analysis was used to investigate the following moderators of the alliance-outcome correlation: (a) research design (RCT or other), (b) use of disorder-specific manuals, (c) specificity of outcomes, (d) cognitive and/or behavioral therapy (CBT) or other types of treatments, (e) researcher allegiance, and (f) time of alliance assessment. RCT, disorder-specific manual use, specificity of primary and secondary outcomes, and CBT did not moderate the alliance-outcome correlation. Early alliance-outcome correlations were slightly higher in studies conducted by investigators with specific interest in alliance than were those in studies conducted by researchers without such an allegiance. Over the course of therapy, these initial differences disappeared. Apart from this trend, none of the variables previously proposed as potential moderators or mediators of the alliance-outcome relation, alone or in combination, were found to have a mediating impact.

Therapist effects in the therapeutic alliance–outcome relationship: A restricted-maximum likelihood meta-analysis☆

OBJECTIVE Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. The purpose of this present meta-analysis was to (1) test for therapist effects in the alliance-outcome correlation and (2) extend the findings of previous research by examining several potential confounds/covariates of this relationship. METHOD A random effects analysis examined several moderators of the alliance-outcome correlation. These included (a) patient-therapist ratio (patient N divided by therapist N), (b) alliance and outcome rater (patient, therapist, and observer), (c) alliance measure, (d) research design and (e) DSM IV Axis II diagnosis. RESULTS The patient-therapist ratio (PTR) was a significant moderator of the alliance-outcome correlation. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance-outcome correlation. CONCLUSION Corroborating previous research, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship.

The alliance in context: Accomplishments, challenges, and future directions.

Research on the alliance is reviewed in a historic context. Different conceptualizations of the nature and role of the alliance are examined within the framework of theories about the role and function of the relationship in treatment. The evolution of these concepts is cast in the broader context of the current debate concerning an appropriate conceptual framework for empirically supported therapy. Using these perspectives, several persistent challenges are highlighted: the need to develop a clearer definition of the alliance; the challenge of reaching a broad consensus about the alliances relation to other elements in the therapeutic relationship; and the task of more clearly specifying the role and function of the alliance in different phases of treatment. The paper concludes with an examination of how such a historically informed perspective might offer useful indicators for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

The Therapeutic Alliance: Concepts, Research and Training

The role of the relationship between the therapist and the client as a core concept in therapy is examined. The historical development of the idea of the therapeutic relationship in general and the therapeutic alliance in particular is critically reviewed. Research evidence pertaining to the significant role of the alliance in therapy and the complex, sometimes paradoxical, effect of training on remediating difficulties some therapists have in developing a positive alliance is presented. Two main components of the relationship from the therapist perspective are identified: interpersonal skills and intrapersonal dynamics. Recommendations for training are summarised.

How collaboration in therapy becomes therapeutic: The therapeutic collaboration coding system

BACKGROUND The quality and strength of the therapeutic collaboration, the core of the alliance, is reliably associated with positive therapy outcomes. The urgent challenge for clinicians and researchers is constructing a conceptual framework to integrate the dialectical work that fosters collaboration, with a model of how clients make progress in therapy. AIM We propose a conceptual account of how collaboration in therapy becomes therapeutic. In addition, we report on the construction of a coding system - the therapeutic collaboration coding system (TCCS) - designed to analyse and track on a moment-by-moment basis the interaction between therapist and client. Preliminary evidence is presented regarding the coding systems psychometric properties. The TCCS evaluates each speaking turn and assesses whether and how therapists are working within the clients therapeutic zone of proximal development, defined as the space between the clients actual therapeutic developmental level and their potential developmental level that can be reached in collaboration with the therapist. METHOD We applied the TCCS to five cases: a good and a poor outcome case of narrative therapy, a good and a poor outcome case of cognitive-behavioural therapy, and a dropout case of narrative therapy. CONCLUSION The TCCS offers markers that may help researchers better understand the therapeutic collaboration on a moment-to-moment basis and may help therapists better regulate the relationship.

Therapeutic collaboration and resistance: Describing the nature and quality of the therapeutic relationship within ambivalence events using the Therapeutic Collaboration Coding System

Abstract Objectives: We understand ambivalence as a cyclical movement between two opposing parts of the self. The emergence of a novel part produces an innovative moment, challenging the current maladaptive self-narrative. However, the novel part is subsequently attenuated by a return to the maladaptive self-narrative. This study focused on the analysis of the therapeutic collaboration in episodes in which a relatively poor-outcome client in narrative therapy expressed ambivalence. Method: For our analysis we used the Therapeutic Collaboration Coding System, developed to assess whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD). Results: Results showed that when the therapist challenged the client after the emergence of ambivalence, the client tended to invalidate (reject or ignore) the therapists intervention. Conclusions: This suggests that in such ambivalence episodes the therapist did not match the clients developmental level, and by working outside the TZPD unintentionally contributed to the maintaining the clients ambivalence.

The therapeutic relationship in action: How therapists and clients co-manage relational disaffiliation

Abstract Over the past three decades a great deal of energy has been invested in examining the consequences of relational stresses and their repair. Less work has been done to examine how therapists and clients actually achieve re-affiliation through verbal and non-verbal resources, how such affiliation becomes vulnerable and at risk, and how therapists attempt to re-establish affiliative ties with the client—or fail to do so. We utilize the method of Conversation Analysis (CA) to examine clinical cases that involve extended episodes of disaffiliation. Clients with different styles of disaffiliation—confrontation and withdrawal—are compared. We show how disaffiliation is interactionally realized in different ways and how this is followed by more or less successful attempts at repair.

How real is the “real relationship”?

I am honored and pleased to be asked to comment on Professor Gelso’s article and see it as an opportunity to start an exchange of ideas on a topic of timely significance: What are the clinically and theoretically important elements in the relationship between therapist and client? Within this broad inquiry, Gelso raises several important issues: Can we reliably separate parts of the relationship that are specific to the therapeutic situation from the personal relationship? Are there distinct functions associated with conscious as opposed to unconscious components of the relationship? Should we earmark some parts of the relationship as ‘‘real’’ to distinguish these from the elements based on some kind of unconscious fantasy? I believe that one of the core arguments underlying Gelso’s study, namely that there is more to the relationship in psychotherapy than those elements that are for the therapy ‘‘as such’’ (p. x), is a convincing one. Clearly, beyond aspects of the relationship that are specific to the purpose and goals of therapy, there are, in addition, nuances of feelings between therapists and clients that are related to the sense of each other ‘‘qua person.’’ I also agree that, conceptually at least, these qua person aspects of the relationship can have different, even opposing, vectors from those feelings and interpersonal connections associated with the professional relationship. Likewise, I am in agreement with the argument that some of these qua person relational dimensions may have an impact on the therapy process and outcome at various points. In a broader perspective, I also appreciate Gelso and colleagues’ sustained focus on the search for clinically meaningful distinctions within the therapeutic relationship. Their interest in developing a more layered, finer grained model of the relationship, in and of itself, has a beneficial impact. It helps to counteract what seems to be a growing trend in the research community: to equate the alliance with the therapeutic relationship. This naı̈ve assumption, I believe, is a serious conceptual error that potentially hinders our understanding of the complexity of the role that relationship plays in therapy (Hatcher & Barends, 2006). In addition, I was also helpfully reminded by this article of the pressing need for an overarching conceptual framework for the relationship in therapy. If we could achieve consensus on an inclusive model, it would serve as an organizing framework for the mosaic of research results and help us to better knit individual investigations into an integrated whole. Such integration, in turn, would be a significant step toward more accurately identifying specific microprocesses that help or hinder the relationship, with the consequent important implications for practice and training (Horvath, 2005). Although I find all of these contributions much needed and valuable, there are also some aspects in Gelso’s proposed model of relationship that I see as problematic. In the rest of this article, I first focus on what I see as problems and then explore some possible alternatives.

“I Can See Some Sadness in Your Eyes”: When Experiential Therapists Notice a Client’s Affectual Display

We use the methods of conversation analysis to examine how therapists draw attention to a client’s verbal or nonverbal affectual stance display and thus place the focus of talk on the client’s here-and-now experience. These therapist practices are referred to as noticings. By investigating four different experiential-oriented therapeutic approaches (Emotion-Focused, Gestalt, Symbolic Experiential, and Narrative), we explore three ways in which therapist noticings manage the progressivity of talk: by facilitating, shifting, or manipulating/disrupting the activity in progress. We also found that therapists would put noticings to use with varying degrees of empathy and cooperativeness. Whereas empathically designed noticings would facilitate progressivity and cede epistemic authority to clients, nonempathic noticings would disrupt sequential progression and challenge the clients’ greater epistemic status pertaining to their domain of experience. Differences and similarities between therapy approaches with respect to how therapists deploy noticings are discussed. Data are in American English.