Therapeutic Alliance: Improving Treatment Outcome

Research Update

The following is a Research Update excerpt from the Butler Center for Research. Download the PDF to read the entire Update.

The relationship between a therapist and a patient is a key component of treatment outcome. Carl Rogers, one of the grandfathers of psychotherapy, even went so far to say that a personality change could only take place in the context of a relationship.15 Building on Rogers' work, subsequent researchers have determined that this therapist-patient relationship needs to have three main components: 1) a spirit of collaboration1,6,10,15,16,18,19,21  2) an emotional bond, and 3) an agreement on goals and tasks.

Formation of the Alliance

Therapists and patients each bring characteristics that affect the strength and success of the therapeutic relationship. For patients, one determinant is level of motivation. Patients who are ready for change are more likely to have a therapeutic alliance with their therapist, are more likely to stay in treatment, and have better outcomes.6

On the other hand, anxiety and cognitive impairment may negatively affect how patients perceive therapists, which in turn affects treatment outcome.22 Patients with perfectionism struggle in the therapeutic relationship.18 In early sessions, their alliance with their therapist is as strong as others'. However, the alliance does not strengthen and build over time, as it does for most patients. This may be because perfectionist patients have more difficulty dealing with the normal fluctuations that occur in the therapeutic relationship.

Factors Associated with Treatment Outcome

In general, patients who are better adjusted at the beginning of treatment build stronger alliances.20 However, therapeutic alliance may be more critical for patients with severe psychiatric problems or those with less confidence in their skills to remain abstinent.9,16,22 Demographic variables do not generally affect the development of the alliance, but some research suggests that males prefer a more utilitarian, practical style of therapy, while females respond better to a more empathetic and caring approach.16

Although patient characteristics affect alliance formation, therapists play a critical role. In fact, as one team of researchers stated, ". . . our findings indicate that what clients 'bring' into treatment is frequently less important than what they find when they get there."8

Two main characteristics of therapy help build therapeutic alliance: expertise and empathy.18,8 The former is demonstrated by therapists who are confident, prepared, clear, and logical. "Empathy" is not simply being kind or pleasant; rather, it is a broader term connoting acceptance and understanding. Therapists can mitigate the effect of patient characteristics by making adjustments in therapeutic technique, by altering interpersonal styles, and by repairing ruptures that occur in the therapeutic bond.9,7,12,13,16,20 Moreover, these therapists, who are more effective clinicians, selectively utilize confrontation but they do not use it as a therapeutic "style" of interaction.13 As Miller and colleagues17 point out, "confrontation and empathy are not, we believe, inherently incompatible" and the etymological origin of the word "confrontation" is simply "to bring face to face."17 Confrontation can be done in many ways, including by actively listening, questioning, or restructuring patients' perceptions.

When the Alliance Forms

Some evidence indicates that the therapeutic alliance forms by the third session and that it does not change,10 while other research finds that it fluctuates between the second and fifth session, possibly dependent on the method of treatment.3 Whether formed or stabilized by the third or fifth session, the literature implies that therapeutic alliance forms early in treatment.1,2,5

Therapeutic Alliance and Treatment Outcome

Researchers have studied the efficacy of the therapeutic alliance in a variety of clinical samples—patients with bereavement, eating disorders, mood disorders, personality disorders, and substance-related disorders, among others,11,15,16,20 and across a range of treatment methods (e.g., Twelve Step facilitation, combination of medication and psychotherapy, cognitive-behavioral therapy) and programs (e.g., residential, outpatient, and aftercare).1,4,10,11,13,14,16,20,22

In these wide-ranging studies of diverse problems and therapies, researchers have found that therapeutic alliance is a moderate but consistent predictor of outcome.15 In one critical review of research on treatment for alcohol, drug abuse, smoking, and eating related problems, researchers found that therapeutic alliance leads to better retention in treatment and better eventual outcome.13 Another review focused only on alcohol and drug patients16 and found that while early therapeutic alliance predicted engagement and retention in treatment, it was not consistent in predicting treatment outcome. It may be that as time goes on, factors outside the therapeutic relationship play a more important role in maintenance of recovery. Lambert and Barley12 reviewed the research and concluded that the patient-therapist relationship is second in explaining treatment outcome, surpassed only by that of extra-therapy variables (e.g., social support and unexpected events in a patient's life). An illustration of their conceptualization is shown in the Figure.

Although therapists, patients, and independent observers have rated the therapeutic alliance, ratings completed by patients tend to be most reliable and most predictive of outcome. If patients perceive the alliance as positive in the initial stages of treatment, it tends to account for multiple dimensions of outcome.1,12,15


Several factors highlight the need to use therapeutic alliance as a tool in substance abuse treatment, specifically, including: (1) resistant, challenging, and/or mandated patients; (2) the historical use of confrontation; (3) the increasing emphasis on evidence-based treatment techniques; and (4) increased pressure to demonstrate more favorable treatment outcomes. When patients and therapists form positive alliances, good outcomes are more likely to occur.

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