working alliance

8/3/2019 Working Alliance

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THE WORKING ALLIANCE: WHERE ARE WE AND WHERE

SHOULD WE GO?

LOUIS G. CASTONGUAYPenn State University

MICHAEL J. CONSTANTINOUniversity of Massachusetts at Amherst

MARTIN GROSSE HOLTFORTHPenn State University and University of Bern

This article describes important find-ings that have emerged from decades ofresearch on the working alliance, as

well as some of the clinical implica-tions of these findings. In addition, fu-ture directions of research on this con-struct are suggested. Our hope is thatthis article will provide useful heuris-tics for better understanding the alli-ance, the therapeutic relationship morebroadly, and the process of therapeuticchange in general.

Keywords: working alliance, psycho-therapy, process of change

Theorists from different psychotherapeutic ap-proaches have long recognized the client-therapist alliance as a crucial component ofchange. We venture to guess that there are notextbooks about psychotherapy published in thelast ten years or so that have not referenced thealliance, and that most current treatment manuals

emphasize its importance (including modalities

that had not traditionally highlighted the patient-therapist relationship as a central change mecha-nism). Empirically, the alliance appears to be themost frequently studied process of change. One

could also argue that, in addition to dominatingprocess research, the alliance has crossed-overinto the domain of outcome studies. In fact, wecannot imagine that a psychotherapy study in thenear future (including clinical trials) would befunded without a measure of alliance included inits design. Clinically, the alliance occupies suchan important place in our conceptualization ofwhat good therapy entails that not paying atten-tion to its quality during practice or supervisioncould be viewed as unethical.

By generating interest from so many perspec-tives, the alliance has provided an optimal venuefor convergence between researchers and clini-cians. As a case in point, the response of Division29 (Psychotherapy) of the American Psycholog-ical Association to the empirically supportedtherapy movement (EST; Chambless & Ollen-dick, 2001) was to create a task force (Norcross,2002) aimed at delineating and disseminating theempirical evidence supporting the role of therelationship in therapy, at the forefront of whichhas been the alliance. In essence, Division 29 (anorganization recognized as an advocate of prac-titioners) has used research to lend credence toand to promulgate what most clinicians have al-ways believed: The relationship matters! Suchconvergence of interest, as well as conciliationefforts, led us to recently label the alliance as theflagship of the scientist-practitioner model(Constantino, Castonguay, & Schut, 2002).

Consistent with the Division 29 task force, we

view the alliance as a component of the therapeu-tic relationship, along (and more than likely ininteraction) with a number of other interpersonalconstructs (e.g., therapist empathy, positive re-gard, and congruence). We also argue that there

Louis G. Castonguay, Department of Psychology, Penn

State University; Michael J. Constantino, Department of Psy-

chology, University of Massachusetts at Amherst; Martin

Grosse Holtforth, Department of Psychology, Penn State Uni-

versity and University of Bern.

This paper was supported, in part, by a fellowship to the

third author (MGH) from the Swiss National Science Foun-

dation (No. 101415). We are also grateful to Joan DeGeorge

and James F. Boswell for their help in preparing this article.Correspondence regarding this article should be addressed

to Louis G. Castonguay, Department of Psychology, 308

Moore Building, Penn State University, University Park, PA

16802. E-mail: [email protected]

Psychotherapy: Theory, Research, Practice, Training Copyright 2006 by the American Psychological Association2006, Vol. 43, No. 3, 271279 0033-3204/06/$12.00 DOI: 10.1037/0033-3204.43.3.271

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is an increasing consensus in the field with re-spect to the characteristics that define the alli-ance. As we wrote elsewhere, it is generallyagreed that the alliance represents interactive,

collaborative elements of the relationship (i.e.,therapist and client abilities to engage in the tasksof therapy and to agree on the targets of therapy)in the context of an affective bond or positiveattachment (Constantino et al., 2002; p. 86).With this definition in mind, the goals of thecurrent paper are to describe briefly what webelieve are the core empirical findings on thealliance to date, to discuss the most obvious clin-ical implications of such findings, and to high-light what we think are the most important direc-

tions for future research on this construct. Wehope that our reflections lead to useful heuristicswith respect to the alliance, the therapeutic rela-tionship, and more generally to the process ofchange in psychotherapy.

What Do We Know?

1. Perhaps the most important finding that hasemerged from a considerable number of studies isthat the alliance correlates positively with thera-

peutic change across a variety of treatment mo-dalities and clinical issues (Castonguay & Beut-ler, 2005a; Constantino et al., 2002). Based onmultiple meta-analyses, the effect size for thealliance-outcome association ranges from .22 to.26 (see Horvath & Bedi, 2002; Martin, Garske,& Davis, 2000). Although the size of this rela-tionship is not large, it appears to be robust.Furthermore, as Horvath and Bedi (2002) haveargued, the effect size is substantial for a variablebeing measured within the complex entity of psy-

chotherapy. Thus, it seems safe to assume thatirrespective of the clinical problem or the treat-ment modality that therapists should strive toestablish, monitor, and maintain a positive bondand a strong level of collaboration with theirclients.

2. The empirical literature also seems to indi-cate that alliance quality correlates positivelywith some client characteristics and behaviors(e.g., psychological mindedness, expectation forchange, quality of object relations) and nega-

tively with others (e.g., avoidance, interpersonaldifficulties, depressogenic cognitions; see Con-stantino et al., 2002). Furthermore, some of theseassociations tend to hold even when accountingfor symptom change prior to when the alliance is

measured, suggesting that the variance explainedin the alliance is not solely due to symptomaticimprovement (e.g., Connolly Gibbons et al.,2003; Constantino, Arnow, Blasey, & Agras,

2005). Clinically, these findings suggest that ther-apists may be able to forecast patients with whomthey will have a more or less difficult time estab-lishing and maintaining an alliance. In those in-stances where alliance quality is challenged, ther-apists should be prepared to address suchrelationship problems, as well as to modify theirapproach in order to be responsive to their cli-ents needs (Grosse Holtforth & Castonguay,2005; Safran, Muran, Samstag, & Stevens, 2002).

3. Research also suggests that certain therapist

characteristics and behaviors are positively asso-ciated with quality alliances (e.g., warmth, flex-ibility, accurate interpretation; see Ackerman &Hilsenroth, 2003). Certain therapist characteris-tics and behaviors may also contribute to alliancedifficulties (e.g., rigidity, criticalness, inappropri-ate self-disclosure; see Ackerman & Hilsenroth,2001). In a theoretically-driven study examininginterpersonal history and in-session behavior,Henry, Strupp, Butler, Schacht, and Binder(1993) showed that therapists who are hostile

toward themselves appear to be particularly atrisk for counter-therapeutic interactions withtheir clients. Similarly, Rosenberger and Hayes(2002) examined in a single-case study how thealliance can be affected if the material discussedin the session touches the therapists own unre-solved issues. Based on qualitative analyses, afew studies have also suggested that when facedwith alliance ruptures or therapeutic impasses,therapists increased or rigid adherence to pre-scribed techniques or the therapeutic rationale

may fail to repair such ruptures and may evenexacerbate them (Castonguay, Goldfried, Wiser,Raue, & Hayes, 1996; Piper et al., 1999).

Although more studies need to be conductedbefore definite conclusions can reached, theabove findings lend themselves to a number ofsuggestions. First, therapists may consider prac-ticing the wise adage of know thyself. If andwhen therapists begin to observe negative feel-ings or counterproductive states (e.g., boredom,frustration), it might be wise for them to adopt

consciously and systematically Sullivans stanceof participant-observer (and perhaps to seek su-pervision) in order to minimize the probability ofbeing hostile with their clients. Second, ratherthan persevering in their emphasis on specific

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techniques or rationales when faced with allianceruptures, therapists might consider using meta-communication skills described by Safran and hiscolleagues (Safran & Muran, 2000; Safran &

Segal, 1990), as well as Burns (1990; e.g., invitethe client to talk about alliance ruptures, explorethe clients experience of the ruptures, recognizetheir own contribution to alliance difficulties).When used skillfully to address the various mark-ers of alliance ruptures (see Safran, Crocker, Mc-Main, & Murray, 1990), these metacommunica-tive interventions may not only improve thequality of the bond (e.g., helping the client to feelmore understood and respected by the therapist),but also foster the collaborative engagement of

both participants (e.g., agreeing on therapy tasksand goals that are more attuned with the clientsneeds, while remaining in sync with the thera-pists conceptual and practical expertise). Al-though mostly preliminary, a few studies havebegun to provide support for the use of thesemetacommunication skills (e.g., Castonguay etal., 2004; Safran et al., 2002).

4. Evidence also suggests that the alliance isparticularly predictive of outcome when mea-sured early in treatment. Furthermore, poor early

alliance predicts client dropout (see Constantinoet al., 2002). A clear implication of these findingsis that therapists would be wise to pay attention tothe alliance as soon as therapy begins. Ratherthan assuming that initial problems of collabora-tion or early signs of disengagement will auto-matically decrease with time, therapists shouldstart fostering the alliance with the first minute oftherapy and be prepared to address alliance rup-tures at their first sign of emergence. However,therapists should not restrict their assessment of

the alliance to the early phase of treatment. Themixed findings with regard to the mid-treatmentalliance-outcome association, for instance, maybe partly due to the fluctuating nature of someprocesses of change. For example, in a study byStiles and colleagues (2004), brief V-shaped de-flections in the alliance over time (interpreted asrupture-repair sequences) were associated withgreater therapeutic gains. Such findings under-score the possible therapeutic benefits of alliancerupture-repair processes over the course of treat-

ment (see Constantino et al., 2002; Safran et al.,2002).5. As a consequence of the many years of

research on the alliance, we now have a numberof psychometrically sound instruments to mea-

sure this construct from client, therapist, and ob-server perspectives (see Constantino et al., 2002;Horvath & Greenberg, 1994). While several ofthe alliance scales have been anchored within the

psychodynamic tradition, at least one of them, theWorking Alliance Inventory (WAI; Horvath &Greenberg, 1989), has been developed from atranstheoretical perspective. Thus, the alliancecan be measured in any form of therapy. Concep-tually, one implication of the availability of suchinstruments is that the alliance can no longer beviewed as a nonspecific variable, i.e., a variablefor which the nature and impact is not yet under-stood (see Castonguay, 1993; Castonguay &Grosse Holtforth, 2005). Contrary to the way

relationship factors have been viewed for manyyears, the alliance has now been clearly opera-tionalized. It is probably fair to say that it hasbeen measured, in a reliable way, more fre-quently than many other process variables (in-cluding psychotherapy techniques). As men-tioned earlier, we also know that the alliancepredicts outcome, suggesting that it might havean impact on client improvement (although, asdiscussed later, the cause and effect relationshipbetween alliance and outcome has not been

firmly established). Thus, while the alliance canbe viewed as a common factor, it is clearly not anundefined or non-specified one.

The most obvious clinical implication of hav-ing viable measures of alliance is that therapistsshould be using themand they should especiallyask their clients to fill them out! Although mosttherapists feel that they are generally able to

judge accurately the quality of the relationshipthat they have with their clients, evidence sug-gests that client and therapist views of alliance

diverge (especially during the early part of ther-apy, see Horvath & Bedi, 2002), and that theclients perspective tends to be more predictive ofoutcome (again, this is most pronounced early,see Horvath & Bedi, 2002). Thus, while we rec-ommended earlier that we, as therapists, shouldknow ourselves, we should also exercise cautionabout how much faith we put into our perceptionof what is going on in the therapy room. Al-though it may not provide them with the mostaccurate predictor of their clients final outcome,

therapists are nevertheless likely to benefit fromcompleting alliance measures. Discrepancies be-tween their own evaluation of the alliance andthat of a client, for instance, may reflect an alli-ance rupture that should be addressed, but could

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otherwise go unnoticed. Furthermore, there issome evidence that similarity between client andtherapist alliance ratings at the middle and latephases of treatment is positively linked with out-

come (see Horvath & Bedi, 2002).

What Do We Need to Know?

1. Although the alliance has been linked withoutcome, the causal direction (if any) of thisrelationship has not been clearly established. Thefact that the alliance measured early in treatmentis a strong predictor of post-therapy change in-creases the likelihood that its quality precedes,rather than follows, substantial improvement.

Moreover, some studies have found that the alli-ance predicts outcome when controlling for pre-vious change (e.g., Barber, Connolly Gibbons,Crits-Cristoph, Gladis, & Siqueland, 2000; Kleinet al., 2003), further suggesting that the alliance-outcome association is not just an artifact ofclients getting better over time. In other studies,however, the alliance has failed to correlate sig-nificantly with outcome when accounting statis-tically for prior symptom change (e.g., DeRubeis& Feeley, 1990; Feeley, DeRubeis, & Gelfand,

1999; Gaston, Marmar, Gallagher, & Thompson,1991).More studies are needed to clarify this issue.

One recently emerging direction is to examinethe alliance within mediational models that ap-proximate causal pathways by virtue of temporalprecedence within prospective treatment designs.For example, analyzing data from the Treatmentof Depression Collaborative Research Program(TDCRP; Elkin, 1994), Meyer and colleagues(2002) found that the alliance mediated a previ-

ously established positive relationship betweenclients pretreatment expectations for change andtreatment outcome. Hardy and colleagues (2001),in a study of cognitive therapy for depression,found that the relationship between clients un-derinvolved style and outcome was mediatedthrough the therapeutic alliance. Thus, some re-search has begun to address the issue of thedirection and nature of the alliances impact onthe process and outcome of treatment. It is prob-able, however, that if and when a resolution is

achieved, the consensus will be more complexthan an either/or type of answer. The process ofchange, in our view, involves interdependent,non-orthogonal, and/or synergistic relationshipsbetween different variables.

2. In addition to clarifying the relationshipsamong alliance, improvement, and outcome, itseems important to add more theoretically-basedexplanations to alliance-outcome linkages. Pres-

ently, there is a dearth of such hypotheses, whichmay be an outgrowth of the fields quest to definethe alliance pantheoretically. As Horvath (2005) hasargued, there needs to be heightened theoreticaldiscourse and debate around the construct of thepatient-therapist relationship. Hilliard, Henry, andStrupp (2000) provided one good example of analliance study that placed the hypotheses, measures,and findings within a specific (psychodynamically-oriented) theoretical framework that involved earlyinterpersonal histories, the quality of the therapeutic

alliance during therapy, and treatment outcome.The authors found that the early interpersonal his-tories of both the clients and therapists had varioustypes of direct or indirect influences on the processand outcome of treatment. More work of this natureis needed, perhaps by using more theoretically spe-cific measures to complement the use of pantheo-retical ones.

3. Grawe (1997) has argued that a particularlyfruitful way to improve the outcome of effectivetreatments is to derive mechanisms of change

from process research and use them to modifytherapeutic procedures. Because the alliance isarguably the most robust predictor of change,training therapists on how to foster the alliance,as well as how to negotiate any emergent allianceproblems is likely to be the first and most logicalstep to follow in order to test this research strat-egy. Several studies have examined the effective-ness of implementing techniques specifically de-signed to foster the alliance (Crits-Christoph,Connolly Gibbons, Narducci, Schamberger, &

Gallop, 2005; Grawe, Caspar, & Ambuhl, 1990)and to address alliance ruptures (Castonguay etal., 2004; Safran et al., 2002; Whipple et al.,2003). While the preliminary findings are prom-ising, we need more convincing evidence, in bothefficacy and effectiveness studies, that such tech-niques have direct, unique, and causal effects onimprovement.

Of course to test rupture-repair strategies, youneed to be able to detect the alliance problems! Inthis regard, Safran and colleagues (Safran et al,

1990; Safran & Muran, 1996; Safran et al., 2002;Samstag, Muran, & Safran; 2004) have delin-eated useful markers, including those character-ized predominately by withdrawal (e.g., clientavoidance maneuvers) or confrontation (e.g., dis-


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agreement between client and therapist on thegoals of treatment). These markers deserve moreempirical attention in order to firmly establishtheir validity, as well as to determine whether

some of them are more prevalent with certaintypes of clients, or whether some others are morelikely to emerge in specific contexts.

In our opinion, one rupture marker that shouldreceive particular attention is client anger or hos-tility toward the therapist. The difficulty of deal-ing therapeutically with such powerful and neg-ative reactions has been addressed by expertpsychodynamic and cognitive therapists (Binder& Strupp, 1997; Burns, 1990; Newman, 1997).Recent empirical findings have provided useful

heuristics for how therapists can effectively ad-dress this issue. For example, Dalenberg (2004)found that clients who completed long-termtrauma therapies reported more satisfaction withtherapists who were perceived as being moreself-disclosing in response to anger as opposed totherapists who maintained a blank screen in theface of anger. Hill and colleagues (2003) foundthat several therapist factors were associated withthe effective resolution of hostile anger events,including genuinely expressing their own feel-

ings of annoyance and frustration with the client,as opposed to turning their feelings inward.While more research is needed in this respect, weare convinced that trying to match specific inter-ventions to significant in-session events such asanger (as opposed to matching theoretical orien-tation to client diagnosis) is likely to enhancesignificantly our understanding of the process ofchange, as well as to make research efforts moremeaningful and relevant to practitioners.

4. Although substantial evidence points to the

importance of a good alliance for treatment suc-cess, we need to have a better understanding ofhow it develops. This is a particularly crucialissue for training. While neophyte therapists areconstantly reminded of the need to establish goodrapport with their clients, there are few empiri-cally based strategies to guide this essential work.Although there is preliminary evidence that ther-apists who undergo structured psychotherapytraining establish better alliances than therapistswith unstructured training (Hilsenroth, Acker-

man, Clemence, Strassle, & Handler, 2002), moreresearch is needed to determine the impact ofspecific alliance-fostering guidelines defined bothwithin and across therapy approaches.

In our efforts to better understand how the

alliance develops, it might be wise to pay partic-ular attention to its very first step. It has beenargued that the early alliance may distinguishitself from later alliance in terms of the impact,

manifestations, and sources of alliance rupturesthat tend to occur (Maramba & Castonguay,2004). Furthermore, a number of clients nondi-agnostic characteristics (a focus of the aforemen-tioned Division 29 Task Force) may influencetheir capacity to develop a collaborative engage-ment with and/or to form a positive attachment tothe therapist early in treatment. For example,recent evidence suggests that clients inherentself-verification strivings (Constantino et al.,2005) or avoidance motivations (Grosse Holt-

forth et al., 2005) may impact early alliancedevelopment.Perhaps one route to better understanding alli-

ance development, maintenance, and negotiationis to study expert therapists to determine, forexample, how they first establish a good alliance,the flow that the alliance tends to take during thecourse of their treatment with responsive and lessresponsive clients, how they attempt (success-fully and unsuccessfully) to repair breaches ofalliance, how they find balance (to use Linehans,

1993, eloquent words) between the skillful use oftechniques and the provision of therapeutic ac-ceptance and support, and how they address all ofthese complex issues with different type ofclients.

5. Related to the previous point, more researchis also needed on the developmental patterns ofalliance during the course of treatment. Someevidence suggests that different patterns of alli-ance development (linear, quadratic, briefV-shape deflections) may be linked with positive

outcome (Kivlighan & Shaughnessy, 2000; Pat-ton, Kivlighan, & Multon, 1997; Stiles et al.,2004; Tracey & Ray, 1984). However, the find-ings have demonstrated some inconsistency and,thus, more studies are needed for definite conclu-sions to be reached about such dynamic patterns.These studies would provide useful informationto clinicians who could use different types ofalliance patterns as feedback on the progressof therapy. For example, if a quadratic (orUshape) pattern does appear to be a reliable

indicator of treatment responsiveness for someclients, then a decrease of alliance scores afterinitially high scores need not be viewed as analarming sign. Instead, it may reflect that thingshave to get worse before they get better. Reliable

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findings from such studies may in turn generateboth quantitative and qualitative investigations inorder to determine if and how differential pat-terns of development of alliance may be a cause,

an effect, or a manifestation of improvement.Additional research should also be conductedon the effect of tracking and responding to alli-ance patterns during therapy. In an innovativestudy, Whipple et al. (2003) examined the impacton treatment duration and client outcome of pro-viding therapists with feedback on variouspatient-rated dimensions (including the quality ofthe alliance) and recommending clinical strate-gies (Clinical Support Tools [CST]) to addressany deficiencies. Compared to a no-feedback,

treatment-as-usual control group, clients in thefeedback plus CST group attended more sessions,achieved higher recovery rates, and demonstratedless deterioration. These promising findingsshould generate further studies on the effect ofhelping therapists to monitor and to react thera-peutically to alliance fluctuations.

6. We also believe that when investigatingeach of the issues and questions raised above, thefield should pay attention to specific populationsof clients and therapists. In particular, more re-

search needs to be conducted with minority cli-ents. For example, it seems important to identifyculture-specific markers of alliance rupture,which may or may not resemble the markersmore generally defined and discussed above (seeConstantino & Wilson, in press). Furthermore,while there is a small literature that suggests thatethnic minority clients are more likely to prema-turely terminate therapy (when being treated byCaucasian therapists [Reis & Brown, 1999]), thereasons for this phenomenon are not well known.

It is possible that the link between ethnicity anddropout is mediated by alliance quality. What isclear is that much more research is needed toflesh out the relationships between minority sta-tus, therapeutic interventions, alliance negotia-tion, and outcome.

We should also conduct more alliance researchwith personality disorders (Bender, 2005). Stud-ies with personality-disordered clients have sug-gested that the alliance is linked with outcome,and that alliance repair techniques appear to be

promising (Smith, Barrett, Benjamin, & Barber,2005). Many questions, however, remainedlargely unexplored. For example, do differenttypes of alliance ruptures and alliance patternstend to emerge for different types of personality

disorders? Are different strategies of interven-tions required for different personality disorderswith regard to the establishment and repair of thealliance?

It also seems important to determine the typeof clients for whom the addition of alliance repairtechniques might not be necessary or not suffi-cient to improve the effectiveness of therapy.Given that a substantial number of clients benefitfrom treatment protocols that do not explicitlyprescribe alliance repair interventions, the addi-tion of such interventions may not show signifi-cant incremental change for these clients. Fur-thermore, alliance ruptures may not be the reason(or at least not the only one) for which some

individuals fail to respond to empirically sup-ported treatments. With such clients, alliance rup-tures, if and when they emerge, may be a reflec-tion of other issues or may simply be lessimportant than other treatment difficulties. Forexample, the recognition of empathic failure maynot add much to a therapists effectiveness whentreating a person with substance abuse who is notwilling to change his/her drinking behavior.

In contrast, the addition of alliance repair tech-niques might be particularly beneficial for some

individuals. For example, cognitive behaviortherapists treating depressed clients with highlevels of reactance (i.e., reluctance to being con-trolled by others) should be aware that directivetreatments do not fair well with these clients(Beutler, Blatt, Alimohamed, Levy, & Angtuaco,2005). However, it is possible that reactant cli-ents might still benefit from cognitive behavioraltherapy if it is used by a therapist mindful of andready to deal with clients potential negative re-actions to perceptions of being controlled (see

Castonguay, 2000; Goldfried & Castonguay,1993). Alliance repair techniques may also beparticularly beneficial with clients with moderateproblems of attachment or interpersonal relation-ships. These strategies may pave the way forcorrective relational experiences and the discon-firmation of cyclical maladaptive patterns.

Conclusion

We believe that after several decades of pro-

cess and outcome research, relationship variableshave reached a new, more balanced status in thefield of psychotherapy. Although the current em-pirical evidence cannot support Rogerss (1957)hypothesis that specific interpersonal conditions


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are sufficient for change, research on alliance, inparticular, has clearly demonstrated that the ther-apeutic relationship cannot be viewed as a non-specific variable that is merely auxiliary to other

active components of treatment. This balancedview is also indicated by the evidence supportingthe role that other factors play on clients change,such as techniques and participant pre-therapycharacteristics (see Castonguay & Beutler,2005b). Hence, it is time to recognize that thecomplexity of the process of change is not re-flected by a sole emphasis on relationship vari-ables, such as the alliance, or any other types oftherapeutic factors. Instead, we need to recognizethat a variety of elements play an important role,

and that these factors are in constant interactionwith each other (Castonguay & Beutler, 2005a).Our quest to better understand the principles ofchange embedded in these interrelated processesremains paramount.

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