An important point emphasized by many theorists was that it was essential for the therapeutic alliance to be flexible in order to accommodate the patient or client's perceptions. Another cardinal aspect that was emphasizes by clinicians and theorists was that the therapeutic alliance had the ability to create and promote change in the client. In other words, the therapeutic alliance should be varied enough to deal with the various levels of functioning of the patient. At the same time, it should be flexible enough to accommodate the interventions of the therapist. (Gaston, 1990)
These theories were reinforced by further studies and statistical measurement. Researchers found that there was a significant statistical correlation between therapeutic alliance and positive outcomes in therapy. In this regard, a study by Horvath and Symonds, (1991) established that alliance accounted for almost fifty percent of the variance in the measurable outcome of therapy. In the words, it could be statistically shown that therapeutic alliance had a profound impact on the issue of outcomes. Furthermore, this finding was shown to be consistent across therapy involving different kinds of theoretical input.
IN 1974, Horwitz conducted a study of 42 patients. While half of these patients were treated with individual psychotherapy and the other half with individual psychoanalysis, the study found that, "....there were no differences in the outcomes of the two methods but that there was a marked difference due to therapeutic alliance" (Delaney R.O. 2006).
These results are therefore generally consistent in different therapeutic categories and forms of therapy. For example, therapeutic alliance has been shown to have a significant impact in drug abuse therapy, as well as in the cognitive-behavioral treatment of children with behavioral problems. (Delaney, 2006)
It has also been found to be consistent in alcoholism therapy and martial therapy. The perceived importance of therapeutic alliance is evident in the following assessment. "The alliance itself appears to have therapeutic properties due to the relationship between client and therapist, involving collaboration and acceptance, providing a mode for treatment that is beneficial in its own right" (Delaney R.O. 2006).
The literature also notes the importance of the agreement about tasks between the client and the therapist in the overall therapeutic alliance. In this regard, a study by Orne and Wender (1968) states that, "...the transactions which take place in psychotherapy... can run their normal course only if the participants are familiar with certain ground rules, including the purpose of the enterprise and the roles to be played by the participants" (Orne and Wender,1968, p. 1202)
Another cardinal issue in the literature relating to the evaluation of the therapeutic alliance in terms of positive outcomes and retention, is that the main body of research on alliance has to date been mostly based on cases with individual clients. (Horvath & Bedi, 2002) the understanding of therapeutic alliance from a system theoretical point-of-view was only researched in the 1990s. This refers particularly to the understanding of the way that that therapeutic alliance affects marriage and family therapy and the importance of the mutual interaction and alliance in groups in the therapy session.
3. The value of therapeutic alliance and its relationship to retention
The term therapeutic alliance has many variations in the literature. The relationship between client and therapist has been termed working alliance, therapeutic bond, ego alliance, and helping alliance. (Delaney, 2006) One definition of therapeutic alliance is "...maintaining open and clear communication that conveys understanding, support, and respect to the client and focuses more on the personal closeness" (Horvath, 2001).
The question of the importance and the significance of the therapeutic alliance have been addressed to a certain extent in the studies cited in the previous section; however the contemporary approach to the issue of therapeutic alliance is also seen to be a matter of perspective. This relates to the important question of the assessment of the quality and the value of a therapeutic alliance by both client and therapist - which is in turn an aspect that directly affects the issue of retention.
The value of therapeutic alliance and its connection to positive clinical outcomes has been noted in various studies. Fenton et al. In an article entitled, Perspective Is Everything: The Predictive Validity of Six Working Alliance Instruments, state the following.
Clinical trials employing cognitive, interpersonal, behavioral, and psychodynamic therapies have demonstrated the robust nature of this finding. A strong alliance has been associated with an improved outcome in the treatment of a variety of psychological problems, including depression, personality disorders, alcohol dependence, and cocaine dependence.
Fenton et al.)
Interestingly, the above study also notes that the more empirical methods of measurement of the relationship between the client and therapist seem to indicate, in some cases, that therapeutic alliance does not dramatically foster positive therapeutic outcomes. However, this result is ascribed in the study to the types of measure techniques used. The study also points out that;
researchers should be aware that when outcome measures are highly objective, therapist- and client-rated measures of the alliance may not be strong predictors of outcome, in contrast to studies that rely on more subjective measures or in which process-outcome relationships are evaluated using only homogeneous perspectives (e.g., patient-patient, therapist-therapist).
Fenton et al.)
This aspect will be embroidered on the later sections of this paper.
What is very clear from a wide range of studies on this issue is that the early development of a positive therapeutic alliance is known to aid in positive outcomes in therapy. In research by Horvath and Symonds (1991) involving more than twenty clinical studies, the findings are enlightening with regard to the impact of therapeutic alliance. The study found that the therapeutic alliance is a significant predictor of individual therapy outcome (Horvath, 2001). Importantly, it was also determined that, "Due to empirical evidence, it has been recommended that the optimal time to document the relation between outcome and alliance is during the early phase of the therapeutic process" (Delaney, 2006).
This optimal period is usually determined as the period between the second and fourth therapy sessions. This question of the most relevant time for measurement of alliance also impacts on the issue of retention and other questions that will be further explored in this paper.
Figure 1: Outline of the relationship between client and therapist in terms of the position and importance therapeutic alliance.
Other studies show that the development of a strong alliance between patient and therapist by the end of the third therapy session is indicative of outcomes that are more positive as well as in follow-up procedures. Johnson and Talitman (1997) also found in clinical tests that it is generally more effective in terms of results to develop a positive therapeutic alliance as early as possible early in the therapeutic process. Conversely, Brown and O'Leary, (2000), concluded that in most cases the lack of a positive therapeutic alliance resulted in a lack of therapeutic progress and poor outcomes and retention. (Brown and O'Leary, 2000)
Similarly, other studies have found that there is a strong positive correlation between positive and early development of therapeutic alliance and positive outcomes.
Horvath and Symonds, (1991), found in a study comparing the time period over which a positive therapeutic alliance was developed, that predictive and positive outcomes were strongly linked to strong bonds or alliances that were established in the initial stages of the therapy. This also applied to the issue of retention. The earlier period of alliance building was seen as a "window of opportunity" which allowed for the possible development of good therapeutic outcomes. This window tends to close as the theory sessions progress.
In this view, it is therefore essential to establish good alliance patterns early on in the therapy. Even more importantly, the above study indicates that the potential of alliance in relation to positive outcomes is largely dependent on the perception that the client or patient has of the alliance.
A it is most important to assess the client's perception of the alliance because the client's assessment of alliance is more predictive of treatment" (Delaney, 2006).
In other words, this finding points to the fact that an assessment of the retention value of a therapeutic alliance can be best determined in the early stages of the therapy. In a meta-analysis of 79 studies involving individual therapeutic treatment, it was found that, "....alliance is consistently related to outcome and that, if a strong alliance is established, the client will experience that relationship as therapeutic. Throughout the meta-analysis, the clients viewed of the alliance remained stable..." This also refers to the finding that the therapy is viewed by patients as being positive if it was perceived as positive at the outset.
Other research even goes as far as to assert that therapeutic alliance is in fact more important than the types of treatment used in theory. (Safran and Muran, 1996) Therapeutic alliance has become so important to therapy that it has even been referred to as the"...quintessential integrative variable"…