Using the HAQ-2 to Assess the Therapeutic Alliance

Introduction: The Therapeutic Relationship as a Predictor of Outcome

The therapeutic relationship, sometimes referred to as the helping alliance or working alliance, is one of the most important predictors of psychiatric patient outcome. This relationship is used as a tool to help promote positive patient outcomes. Relationships are a two-way street, resulting in either transference or a lack of connection between the therapist and the patient. This study explores the ability of clinical psychologists to assess the health of the therapeutic relationship. The ability to accurately assess the therapeutic relationship plays an important role in the ability to adjust treatment regimens accordingly, and the ability to repair an ailing relationship is an important part of the healing process.

This research explores the appropriateness of the Helping Alliance Questionnaire-2 (HAQ-2) as an instrument for measuring psychologist ability to assess the therapeutic relationship in an upcoming study.

Understanding the Elements of the Therapeutic Relationship

Although many factors can affect a client's ability to reach therapeutic goals, the therapeutic relationship is one of the most important predictors of client outcome. The therapist must be able to motivate the patient to participate in the prescribed treatment, take their medications, and make the necessary lifestyle changes for success. A healthy therapeutic relationship can be an excellent tool in achieving these goals. In a positive relationship, the therapist acts as a coach for the patient. However, in an unhealthy relationship, the therapist can cause irreparable damage. It is therefore important for the therapist to understand and be able to assess their relationships with clients.

In order to better understand the dynamics of the therapeutic relationship, one must attempt to understand as much as possible about the factors that influence it. The therapeutic relationship is an important predictor of individual outcomes during psychotherapy (Horvath & Bedi, 2002). It has also been shown to affect the outcome of couples in therapy under a number of circumstances, accounting for as much as 5–22% of the therapeutic outcome (Knobloch-Fedders, 2007). These sources indicate that inconsistency exists between studies that measured different phases of the treatment process; however, this does not undermine the importance of the therapeutic relationship in the final success of therapy.

Many variables affect treatment outcome, and it may be difficult to determine how much of the outcome can be directly attributed to the therapeutic alliance. Llgen, Finney, and Moos (2006) found that the therapeutic alliance could counteract the effect of low self-esteem in patients being treated for alcohol abuse. That study found that in patients with high self-esteem, the therapeutic relationship had little impact on outcomes, whereas in patients with low self-esteem, the therapeutic relationship had the ability to change an otherwise negative outcome into a positive one.

Several factors affect the ability to form a strong therapeutic relationship. The attitude of the patient and their internal motivation can have an impact on this ability. Patients who are highly motivated and ready for change are more likely to form a positive therapeutic relationship than those who are resistant to change (BCR, 2006). Perfectionists also have problems with the therapeutic relationship (BCR, 2006). Anxiety and cognitive impairment can likewise affect the ability to form a positive therapeutic relationship (BCR, 2006). Patients who are better adjusted at the beginning of therapy are more likely to build a positive therapeutic relationship than those who have a poor relationship from the start (BCR, 2006). Patients bring certain personal qualities with them into the relationship, and these have a direct impact on the ability to form a positive alliance.

Therapists must recognize that the patient will bring with them factors that affect the ability to build a positive relationship. It has also been found that therapists must bring certain qualities of their own in order to make the relationship a success. Therapists who bring expertise and empathy are more likely to influence the relationship in a positive manner (BCR, 2006; Feller & Cottone, 2003). A therapist with these qualities will be able to make adjustments throughout treatment in order to build and sustain a productive relationship.

The therapeutic alliance occurs in a number of treatment settings, even in the absence of face-to-face contact. Children who received cognitive-behavioral treatment via telephone formed a therapeutic alliance with their specialists despite having no face-to-face contact (Lingley-Pottie & McGrath, 2008). Both the therapist and the patient share responsibility for developing a positive therapeutic alliance (Meissner, 2006). The therapeutic alliance begins to develop in the assessment stage of treatment and carries through the entire treatment process (Hilsenroth, Peters, & Ackerman, 2004).

Several factors help patients perceive the therapeutic relationship as a positive one: receiving small extras from the treatment, finding common ground, feeling that the practitioner sincerely cares, practitioner availability, practitioner flexibility, and having input into the treatment plan (Ware, Tugenberg, & Dickey, 2004). Communication skills by the therapist cannot be overemphasized in the development of a positive patient perception. Communication by medical practitioners was found to be a factor in patients' overall satisfaction, their willingness to adhere to treatment plans, treatment outcomes, and the likelihood of filing a malpractice claim (Cruz & Pincus, 2002). Notably, that study found that doctors could be more responsive to patient needs without lengthening visits (Cruz & Pincus, 2002).

These studies demonstrate the importance of developing a positive therapeutic relationship early in the treatment process. Both the patient and the therapist play important roles. The patient may carry past emotional baggage that negatively affects the alliance. The therapist must actively work to provide positive communication and make adjustments to promote a productive relationship. These are the key elements that can affect treatment outcomes.

Understanding Client-Therapist Attachment

One can appreciate the importance of developing a positive therapeutic relationship, but sometimes too much attachment develops from the client's side. The therapeutic relationship requires that certain boundaries be set to define where the therapeutic relationship begins and when a taboo boundary has been crossed. Every person has boundaries that help define their personal space. Often these boundaries are not well defined, and it can be difficult to judge where another person's limits lie. Nevertheless, these boundaries play an important role in the therapeutic context.

The technical term for personal space in this context is the intersubjective field. These boundaries fall into the categories of propriety, space, behavioral, verbal, and energetic (Rand, 2008). When boundaries are crossed unintentionally, both the therapist and the client can be emotionally harmed (Rand, 2008). In order to avoid this, the therapist must understand these various types of boundaries in themselves and in their clients, attend to them carefully, and ensure that they are not crossed. Making boundaries concrete can play an important role in preventing undesirable attachments from forming (Rand, 2008).

The inability to adhere to behavioral boundaries often begins in childhood. Crossing behavioral boundaries can result in resentment on the part of either the client or the therapist (Rand, 2008). Verbal boundaries are closely connected to social space (Rand, 2008). A common example of verbal boundaries occurs when the client asks the therapist a question, and the therapist must decide whether to answer honestly or in a way that best suits the client's therapeutic needs. Physical boundaries concern the space around us and the proximity in which we feel comfortable with another person; sometimes one person may feel uncomfortable while the other is unaware of it (Rand, 2008). The therapist must be aware of these various boundaries and ensure they are not violated.

Client attachment to the therapist can stem from a memory of parental caregiving (Woodhouse, Schlosser, & Crook et al., 2003). Clients are more apt to develop an attachment to their therapist after a longer or ongoing therapy plan than during short-duration treatment plans (Woodhouse, Schlosser, & Crook et al., 2003). Clients engaged in more transference when client-therapist attachment developed (Woodhouse, Schlosser, & Crook et al., 2003).

The nature of therapy is such that the therapist seeks to develop relationships with clients that promote the sharing of intimate feelings (Parish & Eagle, 2003). The therapist must seek to understand each patient's attachment style and, in doing so, take steps to prevent the client from forming an unhealthy relationship (Parish & Eagle, 2003). One must also remember that therapy will not continue indefinitely in most cases. At some point, the relationship will end, and a client who has formed an unhealthy attachment may experience the separation as a loss, causing further trauma in the long term.

There has not been a significant amount of literature published on the unhealthy client-therapist relationship, as it is generally considered a social taboo. Often the client is unable to take steps to avoid an undesirable emotional attachment, which means the therapist must take the initiative in maintaining proper distance. It is important to be aware that a positive therapeutic relationship can become too much of a good thing; when it does, it can become toxic to the therapeutic outcome.

Assessing Measurement Instruments and the HAQ-2

The purpose of this research is to develop a means to measure the factors that influence a therapist's ability to accurately assess the status of their client relationships. This study will lead to the development of criteria that therapists can use as guidelines to assess client relationships and ensure that they remain healthy for all parties involved. The development of a meaningful measurement procedure is paramount to achieving this goal.

Over fifteen scales have been used in studies to assess the therapeutic relationship (McCabe & Priebe, 2004). However, no single scale has been widely adopted in psychiatric research, and few studies have used the same instrument (McCabe & Priebe, 2004). This lack of standardization makes it difficult to measure the reliability and validity of any single scale across the research literature.

As the importance of the client-therapist relationship became better understood, several early measures were developed to assess its quality. One of the first was the Barrett-Lennard Relationship Inventory (BLRI) (Barrett-Lennard, 1962). This instrument measures three factors important to the development of relationships: empathy, regard, and congruence (Ganley, 1989). It is typically used to measure family and marriage relationships (Ganley, 1989) and does not specifically address the unique issues of the client-therapist relationship. One of the key drawbacks of the BLRI is its length.

Another frequently used instrument is the California Psychotherapy Alliance Scales (CALPAS) (Gaston, 1991), often used as a shorter alternative to the BLRI. The CALPAS contains five subscales: patient working capacity, patient commitment, goal consensus, working strategy consensus, and therapist understanding and involvement (Gaston, 1991). It uses a 7-point scale with Likert-type responses and is administered to both patients and therapists after every few sessions. This scale can measure changes in the client-therapist relationship and has wider applicability than the BLRI.

These scales are useful for measuring relationship factors in various situations, but they have drawbacks in relation to the proposed research. The BLRI is lengthy, which may deter potential clients from participating, and it does not specifically address client-therapist relationships. The CALPAS more closely addresses the study's topic and is shorter, but it is weighted toward factors that influence patient satisfaction, whereas the focus of the proposed research is on therapist perceptions. These are the primary reasons for deciding not to use either instrument.

The Working Alliance Inventory (WAI) (Horvath & Greenberg, 1989) is another widely used questionnaire measuring the strength of the therapeutic alliance. It bears significant resemblance to the HAQ-2, with 12 items and a 7-point Likert scale. However, the HAQ-2 is more widely used, meaning considerably more is known about its reliability and validity.

The HAQ-1 was one of the first scales to assess the therapeutic alliance between client and therapist. This early version included questions reflecting how much the patient benefited from therapy (Luborsky, Crits-Christoph, & Alexander et al., 1983), which were later dropped because some researchers felt that they addressed the quality of treatment rather than the therapeutic relationship itself. The HAQ-1 used a 7-point scale, while the newer HAQ-2 uses a 6-point scale. The key differences between the two versions lie primarily in content changes.

After examination of the available research instruments, the Helping Alliance Questionnaire (HAQ-2) holds promise as a suitable instrument. It has been used extensively in a variety of research environments and under a number of research constraints. The HAQ-2 provides a quick overview of the patient's perceptions of the quality of the therapeutic alliance with their therapist (DeWeert-Van, DeJong, Jorg, & Schrijver, 1999).

The HAQ-2 examines the therapeutic alliance using a short Likert scale and has both a patient version and a therapist version. The purpose of this study is to determine the accuracy of therapist perceptions as they correlate with client perceptions, and this instrument allows direct comparison between the two. The questionnaire could be administered at the beginning, middle, and end of the therapeutic process, enabling the research to track changes in both client and therapist perceptions of the alliance over time. This approach would also allow investigators to examine a therapist's ability to notice subtle changes as the alliance evolves.

The HAQ-2 addresses the specific client-therapist relationship through a questionnaire given to both parties, with both versions mirroring each other. For instance, the patient version states, "I felt that the therapist wants me to achieve my goals," while the therapist version states, "The patient feels that I want him/her to achieve the goals" (Luborsky, Barber, & Siquiland et al., 1996). This parallel structure makes comparison of patient and therapist responses straightforward.

Statistical analysis is easily achieved through side-by-side correlation of individual responses from a particular client-therapist pair. The therapist's ability to properly assess the relationship is reflected in the number of correlates achieved on the scale: the higher the number of correlates, the more accurate the assessment. This feature also makes comparison of responses over time straightforward to accomplish.

Conclusion: Appropriateness of the HAQ-2 for the Intended Study

Reliability and validity of the HAQ-2 have been proven in the studies discussed above. However, this alone does not demonstrate conclusively that it is the correct instrument for the proposed research study. In order to determine the best fit, it is necessary to examine several factors together.

The first concern in choosing a research instrument is reliability and validity, both of which have been demonstrated across multiple studies. This aspect of the HAQ-2 is considered satisfactory for the intended research. The second factor is that the instrument must be directly related to the topic being studied. The changes made in developing the HAQ-2 from the HAQ-1 created a more focused instrument that eliminated the confounding variable of symptomatic improvement from patient perceptions. Le Bloc, de Roten, and Drapeau et al. (2006) concluded that the HAQ-2 is a valid research instrument for measurement of the therapeutic alliance, and Luborsky (2000) demonstrated that it is at least as reliable and beneficial as other instruments in the field.

Throughout this research, several other measurement instruments were surveyed. Many have reasonable reliability and validity; however, their strengths and weaknesses relative to the proposed study lie in content rather than in psychometric properties alone. The HAQ-2 has greater content validity and construct validity for the specific purposes of this study than the other instruments reviewed. The CALPAS is another possible instrument, but it is best suited for predicting retention and outcome in patients treated for cocaine dependence (Le Bloc, de Roten, & Drapeau et al., 2006) and is more focused on patient satisfaction than on therapist perceptions.

When one considers all variables associated with instrument selection and the desired outcomes of the intended research, the HAQ-2 stands out as the most appropriate choice. Key advantages include its ease of administration, its brevity, and the direct comparability it affords between client and therapist responses. The WAI is another possibility, but it does not allow the same potential for direct comparison of client and therapist results for the same session. The HAQ-2 questionnaire can be quickly and easily administered during different phases of therapy, allowing tracking of how the alliance changes over time, and it can be efficiently analyzed using Pearson's Product Moment correlation to compare responses across both versions. When compared with other instruments that measure the client-therapist relationship, the HAQ-2 offers a combination of advantages that make it the most suitable instrument for this research endeavor.

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