Therapeutic Alliance, Attachment Theory, and Therapy Retention

Introduction: Therapeutic Alliance and Retention

Numerous studies have established that "therapeutic alliance is an essential component of successful therapy. All forms of individual psychotherapy have demonstrated a connection between outcome and therapeutic alliance" (Delaney, 2006). It is important to note that the significance of the therapeutic alliance goes beyond the parameters of any one theory and is considered a "pantheoretical" factor of treatment (Delaney, 2006). While the general concept and practice of therapeutic alliance is associated with outcome, it is also aligned with the issue of retention.

This paper provides an overview of the relationship between therapeutic alliance and retention with reference to the underlying influence of attachment theory. The subject of therapeutic alliance has in recent years been the focus of numerous papers and studies, and it is often seen as an essential element of the therapeutic process.

A central aim of this paper is, through the analysis of the interrelationship between alliance, retention, and attachment theory, to provide the groundwork for determining whether one can detect if a client is experiencing the therapeutic alliance in a positive way. Related to this is the need to ascertain the effectiveness of therapy and alliance from both the client's and the therapist's perspectives.

Another issue addressed here is the most appropriate stage for measuring the status of the alliance. This in turn leads to important practical questions, such as what action should be taken if the therapeutic alliance is not beneficial — whether the patient should be referred to another therapist or work through the alliance difficulties.

Historical Development of Therapeutic Alliance

A brief overview of the history and significance of therapeutic alliance is necessary as a foundation for understanding the variables that intersect between therapeutic alliance and retention.

In a contemporary sense, the understanding of therapeutic alliance as an essential part of psychotherapy can be traced to Bordin's (1979) conceptualization of the alliance. This is a clearly measurable and definable concept. Bordin's definition of therapeutic alliance consists of three interconnected components:

First, the bond of trust between therapist and client. Second, the agreement on the goals of the therapy. Third, the agreement on specific tasks — that is, the particular activities that facilitate the development of therapy toward various intervention goals (Faw et al., 2005).

Furthermore, the therapeutic alliance is considered "the most important determinant in treatment continuance and success, as well as the most frequently identified factor contributing to the outcome of therapy" (Delaney, 2006).

The imperative nature of therapeutic alliance and the collaborative aspect of therapy in psychoanalytic theory can be related back to the work of Freud. This refers to the concept of transference, in which "the client displaces repressed wishes, fantasies, and aspects of past relationships from childhood onto the therapist" (Delaney, 2006). The question of retention — and the reason a patient chooses to endure and remain in the process of therapy — was raised by Freud (1912). His answer reflects directly on the issues at stake in this paper.

Freud concluded that the client was able to view the therapeutic relationship through positive aspects of previous relationships, and that the client could bond with, or form an alliance with, the therapist in order to work together against the client's negative past experiences. Freud then viewed this as an aspect of the client's positive ego that was capable of forming a genuine bond with the therapist's rational ego (Delaney, 2006).

This points to several issues that are explored throughout this paper. First, retention is directly connected to perceptions of the therapeutic alliance. The client's perception of the bond formed — particularly within the first few sessions — is a determining factor in the duration of retention. Second, the process of therapeutic alliance works both ways: it also concerns how the therapist perceives the worth or value of the therapeutic alliance.

In 1934, Sterba defined alliance as the relationship between the reasonable aspects of both therapist and client (Sterba, 1934). To enable positive outcomes and retention, the client's ego "needed to be strengthened in its interactions with the therapist" (Delaney, 2006). This process was facilitated by an intense form of understanding and cooperation between therapist and client. The concept of alliance was therefore seen as an indispensable process whereby the client would accept the therapist's insight into the particular problem, which in turn would increase the likelihood of positive therapeutic outcomes.

The view of therapeutic alliance was taken further by therapists such as Zetzel, Rogers, and Greenson in the 1950s and 1960s. These theorists advanced beyond the concept of transference toward an understanding of therapeutic alliance as a conscious process that leads to the development of trust and cooperation between client and therapist.

For example, Zetzel (1956) redefined the therapeutic alliance as describing "the authentic object relationship which promoted the client's ability to withstand analysis" (Delaney, 2006). This view stresses the way in which the therapeutic alliance alters or potentially changes the perceptions and emotional and cognitive stance of the client. Zetzel believed that "it was the ability to foster and maintain this alliance with even the most disturbed clients that would allow for a successful analysis of the transference and the success of the treatment" (Delaney, 2006).

This view was developed further by Rogers (1957), who placed the therapeutic relationship between patient and therapist at the centre of therapy. A central aim for the therapist was to establish a firm, stable, and consistent alliance with the client. For this to occur, certain preconditions had to exist: there had to be psychological contact between therapist and client; the therapist should invest in the relationship; there should be unequivocal mutual acceptance; there should be empathy; and, importantly, the client should be aware of and understand the aims and nature of the interaction with the therapist.

These theories led to numerous clinical trials in the 1950s and 1960s, which tended to establish the view that empathic client-therapist alliances produced better outcomes (Horvath, 2001). A study by Horvath (2001) reveals a cardinal finding: the behavior and actions of the therapist were not as important as the way the client perceived those actions (Horvath, 2001). In other words, the way that the client reacted to the therapist's intentions and degree of empathy was deemed the most significant aspect of the therapeutic process in terms of positive outcomes and retention. This is supported by Greenson (1967), who noted that positive collaboration between client and therapist was one of the essential components for therapeutic success.

The concept of therapeutic alliance was further developed by Luborsky (1976), who redefined the contemporary understanding of the term. In his definition, the way that the therapist made the client feel safe and accepted was emphasized. The client was also encouraged to cooperate and collaborate with the therapist in the process of therapy (Luborsky, 1976). This type of alliance would lead to a form of shared commitment from both parties, which would have the best chance of producing positive therapeutic outcomes.

Bordin took this redefinition further by establishing criteria that were measurable and clear. In Bordin's view, the alliance between client and therapist was a conscious and collaborative relationship that was not concerned with transference (Bordin, 1979). In essence, this view stresses that there should first be an agreement between client and therapist as to the aims and intentions of the therapy, as well as an agreement on specific tasks and their purposes within the ambit of the therapy. Finally, the tasks, aims, and actions in the therapeutic alliance should be consistent with the lifestyle and personal context of the client (Bordin, 1979).

Agreement on goals occurs when clients and the therapist agree about the targets of change during therapy. The clients must also perceive that the therapist is genuinely invested in helping them achieve their goals, aided by mutual fondness, attachment, and trust (Delaney, 2006).

All these theoretical aspects tended to elevate the importance of therapeutic alliance in psychotherapy. The alliance was seen in many instances as being therapeutic in itself (Rogers, 1957), and by the late twentieth century it was regarded by many as a prerequisite for effective therapy and a crucial factor in both positive outcomes and retention.

An important point emphasized by many theorists was that the therapeutic alliance must be flexible enough to accommodate the client's perceptions and to deal with various levels of client functioning. At the same time, it should be adaptable to the interventions of the therapist (Gaston, 1990).

These theories were reinforced by further studies and statistical measurement. Researchers found a significant statistical correlation between therapeutic alliance and positive outcomes in therapy. A study by Horvath and Symonds (1991) established that alliance accounted for almost fifty percent of the variance in measurable therapy outcome. Furthermore, this finding was shown to be consistent across different types of therapy and theoretical orientations.

In 1974, Horwitz conducted a study of 42 patients; half 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, 2006).

These results are generally consistent across different therapeutic categories. 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 marital therapy. "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, 2006).

The literature also notes the importance of agreement about tasks between client and therapist in the overall therapeutic alliance. 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 & Wender, 1968, p. 1202).

Another cardinal issue in the literature 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 systemic theoretical point of view was only researched in the 1990s, particularly with regard to how therapeutic alliance affects marriage and family therapy and the importance of mutual interaction and alliance in group therapy sessions.

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 the 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 contemporary approach to therapeutic alliance is also understood as a matter of perspective. This relates to the important question of the assessment of the quality and value of a therapeutic alliance by both client and therapist — which 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 same study also notes that more empirical methods of measuring the client-therapist relationship sometimes indicate that therapeutic alliance does not dramatically foster positive therapeutic outcomes. However, this result is attributed to the types of measurement techniques used. The study 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" (Fenton et al.).

What is very clear from a wide range of studies is that the early development of a positive therapeutic alliance aids in positive outcomes. In research by Horvath and Symonds (1991) involving more than twenty clinical studies, it was found that the therapeutic alliance is a significant predictor of individual therapy outcome (Horvath, 2001). 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 defined as the period between the second and fourth therapy sessions.

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 more positive outcomes and better follow-up results. Johnson and Talitman (1997) found in clinical tests that it is generally more effective to develop a positive therapeutic alliance as early as possible in the therapeutic process. Conversely, Brown and O'Leary (2000) concluded that in most cases a lack of positive therapeutic alliance resulted in a lack of therapeutic progress and poor outcomes and retention.

Horvath and Symonds (1991) found that predictive and positive outcomes were strongly linked to strong bonds or alliances established in the initial stages of therapy. This also applied to the issue of retention. The earlier period of alliance building was seen as a "window of opportunity" for the development of good therapeutic outcomes — a window that tends to close as the therapy sessions progress.

Even more importantly, the potential of alliance in relation to positive outcomes is largely dependent on the client's perception of the alliance: "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 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' view of the alliance remained stable." This also refers to the finding that therapy is viewed positively by patients if it was perceived as positive at the outset.

Other research goes as far as to assert that therapeutic alliance is in fact more important than the type of treatment used (Safran & Muran, 1996). Therapeutic alliance has become so central to therapy that it has even been referred to as the "quintessential integrative variable" (Delaney, 2006). More recent research has added to this consensus: Horvath and Bedi (2002) found that constructive change in the therapeutic situation can result from a strong alliance or bond between client and therapist.

These findings also tend to apply to specific types of therapy. In a study of drug addiction — The Role of the Therapeutic Alliance in the Treatment of Substance Misuse: A Critical Review of the Literature by Meier et al. (2005) — it was found that early development of a positive therapeutic alliance was an important aspect of both engagement and retention in patients with drug addiction problems. However, the same study also found that early alliance was inconsistent as a means of predicting long-term or post-treatment outcomes (Faw et al.).

A study that investigates the importance of alliance in terms of both outcomes and retention is Relation of the Therapeutic Alliance with Outcome and Other Variables: A Meta-Analytic Review by Martin et al. (2000). Martin et al. conducted a meta-analysis of seventy-nine studies on alliance conducted over a period of twenty years. An important finding was that alliance showed a "moderate" effect on outcomes, and "this moderate effect was consistent regardless of who rated the alliance (e.g., client, therapist, observer), when the alliance was measured (e.g., early or late in treatment), type of outcome measure, or type of treatment" (Faw et al.). However, in more inclusive analyses it has been found that "over half of the positive outcomes attained in psychotherapy are linked to quality of the alliance" (Faw et al.).

These findings suggest that studies vary in the extent to which they attribute value to therapeutic alliance in terms of both outcomes and retention. The methodologies and measurement techniques employed should be borne in mind when evaluating these findings.

Another factor to consider is that there are relatively few studies on the impact of therapeutic alliance in the treatment of children and adolescents. "Research on therapeutic alliance with children and adolescents lags far behind research with adults. To date, three published studies have focused on instrumentation in measuring therapeutic alliance in youthful samples" (Faw et al.). This also relates to the issue of retention: "In the context of family therapy, a strong therapist alliance with family members other than the adolescent can also affect retention" (Faw et al.).

Specific studies on various types of therapy tend to confirm the positive findings about therapeutic alliance. An instructive study in this regard is Therapeutic Alliance as a Predictor of Outcome and Retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study by Barber et al. (2008). This study explored the relationship between therapeutic alliance, retention, and outcomes for 308 cocaine-dependent outpatients. The results indicated high levels of alliance in supportive-expressive therapy (SE), cognitive therapy (CT), and individual drug counseling (IDC).

Furthermore, the degree of alliance increased between the second and fifth sessions in all instances studied. The study also suggests that therapeutic alliance did predict various levels of retention across the different types of therapy: "In SE and IDC, either higher levels of alliance were associated with increased retention or no relationship between alliance and retention was found, depending on the time alliance was measured. In CT, higher levels of alliance were associated with decreased retention" (Barber et al., 2008). This finding suggests that retention values are related to positive therapeutic alliance, despite differences in the form of therapy employed. However, the results were less positive in terms of outcomes in cases of drug addiction.

Another article examining the relationship between retention and alliance is Predictors of Retention in an Alternative-to-Prison Substance Abuse Treatment Program (Brocato & Wagner, 2008). This study analyzed predictors of retention among alternative-to-prison substance abuse treatment clients, with a sample composed of 141 male felony offenders legally mandated to a community-based, long-term residential drug treatment program. The results indicate that retention is strongly correlated with positive motivation and change in therapy (Brocato & Wagner, 2008).

A related study on the effects of alliance in substance abuse therapy is Early Therapeutic Alliance as a Predictor of Treatment Outcome for Adolescent Cannabis Users in Outpatient Treatment (2006) by Diamond et al. This study examined the association of early alliance with treatment attendance and longitudinal outcomes in 356 adolescents participating in a randomized clinical trial targeting cannabis use (Diamond et al., 2006, p. 26). Both patient and therapist perceptions of therapeutic alliance were observed and studied. The summarized results were as follows:

"Patient-rated alliance predicted a reduction in cannabis use at three and six months and a reduction in substance-related problem behaviors at six months. Therapist-rated alliance did not predict outcomes. Neither patient nor therapist alliance ratings were associated with attendance. The findings support the important and often overlooked role that alliance can play in treating substance-abusing, often delinquent, adolescents" (Diamond et al., 2006, p. 26).

These results lead to several findings that pertain to the central discourse in this paper. Individual and meta-analytic studies on therapeutic alliance with adults have demonstrated that: (a) it is established by the third or fourth session; (b) early alliance is a better predictor of outcome than later alliance; (c) it predicts outcome equally well regardless of theoretical orientation; (d) patient, therapist, and observer alliance ratings are all predictive of outcome, with the patient's perspective being especially predictive; and (e) there is evidence that alliance impacts treatment retention (Diamond et al., 2006, p. 26).

The study confirms the previously mentioned finding that early alliance in treatment is predictive of outcomes and functions equally well regardless of theoretical orientation. Significantly, both patient and therapist views of the alliance are elements that affect outcomes — and these aspects in turn influence retention.

Conclusion: Client and Therapist Perceptions of Therapeutic Alliance

The above discussion and review of the relevant literature is in essence an important background to the central questions suggested in this paper: namely, how the therapeutic alliance is perceived by the patient and the therapist, and how this perception impacts the decision to continue with therapy, change the procedure, or change to another therapist. This is a complex issue that can only be answered with reference to the extensive research available. While answers to these questions have been addressed to some extent in the discussion above, a number of cardinal points can be gleaned from the literature that provide a basis for finding solutions.

The first point is that therapeutic alliance appears to work best when it is developed positively at an early stage of therapy — usually within the first three to five sessions. This aspect is consistent across most of the studies analyzed. In other words, the workability and value of the alliance in terms of outcomes and retention must be perceived as effective within the early stages of therapy. This also means that if a mutual sense of the worth and value of the therapeutic alliance is not experienced or perceived within the first three or four sessions, this is possibly an indication that alternatives should be sought. Whether these alternatives would involve a reevaluation of the therapy, a change in therapeutic style, or a change of therapist is dependent on the level and status of the alliance. As has been noted, this level is difficult to ascertain with any certainty through quantifiable and objective forms of measurement alone, and should also be examined from a more subjective and interpersonal perspective.

Views and perceptions of the level and value of therapeutic alliance are dependent on a wide array of factors and variables — including the challenges of methodologies and measurement techniques relevant to the early stages of therapy. This also relates to the issues raised by attachment theory.

An article that sheds some light on this issue is Patient Attachment Orientation and the Early Working Alliance: A Study of Patient and Therapist Reports of Alliance Quality and Ruptures by Eames and Roth (2000). This study investigates attachment styles in patients in relation to the quality of alliance in the early stages of therapy, and examines how attachment style results in breaks or ruptures in therapy. The Bartholomew and Horowitz categorical model was used to measure patient attachment style. The results indicated that patients with a more anxious and fearful attachment style were associated with lower alliance ratings. Conversely, patients with a more secure attachment style showed high alliance levels and positive outcomes. Furthermore, the study found that a preoccupied attachment style was "negatively correlated with the alliance, although not at a statistically significant level" (Eames & Roth, 2000, p. 421). In essence, this study adds to the view that attachment style plays a significant role in the assessment and perceived value of the therapeutic alliance — which is in turn concomitantly related to retention.

In the final analysis, the literature points to the fact that therapeutic alliance is an essential component in both the positive outcomes of therapy and in retention. This aspect can be effectively correlated with attachment theory and the various attachment styles. Central to the findings of this paper is the view that therapists should evaluate the therapeutic alliance in the early stages of therapy as an indication of whether to change strategy or to alter the planned course of therapy. A recommendation that can be drawn from the literature is that if the therapist, after measuring and ascertaining through both objective and subjective means the levels of alliance in the first five sessions, does not find a positive result, this would indicate that alternative therapeutic methods or avenues should be investigated.