This paper examines the interrelationship between therapeutic alliance, attachment theory, and client retention in psychotherapy. Drawing on a broad range of clinical studies and theoretical frameworks — from Freud's early transference concept through Bordin's measurable alliance model and Bowlby's attachment theory — the paper explores how the quality of the client-therapist relationship influences both therapeutic outcomes and a client's decision to remain in treatment. Key issues addressed include the optimal timing for measuring alliance strength, the divergent perceptions of alliance held by clients and therapists, the role of attachment styles in shaping alliance formation, and practical recommendations for therapists when alliance is weak or absent in the early sessions.
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.
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.
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).
"Bowlby's attachment framework applied to clinical practice"
"How attachment styles shape alliance quality and retention"
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.
You’re 51% through this paper. Sign up to read the remaining 2 sections.
Sign Up Now — Instant Access Already a member? Log inAlways verify citation format against your institution’s current style guide requirements.