The alliance in mental health care: conceptualization, evidence and clinical applications

Abstract

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture‐repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non‐psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face‐to‐face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet‐mediated services. These new research areas clearly require further development.

Microaggressions and dropout when working with sexual minority parents in clinical settings: The working alliance as a mediating mechanism.

“…When microaggressions occur during a clinical consultation, they are likely to convey the message that the therapist-patient relationship is emotionally unsafe, and subsequently mar the patient's trust in the therapist. Research on the working alliance (Wampold & Flückiger, 2023) suggests that the development of tasks and goals, and therapistpatient bonding in the early stages of a clinical consultation, lay the foundation for a strong working alliance, and therefore sound therapeutic work. This is because a strong working alliance represents a relational container in which therapists may manage ruptures, such as those created by microaggressions (Eubanks-Carter et al, 2018).…”

“…Importantly, therapists may also represent a barrier to treatment. Therapists play a significant role in developing and maintaining a positive working alliance (Horvath et al, 2011), which may indirectly improve retention rates (Sharf et al, 2010; Wampold & Flückiger, 2023). In this regard, research on racial-, gender identity-, and sexual orientation-based microaggressions provides useful insight into the association between microaggressions toward patients with marginalized identities and a poor working alliance, decreased treatment effectiveness, and a negative psychological impact on patients (e.g., Anzani et al, 2020; Constantine, 2007; Morris et al, 2020; Nadal et al, 2016; Owen et al, 2011).…”

“…As therapists and patients cannot always be attuned, ruptures are inevitable in clinical work (Safran et al, 2011; Wampold & Flückiger, 2023). However, microaggressions may replicate oppression and discrimination in the larger society, leading patients with marginalized identities (i.e., sexual minority parent patients) to feel misunderstood, invalidated, and demoralized (Shelton & Delgado-Romero, 2013; Yeo & Torres-Harding, 2021), as already shown by previous research with ethnic, gender, and sexual minorities (e.g., Anzani et al, 2019; Nadal et al, 2016; Owen et al, 2011).…”

Within‐ and between‐patients associations between self‐efficacy, outcome expectation, and symptom change in cognitive behavioral therapy for generalized anxiety disorder

“…This indirect therapeutic alliance effect is consistent with goal theory (Eccles & Wigfield, 2002 ), which suggests that people will devote more resources to achieve a goal if they believe that they have a chance of attaining it. Accordingly, when a patient shows high SE levels and positive OE, this will be associated with a more collaborative working alliance with their therapist than when the patient shows low SE levels and more pessimistic OE (reported to patients' own SE and OE average), which, in turn, can improve the symptoms of that particular patient (Constantino et al, 2021 ; Wampold & Flückiger, 2022 ). Moreover, other mechanisms through which OE exerts its ameliorative influence on symptoms have been investigated, such as behavioral and cognitive skill usage (Webb et al, 2013 ) and greater patient homework compliance (Westra et al, 2007 ).…”

“…Patient expectations have long been known to play a key role in successful psychotherapy (Goldfried, 1980 ; Wampold & Flückiger, 2022 ). Frank and Frank ( 1991 ) argued that for any therapy to be effective, the patient must have mobilization of the belief in the ability to improve.…”