A review of therapist characteristics and techniques positively impacting the therapeutic alliance
Introduction
The therapeutic alliance has emerged as an important variable for psychotherapy process/change in various schools of psychotherapy (Orlinsky, Grawe, & Parks, 1994). Originally, the therapeutic alliance was believed to be positive transference from the patient toward the therapist Freud, 1913, Frieswyk et al., 1986. The perception of the therapeutic alliance later developed into a conscious and active collaboration between the patient and therapist. Currently, most conceptualizations of the therapeutic alliance are based in part on the work of Bordin (1979), who defined the alliance as including “three features: an agreement on goals, an assignment of task or a series of tasks, and the development of bonds” (p. 253). The emphasis that contemporary psychotherapy research has placed on the examination of the technical and relational aspects of the alliance has made it an important variable in the understanding of psychotherapy process.
In the last two decades, the technical and relational aspects of the alliance such as patient characteristics and therapist activity have been the focus of a great deal of empirical research studying the relationship between the alliance and therapy outcome (Barber et al., 1999, Blatt et al., 1996; Frieswyk et al., 1986, Gaston et al., 1998, Hillard et al., 2000, Horvath & Greenberg, 1994, Horvath & Luborsky, 1993, Horvath & Symonds, 1991, Martin et al., 2000, Stiles et al., 1998). However, an area of research that has been less developed is the therapists' contributions to the development of the alliance. Although there has been some research focusing specifically on the therapist's in-session activity that impacts the therapeutic alliance (for a review of the literature examining therapist activity to treatment outcome, see Orlinsky et al., 1994), for the most part therapist contributions have been overlooked. More importantly, the findings from these studies have not been integrated across studies in a manner that clarifies the relationship between the therapist's specific in-session contributions (e.g., personal attributes and technical interventions) and the development of a positive alliance.
In a recent review of the literature on alliance and technique in short-term dynamic therapy, Crits-Christoph and Connolly (1999) identified only four studies that directly examined the relationship between technique and alliance. Although the Crits-Christoph and Connolly review had a narrow focus and only surveyed studies using short-term psychodynamic techniques, they concluded that there is not enough evidence to draw a link between technique and alliance. Similar conclusions were reported by Whisman (1993) in a review of the theoretical and empirical literature related to the therapeutic environment in cognitive therapy (CT) of depression. The therapeutic environment included the therapeutic alliance, therapist's adherence, and competence, as well as patient characteristics. Whisman stated that historically research examining the core components of CT have devoted “little discussion to the importance of the therapeutic relationship” (p. 253) and suggested that future research investigations need to focus on this interaction between the patient and therapist.
Therefore, psychotherapy research may benefit from a close examination of the relationship between therapist's variables (including personal attributes and technique) and alliance. As Saketopoulou (1999) states researchers should aim to better understand “the development of alliance in the course of therapy” (p. 338). In order to identify the distinctive elements of the therapist's variables that impact the development and maintenance of the alliance a review of existing empirical findings from a variety of therapeutic orientations (i.e., psychodynamic, cognitive, cognitive–behavioral, family therapy, etc.) is necessary. The present review is a comprehensive examination of the therapist's personal attributes and in-session activities that positively influence the therapeutic alliance from a broad range of psychotherapy perspectives. This broad focus on the therapist's variables positively impacting the alliance facilitates a closer examination of the psychotherapy process and is a step toward the integration of past research. This review is not intended to be a critique of methodological issues or measures of the alliance (although a review of this sort would be a significant contribution to the literature). The present review is clinically focused with the aim of increasing the applied understanding of the therapists' unique contributions to the development of a positive treatment relationship. It is reasoned that focusing on the therapist's positive contributions to the alliance will not only refine and enhance our understanding and assessment of the construct, it may also guide future research toward the discovery of more efficacious and clinically superior therapeutic techniques. More importantly, this review may help therapists with a range of experience, in various forms of psychotherapy to obtain greater success developing stronger therapeutic connections with their patients.
The first step in the present review was a literature search using PsychLIT from 1988 to 2000 with the search terms: therapist activity, therapeutic alliance, and psychotherapy process. We also reviewed Horvath and Greenberg's (1994) book, The Working Alliance: Theory, Research, and Practice, chapters 8 and 11 in Bergin and Garfield's (1994) Handbook of Psychotherapy and Behavior Change, and Psychoanalytic Abstracts through 1999. Next, to identify additional studies we reviewed the references of the material meeting our inclusion criteria. As a final step, we manually reviewed the previous 12 months of the journals that provided therapist activity and alliance material in the previous steps (e.g., Journal of Consulting and Clinical Psychology, Journal of Clinical Psychology, Journal of Counseling Psychology, Journal of Psychotherapy Practice and Research, Psychotherapy, and Psychotherapy Research).
Our inclusion criteria were as follows: (a) The investigation had to report a quantifiable relationship between some index of therapist variables and the alliance. (b) The focus of the study had to be identified as specifically examining therapist's personal attributes and/or technical activity related to the development, management, and/or maintenance of the alliance. This does not include studies examining the relationship between alliance and outcome, unless the author(s) also examined and reported a quantifiable relationship between therapist variables and alliance. We chose to define therapist variables to include only those studies reporting therapist's personal attributes and/or use of therapeutic technique as positively impacting the alliance. Moreover, we chose to define the alliance based on Bordin's (1979) conceptualization of the alliance. These criteria revealed a total of 25 studies reporting therapist variables positively contributing to the alliance. The present review will be organized according to two categories (therapist attributes and therapist techniques) and include recommendations for future research examining the relationship between therapist activity and alliance.
Section snippets
Personal attributes
The ability of a therapist to instill confidence and trust within the therapeutic frame is essential to therapeutic success. Related to the development of these ideals is the therapist's capacity to connect with the patient and convey an adequate level of competence to effectively help patients under distress. Moreover, the therapist's attributes similar to dependability, benevolence, and responsiveness are expected to be related to the development and maintenance of a positive alliance. It is
Conclusions
The studies included in this review suggest that the therapist's personal attributes and the use of therapeutic technique from a range of psychotherapy orientations have been found to positively influence the development and maintenance of the therapeutic alliance. Table 3 summarizes the therapist's personal attributes and techniques that were reported to be important in the development and maintenance of a strong alliance. They include trustworthiness (Horvath & Greenberg, 1989), experience
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