Conceptualisation and Measurement of the Therapeutic Alliance

The featured paper is ‘The Conceptualization and measurement of therapeutic alliance: An empirical review’ by Rachel Elvins and Jonathan Green.

The authors focus on the concept of the therapeutic alliance and begin by citing research which shows a correlation between measures of this alliance and outcomes particularly when these measures occur at the beginning of treatment. However the authors then cite evidence challenging the validity of the concept. The authors state their aims clearly ‘clarifying the conceptual, measurement, and experimental tasks ahead’.

Thereafter the paper can be broadly divided into the conceptualisation of the therapeutic alliance and the analysis of alliance in treatment.

The conceptualisation of alliance is further divided into genealogy, measurement of the concept and aspects of development of the concept. In the genealogy of the therapeutic alliance the authors produce an impressive diagram showing their suggested relationships between therapeutic alliance concepts. They begin with Freud and transference-countertransference. Curiously however they omit Jung who is credited with pioneering the involvement of the patient in the treatment process. There are a number of other figures that are described including Rogers, Bordin, Frank, Strong and Hougaard not just developing but also operationalising the underlying concepts. Curiously in the second section on the measurement of the alliance concept, the authors describe the methodology for this section. Conventionally the methodology is outlined in a separate section allowing the authors an opportunity to expand upon this so as to facilitate reproducibility. One of the problems of including the methodology very briefly in this section is that the years of publication for the database searches were not identified and thus the reader does not have available information which will help to contextualise the papers identified. The authors have however produced an impressive list of papers with corresponding details to accompany the ‘geneaology of alliance concepts and scales’. What is striking, and a point the authors comment on is the numerous concepts of alliance that abound and the corresponding scales for measurement of these concepts. The authors also comment that scales take ‘an empirical and descriptive approach’ to measurement. The authors then look at developmental aspects of the scale and see that in some instances a one factor model of the adolescent’s alliance reflects the underlying conceptual framework where for instance it has been suggested that discrimination of the ‘different aspects of the relationship’ is not fully attained. In future considerations of the therapeutic alliance the authors consider the impact of factors such as medication and even computer-assisted interventions as well as evolving the underlying theoretical constructs by focusing on Bowlby’s Attachment Theory.

The analysis of alliance in treatment is further divided into confounders, criterion validity, construct validity, therapist versus patient effect and psychometric properties of alliance measures. The authors then examine some of the confounders in ratings which involve both therapist and patient. The authors seem to suggest in their examination of criterion validity that this is an area which needs development  as it is unclear if changes in ratings have an therapeutic meaning. Nevertheless, the earlier research they cite showing a relationship between therapeutic alliance measures and therapeutic outcome must surely provide some useful evidence in this regards. An alternative strategy not discussed here might be to invoke the use of biological markers. The authors then cover third factor confounds including baseline social functioning and treatment gain. In therapist versus patient effects, the authors briefly discuss some of the difficulties in distinguishing between the therapeutic alliance and the attributes of the therapist while in considering the construct validity, the authors discuss some of the research establishing construct validity for different scales. In discrimation and therapy outcome prediction, the authors identify the WAI, VTAS and CALPAS as scales with more supporting evidence as well as correlations with outcomes. In future directions in the analysis of the therapeutic alliance, the authors consider a broad range of issues including the use of methodology from econometrics, qualitative research methodology and mediation and process analysis.

The authors have looked at a large body of literature in the course of this review. While many studies provide evidence supporting the different scales in use, there is much to support the development of a generic theoretical model for this area. The authors have suggested Bowlby’s Attachment Theory as one such model.

Steps to Treatment 5 (Development of a model, validation of model empirically, utilisation of model to inform therapeutic alliance, testing of recommendations, incorporation into policy)


Elvins R and Green J. The conceptualization and measurement of therapeutic alliance: An empirical review. Clinical Psychology Review. 28. 2008. 1167-1187.


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The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.


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