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ORIGINAL ARTICLES

The therapeutic relationship: Research and theory

An introduction to the Special Issue

ADAM O. HORVATH

Simon Fraser University, Burnaby, Canada

(Received 16 November 2004; revised 7 December 2004; accepted 8 December 2004)

AbstractThe place of the therapeutic relationship in psychotherapy research is presented in a historical framework, followed by abrief review of the major research themes within this topic and a review of what is covered in this special section. Some of thestrengths of this body of work, as well as the potential challenges arising out of the re-emergence of the alliance as a pan-theoretical concept capturing the relational dynamics of therapy, are discussed. Recommendations for renewing theempirical/conceptual dialogue on what constitutes the therapeutic relationship in different therapeutic contexts anddifferent phases of therapy are provided.

Keywords: Therapeutic relationship, alliance, therapy process research

Research on the relationship in therapy

The dedication of a special issue of Psychotherapy

Research to the topic of the therapeutic relationship

marks a significant milepost in the history of empirical

research on psychotherapy process. The editorsdecision to devote this extended format to the topic is

symbolic of a growing recognition of the maturity and

value of this body of work. This presents an important

opportunity to showcase a new generation of scientific

inquiries highlighting some of the issues challenging

those of us who desire to move the empirical investiga-

tion of the relational aspect of psychotherapy forward.

As a framework for this overview of the current

relationship research agenda, the historical context of

this body of research will be briefly reviewed, followed

by a summary of the empirical investigations of the

alliance in psychotherapy in the past three decades,andmorespecificallyinthisspecialsection.Finally,the

challenges lying ahead are discussed.

Historical context

The relationship between therapist and client has

historically occupied a prominent role in the theories

of therapeutic process. In a brief paper, Freud laid

the foundation of what would be later elaborated as

the concept of the alliance by noting the importance

of the development of the [patient] . . . attach[ing]

himself. . .

to the doctor. . .

and link [him] withimages of people by whom he was accustomed to

be treated with affections (Freud, 1913). While

Freuds insights have done much to enable the

systematic investigation of mental processes, by the

beginning of the nineteenth century it became

apparent that if psychotherapy was to become a

scientifically based profession, it needed a theory

that could generate robust, refutable, hypotheses.

The challenge of developing an empirically testa-

ble model of human change was first taken up by the

behaviorists (Skinner, 1974). The advantages and

opportunities offered by a model based on observa-

ble behaviors were significant. However, excludingall phenomena beyond that which could be observed

and verified at the time meant that not only the

therapy relationship, but cognitive processes as well

were moved beyond the domain of empirical re-

search. By the middle of the twentieth century,

technological innovations made it possible and

Correspondence: Adam O. Horvath, Counselling Psychology Program, Simon Fraser University, 8888 University Way, Burnaby, BC,

V5A 1S6. E-mail: [email protected]

Psychotherapy Research, January 2005; 15(1/2): 3/7

ISSN 1050-3307 print/ISSN 1468-4381 online # 2005 Society for Psychotherapy Research

DOI: 10.1080/10503300512331339143


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practical to produce live recordings of therapy

sessions opening the way to empirically reliable

exploration of the process of psychotherapy. This

new technology, and Rogers interest in the relation-

ship, broadened the horizon of psychotherapy re-

search. The therapeutic relationship became once

again the focus of attention of some researchers.

While much of the post-war research focused on

finding specific ingredients responsible for positivetherapeutic gains, advances in research synthesis

(Luborsky, Singer, & Luborsky, 1975; Smith &

Glass, 1977) yielded compelling empirical evidence

that an element or elements common to the broad

cross section of therapeutic practices are responsible

for a large portion of healing effects. This finding

renewed interest in role of the relationship between

therapist and client. An essential component in the

subsequent momentum behind research on the

therapeutic relationship was the theoretical work of

Luborsky (1976) and Bordin (1976, 1980, 1994).

Their elaboration and extension of Greenson (1965)

and Zetzels (1956) work on the psychodynamicconcept of the therapeutic and working alliance

resulted in a pan-theoretical formulation of the

relational component of therapy.

Between 1975 and 1986 there were a number of

measures developed to quantify the quality of the

alliance in helping relationships. While the instru-

ment development and refinement projects opened

the way to investigate this concept, there remained a

significant residual ambiguity about the theoretical/

conceptual definition of the alliance (Hentschel,

2004; Horvath & Greenberg, 1989; Horvath &

Luborsky, 1993).

Research accomplishments

It is useful to reflect on the growing volume of

research on the alliance as representing two some-

what chronologically and topically overlapping

phases: initially much of the investigators energy

focused on exploring the relation between the

alliance and therapy outcome across various helping

contexts. The variety of contexts explored in this

phase included different types of treatments, diverse

populations and diagnostic categories, gender ef-

fects, as well as some therapist factors such as levelsof therapist training and experience. Another area of

interest from the beginning was the relation between

outcome and alliance assessed from different per-

spectives (i.e., client, therapist, and observer) as well

as the magnitude of the alliance/outcome relation at

different phases of therapy (see Horvath & Bedi,

2002; Horvath & Symonds, 1991; Martin, Garske,

& Davis, 2000). At a risk of ignoring complexity, a

reasonable summary is that the relationships re-

ported across reviews have been quite consistent: the

alliance-outcome correlation is moderate but signifi-

cant (ranges from .22 to .29), clients assessments

tend to be more predictive of outcome than are other

sources, early alliance is as good or better predictor

of outcome than assessments taken later, and the

alliance as measured appears to be related but not

identical to parallel therapeutic gains.

Somewhat overlapping in terms of chronology butdistinct in thematic interests is the second phase of

alliance research; these investigations place less

emphasis on the outcome/alliance relation, as such,

and focus more on the role, development, and

management of the alliance in therapy itself. For

example, researchers have examined Bordins (1980)

propositions about fluctuations (tears and repairs)

in the alliance as core opportunities for therapeutic

gain (e.g., Safran & Muran, 2000), differences across

clients in terms of the kind of relation they desire

with their therapist (e.g., Batchelor, 1988), exam-

ination of therapist qualities and behaviors that are

associated with client perceptions of good alliance(e.g., Henry & Stupp, 1994; Hilsenroth, Ackerman,

Clemence, Strassle, & Handler, 2002).

Challenges ahead

Given the richness and accomplishment of this line of

research, what are the challenges we might antici-

pate? Firstly, we need more theoretical debate about

the construct of the relationship. The relatively brief

period between the initial theoretical/conceptual

formulation and the development of measuring

procedures that in practice defined the construct for

research that followed likely foreclosed the opportu-

nity to examine the implications and possible limita-

tions of the concept as first presented by Luborsky

(1976) and Bordin (1979). Moreover, moving the

concept from its original psychodynamic context and

framing it as a pan-theoretical variable isolated the

alliance from a broad theoretical framework of

therapy and change. Bordin (1994) began the work

of exploring how aspects of the alliance might

articulate with other aspects of therapy, but these

first steps were not taken up by others, and a number

of important unresolved issues remain. Most ob-

viously, the question whether the alliance is in itself acurative component of therapy, or whether the

relationship creates the interpersonal context neces-

sary for other therapeutic elements to come to bear

on the clients problems. In addition the dynamic

evolution of the therapeutic relationship over time

end perhaps its unique unfolding within particular

diagnostic context needs to be investigated.

Second, the field needs to struggle with the

question of how therapists can be trained to develop

4 A. O. Horvath


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better alliances with their clients. Initial efforts to

train therapists resulted in paradoxical effect. Henry

and colleagues, (1993) reported the results of what

appeared to be an excellent training program; but it

failed to improve the quality of alliance in therapy. In

a recent review of research on training therapists to

develop strong alliances, Horvath (2004) reported

that less than half of the projects surveyed obtained a

positive relationship between alliance training andthe quality of the alliance assessed by the client or an

independent rater. The review also indicated that

investigators were more consistent in identifying

therapist attributes (such as flexibility, interest, and

warmth) than therapists activities associated with

positive or improving alliances. It was also noted that

all of the successful training projects involved

individual supervision of trainees, most often within

a structured format (of both supervision and treat-

ment), and these successful training programs each

made use of the therapist current problematic

relationship with their clients. These findings appear

to suggest that it is important to more clearly identifythe interactive elements between therapist and client

related to the alliance, and we need to find methods

to identify and manage therapists problematic reac-

tions to clients in order to improve their relational

effectiveness (Henry & Strupp, 1994; Safran &

Muran, 2000).

Third, we need to examine changes in the quality

of the alliance over time. The majority of the

available research is based on the assumption that

a positive alliance has the same quality over the

length of treatment. Progressive enrichment and

complexity is a characteristic of all intimate relation-

ship over time, so why should we assume that this is

not the case in therapy? The qualities of agreement

or consensus on bonds and tasks, the formation of a

caring and trusting relationship, and even emergence

of a collaborative stance, are likely reasonably uni-

form requirements typical of the beginning phase of

most therapies. It is also reasonable to assume that

these issues retain some relevance in later phases.

But as the relationship evolves and becomes more

complex and as therapy evolves and the client

exposes more sensitive material, the processes like

agreement on tasks and goals become increasingly

embedded in the therapy routine itself. It has beensuggested (Horvath, 2003) that qualities such as

mutual reflexivity and the permission to critically

and mindfully engage in a discourse about the

immediate here and now relational pattern in the

therapy room may be more appropriate in discrimi-

nating the mature phase of the therapeutic alliance.

The lack of success in identifying what Bordin

(1980) predicted as different [patterns of] alliances

corresponding to different kinds of treatments may

be due to such homogeneity myth. A more

detailed and discriminating examination of clients

experience of the therapeutic relationship in later

phases of the work, especially within medium and

longer term treatments might reveal distinctions

useful in clinical practice, research, and training.

Fourth, we need to examine the similarity and

distinctiveness of the alliance concept compared to

other relationship variables. A recent state of theart summary of empirical evidence on the efficacy

of therapists contribution to the therapeutic rela-

tionship (Norcross, 2002) identified 11 relationship

factors as potential contributors to therapy efficacy:

Alliance, Cohesion, Empathy, Goal Consensus and

Collaboration, Positive Regard, Congruence, Feed-

back, Repair of Alliance Ruptures, Self Disclosure,

Counter Transference (management of), and Rela-

tional Interpretation. The significant overlap evident

among these elements, and the lack of a con-

ceptual model knitting these elements into a cohesive

framework, suggests that there is a need to make

some clarifications and distinctions.The time is approaching to renew vigorous dialo-

gue to clarify what we mean by the concepts listed

above. What do these notions share, and what useful

distinctions may be made between them?

Conclusions

The larger context of the research on the therapeutic

relationship is the overarching goal of understanding

how therapy works, and of using what we glean to

from a clearer understanding of the psychotherapy

process leading to better practice. The more we

understand how clients absorb, store, and retrieve

features of the relationship with their therapist and

use it to re-imagine their situation and expand the

options they have available, and the better we

understand how the therapist can create opportu-

nities to enhance this process, the more we fill the

blanks in the puzzle of human change and growth

process.

As several papers in this volume illustrate, research

on the relationship can lead us to better identify

patterns that locate specific micro processes which

can fill important gaps in our understanding of how

therapy works. Examples of investigations reportedin this section with theory building potential include

papers on how clients interpret therapists behaviors

(Benecke et al., 2004; Caspar et al., 2004), cognitive

process that play a formative and maintenance role

in forming a positive relationship with the therapist

(Casey et al., 2004; Rumpold et al., 2004; Sexton et

al., 2004), as well as the identification of clinically

important treatment challenges specific to person-

ality and diagnostic features (Lingiardi et al., 2004).

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It is hoped that the body of research that has

accumulated over the last three decades will serve as

a platform for a renewed dialogue resulting in a

clarification of the concept of the alliance as a

dynamic, situated entity with both generic and

specific elements. Perhaps, as the conceptual/em-

pirical dialogue progresses, we will be able to rise

above the current dichotomy of relational versus

technical elements in therapy and come to under-stand both the relationship and the intervention as

mutually co-determined. Such re-visioning of

the substantive elements of therapy, if warranted,

would offer a new perspective on possible research

agendas.

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Benecke, C., Peham, D., & Banninger-Huber, E. (2004). Non-

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Bordin, E. S. (1976). The generalizability of the psychoanalytic

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Bordin, E. S. (1980, June). Of human bonds that bind or free . Paper

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Bordin, E. S. (1994). Theory and research on the therapeutic

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Zusammenfassung

Therapeutische Beziehung: Forschung und Theorie

Die therapeutische Beziehung wird in einem historischenRahmen behandelt, gefolgt durch eine Kurzubersicht derwichtigsten Forschungsthemen in diesem Bereich und eineUbersicht zu den Themen dieses Doppelheftes. Einigestarke Punkte dieser Arbeiten werden diskutiert, ebensowie die moglichen Herausforderungen einer wiederer-wachten Auffassung von Allianz als pantheoretischem

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Konzept zur Erfassung der Beziehungsdynamik in derTherapie. Es werden Empfehlungen gegeben zu einerErneuerung des Empirie-Theoriedialoges, zu dem, wastherapeutische Beziehung in verschiedenen therapeu-tischen Kontexten und verschiedenen Therapiephasenausmacht.

Resume

La relation therapeutique: recherche et theorie

La place de la relation therapeutique dans la rechercheen psychotherapie est presentee dans un cadre historiquesuivi dune breve revue des themes majeurs de la recherchedans ce domaine et dun resume de ce qui sera traite danscette section speciale. Il sera question des forces de cecorpus de travail ainsi que des defis potentiels emanantde la reemergence de lalliance comme un conceptpan-theorique saisissant la dynamique relationnelle dela therapie. Des recommandations sont fournies pourun renouveau du dialogue empirique et conceptuel surce qui constitue la relation therapeutique dans descontextes therapeutiques varies et des phases de therapie

differentes.

Resumen

La relacion terapeutica. Investigacion y teora

Se presenta un marco historico para ubicar el lugar de larelacion terapeutica en la investigacion en psicoterapia,seguido de una breve revista de los temas principales deinvestigacion dentro de este topico y de una revision de loque se aborda en esta seccion especial. Se debate sobrealgunos de los puntos fuertes de estos estudios, a la par quese senala el desafo potencial que surge de la reemergencia

de la alianza como concepto pan-teorico que rige larelacion dinamica de la terapia. Se dan recomendacionespara renovar el dialogo emprico-conceptual en lo referentea la relacion terapeutica en diferentes fases y contextosterapeuticos de la terapia.

Resumo

A relacao terapeutica: Investigacao e teoria

E apresentado o lugar da relacao terapeutica na investiga-

cao em psicoterapia num perspectiva historica, seguido de

uma revisao breve dos principais temas de investigacao

ligados ao topico e uma revisao daquilo que e abordado

nesta seccao especial. Sao discutidos alguns dos pontos

fortes deste corpo de trabalho, bem como os potenciais

desafios que resultam da re-emergencia da alianca como

conceito panteorico que capta a natureza relacional da

terapia. Sao fornecidas recomendacoes para a renovacao

do dialogo conceptual em que consiste a relacao terapeu-

tica em diferentes contextos terapeuticos e diferentes fases

da terapia.

Sommario

La relazione terapeutica: ricerca e teoria

Attraverso un excursus storico viene presentato il ruolo

della relazione terapeutica nella ricerca in psicoterapia;segue una breve revisione dei temi principali di ricerca

allinterno di questambito e degli argomenti trattati in

questa sezione speciale. Sono discussi i punti di forza di

questo lavoro come pure le potenziali sfide nate dal

riemergere dellalleanza come concetto panteoretico che

cattura le dinamiche relazionali in terapia. Vengono fornite

indicazioni per rinnovare il dibattito empirico/concettuale

su che cosa costituisce la relazione terapeutica nei differ-

enti contesti terapeutici e nelle differenti fasi della terapia.

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