The three 'core conditions' which Rogers (1951) proposed as being both essential and sufficient for therapeutic change-empathy, unconditional positive regard and congruence-are conceptually different from the therapeutic alliance, but there is a clear overlap to which empirical research has testified (Horvath & Luborsky, 1993; Salvio, Beutler, Wood, & Engle, 1992). In Transactional Analysis, by contrast, the therapeutic alliance is conceptualized as 'a contract or agreement between the Adult of the psychotherapist and the Adult of the client' (Clarkson, 1990): what in psychoanalytic terms might be seen as a collaboration between the egos or non-neurotic parts of the therapeutic couple.
Seeking to operationalize this concept and apply it more generally across psychotherapies, Bordin (5) identified three components of the therapeutic alliance-goal, task, and bond. He saw the therapeutic alliance as a mutual construction of the patient and therapist that includes shared goals, accepted recognition of the tasks each person is to perform in the relationship, and an attachment bond. He saw the therapeutic alliance as developing in the relationship between the two and as the vehicle through which psychotherapies are effective.
The quality of the therapeutic relationship has been increasingly recognized as an important predictor of outcomes in mental health service delivery. The therapeutic or working alliance was originally articulated as a key aspect of the therapeutic relationship by psychoanalysts (7, 8), whose formulation of the construct included the capacity to maintain therapeutic work, even in the context of resistance and negative transference.
Our previous research (Bartle-Haring et al., 2007) suggested that therapeutic alliance forms more slowly for individuals who come to therapy as part of a couple in comparison to individuals who come to therapy as an individual. This appears to be the case, specifically from the perspective of the client but not the therapist, for forming a working alliance or perceiving agreement on the work that needs to be done in therapy.
Therapeutic alliance has been proposed as an ideal patient provider relationship in the social-control continuum of compliance, adherence, and therapeutic alliance.10,11 In this continuum, compliance implies that the patient is being coerced and adherence implies conformation to an expected standard. In contrast, therapeutic alliance implies negotiation between the patient and health care provider. As an ideal patient provider relationship, therapeutic alliance is defined as a dynamic interactional process in which the patient and provider collaborate to carry out negotiated mutual goals in a shared partnership.12-15
An argument can be made that alliance may be more important in child than adult mental health settings. Studies on the therapeutic relationship have focused on adults voluntarily engaged in treatment. For the most part, children and adolescents do not voluntarily initiate treatment but are usually involved in treatment because a parent or caregiver deems it a needed service or because they have been referred for treatment from other human service agencies. In addition, many youth in treatment are there because of problems with caregiver, adult, and peer relationships. The clinician's ability to form, model, and maintain a caring and beneficial relationship with the child may be essential to improved treatment outcomes for troubled youth.13
Although findings that a strong, positive therapeutic alliance is related to positive treatment outcome has been quite consistent, (Horvath and Symonds, 1991; Martin, Garske, & Davis, 2000) the exact nature of this relationship has remained less clear. As a result, clinical theorists and researchers have increasingly turned their attention to determining how the alliance functions to foster change. For example, some (e.g., Raue & Goldfried, 1994; Beck, 1995) believe that the alliance serves primarily as a static foundation for the application of curative techniques, while others (e.g., Bordin, 1979, 1994; Safran & Muran, 2000) believe that the alliance is an active agent of the change process in its own right.
The therapist's establishment of a "meta-alliance" with the couple around their loyalty conflicts, avoidance of splits and disruptions, and prioritization of marital distress (versus individual symptoms) as the primary focus of treatment all serve to solidify the therapeutic alliance. In addition, identifying the partners' early family-of-origin distress can help predict and respond to strains in the therapeutic alliance that may occur later in therapy. Finally, the therapist helping the couple to balance their relational power differences in therapy and to address their concerns about the impact of the therapist's gender also strengthens their therapeutic alliance.
Empirical evidence has accumulated over the last several decades suggesting that the therapeutic alliance is a strong predictor of outcome in individual psychotherapy (Horvath & Bedi, 2002; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Therapeutic alliance has also been shown to predict outcome in couple therapy across diverse treatment orientations and modalities (Bourgeois, Sabourin, & Wright, 1990; Brown & O'Leary, 2000; Holtzworth-Munroe, Jacobson, DeKlyen, & Whisman, 1989; Johnson & Talitman, 1997; Quinn, Dotson, & Jordan, 1997; Raytek, McGrady, Epstein, & Hirsch, 1999).
Engagement in treatment has been identified as one of the nine principles of effective adolescent drug treatment (Drug Strategies 2003). Therapeutic alliance, broadly defined as "the collaborative and affective bond between therapist and patient" (Martin, Garske & Davis 2000: 438) is one construct related to engagement. This construct has long been recognized within the field of psychotherapy (Orlinsky, Rønnestad & Willutzki 2004; Horvath & Symonds 1991; Orlinsky & Howard 1986; Gomes-Schwartz 1978; Greenson 1965; Freud 1913) and has been the subject of much research within the substance abuse treatment specialty (Simpson 2004, 2001; Barber et al. 2001; Joe et. al. 2001; Bell, Montoya & Atkinson 1997; Connors et al. 1997).