Research on the alliance: Knowledge in search of a theory

Horvath, Adam O.

doi:10.1080/10503307.2017.1373204

Cited by 137Psychotherapy Techniques and ApplicationsCounseling Practices and SupervisionPsychoanalysis and Psychopathology Research

Research on the alliance: Knowledge in search of a theory

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Horvath, Adam O.·2018·Psychotherapy Research

DOI 10.1080/10503307.2017.1373204

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Abstract

OBJECTIVES: The aim of this review paper is to summarize the challenges facing research on the alliance now and going forward. The review begins with a brief overview of the development of the concept of the alliance in historical context. METHOD: A summary of what has been accomplished both within the psychotherapy research community and in other professions is presented. Current challenges facing this line of research are identified, including the existence of a wide range of operational definitions that results in a diffusion of the identity of the alliance concept. It is argued that the current situation generates risks to incremental growth in several lines of research. CONCLUSIONS: A case is made that a lack of clarity regarding how several variables within the broader category of therapeutic relationships fit together, overlap, or complement each other is also potentially problematic. Efforts to resolve the lack of a consensual definition are reviewed, and in conclusion, it is argued that a resumption of a conversation about the relationship in the helping context in general, and the alliance in particular, should be resumed.

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Alliance is considered a generic common factor, with meaning and usefulness expected to be preserved across theoretical orientations.
“Alliance is considered a generic common factor, with meaning and usefulness expected to be preserved across theoretical orientations [2] and evidence suggests that a range of technology-based interventions can facilitate alliance [36].”
From Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation (2020) · cites this paper as [2]

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STEWART, R. E., & CHAMBLESS, D. L. (2012) · Psychopathology · doi:10.4324/9780203134849-13 · Cited by 27 · see citing works
New, but improved? Comparison between first and revised version of the Helping Alliance questionnaire
Drapeau, M., Le, Y., de, Y., & Despland, J. (2006) · Schweizer Archiv für Neurologie und Psychiatrie · doi:10.4414/sanp.2006.01669 · Cited by 23 · see citing works
Alliance in Couple and Family Therapy
Friedlander, M. L., Escudero, V., Heatherington, L., & Diamond, G. M. (2011) · Oxford University Press eBooks · doi:10.1093/acprof:oso/9780199737208.003.0004 · Cited by 23 · see citing works
The working alliance in psychotherapy: An overview of the invited papers in the special section.
Samstag, L. W. (2006) · Psychotherapy · doi:10.1037/0033-3204.43.3.300 · Cited by 20 · see citing works
The Psychotherapeutic Process: A Research Handbook
Siassi, I., & Wesner, D. O. (1988) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.1988.42.1.154 · Cited by 20 · see citing works
The Alliance Negotiation Scale: A psychometric investigation.
Doran, J. M., Safran, J. D., & Muran, J. C. (2015) · Psychological Assessment · doi:10.1037/pas0000222 · Cited by 19 · see citing works
The Helping Relationship
Barrett‐Lennard, G. T. (1985) · The Counseling Psychologist · doi:10.1177/0011000085132006 · Cited by 14 · see citing works
The development of therapeutic collaboration in a good outcome case of person-centered therapy
Ribeiro, E., Fernandes, C., Santos, B., Ribeiro, A. P., Coutinho, J. F. P., Angus, L. E., & Greenberg, L. S. (2014) · Person-Centered & Experiential Psychotherapies · doi:10.1080/14779757.2014.893250 · Cited by 12 · see citing works
Prevalence of Counselling Alliance Type Preferences Across Two Samples
Bedi, R. P., & Duff, C. T. (2009) · Canadian Journal of Counselling and Psychotherapy · Cited by 12 · see citing works
The problem of therapeutic alliance.
Abend, S. M. (2000) · Cited by 11 · see citing works
Using outcome data to improve the effects of psychotherapy: Some illustrations.
Lambert, M. J. (2010) · American Psychological Association eBooks · doi:10.1037/12141-008 · Cited by 5 · see citing works
The Reciprocal Effect of Theory and Practice.
Ferenczi, S., & Rank, O. (2005) · Nervous and Mental Disease Publishing Co eBooks · doi:10.1037/10664-004 · Cited by 4 · see citing works
An empirical evaluation of Luborsky's biphasic model of the therapeutic alliance within the context of a randomized controlled trial
Davis, M. D. (2011) · Summit (Simon Fraser University) · Cited by 1 · see citing works

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Sorted by citations

The alliance in adult psychotherapy: A meta-analytic synthesis
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018) · Psychotherapy · doi:10.1037/pst0000172 · Cited by 1,763 · see citing works
“More research is also needed that examines the boundary conditions of the alliance measures and their interaction to interpersonal and general process indicators, such as empathy, the real relationship, and corrective experiences (Horvath, 2017).”
BackgroundSelf-citation
An adoption-implementation framework of digital green knowledge to improve the performance of digital green innovation practices for industry 5.0
Yin, S., & Yu, Y. (2022) · Journal of Cleaner Production · doi:10.1016/j.jclepro.2022.132608 · Cited by 388 · see citing works
The alliance in mental health care: conceptualization, evidence and clinical applications
Wampold, B. E., & Flückiger, C. (2023) · World Psychiatry · doi:10.1002/wps.21035 · Cited by 231 · see citing works
The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis
Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., Compare, A., Falkenström, F., Ekeblad, A., et al. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000594 · Cited by 180 · see citing works
“…meta-analytic synthesis of the overall association between the alliance assessed early in treatment and treatment outcome indicated that the early alliance predicted on average 5% of the variance in therapy outcomes including dropout rates (k 295; Flückiger, Del Re, Wampold, & Horvath, 2018).”
BackgroundInfluentialSelf-citation
Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons.
Flückiger, C., Re, A. C. D., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020) · Journal of Counseling Psychology · doi:10.1037/cou0000424 · Cited by 137 · see citing works
Self-citation
The Effects of Health Care Chatbot Personas With Different Social Roles on the Client-Chatbot Bond and Usage Intentions: Development of a Design Codebook and Web-Based Study
(2022) · doi:10.2196/32630 · Cited by 83 · see citing works
“Originally developed for psychotherapeutic settings, the working alliance—often also referred to as the therapeutic or helping alliance—is a key construct in the therapist-client collaboration in the clinical context of mental health disorders, reflecting the collaborative quality between clients and health profession…”
Background
Confessions of a New York rupture researcher: An insider’s guide and critique
Muran, J. C. (2017) · Psychotherapy Research · doi:10.1080/10503307.2017.1413261 · Cited by 79 · see citing works
The therapeutic alliance in exposure therapy for anxiety-related disorders: A critical review
Buchholz, J. L., & Abramowitz, J. S. (2020) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2020.102194 · Cited by 77 · see citing works
“…and literature reviews suggest that the alliance is moderately associated with treatment outcome across psychological diagnoses (Browne, Nagendra, Kurtz, Berry, & Penn, 2019; Flückiger, Del Re, Wampold, & Horvath, 2018; Horvath, Del Re, Flückiger, & Symonds, 2011; Martin, Garske, & Davis, 2000).”
BackgroundMethodInfluential
Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation
Miloff, A., Carlbring, P., Hamilton, W., Andersson, G., Reuterskiöld, L., & Lindner, P. (2020) · Journal of Medical Internet Research · doi:10.2196/16660 · Cited by 60 · see citing works
“Some alliance measures, such as the Helping Alliance Questionnaire (HAq) [5], are an authoritative operationalization of their authors’ key theories; however, the boundaries of the popular WAI were never formalized [2] and researchers continue to refine the measure as they seek to develop a holistic understanding of a…”
Background
A Meta-Analysis on Differences and Associations between Alliance Ratings in Child and Adolescent Psychotherapy
Roest, J. J., de Poll, M. J. W.-V., van der Helm, P. G., Stams, G. J. J. M., & Hoeve, M. (2022) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2022.2093210 · Cited by 60 · see citing works
Elements of the therapeutic relationship in CBT for anxiety disorders: A systematic review
Luong, H. K., Drummond, S. P. A., & Norton, P. J. (2020) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2020.102322 · Cited by 53 · see citing works
The Impact of Clients’ and Therapists’ Characteristics on Therapeutic Alliance and Outcome
Tschuschke, V., Koemeda-Lutz, M., von Wyl, A., Crameri, A., & Schulthess, P. (2021) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-021-09527-2 · Cited by 25 · see citing works
“There has also been increased research interest in the last 10 years in alliance ruptures and their repair (Coutinho et al., 2014; Eubanks et al., 2018; Horvath, 2018).”
Background
The factor structure of the Working Alliance Inventory short-form in youth psychotherapy: an empirical investigation
Cirasola, A., Midgley, N., Fonagy, P., Impact Consortium, & Martin, P. (2021) · Psychotherapy Research · doi:10.1080/10503307.2020.1765041 · Cited by 42 · see citing works
“Yet there is no consensually accepted definition of the alliance and there have been few attempts to differentiate its content and structure in an empirically meaningful way (Horvath, 2018; McLeod, 2011).”
Background
Development of “LvL UP 1.0”: a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders
Castro, Ó., Mair, J. L., Salamanca-Sanabria, A., Alattas, A., Keller, R., Zheng, S., Jabir, A. I., Lin, X., Frese, B. F., Lim, C. S., et al. (2023) · Frontiers in Digital Health · doi:10.3389/fdgth.2023.1039171 · Cited by 42 · see citing works
“Working alliance, also known as therapeutic or helping alliance, is a concept that originates from psychotherapeutic settings and refers to the collaborative quality between clients and health professionals (73).”
Background
The Working Alliance Inventory's Measurement Properties: A Systematic Review
Paap, D., Karel, Y., Verhagen, A. P., Dijkstra, P. U., Geertzen, J. H. B., & Pool, G. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.945294 · Cited by 37 · see citing works
“…with the treatment, symptom change, and other contextual factors (DeRubeis et al., 2006; Webb et al., 2012; Falkenström et al., 2013), also the construct of the working alliance remains psychometrically unclear (Horvath and Greenberg, 1989; Elvins and Green, 2008; Hall et al., 2010; Horvath, 2018).”
BackgroundMethodInfluential
The Impact of Patients' and Therapists' Views of the Therapeutic Alliance on Treatment Outcome in Psychotherapy.
Tschuschke, V., Koemeda-Lutz, M., von Wyl, A., Crameri, A., & Schulthess, P. (2019) · Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001111 · Cited by 22 · see citing works
“Horvath (2018) criticized alliance investigations using a wide variety of time scales: “...there is no evidence to suggest that there is a simple additive relationship between what is measured at different time intervals” (p 512).”
BackgroundInfluential
Alliance Ruptures and Resolutions in Personality Disorders
Schenk, N., Fürer, L., Zimmermann, R., Steppan, M., & Schmeck, K. (2020) · Current Psychiatry Reports · doi:10.1007/s11920-020-01212-w · Cited by 30 · see citing works
Acceptance and commitment therapy and the therapeutic relationship: Rupture and repair
Walser, R. D., & O'Connell, M. (2021) · Journal of Clinical Psychology · doi:10.1002/jclp.23114 · Cited by 30 · see citing works
Working Alliance and Stages of Change for Employment: The Intermediary Role of Autonomous Motivation, Outcome Expectancy and Vocational Rehabilitation Engagement
Iwanaga, K., Chan, F., Tansey, T. N., Strauser, D. R., Ritter, E., Bishop, M. L., & Brooks, J. (2018) · Journal of Occupational Rehabilitation · doi:10.1007/s10926-018-9787-5 · Cited by 29 · see citing works
A Three-level Meta-analysis on the Alliance-Outcome Association in Child and Adolescent Psychotherapy
Roest, J. J., de Poll, M. J. W.-V., van der Helm, P., Stams, G. J. J. M., & Hoeve, M. (2022) · Research on Child and Adolescent Psychopathology · doi:10.1007/s10802-022-00986-2 · Cited by 29 · see citing works
Patient empowerment: a critical evaluation and prescription for a foundational definition
Varela, A. J., Gallamore, M. J., Hansen, N. R., & Martin, D. C. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1473345 · Cited by 33 · see citing works
Relationship and Alliance Formation Processes in Psychotherapy: A Dual-Perspective Qualitative Study
Lavik, K. O., McAleavey, A. A., Kvendseth, E. K., & Moltu, C. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.915932 · Cited by 25 · see citing works
“Although widely used in research, this model has been criticized for being vague and open-ended (Horvath, 2018), especially when it comes to the meaning of the ‘emotional bond.’”
Method
Getting to “Yes”: Overcoming Client Reluctance to Engage in Chair Work
Muntigl, P., Horvath, A. O., Chubak, L., & Angus, L. E. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.582856 · Cited by 25 · see citing works
“…different modes of psychotherapy, the alliance in general and the task component of the alliance in particular (i.e., prizing of, and engagement in, the therapist proposed in-therapy tasks) is the core feature of the productive therapy process (Bordin, 1975; Horvath, 2018; Flückiger et al., 2020).”
BackgroundSelf-citation
The Strength of Alliance in Individual Psychotherapy and Patient's Wellbeing: The Relationships of the Therapeutic Alliance to Psychological Wellbeing, Satisfaction With Life, and Flourishing in Adult Patients Attending Individual Psychotherapy
Prusiński, T. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.827321 · Cited by 29 · see citing works
The working alliance in blended versus face-to-face cognitive therapy for depression: a secondary analysis of a randomized controlled trial
Askjer, S., & Mathiasen, K. (2021) · Internet Interventions · doi:10.1016/j.invent.2021.100404 · Cited by 18 · see citing works
“…that WAI-C was rated slightly higher rated than WAI-T, which are common findings in previous research, but this pattern remains to be established in bCBT (Blais et al., 2010; Horvath and Bedi, 2002; Marmarosh and Kivlighan, 2012; Kooistra et al., 2020; Tryon et al., 2007; Vernmark et al., 2019).”
Result
Defending the art of physical therapy: Expanding inquiry and crafting culture in support of therapeutic alliance
Brun-Cottan, N., McMillian, D., & Hastings, J. (2018) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2018.1492656 · Cited by 18 · see citing works
The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa
Timko, C. A., Bhattacharya, A., Fitzpatrick, K. K., Howe, H. S., Rodriguez, D., Mears, C., Heckert, K., Ubel, P. A., Ehrenreich, J. T., & Peebles, R. (2021) · Contemporary Clinical Trials · doi:10.1016/j.cct.2021.106313 · Cited by 21 · see citing works
The first session is the one that counts: An exploratory study of therapeutic alliance
Olvera, F. J. D. R., Rodríguez-Mora, Á., Senín‐Calderón, C., & Testal, J. F. R. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.1016963 · Cited by 20 · see citing works
“…alliance is defined as a subjective experience and collaborative partnership between patient and therapist, according to the therapeutic goals, tasks or processes defined to achieve these goals, and with positive emotional bonds based on trust in a therapeutic context (Bordin, 1979; Horvath, 2018).”
Background
The working alliance in manualized CBT for generalized anxiety disorder: Does it lead to change and does the effect vary depending on manual implementation flexibility?
Rubel, J. A., Hilpert, P., Wolfer, C., Held, J., Vîslă, A., & Flückiger, C. (2019) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000433 · Cited by 19 · see citing works
Teaching the Fundamentals of Remote Psychotherapy to Psychiatry Residents in the COVID-19 Pandemic
Ruble, A. E., Romanowicz, M., Bhatt-Mackin, S. M., Topor, D. R., & Murray, A. (2021) · Academic Psychiatry · doi:10.1007/s40596-021-01484-1 · Cited by 18 · see citing works
Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy
Saxler, E., Schindler, T., Philipsen, A., Schulze, M., & Lux, S. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1293851 · Cited by 17 · see citing works
“Over the last century, many authors have presented different theoretical conceptualizations of TA and many corresponding questionnaires have been developed (Elvins and Green, 2008; Ardito and Rabellino, 2011; Flückiger et al., 2018; Horvath, 2018).”
BackgroundResultInfluential
A natural language processing approach reveals first-person pronoun usage and non-fluency as markers of therapeutic alliance in psychotherapy
Ryu, J., Heisig, S., McLaughlin, C., Katz, M., Mayberg, H. S., & Gu, X. (2023) · iScience · doi:10.1016/j.isci.2023.106860 · Cited by 19 · see citing works
“Current gold standard assessments of alliance rely on either self-reports or human observers’ qualitative coding of treatment interactions, which are subjective, labor-intensive, and time-consuming.(2) These drawbacks have limited the development of a scalable, real-time feedback system to treatment pairs that can imp…”
Background
Patient–provider therapeutic connections to improve health care: Conceptual development and systematic review of patient measures
Rathert, C., Mittler, J., & Lee, Y. S. H. (2022) · Health Care Management Review · doi:10.1097/hmr.0000000000000339 · Cited by 16 · see citing works
“Key words from foundational articles (Elvins & Green, 2008; Horvath, 2018; Mead & Bower, 2000) and associated concepts identified from our conceptual work (e.”
BackgroundInfluential
Shared decision-making, the working alliance, and patient-centered care: A simultaneous concept analysis and review of the literature
Lee, K. G., Gagliardi, A. R., Lofters, A., Pinto, A. D., & Maunder, R. (2025) · Patient Education and Counseling · doi:10.1016/j.pec.2025.109316 · Cited by 15 · see citing works
Court-Mandated Patients’ Perspectives on the Psychotherapist’s Dual Loyalty Conflict – Between Ally and Enemy
Merkt, H., Wangmo, T., Pageau, F., Liebrenz, M., Cornaz, C. D., & Elger, B. S. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.592638 · Cited by 15 · see citing works
“The therapeutic alliance is one of the common factors of psychotherapeutic practice overarching different techniques (Mulder et al., 2017; Horvath, 2018).”
BackgroundMethod
It takes two to tango: The therapeutic alliance in community brain injury rehabilitation
Williams, L., & Douglas, J. M. (2021) · Brain Impairment · doi:10.1017/brimp.2021.26 · Cited by 15 · see citing works
The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder
McEvoy, P. M., Bendlin, M., Johnson, A. R., Kazantzis, N., Campbell, B. N. C., Bank, S. R., & Egan, S. J. (2023) · Psychotherapy Research · doi:10.1080/10503307.2022.2161966 · Cited by 15 · see citing works
“Working alliance has been defined as the agreed goals and tasks of psychotherapy between therapist and client, as well as the emotional bond (Bordin, 1979; Horvath, 2018).”
Background
Better outcomes through patient - Provider therapeutic connections? An exploratory study of proposed mediating variables
Rathert, C., Mittler, J. N., Vogus, T. J., & Lee, Y. S. H. (2023) · Social Science & Medicine · doi:10.1016/j.socscimed.2023.116290 · Cited by 12 · see citing works
Physical therapist characteristics and therapeutic relationship process construct factors that improve patient health outcomes in physical therapy: a systematic review
Rodríguez‐Nogueira, Ó., Alba-Pérez, E., Álvarez, M. J. Á., & Moreno‐Poyato, A. R. (2025) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2025.2469162 · Cited by 13 · see citing works
“Areas such as education, medicine, nursing, and physical therapy have been incorporated into this research (Horvath, 2018) due to its benefits in both perceived satisfaction and clinical outcomes (Hall et al, 2010; Manzoni, de Oliveira, Cabral, and Ricci, 2018).”
Meaning profiles and the perception of the working alliance at the start of outpatient person‐centered, experiential, and existential psychotherapies
Golovchanova, N., Dezutter, J., & Vanhooren, S. (2020) · Journal of Clinical Psychology · doi:10.1002/jclp.23057 · Cited by 13 · see citing works
Strategies for using metaphor in psychological treatment
Törneke, N. (2020) · Metaphor and the Social World · doi:10.1075/msw.00004.tor · Cited by 13 · see citing works
Teaching Suicide Risk Assessment: Spotlight on the Therapeutic Relationship
Foster, A. E., Alderman, M., Safin, D. S., Aponte, X., McCoy, K., Caughey, M., & GALYNKER, I. I. (2021) · Academic Psychiatry · doi:10.1007/s40596-021-01421-2 · Cited by 13 · see citing works
Five reflective touchstones to foster supervisor humility
McMahon, A. (2020) · The Clinical Supervisor · doi:10.1080/07325223.2020.1827332 · Cited by 13 · see citing works
Patients’ and Psychotherapists’ Combined and Separate Evaluations of the Psychotherapeutic Relationship: The Structure of Working Alliance and Polish Versions of the WAI
Prusiński, T. (2021) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-021-09500-z · Cited by 12 · see citing works
“So far, however, there is no commonly accepted definition of alliance (Horvath, 2018), although there have been many attempts to determine its contents and structure in an empirically meaningful way (Cirasola, Midgley, Fonagy, Impact Consortium, & Martin, 2020).”
BackgroundMethodInfluential
Enhancing working alliance through positive emotional experience: A cross-lag analysis
Notsu, H., Iwakabe, S., & Thoma, N. C. (2022) · Psychotherapy Research · doi:10.1080/10503307.2022.2124893 · Cited by 12 · see citing works
Lived Experience of Treatment for Avoidant Personality Disorder: Searching for Courage to Be
Sørensen, K. D., Wilberg, T., Berthelsen, E., & Råbu, M. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02879 · Cited by 12 · see citing works
“This aligns with the well-established moderate but reliable association between the quality of the relationship and outcomes in therapy (e.g., Ardito and Rabellino, 2011; Horvath, 2018; Noyce and Simpson, 2018).”
Background
The role of the working alliance in psychological treatment of substance use disorder outpatients
Gidhagen, Y., Holmqvist, R., Philips, B., & Falkenström, F. (2020) · Psychotherapy Research · doi:10.1080/10503307.2020.1807639 · Cited by 12 · see citing works
The role of intolerance of uncertainty and working alliance in the outcome of cognitive behavioral therapy for generalized anxiety disorder delivered by videoconference: Mediation analysis
Marcotte-Beaumier, G., Bouchard, S., Gosselin, P., Langlois, F., Belleville, G., Marchand, A., & Dugas, M. J. (2021) · JMIR Mental Health · doi:10.2196/24541 · Cited by 11 · see citing works
“They confirmed the observation of Horvath [15] that there is a “practical vacuum in the literature.”
Background
A path to generative artificial selves
Gabora, L., & Bach, J. (2023) · Lecture Notes in Computer Science · doi:10.1007/978-3-031-49011-8_2 · Cited by 9 · see citing works
Alliance-outcome relation and progress feedback: Secondary data analyses of a randomized clinical trial study in China
Sun, Q., Wu, C., Wang, C. D. C., Yu, L., She, Z., & Falkenström, F. (2020) · Psychotherapy Research · doi:10.1080/10503307.2020.1772517 · Cited by 9 · see citing works
“, 2018), it seems reasonable that progress feedback has been found to influence the quality of the working alliance and the alliance-outcome relation (Horvath, 2018; Miller et al., 2005; Safran et al., 2001).”
Background
Common factors, Responsiveness and Outcome in Psychotherapy (CROP): study protocol for a naturalistic prospective cohort study of psychotherapy in Denmark
Lauritzen, L. R., Jacobsen, C. F., Nielsen, J., Lunn, S., Mathiesen, B. B., Falkenström, F., & Poulsen, S. (2023) · BMJ Open · doi:10.1136/bmjopen-2023-072277 · Cited by 8 · see citing works
How to customize a bona fide psychotherapy for generalized anxiety disorder? A two-arms, patient blinded, ABAB crossed-therapist randomized clinical implementation trial design [IMPLEMENT 2.0]
Flückiger, C., Wolfer, C., Held, J., Hilpert, P., Rubel, J. A., Allemand, M., Zinbarg, R. E., & Vîslă, A. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1666-2 · Cited by 8 · see citing works
Measuring working alliance and technical alliance from the perspective of healthcare professionals working with people with mild intellectual disabilities: adaptation, factor structure and reliability
Oudshoorn, C. E. M., Frielink, N., Riper, H. M., & Embregts, P. J. C. M. (2022) · Journal of Intellectual Disability Research · doi:10.1111/jir.12986 · Cited by 7 · see citing works
The Brazilian-adapted Working Alliance Inventory: preliminary report on the psychometric properties of the original and short revised versions
Serralta, F. B., Benetti, S. P. D. C., Laskoski, P. B., & Abs, D. (2020) · Trends in Psychiatry and Psychotherapy · doi:10.1590/2237-6089-2019-0099 · Cited by 7 · see citing works
Influence of Therapist Attachment Style on the Working Alliance in Individual Psychotherapy: A Systematic Review and Meta‐Analysis
Marín‐Cavestany, M., de la Cruz, M. Á., Durán, J. I., Stiles, B. J., Lahera, G., & Andrade‐González, N. (2025) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70025 · Cited by 6 · see citing works
Longitudinal measurement invariance of the Working Alliance Inventory - Short form across coaching sessions
Stefens, M., Rondeel, E. W. M., Templin, J. L., Brode, D., de Waart, E., de Jong, R. D., ten Hoeve-Rozema, J., Waringa, A., Reijnders, J. S. A. M., Jacobs, N., et al. (2022) · BMC Psychology · doi:10.1186/s40359-022-00968-5 · Cited by 6 · see citing works
“The most widely used conceptualization of working alliance derives from Bordin’s [7] pan-theoretical model that moves beyond the original psychotherapeutic approaches of the construct [8].”
Method
The Working Alliance as a Mediator Between Fidelity to Strengths Model Case Management and Client Outcomes
Roebuck, M., Latimer, E. A., Bergeron‐Leclerc, C., Briand, C., Durbin, J., Goscha, R., Krupa, T. M., Setliff, A., Vallée, C., & Aubry, T. (2022) · Psychiatric Services · doi:10.1176/appi.ps.202100387 · Cited by 6 · see citing works
Factors promoting alliance quality: Differentiation of therapeutic alliance according to the formal aspects of the psychotherapeutic process and demographic variables
Prusiński, T. (2022) · The European Journal of Psychiatry · doi:10.1016/j.ejpsy.2022.11.002 · Cited by 6 · see citing works
Using the primary process emotional–behavioural system to better meet patient needs in psychotherapy
Kuei, T., Tsai, M., McLeod, H. J., White, R. G., & Kanter, J. W. (2018) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2330 · Cited by 6 · see citing works
The Therapeutic Relationship with Clients with Phobic, Obsessive–Compulsive, Eating, and Depressive Disorders: Which Meanings Prevail?
Ugazio, V., Guarnieri, S., Anselmi, P., Castelli, D., & Pandolfi, M. (2020) · Journal of Constructivist Psychology · doi:10.1080/10720537.2020.1828203 · Cited by 5 · see citing works
The Mediating Alliance
Pujol, L., Tremolosa, I. A., Medina, F. J., Munduate, L., & Anguera, M. T. (2023) · Negotiation Journal · doi:10.1111/nejo.12428 · Cited by 5 · see citing works
THERapy–Related InterACTion (THER-I-ACT) in Rehabilitation—Instrument Development and Inter-Rater Reliability
Platz, T., Seidel, J., MÜLLER, A. E., Goldmann, C., & Pedersen, A. L. (2021) · Frontiers in Neurology · doi:10.3389/fneur.2021.716953 · Cited by 5 · see citing works
“It respects the important work alliance dimensions “goal,” “task,” and “bond” (9) and further specifies types of extrinsic feedback (6).”
Background
A Qualitative Study of the Working Alliance in the Strengths Model of Case Management with People with Severe Mental Illness
Roebuck, M., Aubry, T., & Manoni-Millar, S. (2021) · Community Mental Health Journal · doi:10.1007/s10597-021-00903-9 · Cited by 5 · see citing works
“, psychotherapist, case manager) and the degree to which the client and worker agree on the goals of the intervention and the tasks needed to work towards those goals (Bordin, 1979; Horvath, 2018).”
BackgroundResultInfluential
When does doctor’s recommendation become patient’s resolution? The regulatory potential of procedural justice in the context of compliance with medical advice and the treatment process
Prusiński, T. (2023) · Frontiers in Medicine · doi:10.3389/fmed.2023.1004994 · Cited by 5 · see citing works
“Bond is a significant factor in corrective experiences and a vehicle of change for the patient because it allows for maintaining a relationship of cooperation between the helper and the person seeking help (38).”
Background
The therapeutic alliance in context: Institutional factors that impact social work with families
Consuagra, X. D., Sharim, D., Puig‐Cruells, C., & Muñoz‐Guzmán, C. (2023) · Child & Family Social Work · doi:10.1111/cfs.13033 · Cited by 5 · see citing works
Can you see what I see? A comparison of client and observer perspectives of the alliance and group cohesion in CBT
Luong, H. K., Drummond, S. P. A., & Norton, P. J. (2021) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2021.1898463 · Cited by 5 · see citing works
“These observations provide further evidence for the assertion that different raters assess different aspects of the alliance (Horvath, 2018).”
Background
Group‐based processes as a framework for understanding the working alliance in therapy
Lee, G. C., Platow, M. J., & Cruwys, T. (2022) · Counselling and Psychotherapy Research · doi:10.1002/capr.12585 · Cited by 5 · see citing works
Therapists’ questions to clients about what might be helpful can be supportive without being directive: a conversation analysis
Cantwell, S., Rae, J. P., Hayes, J., Vos, J., & Cooper, M. (2022) · Counselling Psychology Quarterly · doi:10.1080/09515070.2021.1997917 · Cited by 5 · see citing works
“Horvath (2018) notes that the alliance is an attempt to operationalise the helping relationship and warns against an overly inclusive definition as a risk to the progressive development of alliance research.”
BackgroundInfluential
Listening quality leads to greater working alliance and well‐being: Testing a social identity model of working alliance
Lee, G. C., Platow, M. J., & Cruwys, T. (2024) · British Journal of Clinical Psychology · doi:10.1111/bjc.12489 · Cited by 4 · see citing works
“While there is no universally-accepted definition of working alliance, it centres on the quality of the relationship between a helper and help recipient (Horvath, 2018).”
“Making a difference”: Interpreting responsivity ambience for parole work
Taylor, M., Ricciardelli, R., & Shively, R. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e39617 · Cited by 4 · see citing works
Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating
Barr, B. L., McIntosh, V. V. W., Britt, E., Jordan, J., & Carter, J. D. (2023) · Psychotherapy Research · doi:10.1080/10503307.2023.2191800 · Cited by 4 · see citing works
“For example, in a recent review Horvath (2018) identified over 70 instruments with varying degrees of scientific validation in use as measures of therapeutic alliance.”
Background
Pitfalls and Opportunities of the Therapist’s Metacommunication: A Self-determination Perspective
Holmström, É., Kykyri, V., & Martela, F. (2023) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-023-09598-3 · Cited by 4 · see citing works
“…there has been a growing interest in psychotherapy research on the formation and maintenance of the therapeutic alliance (Cirasola & Midgley, 2023; Horvath, 2018), as well as factors associated with alliance ruptures and its relationship to outcome (Krupnik, 2022; Monticelli & Liotti, 2021;…”
The linear pattern of therapeutic alliance development: Exploring the relationship between alliance trajectories over time and the outcomes of systemic psychotherapy treatment for adaptation disorders
Prusiński, T. (2024) · Counselling and Psychotherapy Research · doi:10.1002/capr.12753 · Cited by 4 · see citing works
The working alliance and the short-term and long-term effects of therapy: Identification and analysis of the effect of the therapeutic relationship on patients’ quality of life
Prusiński, T. (2021) · Psychiatria Polska · doi:10.12740/pp/onlinefirst/130280 · Cited by 4 · see citing works
Narratives of people with serious mental illness in Housing First: a qualitative analysis of factors contributing to housing instability and housing stability
Nelson, G. B., Roebuck, M., Agha, A., Aubry, T., Purcell, S., Faruquzzaman, O., Kirst, M. J., Macnaughton, E., Isaak, C. A., & Tsemberis, S. J. (2023) · Journal of Social Distress and the Homeless · doi:10.1080/10530789.2023.2176738 · Cited by 4 · see citing works
“This theme is related to the concept of the working alliance in the mental health ﬁ eld which signi ﬁ es a strong bond between the therapist and client, a bond that predicts positive client outcomes (Horvath, 2018).”
Background
Consensus on Alliance Quality in the Psychotherapeutic Dyad and Its Differentiating Effect on Treatment Outcomes in Patients with Adjustment Disorders
Prusiński, T. (2023) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-023-09591-w · Cited by 4 · see citing works
“The WAI has two versions, completed by the patient (WAI-PA) and by the psychotherapist (WAI-PT).”
Influential
Therapist in-session feelings predict change in depressive symptoms in interpersonal and brief relational psychotherapy
Falkenström, F., & Holmqvist, R. (2021) · Psychotherapy Research · doi:10.1080/10503307.2021.1998700 · Cited by 4 · see citing works
Development of “LvL UP”, a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disordersPreprint
Castro, Ó. (2022) · doi:10.31219/osf.io/k5cnm · Cited by 4 · see citing works
Differentielle Beziehungsgestaltung in der Verhaltenstherapie: Auf dem Weg zu einer evidenzbasierten individualisierten Beziehungsgestaltung
Bollmann, S., Köhler, S., Guhn, A., Schamong, I., Sterzer, P., & Brakemeier, E. (2021) · Verhaltenstherapie · doi:10.1159/000511640 · Cited by 3 · see citing works
“…und prozesshaften Charakter seines Konstrukts, indem er die Entwicklung der Allianz und ihr Management (Reparatur und Wiederaufbau) durch die unvermeidlichen Belastungen und möglichen Brüche im Verlauf einer Therapie als therapeutische Kernprozesse der Therapie identifiziert [Horvath, 2018].”
Background
Promoting an Empathic Dialectic for Therapeutic Change: An Integrative Review
McIntyre, S. L., & Samstag, L. W. (2021) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-021-09516-5 · Cited by 5 · see citing works
“An essential part of this relationship is the “working alliance,” which has been defined in many ways, and most commonly by the patient and therapist’s bond and their agreement on tasks and goals (Horvath, 2018).”
Background
Therapist's effect on children's therapeutic alliance: A naturalistic study
Casari, L. M., Areas, M., Ison, M. S., Gómez, B., Roussos, A., Consoli, A. J., & Penedo, J. M. G. (2023) · Journal of Clinical Psychology · doi:10.1002/jclp.23606 · Cited by 3 · see citing works
“Close to the Problem” or “Close to Your Problem”? The Contribution of Bond to the Structure of Early and Advanced Therapeutic Alliance
Prusiński, T. (2024) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-024-09633-x · Cited by 3 · see citing works
“The significance of the bond component in the therapeutic alliance has been theoretically substantiated (Bordin, 1979; Horvath, 2018 ), and its presence has been empirically sup - ported many times (Paap et al., 2022 ).”
Influential
The therapeutic alliance in blended versus face-to-face cognitive behavioral therapy for adolescents and young adults with a depressive disorder
van Seters, M. L. F. M., Rasing, S. P. A., Huvenaars, M. J., Vermulst, A. A., Bodden, D. H. M., & Stikkelbroek, Y. A. J. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100776 · Cited by 3 · see citing works
“As stated before, the way the therapeutic alliance is conceptualized is derived from adult literature and criticized in adolescent literature as it is not developmentally complex enough (such as the need for self-reliance) (Horvath, 2018).”
Background
Trafność pomiaru kwestionariuszem Przymierza w Działaniu WAI-PC (wersja dla pacjenta) w psychoterapii systemowej osób dorosłych. Dowody z eksperymentu przeprowadzonego metodą zmian nieprzypadkowych
Prusiński, T. (2021) · Przegląd Psychologiczny · doi:10.31648/pp.7333 · Cited by 3 · see citing works
“Jak dotąd nie ma jednak powszechnie akceptowanej definicji przymierza (Fitzpatrick i in., 2005; Horvath, 2018), choć było wiele prób określenia jego treści i struktury (Cirasola i in., 2020).”
BackgroundInfluential
Bedeutung der Arbeitsallianz für die Psychotherapie
Flückiger, C. (2018) · Zeitschrift für Klinische Psychologie und Psychotherapie · doi:10.1026/1616-3443/a000480 · Cited by 3 · see citing works
Les spécificités de la psychoéducation dans les processus de création de l’alliance thérapeutique
Beaulieu, M. (2024) · Revue de psychoéducation · doi:10.7202/1111113ar · Cited by 2 · see citing works
Evaluation of assessment instruments for working alliance in psychological interventions with adolescents: A systematic review.
Martins, M., Marjanović, Z. J., Ferreira, N., Hancheva, C., Motrico, E., Mestre, J. M., Witte, N. D. D., Halfon, S., Arnfred, S., Henriques, M. R., et al. (2025) · Clinical Psychology Review · doi:10.1016/j.cpr.2025.102586 · Cited by 2 · see citing works
Becoming a Better Person: Empathy, an Implicit Outcome of Professional Education
Stokken, R., Farstad, B., Sørheim, K. L., & Høydalsvik, T. E. L. (2025) · IntechOpen eBooks · doi:10.5772/intechopen.1011426 · Cited by 2 · see citing works
Trajectories of change in the therapeutic alliance during Cognitive Analytic Therapy for depression
Merzhvynska, M., Simmonds‐Buckley, M., Delgadillo, J., & Kellett, S. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12322 · Cited by 2 · see citing works
PSYKOTERAPIFORSKNING GENNEM 100 ÅR – HVOR LANGT ER VI NÅET?
Hougaard, E. (2021) · Psyke & Logos · doi:10.7146/pl.v42i1.128765 · Cited by 3 · see citing works
Exploring therapeutic alliance in spinal cord injury rehabilitation: Control, identity, and liminality
Lovrić, E., Edwards, N., & King, J. (2024) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2024.2443028 · Cited by 2 · see citing works
“In 1940, Sigmund Freud conceptualized the TA as a mutually understood “pact” between therapist and client, lasting only for the duration of the therapeutic relationship (Horvath, 2018; Messiner, 1996).”
The active factor of alliance in psychotherapy: differentiation of therapeutic alliance quality according to the psychotherapist’s theoretical orientation and type of disorder
Prusiński, T. (2022) · Mental Health Review Journal · doi:10.1108/mhrj-12-2021-0091 · Cited by 2 · see citing works
Η θεραπευτική σχέση στην ψυχοδυναμική συμβουλευτική και ψυχοθεραπεία: σύγχρονα κλινικά και εμπειρικά δεδομένα
Yotsidi, V., & Kounenou, K. (2021) · Psychology the Journal of the Hellenic Psychological Society · doi:10.12681/psy_hps.26886 · Cited by 2 · see citing works
Therapieprozesse in der Kinder- und Jugendlichenpsychotherapie
In‐Albon, T., Munsch, S., Vonderlin, E., Kalmar, J., Brodard, F., Flückiger, C., Gutzweiler, R., Kircher, A., & Mander, J. (2021) · Kindheit und Entwicklung · doi:10.1026/0942-5403/a000332 · Cited by 1 · see citing works
Points of departure: A qualitative study exploring relational facilitators and barriers in the first treatment session
Grindheim, Ø. K., Moltu, C., Iversen, V. C., McAleavey, A. A., Tømmervik, K., Govasmark, H., & Brattland, H. (2024) · Psychotherapy Research · doi:10.1080/10503307.2023.2297996 · Cited by 1 · see citing works
“Despite comprehensive research efforts and the abovementioned findings, there is still a lack of clarity concerning how the alliance concept should be operationalized and how different variables associated with therapeutic relationships fit together (Horvath, 2018).”
How Do Transactional Analysis Counsellors and Psychotherapists Use Outcome Measures in TA Diagnosis, Contracting and Treatment Planning: An Interpretative Phenomenological Analysis of a Single Case Study - ‘Joe’
Foote, C. R. (2024) · International Journal of Transactional Analysis Research & Practice · doi:10.29044/v15i2p3 · Cited by 1 · see citing works
Therapeutic Relationship Coding System (TRCS): An Observational Tool for Moment-to-Moment Analysis of the Therapeutic Relationship
Guerrero-Escagedo, M. C., Elvira, A. C., Fernández-Regueras, D., & González, A. L. (2025) · Clínica y Salud · doi:10.5093/clh2025a10 · Cited by 1 · see citing works
How recent psychological distress relates to session quality in psychotherapy: The mediating roles of the real relationship and working alliance
Stefana, A. (2026) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.70049 · Cited by 1 · see citing works
“Furthermore, the predominance of the task dimension resonates with Bordin's (1979, 1994); Horvath (2018) conceptualization of the alliance as comprising goals, tasks, and bond, in which tasks represent the concrete activities required for therapeutic work.”
The Core Components and Instruments of the Therapeutic Relationship in Musculoskeletal Physiotherapy: A Systematic Integrative Review
Puustinen, S., Kvist, T. A., & Stolt, M. (2026) · Musculoskeletal Care · doi:10.1002/msc.70219 · Cited by 1 · see citing works
“However, the TR is considered a broader concept, with alliances positioned within its framework (Gelso 2014; Horvath 2018).”
Routine Outcome Monitoring Within Child and Adolescent Outpatient Psychotherapy
Huth, D., Ertl, S., Schwenck, C., Lindenberg, K., & Kolar, A. D. R. (2026) · Zeitschrift für Klinische Psychologie und Psychotherapie · doi:10.1026/1616-3443/a000859 · Cited by 1 · see citing works
“Common frameworks for conceptualizing therapeutic processes include (1) the therapeutic alliance (e.g., Bordin, 1979; see Horvath, 2018), and (2) mechanisms of change according to Grawe (1997) that have informed the development of several instruments that typically combine patient self-report with…”

The alliance in context: Accomplishments, challenges, and future directions.
Horvath, A. O. (2006) · Psychotherapy: Theory, Research, Practice, Training · doi:10.1037/0033-3204.43.3.258 · Cited by 189 · see citing works
Self-citation
Therapeutic Alliance and Alliance Ruptures and Resolutions: Theoretical Definitions, Assessment Issues, and Research Findings
Lingiardi, V., & Colli, A. (2014) · Springer eBooks · doi:10.1007/978-3-7091-1382-0_16 · Cited by 16 · see citing works
Η θεραπευτική συμμαχία: ορισμοί, αναστοχασμοί και θεραπευτικές προεκτάσεις
Apostopoulou, A., & Giovazolias, T. (2021) · Psychology the Journal of the Hellenic Psychological Society · doi:10.12681/psy_hps.26870 · Cited by 1 · see citing works
Returning to the roots. A Comment on the Paper Alliance in Common Factor Land: A View through the Research Lens
Colli, A. (2011) · Research in Psychotherapy Psychopathology Process and Outcome · doi:10.4081/ripppo.2011.71 · Cited by 1 · see citing works
Psychotherapy Research
Gelo, O. C. G. G., Pritz, A., Rieken, B., Gelo, O. C. G., Alfred, P., & Rieken, B. (2014) · Springer eBooks · doi:10.1007/978-3-7091-1382-0 · Cited by 130 · see citing works

Authors: Horvath, A. O.
Affiliations: Simon Fraser University (CA)
Corresponding author: Horvath, Adam O.
ORCID: Horvath, Adam O.
Venue: Psychotherapy Research
Publisher: Informa UK Limited
Published: 2017-09-13
Volume: 28
Issue: 4
Pages: 499-516
ISSN: 1050-3307 (ISSN-L)
1468-4381
DOI: 10.1080/10503307.2017.1373204
OpenAlex: W2755354210
Cited by: 137
References: 126
Citations by year: 2026: 14 · 2025: 12 · 2024: 12 · 2023: 18 · 2022: 26 · 2021: 24 · 2020: 20 · 2019: 4 · 2018: 6 · 2017: 1
FWCI: 1.30
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: Psychotherapy Research (publishedVersion)
PubMed (publishedVersion)
Funders: Simon Fraser University (90140)
Topics: Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Social Sciences › Psychology › Social Psychology › Counseling Practices and Supervision
Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords: therapeutic relationship, alliance theory, operational definitions, helping relationship
MeSH terms: Therapeutic Alliance, Humans, Psychological Theory

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