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

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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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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
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
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
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
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
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
“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
“, 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
“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
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
“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
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
“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
“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 5
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
“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
“…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
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
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
“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
“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
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
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
“…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 6
“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
“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 4
“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 4
“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
“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
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 5
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
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
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
PSYKOTERAPIFORSKNING GENNEM 100 ÅR – HVOR LANGT ER VI NÅET?
Hougaard, E. (2021) · Psyke & Logos · doi:10.7146/pl.v42i1.128765 · Cited by 3
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
“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
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
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
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
“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
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
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
“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 2
“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
“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…”

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 › Clinical 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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Research on the alliance: Knowledge in search of a theory

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