The therapeutic relationship (also therapeutic alliance, the helping alliance, or the working alliance) refers to the relationship between a healthcare professional and a client (or patient). It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client.
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Research
While much early work on this variable was generated from a psychodynamic perspective, researchers from other orientations have since investigated this area. It has been found to predict treatment adherence (compliance) and concordance and outcome across a range of client/patient diagnoses and treatment settings. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings. Informal coercion is common, and may be unintentional on the part of the therapist.
In the humanistic approach, Carl Rogers identified a number necessary and sufficient conditions that are required for therapeutic change to take place. These include the three core conditions: congruence, unconditional positive regard and empathy.
Components
In psychoanalysis, the therapeutic relationship has been theorized to consist of three parts: the working alliance, transference/countertransference, and the real relationship. Evidence on each component's unique contribution to outcome has been gathered, as well as evidence on the interaction between components. In contrast to a social relationship, the focus of the therapeutic relationship is on the client's needs and goals.
Transference
The concept of therapeutic relationship was described by Freud (1912) as "friendly affectionate feeling" in the form of positive transference.
Working alliance
Also known as the therapeutic alliance, working alliance is not to be confused with the therapeutic relationship, of which it is theorized to be a component.
The working alliance may be defined as the joining of a client's reasonable side with a therapist's working or analyzing side. Bordin conceptualized the working alliance as consisting of three parts: tasks, goals, and bond.
Tasks are what the therapist and client agree need to be done to reach the client's goals. Goals are what the client hopes to gain from therapy, based on his or her presenting concerns. The bond forms from trust and confidence that the tasks will bring the client closer to his or her goals.
Research on the working alliance suggests that it is a strong predictor of psychotherapy or counseling client outcome. Also, the way in which the working alliance unfolds has been found to be related to client outcomes. Generally, an alliance that experiences a rupture that is repaired is related to better outcomes than an alliance with no ruptures, or an alliance with a rupture that is not repaired. Also, in successful cases of brief therapy, the working alliance has been found to follow a high-low-high pattern over the course of the therapy.
Operationalization and measurement
Several scales have been developed to assess the patient-professional relationship in therapy, including the Working Alliance Inventory (WAI), the Barrett-Lennard Relationship Inventory, and the California Psychotherapy Alliance Scales (CALPAS). The Scale To Assess Relationships (STAR) was specifically developed to measure the therapeutic relationship in community psychiatry, or within care in the community settings.
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