The conceptualization and measurement of therapeutic alliance: An empirical review

Clinical Psychology Review 28 (2008) 1167–1187

Contents lists available at ScienceDirect

Clinical Psychology Review

The conceptualization and measurement of therapeutic alliance: An empirical review Rachel Elvins ⁎, Jonathan Green The University of Manchester, UK

a r t i c l e

i n f o

Article history: Received 7 August 2007 Received in revised form 4 April 2008 Accepted 15 April 2008 Keywords: Therapeutic/working/helping alliance Therapeutic relationship Measurement Assessment tool Child and adolescent

a b s t r a c t Therapeutic alliance constitutes a major variable in explaining the outcome of treatment. However, meta-analytic, narrative, and theoretical reviews have all begun to comment on significant deficiencies in both conceptualization and measurement of alliance. While the evidence on the overall impact of alliance on treatment outcomes is impressive, we know much less about its components, modelling and discrete measurement. We review the conceptual and methodological underpinning of current alliance concepts and measures with the aim of identifying the current status of the methods and clarifying the conceptual and measurement tasks ahead. The review makes clear the diversity of concepts and measures available to address treatment alliance; however there is no one current measure of alliance that meets all the predefined criteria in either adult or child populations. We discuss the most successful measures to date, and recommend future developments in the field of alliance, including conceptual and experimental approaches, developmental issues, and analytic techniques. © 2008 Elsevier Ltd. All rights reserved.

Contents 1. 2.

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Introduction — strengths and shortcomings of the alliance concept Conceptualization of alliance . . . . . . . . . . . . . . . . . . 2.1. Genealogy . . . . . . . . . . . . . . . . . . . . . . . 2.2. Measurement of the alliance concept. . . . . . . . . . . 2.3. Developmental aspects . . . . . . . . . . . . . . . . . 2.4. Future developments in the conceptualization of alliance . Analysis of alliance in treatment . . . . . . . . . . . . . . . . 3.1. Rater and method confounds . . . . . . . . . . . . . . 3.2. Criterion validity . . . . . . . . . . . . . . . . . . . . 3.3. Third factor confounds . . . . . . . . . . . . . . . . . 3.4. Therapist versus patient effects . . . . . . . . . . . . . 3.5. Psychometric properties of current alliance measures . . . 3.6. Construct validity . . . . . . . . . . . . . . . . . . . .

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⁎ Corresponding author. Child and Family Psychiatry, Lane Building, Booth Hall Children's Hospital, Charlestown Road, Blackley, M9 7AA, UK. Tel.: +44 1619185024; fax: +44 1619185725. E-mail addresses: [email protected] (R. Elvins), [email protected] (J. Green). 0272-7358/$ – see front matter © 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2008.04.002

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3.7. Discrimination and prediction of therapy effects . . . . . . . 3.8. Future developments in the analysis of alliance in treatment . 4. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction — strengths and shortcomings of the alliance concept Gathering evidence within empirical studies of mental health interventions suggest that the therapeutic alliance constitutes an important variable in explaining the outcome of treatment (Priebe & McCabe, 2006). Meta-analysis of studies in both adult (Martin, Garske, & Davis, 2000) and child (Shirk & Karver, 2003) mental health research have shown a consistent if modest association between measures of therapeutic alliance, and treatment outcome; particularly when alliance is measured at early stages of treatment (Horvath and Symonds, 1991). These, and findings within rigorous trials (Klein et al., 2003, Zuroff & Blatt 2006), have also indicated the consistency of the alliance effect across different types of treatment (Krupnick et al., 1996). Such evidence is consistent with clinician's views (Kazdin, Holland, Crowley, & Breton, 1997), and patient's views (Johansson & Eklund, 2003) describing the therapeutic relationship as a key determinant of treatment success. As trials of complex mental health interventions increase in sophistication, there is now a new emphasis on research designs that include the measurement of treatment processes such as alliance (Green, 2006; Medical Research Council, 2000). However, as this work gathers pace, meta-analytic (Martin et al., 2000; Shirk & Karver, 2003), narrative (Orlinsky & Howard, 1986) and theoretical (Green, 2006; Kazdin & Nock, 2003) reviews have all begun to comment on the significant deficiencies in both conceptualization and measurement of alliance. While evidence on the overall impact of alliance on treatment outcomes is impressive, we know much less about its components, modeling and discrete measurement. More contentiously, it has been recently argued that most of the work on alliance up until the present may be essentially methodologically flawed because it has not taken into account significant confounds in both measurement and causal analysis (Dunn & Bentall, 2007). If the alliance concept is to fulfill its potential as an explanatory variable in more rigorous studies of mental health intervention, it will have to meet these conceptual and measurement challenges. This review addresses therapeutic alliance from this perspective, with the aim of clarifying the conceptual, measurement, and experimental tasks ahead. 2. Conceptualization of alliance 2.1. Genealogy Treatment alliance (TA) is a summary term referring to a number of interpersonal processes at play in psychological treatment which can generally be considered to act in parallel to (and theoretically independently of) specific manualized treatment techniques (Green, 2006). Hypothesis testing and modeling of such effects depends in the end on the robustness of the concepts being measured. The plethora of measures in current use may reflect an uncertainty about this conceptualization. A genealogy of alliance concepts (Fig. 1) can be traced back to Freud's (1912) description of transference and counter transference as key aspects of process and change in psychoanalysis. The core characteristics of a recognizable alliance concept are first clearly seen in Rogers (1965) work in humanistic psychotherapy, highlighting the core notion of the patient's experience of therapist empathy. Anderson (Anderson & Anderson, 1962) began a process of operationalising the concept of empathy and rapport within the ‘therapeutic bond.’ This operationalisation was continued and subjected to early empirical testing by Orlinsky and Howard (1975), who found that aspects of the therapist's credibility as an expert, as well as treatment engagement, predicted therapeutic outcome. They synthesized ideas from these empirical data and previous theory to propose three dimensions of alliance: working alliance (investment of both client and therapist in the process of therapy), empathic resonance, and mutual affirmation (conceptually close to the Rogerian concept of unconditional positive regard). Bordin (1979) further reworked this tripartite division into goal, task and bond, and began to apply the concept generically across different psychotherapeutic modalities (Summers & Barber, 2003). In parallel to Bordin's work, Luborsky (1984) conceptualized a related bipartite division of ‘Type 1’ signs (the patients experience of the therapist as providing the help that is needed) and ‘Type 2’ signs (the patients experience of treatment as a process of working together toward goals). Bordin's inter-treatment studies contained the implicit idea that TA was a generic phenomenon independent of treatment modality. This idea was further amplified by Jerome Frank in his synthesis of the “common active factors” across different forms of psychological treatment: for instance accurate empathy, task understanding, and the badges of office (Frank & Frank, 1991). Here the separation of TA from specific therapy technique becomes more explicit. Frank's work looking at the generic phenomenon of psychological treatment relates in turn to wider conceptualizations, for instance the notion of the generic counseling relationship as a social influence process (Strong, 1968). Other formulations include perspectives on alliance from sociology and emphasis on patient empowerment (Kim, Boren, & Solem, 2001). There has also been more attention to specific alliance issues in young people (Shirk & Saiz, 1992). Perhaps the most persuasive review (Hougaard, 1994) uses available empirical data to further develop a bipartite conceptual structure for TA. This formulation distinguishes the “personal alliance” (covering the interpersonal relationship between client and therapist) and the “task related alliance” (addressing the more contractual aspects of treatment planning and goal orientation)

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Fig. 1. Genealogy of alliance concepts and scales. See Table 1 for expansion of scale acronyms.

(Green, 2006). While this conceptual division seems heuristic and is consistent with previous work, Hougaard emphasizes that the empirical data shows intercorrelation between different dimensions. Such unidimensionality could, however, be amplified by common rater halo effects — and emphasizes the need for more rigorous conceptualization and testing of the models. This conceptual genealogy provides a template against which we can review the different alliance measures that have been developed over time. In turn, data from the measures may illuminate alliance concepts. As alliance becomes more frequently measured and the field expands, a priority will be the refinement of theoretically driven specific alliance measures: clarification of the concepts underlying alliance will be a prerequisite for this. 2.2. Measurement of the alliance concept For purposes of this review, key alliance measurement scales developed or currently in use were identified using a formal search strategy. Embase, Medline, and PsycInfo databases were searched using all key words “therapeutic/working/helping alliance” “therapeutic relationship” “measurement” “assessment tool.” The key word “child and adolescent” was used when looking for specific child related research. Additional studies were sourced from databases using author names known to be eminent or widely published in this field, and through hand searching of meta analyses and other authoritative papers (e.g., Green, 2006; Martin et al., 2000; Shirk & Karver, 2003). Main scales identified were considered in relation to: a) the conceptual basis of the scale and the context in which it was developed; b) construct validity (how the scales were derived, their internal consistency, rater versions, correlations between different subscales and interrater reliability); c) criterion rated or convergent validity (how the results on the instrument relate to an external measure of the same phenomenon); d) discriminant validity (does it adequately discriminate between different groups in an expected way); e) predictive validity of the scale i.e. relationship to outcome and presence or absence of testing against third factor confounds (e.g., baseline symptoms; Tables 1, 2). Consideration of the conceptual genealogy above against measurement instruments (Fig. 1) shows how key measures of alliance were developed alongside specific conceptual reworking of the alliance concept by different groups — and often developed to synthesize (or in some cases test) new theoretical constructs. This, and the lack of emergence of an overall consensus model of alliance, has led to an evident proliferation of measures. No measure has representative items from all parts of the alliance construct over time. Number of items contained in scales varies widely, and the scales purport to measure different alliance

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Table 1 Conceptual structure Measure

Date Concept/Background developed

Description

Barrett-Lennard's relationship inventory (Barrett–Lennard, 1986)

1962

Patient and therapist versions exist. Four scales. Each subscale comprises 16 items rated on a 6-point scale.

Counseling evaluation inventory (CEI) (Linden, Stone & Shertzer, 1965)

1965

Therapy session report scales (TSRS) (Orlinsky and Howard, 1966)

1966 onwards

The counselor rating form (CRF) (Bachelor, 1987)

1975

The Penn alliance scales (Luborsky, 1976)

1976 onwards

Vanderbilt scales (Gomes-Schwartz, 1978)

1978 onwards

Toronto scales (Marziali et al., 1981; Marmar, Horowitz, Weiss, & Marziali, 1986)

1981 onwards

Adult self report. Narrowly conceptualises patients' view of therapists' socio emotive contribution. Perception of extent to which therapist provides Rogerian qualities, including level of regard and empathic understanding. Originally developed for a doctorate and used in the Wisconsin Psychotherapy Project with hospitalised schizophrenic patients. This scale drew on the work of Anderson (Anderson & Anderson, 1962) on the ideal therapeutic relationship and is a measure of the effectiveness of the helping relationship as perceived by the client. Anderson's initial work was on developing a measure of rapport in therapy i.e. the bond element of the alliance It has been used small trials in different populations of adults (anxiety, interpersonal problems and in drug misuse) and with different therapeutic modalities. Derived from empirical studies in adults on the finding that therapist credibility as an expert, as well as engagement, predicted therapeutic outcome. Three dimensions of the therapeutic bond as defined by these authors: working alliance (investment of both client and therapist in the process of therapy), empathic resonance and mutual affirmation (conceptually close to the Rogerian concept of unconditional positive regard). Original trial used 60 female only patients with a variety of diagnoses (mostly neurotic) and 17 therapists in a variety of modalities of therapy, mostly dynamic (the Psychotherapy Session project). From Strong's conceptualization of the counselling relationship as a social influence process, this scale has been used frequently in adult research in counselling. It was developed with clients with a range of anxiety and interpersonal problems and with a variety of therapies and is a rating of the counsellor by the client. Implicitly tests Bordin's concept of the bond in alliance. Broadly measure everything from Hougaard's generic model. The scales were created to empirically test the authors psychodynamic conceptualisation of the helping alliance, measuring both Luborsky's Type 1 signs (the patient's experience of the therapist as providing the help that is needed) and Type 2 signs (the patients experience of treatment as a process of working together toward goals). Over the years, several scales were constructed to test these two elements. The original studies used small samples of out patients with various conditions treated using psychodynamic therapy. From adult psychodynamic therapy. Influenced by the Orlinsky and Howard (1975) self report instrument and combines dynamic and integrative conceptualisations of the alliance. Heavily weighting on alliance contributions from the patient. The original study used 28 college students receiving a range of different therapies for anxiety, depression and interpersonal problems The original VTAS (Hartley & Strupp, 1983), from the same research group was designed specifically to measure alliance. From psychodynamic conceptualisations of the alliance as well as Bordin's integrative model in adult psychotherapy patients. The TAS mainly assesses the attitudinal-affective aspect of the alliance. It was developed from the work of Luborsky and the concepts behind the Penn alliance scales. After combining items from the VPPS, the VTAS and the HAcs, the authors created the TARS which focuses on affective aspects of the alliance rather than on therapist interventions or specific responses. The initial pilot used patients being treated for anxiety with brief dynamic therapy.

The scale is composed of twenty-one 5-point Likert items which measure the three dimensions of the counselling climate, counsellors comfort and clients' satisfaction. It does not measure task or goal elements of the alliance.

Patients and therapists (form P and form T) experiences during therapy. Four dimensions of therapist subjective experience Similarly, four dimensions describe the client's experience.

Thirty six 7-point bipolar items measuring three dimensions of the counsellors' expertness, attractiveness and trustworthiness rated by the client.

A number of different versions exist including patient, therapist and observer scales e.g. the HAr. The Helping Alliance Questionnaire (HAq), a patient self report measure, is the widest used version of this instrument.

VPPS was originally constructed as an 80 item general outcome measure. Eight subscales were derived from these original items. VTAS is a 44 item 6-point Likert scale observer rated instrument designed for individual dynamic therapy, based on ratings of tapes of treatment sessions by trained clinical observers.

TARS has patient, therapist and observer versions and comprises 42 items rated on a 6-point scale.

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Table 1 (continued) (continued) Measure

Date Concept/Background developed

Menninger alliance rating scale or collaboration scale (Allen, Newsom, Gabbard, & Coyne, 1984)

1984

Psychotherapy status report (PSR) (Frank and Gunderson, 1990)

1984

Patient collaboration scale (PCS) (Svensson & Hansson, 1999)

1985

California scales (CALPAS) (Marmar et al., 1989)

1986 onwards

Therapeutic bond scales (TBS) (Saunders et al., 1989)

1989

Working alliance inventory (WAI) 1989 (Horvath and Greenberg, 1989)

Child psychotherapy process measures (CPPM) (Smith-Acuna, Durlak, & Kaspar, 1991)

1991

Child's perception of therapeutic relationship (CPTR) (Kendall, 1994)

1991

Therapeutic alliance scales for children (TASC) (Shirk and Saiz, 1992)

1992

Treatment alliance scales (TAS) (Sarlin, 1992)

1992

An index of adult patient working capacity or “patient collaboration” in Hougaard's theory of the alliance. The authors argue for a narrow alliance conception which does not include other components. Not derived from a particular theoretical framework, but draws on work by Luborsky. Originally used in small study (n=15) adult psychotherapy outpatients with a variety of diagnoses. Adult patients with severe and enduring mental illness. The original trial utilised 143 patients in different types of individual therapy with diagnoses of schizophrenia. The scale was not developed from a particular theoretical background but from a review of clinical and research literature. Specifically designed for adult inpatients to measure aspects of the patients' active participation in treatment goals and tasks. It was developed from the earlier Menninger scale and a clinican rated scale previously developed by the same authors, and focuses on the collaboration of the patient. Working relationships (based on Luborsky's work) were also rated separately by patients and staff. 107 long term patients (mostly with personality disorder or psychotic illness) were studied in the original trial in “milieu” therapy. Primarily from a psychodynamic point of view and empirical results of older alliance measures in adult populations. Earlier scales were based on the TARS. Large samples of patients consulting in mostly in private practice with various disorders were used in studies developing the scales. Based on Orlinsky and Howard's generic model of psychotherapy. In addition, the TBS provides a Global Bond Scale which is a composite of the three subscales. Original study used 113 psychodynamic psychotherapy outpatients at a university hospital. Designed to measure the three dimensions of Bordin's working alliance concept in adults across all types of therapy. The original three trials used small groups of patients with various diagnoses representing a broad range of therapeutic modalities. A couples version of the WAI has recently been devised (Symonds & Horvath, 2004). Adapted selected scales from the Orlinsky and Howard (1975) adult self report measures to assess the process of individual child psychotherapy. The original trial used 20 children between 6 and 12 in long term individual therapy with a variety of externalising or internalising disorders. Primarily assesses the bond alliance dimension of Bordin. It was not developed from a particular theoretical standpoint but derives from the early work on process factors in adult therapy of Hadley and Strupp. Used in trials of CBT for children. Conceptually based on the work of Bordin. Assesses the bond alliance dimension between the child and therapist. First study with the scales was conducted with a sample of 62 children between 7 and 12 who were referred for inpatient psychiatric treatment at a regional paediatric hospital. The prevailing treatment orientation was psychodynamic. This scale draws on the work of Sarlin and was developed to assess the treatment alliance between families of children with asthma and their physician. Little data is available on the theoretical background as it comes from an unpublished dissertation. It has been used in moderately sized trials with adolescent patients in medical clinics.

Description One factor (collaboration) five point anchored rating scale. Observer rated scale only.

It contains only therapist reported five point Likert rating scales, The scale includes six items pertaining to patients in therapy behaviours which relate to bond, task and goal elements of alliance.

Twelve self report items using a five point Likert scale were developed plus a global rating of the patients own perception of their relationship with the therapist. Staff also rated working relationship.

Patient, therapist and rater versions exist. The 30 item rater version has 5 subscales

Twenty-one point system in client and observer versions.

The authors devised patient, therapist and observer versions of the scales in a 36 item 7-point Likert type scale and also in a shorter 12 item version.

The scales assess four dimensions of therapist subjective experience as above, and four dimensions describe the child's subjective experience. The authors eliminated some subscale items and the entire client's goal scale, which they felt represented complex cognitive emotional concepts not suitable for children. It is a patient - only measure. Seven item 5-point scale. Four items relate to the child wanting to spend time with the therapist. Three items refer to the closeness and quality of the therapeutic relationship. Eight item measure written in parallel forms for the child and the therapist The scales were named “bond”, “negativity” and “collaboration with task”.

Physician, patient and parent versions exist. Questionnaire includes two sub scales. Goal alliance includes seven questions assessing elements of the goal and bond alliance. The adolescent and parent versions parallel the physician versions. However, it only includes only one seven item scale goal alliance measuring sense of shared goals. Subjects respond to these items using the five point Likert type scale. The second physician scale is treatment defeating, which includes five items that measure how much the (continued on next page)

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Table 1 (continued) (continued) Measure

Date Concept/Background developed

Adapted psychotherapy process inventory (PPI) (Gorin, 1993)

1993

Adolescent working alliance inventory (AWAI) (Di Giuseppe et al., 1996; Florsheim et al., 2000)

1993

Helping alliance scales (HAS) (Priebe & Gruyters, 1993)

1993

Empathy and understanding questionnaire (EUQ) (Green et al., 2001)/ family engagement questionnaire (FEQ) (Kroll & Green, 1997)

1996, 2001

Barriers to treatment participation scale (Kazdin et al., 1997)

1997

Therapist alliance focus scale (TAFS) (Molinaro, 1998)

1997

Adolescent therapeutic alliance scale (ATAS) (Johnson et al. 1998)

1998

Description

patient engages in behaviours that undermine the treatment relationship. Baer et al. (1980) developed the original scale to measure Therapist report. Only two of the five point subscales process by therapists. It was adapted here for use in child were used here to measure alliance specifically. 1) populations. It was developed from previous literature Client participation and 2) therapist directive on process measures in psychotherapy, not specifically support. This implicitly tests the goal and task elements of the alliance. in alliance work. This trial used 31 children from five outpatient centres, average age of 11, homogeneous with regard to diagnosis (adjustment disorder). As above. Several adequately sized (e.g. n = 90) studies have used the patient report measure of the WAI in adolescents (the AWAI), adapting it in a minor way for use in this population, for example by rewriting the items to reflect the reading level of a younger audience e.g. adolescents aged 11 to 18 years. Original therapists form also used. Adult self report. Narrowly conceptualises patient's view Patient version only. Five scales plus a Helping Alliance sum score. Answers to the questions were of case manager's understanding, involvement and patient's feeling after the session. Originally developed self rated on a visual analogue scale. The scales have for use in case management for patients with severe and the characteristics of an eleven point rating scale. chronic mental illness in the community. Uses concepts from Frank, Bordin and Hougaard for FEQ - dimensions of the child's relationship with their peer group, staff and orientation towards therapeutic use in outpatient and inpatient CAMHS treatment activities; there are also items relating to the parental research. FEQ is designed for child psychiatry relationship with staff and engagement with tasks, the inpatients. It was initially used in a heterogeneous total set of items numbering 20. Each item was rated on a adolescent inpatient population; The scale was four point visual analogue scale with typical descriptors conceived with reference to literature in adult populations and scarcer literature in adolescents as at each point. EUQ (Green et al., 2001) is rated in separate forms by both the child and parents self report. Covers well as clinicians clinical experience. EUQ was understanding of the treatment rationale, experience of developed by the same research team from instruments used in a study of outpatient treatment empathy from staff and accuracy of the empathy (how well they felt their real problems were understood), with different disorders and treatment rationales. subjects sense of collaboration with the treatment process. Ratings are on a four point Likert scale. The therapist also rated their own empathic contributions and made a prediction of the families responses. Six item sub scale Parent and therapist versions of Not strictly an alliance measure but includes a six the BTPS were developed. Designed as an interview item subscale that evaluates parent's alliance and of 58 items which could be administered in person bonding with the therapist including liking of, or by telephone. perceived support from and disclosure with the therapist. It does not strictly include task or goal elements of the alliance. Child psychotherapy scale was developed in order to understand who drops out of treatment and why. The goal was to evaluate experiences and perceptions of the family during treatment that predict drop out. The conceptual view underlying the development of the measure proposes that families experience multiple barriers that impede participation in treatment. Developed to measure how much individual session A 41 item measure was derived. time therapists spend discussing alliance related issues in adult treatment as well as other aspects of the alliance. The client population and therapeutic modality is not described. Observer rated instrument final scale consisted of 14 Measure salient dimensions of the therapist — items rated on a 6 point Likert scale split into Patient adolescent working relationship in any type of counselling situation. The VTAS was used as starting Contribution and Patient – Therapist Contribution point (Faw et al., 2005) chosen as it most adequately subscales with each item reflecting the bond, task or described Bordin's conceptualisation of the alliance. goal component of the alliance. Revised the scale to make it developmentally appropriate and to make it suitable for a small (n = 51) preventative study (in substance misusing youth). Eliminates the therapist contribution scale in order, the authors' state, to distinguish between therapist techniques and the client's participation in the alliance (Diamond et al., 1999). Some items were modified to more readily relate to adolescents and their families. Additional items were deleted or revised to make the ATAS applicable to any type of counselling situation.

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Table 1 (continued) (continued) Measure

Date Concept/Background developed

Description

Agnew relationship measure (ARM) (Agnew Davies, Stiles, Hardy, Barkam, & Shapiro, 1998)

1998

ARM has five scales comprising 28 items The five scales were bond, partnership, confidence, openness, and client initiative. Parallel forms were created for clients and therapists but no observer form of the instrument exists.

Child psychotherapy process 1999 scales (CPPS) (Estrada and Russell, 1999)

Family therapy alliance scale (FTAS) (Pinsof, 1999)

1999

Early adolescent therapeutic alliance scale (EATAS) (Johnson, 2001).

2000

Kim alliance scale (Kim et al., 2001)

2001

System for observing family therapy alliances (SOFTA) (www.softa-soatif.net) (Friedlander et al., 2006)

2001

The therapy process observational coding system — alliance scale (TPOCS) (McLeod & Weisz, 2005)

2005

Scale to assess therapeutic relationship 2007 (STAR) (McGuire-Snieckus, McCabe, Catty, Hanson, & Priebe, 2007).

Intended to balance broad coverage of previously identified aspects of the alliance with clarity and for use across a range of therapeutic modalities. It was developed using a mixed theoretical–empirical strategy, with items constructed to encompass scale content from previous measures, including the WAI and the CALPAS. Developed for Sheffield psychotherapy project, a randomised comparison of CBT and psychodynamic therapies for depression (n=95). From child psychodynamic therapy. Derived some items from the VPPS and additional items were generated from experienced child psychologists. Primarily assesses task and goal alliance dimensions. The participants of the study were a small group of 13 children between 6 and 12 years with various diagnoses, receiving long term individual therapy. Based on Bordin's conceptualization of the alliance. It has two dimensions, content and interpersonal system. Developed for use within family therapy from qualitative research on client's perception in family therapy (Pinsof & Catherall, 1986). Based on Bordin's definition of alliance and was written to reflect the developmental level of early adolescent clients at risk from substance misuse. No detail is given as to how the scale was derived, as it is an unpublished dissertation. Fifty-four early adolescent clients in a preventive based therapy. Measures the quality of the therapeutic relationship from the adult patient's perspective in general medicine as well as psychotherapy, including “patient empowerment” which the authors define as a fourth element of the alliance, along with the original three elements defined by Bordin. They define this as “the patient becoming more responsible for his own care and more involved in making choices”. Initially trialled using a small sample of nurses evaluating alliance with their own healthcare providers. Observational rating system developed for rating client behaviour in couple and family therapy. Aims to conceptualise Bordin's model plus evidence from qualitative research in family therapy.

Objective observers 33 item scale on a 5-point Likert-type scale.

40 seven point Likert items define a total score, 7 scales and 12 subscales. The FTASR only differs from the original FTAS by the addition of four within system subscales. Observer rated measure

Total of 60 items in 4 dimensions, with 15 items in each dimension on a 4-point Likert scale was chosen by the authors for the initial draft of the scale. The resulting scale was a 48 item self report measure.

Uses frequency of the behavioural items to rate underlying alliance dimensions similar to the counting signs method for the observer Penn Scales. From videotapes, raters record instances of 44 specific behaviours, negative as well as positive. This data is then used to make global ratings on each dimension. Each family member is rated on a continuum and the family unit is rated on shared purpose. The scale uses session observation by independent Novel tool used in one small study examining outcomes in child treatment as usual, with a variety observers. The final version consisted of eight bond items and six task items, rated on a six point Likert of therapeutic modalities for youths with internalising disorders. Assesses child-therapist and scale. parent-therapist alliance and aims to assess both bond and task dimensions of the alliance as described by Shirk and Saiz as important in child therapy (Shirk & Saiz, 1992). Twenty-two participants were drawn from community mental health clinics in the USA participating in the Youth Anxiety and Depression Study. The scale was not developed from a particular theoretical background but created by combining several described scales including the VTAS, CPPS, CPTR and TASC. This scale was developed for use with adult patients Patient and clinician scales exist. Each have 12 items comprising 3 subscales: positive collaboration, with severe and enduring mental illness in positive clinician input, non supportive clinician in the community settings. The scale focuses on the goal and bond aspects of the alliance. It has been used in patient version and emotional difficulties in the clinician version. one large prospective study in community mental healthcare. It draws on ideas from the Working Alliance Inventory, the Helping Alliance Scale and the Barrett Leonard Relationship Inventory and was designed specifically for severe and enduring mental illness.

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Table 2 Validation studies Measure

Construct validity

Criterion validity

Key studies involving predictive and discriminant validity

Comments

Barrett-Lennard's relationship inventory.

Blatt, Zuroff, Quinlan & Pilkonis (1996) found that the four scales of the BLRI formed a single factor and summed scores on the three high loading scales: Empathy, Level of Regard and Congruence. Cronbach's alpha for the composite items was 0.95. The subscales demonstrate high levels of retest reliability, as does the total score (0.87). Devised by asking counselling psychologists and clients to rate items The subscales have been shown to be highly interrelated. The scale is reported as having adequate test–retest reliability (0.83).

In a large randomised clinical trial of outcome of depression in adults (Blatt et al., 1996), BLRI and VTAS both used. Results suggested some convergent validity of the BLRI.

The scales have been used in a large number of outcome trials, in individual, couple and family therapy. One trial controlled for third factor confounders.

Narrow definition may decrease the utility of the measure in describing alliance. Self report only. Good validity data. Widely used.

Convergent validity with the counselor rating form (Bachelor, 1987).

Not triangulated. Needs use in robust outcome studies.

Each group of scales in the TSR were factor analysed - 11 patient factors and 11 therapist factors and 7 dimensions of conjoint experience. Demonstrated adequate internal consistency and inter rater reliability. Four experts agreed on descriptive adjectives which comprised the scale. Twenty-two descriptors yielded 100% agreement. The scale was factor analysed using varimax rotation. Adequate internal consistency has been demonstrated (0.85–0.91). Internal consistency (0.93) and interrater reliabilities for individual items of the therapist and observer scales are acceptable. User friendly global rating method (HAr) used with the observer forms of the scales. HAq recently revised into shorter versions, to minimise confounding the measure with patient outcomes. Research with different groups of adolescent patients has revealed a high level of internal consistency.

No data found.

Used small trials in different populations of adults (anxiety, interpersonal problems and in drug misuse) and with different therapeutic modalities. One small non random trial showed it to predict outcome in adults (Bachelor, 1987). The study did not correlate alliance with outcome

It is reported as having convergent validity with the Counseling Evaluation Inventory.

The form has been shown to discriminate within and between counsellors, discriminant validity in trials with adults and children. Predicts outcome in small non random trials with adults (Bachelor, 1987).

Not triangulated. Needs use in robust outcome studies.

There is less convergent validity when compared with other measurements of alliance, than for example between the WAI and CALPAS.

Devised to measure all aspects of alliance. Well triangulated measure. Less robust convergent validity. Used widely. Used in child groups.

VPPS Subscales derived from principal components analysis with varimax rotation. VPPS: Adequate levels of both internal consistency (0.96–0.82) and interrater reliability (0.94–0.79) were obtained for all subscales. Factor analysis conducted on the two scales found that the VPPS and the VTAS had similar factor structures; therefore VTAS is preferred global alliance scale. The scale has demonstrated solid interrater reliability, internal consistency (Krupnick et al., 1996). Scale was developed through consensus of four raters. It has shown adequate internal consistencies in a small trial comparing therapy completers with those who dropped out.

VTAS: convergent validity with other common alliance measures in several studies (Krupnick et al., 1996).

The Penn scales, particularly patient report versions, have been shown to correlate with outcome in several studies (Martin et al., 2000). However did not include third factor confounders. Discriminant validity has been demonstrated in trials using different groups of patients and therapy. A recent revised version of the HAQ in French (Le Bloch et al., 2006) has demonstrated prediction of outcome independently of pretreatment characteristics such as severity of illness Predictive validity has been demonstrated with a modified VTAS (deleting the items specific to dynamic therapy), used in a large rigorous study in the USA which found that patient alliance was more predictive of outcome than the therapists alliance (Krupnick et al., 1996). Further reports from this study illustrate control for third factor confounders.

Counseling evaluation inventory

Therapy session report scales

The counselor rating form

The Penn alliance scales

Vanderbilt scales

Toronto scales

The self report version of the TARS has demonstrated convergent validity with self report versions of the Penn scales and VPPS (Stiles et al., 2002).

Less robust validity data. No observer form. Used to develop more robust scales.

Combines concepts of alliance to improve utility. Good validity data. Used in several robust trials. Observer rated. Widely used. Adapted for child groups.

Adequate discriminant validity in a Well triangulated. Focuses on bond element of alliance. Less small trial comparing therapy robust validity data. completers with those who dropped out. Martin et al.'s recent meta analysis (2000) suggests that the TARS has failed to demonstrate adequate validity across studies.

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Table 2 (continued) (continued) Measure

Construct validity

Criterion validity

Key studies involving predictive and discriminant validity

Comments

Menninger alliance rating scale or collaboration scale (Allen et al., 1984) Psychotherapy status report

Interrater reliabilities reported as from 0.60 to 0.79 for the subscales Internal consistencies 0.87 to 0.96. Collaboration and patient experience highly correlated. Significant correlations (0.59, p = b 0.01) between the six scales were found and so the authors combined them to form a single measure “active alliance”. High internal consistency (0.89) and good test–retest reliability over a three month period (average r = 0.72) have been reported.

No trials found.

Some evidence for discriminant validity in original trial. Not used widely. No outcome trials found.

Narrow concept of alliance. Lack of validity data. Observer rated.

An attempt to validate the scale was done through comparing it with similar set of tape based ratings of engagement.

No observer report. Good validity data. Little evidence for discriminant validity in non psychotic patient groups

Patient collaboration scale

No data. Scale was factor analysed using varimax rotation, giving three factors, “goal orientation”, “Involvement” and “use of structure”. The internal consistency of the overall measure has been reported as acceptable (0.76). Test retest reliability has been reported as adequate.

California scales

Some confirmation from factor analysis for four factors of CALPAS. Internal consistencies reported for the older subscales (0.94 – 0.76) that are highly similar to the CALPAS subscales, are acceptable. 0.84 reported for the whole patient scale. Inter rater reliabilities for subscales range from marginally acceptable (0.62–0.49) to unsatisfactory (0.25– 0.19. High intercorrelations between subscales — total score used as a global measure. Created by extracting items from the Therapy Session Report (see above) by consensus between the three authors. Internal reliabilities of each subscale and global scale have been reported as adequate (0.62–0.87). Two of the scales failed to correlate (WA and ER), indicating that they are measuring different aspects of alliance. The item pool was rated for construct validity by seven experts in the field of alliance. WAI-P alpha is 0.93 for the full scale and range from 0.85 to 0.88 for the subscales, which are also found to be highly intercorrelated (0.69–.92) (Horvath & Greenberg, 1989). The observer version of the WAI has high internal consistency (0.98) and interrater reliability. There is strong support for the WAIs reliability (0.85–0.93). Several studies have adopted an abbreviated version of this scale (Tracey & Kokotovic, 1989),

Alliance as measured by the scale has been shown to be correlated with outcome in two trials in this group of patients. Third factor variables such as social and vocational adjustment, social class and previous psychotherapy treatment were controlled for in the original trial (Frank & Gunderson, 1990). In a further trial, pretreatment scores on the GAF were controlled for. The scale positively correlated with patients ratings of their own progress. Six items of the scale, measuring task collaboration, have been used in one small outcome trial of cognitive therapy with psychotic drug resistant inpatients and were shown to be negatively correlated with outcome. The authors postulate that the nature of the alliance may be different for patients with a psychotic illness and that those with a good alliance will report more symptoms. A shortened version of the patient CALPAS has been demonstrated to have similar psychometric properties and has been used in outcome trials which measure the effects of alliance against third factor confounds (Barber et al., 2000; Muran et al., 1995). Evidence for discriminant validity in wide range of subjects and modalities used in trials.

Therapeutic bond scales

Working alliance inventory (WAI)

The original study reports adequate criterion related validity data, computing correlations or ANOVA between the patient version and criterion variables and social desirability scores. The CALPAS has shown high convergent validity with the WAI.

No observer form. Needs use in other patient groups for discriminant validity data. No convergent validity data found.

Well triangulated. Good validity data. Total score often used as high intercorrelations between scales? Construct validity not robust?

There is no data from the authors on convergent validity of this scale with others.

Limited validity data. No All scales correlated with session observer form. quality as measured by patients, but only the global scale was correlated with observer ratings of outcome at termination of treatment. Limited outcome research.

Observer version correlates highly with other measures such as CALPAS and VTAS (see below) but more moderately with the Penn alliance scale.

Correlates with a variety of outcome indices (Horvath, 1994). It has been used in several robust outcome trials, including those with account for prior change and patient characteristics (Klein et al., 2003). Evidence for discriminant validity is provided by its use in a large number of different populations with different levels of alliance (Raue et al., 1993; Samstag et al., 1998). Has also been used as a measure of parent–therapist alliance in one outcome study (Kazdin, 2006).

Well triangulated measure. Widely used. Good validity data. Adapted scale used in children.

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Table 2 (continued) (continued) Measure

Construct validity

Criterion validity

Child psychotherapy process measures

particularly utilising the patient report form. No data. Resulting scales demonstrated adequate internal consistency (N 0.60), with no significant correlations between therapist and child subscales.

Key studies involving predictive and discriminant validity

Comments

The scales have not been used in outcome studies and there are no validity data available.

Criticised because the referents for the child's rating of affect were unclear. Unclear whether the reported feelings resulted from therapy content or reflected the child's experience of the therapeutic relationship. Robust validity data not available. Primarily assesses bond only. Self report only. Less robust outcome data.

Used in two small (n b 50) randomised trials of CBT for childhood anxiety. Found minimal associations between alliance and outcome in the first study, in part because of limited variability in alliance scores that were highly positive. The scores correlated with parents perception of gains within therapy however (Kendall, 1994). No observer form. Assesses The Menninger Collaboration No information was found about Items from experienced child Therapeutic Scale was used in this study as the scales use in predictive validity primarily bond aspect of the psychologists and psychiatrists alliance scales alliance only. Needs use in trials. a measure of convergence. Both therapist and child scales for children outcome trials to gain yielded adequate levels of internal predictive validity data. Easy consistency (0.88–0.67). to administer to young Demonstrated adequate interrater children. reliability. No observer form. Needs No data found. One moderate sized study. This Treatment The physician scale has adequate further use in more robust study correlated physician alliance scales internal consistency (alpha = 0.95 outcome studies. Specifically reported goal alliance with and 0.77) as do the adolescent and concurrent family functioning and developed for physically parent versions. No interrater unwell children which may asthma medication adherence. reliability data are available. limit its applicability. Several third factor confounders were accounted for including gender and ethnicity. Less significant associations were found using the adolescents' and parents' ratings of treatment alliance. There is no measure of Evidence for discriminant validity Not triangulated. Not Reported as having high factorial Adapted conceptualised specifically for convergent validity in this trial. is given by its use in different psychotherapy process validity, internal consistency and alliance but has been used to populations. The strongest interrater reliability. 1) Client inventory predictor of outcome was score on measure alliance. Not widely participation (16 items, internal the client participation scale. Third used. consistency of 0.92 and interrater variable confounders were not reliability of 0.76) and 2) therapist taken into account. directive support (eight items, internal consistency of 0.83, interrater reliability of 0.88). The AWAI demonstrated adequate Not specifically tested in this As above. Outcome trials not Adolescent Wider use would provide internal consistency (N 0.90) in the group but likely to be as working alliance more validity data. Patient specifically in this age group but sample and factor analysis yielded above. inventory report measure only. some support for discriminant one large factor, a general alliance validity from use in different trials factor. (Di Giuseppe et al., 1996; Tracey & Kokotovic, 1989). Narrow definition may No data found. The original trial correlated Helping alliance Little information is given on the decrease utility of the Helping Alliance with scales (HAS) derivation of the aspects of the measure in describing hospitalization during the follow Helping Alliance. No data was alliance. Patient report only. up period and indicated a better given on internal consistency or Limited validity data. Needs outcome for patients who interrater reliability. use in robust outcome experienced the Helping Alliance more positively. However the trial studies. did not control for all third factor confounders. The scale has been used subsequently in moderate sized studies of medication compliance in patients with severe and enduring mental illness. Family A factor analysis of the FEQ from 80 Criterion validity was FEQ — adequate discriminant FEQ — used only in inpatient engagement families spanning 5 child and assessed by using correlations validity. Predictive validity — used in populations. No observer Child's perception of therapeutic relationship.

The scale shows adequate internal consistency and reliability limited construct validity in terms of the concept of alliance as a whole.

No data found.

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Table 2 (continued) (continued) Measure

Construct validity

questionnaire/ empathy and understanding questionnaire

between the FEQ and the adolescent units indicated three clinician rating of alliance. child alliance (general child alliance, child confiding and child hostility) and two parental alliance factors (parental engagement and parental hostility). This was replicated in a further national study. Encouraging interrater reliability and consistency data have been published. EUQ — initial psychometric properties of the measure were reported as adequate.

Barriers to treatment participation scale

The scale was developed through focus group discussion with therapists, rather than with service users. Factor analysis showed that barriers were better represented by one general factor so that the total score was used to represent the scale. Published data provides evidence for internal consistency (0.86).

Relation between perceived barriers and measures of participation in treatment provides evidence for convergent validity.

Therapist alliance focus scale

Developed for a PhD dissertation by a series of sequential ratings and evaluations of the initial item pool from 4 alliance experts and 37 doctoral level psychologists. Results suggest good internal consistency and but figures are not reported. No inter rater reliability data were given. Factor analysis did not confirm three predicted dimensions of bond and goal/ task agreement of the scale. Data are not available as unpublished dissertation. Interrater reliability of 0.74 and Cronbach's coefficient alpha of 0.90. Factor analysis suggested that a one factor solution was most appropriate, suggesting that the ATAS measures one construct.

Mixed convergent validity results no data available.

ATAS

Agnew relationship measure

Child psychotherapy process scales

Refined through iteration, administering to therapy dyads and through factor analysis. Intercorrelations on some of the scales were high, however. One of the subscales was reported as having low internal consistency (client initiative alpha of 0.55). Principal components analysis. Internal consistencies and reliability were adequate for most

Criterion validity

Convergent validity with a “therapist rating of engagement” was shown, but testing against a different validated tool was not done.

A subsequent study found that the ARM's core alliance scales were correlated strongly or moderately with the WAI (Stiles et al., 2002).

No data.

Key studies involving predictive and discriminant validity

Comments

one prospective cohort study which suggested that alliance as measured by the FEQ was the strongest predictor of treatment change during admission and into six month follow up (Green et al., 2001). EUQ — parents views of the alliance as measured by the scale correlated with parental report of outcome. The scale has been used in a small (n = 55) sample outcome trial in adolescence where parents views of the alliance correlate less strongly with outcome than the child's (Green et al., 2001). The scale has not been widely used. A meta analysis (Shirk & Karver, 2003) estimated a moderate effect size of the alliance upon outcome (r = 0.58) as measured in this study. Families high on perceived barriers were more likely to drop out of treatment, consistent across both forms of the scale, and accounting for other family factors known to be associated with drop out. Low correlations between perceived barriers and other measures provides evidence of discriminant validity for the scale The scale was used in a subsequent outcome study by the same lead author. Discriminant validity was demonstrated by the absence of a significant positive correlation between therapist focus on alliance issues and a measure of social desirability. No outcome data.

form. Good validity data. Neither scale has been widely used.

Studies give mixed results of the effect of patient–therapist alliance in family therapy on outcome One moderate size adolescent sample recent outcome study used early treatment sessions to help minimise a potential confound between alliance scores and symptom improvement over the course of therapy. Predictive validity of the revised scale was demonstrated in this population. The ARM has not been studied extensively, but one small study of adults with depression using CBT and psychodynamic therapy, broadly confirmed the positive association of alliance with treatment outcomes.

Needs wider use to improve validity data. Good utility (as for VTAS).

Moderate associations found with aspects of the alliance in child process research, such as therapy

Designed as interview — open to reporting bias. No child report. Conceptual model not critically evaluated in the original study. Narrow concept of alliance — bond only.

Not triangulated. Needs use in robust outcome trials. Unpublished dissertation so difficult to evaluate as data not available.

No observer form. Needs use in robust outcome trials. Less robust construct validity.

Observer form. Not widely used in other patient groups. Small sample trial. (continued (continued on on next next page) page)

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Construct validity

Criterion validity

factors identified, but not for all of them (e.g. alpha = 0.82 to 0.49). However, the authors recognise this and suggest how they could improve consistency by adding further items.

bond and treatment involvement Evaluated these in relation to outcome. Not been utilised in subsequent rigorous studies by other authors. Discriminant validity of the scale was demonstrated by differentiating high quality from low quality sessions on the basis of CPPS ratings (differences between two and three standard deviations). Data no available. A recent descriptive study suggests that the within system alliance was highly salient for participants and correlated with their measure of outcome. Adequate convergent validity. No strong evidence for other types of validity was found, in particular no relationship was found between the scale and outcome. The scale has not been used by Convergent validity was other authors in more rigorous assessed by comparing the studies or in outcome research. scale with the Agnew Relationship Measure with which it was highly correlated, but the authors could have chosen a more widely used scale such as the WAI.

Family therapy alliance scale

No psychometric data had been published on the FTASR but the original measure has high internal consistency reliability.

Early adolescent therapeutic alliance scale

Adequate reliability reported. Figures not reported.

Kim alliance scale

Formed by inductive triangulation from a qualitative study and formation of a subsequent conceptual schema. Panel members consisted of 11 nurses undertaking higher degrees. Content validity index (CVI) was used to categorise extent of agreement (Waltz, Strickland & Lenz, 1991). Factor analysis was used to assess construct validity. This resulted in a 30 item scale across four dimensions. Internal consistencies of the subscales and the total score were reported as adequate (0.71 to 0.94) Split half reliability was also adequate. Items were subject to a cluster factor analysis. Reliability ranged from 0.72 to 0.95.

System for observing family therapy alliances (SOFTA)

The therapy process observational coding system — alliance scale

Scale to assess therapeutic relationship (STAR)

The HAQ and WAI couples version suggest some convergent validity with some elements of the SOFTA e.g. shared purpose and engagement in three moderate sized exploratory studies. Reasonable convergent Items from all measures that validity when compared to mapped onto the authors conception of bond and task alliance the TASC. However, since it were retained and redundant items was partly developed from this scale, a non related combined. Clinicians from the measure of alliance should University of California were then have been selected. asked to comment on the items. Both bond and task scales showed marginally acceptable interrater reliability (at least 0.4), good internal consistency (0.79–0.91). No data found. Item pools were generated and reduced through principal components analysis with very max rotation. Clinicians involved in generating and testing the item pool were from a multidisciplinary background. Items for subscales were selected on the basis of internal consistency and predicted validity for the subscale score. Data was reported as adequate. The test retest reliability for all items ranged

Key studies involving predictive and discriminant validity

Comments

Needs use in robust outcome studies. Self report only.

Observer rated. No discriminant or predictive validity data. Not validated with patient groups. Conceptualises “empowerment” as being part of alliance — not widely accepted. Client report only. Less robust validity data.

There were variable relationships with outcome in these studies.

Encouraging psychometric data needs use in robust outcome studies observer scale.

When applied to cases treated for internalising disorders, alliance as measured by both forms of the scale was associated with youth outcomes. The findings held up well after confounding variables were controlled for.

Uses independent observers. Good predictive validity data in one group of patients only. Needs more robust convergent validity.

The scales were tested in two separate groups of patients. The scale has not yet been used in robust outcome trials.

The authors state that new items not covered by established scales are identified including clinician helpfulness, patient aggression and family interference. These ideas may not be widely accepted as delineating alliance. However, no observer version. Needs use in robust outcome trials.

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dimensions. Furthermore the conceptual subscales proposed by developers of measures do not necessarily reflect item factors. For instance, a critical conceptual review of Working Alliance Inventory (WAI) (Horvath & Greenberg, 1989), California Psychotherapy Alliance Scales (CALPAS) (Marmar, Weiss & Gaston, 1989) and Penn Helping Alliance Scales (specifically the Helping Alliance Questionnaire — HAq) (Luborsky, 1976) undertaken by Hatcher and Barends (1996) found six factors common to these scales; (confident collaboration, goals and tasks, bond, idealised relationship, dedicated patient and help received) — but these bore little systematic relation to the a priori conceptual subscales proposed by the developers of the measures. Hatcher and Barends consider the HAq too general and non-specific to distinguish important aspects of the alliance. They argue for a broader conceptualization of alliance, reflecting more of the affective, and interpersonal aspects of the bond. The WAI has conceptual roots in the first generic synthesis of an alliance construct by Bordin. It reflects well the ‘common contributions’ component of a generic alliance concept. Many items in the WAI ‘bond’ scale represent therapist contributions to the personal relationship and the bond scale has been found to correlate highly with therapist empathy as measured by the BarrettLennard Relationship Inventory (BLRI) (Barrett-Lennard, 1986). The WAI less well represents concepts of patient working capacity and motivation; the item factors do not reflect the dynamic purposive mutual work central to Bordin's theory (Hatcher & Barends, 1996). The conceptual focus of the CALPAS subscales is primarily on individual patient and therapist contributions to the alliance, although its actual questions most consistently reflect purposive mutual work between them. The CALPAS and the Vanderbilt scales (Gomes-Schwartz, 1978) reflect well the affective and interpersonal aspects of the alliance bond (Hatcher & Barends, 1996). The Vanderbilt scales, particularly the Vanderbilt Psychotherapy Process Scales (VPPS), influenced by Orlinsky and Howard's work, focus on the patient and patient-therapist aspects of alliance rather than the therapist rated aspects. Most of the scales of the VPPS factor onto one main component of generic alliance. It has no items to cover purposive mutual work or “common contributions” components. The Penn scales are conceptually closest to Hougaard's 1994 generic model. Scales that attempt to measure specific theoretical conceptualisations of the alliance in adult populations, such as the Penn, WAI, CALPAS and Therapeutic Bond Scales (TBS) (Saunders, Howard, & Orlinsky, 1989) can be distinguished from those that measure a blend of alliance constructs, such as Vanderbilt Therapeutic Alliance Scales (VTAS) and Therapeutic Alliance Rating Scales (TARS) (Marziali, Marmar & Krupnick, 1981). Di Giuseppe, Linscott, and Jilton (1996) argued that the conceptualization of alliance for children and adolescents needed specific features — but only the Family Engagement Questionnaire (FEQ) (Kroll & Green, 1997) and the Therapeutic Alliance Scales for Children (TASC) (Shirk and Saiz, 1992) have been specifically designed for this population, rather than being adapted from previous scales. Scales widely used in childhood have usually been developed from adult measures such as VTAS, Haq, and WAI. The VTAS measured adolescent alliance with high interrater reliability and internal consistency (Diamond, Liddle, Hogue, & Dakof, 1999), and factor analysis is available in this population (Hogue, Dauber, Stambaugh, Cecero, & Liddle, 2006). One study adapted a measure (the WAI) by lowering the reading level for adolescents aged 11 to 18 years (Di Giuseppe et al., 1996); others adapted a scale for young peoples' use in family therapy (Diamond et al., 1999). There have been few attempts systematically to measure validity of the alliance construct in young people. Some scales adapted or devised for children include parents' ratings (e.g., the FEQ), most do not. Overall, current alliance scales take an empirical and descriptive approach to measuring notional alliance constructs. There has to date been a lack of more experimental approaches to investigate hypotheses about the interpersonal processes underlying alliance, or to testing competing hypotheses about the most potent parts of the relationship for prediction. 2.3. Developmental aspects Research on therapeutic alliance and process measures in research with children and adolescents lags far behind research with adults (Faw, Hogue, Johnson, Diamond, & Liddle, 2005). Division 29 of the American Psychological Association produced a review of empirically supported therapy relationships with adults to determine which relationship variables are evidence based (Norcross, 2002) but omitted research from the child and adolescent field. Relationship variables may be equally, if not more, critical in child and adolescent work, as these clients are typically not self referred, may not be aware of their problems on entering treatment and may be in conflict with their parents or guardians (Karver, Handelsman, Fields, & Bickman, 2005). It follows that a strong therapeutic relationship with a young person may be particularly important. It has been postulated that an alliance for adolescents may be a one-factor phenomenon, as younger patients may fail to discriminate between different aspects of the relationship; failure to establish one aspect of the alliance may result in a failure to establish it entirely (Di Giuseppe et al., 1996). In young dependent populations there are both developmental constraints that can limit a child's comprehension of the experiences of therapy, and structural issues related to parallel child and parent alliances in treatment. Green et al. (2001) have demonstrated that therapist alliances with parents and child do not always correlate and that in some therapy contexts it is the child's perception of the alliance that was most strongly predictive of outcome, rather than the parent's (Green, 2006). This echoes related literature on the differential predictive value of parent and child perceptions of difficulties in other family work, for instance in anorexia nervosa (North, Gowers, & Byram, 1997). A meta-analysis of the methodologically sound studies of alliance in child mental health (Karver et al., 2005; Shirk & Karver, 2003) found an overall modest association with outcome similar to those findings in adults. This was of an equal effect size in prediction to outcome as factors such as chronicity and comorbidity. However, there was an absence of a most commonly used measure, indicating that child process research has yet to unite around a single construct of the alliance (Creed & Kendall, 2005). The only characteristic which seemed to moderate association between alliance and outcome was the child's presenting problem.

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In one study where the alliance was operationalised according to child and therapist in session behaviors, those behaviors indicative of positive involvement in session tasks were associated with enhanced outcome. This suggests that further analysis of in-session behavior by observers may be helpful (Braswell, Kendall, Braith, Carey, & Vye, 1985). 2.4. Future developments in the conceptualization of alliance One task for the future should be a further examination of the conceptual underpinnings of alliance in the light of advances in basic theory, and use experimental designs to see if the most valid concepts can be identified and thus their measurement refined and made more specific. Alliance concepts initially developed in relation to psychotherapeutic interactions. A strong evidence based case has been made however that alliance phenomena represent common factors operating across a variety of therapeutic interventions beyond the classic interpersonal therapeutic encounter: medication management (Krupnick et al., 1996), and even non interpersonal computer aided interventions (Chu et al., 2004) would be examples. These broad contexts therefore challenge measurement – which is still largely based conceptually in its psychotherapeutic roots – to test out more generic concepts. Shirk and Russell (1996) have suggested that theories from developmental psychology and sociology could be applied usefully in refining the conceptualization of alliance processes. Hougaard's (1994) conceptual distinction between personal and task alliance is one example that lends itself to further testable modeling. Within the personal alliance domain, attachment theory presents a strong candidate theoretical model (Green, 2006). Attachment theory formulation is essentially dyadic. It is a prime evidence based theory for interpersonal relating in childhood and adulthood. A theoretical model of therapy based on attachment ideas has been articulated (Bowlby, 1988; Eagle, 2006), which contains much of relevance to alliance constructs in its description of the ‘secure base’ created for the patient by the therapist. Attachment dynamics within caregiver child interactions have been robustly operationalized; and in addition to this measurement of interactional dyadic behavior, it also contains a well worked theory of the participants' mental representations of the relationship. Additionally, the idea of personal alliance related to attachment constructs conceptually unifies attachment constructs across the life span. Bowlby's alliance theory of treatment (1988) can be applied to both adult and child therapy situations. It can help model complex situations in childhood where, for instance, the child's primary attachment figure, to whom the child may or may not be securely attached, is also involved in the therapy. Using an attachment hypothesis, the challenge will be to adapt the operationalization of attachment relationships into the alliance field and formulate experimental designs to test hypotheses regarding the attachment dynamic at play in alliance and in relation to outcome. An example would be measurement of both alliance and attachment within an experimental treatment trail, so that contributions from each to the outcome could be delineated. In such a study in progress, aspects of patient, and therapist discourse in therapeutic sessions conceptually reflecting the attachment dynamic (significant affect laden disclosures from the patient, and the therapist's response to these) are related to an independent standardized rating of alliance (VTAS). Such an approach will enable a test of the relevance of attachment related components of alliance as the treatment progresses. Hougaard's Task alliance links to wider social issues. Evolution of health care systems and social relationships between health providers and patients has led to growth of a more “contractual culture” of shared decision making and a culture in which knowledge is also more democratically available rather than being embodied wholly in the professional. These secular shifts within developed health care systems have made profound changes in the context within which therapy takes place, and inevitably have an effect on what therapeutic alliance is and how we measure it. There are links also here to the strong current agenda of service user input into measurement and design. Development of more detailed explanatory hypotheses in relation to task alliance could involve sociological considerations of the social construction of illness, role relationships within health care and contractual relationships within clinical decision making. Such considerations have represented only a minor part of alliance theory to this point (Kim et al., 2001; Strong, 1968). One way of looking at this systematically is to explore the elements of “case management” as they appear during therapy. In a further study currently in progress, the quality of the contractual relationship in treatment is being explored using detailed content analysis of treatment as it proceeds. There has been an assumption that the characteristics of alliance in young people are essentially the same as those in adults — but little direct testing of this fact. Few published studies have focused on instrumentation for measuring therapeutic alliance in youth samples. In most studies the alliance construct has been directly imported or mildly revised from adult scales. Given the specific age related issues discussed in relation to alliance, then more specific work should be done in this area. One example would be the issue of alliance in parent mediated treatments such as parent training, such as the initial work done by Kazdin and Whitley (2006) — and whether conceptually the alliance remains an important dimension in this context. 3. Analysis of alliance in treatment Measurement of therapeutic alliance has been approached both by external observation of relevant interpersonal behaviors (e.g. rating video or audio tapes of treatment sessions) or by eliciting attitudes of the client and therapist at various time points during treatment. Each of these measurement methods raises methodological problems. 3.1. Rater and method confounds Kazdin and Nock (2003) argue that the majority of TA studies to date have been compromised by common rater and common method measurement confounds. For instance, common use of patient or therapist rated alliance alongside patient or therapist

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derived measures of outcome demonstrably introduces significant bias into analysis of the relationship between alliance and outcome — often swamping other effects and producing potential type 1 errors in otherwise well designed studies (Klein et al., 2003; Shirk & Karver, 2003). Eugster and Wampold (1996), in their review of the literature, identified four elements of the patient experience that have been repeatedly found to have an association with evaluation of therapy by patients and therapists, including alliance ratings: patient involvement; patient comfort (ease and level of difficulty experienced by the patient); patient progress (e.g., reaching new insights); and the patient real relationship (patients' feelings of liking and realistic perceptions of the therapist). Patients' prior expectations of session usefulness have been shown to predict patient and therapist rated alliance quality in several studies (Constantino, Arnow, Blasey, & Agras, 2005). Since therapist and patient alliance ratings are typically intercorrelated, analyzing therapist-rated outcome against patient-rated alliance is prone to the same confounds. Observer measurement of alliance meets this difficulty but will be unable to capture directly the subjective, attitudinal or motivational aspects of TA. 3.2. Criterion validity Quantification of the alliance concept may result in ‘arbitrary metrics’ (Kazdin, 2006). To what extent do small differences in scalar alliance ratings by patient or therapist have ecological or conceptual validity? This problem is not fully addressed by tests of reliability and validity of measures; but additionally, needs tests against an external criterion of alliance strength. In the absence of a direct measure of this, such an external criterion will need to be inferred from triangulated data related to process and outcome of treatment in well design intervention and treatment studies. 3.3. Third factor confounds Solving rater and method biases with independent blind rating does not, however, address potential third factor confounds behind apparent alliance effects. Most studied potential confounds are baseline social functioning or symptom severity, and latent symptom change during in treatment. Regarding pre-treatment baseline factors, Kazdin and Whitley (2006) have recently reported a study in which baseline social functioning explained part (but not all) of the alliance measurement. Pre-treatment patient interpersonal style has also been shown to predict alliance to some degree (Kivlighan, Patton, & Foote, 1998) as has interpersonal functioning (Couture et al., 2006). Some of these variables have also demonstrated a direct relationship to therapy outcome (Crits-Cristoph, Connolly Gibbons, & Hearon, 2006). Early alliance (before session five) has been shown to predict symptom reduction in PTSD and Bulimia Nervosa (Cloitre, Chase Stovall-McClough, Miranda, & Chemtob, 2004; Constantino et al., 2005); although in bulimia patients, characteristics did partially predict alliance. Howard, Turner, Olkin, & Mohr (2006), suggest that the alliance acts as a mediational variable between patient characteristics and outcome in depression. Several recent studies have addressed the issue of latent symptom change confounds. Barber, Connolly, Crits-Christoph, Gladis, & Siqueland (2000) used a repeated measures design in an adult study of depression treatment and found that alliance at all time points still significantly predicted outcome when prior change in symptoms was accounted for. In a small study which did not include a functionally impaired group, Weerasekera, Linder, Greenberg, and Watson (2001) found that alliance predicted outcome independent of early mood change for two different experiential therapies in depression. Baseline symptomatology also did not affect change in alliance in early therapy. Horvath and Luborsky (1993) make the important point that if alliance is an artifact of early treatment gain, then we should expect that early alliance should not be an efficient predictor of outcome, as therapeutic gains tend to stabilize and accumulate over time. In contrast, other trials have found more mixed effects. Feeley, DeRubeis, and Gelfland (1999), found that alliance is no longer associated with treatment outcome when previous symptom reduction is controlled for. Tang and DeRubeis (1999) reported improved TA observed in therapy immediately after sudden improvements in symptomatology. In a later study, Tang, DeRubeis, Hollon, Amsterdam and Shelton (2007) report that these “sudden gains” (large improvements in measures of depressive symptoms in one between therapy session interval) in cognitive therapy correlated with a lower risk of relapse. The authors postulate two explanations for this result, either both sudden gains and low relapse risks are caused by common process variables such as TA or that sudden gains trigger an “upward spiral” of cognitive change, better TA, and symptom relief. Sudden gains have also been found in other psychotherapies, although predicting long term outcome to a lesser extent (Hardy et al., 2005). In child therapy there are very few rigorous studies attempting to delineate the relationship between alliance and outcome controlling for patient characteristics or prior symptom change (Kazdin & Whitley, 2006). Establishing a causal relationship between alliance and outcome in the future will therefore need careful control of the contribution of symptom change to TA, for example repeated measures of TA before and after important symptom improvements. Research will be needed on the relationship of observed to reported alliance, the complex mutual reinforcement effects of symptom change and improving alliance, and what kind of combined approach to measurement will confer maximum advantage. 3.4. Therapist versus patient effects Recent literature suggests that certain therapist characteristics and behaviors may contribute to quality alliances, for example warmth and flexibility (Castonguay, Constantino, & Grosse Holtforth, 2006). A significant proportion of variability in outcomes has been reported as due to therapists, even when they are supervised and monitored in particular approaches (Wampold, 2001; Kim et al., 2006).

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A study in children (Creed & Kendall, 2005) identified specific therapist behaviors that were predictive of alliance as measured by child, therapist and observer. These were “collaboration,” “pushing the child to talk,” and “emphasizing common ground.” However, directionality could not be determined from the findings. More recently, there have been considerable efforts to detect potential treatment failures or patients who may drop out early, and by providing therapist feedback (using process measures including client rated alliance) modify interventions given (Harmon et al., 2007). Results indicated that feedback to therapists improved functional outcome across clients, especially those predicted to be treatment failures. Providing clients with the same feedback did not yield additional effects. However it is not clear precisely what the mechanism of change was. The study used only patient rated process measures. It remains difficult to differentiate between therapist variables and the therapeutic alliance when looking at sources of variation in patient outcome, in spite of research designs intended to minimize therapist effects (Lambert & Barley, 2001). Asay and Lambert (2002) indeed point out that therapist characteristics are an essential aspect of the therapeutic alliance and that there is some indication that measurement of such variables and therapeutic alliance reflect the same underlying change process. Wampold and Brown (2005) report a naturalistic study attempting to delineate the amount of variability attributable to therapists. Further research in this area should focus on RCTs, where experimental manipulations can be achieved and where specific therapist characteristics accounting for variability can be identified, although there has been recent controversy over the best statistical ways to model therapist effects (Elkin, Falconnier, & Martinovich, 2007). 3.5. Psychometric properties of current alliance measures We conducted a review of all substantive alliance measures in terms of their psychometric properties (Table 2). 3.6. Construct validity Patients are the most common raters of alliance in all scales, followed by therapists and then observers. This may reflect the ease of administering questionnaires to patients and therapists post session, as well as evidence that the patients' alliance rating is more predictive of outcome than other measures in adult studies (Horvath & Symonds 1991). However, in studies involving children, the therapists report is likely to be the best predictor of outcome (Shirk & Karver, 2003). Martin et al. (2000) disaggregated the overall alliance — outcome correlation in their Meta analysis by type of alliance rater, but this failed to account for additional variance in their model. The VTAS uses only observer data. The WAI and the VTAS have received most thorough construct validation; factor analysis of CALPAS and Penn scales has been undertaken. In studies in child mental health, the Adolescent Working Alliance Inventory (AWAI) (Di Giuseppe et al., 1996; Florsheim, Shotorbani, Guest-Warnick, Barrett & Hwang, 2000) demonstrated adequate internal consistency and factor analysis of both the AWAI and the Adolescent Therapeutic Alliance Scale (ATAS) (Johnson, Hogue, Diamond, Leckrone, & Liddle, 1998) yielded a single factor. Factor analysis of an adapted VTAS is also available for this population; a single factor solution explained 57% of the total scale variance (Hogue, Dauber, Stambaugh, Cecero, & Liddle, 2006). The FEQ, the ATAS and adapted measures of the VTAS have also shown promising psychometric characteristics in young people. Specific measures have been used in trials testing alliance against confounding ‘third’ factors, particularly baseline or pretreatment symptomatology and social functioning. The NIMH study using the VTAS controlled for third factor confounds in patient characteristics such as perfectionism (Zuroff et al., 2000) and early latent symptom change. With these factors controlled, alliance was still related to outcome. Early alliance has been shown to significantly predict subsequent improvement in depressive symptoms after controlling for prior improvement or early change (Weerasekera et al., 2001) and patient characteristics in trials using the WAI (Howard et al., 2006; Klein et al., 2003). Outcome trials using versions of the patient CALPAS (Barber et al., 2000; Muran et al., 1995) found that alliance predicted outcome independently of change in depressive symptoms. Saatsi, Hardy, and Cahill (2007) again using the CALPAS found that the association between patients' interpersonal style and outcome was mediated by TA, although it did not mediate between interpersonal style and completion status. The Penn, VTAS and WAI have all been used in studies aiming to identify therapist variables and disentangle the relationship between process variables and cognitive changes in therapy (Harmon et al., 2007; Tang & DeRubeis, 1999). The Penn scales, particularly patient report versions, have been shown to correlate with outcome in several studies (Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen, 1983) but few include the testing of other potential third factor confounds, apart from a non English language version which looked at pretreatment symptom severity (Le Bloch, De Roten, Drapeau, & Despland, 2006). As outlined above there are limitations to these trials and there needs to be further systematic investigation into the origins of alliance or potential confounds with other patient, therapist and contextual variables. 3.7. Discrimination and prediction of therapy effects Studies using VTAS, CALPAS, and WAI, including those that account for third factor confounds, have shown strong association between alliance and outcome in different patient groups and treatment modalities (Horvath, 1994; Klein et al., 2003; Krupnick et al., 1996; Raue, Castonguay, & Goldfried, 1993; Zuroff & Blatt, 2006). Items derived from the WAI and the Penn have also been useful in identifying early treatment failures (Harmon et al., 2007; Samstag, Batchelder, Muran, Safran, & Winston, 1998). Other scales are either moderately related to outcome or robust outcome studies have not yet been completed. Predictive validity of the TARS was poor and led Martin et al. (2000) to suggest that researchers should avoid this scale for outcome studies.

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In young people, the AWAI has shown discriminant validity in different populations (Di Giuseppe et al., 1996). The adult WAI has been successfully used in child therapy with parenting interventions as a measure of parent — therapist alliance (Kazdin & Whitley 2006); the relation between outcome and alliance was partially explained by pre treatment social functioning in the parent. The Penn scales have shown predictive and discriminant validity in the adolescent group (Eltz, Shirk, & Sarlin, 1995) as has the FEQ (Green et al., 2001). Studies using the ATAS or other derivations of the VTAS give mixed results on the effect of patient — therapist alliance in family therapy on outcome. One moderately sized outcome study used early treatment sessions to help minimize a potential confound between alliance scores and symptom improvement over the course of therapy (Faw et al., 2005). The results were non significant, but a positive trend between alliance and one developmental outcome was identified (bonding to school). A meta-analysis of substantive alliance studies in the adult literature (Martin et al., 2000) included comparison of the alliance instruments used in different studies. The WAI was used most often (n = 22), followed by CALPAS (n = 16), Penn (n = 12), Vanderbilt scales (n = 9), TARS (n = 5) and TBS (n = 3). Ten studies used novel scales or combinations of scales, including those developed for use with severely mentally disordered patients. Of these, the WAI showed the best interrater reliability (r = 0.92 overall); the Vanderbilt scales showed best validity (r = 0.86); and the Therapeutic Bond Scale (TBS) (Saunders et al., 1989) least (0.71). No one scale however was significantly more reliable overall than the others. The VTAS has demonstrated convergence with other measures (e.g., the BLRI) in several large trials (Krupnick et al., 1996). VTAS and CALPAS scales show high correlation with the observer version of the WAI. The Penn scale correlates more modestly with VTAS. Self report version of the TARS shows correlation with self report versions of the Penn scales and VPPS (Stiles et al., 2002). In summary, the WAI, VTAS, and CALPAS have received more empirical scrutiny and support in the adult literature than other scales and have all been used in robust outcome trials and tested in a preliminary way against third factor confounds. In young people, modified VTAS, WAI, and Penn scales have been most often used. The VTAS and Penn scales receive some support both for psychometric properties and relation to outcome. We note, however, that in no published study has an alliance measure been subjected to the more stringent tests of mediation such as more recently proposed in the literature (Kraemer, Stice, Kazdin, & Kupfer, 2001), nor have the reported predictive effects of alliance on outcome been comprehensively tested against other latent confounders in randomized trials. 3.8. Future developments in the analysis of alliance in treatment Since typically therapist and patient alliance ratings are intercorrelated, the common procedure of analysing therapist rated outcome against patient alliance rating is prone to very significant common measurement confounds and type 1 statistical errors (Shirk & Karver, 2003). Many of these ascertainment problems can be fairly easily resolved, for instance by using observational measures of alliance rather than patient or therapist report and more independent objective ratings of outcome which are not directly or indirectly dependent on parent report. However, observed alliance behaviours have limitations in turn that they do not directly capture the attitudinal or motivational aspects of TA. Future experimental work needs therefore to purposefully testing whether and what kind of combined approach to measurement will confer maximum advantages in specific situations. Beyond this fundamental questions have been raised above about the analytic techniques for causal analysis within treatment studies. Particular problems here relate to the possibility of latent or hidden third factor confounds which may explain both alliance and outcome variance and also the methods of association analysis against which many conclusions have been drawn. More rigorous and theoretical and practical approaches to mediation and process analysis are now in the literature (Baron & Kenny, 1986; Dunn & Bentall, 2007; Kraemer et al., 2001) and the next generation of studies will need to consider using these analytic techniques. A critical issue in this context will be the stability of alliance in treatment and its interaction with treatment process. The evidence here is mixed. Horvath, Gaston, and Luborsky (1993) postulate a fluctuating “high-low-high” pattern of alliance during therapy in which alliance is intimately responsive to therapeutic crisis and resolution. This kind of pattern has been associated with better outcome in certain groups (Kivlighan & Shaughnessy, 2000) and has also been explored as “rupturerepair” episodes (Safran, Crocker, McMain, & Murray, 1990). Repairing ruptures can provide an opportunity to facilitate change; conversely if not addressed adequately can inhibit change. Better early alliance and rupture repair episodes have been shown to contribute to positive change in personality symptoms, although interpersonal dysfunction scores partially accounted for alliance in this open trial (Strauss et al., 2006). Martin et al. (2000) indicate that observers and therapists evaluation of alliance is more likely to change over time whereas patient ratings remain stable. Models that relate alliance more to independent pre-treatment factors however emphasise the early formation of an alliance which is stable through treatment. There is evidence to support this (Kivlighan & Shaughnessy, 1995), although Horvath and Symonds (1991) found that magnitude of alliance-outcome relation is not a direct function of time. Clinical trials work needs evidence based guidance on the best practice approach to these measurement issues. Following Kraemer et al. (2001), TA factors could here theoretically act in treatment (and treatment trials) as; 1) moderators of treatment effect in so far as they reflect stable pre treatment patient or therapist factors that are independent of the specifics of treatment; 2) non specific predictors of outcome in so far as they are unaffected by intervention (i.e. stable during treatment) but have an interactive or main effect on the treatment outcome; 3) mediators of treatment in so far as they change during the course of treatment and have an interactive or main effect on outcome. Dunn and Bentall (2007) have additionally argued that, because TA represents a post randomization effect, interacting with treatment, there are likely to be further hidden confounds not accounted for in conventional mediation analysis. They suggest more advanced analytic strategies using methods derived from econometrics, such as instrumental variable techniques, to address this issue. Green and Dunn (2008) suggest how trial designs will need to be altered in the future to allow such methods to show best effect. Spinhoven, Giesen Bloo, van Dyck, Kooiman, and Arntz (2007) also

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argue that differentiating between alliance effects on process and alliance effects on outcome may yield a more balanced view of the causal network in which the alliance-outcome link is situated. Recent work by Kazdin (2007), posits that psychological research in general fails to adequately explain or identify mediators or mechanisms of change. He suggests that moderators of convenience are routinely used (such as co morbidity) rather than tests of ideas about what mechanisms are or could be (for example attachment style influencing TA which in turn influences outcome). Multiple methodologies are likely to be needed to converge precisely on what mechanisms are involved. Qualitative work, such as a study in progress looking at dyadic interactions between children, therapists and parents in routine psychiatric care, may help to generate hypotheses regarding mechanisms of change, which can then be used to design new process and outcome trials. Further work should also be done in populations with severe and enduring mental illness. Priebe and McCabe (2006) point out that most of the methods used to investigate TA in psychiatric settings are imported from psychotherapy, despite there being important differences between the two environments. They suggest more operationalised methods of assessing relationships should be employed. These new methodological developments offer the possibility of a step change in the rigor with which we understand and approach the modeling and analysis of the process effects of alliance. Many of the newer analytic techniques are particularly applicable to randomized trial designs. This suggests a further rationale for the effort of including alliance measures in such trials (Green & Dunn, 2008). New causal analytic methods along with more experimental studies to look at third factor explanations of alliance effect are likely to do much to help us understand the dynamics of therapist patient interaction and the reasons for the evident power of the treatment alliance effect on the outcome of psychological treatment. 4. Summary Available evidence supports that view that alliance is an important concept and that its measurement should be part of future well designed treatment trails in mental health across the age range (Green, 2006). The purpose of this review has been to take a critical look at current concepts and measurement in alliance with a view to identifying how the investigation of alliance should proceed in future treatment research. The review makes clear the diversity of measures available to measure alliance. One can identify a fairly stable broad consensus as to the key concepts to be measured, but no unifying alliance model nor has consensus set of measures emerged. Their conceptual basis has evolved over time in an implicit way. Hougaard's (1994) review suggested that the scales represent conceptually different although overlapping constructs. Furthermore, the alliance concept has remained essentially at a descriptive level, with little rigorous fundamental research as yet into the underlying process behind its formation. A feature of alliance theory at present is the relative non-specificity of effects with high inter-correlations on items across personal and task alliance. It is a matter for future work as to whether alliance measurement can be made more specific, or whether part of the strength of the construct is in its generality. There is no one current measure of alliance that comprehensively addresses all the issues outlined above. Most successful are the WAI, VTAS, and CALPAS. 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