The psychoanalytic concept of the working alliance is reviewed and elaborated. It is argued that various modes of psychotherapy can be meaningfully differentiated in terms of the kinds of working alliances embedded in them. Moreover, the strength, rather than the kind of working alliance, will prove to be the major factor in change achieved through psychotherapy. Strength of alliance will be a function of the goodness of fit of the respective personalities of patient and therapist to the demands of the working alliance. Past research bearing on these propositions and indicated future research are discussed. Extensions to changes sought in teaching and other group processes are briefly touched. Proliferation of psychotherapies has dominated the sixties and seventies. Thirty-six psychotherapies (Harper, 1959) had to be supplemented by an additional compilation (Harper, 1975). Unchecked, this trend would come perilously close to the solipsism, a psychotherapeutic method for each psychotherapist. Not unexpectedly, research in psychotherapy has suffered from an analogous lack of convergence, and with it a disappointing impotence about providing empirical tests of competing claims. As Donald Campbell (1976) suggests, given the wide prevalence of the need for psychotherapy, and the continuing ability of individuals or society to pay for it, the winnowing of this harvest of methods must come from research. Campbell (1976) speaks to the practitioner, exhorting him or her to engage in systematic follow-up. This essay addresses those prac1 An earlier version of this paper was given at the annual meeting of the Society for Psychotherapy, June, 1975. * Requests for reprints should be sent to Edward S. Bordin, Ph.D., University of Michigan Counseling Center, 1007 East Huron Street, Ann Arbor, Michigan 48109. titioners who are also research workers, to call attention to a point of view that can encompass most, if not all, approaches to psychotherapy and can lead toward the needed convergence in research. There has been a promising rate of growth of research and research workers, with encouraging trends toward a coming together on basic issues: I aim to contribute to that movement. Moreover, because of the generalizability of my ideas to all change situations, I hope to stimulate research applications to teaching and to community change processes. 1 propose that the working alliance between the person who seeks change and the one who offers to be a change agent is one of the keys, if not the key, to the change process. The working alliance can be defined and elaborated in terms which make it universally applicable, and can be shown to be valuable for integrating knowledge—particularly for pointing to new research directions. As my initial statement suggests, a working alliance between a person seeking change and a change agent can occur in many places besides the locale of psychotherapy. The concept of the working alliance would seem to be applicable in the relation between student and teacher, between community action group and leader, and, with only slight extension, between child and parent. While I believe such extensions to be fruitful, they are beyond the scope of this paper. I shall confine myself to the therapeutic working alliance, making only brief inferences to extensions to other change enterprises.2 2 One might extend the idea of working alliances to nonchange situations. Although prisons, under reform ideology, have been set up as change situations, most observation suggests that staff and inmates typically arrive at a mutually agreed-upon alliance to get through their relationship with as little upset as possible.

https://psycnet.apa.org/journals/pst/16/3/252.pdf

The generalizability of the psychoanalytic concept of the working alliance.

Development and validation of the Working Alliance Inventory.

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.

Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review.

Empirical evidence supports the efficacy of psychodynamic psychotherapy. Effect sizes for psychodynamic psychotherapy are as large as those reported for other therapies that have been actively promoted as "empirically supported" and "evidence based." Additionally, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, non-psychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings. There is a belief in some quarters that psychodynamic concepts and treatments lack empirical support, or that scientific evidence shows that other forms of treatment are more effective. The belief appears to have taken on a life of its own. Academicians repeat it to one another, as do healthcare administrators, as do healthcare policy makers. With each repetition, its apparent credibility grows. At some point, there seems little need to question or revisit it because "everyone" knows it to be so. The scientific evidence tells a different story: considerable research supports the efficacy and effectiveness of psychodynamic psychotherapy. The discrepancy between perceptions and evidence may be due, in part, to biases in the dissemination of research findings. One potential source of bias is a lingering distaste in the mental health professions for past psychoanalytic arrogance and authority. In decades past, American psychoanalysis was dominated by a hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research. This did not win friends in academic circles. When empirical findings emerged that supported non-psychodynamic treatments, many academicians greeted them enthusiastically and were eager to discuss and disseminate them. When empirical evidence supported psychodynamic concepts and treatments, it was often overlooked. This article brings together findings from several empirical literatures that bear on the efficacy of psychodynamic treatment. It will first outline the distinctive features of psychodynamic psychotherapy.

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The Efficacy of Psychodynamic Psychotherapy

The article traces the development of the concept of the therapeutic working alliance from its psychodynamic origins to current pantheoretical formulations. Research on the alliance is reviewed under four headings: the relation between a positive alliance and success in therapy, the path of the alliance over time, the examination of variables that predispose individuals to develop a strong alliance, and the exploration of the in-therapy factors that influence the development of a positive alliance. Important areas for further research are also noted.

The role of the therapeutic alliance in psychotherapy.

This systematic and comprehensive volume, written in a lively and clear style, is devoted essentially to the fundamentals of psychoanalytic technique: transference and resistance. The author approaches psychoanalytic technique from a classical theoretical framework, but he frequently gives an entirely fresh view of traditionally accepted procedures. His most important new contribution consists in the clear distinction between the patient's 'real relationship' to the analyst, the 'working alliance', and the transference relationship. His discussion of the contradictory and often conflicting demands which each of these elements makes on the technical skills of the analyst is particularly illuminating. In many fascinating case illustrations, he shows how the analyst carries out therapeutic psychoanalysis while respecting the diversity of psychic constellations in different patients and at different points in their analyses. This book can be recommended - without qualification - to the beginning student because of the thorough clarification and documentation of the basic principles of psychoanalytic technique.

Ralph R. Greenson

Papers

The Technique and Practice of Psychoanalysis, Volume 1

Dis-identifying from mother: its special importance for the boy

The non-transference relationship in the psychoanalytic situation.

The mother tongue and the mother.

Technik und Praxis der Psychoanalyse