'The vehicle of success': theoretical and empirical perspectives on the therapeutic alliance in psychotherapy and psychiatry.

Psychol Psychother 77(Pt 2):255-72 (2004) PMID 15193196

The importance of the 'therapeutic alliance' has long been recognized in psychotherapeutic theory and research, but is also increasingly researched in psychiatry. This paper examines the clinical and empirical literature on the alliance and asks, first, whether the concept is unrecognizably distorted when it travels from the psychoanalytic context to other therapies and to psychiatry, or when translated into research instruments; and, second, how we are to understand the apparent anomaly whereby its proponents have defined it as a 'vehicle' for treatment rather than curative, whereas quantitative research increasingly associates it with outcome. This paper reviews the evolution of the concept in clinical theory, traces the development of empirical research on the subject and considers its use in psychiatry. It argues that the empirical research misleadingly suggests a curative paradigm, and that it may be unable to illuminate some of the clinical controversies, although its implications for theory demand consideration. It argues for the retention of the alliance concept in psychiatry distinct from the broader spectrum of the 'relationship'. Finally, it argues that the debate about the concept's curative properties may, paradoxically, be more pressing within psychotherapy than psychiatry, and endorses calls for more theoretically driven empirical research into the alliance.