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Aims: To rcviewlhe methodsand findingsfrom studiesol lhe therapoulic
relationship(TR)in ihe trealmenlol severementalillness.
Method:A lileraluresearchwas conductedto identifyall studiesthal usedan
operationalised measuremenl ol theTR in thelrealmentolseveremenlalillness
Resulls:Fifteenscales-ihe maiorityot whichweredeveloped lor psychotheEpy
- andtheexpressed emotionindexhavebeenused.Mostscaleshaveacceptable
As noneof thescaleshasbeenused
internai.intearaterandtest reteslreliabilily.
in morethan five studies,no singlescaleis widelyeslablishedin psychialric
research,A morepositiverelationship consislently prediclsa betlersho - and appearslhal a largegloballacloraccounlslor lhe greatesl
proportion of the variancein the therapeulic relationship.
Conclusiong:Thelherapeuticrelaiionship is a teliablepredictorof patienlout-
come in mainslreampsychiatriccare. Valid assessmentsmay need lo lake
accountol ditferent,specificaspeclsol lhe relationship in psychiatricseltings
suchas greaterheterogeneity ol treatm€ntcomponents and goals,increased
variabilityoi sellingand lhe statutoryresponsibility oJ the clinician.Melhodo
logicalprcgressmay requircconceplualwork to ensurevalidassessmenls ol
lhis centralelementol lrealmenl-


Thc relalionship betwecn patient and rherapisl, lariously referred to as rhe th.rupeutir
r"/ario,rr'p (Alexande. & Cofey. 1997),helpirs rclutionship(Goerins & Stylisnos. 1988),
\nrkins a iu k \Cehs & Goer,ng. 1994).helpiasa/lid.d (Luborsky "t a/.. 1983;Pri€be&
Gruyfers, 1993;Klinkcnberg.r a/.. t998) or therupeutitdllra,cr (Clarkin e/ a/, 1987)hrs
been exlensivelystudied in psycholhcrapy ever sinc€ tle special relalionship rhat cxisls
berlleen tle patient and therapist was hishlighted by Freud (l9ll) This relationship is
dso central to thc practice of psychiary being used as a mcans 10 engagepatr€nts who
may not agrcc thxt tley .e€d lreatnenr and to deliver complet treatment programmes
TheTRisdimcult to definewitl eachdefinitionat leaslparily determinedby the presupposF
tions wilhin the give. lbeorencalframework. However, ihere is consensusthaf iherap€utic
implies thal the relationshipb€tweenrbe thcrapist and patent slould have some curative
Copynehq 2004SagcPublicalions
of SocialPsychiatry.
Intemational (Londo..Thousand
vol 50(2):l151llS DOl: 10.1l??/00207640040'10959
NewDelhi)*ww sagcpnblications.con
INTERN,ITIoN,IL JOtR^",1L at SOCIAL psy(-HlATRf 50t2)

properties.For the presenlpurposes,itrelers ro the reiadonshjDbetweenhealthDrofessionals

trained b provide treahenl to p€ople osrensiblyin need of such rreatment.settins aside
c J . n r .d \ I n s h e r h e ro r n o r r h e r e a l r o n s h i pi . d e e m e dt o b e c u r a ! e
This papcf focusesprimarily on empirical studiesof rhe patient rlidcian relationshiDin
l h e r r e a r m E norl , e v e r em e n r J lr l l n e \ ,l o d J r e q i r h d p a r t r c J t r ri o c u \ o n l h e I n c t h o d .. r . e d
ro assessthe relationship.A searchof electronicdatabases Medline, psychl-lT. CINAHL
and the Cochranc Library in rddition ro a manual searchof Deer-reviewed iournats for
the past lile ycars was conducled. For inclusion in this review, studiesqere required !o
mect three criterij, i.c. involve the trcarment of sevcrernentntiiln€ss.DrofessionalDarient
I n r e pr c \ o n d l r e l : 1 l r o n \ h rr p
r o c e \ \ e \d n J a n o p e r a r i o n J l i \ emd e d s u r E m conir r h er e t d r r ; n \ h i n
Although the term r.rele n€"ral /ncir is widely usedop€rationally(e.g.Kcssletet dl.,lggSl
Tyrer e/ d/., 2000).lhereis no universatlydgreeddeinition. The UK Narional ScrviceFrame_
work (Deparlmcnt ofHealth, 1999)definitio:rilas usedro idendfy studieslbrinclusion in this
rcview. However, breausethe definitionsare somcwhatvariabteand preciseinfomation ro
delerm'nepatienl diagnosticand cUnicalstaruswas not always pubtished.ihis revjew was
over inclusivewith rcsFct to delinitions of severemental illness.This DaDerwill nresent
r i r . r I h c m e r h o d ,r h d r h a ! e h e e nu s e . ir o a \ s e . \ r h e r e t z | | n n \ h r ps.e c o n d l h ; f i n d i n g su i n s
thesemethodsand concludewith a discussionofconceprual issuespertaining ro therapisr
patient reladonshipsin theseseuings.


Fifreenoperadonrlisationsofthe the.apeuticrelationshipwereemptoyedin srudie,jnvolving

scveremental illDessand all bul four of theseneasureswere dcvelopedln psychorherapy.
Most were nol dcrived explicitly from a single theoreticatfomularion of the alliance bur
are brscd on a genedcconc€prof the TR. wirh the prec;sedelinilioD of rhe TR remaininq
H o r < \ c r . m o . l . c J t ( , r . , e * l h e b u n dh e l $ e e nt h en J r i e n a t ndlheraDi;
along with their collaborarion.For each ofthe scates,Table I provides informarion on lhc
structure. number ol ilems. rdter. rating form, time |o complete. the number of sludies
wh'ch ha,"euscdthe scale.psychometricpropenies and main emphasisin the scale.
The two n1ostwidcly used neasurcs in psychiarricresearch.i.c. the Califomi! psvcho_
therap! Alliance Scale (Marmar & casron. 1988)r and rhe workins All;ance Inve;torv
r q A t . H u . ! r r h & U r e e n b e r g . t q \ q r . h d \ e p ! rert \ e r . r o n s r o r c t e n . , t h e r Jrpni o. rr l d e D e n _
, l c , , r. h . e ^ f l . T h e \ e ) c o n c e p r u r l i , . r o no r r h c d a n c eI n r h c C A t p A { i . o t a d } n ; m r c
processinitxenccd by both parties which may either progresscolaboratively or dev€lop
' n r . a c o n f l . c th e r $ e e nc l r e n rJ n J r h e r a p r . l
T h c $ A t L b J \ c J o n A o r d . ns I t o l o ) r n D a r ;
L u n . e p l u a h \ a r i uonr r h e a , l a n c r . J \ \ e s r n g r h < r I | a c h m e n rb < r s e e nn d l r e n la n J r h ; r a D . s l
r b u n d , , .c ^ . l d b o r J r r n n n \ | e c r f i cr h c r i | e u r r cd c r i r i , i e , a . t s , J n J r t i a g r e e m e nt rc r " e e n
therapst and clienr on rhe slobal objeclivesoftherapy (goals).
Threc ofthemeasuresusediraveparallelclient and therapistvelsions.TheTherapistClient
R e l d l r o n ' h i t S c a e r B e n n u o p /lr9/ 8 o rs J ' d e \ e t o p erdo ! ' , e \ , l h ec l i e n r \! n d ; h e r a p i ,. r
pe.ception of cacb other in behaviour therapy: the client assesses the rherapisfs positive
rcsard/inieresr,competencyrerp€rienc€ and activity./direcrsuida.c€ white $e th€rapisl

assesses the client s positiveregard,self-disclosurelcnsasement and co-operationisoal orien-

tation. As t]le name suggests,|he Therapist Patienr RelationshipScalefor Schizophrenic
P{tienrs (TPRS; Stark ?/ a/.. 1992.)was developedfor usc wirh schizophreniapatients:the
tbcrapisl rateshow they pcrceivethenNelveswithin thc rcladonship(deir therapeuriccom-
peence ard feeling of pcrsonal and professionalacccptance)while the patienr rules how
the rherapist reh{es 10 then along witb tbcir therapeulicskills (Stark. 199,1).Finxlly. the
TherapeuticWorkins Alliance scale(TWAj Henbchel e/ d/., 1997).developedspecilically
from a psychoanalyticperspectir€,assesses both posidve3nd negariveaspectsof the relaion-
shjp and the collaboration fron therapisl xnd client perspecrives.
Scalcsraled soielyby t}e client include the pioneeringallian@mcasurein psychotherapy.
rbc Barreli-Lennard Relationship Invenlory (BLRIj Barrctt-Lcnnird, 1962).rhe Helping
Alliance Scale(HASi Pdcbe & Gruyters. l99l) and rhc rlelping Alliance Measurc (lIAMi
Klinkenbers.r al., 1998).The BLRI is basedcxplicitly on the Rogerian proposition lhat
therapeuticchangcoccursin proponion to lhe derapisfs crealionof'facilitative conditions'
in therapy. Tbe HAS is a short questionnairelhar \!as developedspecific.tllyfor use in
psychiatriccommunily carewhile tbe HAM was xdapled lion a lonser scalcoriginally con-
structcd lo $sess client expectancicsin counselling.All three scalescmphasisethe perc€ived
characleristicsof lhe theratislrkeyworker (e.9.honesty.FNrmth, lrusr. LrndersEndins,crili-
Only one scalcis exciusivelyrated by the lherapisl, i.e. the PsychotherapyStatusReporl
(PSRr Stanron.t d/., 198,1),lhich assesses the patienfs ability 10 work purposelully in
therrpy wift r ninor emphasis on the therapists own involvemenl.McNnwhile.Ibur scales
are completed exclusively by an exl)err ratcr. Luborsky e, "/. (1983, 1985)dcvelopedtwo
cLoselyrelatedmeasures(Helping Alliance counring signsand Helping Alliancc ratins) both
ofwhicl were dcrivcd from Freud s rie! of thc transferenceprocessa.d seekto assessthe
non-neurotic. friendly feelngs belweenthc pNlicnt and therapist.The Scaleto Assessthe
TherapeuticAlliance (SATA: Allen .r a/.. 1984,1985)attemptsb distinsuishthc therxpeutic
allianceas distinct iiom thetransfcrenceby referringe{clusivelyto the pNlienl\ colLaborative
Fork and not the patient'scxpenenceofthe relario.ship with the therapist.The T}erapeutic
Alliance raiing (TA: Clarkin €/ a/., 1987)was devisedexplicitl) for use with psychiatricin
paiientsand focuseswholly on the patient s perceivedinsighl needfor and inlolvemcnt in
rrearment.linally. the Vanderbilt Therapeulic Alliance Scale(VTAS: Hanley & Slrupp,
1983) partly basedon the $'ork of Luborsk) and Bordin assesses both therapisl and
patienr individual confibutions rlotrg with lhe extent ofcollaboration betweenthem
A diferenr framework is ollered bv the ExpressedEmorion (EE) inder (Vaushn & LeiL
1976; Doane .t al.. 1981),rhere a trained ratcr counls rhe cnticai a.d bostilc lttitudes
expressed durins an in|erviewrspe€ch samplcalons with the degreeof emotionalinvolveneni
betr€en the parties (Magana cr d/., I986). Ahhoush concemedrith raring is
of i.terest as it was developedspeci6callyto ra|e interactionsberweenpeoplc wilh schizo-
phreniaNndrheircarersand. similarto researchonthe ip 2./ sc.haslinked the nnd-
ings 10 patienl oulcome and relapsc.

Psychometric prop€rties of scal€s

Although most of the scaleshave reponed rcccptabL€inrcrnal, inter-rater {nd tcsl rerest
'thcrapeutic relationship in rbe trcatment of
reliability (seeTable 1), the validity of thc

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severemenral illnesshas not been widely inr€stigared.A cluster anallsis of the therapist
lersion oftbe TPRS (Srark., a1..1992)revealedfour factors relatingro personaland profes-
sionil acceptance ivithin ihe rehtbnsbip wbile rhe clicnt versionyietdedfour facton .elating
to therapisr bchaviour. Salvio er a1. (1992) facror analysedrhe BLRI and WAt rared br
ralients with depresion and lbund ftar all subscalesloadcd subsrantixllyon one general
facror labelled'slrenslh of lhe therapeulicalliance Similarly. Harch€rand krends (1996)
found that a single factor accountedfor over two-thirds oi rhe variancein Dalient ratincs
o r r h ed l r d n c eD . r l l c r e n r . F r d l , o n a l . d t i u n ,o t I r e a l l J n c < . , r cr n d " r o r e t y r " t r g l ' 5 ' n r " ' -
correlated(Tichenor & Hill. l9li9i 8achelor, l99tj Sallio., al., 1992)jndicating rhal rhc),
assessthc sameunderlyingconstruct.
Tbis 'global' factor las beenfurlhcr analysedfron1patient and therapistpcrspectives using
the wAI. CALPAS P and Penn scales(i.e. HA: Luborsky e/ a/.. t983) in psychodynamic
thcrapy. Although a siDglcfactor aclountcd for a signilicant pad of rhe varianc.ein both
palient and therapisl ralings of lhe aLliancie, Hatcher .r al. (1995) found that D.tienls and
r h e r a t i , r ,f r \ e d r f e r e n rr J c ! . a h o u t l h e n a r u r cn t r h ed t t . d n ( eT. \ c ) r e p o n e dr h a rp r r i c n r ,
ratingsof collaborationand hcltfulnessin rreatmcntdivergedfrom $cir raringsof sgreemcnt
on go3ls and tasks.On lhe olher hNnd,therapisls vicws ofthe ertent ofcoltaboration and
agreemenlon goalsrtaskswere more closely linked. Inrcfestingly.Allen e/ a1. (1984) atso
found that an expert's ratings of rhe collaboration and relationshir asDectsof the alliance
couespondedhighly wilh eachother.


lnflu€ntirl factors
Factorsfound to influencea more positiveiherapcuricrelationshipincludeolderase (Draine
& Solonon. 1996)more senice conrrcrslKlinkenbers "r al.. 1998)and lesssc\€resvmptoms
r C l J r l r n , / J / . . l a r 7 . F r u n k & C u n d e r ' o n . t q q 0 i N < . , t (& R n , e n n ( c k .t a q 5 r .i n n a - i r c J h r
hostility (Klinkenbcrs .r al. 1998),bur not the type of rberapv (Salvio €, a/.. 1992).The
sexoftbe therapislappearsto be an inlluential tacror in how thcrapisrsrespondemotionallv
1()prtrcnts wilh schizophreniN.Slark .r d/. (1992)tbund ftar hish enorional responscwds
manitfsted Nsrejecrionin male rherapistsand emotional conmihent in fematetheriDists.
b n r ho r q h i c h $ c r c i , , . c E l e d s r r b h i g h c rr e t r p \ er d r < .r r | { . - } i d r t b u $ - u f . r * ' " r . r . . . , -
cialcd with positivepadcnt ratings oflhe alliancein cognidre theraty were encouragemenr
and.rwdrenessin the inidal phdse.personalinsight and talking b someon€who understands
in the working phase and self undersrandingrnd troblem sotulior in the dischrrge phase
(Svensson & Hansson,1999r).Meanwhile therapistsralesiesfound to diflerenrh|e improved
alliances(and outcorne)and unimproved allianccs(and poor ou|come)were addressinsthc
patienls'defcncesand their problemrtic feelingsin rclation to fie therapistraihe. than ivoid-
ins them (Forenan & Marnar, 1985).

h€dicliye valu€
The prcdictivevalueofthe TR hasbeenthe subjectofmosr resclrcb in rhis arei. Studicsrbat
linked the relationshipto outcome are listed in Table 2 with iDformation Dertaininsto the
V\(ABl dPRlr'Bl lHl lHlRAPl lll. l{rl \TIO\SHI}I\ TPTATVT\T lzl

study samtle. alliNncemeasureused.r{tcr oflhe rlliance, fie nature oft|e treatmenl,lbllo\r-

up period and 6ndings. An associationbetwccn a beller therapeutic relationship and
improved ourcomc hNs been lbund in the trcatmcnr of people rith depression(Ktupnick
.r a/.. 1996jWciss et dl.. 1997:Gaston "r a/.. 1998J,addictive disorder (Luborsky er a/.,
1985) pslchosis (Frank & Gu.demon. 1990;Priebe & Gruylers. 1995iTrttan & Tarrier,
2000).rJosl-rrliumrticsress disordcr (Marmar./ a/.. 1986)and in nixcd diasnosricgroups
(Hansson& Berglund. 1992rNcalc & Rosenheck,1995;Solomon?t a/.. 1995iKlinkenberg
!r d/., 1998).This linding holds acrossdillerent setlings.i.e. in'parient (Clarkin er dl.. 1987i
Frank & Gunderson, 1990iHansson& Berglund. l99l: SvenssoD & H.rnsson.1999b)and
our-patienl treatment (c.9. Gehrs & Goering. 1994iNcalc & Rosenheck,1995; Solomon
./ d/.. 1995jKrupnick e/ d1.,1996;Gaslon ", d/.. 1998;Klinkenberg c/ al., 1998).
Outcomc crileria assessed in rhesesludiesranged iiom symptom severity(Chrkin e. a1.,
1987iTa(nn & Tarrier, 2000) and qualiry of Life (Solomon d/ d1.. 1995i Mccabe .r a/,
1999)lo social functionins (Neale & Rosenheck,1995)and time spcni in hospital over a
20-monrh follow-up period (Priebe& Gruyters, 1995).with rcspcctto hospital lreatment
lhe strengthof t|e alliancc was found to be correlatedwith a bcttcr oulcome at dkcharge
(Hansson& Berslund, 1992).three months tollow uf (Cehrs & Goering. 1994)and two
]€ar follow up (Solomon er a/.. 1995).A poorer aLliancext adnisslon ro |ospital was also
found to predict violent behaviour during |he iirst week of hospitalisalion(Bcauford et a/..
1997).Contrary to res€archin psycholher3pywhere patient ratinss of the alliance hale
greaterpredicdvevalidity than therapislratings( H orvath & Slnond s, 199I ), a strongerasso
ciatlonhasbeenfoundbctweentherapistratier than palient ratingsandoulcomein tlet.eal
menl of depression(weiss ct al.. 1997) and schizop|renia, psychosisor najor aflective
disorder (Gehrs & Goerins. 1994iNe.rle& Rosenheck.I995).
civen that high EE amons fanily menbers appearsto be a consisrcntpredictor ofpoorer
rJadenroutcone in schizophrcniaxnd other djsorders (Kuipers & Bcbbinglon, 1988r
Kavanagh.1992;Moore & Kuipers. 1992),the concetr bas sincebccnappliedlo stalirpatient
interactions(e.s.Moore e/ d/.. 1992:Kuip€m & Moorc. 1995:Tattan& Tarrier,2000).St{trin
hish EE rclarionshipswere found to leavc nesrtile ieelings of the patienr unchallenged
(Moorc ", al.. 1992)and were more likcll, ro c.iricisesspectsof the patient s pcrsoDalily
(Kavanash, 1992).Inreresdnsl]. low criticismuas associatedwith lhe beliefrhat the patieni\
problemswere a result of thcir illDessand high criticism $'ith attributing problenN to the
persons personality.In a recenl study however.Tatran and Tar.ier (2000)Ibund tlat hish
EE amongcascmlnagers was not associatedsith clinicll oulcome.althougha globalNssess-
mcnt ofr positivecasemanager patient relxlionshipwas.


Researchon ihe alliancc in rhe trealment of severemcntNl iilnesshxs adopted conceptral

frameworks Nnd ncasures de!€loped for psychothcrapy.These measuresappear to havc parliculxr reliability, when used in majnstrcampsy-
chialric reatmen!. with respecllo fte validity of the construct assesscd,
lhe fe\l relevanr
studiessuggeslthe existe.ce ofone general lactor accountinS for approximalely tno-thirds
t2l t N T I'RNATIO NA I JO liRNAL.j SO(.I A L PSIC H tATRf 5Al2)

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of thc relationshipvariance(i.e. Salvio ar al., 1992:Slark ?, d/.. 1992;Hatcher ?/ a/., 1995r

Harcher& Barends.I 996).In addilion to a larse gen€ril factor. theremay be specilicfeatures
o f t h c I n e r a p e u t rrcc , u r i o n . h . .pn I r e . es e r n B ,l h a r n e e Jr o b e c o n j d e r c d .
Thc settingand rolc ofthe therapisrin the trcarmenlofseveremenralillnessare lessclcartv
d e l r n ( Jr h a n I n D . ) r h o r h e r J p )T h c r h e r a p r rf r d c r c e sI n n r r r r b . e o r e r n . a r r o n a t r r i n i
including in-patient ralds. out-parient clinics, community mcnlal healfi cenlres nnd lhe
patienl s home. ln pslchiarry there is rarelr'.a fixcd duatjon of treaimenl. wbich can oftcn
last a lifcrime. The profcssionalrasksin caring for a palient wjth tong_tennmental illncss
are nelerogcneous.spanmngtreatment, rehabiliradon.prevenlionof relapseand accessins
' J n r ( e . , l h o r n r c r o f t . l q a l , . T h e . l a r u l u r t r e , p o n ! b t i r i e .l o r c a r c r n a r t r er e q u r r e m e nr o
monitor palienls in tbe conrmunity(i.e. oulside ofthe placeswhere.trcatment.rradilionaltv
Iakesplace)mel}nthat many'rherapeutjcrelationships,arejnitiated and maintainednor by
tbe palient brr by the mcntal h$lth professioDrl,a fealure ofasserlive outreachmodels of
care and dll fonns of compulsory t.catmenl,. In ttris siruadon, rhere is often a conflict
betweenfte client\ ltnd therapisr\ peNpectiveof wbat rrertment is required. ln Ds\cho
r \ e r a p \ s h i l c r h e c l r e n' ar n d r h e r : r p i,.pr e 1 p e c r r , " , . , y n o ' . " , , c , a e i , , t 1, n r - . i r r n . n r .
lhc) are increasinglylikely 10 agreeas $crapy prooecdsand are panicularly likely to agree
durins tle later suses oftherapy (Horvad. 1994).Howcver. Svenssonand Hansson(1999a)
found that concordanccbetweenpatienr and lhcrapist ratings did not increaseover time in
As the lhcrapeuricrelarions|ip is a may overlap with other sxb
Jcct'le outcome evaluation cr;r€ria (e.g. Fakhoury ct .tt.,2002I Both concepruallv and
m e h o d o" g r c a l . r .r h e l h e r J p e J r t r' c l , r i o n s h . pi ' i n l e f l $ n c d q , l h r , . o ' . " n r . a r , , r o , , i c "
wlich is tytically viewed as a cenlral ourcome criterion. Treatmenr($hatcver the comDo_
n e n r sm ! \ h e ) . d e l . ! < , c Jt h r o u g hr h c r e t a u o h h r t J n d r h ( , c u | | ^ n . h r pi r , e . \ a n I n r c ; r u
e . e m e n,rf r r e d r ' n e n tI.n , l c e o . o m e r h e r a p e u r r c t r r r o n . h i p. c a e , e x p l i e r r t,l* e * - r i , t " c _
rion with rrcatmenr(e.g.CALPAS. HAS) and sonc satisfactionscalesassesstie theraDeutic
r c l i r " n , h r p , e . BD.r J . , . , J / . .l q q q ,S u c h i r e m , . e c r n r " h J \ e d . c c p r r h t e r n r e , n J t c o n , r j l e n ( \
$ r r ho r h e rr h e r J p c J r irce i a U u n ' h rirr e m ,r n . j c m p r f i . a tI u d r e .r o n , r r c n r t l . h o " , r , , , r , . . " "
constructsare positively inter-relared(Solonon & Draine. t994i Neale & RoseDheck.1995:
Solomon r/ a/., 1995jKl;nkenbers ?r a/., 1998iTatran & Tarrier.2000).
Anohcr construct of relevancero the therapcuticrelalionshipin the trcahenl of scvere
mentalillnessis insight. Indeed,insight, perceiledncedofreimenr and lrearmentinvolvc-
mcnt compise lhe threedirnensionsassesscd by the ThcrapeuticAlliance scale(Clarkin!/ d/..
l a 8 - r . W h r l eI n . i S h r n : , Jh e m < J , u r e d, n d i f l c r e r l$ : r ) sJ c n e r d r n pu r i r h eu r d e , t ) i n er h e . r e -
tical framework (Markova & Berrios. I 995),how the persoDmakessenseof their expeicnces
is Iundrmentalto fierapeutic interaction(McCNbe& euayle.2002).Nor surprisingly.ifthere
is a mismarchbetweenthe patent and clinicirn in rheir rssessmentof lhe Droblem.narients
are lesssalisfiedwirh rhcif care (Barker ?r a1.,1996).There is increasinsinterestin exDtana_
r o ^ n o d < | , n l i l l r e * . . . < .r l e p a l e n t \ \ , e s o f t h L i rr ' t n e $d n J i r . m e a n r n er o r t r e mn. n r o -
m . r , r e p u , i r i \ e. o t d b o , r , , o nr n d c o m m d n , c d u urn- " " . . n . r , " , . , , " u n a o i , " n r r e s c . i r . , n
& I i l e s o o d .l { , r d :B h u r & B h u e r d 2 . 0 0 2 )w e f o u n J r d I K { u d \ r h r i d b i . t ^ r r ; t e \ p l J
mtory model was relatedto enhancedtreatmenrsatisfaclionand TRs (Mccabe &
press).(;i!€n thar thc predomimnt treatmeDtmodel (beins medicadonbased)is bioloeical.
l h r . . u p f e . l . l h a t c u n L o r d d n cbfe r $ e e np a t r c n rJ, n d p r o r c * o n r t . c o n r - i r , : r er. o a n e r h m c e d

TR. As a neans ofassessingpatie.ts potentialfor fo'mins a thcrapeulicalliance.Rosenberg

and Kesselnan (1993)askedrhe patient about th€ .ature of their illncssin rhe pslchintric
em€rsencyroom and found thatth€question its€lf(alongwilh others)was rclationshipbuild-
ins. In a similar vein, Fmnk and Gunderson(1990)found rhat N bettcr therapeulicrelsiion-
ship after six months of lreatmenrwas associatedwilb lessdeniNlofillness.


All measur€softhe TR idenlifiedin fiis reviewass€sslhe bond betweerthe client and the.a
pisr alons with thcir collaboration,although in slightly difere.t ways.As in psychorherlp),
rhc therap€udcrelationshiphasiepeatedlybe€nshown to haveprediclivcpow€r in relalion lo
lrc.lmenr outcome.Whetherall of the sales developedfor ps!chotherapyxre equally applic-
ableto the treatmentotseverementNlillD€ssis qu€stionable.Ho$ever. fiere may be no such
thing as the ideal assessment ofthe th€rapeuticrelationship.The mosr appropriatemethod
may rather depend o. ihe purpose of lhe ass€ssmenl.For example.studies investjgating
h o $ r h e r a p e J r trre l i t i o n . h i p sJ r e i n B u e n . e db ) ( e ^ i L e . l r u c l u r e o r l r d i n i n Bi n r e n e n r t o n '
may warrant diffcrenr assessments than srudiesidentifying which relarionshipsarc hcLpful
and ellecli!€ with which patientsaod io which etuanon.
In rnentalhealthresearch,the relevanceofthe therapeuticrclNlionshipliesin ils role Iilsl as
an independentpredicror oftrearment oulcome, secondas a medlaling iactor that captures
signiiicantvadance i. the outcome of lftatmenl intervenlions(Frank, 2000;Priebe, 2000),
such as pharnacological tle.apies aDd finally as an ourcome crilerion in ns own ight
(Priebe& Gruyters, 1999).valid assessments may need to take accounrof the diilerences
frorn conventionalpsychorherapy outlinedherein.Spe€ificr€sea.chmay b€crucid to xdvance
our understandingofthepatie.l clinicianrelarionshipin rhetrcNlmcnlofseveremenulillness
and ensurea valid assessmenl oflhis cetrtralcomDonenlof lreatmenl.


1. The CALPAS NaspEeded by the TAS (Mau iali ?r ,4. l98l ) *hicn, in lurn. was pEeded by the TARS
(Mamf crr/. 1936)


A LLXANDER, L.B. & COFFEY.D.S. ( 199?)UndeBtandinerle lndapeuticrelaionshit curtht Olihionih

Pjr.itutr, 10,:13 218.
ALLEN. J.c., TARNOFF, (; & COYNI} L. (1985)Therap€uric aUianceand long-tennhospitaltreahenl
olr.ame Coh?teh?hli,e P\\thiatrr. 26. 181 194.
A LLLN, J.C.. NEWSOM. G.E . GABBA RD. G O. & COYN F., t ( 1984)Scalesto asc$ lhc lhcrapculrc
alliance lron a psycho$alydc l€r\pecri\e. tullztih.l |h! Mehhihser clhir,8. 38i 4$.
BACHELOR, A ( 199l ) comtarisonandrelationship lo oulconeofdile$e dinensionsol thehelOngllliance
rs smn by clicnrand rh€rapisl.tsr.hoth.rary,24,534 549
BARKER. D.A., SHERGTLL,S S.. HrCClNSON,l. &ORRILL. M.W. (1996)Parientsviewslowa.dscare
re*i!€d fnrm tsy.hiatrisrs.,fitth Jatrnal aJPstrhiatry.16a,611616.

BARRETT-LENNARD. G.T. (1962)Dinensionsof theraisr responr as cansalfactors in lh€rap€utic

ctanlge.Psf.haloEitulManogruth\,76.I 15
BEAUFORD. J F, McNlEL, D.L. & BINDIR. R.L. (199?)Uriliry of the nirial thenpeuticlllirne r e!rl-
u,ting $ycniarric patienrsfisk ol !\alen@.An.ri.a Jatrnal aJ lst.htatry. 154, t272 1216
BENNUN. L. HAHLWEG, (., SCHINDLFR.I.. & LANGLOTZ, M (1986)Th.radst\a.d.lient\percep-
rions in bebaliour lherrty: rle derelotmentand .ross-.uhuralanalyshol an a$esnent instrunenl.
Rtitith.l.umut rl ( lihi.dl P!)'tll,sr. 25.2?5 281.
BHUI. K. & BHLTCRA.D (:002)Explanalor]nodels lbr nenlaldntre$: inplicltions practicc
and rcscarch. Br th Jo"rnolal P$rlirtl,181. Gi
BORDI-\. E.S. 11979)The generllnabih! of lh. $ychoanalttic .onccpr of thc sorking alliance l$.1,
thsa,r: Tht,rr. tu!.at.h dhtlPra.ti..,16,252 460.
CALLAN. A. & LITTLEWOOD. R. (1998)PatFnl salislaction:erhnicongin or explanator!modcll /,r./-
natiorol Jowadl ol 5.. iul Pra htur] , 14, | | |
(TLARKIN, J F, HURT. S W. & CRILLY. J L. (1981)Therapeutic allianceandhospilalI'
Ilospital drtl Comuattf Prytltatr], 38, 8?| 8?5
DEPARTMENIOF HEALTH(t999) MoLl. std"drnls ahd s.tri.e J\dtionol S.rri.. rrotn wrklar
Menlul ?dhh. London: DeDarlnenl ofHealth.
nicariondevianceand afiectiveslqle an hiws4 G?n{ul Psyrldkl. 18, 6t9 685.
DRAINE, J & SoLOMON, P. (1996)Cascmana8d alliancc*nh ciEnls in an older cohort Cotnn,aitj'
tttektal tl.dhh Jormal. 32. 125 131.
DRUSS.B.G . ROSENH E(rK. R A & ST()LAR. M. ( 1999)Prticnl satisfadionand adnidslfutivenEasurcs
a rE' . r i a l m t n r . s . 5 0 . 1 0 5 31 0 5 8 .
a s i n d i c r t o r s o f t n c q u a l i t y o f n € n l a l h e a l l h cA
FAKITOURY. W.K . KAISFR, w . RODF.RWANNER,lJ (i & PRtEBE.s. (2002)Snbi€tivccvaluador:
is (herenore than onecrilerionl sLhxatht?rtuBufutih.7a.1t9 127.
F()REM \. S.A. & MARMAR. C.R. (1985)Therapistaclions lhar ndd.ess,nitirlly Nor therapeutic
aUiances in pslcholherapyAn(rnaa al Psiahntfi,142,912 926
F R - A . N K . A F . & G L N D E R S O N . J G( 1 9 9 0 ) T h e r o l e o f r h c l h . r a p c u t i c a l l i a n m i n t h e l r e a t n e n l o f s c h t o
dnelia. 4Aen{al Ptt\hioht,11,22l\ 276
FRANK, J (2000)Hisloiyrrhc rcal basic{icncc ofpsycbotb.npy} Jormdlol r.^.6 dd ll.ttal Dt(d(,
I 8 l l . 7 2 5? 2 7
I REU D, S ( r q r l) On besinnina lhe lreatmenl h Th. StandardEtiitioa al the Com!tuk Prlt h.loEi at ,rlrk!
of Sichtnd rrek| (.en.L Sn&bey). London: Hoglrlb Press.
GASTON. L & MARVAR ( R (1991)Manul for lhc California PsycholhcfapyAlliance Scales
(rALPAS tJnpnblhhednanns.ipr. Deparnerr oi?sychiarrl. Mccill Unrverity. Montreal,Clnadr
CASTON. L.. THOMPSON,L. (;ALLAGHF.R, D. C(XIRN()YER. L & G (;NON. R. (1998)Alliance.
lechnique-and tncn inlcfactionsin prdiclins oulcomeof behavioual.cosnnive.and bnef dlnamic
rhetrty Psrrholtura?, R.\ear.h. A. 19G209.
C LH RS. M & COERING. P ( I994) The relalionshipbelseenrhe wo.kingallirncelnd rehabilrtallon.u!
comesof sch,/ophrsia P\r(hrvriul RehahilitulbnJournul,18,11 t4.
(;()ERIN(i P &STYLIANOS.S (1988)Explorinslhe helpingrelalionshipbelweenthe scbizophrenic cl,ent
a.d rclubililation rhe.!pi!l. , n(rtan .Iturnal.l Orth.?\!Aith, s8 271 130
H A NSSON,L & BERGLLTND. M ( 1992)Stabililyof thcnp.ntic alliane andits relahonshipto oulcomein
shonrcrn inpdtierrpslchiatrieearc.S.o innvat Joumalal Sa.ial ve.hcina,20,15 50
HARTLEY, D. & sTRliPP. H H (198r) The th.raDcuticallirncc: ils rclationsbiplo oulcone nr bief
psy.hothcrapy.In Zrrtr.?1 St"tliesof l\\.haanoLh. Th.ot'.r, t,/ 1 (ed.J. Maslrng) Hilhdalc, NJ

IIATCTIER. R L. & BARENDS. A.11996)Pnrienif vies ofthe,lliance ln $)_chorhcrap,c{tloralorr fictor

analysisol lhreellrian.c measnts .huthnl olohsuhihs uhl Plr.h.Lst. U.1126 1!16
HAT(]HER. R.L.. BARLNDS,A.. HANSELL. t. & J,A.NICE CUTFREUI.JD.M. (1995)Pat@ts'lnd ihera-
pists' snaredand uniqueriews of the lheftpeuricrllinnce:an inleniealion usingconlirmatoryfactor
analysnD. nesteddesignJqtnul ol Onflknq ant ( tbtntl PsrLhol.Kr.6i,616 61i.
HFNTSCHF.L, L, KIESSLING. M. & RUDOLIT. C. (199?)Therap€ulicalii.nce and Iranslirene: $
cxploratorysrudyof their enpnrcalElatioDshrp. Joudl ,1 r\'.r\.u\ an.l M.ntat Di\?ott.1tts,254 262
HORVATH. A.O. (199.11Re€arch on thc allirn.c ttr The Wrtkins Allibre rheor\ R.t..trh @d I'ro.ti..
red A () Honalh & L.S.Crenb€r!]. NewYork: Wilev.

HORVATH. O & CREENBERG. L.S. (1989)Dcvclopmenta.d validatFn of lhe workine Alliance

tn\cntat\. J.umal al CounselhnsPry hnhs.r. 36. 221111.
HORVATH. A.O. & SYMONDS. B.D. 11991)Relalronbelweenworling allirnccand ontcomein pslcho
therapy:!neu anrlysis Jottul ol CaMeIitE Pethor)Er,aa,1t9 t49
L{VANAGH, D.l. (1991)Rsent developn$ts in.xprcssd cnotio! and schizophreniaBriti\h J.tnnt.l
dorogyr'ore{imrting tnc r 2{on1h preralenceol seriousnental illncss.lnltdtal H.ahh, L-ait(l Stut"!
/998 (ed R W Mandenheid& M.J. Hende^on) Rockvillc.MD: C€nlrefor MenralHeal$ Servi.cs
K Ll N KIINBERC. W.D.. CALSYN. R I & M ORStj. C.A ( 1998)The helpingrlliancein ca€ manaacncnl
for homele$ Flfr$ns sith scvcrenental illness Can n,"nr M?ntat E"ulth Jourhdl, 34, 569 518
K R U P N I C K .J L . S O T S K YS , , M O Y E R ,J . ,E L K I N . I . W A T K I N S . J .& P I L K O N I S .
. M . S I M M E N SS
in the naliontr progrannc. J,u al of CarcuhinEaa.l alinnul Pratuhsr.64.512 519.
(urPERS, L. & BLBBINGTON.l. (l9lj8l Extre*cd cmorionrcscarchin schizophrenia: lheoretlcaland
clinical inpliations. 1ry.r,/,,sir,1 M?,tuid. 18, 891 909
KUIPERS, L & MooRE,r. (1995)Exprcssed enorionrnd sdn .licntrclalionships./,r,r,dtiaMlJo*nat.'1
M?,tdl uealth.tA.13 26
TNo helpinc alliance nelhods for predicting outomes ol psych.rherapf .hrutrul .f Ntt,ous ad Mdtal
Dired., l?1.48(1491.
suces a.d ns dereminana. ,rr.hir.s ai General Psr.hiatrr, 12. 61\2 6tl
LR.H. (1986)A bnef nethod Lr a$c$ins exp.essedenotloD in .eldtrvesol $lchiltric paticnt
Pr\ hnn. R?\eanh. 17. 203 112.
V A R KOVA. I S.& BERRIOS.G.E ( | 9951lnsighlin .linical psychiat.,relisned Canpreh('sre Pul hiLtrr,
.167 i76.
MARMAR.C.R &GASTON.I. (I988)ManualforlheCdl omia Psycho$dapySdles CALP S Unpub-
lishedmanu$npl. DepartncnrofPsychialry.UniversityofCal bmid, SanFnn.s.o, cA.
MARMAR, C R , HOROWITZ. M.J.. WEISS.D S & MARZI,{LI. E. (t986) Dclclopnent of tbe lhera
Iieuric ratinC ststdn. In Thc Psrtholhelur,li. Pn ?r A R.\eat.h dhdhaok (ed L GEdberg &
W. PinsofJ.N€w York: Guil,ord
MARZIALI, E (1984)Threeliespoins on the therapeulrc alliance:lihilanries.difr€renasand asociations
wnl Fychorhcrapy ourcone Jautaal oJ a"(r.u\ ntl tttenlul Divust. 172. 411L1.
MARZIALI. E.. MARMAR. C & KRUPNICK. J (1981)Therapeulicalliane scales:devclopmcnland
rehtunship ro psych.tncrapyortome Anernan Jautaul.l Pvrridrrr. 13tl.161 164.
VCCABF, R & PRI EBE. S.(in press) Explannkty frodelsof ilines in schizopnrcnia paliensrA companson
ol fou crhnicsroups.,/tr/r ./oftnul.l P\yhilbt.
MCCABE.R &QUAYIE.E (2m2) Kno{ir8 }our o*n nnrd fi. P!.r,/ian'.ls.14 16.
MCCABE.R . R()DER-WANNER, U. U.. HOFFMANN. K & PRI[B!. S. (1999)T]rerapeutrc telalion
shipsand quahy oflife: li(riltion oftwo subtcctive coniructs m schizopbteni!prh€ns /nra,zri,,,1
Jotnat ol Sr.irt PsrLhidit,15, )1G2Sj
Mo{)RE. L. & K u lPtiRS.L ( 1992)Rehalnruralcorrclxrcsof cxpresedenotion in stafl pntienrinle ctnrns
So.ral l\rrhidnr ann P\Lhnrt)c Epid.hnnqt", 27. 294 301
MOoRE. E KlJtPrRS, L. & BALL. R (1992)Slrll paticnrrclationships nr thecareofthe long temi rdulr
ncntall_vill. S,.rdl P$,.lrrr] an.l P tr. hnrt). Et)id.hioLsr. n , 28 J4
NLALE. M.S & ROSE\HECK- R,\ (1995)TheraDentic alliatrceand oulcobe rn a vA intcns'lc case
nanagflcnt Fl'ogtumn.. Pt r.hi.ti. 16. 119 721
PRIEBE,S. (2000)unsurinsalldnnprovingquahy in c.mnrunitymcnralbealthcaE tntetnationtlR?ri.r o.l
Psr.hidt\. 12.22( 212.
PRIEBE. S. & GRIIYTF.RS,T (l9gl) The role of the helpinc allknce in pslchilhi. .ommu.'l! cre:
! prosr,{ud!. ./,r/d/ ,/ r./v,6 anl ir'?,r,/ D,r?,ff.111t.55: 557.
PRI EBL. S. & (]RL YTERS. T. ( 1995)Patlen* ascsncnl of tcatnenl prediclnrgoulronre St hi:rrhr"iit
Bulletin,2l,81 94
tRIEBE S &GRtiYTERS.T 0999) A prlor fiai ofteatmcnlchangcsaccordinglo schmphrmic lalents
$nncs. J.,rtrd1,/t./r,6 d,l Motul Dit?utt.151.41],41i.

ROSENBERG.R.C & KESSELMAN. M. (1991)The rherapeutic atliane and &e psychiatricenergency

rcom Holpnalantl Cahhnilt P\rdiatr.44.19 nA
SALVIO. M.. BF.LJTLF.R, L.E.. WOOD. J M. & ENCLI, D ( | 992)The i.enstn of therheeoeuricallianccin
l h e e l e r n c n l . . r " e - r v n P . , , h . , h . ' " pE, , , , d t . h2 \ t t a
SOLoMON, P. & DIL{IN!. I (1994)Sarisfactionsnh mentalhealthiieltdenr m a .andomiTedfial ot'
consunercasenranagement. ./,umal al l\errou! unl Mettat, r82. 179 t84
SOLOMON. P. DRAlNF. r. & DELANEY, M.A. (1995)Th. rortins allianceand consume.casemanasc-
n6\. .lorrvl of Mehld EeLh Atlninttd til,|. 22. 126 114.
SCHNITZER, R. & ROSIjNTHAL. R. (1984) of psychothcrapy in sh'zophreniarI Dcsign
and nnpbmcnhtionof d conrrolleAstnd\ S(h':aphrchidButlerr, 10,5:0 581
STARK. F.M. (199.1) Thc th.rapisl parietrtrctarionsnipwrth scnizophrenic prrients.,.rz,k)ut <
2i1 )4\
STARK. F.M. LLWr\NDOWSKI. C. & BUCHKREMER. c. (t992) Therapistpaticnrrelalionshipas a
prcdicrorol the couse ofshi2.threDc ilhes. tz,r.a, t$.hidtr.j. t6t t69.
SVENSSON.a & HANSSON.L. ( 1999a)Reldtronships amongpdrienland thcrafkr ntincs oI therapcutic
alliane and patient as*ssmenLs of therapcuri.p.oe$r a study of cognirrvetherapy{irt lone lemr
menrarryirr prients Jormdl of )ietnut ntulit en1dlDi'!ar. la7. 580 586.
SVENSSON.B & HANSSON. L. (l999bl Therapeuticalliancein cosnitivetncraty lbr schtopnrenicand
orberlonsrcrmmmtrlllill palienc dcvel.pnentandrctationshiprooutcomci. anin iarienr lreatmcnt
r . n g J " n . { , r d P . J, . / , , r \ , . , d . a d r " r 9 9 ^ t t 8 -
TATTAN. T &TARRILR-N. (2000)Theetle$ed enotion ofcasemanagersofrhesnously nentallyitl: th. uenceof exprcsscdcmolion on clinical ourcones. pry.t,/,s,i ut ttre.lntN, yt. 195 104
THORNICRoFT. G (1991JThc conc€ti of casenanagenent for lonsrcm menr'l i|rcss. htequlbnn!
Reri.t.l P trr hntr), 3, 1211 72.
TICH ENOR, V. & HlLl. C.E ( 1989)A conparhon ol \ix nelsurcs oa*,orkiDgalliare psl4.theaqr. 26,

TYRER. P.. MANLEY, C.. vAN HORN. F. LEDDY. D & UKOLTMUNNE. o C l2o(]Otpenonalitr
abnomality in severemenlalillnes and its inllue.€ on oulcone ot ntensivcand standardcae nanasc-
n < l r .d l , i d o l r . . d . n ' l ' . , 1 1 (rJt a l 1 : / , . t , ' r P .) . h n r t . t s to
VAUGHN. C & LEFF. J. (1916)The neasurcmcntof expres*d cmotion in rhe fanities of Dsvchtllric
Drr.n, Btt.,1 Jout4atot \. i"t Jr t | 1.\ dt p. t,.h-14). t5. | <- 6.
WFISS.M , G,\STON, I , PROPST.A.. WISF.BORD.S.& ZICHERI\,L{N.V. ( | g97lThe.ole of fte alianc.
in lhe pharmaloei.trcatnent ol rlepression .t.'utnatofctihi.l/ prr.trnrr.58. t96 20.1

Ro\en,arieVccdb€, PhD.l,nit for Sooal and Communiry Psychiarry.Bans ald rhc london Schooioi Medionc.
N:cwhrm Gnre lor Mcnral H€xlth. Ut{
SrclirnPnebe.MD. UdrturSo.irland Connudy Psychirtrr, Bansand rhe London Sciool ot Medicine.Neshan
(r.nre lnr MmrxlHeahh, ltK
Corespondcne ro Rosenarie Mc(rabc. PhD. Unn aof S@i.l dnd Community psilhnr|. Brns and the London
SchoolofVedicine, Neshan for Meotal Hcahh. London. El3 3Sp, UX