The Development of Therapeutic Alliance During

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The Development of Therapeutic Alliance During

Psychological Assessment: Patient and Therapist
Perspectives Across Treatment
Mark J. Hilsenroth , Eric J. Peters & Steven J. Ackerman
Published online: 10 Jun 2010.
To cite this article: Mark J. Hilsenroth , Eric J. Peters & Steven J. Ackerman (2004) The Development of Therapeutic Alliance
During Psychological Assessment: Patient and Therapist Perspectives Across Treatment, Journal of Personality Assessment,
83:3, 332-344, DOI: 10.1207/s15327752jpa8303_14
To link to this article: http://dx.doi.org/10.1207/s15327752jpa8303_14
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JOURNAL OF PERSONALITY ASSESSMENT, 83(3), 332344

Copyright 2004, Lawrence Erlbaum Associates, Inc.
The Development of Therapeutic Alliance During

Psychological Assessment: Patient and Therapist
Perspectives Across Treatment
HILSENROTH,
ASSESSMENT
PETERS,
ALLIANCE
ACKERMAN
Downloaded by [Instituto Universitario da Maia - ISMAI] at 17:06 15 May 2015
Mark J. Hilsenroth
Derner Institute of Advanced Psychological Studies
Adelphi University
Eric J. Peters
Department of Psychology
University of Tennessee
Steven J. Ackerman
The Erik H. Erikson Institute
Austen Riggs Center
Stockbridge, Massachusetts
We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We
hypothesized that a working alliance developed during psychological assessment conducted
from a collaborative therapeutic model of assessment (TMA; Finn & Tonsager, 1992, 1997;
Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We
also hypothesized that alliance for those patients receiving a TMA would be significantly
greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short FormPatient Version (Hatcher & Barends, 1996) and
the Combined Alliance Short FormTherapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback
session demonstrated positive and significant relationships with alliance throughout formal
psychotherapy and in relation to a control group. The clinical utility and research implications
of these findings are discussed.
The emphasis that contemporary psychotherapy research has

placed on the technical and relational aspects of the alliance
has made it an important variable in the understanding of
psychotherapy process (Orlinsky, Grawe, & Parks, 1994).
Originally, the therapeutic alliance was believed to be positive transference from the patient toward the therapist (Freud,
1913/1958; Frieswyk et al., 1986). However, the perception
of the therapeutic alliance soon developed into a conscious
and active collaboration between the patient and therapist.
Zetzel (1956) used the term therapeutic alliance and maintained that it was essential to facilitate a patients ability to
hold up under the analysis of the transference. Zetzel viewed
the therapeutic alliance as a rational ego function that replaced early deficiencies in helping experiences. Greenson
(1967) also took this understanding of the alliance and ex-
panded it to look more closely at the therapeutic interaction

between the patient and the therapist. Greenson used the term
real relationship to characterize the various patient and therapist components that each brings into the therapeutic interaction. Currently, most conceptualizations of the therapeutic
alliance are based in part on the work of Bordin (1979) who
defined the alliance as including three features: an agreement on goals, an assignment of a task or a series of tasks,
and the development of bonds (p. 253).
In the last two decades, research has often found the relationship of alliance with therapy outcome to be significant
and generally yield small to moderate effects (range of r =
.20 to .30; Horvath, 2001; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). This value may be considered
substantial in comparison with the effect size of .39 associ-
ASSESSMENT ALLIANCE
ated with average treatment outcomes of psychotherapy reported by Smith and Glass (1977). Another significant area
of study has been the examination of patient-to-patient and
therapist-to-therapist ratings of alliance through the course of
treatment.
PATIENT- AND THERAPIST-RATED ALLIANCE

ACROSS PSYCHOTHERAPY
Examination of patient-rated alliance across several studies
has found that patient perceptions of alliance measured early
in treatment is a reliable predictor of patient-rated alliance at
subsequent points in treatment. Paivio and Bahr (1998) utilized the Working Alliance Inventory (WAI; Horvath &
Greenberg, 1989) to investigate the course of patient-rated
alliance measured from the third through the final therapy
sessions. Analyses yielded significant and moderate relationships between the early and late patient-rated WAI (WAIP)
for all of the subscales (Bond Development, r = .56; Goal
Agreement, r = .48; and Task Agreement, r = .48) as well as
the total score (r = .56). In a subsequent study, Paivio and
Patterson (1999) similarly found that WAI patient total
scores at Session 3 exhibited a relationship that was significant and large in effect (r = .65) with WAI patient total scores
at termination. As part of their larger study investigating the
relationship between alliance and outcome, Barber, Connolly, Crits-Christoph, Gladis, and Siqueland (2000) utilized
the California Psychotherapy Alliance Scale (CALPAS;
Gaston, 1991) to measure patient-rated alliance across Sessions 2, 5, and 10. Barber et al. (2000) reported that alliance
scores were very stable across treatment (p. 1030). However, a significant and large effect was reported only for the
relationship between alliance measured at Sessions 2 and 5 (r
= .70), presumably because the course of alliance was not the
main focus of Barber et al.s study. These results suggest that
patient-rated alliance measured early in treatment is a reliable predictor of the patient-rated alliance later in treatment.
In one of the first empirical investigations of therapeutic
alliance, Luborsky, Crits-Christoph, Alexander, Margolis,
and Cohen (1983) provided us with data regarding the predictive capacity of observer-rated alliance across the
psychotherapeutic process. Luborsky et al. (1983) utilized
the Helping Alliance Rating method (HAR; Morgan,
Luborsky, Crits-Christoph, Curtis, & Solomon, 1982) and
the Helping Alliance Counting Signs method (HACS;
Luborsky, 1976) to measure the predictive power of observer-rated alliance (using session transcripts) measured at
two early sessions (third and fifth) compared with two late
sessions (i.e., the session at which 90% of the treatment was
completed and the prior session). Luborsky et al. (1983)
found that HAR and HACS early scores were highly related to
HAR (r = .53) and HACS (r = .58) late scores. These results
suggest that observer-rated alliance measured early in treatment can significantly predict observer-rated alliance measured at the latter stages of treatment. Perhaps of even greater
importance was the finding that alliance was more evident
333
between early and late sessions for those patients described

as the most improved (HAR, r = .59 and HACS, r = .54)
than those who were less improved (HAR, r = .47 and
HACS, r = .47), thereby suggesting that positive alliance
early in treatment may predict positive outcome.
More recent studies incorporating both patient- and therapist-rated perspectives of alliance have built on Luborskys
(1983) seminal research on alliance completed 20 years ago.
Brossart, Willson, Patton, Kivlighan, and Multon (1998) utilized the WAI to investigate the course of patient- and therapist-rated alliance across all sessions for 11 counselor/client
dyads. Patients and therapists alike completed the WAI after
three various measurement points (T1, T2, and T3). From
each individual treatment, Brossart et al. found that the relationships (unadjusted correlation coefficients) between patient-to-patient and therapist-to-therapist ratings for
temporally adjacent measurement points (i.e., T1/T2 patient
r = .59, therapist r = .64, and T2/T3 patient r = .59, therapist r
= .64) exhibited stronger relationships than those between
nonadjacent temporal measurement points (i.e., T1/T3 patient r = .21, therapist r = .12). Barber et al. (1999) also utilized the patient versions of both the CALPAS and the
Helping Alliance questionnaireII (HAqII; Luborsky et al.,
1996) to measure alliance at the second and fifth sessions of
treatment for patients diagnosed with cocaine dependence.
Barber et al. (1999) reported significant and large same-scale
correlations on both patient alliance measures between the
second and fifth sessions for both the completer (HAqII, r
= .83 and CALPAS, r = .62) and intent-to-treat (HAqII, r
= .78 and CALPAS r = .60) subsamples. These results generally suggest that patient-to-patient ratings of alliance measured at subsequent points in treatment are reliable predictors
of alliance. In addition, Bachelor and Salam (2000) examined the developmental course of patient and therapist-rated
alliance throughout the course of treatment in two separate
studies. In their first study, Bachelor and Salam utilized the
Penn Helping Alliance MethodType 2 (HA 2; experience of
being involved in a joint team effort; Morgan et al., 1982) to
examine the relationship of patient- and therapist-rated alliance at the 3rd, 10th, and next-to-last (NL) therapy sessions.
Bachelor and Salam reported significant and large relationships for both patient-to-patient (3rd through 10th r = .62;
3rd through NL r = .51; and 10th through NL r = .79) and
therapist-to-therapist (3rd to 10th r = .47; 3rd to NL r = .43;
and 10th through NL r = .54) ratings of alliance measured at
the aforementioned measuring points. In their second study,
Bachelor and Salam utilized the Helping Alliance Questionnaire (HAq; Alexander & Luborsky, 1986), WAI short version (WAIS; Tracey & Kokotovic, 1989), and the CALPAS
to examine the relationship of patient- and therapist-rated alliance between the 5th and 10th sessions. Bachelor and
Salam reported that eight of nine same-scale relationships
were significant between the 5th and 10th sessions for patient
ratings of alliance (range of r = .52 to .76). The only
nonsignificant variable was the CALPAS subscale Working
Strategy Concensus (WSC). In regards to therapist ratings in
334
HILSENROTH, PETERS, ACKERMAN
Study 2, Bachelor and Salam found that same-scale correlation coefficients for the HA Method-Type 1 (perceived helpfulness and support of the therapist), WAI Goal and Bond as
well as the CALPAS Therapist Understanding and Involvement, Patient Commitment, and WSC subscales were significant between the 5th and 10th sessions (range of r = .51 to
.72). Finally, Hersoug, Hglend, Monsen, and Havik (2001)
also utilized the WAI total scores to investigate patient- and
therapist-rated alliance throughout the course of psychotherapy (WAIP and WAI Form T [WAIT; Horvath, 1984], respectively). Ratings were collected at the 3rd and 12th
psychotherapy sessions. Hersoug et al. found that same-scale
correlations on the WAIP total scores between Sessions 3
and 12 were significant and large (r = .68). Similarly,
Hersoug et al. reported that same-scale correlations on the
WAIT total scores between Sessions 3 and 12 were also significant and large (r = .67). In sum, the results from all of
these studies utilizing a variety of alliance scales generally
have suggested that patient- and therapist-rated alliance measured early in treatment are reliable predictors of what patients and therapists report alliance to be later in treatment.
Many theorists and researchers have examined the temporally patterned changes of alliance throughout the course of
psychotherapy (e.g., Bordin, 1981; Eaton, Abeles, &
Gutfreund, 1988; Gelso & Carter, 1994; Hill & Corbett,
1993; Mann, 1973). Using hierarchical linear modeling,
Kivlighan and Shaughnessy (1995) examined the pattern of
alliance throughout the course of counseling. Utilizing the
total scores of a WAIS, Kivlighan and Shaughnessy (1995)
collected patient- and therapist-rated alliance ratings after
each counseling session. Kivlighan and Shaughnessy (1995)
found that there was a linear as opposed to quadratic (e.g.,
high-low-high) growth pattern in alliance. However, utilizing cluster analysis, Kivlighan and Shaughnessy (2000)
identified three patterns of patient-rated alliance developmentlinear, stable, and quadratic growthin two separate
patient samples. Most recently, Stiles et al. (2004) distinguished 4 patterns of patient alliance developmentlinear,
stable, negative slope, and positive slopeacross 8 or 16
session treatments of psychodynamic-interpersonal and cognitive-behavioral psychotherapy. Although none of their
groups resembled Kivlighan and Shaughnessys (2000) quadratic growth cluster (32% and 26% in their two patient samples, respectively), Stiles et al. (2004) did report on a
subsample of individual patients (22%) who demonstrated
V-shaped, quadratic, rupture, and repair criteria. In addition,
these patients were most often found in the linear growth
cluster and had greater treatment gains than did other patients, supporting the hypothesis that alliance ruptures represent opportunities for patients to learn about their relational
problems with others and repairs represent such interactions
having taken place in the here and now of the therapeutic relationship (Safran, 1993; Safran & Muran, 2000). The results
of the more recent studies, in part, support Mann (1973) as
well as Gelso and Carters (1994) proposition that for some
but not all patients, the high alliance common to early treat-
ment suffers a decline and then a subsequent return to the initial, or higher, level of positive alliance. As such, these three
studies (Kivlighan & Shaughnessy, 1995, 2000; Stiles et al.,
2004) have provided only limited conclusions. Whereas all
studies have validated a linear growth of alliance throughout
treatment, the two more recent investigations found that alliance may exhibit stable as well as quadratic growth throughout the treatment process. Therefore, further research is
needed to determine which patterns of alliance are most
prevalent.
In sum, these findings over the last two decades have assisted researchers and clinicians to better understand both the
predictive capacity and patterns of alliance throughout the
formal treatment process. It is important to note that when using the term formal treatment process, we mean those treatment sessions occurring after a psychological assessment
period. Few studies have longitudinally examined the predictive relationship of alliance beginning with the psychological
assessment phase of treatment.
Alliance and a Therapeutic Method
of Assessment
Ackerman, Hilsenroth, Baity, and Blagys (2000) utilized the
Combined Alliance Short Form (CASF; Hatcher & Barends,
1996) to examine the relationship between patient-rated alliance developed during psychological assessment and an
early session of formal psychotherapy (i.e., third or fourth
session). In this study, Ackerman et al. utilized a Therapeutic
Model of Assessment (TMA; Finn & Tonsager, 1992, 1997;
Fischer, 1994), a relatively new and different approach to
psychological assessment that seeks to integrate aspects of
patientclinician interactions more commonly found in the
course of psychotherapy, especially collaborative goal setting and focusing on developing a therapeutic bond in the assessment phase of treatment (see Methods section following). Specifically, the utility of the TMA model was
compared to a traditional information-gathering (IG) model
of assessment in relation to alliance building. Results indicated that a patients experience of the assessment feedback
session was significantly related to therapeutic alliance total
scale scores (Depth, r = .66; Positivity, r = .64; Smoothness, r
= .46; Arousal, r = .41). Patient-rated alliance measured immediately following the assessment feedback session was
significantly related to patient-rated alliance measured early
(third session) in formal treatment (r = .63). Also, patients in
the TMA group were less likely to terminate before the initiation of formal treatment relative to those patients in the IG
group, 2(N = 128) = 5.5, p = .02. Ackerman et al. concluded
that the additional time investment required for a complex
and collaborative assessment is acceptable to patients given
the positive effects a depth-oriented feedback session had on
alliance at the early stages of treatment. Similarly, Tryon
(1990) reported significant differences for both patient, F(1,
237) = 7.33, p < .008 and therapist, F(1, 237) = 33.88, p <
.0001 ratings of session depth for those patients returning af-
335
ASSESSMENT ALLIANCE
ter an intake interview than those patients who did not return
to begin treatment. In Tryons study, continuation into treatment was associated with higher levels of depth, an active
collaboration, and the development of insight as well as a focus on interpersonal functioning during the intake interview.
In a more recent study, Svensson and Hansson (1999) reported similar results with patient ratings of the therapeutic
alliance in the initial phase of cognitive treatment significantly related (r = .69) to increased session depth (i.e., increased exploration of salient interpersonal themes in a powerful, valuable, deep, full, and special way).
Purpose of This Study

In this study, we examined the utility of the clinical personality assessment process (i.e., integrative assessment and feedback) as a factor influencing psychotherapy process. Several
studies have found that therapeutic alliance established early
in psychotherapy (i.e., by approximately the third session) is
highly related to later process and outcome. In this work, we
examined if patienttherapist contact during psychological
assessment provided the same or similar basis for alliance as
formal psychotherapy sessions with regard to the therapeutic
relationship at the end of treatment. Thus, psychological assessment might be considered as a fertile ground from which
important and longstanding relational interactions with the
therapist may develop. This study is distinctive in that it is the
first to examine the predictive relationship of patient- and
therapist-rated alliance longitudinally from psychological
assessment through the end of treatment. More specifically,
we longitudinally examined the relationship between patient
and therapist evaluations of alliance measured during the
psychological assessment stage of treatment with their later
ratings of alliance (respectively) at both an early and late
treatment session. Specifically, we hypothesized that (a) the
therapeutic alliance reported by the patient and therapist during the assessment phase of treatment would be significant
and positively related to their subsequent alliance ratings (respectively) early in formal psychotherapy, (b) the therapeutic
alliance reported by the patient and therapist during the assessment phase of treatment would be significant and positively related to their subsequent alliance ratings (respectively) late in formal psychotherapy, and (c) the therapeutic
alliance of patients who take part in a more collaborative and
therapeutically oriented model of psychological assessment
would report a significantly greater level of alliance than
those receiving a standard model (i.e., assessment as usual)
of psychological assessment.
METHOD
Participants
In this study, we present an extension of the Ackerman et al.
(2000) investigation by substantially increasing the number
of patienttherapist dyads within the project data set
(Hilsenroth, 2002) as well as the scope of analyses conducted

in that previous work. As such, the patient and therapist ratings presented in Ackerman et al. represent a subsample of
the data we present here. All participants were representative
of those actually seeking outpatient treatment at a university-based community clinic. Cases were assigned to treatment practicum and clinicians in an ecologically valid manner based on real-world issues regarding aspects of clinician
availability, caseload, and so forth. Moreover, patients were
accepted into treatment regardless of disorder or
comorbidity. The participants utilized in this study were 42
patients admitted to a psychodynamic psychotherapy treatment team (PPTT) at a university-based community outpatient clinic. All patients included in the analyses had attended
a minimum of nine psychotherapy sessions and had completed, at least, a ninth session reassessment battery. Table 1
displays demographic information as well as the distribution
of patients primary Axes I as well as Axis II diagnoses for
the entire sample in accordance with the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSMIV];
American Psychiatric Association, 1994). All 42 patients in
this study received a DSMIV Axis I diagnosis. Commensurate with samples drawn from other university-based community outpatient clinics, the level of psychological/emotional distress of the patients in this treatment program was
primarily in the mild to moderate range of impairment as evidenced by DSMIV diagnostic categories, clinician rating
scales, and self-report measures (Hilsenroth, Ackerman, &
Blagys, 2001; Hilsenroth, Ackerman, Blagys, Baity, & Mooney, 2003; Hilsenroth et al., 2000; Hilsenroth, Callahan, &
Eudell, 2003).
Mean number of sessions attended by these 42 patients
was 25 sessions. Premature termination of the patients in this
treatment program has been examined in several different
contexts utilizing various criteria and has ranged from 12%
to 18% (Ackerman et al., 2000; Hilsenroth et al., 2001;
TABLE 1
Demographic Information of Sample
Demographic Variable
Gender
Male
Female
M age (years)
Marital status
Single
Married
Separated/divorced
Primary Axis I diagnosis
Adjustment disorder
Anxiety disorder
Eating disorder
Mood disorder
Substance-related disorder
V Code relational problem
Axis II diagnosis
Axis II traits/features
M Intake GAF
Note.
No.
14
28
30.6
33
67
22
10
10
52
24
24
6
3
1
27
1
4
18
9
61.3
14
7
2
65
2
10
42
21
N = 42. GAF = Global Assessment Functioning.
336
Hilsenroth, Ackerman, et al., 2003; Price, Hilsenroth,

Callahan, Petretic-Jackson, & Bonge, 2004). These values
are substantially lower than the 43% to 51% dropout rate (M
= 47%) that has been found across various clinical settings
(Reis & Brown, 1999; Weirzbicki & Pekarik, 1993).
Therapists
The clinicians who conducted the assessment and psychotherapy were 18 advanced doctoral students (7 men and 11
women) enrolled in an American Psychological Association approved Clinical PhD program. Regarding the patient
sample utilized in this study, 2 of the therapists treated 4
patients, 6 therapists treated 3 patients, 4 therapists treated
2 patients, and 6 therapists treated 1 patient. The study supervisor (MJH), a PhD licensed psychologist, also treated
two patients in this investigation and utilized these treatments in a continuing case conference to augment therapist
training. Each clinician received a minimum of 3.5 hr of supervision per week (1.5 hr of individual and 2 hr of group)
on the TMA, clinical interventions, the organization of collaborative feedback, psychodynamic theory, group discussion, and a review of videotaped case material. Also, clinicians had available additional (blocked) supervision time,
as needed as well as the option to attend the ongoing case
conference (1.5 hr) of a training case provided by the clinical supervisor. All clinicians were trained in
psychodynamic psychotherapy using guidelines delineated
by Book (1998), Luborsky (1984), Strupp and Binder
(1984), and Wachtel (1993) as well as selected readings on
psychological assessment, psychodynamic theory, and
psychodynamic psychotherapy. A major focus of the training was on the supportive/expressive core conflictual relational theme (CCRT; Luborsky & Crits-Cristoph, 1997)
techniques utilizing Book (1998) and Luborsky (1984) as
primary texts. It is important to note that these manuals
were used for intensive training in technique to help aim,
inform, and guide treatment, not for rigidly structuring or
prescribing the treatment or individual sessions. This training method was used to focus supervision and help therapists gain proficiency in key techniques to best address
each individual patients needs in and across different sessions in an optimally responsive manner.
Key features of the short-term psychodynamic psychotherapy (STPP) treatment model used in this study include
(Blagys & Hilsenroth, 2000):
1. Focus on affect and the expression of emotion.
2. Exploration of attempts to avoid topics or engage in
activities that may hinder the progress of therapy.
3. The identification of patterns in actions, thoughts,
feelings, experiences, and relationships. These relational patterns were explored/formulated using the
CCRT format (Luborsky & Crits-Christoph, 1997).
4. Emphasis on past experiences.
5. Focus on interpersonal experiences.
6. Emphasis on the therapeutic relationship/alliance.

7. Exploration of wishes, dreams, or fantasies.
In addition to these areas of treatment focus, case presentations and symptoms were conceptualized in the context of interpersonal/intrapsychic conflict (Luborsky & CritsChristoph, 1997). Finally, when a termination date was set in
the treatment, this became a frequent area of intervention. Issues related to the termination were often linked to key interpersonal, affective, and thought patterns prominent in that
patients treatment. Treatment was open-ended in length
rather than of a fixed duration. The length of treatment was
determined by the clinicians judgment, patients decision,
progress toward goals, and life changes.
Psychological Assessment Process
Patients first received a psychological evaluation from a TMA
(Finn and Tonsager, 1992, 1997; Fischer, 1994) that includes a
broadened focus of attention beyond the scope of basic IG assessment. A TMA attempts to optimize the evaluation phase
with its utilization of a multimethod assessment (i.e., interview, self-report, performance tasks, and free response measures) as well as a heightened focus on collaboration, alliance
building, and factors contributing to the maintenance of life
problems (often relational). In a TMA, the assessors are committed to (a) developing and maintaining empathic connections with clients, (b) working collaboratively with clients to
define individualized assessment goals, and (c) sharing and
exploring assessment results with clients (Finn & Tonsager,
1997, p. 378). By expanding the focus of assessment, both patient and clinician gain knowledge about treatment issues that
in turn provides the opportunity for a more genuine interaction
during the assessment phase as well as subsequent formal psychotherapy sessions. The evaluation method of the TMA used
in this study consisted of four steps including three meetings
between the patient and clinician and one patient appointment
to complete a battery of self-report measures. The three meetings included (a) a semistructured diagnostic interview, (b) interview follow-up, and (c) a collaborative feedback session.
Further details of the measures, methodology, and procedures
utilized in this assessment process are described more fully
elsewhere (see Ackerman et al., 2000; Hilsenroth, 2002). Due
to the distinctiveness of the collaborative feedback session, reiteration is warranted concerning this final meeting of the psychological assessment.
Collaborative Feedback Session
In preparation for the collaborative feedback session, the clinician scored all assessment measures and rated the patient
using the DSMIV multiaxial evaluation report form (MERF;
American Psychiatric Association, 1994, p. 34). The MERF
includes a DSMIV diagnosis, a list of specific diagnostic criteria met, and the Axis V Global Assessment of Functioning
Scale (GAF; American Psychiatric Association, 1994, p. 32).
ASSESSMENT ALLIANCE
All clinicians received a minimum of 1.5 hr of individual supervision to develop a comprehensive outline of the information to be presented in the feedback session. Each collaborative feedback session was guided by the principles of a TMA
(Finn & Tonsager, 1992, 1997; Fischer, 1994). Additionally,
during the feedback session, there was an emphasis on the
factors that contribute to the clinicianpatient interaction.
The goal of the collaborative feedback session was to provide the patient with a new way of thinking and feeling about
self and others. In addition, the patient was given the opportunity to explore these new understandings and apply them to
their current problems in living.
It is recommended in a TMA that clients should first be
given feedback that closely matches their own preconceptions and then be presented with information that is progressively more discrepant from their self-concepts (Finn &
Tonsager, 1997, p. 380; Fischer, 1994). Additionally, in a
TMA, psychological test measures are viewed as opportunities for dialogue between assessors and clients about clients
characteristic ways of responding to usual problem situations
and tools for enhancing assessors empathy about clients
subjective experience (Finn & Tonsager, 1997, p. 378;
Fischer, 1994). This viewpoint is meant to facilitate an empathic connection between the clinician and patient while
helping the clinician work collaboratively with the patient to
cultivate the therapeutic alliance.
In this study, the patient was initially given feedback related to his or her presenting complaints and symptoms (ego
syntonic). Next, the clinician and patient engaged in an exploration of prominent interpersonal and intrapersonal
themes from the testing results. Specifically, the predominant relational themes were explored to foster the development of an initial CCRT interpretation during the feedback
session prior to treatment (see also Malan, 1979). The exploration of the CCRT may help the clinician focus on collaboration, alliance building, examination of factors contributing
to the maintenance of life problems (often relational), and
potential solutions. During this exploration, the clinician often expands the patients understanding of relational themes.
The use of relational data in this manner may increase the patients self-understanding and contribute to the patient feeling even more understood by the clinician.
At this time, the patient and clinician reviewed a Socialization Interview (SI) developed by Luborsky (1984). The SI
reviews what to expect in psychodynamic psychotherapy and
outlines the patients and clinicians role during formal treatment. More specifically, it emphasizes that the clinician will
try to understand the patient and work collaboratively toward
actualizing treatment goals. The SI also reviews with the patient that he or she may become aware of issues that were not
known before the start of psychotherapy and outlines potential reactions (both positive and negative) of this new insight
(Luborsky, 1984). It is believed that the presentation of the SI
at this time enhanced the patients understanding of psychotherapy and highlighted the relational focus of the therapeutic process. Finally, the clinician and patient worked together
337
to develop treatment goals and negotiate a treatment frame

(i.e., scheduling session times, frequency of treatment sessions, and payment plan).
Procedure
Patients seeking treatment were asked to take part in a psychotherapy research study, and no patients were excluded
due to a priori criteria such as diagnosis or comorbidity.
Cases were assigned to therapists on the basis of clinician
availability, size of caseload, and various other practical considerations typical of the routine functioning of a psychological clinic. Each participant provided written informed consent to be included in program evaluation research. In all
cases, the clinician who carried out the assessment was also
the clinician who conducted the formal psychotherapy sessions. Patients and therapists completed assessment of patient functioning on a standard battery of process measures
immediately following the collaborative feedback session
and after selected psychotherapy sessions throughout the
treatment (3, 9, 15, 21, 27, 36, 52, 64, 76, etc.). Thus, each
member of the patienttherapist dyad completed these questionnaires concurrently and immediately after the same session. That is, there were two separate but comparable alliance
measures, one completed by the patient and one completed
by the therapist at any given assessment. At the end of treatment, all patients in the sample completed an exit evaluation.
All patients included in the analyses had attended a minimum
of nine sessions and had completed, at least, a ninth session
reassessment battery. In addition, patients were informed
both verbally and in writing at the top of the measure that
their therapist would not have access to their responses on the
alliance measure.
Measures
CASFP. The CASFPatient Version (CASFP;

Hatcher & Barends, 1996) is a patient-rated alliance measure
created from a factor analysis of the responses of 231 outpatients at a university-based community clinic from three
widely used measures of alliance: (a) the Penn HAq (Alexander & Luborsky, 1986), (b) the WAI (Horvath & Greenberg,
1989), and (c) the CALPAS (Gaston, 1991). The CASFP is
unique in that it consists of those items with the highest loadings when these three widely accepted but somewhat distinct
measures of alliance were examined together. It is also important to note the generalizability of the CASFP test construction sample with the psychodynamic psychotherapy
conducted in this study as well as the similar settings (i.e.,
university-based community clinic) where the data was collected.
The CASFP consists of 20 items rated on a 7-point
Likert-type scale consisting of 1 (never), 2 (rarely), 3 (occasionally), 4 (sometimes), 5 (often), 6 (very often), and 7 (always). An examination of the internal consistency of this
measure has demonstrated a total scale coefficient alpha of
338
.93 (R. L. Hatcher, personal communication, June 24, 1997)

as well as a coefficient alpha of .91 for the total scale using a
subset of these participants (Ackerman et al., 2000).
CASFT. The CASFTherapist Version (CASFT;

Hatcher, 1999) was developed through a factor analysis of
two major alliance measures, the WAIT (Horvath, 1984)
and the CALPAS Therapist Version (CALPAST; Gaston &
Marmar, 1991), using responses from two samples. The first
was a national sample consisting of practicing therapists ratings on one patient from their current practice (n = 251). The
second was a clinical sample consisting of 63 therapists who
completed ratings on 259 different patients.
The results of the principal components analysis yielded
three factors of items and subscales retained from the WAIT
and CALPAST scales. The first two factors were consistent
with items and subscales retained from the original measures.
Previous research has found coefficient alphas ranging from
.75 to .86 for the retained components of the original WAIT
and .79 to .88 for the retained components of the original
CALPAST (Hatcher, 1999). The final scale contains those
items from both the original CALPAS and the original WAI
that loaded as a factor called the Therapist Confident Collaboration scale (TCC; e.g., My patient has confidence in therapy
and me, and As a result of these sessions, my patient is
clearer as to how he/she might be able to change). The TCC
scale is made up of retained items from both the Hatcher
(1999) CALPAS and WAI scales. An alpha of .87 was found
for two samples used in the creation of this scale (Hatcher,
1999). In addition, an examination of the internal consistency
of the CASFT using a subset of our participants found coefficients alphas ranging from .74 to .91 for scales retained from
the original WAIT and CALPAST as well as .88 for the
TCC scale (Clemence, Hilsenroth, Ackerman, Strassle, &
Handler, 2004). Ratings on the CASFT are reported on the
same 7-point Likert-type scale as described for the CASFP,
ranging from 1 (never) to 7 (always).
Statistical Analyses
Mean scores were reported for the different alliance scores
(CASFP Total, WAITotal, CALPASTotal, and the TCC)
at three points: following the assessment feedback session
(assessment), third or fourth session (early), and the session
(M = 23.7) at which approximately 90% of the treatment was
completed (late; see Luborsky et al., 1983). Next, repeated
measures analyses of variance (ANOVAs) were performed to
examine any significant changes across these three points in
treatment. When significant variation was found across treatment, Scheffes procedure for post hoc group comparisons
was used to determine between which assessment points in
treatment this difference occurred. Examination of individual variation in patient alliance scores across treatment were
also evaluated using similar criteria to those described in
Stiles et al. (2004). In addition, Pearson r productmoment
correlations were calculated to examine the relationship be-
tween CASFP Total, WAITotal, CALPASTotal, and the

TCC between three points: assessment, early, and late in
treatment. Partial correlations were then calculated to examine the relationship between assessment and late alliance,
controlling for the effects of early alliance, as well as the relationship between early and late alliance, controlling for the
effects assessment alliance. Finally, a comparison of patient
alliance scores between this sample receiving TMA and a
control group was conducted.
All statistical analyses used an alpha level of .05
(two-tailed) for significance. When group comparisons were
examined, Cohens d was calculated using pooled standard
deviations, and these effects were weighted for unequal sample size when necessary (Cohen, 1988). Based on Cohens
(1998) recommendation, d values of .2, .5, and .8 were used
to represent small, medium, and large effects, respectively.
Estimates of effect size for correlation coefficients are considered small effects around .1, a medium effect around .3,
and a large effect around .5 and greater (Cohen, 1988).
Finally, due to considerations of statistical power and the
presence of other extant research (Clemence et al., 2004), it is
important to note that in this study, we do not report on the relationship between therapist and patient ratings of alliance at
the various points in treatment. Again, all reported correlations compare patient-to-patient and therapist-to-therapist
ratings longitudinally across psychotherapy.
RESULTS
Patient and Therapist Mean Alliance Ratings
Across Treatment
Table 2 represents the means and standard deviations of the
CASFP and CASFT ratings at assessment, early, and late
in treatment. The mean of the patient alliance total score indicated a very positive perception of the therapeutic alliance at
each point in treatment (i.e., 6 = very often). As can be seen in
Table 2, patients reported high levels of therapeutic alliance
throughout the treatment process. Table 2 also reports the
means and standard deviations of the CASFT ratings from
assessment, early, and late in treatment. The means of the
therapist alliance total scores indicated a positive perception
of the therapeutic alliance at each point in treatment (i.e., 5 =
often and 6 = very often). As can be seen in Table 2, therapists
also reported a positive perception of the alliance throughout
the treatment process. All of the alliance ratings are high considering they are on a 7-point scale with higher ratings reflecting a stronger rating of the alliance.
Repeated measures ANOVAs were used to examine any
changes across the three points in treatment for the patient
and therapist ratings of alliance. CASFP scores demonstrated a trend toward significance across the three points in
treatment, F(2, 82) = 2.9, p = .06. An examination of
Scheffes procedure for post hoc group comparisons revealed a trend toward significance between the patient early
ASSESSMENT ALLIANCE
TABLE 2
Means and Standard Deviations
of the CASFP and CASFT Scales
Across Treatment
Assessment
CASF Scale
CASFP
Total score
CASFT
WAITotal score
CALPASTotal score
TCC
Early
Late
SD
SD
SD
6.10
0.64
6.04
0.67
6.21
0.64
5.72
5.21
5.40
0.39
0.54
0.68
6.04
4.99
5.05
0.40
0.58
0.66
5.79
5.37
5.39
0.54
0.79
1.02
Note. N = 42. CASFP and CASFT are 7-point Likert-type scales ranging
from 1 (never), 2 (rarely), 3 (occasionally), 4 (sometimes), 5 (often), 6 (very
often), to 7 (always). CASFP = Combined Alliance Short FormPatient;
CASFT = CASFTherapist; assessment = feedback session; early =
third/fourth session of formal treatment; late = 90% of treatment completed;
WAI = Working Alliance Inventory; CALPAS = California Psychotherapy
Alliance Scale; TCC = Therapist Confident Collaboration Scale.
versus late session alliance scores (p = .07, d = .26), which indicated slightly higher patient alliance scores at the end of
treatment. Although Therapist WAITotal scores revealed
no significant differences across treatment, F(2, 82) = 1.1, p
= .33, Therapist CALPASTotal and TCC subscales demonstrated significant variation across treatment, F(2, 82) = 6.8,
p = .001 and F(2, 82) = 4.2, p = .01, respectively). Scheffes
procedure for post hoc group comparisons revealed a significance difference between Therapist CALPASTotal early
versus late session alliance scores (p = .002, d = .55), which
indicated higher therapist alliance scores at the end of treatment. This same pattern of results was also found in the examination of post hoc group comparisons of the TCC
subscale, with higher levels of alliance reported late in treatment compared to that at the third or fourth session (p = .04, d
= .40). In addition, TCC at assessment was also found to be
significantly greater than at the third or fourth session (p =
.04, d = .52). Finally, it is important to note that in all post hoc
group comparisons of patient and therapist alliance presented
previously, early treatment (third or fourth session) scores
demonstrated lower levels of alliance than alliance ratings at
the assessment and late treatment comparison points.
Although an analysis of group means are important, we felt
that it would also be potentially useful to examine alliance
scores across the course of treatment at the individual patient
level. However, because our assessment points were limited
(i.e., three) and not always consistent (i.e., early session could
be third or fourth session and late session was variable), the
data is not suitable for hierarchical linear modeling or cluster
analysis. Therefore, to evaluate positive, stable, quadratic, or
negative change for each of our patients across the three ratings points during treatment, we utilized a slight modification
of the criteria presented in Stiles et al. (2004). Significant
change across the different assessment points was defined as
movement by at least 2 SDs. For this criterion, we first calculated the pooled standard deviation across the patient alliance
339
ratings at the three assessment points (.65) and then multiplied

this number by 2 (1.30). Thus, a change in a patients alliance
ratings of 1.30 points above or below the assessment or early
evaluations in relation to the late treatment alliance ratings
would constitute one of the three categories of change (i.e.,
positive, quadratic, or negative) and movement of less than
1.30 points across the three points in treatment would be classified as a relatively stable alliance. In regard to the additional
rupturerepair criteria, these were exactly similar to those reported by Stiles et al.: Low score was not the first or last session; overall change was nonnegative (i.e., patient late alliance
rating was at least equal to or greater than alliance score at assessment); and the rupture score was numerically lower (i.e.,
1.30 points) than the preceding score and lower than 6.0 on the
7.0 CASFP scale.
With these criteria in place, we found that 35 (83%) patients demonstrated stable patterns of alliance with limited
fluctuation (< 1.30 points) in alliance scores across these
three points in treatment. It seems our patient sample finished
the TMA feedback session with high alliance ratings (M =
6.1, SD = .64, range = 4.5 to 6.9) that were in large part consistent with their later alliance ratings both early (M = 6.04,
SD = .67, range = 4.45 to 7.0) and late (M = 6.21, SD = .64,
range = 4.0 to 7.0) in treatment. Of the 7 patients showing
fluctuations across the three points in treatment 1 (2%) demonstrated a negative change (1.30 points), 2 (5%) demonstrated a positive change (+ 1.30 points), and 4 (10%)
demonstrated a quadratic ( 1.30 points, high-low-high)
change across treatment.
Patient and Therapist Alliance Ratings
Across Treatment
Table 3 presents Pearsons r correlations between patient assessment and early alliance ratings, patient assessment and
late alliance ratings as well as patient early and late alliance
ratings. All correlations were in the expected positive direction and were significantly correlated at the aforementioned
temporal points of analysis. Patient CASF total scores were
significantly related between the assessment-early session,
assessment-late session, and early-late session. This indicates patients who perceived a strong alliance during the assessment phase also perceived a strong alliance as treatment
progressed. In addition, the partial correlation for CASFP
assessment-late session was significant and exhibited a moderate effect indicating that a significant relationship between
patient ratings of alliance at assessment and late in therapy
occurred independent of patient alliance early in treatment.
Similarly, a significant and moderate to large effect was also
found for the partial correlation for CASFP early-late session indicating that a significant relationship between patient
ratings of alliance at early and late in therapy occurred independent of patient alliance at Assessment.
Table 3 also represents Pearsons r correlations between
therapist assessment and early alliance ratings, therapist assessment and late alliance ratings as well as therapist early
340

TABLE 3
Bivariate (r) and Partial (pr) Correlations
of the CASFP and CASFT Scales
Across Treatment
AssessmentEarly
CASF Scale
CASFP
Total score
CASFT
WAITotal
score
CALPASTotal
score
TCC
Assessment-Late
ratings of alliance early in treatment, although small effects

were still observed.
Impact of TMA on Patient Ratings of Alliance:
Control Group Comparison
Early-Late
pr
pr
.73***
.73***
.39**
.76***
.49**
.44**
.36*
.21
.43**
.32*
.63***
.48**
.55***
.30*
.45**
.11
.36*
.45**
.02
.36*
Note. N = 42. prs examine the relationship between at assessment and late
alliance, controlling for the effects of early alliance as well as, conversely, the
relationship between early and late alliance, controlling for the effects
assessment alliance. CASFP = Combined Alliance Short FormPatient;
CASFT = CASFTherapist; assessment = feedback session; early =
third/fourth session of formal treatment; late = 90% of the treatment
completed; WAI = Working Alliance Inventory; CALPAS = California
Psychotherapy Alliance Scale; TCC = Therapist Confident Collaboration
Scale.
*p .05. **p < .01. ***p .0001.
and late alliance ratings. All correlations were in the expected positive direction and were significantly correlated at
the aforementioned temporal points of analysis. Correlations
for the WAITotal were significant and represented medium
effects for the assessment-early, assessment-late, and
early-late relationships. Correlations for the Therapist
CALPASTotal were significant and large between assessment early and assessment late. The magnitude of effect between early and late was significant and medium.
Correlations for TCC between assessment early, assessment
late, and early and late exhibited significant as well as moderate to large effects. These results suggest that therapists who
perceived a strong alliance during the assessment phase also
perceived a strong alliance as treatment progressed.
The partial correlation for CALPAST was significant
and exhibited a moderate to large effect, which indicated that
a significant relationship between these therapist ratings of
alliance at assessment and late in therapy occurred independent of therapist alliance early in treatment. The same can not
be said of the relationship between early and late alliance
scores on the CALPAST that were found to be virtually unrelated to one another when the effects of alliance at assessment were controlled for. Conversely, the partial correlation
for the WAIT and TCC was significant and exhibited a
moderate effect, which indicated that a significant relationship between these therapist ratings of alliance early and late
in therapy occurred independent of therapist alliance at assessment. Finally, the partial correlation for the WAIT and
TCC were nonsignificant between these therapist ratings of
assessment and late alliance after controlling for therapist
Thus far we have only examined the relationship of the alliance established during the assessment process with subsequent ratings of alliance both early and late in psychotherapy.
However, to evaluate the efficacy of TMA on patient ratings
of alliance at the assessment feedback session, we sought to
compare this group with a set of CASF alliance ratings from
patients who undertook a standard, IG model of assessment.
To conduct such an investigation, we performed two new
analyses on some previously published data (Hilsenroth,
Ackerman, Clemence, Strassle, & Handler, 2002). In this
prior work, Hilsenroth et al. (2002) reported on an investigation of 34 outpatients who received psychotherapy from clinicians who had undergone structured training in TMA as
well as STPP and a second group of 34 outpatients that were
assessed using a standard IG model of assessment and received general, nonstructured (i.e., no deliberate or organized
use of training texts) training in psychodynamic-eclectic
treatment. Groups were matched on key demographic (i.e.,
gender, age, and marital status) and clinical variables (i.e.,
Axis I and II Dx, intake GAF, and Symptom Checklist90RGSI [Derogatis, 1994]). Results demonstrated
significant differences between the two groups early
(third/fourth session) in psychotherapy on both patient and
therapist rated alliance variables of bond, goals, and tasks as
well as overall alliance with higher scores from those in the
structured clinical training group (TMA and STPP).
To provide a greater integration with the findings from the
Hilsenroth et al. (2002) study with our data (the 34 TMA and
STPP patients in Hilsenroth et al., 2002, are a subsample of
our data set here), we decided to return to this matched sample (34 TMA and 34 IG) of patients for two new analyses of
patient rated alliance (CASFP) at different points in the
treatment process. First, we examined the difference between
the 34 TMA patient alliance ratings after the assessment
feedback session (M = 6.13, SD = .59) and the 34 IG patient
alliance ratings after Session 1 (M = 5.44, SD = .75). This
analysis demonstrated significant differences between
groups, F(1, 66) = 17.57, p < .0001, with the TMA group
having demonstrated a large effect over the IG control group
(d = 1.02). This effect remained large (d = .96) when we calculated a weighted effect size using all 42 TMA patient alliance ratings at assessment (M = 6.1, SD = .64) in our current
sample. Second, we examined the difference between the 34
TMA patient alliance ratings after the assessment feedback
session (M = 6.13, SD = .59) and the 34 IG patient alliance
ratings early in treatment (third/fourth session; M = 5.58, SD
= 1.07). This analysis demonstrated significant differences
between groups, F(1, 66) = 6.73, p = .01, with the TMA
group having demonstrated a moderate effect over the IG
control group (d = .64). This effect remained moderate (d =
ASSESSMENT ALLIANCE
.61) when we calculated a weighted effect size using all 42
TMA patient alliance ratings at assessment (M = 6.1, SD =
.64) our current sample.
DISCUSSION
There are six major implications of this study regarding the
development of therapeutic alliance during the psychological
assessment process and subsequently across the course of
treatment. First, an evaluation of alliance ratings at all three
measurement points, in relation to prior research and the
scale point descriptors, suggested that patients and therapists alliance was high, and both parties felt confident in
their work together and connected to one another across the
treatment process. That is, the patients in this study reported
alliance scores as high or higher during the psychological assessment process as other points in their treatment. Thus, the
findings of this study clearly indicate that the process of psychological assessment (or at least the assessment process in
this study) did not impair or inhibit the therapeutic relationship and connection. Second, patient alliance measured as
early as the assessment phase of treatment was significantly
and positively related to alliance at both early and late stages
of treatment. Third, this relationship between patient alliance
developed during the psychological assessment process remained significantly related to alliance late in treatment even
after controlling for the effects of alliance early into formal
psychotherapy. Fourth, therapist alliance measured as early
as the assessment phase of treatment was significantly and
positively related to alliance at both early and late stages of
treatment. Fifth, for some perspectives of therapist alliance,
this relationship developed during the psychological assessment process remained significantly related to alliance late in
treatment even after controlling for the effects of alliance
early into formal psychotherapy. Finally, it appeared that the
collaborative patienttherapist interactions developed during
a TMA helped enhance the patient ratings of alliance. This
was true in relation to alliance measured after the first session
as well as early (third or fourth session) in psychotherapy
sessions when a standard, IG, model of assessment was utilized. In sum, both patients and therapists involved in a TMA
reported having a sense that the treatment was moving in a
forward direction and that the relationship was constructive,
collaborative, and of meaningful effort from as early as the
psychological assessment process that was sustained across
the length of treatment. Thus, the hypotheses that patient and
therapist alliance ratings at assessment would be positively
related to patient and therapist alliance ratings at subsequent
points in treatment were strongly supported by the data in
this study.
The results of this study are supportive of and consistent
with previous research examining patient and therapist ratings of alliance at various points in psychotherapy. Our observed effect between patients rated alliance at two points
early into treatment (r = .73; assessment feedback with Ses-
341
sion 3 or 4) was virtually identical to the findings of Barber et

al. (2000; r = .70, Session 2 with Session 5). The consistency
of these findings makes a great deal of sense in that both samples were outpatients specifically receiving the same manually
guided
supportive-expressive
psychodynamic
psychotherapy (Luborsky, 1984). This finding is also consistent with the large effects that have been reported in other
studies (range of r = .59 to .83) utilizing psychodynamic as
well as other treatment approaches with a variety of diagnostic groups to investigate patient alliance ratings from two sessions early or in the first half of treatment (Bachelor &
Salam, 2000; Barber et al., 1999; Brossart et al., 1998;
Hersoug et al., 2001). Likewise, our observed effect between
patients rated alliance early and late in treatment (r = .76)
were consistent with the large effects that have been reported
in other studies (range of r = .56 to .79) utilizing humanistic,
existential, psychodynamic, and other treatment approaches
with a variety of diagnostic samples (Bachelor & Salam,
2000; Brossart et al., 1998; Paivio & Bahr, 1998; Paivio
&Patterson, 1999).
Our moderate to large effects (range of r = .44 to .63) found
for the therapist alliance ratings between two points early in
the treatment process were consistent with previous findings
during the same time period (range of r = .47 to .67) for therapists of psychodynamic and other treatment orientations
working with a variety of patient samples (Bachelor &
Salam, 2000; Brossart et al., 1998; Hersoug et al., 2001).
However, our observed moderate effects between therapist-rated alliance early and late in treatment (range of r = .36
to .45) were slightly lower than the moderate to large effects
that have been reported in other studies reported by therapists
(range of r = .43 to .64) or trained external raters (range of r =
.53 to .58) from psychodynamic and other treatment orientations working with a variety of patient groups (Bachelor &
Salam, 2000; Brossart et al., 1998; Luborsky et al., 1983).
The consistently largest therapist rated alliance effects in this
study were for the CALPAST scores (range of r = .36 to .63).
It is also important to note a potential methodological issue regarding this finding. A close examination of the WAI reveals
questions that predominantly focus a great deal on the therapists perception of the alliance, whereas the CALPAS items
often elicit therapists inference of how the patient perceives
the alliance (Hatcher, 1999). This difference in item content
between the two measures may lead to qualitative differences
in understanding data as representing the therapists alliance
to the patients or the therapists ability to accurately perceive
the patients investment in the alliance.
The pattern of correlations across the three points in treatment demonstrated markedly large effects (range of r = .73 to
.76) for the patient alliance ratings, whereas primarily moderate to large effects (range of r = .30 to .63) for the various
therapist alliance scales. These results were actually quite
consistent with the findings of Bachelor and Salam (2000;
HA 2, patient range of r = .51 to .79 and therapist range of r =
.43 to .54) who used the most similar dispersion of assessment points to our study, including their mean number of
342
treatment sessions, which was 26. In addition, it has been a

consistent finding in the extant literature that patient ratings
of alliance, in relation to therapist ratings, are generally
higher in magnitude, more related to psychotherapy outcomes, and possess greater consistency across treatment
(Bachelor & Salam, 2000; Barber et al., 1999; Hersoug et
al., 2001; Horvath, 2001; Martin et al., 2000).
Patient and therapist mean alliance scores for the sample
were quite similar at assessment and late therapy sessions,
with a very slight and temporary decrease early
(third/fourth session) in treatment. Examining the individual patient and therapist alliance scores in this study revealed four previously identified patterns of alliance
development (stable, positive, negative, and quadratic
growth). Although, any fluctuations that did occur were
limited in degree, as the vast majority of our patients had
relatively stable and high ratings of alliance at each rating
point during the treatment. It is also quite possible that had
more frequent assessments of therapeutic alliance been
conducted, the opportunity for observing quadratic change
would have increased. The evaluation of alliance at only
three points in treatment is clearly a limitation of this set of
analyses. Additional future research using more frequent
assessments of therapeutic alliance, varying diagnostic
samples and levels of psychopathology, different statistical
methodologies as well as varying treatment modalities
would add favorably to our understanding of alliance from
assessment through the course of psychotherapy.
Although our findings demonstrate that the therapeutic alliance developed during the psychological assessment process
is significantly and positively related to subsequent ratings of
alliance across the course of treatment, one might reasonably
wonder if this finding had any relevance to the other clinical
process or outcomes of this sample. In other words, if this sample failed to demonstrate any significant process or outcome
results, then discussion of alliance developed during the psychological assessment would be largely irrelevant. Or, the focus of this investigation might then shift to the identification of
assessment processes and techniques that are to be avoided.
However, the results of this investigation were consistent with
several positive clinical process and outcome studies from
larger programmatic research on a TMA and STPP
(Hilsenroth, 2002). First, the patients in this research program
demonstrated a significantly lower premature termination rate
during the assessment process than a comparison group (13%
vs. 33%; N = 128; 2 = 5.5, p = .02, r = .21; Ackerman et al.,
2000) as well as a substantially lower rate of premature termination than a comparison group during psychotherapy (12%
vs. 30%; N = 79; 2 = 3.32, p = .07, r = .21; Hilsenroth et al.,
2001). Second, as reviewed earlier, patient and therapist ratings of early (third/fourth) session alliance have demonstrated
significant positive differences (i.e., higher) for the variables
of Bond (patient d = .50, therapist d = .73), Goals and Tasks
(patient d = .66, therapist d = .80) as well as overall alliance
(patient d = .52, therapist d = .69) in comparison with a
nonstructured psychodynamic training/supervision as usual
treatment group (Hilsenroth et al., 2002). Third, as part of a

larger collaborative site project, several significant relationships were demonstrated between patient and therapist alliance scores. Of specific note was the convergence between
patient and therapist confident collaboration subscales (r =
.37, p < .001), which were then also found to be primary predictors of patient rated improvement in psychotherapy (patient r = .60, p < .001; therapist r = .38, p < .001; Clemence et
al., 2004). Regarding outcomes, significant and positive
changes were demonstrated across a range of functioning
early (at ninth session) in treatment (subjective well-being d =
1.1; symptomatic distress d = .62 to .71; social-occupational-relational functioning d = .27 to .53;
Hilsenroth et al., 2001). Subsequently, in an examination of a
depressed subsample, significant and positive changes representing large treatment effects (i.e., d > .80) across a range of
functioning, both globally (d > .85) and specific to depression
(d > 1.3), were found across the full course of treatment. In addition, these improvements in depressive symptoms (clinician-rated r = .57, p = .006, patient-rated r = .49, p = .03) were
related to both global levels of technique and specific therapist
interventions from the STPP treatment model (i.e., engaging,
experiencing, expressing, and exploring uncomfortable emotions; Hilsenroth, Ackerman, et al., 2003).
In this study, therapists use of interventions such as engaging the experience, expression, and exploration of uncomfortable feelings; allowing the patient to initiate
discussion of salient themes; as well as focusing on
in-session relational themes between therapist and patient
may have communicated to the patient that the therapist was
willing (and able) to address issues that have been previously
avoided. This type of therapistpatient working engagement
during the incipient phases of treatment (i.e., psychological
assessment) may lend momentum to the more rapid development of the therapeutic alliance. It seems the establishment
of a secure working alliance in the assessment phase of treatment may have helped address the despair, poor interpersonal relationships, feelings of aloneness, and experience of
distress that frequently motivates individuals to seek psychotherapy. Our results underscore the value of addressing a patients core interpersonal issues during the assessment phase
of treatment and beyond. Other researchers and theorists
have previously highlighted that directing therapeutic attention on a patients interpersonal issues (Foreman & Marmar,
1985; Gill, 1982; Malan, 1979; Safran, 1993; Safran &
Muran, 2000) as well as illuminating in-session therapistpatient interactions early in the treatment process contributed
significantly to alliance building. The techniques used in this
study, specifically, utilizing the CCRT method in the context
of TMA and STPP, highlighted interpersonal themes during
the initial therapeutic encounters. Such an approach may
convey to patients that the treatment process will explicitly
address core-presenting problems as well as require active
participation from both parties involved.
It is important to recognize that treatment can be a painful
process that often asks patients to openly address issues that
ASSESSMENT ALLIANCE
may have been avoided in the past. If a strong alliance is perceived by the patient during the earliest points of treatment
(i.e., psychological assessment), it may increase the patients
willingness to engage in the painful and oftentimes anxiety-evoking process of psychotherapy. A patient may come
to learn that future therapeutic interaction will be based on
feelings of collaboration and sincere interpersonal engagement rather than isolation. That is, patients may be relieved
to realize that they are capable and not alone as they begin to
face the daunting task of making changes in their lives.
Moreover, the results of this study support the idea that the
foundations of therapeutic alliance begin to develop in the
psychological assessment phase of treatment and provide an
initial opportunity for the patient to experience empathic and
collaborative goal development. Consequently, the patients
trust and feelings of relief related to being accepted/understood by the therapist may carry into formal psychotherapy.
The findings of this study suggest that the effects of patient- and therapist-rated alliance developed during the psychological assessment phase of treatment persist across the
course of psychotherapy. That is, these early patienttherapist interactions have a lasting impact on the treatment process and alliance. A better understanding of treatment
relationships may help to identify some of the ways in which
a collaborative assessment facilitates the development of
stronger, more positive alliances throughout the course of
psychotherapy. This increased understanding of the relationship between assessment and alliance throughout the treatment process may help to guide the clinical work, training,
and supervision of therapists. Therefore, the findings of this
study have relevant implications on the applied practice of
the psychological assessment phase of treatment and suggest
that careful cultivation of the therapeutic relationshipas
early as possible in treatment (i.e., psychological assessment)may provide patients with a secure foundation to
stimulate therapeutic progress.
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Mark J. Hilsenroth
220 Weinberg Building
158 Cambridge Avenue
The Derner Institute of Advanced Psychological Studies
Adelphi University
Garden City, NY 11530
E-mail: hilsenro@adelphi.edu
Received August 8, 2003
Revised May 23, 2004

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Journal of Personality Assessment

The Development of Therapeutic Alliance During

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JOURNAL OF PERSONALITY ASSESSMENT, 83(3), 332344

The Development of Therapeutic Alliance During

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The emphasis that contemporary psychotherapy research has

panded it to look more closely at the therapeutic interaction

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PATIENT- AND THERAPIST-RATED ALLIANCE

between early and late sessions for those patients described

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HILSENROTH, PETERS, ACKERMAN

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Purpose of This Study

(Hilsenroth, 2002) as well as the scope of analyses conducted

N = 42. GAF = Global Assessment Functioning.

HILSENROTH, PETERS, ACKERMAN

Hilsenroth, Ackerman, et al., 2003; Price, Hilsenroth,

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6. Emphasis on the therapeutic relationship/alliance.

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to develop treatment goals and negotiate a treatment frame

CASFP. The CASFPatient Version (CASFP;

HILSENROTH, PETERS, ACKERMAN

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.93 (R. L. Hatcher, personal communication, June 24, 1997)

CASFT. The CASFTherapist Version (CASFT;

tween CASFP Total, WAITotal, CALPASTotal, and the

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ratings at the three assessment points (.65) and then multiplied

HILSENROTH, PETERS, ACKERMAN

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ratings of alliance early in treatment, although small effects

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sion 3 or 4) was virtually identical to the findings of Barber et

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HILSENROTH, PETERS, ACKERMAN

treatment sessions, which was 26. In addition, it has been a

treatment group (Hilsenroth et al., 2002). Third, as part of a

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Blagys, M., & Hilsenroth, M. J. (2000). Distinctive features of short-term

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HILSENROTH, PETERS, ACKERMAN

Hill, C. E., & Corbett, M. M. (1993). A perspective on the history of process

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