50<2($)*!):!(#0!(#0%210B($7!2<<$2*70!Z$(#!)B(7)90!2*&!)(#0%! Y2%$23<06?!=!90(2E2*2<4($7!%0Y$0Z!
@2%($*_!O>!i>_!S2%6M0_!i>!/>_!G!O2Y$6_!@>!I>![+,,,^>!50<2($)*!):!(#0!(#0%210B($7!2<<$2*70!Z$(#!)B(7)90!2*&!)(#0%! Y2%$23<06?!2!90(2!2*2<4($7!%0Y$0Z>! N">#+@B&"!&8"+(>B,)+L&@+*&8B)+)?@B&'(A?-"B"LAO& gb[P^_!]PbE].,>!! To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study. In the past two decades, psychotherapy researchers and practitioners have postulated that the therapeutic alliance—defined broadly as the collaborative and affective bond between therapist and patient—is an essential element of the therapeutic process. The primary reason the alliance has grown in significance is the consistent finding that the quality of the alliance is related to subsequent therapeutic outcome. Another reason interest in the alliance has increased in the past 20 years is the inability of researchers to find a consistent difference in the effectiveness of psychotherapy across orientations. Consequently, many contemporary theories of psychotherapeutic change now emphasize the importance of the alliance, so much so that some theorists have referred to the alliance as the "quintessential integrative variable" (Wolfe & Goldfried, 1988, p. 449) of therapy . Although there are differences among the many alliance conceptualizations, most theoretical definitions of the alliance have three themes in common: (a) the collaborative nature of the relationship, (b) the affective bond between patient and therapist, and (c) the patient's and therapist's ability to agree on treatment goals and tasks (Bordin, 1979). Using various techniques, this review indicates that alliance is moderately related to outcome (7 = .22). The average allianceoutcome correlation is within the range of many other effect sizes that are associated with psychotherapy outcome. In addition, the relation of alliance and outcome appears to be consistent, regardless of many of the variables that have been posited to influence this relationship. Indeed, the test of homogeneity suggests that the correlation represents a homogeneous population. In sum, the present metaanalysis indicates that the overall alliance-outcome correlation represents a single population of effects that cannot be reduced by a moderator variable into a more explanatory model of the relation of the alliance and outcome. This meta-analysis supports the belief that the relation of the therapeutic alliance with outcome is consistent within the psychotherapy literature. What is evident from this review is that the strength of the alliance is predictive of outcome, whatever the mechanism underlying the relation. From the empirical review of the reliabilities of the various alliance scales, it seems clear that all the alliance measures have adequate reliability. Although the overall reliability index for the various scales was somewhat lower than that found in the previous meta-analysis (.79 vs. .86), the present index still reaches an acceptable standard of consistency. Moreover, when the overall alliance index was separated by individual alliance scales, every alliance measure had an overall reliability index above .70. Surprisingly, even the scales that are not well established as measures of the alliance had adequate reliabilities. Given these results, all the alliance scales seem to have acceptable reliability. This meta-analysis did not implicate a specific alliance scale
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