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Abstract
<p xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="first" id="d8590238e89">The
concept of alliance reflects the collaborative relationship between a clinician
and a patient, defined as consisting of three elements: a) the agreement on the goals
of treatment; b) the agreement on a task or series of tasks; c) the development of
a bond. Although much of the theory and research on the alliance comes from the domain
of psychotherapy, the concept is applicable to any practice involving a person seeking
help and a socially sanctioned healer. An extensive research evidence suggests that
the alliance (typically measured at the third or fourth session) is a robust predictor
of the outcomes of various forms of psychotherapy, even when prior symptom improvement
and other factors are considered. Both the clinician and the patient bring to the
therapy situation different capacities to form an alliance. Factors concerning the
patient include, among others, the diagnosis, attachment history and style, motivation,
and needs for affiliation. However, the benefits of the alliance have been found to
be mostly due to the therapist's contribution, in particular his/her facilitative
interpersonal skills, including verbal fluency, communication of hope and positive
expectations, persuasiveness, emotional expression; warmth, acceptance and understanding;
empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed
to experimentally manipulate aspects of the relationship between a therapist and a
patient in non-psychotherapy contexts. In these settings, two components of the relationship
have emerged: an emotional one (involving being cared for and understood by the clinician)
and a cognitive one (including the belief in the competence of the therapist to select
and administer an effective treatment). Here we propose a model that describes three
pathways through which the alliance creates benefits, named CARE (caring, attentive,
real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention
have mostly focused on the alliance between a clinician and a patient in face-to-face
interactions, there is preliminary evidence concerning the alliance between patients
and other clinic staff, systems of care, or the program in Internet-mediated services.
These new research areas clearly require further development.
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