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Alliance Items

The Alliance Scale consists of items designed to help clients provide direct feedback on their perceptions of each session. The items assess the clients experience of the working relationship with the clinician. Multiple stuides have demonstrated that a positive working alliance is associated with better outcomes.

However, effective use of measures of therapeutic alliance require greater skill on the part of the clinician than outcome measures. The psychometric properties of alliance scales tend to be much different from other questionnaires, particularly when they are administered by the clinician in the session. In this context, the questionnaires become a form of communication, rather than a measurement activity in the usual sense. On the whole, clients are nice people and will say nice things about their therapists, particularly to their face.

The biggest problem with these questionnaires is that clients will rate the therapeutic alliance very high - in fact "perfect". For example, 54% of clients completing the ACORN seven item Session Feedback Form responded with the highest ratings on all 7 items; a perfect score.

Perfect alliance scores provide the clinician with very little information. The validity of these measures is limited by the client's tendency to say nice things and the clinician's willingness to take such high praise at face value. The challenge for the clinician is to convince the client that less-than-perfect scores are helpful feedback.

A client's perception of the therapeutic alliance is strongly related to treatment outcomes. A disruption in alliance is correlated with poor outcomes, while repairing a ruptured alliance is associated with positive treatment outcomes. The ACORN data reveal that treatment episodes that begin with less than perfect alliance and then improve tend to have large effect sizes. Episodes that begin with perfect or near perfect alliance scores and end with the alliance only little less than perfect tend to have much smaller effect sizes. It isn't the alliance scores themselves that predict outcome (they remained quite high); it is the direction of change. The expression condemnation with faint praise comes to mind.

When used skillfully, the alliance items provide a clinician with a useful barometer of the client's perception of the treatment process and can alert the clinician to any problems in the alliance. The key is to convince clients that we know therapy sessions can't be perfect all of the time and there is no need to rate them as such.

The ACORN data suggest that simply using forms that include alliance items may be associated with better than average outcomes. Clients who completed questionnaires with alliance items at the first session averaged significantly more change than clients who completed questionnaires without alliance items.

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