160 Academic Psychiatry, 27:3, Fall 2003 Therapeutic Alliance as a Measurable Psychotherapy Skill Richard F. Summers, M.D. Jacques P. Barber, Ph.D. OutoftheBabelofpsychotherapymodels,concepts,andtechniques,thetherapeuticalli- ancestandsoutasameasurablephenomenonthathasbeenshowntohavearobusteffect ontreatmentoutcome.Thetherapeuticalliancemaybea“holygrail”ofpsychotherapy competencybecauseitisavalidatedconceptthatispredictiveofoutcome,morepowerfully predictivethanalternativeindices,clearlydefined,easilymeasured,andmayhaveeduca- tionalandtrainingvalue.Thiscommunicationreviewstheconceptoftherapeuticalliance, themethodsformeasuringit,anditsrelationshipwithoutcome.Wealsosummarizethe literatureonhowtraineesacquiretheabilitytodevelopatherapeuticalliance,andevaluate thepedagogicaltechniquesforimprovingtrainees’skillsinthisarea.Finally,wepresent recommendationsfortheuseoftherapeuticalliancemeasurementinresidencytrainingfor competencyassessmentpurposes,andforpedagogicalapproachesforimprovingresidents’ therapeuticalliancebuildingskills.(AcademicPsychiatry2003;27:160–165) Dr. Summers is Clinical Associate Professor of Psychiatry and Associate Director of Education for Residency Training, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. Dr. Barber is Profes- sor of Psychology in Psychiatry and Associate Director of the Center for Psychotherapy Research, University of Pennsylva- nia School of Medicine, Philadelphia, Pennsylvania. Address correspondence to Dr. Summers, Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, 2 nd Floor, Philadelphia,PA19104,summersr@mail.med. upenn.edu. (E-mail). Copyright  2003 Academic Psychiatry. Concept of Therapeutic Alliance R eferred to variously as the therapeutic, working, or helping alliance, the idea that the therapeutic relationship is important for therapeutic success was foreshadowed by Freud’s (1) comments on the posi- tivefeelingsthatdevelopbetweendoctorandpatient. Subsequent psychoanalytic writers such as Greenson (2) and Zetzel (3) articulated this concept more fully, distinguishing between the “real” and adaptive di- mension of the treatment relationship and the trans- ferential and fantasy-laden aspect. In his Client- Centered Therapy, Rogers (4) identified theempathic bond between the patient and therapist as the essen- tial therapeutic agent in treatment. Seeking to operationalize this concept and apply it more generally across psychotherapies, Bordin (5) identified three components of the therapeutic alli- ance—goal, task, and bond. He saw the therapeutic alliance as a mutual construction of the patient and therapist that includes shared goals, accepted recog- nition of the tasks each person is to perform in the relationship, and an attachment bond. He saw the therapeutic alliance as developing in the relationship between the two and as the vehicle through which psychotherapies are effective. He noted that different psychotherapies call upon different aspects of the therapeuticallianceatdifferentpointsoverthecourse of treatment. Althoughtheconceptofthealliancehasemerged historically in the psychodynamic literature, the strengthofthecollaborativerelationshipbetweenpa- tient and therapist has been recognized as crucial by therapists from different theoretical backgrounds. Most theorists, including Beck et al. (6), emphasize theestablishmentofthepatient-therapistrelationship