The therapeutic alliance - also referred to as working alliance - is arguably one of the most studied concepts in psychology. The notion that a friendly and affectionate stance toward the patient by the therapist is essential in order to build rapport has been greatly influential in psychoanalytic theory since the early works of Freud (1913, as cited in Seulin & Saragnano, 2012). Others have elaborated on and amended Freud’s work on the process of collaboration in therapy, introducing the term ‘alliance’ (Sterba, 1934) and its predicates ‘therapeutic’ (Zetzel, 1956) and ‘working’ (Greenson, 1965), while others have defined the alliance as part of the broader term ‘therapeutic relationship’ (Gelso & Carter, 1985).
In recent literature, the therapeutic relationship is often defined as the feelings and attitudes that client and therapist exchange with each other, both consciously and unconsciously (Gelso & Carter, 1985, 1994; Norcross, 2002), while the alliance is defined as “the quality and strength of the collaborative relationship between client and therapist” (Horvath & Bedi, 2002, p. 44; Horvath, 2005; Norcross, 2011). However, the terms ‘relationship’ and ‘alliance’ are often used interchangeably in literature, often conflating the alliance into the relationship altogether (Hatcher & Barends, 2006).
Early conceptualizations of the therapeutic relationship mainly focused on transference and countertransference, and were at first defined as unconscious emotional intra- and interpersonal processes (Freud, 1913; Sterba, 1934; Zetzel, 1956). Later, the concept of therapeutic alliance was introduced, defined as a conscious process relating to the collaborative aspects of the relationship (Greenson, 1965; Rogers, 1957). Rogers’ (1957) person-centered approach emphasized empathy, positive regard, and genuineness of the therapist in interaction with clients, and viewed the therapeutic relationship as curative in itself. Building on the work of Greenson (1965), Gelso and Carter (1985) defined the construct real relationship as the personal (transference-free) relationship between two people that consists of genuineness and the realistic perception of each other, existing at a personal level, both in- and outside therapy. This real relationship is conceived as a different aspect of the therapeutic relationship than the therapeutic alliance and the transference-countertransference interaction, and some argue that the real relationship acts as a precursor of the alliance (Gelso, 2009).