The construct of alliance (alternatively addressed as therapeutic, working or helping) was first formulated within psychoanalytic circles, before it was reconsidered in trans-theoretical terms and became recognized as an integrative variable, common factor, and generalizable change process or “principle of” change^{1, 2}.

Much has been written over the years about the role of alliance in the adherence to various specific treatment tasks defined as critical to change (e.g., emotional insight and skill development), but also about alliance development as effecting change or “curative” in and of itself³.

In the analytic literature, the evolution of the construct can be traced from Freud to Greenson, with a number of notable contributions in between. The construct was developed to highlight the importance of collaboration and the real and human aspects of the patient-therapist interaction. Interestingly, it did not receive much attention in the interpersonal and humanistic literatures, where these aspects were always central.

The construct complemented transferential considerations of patient-therapist relationship and provided a ground for technical flexibility, i.e., for departing from the idealized stance of therapist abstinence and neutrality. It did not come, however, without criticism and concern regarding its orientation towards patient identification or compliance with the analyst’s agenda³.

Bordin⁴ broke boundaries with his seminal reformulation of the alliance as comprised of “purposeful collaboration” (patient-therapist agreement on the tasks and goals of treatment) and their “affective bond” (that is, mutual respect and trust, as well as emotional attunement), thus introducing the application of the construct to other orientations.

This coincided with or contributed to the psychotherapy integration movement that attempted to identify common change processes and that in turn adopted the alliance construct as its poster variable. With its emphasis on mutuality and orientation towards negotiation, Bordin’s reformulation permitted greater attention to therapist participation and subjectivity.

Part of the post-modern turn or relational revolution that chal­lenged the rigid demarcation between subjectivity and ob­jectivity, and recognized the inextricable relationship between the observer and the observed, Safran and Muran⁵ provided an intersubjective elaboration that concentrated on the person of the therapist and the negotiation of existential dialectics around agency/communion and subject/object in the alliance. According to this elaboration, the resolution of these dialectics in the context of the alliance represents an opportunity for change – that is, a new relational or corrective experience.

Beginning in the 1970s, the alliance construct became the focus of the psychotherapy research community, in large part due to Bordin’s reformulation, which led to the development of many measures and a proliferation of research demonstrating the predictive relationship of alliance to outcome (see Norcross and Lambert⁶ for a meta-analysis of 306 alliance studies, N=30,000).

This generation of research did not come without some controversy: multiple measures not surprisingly resulted in some definitional imprecision or confusion, and much of the research was observational and correlational, failing to address the question of causality. However, there have been more recent mediational analyses to establish the causal relationship of the alliance as a “change mechanism”⁷. There has also been some (though limited) research on patient and therapist factors or characteristics that moderate the quality of the alliance^{1, 6}.

An extension of the research on the alliance-outcome relation included analyses of alliance patterns based on repeated post-session ratings to identify “v-episodes” (precipitous drops and then returns to recovery), and pre- to post-session ratings to identify “sudden gains” (significant increases) as proxies for alliance rupture repair. A meta-analysis of eleven such studies (N=180) has demonstrated that precipitous “drops” or ruptures are quite prevalent (15-80% of sessions) and subsequent “gains” or repairs predict outcome⁶.

There is also research that directly assessed the presence of rupture, and found that patients report rupture in 20-40% of sessions, therapists in 40-60% of sessions, and third-party observers in 40-100% of sessions⁶. These direct assessments included self-reports (by patients or therapists) of any “tension or problem, misunderstanding, conflict or disagreement”, and observations (by third parties) of “confrontation” (movements against other) and “withdrawal” (movements away from self or other) behaviors that mark ruptures. The prevalence of rupture that these studies demonstrate highlight the inherent messiness and conflict in human relations, including patient-therapist interactions^{5, 8}.

These efforts (despite limitations in number and other methodological concerns) have been integral to a “second generation” of alliance research, particularly aimed at the construct of rupture (generally defined as deteriorations or breaches in relatedness) and the clarification of repair processes^{3, 6, 9}. This second generation has included mixed method (quantitative and qualitative) efforts or task analyses (six small-scale studies) that have yielded clinically useful “when/then” data and defined stage-process models of rupture repair as a “change event”.

More specifically, these efforts defined specific tasks to carry out in the face of rupture, beginning with an acknowledgement of the rupture and including an exploration of rupture experience and sometimes some renegotiation of the work of therapy and/or a formulation of the patient’s presentation (all of which can be construed as resulting in a new or corrective experience). These efforts also led to experimentally designed studies that evaluated the effect of alliance-focused trainings aimed to advance therapist abilities to address ruptures (six studies, N=276), which provided limited but promising support^{6, 9}.

Future directions for consideration regarding the alliance construct include the need for: a) more definitional clarification and consensus on alliance and rupture (both suffer from too many definitions and methodological translations that seem too removed from the original conceptualization); b) more research on the causal relation of alliance development and rupture repair (more study of how each of these effect overall change); c) more research on patient (personal characteristics, intervention responsiveness) and therapist (personal characteristics, technical interventions) factors (specifically how these variables moderate alliance development and rupture repair).

In addition, there is a need for: d) more research on rupture repair processes, and more efforts to develop observer-based measures and to apply mixed method studies to explore what processes (i.e., specific patient and therapist behaviors and interactions) are essential to repair, and e) more experimental research on alliance-focused trainings (protocols designed to develop therapist abilities to negotiate alliance) and their potential effect on psychotherapy process and outcome.

These second-generation efforts could significantly address the risk of failure posed by alliance rupture and consequently redress the rates of failure in psychotherapy, including premature termination and poor adherence to treatment protocol.

联盟的构造（或者称为治疗、工作或帮助）首先在精神分析界提出，然后以跨理论的术语重新考虑，并被认为是一个综合变量、共同因素和可概括的变化过程或“原则”更改^{1, 2}。

多年来，关于联盟在坚持各种被定义为对变革至关重要的特定治疗任务（例如，情感洞察力和技能发展）中的作用，以及关于联盟发展作为影响变革或“治疗”的作用，已经写了很多。本身³。

在分析文献中，结构的演变可以追溯到从弗洛伊德到格林森，在这两者之间有许多显着的贡献。开发该结构是为了强调协作的重要性以及患者-治疗师互动的真实和人性方面。有趣的是，它在人际关系和人文文学中并没有受到太多关注，而这些方面总是处于中心地位。

该结构补充了对患者-治疗师关系的移情考虑，并为技术灵活性提供了基础，即背离治疗师禁欲和中立的理想立场。然而，它的出现并非没有批评和关注其对患者识别或遵守分析师议程的定位³。

Bordin ⁴打破了他对联盟的开创性重新表述，包括“有目的的合作”（患者-治疗师就治疗任务和目标达成一致）和他们的“情感纽带”（即相互尊重和信任，以及情感纽带）。协调），从而将结构应用到其他方向。

这与试图识别共同变化过程并反过来采用联盟结构作为其海报变量的心理治疗整合运动相吻合或促成了这一运动。博尔丁的重新表述强调了相互性和对谈判的导向，因此更加关注治疗师的参与和主观性。

作为后现代转向或关系革命的一部分，它挑战了主观性和客观性之间的严格界限，并认识到观察者和被观察者之间不可分割的关系，Safran 和 Muran ⁵提供了一种主体间的阐述，集中在治疗师的人和被观察者之间。围绕联盟中的代理/交流和主体/客体进行存在辩证法的谈判。根据这一阐述，在联盟的背景下解决这些辩证法代表了一个变革的机会——即一种新的关系或纠正经验。

从 1970 年代开始，联盟结构成为心理治疗研究界的焦点，这在很大程度上是由于 Bordin 的重新表述，这导致了许多措施的发展和研究的扩散，证明了联盟与结果的预测关系（见 Norcross 和Lambert ⁶对 306 项联盟研究进行荟萃分析，N=30,000）。

这一代的研究并非没有争议：多重测量导致一些定义的不精确或混乱也就不足为奇了，而且大部分研究都是观察性和相关性的，未能解决因果关系的问题。然而，最近有更多的中介分析将联盟的因果关系确立为“变革机制” ⁷。也有一些（尽管有限）关于患者和治疗师因素或特征的研究，这些因素或特征会影响联盟的质量^{1, 6}。

联盟-结果关系研究的扩展包括基于重复的会话后评级分析联盟模式以识别“v-episodes”（急剧下降然后返回恢复），以及会话前到后的评级以识别“突然收益”（显着增加）作为联盟破裂修复的代理。对 11 项此类研究 (N=180) 的荟萃分析表明，急剧的“跌落”或破裂非常普遍（15-80% 的疗程），随后的“收益”或修复可预测结果⁶。

还有一项研究直接评估破裂的存在，发现患者在 20-40% 的会话中报告破裂，在 40-60% 的会话中报告治疗师，在 40-100% 的会话中报告第三方观察员⁶。这些直接评估包括（由患者或治疗师）对任何“紧张或问题、误解、冲突或分歧”的自我报告，以及（由第三方）对“对抗”（反对他人的运动）和“退缩”（远离来自自我或其他）标志着破裂的行为。这些研究表明，破裂的普遍性突出了人际关系中固有的混乱和冲突，包括患者与治疗师的互动^{5, 8}。

这些努力（尽管数量有限和其他方法问题）已成为“第二代”联盟研究的组成部分，特别是针对破裂的构建（通常定义为相关性的恶化或破坏）和修复过程的澄清^{3， 6、9}。第二代包括混合方法（定量和定性）工作或任务分析（六项小规模研究），这些工作产生了临床有用的“何时/然后”数据，并将破裂修复的阶段过程模型定义为“变化事件”。

更具体地说，这些努力定义了面对破裂时要执行的具体任务，从承认破裂开始，包括探索破裂经历，有时重新协商治疗工作和/或制定患者的表现。所有这些都可以解释为产生新的或纠正的经验）。这些努力还促成了实验设计的研究，这些研究评估了以联盟为中心的培训的效果，旨在提高治疗师解决破裂的能力（六项研究，N=276），提供了有限但有希望的支持^{6, 9}。

关于联盟结构的未来考虑方向包括： a) 对联盟和破裂进行更多的定义澄清和共识（两者都受到太多定义和方法学翻译的影响，似乎与最初的概念化相去甚远）；b) 更多关于联盟发展和破裂修复的因果关系的研究（更多关于这些如何影响整体变化的研究）；c) 对患者（个人特征、干预反应）和治疗师（个人特征、技术干预）因素（特别是这些变量如何调节联盟发展和破裂修复）进行更多研究。

此外，还需要： d) 对破裂修复过程进行更多研究，并加大力度开发基于观察者的措施，并应用混合方法研究来探索哪些过程（即特定的患者和治疗师行为和互动）是必不可少的修复，以及 e) 更多关于以联盟为中心的培训（旨在培养治疗师协商联盟能力的协议）及其对心理治疗过程和结果的潜在影响的实验研究。

这些第二代努力可以显着解决联盟破裂造成的失败风险，从而纠正心理治疗的失败率，包括过早终止和对治疗方案的依从性差。