Development Of Therapeutic Alliance Research Articles

Lost in translation: Therapeutic Alliance as a mediator in the relationship between teletherapy and marital satisfaction.

The global impact of the SARS-COV-2 pandemic necessitated a rapid shift to online/teletherapy psychotherapy services. While research suggests the feasibility and efficacy of teletherapy, there is limited investigation into couple teletherapy's impact on satisfaction and therapeutic alliance. This study aimed to address this gap by examining changes in couple satisfaction during tele- and in-person therapy sessions over 12 sessions and exploring whether therapeutic alliance development mediates these changes. Using growth curve modeling in a sample of 416 couples, it found that teletherapy participants initially reported higher couple satisfaction, but improvement in this domain was slower than in-person therapy recipients. The development of the therapeutic alliance mediated this effect via two indirect paths. Implications include the need for focused attention on alliance development in teletherapy and more empirically-informed approaches in couple teletherapy.

The linear pattern of therapeutic alliance development: Exploring the relationship between alliance trajectories over time and the outcomes of systemic psychotherapy treatment for adaptation disorders

AbstractObjectiveThis study aimed to determine the trajectories of therapeutic alliance development in individual systemic psychotherapy for adults with adaptation disorders and the differences in alliance development between groups with different treatment outcomes.MethodThe longitudinal quasi‐experiment included 20 patients undergoing individual outpatient psychotherapy treatment in private practice for over a year. Therapeutic alliance was evaluated three times, by the psychotherapist and the patient simultaneously. Treatment outcomes were estimated twice based on patient ratings. Their clinical significance was assessed using the Reliable Change Index, analysis of variance for independent groups and trend analysis. The analyses concerned global therapeutic alliance and its three dimensions: goals, tasks and bonds.ResultsThe study supported the hypothesised linear trend. It also confirmed a greater increase in alliance quality over the course of treatment in patients whose therapy was more successful.ConclusionThe results indicate that, in patients with adaptation disorders, alliance development in systemic therapy follows a stable linear trend. The linear change observed for global therapeutic alliance is paralleled by similar trends in goals, tasks and bonds. Strong alliance correlates with better treatment outcomes.

Development of Therapeutic Alliance and Social Presence in a Digital Intervention for Pediatric Concussion: Qualitative Exploratory Study.

Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored. This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention. Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention. Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would. Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

A realist review of medication optimisation of community dwelling service users with serious mental illness

BackgroundSevere mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main...

Therapists who foster social identification build stronger therapeutic working alliance and have better client outcomes

BackgroundFor decades we have known that therapeutic working alliance is a key contributor to client engagement and positive outcomes in therapy. However, we have made little progress in narrowing down its determinants, which is critical in supporting trainees to optimize such alliance. We make a case for the value of incorporating social psychological frameworks into models of alliance and explore the role of social identity processes in the development of therapeutic alliance. MethodAcross two studies, over 500 psychotherapy clients completed validated measures of alliance, social identification with their therapist, positive therapy outcomes, and a range of client and therapist characteristics. FindingsSocial identification strongly predicted alliance in both samples, whereas client and therapist characteristics showed few such associations. Alliance mediated the relationship between social identification and positive therapy outcomes. In addition, we found evidence that (a) personal control is a key psychological resource in therapy that arises from social identification, and (b) therapists who engage in identity leadership (i.e., who represent and build a social identity that they share with clients) are more likely to foster social identification and its downstream benefits. InterpretationThese data show that social identity processes are key to the emergence of working alliance. We conclude with a discussion of how recent social identity and identity leadership interventions might be adapted to train therapists in relevant identity-building skills.

Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating

Objective: This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy. Method: Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores. Results: Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores. Conclusion: Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Attachment in individuals with eating disorders compared to community controls: A systematic review and meta-analysis.

Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis. We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model. In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant. Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology. Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

Therapeutic alliance and childhood interpersonal trauma: The role of attachment, cultural humility, and therapeutic presence

AbstractThis study aimed to assess the role of insecure attachment style, cultural humility, and therapeutic presence in the development of therapeutic alliance in a sample of adults with a history of childhood interpersonal trauma (N = 251). Multiple regression analyses indicated that cultural humility, therapeutic presence, and lower levels of attachment anxiety together accounted for 66.6% of the variance in therapeutic alliance. Implications for counselors, limitations, and directions for future research are provided.

Une approche complémentaire dans le trouble de stress post-traumatique chez l’enfant : la médiation équine thérapeutique

BackgroundEquine-Assisted Therapy is a new approach for post-traumatic stress disorder in children, which comes in complementarity with usual therapies and is based on recent scientific studies. Horses and poneys participate more and more often in therapies for people in mental or physical difficulties. The aim is to introduce a horse as an intermediary which intervenes as a mediator for therapy. This care assisted by a horse must be included into the child's global therapeutic program. The horse facilitates development of therapeutic alliance and therapy with the triad child-therapist-horse improves interpersonal adaptation skills, positive attachment and resilience. Some recent studies have shown the interest and benefits for children with post-traumatic stress disorder. AimsA case pilot study is analyzed, starting from an experiment of equine assisted therapy for children with post-traumatic stress disorder symptoms following different psychotraumas (terrorist attack, mistreatment, injury, aggression). MethodTen equine-assisted therapy group sessions have been proposed to three children, aged from 6 to 11 years, addressed by Nice Pediatric Evaluation Psychotraumatism Center, which realizes the follow-up and other therapies. Equine assisted sessions have been carried out by the equine therapist, in presence of the psychomotor therapist, while the psychologist met with the parents. A CPTS-RI questionnaire (index of psychotraumatic stress reaction) was submitted by the psychomotor therapist to each of the three children before the first session of equine assisted therapy and after ten sessions. ResultsAccording to symptoms observed, therapeutic goals, means used and modalities are defined and described. Global results show good joining and participation, and positive evolution. For the three children, equine-assisted therapy has been facilitating for adherence to care, it improved socio-emotional and cognitive functioning, helped regulation in behaviour and emotions, restored confidence and self-esteem, provided wellness. PerspectivesTo understand action of equine assisted therapy for children with posttraumatic stress disorder so as to be able to explain benefits and effectiveness of this complementary therapy. Factors involved are analyzed depending on several approaches: psycho-affective, cognitive, social, neurobiological and therapeutic. This preliminary study must be continued with a larger sample so as to obtain data for evidence based practice and validate equine assisted therapy results in child post-traumatic stress disorder.

Parent engagement and therapeutic alliance in allied health teletherapy programs

Teletherapy services are being increasingly provided by allied health professionals to address major inequities of access. While clinical outcomes and stakeholder satisfaction are crucial for paediatric teletherapy's continued viability, processes for increasing parent/caregiver satisfaction, and for modifying aspects of caregiver engagement to improve outcomes, are under-researched. Studies of in-person therapy have shown that engagement, satisfaction and outcomes are influenced by the development of therapeutic alliance. This study investigates influences on parents' engagement with a teletherapy program and their therapeutic alliance with the therapist. Using a qualitative approach, data were analysed from semi-structured telephone interviews with six parents in rural New South Wales, whose children had completed paediatric teletherapy programs provided by a psychologist, speech pathologist or occupational therapist. Parents described factors that affected aspects of their engagement and alliance. Thematic analysis with constant comparison was used to determine the themes of the interviews, which were (a) initial engagement, (b) collaboration and (c) rapport. The themes demonstrate that parents were evaluating the efforts the therapists were making in (a) communicating, (b) truly partnering with them, both being elements of collaboration and (c) building rapport with them and the child. A conceptual model, Parent And Caregiver Evaluation Cycle In Teletherapy (PACECIT), is proposed by the researchers to explain how parents evaluated the therapist to judge the current state of a personal relationship and to judge the effectiveness of a collaborative relationship, both influencing the therapeutic alliance and motivation for engagement. The findings emphasise the importance of fulfilling parent/caregiver expectations for clear and frequent communication, and discussion of their ideas. Also important is the development of therapeutic alliance through utilising parents' observations of non-verbal communication to maintain an effective rapport and enhance engagement.

Make every session count for clients! Rethinking clinical social work practice from Single Session Therapy (SST): A case illustration of Emotion-Focused Therapy (EFT)

ABSTRACT Re-thinking a service delivery paradigm within a single session therapy (SST) framework inevitably changes the ways we consider the therapeutic process – making each session count! In clinical practice, this means (1) the rapid development of therapeutic alliance and (2) the life of the therapy process, from assessment to intervention to evaluation condensed into a single session. To illustrate, this article analyzes the fully transcribed one of the master tapes in Emotion-Focused Therapy where chair work is demonstrated in a single session, and finds six processes in SST: (1) history taking; (2) formulation; (3) contracting; (4) working-through change; (5) evaluation; and (6) preparing for exit. A micro-analysis of the single session details how the therapist manages multiple tasks in SST. This analysis helps social workers to re-think service delivery and attrition rates in community mental health settings to enhance health equity and the provision of socially just mental health services.

'Getting them on board': Musculoskeletal physiotherapists conceptions of management of persons with low back pain.

Low back pain (LBP) is the leading cause of disability worldwide; however, the majority of LBP is non-specific in nature with no clearly identifiable source of pain. Contemporary understanding of LBP highlights the multidimensional nature of LBP and as a result clinical practice and guidelines have evolved and advocate a multidimensional approach to managing persons with LBP. This change in understanding and practice provides challenges for physiotherapists and persons with LBP, many who have biomedical views. The aim of this study was to explore musculoskeletal physiotherapists conceptions towards the management of LBP. The research employed a phenomenographic inspired approach which aims to explore variations in conceptions, beliefs and understanding of a phenomenon. Six participants (physiotherapists) were interviewed via semi-structured interviews to explore their experiences of managing persons with LBP and the data was analysed using a phenomenographic framework. Three main categories emerged from the participants descriptions: the perceived role of preferences and expectations, therapeutic alliance development and getting the person "on board". Participants descriptions implied a therapist centred view towards the care they provided for persons with LBP. The perceived role of expectations was a significant aspect within the participants descriptions of the management of LBP. Last, the participants described the perceived development of a therapeutic alliance. These categories suggest how the physiotherapists interviewed in this study conceive the management of LBP, and these findings will provide a greater understanding around the physiotherapy management of LBP.

Alliance building in music therapy for forensic psychiatric patients with schizophrenia. An exploratory case study research design

ABSTRACT Introduction: Forming therapeutic alliance with forensic psychiatric patients with schizophrenia is challenging, and there is a gap in knowledge about the dynamics in the initial phase of psychotherapy and how collaboration and trust is developed. Music therapy is described as a motivating approach enhancing the forensic psychiatric patient's ability to engage in a relationship. The purpose of the study was to explore and identify dynamics in the process of forming therapeutic alliance in music therapy for forensic psychiatric patients with schizophrenia. Method: The study adopted an exploratory case study design with data from multiple perspectives providing thick descriptions. Four patients with schizophrenia from a medium secured unit at a forensic psychiatric hospital were offered weekly music therapy sessions for six months. An inductive process based on a hermeneutic phenomenological epistemology and a nine step procedure for the analysis led to a final abductive synthesis. Results: Each of the following themes formed a continuum of dynamic interactional processes within the development of therapeutic alliance with forensic psychiatric patients with schizophrenia in music therapy and were presented as a condensed continua model; (a) Control, (b) Closeness/distance, (c) Structure, (d) Process/product, (e) Focus of attention, (f) Interaction, and (g) Verbal dialogue. A case example is provided. Discussion: The continua model may contribute to the clarification and conceptualization of the developmental dynamics in the initial phase of psychotherapy with forensic psychiatric patients with schizophrenia, and hereby contribute to a recognition of the importance of treatment efforts specifically concerned with relational and musical competencies.

Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder

Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidence-based treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

The impact of seating arrangement and therapy task on therapeutic alliance formation

AbstractPsychotherapists utilise several different seating arrangements in session, including face to face, side by side and the couch. This research investigated seating arrangement's impact on participants' ratings and perceptions of therapeutic alliance formation. A mixed‐methods design was used. Study I was a randomised experiment (N = 60 university students) comparing face to face and side by side seating arrangements, two history‐taking tasks (talking or questionnaires) and gender, in an analogue initial therapy session. Therapeutic alliance was assessed using the helping alliance questionnaire‐II. Study II used qualitative interviews to explore the experiences of five clients who had previously attended psychotherapy. Participants in the face to face questionnaires condition had significantly lower alliance ratings than face to face talking (p = .002) or side by side questionnaires (p = .039) conditions, regardless of gender. Those in the face to face talking condition were significantly likelier to attend a second session (p = .046) compared to the other three conditions. Participants identified eye contact, proxemics, power dynamics and development of therapeutic alliance over time as important factors regarding seating arrangement. Sitting face to face was more conducive for developing a good therapeutic alliance when using conversational history‐taking, while sitting side by side was more effective when completing questionnaires. Practitioners should consider the effects of using different seating arrangements and history‐taking approaches prior to working with clients.

\u2018I didn\u2019t know what to expect\u2019: Exploring patient perspectives to identify targets for change to improve telephone-delivered psychological interventions

BackgroundRemote delivery of psychological interventions to meet growing demand has been increasing worldwide. Telephone-delivered psychological treatment has been shown to be equally effective and as satisfactory to patients as face-to-face treatment. Despite robust research evidence, however, obstacles remain to the acceptance of telephone-delivered treatment in practice. This study aimed to explore those issues using a phenomenological approach from a patient perspective to identify areas for change in current provision through the use of theoretically based acceptability and behaviour change frameworks.MethodsTwenty-eight semi-structured interviews with patients experiencing symptoms of common mental health problems, waiting, receiving or having recently received telephone-delivered psychological treatment via the UK National Health Service’s Improving Access to Psychological Therapies (IAPT) programme. Interviews were recorded, transcribed verbatim, and analysed using the Theoretical Domains Framework (TDF) and Theoretical Framework of Acceptability (TFA).ResultsThe majority of data clustered within five key domains of the TDF (knowledge, skills, cognitive and interpersonal, environmental context and resources, beliefs about capabilities, beliefs about consequences) and mapped to all constructs of the TFA (affective attitude, ethicality, intervention coherence, self-efficacy, burden, opportunity costs, and perceived effectiveness). Themes highlighted that early stages of treatment can be affected by lack of patient knowledge and understanding, reservations about treatment efficacy, and practical obstacles such as absent non-verbal communication, which is deemed important in the development of therapeutic alliance. Yet post-treatment, patients can reflect more positively, and report gaining benefit from treatment. However, despite this, many patients say that if they were to return for future treatment, they would choose to see a practitioner face-to-face.ConclusionsUsing a combination of theoretically underpinned models has allowed the identification of key targets for change. Addressing knowledge deficits to shift attitudes, highlighting the merits of telephone delivered treatment and addressing skills and practical issues may increase acceptability of, and engagement with, telephone-delivered treatment.

Patient-Centered Strategies for Effective Communication During the Initial Audiological Consultation Sessions

Purpose The article focuses on communication during initial audiology consultation sessions and written in two-fold. First, it provides an overview of audiological literature on communication between patients, their significant others, and audiologists. Second, it discusses patient-centered strategies for effective communication based on broader health care literature. Method A discussion was developed based on reviews of relevant literature. Results A recent literature review by Manchaiah, Bellon-Harn, Dockens, Azios, and Harn (2019) examined studies focusing on communication during initial audiology consultations. Five themes were highlighted: (a) interaction balance and reciprocity, (b) discussion of patient concerns and development of therapeutic alliance, (c) patient and family expressions of concerns, (d) audiologist response to patient and family expression of concerns, and (e) conversation patterns related to acceptance of treatment recommendations. Broader health care literature emphasizes some patient-centered strategies for effective communication, which include (a) focusing on patients' perspective, (b) building the therapeutic alliance, (c) attending to psychological consequences and concerns, and (d) understanding the power of turn in conversations. Conclusions Clinician–patient communication especially at initial consultation sessions is important in building a long-term relationship and will have bearing toward patient outcomes. It is essential for audiologists to adopt patient-centered strategies for effective communication, which makes patients comfortable and helps in building trust and positive therapeutic relationships.

Physiological synchrony and therapeutic alliance in an imagery-based treatment.

Client-therapist synchrony in various channels (e.g., self-reported affect or physical movement) has been shown as a key process in the construction and development of therapeutic alliance. However, psychophysiological synchrony between clients and therapists has been understudied, with the few extant studies typically relying on single-session data, and no studies examining it within the context of emotion-focused techniques. The main aim of the current paper is to examine the role of client-therapist physiological synchrony during segments of one emotion-focused technique-namely, imagery (IM) work-in predicting therapeutic alliance, and to compare it to the role of synchrony during segments of more traditional cognitive-behavioral (CB) techniques. We conducted an open-trial study in which 31 clients with test anxiety received a 6-session protocol-based treatment. Both clients' and therapists' electrodermal activity (EDA) were continuously assessed during sessions. The physiological measures for 5 sessions each (N = 128) were used to compute client-therapist synchrony in IM and CB segments. Therapeutic alliance was assessed using the Session Alliance Inventory. Client-therapist dyads' synchrony during IM and CB segments was, on average, greater than chance. Synchrony varied mostly at the session (vs. the dyad) level. Multilevel analyses revealed that the synchrony within IM segments (but not within CB segments) was significantly associated with the therapeutic bond aspect (but not the task/goal aspects) of alliance. Physiological synchrony during emotion-focused IM is tied to the bond component of the therapeutic alliance at the session level. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Development of therapeutic alliance and its association with treatment outcome in internet based Mindfulness-Based Cognitive Therapy (eMBCT) compared to group-based MBCT (MBCT) for distressed cancer patients

Development of therapeutic alliance and its association with treatment outcome in internet based Mindfulness-Based Cognitive Therapy (eMBCT) compared to group-based MBCT (MBCT) for distressed cancer patients

Support for Carers of Young People with Mental Illness

In this article, we show how a technology-mediated mental health therapy involving psycho-education, therapist moderators, and social networking can provide support for carers of young people with mental illness. This multi-faceted tool provides opportunities for users to adapt the system to their needs, leading us to refocus the goal of treatment adherence toward a relatively new phenomenon in HCI, concordance, which has not previously been examined in the HCI literature in relation to online mental-health tools. Concordance shares important links with the development of therapeutic alliance, which is centrally important to mental health therapy, and to Self-Determination Theory (SDT), which informed our approach to design. We present a three-month user study, which provides initial encouraging support for both the suitability of concordance as a lens for viewing user engagement and the idea that users can develop a therapeutic alliance with an online support system. This latter result is surprising as the phenomenon of therapeutic alliance generally describes a relationship between client and (human) clinician. Therapeutic alliance has previously been explored for face-to-face groups, and between individuals and online systems, but not for online groups. We show how even automated system behavior can encourage engagement from users and contribute to alliance formation, if the non-human parts of an online system are interactive. We argue that a design approach involving peer/moderator support as well as automated feedback, and which takes account of SDT, can provide support for therapeutic alliance.