Wampold Bruce E, Flückiger Christoph
Modum Bad Psychiatric Center, Vikersund, Norway.
University of Wisconsin-Madison, Madison, WI, USA.
World Psychiatry. 2023 Feb;22(1):25-41. doi: 10.1002/wps.21035.
The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.
联盟的概念反映了临床医生与患者之间的合作关系，其定义包含三个要素：a）对治疗目标的共识；b）对一项任务或一系列任务的共识；c）情感纽带的建立。尽管关于联盟的理论和研究大多来自心理治疗领域，但这一概念适用于任何涉及寻求帮助者与社会认可的治疗师的实践。大量研究证据表明，联盟（通常在第三次或第四次治疗时进行测量）是各种形式心理治疗效果的有力预测指标，即便考虑到先前症状的改善及其他因素。临床医生和患者在治疗情境中形成联盟的能力各不相同。与患者相关的因素包括诊断结果、依恋史及风格、动机以及归属需求等。然而，已发现联盟的益处主要归功于治疗师的贡献，特别是其促进性的人际技能，包括言语流畅性、传递希望和积极期望、说服力、情感表达；温暖、接纳和理解；同理心以及对联盟破裂的修复反应能力。安慰剂研究使得在非心理治疗背景下能够对治疗师与患者关系的各个方面进行实验性操控。在这些情境中，关系的两个组成部分显现出来：一个是情感部分（涉及被临床医生关心和理解）和一个认知部分（包括相信治疗师有能力选择并实施有效治疗）。在此，我们提出一个模型，该模型描述了联盟产生益处的三条途径，分别命名为CARE（关爱、专注、真实和共情）、期望和特定途径。尽管研究和临床关注大多集中在面对面互动中临床医生与患者之间的联盟，但有初步证据表明患者与其他诊所工作人员、护理系统或互联网介导服务中的项目之间也存在联盟。这些新的研究领域显然需要进一步发展。
