The Helping Alliance Questionnaire

1. Abstract

The Helping Alliance Questionnaire (most widely utilized in its revised 19-item version, the HAq-II) is one of the most rigorously validated and historically foundational self-report instruments designed to quantify the quality of the therapeutic alliance in psychotherapeutic interventions. Developed by Lester Luborsky and his colleagues at the University of Pennsylvania Center for Psychotherapy Research (Luborsky et al., 1996), the HAq-II represents a psychometrically refined evolution of the original Penn Helping Alliance Rating Scale (Penn Method) and the earlier 24-item Helping Alliance Questionnaire (HAq-I). The instrument assesses the collaborative bond, mutual understanding, shared therapeutic goals, and perceived competence that emerge between a client and a clinician across individual, couple, and group modalities.

Comprising 19 items evaluated on a 6-point Likert scale ranging from 1 (“strongly disagree”) to 6 (“strongly agree”), the HAq-II is published in parallel Patient and Therapist versions. Structurally, the questionnaire was designed to operationalize Luborsky’s dual-phase conceptualization of the alliance: Type 1 Alliance (characterized by the patient’s experience of the therapist as warm, supportive, dependable, and empathically engaged) and Type 2 Alliance (characterized by collaborative teamwork, shared responsibility, and joint commitment to therapeutic goals and tasks). Empirical psychometric evaluations demonstrate that the scale exhibits exceptional internal consistency, with Cronbach’s alpha coefficients typically ranging from .90 to .93 for the patient version and .88 to .91 for the therapist version, alongside robust test-retest reliability across mid-treatment sessions ($r = .75$ to $.82$).

Construct validity is evidenced through strong convergent correlations with concurrent alliance metrics—such as the Working Alliance Inventory (WAI) and the California Psychotherapy Alliance Scales (CALPAS)—and significant predictive validity regarding treatment completion, symptom alleviation (e.g., reductions on the Beck Depression Inventory and Hamilton Rating Scales), and long-term psychosocial functioning. Furthermore, the inclusion of reverse-scored items addressing therapeutic strains, misunderstandings, and unproductive exchanges enables the HAq-II to function as a sensitive barometer for detecting alliance ruptures and repair processes in both clinical practice and clinical trial research.

2. Keywords

Helping Alliance Questionnaire, HAq-II, therapeutic alliance, working alliance, Lester Luborsky, psychometrics, psychotherapy outcome, treatment engagement, patient-therapist relationship, rupture and repair, common factors, psychotherapy research

3. Authors

The Helping Alliance Questionnaire was developed and systematically psychometrically revised by a team of prominent psychotherapy researchers affiliated with the Center for Psychotherapy Research at the University of Pennsylvania School of Medicine:

• Lester Luborsky, Ph.D. (1920–2009): Professor of Psychology in Psychiatry at the University of Pennsylvania School of Medicine. Regarded as a founding pioneer of modern empirical psychotherapy research, Dr. Luborsky developed the Core Conflictual Relationship Theme (CCRT) method, the Penn Helping Alliance rating systems, and spearheaded decades-long investigations into the common and specific factors driving psychotherapeutic efficacy.
• Jacques P. Barber, Ph.D., ABPP: Professor and Dean of the Gordon F. Derner School of Psychology at Adelphi University; formerly of the Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania. An internationally renowned expert on dynamic psychotherapy, therapeutic alliance, and treatment outcomes in mood and personality disorders.
• Lynne Siqueland, Ph.D.: Clinical psychologist and researcher at the Children’s Center for OCD and Anxiety; formerly Research Associate at the Center for Psychotherapy Research, University of Pennsylvania.
• Scott Johnson, M.S.: Statistician and psychometrician at the University of Pennsylvania Department of Psychiatry, contributing extensively to quantitative modeling and scale construction.
• Lisa M. Najavits, Ph.D.: Director of Treatment Innovations and Adjunct Professor of Psychiatry at Boston University School of Medicine; developer of the Seeking Safety model; formerly affiliated with Harvard Medical School and the University of Pennsylvania alliance research collaborative.
• Arthur Frank, M.D.: Psychiatrist and clinical trial investigator, Center for Psychotherapy Research, University of Pennsylvania School of Medicine.
• Dennis Daley, Ph.D.: Professor of Psychiatry and Social Work at the University of Pittsburgh School of Medicine, renowned for research on substance use disorders, dual diagnosis, and relapse prevention.

Primary Institutional Origin: Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania Health System, 3535 Market Street, Philadelphia, PA 19104, USA.

4. Purpose

The overarching purpose of the Helping Alliance Questionnaire is to provide a brief, psychometrically sound, theoretically grounded, and clinically actionable metric for evaluating the quality, strength, and affective valence of the therapeutic relationship. Originating from the systematic observation that the client’s experience of the therapist as a helpful and collaborative partner is one of the most reliable predictors of positive psychological change across nearly all psychotherapeutic orientations, the HAq instruments were constructed to move beyond subjective clinician impressions into the realm of standardized, replicable measurement.

Clinical Applications

In routine clinical practice, the HAq-II functions as an essential process monitoring and measurement-based care (MBC) instrument. Administered periodically—typically following early sessions (e.g., sessions 2, 3, or 4) and at regular milestones throughout treatment—the scale enables clinicians to:

• Gauge Patient Investment and Trust: Identify whether the patient feels safe, understood, and emotionally held by the clinician early in the therapeutic process, which is critical for mitigating premature termination and dropout.
• Detect Alliance Ruptures: Systematically flag emergent tensions, misunderstandings, or dissatisfaction through the scale’s negatively valenced items (e.g., Item 4: “At times I distrust the therapist’s judgment”; Item 8: “The procedures used in my therapy are not well suited to my needs”; Item 19: “At times the therapist seems distant”). Early detection allows the clinician to initiate meta-communicative repair strategies before covert disengagement turns into overt drop-out.
• Calibrate Dyadic Consensus: By administering the parallel Therapist Version alongside the Patient Version, treatment teams can detect discrepancies in perspective. Clinical research indicates that dyads exhibiting substantial divergence in alliance ratings—particularly where the therapist substantially overestimates the alliance relative to the patient—are at heightened risk for therapeutic stagnation or negative outcome.

Research Applications

In clinical trials and psychotherapy process-outcome research, the HAq-II serves several indispensable functions:

• Predictor of Treatment Outcome: Serving as an independent or mediator variable predicting primary outcome measures across randomized controlled trials (RCTs) evaluating cognitive-behavioral therapy (CBT), supportive-expressive dynamic psychotherapy (SE), interpersonal psychotherapy (IPT), and pharmacotherapy combinations.
• Testing the Common Factors Paradigm: Allowing researchers to determine whether therapeutic outcomes are attributable to modality-specific techniques or to pantheoretical relational mechanisms (the “common factors” hypothesis advanced by Wampold and Frank).
• Investigation of Dynamic Trajectories: Permitting longitudinal hierarchical linear modeling (HLM) and latent growth curve modeling to examine how alliance patterns (e.g., linear growth, stable-high, or rupture-and-repair U-shaped curves) associate with long-term symptom remission and personality restructuring.

5. Psychological Construct

The Helping Alliance Questionnaire operationalizes the psychological construct of the helping alliance (synonymous in contemporary literature with the therapeutic alliance or working alliance). Rather than viewing the alliance as an intrapsychic fantasy or pure manifestations of classical psychoanalytic transference, Lester Luborsky formulated the alliance as a conscious, reality-based collaboration emerging from the actual relational encounter between patient and helper.

The Dual-Component Alliance Taxonomy (Type 1 and Type 2)

Luborsky’s conceptual architecture divides the alliance construct into two interdependent, developmental phases:

• Type 1 Alliance (Supportive / Relationship Bond): Predominant in the opening phases of therapy, Type 1 alliance reflects the patient’s perception of the therapist as a supportive, warm, empathic, dependable, and capable source of assistance. It encapsulates relational safety and emotional containment. Within the HAq-II, this dimension is operationalized by items such as:
  • Item 1: “I feel I can depend upon the therapist.”
  • Item 2: “I feel the therapist understands me.”
  • Item 9: “I like the therapist as a person.”
  • Item 18: “I believe the therapist likes me as a person.”
• Type 2 Alliance (Collaborative / Shared Work on Goals and Tasks): Becoming increasingly prominent as therapy progresses into active confrontation, interpretation, behavioral exposure, or cognitive reframing, Type 2 alliance reflects the patient’s sense of working together with the therapist in a joint struggle against what is impeding the patient. It represents a mature therapeutic partnership characterized by mutual effort, consensus on the mechanisms of change, and shared responsibility. This dimension is embodied in items such as:
  • Item 3: “I feel the therapist wants me to achieve my goals.”
  • Item 5: “I feel I am working together with the therapist in a joint effort.”
  • Item 6: “I believe we have similar ideas about the nature of my problems.”
  • Item 10: “In most sessions, the therapist and I find a way to work on my problems together.”

Negative Alliance and Rupture Markers

A critical contribution of the HAq-II psychometric structure is its explicit inclusion of reverse-keyed items capturing the shadow side of the relational matrix: strains, perceived invalidation, ideological misalignment, and emotional withdrawal. These items measure:

• Distrust and Skepticism: Item 4 (“At times I distrust the therapist’s judgment”) assesses boundary insecurities and epistemic vigilance.
• Technical and Procedural Discord: Item 8 (“The procedures used in my therapy are not well suited to my needs”) evaluates pedagogical dissonance, where the client experiences the therapeutic methodology as alienating or counterproductive.
• Relational Impediment: Item 11 (“The therapist relates to me in ways that slow up the progress of the therapy”) and Item 16 (“The therapist and I sometimes have unprofitable exchanges”) capture perceived iatrogenic friction.
• Affective Distance: Item 19 (“At times the therapist seems distant”) captures clinician detachment, coldness, or emotional unavailability.

6. Theoretical Framework

The Helping Alliance Questionnaire is anchored at the intersection of psychodynamic relationship theory, humanistic philosophy, and empirical common factors research.

Psychoanalytic Foundations: From Freud to Greenson and Zetzel

Sigmund Freud (1912, 1913) initially acknowledged that before deep psychoanalytic interpretation could be tolerated, the analyst had to establish an affectionate, collaborative attachment with the patient—a rapport rooted in reality rather than neurotic distortion. Decades later, ego psychologists such as Elizabeth Zetzel (1956) and Ralph Greenson (1965, 1967) formalized this concept into the “therapeutic alliance” and “working alliance.” Greenson argued that the patient’s capacity to align their observing ego with the analyst’s analyzing ego against their instinctual conflicts and resistances was the sine qua non of psychoanalytic cure. Luborsky expanded this clinical observation into an empirical paradigm through the Penn Psychotherapy Project, developing observational and self-report scales to quantify these psychoanalytic constructs systematically.

Bordin’s Pantheoretical Working Alliance Model

In 1979, Edward Bordin reformulated the working alliance as a pan-theoretical construct applicable not merely to psychoanalysis, but to all psychotherapeutic modalities (including behavioral, gestalt, and family therapies). Bordin posited that the alliance consists of three interdependent constituents:

1. Bonds: The interpersonal attachments, mutual trust, and positive affective regard linking client and therapist.
2. Tasks: Mutual agreement upon and engagement in the specific in-session activities, exercises, and behaviors that form the substance of the therapeutic work.
3. Goals: Shared consensus regarding the broad targets and intended outcomes of the therapeutic intervention.

Although Luborsky’s HAq-II maintains its distinct historical nomenclature (Type 1 Supportive vs. Type 2 Collaborative), its empirical item content maps directly onto Bordin’s tripartite taxonomy. Items assessing interpersonal liking and dependability reflect Bonds; items assessing procedural suitability and meaningful exchanges capture Tasks; and items assessing agreement on problems and desired ends correspond directly to Goals.

Common Factors and the Contextual Model

In contemporary psychotherapy research, the theoretical framing of the HAq-II is reinforced by the Contextual Model formulated by Bruce Wampold (2001, 2015). Drawing on the classic anthropological and psychological work of Jerome Frank (Persuasion and Healing, 1961), the Contextual Model asserts that the specific technical ingredients of various psychotherapies account for a relatively small proportion of outcome variance, whereas common relational factors—foremost among them the therapeutic alliance—account for a substantially larger proportion. The HAq-II serves as the operational instrument verifying that an emotionally charged, confiding relationship, situated within a culturally sanctioned healing context, has been established.

7. Validity

The psychometric integrity of the Helping Alliance Questionnaire (specifically the HAq-II) has been extensively corroborated across diverse clinical populations, diagnostic categories, and research protocols (Luborsky et al., 1996; Barber et al., 1999, 2000).

Construct and Factorial Validity

In the landmark scale revision study conducted by Luborsky, Barber, Siqueland, Johnson, Najavits, Frank, and Daley (1996), the HAq-II was administered to substantial cohorts of psychiatric outpatients, including patients participating in the National Institute on Drug Abuse (NIDA) Collaborative Cocaine Treatment Study ($N = 200$) and depressed outpatients ($N = 82$). Confirmatory and exploratory analyses supported a predominantly strong general alliance dimension that accounted for the vast majority of shared variance, demonstrating that the 19 items coherently reflect a unified underlying construct of relational collaboration and safety.

Convergent Validity

Convergent validity has been established through moderate-to-high correlations between the HAq-II and other gold-standard alliance measures:

• Working Alliance Inventory (WAI): Correlations between patient-rated HAq-II and the WAI Total Score typically range between $r = .72$ and $r = .86$ ($p < .001$), demonstrating exceptional alignment in assessing the relational bond, task alignment, and goal consensus.
• California Psychotherapy Alliance Scales (CALPAS): Correlations between the HAq-II and CALPAS global scores range from $r = .68$ to $r = .80$.
• Penn Helping Alliance Rating Scale (Penn Method – Observer Rated): Significant correlations ($r = .45$ to $.60$) have been demonstrated between patients’ subjective HAq-II self-reports and external, blinded observer ratings of alliance derived from audio/video recordings of clinical sessions.

Discriminant and Divergent Validity

To demonstrate that the HAq-II does not simply measure generalized positive affectivity, neuroticism, or baseline symptom severity, researchers evaluated its discriminant validity:

• Correlations with baseline intake symptom measures—such as the Beck Depression Inventory (BDI), the Symptom Checklist-90-Revised (SCL-90-R), and the Hamilton Rating Scale for Depression (HRSD)—are characteristically low ($r = -.10$ to $-.22$, often non-significant), demonstrating that the HAq-II captures interpersonal process rather than initial psychiatric distress.
• Correlations with social desirability indices (such as the Marlowe-Crowne Social Desirability Scale) remain low ($r < .20$), indicating that high alliance scores are not merely artifacts of impression management.

Predictive and Criterion Validity

The hallmark of the HAq-II is its robust predictive validity regarding psychotherapy outcomes:

• In the NIDA Collaborative Cocaine Treatment Study, early-treatment HAq-II scores (measured at Session 2 and Session 5) significantly predicted subsequent drug abstinence, reductions in craving, and treatment retention ($p < .01$).
• Meta-analytic syntheses (e.g., Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000; Flückiger et al., 2018) encompassing HAq instruments establish an overall average alliance-outcome correlation of $r = .26$ to $.28$, which translates to roughly 7% to 8% of the total variance in clinical outcome directly attributable to the alliance—an effect size rivaling or exceeding that of specific treatment modalities.

8. Reliability

The Helping Alliance Questionnaire demonstrates high empirical reliability across multiple operational parameters, satisfying the psychometric standards required for both research investigations and individualized clinical assessment.

Internal Consistency

In the seminal psychometric re-evaluation by Luborsky et al. (1996), the HAq-II displayed outstanding internal consistency:

• Patient Version: Cronbach’s alpha ($lpha$) coefficients have been consistently reported between .90 and .93 across diverse clinical samples (e.g., major depressive disorder, generalized anxiety disorder, substance dependence).
• Therapist Version: Cronbach’s alpha coefficients for the therapist parallel form range between .88 and .91.
• Item-Total Correlations: In the revised 19-item version, Luborsky and colleagues eliminated items from the original 24-item HAq-I that exhibited low item-total correlations. All remaining 19 items on the HAq-II exhibit corrected item-total correlations exceeding $r = .40$, with the majority exceeding $r = .55$.

Test-Retest Reliability and Stability

Assessing the temporal stability of the therapeutic alliance requires careful psychometric calibration, as the alliance is theoretically expected to fluctuate in response to clinical events, session content, and developmental phases. When measured across brief intervals where treatment conditions remain stable (e.g., between Session 2 and Session 3):

• Test-retest reliability coefficients for the HAq-II typically fall in the range of $r = .75$ to $.82$ ($p < .001$).
• Over longer intervals (e.g., between early treatment at Session 3 and late treatment at Session 20), stability coefficients diminish moderately ($r = .50$ to $.65$), reflecting authentic dynamic shifts, relational deepening, or mid-treatment alliance ruptures and repairs.

Inter-Rater Reliability (Observer Contexts)

While the HAq-II is designed primarily as a client- and therapist-completed self-report measure, its precursor and companion observational systems (the Penn Helping Alliance Rating Scale, Penn Global Rating Scale) demonstrate intraclass correlation coefficients (ICC) ranging between .78 and .88 among trained clinical raters evaluating videotaped sessions.

9. Factor Analysis

The structural dimensionality of the Helping Alliance Questionnaire has been the focus of extensive psychometric exploration using both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (Luborsky et al., 1996)

During the development and revision of the HAq-II from the original 24-item HAq-I, Luborsky and his team conducted principal components analyses (PCA) with both orthogonal (Varimax) and oblique (Promax) rotations:

• The scree plot and eigenvalue examination ($\lambda_1 > 8.0$) revealed a massive first unrotated factor accounting for approximately 45% to 52% of the total variance across clinical samples.
• All 19 items loaded substantially on this primary factor (factor loadings ranging from $.45$ to $.82$).
• Although Luborsky historically distinguished Type 1 (supportive) from Type 2 (collaborative) alliance at a conceptual level, EFA results demonstrated that in self-report questionnaires, patients do not sharply dissociate feeling supported from working collaboratively. Instead, the patient’s experience forms a cohesive, unitary Gestalt of relational safety and cooperative striving.

Subsequent Confirmatory Factor Analyses and Structural Modeling

Subsequent psychometric examinations (e.g., Fenton et al., 2001; Crits-Christoph et al., 2011) have evaluated bifactor and multidimensional models of the HAq-II:

• Two-Factor Oblique Model: Several investigators have identified a robust two-factor solution distinguishing Positive Alliance / Collaboration (comprising positively worded items such as 1, 2, 3, 5, 6, 7, 9, 10, 12, 13, 14, 15, 17, 18) and Negative Alliance / Relationship Strain (comprising the reverse-scored items: 4, 8, 11, 16, 19). Model fit indices for this two-factor correlated structure frequently outperform the strict single-factor model: Comparative Fit Index ($ ext{CFI}) ge .94$, Tucker-Lewis Index ($ ext{TLI}) ge .93$, and Root Mean Square Error of Approximation ($ ext{RMSEA}) le .058$.
• Bifactor Model: A bifactor configuration—consisting of a general Helping Alliance factor ($G$) capturing universal relationship quality, alongside orthogonal group factors representing specific collaborative work and negative process—yields an exceptional fit ($ ext{CFI} = .97$,$ ext{RMSEA} = .044$), supporting the reporting of a single composite total score while retaining clinical utility for examining negative strain items separately.

10. Instrument / Measurement Tool

• Instrument Name: The Helping Alliance Questionnaire (Revised Version: HAq-II).
• Instrument Type: Standardized psychological self-report inventory; dyadic psychotherapy process measure.
• Versions Available:
  • Patient Version: Completed by the individual undergoing psychotherapy to evaluate their subjective experience of the therapist and collaborative process.
  • Therapist Version: Completed by the treating clinician to rate their perception of the client’s engagement, shared understanding, and dyadic bond.
• Item Count: 19 items (identical core semantic content across both parallel forms, adjusted for grammatical perspective).
• Administration Format: Paper-and-pencil, computerized assessment system, or integrated electronic health record (EHR) rating portal.
• Administration Time: Approximately 3 to 5 minutes.
• Target Population: Adolescent and adult psychotherapy outpatients and inpatients across all diagnostic categories; suitable for individual, couples, and group psychotherapeutic interventions.
• Response Format: 6-point Likert rating scale:
  • 1 = Strongly disagree
  • 2 = Disagree
  • 3 = Slightly disagree
  • 4 = Slightly agree
  • 5 = Agree
  • 6 = Strongly agree
• Scoring Methodology:
  • Positively Worded Items (14 items): Items 1, 2, 3, 5, 6, 7, 9, 10, 12, 13, 14, 15, 17, and 18 are scored directly as marked (1 to 6).
  • Negatively Worded / Reverse-Scored Items (5 items): Items 4, 8, 11, 16, and 19 reflect therapeutic discord, distrust, or procedural dissatisfaction and must be reverse-coded prior to computing composite totals:
    
    $$6
    ightarrow 1,\quad 5
    ightarrow 2,\quad 4
    ightarrow 3,\quad 3
    ightarrow 4,\quad 2
    ightarrow 5,\quad 1
    ightarrow 6$$
    
    (Formula: $\text{Reversed Score} = 7 – \text{Raw Response}$).
  • Total Alliance Score: The grand score can be expressed as either:
    • Summed Score: The sum of all 19 items (ranging from a minimum of 19 to a maximum of 114 points). Higher scores signify stronger, more collaborative helping alliances.
    • Mean Item Score: The total summed score divided by 19 (ranging from 1.00 to 6.00), which retains the interpretable metric of the original Likert response scale.
• Clinical Interpretation Guidelines:
  • Mean Score $ge 5.0$ (Sum $ge 95$): Strong to exceptionally high alliance. Reflects deep mutual trust, clear procedural consensus, and warm emotional bonding.
  • Mean Score $4.0 – 4.9$ (Sum $76 – 94$): Moderate alliance. Represents adequate working collaboration but may contain areas of minor friction or ambivalent engagement.
  • Mean Score $< 4.0$ (Sum $< 76$): Fragile or compromised alliance. Strongly suggests covert or overt relational strain, lack of agreement on therapeutic tasks, or epistemic distrust; warrants immediate clinical attention and direct meta-communicative processing.

11. Permissions & Fee and Test Year

• Original Publication Year: 1996 (HAq-II revised scale published in the Journal of Psychotherapy Practice and Research); precursor HAq-I and Penn scales introduced in 1976 and 1984.
• Copyright & Intellectual Property: Copyright © 1996 by Lester Luborsky, Jacques P. Barber, and co-authors; Center for Psychotherapy Research, University of Pennsylvania Health System.
• Licensing and Accessibility: The Helping Alliance Questionnaire (HAq-II) was placed in the public and academic research domain by its creators to foster empirical investigation into psychotherapy processes. It may be utilized freely without licensing fees or commercial royalties for non-profit clinical practice, educational instruction, and academic research purposes.
• Reproduction and Archival Access: Instrument forms, scoring manuals, and normative validation documents are publicly accessible via the Center for Psychotherapy Research at the University of Pennsylvania Perelman School of Medicine web archive (Center for Psychotherapy Research). Commercial software platforms or proprietary assessment systems embedding the instrument for commercial sale should seek formal authorization from the primary surviving authors and institutional copyright representatives.

12. References

• Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2000). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Journal of Consulting and Clinical Psychology, 68(6), 1027–1032. https://doi.org/10.1037/0022-006X.68.6.1027
• Barber, J. P., Luborsky, L., Crits-Christoph, P., Thase, M. E., Weiss, R., Frank, A., Onken, L., & Blaine, J. (1999). Therapeutic alliance as a predictor of outcome in treatment of cocaine dependence. Psychotherapy Research, 9(1), 54–73. https://doi.org/10.1080/10503309912331332591
• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885
• Crits-Christoph, P., Hamilton, J., Gallop, R., Connolly Gibbons, M. B., Ring-Kurtz, S., & Barber, J. P. (2011). A multidimensional meta-analysis of alliance and outcome in dynamic therapies. Journal of Clinical Psychology, 67(11), 1075–1089. https://doi.org/10.1002/jclp.20842
• Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172
• Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Johns Hopkins University Press.
• Greenson, R. R. (1965). The working alliance and the transference neurosis. The Psychoanalytic Quarterly, 34(2), 155–181. https://doi.org/10.1080/21674086.1965.11927403
• Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149. https://doi.org/10.1037/0022-0167.38.2.139
• Luborsky, L. (1976). Helping alliances in psychotherapy: The groundwork for a study of their association with outcome. In J. L. Cleghorn (Ed.), Successful psychotherapy (pp. 92–116). Brunner/Mazel.
• Luborsky, L., Barber, J. P., Siqueland, L., Johnson, S., Najavits, L. M., Frank, A., & Daley, D. (1996). The Revised Helping Alliance Questionnaire (HAq-II): Psychometric properties. The Journal of Psychotherapy Practice and Research, 5(3), 260–271. PMCID: PMC3330424
• Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. https://doi.org/10.1037/0022-006X.68.3.438
• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge. https://doi.org/10.4324/9780203582015
• Zetzel, E. R. (1956). Current concepts of transference. The International Journal of Psycho-Analysis, 37, 369–376.

13. Items of the Scale (Questionnaire)