The Helping Alliance Questionnaire

1. Abstract

The Helping Alliance Questionnaire (most prominently operationalized in its revised 19-item version, the HAq-II; Luborsky et al., 1996) is one of the most widely utilized and empirically validated self-report instruments designed to assess the quality of the therapeutic alliance in psychological treatment. Originally derived from the Penn Helping Alliance rating system and the initial 24-item Helping Alliance Questionnaire (HAq-I; Luborsky et al., 1983), the HAq-II was engineered to eliminate psychometric weaknesses inherent in early alliance measures, such as conflation with general symptom improvement, ambiguous item wording, and unstable factor structures. Comprising 19 items evaluated on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree), the HAq-II captures core pantheoretical dimensions of the therapeutic relationship, including collaborative goal alignment, mutual trust, interpersonal warmth, perceived therapist competence, and the perceived utility of therapeutic procedures. The questionnaire features parallel forms for both patients and therapists. Psychometric evaluations across diverse diagnostic populations demonstrate excellent internal consistency, with Cronbach’s alpha coefficients routinely exceeding .90, stable test-retest reliability across early and mid-treatment phases, robust convergent validity with concurrent instruments such as the Working Alliance Inventory (WAI) and the California Psychotherapy Alliance Scale (CALPAS), and significant predictive validity regarding treatment retention and clinical symptom reduction. This article provides a comprehensive academic analysis of the HAq-II, examining its theoretical lineage, psychometric properties, factor structure, scoring mechanics, clinical utility, and complete scale items.

2. Keywords

Helping Alliance Questionnaire, HAq-II, therapeutic alliance, working alliance, Lester Luborsky, psychotherapy process research, collaborative relationship, treatment outcome, psychometrics, patient-therapist relationship

3. Authors

The Revised Helping Alliance Questionnaire (HAq-II) was developed by a team of leading psychotherapy researchers at the Center for Psychotherapy Research, Department of Psychiatry, University of Pennsylvania School of Medicine:

• Lester Luborsky, Ph.D. (1920–2009): Renowned clinical psychologist and pioneer in empirical psychotherapy research, Professor of Psychology in Psychiatry at the University of Pennsylvania, and originator of the Core Conflictual Relationship Theme (CCRT) method.
• Jacques P. Barber, Ph.D., ABPP: Professor and Dean of the Derner School of Psychology at Adelphi University; formerly Associate Director of the Center for Psychotherapy Research at the University of Pennsylvania.
• Lynn Siqueland, Ph.D.: Clinical psychologist specializing in anxiety disorders, formerly affiliated with the Department of Psychiatry, University of Pennsylvania School of Medicine.
• Suzanne Johnson, Ph.D.: Psychotherapy researcher and clinician affiliated with the University of Pennsylvania psychotherapy research group.
• Lisa M. Najavits, Ph.D.: Professor of Psychiatry, Boston University School of Medicine, and Director of Coping Skills Review; developer of Seeking Safety.
• Arthur Frank, M.D.: Clinical psychiatrist and clinical investigator in addiction medicine and psychotherapeutic processes.
• Dennis C. Daley, Ph.D.: Professor of Psychiatry and specialist in substance use disorder interventions at the Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine.

4. Purpose

The fundamental purpose of the Helping Alliance Questionnaire is to quantify the strength, quality, and therapeutic viability of the collaborative relationship forged between a client and their clinician. Across decades of psychotherapy outcome investigations, the therapeutic alliance has consistently emerged as one of the most robust, cross-cutting common factors predicting therapeutic change, accounting for a statistically significant proportion of outcome variance across divergent theoretical orientations, including cognitive-behavioral therapy (CBT), psychodynamic psychotherapy, humanistic-experiential treatments, and pharmacotherapy combined with clinical management (Horvath et al., 2011; Flückiger et al., 2018).

The HAq-II was specifically developed to address methodological and conceptual limitations identified in the original Helping Alliance Questionnaire (HAq-I; Luborsky et al., 1983) and other first-generation alliance inventories. Psychometric critiques of the HAq-I highlighted that several items reflected treatment outcome or early symptom improvement rather than the therapeutic relationship itself (e.g., items asking whether the patient felt their symptoms were improving). Inclusion of such outcome-laden items artificially inflated correlations between early alliance ratings and ultimate treatment success, creating an artifactual confounding of process and outcome. To remediate this, Luborsky and colleagues (1996) rigorously re-engineered the instrument to remove symptom-change indicators, purge psychometrically ambiguous or redundant phrasing, balance positive and negatively keyed items, and optimize item-total correlations.

In clinical practice, the HAq-II serves as a rapid, unobtrusive monitoring tool capable of tracking the evolving relational climate of therapy. Administered after initial consultation sessions or at recurring intervals (e.g., sessions 3, 5, and terminal phases), the questionnaire alerts clinicians to emerging alliance ruptures, latent patient dissatisfaction, misalignments in therapeutic goals, or interpersonal detachment. In clinical research, the HAq-II operates as a standard covariate, mediator, or moderator in randomized controlled trials (RCTs), comparative efficacy studies, and process-outcome investigations examining mechanism-of-action models in mental health treatments.

5. Psychological Construct

The psychological construct measured by the HAq-II is the helping alliance, an empirical operationalization of the therapeutic working relationship that integrates interpersonal, psychodynamic, and pantheoretical conceptualizations. Within the Penn Helping Alliance tradition initiated by Lester Luborsky (1976), the alliance is conceptualized as evolving through two interdependent developmental forms, while converging into a unified, synergistic relational bond:

Type 1 Alliance: Perceived Therapist Support and Warmth

Early in treatment, the alliance is characterized predominantly by the patient’s experience of the therapist as a supportive, warm, empathic, and dependable ally. This dimension reflects the interpersonal safety necessary for psychological exploration. Items reflecting this facet assess whether the client perceives the therapist as benevolent, understanding, and capable of holding the therapeutic frame securely (e.g., 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”). A deficit in Type 1 alliance manifests as interpersonal alienation, fear of clinician judgment, or emotional withdrawal.

Type 2 Alliance: Collaborative Work and Shared Responsibility

As psychotherapy progresses, the alliance matures into a mutual partnership centered on active, joint problem-solving and shared labor toward overcome psychological distress. Type 2 alliance reflects the patient’s active commitment to therapeutic tasks, reciprocal collaboration, and alignment regarding treatment rationale (e.g., 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”). This dimension captures the operational engine of change, wherein patient and therapist function as an investigative team.

Impediments and Relational Ruptures

The construct measured by the HAq-II explicitly incorporates the presence or absence of relational strains and impasses. Negatively valenced items systematically evaluate perceived incompetence, procedural discordance, affective distance, and unproductive communication (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 11: “The therapist relates to me in ways that slow up the progress of the therapy”; Item 19: “At times the therapist seems distant”). Capturing both supportive affirmations and relational frictions enables the HAq-II to yield a nuanced, ecologically valid metric of the therapeutic dyad.

6. Theoretical Framework

The theoretical architecture of the Helping Alliance Questionnaire traces its lineage to early psychoanalytic formulations of the relational matrix, modern pantheoretical alliance paradigms, and empirical attachment theory.

The Psychoanalytic Roots of the Alliance

Although Sigmund Freud initially identified the necessity of an affectionate, non-neurotic attachment between patient and analyst to sustain the rigors of analysis, formal theoretical distinction of the alliance emerged with Richard Sterba (1934), who described the therapeutic “ego alliance,” and Elizabeth Zetzel (1956), who coined the term therapeutic alliance. Zetzel posited that successful therapy relies on the patient’s capacity to establish a stable, trusting object relationship mirroring healthy maternal-infant attachment. Ralph Greenson (1965) further delineated the working alliance from transference and the real relationship, defining it as the non-regressive, rational collaboration between patient and analyst focused on analyzing resistance and unconscious conflict.

Luborsky’s Empirical Penn Alliance Model

Lester Luborsky (1976) revolutionized alliance scholarship by translating abstract psychodynamic constructs into empirically measurable observational and self-report dimensions. Luborsky established the Penn Helping Alliance rating method, positing that a viable alliance requires both a supportive emotional climate (Type 1) and collaborative goal-directed engagement (Type 2). Luborsky’s empirical framework asserted that the alliance is not merely an absence of negative transference, but an active, positive psychotherapeutic mechanism that facilitates cognitive restructuring, emotional processing, and behavioral experimentation across all treatment modalities.

Bordin’s Pantheoretical Working Alliance Tripartite Model

The conceptual framework of the HAq-II aligns closely with Edward Bordin’s (1979) seminal pantheoretical formulation. Bordin posited that the working alliance across all therapeutic disciplines consists of three interdependent components:

1. Bonds: Mutual affective attachments, trust, liking, and shared respect between participant and practitioner.
2. Goals: Explicit or implicit consensus regarding the overarching targets, objectives, and anticipated outcomes of intervention.
3. Tasks: Mutual agreement upon and engagement in the specific in-session activities and out-of-session behaviors perceived as relevant to achieving therapeutic goals.

The HAq-II maps directly onto Bordin’s triad: bond items evaluate interpersonal trust, warmth, and respect; goal items assess congruency regarding symptom reduction and personal aspirations; and task items evaluate whether treatment procedures and communicative exchanges are perceived as effective and mutually endorsed.

7. Validity

The psychometric validity of the HAq-II has been extensively demonstrated across clinical trials, naturalistic outpatient samples, and diverse psychiatric presentations, including major depressive disorder, substance use disorders, generalized anxiety disorder, and personality disorders (Luborsky et al., 1996; Fenton et al., 2001; Barber et al., 2000).

Construct and Factorial Validity

In the original validation study by Luborsky et al. (1996), which evaluated 249 patients across four independent clinical cohorts (including patients receiving psychotherapy for depression and substance abuse), the 19 items demonstrated strong construct integrity. Factorial analyses established that the scale’s items load uniformly on a dominant overarching alliance dimension. Item-total correlations for the 19 retained items ranged from .35 to .75, confirming that each item contributes meaningfully to the shared variance of the core construct without excessive conceptual overlap.

Convergent Validity

Convergent validity has been established through high correlations with established psychotherapy process measures:

• Working Alliance Inventory (WAI): Correlations between the HAq-II and the WAI total scores typically range between r = .70 and r = .84, demonstrating substantial construct concordance across divergent operational frameworks (Barber et al., 2000).
• California Psychotherapy Alliance Scale (CALPAS): The HAq-II correlates significantly with CALPAS global scores (r = .65 to .78), showing particularly high associations with the Patient Working Capacity and Therapist Understanding subscales.
• Vanderbilt Psychotherapy Process Scale (VPPS): Significant positive associations are observed between patient HAq-II ratings and observer-rated patient participation and therapist exploration subscales of the VPPS (r = .45 to .62).

Discriminant Validity

Crucially, the HAq-II demonstrates superior discriminant validity compared to its predecessor, the HAq-I. By removing symptom-contingent items, the correlation between HAq-II scores and baseline symptom severity measures—such as the Beck Depression Inventory (BDI) and the Symptom Checklist-90-Revised (SCL-90-R)—was reduced to near-zero levels (r = -.05 to -.14, non-significant), demonstrating that the HAq-II assesses the relational bond independent of initial psychological distress (Luborsky et al., 1996).

Predictive Validity

The HAq-II consistently predicts clinical outcomes across diagnostic cohorts. In the Luborsky et al. (1996) multisite analysis, early-session HAq-II scores (measured at sessions 2 to 4) significantly predicted post-treatment symptom reduction (accounting for 5% to 12% of unique outcome variance) and premature termination/dropout status. In studies of substance use disorders (e.g., the NIDA Collaborative Cocaine Treatment Study), early patient-rated HAq-II scores predicted cocaine abstinence, treatment retention, and counseling session attendance beyond the influence of demographic and baseline addiction severity indicators (Barber et al., 2001).

8. Reliability

The reliability of the HAq-II has been confirmed across independent clinical research laboratories, establishing both internal consistency and temporal stability.

Internal Consistency

Across validation cohorts, the HAq-II exhibits high internal consistency:

• In the original Luborsky et al. (1996) development study, Cronbach’s alpha for the full 19-item patient version was α = .93 across combined treatment samples.
• For the therapist version, Cronbach’s alpha was documented at α = .88 to .91, indicating comparable internal coherence from the clinician perspective.
• Independent replications in outpatient psychiatric clinics have yielded alpha coefficients consistently spanning α = .89 to .94 for patient forms, confirming that the questionnaire retains strong internal metric precision across varying clinical environments (Fenton et al., 2001; Busch et al., 2008).

Test-Retest Reliability and Stability

Because the therapeutic alliance represents an evolving interpersonal process rather than an immutable personality trait, test-retest reliability assessments are typically conducted across adjacent treatment sessions early in care:

• Luborsky et al. (1996) observed test-retest correlations between early consecutive sessions (e.g., Session 2 to Session 3) ranging between r = .75 and .82, demonstrating appropriate stability alongside expected sensitivity to session-by-session clinical dynamics.
• Intraclass correlation coefficients (ICCs) evaluated over short non-treatment intervals (48–72 hours) demonstrated temporal measurement stability of ICC = .85.

9. Factor Analysis

Extensive exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) have been performed on the HAq-II to clarify its latent dimensionality.

Exploratory Factor Analysis (EFA)

During scale construction, Luborsky and colleagues (1996) performed principal components analyses with varimax and oblimin rotations on the original pool of Penn Alliance items. While theoretical models delineated Type 1 (support) and Type 2 (collaboration) processes, EFA consistently extracted a single dominant primary factor accounting for approximately 45% to 54% of the common item variance. All 19 items demonstrated primary factor loadings exceeding .40, with the vast majority loading between .52 and .78 on this general “Alliance” factor. Although secondary minor factors occasionally emerged—reflecting positive emotional bond versus procedural disagreement/rupture—these factors exhibited high intercorrelations (r > .60), supporting the use of a unified global alliance composite score.

Confirmatory Factor Analysis (CFA)

Subsequent confirmatory investigations (e.g., Fenton et al., 2001; Crits-Christoph et al., 2011) evaluated rival structural models: a strict unidimensional model, an oblique two-factor model (Positive Collaboration vs. Relational Discord), and a bifactor model featuring a general alliance dimension alongside specific method/valence factors. Structural findings indicate:

• Unidimensional Model: Demonstrates acceptable to good fit when accounting for method effects associated with reverse-keyed items: Comparative Fit Index (CFI) = .92 to .95, Root Mean Square Error of Approximation (RMSEA) = .058 to .072.
• Two-Factor Model (Positive Connection vs. Negative Rupture): Yields marginally superior fit indices (CFI = .96, RMSEA = .051), with items 4, 8, 11, 16, and 19 loading robustly onto the discordance factor. However, because the positive and negative latent factors correlate inversely and strongly (r = -.68 to -.76), clinical researchers and trialists overwhelmingly utilize the global unidimensional composite score for empirical analyses.

10. Instrument / Measurement Tool

The structural, operational, and scoring parameters of the Helping Alliance Questionnaire (HAq-II) are summarized below:

• Instrument Designation: Helping Alliance Questionnaire (HAq-II) — Patient Version & Parallel Therapist Version.
• Construct Measured: Quality of the therapeutic alliance, collaborative relationship, and mutual interpersonal engagement in psychotherapy.
• Test Type: Standardized self-report rating scale (completed independently by the patient, clinician, or both).
• Total Item Count: 19 items.
• Response Format: 6-point Likert scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Slightly Disagree
  • 4 = Slightly Agree
  • 5 = Agree
  • 6 = Strongly Agree
• Direction of Scoring: Higher scores denote a stronger, more positive helping alliance.
  • Positively Scored Items (14 items): Items 1, 2, 3, 5, 6, 7, 9, 10, 12, 13, 14, 15, 17, and 18 are scored directly as rated (1 = 1, 2 = 2, 3 = 3, 4 = 4, 5 = 5, 6 = 6).
  • Negatively Scored (Reverse-Coded) Items (5 items): Items 4, 8, 11, 16, and 19 indicate alliance ruptures, skepticism, or procedural discord and must be reverse-coded prior to computing aggregate metrics (1 = 6, 2 = 5, 3 = 4, 4 = 3, 5 = 2, 6 = 1).
• Scoring Algorithms:
  • Total Sum Score: Sum the scores of all 19 items after reversing items 4, 8, 11, 16, and 19. Total raw scores range from 19 to 114.
  • Mean Item Score: Divide the total sum score by 19 (range: 1.00 to 6.00). This metric is widely favored because it retains the original 1–6 response scale metric, allowing intuitive clinical interpretation (e.g., scores > 5.0 denote a strong alliance; scores < 4.0 warrant immediate clinical exploration of potential relational impasses).
• Administration Duration: Approximately 3 to 5 minutes to complete; scoring takes under 2 minutes.

11. Permissions & Fee and Test Year

The Revised Helping Alliance Questionnaire (HAq-II) was formally published in 1996 by Lester Luborsky and colleagues at the University of Pennsylvania. In alignment with Dr. Luborsky’s commitment to advancing empirical psychotherapy science, the HAq-II was placed into the academic public domain for scientific, educational, and non-commercial clinical use. No licensing fees or royalty payments are required for academic investigators, hospital departments, or clinicians utilizing the scale for non-commercial purposes.

Researchers and practitioners may access the instrument and official scoring guides through academic research repositories or the historical archives of the Center for Psychotherapy Research at the University of Pennsylvania Perelman School of Medicine. Any commercial adaptation, inclusion in fee-for-service digital assessment platforms, or commercial software integration requires permission and adherence to copyright stipulations originating from the author estate and the original publishing entity (The Journal of Psychotherapy Practice and Research / American Psychiatric Press).

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., Gallop, R., Crits-Christoph, P., Frank, A., Weiss, R. D., Thase, M. E., Connolly, M. B., Gladis, M., Foltz, C., & Siqueland, L. (2001). Therapeutic alliance as a predictor of outcome and retention in group therapy for cocaine dependence. Psychotherapy Research, 11(4), 421–435. https://doi.org/10.1080/713664052
• 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
• Busch, A. M., Kanter, J. W., Landes, S. J., & Kohlenberg, R. J. (2008). Measuring the working alliance in functional analytic psychotherapy: Psychometric properties of the Helping Alliance Questionnaire II. International Journal of Behavioral Consultation and Therapy, 4(3), 262–273. https://doi.org/10.1037/h0100855
• Crits-Christoph, P., Gibbons, M. B. C., Hamilton, J., Ring-Kurtz, S., & Gallop, R. (2011). The dependability of alliance assessments: The Helping Alliance Questionnaire II. Psychotherapy Research, 21(3), 267–278. https://doi.org/10.1080/10503307.2011.559556
• Fenton, L. R., Cecero, J. J., Nich, C., Frankforter, T. L., & Carroll, K. M. (2001). Perspective is everything: The predictive validity of concurrent ratings of the alliance by patients, therapists, and observers in substance abuse treatment. Journal of Psychotherapy Practice and Research, 10(4), 262–268.
• 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
• Greenson, R. R. (1965). The working alliance and the transference neurosis. The Psychoanalytic Quarterly, 34(2), 155–181. https://doi.org/10.1080/21674086.1965.11927429
• Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16. https://doi.org/10.1037/a0022186
• Luborsky, L. (1976). Helping alliances in psychotherapy: The groundwork for a study of their methods and curious differences in outcomes. In J. L. Claghorn (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. Journal of Psychotherapy Practice and Research, 5(3), 260–271.
• Luborsky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. The Journal of Nervous and Mental Disease, 171(8), 480–491. https://doi.org/10.1097/00005053-198308000-00004
• Sterba, R. (1934). The fate of the ego in analytic therapy. International Journal of Psychoanalysis, 15, 117–126.
• Zetzel, E. R. (1956). Current concepts of transference. International Journal of Psychoanalysis, 37, 369–376.

13. Items of the Scale (Questionnaire)