THE HELPING ALLIANCE QUESTIONNAIRE

Abstract

The Helping Alliance Questionnaire (HAQ), particularly its revised iteration, the HAQ-II, is a widely recognized self-report instrument designed to measure the quality of the therapeutic alliance between a patient and their therapist. Developed by Luborsky and colleagues in 1996, the scale provides parallel versions for both the patient and the clinician, allowing for a comprehensive, dyadic assessment of the working relationship. The core purpose of the HAQ is to quantify the strength of the collaborative bond and shared goals in psychotherapy, which is a critical predictor of treatment outcome.

The instrument consists of 19 items scored on a 6-point Likert scale. Research consistently supports the HAQ-II’s strong psychometric properties, affirming its utility in clinical research for studying the mechanisms by which the patient-therapist relationship influences therapeutic success.

Keywords

Helping Alliance Questionnaire, HAQ-II, therapeutic alliance, psychotherapy outcome, Luborsky, patient-therapist relationship, self-report scale, psychometric properties, clinical assessment.

Authors

Luborsky L, Barber JP, Siqueland L, Johnson S, Najavits LM, Frank A, Daley D.

Purpose

The primary purpose of the HAQ is to provide a standardized, quantifiable measure of the therapeutic alliance within the context of ongoing treatment. It is used extensively in clinical research to investigate the relationship between the quality of the alliance and various treatment outcomes, including symptom reduction, retention rates, and overall treatment success. By providing both patient and therapist perspectives, the HAQ facilitates the comparison of these viewpoints, which often diverge, offering richer data for meta-analyses and clinical supervision.

The instrument is designed to be administered early in treatment and periodically thereafter, as the alliance is a dynamic construct that evolves over time. The results help researchers and clinicians identify potential ruptures or strengths in the working relationship, which can then be addressed to optimize the therapeutic process and improve patient engagement.

Construct

The HAQ measures the Therapeutic Alliance, often referred to as the Helping Alliance. This construct is generally understood as the collaborative and affective bond between the patient and the therapist, encompassing three core components as defined by Bordin (1979): the development of a strong personal bond, agreement on the goals of treatment, and agreement on the tasks or methods used to achieve those goals.

Specifically, the HAQ assesses the patient’s and therapist’s perceptions of mutual trust, understanding, shared responsibility, and commitment to the therapeutic process. Items reflect feelings of dependability, shared purpose, respect for judgment, and perceived understanding, providing a multidimensional view of the working relationship essential for effective psychotherapy.

Validity

The revised version, the HAQ-II, demonstrated strong evidence of construct validity across various clinical populations. Studies, including the original 1996 publication, confirm that HAQ scores consistently correlate positively and significantly with favorable treatment outcomes. This predictive validity is a cornerstone of the scale’s utility, confirming that a stronger measured alliance leads to better clinical results across different therapeutic modalities.

Furthermore, evidence for discriminant validity shows that the HAQ measures the specific relational construct distinct from general patient satisfaction or symptom severity, although a strong alliance often leads to improvements in both. The parallel structure of the patient and therapist versions allows for examination of inter-rater reliability and agreement, which is a crucial aspect of its validation in dyadic research settings.

Reliability

The HAQ-II exhibits high internal consistency, typically measured using Cronbach’s alpha. The internal reliability coefficients reported in the literature often exceed the acceptable standard of .80 for both the patient and therapist versions, indicating that the items within each scale reliably measure the same underlying construct. This consistency holds across different treatment modalities and patient demographics.

Test-retest reliability has also been investigated, generally showing moderate to high stability of alliance scores over short intervals, confirming that the scale provides consistent measurements of the relational bond, particularly when administered during stable phases of treatment.

Factor Analysis

Early factor analyses of the HAQ suggested a multi-factor structure, but subsequent analyses of the revised HAQ-II generally support a strong unitary factor model, reflecting the overall quality of the helping alliance. However, some researchers interpret the items as loading onto subscales reflecting ‘Bond’ (relational warmth and trust) and ‘Task/Goal’ (agreement on treatment methods and objectives).

The authors of the HAQ-II primarily emphasized its overall utility as a measure of the total alliance score, given the high correlation between potential subfactors. This structure distinguishes it from other alliance measures that strictly adhere to three separate, orthogonal factors.

Instrument

Test Type: Self-report questionnaire (with parallel versions for patient and therapist).

Format: 19 items (HAQ-II version) scored on a 6-point Likert scale, ranging from 1 (strongly disagree) to 6 (strongly agree). Reverse scoring is applied to negatively worded items (e.g., items 4, 8, 11, 16, 19 in the patient version).

Language Available: Primarily English, though translations exist due to its widespread use in international research.

Population Group: Clinical population undergoing psychotherapy.

Age Group: Adults (typically 18+).

Population Details: Used across various diagnostic categories, including depression, anxiety disorders, and substance use disorders, demonstrating its applicability regardless of specific pathology.

Test Methodology: Paper-and-pencil or digital administration. Scores are summed or averaged, yielding a single total score representing the strength of the helping alliance from the perspective of the respondent (patient or therapist).

Keywords

Psychological assessment, clinical research, therapeutic relationship, HAQ, psychometric instrument, outcome prediction, alliance rupture, self-report measure.

Authors

Author ORCID Identifier: Information not provided in source.

Affiliation Email addresses: Information not provided in source.

Correspondence Address: Information not provided in source.

Permissions & Fee and Test Year

The HAQ-II was formally published and validated in 1996. The instrument is generally considered part of the public domain for academic research purposes, though specific permissions or fees may apply depending on the source and context of use. Information regarding the instrument and related materials can often be found through the Center for Psychotherapy Research at UPenn.

The original PDF of the Revised Helping Alliance Questionnaire (HAq-II) is available here: HAQ2QUES.pdf. The scoring instructions are available here: HAQ-II_scoring.pdf.

Reference’s

Luborsky L, Barber JP, Siqueland L, Johnson S, Najavits LM, Frank A, Daley D. (1996). The Revised Helping Alliance Questionnaire (HAq-II): Psychometric Properties. J Psychother Pract Res. 5(3):260-71.

The scale utilizes a 6-point Likert scale defined as: 1= strongly disagree, 2=disagree, 3=slightly disagree, 4= slightly agree, 5=agree, 6= strongly agree.

Items of the THE HELPING ALLIANCE QUESTIONNAIRE

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

Patient Version

INSTRUCTIONS: These are ways that a person may feel or behave in relation to another person — their therapist. Consider carefully your relationship with your therapist, and then mark each statement according to how strongly you agree or disagree. Please mark every one.

1. I feel I can depend upon the therapist.
2. I feel the therapist understands me.
3. I feel the therapist wants me to achieve my goals.
4. At times I distrust the therapist’s judgment.
5. I feel I am working together with the therapist in a joint effort.
6. I believe we have similar ideas about the nature of my problems.
7. I generally respect the therapist’s views about me.
8. The procedures used in my therapy are not well suited to my needs.
9. I like the therapist as a person.
10. In most sessions, the therapist and I find a way to work on my problems together.
11. The therapist relates to me in ways that slow up the progress of the therapy.
12. A good relationship has formed with my therapist.
13. The therapist appears to be experienced in helping people.
14. I want very much to work out my problems.
15. The therapist and I have meaningful exchanges.
16. The therapist and I sometimes have unprofitable exchanges.
17. From time to time, we both talk about the same important events in my past.
18. I believe the therapist likes me as a person.
19. At times the therapist seems distant.

Therapist Version

INSTRUCTIONS: These are ways that a person may feel or behave in relation to another person — their therapist. Consider carefully your relationship with your patient, and then mark each statement according to how strongly you agree or disagree.

1. The patient feels he/she can depend upon me.
2. He/she feels I understand him/her.
3. The patient feels I want him/her to achieve the goals.
4. At times the patient distrusts my judgment.
5. The patient feels he/she is working together with me in a joint effort.
6. I believe we have similar ideas about the nature of his/her problems.
7. The patient generally respects my views about him/her.
8. The patient believes the procedures used in his/her therapy are not well suited to his/her needs.
9. The patient likes me as a person.
10. In most sessions, we find a way to work on his/her problems together.
11. The patient believes I relate to him/her in ways that slow up the progress of the therapy.
12. The patient believes a good relationship has formed between us.
13. The patient believes I am experienced in helping people.
14. I want very much for the patient to work out his/her problems.
15. The patient and I have meaningful exchanges.
16. The patient and I sometimes have unprofitable exchanges.
17. From time to time, we both talk about the same important events in his/her past.
18. The patient believes I like him/her as a person.
19. At times the patient sees me as distant.