THE HELPING ALLIANCE QUESTIONNAIRE

Abstract

The Helping Alliance Questionnaire (HAQ), specifically the revised version (HAQ-II), is a widely used psychometric instrument designed to measure the quality and strength of the working relationship, or therapeutic alliance, between a patient and their therapist. Developed by Luborsky and colleagues in 1996, the HAQ is distinguished by its parallel structure, featuring both a Patient Version and a Therapist Version, each containing 19 items. This dual perspective allows for a comprehensive assessment of the perceived collaboration, goal agreement, and affective bond, which are critical predictors of positive psychotherapy outcomes.

Keywords

Helping Alliance Questionnaire, HAQ, Therapeutic Alliance, Psychotherapy Outcome, Working Relationship, Patient-Therapist Bond, Psychometric Properties, Luborsky.

Authors

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

Purpose

The primary purpose of the HAQ is to quantitatively assess the quality of the therapeutic relationship during the course of psychological treatment. Research across various modalities consistently demonstrates that the strength of the helping alliance is one of the most reliable predictors of treatment success, often more significant than the specific therapeutic approach used.

The instrument is intended to provide clinicians and researchers with a measurable outcome variable related to the collaborative interaction, evaluating the degree of mutual commitment to the process. By administering parallel forms to both parties, the HAQ helps identify potential divergences in perception regarding the relationship, tasks, or goals, which can inform clinical interventions aimed at repairing alliance ruptures.

Construct

The HAQ measures the psychological construct of the Helping Alliance, which is defined by the quality of the collaborative bond between the patient and the therapist. This construct is generally understood to encompass several inter-related components crucial for effective therapy:

• The Bond: The affective component, reflecting mutual trust, respect, and positive regard.
• Goals: The agreement on the specific objectives and desired results of the therapy.
• Tasks: The consensus on the methods and procedures utilized during sessions to achieve those goals.

The questionnaire items are designed to capture the patient’s and therapist’s subjective experience of this collaboration, focusing on dependency, understanding, joint effort, and respect for views.

Validity

The revised HAQ (HAQ-II) has demonstrated robust evidence supporting its validity. Studies have established strong Predictive Validity, showing that higher alliance scores, particularly those provided by the patient early in treatment, are significantly correlated with positive treatment outcomes, including greater symptom reduction and lower rates of premature termination.

Furthermore, the scale exhibits sound Construct Validity, as confirmed by its ability to differentiate the therapeutic relationship from general patient satisfaction or transference phenomena. The HAQ-II’s focus on measuring collaboration and mutual commitment aligns well with established theoretical models of the therapeutic alliance.

Reliability

The HAQ-II possesses strong measures of Reliability, essential for a psychometric instrument used in predicting clinical outcomes. The scale typically reports high internal consistency (e.g., Cronbach’s alpha often exceeding 0.80) for both the patient and therapist versions. This high consistency ensures that the items within each version reliably measure the same underlying construct of the helping alliance.

Test-retest reliability has also been deemed adequate, indicating that HAQ scores remain consistent over time during stable periods of therapy. The strong Psychometric Properties of the HAQ-II confirm its suitability for longitudinal research and clinical monitoring.

Factor Analysis

Initial investigations using Factor Analysis often indicated that the HAQ measures a dominant, overarching factor representing the global quality of the helping alliance. However, closer examination of the HAQ-II structure frequently supports a two-factor model that aligns closely with theoretical divisions of the alliance:

1. The Relational Factor (Bond): Items pertaining to mutual trust, liking, and emotional connection between the patient and the therapist.
2. The Task/Goal Factor (Collaboration): Items related to agreement on the procedures, goals, and the perceived effectiveness of the joint work in therapy.

These findings reinforce the scale’s capacity to measure both the affective and technical aspects of the collaborative relationship.

Instrument

Test Type: Self-report questionnaire (Patient Version) and Observer-report questionnaire (Therapist Version).

Format: 19 items scored on a 6-point scale, ranging from 1 (strongly disagree) to 6 (strongly agree). The original PDF questionnaire can be downloaded here: http://www.med.upenn.edu/cpr/documents/HAQ2QUES.pdf

Language Available: English (original). Widely translated for international research use.

Population Group: Patients receiving psychological treatment (psychotherapy, counseling) and their respective clinicians.

Age Group: Primarily used with adults (18+).

Population Details: Applicable across diverse clinical settings and treatment modalities, including psychodynamic, cognitive-behavioral, and supportive therapies.

Test Methodology: Parallel self-report forms administered to both participants, typically administered after the third or fourth session to capture the early formation of the alliance, and sometimes repeated throughout treatment.

Keywords

Psychotherapy Research, Collaborative Bond, HAQ-II, Alliance Rupture, Treatment Outcome Prediction, Factor Analysis, Luborsky.

Authors

Author ORCID Identifier: Not provided in source.

Affiliation Email addresses: Not provided in source.

Correspondence Address: Correspondence is typically handled through the Center for Psychotherapy Research (CPR) at the University of Pennsylvania, where the research originated.

Permissions & Fee and Test Year

The revised instrument, known as the HAQ-II, was formally published and validated in 1996.

The instrument and its scoring guidelines were made publicly available for research purposes by the University of Pennsylvania Center for Psychotherapy Research (CPR). The scoring instructions PDF can be downloaded here: http://www.med.upenn.edu/cpr/documents/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. 1996; 5(3):260-71.

University of Pennsylvania Center for Psychotherapy Research (CPR). Instruments. Available online at: http://www.med.upenn.edu/cpr/instruments.html

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.

THE HELPING ALLIANCE QUESTIONNAIRE

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.