Helping Alliance Questionnaire-Short version 
HAQ-6

HAQ -6 Eng .pdf

 HAQ -6 Thai.pdf ฉบับภาษาไทย

 

 

Development of the Helping Alliance Questionnaire (HAQ-I)

The original Helping Alliance Questionnaire, sometimes referred to as HAQ-I, was developed by Lester Luborsky and his colleagues as part of the Penn Helping Alliance Scales.

• Core Concept: The questionnaire is rooted in Luborsky's concept of the "helping alliance," which refers to a patient's experience of therapy or the relationship with their therapist as being helpful or potentially helpful .
• Purpose: It was created as a patient self-report measure to assess the quality of the patient-therapist relationship from the patient's perspective. A parallel version was also developed for therapists to complete.
• Structure and Content:
  • The HAQ-I consists of 11 items rated on a 4-point scale (complete disagree, disagree, agree, completely agree) .
  • The items were designed to capture two types of helping alliance:
    • Type I (Perceived Helpfulness): The patient's experience of the therapist as providing or being capable of providing the help that is needed.
    • Type II (Collaboration or Bonding): The patient's experience of treatment as a process of working together with the therapist toward shared goals.
• Identified Limitations: Over time, researchers became aware of two primary limitations of the HAQ-I:

1.    Some items were explicitly assessing early symptomatic improvement, which potentially confounded the measurement of the alliance with therapy outcomes.

2.    All items were worded positively, which could introduce response bias.

Development and Improvement of the HAQ-II

To address the shortcomings of the original, Luborsky and his team published a revised version, the HAQ-II, in 1996.

• Goals of the Revision: The revision was guided by two main goals: to reduce the scale's inclination to measure symptomatic improvement and to better incorporate the various aspects of the alliance related to the collaborative effort of the patient and therapist.
• Methodological Changes: The developers significantly altered the questionnaire by :
  • Deleting the six items that reflected early symptomatic improvement.
  • Adding 14 new items to more fully tap into different aspects of the alliance, including the collaborative effort, the patient's perception of the therapist, the patient's motivation, and the patient's perception of the therapist's feelings.
  • Introducing five negatively worded items to reduce response bias (e.g., "At times I distrust the therapist's judgement," "The procedures used in my therapy are NOT well suited to my needs").
• Resulting Structure: The final HAQ-II is a 19-item questionnaire. Unlike the two-subscale structure of the HAQ-I, the HAQ-II is generally treated as a unidimensional measure, providing a single overall score for the therapeutic alliance. It uses a 6-point Likert scale from "strongly disagree" to "strongly agree”.

Comparison and Psychometric Properties of HAQ-II

Research has shown the HAQ-II to be a psychometrically sound instrument, representing an improvement over its predecessor.

• Reliability: The HAQ-II demonstrates excellent internal consistency, with Cronbach's alpha values reported to be between 0.90 and 0.93 . Test-retest reliability is also good, ranging from 0.56 to 0.78.
• Validity:
  • It shows good convergent validity, correlating highly with other established alliance measures like the California Psychotherapy Alliance Scale (CALPAS).
  • A key improvement over the HAQ-I is that HAQ-II scores are less influenced by the patient's pretreatment psychiatric severity or level of depression. This means it more purely measures the alliance itself, rather than patient symptoms.
  • Studies confirm that the HAQ-II is a valid instrument for measuring the helping alliance and that it better relates to the alliance construct than the original HAQ-I.
• Recommendation: Due to its better construct validity and reduced influence from patient symptoms, the use of the revised HAQ-II is recommended over the original HAQ-I.

The following table summarizes the key differences between the two versions of the Helping Alliance Questionnaire.

 

 

 

The Development of Thai version of HAQ-II

         

          Prof. Wongpakaran was granted permission by Prof. Dr. Jacques P. Barber to translate the original 19‑item English version into Thai. The Thai version of the HAQ was subsequently shortened to HAQ‑13, and later to HAQ‑6, to facilitate ease of use in clinical settings while maintaining its psychometric properties.

Scoring Guide for the 6-item Helping Alliance Questionnaire

This instrument is a short version of the Helping Alliance Questionnaire. It uses a 6-point Likert scale, and all items are positively worded.

1. Item Scoring

Respondents circle the number that best represents their agreement with each statement.

• 1 = Strongly Disagree

• 2 = Disagree

• 3 = Slightly Disagree

• 4 = Slightly Agree

• 5 = Agree

• 6 = Strongly Agree

Note: Because all 6 items are worded in a positive direction (a higher score indicates a better alliance), no reverse scoring is required.

2. Calculating the Total Score

The most common method for scoring is to sum the scores of all individual items.

• Total Score = Item 1 + Item 2 + Item 3 + Item 4 + Item 5 + Item 6

• Score Range: 6 to 36

• Interpretation: A higher total score indicates that the patient perceives a stronger therapeutic alliance (feeling of collaboration, trust, and helpfulness) with their therapist.

3. Calculating the Mean Score

Researchers sometimes use the mean score, especially when comparing this scale to others with a different number of items.

• Mean Score = Total Score ÷ 6

• Mean Range: 1.0 to 6.0

• Interpretation: A mean score closer to 6.0 represents a very positive helping alliance.

4. Interpretation Guidelines

Since this specific 6-item version may not have established national norms, interpretation is often done in one of the following ways:

1. Comparing within a sample: Patients can be grouped into those with "above-average" or "below-average" alliance scores based on the average score of the study group.

2. Using theoretical cut-offs: For example, you can divide the total score range (6-36) into tertiles or quartiles.

   • Low Alliance: 6 - 16

   • Moderate Alliance: 17 - 26

   • High Alliance: 27 - 36

 

Psychometric properties

 

Psychometric properties of the revised HAQ‑13: The questionnaire functions as a unidimensional scale, with all items measuring the construct of the “relationship” between patient and therapist. The items were tested on a sample of 60 psychotherapy clients [1]. Reliability assessment using internal consistency yielded a Cronbach’s alpha of 0.93 (values above .80 are considered good). The HAQ‑13 showed significant correlation with the Safety Scale, but not with the Pathogenic Belief Scale, indicating its convergent and discriminant validity. In the present study, Cronbach’s alpha was found to be 0.85.

 The HAQ‑6 was administered to 380 clinical patients across various clinics. The scale demonstrated strong internal consistency, with a Cronbach’s alpha of 0.89. The unidimensional model was supported by the following fit indices: CFI = .991, TLI = .972, and RMSEA = .079 (90% CI: .040–.122).

Ref

1.                 Wongpakaran T, Wongpakaran N: Using Control Mastery Therapy with Borderline Patients. In: Society of Psychotherapy Research (SPR), 44th. Brisbane, Australia; 2013.