Therapeutic alliance

A good therapeutic alliance is essential for successful therapy. In fact, some would argue there is nothing more important. But what is exactly meant by the “therapeutic alliance” and how do you build one that works? Let’s take a closer look at the therapist-client relationship and what you can do to foster an effective connection with your clients.

What is a therapeutic alliance? 

Most people know that the therapeutic alliance is the relationship a therapist has with their client. But what are the components of that relationship?

What are the key elements of a therapeutic alliance?

Collaboration of goals. Clients come to therapy for a reason. They have goals that they want to achieve. The therapist must work with the client on shaping those goals as realistic and effective. The therapeutic alliance is strongest when the client knows that they are on the same page as the therapist, working toward a common destination. 

Agreement on tasks. The second component of a successful therapeutic alliance is agreeing on the tasks, or how those goals will be achieved. This can be tricky as the client may exhibit resistance toward uncomfortable tasks. Objectives must be palatable to the client while, at the same time, effective in accomplishing goals. The alliance can be injured when there is disagreement on the speed or nature of completing certain tasks. It is the therapist’s job to keep the alliance on track. 

Development of a personal bond. This is the component most people think about when you say “therapeutic alliance”. This is the bond that develops between client and therapist, hopefully made up of shared positive feelings. For the client, it is based upon the confidence the client has in the therapist being able to help them with their problems. In turn, the therapist trusts that the client is committed to therapy and will work toward their goals. It is this bond that allows the relationship to survive the ups and downs of the therapeutic process. 

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Phases of the therapeutic alliance

The foundation

The three components of the therapeutic alliance are developed during the initial phase of therapy, which can be termed the “foundation”. It is about five sessions and serves as the building blocks for the rest of the treatment. It is during this time that the client dedicates themselves to therapy because they believe that their therapist can assist them in reaching their goals.

On the flip side, the therapist must sense a genuine commitment from the client that will result in productive effort on therapeutic tasks. In the initial phase, feelings of support, confidence, and positive collaboration are fostered.

The work

In the second phase, the meat of the therapy takes place. The focus is more on tasks as the bond continues to develop. As part of this phase, therapists may become more confrontational and challenge clients’ thoughts and behavior.

As you might imagine, these interventions can put a strain on the therapeutic relationship. To the client, these techniques may be seen as a reduction in support and empathy. A strong bond can help the relationship survive these difficulties but how a therapist negotiates uncomfortable moments is of utmost importance. Ruptures in the alliance must be repaired and resolved if therapy is to proceed successfully.

Termination

Every relationship has an ending and therapy is no different. Clients (and therapists) move on for different reasons but how you terminate the client-therapist connection is as important as how you begin it.

Ideally, termination represents the client’s ability to deal with their problems independently. Of course, therapy does not always stop for positive reasons. However it ends, it is important to recognize that the therapeutic alliance models other relationships. You want to try and conclude therapy in a positive fashion that helps both the client and the therapist. Burning bridges benefits no one.

The importance of the therapeutic alliance

The therapeutic alliance has consistently been found to be a significant predictor of therapy success. What may be surprising to some is that the therapeutic alliance is as—or more—important than the type of therapy used.

While a positive alliance can produce considerable progress, significant injury can come from a poor therapeutic relationship. Weak boundaries and questionable ethics (e.g., verbally abusive behavior, sexual activity, or business relationships) may do significant harm to both the client and the therapist.

Tips to build a positive therapeutic alliance

A good therapeutic alliance may be largely responsible for positive therapy outcomes. But how do you create one with a client? The following are suggestions for building a beneficial therapist-client relationship:

Setting strong boundaries and expectations. The therapeutic relationship is likely to suffer if the client is not told what to expect from therapy. This includes the frequency, cost, length of sessions, and how long therapy is likely to take to achieve the desired results. Further, it is imperative to make clear your professional boundaries.

For example, during intake, you may want to outline acceptable types and times for communication, including potential social media interactions. 

Collaboration. Working together with your client to make sure you remain on the same page in terms of goals and tasks. It is important that the client feels like you are a team on their journey toward personal improvement. 

Utilizing feedback. Obtaining client feedback and using it to make adjustments to the therapy is one of the most important aspects of building the therapeutic alliance. This factor is strongly related to positive treatment outcomes. One popular way to measure feedback is the OQ®-45.2, an outcome measure that can be given to clients before sessions to calculate progress. 

Empathy. No surprise here. Exhibiting an understanding of the client’s troubles and being able to take their perspective is sure to improve the relationship. 

Positive regard and a lack of judgment. Taken directly out of Carl Rogers’ playbook, having  positive regard for the client and withholding judgment are effective tools in developing the therapeutic alliance. 

Being flexible. This refers to the ability to adjust the therapy to fit the client, rather than the other way around. A client’s race, culture, religion, and/or sexual orientation may require the therapist to approach the client in a particular way. It also means that you may need to change your intervention if it doesn’t seem to be working. For example, maybe you see that your client is never doing their homework. Instead of trying to ram it down their throat, you need to investigate why and possibly alter your approach. 

Handling negative emotions. Therapy often doesn’t go smoothly. Clients frequently express negative feelings and may direct them toward the therapist. In more extreme cases, there may be a rupture in the therapeutic alliance. It is helpful to explore your feelings about the situation and address possible triggers. Additionally, the therapist must address these interactions with the client directly rather than shying away from an uncomfortable situation. Difficult exchanges highlight the need for all therapists to be involved in some form of supervision or support group.