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Understanding the Therapeutic Alliance

Annie Gurton uses a mixed toolbox of psychotherapeutic techniques, theories and approaches which include elements of classical Rogerian Person-Centred, Human Givens, Freudian, Adlerian, NLP, CBT ...Read More

It comes as no surprise to any experienced therapist that the therapeutic alliance – that felt bond between therapist and client – is the most powerful factor in the process of emotional and psychological healing.

There are hundreds of studies that show that a purposeful collaborative relationship between a therapist and the patient correlates with positive therapeutic progress. The most important aspect of effective therapy requires the patient and the therapist work collaboratively. But even so, the power of the alliance is often far stronger than many realize, and the most effective therapists are those who focus specifically on building the alliance.

Research shows that many clients make an improvement between making the telephone call to book the first session, and the actual first session (Wampold, 1997). By the time they arrive in the therapy room and meet the therapist for the first time, they are often feeling better, more empowered.

It’s not really rocket science – in a life where they may feel out of control, at last they have taken control and initiated action, hoping it’s a positive step towards change. So, it’s natural that they can feel suddenly less depressed or anxious.

However once in the therapy room there are many factors that can help build empathy and accord, as the smart therapist knows, and equally, many factors that can undermine it.

All successful psychotherapeutic approaches share many common factors, such as the therapist’s ability to use non-verbal techniques to validate the client, and the therapist’s ability to detect obstacles that may impede change. One of the most powerful is the client’s expectations, something that the adroit therapist will capitalize on. Another is the therapist’s perceived credibility, partly of their level of experience and record of success but also in the modality they choose to use. The link between expectancy and outcome is directly mediated through the therapeutic alliance (Roth & Fonagy, 2006) and the therapist is able to manipulate these factors.

But while the therapeutic alliance is a common factor across all therapies, it is more than the bond between therapist and client. The therapist needs to be experienced and intuitive enough to critically formulate and apply judgment, and help the patient define and reach their goals in therapy. Not that experience itself is necessarily the key to a powerful and effective alliance – in fact in some studies (e.g. Castonguay et al, 1996) it has been shown that as some therapists became more technically able, paradoxically they can became less effective therapeutically. It’s as if they become so fixed on techniques that they lose sight of the power of human empathy and intuition.

So we know that the effect and outcome of therapy depends on more than the skills and training of the therapist, and their technical competence. We know that positive alliances tend to be fostered by the therapist being warm, understanding and empathetic. It also helps if they have perceived experience, confidence, training and qualifications, and trustworthiness. It also helps if they come recommended, and if the client is making a significant investment in the sessions, either financially, in time or emotion.

On the other hand, therapists who fail to convey that they are really listening, or are rigid, critical, uninvolved or uncertain are more likely to have poor or negative alliances with their clients. A weak and unhelpful alliance also happens if the therapist is overly structured, perhaps uses inappropriate self-disclosure, insensitively maintains silence, or is too intense in their interpretation of any transference in the room.

Clients who are asked at the end of sessions to rate the alliance fare better than those whose feedback is not measured and acknowledged. In fact, the key lies in the term itself: ‘alliance’ means that there is a sense of working together, that the therapist is not more powerful or privileged, and that it takes work on both sides to make progress.

What this means for clients is: choose to work with a therapist who you feel ‘gets you’ and is working alongside you. And for therapists, it means that while ongoing professional development and supervision are important, the critical thing is not to lose touch with the fundamental concept that it’s all about the client, and your ability to connect and support them.

Sources

Castonguay, L.G., Godfried, M.R., Wiser, S., Raue, P.J., & Hayes, A.M., (1996), Predicting the effect of cognitive behavioural therapy for depression: A study of unique and common factors, Journal of Counselling and Clinical Psychology, Vol 64, pp 497-504
Roth, A. & Fonagy, P., (2006) What works for Whom? A Critical Review of Psychotherapy Research, The Guilford Press, New York & London
Wampold, B.E., (1997), Methodological Problems in identifying efficacious psychotherapies, Psychotherapy Research, Vol 7, pp 21-44
Keep Reading By Author Annie Gurton, MA
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