What Works in Therapy  |  Douglas Behan, DSW, LCSW

The Therapeutic Alliance

“ ...irrespective of the clinical problem or treatment modality, therapists should strive to establish, monitor, and maintain a positive bond and a strong level of collaboration with their clients.“

(Castonguay, Constantino, Holtforth, 2006, p272)

For psychotherapy to be effective, a therapeutic alliance needs to be developed between the therapist and client (Behan, 2018; Horvath, Del Re, Flückiger, & Symonds, 2011). The alliance (also called the working relationship) includes: 

 

  1. An affective bond between therapist and client, typically called the "therapeutic relationship."

  2. Agreement on the goals and objectives of therapy (typically called "goal consensus").

  3. Agreement on the tasks that will be used to achieve the goals.

 

In short, there needs to be agreement on what the problem is, what will be targeted in the therapy, and how this will be achieved - all embedded within the context of a warm supportive relationship (Safran, Muran, & Proskurov, 2009).

Effective Therapy is a  Joint Quest

 

The therapeutic alliance is one of the most studied aspects of psychotherapy. Decades of research studies have repeatedly shown the alliance has a significant impact on treatment outcomes. A 2018 meta-analytic study, incorporating 295 studies and over 30,000 patients, confirmed the importance of alliance on psychotherapy outcomes – a relationship that proved consistent across treatment approaches, patient characteristics, and countries (Flückiger, Del Re, Wampold, & Horvath, 2018).

What the Research Says...

What it Means for Therapists

A strong therapeutic alliance exists when clients feel bonded to their therapist and confident in the collaborative direction that they are taking to resolve the client's concerns.

 

It is possible for there to be a strong therapeutic relationship without a strong therapeutic alliance (a mutual understanding of what the problem is and what is being done about it).

Therapists should be on guard if they are experiencing compassion fatigue, boredom, or frustration, as these factors are toxic to the therapeutic alliance.

Recommendations from the 2018

Meta-Analytic Synthesis of the Research on

the Alliance in Adult Psychotherapy

(Flückiger, Del Re, Wampold, & Horvath, 2018).

Build and maintain the alliance throughout the course of psychotherapy - creating a warm emotional bond and collaborative attachment with the client.

1.

Develop agreement on therapy goals and tasks early in treatment.

2.

Goal and task agreement does not mean that the therapist automatically accepts the patient’s goals and tasks or vice versa. A strong alliance is often a result of negotiation.

3.

Create a customized case formulation based on the client’s unique situation and preferences.

4.

Address ruptures in the alliance directly and immediately.

5.

Regularly assess the strength of the alliance from the client’s perspective. Consider implementing routine outcome measurement (ROM) to detect unsatisfactory progress and identify premature terminations.

6.

The different intersectional identities of the therapist and client can sometimes hinder forming a therapeutic alliance. Differences should not be misinterpreted by the therapist as disagreement or “resistance”.

7.

Use language that conveys inclusiveness and negotiation.

8.