As it turns out, the strength of the therapeutic alliance is indicative of the effectiveness of the clinical work.
“In my early professional years, I was asking the question, How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” –Carl R. Rogers
As a therapist, you’re probably reading this crawling out of your seat, eager to fill in the blanks of what’s to come (who doesn’t love to discuss the power of the therapeutic relationship?) As a ‘veteran therapy patient’ with good therapist experiences, you’ll likely be nodding along as you go. And for a person who is curious about this whole therapy business, you may be wondering what the heck is so ‘sacred’ about this therapist-patient relationship?
If you’re in the world of therapy (in any capacity), it’s likely you have heard a thing or two about the therapeutic relationship, also referred to as the ‘therapeutic alliance’. A strong therapeutic alliance refers to the professional, boundaried and trusting relationship established between therapist and patient that serves as a ‘container’ for the therapeutic work. It includes the fundamental elements of clarity, collaboration, caring, respect, and mutual understanding of goals and processes.
Ask any therapist about the importance of this relationship and you’re bound to hear a mouthful (make sure to have some time on your hands). Many of us believe, myself included, that the strength of the therapeutic alliance is indicative of the effectiveness of the clinical work. In fact, research from the American Psychological Association (APA) Evidence-Based Relationships and Responsiveness Task Force shows “Better relationships with patients lead to better outcomes.” This article aims to demystify what the therapeutic relationship can actually mean for the therapeutic process.
In it’s 16 meta-analyses on elements of the therapeutic relationship, the APA task force concluded the following summary:
- Agreeing upon goals, getting patient feedback and ability to effectively navigate and repair ruptures in the relationship are as vital to positive outcomes as treatment approach.
- A good relationship allows the patient to connect with, commit to and thus, get the most results from therapy.
- A strong therapy relationship allows the therapist to better attune to the clients needs and motivations, translating to the effectiveness of the approach.
Studies have indicated that the therapeutic alliance may be therapeutic to some degree in and of itself, regardless of further interventions. Therapy takes place first and foremost within the context of a relationship. Similarly, many of the issues that bring patients through the door happen within the context of the relationships in their lives. In this way, we are conditioning toward creating the possibility of a ‘safe’ relationship forming from the first moment of contact, which ultimately ideally translates to the patient recognizing that safe relationships are in fact, possible for them. “A solid therapeutic relationship teaches clients that they can continue to stay close to those they are vulnerable with. It makes outcomes more long lasting, and increases their nervous system’s awareness and tolerance for the discomfort that growth brings. It eventually may alert their nervous system to the difference between an unsafe situation versus one that is safe”, says Eden Below, Licensed Clinical Social Worker and Clinical Supervisor at Let’s Talk Psychological Wellness P.C.
In my training, I was taught that the quality of the therapy begins and ends with the quality of the therapeutic alliance. Without it, there would be no foundation for the rest of the work to rely upon. This has only become more evident in my work with patients throughout my career, in all cases, but particularly in working with patients with sensitive issues such as trauma histories. Many individuals who enter the counseling door have come across great reason in their lives to feel as though they cannot fully trust others. Thus, the trust part of the relationship is the greatest responsibility and privilege a therapist can have. It is this same part that requires the therapist to bring their humanness into the room via genuine empathy and responsiveness. A therapist who effectively prioritizes the therapeutic alliance in their approach will also have the ability to professionally speak to dynamics unfolding between therapist and client, ability to lead in repairing conflict, as well as one that holds firm to boundaries for expectation management purposes (such as reliability and clarity, which sets the stage for consistent therapy work to unfold).
Checking in with other mental health experts and colleagues, I gathered some of their insights on the matter as well:
“As humans, we are wired to to connect to others for survival. When we feel securely attached to others, it provides the safety and groundwork for one to engage in deeper intimate relationships, reducing isolation and loneliness. The therapeutic relationship models secure attachment, creating a safe environment, allowing vulnerability, corrective emotional experiences and healthy boundaries, resulting in deeper work and collaborative healing.” – Tamar Tenenbaum, LMSW
“When a good therapeutic relationship is established in therapy it allows room for the client to openly discuss sensitive topics in a safe, sound and non-judgmental space. It encourages the client to be honest and truthful as they feel seen and understood. The client is then receptive to explore, gain awareness, process and heal from past traumas. This ultimately, leaves the client feeling empowered and open to change.” – Dianna Calderon-Triminio, LMHC
“When genuine human connection is formed in the therapeutic space, clients can feel safer to tap into their own vulnerability, take risks, and show up for themselves both within and between sessions in a way they might not otherwise learn to do.” – Ava Pollack, MA, LCMHC
As a client, one way to be proactive on your hunt for good therapy is considering fit. “Many people outside of the therapy “world” don’t realize how important fit between therapist and client is; as it is fit that creates the most meaningful and effective change. Finding a good fit takes time, effort and patience. If you feel like your therapist isn’t a good fit for you, it’s okay to try again with a different therapist. A good “fit” therapist should help you feel comfortable and instill hope in creating impactful change, and it is this hope that can also lead to healing. Before an initial phone consultation or intake, think about what’s important to you” says Dr. Debleena Das, Licensed Clinical Psychologist. She suggests asking yourself what your needs are in a therapy relationship, whether that be similar identifying factors and/or a willingness to understand and seek clarification if they are unfamiliar with an aspect of your identity, for examples.
Another way as a client one can engage meaningfully in creating a positive working alliance with your therapist is to consider, at your comfort level, to offer feedback to them. Nathilee A. Caldeira, Clinical Psychologist, Founder and CEO of Let’s Talk Psychological Wellness, P.C. states, “If a client does not feel respected and understood by their therapist, it is important that this is discussed as early as possible, as failure to address this rupture in alliance can risk negative outcomes. Addressing such issues early on in therapy may strengthen the relationship, bond, and alliance between client and therapist thus leading to better outcomes in short-term as well as long-term therapy.” Truth is, we want to hear it: the good, bad and the ‘ugly.’ Our top priority is understanding what is in your best interest.
Horvath, A. O. (2001). The alliance. Psychotherapy: Theory, Research, Practice, Training, 38(4), 365–372. https://doi.org/10.1037/0033-3188.8.131.525
DeAngelis, T. (2019, November 1). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10). https://www.apa.org/monitor/2019/11/ce-corner-relationships
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450. https://doi.org/10.1037/0022-006X.68.3.438
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Originally published on ThriveGlobal.