June 2, 2021

The Therapeutic Alliance: How Your Client Relationship Impacts Outcomes

Therapy can be life-changing, but how does it work? Therapists shepherd us through some of our most deeply personal, and oftentimes painful experiences. The process often seems mysterious and the outcomes sometimes miraculous. 

Therapy is an active process and therapists are trained to pay attention to the ups and downs of their working relationships with clients. There’s a good reason for this. 

Research tells us that the relationship between the therapist and client is a key factor in the success and helpfulness of therapy, regardless of the theoretical orientation

A 2018 review of 295 studies covering more than 30,000 clients participating in in-person or internet-based psychotherapy showed a robust and consistent positive link between the therapeutic relationship and patient mental health outcomes. This was irrespective of treatment approach, patient characteristics, or country. 

The therapeutic alliance, which is sometimes also called the helping alliance, working alliance, or therapeutic relationship is therefore universally important in mental health treatment.

What is the Therapeutic Alliance?

A strong therapeutic alliance is consistently linked to positive outcomes, but what is it, exactly? 

Freud discussed the importance of the therapeutic relationship more than 100 years ago, focusing on the concept of transference, an unconscious process in which the feelings and expectations from a person’s past are directed towards the therapist.  

Further research highlighted empathy, positive regard, and rapport as essential components of the therapeutic relationship in counseling. And in 1956, Elizabeth Zetzel coined the term therapeutic alliance to describe the capacity for the therapist and client to develop a healthy emotional bond and work together towards therapeutic goals.

To put it simply, the therapeutic alliance is the measure of collaboration and partnership between the therapist and client. It has been characterized by three features including

  • Mutually developed treatment goals 
  • Alignment on treatment tasks 
  • The emotional bond between the therapist and client 

The agreement and alignment from the first two components can be described as shared decision making, where the therapist provides information, offers options, elicits preferences, and co-develops treatment goals and processes.

Which would you work harder for, a goal that you helped to come up with, or one that someone else imposed on you? When the client has a say in the aim and experience of treatment, it improves their engagement and adherence to the therapy process. 

The third component, the therapeutic bond, can be strengthened by good communication–including listening, empathy, encouragement, and individualized care. The therapist’s non-verbal communication, capacity to resolve discord, and awareness and attention to clients’ ambivalence are equally as important. 

Each of the three features can be thought of as an independent component of the alliance and as a synergistic element of a larger whole. In other words, the therapeutic alliance in counseling is how a therapist and client connect, collaborate, and engage with one another.

Measuring the Alliance

The therapeutic alliance can be measured using several validated scales including the Working Alliance Inventory (WAI), California Psychotherapy Alliance Scale (CALPAS), Helping Alliance Questionnaire (HAQ), and Vanderbilt Psychotherapy Process Scale (VPPS). These have been studied for over 30 years and seem to consistently measure their version of the therapeutic relationship.

While the lack of a general consensus around one measure for the therapeutic alliance leaves room for flexibility and creativity, it also makes it challenging to draw comparisons across multiple studies. Yet, even with this obstacle, the importance of the alliance is undeniable. Research exploring 39 different measures of the therapeutic alliance found an across-the-board positive impact on client outcomes.   

The scales include items like 

I feel I am working together with my therapist in a joint effort. 
My therapist and I agreed about the things I will need to do in therapy to help improve my situation. 
I believe my therapist is generally concerned about my welfare. 
Did you feel pressured by your therapist to make changes before you were ready?

The therapist also brings their experiences and perspectives into the dynamic. In fact, most scales include a version to measure the relationship from the therapist’s perspective, highlighting the collaborative and interdependent quality of the alliance.

Phases of the Therapeutic Relationship

The therapeutic relationship infuses every aspect of the therapy process. Far from static, it fluctuates throughout treatment and can even change from session to session. One study found that measures from at least 4 sessions were needed to capture the overall alliance between a therapist and client. 

Despite these ebbs and flows, the alliance has been conceptualized in two phases. The first involves the client’s belief that the therapist can be of help. It is a time in which confidence and collaboration are fostered. 

The second phase revolves around the client’s level of engagement in the therapy itself, and their willingness to share ownership of the process. Deeper into treatment, phase two can also challenge the client’s harmful and dysfunctional thoughts and behavioral patterns, which may lead to ruptures in the alliance. These must be resolved for a strong alliance to persist. 

How the Therapeutic Alliance Can be Predictive of Outcomes

Therapists work with us to cope with grief and loss, overcome depression and anxiety, break free from destructive cycles, deal with relationship issues, divorce, parenthood, retirement, and much more. Part of the healing power of therapy comes from the rich and meaningful relationship between the therapist and the client.

In his book, The Body Keeps the Score, Bessel A. van der Kolk wrote, Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives.

Learning to trust and feel comfortable with another human is therapeutic, particularly when that was not available early in life or when stressors are chronic. Some of this sense of safety also stems from developing the capacity to tolerate ruptures and repairs in the relationship and knowing that it can survive discord.

This might be part of why a strong therapeutic alliance has been shown to improve mental health outcomes across a variety of settings with multiple mental health issues and among both adults and youth. These issues include first-episode psychosis, bulimia, dissociative disorder, depression, anxiety, and personality disorders.

The alliance is also important in group therapy settings. And, surprisingly, more than group cohesion or therapist competence, the therapeutic alliance was found to be the key factor in reducing psychological distress among cancer patients receiving group therapy.  

Adults with substance use disorders and eating disorders have shown the smallest correlation between therapeutic alliance and treatment outcomes, though it is no less important when treating people with these issues.

Interestingly, it’s just as possible to establish a positive therapeutic alliance using technology-based interventions including apps, email, texting, phone, and video visits. Under the right conditions, online therapy can also boost the therapeutic alliance by balancing the power between the therapist and client and creating a heightened sense of safety for the client, thus increasing their capacity to open up. 

While face-to-face has been the longstanding psychotherapy model, COVID-19 accelerated the expansion of online therapy as a viable option.

Mechanisms of Change

While there is no single and definitive answer that explains the exact mechanism linking alliance-to-outcome, research has uncovered many layers of this complex process. 

For one thing, we know that relationships can change your actual brain. And therapists who model compassionate, empathetic, and collaborative relationships can engender a neurobiological shift within their clients that promotes healing. 

In addition, studies have linked strong therapeutic relationships with improving medication adherence, treatment retention, patient activation–or readiness to take on a role in one’s own mental health, and mood while reducing distress.

How to Build a Therapeutic Alliance

Now that we’ve established the incredible importance of the therapeutic relationship, you might be wondering how therapists can build a strong alliance with their clients. 

The alliance is not created from one single action or activity by the therapist–simply making eye contact or smiling, for example, does not guarantee a strong relationship. On the contrary, without mindful attention, these behaviors might easily detract from the relationship in certain instances. 

Building a strong therapeutic alliance is an ongoing process that is unique for every individual and situation. It can be developed quickly or take a while to form. And like any relationship, it must be nurtured over time.   

Some general guidelines to promote a strong working alliance include

  • Paying attention to the alliance throughout the course of therapy and addressing and repairing ruptures as they arise.  
  • Co-developing and negotiating therapy goals and tasks that are responsive to the client’s readiness, current capacities, and preferences.
  • Recognizing the client as existing within a broader context. This involves being curious about their upbringing, culture, environment, family, and other life experiences that have impacted who they are today and how they experience safety and trust in relationships. In doing this, it is important to avoid assumptions or stereotypes. 
  • Moving beyond the expert-patient dynamic to one that shares power and values the expertise that each client brings in relation to their life experiences and needs. 
  • Understanding the therapist’s own contribution to the dynamic and doing their own separate work to ensure that they have a handle on how their early experiences with relationships impact the ways that they engage with clients. 
  • Maintaining empathy, compassion, and positive regard for all clients–which is distinguished from always agreeing with or condoning all behaviors. 
  • Regularly collecting patient-self-report questionnaires to track, discuss, and take actions around changes in symptomatology over time. 
  • Eliciting feedback about the alliance to detect and address issues. This can be done using measurement-based care to track and give needed attention to the therapeutic relationship in consistent and concrete terms. 

The Therapeutic Alliance Improves Mental Health   

Humans are wired to connect, and therapy offers a powerful stage for healing. The therapeutic alliance is one of the most frequently researched elements contributing to the effectiveness of therapy. It functions as a microcosm in which clients are able to work through deep-seated issues, build trust, take risks, and learn how to relate in healthy ways. 

While there is no simple instruction manual for building a strong therapeutic alliance, collaborating in a joint exploration of the underlying issues and developing mutually agreed-upon goals is a good first step.

In psychotherapy, it’s critically important to foster a respectful, caring connection that’s both helpful and healing. Measurement-based care offers the opportunity to track and make adjustments to the alliance throughout treatment.