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Most common definitions of therapeutic alliance describe the construct as to the degree to which the client and therapist agree on the goals of treatment and agree on the method to achieve them. If agreement is strong in both domains, then the therapeutic alliance is said to be strong overall.
But there is a third element that is often overlooked.
Take this scenario, for instance. Suppose you and a friend decide to go hiking. Together, you choose which summit you want to achieve (your goal) and which trail you will use to get there (your method). Great! You set out on your hike. After about an hour, you realize you and your friend have been using different strategies to track your progress. You’ve been watching for faded trail markers while your friend has been using their compass. You agreed on the trail, but aren’t sure if you’re actually still on that trail. It’s getting dark. Panic ensues.
The problem, of course, is that even though you and your friend decided on your method, you used different strategies to check whether you were adhering to your method. You and your friend mastered the first two components of alliance but were missing the third: you were not aligned on the way you evaluated whether you were staying the course.
The same is true in the therapy room. You and your client may be in full agreement on the goals of treatment and the specific interventions you will use to achieve this goal. But, if you haven’t agreed on the tools you will use to evaluate progress, then you risk future disagreement on whether your approach is working, which can damage the alliance.
You can preempt this potential for alliance breakdown by making measurement-based care part of your therapeutic approach. If you’re worried that this conversation might feel more paternalistic than collaborative, you might try:
- Explaining why you think objective assessment is a useful tool, while remaining genuinely open to other ideas they may have to measure progress
- Selecting several measures and allowing your client to pick the one that feels like it captures their symptoms best
- Provide a range for how often these assessments are typically administered, and ask your client how often they’d like to plan to complete them
These strategies allow you, as the therapist, to retain your status as expert in the treatment, and your client to retain their status as expert on themselves. Thus, the spirit of therapeutic collaboration is preserved.
Imagine you’re back out on the hiking trail with your friend. You decide together that the best way to make sure you’re on the correct trail is to check for little red boxes painted on tree trunks. You now have two sets of eyes looking out for these markings, so you never miss one. You make it to the summit just in time to see the sunset.
