If you’ve sought mental health treatment for yourself or someone you care about, you’re aware there’s no single path to improved mental health. There’s rarely one standalone treatment that works effectively. For virtually all mental illnesses, optimal treatment occurs at multiple levels and includes myriad therapies and support services.
Often, the greatest challenge isn’t finding care – it’s finding the type of care that’s best for you or your loved one.
In many cases, identifying the right type of mental health treatment involves assessing the effectiveness of different therapeutic approaches. However, a growing body of research suggests successful treatment may depend not only on the type of therapy a patient receives, but also on the quality of the patient’s relationship with their clinician.
Mental health professionals refer to this relationship as the therapeutic alliance. Experts have understood the importance of this relationship for more than a century, but recognition of its full effect on successful treatment has increased considerably in recent years.
In fact, the authors of an October 2011 study in the journal Frontiers in Psychology reported states our new point of view on the therapeutic alliance like this:
“The quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures.”
This suggests that the strength of the therapeutic alliance may be more influential than the type of therapy a patient receives.
What is the Therapeutic Alliance?
For a factor that has such a significant impact on the quality of the patient experience and the likelihood of treatment success, the therapeutic alliance is not a particularly complex concept:
- The American Psychological Association defines the therapeutic alliance as “a cooperative working relationship between client and therapist.”
- The Frontiers in Psychiatry study cited above refers to the therapeutic alliance as “the collaborative relationship between patient and therapist in the common fight to overcome the patient’s suffering and self-destructive behavior.”
- An October 2018 article in Focus: The Journal of Lifelong Learning in Psychiatry describes this alliance as “a measure of the therapist’s and client’s mutual engagement in the work of therapy.”
The idea of a therapeutic alliance originated with Sigmund Freud, who first discussed the power of patients’ unconscious feelings about their therapists – and therapists’ unconscious feelings about their patients – in 1912.
Over the past 110 + years, mental health treatment experts modified and refined this concept, with significant additions, including the incorporation of empathy, rapport, and collaboration into Freud’s original definition.
Edward S. Bordin, a highly respected American clinician, researcher, and teacher, shaped our modern understanding of the therapeutic alliance.
In a 1979 article in the journal Psychotherapy, Bordin established the three fundamental components of what he referred to as “the working alliance.”
Therapeutic Alliance: Three Components
- Agreement on goals
- Assignment of tasks
- Development of bonds
The first two fundamentals (agreement on goals and assignment of tasks) emphasize the value of collaboration in a successful therapeutic alliance. Instead of the clinician alone determining the objectives of therapeutic sessions and the steps necessary to achieve those objectives, Bordin emphasized that clinician and patient should work together to make these decisions.
The third fundamental (development of bonds) refers to the emotions, feelings, and attitudes that the clinician and patient develop about each other. When these emotions, feelings, and attitudes are positive and reciprocal, research indicates patients are more likely to achieve therapeutic goals.
Assessing the Therapeutic Alliance
The fundamentals that Bordin established for the therapeutic/working alliance are easy to understand on a basic level. But how can we accurately measure and assess a framework based on concepts such as agreement, cooperation, and positive emotions?
In their Frontiers in Psychiatry article, authors Rita B. Ardito and Daniela Rabellino acknowledge the challenge of evaluating the alliance:
“Any attempt to measure something as complex as therapeutic alliance involves a series of conceptual and methodological shortcomings, which have probably hindered the development of research in this field.”
They note additional difficulties:
“Each single aspect of therapeutic alliance may be perceived very differently by the therapist, patient, and clinical observer, which raises the question of objectivity.”
To overcome these obstacles, separate efforts led to the development of six assessment instruments: CALPAS, Penn Scale, VTAS, WAI-Observer, WAI-therapist, and WAI-Client. Ardito and Rabellino report all six of these measurement tools are equally effective at predicting therapeutic outcomes.
In addition to paying attention to the fundamentals of the therapeutic alliance, researchers now understand the value of focusing on two distinct phases in its development and maintenance.
Phase One
The first phase typically encompasses the initial five therapy sessions, during which the clinician and the patient work together to identify goals, and the patient begins to develop confidence in this collaborative model.
Phase Two
The second phase occurs when the clinician begins to challenge the client’s dysfunctional thought and behavior patterns, which the patient may misinterpret as a diminishment of the clinician’s compassion and a withdrawal of their support.
At first glance, it might seem like a steady progression in terms of both collaboration and confidence would be the most accurate predictors of a successful therapeutic alliance. However, Ardito and Rabellino report this is not supported by research.
Instead, they cite prior studies that identify the ability of clinicians and patients to resolve conflicts in the alliance as having the greatest impact on the eventual success (or lack thereof) of the therapeutic process.
The effect depends on the timing of any difficulties:
- During the first few sessions, disagreements with the clinician may undermine patient confidence and commitment, which can increase the likelihood they’ll discontinue their participation in therapy.
- In later sessions, if the patient feels the clinician invalidates their thoughts, feelings, or experiences, this can disrupt the quality of the alliance.
- If the patient develops unrealistic or unachievable expectations of the clinician, they may be incapable of making appropriate progress in important areas.
A successful therapeutic alliance, Ardito and Rabellino propose, doesn’t eliminate the likelihood of these types of challenges. A successful alliance is one in which the clinician and the client can work together to identify and address these challenges before they cause irreparable harm.
Cynthia Baum-Baicker, Ph.D., a clinical psychologist, addressed this phenomenon in a January 2024 article on the Psychology Today website:
“The action of many therapies is to help people know – and experience – that it takes two to understand one, and that attachments and meaning are crucial to a good life. If you have a rapport with a person, they trust you, they believe you, then they feel like they have a hand to hold when they go out and do something scary.”
Keys to a Strong Therapeutic Alliance
While opinions differ about the best way to evaluate the strength of the therapeutic alliance, there’s little debate about the importance of a strong alliance.
But what specific steps should therapists and clients take in order to develop a healthy alliance? And, given Ardito’s and Rabellino’s emphasis on the importance of resolving disruptions, how can participants rebuild or reinforce an alliance in danger of falling apart?
In the Psychology Today article we cite above, social psychologist Jeremy Nicholson says the following three elements indicate the presence of a healthy therapeutic alliance:
- Authenticity: Patients should feel “physically and emotionally comfortable” with their therapist, Nicholson said. This comfort empowers the patient to openly address difficult concerns and collaborate more fully with the clinician.
- Attentiveness: The patient should feel their clinician cares about their thoughts and feelings, and acts in a manner that shows they have the patient’s best interests in mind.
- Positivity: Patients should not feel they’re being judged. Instead, conversations should feel “friendly, perhaps even collegial.”
In the same article, psychiatrist Ying Wang, MD, agrees the elements Nicholson identified can be valuable both for building a strong alliance and for repairing one in the aftermath of conflicts or unmet expectations:
“It can be helpful, if there is discomfort, to bring it up in session. If the discomfort is because the therapist conducts the session in a certain way, that can be changed. But if it’s about something else, it can provide insight into what it is about this person that’s causing a difficulty in opening up, which may inform treatment.”
Find Mental Health Help in Southern California
At Crownview Psychiatric Institute, we believe trusting relationships between clients and clinicians form the foundation of recovery and act as catalysts for life-affirming transformation.
We consider the full scope of each client’s unique strengths and needs when developing their customized treatment plan and match them with therapists with the skill and experience to form the most meaningful connections and strongest treatment alliance.
The day a client enters treatment at our center in Oceanside, California, we welcome them into a dynamic community where they are valued and respected. Throughout their time with us, we encourage them to play a proactive role in all aspects of their care. We listen, respond, and follow their lead: the ultimate goal is their long-term treatment success.
To learn more about our programming, or for answers to specific questions about how we can help you, a family member, or someone you love, please visit our Contact page or call us today.
Gianna Melendez
Jodie Dahl, CpHT