The Therapeutic Alliance


Have you ever tried to change the way you do something? It could be anything — the way you hold your tennis racket, blow into a flute, meditate — you name it. If so, think about that experience. No matter how motivated you were to change, and no matter how much you knew that it would help your serve, musicality, or sense of inner peace, it can be difficult and scary to change even the smallest thing. In order to change, you have to give up your old way of doing something first and then try a new way. That means that for a while you’re in a free fall — you no longer have your old habit to rely on and you don’t yet have the new one.

The anxiety of trying to change something as complex and entrenched as how you relate to people close to you or manage stress takes the feeling to a whole new level. Yet, that’s just what you do when you enter psychotherapy. Just as you had to put yourself into the hand of your teachers and coaches, in therapy you need to gradually do just that with your therapist to help you through what can be a harrowing adventure. The foundation for therapy is called the therapeutic alliance. When it’s there, you know that your therapist is there to help you, no matter how hard the going gets.

The therapeutic alliance might be the most important part of beginning a psychotherapy. In fact, many studies indicate that the therapeutic alliance is the best predictor of treatment outcome.

What is the therapeutic alliance? It is the trust between you and your therapist that allows you to work together effectively. It’s what helps you to believe that your therapist is trustworthy and has your best interest at heart — so even if you become angry or disappointed with your therapist, you can believe you can continue to work together productively.

This type of trust takes time to develop — and in a long-term psychodynamic psychotherapy this can take months — but good therapists will begin to establish this during the first meeting. How do they do that?

First, they let you know that they are interested in you and in what is troubling you. Think about the last time you were seated next to someone you didn’t know at a dinner party. Did that person ask you questions about yourself or did they talk about him or herself? A person who is genuinely interested in you makes you want to talk to them and makes you feel that they care about what you are saying. Therapists do this in many ways: by being attentive (not answering the phone, pagers, or checking email), by asking relevant questions (not just “name, age, serial number” type questions), by demonstrating that they’re listening (following up on things that were said a few minutes ago, remembering details) and by making eye contact.

Second, they let you know that they have a sense of how difficult or sad or painful your problem is to you. People who enter therapy are usually in some sort of pain. They’re depressed, getting divorced, recently unemployed, worried, and their therapists have to let them know that they understand this. Sometimes, therapists show this in their facial expressions, but actively making empathic remarks is essential to building the therapeutic alliance. Therapists shouldn’t be afraid to show some feelings — wooden statues are for tobacco stores, not therapy offices.

Finally, they give you a good sense that they understand something about the trouble that brought you to therapy. You may ask, “How can a therapist understand my problems when it’s the beginning of the treatment? We’ve just met!” This is true, but good therapists should be able to understand something — even from the get-go. They may not yet fully understand why you have the difficulties you have, but they should be able to understand things like the nature of the problem and the issues involved, and they should be able to communicate that understanding to you.

How do you know if you and your therapist have a good therapeutic alliance? Ask yourself, do I feel comfortable talking to my therapist? Am I able to talk freely in sessions? Do I feel relieved after I’ve been there? Do I want to go back? You don’t have to feel that your therapist has all the answers, but you should have a sense that he or she is trying to understand and is on your side. If you have a good coach, the feeling that you have at the end of a practice is that you’d worked hard and that you will continue that work the next time — together. If you have a good alliance with your therapist, you’ll have that same feeling at the end of your sessions — perhaps with a little less sweat and a little more hope.

The alliance between patient and therapist develops through shared work. The work of therapy is both a labour of love and a collaborative commitment. Though the therapeutic alliance partakes of the custom of everyday contractual negotiations, it is not a simple business arrangement. And though it evokes all the passions of human attachment, it is not a love affair or a parent-child relationship. It is a relationship of existential engagement, in which both partners commit themselves to the task of recovery. This commitment takes the form of a therapy contract.  Their terms of this contract are those required to promote a working alliance. Both parties are responsible for the relationship. Some of the tasks are the same for both patient and therapist such as keep appointments faithfully. Some tasks are different and complementary: the therapist contributes knowledge and skill, while the patient pays a fee for treatment, the therapist promises confidentiality, while the patient agrees to self-disclosure; the therapist promises to listen and bear witness, while the patient promises to tell the truth. The therapy contract should be explained to us as patients explicitly and in detail.

We enter therapy relations with severe damage to our capacity for appropriate trust. Since trust is not present at the outset we should expect for repeated testing, disruption and rebuilding of the therapeutic relationships. As we have become more involved with the therapist we inevitably re-experience intense longing for a rescue that we felt at the time of the abuse. It is crucial that the therapist gives careful attention to the boundaries of the therapeutic relationship to provide protection against excessive, unmanageable transference and countertransference. Secure boundaries create a safe arena where the work of recovery can proceed. Transference describes a situation where the feelings, desires, and expectations of one person are redirected and applied to another person. Most commonly, transference refers to a therapeutic setting, where a person in therapy may apply certain feelings or emotions toward the therapist. Countertransference occurs when a therapist transfers emotions to a person in therapy, is often a reaction to transference, a phenomenon in which the person in treatment redirects feelings for others onto the therapist.

I would love to hear from you so please leave a comment. All feedback is much appreciated. Thank you. Erin

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