The Therapeutic Alliance
If you’ve read any of our other posts about CBT, CFT, DBT or any other acronym’s, not to mention the vast number of other online sources, then you may be feeling slightly overwhelmed by so many seemingly different options for therapy. That’s fair. We reflect, perhaps identify an issue we want support dealing with, and then finally take the plunge to make an appointment with a therapist only to start seeing info. about all these types of therapy. So what to make of it?
Well, I would like to offer a perspective on one factor that is perhaps less well known but undoubtedly the most important when it comes to effective therapy. As much as we all deserve to be taken care of, a central part of the healing process is our own engagement, our own thinking, motivation, resistance and efforts to work for ourselves to achieve desired outcomes. The following post aims to increase awareness and provide information about this vital part of all medical and mental health interventions and treatment. Hopefully by the end of it you will feel more comfortable searching for a psychologist, less worried about the type of therapy being used or issue you are facing, and more confident to make a decision.
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Generally speaking, when we refer to psychotherapy we mean talk therapy, types of therapy rooted in the concept of talking with a trained professional who can guide us, through conversation, to heal. The ‘modalities’ you may have seen elsewhere, like the acronym’s mentioned, refer to specific techniques, foci, taught skills etc. of the various approaches that professionals use within talk therapy. For example, Compassion-Focused Therapy (CFT) has a focus on the role of self-criticism and shame in our mental health issues, and often uses more experiential techniques, like embodying a compassionate self, in its approach.
There are many other ways to go about the healing process besides talk therapy, like medication for example. But the relationship with the treating professional, whether a psychologist or Doctor or physiotherapist, is always a factor when it comes to positive results, even for prescribed medication. This relationship, between the client or patient and the professional, is referred to as the therapeutic alliance.
Regardless of the type of therapy, which modalities are being used, what we’ve been diagnosed with or as, how severe our presentation, the number one predictor of positive therapeutic outcomes is the relationship between client and therapist.
In the past we see countless examples of treatments, for a variety of things, that we now know ‘don’t work’. Even recently, research into medical treatments, from knee surgery for osteoarthritis to stent operations for chest pain, have been found to be no more or less effective than sham surgeries (A sham surgery is basically when the surgeon does everything the same, anesthetic, post-op., everything except providing the actual intervention – listen to chapter 10 of Dan Ariely’s book ‘Predictably Irrational’ on Spotify for some other examples).
Can you think of any times that you have felt a benefit from doing or taking something that may have been a placebo? Maybe even feeling a bit tipsy as a child because you thought you’d sipped something alcoholic that was actually juice!
This history of seemingly effective but scientifically debunked treatment tells us that if we trust and believe our physician, that alone will have some positive effect. There is even research to show a difference between the placebo effect and a positive relationship with a psychiatrist – both add to the effectiveness of the treatment in their own right, with medications and placebo’s both more effective when prescribed within a positive, therapeutic relationship.
This may seem discouraging at first, but if we consider it for a moment we see the huge positive potential of findings like this: making the effort to consider and prioritize our relationships with treating professionals not only makes us feel more comfortable, but increases the effectiveness of our treatment. It is well worth our time.
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Obviously, this is a two-way street, and we hope that our Doctor’s and therapist’s are putting in the effort to develop how we communicate in session, but as clients and patients, what is our role? So how can we develop our relationship with our therapist? How does a therapist develop this alliance? I would like to propose three things that we can do in this area, and briefly explain one key way that therapists address this.
Firstly, as clients and patients, we can take an active role in identifying and agreeing on our goals for our treatment. We work together with the professional to establish mutually agreed-upon goals for treatment, as well as how we are going to work towards these goals. This might mean making suggestions for the agenda of the session, or being open about what we expect to achieve or discuss within that session. In this way, we are making our needs and expectations known, so that our therapist can take this into account as the session progresses but also so that we remain active within the relationship.
Collaborating on tasks is another way we can track how we and the treating professional are involved in the relationship. Both parties engage in the tasks and interventions necessary to achieve the agreed upon goals, whether this is being open about our feelings towards the treatment, or the therapist utilising our feedback (more on this below). Discussing the tasks that are being used in session or set for homework will depend on how functional or intimate we prefer the relationship to be – some of us want to keep the focus on developing skills and doing practical things like homework tasks, while others prefer to have a deep, emotion-focus to our sessions. Whatever the preference, making sure we and our therapist are aware and in agreement about these expectations is extremely beneficial to the therapeutic alliance.
Developing a bond, a strong emotional connection and trust, with our therapist is ultimately what we are aiming for when addressing the therapeutic alliance. In addition to identifying goals and agreeing on how we are going to reach them, our bond with our therapist goes deeper into how we relate to them, how safe we feel being with them and hearing their perspectives on our lives. There are many ways that we can intentionally focus on the connection with our therapist, and make sure it works for us and meets our needs, including:
- establishing boundaries with respect to what we discuss and when, not going deeper than we are comfortable with too soon, for example;
- exploring the kind of communication we are comfortable with, whether this is more guidance and direction from the therapist, or a stronger focus on collaboration, and;
- perhaps most importantly, making sure we are confident and able to change this relationship when we think it needs it.
Lastly, what exactly is the therapist doing? Well, in addition to their own part in all the above suggestions, one thing you may be aware of is what is known as Feedback Informed Therapy. This involves the therapist getting our feedback, in the form of a questionnaire or direct questioning, so that they have some idea about how whatever we are working on in session is effecting the rest of our lives. This is something many of us aim to do as therapists at Psychology Consultants, but it does vary from psychologist to psychologist. Some of us might discuss the results every session, others may only use questionnaire’s at the beginning and end of therapy. Whatever the situation, it may interest you or even boost the therapeutic alliance to ask your therapist how they are using the results to the questionnaire’s they are sending your way.
These are just a few ideas about how the therapeutic alliance impacts medical and mental health treatment, and some of the ways that I have found to be most effective for me to take responsibility for it, as a therapist and a client. I hope you have found it informative and useful to your own journey, and that is has in some way helped to build your confidence in your ability to be active on that journey.
If any of these ideas have raised questions or struck a chord with you, please reach out to discuss this with me – I love to hear about how others navigate their relationships in professional settings, most of all within the therapeutic alliance.
By: Seton Jubb
