The Alliance IS the Therapy

The fact of the matter is that the alliance is our most powerful ally and represents the most influence that we can have over outcome. The alliance is the soul of change. But it’s hard not to take it for granted when it gets such little press compared to models and techniques. As I scroll down Facebook, I see models, techniques, and miracle cures aplenty, but rarely anything about our tried and true, but neglected, old friend, the therapeutic alliance. Ironic, really, because the best therapists tend to form strong alliances with more people across their caseloads; average alliance scores account for 50 to 97 of therapist differences.

Bordin (1979) classically defined the alliance with three interacting elements: (a) a relational bond between you and the client—the client’s perception of your empathy, positive regard, and genuineness; (b) agreement on the goals of therapy; and (c) agreement on the tasks of therapy, which includes the client’s theory of change and all the accompanying details—including topics of conversation, frequency of meetings, handling cancellations, payment, etc. The alliance is an all-encompassing framework for psychotherapy—it transcends any specific therapist behavior and is a property of all. The alliance is evident in anything and everything you do—from offering an explanation or technique to scheduling the next appointment. In short, it calls for your utmost attention and best clinical skills in every client encounter—your conscious, proactive efforts to make it happen.

We should think of the alliance as the central filter of all words and actions: Is what I am saying and doing now building or risking the alliance? Few things are worth risking the alliance. This doesn’t mean that you can never challenge clients; it just means that you have to earn the right to do so and must always consider the alliance consequences. At the very least, a discussion with the client about the value of challenge and securing permission is advisable. Our behavior should be designed to engage the client in purposeful work. That is what the alliance is supposed to do.

The Relational Bond: Empathy, Positive Regard, and Authenticity (The Big Three)

It is helpful to think of each meeting with a client as a first date (without the romantic overtones, unless you want a very short career development trajectory), in which you make a conscious effort to put your best foot forward, actively woo the client’s favor, and entice their participation. This requires listening intently, staying close to the client’s experience, not steering the conversation elsewhere unless invited, and just plain being likable, friendly, and accommodating. Because clients vary widely in their experience of what constitutes a good relationship, your flexibility is important. Pay particular attention to what excites clients: What topics and ways of relating raise their activity and engagement?

The relationship big three correlations with outcome are much higher than those of specific treatments and outcome. In fact, your client’s perception of any of the big three relational variables is more powerful than any technique you can ever wield.

Accepting the Client’s Goals

When we ask clients what they want to be different, we give credibility to their beliefs and values regarding the problem and its solution. Accept client goals at face value because those are the desires that will excite and motivate—that will engage them in purposive work. If we are straining our actions through the alliance filter, goals other than those of the client will likely not fit through. Collaborative goal formation begins the process of change, wherever the client may ultimately travel.  Bottom line: Work on client goals. Period.

Agreement about the Tasks of Therapy

Asking for help to set the tasks of therapy further demonstrates respect for client capabilities, as well as our efforts to enlist participation in a collaborative endeavor. This is probably our biggest alliance blind spot. After all, we’re supposed to be the experts, right? The beauty of collaboratively setting the tasks of therapy is that we not only ensure the alliance is on track with an approach that resonates with everyone involved, but that this process also provides a continual impetus to broaden our theoretical horizons. Negotiating the tasks of therapy sets the stage for expanding your conceptual repertoire, your theoretical breadth.

This third aspect of the alliance,  agreement about tasks—finding a framework for therapy that both you and the client can believe in—is why it makes a lot of sense to ask clients about their ideas on how to proceed, or at the very least getting client approval of any intervention plan. Such a process has not been highly regarded in traditional psychotherapy—the search has been instead for interventions that promote change by validating the therapist’s favored theory. Serving the alliance requires taking a different angle—searching for ideas that promote change by validating the client’s view of what is helpful, the client’s theory of change.

It is important to recognize that the alliance is the therapy, and that everything you do must be strained through the alliance filter. Does your behavior build or risk the alliance? Does your model and technique engage or not engage the client in purposeful work? And, of course, the proof of the pudding is in the eating. The answer can only be derived from the client’s response to any treatment delivered—the client’s feedback regarding progress in therapy and the quality of the alliance. Yes, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS).

Better Outcomes Now

By the way, the Partners for Change Outcome Management System (Better Outcomes Now) is the first and only system that includes every session use of an alliance measure. From the beginning, over 20 years ago, we valued the client’s voice about the relationship.

There are several reasons to monitor the alliance session by session,

• The alliance is a robust predictor of outcome.
• It is the client’s perspective that is predictive, not the therapist’s.
• Administering the SRS creates space for collaboration and the structure to build the alliance—sends message that client experience matters.
• Promotes discussion of cultural differences.
• Provides opportunity for clients to use their voice in a safe space which may empower them to speak up in other situations; allows us to model accepting critical feedback.
• Helps us expand our relational repertoire and form better alliances across clients—to get better results.

The alliance is your craft. Practice well the skills of your craft. At some point, your craftsmanship elevates to art.