If The Alliance Is So Important, Why Don’t More Therapists Monitor It?

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. It also accounts for why one therapist gets better results than another. The best therapists form strong alliances with more people across their caseloads. Consequently, it would seem only common sense to monitor the alliance. The Session Rating Scale (SRS), a four-item alliance scale, provides a feasible, user-friendly way to incorporate the many benefits of routine alliance monitoring:

• 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 the message that the client’s experience matters.
• Promotes discussion of cultural differences between therapist and client.
• Provides an 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 enable better results.
• Helps prevent dropout by addressing potential alliance ruptures.

But mysteriously, many do not use the Session Rating Scale or other measure despite over 1000 studies showing the relationship between a good alliance and positive outcome. I have often pondered how in the world so many therapists profess their allegiance to the power of the alliance, be are so enamored of it, while simultaneously failing to give it the attention it deserves. There are three reasons that therapists struggle with administering and discussing the SRS: a lack of a planned way to end sessions; fear of criticism; and a belief they already know the client’s perspective of the alliance.

No Planned Way to End Sessions

Many therapists just plain run out of time to administer the SRS. This could happen to anyone on occasion but not as a regular way of running a session. You must have an exit strategy, a way to gracefully end a session, what I like to call a closing ritual. Therapists who allow clients to talk until the very end of the session and then cut them off in desperation of not running over into the next client, are setting themselves up for a dropout. Each session needs closure, a planful ending that makes sense of what just happened and connects the current session to the next. For example, one way is to do your wrap-up of the meeting, give the take-home message (perhaps a homework assignment or what you want the client to remember or reflect on about the session), and then administer the SRS.  Five minutes before the end of the session, at minute 45, I wind the discussion down and transition to the closing ritual. I summarize what happened and, in the process, validate both the client’s struggles and their capacity for change. This includes a “take home” message and maybe a  homework assignment. I check in with the client if it makes sense and ask them if they have anything to add or their own take-home message. Then I administer the SRS which takes the client less than 30 seconds to complete followed by a discussion of their alliance feedback and what I might either continue to do or do differently in the next session.

Fear of Criticism

Sadly, many therapists don’t give the SRS for fear of receiving negative feedback. And not just young clinicians fall prey to this concern. Such a reaction reflects a basic misunderstanding of the purpose of the SRS. There is no bad news on the SRS.  It’s not about you—it’s not about competence as a therapist or overall alliance abilities. Rather the SRS is about this client’s perspective of this session so that the therapist can address any concerns and alter services accordingly. It is not about getting high scores and kudos, it’s about building a culture of  client privilege and feedback, opening space for the client’s voice about the alliance, including exploration of any ethnic/cultural/racial/orientation differences.

Beyond being an alliance measure, the SRS represents a nuanced relational process designed to ensure that clients feel safe about offering feedback. This requires therapist’s comfortability about asking for feedback and a graceful response that accommodates the work to the feedback—an authentic desire for a frank discussion about client preferences regarding the alliance.

Graceful acceptance of any problems and a willingness to be flexible speaks reams to the client and usually turns things around. Punctuating this point is the finding that clients who report alliance problems are twice as likely to achieve a successful outcome. Negative scores on the SRS, therefore, are good news and should be celebrated. Practitioners who elicit negative feedback tend to be those with the best effectiveness rates.

They Think They Already Know

Finally, many believe that they already know whether they have a good alliance with a given client. Wow, hard to believe this misguided assumption has persisted despite the robust long-term finding that it is the client’s perspective of the alliance that predicts outcome, not the therapist’s. We simply don’t know there is a problem until it is too late, and the client doesn’t return for the next session. The SRS itself is a bit of an externalization of the alliance. It is a lot easier to mark the scales lower than to talk about it. That’s the whole idea. People will indicate a concern on the SRS when they never would have brought it up otherwise. Consider our Norway couple trial. We asked the therapists whether they thought progress and alliance feedback would improve their outcomes. All ten said no, that they already knew when clients were not progressing or there wasn’t a good alliance. Only one therapist was correct because 9 out of 10 therapists in the study realized significantly better outcomes with PCOMS. The truth is we don’t know if we have a good alliance unless we ask and are open to hearing that we don’t.

Know that when clients trust you enough to report an alliance problem, you have truly arrived at a different level of engagement, and your outcomes will likely reflect it.

The alliance is your craft. The SRS can help you elevate your craftsmanship to art.