Therapeutic Alliance: A Complete Guide

Mental health clinicians use various therapeutic modalities to help treat their clients. Some therapists are rigid in their practice, and others are more laid-back. Many times, mental health professionals gravitate towards modalities and methods of treatment that match their style.

Despite the modalities used, the therapeutic relationship is one of the most essential elements of mental health treatment. Research has consistently shown that the strength of the therapeutic alliance is linked to more substantial therapeutic outcomes.

The therapeutic relationship must be one of collaboration and trust. Developing a relationship where your clients trust you is essential for them to share more about themselves in therapy. Building a strong bond with your clients makes you a better clinician and helps clients achieve their goals.

What is a therapeutic alliance in counseling?

The therapeutic alliance is a term used to describe the strength of the relationship between a therapist and client in the therapy setting. The therapeutic alliance is vital for many reasons, but one of the main reasons is to build trust between the client and therapist.

Developing trust between a client and therapist fosters higher levels of honesty and the ability to do deep work in therapy. The stronger a therapeutic relationship is, the better the outcomes are for clients.

Therapeutic alliance example

There are many examples of the therapeutic alliance. A therapeutic alliance may look different for every client-therapist relationship.

A few examples of the alliance may look like this:

• The therapist uses deep questioning to help the client clarify their goals and restates the goals to the client to ensure agreement
• The therapist increases their bond with their client over a common interest they may both share
• The therapist supports their client by gently challenging them
• The therapist validates and shows the client understanding

If you’re a psychotherapist, how you form connections with each client may look different from one client to the next. The therapeutic alliance can exist in many ways in a therapist-client relationship.

What are the key elements of the therapeutic alliance?

There are several key elements to the therapeutic alliance.

The famous psychotherapist Carl Rogers identified three core conditions of the therapeutic relationship:

• Empathy
• Unconditional positive regard
• Congruence

Empathy is the ability to put yourself in another person’s shoes and try to understand things from another person’s perspective.

Unconditional positive regard means you positively regard your clients no matter what they do. Providing unconditional positive regard is different from agreeing with everything your clients do.

Congruence refers to the ability to be your authentic self with clients. The therapist shows up consistently and is genuine in their ability to help the client develop their own solutions.

Rogers believed these core conditions were necessary in psychotherapy to have a solid therapeutic relationship and provoke change in the client.

The role of the therapeutic alliance in psychotherapy

In psychotherapy, Carl Rogers, a famous person-centered psychotherapist, believed that six conditions were necessary for client change.

The six conditions he believed were necessary for client change included:

• The therapist and client are in psychological contact
• The client is experiencing incongruence within themself
• The therapist is congruent or authentic with their clients
• The therapist shows unconditional positive regard toward their clients
• The therapist is empathetic towards their clients and shows they can communicate in an empathetic way
• The client perceives the therapist as genuine, as having unconditional positive regard, and as empathetic

There are the factors Carl Rogers believed lead to a strong therapeutic alliance in psychotherapy, allowing clients to work towards growing and changing in the ways they want to.

Why is therapeutic alliance important?

According to 2018 research, the therapeutic alliance measures the client and therapist’s collaboration in the therapeutic process. The therapeutic alliance or relationship can include how the client and therapist interact and engage with one another. The better the collaboration, the more likely the client will have positive outcomes from therapy.

Building trust and holding ethical boundaries is essential for mental health professionals to develop with their clients. It’s part of the therapeutic alliance and helps clients disclose and share the innermost parts of themselves with their therapist.

Clients with a deep professional relationship with their therapist can do the hard work leading to change. They may also be more likely to take the therapist’s suggestions and use the skills that the therapist teaches them.

The five therapeutic relationships

Psychotherapist Petruska Clarkson proposed five phases of relationships that can occur within the therapeutic alliance.

The working alliance

A vital characteristic of the working alliance relationship is that the client and therapist must collaborate and form and build trust. This trust and ability to work together must occur for the client to grow from therapy.

The working alliance includes parts such as:

• The therapeutic contract
• Presenting problems that bring the client to therapy
• Acceptance that there may be times when one does not want to engage in the therapeutic relationship

The working alliance relationship involves cooperation from both the psychotherapist and the client.

The transference/countertransference relationship

This transference/countertransference relationship in therapy occurs when unconscious wishes, fears, or desires are projected onto the therapeutic relationship. Countertransference occurs when the therapist projects their own thoughts or feelings onto their client. Transference occurs when clients project their feelings about someone else onto the therapist.

In this phase, the therapist and the client must know how these dynamics impact the therapeutic alliance. Transference and countertransference can be helpful in some situations, but only sometimes. Countertransference on the part of the therapist can be dangerous at times and shows that the therapist may need to do personal work or consult with someone to ensure they aren’t harming their clients.

The developmentally needed or reparative relationship

This phase of psychotherapy can occur when the client experiences parenting that is insufficient in some way, such as the client having abusive or overprotective parents. The therapist acts as a secure relationship and may be a “parent figure,” allowing the client to experience corrective, reparative, or replenishing action.

The person-to-person relationship

This phase of psychotherapy involves a therapist-client relationship where deep trust can be built. The relationship at this point in psychotherapy involves a deep and authentic connection between the therapist and the client.

The transpersonal relationship

This phase of psychotherapy can occur when clients can expand their level of consciousness and heal. It describes the spiritual dimension of the healing relationship.

How can therapists build and strengthen the therapeutic alliance?

There are many ways therapists can build and strengthen the therapeutic alliance. Some therapists may find establishing a therapeutic alliance complicated with some clients and not with others.

Research suggests that within the therapeutic relationship, there are two core essential alliance-building needs.

The first is the task-alliance need. Goals for the therapist in meeting the task alliance need might include:

• Collaborating with your clients on their goals for treatment
• Explaining or educating your clients on the purpose behind interventions
• Educating your clients on tasks they can do to meet their goals
• Challenging your clients by giving them tasks aligned with their goals

The second alliance-building need is the relationship alliance. Goals for the therapist in meeting the relationship alliance need might include:

• Establishing trust and building rapport with your clients
• Finding common interests
• Collaborating and educating your clients
• Making strong connections with your clients

Rapport building may look different for every client you encounter. When working on the relationship alliance, you are working towards a relationship that can empower your client to make needed changes in their life.

What is the therapeutic alliance in CBT?

In cognitive behavioral therapy (CBT), the therapeutic alliance includes additional components outside of the core conditions proposed by Rogers. Research indicates that the therapeutic alliance in CBT also involves collaborative empiricism and Socratic dialogue.

Collaborative empiricism involves two distinct pieces: collaboration and empiricism. Collaboration involves therapists and clients acting as a team. A collaborative relationship can look like sharing ideas, therapists utilizing client input to guide discussions, and the therapist soliciting client feedback.

The empiricism piece involves the processes in which the therapist and client formulate goals and hypotheses and test them out. It also consists of the therapist asking for client feedback and measuring outcomes. The outcome measurements can be conducted through assessments or self-reports.

The Socratic questioning piece of the therapeutic alliance used in CBT involves questioning and helping the clients determine the accuracy of their thoughts. Socratic questioning can, in turn, lead to changes in perception, behavior, and emotion. It involves the techniques used in CBT to help the clients grow and make changes.

What is the goal of a therapeutic alliance?

According to 2022 research, the therapeutic alliance has three key goals. The first is for the therapist and client to develop a bond that feels authentic and trusting enough. This type of relationship allows clients to work toward their goals and use therapy as a guide.

The second goal is the agreement of therapy goals between the therapist and the client. Clients often have an idea of what they would like to work on and what they might want to get out of therapy. The therapist and client agree on the goals to help guide treatment and ensure you stay on track with the client's goals.

The third goal is task assignment. Task assignment is work that the therapist may instruct or guide the client to do. Essentially, the therapist’s interventions demonstrate how they help clients achieve their goals.

What is another term for therapeutic alliance?

Another term for therapeutic alliance is therapeutic rapport. Therapeutic rapport refers to the strength of the relationship between a therapist and client. It can also describe how caring and empathetic the relationship is. Stronger therapeutic rapport genuinely leads to better trust and more substantial therapeutic outcomes.

Therapeutic alliance recap

The therapeutic alliance or therapeutic rapport refers to the strength of the relationship between a client and therapist. Many factors make up the therapeutic alliance, but using the core conditions proposed by Carl Rogers can help improve the therapeutic relationship.

Mental health clinicians who understand where their own issues lie and seek help and consultation can minimize countertransference in therapy. Many times, countertransference can be damaging. Eliciting client feedback can also help the clinician grow and have a solid therapeutic relationship with their clients.

The therapeutic alliance may present differently in clinicians’ relationships with each client. Building rapport involves holding space for the client, validating, challenging, and expressing understanding. Clinicians must do this nonjudgmentally to develop trust with their clients.

The therapeutic relationship can be successful if the client trusts the therapist to help guide them. Deep change can happen with positive therapeutic rapport.

References:

• Antoniou A, et al. (2006). The five therapeutic relationships. http://www2.arnes.si/~rcvete/drugi letnik/studija primera/6.pdf

• Kazantzis N, et al. (2022). Therapeutic relationships in cognitive behavioral therapy: Theory and recent research. https://www.tandfonline.com/doi/full/10.1080/10503307.2022.2124047

• Prusinski T. (2022). The strength of alliance in individual psychotherapy and patient’s wellbeing: The relationships of the therapeutic alliance to psychological wellbeing, satisfaction with life, and flourishing in adult patients attending individual psychotherapy. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2022.827321/full

• Stubbe D. (2018). The therapeutic alliance: The fundamental element of psychotherapy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6493237/

• Thompson S, et al. (2007). Treatment engagement: Building therapeutic alliance in home-based treatment with adolescents and their families. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2885699/

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About the author

Marissa Moore

Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. She specializes in providing affirming counseling services to the LGBTQIA+ community. Marissa has 11 years of experience working in the mental health field, and her work experience includes substance use treatment centers, group homes, an emergency room, and now private practice work.

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