Why the therapeutic alliance is key

By: Dr. Cheri Shapiro

One area that providers think about, a lot, is the therapeutic relationship or alliance.  Without a strong working relationship between providers and clients, progress will not be made.  But, how much of our outcomes are due to the therapeutic relationship?

Many studies have been conducted to better understand the role of the therapeutic alliance in treatment outcomes.  From this body of research, it appears that the alliance consistently accounts for about 10% of the variance in outcomes.  Thus, it appears that there are likely a number of factors that contribute to client outcomes.  These include factors that are likely related to the client, to the therapist, and to the treatments selected, among other things.

Given that the therapeutic alliance is important, what can we do to address this within the context of evidence-based treatments?

The first suggestion is to act right away.  Signs of trouble can include clients missing appointments, arriving late or on the wrong day, or direct statements that the treatment “won’t” or “can’t” work.  Clients may appear bored or disengaged in sessions, or they may not work on assignments or homework from sessions.  As soon as these challenges arise, it is important to talk directly to your clients about what the concerns or problems are, and to create steps to address them.  Then, it is important for the provider to notice and reinforce when clients are on the right track (e.g., “Awesome job getting here by 6:00, this gives us plenty of time to work together today!”).

Providers often need to help clients brainstorm and problem solve the many obstacles to getting to or participating in sessions.  Additional resources may also be needed to resolve concrete barriers such as lack of transportation or money for gas.

As providers, we can also measure how much we are on the same page, even session by session.  One example is the Session Rating Scale, a four-item measure that can be used to track the alliance session by session.  This scale, created by Scott Miller and colleagues, along with a related measure called the Outcome Rating Scale, is available here at no cost.

Building the alliance with clients and noticing changes and acting quickly on them can set the foundation for our work and allow us to achieve to our ultimate goal of helping those we serve to feel better and to lead the lives they would like to lead.

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