The Therapeutic Alliance: The Fundamental Element of Psychotherapy

In my early professional years, I was asking the question, How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?

–Carl R. Rogers

There is consistent evidence that the quality of the therapeutic alliance is linked to the success of psychotherapeutic treatment across a broad spectrum of types of patients, treatment modalities used, presenting problems, contexts, and measurements (1–4). Although scholars may differ in how the alliance is conceptualized, most theoretical definitions of the alliance have three themes in common: the collaborative nature of the relationship, the affective bond between patient and therapist, and the patient’s and therapist’s ability to agree on treatment goals and tasks (2, 3). The therapeutic alliance is posited to be a measure of the therapist’s and client’s mutual engagement in the work of therapy—thus representing an important component for achieving treatment success, regardless of the specific treatment modality employed (3). The statistical relationship between alliance and outcome is modest—approximately 7% of the variance and an average effect size of .26. However, this link has proven to be robust across multiple meta-analyses (1–4).

Studies suggest that patients tend to view the alliance relationship as stable, whereas therapists and observers tend to indicate more change over time in their alliance ratings (2). “Because patients tend to view the alliance consistently throughout treatment, they are more likely to view the alliance as positive at termination if their initial assessment was positive. Thus, therapists must be effective at establishing positive alliances with their patients early in the therapy process” (2, p. 447).

Therapeutic engagement of adolescents in psychotherapy may be particularly challenging. For instance, adolescents may feel forced into the psychiatric treatment by parents. They may feel stigmatized by the necessity of going to psychotherapy. They may find the therapeutic methods, which might have been developed for adults, not conducive to their developmental stage and interests.

However, forming a strong therapeutic alliance may be particularly important in this age group. Many mental health disorders begin in adolescence, and optimizing treatment at this stage of development may improve overall prognosis. Interacting with empathy and genuinely, using developmentally appropriate interventions, providing options of therapeutic modality, and addressing the issue of stigma may enhance the therapeutic alliance with adolescent patients (5).

Clinical Vignette

Mr. Tirell Jones is a 26-year-old man who is employed in the construction industry. He has been experiencing sleep difficulties, lack of energy and motivation, lack of patience, and less productivity at his job. His boss encouraged him to see a doctor about these symptoms. His primary care physician referred him to a psychiatrist, Dr. Kurtz, after a normal medical workup.

Mr. Jones appeared uncomfortable when Dr. Kurtz met him in the waiting room. Dr. Kurtz smiled encouragingly when they sat in his office.

“Your primary care doctor referred you to me, thinking you might be depressed. Have you seen a mental health professional before?” Dr. Kurtz queried.

“No,” Mr. Jones replied curtly.

“Hmm. Well, if I am the first psychiatrist you’ve seen, I guess I’d better make a good impression,” Dr. Kurtz quipped humorously, in an obvious attempt to help Mr. Jones feel more comfortable.

Mr. Jones donned a wry smile and replied frankly, “Doc, let me be honest with you. I don’t want to sit and talk about my problems. I have enough on my plate without having to spill out my guts about everything that is bothering me. I just want to be able to sleep and get my energy back. I’m afraid I am going to get fired from my job.”

Dr. Kurtz gazed empathically at Mr. Jones. “Wow. It must have been really hard to come here. I’m sorry life has been so hard. How do you think I can be helpful?”

“Honestly, I don’t think you can help me. Maybe give me a medicine that I don’t really want to take and robs me of my sex drive. I don’t know,” Mr. Jones replied sarcastically, with a hint of defeat in his tone.

Dr. Kurtz pursed his lips thoughtfully, still gazing at Mr. Jones. “Thank you for being honest, Mr. Jones. And I’m glad you came here. You know what you want and what you don’t want. I admire that. I think we can work together, if you agree.”

Dr. Kurtz went on to ask more diagnostic questions and to learn of Mr. Jones’s fears and hopes about mental health treatment. They reviewed safety concerns, stressors, and supports. Mr. Jones even admitted that he didn’t think a Jewish doctor could understand or “really ‘get’ a black working man.”

Dr. Kurtz smiled. “I really do love your honesty. Some people never are aware enough and brave enough to say what they feel. I’ll really try to listen and understand you. I hope you will let me know if you feel I am or am not ‘getting’ you.”

They discussed an antidepressant medication and chose bupropion because it has fewer sexual side effects. They also made a plan to increase Mr. Jones’s socialization with friends and family, add sleep hygiene and melatonin as needed to improve his sleep patterns, and include psychotherapy with the medication treatment when he returned in one week.

“Hey, doc, you’re not so bad,” Mr. Jones said with a broad, relieved smile as he was leaving. He firmly shook Dr. Kurtz’s hand and stated, “See you next week.”

Psychiatrist-Patient Engagement

Psychiatric patients miss appointments more often than patients in other medical specialties. A study in England reported that 19.1% of psychiatry outpatient appointments were missed, compared with 11.7% of other health care outpatient appointments (6). It is estimated that 31% of community psychiatric patients drop out over the course of a year (7). Poor attendance with missed appointments is closely linked with medication nonadherence (8).

Psychiatry patients who miss their first appointment are different from those who miss a follow-up appointment. The first appointment is heavily influenced by an individual’s pre-existing health beliefs and the quality of the information given by the first referrer. Attendance at follow-up appointments is a reflection of the patient’s overall satisfaction with care, engagement, and perceived need for further help (9).

The following are communication tips to enhance the psychiatrist-patient therapeutic engagement (1, 2, 8, 10):

1. Begin with a patient-centered approach.

   1. Inquire about the patient’s hopes and concerns about the treatment. What outcome is the patient seeking from the treatment?

   2. Be clear and specific about the importance of the therapeutic alliance. Convey that you strive to ensure that the patient is getting his or her needs met and that barriers to the alliance can be openly addressed.

   3. Let the patient know that you appreciate his or her attendance and engagement. Make a plan for how to communicate outside of appointments if the patient has questions or concerns. Discuss any potential barriers to attendance and problem solve those.

   4. Begin with open-ended questions and empathic responses. Listen carefully to motivations as a guide to what is most important to the patient.

   5. Cultivate an attitude of cultural humility. Reflect regularly on your automatic reactions and potential unconscious biases toward patients to improve your cultural humility quotient.

2. Set clear goals by coconstructing the treatment plan.

   1. Set the expectation that you and the patient will discuss and agree on the therapeutic goals through coconstruction—that is, by formulating the treatment plan together.

   2. Review the therapy progress regularly, with discussion of what is working and what is not—making modifications as appropriate.

   3. Be sure your patient knows that you appreciate honesty and candor about adherence to the treatment plan.

3. Regularly review satisfaction with the therapeutic process, relationship, and treatment plan.

   1. Discuss patient satisfaction with treatment, the therapeutic relationship, and communication practices regularly, with dialogue about any concerns.

   2. Directly address the potential that the patient may feel skeptical about your diagnoses, medications, and treatments and that this is important to discuss.