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The Therapeutic Alliance for Dummies

The Therapeutic Alliance for Dummies

The aim of this post is to provide a simple overview of the the concept of the Therapeutic Alliance, the reasons why it is seen as important and some wasy to recognise when it is working (or strong) and when it is not working (a weak alliance showing strains and ruptures).

The phrase 'therapeutic' or 'working alliance' is often used to describe the relationship between a person seeking help and the person providing that help. It is considered that a working alliance can occur between any two people where one is seeking change and the other is an agent of change, for example in the relationship between student and teacher. As such, the concept is not restricted to psychotherapeutic relationships, although the term ‘therapeutic working alliance’ is commonly used when refering to the concept when applied to therapeutic relationships within psychotherapy.

Applying the concept to the student-teacher relationship is a useful way to highlight the impact of it though. Think back to when you were at school, college or university.

  • Did you have a favourite teacher? 
  • What did he or she do that made you eager to attend their class and participate?

The chances are that some of the reasons may have been that they created a strong 'working alliance' with you.

Similarly you might prefer one doctor to another at your medical practice.

In the 1970's Edward Bordin suggested that the three components of the therapeutic working alliance could be labelled 'Goal', 'Task' and 'Bond'.

Goal

Bordin suggested that both the person helping and the person being helped need to agree on what they are trying to get out of the process. For example, if the doctor just wants to tell you about quiting smoking, but you want help managing your anxiety, you are unlikely to find it an beneficial relationship. Treatment or support is less likely to be successful when the client perceives that it is something that is ‘done to’ them rather than ‘done with’ them, so collaboration on the setting of realistic and achievable goals in vital.

Task

Whilst goals are the outcomes that the client wishes to achieve, the ‘tasks’ of treatment are the strategies required to achieve them (and sometimes who will do what to reach them). Tasks are the behaviours and processes within treatment sessions that form the actual work or intervention, and both the practitioner and the client must believe that these tasks are important and relevant for a strong alliance to exist. If both you and the doctor agree that you want to give up smoking, but you want nicotine patches and the doctor suggests a self-help group, then again, this is less likley to result in the strongest working relationship, or the best outcomes. Thus a collaborative approach to identifying who will do what and how, in order to achive the defined goals is again important. Although the practitioner and client do not need to be in total agreement as to how best to work toward achieving the goals set, a ‘goodness of fit’ between the tasks that the client may find helpful and the approach taken by the practitioner is essential for good outcomes. Client belief that the tasks of treatment are relevant to achieving their goals is essential. It is also important when discussing the tasks of treatment that practitioners explore what strategies a client has previously tried, whether they were effective, and whether they are likely to be effective this time.

Within a cognitive-behavioural approach to addressing problematic substance use, the goal of treatment may be to maintain abstinence from drugs and alcohol. The task of treatment in this instance may be to explore triggers to substance use and develop relapse prevention strategies to help the client to overcome or avoid their triggers. Alternatively, within a Twelve-Step or mutual-aid approach, the tasks required to meet the goal of maintaining abstinence may be to attend mutual aid meetings such as Narcotics Anonymous (NA) or SMART Recovery.

There are three main types of task: session tasks; home (or homework) tasks; and environmental tasks.

Session tasks are those that are carried out by both the client and practitioner within each session. In the example given, this may involve the client and the worker developing relapse prevention strategies together.

Home or homework tasks are those carried out by the client outside of sessions, such as attending NA or practising relapse prevention skills.

Environmental tasks are those that involve liaison with other agencies and can involve the practitioner, other professionals, the client, the client’s family or others within the client’s social network.

Bond

Collaboration in identifying and agreeing the goals and tasks of treatment makes practitioners appear more empathic and respectful instead of confrontational and critical, and this facilitates a positive working relationship and improves the ‘bond’ between practitioner and client.The bond element is therefore about whether or not you like and respect each other, whether a 'rapport' developes between you, and whether you share the same view on what a desireable outcome from the support provided would look like. This is more likely to happen if the person helping you takes time to listen to what you want, shows in interest in you, values you opinions and sincerley appears to want to help you. If the reverse is true, the bond is most likely to be poor.

Therapeutic Alliance RuptureWhere the bond is poor, or there is little agreement on the goals or tasks, what are called 'strains' or 'ruptures' often occur. This is when the relationship breaks down and is often characterised by observable changes in behaviour. Learning to recognise strains and ruptures can enable helpers to 'backup' and respond appropriately to the rupture. Importantly, where strains and ruptures are successfully responded to, this can actually strengthen the relationship.

There are usually seen as being two different types of rupture, confrontation ruptures and withdrawal ruptures.

Confrontation Ruptures

As the name suggests, confrontation ruptures usually result in disagreements, anger, frustration, resentment and dissatisfaction with the person helping, or the process of being helped. They are usually the esaiest to spot.

Withdrawal Ruptures

These can be more subtle and are characterised by the person becoming disengaged from the helping process. They may try to change the subject or provide minimal responses. As we can see in the video clip below, sometimes withdrawal rupture involve the person being helped just agreeing with the helper in order to end the encounter and get away:

 

A 'Pan-Theoretical' Approach

The Therapetic Working Alliance is often described as being 'pantheoretical' because it appears to apply equally to all therapeutic approaches. It is also seen as being the variable that makes the most difference across different approaches to help and support, as most commonly, the approaches that emphasise the therapeutic working alliance, such as Motivational Interviewing and Solution-Focused Therapies, tend to perform best.

How the Alliance Differs From Other Approaches

The alliance concept differs from both the client-centred approach and the psychoanalytic approach in the emphasis on the collaboration and negotiation of goals and tasks. The therapeutic alliance is seen as bi-personal, in that both client and practitioner contribute to the relationship. Formation of the therapeutic alliance is seen as a joint effort in
which both parties ‘work together’. Bordin theorised the therapeutic alliance as enhancing the efficacy of therapeutic interventions, rather than being curative in itself, in contrast to Rogers’ theory that clients automatically respond to a practitioner’s positive attitude - it is the client, rather than the practitioner, who is the primary driver behind the change process, as without their active involvement, nothing that the practitioner does is likely to have any effect. Such positive relationships between practitioners and their clients are seen as essential, even if not in themselves sufficient, to produce desired outcomes.

 

          Click on the lightbulb to the left for more information on the Therapeutic Working Alliance Focused Training that Soma deliver.

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