Foster the Therapeutic Alliance

As we continue our exploration of client retention and how this can decrease stress for clinicians by decreasing early termination of clients, we will be looking at Chapter 9 - “Foster the Therapeutic Alliance” from the book, Premature Termination in Psychotherapy - Strategies for Engaging Clients and Improving Outcomes, written by Joshua K. Swift and Roger P. Greenberg.

When the therapeutic alliance is strong, the perceived benefits of working collaboratively with an understanding and empathic therapist can help outweigh almost any other costs associated with attending therapy.  In contrast, if the therapeutic alliance is weak, the lack of a relationship itself may lead a client to prematurely terminate from psychotherapy.

Bordin (1979), suggested a pantheoretical definition of the therapeutic alliance that includes three central components:

• (a) agreement on the therapeutic goals,
• (b) agreement on the assignment of tasks for therapy, and
• (c) the development of a bond between the client and the therapist.

The first two components of this definition are related and relatively straightforward.  Although each theoretical approach proposes its own set of objectives and methods for reaching those purposes, for a client and therapist to work together, they must have at least some level of agreement as to what those objectives and methods are to be.  If clients and therapists are not on the same page about the purposes of therapy or the most appropriate ways to achieve those purposes, clients are not likely to remain in treatment.

The therapeutic bond, the third component of Bordin’s (1979) definition, includes the feelings that the client and the therapist share for one another.  The bond is often considered to be strengthened by the therapist's ability to display Carl Rogers’s necessary and sufficient conditions for therapeutic change, such as unconditional positive regard, accurate empathy, and genuineness (Rogers, 1957), as well as nonpossessive warmth and respect for the client.  A therapist’s display of these characteristics in turn leads to the client’s feelings of safety, trust, liking, and respect for the therapist.  In addition to making it possible for a client to feel safe to be open with the therapist and trust the goals and techniques the therapist proposes, the bond is what keeps the client coming back, even when the therapeutic work might be difficult.  Without a positive relationship with the therapist to keep them in therapy, clients are likely to follow any number of competing reasons to discontinue.

In addition to developing the therapeutic alliance early on in therapy, therapists should seek to maintain the alliance throughout the therapeutic process.  In therapy, there can occasionally be a tension or breakdown of the relationship between the client and the therapist - sometimes referred to as an alliance rupture.  Although the therapeutic alliance may be one of the best ways to keep a client in therapy despite other costs that might be present, a client’s perceptions of being hurt by his or her therapist will almost surely lead to premature termination unless it is recognized and ameliorated quickly.  In contrast, when the therapist is successful in perceiving and repairing an alliance rupture, the bond between the client and therapist will likely be strengthened, making it all the less likely that the client will discontinue prematurely.

Recommendations for fostering the therapeutic alliance:

1. Make sure that there is some agreement on the goals and tasks of therapy before jumping into treatment.
   1. Work collaboratively with your clients
   2. Educate clients about appropriate therapeutic roles and about the different treatment options that might be available, and provide a rationale for why one might choose one treatment approach over another.
2. Focus on developing a relational bond with your clients.
   1. Listen to your clients, display characteristics of warmth and acceptance, seek to really understand clients’ individual problems rather than just deciding on a diagnosis, and seeking to respond empathetically to what the client shares.
3. Routinely monitor clients’ perspectives on the alliance throughout therapy.
4. Seek to repair alliance ruptures as soon as they occur.