The Therapeutic Alliance

The therapeutic alliance has been described as a good personal match between the personalities of patient and psychotherapist, or a specific type of helpful relationship between therapist and patient. How therapist and patient relate to one another, and how this relationship affects and is affected by the patient’s emotional difficulties effectively shapes how the duo understands the patient’s difficulties, and how each participant discusses or addresses managing these difficulties. Attention by the therapist to the therapeutic alliance is now considered of paramount importance in what happens in psychotherapy.

Some factors that affect the therapeutic alliance predate the patient meeting the psychotherapist. Both therapist and patient have, after all, different temperaments, they may have lived in distinct cultures, and they have each developed somewhat-distinct ways of thinking or styles of relating to others. Recently, studies have demonstrated that the degree to which these personality factors converge or complement one another in therapist and patient affect how they converse with one another, and whether the conversation becomes therapeutically productive (Lingiardi et al., 2017; Werbart et al., 2018). The therapist should be mindful of these various attachment and personality factors, and he/she should engage in conversation about this with the patient as it affects their relationship, in order for patient and therapist to achieve enough common ground to work together.

Essentially, therapists soon become involved in a subtle process in which they alternate between sharing in the patient’s emotional experiences and separate themselves enough from them to examine them in a different light. The tactful oscillation between empathic resonance on the one hand, and novel reflection and change on the other has been described in a number of different ways across types of psychotherapy. By attending to this process carefully, we hope to forge a relationship in which patient and therapist sufficiently agree on the nature of the patient’s difficulties, develop a working collaboration on specific goals and how to achieve them, and think together about how the therapist fits into the patient’s mental life.

Listening attentively and encouraging elaboration on particular aspects of the patient’s conversation are early and general strategies for creating and maintaining a collaborative relationship with the patient. Below are a few more examples from the PRC Manual, relevant to the task of forging and maintaining the therapeutic alliance. Of course, the entire manual could be thought of as providing examples of such clinical moments, ripe for further collaboration and therapeutic progress.

1. In an effort to create an environment in which he/she is attuned to the patient, the therapist follows the psychological focus of the patient.

2. The therapist acknowledges his/her own feelings in the conversation to develop trust and open the conversation to new meaning.

3. The therapist acknowledges the full complexity of what a patient means in feeling a certain way, to allow collaboration with the patient.

Of course, there are many other kinds of interventions that therapists employ as healers, to develop a collaborative and productive conversation. Click here to read about other specific interventions used by therapists in working with their patients.