Therapeutic alliance

Goals1

Client and therapist agree on what therapy is for.

Tasks1

They agree on what they will actually do in sessions to get there.

Bond1

There is enough trust and liking to do hard work together.

Agreeing a goal1

For example, client and therapist agree that the point of therapy is for the client to ride the bus again without panicking.

Agreeing the tasks1

For example, they agree that the client will ride one stop further each week and that each session starts by going over how it went.

The bond1

For example, the client trusts that doing these hard exercises with this therapist will actually bring them closer to that goal.

A withdrawal rupture4

For example, after a suggestion the client goes quiet and says "it's fine": a move away from the therapist, by shutting down, avoiding or masking what they feel.

A confrontation rupture4

For example, the client says the exercises are pointless and the therapist doesn't get it: a move against the therapist, by complaining, defending themselves or trying to control the session.

Repair by renegotiating4

The therapist acknowledges the rupture, explains the rationale for the task, clarifies what got in the way, discusses alternatives and modifies the plan.

Repair by exploring4

Therapist and client acknowledge the rupture, explore it together, and clarify the needs underneath it (Safran and Muran's 1996 model).

A simple repair4

With clients who relate well to others, many ruptures are easily repaired with surface techniques such as explaining a misunderstanding.

A robust predictor2

The 2018 meta-analysis found the alliance-outcome link held across raters, measures, approaches, patient types and countries; only about 2% of effects were negative.

Ruptures and repair1

An alliance that strains and is repaired goes with better outcomes than one never strained or never repaired; good brief therapies show a high-low-high pattern.

Correlation, not proof2

These studies show that a strong alliance goes with better outcomes; they do not by themselves show the alliance causes them.

Rigid adherence can hurt it3

Sticking rigidly to a manual may weaken the alliance, while flexibility relates to better outcomes.

Agree before you intervene3

In Wampold's model, clients only carry out a therapy's healthy actions when they agree on the tasks.

First impressions count3

People judge trustworthiness from a face within about 100 ms, and dropout is highest after the first session.