The Role of the Therapeutic Alliance in Effective Therapy

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What makes therapy work? To fully answer that question would require all the books and studies that have been written and conducted on the topic over the decades, and even then one might fall short of a full answer. Successful therapy, like all important interpersonal endeavors, depends on one or more “X” factors. But there is one factor that all agree upon: the important role of the relationship between client and therapist.

This relationship, often called the therapeutic alliance, is a partnership between the therapist and client for the purpose of achieving the goals of treatment. It requires mutual trust and honest communication.

The therapeutic alliance consists of three elements: agreement on the goals of the treatment, agreement on the tasks required to achieve those goals, and the development of a personal bond between the client and therapist that is positive in nature for both.¹

Why Is a Connection Important?

In a word: Results. According to researchers Ardito and Rebellando (2011), “The quality of the client-therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures.”² In other words, a strong alliance can make for successful therapy, regardless of the modality employed.

In 2000, for the Journal of Consulting and Clinical Psychology, researchers conducted a meta-analysis of 79 studies on the therapeutic alliance and found the correlation between the outcome of therapy and the therapeutic alliance to be significant and consistent across types of therapy.³

Effective therapy sometimes requires a therapist to ask a client about difficult or painful parts of their experience, and for that client to accept the challenge of talking honestly about such topics. As such, trust in each other and the overall process is paramount.

“Sometimes, when you’re uncomfortable in session, it’s actually a good thing,” says Ying Wang, M.D., a psychiatrist in Pennsylvania. “Sometimes, you don’t walk away feeling lighter. Therapy is a safe space for you to dig into messy feelings. It will hopefully lead to healing, but it may make you feel bad. That relationship of trust allows a therapist to challenge the client and go deeper.”

Clinical psychologist Cynthia Baum-Baicker, Ph.D., puts it another way.

“The action of many therapies is to help people know—and experience—that it takes two to understand one, and that attachments and meaning are crucial to a good life,” she says. “If you have a rapport with a person, they trust you, they believe you, then they feel like they have a hand to hold when they go out and do something scary.”

Signs of a Strong Connection

A strong therapeutic alliance can be gauged in part by whether you’re fully yourself with your therapist, if you’re mutually interested in what you’re each saying, and if there’s a feeling of positivity in your conversation.

“If you feel relaxed and supported (not judged), and able to be open about things that you’re worried about, that’s really the center of rapport,” explains Jeremy Nicholson, a social psychologist in Western Massachusetts. “Can you tell this person things that are really bothering you that you wouldn’t feel comfortable telling other people? That trust is the beginning of a successful therapeutic relationship.”

• Authenticity: You feel physically and emotionally comfortable in their presence. This allows you to be open with your therapist about the root causes of your challenges, and to create a strategy with them to cope with the feelings and set goals for the future together.
• Attentiveness: You can tell your therapist has your best interests in mind at all times. You listen to and consider what your therapist says, and your therapist responds in kind. You might find yourself leaning in and making eye contact during a conversation, rather than sitting stiffly or with arms crossed. The conversation is easy: You’re not interrupting each other, and there’s a natural back-and-forth.
• Positivity: You never feel judged during a session. Therapy is a safe space in which you’re emotionally supported and empowered. The relationship between you and your therapist feels friendly, perhaps even collegial. You may find yourself smiling and nodding your head during the conversation.

Each of these elements leads to a relationship characterized by support and collaboration. They create a space where you and your therapist are able to talk honestly and positively about your thoughts and behaviors and develop a deeper understanding of who you are and what you can accomplish together.

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Don’t assume that there is a problem if you and your therapist do not fully connect immediately. It can take time to build rapport.

If you don’t feel a strong connection, it may be worthwhile to tell your therapist how you’re feeling. They may be unaware and able to alter their methods or approaches to better fit personalities and situations.

“It can be helpful, if there is discomfort, to bring it up in session,” says Wang. “I would not be offended or upset if a client did this. In fact, I would view it as a valuable input. If the discomfort is because the therapist conducts the session in a certain way, that can be changed. But if it’s about something else, it can provide insight into what it is about this person that’s causing a difficulty in opening up, which may inform treatment.”

There are also times when a good therapeutic alliance sours. Psychodynamic therapist Santiago Delboy recalls an interaction he had with a client where the individual became frustrated that Delboy wouldn’t give his own opinion on their predicament.

“In my experience, ruptures are unavoidable,” Chicago-based Delboy says. “Therapy is a professional relationship, but it’s also a personal relationship between two humans. Ruptures also offer an opportunity not only for repair but growth for increased closeness. We can think of repair as the outcome: the relationship is repaired. But we can also think of it as a process: the experience of a patient sharing openly and honestly what hurt them and being listened to by a receptive therapist is itself a healing experience.”

These instances don’t necessarily require an end to treatment. Open communication with your therapist about your concerns often has value. A study that appeared in the Journal of Consulting and Clinical Psychology, found that addressing and repairing ruptures in the alliance can lead to even stronger therapeutic relationships and improved outcomes.⁴

Ultimately, therapy is a relational endeavor. It exists in the space shared by therapist and client. The size of that shared space and what is possible therein relies on the strength of the relationship between the people sharing it.

As the field of therapy evolves, as techniques are refined and technology is introduced, the cultivation of a robust therapeutic alliance seems certain to remain an essential pursuit for those seeking to heal and those wishing to help them.

To find a therapist near you, visit the Psychology Today Therapy Directory.