The working alliance is one of the most robust predictors of positive counseling and psychotherapy outcomes. This excerpt, from the forthcoming 6th edition of Clinical Interviewing, describes five recommendations. You can always email me directly if you have questions about these resources I post. Have an excellent Wednesday evening.
Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using Bordin’s (1979) model, alliance-building strategies focus on (a) collaborative goal setting; (b) engaging clients in mutual therapy-related tasks; and (c) development of a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:
- Initial interviews and early sessions are especially important to alliance-building. Many clients will be naïve about psychotherapy. This makes role inductions essential. Here’s a cognitive-behavioral therapy (CBT) example:
For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)
- Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan helps build the alliance. In CBT this includes making a problem list (J. Beck, 2011).
Clinician: What brings you to counseling and how can I be of help?
Client: I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.
Clinician: Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we say, “Find ways to help you start feeling more up?”
Client: Sounds good to me.
- Engaging in collaborative goal-setting to achieve goal consensus is central to alliance-building. In CBT this involves transforming the “problem list” into a set of mutual treatment goals.
Clinician: So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?
Client: Totally. It would be amazing to tackle those successfully.
Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (TP) for moving from problems to goals. The TP includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here’s an example of a “Devil’s Advocacy” technique where the clinician takes on the client’s negative thoughts and then has the client respond (Newman, 2013). You’ll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:
Clinician: You said you want a romantic relationship, but then you start thinking it’s too painful and pointless. Let’s try a technique where I take on your negative thinking and you respond with a reasonable counter argument. Would you try this with me?
Client: Sure. I can try.
Clinician: Excellent. Here we go: “It’s pointless to pursue a romantic relationship because they always come to a painful end.”
Client: That’s possible, but it’s also possible to have some good times along the way toward the painful end.
Clinician: [Smiles, breaks from role, and says] . . . That’s the best come-back ever.
- Soliciting feedback from clients from the first session on to monitor the quality and direction of the working alliance contributes to the alliance. Although you can use an instrument for this, you can also ask directly:
We’ve been talking for 20 minutes and so I want to check in with you on how you’re feeling about our time together so far. How are you doing with this process?
- Making sure you’re able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance (Linehan, 1993). Here’s an excerpt from an initial session with an 18-year-old male where the clinician accepted the client’s aggressive message and transformed it into a relational issue:
Clinician: I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.
Client: You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).
Clinician: Thanks for telling me that. I’d never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you’ll just tell me, and I’ll stop.
2 thoughts on “Five Recommendations for Developing a Positive Working Alliance”
Thanks for this post John. Managing (and communicating) client expectations for treatment is certainly challenging, particularly as people can’t always communicate what they want to achieve with treatment, or have preconceived notions about what their relationship with the practitioner should be like.
Thanks Olwen. I agree that understanding client expectations and needs is a complex communication dance; preconceived notions are a fascinating part of that process. Have a great weekend. John