Therapeutic alliance stays strong - NADA

By Dr Karen Hallam Director The Centre for Youth AOD Research and Policy, YSAS
Just as we see in the fashion world, trends come and go  in the psychotherapeutic community. New approaches are developed, old methods are supported with new evidence and emerging paradigms are placed on pedestals for scrutiny or worship. Underlying all of these changes, the single greatest predictor of therapeutic outcomes remains constant—the therapeutic relationship.

Therapeutic alliance is the most robust predictor of treatment outcome and mediator of therapy change.¹,² In my own undergraduate training we were reminded that despite therapeutic orientation the single greatest predictor of positive outcomes in therapy is how much the person seeking help feels heard, understood and supported by the therapist. This does not imply that therapeutic orientation is unimportant. Having a strong sense of therapeutic orientation helps therapists remain consistent, grounded and develop a strong voice.

Irvin Yalom described the important relationship in therapy as that of ‘fellow travellers’.³ When viewed this way the role of therapist is that of a guide, to walk alongside the person, not ahead and not behind on their life path. Our role is to gently point out obstacles that may fall in their way and note the times when similar obstacles seem to keep re-appearing. This stance is at the very foundation of a strengths based approach to wellbeing and resilience based frameworks. Importantly it also removes the ‘us  and them’ of therapy which dehumanizes both people  and the relationship between them. Dehumanization is  a distressing yet prevalent experience for those engaged with both mental health and AOD services, an experience that leads to significantly poorer outcomes.⁴

An ever-present awareness of therapeutic alliance is often most important at the moments of intense distress when the person seeking help asks ‘have you lost someone to cancer?’ or ‘have you been divorced?’ or ‘have you suffered depression?’ Strangely these are the questions my students most fear. If we look beyond the superficial of the question and focus on the meaning the person is often asking ‘can you understand the depth/pain/intensity of my experience?’, ‘am I alone?’ and ‘will I be ok?’. All who are asked these questions should answer with honesty… but not your story. It does not take much for any of us to remember these universal feelings. Typically I will answer that I, like all who have lived a meaningful life have experienced pain/ loss/fear, etc. Our job is then to acknowledge the feeling this causes inside and let them know that I hear their experience and ask them about their distress.

One of the rather beautiful quotes that most befits this discussion is from Carl Rogers who in the 1950s was one of the founders of the client centred therapy and humanistic movements. Rogers remarked:

Hearing has consequences. When I truly hear a person and the meanings that are important to him at that moment, hearing not simply his words, but him, and when I let him know that I have heard his own private personal meanings, many things happen. There is first of all a grateful look. He feels released. He wants to tell me more about his world. He surges forth in a new sense of freedom. He becomes more open to the process of change. I have often noticed that the more deeply I hear the meanings of the person, the more there is that happens. Almost always, when a person realize he has been deeply heard, his eyes moisten. I think in some real sense he is weeping for joy. It is as though he were saying, ‘Thank God, somebody heard me. Someone knows what it’s like to be me.’⁵

The notion of being heard, truly heard by someone who is there as a support is the very foundation of the therapeutic encounter. It is interesting to note here that the therapist retelling their own specific experiences is in no way necessary to support this growth as it unnecessarily  moves the focus to the therapist and their experience.

Rogers describes three central tenets of client centred therapy which directly relate to the formation and maintenance of a strong therapeutic alliance. These elements include empathy, unconditional positive regard and congruence. Whilst empathy and positive self-regard are somewhat clear to most, there is some lack of clarity over what congruence means in therapy. Lietaer indicates therapeutic congruence may include a reflection of one’s own internal experience and then the willingness to communicate to the other this sense.⁶ When considering  this authenticity, Yalom again highlights the conditions necessary for disclosure to be appropriate.⁷ On the broadest level, disclosure about the therapists observations and reflections of the individual’s behaviour are helpful (remember the pointing out obstacles on the path). The advantages of the ‘here and now’ discussion include that it is immediate feedback creating a dynamic place where people can test new styles and make different choices and that accurate (not second hand) data is available. In turn, this talk deepens therapeutic alliance.

On the opposite end, personal self-disclosure (whether details about one’s personal life or one’s own struggles with mental health or substance issues) needs very careful consideration and would generally be advised against. Evidence indicate this type of disclosure does not add to therapeutic outcomes and may contribute to changes in how the individual sees the therapist, compromises how the individual sees the roles of therapy and reduce perception of therapist credibility and competence.⁸

Overall, the evidence is clear that fostering a strong therapeutic alliance is one of the key determinants of good outcomes for people seeking support. The approach taken should be consistent within the therapist but the effectiveness of the approach itself may reflect the personal preference of modality. In contrast, a strong working relationship is essential and should include empathy, regard and authenticity in sharing with the individual important observations of the obstacles and challenges they are facing. When walking alongside people willing to share their story and experience, it is a constant privilege to be welcome into their lives.

References

1. Langhoff, C., Baer, T., Zubraegel D., and Linden, M. (2008). Therapist-patient alliance, patient-therapist alliance, mutual therapeutic alliance, therapist-patient concordance, and outcome of CBT in GAD. Journal of Cognitive Psychotherapy: An International Quarterly, 22(1), 68-79.
2. Hersoug, A. G., Hoglend, P., Havik, O., Lippe, A., and Monsen, J. (2009). Therapist characteristics influencing the quality of alliance in long-term psychotherapy. Clinical Psychology and Psychotherapy,16, 100-110.
3. Yalom, I. (2009). The Gift of Therapy. Harper Collins Publishers: New York.
4. Fontesse, S., Demoulin, S., Stinglhamber, F., and Maurage, P. (2019). Dehumanization of psychiatric patients: Experimental and clinical implications in severe alcohol-use disorders. Addictive Behaviors. 89; 216-223.
5. Rogers, C. (1980). A Way of Being. Cengage  Learning: New York.
6. Lietaer, G. (1993). Authenticity, congruence and transparency. In D. Brazier (Ed.). Beyond Carl Rogers. Constable Publishing: London; 17–46.
7. Yalom, I. (2009). 8. Audet, C. T. (2011) Client perspectives of therapist selfdisclosure: Violating boundaries or removing barriers? Counselling Psychology Quarterly. 24, 85-100. 9. Turns, B., Springer, P. R., and Scott S. R. (2019) Removing the ‘mystery’ in therapy: transparency as a continuous intervention in family psychotherapy. Journal of Family Psychotherapy. 30: 1-9.

Photo cc by sa 2.0 Jeff Kunbina