The Therapeutic Alliance: The Essential Ingredient for Psychotherapy

The anxiety of trying to change something as complex and entrenched as how you relate to people close to you or manage stress takes the feeling to a whole new level. Yet, that's just what you do when you enter psychotherapy.
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Have you ever tried to change the way you do something? It could be anything -- the way you hold your tennis racket, blow into a flute, meditate -- you name it. If so, think about that experience. No matter how motivated you were to change, and no matter how much you knew that it would help your serve, musicality, or sense of inner peace, it can be difficult and scary to change even the smallest thing. In order to change, you have to give up your old way of doing something first and then try the new way. That means that for a while you're in a free fall -- you no longer have your old habit to rely on and you don't yet have the new one.

The anxiety of trying to change something as complex and entrenched as how you relate to people close to you or manage stress takes the feeling to a whole new level. Yet, that's just what you do when you enter psychotherapy. Just as you had to put yourself into the hand of your teachers and coaches, in therapy you need to gradually do just that with your therapist to help you through what can be a harrowing adventure. The foundation for therapy is called the therapeutic alliance (1, 2). When it's there, you know that your therapist is there to help you, no matter how hard the going gets.

The therapeutic alliance might be the most important part of beginning a psychotherapy. In fact, many studies indicate that the therapeutic alliance is the best predictor of treatment outcome (3-5).

What is the therapeutic alliance? It is the trust between you and your therapist that allows you to work together effectively. It's what helps you to believe that your therapist is trustworthy and has your best interest at heart -- so even if you become angry or disappointed with your therapist, you can believe you can continue to work together productively.

This type of trust takes time to develop -- and in a long-term psychodynamic psychotherapy this can take months -- but good therapists will begin to establish this during the first meeting. How do they do that?

• First, they let you know that they are interested in you and in what is troubling you. Think about the last time you were seated next to someone you didn't know at a dinner party. Did that person ask you questions about yourself or did they talk about him or herself? A person who is genuinely interested in you makes you want to talk to them and makes you feel that they care about what you are saying. Therapists do this in many ways: by being attentive (not answering the phone, pagers, or checking email), by asking relevant questions (not just "name, age, serial number" type questions), by demonstrating that they're listening (following up on things that were said a few minutes ago, remembering details) and by making eye contact.

• Second, they let you know that they have a sense of how difficult or sad or painful your problem is to you. People who enter therapy are usually in some sort of pain. They're depressed, getting divorced, recently unemployed, worried, and their therapists have to let them know that they understand this. Sometimes, therapists show this in their facial expressions, but actively making empathic remarks is essential to building the therapeutic alliance. Therapists shouldn't be afraid to show some feelings -- wooden statues are for tobacco stores, not therapy offices.

• Finally, they give you a good sense that they understand something about the trouble that brought you to therapy. You may ask, "How can a therapist understand my problems when it's the beginning of the treatment? We've just met!" This is true, but good therapists should be able to understand something -- even from the get-go. They may not yet fully understand why you have the difficulties you have, but they should be able to understand things like the nature of the problem and the issues involved, and they should be able to communicate that understanding to you.

How do you know if you and your therapist have a good therapeutic alliance? Ask yourself, do I feel comfortable talking to my therapist? Am I able to talk freely in sessions? Do I feel relieved after I've been there? Do I want to go back? You don't have to feel that your therapist has all the answers, but you should have a sense that he or she is trying to understand and is on your side. If you have a good coach, the feeling that you have at the end of a practice is that you'd worked hard and that you will continue that work the next time -- together. If you have a good alliance with your therapist, you'll have that same feeling at the end of your sessions -- perhaps with a little less sweat and a little more hope.

Deborah L. Cabaniss, M.D., is Director of Psychotherapy Training and Clinical Professor of Psychiatry at the New York State Psychiatric Institute/Columbia University Department of Psychiatry. She is the lead author of "Psychodynamic Psychotherapy: A Clinical Manual."


1.Bender, D.S. (2005) Therapeutic alliance, in The American Psychiatric Publishing Textbook of Personality Disorders (eds J.. Oldham, A.E. Skodol, and D.S. Bender), American Psychiatric Publishing, Inc., Washington, DC pp. 405-420.

2.Ackerman, S. and Hilsenroth, M (2003) A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1-33.

3.Safran, J.D., Muran, J.C., and Proskurov, B. (2009) Alliance, negotiation, and rupture resolution, in Handbook of Evidence Based Psychodynamic Psychotherapy (eds R. Levy and S.J. Ablon), Humana Press, New York, pp. 201-5.

4.Horvath, A.O. and Symonds, B.D. (1991) Relation between working alliance and outcome in psychotherapy: a meta-anaysis, Journal of Counseling Psychology, 38 (2), 139-149.

5.Martin, D., Garske, J., and Davis, M. (2000) Relation of the therapeutic alliance with other outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450.

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