Making a Difference as a Counselor: Building a Therapeutic Alliance
What makes the difference between an effective and ineffective counselor? Some therapists stress the importance of technique — behavioral, cognitive, humanistic — but research shows that the therapeutic relationship is the most important factor in a patient’s treatment success.
For some, catching up on the newest trends and methodologies can get in the way of your true purpose. Always ask yourself, “What is my mission?” Your answer should be to improve the well-being of your patients.
Are you an agent of change?
The definition of a “change agent” varies across the spectrum. However, for this purpose, we will limit the idea to someone that makes significant and lasting changes in the quality of their patients’ lives. Is your client notably improving in any or all of the following areas?
- Emotional tolerance
- Taking responsibility
Chances are, you can answer at least of these questions without asking the client directly. However, if you are unsuccessful in building a strong therapeutic alliance with your client, then treatment will be ineffective — and you will be unable to answer any of the questions. Starting a private practice requires you to review your methods and outcomes on a regular basis.
Therapeutic alliance: A foundation of successful therapy
Most scholars describe a therapeutic alliance as a collaborative working relationship between client and therapist, consisting of:
- Goal consensus between counselor and client
- Collaboration on counseling-related tasks
- Emotional bonding
The importance of a robust therapist-client relationship is not a new concept. In a 1957 article, Carl R. Rogers, one of the founders of the humanistic approach to psychology, stressed that the therapist should be genuinely engaged in the relationship, have unconditional positive regard and empathy for the client, and communicate these attitudes clearly to the client.
Why a robust relationship is crucial to favorable outcomes
A recent study by the American Psychological Association (APA) took a close look at relationship factors thought to enhance psychotherapy outcomes, and confirmed a valid causal link between a strong therapeutic relationship and a positive result of therapy in the following areas:
- Alliance: Build a strong working relationship with your patient or patients.
- Collaboration: Get on the same page as your patient.
- Goal consensus: Reach an agreement on the goals and expectations of therapy.
- Positive bond: Create an environment of openness, warmth, and equality.
- Empathy: Understand the patient’s feelings and challenges.
- Client feedback: Gauge how a patient is doing and adjust their treatment accordingly.
- Encouragement: Demonstrate support regardless of a client’s behavior, attitudes, or emotions.
The key takeaway from the analysis is that the relationship between patient and counselor matters — a lot. It’s a direct indicator of whether or not a patient’s therapy will be successful.
Let’s examine how meaningful the therapist-client relationship is by looking at one patient’s struggle to find a counselor who could impact her treatment, and ultimately, save her life.
Our sister’s and brother’s keepers, one patient’s perspective
Debbie Bellance, 54, was overwhelmed with an increasingly demanding job. Over several years, the more stressful her career became, the more anxious and depressed Debbie felt. In 2004, she finally broke. Her will and mind were broken.
Debbie’s doctor prescribed her medication and recommended she see a counselor. So began Debbie’s ten-year search for a therapist who could help her. A therapist who cared enough to perceive her as something more than another patient, in a line of many, to treat.
A lack of therapeutic alliance fails the client
Debbie laid on the couch of many therapists before finding her agent of change. Desperate and aimless, she told her story, again and again, hoping this time would be different. Instead, she found a series of experiences that left her confused, hurt, disappointed, and discouraged.
“It is difficult enough just to make the effort. Research and find someone you think is a good counselor. Ask doctors for their recommendations, finding someone who is covered under your insurance, waiting weeks for an appointment. Then you go to the appointment, and it’s awkward, it’s uncomfortable. You’re expected to jump right in and bare your soul to this person you just met,” Debbie says. “Remembering the process, in the beginning, is upsetting.”
The first counselor who treated Debbie hit some marks on the list of what not to do during a therapy session:
- Fall asleep
- Talk nonstop about their problems
- Forget important details
- Give inappropriate advice
“After ten minutes of complete silence, she woke up,” Debbie says. “No apology. No acknowledgment. She just acted like she had been listening. All she had to do was make an excuse. Instead, she said nothing. I left feeling worthless. I couldn’t even pay someone to pretend they were interested.”
The counselor spent large portions of the session talking about her children’s eating habits, her husband’s bowling league, and about how she didn’t make enough money. Even after two years of therapy, she would still check her notes before addressing Debbie by name.
“She wasn’t helping me, and I never really trusted her. We never formed any kind of relationship, I’m pretty sure she didn’t even know my name after two years, but I kept seeing her because I couldn’t imagine starting all over with someone new,” Debbie says. “I figured that’s just how therapy was; I didn’t know any better.”
Patients encounter many therapists during their journey
Over the next eight years, Debbie went from one bad experience to another.
“I saw a counselor one time who didn’t even introduce herself. She just hurled some papers at me and told me to write down ‘in graph form and with pictures,’ my life story. I don’t know this person. She expected me to just pour out my life to her, on paper with colored pencils. She didn’t even spend five minutes getting to know me, or making me feel comfortable.”
Next, was the counselor who liked to talk about her other patients.
“She told me that her other patients had stressful jobs and managed just fine. I just needed to make myself do it. As if I didn’t feel like a big enough failure, I had this trained professional telling me I wasn’t as good as her other patients. I had zero self-esteem; none. Instead of building me up, she tore me down,” Debbie recalls.
The specifics were different. The techniques were diverse and the competence levels varied, but one common thread amongst every failed attempt remained:
“I was just a number.”
Building a therapeutic relationship makes all the difference
After numerous failed attempts at therapy, Debbie took some time off. She was still battling depression and crippling anxiety, and although she was desperate for help, she couldn’t bear another disastrous experience.
Previous therapists failed her, leaving her feeling “small and insignificant,” but Debbie needed help, and she slowly built up the strength to try again. Enter Jennifer Beck, a licensed clinical professional counselor (LCPC).
“The sessions were different from the start. She put me at ease,” Debbie says. “She asked me questions based on the things I told her, and she remembered things I told her, without constantly checking her notes. She seemed genuinely interested in getting to know me.”
Beck did things a little differently than her predecessors. She took the time to build a therapeutic relationship by implementing the following guidelines:
- Committing to developing a meaningful relationship
- Interacting on a personal and appropriate level
- Preparing for sessions
- Building trust and intimacy
- Listening to the patient
“Jen never acts like my problems are small. The only thing she dismissed is my constant apologies for complaining. She tells me instead that my issues are just as meaningful as anyone else’s and are very important,” Debbie says.
Although not every session is a feel-good moment.
“Don’t get me wrong. Jen challenges me. Sometimes I leave completely ticked off at her. Which is good, I think. Because I always realize eventually, she was pushing me for my own good.”
The benefit of Jennifer taking the time to understand Debbie is that she knows when and how hard she can push her. “Other times, she knows, just by looking at me, to be delicate. She knows me.”
The lasting impact of therapeutic alliance
Beck is an excellent therapist with strong relationship building skills. Below are some of the techniques she uses that have had a lasting impact on Debbie’s success in therapy:
- Validate clients feelings
- Push the patient when appropriate
- Hold self and the patient accountable
- Set goals together
- Give sound advice tailored to patient’s needs
- Offer positive reinforcement
- Proceed with care
After three years, Debbie continues to see Beck regularly; sometimes once a week, sometimes once a month, depending on her need. She considers herself a much healthier and capable person, attributing the credit to therapy.
“I don’t know where I’d be if I hadn’t found Jen. Not to sound melodramatic, but she probably saved my life.”
How to build a strong therapeutic alliance
A counselor should possess solid interpersonal skills, the most crucial of which is active listening. Lacking in this area will prevent you from building an alliance with your client. Active listening consists of five essential behaviors:
- Paying attention
- Withholding judgment
- Summarizing and sharing
After establishing active listening skills, move on to steps to build a relationship with your patient. Use a combination of tactics and a secure telemedicine platform to enhance the client experience.
Shift the focus to mutual and collaborative approaches
Research supports the benefits of complementary and collaborative approaches. When therapists engage in a method known as immediacy, the patient’s mental health functioning and insight improve. Patients can also show marked improvement when the therapist and patient agree and collaborate on patient goals.
Be flexible and responsive
A therapist’s ability to tailor treatment to patient characteristics, such as cultural background, attachment style, therapy preferences, religious or spiritual beliefs, sexual orientation, and gender identity, is crucial to successfully building an alliance.
Also consider innovative approaches, such as online therapy sessions, to satisfy the various needs of your clients.
Another essential way to boost the therapeutic relationship — as well as patient outcomes — is to gather patient feedback and incorporate it into treatment. There are a variety of ways to obtain feedback from a client, including using in-depth, validated outcome questionnaires, creating custom forms, and simply asking your client periodically for feedback.
Several factors can break down the therapy alliance, such as a mistrust of therapy, disagreement on treatment goals, or a misinterpretation of something the therapist or patient has said. Research shows that resolving these difficulties, known as therapy ruptures, can lead to better outcomes.
You can make a real difference in someone’s life
The road to positive change begins with building a strong therapeutic alliance. You can be an agent of change if you choose to be. Or, you can be the one who uses their patient’s time to vent personal problems; the one who cancels on a patient three times when they are in crisis. It’s a hard line to walk — caring too much or too little — but if you don’t care at all, you are clearly in the wrong business.
It took Debbie Bellanca 11 years and two nervous breakdowns to find her agent of change, and thousands more like her are still searching. They are scared, they are in pain, and they need help. When you start a therapy practice, your mission is to help others. Are you the one they’re looking for?