Therapeutic Alliance – How to Achieve Success

The key factor to a success, according to pioneering psychotherapist Carl Rogers, and affirmed by contemporary research, begins with the mutual belief in equality between the client and therapist as well as the mutual development of treatment goals and tasks.

In this article we will explore how these components foster a strong therapeutic alliance, and how these underlying tenet of therapeutic success align with some of the oldest known wisdom in the western world.

An ancient antecedent of therapeutic success

The expression quoted above — friendship is an equality made of harmony — was recorded by an ancient biographer of Greek philosophers and attributed to the Pythagoreans who flourished in the 6th Century BC.

The Pythagoreans are known today for their accomplishments in mathematics and geometry (i.e. the Pythagorean theorem), but they were also highly influential and groundbreaking philosophers. Plato, perhaps the most influential of all Western philosophers, was himself deeply influenced by Pythagorean thought.

So what does this rather puzzling Pythagorean saying mean? 20th Century philosopher Simone Weil provides our interpretation:

This [“friendship is an equality made of harmony”] is when two human beings meet in such circumstances that neither is subject to the other and each has to an equal degree need of the consent of the other. Each one then, without ceasing to think in the first person, really understands that the other also thinks in the first person. Justice then occurs as a natural phenomenon.

Simone Weil, The Pythagorean Doctrine (1941)

Weil states that natural justice — a sort of social harmony — occurs when two people meet as equals (with neither having power over the other) and engage in a voluntary and reciprocal relationship. “Friendship” in this sense means any sort of friendly association whether social, business, or other.

Weil’s reading of this Pythagorean maxim is remarkably similar to the ideal state of the therapeutic alliance; specifically, the idea that the quality — and the mutual belief in equality — of the therapeutic alliance, and the mutual goals established by client and therapist (which create therapeutic harmony), are the most important contributing factors to a successful therapeutic outcome.

Let’s dive further into the specific qualities that foster a strong therapeutic alliance.

Therapeutic success: a meeting of equally devoted minds

Psychologist Carl Rogers, the pioneer of person-centered psychotherapy, was among the first to explore the importance of the therapeutic alliance (which he referred to as the client-therapist relationship).

Contemporary research suggests confirms Rogers’ belief that the quality of the therapeutic alliance is as important as any other factor, including the specific theoretical orientation of the therapist. The Ardito & Rabinello state:

The emerging picture suggests that 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.

Ardito & Rabinello (2011)

Ingredients for a strong therapeutic alliance

Rogers identified three factors that contribute to a successful therapeutic alliance:

• empathy
• unconditional positive regard
• openness

Empathy is the ability to understand and experience the feelings of others; unconditional positive regard is the unwavering acceptance of another person’s innate dignity and worth; and openness is the willingness to explore new ideas.

These three factors, Rogers concludes, are biproducts of a shared belief in equality. When these values are embraced by both the client and therapist, they create the harmonic circumstances in which therapeutic healing can occur.

Ardito & Rabinello (2011) give us three additional factors to a successful therapeutic alliance:

• agreement on the goals of treatment
• agreement on the tasks of treatment
• a personal bond developed by positive reciprocal feelings

The tenet underlying these three factors is not only a sense of social harmony, but also a harmony or congruence relating to the goals and objectives of the therapeutic process.

A geometric model of the therapeutic alliance

As we’ve reviewed, the Pythagoreans viewed relationships in geometric terms. This model is helpful to visualize a successful therapeutic alliance.

The therapeutic alliance begins when both the client and the therapist chose to engage in a therapeutic relationship. When this happens, the two parties become connected by this mutual decision. A simple visualization of this relationship can be seen below:

The decision to engage in the therapeutic alliance alone will not ensure success. The client and therapist must also hold harmonic (shared) beliefs about the therapeutic alliance. This harmony of beliefs brings a geometric shape to the therapeutic alliance and thus completes the connection.

When the client and therapist maintain a mutual belief in equality of the two parties, and when this mutual belief in turn leads to mutual decision-making regarding the therapeutic process, then the therapeutic alliance is a success.

How to create a strong therapeutic alliance

Now that we’ve reviewed the aspects of a successful therapeutic alliance, let’s take a look at how to put them into practice.

For the client

The most important things the client can do are:

• know your goal(s) for therapy
• express your goal(s) for therapy

As simple as it sounds, it can be a lot harder in practice to articulate these things. If you knows them on day one, that’s great . . . but it isn’t necessary. Maybe at this point you just know that you want to change something. In that case, be open with your therapist about your process of discovering your goals, and your thoughts and feelings about the direction that may be offered by your therapist as you clarify your goals.

Finally, be sure to provide ongoing feedback to your therapist about how you think the therapeutic process is going, and whether you’d like to alter or end the course of treatment. Both of these are natural and normal parts of treatment.

For the therapist

The most important things the therapist can do to forge a strong therapeutic alliance are:

• help the client to feel comfortable with and in the therapeutic process and environment
• help the client to feel like he or she is an equal participant in his or her treatment through the mutual creation and augmentation of treatment goals and objectives
• Elicit feedback from the client about his or her experience in therapy.

It is beyond the scope of this article to dive into specific strategies to achieve the above listed goals. Some of my favorite strategies can be found here.

Therapists are geometers

In this article we’ve explored the geometry of the therapeutic alliance: when the client and therapist recognize each other as equals and share beliefs about the therapeutic process, the therapeutic alliance itself becomes a powerful medium of healing.

Simone Weil states in her essay “The Iliad, Or the Poem of Force that “the geometry of virtue” is central to the philosophy of ancient Greece that ran from the Pythagoreans to Plato and beyond. This can be seen in the tradition that inscribed over the entrance to Plato’s Academy was the phrase: Let no one enter who is not a geometer. Perhaps the same should be inscribed over every therapist’s office.