Psychotherapy has been described as a dance, “a synchronicity of the mind and body that occurs between therapist and client” (Schore, 2014, p. 388).
Psychotherapy and counseling in general are arenas for authentic, intimate, and unique interactions between a client and a therapist.
With over 200 different approaches to counseling, there are a few key points that all the methods share (Rivera, 1992).
Every form of therapy requires an interpersonal relationship, with the goal of helping a client heal or relieve distress. Therefore, understanding this sacred relationship is something that anyone in a helping position should seek to do.
We call this incredible and unique relationship the therapeutic alliance, and in this article, we explain its four phases.
Before you continue, we thought you might like to download our three Positive Relationships Exercises for free. These detailed, science-based exercises will help you or your clients build healthy, life-enriching relationships.
This Article Contains:
- What Is the Therapeutic Alliance in Psychology?
- Therapeutic Relationship Model: 3 Components Explained
- 4 Phases & Stages of the Alliance
- 4 Real-Life Examples
- A Look at Healthy Boundaries in Therapy
- Therapeutic Relationships vs Social Relationships
- PositivePsychology.com’s Relevant Resources
- A Take-Home Message
What Is the Therapeutic Alliance in Psychology?
Research examining outcomes of psychotherapy and counseling have found that only 15% of treatment success can be attributed to the type of therapy or the techniques administered (Hubble, Duncan, & Miller, 1999).
More important than technique or type of therapy are therapist qualities and the overarching therapeutic alliance.
For the past 80 years, psychotherapists have advocated that nonspecific common factors are responsible for the success of their work (Groth-Marnat, 2009). Within the field of psychology, the therapeutic alliance is foundational to these common factors.
The concept of therapeutic alliance can be traced back to Freud’s (1913) idea of transference, which was initially thought to be completely negative. Later, Freud considered the idea of a beneficial attachment between therapist and client rather than merely labeling it as a problematic projection.
Zetzel (1956) later defined the therapeutic alliance as a non-neurotic, non-transferential relationship component between a patient and therapist that allows the patient to understand the therapist and the therapist to understand interpretations of the client’s experience.
Rogers (1951) is probably best known for emphasizing the therapist’s role in the relationship, leading to what we now know as client-centered therapy. The active components of a therapeutic relationship, according to Rogers (1951), are empathy, congruence, and unconditional positive regard.
We also know the therapeutic relationship as the therapeutic alliance, the helping alliance, and the working alliance, all referring to the relationship between a healthcare professional (counselor/therapist) and the client or patient.
It is the collaborative relationship between these two parties engaged in the common fight to overcome the patient’s suffering and self-destructive thoughts and behaviors, and effect beneficial change.
Research on the power of the therapeutic relationship has accumulated over 1,000 findings that include its ability to predict adherence, compliance, concordance, and outcomes across a wide range of diagnoses and treatment settings (Orlinsky, Ronnestad, & Willutski, 2004).
Therapeutic Relationship Model: 3 Components Explained
It is no secret that relationships affect personal healing.
The therapeutic alliance is a unique relationship; the interactions, bonds, and purpose play a role in a client’s healing, treatment progress, and outcome success.
Freud (1905) was the first to describe transference as the repetition of an old relationship. It occurs when feelings from an old significant object/event create feelings and impulses that are transferred onto the therapist.
Transference is not based on the actual relationship, but on unconscious and regressive distortions. A new conception of transference describes it as an interactive communication, where symmetry between the client and therapist is the true engine of treatment and change (Lingiardi, Holmquist, & Safran, 2016).
Simply stated, transference is the ‘transfer’ of feelings from old relationships onto the therapist. This can create space for reflection, healing, and learning healthier patterns of relating with others.
The working alliance is a component of the therapeutic relationship. It can be defined as the joining of a client’s reasonable side with the therapist’s analyzing side.
Bordin (1979) is famous for conceptualizing the working alliance in three parts: tasks, goals, and the bond.
- Tasks are the steps, methods, and techniques that need to be implemented to reach the clients goals.
- Goals are what the client wants to gain from therapy and depend on the presenting problem.
- The bond between the therapist and client is formed from trust and confidence that the selected tasks will move the client toward their goals.
The real relationship comprises the interpersonal attraction and compatibility that take place between the client and therapist.
Gelso (2011) has described the concept of the real relationship in therapy as having two parts: genuineness and realism.
Genuineness is the intent to avoid deception, including self-deception. The therapist must know themselves and present an accurate picture of who they are in the relationship.
Realism is experiencing the client in a way that benefits them. This idea of realism within the relationship encompasses both empathy and understanding.
4 Phases & Stages of the Alliance
The therapeutic alliance is dynamic in nature. A healthy alliance will include ruptures and repairs throughout the stages of therapy.
Luborsky (1976) distinguished two broad phases of the therapeutic alliance. The early stages of therapy are based on the client’s perception of the therapist’s support and empathy.
In later stages of therapy, a collaborative relationship develops to overcome or address the client’s problems. During this second phase, there is a shared responsibility in working toward goals.
Rivera (1992) has outlined four stages of the therapeutic relationship.
In the initial stage, the patient and therapist make an agreement to devote time and energy to achieve specific goals. In this stage, the perception of the therapist, intensity of client motivation, and compatibility of personality/experiences are important factors.
The Miracle Question Worksheet is a great way for the client and therapist to identify what goals they will work toward together. As the client writes out and draws their ideal life/world/emotional state, it enhances their ability to commit toward working for it. It further clarifies the client’s ideals for the therapist to achieve a common direction.
This is the most complex stage and is the body of treatment and the relationship. This is when the therapist searches for patterns, gathers information, and consolidates it.
The therapist will look for triggers, cycles, and repetitive interactions in the client. This stage is also when the therapist will gain additional information and seek to implement change.
Various therapeutic tasks, techniques, and approaches may be used in the process stage.
This stage represents a conclusion and success of the treatment plan. The client can accept their mental or emotional state and adopt habits to improve wellbeing.
During this stage, the client “graduates.” The therapist and client can recognize each other as autonomous and independent individuals.
By this stage, positive transference and regressive forms of dependence have been resolved. The client has been handed permission and rights to develop their life independently.
The Preventing Mental Health Relapse worksheet is a wonderful tool to implement in the termination stage of treatment. This worksheet highlights warning signs and triggers the client should be aware of as they leave treatment. It is also a great way for the client to take ownership of the work they have done in therapy and their future mental health.
4 Real-Life Examples
It is important to identify specific examples of the components and phases of therapy.
In the first stage of commitment, the client’s impression of the therapist is critical to deepening the relationship and moving to successful subsequent phases.
Below are examples of helpful practices therapists can implement to optimize the therapeutic process, and a harmful one to avoid.
Empathetic responses are key to establishing a strong therapeutic alliance in early stages of therapy.
Research has specifically monitored client response to treatment using “client feedback” as a measurement of the therapist’s level of empathy and the client’s rating of the therapeutic alliance, compliance, and retention in therapy. Therapists who exhibit the highest levels of empathy had the highest ratings of client feedback and client success (Duncan, 2010).
Empathetic responses reflect both the content of what the client is saying and how the client feels about it. Here is an example of such a discussion.
Therapist: So what is it you are experiencing?
Client: I have a lot of anxiety about school.
Therapist: Can you explain more?
Client: My parents are always nagging me about my grades, and they are never good enough.
Therapist: I hear you saying that your parents nagging you about your grades never being good enough makes you anxious about school?
Client: Yes, exactly. It is so hard.
In the process stage of therapy, transference and countertransference become important aspects of the therapeutic alliance.
Transference occurs in therapy when the client projects feelings they have (or are experiencing for another person in their life) onto the therapist. In this example, the client is projecting the anger they have toward their parents onto the therapist.
Therapist: You mentioned that you were hurt by your father at a young age.
Client: That’s not what I said! You never listen to me or hear me right. You are just like my parents, misinterpreting everything I say.
This video provides another clear example of how transference plays out by looking at past relationships and current actions.
Transference can occur in any relationship, but therapists need to be acutely aware of when it happens in a session to create a healthy relationship (Shimokawa, Lambert, & Smart, 2010).
When therapists can identify transference and create healthier responses, it strengthens the therapeutic alliance and teaches clients healthier ways of interacting with others.
Countertransference is when the therapist projects their feelings onto the client. This can be detrimental to the therapeutic alliance and the client’s progress. Awareness of countertransference is an important part of the process and professional growth of the therapist.
In the following example, the therapist is offering advice rather than listening to the client, offering space, and creating an atmosphere to find their own solutions or process emotions.
Client: My husband expects me to work full time and still keep up with all the housework. I just can’t do it all, it feels impossible, and he is so demanding.
Therapist: Why don’t you hire a maid to do the housework? You both make enough money to afford it.
Other areas of countertransference include therapist attraction to the client or becoming over- or under-involved in the situation.
An example of under-involvement might occur if a client was sexually assaulted, and the therapist blames the victim. Rather than hearing the client, the therapist identifies with the perpetrator and discourages the client from pressing charges. This example would qualify as negative countertransference (Jorgenson, 1995).
This short video of “Jane” and “John” demonstrates the obstacles many new counselors face in establishing a solid therapeutic alliance during the first session or in the early stages of therapy.
A Look at Healthy Boundaries in Therapy
While emphasizing the importance of the therapeutic relationship, it is important to address the issue of boundaries in professional relationships. Setting healthy boundaries at the beginning of therapy is a way to set up a healthy therapeutic environment, which leads to effective therapy.
Healthy boundaries include appropriate self-disclosure to establish trust and a connection with the client (Zur, 2018). Self-disclosure can help clients feel accepted and can normalize their situation.
Rules and rituals are other ways to establish healthy boundaries (Zur, 2018).
Rules give a client parameters within a session to have the freedom to explore themselves, their thoughts, and their emotions. Rules may include limiting cell phone use or not allowing derogatory or negative language.
Rituals help provide stability and consistency for the client from session to session. They can be created in collaboration with the client. A ritual might include doing a mindfulness exercise to begin each session or ending the session with a final thought or a word of gratitude.
Boundary violations are always unethical, usually illegal, and occur when a therapist crosses the line of integrity, using power to exploit the client (Lazarus & Zur, 2002).
However, when therapists cross boundaries with the client’s welfare in mind, it is likely to enhance the therapeutic alliance. It can be an effective part of establishing, maintaining, and repairing the valuable therapeutic relationship.
The following are examples of beneficial boundary crossing, and none constitute a “dual relationship” (an unethical relationship):
- Walking with a client in an open space outside the office to fly a kite to overcome a fear of kites
- Appropriate self-disclosure to provide an alternative perspective, create authentic connections, or level the playing field
- Attending a client’s performance to show support for their hobby or passions
- Joining an addict for their first 12-step meeting
“Boundaries are like fences; they are manmade and are designed to separate. Being manmade, they can be constructed or dismantled, heightened or lowered, and made more or less permeable.”
(Zur, 2018, p. 29)
Crossing boundaries should be approached with two things in mind: the welfare of the client and the goal/effectiveness of the technique. It should be part of a well-designed treatment plan that considers the individual client’s presenting problem, personality, environment, culture, history, and the therapeutic setting/context.
In this article, we share more interventions for using mindfulness in counseling.
Therapeutic Relationships vs Social Relationships
The difference between the therapeutic relationship and a nonprofessional social relationship can be highlighted in this definition of psychotherapy:
“A purposeful and willing relationship between at least two people, one who is supposed to know what he is doing, to the other who wants help to change his life for the better.”
(Rivera, 1992, p. 52)
This definition emphasizes that therapy is a relationship with a distinct purpose. It is not accidental, and there are goals set forth within the duration of the relationship. It is a willing and formal relationship that requires consent and a commitment to work toward the agreed-upon goals.
Ideally, the therapeutic relationship has a clear starting point and ending point. It progresses through the four stages outlined above: commitment, process, change, and termination.
There is a clear power dynamic within the therapeutic relationship, which is why ethics, boundaries, and dual relationships are a crucial part of psychotherapy training and certification.
The therapist is in a position of power because they have professional skills and abilities. The therapist is aware of the techniques and interventions required for change and can interpret data presented by the client.
It is a one-sided relationship, in that the therapist is serving the needs of the client with no emotional/mental reciprocation.
PositivePsychology.com’s Relevant Resources
Our Positive Psychology Toolkit© provides a wealth of resources for therapists that are relevant for every stage of the therapeutic process.
Whether the client must work on communication, emotional regulation, setting boundaries, self-reflection, coping, resilience, relationships, or self-acceptance, our extensive database of worksheets, assessments, and interventions can be tailored to any therapeutic process or relationship.
Here are three worksheets that are especially beneficial:
- Assess Barriers to an Accepting Attitude
Therapists can use this sheet to reflect on what thoughts and beliefs may be holding them back from a more accepting attitude. This worksheet can be used after individual therapy sessions or at the end of the day.
- What is your Validating Style?
This tool can also be an effective tool for therapists to use with their clients. It provides a helpful way to practice and verify professional validation skills in any situation.
- Understanding Context and Differences
Without realizing, the therapist may be letting contextual and client-therapist differences cloud their judgment, preventing empathy and understanding from growing and being communicated. This tool can be used to review a session and interaction with a client to see if there was any bias that could harm the therapeutic alliance.
17 Positive Psychology Exercises – If you’re looking for more science-based ways to help others enhance their wellbeing, this signature collection contains 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.
A Take-Home Message
Time and time again, clients and practitioners see that education, skillsets, certifications, degrees, techniques, and types of therapeutic approach matter very little without a strong therapeutic relationship.
Yet a therapeutic relationship is something that cannot be explicitly taught.
Through understanding, experience, practice, and self-reflection, therapists can work to master the therapeutic alliance and the stages of the therapeutic process. It is worth investing time and energy to foster these important relational skills to improve both personal and professional life.
Establishing a meaningful relationship is possible through quality communication skills, empathy, openness, genuineness, and the ability to collaborate with a client’s goals and desires (Horvath, 2001).
The therapeutic relationship is one of intimacy and strength. It is different for every client, a balance between hard and soft, give and take. It is a relationship that provides space for reflection and healing, and it is a therapist’s greatest tool to elicit positive change in the lives of others.
We hope you enjoyed reading this article. Don’t forget to download our three Positive Relationships Exercises for free.
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