How to establish a therapeutic relationship in counselling

A solid therapeutic relationship is vital for clients to get the most out of therapy and remain in treatment (DeAngelis, 2019).

It’s as powerful, if not more so, than the treatment chosen by the therapist (DeAngelis, 2019).

Because we can use the quality of the therapeutic relationship to predict clinical outcomes, it’s essential to get the alliance right (Ardito & Rabellino, 2011).

This article explores the skills and techniques that therapists need to build a healthy therapeutic alliance and successful outcome.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free. These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

How to Establish a Healthy Therapeutic Alliance

All therapists require a depth of relating with their clients. In Cognitive-Behavioral Therapy (CBT), this may be described as a close relationship, while for person-centered and experiential therapy, it is considered core to the treatment (Knox & Cooper, 2015).

Even though the therapeutic alliance may vary over the course of therapy, its quality impacts the successful outcome of treatment and, therefore, deserves special attention (Ardito & Rabellino, 2011).

The degree to which the alliance is correlated with the therapeutic outcome is clear; its growth is linked to the successful resolution of ruptures, breaches, and repairs (Ardito & Rabellino, 2011).

There are two clear phases in establishing a healthy therapeutic alliance (Ardito & Rabellino, 2011):

First phase:
The alliance develops in the first five sessions of short-term therapy, peaking around the third. Typically, during this phase, collaboration and mutuality are fostered, goals are agreed upon, and the client develops confidence in the therapist and therapeutic process.
Second phase:
During this phase, “the therapist begins to challenge the patient’s dysfunctional thoughts, affects, and behavior patterns, with the intent of changing them” (Ardito & Rabellino, 2011). Such interventions can lead the client to feel reduced empathy and a lack of support from the therapist, temporarily weakening or damaging the relationship.

Early on in therapy, a rupture to the therapeutic relationship can affect commitment to the process, potentially leading to early termination. As long as it is repaired and resolved quickly, conflict may be positive and even necessary to a successful outcome (Ardito & Rabellino, 2011).

So how do we establish a healthy therapeutic alliance?

The therapist must begin the relationship by considering the therapeutic frame and boundaries they want to put in place (Knox & Cooper, 2015).

“The therapeutic frame refers to the fixed elements of the therapeutic relationship that provide the context for the therapeutic work” (Knox & Cooper, 2015, p. 1). The boundaries define the rules and limits to the relationship from the outset and ensure a safe, supportive, and contained environment for work to take place.

The setting in which counseling takes place is vital. While it will vary depending on the context in which the client is seen, points to consider include the following (Knox & Cooper, 2015):

Therapy rooms should be calm, quiet, and clear of clutter.
Chairs should be similar and comfortable.
Lighting should neither be harsh nor so soft that it appears romantic.
A comfortable temperature should be maintained.

Ultimately, the location should feel safe and secure, a place where the client can talk openly without being overheard or interrupted. If the therapy space is located within the therapist’s home, it is vital to consider the visibility of personal items and their potential impact. For example, family pictures may be upsetting if the client discusses losing a loved one (Knox & Cooper, 2015).

The timing for the therapeutic work should be agreed upon and set early in the process. Consider the following questions with the client (modified from Knox & Cooper, 2015):

How many sessions?
If a workplace has arranged the sessions, the organization may decide how many and how long they continue. Otherwise, it is typical for private clients to agree to review progress after a set period, perhaps four to six weeks.
How long should sessions be?
Typically, sessions last between 50 and 60 minutes. This allows time to dig sufficiently deeply into issues and prevents the client from becoming exhausted. Consistency can be helpful.

Clients need to become comfortable and familiar with the process, and knowing the time remaining in a session can influence the degree to which they open up.

How often should I meet my clients?
While sessions are often weekly, some client treatments may require more frequent meetings. Factors to consider include costs, context, therapeutic approach, approaching the end of therapy, and the need for ongoing support.
External contact
Communication outside of sessions is often best kept to a minimum. The therapist may limit contact to administrative matters, such as rescheduling or canceling appointments. However, there may be exceptions, so it is vital to convey a warm, caring attitude and agree early in therapy.

Social media can bring other issues and challenges, and it is advisable to keep therapeutic relationships separate from social ones (Knox & Cooper, 2015).

Putting in place the practices above and ensuring that the following softer components are addressed can lead to a healthier and more productive therapeutic alliance.

Components of the Therapeutic Relationship

There are several crucial factors and components to building and maintaining a therapeutic relationship.

While not exhaustive, the following sections introduce key features of therapy that require focus and, often, ongoing attention.

While the idea of confidentiality may seem straightforward, it can be complicated. At the beginning of the therapeutic journey, it is vital to explain to clients that the relationship is confidential. The only circumstances where the counselor may break it are when the client or someone else discussed is at risk of serious harm or death (Knox & Cooper, 2015).
Therapists have come to recognize, especially over recent decades, that successful treatment relies on mutuality and collaboration. Forming an equal partnership between clients and therapists involves a commitment to a two-way relationship, “working together to define and actualize therapy goals, including the direction the therapy is taking” (DeAngelis, 2019).
Client feedback lets the therapist know what works well and what does not. Allowing the client to provide input into the therapeutic process and relationship supports client agency and ensures both are working together in the same direction (Knox & Cooper, 2015).

Then, of course, feedback must be put into action, with therapists improving their skills, managing their mistakes, and trying new or alternative interventions (DeAngelis, 2019).

When therapeutic relations break down, ruptures must be repaired. They typically occur when the client withdraws or is confrontational, including verbal and nonverbal expressions of frustration or anger (DeAngelis, 2019).

Such distancing behavior may result from a lack of trust or the client feeling judged or misunderstood. If the therapist senses the start of a breakdown or a strain in the relationship, they must not let it grow but clarify any issues and repair mistakes (Knox & Cooper, 2015).

“Empathic listening is often said to be at the heart of a facilitative relationship” and a vital predictor of therapeutic success (Knox & Cooper, 2015, p. 40). The client must be given the therapist’s full attention and listened to with empathy.

Empathic listening requires that the counselor experience the client’s feelings as though they were their own; such active listening is more intense than typically found in our daily lives.

Research suggests that warmth and caring in therapy are critical factors in a solid therapeutic relationship. The client must feel that their lives and problems are essential to the therapist and that they care. Sometimes this is as simple as seeing a natural, unprompted human response to what they say (Knox & Cooper, 2015).

A strong, authentic therapeutic relationship can facilitate a positive and deep connection between the therapist and client that will benefit the treatment and outcome (Knox & Cooper, 2015).

2 Examples of a Supportive Therapeutic Alliance

A supportive therapeutic alliance is crucial to client perseverance and a positive treatment outcome (Ardito & Rabellino, 2011).

The following two examples taken from case reports provide examples of the results of healthy therapeutic relationships between the client and therapist.

Psychodynamic therapy

Having been married for 29 years, ‘Wendy’ was shocked to be told by her husband that he wanted a divorce (Tamplin, 2014). Unable to cope with constant crying and feelings of extreme anxiousness, Wendy sought help.

Wendy attended 18 therapy appointments over 8 months to help her cope.

From the outset, her therapist, ‘C,’ encouraged Wendy to express her feelings as much and as often as possible regarding the sudden and drastic life changes. Wendy found support in the empathy and understanding that her relationship with C fostered (Tamplin, 2014).

C asked Wendy to think of the things she had wanted but had previously sacrificed for the sake of her marriage. With the support of their alliance, Wendy ultimately found the courage to move forward and live her life as though her husband wasn’t returning.

Obsessive-Compulsive Disorder

‘Darcy’ and her psychologist, ‘Marian,’ had a particularly strong therapeutic alliance that got them through 12 years of treating Darcy for obsessive-compulsive disorder (Australian Institute of Professional Counsellors, 2013).

Following decades of compulsive behavior that included elaborate prayer routines to keep everyone safe, Darcy had sought treatment.

Marian felt and displayed enormous compassion for Darcy. She began by working with her to achieve emotional stability before starting a long-term process of changing her thinking habits. Over the years, Darcy discontinued all medication and ultimately married a “wonderful” man with whom she had a daughter. “Marian felt blessed to have had Darcy as a client” (Australian Institute of Professional Counsellors, 2013).

10 Skills of Effective Therapists

International research about what makes a great therapist explored what such professionals were doing, thinking, and feeling when they were at their most effective (Novotney, 2013).

Results suggest that effective therapists have sophisticated interpersonal skills, including (Novotney, 2013):

Verbal fluency
Warmth
Acceptance
Empathy

And they are highly capable of:

Identifying how a person is feeling
Forming strong therapeutic alliances with a range of patients
Helping clients accept treatment and engaging in positive work with them
Being highly tuned to patient progress
Taking the actions needed to address issues that impede progress
Choosing the right treatments for specific client problems

Identifying these characteristics of effective counselors is crucial to providing the best training for healthy therapeutic alliances.

3 Helpful Techniques for Counselors

There are several techniques that counselors can adopt to improve the therapeutic relationship.

Create a therapeutic bond

Creating a bond requires building warmth and trust within the relationship. The client should feel heard, supported, and able to connect deeply with the therapist when needed (Knox & Cooper, 2015).

While the counselor cannot always change whether the client sees them as the right person to work with, there are some techniques that can help them foster client trust (modified from Knox & Cooper, 2015):

Create an atmosphere that is friendly, warm, and welcoming.
Remain sensitive to why the client has sought help.
Maintain consistency in the approach.
Maintaining reliability is vital to gaining and maintaining trust.
Form boundaries and maintain confidentiality.
Do not judge.

There is no single recipe that works for all clients, but an ongoing awareness of client needs will improve trust conditions.

Ask for feedback

Sometimes the best way to find out what is working and what needs to change is to ask. At the end of each session, consider asking your client the following questions (modified from Knox & Cooper, 2015).

What did you find helpful today?
What worked well for you today?
What did not work so well today?
Was anything in this session particularly unhelpful or annoying?
What would you like to see more or less of in future sessions?

Prepare for empathy

Empathy is one of the most important aspects of being a good therapist and developing successful alliances.

Some techniques can help you prepare for empathic listening, including (modified from Knox & Cooper, 2015):

Practice putting aside judgments in your everyday conversations with friends, families, and strangers.
Explore issues that make you uncomfortable. As your understanding grows, consider whether your feelings and opinions have changed.
Be ready to say ‘no’ if you feel unable to work with a particular client.
Discuss with a colleague or supervisor any feelings you need to sideline to be successful with a client.

6 Communication Tips

When the therapeutic alliance appears to fail, it is worthwhile considering your approach to communication (Knox & Cooper, 2015).

Reflect on your skills and ability to relate in depth.
Consider how you personally disconnect (or appear to) from others or actively prevent connection with others.
Does your theoretical approach impact how you relate to the client?
When you have experienced deep connections with clients in the past, what were you doing to facilitate the experience? What qualities were you using or displaying?
Having reflected on your abilities to relate in depth, consider what you could do to develop these skills further.
How might you relate in depth to someone with communication difficulties? How might you adapt your style?

Reflect on your answers to these questions and consider how you can improve your ability to build rapport with your clients.

Assessing Your Relationship: 2 Questionnaires & Scales

Client feedback can help therapists recognize psychological distress and improvements to wellbeing (Knox & Cooper, 2015).

The Outcome Questionnaire-45.2 is a 45-question instrument valuable for collecting feedback before each therapy session and assessing psychological symptoms. Results help counselors identify clients likely to drop out of therapy, assisting them in tailoring future treatments (DeAngelis, 2019).

The Penn Helping Alliance Scales measure how supportive the therapist is perceived to be and the degree of therapeutic collaboration (Ardito & Rabellino, 2011).

Rita Ardito and Daniela Rabellino (2011) from the Department of Psychology at the University of Turin offer a complete review of questionnaires and scales for scoring the therapeutic alliance.

PositivePsychology.com’s Relevant Resources

For even more resources to help strengthen the therapeutic relationship between you and your clients, check out the following free worksheets and exercises.

The EQ 5 Point Tool
This tool can help you or your clients defuse conflict in an emotionally intelligent way using brief, respectful, and clear communication.
What is Your Validating Style
This worksheet offers a useful list of different validating statements (and reflections) you or your clients can use to reduce judgment and increase empathy.
Problem-Solving Self-Monitoring Form
This worksheet helps therapists gain a basic understanding of their clients’ presenting problems and actions they’ve taken so far to attempt to resolve them.
Toxic Behaviors in Therapy
This self-evaluation helps therapists and clients identify and prevent behaviors that threaten to damage the therapeutic relationship.
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

Research confirms the importance of the link between healthy therapeutic relationships and positive treatment outcomes. The quality of the alliance appears even more crucial than the type of intervention or therapeutic model employed (Ardito & Rabellino, 2011).

Indeed, “a good relationship is essential to helping the client connect with, remain in, and get the most from therapy” (DeAngelis, 2019).

Setting up a calm and safe environment and ensuring empathy, confidentiality, warmth, and caring help build and maintain a healthy relationship between the client and therapist. Furthermore, through adequate preparation, feedback, and reflection, mistakes can be managed and a rupture to the therapeutic process overcome.

Therefore, it remains vital that soft skills that build the therapeutic relationship receive the attention needed and are tailored according to clients’ needs. As therapists and counselors, we must continue to seek training, supervision, and feedback to identify further growth and development opportunities.

Why not use this article and awareness of your strengths and weaknesses to reflect upon how you can develop your skills? Use the learnings to put in place robust and healthy relationships with your clients and increase the potential for a successful treatment outcome.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.

References

Ardito, R. B., & Rabellino, D. (2011, October 18). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2. Retrieved July 6, 2021, from https://www.frontiersin.org/articles/10.3389/fpsyg.2011.00270/full
Australian Institute of Professional Counsellors. (2013, June 7). Case study: Obsessive-compulsive disorder. Retrieved June 18, 2021, from https://www.aipc.net.au/articles/case-study-obsessive-compulsive-disorder/
DeAngelis, T. (2019, November 1). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10), 38. Retrieved May 11, 2021, from https://www.apa.org/monitor/2019/11/ce-corner-relationships
Knox, R., & Cooper, M. (2015). The therapeutic relationship in counselling and psychotherapy. SAGE.
Novotney, A. (2013). The therapist effect. Monitor on Psychology, 44(2), 48. Retrieved June 18, 2021, from https://www.apa.org/monitor/2013/02/therapist
Tamplin, L. (2014, November 27). A case using brief psychodynamic therapy. Australian Institute of Professional Counsellors. Retrieved June 18, 2021, from https://www.aipc.net.au/articles/a-case-using-brief-psychodynamic-therapy/