Establishing the Therapeutic Alliance with Clients in Counseling

When Counselors are earning their degrees, a significant amount of time is spent exploring various therapeutic approaches and their benefits in therapy. One of the most significant skills that Counselors can develop is their ability to build rapport with clients in therapy. Keep reading how to build the therapeutic alliance with clients in counseling.

Carl Rogers’ work exemplifies the importance of establishing a therapeutic relationship in counseling. Carl Rogers identified three active components of the therapeutic relationship; empathy, congruence, and unconditional positive guard. Ideally, these three characteristics would be present in a counseling relationship for individuals using Person-Centered Therapy.

Since the 1950s, research has been providing us with valuable information regarding the importance of the client and counselor relationship in regard to clients’ outcomes. This research has helped counselors, including Carl Rogers, understand and guide future clinicians in their work. 

Why is the Therapeutic Alliance Important?

Luborsky’s research findings proposed two main phases for the development of the counseling relationship in 1976 (Arditio, R.B. & Rabellino, D., 2011).   The early phase of the counseling relationship focuses on the client feel supported within the counseling relationship, while the later phase includes collaboration between the counselor and client to address the client’s current concerns and challenges  (Arditio, R.B. & Rabellino, D., 2011).  This research supports the notion that the early stages of the therapeutic alliance have a significant impact on the client’s overall experience in counseling.

A study by Gibbons et. al published in 2019 investigated the prevalence of clients who terminate counseling early. This study found that approximately 27% of participants who were receiving Dynamic Psychotherapy and Cognitive Therapies discontinued therapy before their goals were met (Gibbons,M.B.C., et.al, 2019). 70% of the participants who discontinued therapy early did so after 1-2 sessions (Gibbons, M.B.C., et.al, 2019). The study conducted by Gibbons et. al identified several potential predictors of early discharge including treatment expectations and perceptions, clients’ baseline functioning, their treatment history, and the early stages of treatment. 

What are Some Barriers That Can Impact the Therapeutic Alliance?

There are many reasons why a Counselor can experience difficulties in establishing a therapeutic alliance. Common barriers that clients can experience within the therapeutic experience include:

  • Clients who find that they don’t feel comfortable within your space may hold back in sessions. This could be because of aesthetics, the attitudes given off by staff, or even the office’s temperature. While some of these factors can easily be adjusted, it is important to be mindful of what your clients experience from the time they enter your building, to the time they sit down in your office space.
  • Clients may be worried or fearful of being judged.  This is often tied to their previous experiences, including talking to others in their life and previous counseling experiences. The social stigma associated with various mental health and life circumstances may also be a contributing factor.
  • Having a negative counseling experience beforehand. Many times, when we think of new clients, we think of individuals who have no previous counseling experiences. The reality, however, is that many of the individuals we work with do have previous mental health treatment experiences. This can include crisis interventions, psychotherapy, and working with a prescriber for their medication needs. Whatever your client’s previous experience was, this can have an impact on their perception and expectations of their counseling experience.
  • Struggling with motivation can also act as a barrier to developing the therapeutic alliance. This would be more prevalent with individuals who are in treatment at the request of others including the legal system, family, and work. It is possible to begin developing a therapeutic alliance with an external motivation source, and you can work towards finding internal motivation through the use of various treatment modalities.
  • Mental health concerns can have a direct impact on the therapeutic alliance. As an example, clients who are struggling with paranoia, or isolation behaviors, may have a hard time developing a healthy connection with a counselor. Additionally, clients may “be on the fence” in regards to feeling as though their current struggles warrant the need for mental health counseling.
  • If a client feels as though their counselor is struggling with their own concerns, such as anxiety, distractions, and stress, the client may not be inclined to open up due to worry about burdening the counselor. Additionally, clients who do not feel included in the development of their treatment plan and goals may not feel connected or heard by their counselor.
  • Financial concerns can be an additional barrier that clients experience. Individuals who worry about being able to afford their copay may find themselves holding back and not being as vulnerable in session as they would be if they were not concerned about being able to afford counseling for the appropriate duration. 

How to Build Trust with Clients in Counseling

When counselors are working to establish a therapeutic relationship in counseling, there are things that can be done to encourage this process. It is important to recognize the individual differences that we will see among our clients in regard to developing a trusting relationship. For clients who have struggled to have healthy, trusting relationships in the past, it may take longer to develop rapport. Examples of what counselors can do to enhance the therapeutic alliance include:

  • Following Carl Rogers framework and showing empathy, unconditional positive regard, and congruence can help establish the foundation for the therapeutic alliance. This can help clients who are worried about being judged, and those who have had negative experiences in counseling.
  • Effective communication skills can go a long way in facilitating the therapeutic relationship. Communication skills can help us discuss the roles that both the counselor and client have, explaining what they can expect from counseling, establishing boundaries, and understanding the various consents and forms completed which can aid in the development of the client’s treatment plan and goals.
  • Active listening skills can help clients feel as though what they say matters, and that they are being heard. Active listening skills can also be used to clarify details that may be confusing for the counselor.
  • Providing a welcoming environment can help clients feel comfortable within the counseling space. This should include any waiting areas, counseling rooms, and other areas that the clients have access to. An example of this would be to have different seating options within your office so that your client has the opportunity to position themselves in your space that feels comfortable to them.
  • Taking care of ourselves and our own needs allows us to provide the best possible care. Ensuring that we are engaging in regular self-care can aid in managing our own stressors and challenges. Participating in supervision regularly can help us feel connected and supported within our working environment which can also have a positive impact on our work. An important part of taking care of ourselves is being mindful of our limitations. This can include the size of our caseloads, as well as the specific cases we take. Ensuring that we have the proper training and experience is vital to providing quality care for our clients.
  • Collaborating with clients means that, together, we develop treatment plans and goals. This can also help us explore our client’s expectations and perceptions of counseling to ensure that we are all on the same page.
  • Being consistent in our behaviors and reactions can promote trust and accountability within counseling relationships. This can begin by having a consistent appointment time and responding to the client’s calls or emails in a timely manner. Following through with what we say we are going to do, such as checking in on homework assignments, can also promote trust.
  • If you have the opportunity, it can be helpful to prepare for your session. This can include reviewing previous session notes, getting assessment or intervention materials ready, or simply engaging in some mindfulness practices to prepare ourselves to sit with our client. Doing this can help you feel relaxed and prepared during your session. 

Final Thoughts on Building the Therapeutic Alliance with Clients in Counseling

Developing trust with our clients is a vital component of what we do as counselors. Research has shown that a strong therapeutic alliance can predict treatment outcomes for our clients (Gibbons, M.B.C., et. al,2019). More specifically, the therapeutic alliance is responsible for an estimated 5% of the treatment outcome (Gibbons, M.B.C., et. al,2019).

Developing the therapeutic alliance begins to feel natural as we gain more experience doing this. During the course of your career, you may work in different counseling settings that have different needs for developing a healthy relationship with your clients. Acting as a natural self can make aspects of this, such as being consistent, and simple. By being ourselves with clients, we are modeling to them what it looks like to sit in a room as our authentic selves. This is often necessary for clients to be vulnerable and open during sessions.

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References:

Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy historical excursus, measurements, and prospects for research. Frontiers in psychology, 2, 270. https://doi.org/10.3389/fpsyg.2011.00270

Gibbons, M. B. C., Gallop, R., Thompson, D., Gaines, A., Rieger, A., & Crits-Christoph, P. (2019). Predictors of treatment attendance in cognitive and dynamic therapies for major depressive disorder delivered in a community mental health setting. Journal of consulting and clinical psychology, 87(8), 745–755. https://doi.org/10.1037/ccp0000414

Kayla VanGuilder, MA, LCMHC
Author: Kayla VanGuilder, MA, LCMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.

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