What is the therapeutic relationship and the therapeutic alliance?

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Jonah Lester
What is the therapeutic relationship and the therapeutic alliance?

Undoubtedly, the relationship established between the therapist and the client is an essential element in psychotherapy. Some authors even go so far as to affirm that "it is the relationship that cures".

It must be understood that therapist and client work together within the framework of a well-understood therapeutic relationship to achieve improvement and / or change in the patient. The therapeutic relationship is not the same as friendship or any other type of interpersonal relationship that the client may have.

An adequate therapeutic relationship has some characteristics that make it unique and distinguish it, which we will describe below..

Contents

  • Characteristics of the therapeutic relationship
    • Asymmetry
    • The therapeutic setting
  • The therapeutic alliance

Characteristics of the therapeutic relationship

Asymmetry

The therapeutic relationship focuses on the problems and needs of the client based on their demand. For the therapist it is a regulated professional activity.

The therapeutic setting

The term therapeutic framing designates the set of rules that allow psychotherapy to be made viable. These are both external and internal elements (attitudes of the therapist).

  • The external therapeutic setting includes the following aspects: place where the therapy is carried out, duration and frequency of the sessions, fees, etc. On the other hand, it is highly recommended that the therapist does not maintain any other type of relationship (personal, commercial or professional) with the client outside of the therapeutic sessions. This includes not dealing with family members or friends, with whom you already have a previous relationship..
  • The internal therapeutic setting refers to the therapist's attitudes necessary for a relationship that favors the process of change. The various theoretical models (psychoanalytic, behavioral, cognitive, experiential and systemic) present some differences as to which therapist attitudes are appropriate according to the different conceptions of the therapeutic relationship. These characteristics are briefly presented in the following table:
ModelsTherapeutic relationshipTherapeutic attitude
Psychoanalytic Main healing element: allows insight into the client through the transference relationship.Reserved, passive and detached.
BehavioralFramework in which the client's learning processes are developed and behavioral techniques are implemented.Safe, acts as a model and social enhancer.
CognitiveCooperative relationship, a mutual collaborative effort to solve the client's problem.Active and logical.
ExperientialEnabling context for personal developmentAuthentic, empathetic, warm, unconditional customer acceptance.
SystemicThe vision of the therapeutic relationship stands out from the other models, since "the system" and its circular causality come into play. The therapist and his team join the family system in order to alter the patterns of interaction, but at the risk of becoming part of its dynamics.Participant observer.

The therapeutic alliance

Bordin (1979) proposes the concept of therapeutic alliance as an indispensable element in psychotherapy. It has its origin in the psychoanalytic model, but today it has become a common concept to all theoretical models. It refers to three interrelated components: the therapist-client bond, the goals and tasks of therapy.

  • The bond between therapist and client determines "the emotional tone of the experience that the client has of the therapist" (Feixas and Miró, 1993). In other words, the therapeutic process is intensely influenced by the bond established between therapist and client, a bond that originates from the impressions that the therapist arouses (the person living as a warm or understanding person, or cold or scrutinizing or distant).
  • The goals of the therapist and client must be in line to establish a good therapeutic alliance. Sometimes the client is interested only in solving the symptom, while the therapist tries to analyze the problem in depth or treat the causes; but, on the other hand, it can also happen the other way around. It is essential that the therapist and the client agree on the goals to be achieved in therapy.

An example of a low agreement on the objectives can be when the client wants to solve his fear of speaking in public, but the therapist considers that the origin of his anxiety related to childhood intrapsychic conflicts and defense mechanisms should be treated..

  • The tasks to be carried out in therapy are another factor that therapist and client must agree on. Often, the client has expectations about therapy that are far from reality (or what the therapist wants to do), such as the notion that things will change just by attending therapy sessions . Not only must the tasks be appropriate to the client and their problem, but the client also has to understand what he has to do and why he does it since, after all, he is his own agent of change..

Examples of disagreement about tasks may be that the therapist wants to use records as homework, between sessions, and the client thinks that the same dialogue from the therapy session is sufficient. Another example would be the case of a client who believes that the therapist has to give him practical advice strictly related to the problem and the therapist asks questions about the family context in which the patient lives.

Over time, these notions have received empirical support and are widely accepted. As Semerari (2002) says, "the alliance will be perfect when the therapist and the patient share the objectives of the treatment and agree on the need and usefulness of the means adapted to achieve it […]". If we also add a good quality of bond between therapist and client, we are in the best conditions to predict a favorable outcome of psychotherapy.


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