As a therapist, you’re probably aware of the impact your relationship with your client can have on the outcome of their treatment. But just how important is it? And how do you measure and improve your client-clinician relationship?
To put it simply, therapeutic alliance is the bond between a therapist and their client.
Research shows that the client-clinician relationship (AKA therapeutic alliance), is the most important predictor of positive outcomes in treatment1. The concept has been researched and theorized for years— starting with Freud in 1912— when it was recognized that consistent, measurable factors of this relationship play a significant role in the effectiveness of therapeutic practice, regardless of the approach2,3,4.
Measuring therapeutic alliance is one of the most reliable ways to determine the strength of this bond, and it allows the therapist to identify how comfortable their client might be in sharing their thoughts, experiences, struggles and goals with them throughout care.
So let’s start with that: How do you measure therapeutic alliance?
Measuring Therapeutic Alliance
Throughout the years, there have been many validated measures created to help clinicians monitor therapeutic alliance, including the California Psychotherapy Alliance Scales (CALPAS), Helping Alliance Questionnaire (HAQ), Counselor Rating Form (CRF), Therapeutic Bond Scale, Working Alliance Inventory (WAI), Brief-Revised Working Alliance Inventory (BR-WAI), Vanderbilt Therapeutic Alliance Scale (VPPS), The Session Rating Scale (SRS), the Agnew Relationship Measure (ARM), and Therapeutic Alliance for Youth and Caregivers (TASC).
Despite their varied approaches, these assessments all look at three core components of the therapeutic relationship:
- The bond between client and therapist;
- The collaborative approach and agreement on treatment goals;
- The collaborative approach and agreement on treatment tasks.
All Greenspace partner clinics have access to several assessments which help to measure therapeutic alliance. The Brief-Revised Working Alliance Inventory (BR-WAI) is one of those assessments and it is one of the most frequently used assessments on Greenspace, with over 100k completed assessments. The BR-WAI is based off the original Working Alliance Inventory (WAI), which is heavily used within clinical studies and research. In fact, since it was published, the WAI has become the second most cited article in the Journal of Counseling Psychology and has been used in more outcome studies than the CALPAS, VPPS, HAQ combined5.
The BR-WAI is often viewed as more practical in the therapeutic setting, where the brevity of the assessment helps to engage clients and ensure completion, while still addressing the most important aspects of the therapeutic relationship. The BR-WAI can also be more accurate in demonstrating a change in therapeutic alliance, due to the 5-point likert scale used to gather client response instead of the 7-point scale in the WAI5.
While there’s no true consensus surrounding one particular measure, the important part is ensuring the assessment you choose is providing the insight that you—and your client—find valuable in practice. Understanding the bond you have with your clients is the first step towards strengthening that bond, which is a core component of positive treatment outcomes.
Why is a Strong Therapeutic Alliance Important?
Through the process of measuring therapeutic alliance with your clients, you can begin to understand and improve a vital channel of communication that helps clients feel comfortable sharing their thoughts, feelings and behaviours and allows you to work collaboratively in care. In doing so, you’ll see many other benefits:
Increased Trust and Comfort
At it’s core, therapy is vulnerable. In order for clients to open up and share their experiences with their therapist, they need to feel that they’re in a safe environment with someone that they can trust. Clients who have a strong therapeutic alliance with their therapist are more likely to feel comfortable, allowing them to be more open and honest through treatment6,7.
Increased Patient Self-Awareness and Motivation
A strong therapeutic alliance can help patients become more self-aware and understand their problems more deeply7. It promotes self-exploration, where clients are encouraged to dive deep into their thoughts, feelings, and motivations. This process can help clients gain insight into their symptoms and empower them to work together with their therapist to develop the skills needed to improve symptoms, take ownership over their mental health, develop effective coping skills, and build resilience, all of which is beneficial in managing current and future stressors6.
Better Understanding of Your Client
As a therapist, your goal is to develop a deep understanding of your client so you can best support them throughout treatment. A major part of this is to understand how they perceive your relationship and are responding to sessions. Not only does this allow you to gain insight into their ability to trust and openly share their experiences, it also allows you to better identify their needs and provide a tailored approach to treatment.
Collaborative Approach to Treatment
Therapy should be a collaborative process. In order to most effectively target the goals of the client, you need to ensure you’re on the same page about what you’re working towards and how you’re going to get there, while creating that open channel of communication from the start.
Increased Client Satisfaction
When clients feel that their therapist understands them and their needs, they report a greater satisfaction with treatment6,8. Knowing that you are aligned with the provider who is working with you toward your mental health goals increases comfort in treatment and the likelihood of clients reaching their goals.
Reduced Drop-Out Rates
Studies have also found that a strong therapeutic alliance is associated with decreased drop-out rates8,9. When clients feel a strong attachment to their therapist, it increases the likelihood of continued engagement in therapy, as clients are more likely to return for subsequent sessions.
Improved Treatment Outcomes
Research has shown that a strong therapeutic alliance is associated with better outcomes in psychotherapy across a variety of disorders6,7,8,9. It’s clear that if you and your client are aligned on your goals, have a strong working relationship, and ultimately understand each other, the client has a higher likelihood of seeing improved outcomes with treatment.
It’s important to remember that the client-clinician relationship is a relationship like any other in our lives; it relies on trust, communication, and a shared understanding of the roles within that relationship. When it comes to therapy, this relationship is a proven predictor of success—which means that enhancing that relationship can have massive benefits on the outcomes of the client.
When we measure something, we can improve it. So how do you measure therapeutic alliance and respond to the results?
We hosted a virtual event with featured experts on the topic, Dr. Brent Mallinkrodt, co-author of the BR-WAI, and Emily Miller, a Master’s Level Psychotherapist and National Clinical Counselor from Pinebrook Family Answers in Pennsylvania, so we could answer this very question. Watch the recording here: How to Measure and Improve Therapeutic Alliance
- Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172
- Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. Johns Hopkins Univer. Press.
- Horvath, A. O., & Symonds, B. D. (1991). Relation between Working Alliance and Outcome in Psychotherapy: A Meta-Analysis. Journal of Counseling Psychology,38, 139-149.
- Wampold, B. E., & Imel, Z. E. (2nd ed.) (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge/Taylor & Francis Group.
- Mallinckrodt, Brent & Tekie, Yacob. (2015). Item response theory analysis of Working Alliance Inventory, revised response format, and new Brief Alliance Inventory. Psychotherapy Research. 26. 10.1080/10503307.2015.1061718.
- Luborsky, L., Crits-Christoph, P., Mintz, J., & Auerbach, A. (1988). Who will benefit from psychotherapy? Predicting therapeutic outcomes. New York: Basic Books.
- Norcross, J. C. (2002). Psychotherapy relationships that work. New York: Oxford University Press.
- Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450.
- Horvath, A. O. & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223-233.